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President Barack Obama holds a press conference in the James S. Brady Press Briefing Room of the White House, April 17, 2014. (Official White House Photo by Chuck Kennedy)
Markos argued last week that the harder the Republicans fight Obamacare, the easier it's going to be to make a single-payer system happen. He uses Vermont, which is working now to implement a statewide single-payer system under an Obamacare waiver, as his example. Is he right? From a political perspective, yes, though there's more to the picture than he included. From a policy perspective, things get a lot murkier, and a lot harder. Still, there's good reason to look to the law as it stands, what Vermont is trying to do, and how Republican intransigence is going to help move the cause beyond expanded insurance coverage to actual universal health care.

On the Republican side, yes, as Markos writes, their intransigence means that the Heritage-devised plan they should have embraced and worked with Democrats to home and perfect is less than perfect, still leaving out too many people. That's particularly true of all the people in the Medicaid gap. Those millions, as many as 6 million, are in health insurance purgatory—too poor to qualify for subsidies to buy private insurance, making too much to qualify for traditional Medicaid.

Graphic showing Medicaid coverage, the Medicaid gap, and private coverage percentages.
Righting that wrong, making access to health coverage more universal, can be the rallying cry for progressive activists, for Democrats. Most of us who had great hopes for health care reform have had to accept the Affordable Care Act as a step toward the ultimate goal of universal health care. When it passed, and many of us ended up grudgingly lobbying for it to pass, we hoped to take the momentum from its passage to start working on expanding it. Instead, it's been more than three years of a rear-guard action to fight Republican efforts to kill it. That wasn't just necessary to keep Obamacare alive, but to convince Democrats that health care reform is not the kiss of political death and it's something they shouldn't be running away from. If this reform effort didn't work, it could take decades longer for a political generation willing to take it on again.

But, now that Obamacare's success seems to be firmly assured, we can press its shortcomings and highlight it as the first step toward the universal health care. Vermont is a great place to start and plays a key role here, but it can't do it alone. Below the fold, we'll talk about why that's the case.

Vermont is working toward obtaining a waiver from the federal government to create what would be the first single-payer system in the country. The state can't actually put it in place until 2017, because the law requires all states to follow the new law until then. But they have a small window to do it, too, because there's no guarantee a 2017 White House will be cooperative.

Vermont wasn’t satisfied with the health reform law that Washington passed in 2010, the Affordable Care Act. That law expands health coverage by growing the existing health-care system. Americans who already had health insurance have seen barely any change. Uninsured people have gotten covered through two existing programs: the individual insurance market (where millions of Americans now receive subsidies to help buy coverage) and Medicaid, a public program for low-income people.

[Gov. Peter] Shumlin had a different idea. He didn’t want to build on what existed. He wanted to blow up what exists and replace it with one state-owned and operated plan that would cover all of Vermont’s residents—an example he hopes other states could follow. […]

On May 26, 2011, Vermont passed Act 48, the first law in the nation that provides health coverage to all residents of a state. Act 48 established Green Mountain Care, a health insurance plan that all Vermont residents would gain access to, by virtue of being Vermonters.

Green Mountain Care cannot start until 2017 because the Affordable Care Act requires states to hew to the federal health reform model for the next three years. […]

Between now and then there are two big questions that Vermont has to answer: how much will single-payer cost, and can the state find a way to pay for it?

There's the rub for a small state like Vermont, operating as it does within the national health care system—an extremely expensive system. A team of economists the state contracted with to determine how much it might cost estimates that the state will have to come up with an additional $1.6 billion in tax revenue in 2017 to pay for a single-payer system. Shumlin and his advisors think that they'll be able to save $36 million in statewide health spending in its first year, $86 million in the second year, and $158 million in the third, mostly from administrative expenses. But a second estimate by research company Avalere Health, obtained by the state's medical community, puts the price tag on the first year of the system at $2.2 billion.

The state's providers question that they'll see as much as Shumlin is predicting in the way of administrative cost cuts. The genius behind a single-payer system is that there's only one entity that a provider has to bill, significantly reducing administrative costs. The problem with trying to superimpose that idea into our existing national system is that there will be other insurers that Vermont's providers have to deal with, because they see a lot of patients from surrounding states, and they have to deal with all of the insurers that cover those folks.

"In Vermont we’ll go from four to five commercial payers to one," Fletcher Allen chief executive John Brumsted says, "But we still have a dozen or so more than we’re negotiating with and interacting with in Northern New York and New Hampshire. We still have to have the infrastructure in place to support multiple payers."
It's not just negotiating with multiple payers, but trying to set up a cost-controlled system within the context of a national system that has exorbitant, irrational costs in its DNA. One small state going up against that Vermont might have greater success if it could convince New York, New Hampshire, Maine or Massachusetts to join in. A regional single-payer system would have the advantage of a larger market capacity for negotiation.

Vermont, whether it succeeds or not, will provide critical experience for all the states—or potentially regions—to experiment with health care. But what it's demonstrating now is that Obamacare alone is not enough to reach the goal of universal health care. It should provide key lessons for how to get there, however.

In the meantime, President Obama and Democrats in Congress have to focus like a laser on both the achievements of Obamacare—8 million enrollments in the exchange market, millions more in Medicaid, at least 1 million adult children on their parents' plans, and as many as 8 million in new employer-sponsored plans off the exchanges. That's huge. It's working and Democrats need to yell that from the rooftops, particularly as Republicans have nuthin' but repeal.

But there are still millions of people left out, and that's the message Democrats need to run on as well. They need to run on it and win, and then fix it. Vermont will have a much easier time in making a transition to single-payer if the federal government works to incorporate a public option component into Obamacare. Say, for example, using the Medicaid funding forfeited by red states to create a Medicare buy-in on the exchange in those states.

The whole 2014 and 2016 table has turned with the remarkable success of the Affordable Care Act. The law finally has the momentum denied by Republicans and the courts after its passage. So now's the time for Democrats to build on it, energize the base and start talking more reform.

Originally posted to Daily Kos on Sun Apr 20, 2014 at 12:00 PM PDT.

Also republished by Obamacare Saves Lives.

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Comment Preferences

  •  Thank you for this diary! One of my main... (13+ / 0-)

    complaints around here has been no front pagers trying to express the flaws and possible fixes.

    I am so glad someone finally has though now I can't use that complaint any more :p

    Join the DeRevolution: We are not trying to take the country, we are trying to take the country back. Get the money out of politics with public financed campaigns so 'Of the People, By the People and For the People' rings true again.

    by fToRrEeEsSt on Sun Apr 20, 2014 at 12:06:12 PM PDT

    •  Well, it's kinda been (25+ / 0-)

      all hands on deck to fight the GOP on trying to keep this alive.

      I firmly believe that if Obamacare doesn't have a measure of success, Democrats will be way too scared to take on the next, necessary reforms.

      "The NSA’s capability at any time could be turned around on the American people, and no American would have any privacy left, such is the capability to monitor everything. [...] There would be no place to hide."--Frank Church

      by Joan McCarter on Sun Apr 20, 2014 at 12:13:04 PM PDT

      [ Parent ]

    •  It's not "finally." Joan has always been... (15+ / 0-)

      ...made clear that the system as passed has serious problems and has always been a public supporter of a single payer system. But, yes, this is a good post, and an excellent reminder of where we need to be headed in taking the improvements ACA has achieved and improving still more.

      Don't tell me what you believe, show me what you do and I will tell you what you believe.

      by Meteor Blades on Sun Apr 20, 2014 at 12:15:04 PM PDT

      [ Parent ]

      •  Well if there has been any other front page... (1+ / 0-)
        Recommended by:
        limpidglass

        diaries willing to express the flaws in the ACA I have missed them (or intentionally forgot them, which I hope isnt true).

        If thats the case then my apologies!

        Join the DeRevolution: We are not trying to take the country, we are trying to take the country back. Get the money out of politics with public financed campaigns so 'Of the People, By the People and For the People' rings true again.

        by fToRrEeEsSt on Sun Apr 20, 2014 at 12:22:07 PM PDT

        [ Parent ]

    •  You don't try to force feed a newborn (5+ / 0-)

      Look, you don't try to force feed an infant with steak and alcohol even if he will like those things when he grows up--even if you are trying to fatten him up.  Too much too fast is a recipe for disaster.

        The ACA has been up and running for literally only a few months. The time to bitch and moan and carp about things that could be fixed wasn't right at the start --and refusing to join in the circle jerk of people screaming about how terrible a compromise the ACA was in the firstplace was not a good idea.

      We are in a tug of war with the other side--their whole goal is to drag us into a pit that lies halfway between our sides. While ours is to drag the team to safety.  The people who have been most vociferously anti-ACA were not helping us do that. They were like people who throw their weight behind the other team--not like people who are working to help our team do better.  

      •  Honestly there are some glaring flaws in the law.. (0+ / 0-)

        to the point I am not sure at this point how good/bad it will be till these flaws play out.

        My personal biggest issue has to do with the combined factors of there being little in the law to keep the costs down below the insurer level, with the fact that the insurers make a flat 20% of all money moved through the system, thus not giving them any reason to keep those costs down either.

        This wouldn't be as big a factor if the economic trends weren't so dismal which will likely lead to more and more needing subsides and the fact more and more of the tax burden is being put on the backs of the lower and middle classes.

        If the rich have nothing to lose and everything to gain with costs going up and the average citizen must cover those costs, then the law will be much more flawed 10 years from now than it even is today.

        Join the DeRevolution: We are not trying to take the country, we are trying to take the country back. Get the money out of politics with public financed campaigns so 'Of the People, By the People and For the People' rings true again.

        by fToRrEeEsSt on Sun Apr 20, 2014 at 12:32:28 PM PDT

        [ Parent ]

        •  You really need to read up (8+ / 0-)

          You really need to read up on how the act was funded.  Also you need to read up on how insurance works and what the "medical loss ratio" means.  At a certain point natural scepticism becomes just a refusal to listen to the facts.  I highly recommend the series of occasional blog posts by Richard Mayhew over at Balloon Juice--these explain just what is at issue in the ACA and its Insurance Component.

          Basically: Insurance companies under the ACA model are largely managing--they are managing the paperwork and they are managing and attempting to limit patient choices, nudging patients into more cost effective treatments and more cost effective providers.  That is what the "networks" are all about.  They are making their money off of volume enrollments, not out of gouging individual patients at this point. That is because the new laws preventing recission (dumping people out of the policy when they get sick), the caps on costs, the busting of the lifetime payouts, and the "must issue" laws which prevent them from denying you insurance for pre-existing conditions all create a situation in which individual customers sort themselves into insurance pools without the insurance company being able to game them.

          This creates larger insurance pools which have more money sloshing around in them to pay for stuff--but it also prevents the insurance company from cherry picking healthy clients, selling them junk insurance, taking too much of the premium money in profit (the medical loss ratio) or throwing them out of the pool if they get sick.  

          Slowly but surely insurance companies are being turned into utilities--rather than having an incentive to inflate the costs of healthcare so they can inflate the 20 percent cut they get they have an incentive to hold care costs down.

          At any rate-there are definitely problems with the ACA but any large system is going to need a lot of tinkering over time to come into balance, especially one in which a shitload of people have gotten health care for the very first time and in which hospitals and doctors were used to trying to recoup their real costs in serving indigents by overcharging the rest of us. Its going to take time to shake out. Rather than being so negative why don't you inform yourself about what the real problems are and start helping the Obama administration and the Democrats find workable solutions?

          •  Sorry, missing link. (1+ / 0-)
            Recommended by:
            Eric Nelson

            Here's a link to the Balloon Juice series. It dropped out accidentally.

          •  I don't see the logic or how making them (1+ / 0-)
            Recommended by:
            limpidglass

            'utilities' means anything positive.

            If they have to pay a bill of $20k to the hospital they make $2k and if the bill is $40k they make $4k. Its still just paying a bill there is no more cost in paying $20k then $40k.

            Your whole premise seams unsupported by facts or reason.

            Join the DeRevolution: We are not trying to take the country, we are trying to take the country back. Get the money out of politics with public financed campaigns so 'Of the People, By the People and For the People' rings true again.

            by fToRrEeEsSt on Sun Apr 20, 2014 at 01:10:54 PM PDT

            [ Parent ]

            •  Their profit doesn't depend on individual bills (4+ / 0-)

              Like your post alludes too. If they pay a $40k, they aren't  necessarily making an profit off that patient  or bill. If that patient has been a member for a year and pays $300/month in premiums than the insurers is losing $40k minus $3600k in premiums.

              The aca contains costs because it dictates that annually, payers must pay out at least 80% of their premiums collected on medical care for their members. Hence, incentivizing insurers to keep members healthy and accessing care. If 80% isn't spent, the insurer is required to refund members with cash to reach the 80% medical loss ratio.

              Now think about this, insurers can't charge crazy rates because no matter how much the bring in, 80% of it has to be spent on medical care. No use overcharging premiums to make an astronomical profit off of sick people to just turn around and give the money back. 20% may sound like a lot, but consider the overhead...admins, physicians to review appeals, pharmacists to managing your formulary, RN case managers, call centers, legal and regulatory departments... Adds up quickly.

              On the healthcare provider side, the aca addresses cost in several ways. Medicare reimbursements are now tied to real results via HCAHPS and Press-Ganey surveys. ACO pilot programs (funded via aca) are showing promise at driving down costs also. It's a massive shift away from fee for service into quality driven payments models. It's huge for the healthcare industry.

              As a hospital administrator, I can tell you first hand, the ACA has drastically change the way hospitals operate in the last 4 years. The individual mandate and exchange marketplace to buy policies is just one small part of the reform.

              •  Of course not, insurance doesn't work that way... (0+ / 0-)

                They don't make money on an individual basis, but on a group. Sure if they pay $20k they don't make money on that person, but at the end of the year they get profit like they do.  They taken in X dollars and spend Y and get to keep Y+20% and have to refund X-(Y+.20Y) and must refund the rest.

                Given people are receiving refunds and those refunds are like $2 its exactly like they make $4k on a $40k bill.

                Your whole premise has no foundation in reality and your original point is a poorly constructed straw man.

                Join the DeRevolution: We are not trying to take the country, we are trying to take the country back. Get the money out of politics with public financed campaigns so 'Of the People, By the People and For the People' rings true again.

                by fToRrEeEsSt on Sun Apr 20, 2014 at 06:01:38 PM PDT

                [ Parent ]

                •  I wasn't trying to (2+ / 0-)
                  Recommended by:
                  mjd in florida, frostieb

                  Discredit your point. The way I read your post made me think you might have been viewing the medical loss ratio caps incorrectly. But obviously you are not.

                  I do think your under valuing the requirement that they have to refund premiums. Sure it may only be $80 or $100 (or $10) per member but it's likely millions for a large insurer and it effectively limits the premium they can charge. Is that not good? They can charge outrageous amounts but will be refunding it if they don't spend it on medical care. Suddenly insurers are doing things like providing free diabetic test strips or using case managers to monitor CHF patients or providing rides to dialysis patients to get to treatment because they have to spend the money on their customers AND only have 20% "fat" to spend on operations. Those things  are leading to more effective and efficient delivery of care which will lower the cost of care over the long run

                  Do I want single payer? Absolutely. Do i think it will happen? No, the payers are to powerful and won't let the government squeeze them out.

                  It's indisputable that single payer is more efficient and cheaper. The US outspends every developed country on healthcare and has outcome outside of the top half, similar to the clinical outcomes in Iraq and Costa Rica.

                  The aca is a start. We spent over $3 trillion on health care as country last year and still people die in America everyday due go lack of care. I'm glad we finally have started to address that.

                  If you still think I'm making straw man arguments then you are obviously way more invested in this than I am. I maybe to close to some of this and biased. As i said previously I work at a hospital so maybe I'm overstating the things that I have begin to make incremental change to healthcare in America.

            •  The insurance company has collected its premiums (1+ / 0-)
              Recommended by:
              bluenick

              from the insured for the month, and can legally keep 20% of that for expenses and profit. Or maybe only 15%, depending on conditions that I have not seen explained. When they get a bill from a hospital or whatever, they have to pay it without raising premiums until next year. So they fight for lower payments and reject some unnecessary care. The intention is to make those effects stronger over time.

              They also have to consider the competitive situation they will be in next year, when they can raise premiums. Will they lose customers if they raise rates more than the competition does? Does keeping costs down become a competitive advantage?

              Also, there are specific provisions in the ACA to mandate lower costs and more efficient and more effective care, also lowering costs. The rate of infections in hospitals is down this year, because hospitals now get dinged for them. For some causes, it is down by half. The rate of hospital readmissions is down, because hospitals get dinged for them. There will be more negotiations over medical equipment prices.

              These are just a few existing provisions. The ACA also funds research to find more possible improvements.

              A lot of this is in Zeke Emmanuel's book, Reinventing American Health Care: How the Affordable Care Act will Improve our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System.

              Back off, man. I'm a logician.—GOPBusters™

              by Mokurai on Mon Apr 21, 2014 at 09:51:39 AM PDT

              [ Parent ]

  •  The Heritage plan was to stop Hillarycare (11+ / 0-)

    not insure poor people. They had 8 Bush-tastic years to pass it and didn't because (and I think they've made this very clear) they are loath to do any social program that doesn't help the wealth.

  •  If we could take back the house and keep the Senat (13+ / 0-)

    If we could take back the house and keep the Senate we could easily fix these problems--one by going back and expanding Medicaid itself to cover the new kinds of people the expansion covers but as of right, or taking back Medicaid and making it a federal program instead of having it handled by the states. Or we could drop the subsidies portion of the ACA down to 130 percent of the poverty line so that the people who would have been covered by medicaid under the expansion simply receive subsidies through the exchanges.

    There are more than several ways to skin the cat but the first thing is to recapture the House, Senate, and keep the Presidency.

    •  Yep (5+ / 0-)

      At the very least, we've got to keep the Senate and White House. I don't see getting the House back in the near future, certainly not in 2014, but if we could have a 2016 wave....?

      "The NSA’s capability at any time could be turned around on the American people, and no American would have any privacy left, such is the capability to monitor everything. [...] There would be no place to hide."--Frank Church

      by Joan McCarter on Sun Apr 20, 2014 at 12:24:41 PM PDT

      [ Parent ]

      •  Last week kos wrote about a poll (0+ / 0-)

        indicating that we have a fair chance of taking the House in this cycle. That is an early, generic poll. We have yet to see who the real candidate will be in many races, and we have yet to see what creative ways Republicans will find to shoot themselves in each other's feet. Certainly Republican voter suppression and the War on Women are two of our best GOTV tools, and refusing Medicaid expansion should soon join them.

        Gallup has clearly shown that Red states have much worse outcomes under the ACA, and we know that that is intentional. The numbers for April are supposed to be even better.

        Back off, man. I'm a logician.—GOPBusters™

        by Mokurai on Mon Apr 21, 2014 at 10:03:08 AM PDT

        [ Parent ]

  •  The successful roll out and improved polls (11+ / 0-)

    has Democrats finally starting to run towards and not away from ACA...

    I very much want us to be able to expand on this - through states like Vermont creating a single payer system, through increased subsidies, through adding a Medicare buy in and increasing the Medicaid expansion, and adding a PO..

    •  I'd really like to see (6+ / 0-)

      more states going the VT route. I do think that the economies of scale are going to make it hard for one state alone to be successful, so I'd like to see states teaming up.

      "The NSA’s capability at any time could be turned around on the American people, and no American would have any privacy left, such is the capability to monitor everything. [...] There would be no place to hide."--Frank Church

      by Joan McCarter on Sun Apr 20, 2014 at 12:25:45 PM PDT

      [ Parent ]

      •  A New England regional plan would be nice (8+ / 0-)

        But that would require Dems retaking the Gov mansion in Maine and holding or taking all the other states legislatures.  

        I think we'll have a better chance of seeing California going single payer and individual states doing their own thing once Vermont shows that it can be done.  They maybe down the road they'll grow into something regional like New England or Pacific Coast plans.

        This is your world These are your people You can live for yourself today Or help build tomorrow for everyone -8.75, -8.00

        by DisNoir36 on Sun Apr 20, 2014 at 12:33:22 PM PDT

        [ Parent ]

  •  A regional plan in the Northeast could eventually (7+ / 0-)

    lead to a regional plan on the Pacific Coast, with WA, OR and CA all participating. At least, it is a possible scenario.

    Of course, it would do nothing to help those who need it most, and unfortunately live in states controlled by Republicans.

  •  We'll get there (6+ / 0-)

     photo b80a2441-25b2-4674-a969-f62600aef8a1_zps0df8272b.png

    Daily Kos an oasis of truth. Truth that leads to action.

    by Shockwave on Sun Apr 20, 2014 at 12:44:28 PM PDT

  •  not going to happen (2+ / 0-)

    We touch health care once every thirty to forty years, if that. All that political capital that was behind reform has been spent. It'll take years of anger and dissatisfaction at the system to build up again.

    It's not the desire to improve upon what already works, but a state of imminent crisis, that drives health care reform in America.

    I mean, we've had Medicare for fifty years. If the incremental approach worked, if things really did progress steadily forward, we should have had universal single-payer by now.

    Instead we got Bob Dole's warmed-over response to Hillary's health care plan. Instead of lowering the Medicare age to zero and having the government cover everyone, which would be cheaper and more efficient, we require everyone to purchase health insurance and tell ourselves it's a brilliant innovation.

    We celebrate the number of people who registered with a website as if it were some kind of meaningful metric. Even the thinnest of the thin gruel is hailed as a great leap forward.

    The sooner the Dems stop flogging this dead horse, the better. The only reason they're even talking about it now is because they think it'll bring them victory in November. They don't really care, and neither do the voters. The voters have moved on and accepted the ACA, for better or worse. There are other things to worry about now.

    Anyone who hopes for an improvement on the ACA is forced to pray for a massive economic crisis that will expose the fatal flaws in this captive-market scheme. Otherwise you can simply expect things to get worse, for the ACA to be stripped of whatever little fig leaves they put on to lure people into supporting it, and for the tentacles of the health insurance-industrial complex to wrap around us even more tightly, thanks to the law that requires us to buy from them.

    "In America, the law is king." --Thomas Paine

    by limpidglass on Sun Apr 20, 2014 at 12:49:57 PM PDT

    •  Obviously, I disagree (11+ / 0-)

      I do happen to think it's a good thing that millions of people who didn't have any hope of getting health insurance now have it. Is it as much as I wanted or think we really need? No, but it is an improvement.

      As for the rest, I sure hope you're not suggesting that I--or anyone else looking for more out of reform--is actually rooting for an economic collapse. Because, you know, that's ridiculous.

      "The NSA’s capability at any time could be turned around on the American people, and no American would have any privacy left, such is the capability to monitor everything. [...] There would be no place to hide."--Frank Church

      by Joan McCarter on Sun Apr 20, 2014 at 01:04:55 PM PDT

      [ Parent ]

    •  Nah. (9+ / 0-)

      We don't have major overhauls very often....we "touch" health care with fixes all the time.

      Look at Medicare Part D and SCHIP.

    •  Fortunately, this turns out not to be the case (0+ / 0-)

      The anger at Red state governors and legislatures is palpable, and can only grow, because Obamacare Saves Lives and the only Republican plan is to destroy hospitals by sending the uninsured to the ER, which is no longer being reimbursed for a lot of that care.

      You would be correct in proposing a lengthy delay if we had no ACA, but even there the intervals have been 15 or 20 years, not thirty. Nixon tried for a health care plan, not just FDR and Truman and LBJ and Clinton.

      But we do have the ACA, which is working as designed in Blue states, and much less well in Red states. We have insurers and doctors and hospitals and pharma and medical device companies all aligned against refusal of Medicaid expansion. It is an issue in this year's midterms, with the next open enrollment period coming up, and will be a much bigger issue in the 2016 Presidential campaign when it will be Hillarycare all over again.

      Back off, man. I'm a logician.—GOPBusters™

      by Mokurai on Mon Apr 21, 2014 at 10:13:41 AM PDT

      [ Parent ]

  •  The problem (4+ / 0-)
    Recommended by:
    AlexDrew, limpidglass, ferg, fToRrEeEsSt

    I'm not so sure I agree with the claim that Republican's opposition to PPACA makes a more progressive alternative more possible. I frankly don't see the logic there. Democrats, in the face of opposition, stress how great PPACA is and (falsely) say that we have achieved "universal healthcare." They act as though the job's done. Very few actually are talking about moving beyond it.

    And the law is the rube Goldberg device that it is not because of Republicans, but because of Democrats. (You can, though, blame the curtailed Medicaid expansion on Republicans because that was the Supreme Court.) But Obama and Max Baucus (who was one of the chief architects, if not the chief architect, of the bill) wanted to craft something that AHIP and PhRMA would get behind. And the Democrats still want the support of AHIP and PhRMA and are not likely to actively seek to implement the reforms that would challenge those groups.

    And I doubt that the political will is there (in Congress or the Oval Office) for something beyond PPACA in the near future.

    It's really quite a shame to see how much potential was given up in 2009 in order to cater to entrenched interests.

    •  we do tend to forget that we wrote the damn bill (2+ / 0-)
      Recommended by:
      AlexDrew, RUKind

      All by ourselves.  The goppers were just standing on the sidelines waving their arms impotently. They weren't even invited to the meetings.

      In the end, reality always wins.

      by Lenny Flank on Sun Apr 20, 2014 at 01:15:03 PM PDT

      [ Parent ]

    •  From the standpoint (4+ / 0-)

      that their sabotage of this one means that further reform is necessary, then I think Markos's argument stands. Had they gotten behind this and had all the states embraced it, along with Medicaid expansion, then it would be succeeding to the point that more reform wouldn't be necessary, not for a while anyway.

      I see it as our job from here on out to make sure Democrats don't get away with saying it's all fixed now, that we've got "universal" care.

      "The NSA’s capability at any time could be turned around on the American people, and no American would have any privacy left, such is the capability to monitor everything. [...] There would be no place to hide."--Frank Church

      by Joan McCarter on Sun Apr 20, 2014 at 01:15:30 PM PDT

      [ Parent ]

    •  I agree. I hear no talk at all about any (3+ / 0-)

      approach toward single payer.  All I am hearing is "the ACA is great", "it is settled law", "it is working wonderfully", "it has been proven a success", "the ACA is here to STAY", "the debate is done and over with", "the people will love it!"..... etc.

      None of the above suggests to me that anyone is seriously considering opening the floor to the real idea of single payer in the near future or even baby steps towards that goal.   It sounds to me as if the ACA is a done deal and final.  

      It is very frustrating considering that I wholeheartedly support the ACA BECAUSE I want it to go further and fast, not because I think this is where we wanted to be in any shape or form.

      If we want single payer or a public option or universal care, then we need to start demanding it now.  We need to point out why and how we are going to do it.  We need a time line.  We need politicians to be on board and demand they begin talking about it.

      •  Then you haven't been paying attention (1+ / 0-)
        Recommended by:
        bluenick

        to Vermont.

        All of what you quote is aimed at denialist Republicans. It has nothing to do with where we go next.

        I can hear the discussions about how to improve the ACA and go beyond it, because I search them out.

        Back off, man. I'm a logician.—GOPBusters™

        by Mokurai on Mon Apr 21, 2014 at 10:18:26 AM PDT

        [ Parent ]

  •  one way to make it better . . . . (2+ / 0-)
    Recommended by:
    AlexDrew, Bailey2001

    Lower the deductibles.

    Here in Florida, ALL of the Bronze Plans available when I signed up had deductibles of $5000 to $6300.  ALL of them.

    That is fucking ridiculous.

    In the end, reality always wins.

    by Lenny Flank on Sun Apr 20, 2014 at 01:12:49 PM PDT

  •  So why aren't states setting up public options? (3+ / 0-)
    Recommended by:
    GayHillbilly, ferg, GleninCA

    California?  Washington?  Massachusetts?

    O'Malley wants to run for president, why isn't he working on one in Maryland?  If several states developed public options, maybe these could be melded into a regional plan.

    Illinois?  Minnesota?  Anyone?

  •  On a more incremental note (2+ / 0-)
    Recommended by:
    Slightly Wobbly, GayHillbilly

    My wife does HR for a non-profit pre-school here in the S.F. Bay Area. The teachers at the school get s**t salaries but pretty generous health benefits. This year, she worked out that the school would save a lot of money if the employees got their insurance through CoveredCalifornia and had their individual premiums reimbursed by the school. All this is well and good, but there was a hitch. The changeover generated a huge amount of paperwork, NONE OF WHICH COULD BE HANDLED BY THE SCHOOL. Since each employee now had their own CC account. She had extreme difficulty even talking to CC (for security reasons) to resolve the inevitable payment and coverage issues.

    So my suggestion for improving Obamacare is that there should be a way for employers to manage multiple accounts on the exchange for their employees for the purpose of paying premiums. I know, this sounds oxymoronic, since it's supposed to be an "individual" exchange, but it would make the exchange much more user-friendly for small businesses.

    Keep fruit flies from having sex and they will turn to booze

    by 1arryb on Sun Apr 20, 2014 at 01:19:42 PM PDT

  •  ideas (0+ / 0-)

    1. provide subsidies for low income people in states that refuse to expand Medicaid.

    2. have a catastrophic-single payer: the federal government takes over catastrophic costs (paying for any medical costs more than 5% of a person's/family's yearly income).

    3. somehow get support for a real single payer system. cover everyone.

  •  Want to improve the law? (2+ / 0-)
    Recommended by:
    AlexDrew, Kentucky DeanDemocrat

    Get rid of the 2017 date for the waivers and allow States to innovate now.  Makes no sense that Vermont has to go thru the motions with the ACA for three years.  The cynical side of me says this wait is delibrate to allow the ACA to become entrenched, making single-payer or any other reform harder.

    It's time now(not 2017) to move past the ACA and onto real health care reform.

  •  Obviously not possible for now, but... (1+ / 0-)
    Recommended by:
    Kentucky DeanDemocrat

    ...the logical solution is federalizing Medicaid so that states "don't have to worry" about future promises being broken by Washington.

    Change does not roll in on the wheels of inevitability, but comes through continuous struggle. --Martin Luther King Jr.

    by Egalitare on Sun Apr 20, 2014 at 01:28:30 PM PDT

  •  Every Day in every way (1+ / 0-)
    Recommended by:
    buffie

    We the People need to shout this from the rooftops..

    One can only hope that the DNC, Et, Al. will get the message that it is a winning message and hang the GOP's hurting the poor and needy around their necks...

    U.S. Navy '64-'85 | The man who knows and knows he knows not is a wise man.. - The ink of scholars is worth more than the blood of martyrs.

    by OpherGopher on Sun Apr 20, 2014 at 01:32:41 PM PDT

  •  Political Success Needs to be Assured (0+ / 0-)

    While economic and functional success of the ACA seems assured, we still need to assure it political success. Economic and functional success does not guarantee that the proponents of Obamacare is going to win at the ballot box. The GOP's number one priority for 2017 is to repeal Obamacare. Democrats must go on the attack.

  •  Yes: Keep pushing forward. (2+ / 0-)
    Recommended by:
    ybruti, Eric Nelson

    I'd say "make it better," as you do in your headline, versus "fix it."

    Can't show weakness.

  •  The popular parts of the law are consistent w SP (2+ / 0-)
    Recommended by:
    buffie, Kentucky DeanDemocrat

    Namely, protection from bankruptcy and access to doctors. At least, I haven't heard any stories from Obamacare enrollees about how happy they are about finally having a relationship with the customer service line at BCBS or Anthem.

    If people are happy with Obamacare it's because their health and their wallets are better protected than they were before. And what is protecting them? Our very own federal government.

    The better the outcomes we see from the government stepping in to protect health and wallets, the more credible we are in pointing out the benefits of further intervention to do even more. Even more meaning, in particular, include everyone, and stop wasting so much money.

  •  Making it better... (1+ / 0-)
    Recommended by:
    Kentucky DeanDemocrat

    Stop nickel and diming people (and this goes for Medicaid and Medicare as well) with co-pays and deductibles.

    And ensure that the insurers and providers stop picking our pockets by having the patient agree to balance billing when the insurer and provider don't agree.

    And then work on cost control.

    Being able to do those likely reopens the issue of single payer.  If it doesn't there better be assurances that the purpose of the program is: universal care, best healthcare outcomes in the world, and lowest per person cost in the world.  I don't believe that can happen without disintermediation of the private insurance companies and a single nationwide community risk pool.

    50 states, 210 media market, 435 Congressional Districts, 3080 counties, 192,480 precincts

    by TarheelDem on Sun Apr 20, 2014 at 02:05:45 PM PDT

    •  Nickles and dimes would be nice (4+ / 0-)

      Recently, I had a MRI. My co-pay?  $150.  It will take me several months to pay that off.  Since my life's savings were destroyed in 2008 (along with millions of others) all I have is my Social Security.

      The Licans would like to get rid of Social Security, Medicare, Medicaid and the Patient Protection Affordable Care Act.

      It is strange that people hate Obamacare, but like the Affordable Care Act.  It has to do with labels.

      People who think that Medicare is free needs to understand that those of us who are on it have paid into FICA for years and pay over $100 a month for their Part B coverage.  It isn't free.

  •  Joan, you consistently knock it out of the park. (4+ / 0-)

    You're one of this site's most valuable voices, IMHO. Thanks for your great work.

  •  Thanks Joan nt (2+ / 0-)
    Recommended by:
    buffie, Eric Nelson

    nosotros no somos estúpidos

    by a2nite on Sun Apr 20, 2014 at 02:18:47 PM PDT

  •  Texas' Governor Could Care Less (2+ / 0-)
    Recommended by:
    buffie, mjd in florida

    Rick Perry could care less about the people who don't have the money to pay for health insurance.  As far as he is concerned, let the poor die and reduce the surplus population.

    The ONLY reason that he decided to not permit the expansion of Medicaid is because he is A LICAN!  Licans are at war with the middle class and the poor, and women.

    Thank goodness I'm over 65 and am on Medicare. I have Medicare Plus, thus pay less than straight Medicare. What scares the HELL out of me is that the freaking Licans want to CUT the pay that Medicare doctors get.  That will simply decrease the number of doctors who will accept Medicare.

    Licans need to be voted OUT in '14.  Get rid of ALL of them. Why ANY woman would vote for a Lican is beyond my ability to understand.  Why ANY person who is falling out of the middle class would vote for a Lican, again, is beyond me.  Any poor person who would vote for ANY Licans is WAY beyond my ability to begin to understand.

    Any "minority" voter, unless they're part of the 1%, and some are, who votes for the Licans deserves whatever they get.  The Licans, especially their tea party element, are as racist as the KKK.  Check out some of the videos on YouTube if you think I'm kidding.

    Most of the Republican states turned down the expansion of Medicaid even though it wouldn't cost the states a cent. It was pure meanness on their part.  Licans only care abut how much money they can get to run for office or put in their pockets.

    I used to be an Independent voter, now I am solidly in the Democratic camp.  I give a damn about others, and that's why I'm a Democrat and not a Lican.

  •  Re the numbers enrolled off-exchange, (2+ / 0-)
    Recommended by:
    elfling, Eric Nelson

    Brainwrap wrote on April 15:

    today Kaiser Health News reports that Larry Levitt, one of the most respected experts on health insurance in the country, has openly stated that: "I think it's probably the case that there are more people insured in the individual market off the exchange than on the exchange right now. "http://obamacaresignups.net/...

    I suspect the millions in the individual off-exchange market mentioned by Larry Levitt are not among the 8 million in the "new employer-sponsored plans off the exchanges" that you mentioned in the diary. For example, Brainwrap's graph updated 4/17 does not include the 8.2 million enrolled in additional Employer-Supplied Insurance (ESI). http://obamacaresignups.net/...

    The spirit of liberty is the spirit which is not too sure that it is right. -- Judge Learned Hand, May 21, 1944

    by ybruti on Sun Apr 20, 2014 at 02:46:04 PM PDT

  •  Well, that made sense (2+ / 0-)
    Recommended by:
    Kentucky DeanDemocrat, ferg

    Yes, this is correct.  The ACA is already better than the horrible system it supplements, but it isn't good enough yet.

  •  Pipe Dream (2+ / 0-)
    Recommended by:
    Justanothernyer, OIL GUY

    There are two approaches to single payer: Socialized medicine (as in Great Britain) and national health insurance (as in Canada). Both have proven effective at controlling costs without compromising quality of care.

    There's also virtually no chance that -- barring a complete collapse of the sector -- we'll ever see it in the United States, especial since Obamacare has rendered the possibility of collapse unlikely. Pursuing single payer is high effort-low probability-of-success proposition, a waste of time, energy, and resources that would be better put to improving what we have.

    The reasons that single-payer won't take hold have nothing to do with Republican intransigence.

    First and foremost, there's no outcry for it, nor is there likely to be one. Most people feel secure with the insurance that they have, and have little appetite for trading it in for an unknown.

    Second, a campaign for single payer would be fiercely resisted by insurers, device makers, pharmaceuticals, and many (although not all) providers. After, single payer means putting the first out of business, putting regulatory clamps on the next two, and turning doctors into civil servants.

    I'm not saying that any of this is necessarily a bad thing. But, you have to pick your battles, and there's no point in picking a big one that voters aren't interested in, especially when it means threatening the massive financial interests of entrenched opponents.

    Moreover, there's no point in not recognizing what is at risk: Defeat would embolden the opponents of reform and undermine Obamacare.

    Better to focus on improving what is there. It's not perfect, but it is improvable. And it is the winning hand. So why throw it in in the hopes of drawing to an inside straight?

    "There is no room for injustice anywhere in the American mansion." Lyndon Johnson

    by pkgoode on Sun Apr 20, 2014 at 03:04:02 PM PDT

  •  VT could buy the hospitals in state (1+ / 0-)
    Recommended by:
    ChuckChuckerson

    and then either tell doctors
    A) You practice but, we set your fees for VT residents
    to Medicare+12%  

    or

    B) We give you a fixed salary, office budget and
    staff allowance. You take what comes in the door for 40 hours.

  •  This is a rotten time to push for single-payer. (0+ / 0-)

    ACA appears to be off to a great start and it will become as popular as Medicare over time. Single-payer adds little in benefits while forcing nearly everyone to change how their care is provided

    The fact is, most people are happy with their existing plans. The beauty of ACA is that it allows most people who already have insurance to keep it. That is its greatest political virtue. The Republican attacks have failed because almst everyone realizes their policy is the same accept the ACA added a number of protections to encourage wellness, and to prohibit the most abusive practices on Insurance providers, such as lifetime caps, pre-existing conditions, etc.

    As to the people who are denied the medicaid benefits they deserve by Republican governors and legislators, the best way to address their concerns is through education and political action. They need to be organized into a powerful voting block whose goal is to elect Democrats who will provide them and their families with health insurance.

    By 2016 we should be able to flip at least half of these Republican ACA opponents' seats to the Democratic column, at which point Republican politicians everywhere will start to publicize their undying love of ACA and the immediate need to get those 4 million  eligible people on Medicaid.

    Here's my take on it - the revolution will not be blogged, it has to be slogged. - Deoliver47

    by OIL GUY on Sun Apr 20, 2014 at 10:28:28 PM PDT

  •  Shouldn't be ACA, should be AIA (0+ / 0-)

    Okay, look. The ACA is really about care. It's about insurance. It's not affordable care, it's about affordable insurance. And anyone who thinks that the insurance companies don't have about an infantry divisions worth of lawyers looking for loopholes around the ACA provisions is fooling themselves. In two years. there are going to be dozens of cases undoing what ACA does.

    The point is, the solution to affordable health care in this country is a single payer system. That's how we're both going to control costs and insure everyone.

    The whole reason that ACA is as complicated as it is, is that the right wing is terrified that someone they don't like (ie brown/poor) is going to get "free" healthcare. Without that, ACA would be a lot further along and would work a lot better.

    ACA has done a lot of good things. It has reformed insurance coverage for now. It has reduced costs and covered a lot of people who weren't covered before.

    But if we think that the fight is over, that ACA is a done deal and settled law and we can move on to the next thing, we are in for a sorry disappointment.

    It's only just begun. ACA is a tiny first step toward health care reform in the US.

  •  Publicly-Funded Healthcare (0+ / 0-)

    The next target should be publicly-funded healthcare, where all essential healthcare is paid for by the federal government out of a progressive tax.

    There's no reason to leave anyone uncovered. Why is it that after all these years we STILL don't have universal, affordable healthcare?

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