The Obamacare “Wonks” Are Awfully Selective about Which Taxes and Costs They See

Let me start this critique (what may be the first of two parts) of Jonathan Cohn’s scolding of Bernie Sanders on health insurance by looking at this passage, from the end of his piece:

[Bernie] might not get his plan through Congress, sure, but he could use his promise to extract other useful legislation from Congress. Maybe he could win approval for the “public option” insurance plan that was originally part of Obamacare, or for allowing the non-elderly to buy into Medicare.

These are legitimate arguments. But liberal policy wonks remember the struggle to enact and then implement Obamacare. They also also remember that universal health care was a progressive dream for nearly a century, one that proved impossible for presidents with names like Roosevelt and Truman (and Clinton!) to realize.

One reason reform took so long is that, for most of that period, activists and the wonks were pulling in different directions, with the activists pursuing single-payer and the wonks looking for compromises. The (mostly) unified front they showed in 2009 and 2010 was a big reason Obamacare became law. Now that unity is fading, creating a key divide in the Democratic campaign.

In this passage, Cohn talks about the things that Bernie Sanders might do as President that fall short of his goal of “single payer” health care (I put that in quotes because what we’re really talking about is government paid health insurance — as providers pull out of exchanges in Obamacare we’re actually moving closer to a much more alarming sort of single payer model).

He suggests that President Bernie, brought to earth by a reality of which, his critics suggest, he is woefully unaware right now, might set up the government as a competitor to private insurers within the Obamacare structure. Cohn then moves from that possibility (which I would suggest would be remote except for some realities about Obamacare as enacted) to saying “liberal policy wonks” know that Obamacare was a struggle and they know how hard it was to get even what we got (Bernie, who was in the Senate fighting to make Obamacare better at the time, apparently is too senile to remember all this, I guess).

As a reminder, one reason both the public option and Medicare buy-in were opposed by some Democratic Senators (and especially insurance state Independent Joe Lieberman, whom Bill Clinton had a big hand in getting reelected in 2006), meaning we couldn’t even pass it with a supermajority, is because they would make it too easy to move towards single payer. The idea was private companies could not compete, and so would slowly lose most exchange business to the government.

Now, if I were someone pushing for the improvement of healthcare delivery in this country, I’d say, “wow, if Bernie could pull off Medicare buy-in, that’d get us closer to single payer! That’d be a huge win!” I also might consider ways that true Medicare buy-in (rather than just gradually lowering the age at which you could buy in) might address some of the problems with cost sustainability with Medicare. I’d further applaud that getting more people into Medicare would expose more people to the innovations in delivery tied to it (one of the two best things about Obamacare), and therefore would move delivery as a whole down that path.

In short, I’d be applauding.

But Cohn doesn’t do that.

Instead, he decries what he calls a split between “wonks” and “activists.”

Can someone please define what those words mean for me? Can you explain how a man who has spent a decade writing about ways to improve health insurance and even sometimes healthcare, as Cohn has, is not an activist of sorts? Has he just been writing for a paycheck all these years?

Don’t get me wrong. I consider Cohn an expert in the subject, unlike some other people who get included in Paul Krugman’s club of wonks. I respect much of what he writes. And I have no doubt that he has become an expert on this topic because he’d like to improve a shitty system.

But setting up a dichotomy between “wonks” (“yes, I am one of those wonks,” Cohn says elsewhere) and “activists” is an insidious way of saying “some of the people who work on this issue are not as smart as me.” Would anyone suggest such a thing about insurance company lobbyists, who are themselves “activists”? Nope. They’re just experts who use different methods to press for their desired outcome. But somehow people who lobby and organize on the other side are presumed to be unicorn sniffing half-wits.

Calling oneself a wonk is also an easy way absolve oneself of examining what function wonk-scolding plays — a way to pretend one is delivering just unmediated rationality and not an argument designed to bring about some outcome. Here, the desired outcome seems to be the restoration of unity between those deemed “activists” and those deemed “wonks.” But not just to restore unity, mind you, but to restore unity by getting “activists” to be satisfied with what “wonks” tell them is realistic.

In other words, it’s a plea from one kind of activist for another kind of activist to fall back in line behind the policies the first kind of activist espouses, and, especially, to stop suggesting Obamacare (and, frankly, a whole bunch of other policies enacted by Obama and defended by Hillary Clinton, as well as some foreign policy ones that go beyond what Obama has done) isn’t an adequate solution.

So let’s go back to what else Cohn says. First, he explains why (unnamed) “liberals sympathetic” to government insurance consider it unrealistic by warning that even trying to move towards government insurance will “produce a major public backlash.”

Even many liberals sympathetic to the idea have said that Sanders’ scheme is simply not realistic. They worry that trying to push through another comprehensive health care package so soon after the Affordable Care Act’s tumultuous enactment would produce a major public backlash.

Note what Cohn has done here (besides putting his own argument in the mouths of unnamed anonymous liberals). In the rest of his piece, Cohn suggests that achieving government insurance is unrealistic. Fair enough — in a four year term it may well be. But here, he somehow ties what might fairly be considered the impossibility of actually achieving it with the specter of “major public backlash” if someone even tries.

I’m not sure if Cohn has noticed, but there is an ongoing major public backlash already. It was so bad in 2010 that it made predictable off year congressional losses far worse than they might have been. Much of that backlash is just Republican posturing. But not all of it. Some of the backlash comes from legitimate complaints about Obamacare: the government botched the original sign up, people actually weren’t able to keep their insurance plans, their selection of doctors has gone down, people are being forced to buy shitty insurance they can’t afford that won’t even make care affordable. Some of the backlash is unjustified, but some of it actually is justified.

But Cohn says we can’t talk about moving to government insurance because if so it will … cause what is already happening to continue happening? Or perhaps because it will legitimize some of the legitimate critiques of the Obamacare that activists like Cohn pushed back in 2009? Is that it? We can’t even talk about government insurance because doing so would bring people like Cohn in for some criticism?

Finally, here’s the line from the debate that Cohn frames this entire discussion around, where Hillary attacked Bernie’s plan because it would impose a $2,300 tax on the working poor.

But during the debate she also made another claim: That under the Sanders plan, some low-income people now on Medicaid would be much worse off. “A working woman on Medicaid who already has health insurance would be expected to pay about $2,300,” Clinton said.


Here’s why. If the federal government is going to provide everybody with health insurance, then it must raise enough money to pay for those benefits. To do this, Sanders has said, he’d create a new payroll tax, equal to 8.9 percent of wages. In theory, employees would pay only a portion of that, with employers covering the majority. In reality, economists say, the employer share also comes out of workers’ paychecks, if not right away then over time.


An 8.9 percent payroll tax would work out to a new payroll tax burden of $2,314 — just as Clinton said.

Today, by contrast, you’d be getting Medicaid without having to pay any new taxes. The money for the program comes out of general revenue and if you’re one of the newly eligible folks, then the money is coming almost entirely from taxes that fall on the wealthy and on corporations in the health care industry.

Now, “wonks” love to criticize Bernie for promising things he can’t deliver. But note what Cohn has done in this last paragraph: under Obamacare this working poor mother of two gets health insurance “without having to pay any new taxes.” Her health insurance “comes out of general revenue” which comes from “taxes that fall on the wealthy and on corporations in the health care industry.”

I think Cohn means to suggest that the revenue passed under Obamacare fall on the wealthy and corporations. He surely doesn’t mean that general revenue funds generally come from taxes that fall on the wealthy and corporations, because many rich people and corporations actually don’t pay income taxes. Indeed, it’s all that we can manage to keep corporations — some of them the health care ones Cohn says pay for all this — paying any taxes at all. What he really means is the taxes that pay for Medicaid come largely from the affluent and middle class taxes and even borrowing. That single mom likely still isn’t paying for her own Medicaid, but it’s not actually rich corporations that are doing so.

But even if Cohn meant only to refer to the planned funding method for Obamacare, his claim is problematic. That’s because one of the taxes targeting the industry, on medical devices, has already been suspended. Another tax that Obamacare boosters liked to pretend will only affect the wealthy, the Cadillac tax, will actually affect more people than that, including unions (which is why Hillary has promised to scrap it, as has Bernie). Plus, the Cadillac tax boosters sold it with a claim that workers wages would go up after their companies cut their health insurance. Those claims always seemed like fantasy — at least to me and actual experts like Larry Mishel, the latter of whom was pretty much ignored by the “wonks” during the debate. In the last six years that has become even more clear.

This is important: In a key fight about funding during Obamacare, the “wonks” promised workers (especially union workers) a wage increase, but evidence now strongly suggests it would lead instead to a wage cut. Yet those same “wonks” (though Cohn wasn’t one of the more obnoxious Cadillac tax defenders) are now scolding Bernie about the realism of his claims. Why should we listen to the “wonks” when they too promised illusory unicorns?

Finally, though, I want to look at the premise of Hillary’s attack, that Bernie’s plan would be bad because it would impose an 8.9% tax on a working poor woman. Cohn admits that’s surely something Bernie would fix before implementation, but he apparently finds the criticism legitimate because “doing so would require new trade-offs.” Trade-offs like those that continue to need to be made on Obamacare to make up for the medical device and Cadillac tax, I’d respond.

But here’s the other thing about that 8.9% tax. I absolutely agree that an 8.9% tax on the working poor in exchange for health insurance would be steep. But let’s consider what Obamacare is for a segment of the middle class that are forced to buy insurance — spending up to 13% of their income — that they can’t use. Sure, it will minimize but by no means eliminate the problem of medically related financial crisis in the case of a catastrophe. But the rest of the time, it functions as a tax, a payment necessitated under this scheme to make care accessible for others. One that — unlike that poor woman who’d pay $2,300 if Bernie’s implementation of single payer somehow didn’t fix things along the way — wouldn’t necessarily provide care in response. (Note, in reality, 22% of Medicaid recipients also can’t afford to use their insurance, though unlike the general number of underinsured, that’s a number that Obamacare has improved.)

Now, we knew this was going to be a problem, though the “wonks” generally didn’t like to talk about it during the debate (though Cohn is actually one who did admit it at least once in response to me raising it), because somewhere between 16 and 21% of people in Massachusetts couldn’t afford to use their RomneyCare. Hillary has suggested she’d throw more money at the problem (and, ultimately, insurers) to address the problem, but she hasn’t actually explained what trade-offs she’d make to achieve that. Again, it seems okay for Hillary to remain silent about the trade-offs she’d have to make whereas when Bernie does he’s a fantasist.

Partly, though, Obamacare is designed to underinsure people, because there’s a belief that unless people feel the sting of obtaining care, they’ll get too much of it. “Bending the cost curve” under Obamacare is largely driven by increasing the costs of actually using insurance to the end user as opposed to, say, eliminating the many layers of private profit that doesn’t actually improve health care but makes it expensive.

In truth, the people the “wonks” deem “activists” aren’t actually stupid, or naive, or unicorn herders. Some of them are actually experts of longer standing than those writing in favor of Obamacare. Rather, they disagree about what acceptable costs are, as well as about whether it makes sense to continue pointing out that the US has an unbelievably ineffective healthcare delivery system with terrible outcomes that not only is immoral, but saddles our economy with a burden that other developed countries don’t have, making us less competitive in any industry not driven by this exorbitant spending. Yes, there is also a difference of opinion about whether it is more effective “activism” to set the goal where everyone agrees it should be — providing actual health care — or to instead set more moderate goals that also have the effect of naturalizing a particular ideology. But ultimately there is a real debate about policy here, and rather than use “activists” to continue to set the bar on the most efficient way to provide the best health care, a lot of those close to Hillary would prefer they just shut up.

Update: First, Cohn has corrected his piece to note that the single mom he discusses would actually pay $1,600, and that it would actually come from her employer.

Dean Baker (another expert often ignored during these debates) not only reminds that if Bernie were able to pass both his single payer and his $15 minimum wage proposals, the single mom would be better off overall (and he used Cohn’s uncorrected number). He also provides the equivalent example to the one Cohn offers, to note (as I did) that Obamacare requires some people to pay for insurance they won’t use.

Let’s take the case of a young African American woman just out of college, with $30,000 in debt. Let’s suppose this woman has an income of $35,000 a year. Let’s say she is in excellent health and from a family of people enjoying excellent health. In the pre-Obamacare days she might have opted to either buy one of the low-cost catastrophic plans that is no longer available under the ACA, or go without insurance altogether.

Under the ACA, this young woman will be expected to pay roughly 8 percent of her income, or $2,800 a year, for health insurance that she does not want. Should we feel bad about this young woman struggling to meet a large debt burden, while working at a low-paying job and now being forced to buy insurance?

Well, that is a bad story and there are many like them. But many of the same policy wonks who have endlessly highlighted the plight of the Medicaid mother under the Sanders plan (I have seen it featured as a news article in the Washington Post and also as a topic of numerous columns and editorials), have been content to largely ignore the plight of young people struggling to pay their ACA premiums. At least they don’t see it as a basis for rejecting the Affordable Care Act.

24 replies
  1. bevin says:

    “Activists” believe in politics: if you want single payer healthcare elect a President, a Senate and a House committed to the same.
    “Oh no!” cry the Wonks “that will never work. It’s dreaming !”
    (Sotto voce the wonks are praying because their business is to water down reforms to the point that they are barely reforms at all and, within a short while, become the opposite if reforms, as the vested interests bend them to their benefit.)

    That is what is happening to Obamacare. It’s what happened to Romney’s plan. It’s why hard nosed businessmen love making deals with wonks desperate for paper victories. And jobs for life.

    Anybody who didn’t realise what Obama was about after the 2010 mid-terms-uncontested by the Democratic leadership- and the time that he neatly excused himself from visiting Wisconsin when it looked as if a movement might be developing, just wasn’t paying attention.

  2. lefty665 says:

    Obama sold out to PHARMA, providers and for profit insurers in the spring of ’09. The subsequent extended fight looked like how long it took to kill single payer and its weak sister public option. F*** the neolibs and the horse they rode in on.

  3. Brendan says:

    Could you elaborate on this?

    “Partly, though, Obamacare is designed to underinsure people, because there’s a belief that unless people feel the sting of obtaining care, they’ll get too much of it. “Bending the cost curve” under Obamacare is largely driven by increasing the costs of actually using insurance to the end user as opposed to, say, eliminating the many layers of private profit that doesn’t actually improve health care but makes it expensive.”

    I think that is the rationale behind the Cadillac Tax, and one could argue that subjecting chronically uninsured consumers to private insurance, which typically offer plan designs that feature no first dollar coverage at comparatively lower premiums, reflects this rationale as well, but that might be a bit of a reach. What else did you have in mind?

  4. No Use for a Name says:

    As someone that lives in a place with government provided health care I can tell you without reservation that the people that “overuse” and exploit the healthcare system are all upper middle class and more, there are still sever access issues, and may doctors charge (they where allowed to do this from Con/Liberal Governments) a yearly fee (it’s only a few hundred in most cases, but still) the people exploiting the system are not the poor and the disenfranchized it is the wealthy and the powerful

  5. Displaced Person says:

    Single payer is not synonymous with universal healthcare. There are two large single payer systems that we can look at – Canada and the U.K. The other countries with universal health care have different systems usually involving several layers of insurance. If we are going to try make national policy rationally we should look at the trade offs between these systems. Medicare for all sounds better than it would be in practice because it is a fee for service system and the reimbursements are skewed against primary care physicians. Obamacare was and is a great advance. Now we need to devise a plan to cover the poor and chronically ill and move substantially away from fee for service for primary care.

    • emptywheel says:

      That is certainly an opinion one is entitled to have.

      Others might think that dumping as much $$ as we do under Obamacare is a dead weight for the American economy, especially since our health CARE is so much less effective than our peers.

      • Displaced Person says:

        Obamacare greatly improved access to health insurance for millions. As I tried to suggest it was only a beginning not an end solution. The pockets of massive profits in US healthcare – Big Pharma, big surgery, hospital systems and hospital administrators – are powerful parts of our political system and healthcare system. Obamacare made significant inroads in the profit taking in important areas such eliminating denial of care for pre-existing conditions, requiring a percentage of revenues to spent on care and, least well known , not permitting hospitals to be reimbursed if a patient is readmitted for the same complaint within a reasonable period.

          • jerryy says:

            Pick any one from the list and you can find someone claiming that it too is a tyranny. There are several in that list ranking above the U.S., that our propagandists do not like as well as some ranking below our standing.
            Bloomberg did not take political systems into consideration, at least in their article explaining how they ranked the systems.
            Shame though, is it not, that those tyrannies can somehow manage to deliver better care than our system?

  6. der says:

    Wonks is to Activist as Advocates are to Leaders:
    “Pelosi is married to a multimillionaire investor, and her comments were charged with social resentment as well as political hostility.
    Pelosi’s remark—imagine that riffraff “sleeping on my sidewalk”—reveals the enormous social distance between the masses of working people, housewives, students who oppose the war, and the privileged ruling elite. And her disparaging reference to the First Amendment demonstrates the hostility of a big business politician towards the democratic rights of the working class.
    In elaborating on this comment, Pelosi tried to backtrack from her spontaneous display of her real attitude towards antiwar activists. “They are advocates,” she said. “We are leaders.” And “leaders,” of course, have to be practical.
    2 weeks ago James Carville, in an interview with Chris Hayes, went on a rant about voters supporting “Independent, not a Democrat” Sanders. Last week on Democracy Now it was Torie Osborn rolling her eyes at Robert Scheer’s support for Bernie, who, according to Osborn is still singing the same song she heard Sanders sing in the ’70’s (like she’s given up on all the values she held dear from her “pie in the sky” college daze). “That crazy Bernie! stuck in paisley time, We still love him though, dear man.”
    Some years ago there were reports about Rahm the Enforcer stabbing a table with a knife pissed at the “progressives” in The Party, Wasserman-Schultz too was reported to shut down a conversation with an “activist” saying “don’t give me any of that progressive crap!”
    I’ll remind the Wonks that they’ve been in charge for a long, long, long time and, in the words of Duncan Black – “Shit is fucked up and bullshit!”
    Hillary will be the next president, the big 3 of Wall Street, National Security “wonks”, and the Pentagon want it that way. The Party’s Wonks I would think know this, if they would stop being such assholes I might consider placing an X next to her name when the time comes.

  7. lefty665 says:

    It is not a surprise that similar percentages of people cannot afford to use insurance they have been forced to purchase under both Obamacare and its model Romneycare. They are both Repub plans that institutionalize health care industry profits.
    The difference in premium for Obamacare plans from cheapest (Bronze) to more expensive (Gold) is not huge, but the deductibles and copays escalate hugely for the cheaper premium plans. That’s another gotcha for people who have struggled just to purchase mandated insurance and contributes to their inability to use it.
    Of course Hillary does not want material changes to Obamacare, she and the health care industries (PHARMA, providers & insurers) that have bought her soul have things arranged just the way they want them. That is more services covering more lives with Federal subsidies. Anything that changes that might derail the gravy train.

  8. earlofhuntingdon says:

    The American health care system is so expensive and so broken – from the perspective of delivering health care to as many people as possible at affordable prices – that causing a major backlash among a lot of people would seem a good thing. The current systems is a profits protection racket, cooked up by WASPs instead of Sicilians. Mr. Obama’s solution was not to fight it, but to strengthen it. His patented one step forward, two steps back approach seems to be how he approaches every conflict with the powers that be.

    The added protections from Obamacare are welcome. Mr. Obama bought them at the cost of strengthening insurers, drugs companies, and health care providers. That will be extraordinarily costly, both in direct costs as well as the political cost of changing tack by reducing the profit margins of those industries.

    • emptywheel says:

      Right: It will be very hard to make any further progress bc this will expand health delivery as a proportion of our economy, making it too costly to do it right.

  9. earlofhuntingdon says:

    People face more than the sting of health care; they are losing organs and limbs to it. Premiums shoot up 20-30% a year, drugs pricing sometimes more than double, while drugs companies spend far more in marketing expenses every year than they spend on oft-touted research and development. Even that leaves open the question whether “marketing” expenses include lobbying. Besides, feeling the sting is not something its opponents every open themselves to; they work as hard to avoid it as Dick Cheney did in avoiding the Vietnam draft.

    • earlofhuntingdon says:

      As for that sting, it’s well documented that many people don’t use the health insurance they have because, even with it, they still can’t afford the cost of Health Care. In effect, they are subsidizing health insurer profits while getting as much care as if they had no insurance. That is not a sustainable arrangement.

  10. exiled off mainstreet says:

    I consider myself lucky that since my mother was born in Canada I had dual citizenship. Therefore I was able to emigrate seven years ago. At age 63 (56 then) I would have paid around $100,000 to parasite insurance companies or gone bare. Even though I had to give up a professional license since Canada wouldn’t recognize it, I’m ahead of the game since I was able to retire. Other factors, such as meeting my wife, have helped out, but the fact I inherited the dual nationality was my biggest break.

  11. jonf says:

    I still don’t understand why we have to use a payroll tax or other special tax to pay for health care. I would think medicare for all could cover 80% or 90% of cost and insurance and subsidies the remainder. The plan could be funded through ordinary taxes, perhaps increased as needed. A payroll tax may not be the fairest way to spread the cost. The problem, of course, is taxes are a dirty word even if the total cost is less than the Obamacare bill with its narrow networks, deductibles and narrow networks – what you call shitty insurance. We are too often told NO, and we too often just sneak away.

  12. Anonymous says:

    A dedicated research journalist could write several articles on the shortcomings of the whole scenario covered by the Marketplace insurance scheme – and scheme it is.

    “the government botched the original sign up, people actually weren’t able to keep their insurance plans, their selection of doctors has gone down, people are being forced to buy shitty insurance they can’t afford that won’t even make care affordable.”

    From an anonymous insider at one of the larger health care insurance plans in a larger MidWest state comes this brief description of the nightmare known as the Affordable Care Act:

    1. Administratively, the Exchanges, known as the Marketplace when you call on the phone, are as inept, arcane and maddening as anything Kafka might imagine. Need to report income changes? O.K, yes mail that information in so it will then subsequently be lost and then you will need to file an appeal (90 days to process) to get your tax credit restored which was taken away from you because you did not report income change. Want to remove a family member off the plan because they are medicaid or medicare eligible? OK. Watch as the Market place closes the whole plan and eventually (after a two week wait) nobody in the household has insurance.

    But wait there’s more,
    Medicaid will cover an eligible person right? once that determination is made? Nope because the commercial carrier did not receive notification of the move to Medicaid so they carry the person along up to the max (90 days of premium delinquency are allowed). People end up sobbing on the phone line to the commercial carrier for the plan to be closed. The law forbids the carrier to end a plan until the Marketplace (MP) submits a termination. Meanwhile Medicaid sees the commercial plan as being in effect so again making that plan primary. And yet one more victim of the ACA falls to the wayside without any coverage. And so it goes.

    Need to have your address updated with the insurance carrier? That has to come from the MP so dutifully you call them, they send the update to the carrier but at the beginning of 2016 all of your old information comes out of the woodwork, electronically speaking putting your old address up to the carrier, and now you have to call to the MP again. Oftentimes the wait on the MP phonelines is over an hour. Of course you could do the thing but that website wants you to enroll all over again, so you do that thinking that is what is needed and now you have two plans at the insurance carrier and two premium bills. Which one do you pay? You call the insurance carrier and are told to call the MP.

    Say you do successfully report your income change to the MP via phone in say the second week of the month-March in this scenario. You are assured the new amount of the tax credit will be applied back to the first of the month. But that does not happen and the bill for the next month looks like it is the result of a random number generator. You call the carrier and the rep reviews the last four months and after 40 minutes you realize an appeal will have to filed with the MP – 90 days to restore about 1/3 of what you take home in a month.

    Shopping for plans (as the progenitor of Obamacare called it) is also a nightmare. In frustration you call an insurance sales rep and pick out a plan because it has low premiums and you’re assured basic care (preventive services like yearly physical exams and immunizations) are covered. You go for your first exam and are stunned the day your doctor’s office bill arrives in the mail for about $167.00-a major slice out of the weekly paycheck. The insurance carrier rep explains (your brain is on overload from the stress and the incomprehensibility of what’s being told to you): preventive screenings is a term used to apply when there is no diagnosis for any condition on the claim. A ‘sick patient’ diagnosis like high blood pressure, diabetes or obesity will result in the claim being applied to your deductible-which is $5950.00. Right after the physician visit you go to the drugstore and are given a ridiculous number for the cost of a medication you had been taking for years. You believe there was an error committed and the pharmacy and because it’s late in the day you trudge home without the script. The call to the carrier is now outlining a horror story- the plan that had such low premiums is not the correct plan for you because you see your doctor about six times a year and take three meds. Your annual costs are going for your health care are going to be about $3000.00 plus the approximately $2500.00 per year for the premium.

    There’s more-maybe next time

    • emptywheel says:

      Thanks for sharing. I learned pretty quickly about that “preventative” versus “diagnostic” as a breast cancer survivor. My insurance had always covered my mammograms, which is good because I always needed state of the art. But as soon as Obamacare passed, insurers started treating follow-up mammograms as diagnostic, which as you note is far more expensive.

      Now, providers have figured out how to game the system, a bit. But it’s really problematic, as you say.

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