Democrats Can Do Better than “Wonk Harder” on ObamaCare Going Forward

Sarah Kliff has finally done what left wonk journalists should have done years ago: go interview people from Kentucky about their understanding of and feelings about ObamaCare. KY is, with WV, the state in which ACA achieved its best results, with the number of uninsured going from 25% to 10% of the state. And yet Democrats in KY have been utterly hammered since ACA passed.

Kliff spent a lot of time actually listening to voters to understand why they voted overwhelmingly for a guy who promises to scrap ACA in its existing form (though he always promised to replace it with something better).

Definitely go read the whole thing, because the degree to which Kliff let these voters speak for themselves (and the degree to which they appear like real and often thoughtful people) is admirable.

Here’s how she summarizes what she heard.

Many expressed frustration that Obamacare plans cost way too much, that premiums and deductibles had spiraled out of control. And part of their anger was wrapped up in the idea that other people were getting even better, even cheaper benefits — and those other people did not deserve the help

There was a persistent belief that Trump would fix these problems and make Obamacare work better. I kept hearing informed voters, who had watched the election closely, say they did hear the promise of repeal but simply felt Trump couldn’t repeal a law that had done so much good for them. In fact, some of the people I talked to hope that one of the more divisive pieces of the law — Medicaid expansion — might become even more robust, offering more of the working poor a chance at the same coverage the very poor receive.

Significantly, Kliff dispels one explanation always given for why Kentuckians hate ObamaCare so much: purportedly because the state had hidden that the state’s program was actually ObamaCare. All but one of the people she talked with knew they were getting ObamaCare.

All but one knew full well that the coverage was part of Obamacare. They voted for Trump because they were concerned about other issues — and just couldn’t fathom the idea that this new coverage would be taken away from them.

Which leaves the two major complaints with the law: expense and the divisiveness associated with two-tiered benefit programs.

We’ve known since before the bill passed that it was too expensive, such that middle class families would still go into debt even with fairly normal life medical care, including normal childbirth. At the time, the wonk boys were talking among themselves about how they needed to push back against such claims.

But Kliff puts a face to the consequences of that expense, where people use precious disposable income for insurance they know they won’t use.

The deductible left Atkins exasperated. “I am totally afraid to be sick,” she says. “I don’t have [that money] to pay upfront if I go to the hospital tomorrow.”

Atkins’s plan offers free preventive care, an Obamacare mandate. But she skips mammograms and colonoscopies because she doesn’t think she’d have the money to pay for any follow-up care if the doctors did detect something.

Atkins says she only buys insurance as financial protection — “to keep from losing my house if something major happened,” she says. “But I’m not using it to go to the doctor. I’ve not used anything.”

She also focuses on something that got discussed during passage, but not in as much detail: the degree to which the two-tiered method of expansion, with some getting Medicaid and some getting subsidized shitty insurance, would poison the perception of the law, because the working poor would get fewer benefits than people who were or believed to be not working.

“I really think Medicaid is good, but I’m really having a problem with the people that don’t want to work,” she said. “Us middle-class people are really, really upset about having to work constantly, and then these people are not responsible.”

This has long been the basis for (often GOP-stoked) opposition to government support in the US, the resentment that others are getting more, a resentment that often gets racialized via stereotypes about welfare queens.

Importantly, Kliff also dismisses those who complain these rube voters should have known the stakes of voting in Donald Trump, because she didn’t know either.

I spent election night frantically reporting and calling sources, trying to understand what parts of Obamacare Republicans could and couldn’t dismantle. I didn’t know at the time, nor had I devoted the necessary time to learn, until election night.

Mills was wrong about what Republicans would do to Obamacare. But then again, I write about it for a living. And I was wrong too.

In any case, it was a sobering, humanizing report. I hope Kliff follows up on as Governor Matt Bevin makes KY’s ACA worse this year.

Democrats need to learn this lesson because, even if they can’t impose a penalty on Bevin and other KY Republicans for taking away benefits that people currently have, the same process is bound to roll out in states across the country. That is, liberals need to understand this dynamic if they want to reverse the policy changes the GOP are about to roll out.

Unsurprisingly, Democrats are taking away the wrong lesson about ObamaCare from the election. Markos Moulitsas rather notoriously offered this lesson (though not in the context of Kliff’s report).

But even Kevin Drum, after reading Kliff’s report, seems to have come up with the wrong lesson.

Obamacare has several smallish problems, but its only big problem is that it’s underfunded. The subsidies should be bigger, the policies should be more generous, and the individual mandate penalty should be heftier. Done right, maybe it would cost $2 trillion over ten years instead of $1 trillion.

Republicans wouldn’t have cared. If this were a real goal—like, say, cutting taxes on the rich—they’d just go ahead and do it. If the taxes didn’t pay for it all, they’d make up a story about how it would pay for itself. And if you’re Donald Trump, you just loudly insist that,somehow, you’re going to cover everybody and it’s going to be great.

But Democrats didn’t do that. They didn’t oversell Obamacare and they didn’t bust the budget with it. They could have. It would have added to the deficit, but that wouldn’t have hurt them much. Politically, the far better option was to go ahead and run up the deficit in order to create a program of truly affordable care that people really liked.

Even setting side whether the problem of providers exiting the marketplace is “smallish” or actually quite big, the one takeaway Drum takes from this article about how a technocratic solution sows hatred for that technocratic solution is just to wonk harder. That is, he wants to keep the existing program, and just throw more money at the providers via subsidies and more penalties at people who are literally choosing between paying for insurance they won’t use or making other choices with limited disposable income.

He ignores entirely how the two-tier system of benefits feeds resentments (not to mention all the unnecessary complexity it entails).

Luckily, being completely out of power, Democrats have another alternative besides just “wonk harder.” Since Republicans will already in in the difficult position of taking away benefits, Democrats can make that much harder — and play to what we’ve learned from the roll out of ObamaCare — by calling for what they should have called for in the first place: something that moves us towards true universal care, rather than just aspirationally universal insurance coverage. Not only is that what KY voters appear to want, but it is a more efficient way of providing health care. Implement it via subsidized Medicare (well-loved because it is universal) buy-in, I don’t care. But this is the opportunity for Democrats to turn the Republicans’ attacks on ObamaCare on their head, and make the policy much smarter at the same time.

12 replies
  1. der says:

    Democrats could do better but they won’t because their wretched base wouldn’t get it (it being the wonky stuff, deplorables). Arlie Hochschild’s Louisianans (Strangers in Their Own Land) and Sarah Kliff’s Kentuckians see the same ‘line jumpers’ getting free stuff from big government for doing nothing in return, so they vote for “change” and for no socialism. Thomas Frank’s “Professional Democrats”, the ones running things, are Pelosi’s “leaders” (not advocates) with the smart answers, the ones Edward-Isaac Dovere describes in:

    How Clinton lost Michigan – and blew the election
    Across battlegrounds, Democrats blame HQ’s stubborn commitment to a one-size-fits-all strategy.

    Russia’s fault. The Professionals have all the answers why should they ask anyone’s opinion on anything? The Berniebros, Stein Greens, cross-checked voter get what they deserve, good and hard. Those Professional Democrats? Of six figure incomes, part of the upper D&R ruling classes, our betters making common ground with the next administration?  They’ll be ok and will survive to run again in 2018. Shit is fucked up and bullshit, still, 30 years on.

    • RUKidding says:

      Nope. Not dead yet, and my understanding is that Japan recently passed it.  I fully expect this go forward at some point.  Trump has basically walked back just about every single major (forget all the minor junk) campaign promise already… and he’s not even in office.  I never believed a word he said and figured any of the Big Promises should be viewed that the complete opposite would happen.  So far, I haven’t been wrong.

  2. Ed Walker says:

    Although not directly responsive, I should note that we also predicted that health insurance companies would reap a bonanza from this idiotic scheme. That’s why suddenly we see mergers and other forms of consolidation in the business of health.

    The absurd idea behind Obamacare is that a market can be constructed starting from scratch, and that idea is a foundation of the neoliberal economic project. In Never Let A Serious Crisis Go To Waste, Philip Mirowski points to the new consulting business of market design, a truly weird idea.

    Democrats adopted this foolish view under the rubric of “market-driven solutions”. There aren’t any such things. The idea that there is a market for health insurance is wrong. There are too many variables that create too much possibility of loss for the business to succeed at driving down prices. In general, for this to work, the prices have to be fixed for a set period of time, so that the companies can use statistics to generate premiums that are sufficient to pay claims and produce a profit, as well as some margin for error. There are too many other factors working to push up rates, not least of which is the ability to tap into the US Treasury. And the general trend of expense is higher, which pushes up rates.

    The government programs that work are the ones that benefit everyone according to the same schedules, namely Medicare, Medicaid, Unemployment insurance and so on. This entire structure was a disaster from the word go, The side that got it right is still ignored by the people that got it wrong.

    • John Casper says:

      “Although not directly responsive, I should note that we also predicted that health insurance companies would reap a bonanza from this idiotic scheme.”

      Thank you.

      Remember that from FDL.

    • Jond says:

      So we tried a little experiment and discovered people wanted health care but they also didn’t want to go broke buying it and then not being able to afford to use it. Who coulda known?

      Time to expand medicare to all people. Period. And the way to pay for it is progressive taxation. Forget trying to tap into Wall Street, like Obamacare and taxes on investment income or some such scheme. That won’t work you know. Some folks notice and they don’t like it. Make it universal and pay it out of taxes. Didn’t some bright and very popular guy say something like that, even wanted it as part of social security they say. Doctors just said FU.

      We pay over three trillion a year and that is more than twice our nearest competitor. Somebody is ripping us off and I have an idea who they are. Maybe Trump will do us a favor and make a really super duper for profit plan but I doubt it.  I really doubt that.

  3. earlofhuntingdon says:

    Divide and conquer.  Worked for the Brits, worked for Gilded and New Guilded Age robber barons, works for neoliberal pols.

  4. greengiant says:

    No prosecution of medical monopoly and price fixing activities.   Monopoly mandated by big government to limit the number of facilities providing services.  Extremely minimal auditing of the Medicare Advantage providers with 15 million of the 57 million people on Medicare.    The average Medicare cost is 4x the designed Medicare premium, ( say 4 times 130 dollars ).    The average Medicare Advantage monthly cost was over 880 dollars.    The industry jacks the drug prescriptions to get the patients into the drug doughnut hole as quickly as possible.   Patent protected drugs see 400 percent price increases during the course of the patent protection.    Drugs are knocked out of the Advantage and D plan formularies.  The mantra of business is “people will die”.    How else would a business maximize profits?   Government subsidies for medicine have the same spawn the government subsidies of student loans for private colleges have wreaked,  that is  waste,  fraud, and lives ruined.   US voters have enabled this craziness.   US spends 3 trillion on health care when wage income is 9 trillion before subtracting a trillion for social security.   How is that working for you?   How soon do you think the wheels are going to come off?   Well a little cognitive dissonance,  a desire to keep ones place or future turn at the trough.   Before 1965,  families had a choice,  minimize health spending for old folks or “sell the farm”.   The addictive poison is that with Medicare families do not have to make that choice,   let the commons pay to extend life at any, ( practically speaking),  cost.   That cost is increasingly dictated by the medical business to maximize revenues and profits.   You just want to go home to die?    We will have adult protective services put your relatives in jail and you will behind a locked door.   Obamacare was written by the medical business to support the medical business.   If treatment cost as much of the rest of the world,  then people would only need catastrophic insurance and the “prexisting condition” gun to the head exercised by the insurance industry would be finessed.

    If you are getting Obamacare subsidies,  your deductible and maximum out of pocket were jacked,  but true expenses paid did not jump at the same total amount as the premiums.    For those above 450 percent of poverty income they are going to feel the full burn of the increasing monopoly and unnecessary medical treatment taxation.    So here is the dissonance,  how many voters swung to Trump who are over the 450 percent of poverty income?     For the rest,  it is mot the first time voters emotionally support bigger tax cuts for the rich and more regressive taxes for themselves.

  5. lefty665 says:

    Obamacare was designed for the medical industry from the beginning. The deal with PHARMA was March ’09, providers was April ’09, insurers May ’09. The year and a half from then until passage was mostly spent ensuring that any variation of single payer and cost containment was snuffed out.  That was done during a period when Dems had veto proof majorities in both houses of Congress. What makes anyone think that as minorities today Dems will have any better sense or influence?  What makes this day different?

    In the for what it’s worth department, Medicare has provided us good coverage, but it’s not cheap.  Medicare premiums plus a medigap policy cost us more than twice what the prior employer based policy cost us. Prior employer provided coverage was undoubtedly very good, at least partially in lieu of wages. But, current out of pocket Medicare cost is on top of paying Medicare taxes over life times of work for us, and in my case, the employer’s matching share for me and my employees. I’m not bitching, just noting that in America even single payer ain’t thrifty, and that’s with employers picking up a piece of the cost.

    Personal experience with a relative who has very moderate income is that a Silver Obamacare plan that has subsidies based on income has had decent coverage at a moderate out of pocket cost to the insured.



  6. Bill Michtom says:

    That the discussion is so much about how the percentage of people without insurance is way down shows exactly how stupid the whole Obamacare argument has been.

    We should always have been talking about healthcare, not insurance. Until there is universal healthcare, people will be going into bankruptcy or the morgue unnecessarily.

    It’s disgusting.

    • John Casper says:


      Think Warren Mosler’s plan is the way to go.

      “Everyone gets 5,000 on January 1 each year to spend on health care.

      $1,000 is for preventative care, and the other $4,000 is for all other health care needs.

      If you need more than that you are covered by a form of Medicare.

      At year end you get the unused portion of the 4,000 as a gift with no strings attached.

      You are free to buy any private insurance or medical plan you wish.”

      This puts the quality control at the front end at the same time it encourages early recognition and intervention. The opposite of the “disaster medicine” when the ER is the primary entry point. It also paves the way for tele-medicine. Over the long term this drives down the total cost of health care. It eliminates Medicaid. People will be fighting to stay OFF Medicare.

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