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Affordable Care Act down the mindshaft: asking what it reveals about us

18 July 2012

Summary:  Why do Americans oppose the the Affordable Care Act (ACA, Obamacare) while supporting so many of its provisions? What does this tell us about America? Today Chet Richards “asks the mineshaft”  for answers. It’s a community exercise, from the German Gemeinschaft (see Wikipedia).  Please post your views in the comments!

Contents

  1. The oddity of Americans’ view of the ACA
  2. Polls of US public opinion on the ACA
  3. For more information: other posts about health care

(1)  The oddity of Americans’ view of the ACA

One of the more curious aspects of the current political season is opposition to the Patient Protection and Affordable Care Act (aka PPACA, ACA, Obamacare).  Polls (such as this recent one by Gallup) show that 31% of Americans say they want Congress to entirely repeal ACA — and another 21% want certain parts repealed (most the individual mandate, which finances much of the rest). On the other hand, when the provisions are listed individually, most Americans support them.

One way to explain this phenomenon is that most Americans are “fatally stupid,” to quote University of Michigan professor Juan Cole.  But this is intellectual laziness.

A better approach is to understand the orientations of the people who oppose ACA, although they may support the provisions outside of the act. Can we do this? That’s the question we’re posing to the mineshaft in this posting.

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Well-informed citizens are necessary for the Republic’s survival

Here’s an example of the type of question we’re asking. Polling after the OJ Simpson trial (1995) showed that a majority of white Americans believed that OJ was guilty and that the largely African-American jury had erred, or worse, had refused to convict because of race. Interviews with jurors after the trial however, painted a different story.

Jeffrey Tobin, for example, who sat through the entire trial and firmly believes that OJ is guilty, explained it this way (in a PBS interview):

Look, I think if you asked the jury why they reached their verdict, as I did, they’ll say, “Well, there was reasonable doubt.” I think the reason they thought there was reasonable doubt was it fit into their conceptions of how the LAPD acts towards black people, which I think is true in general. I think it is not true specifically in the case of O.J. Simpson.

But I believe the jury was sincere. I don’t think they were faking. But I think they’re just wrong.

Tobin was referring to errors made by the prosecution and allegations of evidence tampering that are described by other commentators in the PBS series.

In other words, if you shared the jurors’ orientation on previous misconduct by the LAPD towards blacks, and saw attempts by the LAPD to manipulate evidence in this case, you might logically conclude that there was reasonable doubt. Something that originally seemed beyond logic suddenly seems plausible.

As Charles Ogletree (Prof. Law, Harvard) put it:

They can’t make up evidence; they can’t assume evidence. They have to evaluate the evidence that was presented to them, and having done that, having seen the examination by [defense attorney] Barry Scheck of the DNA evidence, having seen the cross-examination by Johnnie Cochran of police witnesses, having seen the cross-examination of Mark Fuhrman by F. Lee Bailey, they had plenty of doubt about what happened, and all they had to do was to go in and take a poll. And I think it wasn’t a hard job to do.

What’s going on with ACA? We invite our readers to comment on the orientation of people who oppose ACA and particularly by those who would either be helped by it or who generally support its provisions outside the context of the act itself.

We are NOT asking for comments on the act (or on the guilt or innocence of OJ Simpson).

(2)  Polls of US public opinion on the ACA

(a)  How much do Americans know about ACA’s features?

Polls show the answer to be “not much” (but they nonetheless have strong opinions on the ACA).  Here’s one example:  “Public Opinion on Gender Rating“, Kaiser, 2 May 2012 — Excerpt:

{T}he majority of Americans like the idea of getting rid of gender rating, but at the same time most aren’t aware that the health reform law already has plans to do so. … Gender rating refers to the practice of charging women higher health insurance premiums than men.

{R}oughly a third (35%) of Americans were aware that the health reform law prohibits insurance companies from charging women higher premiums than men, down from about half (48%) in June 2010, just 3 months after the ACA was signed into law. Although the provision directly impacts women, particularly those under the age of 50, women as a whole were no more likely than men to be familiar with it. Democrats were more likely than Republicans to be aware of this provision (43% versus 25%), but still fewer than half were familiar with its inclusion in the law.

(b)  What do they think of the ACA’s features?

Most show that many of the ACA’s provisions are quite popular.   “Poll shows Parts of Health Reform Law Gaining in Acceptance“, Harris, 30 January 2012 — “While it remains controversial, many support key elements of the bill” — The trends in this continued though the year, as shown by the CBS/NY Times Poll and Kaiser Poll in March.  Excerpt:

… support for certain components of the law seems to be slowly increasing with time. For instance, 71% support for certain components of the law seems to be slowly increasing with time. For instance, 71% of those polled now back the law’s provision that prevents insurance companies from denying coverage to those already sick. At the end of 2010, a Harris Interactive/HealthDay poll indicated that 64% supported this provision.

The poll released today shows some other provisions of the health reform law gaining acceptance. They include:

  • Allowing children to stay on their parents’ insurance plans until they turn 26 — 57% in Jan. 2012 versus 55% in Nov. 2010.
  • Creating insurance exchanges where people can shop for insurance — 59% versus 51%.
  • Providing tax credits to small businesses to help pay for their employees’ insurance — 70% versus 60%.
  • Requiring all employers with 50 or more employees to offer insurance to their employees or pay a penalty — 53% versus 48%.
  • Requiring research to measure the effectiveness of different treatments — 53% versus 44%.
  • Creating a new Independent Payment Advisory Board to limit the growth of Medicare spending — 38% versus 32%.

(c)  The result is a paradox

The Paradox of the Affordable Care Act and Public Opinion“, Gallup, 28 March 2012 — Conclusion:

We are thus faced with a “Paradox of the PPACA.” To attempt to fix some self-evident problems with access to healthcare and the cost of healthcare, experts in the federal government concluded that the federal government needed to go all out and bundle together a wide range of changes in the system. In particular, the experts decided that it was necessary to include the very wide-ranging individual mandate. But by bundling together the mandate with all of the other changes in the system, the federal government increased the concern and angst of average citizens who were already worried about the federal government’s power and influence.

Hence the current public opinion stalemate. Americans don’t like the individual mandate, but might be willing to support a number of the individual provisions of the law if they were passed individually and without the mandate. But, the argument is that it is not possible to pass the individual tweaks without passing the mandate. So, those in favor of the federal government’s attempting to “fix” the nation’s healthcare problems have a conundrum on their hands.

(d)  Other polls:

(3)  For more information: other posts about health care

  1. Beginning of the end of the Republic’s solvency. Soon come the first steps to a reformed regime – or a new regime., 14 August 2009
  2. Hidden truths about American health care, 19 January 2010
  3. A note about practical propaganda, 22 March 2010
  4. About the political significance of the conservatives’ health care propaganda, 23 March 2010
  5. The core truth about our health care system, 3 April 2010
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53 Comments leave one →
  1. 18 July 2012 5:04 am

    I say the fundamental reason that people don’t like it is because Obama basically promised a Public Option(which is what people really want) and when he didn’t deliver he has lost all credibility. The people feel mis-led by ABM.

    • 18 July 2012 5:32 am

      Great point. And not for first time in his term. Or the 12th time.

  2. 18 July 2012 12:06 pm

    America’s response to the Affordable Care Act is easy to understand. On the positive side Americans like the free stuff like closing the donut hole. They like free health insurance provided at work. Free stuff polls real well.

    On the negative side they hate being told that they have to buy something and they see the Affordable Care Act as a wealth distribution scheme by one party that does nothing to bend the cost curve. Health care reform that does not bend the cost curver is not health care reform. Americans don’t like paying their medical bills and especially don’t like paying other people’s medical bills. Grace and self preservation is at war.

    We have important uses for our money other than paying for health insurance. The more frequently the payment for the bills come out of their pocket the madder Americans get. On the suspicious side they wonder how you give out all this free stuff, expand health care coverage, and it not cost you a lot more money.

    • 18 July 2012 1:26 pm

      Hubert,

      You’ve probably nailed it, the contradictory mass of beliefs and ignorance that drives the US polls about ACA.

      People like the benefits, don’t like the tax & mandate that pay for some of the benefits, don’t know that ACA is the GOP’s (and conservative think-tanks’) best efforts to “bend the cost curve” — and object to giving health care to the poor (many of whom are brown!). Are there no streets to die on?

      But then, isn’t that Juan Cole’s summary also?

      And probably (I’ve seen no polls on this) the opinion of our peers in other developed nations? For them it’s like watching someone unable to spell his name on the cover sheet of the SAT. They have health care systems (of varying types, most public-provate mixes) that provide universal care, get equivalent overall results to ours, at 1/2 to 2/3 the cost of ours.

    • 18 July 2012 8:26 pm

      I disagree with Juan Cole’s quip that Americans are “fatally stupid” or that this is a sign of intellectual laziness since Americans are responding exactly as expected. They like free stuff, and they hate paying for stuff they thought was free. This is not unusual. Free vacations are used to sell time share condos. I still get a letter with a key in it every week telling me I have a won a prize and this key could be the key to a new car. The Affordable Care Act’s marketing is not much different so I don’t know why we should expect the consumer to act more rationally toward health care providers than they do to car dealers and time share marketers. Until the Affordable Care Act proponents start bending the cost curve they really do not have a product they can market effectively to the majority of the population. Unfortunately they have to dismantle the Affordable Care Act to bend the cost curve.

      Recently I listened to a Planet Money podcast that discussed the very strong dislike veterans have towards the Red Cross. Evidently the Red Cross briefly charged soldiers for donuts and coffee during World War II. The donuts and coffee were free and the soldiers felt betrayed when they were asked to pay for it. Today you can still find veterans who feel betrayed. If World War II veterans can hold a grudge after 70 years over some donuts, I don’t have a lot of hope that the Affordable Care Act can be the first step to health care reform. The well might be poisoned.

    • 18 July 2012 9:29 pm

      That is a powerful comment (I too have heard from vets that about the WWII Red Cross).

      It’s also a depressing observaton and forecast. We seem to be accumulating “third rail” issues in US public policy: issues with desparate need for reform, but politically fatal to substantially change. Social security, health care, defense spending…

      Eventaully the pressure will build to force radical change. As Herbert Stein (economist) said “If something cannot go on forever, it will stop”.

  3. SDW permalink
    18 July 2012 2:41 pm

    I think people hate and fear complexity, from math problems in school to complex laws passed by Congress. You really have to WORK to understand the Affordable Healthcare Act! A more streamlined bill would probably be better accepted, just as breaking down the bill and asking about each provision leads to more positive answers. This topic of overly complex laws has been discussed in the past.

    • 18 July 2012 4:25 pm

      SDW,

      I don’t understand your reasoning.

      (1) “people hate and fear complexity”

      Than people should hate the DoD budget. DoD has never passed an audit (repeatedly being declared in effect unauditable in its current form). It’s combination of size and complexity are almost beyond imagination, compared to which ACA is a spelling bee.

      For that matter, what about farm subsidies? Large, complex, AND irrational.

      Looking at the big picture, the entire federal budget is complex beyond most people’s understanding. As proven by polls asking people what the government spends its money on. For example, most people think the government spends astronomical sums on foreign aid — when in fact that’s less than 1% of spending.

      So what’s special about ACA?

      (2) How do you connect the opposition to the mandate (which is hardly a unique or new feature to US law) and other provisions to “hate complexity” and that “more streamlined … would be better accepted”?

  4. 18 July 2012 3:29 pm

    I think why a lot of Americans oppose the ACA is multi layered. Some are the conservatives who think it’s that dreaded “sohalized medicine” and others are just pissed it didn’t provide things like a public option (a very popular proposal) and reforms to reign in industry abuse (does little to nothing in that regard)

    • 18 July 2012 4:27 pm

      “others are just pissed it didn’t provide things like a public option (a very popular proposal) and reforms to reign in industry abuse (does little to nothing in that regard)”

      Can you cite anything in the polling data to support this as a reason substantial numbers of people oppose ACA? From what I see, many people (as you note) would have preferred a bolder bill, but most of those people appear to support ACA.

    • 19 July 2012 4:39 am

      Good question. I’ll see if I can dig anything up. Perhaps it’s something more akin not to “opposition”, but lack of enthusiasm (though I know a number of people who do oppose it from a more left of center/left wing view, rather than the whole “GOVERNMENT TAKEOVER” view”.

  5. Alex permalink
    18 July 2012 3:56 pm

    Here it is not affordable to everybody. And now … close your eyes … it is affordable!!
    I love that Santa Claus economy. Why would anybody oppose to Affordable Care Act?

    • 18 July 2012 4:18 pm

      “Here it is not affordable to everybody.”

      Can you provide any supporting evidence for this assertion? Why is the US so different than its peers that we cannot adopt methods used successfully elsewhere in health care systems broadly similar to ours (ie, mixed public-private)? This seems to take “American exceptionalism” a bit too far.

      “And now … close your eyes … it is affordable!!”

      Most analysis shows that the ACA either reduces the Federal deficit (eg, CBO) or is deficit-neutral.

      I believe you should provide supporting evidence before resorting to mockery. Even the assumptions behind your statement seem questionable at best.

    • Alex permalink
      18 July 2012 6:35 pm

      Every single governmental program of such type exceeds initial estimates by many times.
      And everybody who knows US political system perfectly understands how these “unfortunate miscalculations” happened. So don’t bring me CBO estimates.
      You are going to take additional 30 mil. uninsured on payroll and reduce deficit in the same time? Don’t make me laugh.

      I was trying to follow your advice to find a US peer with 200 military bases around the globe and projects of permanent moon station, but I failed to find any.
      Or all theses ambitions supposed to be taken under control according to Obamacare?

    • 18 July 2012 7:21 pm

      (1) “Every single governmental program of such type exceeds initial estimates by many times.”

      Can you provide a citation for that? It’s not true even among the programs prone to over-runs: extremely high-tech aerospace developments (eg, Polaris, Project Mercury).

      Also, social service programs tend to follow a logical pattern: rollout a new prorgram on a small scale, then expand it if determned to be worthwhile. If it’s a failure, in terms of public policy (ie, voters hate it), then cancel it. That results in cost above initial forecasts, but is not a “overrun”.

      Also — ACA is different than most of the post-WWII programs (eg, Medicare). It’s explicitly designed to control costs, in this case heealth-care costs (public and private) that are imperiling our competitiveness and even the government’s solvency.

      So we’re back to the original question. Do you have a citation for research supporting your assertiong?

      (2) “I was trying to follow your advice to find a US peer with 200 military bases around the globe and projects of permanent moon station”

      My advice? I don’t understand. To what are you referring? I don’t see the relevance.

    • Alex permalink
      18 July 2012 8:26 pm

      FM: “Do you have a citation for research supporting your assertiong? (“Every single governmental program of such type exceeds initial estimates by many times.”)”

      Alex: Sure. “Social Security Facts“, James D. Agresti and Stephen F. Cardone, Just Facts, 27 January 2011:

      * At the outset of the Social Security program, the federal government published an informational pamphlet that stated the following with regard to Social Security taxes:

      “And finally, beginning in 1949, 12 years from now, you and your employer will each pay 3 cents on each dollar you earn, up to $3,000 a year. That is the most you will ever pay.[48]”

      * Accounting for inflation, this promise equates to a maximum tax collection of $1,655 per person in 2010 dollars.[49]

      * In 2010, the maximum payroll tax collection per person was $13,243 or eight times the promised maximum.[50]

      and much-much more in this article. So, FM… you are saying …?

    • 18 July 2012 9:02 pm

      Alex,

      Thank you for that information. Social Security exactly makes my point. The program has been vastly expanded since the initial proposal in 1935. Here are a few examples:

      • 1939: benefits to spouse & children (perhaps the largest single change in nominal $)
      • 1950: first cost of living adjustment
      • 1956: big increase in disability coverage
      • 1961: lower the retirement age to 61 from 65
      • 1972: creation of the Special Primary Insurance Amount, a higher minimum payment to people with 10 years of participation into SS.

      And, of course, benefits have been raised in real terms. The 1940 minimum was $10/month ($153 in 2010 $); it’s now $403/month — a 260% increase.

      These changes were made because the program — and most of the changes — were VERY popular. And remain so to this day.

      This is a more logical process than guessing about the effects and public acceptance of programs, then implementing them on a full scale all at once (which has been done; the results are often not pretty).

    • 18 July 2012 9:22 pm

      “Every single governmental program of such type exceeds initial estimates by many times.”

      Giving one example does not show that its true for “all programs.” We’re not talking about the burning bush, where one example can prove the existance of a far greater thing.

      As I said, most social programs tend to grow. Until and unless they’re cut back or killed as times and conditios change. That’s a logical form of evolution.

      I don’t understand what point you’re attempting to make about ACA, or the evidentiary & analytical basis for making it.

      If you’re stating something as a matter of faith, just say so. Everybody here respects your freedom of religion.

  6. 18 July 2012 4:25 pm

    I’d say the problem is mostly Obama’s fault. He was recently interviewed by Charlie Rose who asked him what he could have done better during his first term. Obama said he should have been a better salesman. That as important as getting the “policiy” right the most fundamental and important job of a President was “narrative,” getting the story right between himself and the American people.

    There’s no question Obama is in the top of his class at speechifying, but he lacks that Reaganesque or FDR touch in communicating policy to the American people. Obama himself recognizes this and said as much on several occasions concerning the low approval ratings of the ACA. Obama shouldn’t run away from the label “Obama Care,” he should embrace it and ascribe all the individual specifics of the ADC the people want explicitly to it.

    Obama needs to be a better storyteller, besides a speechifier.

    • 18 July 2012 5:14 pm

      ahhlijawarfkj,

      I wonder if either of those assertions are correct.

      (1) “most fundamental and important job of a President was “narrative,” getting the story right between himself and the American people.”

      That’s a widespread belief. It’s probably right at some level. But a common form of this is belief that the “bully pulpit” is one of the President’s greatest powers. A large body of political science research suggests that is not so. Not remotely true.

      (2) “Obama is in the top of his class at speechifying”

      Perhaps one must hear or even see Obama to sense his magic. I only read them, and IMO most read like extended Hallmark greet card essays. But then I’ve been an Obama-sceptic since January 2008.

    • 18 July 2012 5:26 pm

      ” But a common form of this is belief that the “bully pulpit” is one of the President’s greatest powers. A large body of political science research suggests that is not so. Not remotely true.”

      I know this is off topic, but is this true? I’m often told this as well, and I kind of just accepted it as “common knowledge”. How is it untrue? (Genuine question)

    • 18 July 2012 6:54 pm

      That’s an important question! I’ll try post some references on this later today.

      Just from memory, a major work on this is On Deaf Ears: the limits of the Bully Pulpit, George C. Edwards III (2003).

    • 19 July 2012 4:07 am

      Some more by political scientists and other experts about the effectiveness of the bully pulpit.

    • 19 July 2012 4:41 am

      Thanks for those, I’m going to give me a read.

      What about the claim that Barack Obama’s newfound “support” for gay marriage help shift African American opinion on the issue? As someone who always just accepted the idea of the presidential “bully pulpit”, even I’m skeptical of that.

  7. jonh permalink
    18 July 2012 4:48 pm

    Could the aversions to socialism be the ethnic variety in the USA versus small, individual countries in Europe?

    Also, do you think Europe could have a Euro-wide health care system? I don’t think the Swedes would like paying for the Greeks, do you?

    • 18 July 2012 5:08 pm

      Jonh,

      (1) Why is ACA “socialism” but Medicare and Medicaid (both of which are quite popular) are not socialism?

      (2) Current evidence suggests that Europe is not ready for an significant euro-wide public systems, including the current European Monetary System. How is that relevant to the discussion about the ACA?

    • jonh permalink
      18 July 2012 5:38 pm

      Haha, yep, I was just using the local vernacular. Of course you are right, and the humor conveyed in the image that reads “keep the gov’t’ out of my healthcare is there too.

      My thoughts are that the USA has structural differences that make it harder to be as rational as some of our peers.

    • 18 July 2012 6:49 pm

      “My thoughts are that the USA has structural differences that make it harder to be as rational as some of our peers.”

      That’s a really grim outlook! But (fortunately?), the societies of Japan and Europe seem to have just as much difficulty acting rationally as we do!

  8. The Hammer permalink
    18 July 2012 5:56 pm

    You are asking a question that likely has a complex answer. I realize that statement does not help much in terms of understanding this paradox. I offer that the opposition to the general bill reflects a visceral or belief-driven reaction to the perceived increase in government power and intrusion into our lives.

    I think that a key value for Americans is the idea of independence from a strong government, and the constitution is framed to protect citizens from government. This value is pretty much inculcated in Americans from a young age, and, given brain function, will set in as a strongly held belief. Research demonstrates that beliefs are extremely hard to change, even in the face of strong evidence – our brains evolved to hold beliefs for survival (e.g. that smell really is a lion and I better run for the trees immediately without thinking about it or I will be lunch), and I believe that people will react to more complex “threats” with a belief-driven reaction.

    For the ACA, the threat is perceived as a stronger or more intrusive government taking away “liberty” (choice) and the reaction is immediately to reject the idea. So the concept of a threat to liberty engenders rejection of the “idea” of the ACA, while specific elements within the law may appeal at the micro level, because they make sense, or are not perceived as an overall “threat to liberty” since a detail of the Act does not represent a broad usurpation of healthcare as much as the Act itself does.

    I am sure there are others more qualified than myself to pronounce on this topic, but I think at least part of the answer to the paradox is that some Americans are reacting, almost instinctively, to a perceived threat.

    • 18 July 2012 7:28 pm

      I understand your logic, but not the assumptions.

      (1) “For the ACA, the threat is perceived as a stronger or more intrusive government taking away “liberty” (choice)”

      How? Other than the liberty to not get insurance, and then have the public pay for essential treatment.

      (2) “the reaction is immediately to reject the idea.”

      Sounds like a narrow conception of liberty. Since 9/11 key civil liberties have been erased with no public protest. Especially since the “intrusive” provisions of ACA affect a small fraction of the public. The tax affects high-income Americans, but is only a tiny offset to their tax cuts under Reagan and Bush Jr (reducing their rates to far below the 1950-1980 average, when America had far higher growth rates).

      (3) “since a detail of the Act does not represent a broad usurpation of healthcare as much as the Act itself does.”

      Again, to what are you referring? I don’t see anything in ACA that remotely matches that description.

  9. SDW permalink
    18 July 2012 6:25 pm

    “people should hate the DoD budget and farm subsidies because of their complexity.” These issues are not on the public agenda at present. Bank reform is on the agenda. And despite its complexity, Dodd Frank is a clear public favorite, at least according to this poll released today of 800 likely voters. Poll performed by Lake Associates, sponsored by AARP amongst others. So the public can see through the smoke and mirrors and I stand corrected.

    Key survey findings include the following:

    — Voters favor the Dodd Frank financial reform law by a 53-point
    margin (73-20). The support crosses party lines, with
    Republicans in favor by a 20-point margin, Independents by a
    50-point margin and Democrats by an 83 point margin.
    — Voters support the CFPB by a 40-point margin. Two-thirds (66
    percent) of voters overall and 69 percent of independents agree
    that the CFPB is needed.
    — Two-thirds of voters — including 78 percent of Republicans –
    support a state’s right to pass and enforce stronger consumer
    protections and preventing federal law from overriding them.

    • 18 July 2012 6:44 pm

      “So the public can see through the smoke and mirrors and I stand corrected.”

      There are 22,000 comments on the FM website. Other than my comments (which are littered with admissions of error), there are only a handful like yours.

      This shows, IMO, considerable greatness of spirit.

  10. REB permalink
    18 July 2012 10:22 pm

    Based on Dr. Juan Cole’s theory of the human species, if one does not accept Obama’s healthcare plan and its twenty-five hundred pages of “cherry picking” socialized medicine with a European flavor, you must be a red-neck from the south. Of course, my perception could be off by several country miles.

    When intellectuals of the ivory tower variety, elitist groups and the politicians who are owned or bought by the elitists groups want the majority to accept their personal and omnipotent (they are not worth a capital O) agenda, they go right to running down those “poor white uneducated people in the south”. When they want to write a book, do a documentary or just plain get a vote, they leave their gated rich communities and head south to talk to poor blacks. They go back to their gated communities and brag at cocktail parties how they made the world take notice.

    The world must not be too impressed; the unemployment rate for Black American men is 19.1%. Of course, during those wonderful Regan years, the unemployment rate for Black Americans was only 11.1% in 1989. Wow, that’s really something to brag about. “Fatal stupidity” or since Dr. Juan Cole’s area of expertise is the Middle East, and not humility, let’s call it “fatal infidels” (my italics). One must admit that “fatal stupidity” best describes a Nation whose poor children of all colors walk in dangerous school zones and receive a sub-standard education.

    Could that be why the unemployment rate for Blacks is on average 16.1%? Truth be known, this country gets back what it puts in. Speaking of inputs, Obamacare is a government monopoly that will subsidize insurance monopolies at tax payers’ expense. If the consumer has no close-substitutes then supply (healthcare) is less and the price of healthcare is higher. That’s a monopoly with a lot of deadweight loss (inefficiency). Since I live in the south and not expected to live past seventy, I’m really confused about everything.

    • 19 July 2012 12:55 am

      Reb,

      Thank you for your comment. It raises a number of interesting points, most beyond my ability to respond to in comments. However, we can look a some of the facts you mention about unemployment of Black Americans.

      BLS provides many ways to crunch the employment data, I don’t see which specific you are using. Here is the most commonly used metric: unemployment (seasonally adjusted) for Black Americans, 16+. The relative levels and trends over time are similar no matter what demographic of Black demographics is examined.

      In brief, although it’s complex to directly compare economic levels during different periods, I believe Obama’s record looks better than Reagan’s by this metric. Especially as the economic collapse he inherited was the worst since the Great Depression by most metrics.

      June 2012: 14.4%

      Reagan

      • When he took office in January 1981: 14.6%
      • It remained at or above 14.4% for 71 months, until December 1986; peaking at 21.2%
      • It was 11.8% when he left office in January 1989.

      Bush Jr:

      • When he took office in January 2001: 8.2%
      • It was 12.7% when he left office in January 2009.

      Obama

      • When he took office in January 2009: 12.7%
      • It remained above 14.4% for 33 months from April 2009 – December 2011; peaking at 16.5%
      • June 2012: 14.4%

      Also: I don’t believe this is correct: “Obamacare is a government monopoly that will subsidize insurance monopolies at tax payers’ expense”.

  11. Unna permalink
    19 July 2012 12:47 am

    Maybe America is simply too big and culturally diverse to have any sort of universal system, even some watered down pro insurance and pro drug industry creature such as Obamacare.. Remember: Canada’s universal single payer system was first enacted in one province, Saskatchewan. After that, the Canadian people in other provinces simply demanded single payer after having observed how well it worked.

    So my thought is to let the states experiment. Why should Texans be forced to endure French style socialized medicine – even though the French system appears to be rated the best in the world. If they don’t want that, well, OK. By the same token, why force Vermonters to endure for profit industry controlled system that costs twice what any other country in the world pays? Let each state choose for itself.

    The problem is it’s not that simple because money is involved. How many pro corporate Dems and Repubs would be willing to let Vermont go its own way? The Obama administration won’t move to give Vermont it’s necessary waivers. Why? Isn’t it obvious? I say. Let freedom ring America. Let each state choose – but watch the powers that be say no.

    • 19 July 2012 1:04 am

      “Maybe America is simply too big and culturally diverse to have any sort of universal system”

      Like Medicare? Social Security? Unemployment Insurance? Food Stamps? Like the draft, the Federal Reserve, the Army Corps of Engineers (which regulates every US waterway larger than a pond), the IRS?

      I think the most useful conclusion is that if the GOP decided to convince Americans that pi=3, we’d have people taking the tires off their cars — convinced that they’d no longer be round! We have got to be one of the most credulous, even gullible, people walking the face of the Earth.

    • Unna permalink
      19 July 2012 7:08 am

      “Like Medicare? Social Security? Unemployment Insurance? Food Stamps? ”

      Those programs were enacted at a time when America had a different understanding of itself; long ago and far away in a previous America. Consider, there may be no such thing as a permanent national character. What people can or may want to accomplish in one era may not be true of a future era. Consider further, America may be entering, or have already entered, a period of growing disunity.

      Concerning Obamacare: I think that down deep, Americans feel that Obamacare, except for a few things, is really not such a great deal. My understanding is that it was originally a republican idea formulated to head off any push for a single payer system which would have put the insurance companies essentially out of business and curtailed big pharma profits. See Gov. Romney re Mass. Health Care. And here we have democrats feverishly promoting what is essentially a republican plan.

      I remember Obama saying “everything is on the table”, well I guess, except for the kind of system that most every other wealthy democracy has. And Obama’s explanation? I remember his mumbling something about “America is not Canada.” What’s that supposed to mean? Obama is very bright guy, and he can’t go beyond something that might have just as easily come out of the mouth of Sarah Palin.

      This after he promised during the campaign the following: Drug importation from Canada (Canada might just have something to say about that…), an open and transparent process, negotiate drug prices for medicare, no mandate, strong public option etc. He absolutely broke every promise except to pass something with the word “universal” in it.

      Obama has been the biggest bonanza the republican party ever had. He passes a republican plan that many people don’t like, and takes full blame for it. And now the Republicans are whipping him with it in the election.

    • 19 July 2012 1:06 pm

      Unna,

      (1) The polling data shown in this post is clear and unambiguous: the opposition to ACA is largely a partisan affair. Gallup’s summary:

      Gallup polling on the topic shows Republicans have overwhelmingly negative views of the healthcare law, and Democrats, overwhelmingly positive. Specifically, 71% of Democrats said it was a good thing the law passed and 81% of Republicans said it was a bad thing in Gallup’s most recent update.

      Look at the 2 July 2012 Gallup poll, a detailed examination of American’s attitudes to ACA by political party.
      (a) Will ACA benefit you?

      • GOP: 14% yes; 73% no
      • Dem: 61% yes, 17% no

      (b) Will ACA will benefit businesses and taxpayers. The answers were almost identical:

      • GOP: 8% yes; 88% no
      • Dem: 55% yes, 34% no

      (2) Your and More’s belief that a large fraction of American’s oppose it because thay wanted something more is true for some Democrats, and is logical because ACA is (as you note) a plan designed by conservative think=tanks and originally promoted by GOP leaders (eg, Newt, Romney). Like so many of Obama’s policies. Look at the 2 June 2012 Gallup poll. What kind of health-care system would you prefer?

      • Government-run: 39%/li>
      • Based on private insurance: 56%

      (3) “I think that down deep, Americans feel that Obamacare, except for a few things, is really not such a great deal.”

      Again the polls are clear (see the excerpts in this post): American don’t know much about Obamacare. Mostly they know what they’re told about it. If they listen to Rush or Fox, it’s the work of the devil — as seen in many of the comments on this thread, making outlandish claims about ACA. To a large degree I suspect that results from the phased implementation, with much of it starting in 2014. Aain note — few people know this, so they see it’s done little or nothing for them — and believe that its horrfic features have not had time to wreck America’s health care system.

      (3) “Those programs were enacted at a time when America had a different understanding of itself; long ago and far away in a previous Americ”

      Perhaps. But they remain very popular today. Which is, I believe, fairly strong proof that it is not accurate to say “America is simply too big and culturally diverse to have any sort of universal system”.

  12. Thomas More permalink
    19 July 2012 3:08 am

    Both Bill Huber and slapout9 make superb points. First, the ACA represented a monumental game of bait-and-switch: voters were assured in 2008, when voting for Obama as president, that Obama opposed forcing individual citizens to buy unaffordable private health insurance, especially when there were no cost controls imposed.

    “Let’s break down what [Hillary Clinton] really means by a mandate. What’s meant by a mandate is that the government is forcing people to buy health insurance… (..) Here’s the concern. If you haven’t made it affordable, how are you going to enforce a mandate? I mean, if the mandate was the solution, we can try that to solve homelessness by mandating everyone to buy a house.” — Candidate Barack Obama, MEET THE PRESS, 2008

    Then Obama turned around and backed a health care non-reform bill which…forced individual citizens to buy unaffordable private health insurance without imposing any cost controls whatever. In effect, it was a bait-and-switch which culminated in a gigantic giveaway to the medical-industrial complex in America.

    Second, contra Juan Cole, the American people are not stupid. Americans produced the first airplane, the first polio vaccine, we put men on the moon, we produced the first nuclear submarine and the first atom bomb. If Americans are so stupid, how did they accomplish these things? Juan Cole gives an excellent inside view on why liberals continue to lose elections — instead of fixing their catastrophically broken policies, liberals prefer to lash out with name-calling against the American people.

    We have hard evidence that the ACA is bogus, not a genuine reform, and that it is headed for disaster because it does not control costs while at the same time forcing Americans to buy private for-profit health insurance with infinitely rising premiums and no cost controls. The hard evidence comes from the state of Massachusetts, which implemented a health care “reform” (so-called) very similar to the ACA. The state of Massachusetts is now in panic mode, with health care costs rising through the roof. After enacting a plan very similar to the ACA, health insurance in Massachusetts now costs more than in comparable states — 6% more. Yet the Massachusetts plan was supposed to cut costs. Permit me to quote from the report of the Massachusetts attorney general in 2011:

    Office of Attorney General Martha Coakley – Examination of Health Care Cost Trends and Cost Drivers Pursuant to G.L. c. 118G, § 6 1/2(b), REPORT FOR ANNUAL PUBLIC HEARING UNDER G.L. c. 118G, § 6 1/2, June 22, 2011, EXECUTIVE SUMMARY:

    “In the 2010 Report, we examined whether the existing health care market has successfully contained health care costs, and found the answer to be an unequivocal –no.

    “The market players – whether insurers, providers, or the businesses and consumers who pay for health insurance – had not effectively controlled costs, in part, because the prices negotiated between insurers and providers were not designed to encourage or reward provider efficiency. The resulting market dysfunction has threatened the viability of efficient providers, who have lost ground on payment rates while also losing patient volume to higher priced competitors.”

    Source: Massachusetts Attorney General’s report on health care cost trends and cost drivers, 2011.

    Moreover, in those areas where health insurance premiums have dropped since the passage of the ACA, they’ve only done so because employers are now shifting the burden of paying for health insurance increasingly to workers, because health insurance premiums are rising so fast employers can’t afford to pay them. As the article “Mandatory Health Care a Bitter Pill for Massachusetts Low-Wage Workers”
    points out:

    “Take a look at the far right column on this chart and note the premium increase in 2010 when `adjusted for benefits.’ If you put back all the costs that have shifted to members (higher co-pays, deductibles, co-insurance, etc.), premiums in 2010 would be rising at almost the same rate they have for the last decade or so. In healthcare-speak, this is called `benefit buydown.’ The market is producing lower premiums, but it is because patients are paying more health care costs on their own.”

    And it’s not as if proven well-known tested cost control measures don’t exist. They do. Other countries like France and Germany have implemented them. But Obama also explicitly rejected these known proven cost controls when he signed off on the bait-and-switch scam misnamed the ACA:

    “Not only did the Affordable Care Act not contain single payer or all-payer, but it also purposely excluded provisions that the CBO said would reduce cost, like drug re-importation, because a deal was made with the drug lobby to keep their prices artificially high.”
    — Source: “More Health Care Cost Control Nonsense From Jon Gruber,” Jon Walker, 30 May 2012, firedoglake

    And the evidence is overwhelming that medical costs in America are higher than in other countries because prices for individual services are higher. The source of high health care costs in America is simple greed. Greed by medical devicemakers, greed by hospitals, greed by doctors, greed by testing labs, and greed by imaging labs. See Ezra Klein’s columns “High health care costs: it’s all in the pricing,” 2 March 2012, and “Why an MRI costs $1080 in America and $280 in France,” Washington Post, 3 March 2012.

    “There is a simple reason health care in the United States costs more than it does anywhere else: The prices are higher.”
    – Ezra Klein, op. cit.

    Yet Obama’s bait-and-switch health care non-reform systematically refuses to implement any of the known cost control measures which have worked in Europe, Japan and elsewhere to rein in the cost of health care. Obama refused to do this because he needed the support and campaign conations of the American medical-industrial complex in order to get re-elected, so he turned around and engineered a colossal giveaway to the greedy corrupt American medical devicemakers and hospitals and doctors and imaging clinics and medical testing labs that charge $1080 for an MRI in America, while the exact same MRI scan with the exact same machine costs $280 in France. Doctors in America make between 200% and 500% of what M.D.s in other countries make. The AMA artificially restricts admissions to medical school in order to reduce the supply of doctors in America and keep doctors’ salaries sky-high.

    That’s why the American people don’t support the ACA. It was a gigantic bait-and-switch scam, and the plan on which the ACA was based has increased costs in Massachusetts rather than reducing them as was promised — and the American know it, and they’re angry.

    • 19 July 2012 3:54 am

      More,

      You appear to believe that if Obama had suggested a radical reform — far larger than NixonCare, HillaryCare or ObamaCare (all defeated in Congress) — then the American people would have risen up to overcome the massive opposition of the GOP AND the powerful collection of health care industries.

      Can you provide the slightest amount of evidence for this astonishing theory? The GOP attack ads would have been something to see if Obama attempted to give America a system like the hellhole healthcare system of those socialist euro-weenies — no matter how false the ad’s contents.

      In fact many American’s thinking have been shaped by an intense campaign of propaganda, including lies about the European health care system. I give some specific examples here: About the political significance of the conservatives’ health care propaganda, 23 March 2010

      Some hoped that the debate about the bill would cut through the fog. Such as this “The changing tide“, Matthew Yglesias, ThinkProgress, 22 March 2010:

      {C}overage of the actual content of the bill is by necessity more favorable to the bill than the hokum that’s dominated the conversation thus far. After all, most of what people have been talking about is either straight-up lies — death panels — or hystical mewling about the death of freedom and the gulag. Any time you have medical doctors on television talking about new insurance rules, or newspaper writers drawing up charts showing what kinds of people will be impacted in which ways, you’re into the universe of sober-minded discussion of an importance series of tweaks to people’s existing care, and the expenditure of a bunch of money to make insurance affordable to those who don’t have it.

      Now realistically, the evidence suggests that once misconceptions get into people’s heads they’re hard to dislodge. So I wouldn’t count on enormous changes in public opinion ensuring from this shift in coverage. But it’s bound to help at the margin.

      Time has proven these gentle expectations to be wrong.

    • 19 July 2012 4:37 am

      “the hellhole healthcare system of those socialist euro-weenies”

      I presume that’s just sarcasm? Sometimes that’s hard to pick up over text…

    • 19 July 2012 4:39 am

      Apologies. I don’t do sarcasm well (should use s and /sarcasm).

    • Unna permalink
      19 July 2012 7:25 am

      @Thomas More,

      Beautiful. So nicely put. Except for a few crumbs, Obamacare is a step backwards in so many ways. Really originally a Republican plan which he passed all by himself. And now he gets beaten over the head with it by the Republicans. Question: after so much bait and switch, can it really be said that Republicans are lying to Americans more than Obama “switched(?)” about this issue.

    • 19 July 2012 1:14 pm

      This is the essence of polarization. The Right opposes it because it is too much. The Left because it is too little. Since reform is usually incremental, the result is that America is trapped by the ideologues on both sides.

      “The best is the enemy of the good.”
      — Voltaire in La Bégueule (Contes, 1772)

    • 20 July 2012 12:18 am

      “The Right opposes it because it is too much. The Left because it is too little.”

      I think that’s what I was gunning at earlier, how some of the opposition to the ACA is coming from a more left perspective, rather than the right perspective, though I still haven’t found any polls indicating how large of the opposition they make up (probably doesn’t help that most polling seems to automatically think if you oppose the ACA you’re coming from a right wing perspective)

      To be fair though, I can understand the point that it doesn’t go far enough. It’s a deeply flawed bill, and if Massachusetts is any example, it won’t contain costs either, or actually provide the universal decent coverage Americans desperately need.

    • 20 July 2012 1:38 am

      That’s an important point about the polls (eg, those I cited earlier) not showing why Democrats oppose ACA. Note however that the reasons for opposition center on the effects on businesses and taxpayers — not benefits to those receiving healthcare or “me” — which suggests to me (guessing) that this reflects the view of conservative democrats — not left-wing opposition.

      Re:cost control

      Agreed. It will take far greater structural changes than ACA’s tinkering to achieve cost control over the out-of-control US health care system. Reforms tend to increase revenue for the h/c industries. Such as Bush’s medicare drug benefit — explicitly outlawing medicare cost-controls on drugs while boosting spending on drugs. And ACA’s give-aways to the drug and h/c insurance industries.

  13. 19 July 2012 3:37 am

    I think the reason why Americans love all giveaways in the ACA, but hate the individual mandate, is because they think it’s possible to have their healthcare cake and eat it too.
    It seems to me they think it’s possible to get a bunch of nice things (like not having to worry about pre-existing conditions or keeping their 25 year old kid on a plan), but not have to give anything back in return.
    The best culprit I can think of for this belief that government exists to give us lots of nice things for free are the persistent and growing deficits, financed largely by monetization, which seem to confirm the wild promises of politicians.
    This all tells me one thing: lots of people, including many of those in power and even some economists, believe that the primary purpose of government is to provide a free lunch.

    Of course government can provide a very cheap lunch by borrowing from a printing press during a recession, and maybe that sandwich will be very tasty and totally worth it, but you still should make a rational plan about what to do for dinner.

  14. 19 July 2012 1:33 pm

    There is one reform that all Right-thinking Americans will support, repulsing the beachhead of Socialism — nay, Communism — in America: radical reform of TRICARE, the military’s health care system. Why isn’t it closed, replaced by systems like those used by our major corporations? The officers of our military are largely conservative — or extremely so. We can count on them to echo this call to bring free-market principals back to this important sector of government spending.

    TRICARE is consuming our precious military funding, and according to a new CBO report will do so at an accellerating rate in the future.

    Long-Term Implications of the 2013 Future Years Defense Program“, CBO, July 2012 — Excerpt:

    The TRICARE program provides health care for the military’s uniformed personnel and retirees and for their eligible family members and survivors. Almost 10 million people are eligible to seek subsidized care from military treatment facilities, from regional networks of civilian providers under contract with TRICARE, or from other civilian providers. DoD also manages TRICARE for Life, a program that the Congress authorized in the 2001 National Defense Authorization Act to supplement Medicare for beneficiaries eligible for both Medicare and the military health benefit.

    DoD’s plans for 2013 include $47 billion for military health care, or about 9% of the requested budget for all activities covered by the department’s base budget. According to the CBO projection, however, the costs of DoD’s plans for its military health care system for 2013 would be $51 billion. CBO projects that such costs would reach $65 billion by 2017 and $95 billion by 2030 (see Figure 2-2). Over the FYDP period from 2013 to 2017, CBO’s projection has average annual growth of 6.0% …

    Low out-of-pocket expenses for TRICARE beneficiaries (many of whose copayments, deductibles, and maximum annual out-of-pocket payments have remained unchanged or have decreased since the mid-1990s), combined with increased costs of alternative sources of health insurance coverage, make the TRICARE program relatively more attractive each year. As a result, a larger share of military retirees and their dependents are relying on the program rather than participating in health insurance provided by civilian employers or purchasing insurance on their own.11 In addition, low out-of-pocket costs and other factors have led to utilization rates for inpatient and outpatient care that are significantly higher for TRICARE beneficiaries than for people with other insurance. For example, DoD found that enrollees in TRICARE Prime (a managed care program that covers more than half of the people eligible for TRICARE and offers the lowest out-of-pocket costs) used services at a higher rate than did comparable civilian enrollees in health maintenance organizations (HMOs).

    /sarcasm

  15. Unna permalink
    19 July 2012 3:56 pm

    FM, you are right. There is too much polarization. So why don’t Americans agree to disagree and let each state decide. Allow them to join together in interstate compacts if necessary. Single Payer started in Canada in one province. It worked so well, Canadians forced the other provinces to enact single payer until federal legislation created the present system. Wasn’t there a Supreme Court case where the court referred to the states as laboratories of experiment, or some such phrase? Why the passion for a single system?

    But if I judge American elites correctly, both the Republican and Democratic leaderships are united in that there shall be no Single Payer system ever anywhere in America. If even a single state went single payer, within a decade much of the rest of the country might be so too, and the elites know this.

    • 19 July 2012 5:31 pm

      “But if I judge American elites correctly, both the Republican and Democratic leaderships are united in that there shall be no Single Payer system ever anywhere in America.”

      My guess is that you greatly underestimate their ambitions. You describe them as defensive — prevent the spread of single-payer (eg, Medicare, Medicaid, Tricare) insurance.

      My guess is that they’re running a counter-revolution, seekng to roll-back as much as possible of the New Deal. They have had great success so far — such as repealing much of the New Deal’s regulation of the financial sector. They say they want to roll back much of the social saftey net. Unemployment insurance, social security, medicare. I suggest we believe them, and act accordingly.

  16. Mário Fernandes permalink
    21 July 2012 8:25 am

    From this side (Portugal), simply, we can´t understand why you don´t have an open universal health system. Portugal is so small but no one is out of system…try to spend less in “army toys” and you have enough to help the poor.

    I think it is a shame for America and for is greatness the people could die without help. This is not right!!

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