I’m as confused as everyone else by how to perceive my fellow Americans after the recent election, and I’m just as confused as everyone else when I try to understand whether policies even make any difference toward electoral outcomes; Achen and Bartels certainly suggest that policies are much less important in that regard than tribal loyalties. (Review forthcoming, I swear.)
But the tweetstorm below makes a lot of sense to me on why Obamacare might not have swayed many minds. To me it seems much simpler to explain Medicare or — better yet — the VA: you pays your taxes and you gets your services. By contrast, Sarah Kliff of Vox — whose work I adore — appeared on The Gist the other day to explain, among other things, that any forthcoming GOP replacement for Obamacare might contain a continuous-coverage requirement: insurers can raise rates on you if you’ve gone without coverage for some length of time. This is similar to the individual mandate, in that it’s trying to discourage people from getting coverage only when they think they’re going to need it. But honestly: what fraction of Americans could explain the mandate; what fraction would be able to explain the continuous-coverage requirement; and what percentage of Americans could explain the adverse-selection logic underlying any of these policies? Instead, as the fellow below notes: they just know that their coverage sucks, and that it can be nightmarishly difficult to obtain it. The continuous-coverage requirement, if that’s what we get, is just going to make insurance even more annoying. I can do no better at presenting the socialist alternative than Corey Robin’s piece, which I need to reread every year or so. “Pay taxes; get services” is a hell of a lot easier than what Obamacare gave us. And I say this as someone who was effectively a single-issue voter in 2012; I would have voted for whichever candidate ensured the continued survival of Obamacare. And now it looks likely that it’ll die soon.
I’m not nearly hopeful enough, at this moment, to believe that our current crisis will somehow, underpants-gnomes style, lead to single-payertopia in a few years. At the moment, in fact, I assign probability less than 1 to their being another election again in American history. And, just in case it needs to be said: I’m also not slagging on anyone for failing to pass single payer back in 2009; lots of people I trust have written that this was just not in the cards. So I don’t know the future, and I’m confident that the past is the best we could have gotten. It even seemed, for a time, that the thin edge of the single-payer wedge might be by way of Obamacare waivers (akin to the existing Medicaid waivers) in Vermont, just as I understand that Canadian single payer got started in Saskatchewan. That didn’t work out, either.
So I don’t know how the world will look, and on most days I’m not even confident that I understand half of America. But single payer is probably worth a shot, for electoral reasons alone.
OK. a lot of Dems seem confused why more poor ppl don't vote D. i'll try to explain
setting: 2014, doc clinic in the middle of nowhere, TX
— Mark (@haircut_hippie) December 8, 2016
my first rotation as a med student. Obamacare had kicked in. but I kept seeing ppl coming in far too late, refusing followup care, etc. why?
— Mark (@haircut_hippie) December 8, 2016
they had insurance! Obamacare meant that they'd be spared from truly financially disastrous illnesses like cancer. so what was the deal.
— Mark (@haircut_hippie) December 8, 2016
talk to guy. fam history of esophageal cancer. guy has severe acid reflux. recommend endoscopy. he refuses. why?
see his deductible: $5000!
— Mark (@haircut_hippie) December 8, 2016
for you non-Americans: the first $5000 of his medical care in the calendar year, he pays for out of pocket.
answer is obvious: can't afford
— Mark (@haircut_hippie) December 8, 2016
cost just of scoping to diagnose problem: ~$1500. biopsy, $100. add a $100 specialist followup, and you still haven't even touched treatment
— Mark (@haircut_hippie) December 8, 2016
the doctor works 7am-7pm M-F. Saturdays @ hospital. b/c she sees poor pts, she pays her staff thru her salary. earning ~$10k/year herself
— Mark (@haircut_hippie) December 8, 2016
this is b/c she does "long" (half-hour) appts. doesn't over-book. many indigent patients, even if they have insurance.
— Mark (@haircut_hippie) December 8, 2016
i can tell you this story again and again. this isn't even a particularly poor area, but docs who saw poor pts were taking >100k/yr pay cuts
— Mark (@haircut_hippie) December 8, 2016
had multiple child psych docs quit b/c our new guidelines changed to basically: just give the kids drugs. b/c TX social services are fucked
— Mark (@haircut_hippie) December 8, 2016
so this is the problem: Obama's signature accomplishment, Obamacare, had almost zero influence on any of the poorest patients we have
— Mark (@haircut_hippie) December 8, 2016
the effect was to transform healthcare from totally unaffordable to totally unaffordable. most ppl still had impossible barriers to care
— Mark (@haircut_hippie) December 8, 2016
"what about Medicaid?"
I live in Texas. we refused Medicaid expansion. & even if you're (magically) eligible, getting it can be a nightmare
— Mark (@haircut_hippie) December 8, 2016
In medical treatment, there's a ~guideline of the simpler the better. One pill a day, OK. Two pills, not good. Three pills, too difficult
— Mark (@haircut_hippie) December 8, 2016
Every single extra step a patient has to take reduces the odds that a patient will/can be treated properly. It's a big deal.
— Mark (@haircut_hippie) December 8, 2016
All this wonk bullshit in Obamacare? I've seen grown adults cry b/c they can't figure out wtf is going on w/their care. it's a nightmare
— Mark (@haircut_hippie) December 8, 2016
if me, the doc, the nurse, a social worker, the patient, & the insurance co can't figure out what's going on, maybe your bill sucks
— Mark (@haircut_hippie) December 8, 2016
if you need a team of economists, Vox, and two hundred men wearing lanyards to explain how you're helping the poor, maybe you aren't
— Mark (@haircut_hippie) December 8, 2016
b/c for the poor, in the case of Obamacare the test came when they went to the doc for the first time & it was still hellish & unaffordable
— Mark (@haircut_hippie) December 8, 2016
oh, and I can't tell you whatever happened to the reflux + family history of esophageal cancer guy. b/c he never came back
— Mark (@haircut_hippie) December 8, 2016