And The Obamacare Ethics Train Wreck Rolls On…

Barack Obama’s legacy is a series of ethics train wrecks of remarkable and depressing longevity. The oldest of them, the Obamacare Ethics Train Wreck. may never stop rolling, leaving destruction in its wake forever..


1.   It is clear that the Republicans will not be able to repeal, undo, repair or reinvent Obamacare, aka The Affordable Care Act, consistently with their rhetoric and the wishes of the thoroughly messed-up law’s abundant critics. The many bills passed by the GOP-controlled House to that end during the Obama Administration were grandstanding only: they passed because there was 100% certainty they would be vetoed. Now that such bills actually risk becoming law, Republicans are, reasonably enough, not willing to take the leap into the void.

2. The President has told Congress that if they are not prepared to deal with the repeal and replacement of the ACA now, he will move on to other priorities.  This is entirely responsible, both politically and pragmatically. Passing a sweeping law in haste that will affect millions of Americans would be irresponsible.

3. This means, of course, that the President’s campaign pledge to repeal Obamacare and replace it with something “great” “on Day One” was nonsense. On one hand, it was reasonable for him, or anyone, to assume that after seven years of complaining the party’s legislators had a viable plan ready to replace the affordable Care Act. On the other, it was dishonest to make such a pledge without ascertaining with certainty that what Candidate Trump was promising was within the realm of possibility. “Day One” is obvious hyperbole, but anyone making such a statement must assume that it will  be widely interpreted as “before the next Ice Age,” and thus should not be uttered unless the pledge can be fulfilled eventually.

4. The Republicans cannot, however, as the President implies, simply allow the ACA to crash and then point to the Democrats saying “See? Told you so!” That is neither responsible nor ethical governance. It doesn’t matter that Democrats unethically, deceptively and worst of all, incompetently passed an over-hyped law and badly-conceived entitlement. The consequences of that botch have to be dealt with. Harm must be mitigated, and the duty to do that is bi-partisan.

5. Entitlements cannot be undone. The Democrats knew that. It is socialism’s great advantage. Once something is promised to a large number of citizens, it can’t be taken away unless a dire crisis is imminent. The crisis of exploding health care costs and the crisis of the out-of-control U.S debt are both dire, but not imminent enough to make undoing this latest entitlement politically feasible. Obamacare essentially made health care a right, in willful defiance of financial realities and without any acknowledgment of the need to stop rising costs and insist on personal accountability for health-affecting life-style choices.

6. It’s a national, bi-partisan problem now. If Republicans think they can benefit by emphasizing that Democrats got the nation into this mess and fiddling as the ACA burns, they are as stupid as they are incompetent.

7. The Democrats, and especially President Obama, have nothing to be smug about. The Affordable Care Act should stand as a cautionary tale warning of the consequences when massive, transformative  laws are passed by one party without transparency, honesty, or humility.

8. When the ACA approaches collapse, as it will, the ethically responsible course for Republicans is uncertain, and perhaps non-existent.

9. Regarding Obamacare, then, the Republican Party is in Ethics Zugswang. No doubt Democrats consider this a great victory: true, health care is a mess, costs are still rising, and people who once could afford their insurance can’t… but more Americans are insured (even some who don’t want to be), and the GOP is stuck in the middle!  Meanwhile, the country is stuck with rising health care costs, less consumer freedom, bad insurance plans, and unaffordable premiums.

10. Good job, everybody!

48 thoughts on “And The Obamacare Ethics Train Wreck Rolls On…

  1. 1) because they are all cowards

    10) quantity of coverage is the world’s dumbest standard and is only held up as a standard because it fits the ultimate leftist objective- socialist health care.

    Quantity is a patently ignorant standard since quality is taking and will co tinue to take a massive hit.

  2. 2. They want to cut taxes, they can only do it with 51 votes if they’ve already taken money out of the budget, ergo they need to get rid of the ACA money first.

    They can’t move on and still get their tax cuts.

    • Good point.

      Repealing the ACA is the least problamatic of several alternatives to tax cuts, but there are others. They just suck harder for Republicans to do (and hoist on their own petard, they are!)

      • It isn’t an alternative, it’s a prerequisite. With the ACA money out of the budget they can lower taxes. Without it, doing so will increase the deficit and thus require 60 votes in the senate. Right now getting 60 votes for anything looks impossible. The democratic base wants Trump treated the way Obama was treated by the tea party.

        Jack calls that tit for tat, I look at it differently. Politics is prisoner’s dilemma. If a party does something and isn’t punished by the voters for it, the other party is obligated to do the same or live at a permanent disadvantage. The only way out is for the original offending party to roll over and take one for the team to even the score and go back to the old way of operating.

        Good luck getting anyone to agree who the offending party is.

        • If a party does something and isn’t punished by the voters for it, the other party is obligated to do the same or live at a permanent disadvantage.

          Of course, this begs the question of why that “something” was not punished by the voters.

          • From a strategic perspective it doesn’t matter. Low information voters, apathetic voter, voters who valued other issues more, gerrymandering, mind control rays from planet Xebex, or even they approve of such tactics. What matters is for whatever reason it was deemed acceptable and thus becomes the new normal. It’s why I got so upset, once there’s an escalation, there’s no going back, at least so long as both sides have the same tools available.

  3. As long as we insist on a for profit, insurance dominated healthcare system, nothing will change, and we’ll all pay one way or another. You rightfully point out the failings of Obamacare on the “cost of care” side of the equation. The lack of progress, or even viable alternatives to combat this are just as responsible for the current mess as any other factor. All that aside, this was never a bill about healthcare. It was an attempt to roll back taxes on the wealthy, and that is fine. But call it what it is. The lack of honesty (on all sides) is disappointing….

  4. While I am not usually of the opinion that more governmental regulation is desired, we already have a mess of regulation in health care. Therefore, rather than approaching this as a matter of insurance, shouldn’t we look instead at reducing health care costs in a moderate fashion?

    I did a google search on why the US has comparatively high health care costs even when considering quality differences. It seems that, among the detritus that usually accompanies such a search, there was a lot of information about how approximately a quarter of the bill from a hospital is used to pay administrative costs. While I agree that every employee must be paid, this is high. Hospitals need many more billing specialists in the US than anywhere else because of the differences in filing requirements of every different insurance company. Could there be a law passed that standardized the filing requirements of companies? It seems that this would be a simple start to decreasing costs.

    In addition, while I cannot find recent information on this, if there are any remaining recommendations from the National Commission of Physician Payment Reform that would affect cost but not quality of service, would that not be worth at least looking into?

    Finally, how about some tort reform? Perhaps look into ways to decrease malpractice insurance costs? I know a nurse in a rural practice who has never had a malpractice suit filed against her. She has to pay $600 a month for insurance. Her salary has to be increased by that much a month for that cost. Thus, every bill I receive must be adjusted to cover a portion of that cost, for her, every other nurse in the practice, and of course every single doctor as well. Also, if malpractice reform occurred, there would be a decrease in “defensive medicine,” or tests performed multiple times when once is plenty to avoid a law suit. This would also decrease costs.

    In summation, I feel that the ethical way to handle this would be an effort (preferably bipartisan, but I won’t hold my breath) to look at why the costs are high and moderate those.

    • Tort reform sounds great, but proposal usually ends up being a polite way to tell patients injured by doctor to go away. Malpractice insurance premiums are high, because the risks are proportionately high.

      Let us say that a healthcare professional can be expected to have a 30 year career. And let us say that average practitioner makes one mistake that cost $225,000 to treat over the course of that career (this could be the cost of a surgery and a few nights in the hospital, given current medical costs).

      Any given year, he or she has a 1/30 chance of committing that error: $225,000/30yr = $10,000/yr expected cost; monthly, you get your nurse’s $600 premium!

      I do not know the exact rates of malpractice, but high insurance rates are simply an artifact of high health costs, not themselves a driving factor.

          • In Japan the cost of every drug and procedure is set, it’s the same nationwide. The prices are set with input from the medical association (I can get info on the actual process, if there is interest in this) , and are raised or lowered over time to reflect conditions. There are also standards for treatment, and the billings of every hospital and clinic are reviewed monthly to weed out abuses. When a treatment is dinged, the doctor or an admin from the facility can make an appointment to come in for an interview to contest it. Two examples-

            An orthopedic clinic in town installs a state of the art new MRI machine. Orders for MRIs double…everybody who walks in the door with any kind of knee pain gets one, of both knees, two angles…go in with frozen shoulder, you get an MRI. They get dinged by the review board, because for one, simple physical tests can tell you a lot about what’s going on in someone’s knee or shoulder, and for anyone from their late 70s upward (and they had 89-year-olds getting knee MRIs) it’s a given that the cartilage in their knees is very worn to non-existent, you don’t need an MRI. They contested, but their appeal was denied, and they have to go by the industry standard for MRI frequency.

            A rheumatoid arthritis treatment center of course uses Rheumatrix more often than a general hospital. A new reviewer, not used to the process, or perhaps that specialist field, dinged every single Rheumatrix prescription for a rheumatoid center for two months. They contested, and it was found that the prescriptions were appropriate, the reviewer was mistaken, and the facility was reimbursed.

            There are two types of insurance, Shakai Hoken and Kokumin Hoken. Shaho is used by corporations (over a certain size) and generally Kokuho is used by the self-employed, smaller companies, and family-owned businesses. Shaho is calculated by wage, Kokuho is a lower fixed rate. Co-pays range from 10% (for union employees) to 20-30%, with 30 being the highest rate. The combination of unified procedure and drug prices, and wage-based premiums means that most people have access to health care. If your bills mount, say you have lengthy cancer treatment, or have a huge accident requiring multiple surgeries or a long stay, there is assistance available from your local government that takes care of anything over $750 a month. The system isn’t perfect, and we’ll have to see how it survives once a third of the population is elderly (2050).

            I don’t see how health care in the US can be achieved without some kind of regulation. Drug prices in the US are several times what they are elsewhere for the same drug. I know from my father’s cancer treatment that 3 Ativan tablets were $1500 in 2005. When his nausea was severe they wouldn’t prescribe any more of them because of the cost. It seems ass-backwards to cut patient treatment to reign in cost, instead of doing something about the high prices that make that decision necessary in the first place.

            • Well discussed.

              A great analogy I heard was house insurance. We buy house insurance for fires. We don’t buy it to change light bulbs.

              However, the way we treat healthcare in the modern era would be like expecting my house insurance to cover the change of a lightbulb… only the market hidden behind a network of insurance will tell me I need to pay for a fully licensed electrician to discuss with an interior designer about which lightbulb to install.

              • Good analogy. Also car insurance. Doesn’t pay for routine maintenance and if you get a ding you have to decide if the $500 or $1000 or whatever copay is worth it to get it fixed. If you want a lower copay or more coverage, you pay more for the insurance.

            • In my seven-year (non-itching) stay in Japan, I never had reason to enter a hospital except to visit* but on those visits I learned one of the biggest reason they keep hospital costs down … and patient recovery rates high: family care. At nighttime (the only times this happened – I don’t know if it’s still done), the nurses were available for dispensing what we call Schedule 6-and-above medications and on call for special treatments; everything else was kept to a minimum. Even with cases of special diets, the family brought in the food, and spoonfed those who needed it. A member of the family also brought in a fresh nightshirt or laundered the hospital gown daily, did the necessary nighttime cleaning of the patient, turning the bedbound, changing sheets, bringing and cleaning out the bedpan, doing passive exercise and giving routine medications on schedule, and recording every action and patient condition. The doctors were often available at night to consult with family who couldn’t come by in the daytime. This, and more, took the place of many of the usual charges, most of a nursing shift (sometimes a family member brought a futon and slept at the bedside, especially with terminal cases), and most of all, reduced the patient’s fear and isolation to a minimum, thus automatically improving their chances of a good, quick recovery.

              *As noted, I never needed hospital care myself, but I had annual checkups, as did everyone else, as far as I know, who was employed in the country, foreign resident to citizen. These are given from early childhood: basics are free, lab and other outside tests had low costs — relative to US costs, perhaps 1/10th. But that wasn’t what was so amazing. I had major dental work done in Japan — some of which has outlasted anything here beyond forty years — for a few hundred dollars, total. When the teeth finally lost their bite a couple of years ago, I sold the gold crowns on my present dentist’s advice (they were “invisible” back molars I’d almost rejected on cosmetic grounds!) for nearly $100.00. Sigh. For some weird reason, the Japanese believe preventive dental care is more important than later treatment, which might be why children are treated for free. There are steady objections by Westerners to Japanese health care. For one thing, it’s hard enough to learn to carry on a simple conversation in Japanese much less discuss intimate physical problems with the doctor in it, and those “regular” tests don’t aim for the same targets– as far as cancers go, ours are for the colon, theirs for the stomach: our diets are very different — but no one finds the cost prohibitive.

              The family in the hospital idea … that’ll never work here, for obvious reasons. But the mandatory annual pediatric exam (including preventive dental care!), and the adults’ encouraged ones (once upon a time here, larger companies used to employ a physician, and schools, a nurse), just imagine!

              • “Even with cases of special diets, the family brought in the food, and spoonfed those who needed it. A member of the family also brought in a fresh nightshirt or laundered the hospital gown daily, did the necessary nighttime cleaning of the patient, turning the bedbound, changing sheets, bringing and cleaning out the bedpan, doing passive exercise and giving routine medications on schedule, and recording every action and patient condition. ”

                To my knowledge it’s no longer done. There used to be a huge nursing shortage here, and families were expected to do a lot. MIL is in the late stages of Lewy Body Dementia and is on a special diet for choking issues, but I don’t have to do anything care-wise when I spend time with her. The hospital has a cleaning service that picks up all the hospital gowns, bedsheets etc. A nurse or a nurses’ assistant will either feed her, or sit with her while she eats if it’s a day she wants to eat herself. They have in-house PTs that come around and do exercises with patients in their rooms. They have a big onsen-like bath for mobile patients, and lifts for a smaller individual bath for those who are incapacitated.

                The only thing I have to wash are her personal clothing items that she wears to go to day care. We have kaigo hoken (care insurance) now that’s mandatory for all to pay after the age of 45 that covers home helpers and adult day care. She goes to day care from the hospital a couple days a week when she’s well enough. DH and I are renting out the family home to the local adult day care providers, so she actually goes to her own house for day care and loves it.

                There aren’t enough places for all the bedridden elderly, however, so many families are caring for loved ones at home, doing a lot of what you described, with the help of home helpers, private nurses, and the mobile bath service that goes to the patient’s house, bringing a large collapsible bathtub that’s set up in the house.Three staff come along to bath the patient. Some home bathrooms are too small to get enough people into to lift and bathe someone, so they bring a tub.


                • Thanks so much for the update, Crella. I knew there were many changes: I saw the death of zaibatsu-type corporations and the tofu sellers, as well as the first grapefruit (touch-and-go), Colonel Sanders (range-free yummy chicken) and ATMs that gave exact amounts to the yen. Reading your post, though, I do have a feeling the family and extended family centering and strength is still there, if somewhat attenuated by misappropriated Western ideas of “independence.” It is at the core of the Japanese culture after all.

          • Assuming that all of the things like freedom to decide what you want to charge for your labor were not an issue, I have to ask, do you want some legislative body to decide how much you will be paid for whatever it is you do?

              • I was replying to Joe who asked about “price of whatever you do for a living” not specifically health care. Why should wages for healthcare providers, doctors, nurses, dentists, respiratory therapist, radiology technicians, etc., be regulated by law and not those of other occupations?

                • do you really think the health cure industry is about curing people. If so, why has there been absolutely zero progress in curing paralysis since 2017 B.C.?

                  The industry is not about making sick people well, but milking sick people for all that they are worth. You make more money selling a lifetime of treatment than a one-time cure. More and more people are waking up to this now.

                  Price controls would put a limit as to how much these quacks can milk the sick.

                  • I don’t think that’s true. I see the ‘make more money off a lifetime of treatment than a one-time cure’ thing a lot on Facebook, but it makes no sense. It completely disregards free will, the free will that keeps patients overeating, drinking, smoking, and doing all kinds of destructive things that keep them sick despite their doctor’s best advice to stop. How many Type 2 diabetics wouldn’t be, with better lifestyle choices? Approximately 80% of diabetics whose a1C is 8 or over for a period of years develop dementia, now more frequently being called ‘diabetes of the brain’. High blood pressure, dyslipidemia, ruined backs and knee joints, all ‘lifestyle diseases’. You have no idea how frustrated doctors get when patients destroy themselves over decades despite their doctor’s best efforts.

                    I usually see this ‘lifetime of treatment’ thinking referring to cancer, that doctors don’t want to cure cancer, because they’d stop making money. ‘Curing’ cancer, curing it in each individual who presents with it, would not eradicate cancer from the earth. As long as the human genome exists as it is, and we can’t alter it to eliminate the genes that cause cancer yet, people will continue to present with all the cancers we have now, at the same rates (partially because of heredity and partially because you really can’t get people to change their lifestyles drastically), so no one loses any money even if treatment changes from as many rounds of chemo or radiation as necessary for each patient, to a ‘cure’ that cures them of it in one treatment. It’s not doctors wanting money that keeps cancer from being cured, it’s the complexity of the disease, a hundred types (or more?) with a hundred different triggers..a single magic treatment just isn’t possible.

                    Brain and spinal cells are the only human cells that don’t regenerate, which is why zero progress has been made until recently. It’s only in the past couple of decades that real stem cell progress has been made. There is finally realistic hope for paralysis for the first time in history. One man has had the feeling in his arms restored with stem cell treatment, so there is hope.

      • I do not think that the reform of malpractice could solve issues by itself. I believe it would have to be included in any other cost reduction mechanism because insurance companies are for profit. Therefore, if other options reduce cost, malpractice would need to go down. In an ideal world, it would be driven down, but I am not sure that we could actually state that as a probable effect.

        Also, we can all probably think of a doctor (I know multiple) who has been hammered with false malpractice lawsuits. Their malpractice premium is more like an extra house payment instead of a car payment. When a false lawsuit came up for a doctor of my acquaintance, they were told by the insurance company’s lawyer that, even though there was a very high probability that they could not be indicted and would be found innocent, that the insurance required them to settle and then increased their premiums. A lawyer of my acquaintance told me that this is a standard practice. If an innocent person must pay money for being falsely accused, and then is charged higher costs because they followed their legal representation’s advice, how is that right? It increases costs all around, and affects each of us, especially with “universal” health insurance.

        At least looking into how to minimize these incidents, would be a better use of time and money than the current finger pointing. But I agree, tort reform, by itself, is not the solution, and the reform needs to account for people with legitimate complaints.

        As a side note, last month’s hospital bill says that you made one slight error in your math. At a well regarded, but not nationally recognized (i.e. Mayo Clinic) institution, the cost for six specialists, one surgery, and three weeks hospital stay was about $115,000. I am not saying that errors cannot be made to easily overcome that cost, but $225,000 is a lot of money and might be slightly egregious for mistake a clinic (not hospital) nurse could make. However, I will not argue this point further because I feel inadequately informed to say what is or is not an appropriate amount. I simply feel that an investigation into an appropriate amount might be the way to go.

        • At a well regarded, but not nationally recognized (i.e. Mayo Clinic) institution, the cost for six specialists, one surgery, and three weeks hospital stay was about $115,000

          Why are such high prices allowed to exist? the only surgical procedure I can think of that should be allowed to be even half that is open brain surgery.

          We know what the problem is, which is high prices by health care providers.

          One hospital, according to Brill’s math, bills $1,200 per hour for one nurse’s services.

          Can you think of a nurse that makes even $600 per hour? There can be no justification for these prices. Prices should be contained by capital legislation.

      • Rich, this analysis is incomplete. You appear to only be looking at the economic damages in assessing the risk. Non-economic damages, pain and suffering and punitive damages, are where the big money awards come in. Tort reform legislation caps pain and suffering awards and sometimes punitive damages but not economic damages.

        To look at your example, if that provider has one $1,000,000 judgement against him or her for pain and suffering over that 30 year period that would result in a monthly premium of approximately $2,800. Of course it is much more complicated because some specialties such as neurosurgery and Ob-Gyn are at much higher risk than others and risk also varies by location. In states where risk is highest, malpractice insurance for Ob-Gyns may be greater than $8,000 per month. That said, malpractice insurance costs are only one aspect of an extremely complicated problem.

  5. Too bad the Republicans couldn’t get their act together and come up with a bill that would be acceptable to all spectrums in the party. Now it looks like we’re stuck with Obamacare which is a giant financial sinkhole. I blame Ryan’s dreadful leadership in the House. He should be put out to pasture permanently.

  6. On one hand, it was reasonable for him, or anyone, to assume that after seven years of complaining the party’s legislators had a viable plan ready to replace the affordable Care Act.

    I guess it would be reasonable if one didn’t watch or read any news about the Republicans’ healthcare proposals (and lack thereof) in the six years since the ACA passed…

    So, yeah, totally reasonable for Trump, then.

    I think you oversell the negatives in Obamacare. Premiums are rising, but more slowly than they did prior to the law, so how can the rises be blamed on the law? As far as quantity vs. quality, the percentage of people who say they’re satisfied with their health insurance plans hasn’t budged much since Obamacare.

  7. Whether Obamacare continues or some type of replacement plan is passed, there will have to be decisions made that will very challenging fiscally, morally and ethically. There is no way that everyone can be provided with unlimited care without huge increases in government spending. How will the decisions be made regarding allocation of resources? How much should be spent to keep a premature, brain damaged infant alive, an elderly mother with end stage renal disease? What if it’s your child or mother? Sarah Palin was lambasted for her statement about Death Panels because it’s hard to talk about questions like these and politicians would certainly like to pretend they don’t exist. But in this day and age with skyrocketing healthcare costs that don’t show any sign of moderating, to ignore these questions is simply to wait for the entire system to collapse. Any plan that doesn’t address these questions or provide a realistic method of funding this huge expense is a sham.

  8. The stupidity of the Democrats is stunning! (It is only not stunning in comparison to the Republicans.) They are gloating??? They should use this opportunity to offer to work with the GOP on a bipartisan fix. No, they’d rather celebrate the survival of a bad law that is failing and will be sure to crash. (Simple: insuring pre-existing conditions loses money. Companies are racing to provide WORSE coverage, so pre-existing coverage goes elsewhere. Good coverage loses money, bad coverage gets fewer money losing insured. Got that? Eventually, there will be no coverage, or huge government outlays. It’s still called Obamacare, and the democrats passed it alone. Gloating! Unbelievable.

    • Of course they’d gloat. Failure of Obamacare actually helps the end-state of government owned and operated health care.

      Barring a market solution, which historically always INCREASES quality while DECREASING cost, all other solutions *will* fail, and given our culture’s education that government is the answer…well, when it fails or when Obamacare-Lite fails…the Dems will begin the cacophony of “Socialized Health Care”…then they really get what they want.

    • I never really understood insuring pre-existing conditions. The concept behind insurance is you are betting that something bad will go wrong and the house (insurance companies) covering the bet on the assumption that everything will be fine. Insuring a pre-existing condition is like betting on a sure thing.

      Yes there’s the empathetic argument and it’s not without merit. There’s also an argument to be made that health insurance functions more as a consumer union, providing bargaining power to counteract arbitrarily high prices that a lone actor just can’t bring to bear. At that point though, it’s not really insurance now is it? Maybe I’m being overly pedantic, but I tend to feel very strongly that most of the time, it’s better to just call a spade an entrenching device.

      • I never really understood insuring pre-existing conditions. The concept behind insurance is you are betting that something bad will go wrong and the house (insurance companies) covering the bet on the assumption that everything will be fine. Insuring a pre-existing condition is like betting on a sure thing.

        Health insurance is the only form of insurance that barred coverage of pre-existing conditions.

        It is not as if auto insurance refuses to cover people with multiple pre-existing drunk driving convictions.

        • Multiple “pre-existing” drunk driving convictions are not a pre-existing condition. It affects the odds, and I suspect those with the are paying substiantially higher rates as a result. Long odds are not guaranteed odds. Someone with a pre-existing condition is not likely to avail themselves of their coverage, they are guaranteed to. That would be like me walking into an All State agent an telling him that I will crash my car a week from now, so can I please get some collision insurance?

          I’m not saying deny healthcare to people with pre-existing conditions, but have the decency not to call it “insurance”.

  9. The joke that is the American health care system makes me grateful to be Canadian and though our system isn’t perfect, I’ve received all the treatment I need for a lifelong expensive chronic illness, and have no clue what a medical bill looks like. Please note that in no way am I saying it’s “free.”

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