Medicaid or Medicare? Edits needed, 1st and 2nd paras. (I know you know the difference; some readers may not - it can get confusing.)

Personally, I wonder if the whole Obamacare debacle wasn't a red herring which blows up the existing system. Seems like one of its largest effects has been to force people into Medicaid, which then becomes the default single-payer system the Dems have wanted all along.

And the GOP plays right into it by whining about it for years and then having (unsurprisingly) no viable, fiscally feasible alternative ready when they're finally in a position to do something about it. What were those clowns doing all these years but b**ching, anyway?

There's got to be an island somewhere - small landing strip, adequate fresh water, within range of Amazon drones, decent Internet access - where a person could just be left alone.

Thanks -- corrected. Medicaid. I was just tired when I blogged this.

I suspect it was intended to blow up the whole system in exactly the way you say. I don't understand why there's no choice allowed for people who qualify for Medicaid but would like to take less of a subsidy (in the wake of having their care ruined, that is, made very expensive) by Obamacare.

I find it hilarious that the CBO is puzzled about why people wouldn't be enthusiastic about Medicaid. I guess they've never heard of the VA.

As for why? The answers are pretty transparent:

1. In lefty-land, expanding the scope and reach of government is an inherent good.

2. Expanding a welfare program plays well with the Democrat base.

3. It lets them crow about how so many more Americans are now "covered".

I forgot one thing:

4. By pushing people into Medicare, they effectively push some of the cost of Obamacare onto the states, which artificially improves Obamacare's budget score.

1. Why force people onto Medicade due to no subsidies?

At the time Obamacare was already too expensive and they were pulling all kinds of gimmicks to keep the CBO numbers down so they could keep all the votes they needed. (Remember when Scott Brown was elected and they had to use reconciliation to pass the final version.) Medicade and medicare was under a different accounting item. There are a number of other budgeting gimmicks that have shown up with the law elsewhere.

2. Was Obamacare intended to lead to single payer?

Several of the original writers said so. They just didn't have the votes to pass it then. Even with full control of the government enough Democrats knew they would never get reelected if they passed single payer. Was this how they planned to get there? Probably not. People weren't that organized at the time. Remember Obamacare the law is over 10k pages long. There are at least 20k more pages of regulations related to the law. It is a giant mess full of conflicts and errors.

3. Why doesn't the GOP have a good alternative?

Are there any good alternatives? The only real solution I can see is to completely repeal the law and let things default back to the states. There are no minor changes that can be made to Obamacare that will make any difference. The concept is inherently flawed.

Beyond that you have some internal politicking going on. Mitch McConnell is very much a COC Republican. He hates the Tea Party with a blazing passion. In fact far more than he hates any Democrats. He is also extremely hidebound. He wants to go back to how things were when Regan was president but that really isn't an option. So while Harry Reed partially removed the filibuster McConnell wants to put it fully back in and absolutely refuses to do without it. Since the Republicans don't have 60 senators and the Democrats refuse to do anything with Obamacare other than single payer the current law Ryan is pushing is going through reconciliation just like when PPACA was first passed. So only budget issues can be dealt with. Not basic concepts or regulations.

I'm still suspicious the Ryan plan is intended to repeal Obamacare without actually repealing it. By removing the mandate and reducing subsidies he is accelerating the Obamacare death spiral. I'm not sure if it is legal to offer noncompliant insurance plans. If it is possible and you just don't get any subsidies then in a few years you will have 30k pages of law that no one has to pay attention to because the benefits are far outweighed by the costs.

4. Why won't people sign up for medicade without a tax?

Have you ever tried to sign up? My wife did back when she was eligible. She never successfully made it onto the rolls even after trying multiple times. It has all those welfare rules where if you make one mistake on this one obscure page, bang, no healthcare for you! Just like when you file for unemployment and they tell you that you have to apply for x job where you will likely be killed before you get to the interview because the neighborhood is so unsafe. But if you don't show up or refuse to go you are off the rolls. States don't want to pay for medicade. It costs too much and they can't really afford it.

One aspect of Medi-Cal that gets ignored is that they don't pay for everything. (I don't know if this is the same for Medicaid in other states.) I work for a medical foundation. If we send Medi-Cal a claim for an office visit worth $100, they'll send us $20 and say, "That's it! We can't pay more than that!" Even if we lowered the cost of our office visits to $5, they would only pay $1. Our foundation will accept current patients with Medi-Cal, but will not take new patients. We have to raise the rates on our services to make up for the loss we experience in unpaid Medi-Cal claims. And every day, we have to turn down about a hundred new patients, begging and pleading with us to get into our practice because they get terrible service from the ones they're assigned to. Even after I explain the discrepancy in payments, they still try to lay on a guilt trip to come see us.

"Are there any good alternatives?"

OF COURSE there are, but first, one has to get rid of the idea that paying for something you will not receive is a good idea. Credit will guarantee that doctors get paid, while seeing that the bulk of medical treatment is paid for by the recipient.

The whole point of a policy is to pay doctors. Nothing else. If you can do that - and the concept of using credit will do that - you can eliminate most claim processing and take hundreds of thousands of people off the healthcare payroll that have nothing to do with treatment but everything to do with how much "health care" costs today.

Glad that you pointed out the confusing mess of being near or crossing over from ObamaCare subsidies to Medicaid. Smart people who have lots of money but no income (or, shall we say, a 'variable' income for income tax purposes) make sure they report just enough income to stay above the Medicaid threshold, pay the small tax, and then get some serious ObamaCare subsidies. Having subsidies increase with decreasing income until hitting a must-go-to-medicaid threshold, where then they examine net worth for final eligibility has to be one of the stupidest things done in the history of mankind, right up there with prohibition. People lie about having more income than they actually have to save money, how effed up is that?

Another point that rarely, if ever, is brought up in this discussion (there are several but time and electrons are limited)-- while ObamaCare did expand Medicaid eligibility to higher incomes, a good chunk of the increased Medicaid enrollment came from funding a full-court press outreach to sign people up for Medicaid. That started well before ObamaCare officially started. This was witnessed by a family member who had occasions to attend large meetings in poorer areas (e.g., the projects). Many people, pre-ObamaCare, who were eligible for Medicaid never signed up for it, well we got them on board now. One wonders just how many of these people represent the newly insured under ObamaCare. More government coercion, no one got more healthy, more failure.

Though the Republicans -- at the zenith of their cluelessness -- are trying to make it all worse, I don't think they can. But we shall see...

I don't see how you want that implemented given McConnell's refusal to do away with the filibuster and Democrats refusal to accept any changes, Rad. I can agree it is a good idea and far better than the current or previous system but it can't get passed in the current environment.

"One wonders just how many of these people represent the newly insured under ObamaCare."

That is roughly 100% of the newly insured under Obamacare. The Obama administration fought tooth and nail to not admit that but eventually the numbers came out and that is pretty much the entire increase.

Ben, you should know that the worth of any program is not related at all to support for it.
Examples abound.

Thanks for these explanations.

"People lie about having more income than they actually have to save money, how effed up is that?"

It's horrible.

I've thought about that, but the problem is, I need good health care and I can't afford to lose the wonderful, understanding psychiatrist I have who gets me. He prescribes the Adderall I need to focus and get my writing done. He, in fact, figured out that I needed to be on Adderall, not Ritalin. The last guy was too busy believing that ADHD doesn't exist. Now, the testing for it is really bullshit, but after taking Adderall, I noticed stuff on surfaces here that had been in place for seven years. It isn't an upper for me. In fact, I can take it and take a nap. It's what helped me get this next, intensely hard book done. (Though I'm still making corrections now, so it's not officially done yet.)

I can accept that Rad. But complaints about things not getting passed without accepting why they aren't getting passed doesn't cut the mustard either.