For context, the original intention was that states would run their own exchanges, only if they refused would residents of the state use the federal exchange.
36 states initially did not set up their own exchanges.[0]
It appears that currently, 20 states (including D.C.) have their own marketplace.[1]
>The shutdown prevented anyone from outside the main team working on HealthCare.gov from coming in to help
That government shutdown in 2013 was instigated entirely by one U.S. Senator, Ted Cruz, expressly for the purpose of sabotaging ACA.[2]
If I was running a state agency and the federal government told me I could just use their system instead of spending my own money I would definitely take on the federal government instead of paying for it. Sometimes the whole "states are their own thing" here in the US goes way too far.
Would you also take federal money to expand medicaid coverage to the poor citizens of your state?
If so you might not be qualified to be a republican governor.
Wouldn't it be much better to hire your friends as IT consultants, make broken systems as confusing as possible, and continuously change the rules, and then starve the half-assed system of funding in an attempt to keep people from signing up for coverage at all? What makes this plan doubly republican-friendly is that all players are your donors and most victims are minorities.
I can disagree with Republican cronyism and the endless "let some private contractor do it poorly" when the Federal government could just do it directly, and poorly, but with less indirection.
… I can also disagree with blue state's NIMBYism, "I got mine and screw you" attitudes towards housing, and work to promote things like better zoning laws, fairer tax legislation, better public transit, etc. at the same time.
(Note: the parent edited the above comment to add the CNN article. At the time I replied, it was only the NYT link.)
Where did I say that? I was responding to the ill-informed rant about state-govt websites and corruption while hilariously ignoring the article stems from corruption and issues in the original healthcare.gov website.
if you weren't addressing my point (medicaid expansion) then why are you responding with random articles?
I, in fact, think things like negotiating drug prices is good, sadly it was outlawed by republican policy: Medicaid Part D (One of the most expensive policies ever) -- the Biden "Inflation Reduction Act" addresses this Bush-era money-grab for drug companies.
I will still give Bush immense credit for passing Part D, even if it blew a hole in the federal budget - there is no way politically it would be possible today, and it was almost not possible then.
Providing lower-cost ways of providing health care is directly contrary to the interests of anyone with political or economic power in our country: the hospitals and pharmaceutical companies that directly benefit from high prices, the politicians who receive bribes in exchange for passing laws that keeps prices high (or just failing to pass laws that would lower prices), and the typical employer who can use the increasing importance of health insurance and the threat of medical bankruptcy as leverage against his employees when negotiating work conditions and pay.
Our health care system is, like basically any other institution of note in the US, first and foremost a means to effect the transfer of wealth to our economic and political elites from the rest of us. We need to first come to recognize that our system is currently working as intended before we can think clearly on what to do about it and take effective action.
"Our system is currently working as intended" implies that someone designed the system to work the way it does. What you're really arguing is that no actor is incentivized to improve things, and multiple actors are incentivized to preserve the status quo.
I'd argue that strident condemnations (ala your "our system is currently working as intended") is actually one of the features of the US political system that tends to create/preserve a subpar status quo: https://twitter.com/JohnArnoldFndtn/status/11063022464493690...
I don't believe that the US has a monopoly on greedy businesspeople or politicians, relative to other countries. But I do find myself wondering if the toxicity of our politics tends to filter out candidates with a good faith desire to serve the public. People who enjoy conflict tend to be jerks.
EDIT -- Here is some specific evidence that US elites are not uniquely rapacious:
You linked me to a website for a US organization that apparently encourages the extremely wealthy to create more tax shelters for themselves, and followed that up by pointing out that the US accounts for 28% of the world's billionaires while making up 4% of its population.
I'm not sure what point you were trying to make. I don't think we have a monopoly on greedy businesspeople or politicians either, but I do think that as the epicenter of global capitalism, we dominate the market. You can't hope to solve problems if you won't allow yourself to accurately define them.
I hope you don't actually believe that providing health care is exorbitantly expensive. Providing health care is absolutely not exorbitantly expensive. It just isn't. Paying the prices that our hospitals, insurance companies, and drug companies charge is exorbitantly expensive.
I propose cutting administrative costs by 90%. A bunch of paper pushers in meetings all day making too much money driving up the cost of everything they touch.
That's a good area to start, although 90% might be optimistic.
See this paper: Pozen, Alexis and David M. Cutler. 2010. Medical spending differences in the United States and
Canada: The role of prices, procedures, and administrative expenses. Inquiry 47(2): 124-134.
Look at Table 1 and Table 2, page 19/20; the difference in cost due to salaries/income is $490 per capita, the difference in cost due to administrative overhead is $616 per capita.
Throw it all away and go single-payer like the rest of the world. This isn’t some unknown mystery to be discovered. It’s been implemented and proven over and over again.
First fix the difference in drug pricing between the US and other countries.
> Prescription drug prices in the United States are significantly higher than in other nations, with prices in the United States averaging 2.56 times those seen in 32 other nations. ... The gap between prices in the United States and other countries is even larger for brand-named drugs, with U.S. prices averaging 3.44 times those in comparison nations. ... “Brand-name drugs are the primary driver of the higher prescription drug prices in the United States
I think breaking the hold of the AMA on things like residency slots that has caused physician shortages. Increasing supply should eventually have an effect on wages.
We could also move to 5 or 6 year degrees for doctors, like Ireland, instead of 4+4 schemes.
We can do more targeted immigration for doctors.
We can continue to expand the activities that can be done by non-doctors.
We can massively reduce the number of things that require a prescription.
Can you read? That's literally what I said. (with the exception of insurance, which is just a reflection of the prices charged by providers and drug companies)
I think it depends on the definition of “exorbitantly”. US healthcare costs are absolutely extreme but even European countries with universal healthcare still struggle with healthcare expenditure.
> The report shows that global spending on health continually rose between 2000 and 2018 and reached US$ 8.3 trillion or 10% of global GDP
When someone points out Republican's cronyism leads to bad outcomes in healthcare, and you respond with an opinion piece whose thesis is roughly "Blue states have bad policies that lead to unaffordable housing" … like that's basically textbook whataboutism:
> the technique or practice of responding to an accusation or difficult question by making a counteraccusation or raising a different issue.
Literally "what about housing" is raising a different issue here, one that's not related to healthcare, nor the Republican anti-pattern being discussed in this subthread…
You're further implying that Democrats are hunky-dory with the housing policy in states like CA, when they're not. Some are, some aren't, and AFAICT it wasn't exactly a partisan thing. As I alluded to, a lot of the YIMBY-iers there advocated for things like better mass transit — which isn't exactly a very Republican position.
> You know how NIMBYism is done in California?
> It is usually along the lines of "We can't let developers profit!!" and "They are going to build luxury homes!!".
I'm a former resident of Silicon Valley. I'm well aware how it's done. That doesn't make this not whataboutism, and it doesn't mean that there aren't democrats in those states who are fiercely against that line of argument.
> When someone points out Republican's cronyism leads to bad outcomes in healthcare
Why would you expect a party's cronyism to be restricted to one industry? If you're implying that Republican's shouldn't be in charge of healthcare because it will result in cronyism, pointing out the cronyism is far from a partisan issue is not whataboutism.
The latter isn't cronyism. There isn't some anti-developer who is lining politicians' pockets with money created by not developing. In fact, what we're seeing is Democratic state politicians in these blue states making laws that limit NIMBYism like SB 35, against the wishes of local governments voted in by local NIMBYs.
I dont believe the dichotomy that its a choice between government and public.
Both parties are fundamentally wrong on a whole host of issues - the democrats are wrong on how markets work, and republicans treat poverty like it's a moral failing.
I dont know how to fix this situation, I need to see how the realignment we're in works out.
> Would you also take federal money to expand medicaid coverage to the poor citizens of your state?
The federal money is an extortion scheme.
The way federal programs nominally work is that people with money pay taxes to fund the programs. The people with money disproportionately live in certain states, which is the justification for making it a federal program -- then you can have a uniform national program even if some states don't have the tax base to provide it themselves.
But then the representatives from the states with money make it so the federal government doesn't fund the entire program. This benefits them first because they can shift some of the tax burden from the rich taxpayers in their state to the poorer taxpayers in some other state where any of the program's beneficiaries are. It tries to force every state to fund part of the program from their own tax base even if the people in that state didn't want it, because the alternative is to pay the federal taxes anyway but not get any of the federal money.
Then it benefits rich people again because the rich states, of course, implement the programs and get the federal money, but any state that refuses the scheme that disadvantages them is still paying federal taxes and gets nothing. So now you're getting a transfer of wealth from poorer states to richer states -- a penalty the representatives from the richer states intended when they constructed the program that way.
But the poorer states may not have the money to fund the state's portion of the program, and in any event refusing it is the only way the state government has to protest the federal program being constructed in that way. It puts pressure on that state's federal representatives to reform or remove the program.
So don't blame the poorer states for not implementing the program, blame the richer states for passing it without funding it.
States pay for the health care of their poor residents either way.
Residents who do not have private or public health coverage still get health care. They go to the ER when they need help and they receive care in the most transactional and expensive way possible. The cost for this care is paid by all the other residents who do have private care (via higher prices) and in their taxes.
The goal of Medicaid is not to pay for more care, it is to better organize the care that is being provided, and in doing so, improve outcomes and lower the overall cost.
One reason Medicaid expansion has seen steady adoption, even in “red” states, is that earlier implementations have shown that this happens and the program is a net improvement.
> States pay for the health care of their poor residents either way.
Implying that a federal program is unnecessary because the states would have the incentive to do something anyway, but could then tailor the program to the geography and economy of their state instead of having something imposed on them that was drafted by Washington lobbyists.
> The goal of Medicaid is not to pay for more care, it is to better organize the care that is being provided, and in doing so, improve outcomes and lower the overall cost.
The problem is not that the patient pays otherwise, it's that the state if they want to implement Medicaid and get the federal money their tax base is paying taxes for regardless, has to put up even more money only to have the federal program dictate how they can spend their own money. That's the extortion -- they remove money from the state's tax base and only give it back if the state provides even more money and implements the program under the federal terms.
It gives the state no opportunity to make their own choices, which might have been more cost efficient. It destroys the "laboratories of democracy" the federal system was intended to have before lobbyists found a bunch of ways to cheat the constitution and take everything over centrally.
> One reason Medicaid expansion has seen steady adoption, even in “red” states, is that earlier implementations have shown that this happens and the program is a net improvement.
The main reason is because states can't afford to run their own equivalent program under their own terms when the federal government is raiding their tax base and then only returning the money with strings attached -- one of the major ones being that they have to spend even more of their tax dollars on the program whose terms are dictated by the federal program.
And this is not the only federal program that operates this way. So much of the poorer states' budgets go to spending money in order to get federal tax dollars under federal terms that they can't afford to do something different. Both accepting and refusing the money leaves them with not enough resources to do something on their own -- if they refuse it they end up with less money than they started with because tax dollars leave the state only to fund the program in other states, but if they accept it they have to pay even more and lose the ability to make their own choices.
It's unsurprising that many states would knuckle under to that level of coercive pressure -- the coercion is the intent. Otherwise the program would be a block grant, or simply not exist at the federal level so that federal taxes would be lower and state taxes higher, allowing similar programs to be operated by the states.
Notice that of all the people who downvoted that comment, not a single one attempted to defend having the program as a coercive centralized mandate from the federal level -- which was the criticism -- and instead the only argument is that a program of that nature is good. But whether the general idea is good or not is a separate question from which level of government should construct it.
States do have strong incentives to improve things for their residents, which is why, once ACA programs like state exchanges and Medicaid expansion are implemented, they are popular.
Many state elected leaders, however, have strong individual incentives to avoid any change that exposes previously hidden costs to their constituents, because then their opponents can accuse them of raising spending and/or taxes. (Even though they all know the cost has been there hidden all along.) This is the same incentive structure that inclines state politicians against spending state money on environmental protection, workplace safety, infrastructure, and many other areas where the federal government ends up taking the lead.
You seem pretty plugged in and sympathetic to the point of view of state elected officials. The idea that federal taxes are money stolen from states, for example, is a classic state politician talking point.
But I think you might be surprised how many federal actions are secretly supported by state officials who publicly campaign against them. They get to benefit from the material improvements delivered by the federal program, while blaming Washington for out of control spending, unfair coercion, etc.
> States do have strong incentives to improve things for their residents, which is why, once ACA programs like state exchanges and Medicaid expansion are implemented, they are popular.
But this is just defending the general concept of such a program, not a reason it has to be constructed at the federal rather than state level.
> Many state elected leaders, however, have strong individual incentives to avoid any change that exposes previously hidden costs to their constituents, because then their opponents can accuse them of raising spending and/or taxes.
How is it that federal elected leaders are immune from this incentive? And if they are, isn't that bad, because they would then for the same reason have no incentive to implement programs efficiently?
> The idea that federal taxes are money stolen from states, for example, is a classic state politician talking point.
It's a straightforward economic effect. Bob earns his wages which are then spent by some combination of Bob, the state government and the federal government. If the federal government takes more then the state government and Bob get less, and Bob is going to be in a bad way if there isn't enough left to make rent.
Meanwhile if the federal government uses the money for Medicaid then the state doesn't have to collect the money the federal government spends on it, but then it's the federal program setting the terms -- and if the state doesn't like those terms, Bob still has to pay all of the same federal taxes. The state can't use his money to operate their own program instead.
Federal spending is currently ~25% of GDP, which is more than it is for most states -- and a huge chunk of the money attributed to states is the state portion of the money required to implement federal programs. By the time you also pay for state programs whose funding couldn't reasonably be reallocated to something else, there is nothing really left. The states have lost the ability to try to do better because the federal government has locked up all the money.
> But I think you might be surprised how many federal actions are secretly supported by state officials who publicly campaign against them.
Well of course they do. They're opportunistic politicians. If they can't reasonably implement useful programs because the money they'd have to spend is already going to the feds then their remaining option is to claim credit for not spending it.
The point is, what would happen if the states were actually left with both the problems and the resources to solve them?
We know what would happen because that’s how things were before the federal programs were created. It’s not like all the states had everything solved and then the feds came in on top with Medicaid etc for no reason.
The federal government has been doing this since the depression/WWII, before which there wasn't enough of a tax base to support these kinds of programs at any level of government.
Most people with normal morality think expanding health care access to the poor is a good thing to do, which is probably why they don't feel compelled to defend the "extortion".
If you have someone running around threatening people with a bow and arrow if they don't give up their money on the claim that Robin Hood will give it to the poor, the people who refuse are not inherently doing it because they hate poor people.
Especially when it turns out that a lot of people the money is coming from aren't actually rich, and a lot of the "people" the money is going to aren't poor people at all but major corporations.
Such a stupid ideological take from these places, if they really wanted to tank the whole thing they should have built their own exchanges and make them suck just like some states (like Florida) make the unemployment system so insanely complicated many just don't even try to apply for it.
I'm glad they're not smart enough to do that though and people were able to get healthcare through the federal exchange. I hope these bigots continue to be evil and dumb, if they get smart then we're really in for a bad time.
maybe if the centralized government gets smart we'll actually have a good time...as it stands our healthcare in the US is abysmal and neither political leaning has any right in name calling - both ideologies have failed miserably.
Y'know the ACA originally had a public option in the bill. Guess which side killed that? Why did we even need an ACA-with-private-insurance-companies anyway? The ACA was initially copy of what was implemented in Massachusetts by Mitt Romney. It's frustrating that Democrats had to compromise just to end up with a system that only somewhat better than what it replaced, and then get blamed for the result.
The public option was killed by Arlen Specter, a Democrat, who refused to go along with the other Democrats. Rs were united, which made his defection critical. Kind of like how Joe Manchin throws a wrench in the works every few years in return for oil and coal extraction benefits for his company in WV
The creation and implementation of the Massachusetts health care system had little to do with Mitt Romney other than him trying to outdo Senate President Robert Travaglini's initial proposal for reducing the number of uninsured people in the state and later attempting to veto parts of the proposed legislation such as making employers contribute towards their employees coverage, letting legal immigrants with jobs use the system and providing dental care to those in the lowest income brackets. "Romneycare" was a pejorative term used by other Republicans to attack Romney when he was going to run for President.
The group responsible for the actual legislation was the Affordable Care Today Coalition which consisted of a lot of different interests:
Most policy changes in a democracy are going to be frustrating compromises. That is a feature, not a bug. While this produces suboptimal results on individual issues like healthcare coverage it helps to maintain broad public support for the overall democratic system. Everyone is unhappy for different reasons, but not unhappy enough to revolt over it.
Americans talks as if their democracy was fine, that the last president didn’t spend months telling everyone the results were fake and how a revolt happened on January 6th.
It’s not a frustrating outcome of democracy. It’s a failure of democracy with one party trying to take over and destroy all other opinions by all means necessary, which includes an open revolt and election stealing.
Further in this direction, currently the lower house is being held hostage by a small group of extremists from the majority party who have no interest in governance. I don't actually share the opinion that this is a breakdown of democracy per se, but rather believe that this is democracy working as intended (by a certain few wealthy people).
If the lights stay on and food stays on grocery store shelves and people aren't getting dragged out of their homes by revolutionary militias, then democracy is still succeeding in broadly keeping the peace and keeping things humming along. If half the population wants to believe stupid conspiracy theories about the last election, that's fine so long as most of them don't act on it. So long as their attempted coups or revolutions die in the crib before they can do much damage, then democracy is working.
> It’s a failure of democracy with one party trying to take over and destroy all other opinions by all means necessary
Lots of people talk shit but almost everybody is still going about their daily lives in a normal civil manner. Obviously the state of American democracy could be better, but don't pronounce the patient dead just because he tripped and got his knee bloodied.
Are they otherwise managing to go about their daily life in a civil productive manner? People believing stupid things isn't a failure of democracy, democracy is tolerant of this.
The institutions did their jobs. Trump failed to seize power extralegally, despite populist support. The US system of government could be better, but it is functional.
The institutions didn't do their job. He walked away from an attempted coup with zero consequences to him, and is currently the favorite to challenge at the next election.
> The institutions didn't do their job. He walked away from an attempted coup with zero consequences to him,
Indictments on 91 felony charges across three different sovereignties in four different proceedings is...not what most people would describe as zero consequences.
(Also, there are several other active state criminal investigations relating to the fraudulent electors scheme, some of which have produced criminal charges against other people and any of which could very easily also result in further indictments for Trump.)
There are more issues with not prosecuting people for crimes simply because they were in positions which magnify the threat and impact of those crimes, and both states and the federal government have prosecuted former leaders including state governors, state and federal legislators at all levels, state and federal cabinet secretaries, and even US vice presidents in the past.
There is neither a Constitutional nor a rational basis for a special
unique exemption for past Presidents, and fortunately state and federal prosecutors seem to recognize that.
No, it really is completely unproblematic; "But", you might ask, "what if a current leader does so as partisan retaliation, is not constrained by other forces, and starts of a chain of retaliation against past leaders?"
Sure, but using criminal process or any other power of office to punish partisan enemies is a problem whether or not the target is a past leader; there's no special danger around past leaders. if anything, there is less danger around past or current high government officials in general, and past Presidents in particular, because of the extraordinary degree to which those persons tend to be visible and well-connected politically.
There are multiple court cases active against Trump and even his lawyers for advising him. He's recently been barred from speaking on certain topics as a result of those cases. These are absolutely consequences, in my opinion.
American democracy is mostly fine. There are certainly some problems and room for improvement, but overall it's doing better than any other major developed country. This is largely thanks to our wonderful written Constitution.
I grew up in a country without a written constitution (but have lived under the US one for 34 years). I can say with much feeling that it is wonderful to have a written constitution.
But this particular one? Not so much. Vastly better ones elsewhere, if only because they have less veto points and a better amendment process.
It is telling that when the US has helped developing countries write their constitutions, they have not modeled them after their own.
The bulk of it was largely designed around the specific circumstances of them 13 colonies->states, many of whom kind of hated each other, and full of appeasements to their different concerns at that time. Everything else has been retrofitted into it since then.
Not to mention that we then had a massive civil war, which left many of the underlying representative issues unresolved. It’s 2023 and we still have states trying to re-write their Congressional maps in ways that violate the law. https://www.npr.org/2023/09/05/1193749552/alabama-congressio...
> but overall it's doing better than any other major developed country
Which ones?
Canada? Japan? Australia? Germany? Even places with significantly unpopular governments like France and the UK don't have a situation where one of the houses of government can't function.
I think if the Italian government is more functional than the US then it's time to realize there is a real problem.
Here's a list of countries by GDP[1]. I'm looking at it and struggling to find a country that is (a) developed[2] and (b) a democracy and (c) doing worse in terms of functional governance than the US.
Turkey and Thailand are two options where they had attempted or actual coups, but neither are classed as developed.
If you can't provide better than "a somewhat better" system at continually growing extraordinary costs[1] then you have no business doing anything.
Pointing fingers is getting us nowhere. Someone needs to behave rationally and neither side is willing to do that. I don't really care who the worst offender is, we just need someone to step up and not be an offender
The problem is in a democracy someone stepping up does nothing, you need a solid majority of people to step up which is were the problems begin unfortunately.
I think it's a mistake to view the two parties as representing two distinct ideologies, and further to believe either parties rhetoric about what constitutes their ideology.
Most of the game of US politics is to see how many terrible/unpopular deeds you can perpetrate against the public on behalf of the moneyed interests (not voters) that supported your campaign without losing votes to the opposition.
Wedge issues and propaganda keep people voting on party lines for candidates that only occasionally act in the majority interest of their own voters, let alone the interests of the greater public.
There are good, well-meaning politicians out there. They are often the ones most vilified by the media. The chief enablers of bad politicians are people who refuse to discern between good politicians and bad politicians. Enablers like you.
I can understand why you would take me for an apathetic non-participant given my cynical comment, but I do agree that there are well-meaning people trying to be more than cogs and I do try to discern the difference.
for what its worth, the vast majority of republican senators are ivy league educated lawyers... just like the democrats. Its too simplistic to boils views you disagree with to "dumb"
When those individual reasons lead to a net migration from blue states to red states (e.g. more people being recruited in red states in the aggregate than in blue states) that’s meaningful.
I’ve got some cousins in DFW now and they love it. One, after studying in Queens, is marveling at how “everything is bigger in Texas.” They move for jobs and schools and neighborhood safety; same reason my parents immigrated to red state Virginia instead of blue state Maryland. (Then they helped turn Virginia into a blue state and are now surprised at e.g. democrats trying to “equity” TJ.)
I think your point even cuts in the opposite direction. The Bangladeshis I know who moved to Queens did so not because they think New York City is great, but because of the large community of other Bangladeshis. Most of the folks who could afford it migrated out to purple Long Island, etc.
Another possibility: Blue states got so expensive precisely because so many people wanted to live there and consequently moved there — supply and demand, etc. And so, when opportunities opened up in red states, it made sense for some of the newly-dissatisfied blue-staters to relocate there. Yeah, they might well gradually turn some of those "nice" red states purple, or even blue — c'est la vie.
Yes, it’s ideology at the expense of your population. As long as they have the right ideology on trans people, that’s enough for 50% of this country to let them get away with anything.
It’s a public-facing IT system owned by some government agency in the United States. “Sometimes” is an understatement. (Though maybe this is a failure on my part to update my priors. I’ve noticed that recently some of the systems that led me to form this opinion in the past have become very functional, if not exactly pleasant to use.)
There has been a massive effort to improve various federal websites(of which I believe there are hundreds of thousands). These folks have done some really impressive work on overhauling a lot of said systems:
I must say I am SOMEWHAT happy with USCIS and IRS, which are the two ones I deal with the most, they actually resemble modern systems and not something made in the 90s.
This often depends on how the program is funded. The state may be able to get money to run the system and if they are ok with becoming dependent on that, they might take it.
See also, NEVI, where the government is spending billions of dollars to build chargers via a complicated system involving state managed programs. It was passed almost two years ago and hasn't deployed a single site.
> If I was running a state agency and the federal government told me I could just use their system instead of spending my own money I would definitely take on the federal government instead of paying for it.
That’s because you completely misunderstand how government bureaucrats think. You’re not paying for it - the taxpayers do
This application is one that makes sense to run locally with the fed's implementation as a backstop and baseline (that rases the standard of minimally acceptable) -- and in this case bootstrap as well.
California has a good system that is roughly standalone while NY has one (also good) that is integrated into other NY programs. Both fan out into a network of actual humans (mix of private and public sector) that help make it work for people who for whatever reason can't use the online service. It's hard for the feds to do something like that at scale -- for example to have it integrate into other lcal programs.
The state-run exchanges solution was itself a compromise for Republicans and on the fence Democrats, particularly Arlen Specter, who feared a federal healthcare system would inevitably lead towards universal healthcare. They received their compromise, then refused to implement the exchanges in the hopes that the law would die.
As I understand it it's common for one Dem senator to "take the PR hit" when there are actually multiple members who would not want a bill to pass. A bit of kayfabe.
Your comment about states running marketplaces reminded me of the ill-fated Clinton-era welfare "reform". This moved Federal funds to state block grants and states managing programs and eligibility (ie TANF) [1]. The result? The system became significantly less efficient in terms of how much of each Federal dollar resulted in aid as well as how many people received assistance and how much assistance recipients got.
I'm not sure what the basis was for state marketplaces for the ACA but the history of involving states seems to make everything worse. Adding an intermediary allows programs to be scuttled and money diverted (if not outright stolen) by other programs and participants.
As an example, Texas refused free money from the Federal government for Medicaid expansion, amounting to $5-6 billion per year [2].
To be fair, there is no such thing as "free money". Every "free" dollar the feds give out is that much more inflation and devaluation of the dollar, and it's been skyrocketing every since the Feds started giving out this type of free money to the states.
I doubt Texas refused on this principal, but states viewing Federal money as free is irksome. It's not free. It's a hidden tax on both your current citizens in terms of devaluation of their savings, and future citizens to pay off the debt the Feds are creating with this "free" money.
Talking about inefficiency - it'd probably be significantly more efficient to stop requiring this money to funnel through DC. But it's more about power than efficiency.
Some people don't have the intellectual capacity to grasp the fact that a healthy populationin working age brings more wealth to everyone in the long run
This is always what amuses me from my European perspective. Large parts of the insurance systems where created for ensuring workers are healthy and productive. And it is an understanding that bad care causes permanent reduction in work output.
It's part of the "if you are successful it is because you worked hard and deserved what you get" and the "if you are a failure, it is because you are stupid and lazy".
There are no unfortunates in the USA, there are only losers and winners.
If more welfare spending creates more wealth, then wouldn’t you expect the median Western European to be wealthier than the median American? Yet the opposite is true. How do you reconcile this?
First we talk about Healthcare Spending.
The US spends the most and get the worst outcomes in G7. Also you have universal health insurance for Elder People (Medicare).
It just doesn't make any sense to have perfectly capable workers to loose their ability to work because they couldn't get a treatment for 10.000$ in real cost (not the marked up price for Uninsured people, because the insurance companies want a rebate from the sticker price)
Also if you look at GDP measured in PPP the US doesn't really have an advantage. In other measurements as HDI they trail even behind
Just because you don't use "free" federal money doesn't mean you can't provide for those people.
We don't live in a black and white world where Medicaid alone is the answer to all our problems. If anything, these centralized mandates have caused significant price increases and less competition, in multiple sectors, including thr currently apparent housing shortage and affordability crisis.
I *swear* that a year or two into this whole thing there were a wave of articles about how individual state marketplaces were having insurers exit the state marketplace. The story which I am *sure* I read more than once said that an insurer found they were losing money on a small number of patients with very expensive treatment needs which drove up their costs so much that no one else wanted to buy their product at its new price.
I went looking for articles about this recently and couldn't find them any more. Did I imagine this happening?
I think a lot of this was related to the risk corridor payments insurers were entitlted to for 2014-2016 but which Congress simply refused to fund, resulting in a lawsuit that reached the Supreme Court in 2020 ruling that, yes, the payments had to be made.
> The individual mandate was intended and served more healthy individuals into the insurance pool.
More people in the pool makes costs more predictable, and more healthy people in the pool makes them lower. The loss lf the individual mandate driving them out made costs less predictable and on-average higher, and higher rates themselves increase opt-outs, reinforcing the effect.
Yah I recall hearing stories of that. I was in the individual market at this time shopping for bronze silver and gold plans and trying to make sense of it all. This was the era where the world of https://www.hhs.gov/healthcare/about-the-aca/pre-existing-co... entered the lexicon.
Well, for one thing, open enrollment starts on November 1, so you can't get an ACA plan anywhere until then without a qualifying life event.
Also, if the website is broken, you should be able to call and talk to someone to get a plan. Not ideal but it's not like you're completely out of options.
The phone support just leads to a ticketing system that responds via the web app. You can’t log into the webapp from foreign IPs without locking out the account (which can only be unlocked via the phone number on file, which only supports US mobile numbers and not Google Voice). They don’t use email. If your autopay credit card expires, they cancel your policy without any notice but paper mail, which is insane in 2023. They won’t let you reinstate it, even if you backfill pay your unbilled months.
It only works for people with a single US number who get their paper mail on a regular basis and never travel for long periods of time. I live in Europe half the year and the service is unusable.
I don't know about NV specifically, but in both PA and NM nothing requires you to buy insurance through the state marketplace, and some insurance companies operate inside, outside or both. You can get back the subsidies that might have been prepaid for you via your tax return. The prices may or may not be as good, but hey, that's the free market for you!
And a separate federal crime if messed with. Impersonating the IRS over USPS has to be one of the fastest ways to end up with two federal agencies after you…
> That government shutdown in 2013 was instigated entirely by one U.S. Senator, Ted Cruz, expressly for the purpose of sabotaging ACA
You say it like it's a bad thing. ACA is horrible -- extremely expensive, few options, huge deductibles, virtually zero transparency, "keep your doctor" turned out not to be true in many cases.
I'm no Ted Cruz fan, but I wish more people had stood up and admitted this thing was a total piece of shit and tried to prevent it from passing.
The US government has an annual budget. Normally before a new year starts, there needs to be a new budget. The House of Representatives nominally has the full responsibility of creating the budget, but it's also subject to approval by the senate and president.
IIRC, in 2013 Republicans had control of the house and didn't pass a new annual budget. In the last few weeks of the year they did pass a continuing resolution saying something along the lines of "continue the government funding for 2 months at last year's levels until we pass a more complete new budget, and also repeal the Affordable Care Act". The Senate voted in favor of most of the continuing resolution but not the ACA repeal, which caused deadlock when the HoR and Senate couldn't reconcile the 2 versions of the bill that passed.
36 states initially did not set up their own exchanges.[0]
It appears that currently, 20 states (including D.C.) have their own marketplace.[1]
>The shutdown prevented anyone from outside the main team working on HealthCare.gov from coming in to help
That government shutdown in 2013 was instigated entirely by one U.S. Senator, Ted Cruz, expressly for the purpose of sabotaging ACA.[2]
[0]https://aspe.hhs.gov/reports/health-insurance-marketplace-pr...
[1]https://www.healthcare.gov/marketplace-in-your-state/
[2]https://www.texastribune.org/2016/02/16/ted-cruz-2013-obamac...