If enacting the PPACA means that there is now a right to healthcare in the United States, it’s not because most Americans believe that it’s the government’s responsibility that everybody have healthcare insurance:

PRINCETON, NJ — The 56% of U.S. adults who now say it is not the federal government’s responsibility to make sure all Americans have healthcare coverage continues to reflect a record high. Prior to 2009, a clear majority of Americans consistently had said the government should take responsibility for ensuring that all Americans have healthcare.

or that the PPACA’s popularity has convinced people that healthcare is a right. Indeed, not only do a majority of Americans believe that the government has no responsibilty to ensure that everybody has healthcare insurance, the percentage of Republicans, independents, and Democrats who believe that the government does not have that responsibility has increased since 2009. The trend is downward.

People in different countries believe in different things. In Russia people are uncomfortable with differences in incomes that people here aren’t. In France a broadly-defined “equality” is a high value in a way it isn’t here.

IMO some of the reasonable objectives of the PPACA have popular support. For example, I strongly suspect that most people see rescission, arbitrary cancellation of insurance, as unjust. A law banning rescission other than in cases of fraud could have been written in a paragraph.

At National Journal Josh Krashaur does a pretty fair job of laying out the road ahead for the PPACA, particularly from a political standpoint. The short version is that a) Healthcare.gov better be usable pretty darned quick and b) that had better be the extent of the administrative problems with the healthcare exchanges or we will have nothing more than ongoing political damage control from here on through 2016. We may have that anyway.

The rest of this post will be sort of rambling. I haven’t really thought it out completely. It should be obvious to anyone who’s paying attention that healthcare costs are increasing out of control. Even with the decline in their rate of increase they’ve just slowed down to increasing more than twice as fast as incomes and revenues rather than three times as fast or more. Today we’re issuing bonds to pay for healthcare expenses. There are lots of good reasons to issue bonds but paying operating expenses isn’t one of them.

So, how can healthcare costs be brought under control? I think there’s general agreement that there will need to be some sort of change in allocation of scarce healthcare resources. If you don’t like the idea of that, you’ll probably call it “rationing”. If you do like it, you’ll probably think of it as “letting market forces work”.

As I’ve written before, there are basically two different ways of allocating resources: by fiat or via a market system. The starkest example of a fiat system is Soviet Russia. Commissars decide how much of each good will be produced and at what price it will be sold (if any). Sometimes they get it right. Very little of the good remains on the shelf and nobody who wants the good is forced to do without. More often they produce far too much or too little; the fiat prices are too high or too low; people go without.

Market systems have been commonplace for thousands of years. You can see them in operation at any farmers’ market. When the vendor selling at the market are actual farmers rather than middlemen, that is.

Most real systems for allocating resources combine the two systems. Our healthcare system is such a hybrid.

All of the plans that have been discussed for reforming our healthcare system are such hybrids. The largest difference among them is not so much whether they think that influencing how consumers make their purchasing choices is the way to control costs as to who they think the consumers/buyers of healthcare services are.

The plans produced by Republicans have tended to think of patients as the consumers who must learn to economize. For the PPACA it’s some combination of insurance companies, consumers, providers, and government.

My view is that the primary consumers of healthcare are providers and no system that does not start with incentives for providers to economize has a chance of reducing costs.

Hidden inside this Wall Street Journal editorial there’s a neat explanation of how most “employer-provided” insurance plans are actually paid and administered, at least in the case of large companies:

In an aside in a Federal Register document filed this month, the Administration previewed its forthcoming regulation: “We also intend to propose in future rulemaking to exempt certain self-insured, self-administered plans from the requirement to make reinsurance contributions for the 2015 and 2016 benefit years.”

Allow us to translate. “Self-insured” means that a business pays for the medical expenses of its workers directly and hires an insurer as a third-party administrator to process claims, manage care and the like. Most unions as well as big corporations use this arrangement.

But the kicker here is “self-administered.” That term refers to self-insured plans that don’t contract with the Aetnas and Blue Shields of the world and instead act as their own in-house benefits manager.

Almost no business in the real world still follows this old-fashioned practice as both medicine and medical billing have become more complex. The major exception is a certain type of collectively bargained insurance trust known as Taft-Hartley plans. Such insurance covers about 20 million union members, and four out of five Taft-Hartley trusts are self-administered.

There’s no conceivable rationale—other than politics—for releasing union-only plans from a tax that is defined as universal in the Affordable Care Act statute. Like so many other ObamaCare waivers, this labor dispensation will probably turn out to be illegal.

More than half of all employer-provided healthcare insurance is self-insurance and very, very few companies actually administer the claims themselves. However, unions do. If you add up all of the employers who self-insure plus unions and grandfather their plans, there isn’t a whole lot in employer-supported healthcare insurance left except for what’s been characterized as “substandard plans”, as circular a term as I’ve ever heard.

Right now we’re hearing about cancellations of plans in the individual insurance market but next year the big news will be the cancellation of small group plans.

Yesterday was my mom’s birthday. I’d intended to post on the occasion but was overwhelmed by events. In the past I’ve posted a number of pictures of her—as an infant, as a toddler, as a young wife, and as a mature woman. There are gaps in my catalog of pictures of her. I don’t believe I have any pictures of her between roughly the age of four and the age of 16, when she graduated from high school. I don’t have anything from 16 to her mid 20s. Once my dad started taking pictures of her she had hardly an unphotographed moment. Those ended when he died and she was at a relatively young age.

Rather than post a picture I thought I’d do something different. As you may recall my mom and her parents were in vaudeville. Theirs was an unsettled existence, moving from town to town, mostly in dusty western towns. Not hitting the high spots.

Above is an image of her first contract. As you can see, it’s with the owners of a theater in Houston, Texas when she was three years old. She might have been three but I suspect she was actually two. It’s hard to know for sure. I have three birth certificates for her, each with a different year of birth. Even she didn’t actually know when she was born.

Something else worth mentioning is the name. I don’t know that my mom went by the name “Coleen Neff” as anything but a stage name. Her mom at that point was known as “Babe Neff”. I’ve got some old clippings with those names I’ll show you some time.

Yesterday when I was sitting in one my clients’ offices, an elderly woman hobbled up to me and engaged me in conversation.

“I’m a Survivor”, she said.

She rolled back her sleeve to show me the tattoo on her arm.

She then showered me with a litany of blessings.

“May the Lord bless you… May the Lord bless all your undertakings… May the Lord bless you…”

I hope they take. I can use all the help I can get.

Fouad Ajami has an interesting op-ed in the Wall Street Journal on the fading of the Obama “magic” that I’m still trying to get my mind around. I never really “got” the president’s charisma. It may be that I’m tone-deaf but I think it was never the singer. It was always the song. The idea of Obama and the things he spoke about rather than Obama himself. A lot of Americans really liked the idea of a black president. They liked the idea of “post-partisanship”. They liked that he wasn’t George W. Bush.

I largely agree with this snippet:

A leader who set out to remake the health-care system in the country, a sixth of the national economy, on a razor-thin majority with no support whatsoever from the opposition party, misunderstood the nature of democratic politics. An election victory is the beginning of things, not the culmination. With Air Force One and the other prerogatives of office come the need for compromise, and for the disputations of democracy. A president who sought consensus would have never left his agenda on Capitol Hill in the hands of Harry Reid and Nancy Pelosi.

That is, after all, what I’ve been complaining about around here for the last five years.

I think this is overstated:

Valerie Jarrett, the president’s most trusted, probably most powerful, aide, once said in admiration that Mr. Obama has been bored his whole life. The implication was that he is above things, a man alone, and anointed. Perhaps this moment—a presidency coming apart, the incompetent social engineering of an entire health-care system—will now claim Mr. Obama’s attention.

I’m interested in hearing your opinions.

Step 1: Enact a hellaciously complicated healthcare insurance reform plan.
Step 2: Enact a plan with the “insider-outsider” problem noted in The Economist.
Step 3: Enact it strictly along partisan lines.
Step 4: Neglect the implementation of its entry portal until after a disastrous debut.
Step 5: Oversell it and give a mealy-mouthed apology for overselling it.

The president and the Democrats better hope that Peggy Noonan’s assessment is wrong:

A great deal is possible because the people are coming around to the Republican point of view on the program: They do not like it, do not trust it, do not believe it will make things better. The president got caught—and it’s amazing he did it, because he must have known he’d be caught when the program debuted—dissembling, for three years, as he sold and attempted to popularize his program. In fact if your insurance isn’t provided by an employer or the government, chances are pretty good you will soon lose your policy, your doctor, your premium price.

[…]

The mainstream press is already beginning to peel off. Bill Clinton gave them permission for that. Big Dawg was right: The president has to honor his own word and protect those who trusted him and been thrown off their plans. The press, and congressional Democrats, are no longer disloyal if they say the same thing.

Democrats in the House seem near to snapping, and you never know what the House will do. They’re elected every two years. They’re always in an election cycle, and are thus more reactive to and sensitive to shifts in public thinking.

It would make history if congressional Democrats proved to be serious, equal to the moment, if they pushed back against the White House and came through for the American people by moving, in a real move, not a cosmetic gesture—too late for that, that’s what they should have been doing a month ago!—against ObamaCare.

It’s honestly not clear to me whether getting Healthcare.gov mostly working by the end of the month is important or not. Oh, it not mostly working would be important. If you think the flailing around for solutions is desperate now, wait until then. I’m not even sure mostly working will help.

The sad reality is that once any computer program has reached a certain levevl of complexity it will inevitably have bugs. There may be no fixes, just trade-offs. The president’s political opponents will be able to trot out a continuing stream of horror stories, a torrent of fear, uncertainty, and doubt.

What worries me is the dwindling elapsed time. How many end-to-end enrollments will the site support per hour? If your experts tell you there is no maximum number, get better experts. The closer we get to critical deadlines, e.g. the middle of December, the middle of February, the greater the demands that will be placed on the site and, inevitably, the more system failures.

What percentage of those who were crowing a week or so ago about the PPACA’s favorability going up will take the latest Gallup poll’s finding that its approval had gone down seriously? My guess is that it’s down the memory hole time.

I’ve been ruminating on the observation by an OTB commenter I mentioned the other day, that in the PPACA the Pelosi-Reid Congress enacted the “least disruptive meaningful change” to the system of healthcare insurance, trying to reconcile that observation with my own view of the law. Here’s what I’ve come up with.

I think it depends on how you define “meaningful”. I think that the Congressional Democrats defined meaning in terms of a list of buzz words, e.g. “guaranteed issue”, “community rating”, “market-based”, and so on, and their idea of meaningful resulted in the neoliberal mare’s nest of the PPACA. I don’t buy the apologist’s “60th senator” explanation. I think the PPACA is exactly what the Congressional leadership wanted.