Cartoon: On the revised American Health Care Act

republican-health-care-plan

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Transcript of cartoon:

Panel 1
A man in a suit is standing on a stage, in front of a crowd, grandly introducing a furry, fanged, unicorn-horned, pointy-eared, polka-dot dinosaur-tailed monster. The monster waves at the crowd.

SUIT GUY: Introducing… the Republican Health Care Plan
CROWD: Boo! Boo! Boo!

Panel 2
CAPTION: Weeks later
The same man is grandly introducing the exact same monster, except that the monster is now wearing a fake nose and glasses. The crowd glares.
SUIT GUY: We listened to you and we made big changes! Introducing the NEW Republican health care plan!

Kicker panel
A few members of the crowd are talking to Suit Guy.
PERSON IN CROWD: Just how stupid do you think we are?
SUIT GUY: You elected Trump.

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21 Responses to Cartoon: On the revised American Health Care Act

  1. 1
    Harlequin says:

    Amp, do you mind if I ask you a bit about your process? Knowing that describing this is sometimes not useful or not possible–I won’t be offended if you don’t or can’t answer.

    I’m just wondering how you come up with your monsters, like the one above. Did this one require a lot of character design, or did your first draft fit well with what you wanted? (It looks great to me.) Do you enjoy that kind of thing, or is it less fun than coming up with human characters?

    I really like this, in case that wasn’t clear!

  2. 2
    David Simon says:

    I agree with Harlequin about the monster design, it’s excellent.

    I feel sorry for the poor thing. They can’t even be bothered to patch its jeans!

  3. 3
    Ampersand says:

    Thanks to you both!

    Harlequin, I just answered your question over here. (I’d post it here as well, but that would be more effort and it’s 1am here. :-p )

  4. 4
    Harlequin says:

    Oh awesome, thanks!! That was super interesting.

  5. 5
    Humble Talent says:

    I think this is a story that only gets worse. Obamacare as it stands is basically isn’t good for anyone. The argument could be made that more people are technically covered, but just being covered really isn’t meaningful when you have a five-figure deductible that you’ll never be able to pay. Premiums are up across the boards, and while it could be argued that premiums have always risen, one of the selling points of a socialised system is benefitting from economies of scale, and that didn’t actually happen. Now, we’re seeing exchanges start to fail and close, we’re currently sitting at 226 exchanges in 2017, down from 258 exchanges in 2014, and quite frankly I couldn’t find earlier numbers, but I would be gobsmacked if 2014 was the high water mark.

    Right now, people aren’t happy… But the system at least exists. If something doesn’t pass soon, even something imperfect, then I have the feeling that when things REALLY start to go sideways, there’s going to be more leverage on both sides to get something, even something objectively awful, out to fill the gap. That monster could be downright cute compared to what could make it down the pipe then.

  6. 6
    delurking says:

    I disagree with Humble Talent. Obamacare has been good for me — (1) the prices of my prescription medications have plummeted, and some that were not covered at all are now covered, which makes a huge difference in my household budge and (2) psychiatric care no longer has a cap, which means I have been able to get help for my child without going into debt: this is also huge.

    Further, Obamacare has been an enormous good to a number of my students, who were not able to get health insurance previously, due to their pre-existing conditions. In at least one case I know of, the best young writer to come out of my program so far, Obamacare literally saved her life. Without the insurance she was able to obtain through ACA, she could not have received the medical she needed when her immune system failed earlier this year.

    Finally, as a parent, I know a lot of other parents. Many of us have children who are 18-26. Obamacare allows us to keep our children on our insurance. One of my closest friends has a son who is a diabetic. Without Obamacare his son (1) probably wouldn’t have been able to get insurance, due to the pre-existing condition and (2) certainly wouldn’t have gotten it at the same cost he had been getting it, through his father’s insurance.

    I have heard similar reports from all over the country. It is true that in some states, the Republican government refused the medicaid expansion which would have allowed their working class citizens to obtain insurance without paying huge premiums — but that is not the fault of ACA. That is the GOP doing everything they can to destroy ACA.

  7. 7
    Jake Squid says:

    The argument could be made that more people are technically covered, but just being covered really isn’t meaningful when you have a five-figure deductible that you’ll never be able to pay.

    The max out of pocket for 2017, under the ACA, is $7,150. That’s the Max Out of Pocket, not the deductible. It is not possible to have a deductible that is higher than the max out of pocket. There’s a lot more in your comment that is untrue, but this one is so easy to debunk and your lead into your counterfactual opinions on Obamacare.

  8. 8
    Ampersand says:

    Obamacare as it stands is basically isn’t good for anyone.

    Obamacare has been amazing for me. I’m not getting perfect medical care – for instance, my insurance is phasing out coverage of the insulin I like and am used to. But although that’s an inconvenience, I think the reason for this – the insulin I use is very expensive, and there are alternatives that seem to work as well – is actually reasonable, in my case.

    My primary care provider knows my name and my case and answers quickly when I have a question (and is willing to use! email!, rather than requiring me to use the stupid goddamn phone). I have a separate specialist, a pharmacist specializing in diabetes treatment, who is available for advice and really seems to know her stuff. I have dental care. My annual vision test is partly covered (because of diabetes), and when I forget they remind me. I went to a specialist for a sleep study after I asked if I might have sleep apnea, and after being diagnosed I was given a CPAP machine which has made me sleep much better. The machine also automatically sends my sleep data over the internet to a lab, so that they can tell if I’m having too many sleep events and need CPAP adjustment. (Hasn’t happened so far, knock wood.)

    I have never had better medical care in my life.

    The argument could be made that more people are technically covered, but just being covered really isn’t meaningful when you have a five-figure deductible that you’ll never be able to pay.

    Again, when you make factual claims, it would be helpful if you’d include a link.

    In addition to what Jake said:

    Somewhere between half and three-fourths (depending on how you measure) of the people who gained insurance because of the ACA, are getting their insurance through Medicaid or CHIP. None of those people are paying a deductible at all. How are they (or, rather, we) not benefiting from the ACA?

  9. 9
    pillsy says:

    A lot of the remaining “problems” with the ACA are smaller than they look, not necessarily in terms of their severity for the people they do affect, but in terms of the number of people actually affected. That doesn’t mean they shouldn’t be fixed–the goal is, of course, good, universal coverage–but problems that only affect a few people are generally a lot cheaper to fix than problems that affect a ton of people.

    Some of the provisions from the original ACA that didn’t quite make it through would help a lot.

    The maximum multiplier is too small? OK, lower the Medicare eligibility age to 55.

    Some exchanges have only one (or even zero) insurers? The public option would help there. It would also limit the ability of big insurers to intentionally dick around with the exchanges in order to push the government around.

    And you know, the GOP could stop trying to sabotage everything. Really.

  10. 10
    Humble Talent says:

    On premiums:

    In 2008, the average employer-sponsored family plan cost a total of $12,680, with employees footing $3,354 of the bill, according to Kaiser data. By 2016, the cost of the average employer family plan was up to $18,142 for the year, with workers picking up $5,277 of the tab.

    http://time.com/money/4503325/obama-health-care-costs-obamacare/

    Which means that everyone who had some kind of healthcare is now paying about 50% more for healthcare than they had previously. It might be different, better coverage, but the fact of the matter is that it’s more expensive and if you aren’t able to suck up a $2000 difference as a family, it put you in a really rough spot. To put that into perspective, Forbes estimated that 63% of American households are so on the brink that a $500 emergency would wipe them out.

    https://www.forbes.com/sites/maggiemcgrath/2016/01/06/63-of-americans-dont-have-enough-savings-to-cover-a-500-emergency/#749bb2e04e0d

    And let’s not forget… Obama, said a whole lot of things that weren’t true, but the most pertinent was that he would save families thousands of dollars annually.

    http://www.politifact.com/truth-o-meter/promises/obameter/promise/521/cut-cost-typical-familys-health-insurance-premium-/

    All of which reinforces what I said on the topic of premiums and deductibles, which was:

    “Premiums are up across the board, and while it could be argued that premiums have always risen, one of the selling points of a socialized system is benefiting from economies of scale, and that didn’t actually happen.”

    Nothing anyone wrote actually contradicts that.

    On deductibles:

    The max out of pocket for 2017, under the ACA, is $7,150. That’s the Max Out of Pocket, not the deductible. It is not possible to have a deductible that is higher than the max out of pocket.

    Well, first off:

    “For 2017, your out-of-pocket maximum can be no more than $7,150 for an individual plan and $14,300 for a family plan before marketplace subsidies.”

    https://obamacarefacts.com/out-of-pocket-maximums-and-deductible-limits-for-2017-health-plans/

    Look, whether it’s $7150 or $14,300, the fact of the matter is that the amount is more than the $500 I mentioned earlier that the vast majority of Americans just can’t come up with.

    Second:

    “According to HealthAffairs,back in 2009 the average out-of-pocket maximum for an individual was around $2,700. Now, Healthcare.gov says that the maximum out-of-pocket limit in a 2016 Marketplace plan is $6,850.”

    https://www.parasail.com/2017/01/09/deductible-out-of-pocket-maximum/

    Deductibles for individuals enrolled in the lowest-priced Obamacare health plans will average more than $6,000 in 2017, the first time that threshold has been cracked in the three years that Affordable Care Act marketplaces have been in business, a new analysis finds.

    Families enrolled in bronze plans will have average deductibles of $12,393, according to the study by the consumer insurance comparison site HealthPocket.”

    http://www.cnbc.com/2016/10/26/obamacare-deductibles-are-on-the-rise-for-2017-along-with-monthly-premiums.html

    I just don’t find your argument meaningful… I mean, sure, individuals ONLY have to pay an average of $6000, and a max of $7150. But families DO have five figure deductibles, the increase IS about double what they paid prior to Obamacare, and the amount IS more than the average American can spend. My original point was:

    “The argument could be made that more people are technically covered, but just being covered really isn’t meaningful when you have a five-figure deductible that you’ll never be able to pay.”

    And excluding a disagreement over personal/family scale… It’s still true.

    Somewhere between half and three-fourths (depending on how you measure) of the people who gained insurance because of the ACA, are getting their insurance through Medicaid or CHIP. None of those people are paying a deductible at all. How are they (or, rather, we) not benefiting from the ACA?

    Because while the legislation that created the ACA included expansions of Medicare, Medicare is not functionally part of ACA exchanges… If the ACA exchanges across America failed tomorrow, Medicare would still exist. Do you have ACA insurance or Medicare coverage?

    Obamacare has been amazing for me.

    Obamacare has been good for me

    This is where things start to get interesting. You’re right. And I’m glad for you. No really, I am. As a Canadian, I take for granted our health system, and the idea of paying half the costs I described above makes me sick, I don’t think I could do it.

    I think there’s two positions that make sense…

    A pure insurance model, regulated properly, where people can’t be removed from coverage after a diagnosis, but people also can’t sign up for insurance after a diagnosis. It’s premium… Fast service, high quality, and without subsidizing people who don’t pay, it’s probably the most cost effective for those that do, but it’s invariably going to be bad for the poor.

    Or a pure national program. None of this BS regarding insurance premiums and deductibles, cover everyone, tax everyone, get ‘er done. This will effect wait times, it just will, our wait times up here suck, and it will probably effect quality… But it will be available. And using the example of other nations with national programs, economies of scale will usually positively effect costs.

    Believe it or not, I root for the second one.

    When I say “Obamacare isn’t good for anyone”, obviously it’s good for certain people in the short term… But does having the best coverage of your life right now really matter if your exchange goes tits up next month? Half of the Co-ops that were created to keep exchange costs down failed after running out of money, and 30 of the 250 exchanges that were existent in 2014 are gone.

  11. 11
    Harlequin says:

    Humble Talent, you’ve noted many problems with the US healthcare system. But it is not necessarily true that one should attribute them to the ACA. For instance, you cite a paragraph from a Time article as your first quote, but the very next paragraph in that article is:

    These increased costs for employers and employees alike may seem steep—up around 50% over the past eight years—but they could have risen far higher had the Affordable Care Act never passed. The Kaiser study shows that average family premiums rose 20% from 2011 to 2016. That rate of increase is actually much lower than the previous five years (up 31% from 2006 to 2011) and the five years before that (up 63% from 2001 to 2006).

    What’s more, a lot of the premium increases this year and next are due to uncertainty because the Trump administration keeps threatening not to pay insurers everything the law originally promised. And deductibles were rising before the ACA, too.

    Can the American health insurance system be improved? Hell yes. Is it reasonable to attribute the failures of the American health insurance system to the ACA? For the most part, no. It has made things better on average, with significant tradeoffs, though not enough better.

  12. 12
    Humble Talent says:

    Also… I just thought of this:

    I just don’t find your argument meaningful… I mean, sure, individuals ONLY have to pay an average of $6000, and a max of $7150.

    If the MAX is $7150 and the AVERAGE is $6000, then wait is the minimum? I mean, the expectation would be that generally, there’d be about as much difference between the average and the max as the min and the average, which means that you’d expect $4850… But if there’s someone out there with a $1000 deductible… That means that there’d have to be 7 people at the max to average $6,000. Gross.

  13. 13
    Humble Talent says:

    These increased costs for employers and employees alike may seem steep—up around 50% over the past eight years—but they could have risen far higher had the Affordable Care Act never passed. The Kaiser study shows that average family premiums rose 20% from 2011 to 2016. That rate of increase is actually much lower than the previous five years (up 31% from 2006 to 2011) and the five years before that (up 63% from 2001 to 2006).

    What’s more, a lot of the premium increases this year and next are due to uncertainty because the Trump administration keeps threatening not to pay insurers everything the law originally promised. And deductibles were rising before the ACA, too.

    I still can’t reconcile this with what I know of out national healthcare system up here… The whole point of having a single desk is in theory that single desk can negotiate better prices. It’s changed over time, but Canadian procedures are something like half the average cost of similar American procedures, and then there are HUGE outliers like the EpiPen. Yes, our costs are rising up here too, but you never saw that decrease… You’d expect that if in no other year than the first you’d see SOME decrease, and then the increases would build from there… But I don’t see any indication that happened… As far as I can tell it’s because the ACA didn’t actually try to incorporate economies of scale. While that might have just been a design failure, if the ACA was never going to take advantage of Economies of Scale, how on Earth did anyone think that including people who had great need of healthcare, but little ability to pay was going to decrease premiums for people that already had it? It just… It never made sense.

  14. 14
    Jake Squid says:

    From 2008 through 2012, our group insurance premiums increased more than 10% each year (it was 34% one year!) except for the year we were able to keep the increase to a mere 7%. In order to keep premiums down, we kept having to go to higher deductible plans. From $500 to $1000. From $1000 to $1500. From $1500 to $2500. Since 2012, our premiums have increased by no more than 4% in any single year and twice (twice!) they decreased, we have not increased the deductible and allow employees, for $68/month to buy up to a lower deductible. So, yeah, premiums are up by 50% since 2008 but the vast majority of the increase happened prior to 2013. Obamacare has been great for medical insurance for the 3 companies for which I evaluate and purchase medical insurance.

  15. 15
    Kate says:

    Humble Talent – If your point is that we’d be better off with single payer – you’re speaking to the converted here. The ACA was an attempt at a market-based appraoch. I think things are better than they would have been without it. But, improvement will require more government intervention and subsidies, not less.

  16. 16
    Grace Annam says:

    Humble Talent:

    Also… I just thought of this:

    If the MAX is $7150 and the AVERAGE is $6000, then wait is the minimum? I mean, the expectation would be that generally, there’d be about as much difference between the average and the max as the min and the average, which means that you’d expect $4850… But if there’s someone out there with a $1000 deductible… That means that there’d have to be 7 people at the max to average $6,000. Gross.

    Fair enough. Now think it through. If you’re criticizing Obamacare (the ACA) because it’s not fair, and the Republicans succeed in repealing Obamacare and replacing it with the AHCA, do you think the result will be:

    (a) more fair?
    (b) less fair?
    (c) the same degree of unfair?

    Grace

  17. 17
    Jane Doh says:

    Humble, I will respectfully say that as a Canadian, you have never been exposed to the horror that is the US healthcare system, especially pre-Obamacare, even ignoring the high costs.

    I have lived in places where it was not possible to buy individual health insurance (Washington State), so it was employer based insurance or nothing. I have lived in places where many doctors decided to cater to the wealthy with boutique practices (annual fee, but much better access) and/or not take insurance, which left so few endocrinologists that the wait time for a standard appointment was 12-18 months. For established patients. I needed annual monitoring, and had to schedule my appointment for the next year on the spot if I wanted to be seen 12 months later. I was told if I ever became pregnant, I had to make that clear right away to get a faster appointment. I also lived in a state where some, but not all locations for a large drug store chain were in network (and this changed every year), making it a total nightmare to figure out where to get prescriptions filled.

    When I had catastrophic insurance, I did not benefit from the negotiated rates that more expensive insurance gives you. I had symptoms that may have been meningitis, and had to pay $350 for an office visit and $500 for blood tests. My insurance company paid $50 and $75 for those things (plus my copay). Even in my deductible period, I only had to pay $50 and $75, not $350 and $500 because I benefited from the negotiated rates.

    Spouse needed a procedure that required multiple providers (anesthesia, doctor, etc). It was done at a surgery center in network and the doctor was in network. I told my spouse to ask if everyone in the room was in network before they did anything, and spouse was assured yes. Lo and behold, we got a $6000 bill from the anesthesiologist, who was out of network, but in the process of joining, despite our best efforts to make sure we were covered.

    Obamacare didn’t even begin to get rid of some of these things, but until more Americans get rid of their irrational fear of single payer systems, it will be one fix at a time at best. Obamacare is part of a one fix at a time sort of solution, but it is certainly better than how things were for many people.

  18. 18
    Humble Talent says:

    If you’re criticizing Obamacare (the ACA) because it’s not fair, and the Republicans succeed in repealing Obamacare and replacing it with the AHCA, do you think the result will be:

    (a) more fair?
    (b) less fair?
    (c) the same degree of unfair?

    B. Screaming from the rooftops B. Look at my first comment:

    Right now, people aren’t happy… But the system at least exists. If something doesn’t pass soon, even something imperfect, then I have the feeling that when things REALLY start to go sideways, there’s going to be more leverage on both sides to get something, even something objectively awful, out to fill the gap. That monster could be downright cute compared to what could make it down the pipe then.

    My point is that we live in the real world, and there’s no universe where Republicans pass single payer. I think they’re wrong, I don’t have to agree with them on everything, but it’s the truth. If they continue to push like they have, and I see no reason to assume they won’t, and if the exchanges start to freefall collapse, which they might, I think that all of a sudden everyone will have some really strong motivation to pass anything as a stop-gap.

    And quite frankly, rushed legislation has a storied history of being shit. The ACA? Despite all these protestations? Shit. Poorly written, ill concieved shit. Better than what you had before? Sure. But picking the corn nubs out of it might have made it look more like chocolate ice cream, but ice cream it ain’t. It doesn’t function like single payer, it didn’t translate into savings, coverage under it is, at best, spotty, and every indication is that it’s unsustainable.

  19. 19
    Jake Squid says:

    It doesn’t function like single payer, it didn’t translate into savings, coverage under it is, at best, spotty, and every indication is that it’s unsustainable.

    Yet, it still manages to be significantly and measurably better than what it was. It surely does have problems and it surely wasn’t designed in a manner that would make it more effective than it is. But it was designed in a manner that allowed it to pass through congress and into law. Something that my preferred law, single payer, would not have been able to do at the time.

    So do we want to talk about how awful it is, even though it was the best thing politically possible? Do we want to talk about how awful it is while pretending it wasn’t the best option politically possible?

    Or should we, maybe, discuss how to prevent the GOP from eliminating it and going back to the, as the kids say, status quo ante?

  20. 20
    Ampersand says:

    Because while the legislation that created the ACA included expansions of Medicare, Medicare is not functionally part of ACA exchanges… If the ACA exchanges across America failed tomorrow, Medicare would still exist. Do you have ACA insurance or Medicare coverage?

    The comment of mine you’re responding to was about about Medicaid, not Medicare. To oversimplify, Medicaid is for the poor, while Medicare is for the elderly and the disabled. (CHIP, which is sort of Medicaid’s Siamese twin, is for poor children.)

    You’re right, Medicaid is not part of the exchanges – but it’s a major part of the ACA, and it’s the major way that the ACA helps people. You said “Obamacare as it stands is basically isn’t good for anyone”; if you want to now say that you only meant the exchanges, not all of Obamacare, that’s okay, but that’s a very different thing than the claim I was responding to.

    The single largest effect of the AHCA would be to make huge cuts in Medicaid, which would be used to pay for enormous tax cuts for the rich. And that’s what the Republicans are calling an Obamacare repeal.

    Obamacare definitely hasn’t delivered all that Obama promised when he was running for President – but of course, despite the name, “Obamacare” wasn’t written by Obama, nor is it identical to what Obama proposed. That’s because Congress wrote the ACA (and a later Supreme Court ruling also changed it enormously), not Obama. Some of the things Obama proposed (such as the public option, and such as incentives to make states go along with Medicaid expansion) didn’t make it it into what we now call “Obamacare.”

    Of course, even if Obama had gotten all he asked for, some of his promises – in particular, the “if you like your insurance you can keep it” promise – were ridiculous and unachievable. But there’s also the extreme difficulty of getting any large, complex law to function well when one major party is attempting to sabotage it at every turn. Even if price-setting (which is really the difference here, not single-payer vs insurance models – lots of countries with much cheaper universal health care use private insurance in their systems) could have passed Congress (and in reality, it couldn’t have), it would also have had a very troubled first decade, for the same reason.

    I’m not sure why you say the ACA was written in a rush. It really wasn’t.

    In June 2009, House Democratic leaders unveiled the first draft of legislation that would ultimately become the Affordable Care Act. A month later, three House committees began formally drafting the bill ahead of a House vote that came well into the fall, after the summer heat had dissipated and the leaves had begun to change.[…]

    In June in addition to July 2009, with Democrats in charge, the Senate health committee spent nearly 60 hours over 13 days marking up the bill of which became the Affordable Care Act. of which September in addition to October, the Senate Finance Committee worked on the legislation for eight days — its longest markup in two decades. of which considered more than 130 amendments in addition to held 79 roll-call votes.

    The full Senate debated the health care bill for 25 straight days before passing it on Dec. 24, 2009.

    There are a lot of problems with the ACA – and it’s also helped millions of people. But given the legislative realities – which include a completely intransigent Republican party, and the enormous pragmatic power held by the right wing of the Democratic party – I honestly don’t see how better legislation could have been passed. And since the ACA was a big improvement on the status quo, I think they were right to pass it.

  21. 21
    Humble Talent says:

    I’m not sure why you say the ACA was written in a rush. It really wasn’t.

    We might disagree on interpretation, but we might agree on scope. It was 1100 pages long, and obviously no one had actually read it start to finish with any amount of real understanding, because SCOTUS had to rule on, and rewrite, some fairly serious self-contradictions. Is 6 months rushed? I mean, not if you’re ordering dinner, but for healthcare reform? With a dysfunctional congress?

    I honestly don’t see how better legislation could have been passed. And since the ACA was a big improvement on the status quo, I think they were right to pass it.

    I actually agree. I think there’s an amount of settling at play here. The reality of the situation is that you couldn’t have reasonably expected better, so America settled for what it could get. Now, knowing that with Trump and a GOP congress, that deal isn’t going to get better, people that realise that the ACA is a deeply flawed peice of legislation are nevertheless defending it tooth and nail because they’re afraid what will replace it will be worse. I get it. I agree. That was my point.

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