Recently, the New York Times ran a front-page story reporting that Democrats running for Congress are reluctant to “run on Obamacare.” Instead, they are “running away from it, while Republicans are prospering by demanding its repeal.” The problem, according to the Times, is that discussions of the Affordable Care Act (ACA) tend to focus on “coverage for those of modest means,” and this “has led white voters to see the law as an act of government redistribution to the 15 percent of the population that is uninsured.”
As proof, the paper cites a five-month-old New York Times/CBS News poll showing that “just 17 percent of whites said the health law would help them while 41 percent said it would hurt; among blacks, 42 percent said it would help them while 15 percent predicted it would hurt.”
“Democrats could ultimately see some political benefit” from Obamacare the story acknowledges. But as candidates prepare for mid-term elections, “they are confronting a vexing reality: Many of those helped by the health care law — notably young people and minorities . . . tend to vote in midterms at lower rates than older and white voters.”
The reporter points to two Democratic candidates in Georgia who are doing their best to distance themselves from reform: “Jason Carter, the grandson of former President Jimmy Carter, who is running for governor, and Michelle Nunn, the daughter of former Senator Sam Nunn, a candidate for the Senate.. . . They have spoken in public about the law mostly to criticize it, did nothing to promote enrollment for insurance before last month’s deadline and declined interviews to even discuss the law.”
Who Benefits From Obamacare?
The Times describes those who will be helped by reform as people “of modest means.” This is a phrase that newspapers such as the New York Times, The Washington Postl and the Wall Street Journal often use to refer to the poor or the lower-middle-class –i.e., not you, dear reader.” (Try Googling this rather old-fashioned, faintly British phrase, along with the names of these papers, and you will be startled by how often it pops up.)
In this country, we do not like to talk about class. I recall that when I first became a journalist, I was told that if I wanted to write about “the rich” and “the poor,” I should refer to them as “the have’s” and “the have not’s.” Of late, “people of modest means” seems to have become the preferred euphemism for the working-class. That phrase makes it clear that these are plain, hard-working folks, and we respect them– or at least we would if we knew any of them.
What is peculiar about this story is that it overlooks the fact that there are a great many white, middle-aged Americans “of modest means” who now have affordable insurance, thanks to the ACA. Perhaps they don’t read the Times, but they do vote. Why wouldn’t they cast their ballots for candidates that support Obamacare?
As for “government redistribution” of income, the article seems to suggest that middle-class white Americans will be paying more in taxes in order to help “the 15% of the population that is uninsured.” In fact, only the wealthiest 2% (those earning more than $200,000, $250,000 for couples) face tax increases that will help fund universal health care for working-class, middle-class and upper-middle-class Americans of all ages and colors.
Obamacare Protects the Under-insured
Moreover, the group that benefits includes not just “the 15% who are uninsured,” but millions of Under-insured Americans who have been trying to get by on cheap policies that did not cover:
— brand-name drugs, even if there was no generic substitute;
— doctors’ visits while the patient is in the hospital.
Subsidies for the Upper-Middle Class
Some readers may be surprised by my claim that the ACA helps not just the middle-class, but many in the “upper-middle-class.”
Admittedly, “middle-class” and “upper-middle class” are slippery terms. This is why I prefer to define them in terms of what an average household of a particular size living in a particular place earns.
For instance, according to the Census Bureau, “median income” for a family of four living in Indiana is $70,760: Half of all Hoosier households of that size bring home less than $70,760; half make more. In my book, this makes an Indiana family that clears, say, $68,000 to $78,000 solidly middle-class.
By the same measure, an Indiana family of four grossing $20,000 more than the median –or about $90,000–might reasonably be called “upper-middle-class.” (Let me be clear: I am not suggesting that they are “rich,” but they are, without question, living at the upper end of the middle-class.)
On the other hand, in Pennsylvania, where median income for a family of four is considerably higher ($82,078), a household probably would have to earn something north of $100,000 to be able to afford an “upper-middle-class lifestyle.”
These are, of course, very crude numbers; cost of-living varies in different parts of a state. But, while rough, these are real numbers based on what Americans actually earn. As this Census Bureau table reveals, median income for a family of four exceeds $85,000 in just ten states. And it tops out, in Maryland, at $108,915.
It turns out that in most states, a family of four pulling in somewhere between $64,000 and $80,000 is perched, however precariously, on a middle rung on the income ladder. The good news is that the Affordable Care Act provides subsidies to help a family of four earning up to $95,400 This is why I say that, in the majority of states, Obamacare helps upper-middle-class families purchase comprehensive insurance..
For example, a 40-year-old couple with two children living in Winston-Salem, North Carolina and reporting joint income of $90,000 would be eligible for a subsidy of $2,548. (Note: in North Carolina, median income for a family of four is $64,983; a family clearing $90,000 brings home $25,000 more than average.)
Do Americans Perceive Obamacare As “Social Welfare”?
The Times quotes David Axelrod, a long-time adviser to President Obama, saying : “I think [the ACA] is viewed more as a social welfare program than a social insurance program.”
“That contrasts sharply with Medicare and Social Security” the reporter adds, “which remain popular because almost everyone who benefits paid something into the system.”
Neither the Times nor Axelrod is saying that Obamacare is a “social welfare program.” But the story argues, “white Americans” perceive it as “an income transfer program from the better-off to the poor.”
The reporter explains: “The focus on the law’s expansion of coverage for those of modest means has . . . overshadowed popular, more broadly enjoyed benefits like allowing parents to keep their children on their plans until they are 26 and barring insurance companies from denying coverage because of pre-existing conditions.
He quotes Ezekiel J. Emanuel, formerly a White House healthcare advisor: “This is where the communications failure has been so problematic. We haven’t really alerted Americans to the fact that there is much more to this than the exchanges that’s going to be really, really positive for all of us, not just those getting insurance.”
But, the Times argues: “that view has not taken hold, especially among white voters.” The story then quotes Judy McDaniel, a mother in Atlanta Georgia. McDaniel confides that she had “mixed feelings” about Obamacare, “even after her 42-year-old son was finally able to sign up for health insurance under the law: ‘I’ve been lucky enough in my career to afford my own insurance, and I’m not sure how I feel about supporting others.’” The reporter notes that McDaniel “is white and said she had voted against Mr. Obama.”
The truth is that, as Emanuel stresses, the ACA helps all of us, even if we haven’t purchased insurance in an Exchange. Anyone with health benefits at work now knows that if he loses his job, he will not lose his insurance. He can immediately purchase coverage in the Exchange where he is very likely to qualify for a subsidy.
Moreover, anyone who buys a policy outside of the Exchange now knows that the insurer must provide free preventive care, and cannot cap how much it will pay out over a year, or over the course of a lifetime.On the other hand, the amount that a carrier can ask him to ever pay out-of-pocket, is capped. This is why the law is called the Patient Protection and Affordable Care Act
In Part 2 of this post, I will ask: Is Judy McDaniel representative of most white Americans? Wouldn’t most mothers be happy that the ACA helped their sons? Are Republicans “prospering” as the Times claims, by continuing to demand repeal?
To answer those questions, I will look at recent polls.
They reveal that when it comes to supporting the ACA, the biggest difference cannot be framed in terms of “older whites” vs.“minorities,” but rather in terms of Democrats vs. Republicans. And in the past couple of weeks,the polls make it clear that as exchanges hit their goals, Democratic support for the law has rebounded.
Pretending that Obamacare (or President Obama himself) does not exist will not be a winning strategy for Democrats facing mid-term elections. This will be the time for them to reap the benefits of being members of the party that has, at long last, taken a gigantic step toward reforming our fractured healthcare system.
Just as in 2006 and 2012, they will win if they bring their constituency out to vote: Registered Democrats, well-educated young Americans of all races, women of all races (particularly single women), African-Americans, Latinos, Asians and new immigrants have become the Democratic party’s new base. For many of those voters, the ACA is no longer an issue: it’s a done deal. Now, they want to hear about raising the minimum wage, immigration policy, equal pay for women, voting rights, making college more affordable, and expanding Medicaid in states that haven’t yet taken Washington up on its offer to pour millions of dollars into their states.
Maggie:
You still fail to understand that Obamacare is a grab to take over healthcare. When the premiums explode next year because not enough young people signed up and they start to leave in droves as the premiums go through the roof the suggestion will be to go to a single payer system.
You cannot charge the young a third of what you charge the sick and old and make the system work. The young that have little need will either rebel, or if you institute a sigle payer system use it to the max since they are paying for it. The government will decide how many MRI machines in an area and the wait time will go from a few hours to a few months. The problems that have happened at the Arizona VA will be everywhere.
One of your problems is that you believe government can solve problems. I don’t believe that government can. A monolithic government cannot respond to individual, regional or even national situations. They have somebody, or a small unelected and insulated overpaid bureaucrats, that think they know how things should be done and damn it, that’s the way it will be done. Occasionally someone gets it right but not very often or for very many. The market is much more responsive. The invisible hand still works!
And it is an income redistribution system. If you only think the rich are paying talk to you CPA about the tax increases this year and what it did to many of his clients. Also talk to him about how many preparers are in trouble over fraudulent EIC and Child credits. The poor are raping the system every chance they get.
Charles
Charles–
Premiums won’t shoot up next year.
“The CBO is also expecting a small increase in 2015 premiums. The premium for the benchmark silver plan, which is used to determine subsidies, is expected to rise from $3,800 in 2014 to just $3,900 in 2015.”
(I realize that you believe you know more than the CBO, but so far, their projections regarding Obamacare have been generally correct, though often too pessimistic.)
CBO tells us that Obamacare is already reducing deficit projections.
Throughout the developed world, government is solving social welfare problems.
By contrast, in the U.S. a larger share of children are living in poverty than in any other country in the world.
Children in this country go to bed hungry.
This is because, for years, people who share your ideology (and talk about “the poor raping the system” have said that government cannot solve problems.
But now, gov’t is solving problems.
Apparently you haven’t checked the numbers– during the final surge of enrollments many young people signed up.
More will sign up this summer (as they marry, have a baby, turn 26 and age out of their parent’s program, or graduate from college and lose the insurance they had at school. (Any of those changes in life circumstances allows them to enroll even though the official enrollment period has ended.
Next year, more will sign up (after hearing about the subsidies friends received.)
Charles, you have been wrong about the ACA from the outset.
People like said that it would never pass Congress, that it would be repealed, very few people would sign up in the
Exchanges, that doctors would stop taking patients, that premiums would be unaffordable.
Face it: you have been wrong all along. As President Obama suggested, you really need to move on from denial to acceptance.
Maggie:
Interesting to see you having your burden to carry in readership. He does have a point on healthcare being taken over; but, it is not in the manner in which he believes. Pre-PPACA, healthcare was being taken over by those who could afford to pay the premiums leaving many others on the sidelines seeking stabilization in ERs across America. Even today and after the implementation of the PPACA, there are pockets of this country resisting the sharing of healthcare with those who more than likely need it the most. Yes healthcare was taken over by those who could afford the $1,000/pill for fighting Hepatitis C leaving others to suffer consequences.
Since the attempt at Hillarycare, we have waited for the invisible hand to move in the direction of healthcare for all. 20 years passed and no movement was made by the healthcare industry hand to assist those who needed help the most. In fact the numbers of uninsured increased as the cost of healthcare increased. There were no “Charles” waving the magic wand of healthcare for all. Today, at least there is hope and a step forward in the right direction.
run 75411,
Since 1980 (the beginning of Reagonomics) we have waited for the “invisible hand” to descend on us and strengthen our economy.
It hasn’t happened. The rich have gotten richer, while the middle-class became working class, the working class became poor, and the poor became homeless. (I recently discovered that homelessness is at a all-time high in NYC. We have just gotten better at “hiding” the homeless–you are less likely to see families camping out on the sidewalk, but there are more of them than ever before.)
I’d like to comment on Charles’ remark, “If you only think the rich are paying talk to you CPA about the tax increases this year and what it did to many of his clients.” I had a friend that said the same thing, “Taxes are really going up in 2013!” I was puzzled by this, yes they are going up for some. The idea that the Social Security tax had to go back to 6.2% shouldn’t even be included in the argument, although it is especially hard for the very low income folks after having a break at 4.2% for two years. Social Security has been 6.2% (only talking about employee share) since about 1990, it just wasn’t feasible to continue at 4.2%. Here’s the thing about tax brackets, as it is every tax year each bracket maximum is increased to capture more at a lower level–so for 2012, married filing jointly, the 10% bracket max was $17,400 income; 2013, $17,850 & so on. So a couple, filing jointly, whose Taxable Income (not AGI) was $50k in 2012 paid $6,634; in 2013, $6,611. Small savings @50k but by the time it gets to $450K a couple paid $793 less in 2013 than in 2012, how is that more as people like Charles state? Of course there is the .9% medicare tax on earned income over $250K (married/jointly)–my husband & I paid an extra $116 for this tax, that’s $9 on every $1,000 over 250k–ouch, that really hurt! Then there’s the 3.8% medicare surcharge on investment income on MAGI over, 250K. Our total investment income was $52K–after subtracting the 250K from our MAGI that left 45K that we had to apply the 3.8% tax on, which came to $1,730. Survived that. We didn’t make over 450K, for the Capital Gains 20% to apply, but AMT kicked in for an extra $6K. Last year we didn’t pay AMT & our AGI was nearly 200K. Another example of the 3.8% would be if a couple had earned income of $150K & Investment income of $100K, the 3.8% wouldn’t apply at all since it only applies on MAGI over 250K. Let’s not forget 401K contributions that are not part of AGI, we contributed $15K, lucky us. Personal exemptions are phased out at around 300K for filing jointly, we missed that mark by a few dollars. Too many people don’t know the facts & if I missed something let me know. Yes, there is a new marginal tax rate of 39.6%, I’d like to know who doesn’t wish they were in it?! The tax system benefits the wealthy the most, period. My family was hit by the recession too & my husband had to take a 50% pay cut back then, plus no bonuses (he’s a partner in his firm) I’m being brutally honest here with my family’s monetary information–we paid a lot in taxes back then, sure wouldn’t mind being in that situation again! I’ll add one more thing, as far as the medicare taxes go–studies have shown wealthier people live longer on average than poorer people, so if we wealthier people are paying a little more, looks like it will be for us anyway–so stop complaining :)—-Really enjoy your articles Maggie
Sally Stewart–
Thanks very much. I do appreciate your candor about your financial situation.
You were, as you suggest, lucky when you paid more in taxes because you were making much more money!
(Warren Buffet always says: Don’t complain about paying taxes. Just be glad you have that much money.)
As you say: “the tax system benefits the wealthy most,” period.
People who earn over $200,000 ($250,000 for a couple) now pay more in taxes to help pay for health care reform.
But what many of them don’t realize (or don’t want to realize) is that they earn more than 97% of their fellow citizens.
And yes, wealthy people do live longer than the rest of us. This means that, on average, they “get back” more from Medicare.
Finally, I agree that had to revert to the old Medicare tax, though I wish it were more progressive at the lower end.
Scott Atlas posted an op ed in the WSJ yesterday, OPINION
The Coming Two-Tier Health System
ObamaCare is already creating one class of care for the poor and middle class and another for the affluent.
It points out what we may already know that there are many tiers for medical care and the top tier belongs to the wealthy who go to Thailand or Seoul for specialty concierge procedures and their cohorts who are in congress. There are those who fear that they will be spending huge amounts for entitled lazy smokers.
Atlas does echo some common perceptions. Your insight will be helpful.
He bemoans the inability for Obamacare to use the finest oncologist institutions we have. I question who shuns whom. Oncologists may find it worthwhile to treat those willing to pay for whatever procedure may work if proven or unlikely. Groopman wrote years ago of a fellow physician who chose a treatment and ended up free of disease. Great, but for most of us this route is I possible and not affordable. A perception from one who joined the war on cancer as a callow excited youth but who found with time that the war is not always winnable. All of us able to remember the hope we had and unaware of the increasing knowledge we now,have certainly believe that the thing in them can be cured my medical science, or perhaps apricot pits or the invisible hand. Humor aside, does the profit motive of tertiary care centers outweigh the altruism of medical care?
Richard–
Thanks for your email.
As it happens, I know Scott Atlas. He was in my undergraduate class at Yale. (I didn’t know him well–
he was conservative, wealthy, and belonged to a very different group.)
He is now a member of the conservative Hoover Institute, appears on FOX and write for Forbes. He admires Avik Roy.
He is also a venture capitalist– principle in a firm called “Venture Imaging” which has imaging facilities in Mexico, Brazil and Canada.
“Remote” offshore imaging has become popular– hospitals send x-rays etc. to be read off-shore (think Mexico, Brazil)
This can lead to confusion –the radiologist and the doctor in charge of the case may be in different countries and time zones. They may be playing telephone tag. Sometimes, patients die. (It strikes me that off-shore reading of X-rays makes sense for a broken wrist, but not if someone is suffering from a fierce headache that may be a brain aneurysm.)
There also is some question as to whether the people reading the images are actually doctors.http://www.nbcnews.com/id/44949425/ns/health-cancer/t/doctor-reading-your-x-rays-maybe-not/#.U2PqcfldU1k
Clearly Atlas is cashing in on this industry. His company (Venture Imaging) may be playing by the rules-I have no way of knowing..
Atlas is a radiologist, and his complaints about Medicare stem, no doubt, from the fact that after letting radiologists fees spiral, in recent Medicare has been cutting their fees.
Meanwhile, demand for their services has fallen. The NYT explains:
“The demand for imaging began to slow after 2006, even as technology increased productivity, studies show. Besides reimbursement cuts and rising deductibles, factors that curbed the scans included new concerns about radiation and useless tests. Compensation began to drop.”
As for “narrow networks” and the fact that insurers are not including institutions like “Memorial Sloan Kettering”, Atlas offers no evidence that MSK is one of the best. In fact, I recently wrote about Memorial Sloan Kettering in this two-part post. here https://healthbeatblog.com/2014/02/the-french-way-of-cancer-treatment-part-1/ and HERE https://healthbeatblog.com/2014/02/single-payer-health-care-is-that-what-makes-cancer-care-in-france-so-different-the-french-way-of-cancer-care-part-2/ (In this, the second part of the post, I focus in on Memorial Sloane Kettering.)
Clinical care at MSK is not the best. Since I wrote the post, I happened to talk to a benefits manager in NYC who said “Don’t get me going about MSK–I try to make sure that our employees do not wind up there.”) Most of NYC’s major academic medical centers are in the Obamacare networks. The networks are not limited to second-tier hospitals. All of my NYC doctors also are in the Obamacare networks. If I was diagnosed with cancer, I would want to be treated at Mt. Sinai–it has the best
palliative care in the city.)
Atlas also mentions M.D. Anderson Cancer Center– major scandals there recently (See “”The Cancer Letter.)
Much medical research shows that the most expensive hospitals are not the best–often patient care is a low priority. (Research is more important.)
Insurers are wise to shun these institutions–and not just because they are expensive.
As for the war on cancer– have you read Clifton Leaf’s book explaining why we’re losing the war on cancer? It’s excellent.
Finally, Atlas’ Op-ed is filled with misinformation and assertions without evidence.
Doctors are not closing their doors to Medicare patients. Recent research shows that Medicare patients have access that is as good or better than the private insured. Concierge practices are not taking off. Very few people can afford concierge medicine. And concierge medicine was around long before Obmacare. Many doctors do refuse to take Medicaid patients –but again, this has been true for a long time. It has nothing to do with Obamacare. If anything, Obamacare expands access by raising fees for PCPs who take Medicaid patients to Medicare levels, and
by expanding funding for Community Health Centers that provide much of the care that Medicaid patients receive.
One thing I hate about OP-eds is that anyone can write anything–without evidence– and no one questions what they say. This is after all an “opinion”–and everyone has a right to has opinion . . .
The good news is that Atlas is wrong on all counts.
Obamacare is succeeding. Over the next ten years, we’ll refine and improve the law. Reform will always be a process. But there will not be any major backlash against the ACA. Too many people are being helped. And there is no indication that the ACA is creating a “two-tier system.”
And if Atlas thinks that the super-rich are getting better care by jetting to Thailand–well I can only hope that he has surgery in
Thailand sometime soon
(Some off-shore medical care is very good. India, for instance, has some excellent hospitals and doctors. But the risks are real–if you run into problems after surgery,it’s hard to go back and see the doctor. And if a hospital or doctor is negligent, there is no recourse.
You can’t sue.
As for Healthcare in Thailand– see this report on medication errors, suicides in hospitals, wrong site surgery, infections, etc. etc.
This is why I like to think of Atlas receiving “concierge care” in Thailand.
Thanks . One of my wsj subscribers sent me the op ed and I told him I would ask you opinion.
He responded who cares. I saId I did and later wrote a long note to him explaining why regardless of personal opinions one should evaluate opinions of others, ass Douthat indicated in a NYT op ed. To only accept opinions of one in your own club, or tribe as Mark Weiner says in “the rule of the clan” is bad for society. The essays discussing this in The Cato institute are enlightening.
My friend and I many decades ago had the good fortune to learn at MSK. It was different then.
My experience with teleradiology twenty years ago different. A MRI guru had invested in a number of free standing MRI sites in Detroit and he reviewed difficult cases from his office in Ohio. My friends mom presented with a large unusual mass on her elbow and I sent her for MRI. That afternoon he called me on my cell phone and informed me it was a sarcoma and that whatever anyone said he was correct as he knew more about musculoskeletal MRI than anyone. My radiology friends agreed. I told my son that that could be called hubris.
After chatting with her son she went to his hospital and had repeat study and excision…it was benign.
Bottom line the radiologist over long range reported findings quickly and his techs in Mich did loads of various spin sequences and sectionals. Well beyond what is done today. It can work.