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ObamaCare Clusterfuck: Obama’s April 30 presser on the ObamaCare “train wreck”

Here's another color-coded annotation of an Obama transcript (via Kaiser), this one from his news conference right after Senator Max Baucus warned that ObamaCare would be "a huge train wreck". The contrast between Obama working from a prepared text (Inaugural, 2013; Hamilton Project, 2006) and Obama improvising at the podium is quite remarkable; we see no intricate verbal patterning at all.

Whereas the prepared texts are bright with color coding, Obama's health care presser -- and I know this will come as a shock to you -- codes as equivocation (with one neoliberal code word, "market," a little nonsense, and few lies). No secular religion or flights of populism whatever. Nevertheless, for all its banality and woodenness, the presser contains some remarkable passages.

I'm going to color code the transcript using the same scheme I used for the Hamilton Project speech:

Category

Note

Secular religion

A mish-mash of phrases from the Framer's, Lincoln and MLK echoes, and so forth

Bathos/MBA-speak

Bathos is an abrupt transition in style from the exalted to the commonplace

Neo-liberal catchphrase

“Free market,” “innovation,” “hard choices” etc.

Populism

“Our most vulnerable citizens”

Bipartisan shibboleth

“The troops,” for example

Dead metaphors/cliche

“Ring the changes on,” “take up the cudgel for,” “toe the line,” “ride roughshod over,” etc. (Orwell)

Sheer nonsense

Word salad

Falsehood or truthiness

A terminological inexactitude

Blank screen

Placeholder material onto which the audience may project what they like. The phrase comes from Obama's famous remark in the preface of the second of his two autobiographies: “I serve as a blank screen on which people of vastly different political stripes project their own views.”

Equivocation

Lawyerly parsing and weasel wording

Boilerplate

“Ladies and gentleman,” and so forth.

Here's the transcript. My comments are footnotes:

CHUCK TODD, NBC NEWS: Max Baucus, Democratic senator, referred to the implementation of your health-care as a potential train wreck. (We've had ?) other Democrats been whispering nervousness about the implementation and the impact -- (inaudible) -- the impact that it might have on their own political campaigns in 2014. Why do you keep -- just curious, why does Senator Baucus, somebody who extensively helped write your bill, believe that this is going to be a train wreck?1 And why do you believe he's wrong?

  1. Your mileage may vary, but I don't think Obama ever answered Todd's first question.

PRESIDENT OBAMA: Well, I -- you know, I think that any time you're implementing something big, there is going to be people who are nervous and anxious about is it going to get done until it's actually done. But -- but let's just step back for a second and -- and -- and1 make sure the American people understand what it is that we're doing. The Affordable Care Act, 'Obamacare,' has now been with us for three years2. It's gone through Supreme Court tests. It's gone through efforts to repeal. A huge chunk of it's already been implemented.3, 4

  1. The Obama improvising at a presser is not the Obama delivering a speech.
  2. And after three years of picking low-hanging fruit -- putting childen on their parents policies, pre-existing conditions, rescission -- only now do we arrive at the health insurance exchanges, which are the heart of the plan. LBJ implemented Medicare for all over-65s in one year. And that was back in the days of mainframes and paper checks, when gentlemen still wore hats.
  3. So, “already implemented” for some definition of “huge.”
  4. Obama is, in essence, suggesting that all is well because ObamaCare is settled law. But that's off point; Baucus is talking about implementatoin.

OBAMA: And for the 85 to 90 percent of Americans who already have health insurance, they're already experiencing most of the benefits1 of the Affordable Care Act even if they don't know it.2 Their insurance is more secure. Insurance companies can't drop them for bad reasons.3 Their kids are able to stay on their health insurance until they're 26 years old. They're getting free preventive care.4

  1. “Most of the benefits” if you already have health insurance, that is. That sets the baseline about as low as it can possibly go, and is an almost direct admission that ObamaCare won't control costs.
  2. The baseline goes even lower. Significant benefits that people don't even notice?
  3. I assume Obama means rescission. But is there ever a good reason?
  4. Proponents claim 54 million are getting free preventive care, of 195.9 million (2012) with private health insurance.

OBAMA: So there are a whole host of benefits that -- for the average American1 out there, for the 85 to 90 percent of Americans who already have health insurance, this thing's already happened, and their only impact is that their insurance is stronger, better, more secure than it was before. Full stop. That's it.2Now they don't have to worry about anything else.3

  1. Cheerfully tossing the 48.4 million uninsured (2013) under the bus.
  2. Once again, an admission that ObamaCare won't control costs. The dog that's not barking here is that Obama is careful never to mention price, or to say that premiums would go down. And if he had any warrant at all for saying that, he surely would.
  3. People will still need to worry about going bankrupt, in addition to all the games insurance companies play besides rescission; see NC commenters here for many examples, including “losing” the paperwork—just like mortgage servicers!

OBAMA: The implementation issues come in for those who don't have health insurance,1 maybe because they have a pre-existing condition and the only way they can get health insurance is to go out on the individual market and they're paying 50 percent or a hundred percent more than those of us who are lucky2 enough to have group plans. People who are too poor to get health insurance and the employers don't offer them. Maybe they work for a small business and that small business can't afford right now to provide health insurance.3

  1. As such issues indeed would, since health insurance companies have already implemented systems for consumers who (actuarially) will be profitable to them.
  2. A remarkable admission. One would think — in a “moral environment” that is not “pathological” — that the logical next step would be to make insurance universal, so that nobody unlucky could fail to have it. Not Obama.
  3. Small business coverage was dropped, since it faced “operational challenges,” i.e. implementation issues.

So all the implementation issues that are coming up are implementation issues related to that small group of people, 10 to 15 percent of Americans -- now, it's still 30 million Americans,1 but relatively narrow group -- who don't have health insurance right now or are on the individual market and are paying exorbitant amounts for coverage that isn't that great.2

  1. About 18%, and 48.4 million. Of course, I can't know whether Obama's lying about the numbers to further minimize the train wreck, or whether he simply hasn't mastered the material. Regardless, he thinks or at least says that the uninsured population is ~62% of what it really is.
  2. Remember, ObamaCare's central innovation — the health insurance exchange (“marketplace”) — was at least ostensibly supposed to help exactly this “small group of people,” who are now marginalized (“relatively narrow”) and who Obama now presents as an implementation problem! It bodes very ill for the health insurance exchange implementation that Obama's backing away from it like this.

OBAMA: And what we're doing is we're setting up a pool so that they can all pool together1 and get a better deal from insurance companies.2 And those who can't afford it, we're going to provide them with some subsidies.3That's it.4 I mean, that's what's left to implement because the other stuff's been implemented and it's working fine.5

  1. Plans offered will differ by the state. Some states have little competition.
  2. It's unclear that this will happen, or how much better “better” will be. So far, insurance companies have been reluctant to enter the exchanges. If and when they do, it's likely they'll collude to keep prices high.
  3. Leaving them underinsured.
  4. Second use of “that's it.”
  5. This is breathtaking. Again, “Other than that, Mrs. Lincoln....”

OBAMA: The challenge is that, you know, setting up a market-based system,1 basically an2 online marketplace where you can go on and sign up and figure out what kind of insurance you can afford and figuring out how to get the subsidies, that's still a big complicated piece of business.

  1. The health insurance system is already “market based.” That is the problem.
  2. No, multiple online marketplaces, plural: 18 State-based Exchanges, seven State Partnership Exchange, 1 Federal Exchange which the remaining 25 states will use. Obama jiggers the numbers to hide the complexity.

OBAMA: And when you're doing it nationwide, relatively fast,1 and you've got half of Congress who is determined to try to block implementation and not adequately funding implementation, and then you've got a number of members of -- or governors -- Republican governors who know that it's bad politics for them to try to implement this effectively2 -- and some even who have decided to implement it and then their Republican-controlled state legislatures say don't implement and won't pass enabling legislation -- when you have that kind of situation, that makes it harder.

  1. Again, not by LBJ's standards, who got Medicare up and running in one year. That's because Medicare is a well-architected single payer system, and ObamaCare is a Rube Goldberg device (illustrated below). Except with more moving parts.
  2. There's a case to be made that there's no reason for states to get involved in a “train wreck” by building their own exchanges, implying that ObamaCare will end up making Rick Perry look good. Yikes.
rubegoldberg_photo_gal_4155_photo_1695691461_lrOBAMA: But having said all that, we've got a great team in place1. We are pushing very hard2 to make sure that we're hitting all the deadlines3 and the benchmarks.4 I'll give you an example -- a recent example5. You know, we [CMS] put together initially an application form for signing up for participation in the exchanges that was initially about 216 pages long.
  1. Henry Chao, the HHS official who’s overseeing the technology for the health insurance exchange launch, set the following baseline: “Let’s just make sure it’s not a third-world experience.”
  2. Partly by dropping requirements (small business coverage), a sure sign of a project in trouble.
  3. So far (“October 1 might get pushed”). HHS has contingency plans in place in case deadlines slip.
  4. ~70% of all IT projects fail.
  5. There are others less recent?
  6. The condensed paper version was 21 pages. The online version was 60, and included about 1000 discrete queries (PDF).

OBAMA: And immediately everybody sat around the table and said: 'Well, this is too long, especially, you know, in this age of the Internet. People aren't going to have the patience to sit there for hours on end. Let's streamline this thing.'

So we cut what was a 21-page form now down to a form that's about three pages for an individual, a little more than that for a family,1 well below the industry average.2 So those kinds of refinements, we're going to continue to be working on.3, 4

  1. And because of Obama's public relations push, families with more than two members are going to end up xeroxing extra copies of the forms.
  2. And because of Obama's public relations push, states that were furthest ahead on their implementations are penalized by having to go back and recode for the new form.
  3. In other words, top management is going to keep changing the requirements up until the very last minute. At least in some software development methodologies, that is not a recipe for success. (Readers, do any of you know what methodology the developers of the Federal Exchange are using?)
  4. The revised form is also simplified, in that many of the eligibility questions asked on the first version are now calculated from data supplied from outside the health exchange system. (For example, data can be grabbed from IRS computers instead of making the applicant fill in a blank.) However, that means that the simplified form is a gamble on a fully functional back-end system.

OBAMA: But I think the main message I want to give to the American people here is despite all the hue and cry and, you know, sky-is-falling predictions about this stuff,1 if you've already got health insurance, then that part of "Obamacare" that affects you, it's pretty much already in place. And that's about 85 percent of the country.2

  1. Predictions made by people like Max Baucus, the putative author of the bill! (It was actually drafted by Liz Fowler, a Wellpoint VP on secondment to Baucus as his chief of staff.)
  2. More minimization, and in the same terms as earlier. We'll see if, come 2014, this looks like denial.

OBAMA: What is left to be implemented is those provisions to help the 10 to 15 percent of the American public that is unlucky enough that they don't have health insurance.1 And by the way, you know, some of you who have health insurance right now, at some point you may lose your health insurance, and if you've got a pre-existing condition, this structure will make sure that you are not left vulnerable.

  1. More minimization, and in the same terms as earlier, including “unlucky”!
  2. No. Only a system that guarantees health care can do that. In any case, what about people who don't have pre-existing conditions?

OBAMA: But it's still a big undertaking. And what we're doing is making sure that every single day we are constantly trying to hit our marks so that it will be in place.

And -- and the last point I'll make, even if we do everything perfectly, there'll still be, you know, glitches and bumps, and there'll be stories that can be written that says, oh, look, this thing's, you know, not working the way it's supposed to, and this happened and that happened. And that's pretty much true of every government program that's ever been set up.1

  1. Pre-positioning the alibi is always useful. Anyhow, it's only people's health that's at stake.

OBAMA: But if we stay with it and we understand what our long-term objective is, which is making sure that in a country as wealthy as ours, nobody should go bankrupt if they get sick and that we would rather have people getting regular checkups than going to the emergency room because they don't have health care1-- if -- if we keep that in mind, then we're going to be able to drive down costs, we're going to be able to improve efficiencies in the system, we're going to be able to see people benefit from better health care, and that will save the country money as a whole over the long term.2

  1. Again, a remarkable lowering of the baseline. Here's Obama on health care in run-up to the 2008 campaign:

"Every American should have health care coverage within six years, Democratic Sen. Barack Obama said Thursday as he set an ambitious goal soon after jumping into the 2008 presidential race:

"The time has come for universal health care in America," Obama said at a conference of Families USA, a health care advocacy group.

"I am absolutely determined that by the end of the first term of the next president, we should have universal health care in this country," the Illinois senator said.

Now all that is gone. Obama does not even bother to pretend that ObamaCare is or will be universal. In fact, ObamaCare will only cover 7 million additional people in its first year, and approximately 30 million when fully rolled out, leaving out 26 million Americans -- second-class citizens, simply because, as even Obama admits, they are unlucky -- without coverage.

2. Dubious, if the idea is that informed consumers will drive down prices through the marketplace.The career “progressives” are already pre-positioning their alibi, that ObamaCare is “a work in progress,” and that once ObamaCare is in place “we can begin to look at serious problems with the new system.”

QUESTION: Do you think without the cooperation of a handful1 of governors, particularly large states like Florida and Texas, that you can fully implement it?

  1. 25 states is not a “handful.”

PRESIDENT OBAMA: I think it's harder; there's no doubt about it.

QUESTION: But can you do it without those?

PRESIDENT OBAMA: We -- we will implement it. There will be -- we have a backup federal exchange. If states aren't cooperating, we set up a federal exchange, so that people can access that federal exchange.1

  1. Of course, if there were one Federal system, that would be even easier, right? And if the Federal system were single payer Medicare for All, that would be even easier still, wouldn't it?

But yes, it puts more of a burden on us. And it's ironic, since all these folks say that they believe in empowering states, that they're going to end up having the federal government do something that we'd actually prefer states to do if they were properly cooperating.1

  1. If I'm Rick Perry, I'd be asking Obama how my state is going to be “empowered” by getting involved in a “train wreck.”

* * *

Since the White House has committed itself to a deadline, the deadline must be seen to be met, without fail ("We will implement it"). It only remains to spin whatever system is actually delivered as a success, a process that career "progressives," and perhaps even our famously free press will be cheerfully complicit in.

Obama, in his presser, began that public relations process, by setting an extraordinarily low baseline for project success, marginalizing those without insurance, pre-positioning alibis, and presenting poor system architecture driven by the requirement to keep private health insurance companies in place as a natural and normal case of TINA (There Is No Alternative).

Obama's presser is a morally reprehensible though typical effort to encourage a majority of Americans to throw a minority under the bus—even though they, too, may one day be members of that minority if they are "unlucky"!

NOTE Query: ObamaCare subsidies are tax credits. Does anybody know whether student loan defaulters will have their ObamaCare tax credits confiscated? Readers?

NOTE Adding. ObamaCare is extremely complex -- indeed, obfuscated. I welcome corrections and emendations in comments. I mean, at some point, a goodly number of us are actually going to have to figure this thing out.

NOTE Originally published at Naked Capitalism.

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beowulf's picture
Submitted by beowulf on

"During the 11-month period between enactment of the Social Security Amendments of 1965 and the start of operations, the administrative design for operation of the new program was established. The Social Security Administration and other components of the Department reorganized, recruited and retrained personnel, and re-programed systems and operations to accommodate their broadened responsibilities; regulations, policies, procedures and systems were developed for the Medicare program; contracts were negotiated with State agencies, intermediaries, and carriers, covering the role each would play in the administration of the program; eligible people were enrolled in the program; thousands of hospitals and other health care institutions were surveyed and certified to participate as providers of services under the program; and public information programs were launched to inform affected individuals of their rights and responsibilities under the new program."

http://www.ssa.gov/history/ssa/lbjmedicare1.html

Submitted by lambert on

This is actually a serious question. I'd always attributed the phasing of the rollout to electoral politics, i.e. make sure that perceived benefits are experienced in election years, and problems in off years; and roll out benefits by voting demographic (meaning that Obama's youthful vote got bennies, even though medically that's an awfully weird triage).

Perhaps the poor system architecture makes implementation extraordinarily difficult.

Perhaps the "creative class" like the good consultants they are, are simply maximizing billable hours and not deliverables. (Clearly, among other things, ObamaCare is pork for the technocracy).

Perhaps the adminstration is incompetent as well as malevolent (though I distrust the incompetence meme).

Thoughts?

beowulf's picture
Submitted by beowulf on

Blame the budget calendar, for some reason Obama got himself locked into a price ceiling of $1 trillion over 10 years (a silly number because it only counted federal revenue and not what individual taxpayer premium payer would be be mandated to shell out every month to a private insurance company,) .
Obama and his crew worked hard to make Obamacare fit that $1T in 10 ceiling-- they squeezed benefits and limited tax credits-- but the only way the number could work was withholding services for the first 4 of the 10 years. Which seems kind of dishonest.

As for Medicare, it was designed to build on the existing Social Security infrastructure. They already had all of the "customers" in the database--- current Social Security recipients-- and Medicare premiums could easily be deducted right out of Social Security checks (which is why Sam Gibbons' universal Medicare plan eliminated premiums, they'd be a bear to collect from everyone when there aren't SS checks to deduct it from).

In the late 70s, Carter's HEW Secretary Joe Califano transferred Medicare out of the Social Security Administration and combine it with Medicaid to create CMS (originally called HFCA). I think Califano assumed that there'd soon be a single payer system and he wanted to get all of his bureaucratic ducks in a row A Medicare for All plan wouldn't take a months to set up, it would take days, the infrastructure is already in place in Baltimore.

To this day, everyone who signs up for Medicare goes through SSA (even those folks in Libby Montana who were deemed eligible for Medicare years before they're entitled to Social Security). Medicare for All would be the easiest thing in the world to enroll people in--- if you have a Social Security number (which are issued at birth these days), you've already signed up.
http://www.ssa.gov/libby/