Kip Sullivan and I have had a running dialogue over the last year or so. Kip has been writing for such sites as The Health Care Blog, other blogs and newspaper. I find his knowledge insightful as we discuss what we know and where we are going with healthcare. Today Kip is working on implementing “Health Care For All – Minnesota” and is also developing a 3-year research and public education campaign. If you have questions this is the person to ask them.

This review was written in 2015 and is still relevant in 2020 in terms of how we started to arrive at where we are in healthcare. I have read some of the same complaints he outlines in his dialogue.

“America’s Bitter Pill: CBO was Right. The White House and Steven Brill Were Wrong.”

Steven Brill’s latest book, America’s Bitter Pill, is a frustrating mix of excellent history and muddled health policy analysis. The book is a very good addition to the literature on the history of the Affordable Care Act and by far the best reporting I’ve read on the bungled implementation of the federal health insurance exchange. But Brill’s analysis of why the ACA cannot reduce health care costs is naïve and confusing. Brill claims a few smart men on the White House “economic team,” including Peter Orszag and Ezekiel Emanuel, fought hard to push “game-changing” cost-containment into the ACA but were defeated by others who were less interested in cost containment.

That explanation is wrong on two counts:

Massachusetts ACA Enrollment Exceeds Last Year, Charles Gaba, ACA Signups Blog

Massachusetts: (January 14, 2018) saw an increased 285,000 signups for healthcare for 2019 which is up 6.6% YOY and with 9 days left until the ACA signup deadline. This comes even though Republicans and Trump have been sabotaging the ACA. Even more impressive, 97.2% (90% National Average) of enrollees have paid their 1st month fees.

Republicans and Trump Implement the CSR again, Ban Silver Loading, and then Kill the CSR in 2021, Andrew Sprung, xpostfactoid blog

The Trump administration has called for an appropriation to fund CSR the old way — by reimbursing insurers directly for providing it. This comes after President Trump revoked the CSR subsidy used to help pay for deductibles, copayments, and coinsurance. When the CSR was revoked, ACA companies loaded the costs solely into the Silver plans in which they were used and resulted in Bronze and Gold plans to become less costly. Income-based ACA premium subsidies are based on a silver benchmark and silver loading generated major discounts in bronze and gold plans.

“For the first half of 2018: 16% percent of enrollees were enrolled in a plan with zero premiums after application of advance payments of the premium tax credit, 19 percent of enrollees paid a premium of less than 5 percent of the total plan premium.” This is largely the result of Silver plan loading, which created $0 premium bronze plans widely available and less costly gold plans which doubled in enrollments in 2018. There was also an increased enrollment of approximately 300,000 enrollees in 2018 with the likelihood of a 2-3 million boost in subsequent years.

So what is the issue? CMS released the annual Notice of Benefit and Payment Parameters (NBPP) January 17th. In its efforts to kill the ACA, CMS is calling for an elimination of Silver loading in 2021. Given the lowered cost of various plans resulting from Silver loading, Democrats should not be willing to sacrifice the silver loading windfall without trading it for a less haphazard boost to marketplace funding.

As xpostfactoid blog suggests, perhaps a cap on premiums as a percentage of income for all enrollees up to 600% FPL and improved subsidies for the 200 – 400%FPL.

Healthcare Job Growth Outpaces Nearly Every Sector in 2018, MedPage Today, John Commins

For 2018, healthcare created a total of 346,000 jobs or nearly 29,000 new jobs each month which is up from 284,000 jobs created in 2017. The 2018 figure includes 219,000 new jobs in ambulatory services and 107,000 new hospital jobs.
Healthcare job growth outpaced nearly every other major sector of the economy in 2018, including food services (261,000), construction (280,000), manufacturing (284,000), and retail sales (92,000).

The new data is in line with Bureau of Labor Statistics projections that healthcare sector employment will grow 18% from 2016 to 2026, much faster than the average for all occupations, adding about 2.4 million new jobs.

The VA’s Choice Program Meant to Eventually Replace the VA Gave Companies Billions and Vets Longer Waits, Isaac Arnsdorf & Jon Greenberg, Politifact

As a short-term response to a crisis, the VA paid contractors at least $295 every time it authorized private care for a veteran. The fee was high because the VA hurriedly launched the Choice Program to meet a ninety-day deadline from Congress in response to an Arizona VA facility not responding quick enough to veteran’s needs for healthcare and resulting in deaths.

Four years later, the fee never subsided — it went up to as much as $318 per referral.

Since 2014, 1.9 million former service members have received private medical care through Choice. It was supposed to give veterans a way around long wait times in the VA or travel long distances to be seen. But their average waits using the Choice Program were still longer than allowed by law, according to examinations by the VA inspector general and the Government Accountability Office. The watchdogs also found widespread blunders, such as booking a veteran in Idaho with a doctor in New York and telling a Florida veteran to see a specialist in California. Once, the VA referred a veteran to the Choice Program to see a urologist, but instead he got an appointment with a neurologist.

While it was true officials at the Phoenix VA were covering up long wait times, the inspector general eventually concluded that no deaths were attributable to the delays. However, critics seized on this scandal to demand that veterans get access to private medical care. As a safety valve for veterans, the Choice program is an alternative provided the quality of outcomes is there. My own experience with the VA has not been bad nor did my appointments take months. On the other hand, there are times I end up at clinics or the ED when I can not see my PCD.

An IG of the Choice program found the VA overpaid by $140 million besides other issues with the program.

Access to VA Health Services Now Better Than Private Hospitals? Nicole Lou, MedPage Today

Researchers find some wait times generally improved since 2014.

In 2014, the average wait for a new VA appointment in primary care, dermatology, cardiology, or orthopedics was 22.5 days, compared with 18.7 days in private sector facilities (P=0.20). Although these wait times were statistically no different in general, there was a longer wait for an orthopedics appointment in the VA that year (23.9 days vs 9.9 days for private sector.

The study, published in JAMA Network Open, found that wait times in 2017 favored VA medical centers (17.7 days vs 29.8 days for private sector facilities). This was observed for primary care, dermatology, and cardiology appointments — but not orthopedics, which continued to produce appointment lags in the VA system (20.9 days vs 12.4 days), the authors stated.

As resources in the VA are increasingly diverted to purchase care in the community, it remains to be seen if access to healthcare services can be maintained while access in the private sector continues to deteriorate, adding that virtual care may be one way to improve access given the non-infinite supply of face-to-face appointments.”

Fee-for-Service Must Go Says Ex-Vermont Governor Howard Dean, Joyce Frieden, MedPage Today

Dean, an internist and former Democratic governor of Vermont: “Under the current system, you only make money if people get really sick. Every financial incentive we have in American healthcare is to spend as much as we possibly can.

“We’re not getting paid for keeping people healthy in our system. I don’t believe that doctors think it’s a wonderful idea to have people get sick. But incentives work in every system … and monetary incentives always work in human beings. If you keep the incentive system the way it is, you have a distorted system that works against good health.”

As for universal care in the U.S., I’m not necessarily opposed to Medicare for All, but the problem is it’s a fee-for-service system so we’d have to fix that. The only way you can really save money is with capitated care.”

by run75441 (Bill H)

Michigan 8th District Congressman Mike Bishop’s ad:

“Additionally, under the American Health Care Act (AHCA), insurance companies cannot deny coverage based on pre-existing conditions – yet Elissa Slotkin continues to lie about Mike Bishop’s record.

Sec. 137 of H.R. 1628 of the AHCA states:

“Nothing in this Act shall be construed as permitting health insurance issuers to limit access to health coverage for individuals with preexisting conditions.”

Under the bill, health status cannot affect premiums, unless a state asks for and receives a waiver — a condition of which is the state having other protections in place for those with pre-existing conditions. To obtain a waiver, states would have to establish programs to serve people with pre-existing conditions. No matter what, insurance companies cannot deny coverage based on pre-existing conditions.”

It is a tossup in Michigan and Mike Bishop and his campaign manager “Stu” are scrambling and slinging all the mud they can to sway many of the voters he ignored over the last two years when he was invited to meet in townhall meetings. He could care less and there was always an excuse not to be there and listen to the people talk about his priorities and what he is doing as their Congressional Representative. He will ignore many of his constituents again over the next two years if we return him to office.

Everyone can have access to buy anything they want to buy; but, can they afford it is the question? Charles Gaba at ACA Signups; “The AHCA did not protect pre-existing conditions” the same as the coverage under the Affordable Care Act (ACA). What the AHCA does do is allow states to strip away those protections via the waiver process.

Quickly, the ACA prevents insurance companies from: refusing to insure someone with pre-existing conditions, charging more for pre-existing conditions, denying coverage of the condition, not covering a minimum of 60% of enrollee medical costs, having an arbitrary maximum annual or lifetime claims cap, and capping maximum out-of-pocket costs for in-network healthcare expenses.

Except for preventing insurance companies from refusing to insure someone with pre-existing conditions, the AHCA Mike Bishop voted for allows states to opt out of all of the other protections of the ACA. If we were living in a state which sought to protect its citizens from predatory insurance companies and assist them in getting affordable healthcare and healthcare insurance, I would not worry as much as to what Michigan Republicans would do.

Since 1992 Michigan has been controlled by a majority Republican Senate, a Republican majority House 18 of 26 years, and a Republican governorship 20 of 28 years. During that time period, Republicans have favored business over its constituents. The Medicaid expansion barely passed in Michigan with Senator Joe Hune (Senate Insurance Committee Chair) proclaiming he was sick to his stomach with its passage. Lana Theis is running for his seat as well as Adan Dreher. Lana favors farming out the administration of Medicaid insurance to insurance companies such as what might be found in an Advantage Plan which produces no better results than Medicare and costs taxpayers and Medicare recipients 14% more. Adam Dreher is more in tune with the constituency.

In the end Elissa Slotkin is not lying about Mike Bishop and the AHCA as Congressman Mike Bishop’s AHCA which he voted for does not protect constituents with pre-existing conditions in Michigan in the same manner as the ACA. His vote for the ACHA allows states to wavie the ACA protections in favor of insurance companies who can charge more, limit coverage, or deny coverage.

Healthcare Insurers Lose in Court Over Risk Corridor Funds

I have written a couple of times about Sessions, Upton, Kingston, and Republicans sabotaging the ACA Risk Corridor Program with the insertion of Section 227 in the CRomnibus Bill signed in December 2014. Not only did Senator Sessions, Representative Upton (MI), and Representative Kingston (CO) block the funding of the Risk Corridor Program; with the insertion of Section 227 by Representative Kington, they blocked any transfer of funding from other programs as well. A rehash of the results of Republican sabotage shows, it caused a rise in premiums for the unsubsidized (others were picked up), Coops to go bankrupt, and insurance companies to withdraw from the healthcare exchanges.

Today a Federal Appeals Court ruled; “the U.S. government does not owe health insurers $billions in unpaid risk-corridor funds meant to offset losses during the early years (3 years) of the Affordable Care Act exchanges.

More than three dozen insurers claimed the federal government owed them more than $8 billion in risk corridor payments. Ruling 2-1 the COA determined the payments were not necessary since Congress deemed the program had to be budget neutral after the legislation was passed.”

In other words, the court decided a different Congress and/or the administration made up of different political interests can change the intent of another Congress or Administration.

A similar Risk Corridor Program exists in the Medicare Part D program for drugs which has no life time limit and was put in place by Republicans and Bush to cover any risk which may occur from getting too many higher cost insured.

by run75441 (Bill H)

This will be short and sweet, consider it a Health Care Open Thread.

‘Repeal and Replace’ is a pipe dream. Because all the good parts of ACA including guaranteed issue, coverage of pre-existing conditions and inclusions of young people on their parents’ policy actually cost money. At least up front. Which has to come from somewhere. And that ‘where’ tends to come from the pockets of Republican leaning constituencies including medical equipment manufacturers, insurance companies, and medical providers generally. For example a huge part of projected ACA savings comes from reduction of payments for Medicare Advantage, originally billed as a way to leverage the ‘efficiency’ of private (and profit making) economic entities to public ones. Which efficiency calculation has proved problematic even before you calculate the ‘profit’ thingee. With the result that Medicare reimburses Medicare Advantage providing insurance companies with a 14% surcharge over traditional Medicare. Or I should say “reimbursed”, because most of the much ballyhooed “cuts” to Medicare trumpeted by Republicans have come from elimination of the surcharge. Itself rather problematic given that there seems to be no evidence of actual “efficiencies” in MA.

Republicans have no answer for this dilemna. Just about every specific item they oppose about ACA serves as an offset to the increased costs of guaranteed issue and coverage of pre-exisitng conditions. Including their so-called ‘death panels’ which after all are simply cost-benefit analyses of current provision of medical care. Or the same thing that private corporations spend millions on hiring consultants to address. Because when it comes right down to it ‘efficiency’ in the private corporative sense boils down to cost controls.

As a result Republicans are flailing. Their ‘solutions’ such as they are, including cross state border insurance sales and tort reform do little to nothing to having negative consequences on the actual provision of medical care to end-users (aka ‘patients’) but instead reduce burdens on insurance company and provider bottom lines. The same for repeal of the medical device tax and employer mandates and individual mandates. All increase cost while providing bubkis on the ‘available’ and ‘affordable’ fronts.

Those of us who followed health care reform on a daily basis back in 2009 saw that it was at times the rawest form of legislative sausage making. In order to enjoy the nice juiciness of the Bratwurst of Affordable Health Care you had to stomach the knowledge of the nasty bits that actually saved money on the price of the resulting Sausage Dog. And Republicans have no recipe to provide that same Red Hot that doesn’t decrease the quality or increase the sawdust component.

Hoisted by their own Weinar, err Petard.

Reader Alex Bollinger posted this this morning in the Comments thread to this post of mine from yesterday:

Not only would low-info voters benefit from actually knowing that the ACA is doing good, but a few lefties could use a reminder that it’s not just a neoliberal gift to the insurance industry.

I responded:

Yes, Alex.  Exactly.  It surprises me that the insurance industry hasn’t been sponsoring pro-ACA, anti-AFP-disinformation ads.  I realize that it would involve implicitly acknowledging that their past policies–e.g., denying individual-market coverage to anyone who had even a minor preexisting condition–but they’re in real danger of losing the single-payer war (or at least the public-option) war.

Here’s our offer.  It’s a very good offer.  And a serious one.  Seriously.

(Yeah, I’m venting my frustration.)

Who, the HELL, is running the House and Senate Campaign committees? My guess: People who have some personal or financial connection to the usual-suspect Dem consulting firms. Or who just can’t even imagine that, y’know, maybe it’s time to look elsewhere.

So, folks, let’s start a protest movement, right here at AB, and demand a change.

—-

UPDATE: Reader Alex Bollinger posted this in the Comments thread this morning:

Not only would low-info voters benefit from actually knowing that the ACA is doing good, but a few lefties could use a reminder that it’s not just a neoliberal gift to the insurance industry.

I responded:

Yes, Alex.  Exactly.  It surprises me that the insurance industry hasn’t been sponsoring pro-ACA, anti-AFP-disinformation ads.  I realize that it would involve implicitly acknowledging that their past policies–e.g., denying individual-market coverage to anyone who had even a minor preexisting condition–but they’re in real danger of losing the single-payer war (or at least the public-option) war.

Back last December, after it had become clear that many of the state Blue Cross companies–which had by far the largest market share of the individual market in many, many states–was taking obscene advantage of the ACA (and then the healthcare.com debacle) to imply to policyholders of canceled plans that their only option was a very high-priced plan, I wrote here in AB that they were presuming that single-payer or at least the public option could not become a real possibility as a result. And by the very end of the year, after several pundits began making the same point, and it looked like the issue could really take off, the industry apparently did recognize it; it did stop the deceit.

What everyone seems to forget is that until last fall, the wingnut argument, including in the court challenges, was “Freedom! Liberty!”  You never hear that anymore.  Now all you hear is that premiums and out-of-pocket caps are too high and provider networks are too narrow.

Um.  Single-payer would take care of those things.  So maybe sometime before November the industry will realize that it’s very much in its interest to counter the AFP with a massive ad campaign.  Call it survival instinct.

And, who knows?  Maybe by the time the insurance industry realizes that the AFP ads need to be countered with an ad campaign of hard-hitting refutations and real-people  stories, the Dems will have figured that out, too. I never got this idea of addressing the ACA with generic we-need-to-fix-rather-than-repeal it, and hope that that nullifies the law’s unpopularity as a political problem.

The way to nullify the law’s unpopularity as a political problem is to make the law popular.  And all that would take is a good ad campaign.

Please, no more generic keep-and-fix. Please, now, specific refutations and explanations from actual real people .  And, fix?  A public option, maybe?

Seriously, Dems.  Go for it. There’s nothing to lose but loss itself.

Just when I thought I’d written my last post on Julie Boonstra, I read Kenneth Thomas’s post below, from Sunday.  The only comment to that post–mine, which I just posted–reads:

How very, very, very sad that there was no ACA during his years of leukemia treatments and hospitalizations, and that we still do not have single-payer.

And how ironic that he had the very same fatal illness that Julie Boonstra has.  I’d like to shove your post in her face, Kenneth.

I’d also like to see Rep. Gary Peters use this family’s situation in his Senate campaign ads in Michigan, and ask whether Julie Boonstra has any idea of what “unaffordable” means with respect to medical care for leukemia.

When she cut the first of her two ads for AFP in mid-February, Boonstra apparently was genuinely unaware of the full terms of her new Blue Cross plan and of the out-of-pocket-costs limitations legislated in the ACA.  And part of the reason why was the failure of healthcare.com to work in October and November and, apparently at least for Michigan’s exchanges, during early December–coupled with Michigan’s decision to not provide its exchange system through a webstie and run and operated by the state.

Boonstra is the ex-wife of Mark Boonstra, the former Washtenaw County GOP chairman whom Gov. Rick Snyder appointed to the Michigan Court of Appeals in 2012. Julie Boonstra said she’s never been a political person beyond advocating for lower-cost oral chemotherapy treatment in Washington. [My boldface.]

— Dexter cancer patient who called health care ‘unaffordable’ will save more than $1K, Marisa Schultz, Detroit News, Mar. 10

Boonstra famously was quoted in that article as saying when told the details of her new Blue Cross plan that it  “can’t be true” that that plan is cheaper, by a minimum of $1,200 for the year, than her old plan. “I personally do not believe that,” Boonstra told Ms. Schultz.   Schultz continued:

She said she still fears her costs will be unaffordable because she could be hit with large out-of-pocket bills in the early months when she wouldn’t have the money to pay. She also said her out-of-pocket maximum could be higher than advertised because there’s one prescription that was previously covered by her old plan that isn’t and she now buys with a separate prescription discount card.

An interesting comment thread developed here during the last few days in response to my post on Tuesday about the Detroit News article.  I titled that post “Julie Boonstra Tells the Detroit News Why Her New Healthcare Plan Doesn’t Work for Her: It Requires Her to Read the Policy or Ask Blue Cross a Few Basic Questions In Order to Learn What the Plan Actually Covers and What Her Expense Cap Is.”  One subject of the discussion concerned her statement that there’s one prescription that was previously covered by her old plan that isn’t and she now buys with a separate prescription discount card.  I pointed out that she does not say that that prescription is part of her cancer treatments, and that according to a Blue Cross spokesperson Ms. Schultz contacted for the article, it is not; all her cancer drugs are covered.

I also noted that Boonstra has not said that her old plan covered all medications.  She just said it covered all of her current medications.  And since I happen to know, having shopped there many times, that there is a Rite Aid pharmacy on the far west side of Ann Arbor, just east of Dexter, a village that is a small bedroom community mainly for people who work in Ann Arbor, I posted this from Rite Aid’s website:

Rite Aid, 500 generic-brand prescriptions available: $9 for a 30-day prescription; $16 for a 90-day one.

I also said in that comment something that, surprisingly, no one else (to my knowledge) has mentioned:

She also, by the way, has not said–because she doesn’t know, and either does Blue Cross–what her old plan would have cost in monthly premiums and out-of-pocket expenses and co-pays THIS YEAR, had the plan not been discontinued. But it sure as hell would be interesting to know how her old plan differed in costs and coverage last year from the year before, and how much her premiums and out-of-pocket and co-pay costs went up in, say, the last five years on that plan.

But there’s an even more fundamental question about Boonstra’s comments to Ms. Schultz: Why was Boonstra advocating for lower-cost oral chemotherapy treatment in Washington during a period when she was paying set, low monthly out-of-pocket costs and was happy with her plan?

When I first read the article it seemed strange to me that this anti-federal government Republican was advocating in Washington for federal regulation of the cost of a particular medical prescription.  But only after reading through the comments to my post on the article, in which I did not mention that statement of hers, but a commenter to the post did, did it occur to me that there was something more, something fundamental, wrong with this picture.

This clearly is someone who is locked deep inside the Fox News/Rush Limbaugh sphere of reality.  She seems to want a single-payer, Medicare-for-all type of healthcare insurance system, and wants the actual benefits of the ACA, including, apparently–no, undoubtedly–the removal of annual and lifetime caps on coverage. And it’s a safe bet that she personally does not believe that the ACA includes these bars, and that that is why her old plan was cancelled.  It can’t be true, because Fox News and Rush Limbaugh haven’t mentioned it.

This woman is among those who cannot be reached with facts.  But they are in the minority among the electorate. It’s deeply unfortunate that our Democratic president won’t educate the public about the actual specifics of the plan.  He doesn’t do specifics in speaking to the public, and doesn’t do facts and explanations at all. And he certainly doesn’t do refutations of misinformation.

We know by now that hell will freeze over before he refutes Boonstra, Emilie Lamb and the others in the AFP ads, and I guess that’s okay, because everyone’s tuned him out anyway.  But why has it taken so very, very long for the Dems to begin to take over this slack?  Their failure to do do this because Obama is unpopular is a key reason why Obama is so unpopular. Or at least a key reason why Obamacare is unpopular.  Which, apparently more than anything else, is what matters this election cycle.

As for Boonstra, reader Alex Bollinger posted this comment this morning to my earlier post:

Yes, we should feel compassion for this woman. And our blame should be mostly on the political consultants who are taking advantage of her loyalty to movement conservatism (I don’t think she’s stupid at all because I’ve seen very intelligent people really, really want to believe something is true so much that they believe their rightthink).

But her comments are intended to rescind the ACA, which has already insured over 12 million people. I’m sure there are people who either have or will get cancer among those 12 million. Just because they don’t have TV ads doesn’t mean that their lives aren’t important as well, and Boonstra has the ability to temper her ideological fervor with, you know, having a basic understanding of her plan before going on national TV to talk about it.

Exactly.

When millions of health-insurance plans were canceled last fall, the Obama administration tried to be reassuring, saying the terminations affected only the small minority of Americans who bought individual policies.

But according to industry analysts, insurers and state regulators, the disruption will be far greater, potentially affecting millions of people who receive insurance through small employers by the end of 2014.

— Second wave of health-insurance disruption affects small businesses, Ariana Eunjung Cha, Washington Post, today

[W]ith the single exception of the disastrous rollout of Healthcare.com, which is purely a technology issue, the high-profile issues concerning Obamacare since Oct. 1 highlight not generic problems with government involvement in healthcare insurance but instead the problems of a system that piggybacks on the for-profit private insurance industry and neo-federalism-structured federal programs that rely heavily or entirely upon cooperation of state governments.

— What to Do When a High-Profile U.Chicago Economist Says the Airline, Telephone and Package-Shipping Industries Prohibit Use by Preexisting Flyers, Callers and Shippers: If you’re a liberal, take this ball and run with it!, Me, Angry Bear, Dec. 26

The Washington Post article goes on to say that many of the small-business cancellations are occurring not because the current policies are substandard under the ACA, but instead are only indirectly related to the statute. Insurers, the article explains, want to “move customers to new plans designed to offset the financial and administrative risks associated with the health-care overhaul.” To that end, “they are consolidating their plan offerings to maximize profits and streamline how they manage them.”

To which I say: Go for it, insurance industry. Please do.  In my Dec. 26 post, I wrote:

[W]hat’s happening, suddenly, is something I predicted in recent posts here: That the individual-market insurance industry’s fall-of-living-dangerously, during which (led apparently by the various Blue Cross companies) it drastically overplayed its hand in the last three months by, for example, telling premium-holders, falsely, that their cancelled policies could be replaced only by vastly-more-expensive policies, would trigger reinvigorated calls for a “public option for the single-payer market and maybe even for a single-payer option across the board.

But something else is happening, as well: The right is recognizing that the problems with Obamacare, rather than broadening the appeal of a return to the status quo, is instead more likely to dramatically broaden the appeal of a public option.  And, because employers that provide healthcare coverage are scapegoating Obamacare for their unrelated decisions to further limit their already-increasingly-limited premium contributions and the like, the formerly unthinkable–a single-payer-for-all option–may well soon become the very thinkable.

The “right,” in that last paragraph, refers to U.Chicago Business School economist John Cochrane and a recent article of his that my post’s title summarizes. Cochrane’s piece, an op-ed published in the Wall Street Journal titled “What to Do When Obamacare Unravels,” struck me as bearing the earmarks of rightwing desperation.

Late this month in his State of the Union address, Obama will discuss Obamacare.  He will use the tired-but-by-now-obligatory tactic of having real Americans in the audience, whom he will name and whose family is benefiting tremendously from the law. He may even be astute enough–although I doubt this, since astuteness is not his thing–to include among those Americans people who panicked after receiving cancellation notices from one of the Blue Cross affiliates (it’s virtually always one of the Blue Cross affiliates, usually but not always an AnthemBlueCross affiliate) and was profiled in some news article as being told in the cancellation letter that the only option henceforth was some poorer-coverage or wildly-more-expense (or both) policy, only to learn later about the actual options.

What he won’t do, though, is what most he should do: Explain, in actual detail, using genuine specific data depicted in charts, that for decades now the unremitting and rapidly-accelerating trends in healthcare insurance have been ever-narrowing provider networks and large increases in premiums and out-of-pocket costs in both the individual market and the employer-based group-insurance market.  And to say that it soon will be clear whether or not the private for-profit healthcare-insurance market can meet the needs of the general public or whether instead those needs can be met only through a government-run single-payer insurance system or some other non-profit system similar to one or another approach that works so well in, say, Australia, France, or Germany. And then propose a public option, not just for the individual market but also for employer-based group insurance.

No, Obama himself won’t propose this.  But progressive Democratic congressional candidates should, and soon. Obama, like most Washington pols and almost all political pundits, is always incredibly late to the change-in-progressive-and-mainstream-political-winds party. If he ever arrives at the party at all. (He’s still appointing federal judges whose main credential is a history as a prosecutor or some other tough-on-crime, pro-police background–he hasn’t noticed that this no longer appeals even to Republicans, at least not those of the libertarian variety–but that’s a subject for a later post.) The Washington Post piece notes that most of the small-business-group policy cancellation notices will be sent in October, near the start of the open-enrollment period and also just before the midterm elections.  This, the writer points out, “could be difficult for Democrats who are already fending off Republican attacks about the Affordable Care Act and its troubled rollout.”

Then again … maybe not so difficult, after all. The political winds are moving forward, not backward. All the Dems need is a coherent progressive policy proposal.  And a few coherent messengers for it, who no longer need fear that they will be killed.