Parallel Universes

A short while ago I asked a Boston cab driver how she liked the health care system there. “It’s a hassle,” she said. “I had to go down a list of two dozen doctors before I could find one who would see me.” Turns out, she was on MassHealth (Medicaid). So I asked, “Did the list of doctors come from the Yellow Pages?” “No,” she said, “MassHealth gave it to me.”

Why am I telling you this story? Partly because I live in two parallel universes. One is the universe of health policy conferences at the Brookings Institution and the American Enterprise Institute and articles published in such places as Health Affairs and the New England Journal of Medicine. In the other universe, I quiz taxi cab drivers and others about what their life is like. I would lose a lot of good friends if I told you which universe is more informative.

Yet the more important reason for the story is that fully half of all the people who will be newly insured under ObamaCare are going to be in Medicaid. And if Massachusetts reform is the guide, most of the rest will be in highly subsidized plans that pay doctors little more than what Medicaid pays.

That brings me to the second set of parallel universes I live in: the world of public policy and the world in which people talk about public policy. Those two worlds are as different as night and day. Consider that:

  • While defenders of the new law have chattered endlessly about people who are uninsured because of pre-existing conditions (turns out there are only 12,500 of them) almost no one seems to have noticed that 16 million people are not only going to be forced into Medicaid, they are effectively going to be denied the right to buy any private insurance — whether or not they have a pre-existing condition.
  • While the Obama administration takes every opportunity to boast about the removal of annual and life-time private health insurance benefit limits, almost no one seems to have noticed that we are about to put 16 million people into plans that routinely limit benefits — regardless of what was promised at the point of enrollment.
  • While a case challenging the constitutionality of a federal mandate to buy insurance wends its way toward the Supreme Court, fully one-half of the newly insured under ObamaCare won’t be paying any premium at all and most of the rest will be paying premiums that are only a fraction of the real costs of the insurance.

It isn’t that what people talk about is unimportant. It’s that what they choose to talk about is only tangentially related to what they are about to do.

Let me briefly review the bidding. In the 2008 Democratic primary virtually all serious candidates endorsed the principle of “universal health insurance.” After Barack Obama became president, a Democratic Congress proceeded to draft legislation that would insure about 60% of the uninsured. These days, all of this seems to have been forgotten.

Just to keep perspective, insuring people who have been denied coverage because of a pre-existing condition is going to cost about $5 billion over 5 years. Insuring all the rest of the uninsured is going to cost almost $1 trillion over 6 years. Almost all the political conversation for the past two years has been about the $5 billion problem. No one is talking about the $1 trillion problem.

In terms of money spent, ObamaCare is mainly about the expansion of Medicaid and Medicaid-like private insurance. In fact, if the reform had done only this it not only would have insured about half the uninsured, there might have been no general voter interest in the law’s repeal!

This brings us to the third set of parallel universes: the world of the poor and the world of the middle class. Take the issue of a health insurance mandate. Whatever the argument for requiring middle class families to buy insurance, there is almost no valid argument for fining poor people if they do not enroll in a program for which no premium is charged in any event. Currently, there are about 10 million uninsured people who are eligible for Medicaid and S-CHIP, but who have not enrolled. In another three years, these people will be hit with fines totaling $695 per person by 2016. (Or will they get a hardship exception? Who knows?)

Does this make sense? I suppose you could argue that being uninsured is anti-social behavior, but so is a lot of other behavior. Should we fine poor people if they drop out of school? Smoke? Eat fatty foods? Have children out of wedlock? Fail to become employed? If these ideas appeal to you, you’ll love ObamaCare.

The final set of parallel universes is the world of the elderly and the world of the poor. But in this case, the universes are connected. Roughly half the cost of insuring low- and moderate-income families is being paid for by Medicare enrollees. Okay, in politics there are always winners and losers. But if you watch TV or listen to White House press conferences, you would be led to believe that only one of those two worlds actually exists.

How many television commercials have you seen touting new, free insurance that will soon be available to low-income families? I haven’t seen one. But Andy Griffith has been all over the cable channels, trying to explain to seniors why they should like health reform. Medicare has spent millions saying much the same thing.

It’s as though the White House has concluded that seniors matter and poor people don’t — at least in politics. If they’re right, ObamaCare is in big, big trouble.

Comments (19)

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  1. Joe S. says:

    John, are you saying you learn more talking to taxi cab drivers than you learn attending health policy conferences? Or are you just hinting that that might be the case?

  2. Vicki says:

    I thinks cab drivers are probably a very reliable source of information about access to care in a city.

  3. Paul H. says:

    You are absolutely right about seniors and poor people and no one else is talking about it. We are about to distribute billions of dollars from the elderly to the poor and near poor and the health care reporters have said not one word about it.

  4. Andy says:


    You didn’t menntion the other universe – that of the medical schools in the US that are graduating very few primary care physicians. Take the baby boomer aged physicians who will be exiting the system, and the very few primary care docs who will be entering the system…and there’s a little problem. WHO WILL TAKE CARE OF ALL THESE PEOPLE ENTERING THE SYSTEM?

    In a couple of years, your cab driver friend will have to call a lot more physicians than a couple of dozen….or he’ll have to go to a clinic and sit and wait…and wait….and wait.

  5. Devon Herrick says:

    Most policy proposals begin as political rhetoric. Political parties formulate policy proposals and platforms based on political ideology. That was the case with health reform. Many of the people who supported the PPACA are secure in the knowledge that was a winning strategy – but don’t know how the PPACA is supposed to work once implemented. Yet they assume that is now HHS’s problem to figure that out.

    Critics complain that corporations are too focused on short-term profits at the expense of long term good. Yet politicians have a time horizon that’s even shorter. Politicians focus on getting re-elected even when the promises they make are unsustainable and must be paid for by voters’ children and grandchildren.

  6. Larry says:

    Frankly, John, I thought you were going to go into an entirely different direction. Rather than dealing with the demand side, I thought you were going to discuss the supply side.

    Whether we have health reform or not. Whether we have health reform in its current form, a form that John Goodman proposes, Atul, Elliot, Mark, or Uwe recommend, sooner or later we will have to deal with the supply side equation. What the cab driver is telling us is worth listening to carefully.

    We need to deal with the process of health care. We need to have all providers working at the ‘top of their license’ no matter what role they play. We need to find alternative ways to deliver care – whether that’s self care, app care, nurse care or doctor care. It needs to change to become more effective and efficient.

  7. Nancy says:

    I agree with the above comments on the supply side. Get ready to get your health care from nurses. There’s nothing wrong with that if you are going to a Minute Clinic. But if your medical problems are more serious, good luck.

  8. Ralph says:

    The most bizarre of the parallel universes is the complete disconnect between what politicians talk about and what they do. I think what they talk about is poll driven. What they do, is special interest driven.

  9. Ken says:

    Ditto Ralph’s comment.

  10. Jim Morrison says:

    John, Shhhh. I’d prefer you not give away my secret sources of sound public policy information. During a career in Washington, I learned that taxi drivers, waiters, and bartenders are very reliable sources of information about the real impact of public policy on everyday Americans. They also frequently have advance information about the thinking of the “movers and shakers” who talk incessantly about their “brilliant” policy proposals while being completely oblivious to the presence of these “invisible” Americans.

  11. Virginia says:

    “It’s as though the White House has concluded that seniors matter and poor people don’t — at least in politics. If they’re right, ObamaCare is in big, big trouble.”

    It has always amazed me that Americans are comfortable essentially admitting that seniors are more important than poor people. Why do we allow two different types of health care? It makes no sense to me. I suppose the new cuts to Medicare are supposed to eliminate some of that, but still.

  12. Neil H. says:

    Virginia, seniors vote and their votes are up for grabs. Poor people usually don’t vote and when they do they tend to always vote Democrat — so their votes are not up for grabs.

  13. steve says:

    Thomas Friedman also gets advice from cab drivers.


  14. artk says:

    Sure Taxi driver anecdotes are a good a judge of public policy and their investment advice is a road to wealth. Who needs statistics and regressions or deep analysis when you have anecdote. So, I have my own anecdote. I have as blue chip a health care plan as you’ll find anywhere. Several years ago I went looking for an in network primary care provider. After trying dozens, all of whom weren’t accepting new patients, I finally went out of network. I guess what was happening that in anticipation of Romney Care in Boston the availability in NYC dried up.

  15. Let’s see….
    A taxi driver can use his first $4 of everyday to pay for unlimited access to primary care 24/7 including cell phone, texting, email, same day access…

    When I ask working people at the county hospital and elsewhere if they would pay $10/month for this service I have never heard anyone say no.

    I usually get to $50-100/mo.

    What would you pay directly to a primary care physician for this service???

    Please give an amount, if you care to do so, before your comment.

  16. artk says:

    Well Doc, I hate to break it to you, but your 100/month is more than I pay for my hot shot former head resident at New York Hospital primary care doctor. I see him for an annual checkup that’s five or six hundred, then I usually need to see him a couple of times a year, for another 500 or so. All that nonsense of your about returning phone calls or email, that’s just common courtesy. The fact is that you ignore the real money, CAT scans, MRI, fancy procedures, drugs that there are no generic versions that cost 10 or 20 dollars a day. You may have figured out a pitch that lines your pocket, but when you come down to it you’re selling vaporware.

  17. Al says:

    Artk, can you let us know what drugs cost $20 per day where there are no generics and no discounts? Can you let us know the disease and how many people require that $20+ medication? I just want to better understand what you are trying to say.

    It is an important issue as $20 amounts to ~4 latte’s per day or 2 – 3 packs of cigarettes per day.

  18. Al says:

    John G. When you write “(turns out there are only 12,500 of them)” is it possible to notate where the number comes from? You mentioned it before and I believe the number, but sometimes would like to look up the associated information.


  19. ArtK
    good question..
    The real money is in hospitalizations…
    We decrease hospitalizations by 60%.
    If I treat you early on as an outpatient with pneumonia, I save you so much money and time…Your biggest expense is loss of wages if you are not working. If you miss one day of work, how much does that cost you.
    MRI’s next door are >$2,000…My patients with no jobs like that…but particularly since I can treat them clinically and they have easy access in case they don’t improve…
    A Medicare patient of mine was in the donut hole a few years ago. She pays me $180/mo…. Her drug costs were over $300/month…I got them down to $16/mo b/c I knew what to do…They are now about $100/month b/c I’ve had to fine tune some things…
    She now gets free health care and makes $80/mo…

    It’s all about quality care, lower cost for the patient and access. They decide and if someone doesn’t want my service, then I don’t have a problem with that. I can only take care of so many people and do it well.