Jonathan Ernst / Reuters

On Monday, Donald Trump presented Americans with a puzzle of a sentence: “All of my employees are having a tremendous problem with Obamacare.”

At first it seemed like Trump might be admitting to something illegal. Employers have to provide health insurance. The candidate seemed, to some, to be implying that his employees were buying their own insurance (“with Obamacare”) and having tremendous problems.

But later that day, on Fox News, Trump said something equally confusing: “Well, I don’t use much Obamacare, I must be honest with you …”

Together these sentences raised the possibility that the candidate believes Obamacare is a product or service. And so maybe, like so many Americans, Trump isn’t clear on what Obamacare is.

* * *

The health system is one of those things that, past a certain point in life, it’s embarrassing to admit to not understanding. One of those things you hope will just go away. I do this with carburetors. Someone mentions a carburetor, and I just nod and say something like “those things are always breaking.”

But this isn’t going away. While any other area of health is more interesting than medical care to most people—food, sports, sex, sleep—the single most consequential choice we’ll make for our health is happening on November 8. So everyone really should know what’s at stake.

In terms of health care, the U.S. may be, to use a Trump-style superlative, the worst country in the world. Spending on health care will soon account for 20 percent of our gross domestic product, which is about twice that of other wealthy countries. And we have little to show for it. Americans aren’t healthier than people elsewhere—in many ways the opposite—and are more likely than most to have no access to health care at all.

Our system is inferior and getting worse, and as spending increases, the system stands to take the rest of our economy down with it. It’s critical that everyone know more about health care than Donald Trump appears to.

That’s why I call it Ol’Bummercare lol. So you’re saying Mr. Trump doesn’t know what Ol’Bummercare is?

After his comments on Monday, Trump’s people later clarified that he does provide health insurance to his employees. The requirement for employers to provide health insurance to employees is a part of the enormous system created by the Affordable Care Act, often referred to as Obamacare, in 2010.

So Trump may not understand that Obamacare is not a product, or a service, or a type of insurance—but a complex, multifaceted system. The most talked-about part of that system is marketplaces (called exchanges) where people can buy insurance.

Exchanges?

Yeah, I hate the name. Calling them marketplaces would’ve been clearer. They’re meant to be like Expedia for Health Insurance: One site where you can see all the options and pick whatever you like.

The idea was that this would be good for capitalism. It should encourage insurance companies to compete for customers. They would have to be more transparent about their charges and what they’re offering. Historically they haven’t been.

Just like airlines don’t have to take part in Expedia but still do—even if they don’t love the pressure it puts on them to be competitive—they will want to be part of the system as long as people are using it. (Unless they’re Southwest.)

And people who work for Trump are having tremendous problems with Expedia for Health Insurance. I get it now.

No. They work for him, so they get insurance through him. So they aren’t buying their own.

But other people are having problems with Expedia for Health Insurance. And this is a big deal for everyone, even people who get their insurance in other ways, because insurance companies pass their costs to whoever has money. Hillary Clinton’s staff has privately acknowledged that this is dire. In an email exchange hacked and published by Wikileaks last week, her campaign chair, Chris Jennings, admitted in a memo from November 2015: “The health insurer and enrollee participation issues in the exchanges are, at best, disconcerting.”

That’s what all the news was this week about insurance becoming more expensive.

I don’t trust the news.

Well, this news was bad for Obamacare.

Then I trust it. What was it again?

Even THE MEDIA couldn’t keep this news quiet, because THE MEDIA had been anticipating and reporting on it all year. Projections said all along that premiums (monthly costs) would continue to rise, despite Trump’s implication that these costs are the result of the Obamacare law. In the decade prior, premium costs rose at 9 percent per year, on average.

And this week President Obama said that many people who buy their own insurance through exchanges without subsidies—around 6 million Americans—are going to be paying more for health insurance than they did last year. That’s only about 2 percent of people.

Still, Trump wasted zero time saying that Obamacare was “blowing up.”

He meant it in the bad way, like a bomb. Not blowing up like Drake.

I got it. A price increase for two percent of people isn’t a big political issue in itself. But it’s part of the bigger picture that’s concerning: What Trump didn’t mention was that it’s not just premiums that are going up. Deductibles and co-pays (what you pay when you actually receive health care) have increased, too.

The cost increases aren’t limited to people who buy on Expedia for Health Insurance, either. Ten years ago, fewer than 10 percent of employees with health insurance had a plan with a deductible bigger than $1,000. Today that number is 46 percent. Those deductibles have even given rise to people buying “gap insurance” to cover what’s not otherwise covered.

So this could’ve been what Trump was referring to when he said his employees were having problems.

Definitely seems like Obamacare is blowing up like a bomb, in the bad way. That would be great.

If it’s not updated and tweaked, the whole system will definitely fall apart. No one disputes that, including Obama.

Essentially, he tried to build this huge brick house, but what went through after a lot of political bargaining was a compromise—sort of like the frame to a house, and using whatever’s available to cover the roof and walls. It kept some people warm for a while. Reasonable people question how much of the structure is holding up as planned. But it’s an odd solution to propose demolishing the whole thing. As the kids say, winter is coming.

The question is, when does the frame we have collapse? Some people argue that rising costs aren’t a serious problem (yet).

Bob Kocher and Zeke Emanuel, who worked with President Obama in drafting Obamacare, wrote this week in Vox that the very claim that the exchanges are leading to higher health insurance premiums “is a myth. While insurance premiums have gone up, they have actually gone up less quickly than in the past, and 20 percent less than the Congressional Budget Office predicted in 2009.” They cite a study from the Brookings Institute which said that while premiums are indeed increasing, they would likely be 30 to 50 percent higher had Obamacare never gone into effect.

The conservative think-tanker Avik Roy (who Vox has described as “a Republican intellectual”) was having none of this. He offered a rebuttal of the most damning type, analogy: If the price of a Honda Civic went up $15,000, it’s little consolation to buyers who can’t afford the car. Nor should anyone feel consoled by statements like, “Well, you should feel lucky! The Congressional Budget Office predicted that our regulations would make your car cost even more!”

Though, what if those “regulations” were, say, that the car needs to guarantee that its brakes work, and it has to be sold to people even if they’re overweight?

Damn government. Let the corporations do whatever. It’s called freedom.

Is it?

Roy was a three-time advisor to Republican presidential nominees. He says that insurance companies are suffering under Obamacare because the law required the insurance they provided to meet certain standards (like not excluding people based on pre-existing conditions) and to compete with one another.

Of course, insurance companies are still posting enormous profits. Specifically $65.5 billion among the five largest insurance companies since the launch of Obamacare.  Those who move outside the exchanges do so strategically—to optimize profit, not as a matter of basic survival. UnitedHealth reports that 2015 earnings fell to $6.8 billion from $7 billion the year prior due to “losses related to individual exchange-compliant insurance business.” Aetna and Humana have said the same, reporting smaller losses on exchange products, but exiting nonetheless.

It seems they have decided that the number of people buying through the exchanges is small enough to do without. They don’t need to compete in a market where their product is held to minimum standards. Any structure that reins in the profits of these corporations will be circumvented or eradicated: They will either leave the market or ensure profit by passing costs to consumers.

This is the fundamental problem of insurance: When the number of consumers is too small, the corporations give zero shit about those people. The bottom line, though: Arguing about the causes of the increases in price is becoming moot, because now the critical, undeniable fact is that insurance is too expensive, so not enough people are buying it.

Obamacare will fail—without any question—if not enough people buy insurance.

Good. I hope they don’t.

Right now, the number of people who have chosen to buy insurance through the exchanges is barely more than half of what was projected at this point.

(President Obama is quick to say that he has gotten insurance to 20 million Americans who previously didn’t have it—which is entirely true, but somewhat misleading in that 8 million of those people are insured through expansion of Medicaid.)

When not enough people buy insurance and join the pool, that insurance becomes more expensive for people who do. We know that the people who are signing up in droves are those who either expect to use a lot of medical care or who were close to the poverty line and get big subsidies. Young, invincible people are taking their chances and paying the penalty (a legal requirement to be insured) instead of signing up—and those are the people who are supposed to make insurance profitable for the people who sell it. As insurance becomes more expensive, more people opt to pay the penalty than to buy insurance. It’s a vicious cycle, like pursuing happiness through drinking or Twitter.

Yep, Ol’Bummercare is blowing up.

Well, Emanuel and others say the “risk pool” still isn’t as skewed toward sick people as it seems. Though the fact that insurance companies are leaving the exchanges does suggest otherwise, and the leaked Clinton email said as much a year ago: “It is becoming painfully clear that many of these plans underpriced their original premium as they assumed a broader, healthier risk pool.”

But there are ways to recalculate and recalibrate. One way in particular is at the heart of the presidential race—and all of this week’s news. People with incomes near the Federal Poverty Level have been insulated from price increases by the government picking up the cost (with subsidies). The people who aren’t signing up due to the high cost, according to Clinton’s internal memos, are Americans who take in more than 250 percent of the poverty level, who are getting little to no tax credit subsidies.

Clinton’s intent has long been to increase these subsidies—to get more people into the pool. The idea is that ultimately saves everyone money. Obama initially wanted the subsidies to be bigger, too, but they didn’t make it into the Obamacare law. Kocher and Emanuel agree that subsidies need to be expanded to get people into the pool. Even Roy agrees. This pool of people must grow. Health insurance only works if a lot of people come together to do create a system. Like bridges or fire departments or prisons. It doesn’t work to leave people on their own to try and pay whatever pharmaceutical companies and hospitals want to charge them.

But Trump disagrees?

He says that these subsidies are a bad way to get people into the pool.

So how would he get people into the pool?

That’s the thing. We don’t know.

Almost all that Trump will say publicly to “repeal and replace Obamacare.” His official “policy statement” on health is a vague screed on the “suffering” born of Obamacare. It repeats the same paragraph twice.

The rest is a call to deny care to illegal immigrants (citing the cost at $11 billion annually, out of $3 trillion) and giving people tax breaks if they put money into “health savings accounts”—which “could be passed on to heirs” without any estate tax. This actually seems like it would be a serious loophole for wealthy people. And that’s all.

Oh also, he’s against anything Clinton proposes. Especially the public option, which is the actual glimmer of hope in her ultra-politically-practical proposal.

Hold up. Public option?

We’re getting to the heart of it. The key idea in Clinton’s plan is that she wants a public option.

If Clinton wants it, I’m against it.

Well, wait. Because it’s about freedom. Really. A public option is about people coming together on their own, without a corporation taking their money. It’s meant to let people not be beholden to insurance companies.

I will listen to this.

It’s the most straightforward idea for an insurance plan. People pool their money together, with no insurance company trying to take any of that money. Instead the money pool is organized by the government.

Nope, nope, you said government.

Someone has to be in charge of the pool. It isn’t going to run itself. We have to choose: It’s either run by people we elect, or by huge for-profit corporations.

Adding a public option is about giving people the choice. It’s an option.

Ideally it would create competition in the insurance market, which right now is an oligopoly. A public option would mean that insurance companies have to provide a product that’s better than the public option: if not cheaper, then justifiably better.

Obama wanted this to be part of his original law, too, but it didn’t make it through Congress.

Why?

For the same reason that Trump is having none of this! On his website, he says that a public option will “drive out private health plans and leave Americans with fewer options and eventually no choices but a government run plan.”

So he’s protecting corporations from competition?

That seems to be his reasoning.

But anything that involves the government is socialized medicine, and that is bad.

No.

It’s so different from “socialized medicine.” This misunderstanding has been around since Lyndon Johnson passed Medicare, in 1965. Detractors then called it “socialized medicine.” Trump did the same thing 50 years later in the last debate, saying, “She wants to go to single-payer, which means the government basically rules everything.”

Which is false on two counts. Clinton isn’t proposing single-payer, and single-payer doesn’t mean the government rules everything.

Socialized medicine is when the government actually owns and operates the medical system. The common analogy is a hospital that operates like a DMV. Nobody wants that.

A single-payer system is when there is a single payer (insurer) for health care. Usually it’s the government.

A public option is when people pooling their own money—bypassing an insurance company—is at least on the table. It’s there on the Expedia for Health Insurance page.

If everyone chooses to enroll in the public option, that would become a single payer. And actually for decades, when single-payer has been alternatively called “Medicare for all,” people are pretty into it. Around 60 percent of Americans have reliably said in polls that they would support “Medicare for all.” People don’t really care who pays their bills, as long as they can go to the doctors and hospitals they want to go to. (Evidence that some people just don’t understand the terms, at least one Tea-Party advocate notoriously carried a rally sign that said, “Keep your government hands off my Medicare.”)

Detractors like to say that a single-payer system like Medicare stifles competition, but there’s always market share to be competed for—between healthcare systems, between pharmaceutical companies and medical-device manufacturers. Rather, what we have now is anti-competitive, where pharmaceutical companies, insurers, and hospital systems are merging. They have created a cost structure that is untenable—sucking down a rapidly growing 17.5 percent  percent of our gross domestic product in exchange for mediocre health outcomes—and on pace to destroy the U.S. economy. Coming together under a single payer can prevent price gouging by the pharmaceutical industry. By one recent estimate, our system has become so complex that simply eliminating the administrative costs that result from hospitals and doctors trying to navigate for-profit insurance companies could save the country $350 billion every year. Not to mention eliminating all the obstacles to care that come from insurance companies making life difficult for patients and doctors.  

No approach to getting health care for everyone is ideal. Getting sick isn’t ideal. None of this is ideal. But an every-person-for-herself approach is a guaranteed failure when going up against corporations who will offer care on their terms. What if a pool that’s run by elected officials is the only way to create an entity that has no incentive to deny our medical claims? No incentive to charge us as much as they possibly can?

As physician John Geyman, a professor emeritus at the University of Washington, wrote last week: “We should have learned by now that segmented risk pools designed for profits by private health insurers will never provide universal access to affordable health care in this country. Virtually all advanced countries around the world learned this long ago with one or another form of universal health insurance.”

Because health insurance only works when people work together, every approach to universal health care involves the government, either via a law that says everyone has to buy insurance from private companies (and/or require employers to buy insurance from these companies), or a law that says everyone has to pay into a national health-insurance fund (single-payer). A public option is a compromise.

Screw the government. I’m going to commandeer a wildlife refuge.

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