The ugly truth about yesterday in Risk Pool terms.

 

You'll have to forgive me my poor metaphor below, but it's the best I can think of at the moment. I've been awake for 29 hours straight now, as I woke up at 5am yesterday for a 15-hour shift as a poll worker in Pontiac, Michigan, and, like many of you I'm sure, I was unable to sleep at all last night. I just got off a devastating phone call with my son who's a freshman in college who doesn't understand why what just happened...happened.

There's going to be a mountain of digital & physical ink spilled and a cacophony of talking heads on the Sunday morning shows yapping about What Went Wrong, yadda yadda yadda. Most of it will be bullshit. Some of it will be accurate.

Since writing about healthcare is my thing, and writing about the ACA specifically is very much in my wheelhouse, I'm going to put my take on this into healthcare risk pool terms. Besides, assuming the GOP also keeps control of the House, the ACA is likely gone (and even if they don't, it's about to be radically gutted via regulatory actions anyway), so I might as well.

In late September I wrote a lengthy explainer about how healthcare risk pools work and how & why the ACA changed the way they work for the individual health insurance market.

The very short version is that given how insanely expensive healthcare is for sick people, and given how difficult it is to actually reduce the overall cost of it, there's really only two other ways to reduce the cost to the enrollees:

1. You can put healthy and sick people into the same risk pool to spread the financial risk, and then provide generous financial subsidies to reduce the net cost for all of them while providing fairly equitable care (paid for primarily by raising taxes nominally, mostly on the wealthiest Americans).

This approach reduces the net healthcare costs for everyone in the risk pool...while upsetting those who see their taxes go up to help pay for that reduction.

2. You can separate out the sickest 10% or so (who account for a stunning 2/3 of total healthcare spending) from the other 90%, and throw the 10% under the bus (ironically, some of their medical expenses might have been due to literally having been thrown under a bus).

The second approach theoretically reduces healthcare costs dramatically for 90% of the population...which would be great except that it basically dooms the other 10% to suffering and/or death...and of course sooner or later everyone in the first 90% will find themselves part of the other 10%, since on a long enough timescale, everyone develops a pre-existing condition.

Yesterday, whether they admit it or not, most U.S. voters decided that they'd rather throw the most vulnerable among us under the bus in order to make things better for themselves...even though for the vast majority of them it won't.

Unlike 2016 when you might have argued that Hillary Clinton ran a poor campaign, or "didn't visit Wisconsin enough" or whatever, by most accounts Kamala Harris ran a nearly pitch-perfect campaign from start to finish.

Unlike 2016 when they might have been excused for doing so because they weren't paying attention or thought Trump was just kidding when he promised to do terrible things, this time around they did so with clear heads and a full understanding of exactly what it is they were voting for. Project 2025 was literally published in full online and promoted by the Republican Party. Donald Trump openly promised to be a dictator on Day One. He's been convicted of 34 felonies and is an adjudicated rapist.

His own running mate once speculated about him being "America's Hitler," and the only reason Vance replaced Pence as his running mate is because he refused to endorse Trump after Trump encouraged his own followers to hang Pence for refusing to overturn the 2020 election in the first place. Virtually none of his cabinet officials endorsed him and many, many of them publicly warned people not to vote for him again, up to & including labeling him a bald-faced fascist.

And much of this has happened after the Supreme Court, 1/3 of which was hand-picked by Trump, ruled that he has carte blanche to basically do whatever the hell he wants to if he becomes President of the United States again.

NO ONE who voted for Donald Trump in the 2024 election can claim they "didn't know" or "didn't think he was serious." They decided that this was exactly what they wanted more of for at least another four years (or eight, or possibly forever since there'd presumably be no way of stopping him from declaring himself President for Life once he takes office on January 20th).

Hell, there's even a chance that more people voted for him after all of the above AND after leading an insurrection attempt on the federal government AND after repealing Roe v. Wade than he did in 2020 (as of this writing he's down about 2.5 million votes from then, although votes are still being tallied in many states).

The thing is, unlike my healthcare risk pool metaphor above, it's not just 10% of the population (which would be horrific enough). It's most of us...including many of those who voted for him.

And again, just as everyone develops a pre-existing condition eventually, sooner or later he'll throw most of them under the bus for one reason or another as well.

That's what dictators do.

I've often thought of Martin Niemöller's famous quote:

First they came for the socialists, and I did not speak out—because I was not a socialist.

Then they came for the trade unionists, and I did not speak out—because I was not a trade unionist.

Then they came for the Jews, and I did not speak out—because I was not a Jew.

Then they came for me—and there was no one left to speak for me.

The thing is...we did speak out. MILLIONS of us did. Loudly. Repeatedly. From the rooftops.

And they DIDN'T CARE.

In fact, many of the very groups that they're going to "come for" actually voted for exactly that.

I'm going to try to get to sleep now. I doubt I'll be successful.

We have 75 days left. I have no words of comfort this morning.

God help us all.