Krugman asks: So does this mean that liberals should have insisted on single-payer or nothing?

[TheKentuckian]

17. False choice, I never was a single payer or bust sort but still believe that reform

even under this general paradigm could contain more actual reform and less papering over of the existing nightmare.

The idea that this was some binary choice between single payer, what we got, and nothing is lazy and unsupported. Broad outlines used to obscure the details. I can construct a form of and revenue streams for single payer that would make such a good basic idea, hellish.

Is what we got the worst permutation of a market based scheme? Certainly not. It's it the best plausible construction under even that framework? Not even close, I fact so weak that escape velocity from the current paradigm is a matter of faith than the actual structure of the law. Not by the CBO projections it doesn't.

Does this law make some meaningful changes to the existing system?

Yes, particularly in a very abusive individual market but it does so by emulating a large group market that is no world model, giving the insurance cartel a key to the treasury, managing customers to a still loosely regulated cartel with an antitrust exemption, giving pharmaceutical manufacturers an even greater hand to extract wealth rather than forcing them to the negotiation table, taxing benefits, shoving self rationing and greater cost sharing down or collective throats, and no small amount of robbing "Peter" to pay "Paul" to spread the pain rather than going after those with resources in a significant way because a fees for service model will always do that when from within that structure those with the least are given aid and support.

The bite is less as you go up the ladder, cost are spread in an anti-progressive fashion one you leave the tier of greatest benefit up to the point where the scale of economy dictates that in the wash, those at and near the top actually save significantly as a share of income with less financial exposer than they had before reform and avoid any significant taxes in the exchange.

The support for the most vulnerable has been structured in a fashion that also greatly aids the well of at the expense of the rapidly shrinking middle, especially in attacking plans that folks have traded lots of income with no legislated path to recover those wages.

Ramping to subsidized plans on the exchanges is close to nonexistent. Cost controls were an afterthought, let to a poorly thought out MLR provision which is an open invitation for increased systemic costs. Universal coverage is silk not in the cards and want even before the Supreme Court hobbled the Medicaid expansion.

No, even under this structure the final product could be very different and this is not the only conceivable structure that isn't a form of single payer or the preexisting system.

Is everyone's brain stuck in weird little boxes, THINK PEOPLE! Stop being herded like sheep into false choices.