Archive for the ‘Healthcare’ Category
Good news, which should be cheer to Congress, which was complaining mightily when the exchange wasn’t working. I expect to see some guarded praise from the Right… well, no, not really. Lizette Alvarez and Jennifer Preston report in the NY Times:
After two months of false starts, error messages and pleas for patience from the once-hobbled federal online health care exchange, Karen Egozi, the chief executive of the Epilepsy Foundation of Florida, watched on Monday as counselors navigated the website’s pages with relative ease.
Click. Next page. Click. Next page. The website, HealthCare.gov, was working so well that Ms. Egozi, who oversees the 45 navigators in eight locations who help consumers enroll in health plans, said her team gave the system an 8 on a scale of 1 to 10, meaning that most people got as far as selecting a plan or taking home information to select a plan. It felt like a champagne moment.
“I’m 80 percent satisfied,” Ms. Egozi said. “I think it will be great when it’s 100 percent.”
A little over a week after the deadline that President Obama gave for fixing the federal health care exchange, the system is definitely working better, according to consumers and navigators interviewed in several states. The technical errors that had bedeviled visitors to the site for weeks seemed to have been tamed by the patchwork of hardware and software fixes ordered by the administration, and applicants were finally selecting health care plans under the president’s new law, the Affordable Care Act. By last week, the number of applicants who dropped a plan into their virtual grocery carts was climbing at a rapid clip.
Still, the interviews indicated, some technical obstacles persist. After shoppers clicked all the way to the plans, for example, the system was not letting some people actually choose one. In other cases, people were asked to try again later.
Improved entry into the online marketplace has also exposed a new layer of problems and confusion for applicants who are suddenly finding their efforts to buy insurance delayed by requirements that they provide proof of identity or citizenship or that they wait for determinations on Medicaid eligibility.
For the most part, though, the news for the beleaguered online exchange, which serves 36 states, is improving. Since early December, the federal exchange website has run without crashing, officials said. In the first week of December, about 112,000 people selected plans — compared with about 100,000 in all of November and only 27,000 in October. Last week, more than half a million people created accounts on the federal website, according to people familiar with the health care project.
Technical experts involved with the exchange said they are now preparing for a surge of applications before Dec. 23, the enrollment deadline to receive coverage by the first of the year. Although those preparations will require some significant changes to the system, the work will be easier now that the site seems stable during heavy use, the experts said.
In offices spread across the country, from Florida and Pennsylvania to Wyoming and Wisconsin, all of them states that rely on the federal government’s insurance exchange, navigators and applicants reported far fewer problems.
“I was hearing so much about the glitches in the system that I was worried that it wouldn’t work,” said Caroline Moseley, 54, who lost her job as a housing program analyst for the City of Philadelphia. After asking a navigator from the nonprofit Resources for Human Development for help in finding a plan, Ms. Moseley chose one that costs $27 a month with a $6,000 deductible. “It was a great experience,” she said. “The site was running very smoothly. It took about 30 minutes tops.”
Stephanie Lincoln, 60, of Lansdowne, Pa., also had quick success with the exchange — after a frustrating experience trying to submit an application online in October and November. With the help of a navigator, Caroline Picher, working at the local library, Ms. Lincoln signed up in just one hour on Friday for a policy that will cost $113 a month, with no deductible.
“I am one of the people whose plans were canceled,” Ms. Lincoln said. “It was just the easiest thing in the world.” . . .
Brian Beutler discusses the improved performance and links to other reports of progress; from his article:
. . . Here’s one from the State in South Carolina:
An elbow-injuring fall in March proved nearly as painful financially as physically for Carolyn Gates, who was uninsured and ended up with an $8,000 bill for her emergency room visit.
She felt much better Wednesday after a visit to the S.C. Progressive Network’s Columbia office, where she worked with Navigator Tim Liszewski to sign up on the Health Insurance Marketplace under the Affordable Care Act. While Gates and her husband slowly pay off that emergency room debt, she’ll also be paying a $107-per-month health insurance premium next year.
“As far as I’m concerned, it was the best thing ever,” Gates said. “I told my Bible study about it, and three said they’re going to sign up.”
And here are several more from the St. Louis Post Dispatch:
At the Columbia location of Primaris Healthcare Business Solutions, an enrollment event Monday proved successful for all of its visitors. Jeremy Milarsky, navigator program manager, said he didn’t experience any website glitches and all of his appointments with consumers ended in successful plan selections.
“Today was, I would say, an enrollment event with a capital ‘E,’” he said.
The St. Louis Area Agency on Aging, another nonprofit group assisting consumers with health insurance enrollment, held several outreach events this week. Mark Smith, case management coordinator, said navigators are still seeing some website problems, but also significant improvement. The new feature that allows users to delete their applications and begin again has helped, he said, and the majority of people at the events have been able to select a plan. . . .
Progress is good, right? Things are looking up (except for those in states that refused to expand Medicare for their citizens).
Becky Bach reports in Pacific Standard:
Thousands of veterans suffering from post-traumatic stress disorder rely on the Department of Veterans Affairs for relief. They might be better served, however, if they tapped the hard-won wisdom of incarcerated Vietnam veteran Michael “Doc” Piper.
Piper knows, though the VA has yet to acknowledge, that community service could be the most effective treatment available for PTSD, a debilitating condition marked by nightmares, anxiety, flashbacks, pain, anger, self-blame, alienation, and depression.
Despite his confinement in Soledad Correctional Training Facility, a California state prison, 67-year-old Piper is a professional volunteer. From a 106-square-foot former broom closet with no Internet access, Piper helps fellow incarcerated veterans access VA benefits. By helping others, Piper says he’s been able to cope with his anger, nightmares, and flashbacks. But he’s not the only one who understands the power of community service.
Mission Continues, a St. Louis-based organization, is generating national attention, including a June 2013 Time cover story, for its success helping veterans who served in Iraq and Afghanistan integrate into society. It’s a dire need: The VA has treated nearly 300,000 veterans from those conflicts for PTSD symptoms, according to a November report. Mission Continues, which was founded in 2007 by a group of veterans, places veterans in six-month service fellowships in community organizations across the country.
Fellows paint hospital walls, collect food donations, and plant gardens, developing career and life skills in the process. And although in-depth studies are lacking, an investigation (PDF) by Washington University in St. Louis social scientist Monica Matthieu, found that Mission Continues helps.
Matthieu and her team surveyed 27 Mission Continues fellows, many of whom have been diagnosed with PTSD. Following their fellowship, 71 percent continued their education and 86 percent were able to find employment.
The VA currently assaults PTSD with a grab bag of treatments. It recommends (PDF) a combination of drugs, most commonly anti-depressants, and therapies including individual and group psychotherapy, hypnosis, and meditation. The department’s 2010 guidelines also recommend social and family skills training, job training, education, and spiritual support. VA therapists even teach stress-tolerance techniques.
For example, . . .
Now this is good legislation, whatever the motive: in 2009 the GOP votes to require that Congress be covered under Obamacare. While the intent was political theater and punitive, the effects are likely to be salutary and good for the country. One has to recognize positive legislative action when it occurs, whatever brings it about. Ryan Cooper writes in the Washington Post:
Right now, one of the primary ways Congressional Republicans are attacking Obamacare is to cite the sob stories of Congressional staffers — and lawmakers themselves — who are having a bad experience with the law. Thanks to a bit of Republican legislative trolling that forced Members and their staffs onto the exchanges to make a political point, some are discovering that premiums are higher than they would have expected, having previously enjoyed the protection of government benefits that essentially shielded them from reality.
But if anything, the fact that Members of Congress are now having an unpleasant brush with the American health care system is a good thing. These Members are experiencing the same American health care system that the uninsured and people with preexisting conditions have been experiencing for many years. They are being forced to face the fact that American health care costs a lot, which, of course, is one of the reasons reform is so hard.
The health care system is already deeply unjust. A good article in the New York Times sheds light on this, and on how Obamacare is changing things for the better:
More than 243,000 have signed up for private coverage through the exchanges…and more than 567,000 have been determined eligible for Medicaid…For many, particularly people with existing medical conditions… the coverage is proving less expensive than what they had. Many others are getting health insurance for the first time in years, giving them alternatives to seeking care through free clinics or emergency rooms — or putting it off indefinitely.
Kevin Drum adds a related note about how hospitals routinely gouge uninsured people for everything they’ve got:
A heart attack that gets billed—profitably!—to Blue Cross at $50,000, can end up costing you $200,000 if you’re unlucky enough to suffer that heart attack while you’re uninsured. Think about that: for decades, the health care industry has deliberately taken ruthless advantage of the very people who are the weakest and most vulnerable—those who are poor or unemployed… It’s shameless and obscene. It’s like kicking a beggar and stealing his coat just because you know the cops will never do anything about it.
Obamacare, by slowing bringing everyone into the insurance system, will eventually stop this. Compare that to Rep. Michael McCaul (who with at least $114 million is the second-richest member of congress) complaining that the new plans on the DC health exchange are expensive.
This sort of experience is unvarnished good news. Finally, wealthy members of congress are getting a tiny, tiny taste of how the healthcare sector actually works. Five decades of skyrocketing health price inflation didn’t inspire so much as a peep when Republicans held all three branches of government. But now that Republicans have derped themselves onto the exchanges, they’re shocked, shocked at how expensive things have gotten. . .
The NY Times has an excellent editorial:
Beyond new state efforts to restrict women’s access to proper reproductive health care, another, if quieter, threat is posed by mergers between secular hospitals and Catholic hospitals operating under religious directives from the nation’s Roman Catholic bishops. These directives, which oppose abortions, inevitably collide with a hospital’s duty to provide care to pregnant women in medical distress. This tension lies at the heart of a federal lawsuit filed last week by the American Civil Liberties Union.
The suit was brought on behalf of a Michigan woman, Tamesha Means, who says she was subjected to substandard care at a Catholic hospital — the only hospital in her county — after her water broke at 18 weeks of pregnancy. Doctors in such circumstances typically induce labor or surgically remove the fetus to reduce the woman’s chances of infection. But according to the complaint, doctors acting in accordance with the bishops’ directives did not inform Ms. Means that her fetus had virtually no chance of surviving or that terminating her pregnancy was the safest treatment option.
Despite acute pain and bleeding, Ms. Means was sent home twice, and when she returned a third time with a fever from her untreated infection, she miscarried even as the paperwork was being prepared to discharge her again. The fetus died soon after.
The case has gained attention because Ms. Means is not suing the hospital for medical negligence but the United States Conference of Catholic Bishops. The A.C.L.U. is arguing, on her behalf, that having issued the mandates and made them conditions of hospital affiliation, the conference is responsible for “the unnecessary trauma and harm” that Ms. Means and “other pregnant women in similar situations have experienced at Catholic-sponsored hospitals.”
How the suit will play out is unclear, but it showcases an important issue. Catholic hospitals account for about 15 percent of the nation’s hospital beds and, in many communities, are the only hospital facilities available. Allowing religious doctrine to prevail over the need for competent emergency care and a woman’s right to complete and accurate information about her condition and treatment choices violates medical ethics and existing law.
The problem Ms. Means encountered is not unique or limited to her particular medical needs. In 2010, the Diocese of Phoenix punished a nun and stripped a hospital of its affiliation after doctors there performed an abortion to save a mother’s life.
In a statement last Friday, the president of the bishops’ group, Archbishop Joseph Kurtz, said that the religious directives did not encourage or require substandard medical treatment. He also portrayed the case as an attack on religious freedom — the same unpersuasive argument the bishops are making against the new federal health care law’s requirement that all plans include contraception coverage.
The bishops are free to worship as they choose and advocate for their beliefs. But those beliefs should not shield the bishops from legal accountability when church-affiliated hospitals following their rules cause patients harm.
Harold Pollack has an interesting column in the Washington Post:
Healthcare.gov’s troubled rollout brings new attention to competing proposals to alter health coverage for low-income Americans. One group of Republican analysts would largely replace Medicaid with some combination of primary care supports and catastrophic coverage. Others wouldn’t go that far but would make greater use of patient cost-sharing to provide incentives for disciplined use of medical services.
Ross Douthat has put the argument well in some thoughtful columns.
[C]omprehensive health insurance is, at its heart, a deeply wasteful use of resources: Modern people, and especially modern Americans, are much more likely to overconsume health care than to underconsume it… This doesn’t mean that social insurance shouldn’t protect people against adverse medical outcomes and unaffordable medical bills, but it suggests that there are better ways to allocate our resources than comprehensive coverage, and that most people would be better off if public policy didn’t push so much money into that direction.
Economic intuition suggests that Harold Pollack and Ross Douthat alike would use care more efficiently if we had more skin in the game, if we were less comprehensively insured. Sure enough, non-poor participants in the RAND Health Insurance Experimentused roughly one-third less care when they were enrolled in something akin to a catastrophic plan than did their counterparts who were enrolled in more generous plans. Despite their reduced service use, participants in the catastrophic plan also appeared, on average, to be just as healthy. Such findings provide a powerful argument for catastrophic plans. (Recent results from the Oregon Medicaid experiment are another matter.)
The cracks in this argument become more noticeable when one shifts attention from the typical insured person to the typical insurance dollar spent for patient care, particularly when one considers the vulnerable populations overrepresented among public insurance recipients.
Most people are light users of medical care. As Aaron Carroll regularly emphasizes, expenditures are concentrated within a group of costly patients with complex conditions, many of whom would hit any reasonable catastrophic coverage cap and who are poorly placed to manage the practicalities and financial risks associated with their medical care.
Although I’m curious to see how healthy, affluent professionals would purchase (say) knee and hip replacements if they faced the full costs, this won’t save much money. Most people in a position to make such choices don’t consume much health care. The real money is spent on patients like my relative who is recovering from a nasty stroke. For all sorts of reasons, giving him something other than comprehensive coverage seems unwise.
These distributional realities hold especially true among poor people. Figure 1 shows 2012 data for Illinois’s 3.2 million Medicaid recipients, ranked by percentile from lowest to highest expenditure. The top line shows cumulative Medicaid spending. The bottom bars show average annual expenditures in dollars. (If you look closely, you’ll notice straight lines where I interpolated between available data points.)
The bottom 72 percent of Illinois Medicaid recipients account for 10 percent of total program spending. Average annual expenditures in this group were about $564, virtually invisible on the chart. We can’t save much money through any incentive system aimed at the typical Medicaid recipient. We spend too little on the bottom 80 percent to get much back from that. We probably spend too little on most of these people, anyway. For the bulk of Medicaid beneficiaries, cost control is less important than improved prevention, health maintenance and access to basic medical and dental services.
The real financial action unfolds on the right side of the graph, where expenditures are concentrated within a small and incredibly complicated patient group. The top 3.2 percent of recipients account for half of total Medicaid spending, with average expenditures exceeding $30,000 annually.
Many of these men and women face life-ending or life-threatening illnesses, as well as cognitive or psychiatric limitations. These patients cannot cover co-payments or assume financial risk. In theory, one might impose patient cost-sharing with some complicated risk-adjustment system. In practice, that is far beyond current technologies and administrative capabilities. Even if such a system were available, we couldn’t push the burden of medical case management onto these patients or their families.
The Affordable Care Act’s Medicaid-expansion population won’t include traditional dual-eligible and nursing home patients who make up much of that 3.2 percent. The new group will still include a mix of basically healthy adults alongside more costly recipients with complicated problems who will account for the bulk of actual spending.
In my view, the best way to improve Medicaid is to tackle three inter-related challenges.
First, . . .
Kevin Drum calls it like it is. Some Republican states seem desperate to prevent the poor from getting any help whatsoever. A friend in a red state who is a rabid Republican (and former Methodist minister) explained that they don’t want the poor to get such help because it will foster “dependency”. By preventing the poor from getting (for example) healthcare, they are actually helping the poor. Jesus wept.
And do read the article linked in Drum’s post:
Under Obamacare, if your income is less than 100 percent of the poverty line, you don’t qualify to buy subsidized insurance on the exchanges but you do qualify for Medicaid. Unless, that is, your state has refused to participate in Obamacare’s Medicaid expansion. In that case you don’t qualify for anything.
Dylan Scott has a piece at TPM about health care navigators who have to break this news to people. Here’s the saddest passage:
In some cases, those being left out seem to understand, having been left out of the health insurance complex for a while, said Cynthia Rahming, who is heading the Houston, Texas, navigator program. She did agree, though, that her team is “often” coming across people who are part of the Medicaid gap in that state.
“They were excited. They were trying to see what’s available to them,” she said. “But they’re still okay. They know it’s just a chance.”
These are poor people. They mostly represent families making less than $20,000 per year. And yet in many cases, they greet the news that they’re completely excluded from access to health care with weary acceptance. They probably never really believed that anything good might come their way in the first place. In the meantime, multi-millionaires can virtually bring the government of the United States to a screeching halt over the prospect of a 2 percent increase in the marginal rate they pay in income taxes.
The refusal of Republican states to accept Obamacare’s Medicaid expansion surely ranks as one of the most sordid acts in recent American history. The cost to the states is tiny, and the help it would bring to the poor is immense. It’s paid for by taxes that residents of these states are going to pay regardless of whether they receive any of the benefits. And yet, merely because it has Obama’s name attached to it, they’ve decided that immiserating millions of poor people is worth it. It’s hard to imagine a decision more depraved.
Conservatives hate it when you accuse them of simply not caring about the poor. Sometimes they have point. This is not one of those times.
And, unfortunately for her, Missouri is one of the 24 states that refused to expand Medicare (though it would have cost them nothing), so that many in those states are out of luck:
I think it’s worth noting that the legislators who refused to accept the expansion of Medicare do not fall into that gap, and they couldn’t care less about those who do. Obviously.
Here’s the story, by Charles Ornstein in Pacific Standard:
For Missouri public radio reporter Harum Helmy, the Affordable Care Act is more than just a story she covers. It is also a story she’s living.
“I know — an uninsured health reporter,” she wrote to me last month. “The joke’s not lost on me.”
Helmy, 23, a part-time reporter/producer for KBIA in Columbia, Missouri, recently completed her coursework at the University of Missouri. She’s on her first professional job. At the station, she covers Obamacare, among other things. But she doesn’t make much money, and if the law worked as it was intended, she would be covered by Missouri’s Medicaid program beginning January 1.
That wasn’t meant to be.
As signed by President Obama, the Affordable Care Act (ACA) would have required every state to expand its Medicaid program for the poor to include adults earning less than 138 percent of the federal poverty level. Those earning more than that, up to four times the poverty level, would qualify for subsidies to purchase health insurance in marketplaces.
But the Supreme Court ruled last year that states could opt out of the Medicaid expansion without consequence, and Missouri along with 24 other states have done just that. The problem is that the law didn’t include subsidies for people in those states who earn less than the federal poverty level to buy coverage through the exchanges—they were supposed to be covered under Medicaid.
That’s the gap in which Helmy sits.
She earns less than the poverty level ($10 an hour for 20 hours per week) and qualifies neither for Medicaid nor a subsidy. Helmy was born in Texas and is a U.S. citizen, though her parents live in Indonesia. While she attended classes at the university, her parents paid for her health coverage.
According to the Kaiser Family Foundation, a non-partisan think tank, “In states that do not expand Medicaid, nearly 5 million poor uninsured adults have incomes above Medicaid eligibility levels but below poverty and may fall into a ‘coverage gap’ of earning too much to qualify for Medicaid but not enough to qualify for Marketplace premium tax credits.” In Missouri, 193,000 people, including Helmy, fall into the gap, Kaiser estimates.
On paper, the Medicaid expansion seems like a great deal. The federal government has agreed to pick up 100 percent of the cost of the expansion for the first three years, phasing down to 90 percent in 2020. But officials in states that have declined to take part view Medicaid as a broken program. They don’t trust the federal government to keep its funding pledge and do not believe they have adequate state funds to cover their portion.
Missouri Governor Jay Nixon, a Democrat, wants to expand Medicaid in his state, but the Republican-controlled Legislature won’t go along with it.
Helmy discussed her situation in a podcast in October (around the 12-minute mark). “I would just get a little bit personal here and say I’m one of those people,” she said. “I’m in this weird gap where I need insurance, my employer doesn’t give me insurance, but I don’t make enough to get a subsidy.”
I asked her what it felt like to be affected by the act. . . .
I think as people in the 24 states become aware that their legislators turned down free money that would have enabled them to have healthcare insurance, and they see that people making less than they get coverage, and people getting more than they are covered, the people left out in the cold are going to get amazingly angry. We may seem some interesting surprises in the November 2014 elections in those states.
Ezra Klein makes a very good point: in the old days, people were terrified of losing their healthcare insurance (employer provided or not). If they left the company, they would lose their medical benefits. If they were covered on an individual plan that was cancelled for any reason, there was no guarantee that they could get another. If they had a chronic illness, they were unable to get any individual healthcare insurance at all. Klein writes:
The furor over “if you like your plan, you can keep it” touches on a deep fear in American life: That your health-care insurance can be taken from you. That fear is so powerful because it happens so often: Almost everyone in the country can lose their health insurance at any time, for all kinds of reasons — and every year, millions do.
If you’re one of the 149 million people who get health insurance through your employer, you can lose your plan if you get fired, or if the H.R. department decides to change plans, or if you have to move to a branch in another state.If you’re one of the 51 million people who get Medicaid, you could lose your plan because your income rises and you’re no longer eligible or because your state cut its Medicaid budget and made you ineligible. You could lose it because you moved from Minnesota, where childless adults making less than 75 percent of the poverty line are eligible, to Texas, where there’s no coverage for childless adults.
If you’re one of the 15 million Americans who buys insurance on the individual market, you could lose your plan because your insurer decides to stop offering it or decides to jack up the price by 35 percent. And that’s assuming you’re one of the lucky people who weren’t denied coverage based on preexisting conditions in the first place.
Then, of course, there are the 50 million people who don’t have a plan in the first place. The vast majority of them desperately want health-care coverage. But it turns out that just because you want a plan doesn’t mean you can get one.
Virtually the only people whose health coverage is reasonably safe are those on fee-for-service Medicare and some forms of veterans insurance. And even there, enrollees are only safe until the day policymakers decide to change premiums or benefit packages.
President Obama’s critics are right: Obamacare doesn’t guarantee that everyone who likes their health insurance can keep it. In some cases, Obamacare is the reason people will lose health insurance they liked.
What Obamacare comes pretty close to guaranteeing, though, is that everyone who needs health insurance, or who wants health insurance, can get it.
It guarantees that if you lose the plan you liked — perhaps because you were fired from your job, or because you left your job to start a new business, or because your income made you ineligible for Medicaid — you’ll have a choice of new plans you can purchase, you’ll know that no insurer can turn you away, and you’ll be able to get financial help if you need it. In states that accept the Medicaid expansion, it guarantees that anyone who makes less than 133 percent of poverty can get fully subsidized insurance.
Health insurance isn’t such a fraught topic in countries such as Canada and France because people don’t live in constant fear of losing their ability to get routine medical care. . .
A series of charts that compares various aspects of healthcare:
Total expenditures, with proportion covered by government and not
Out-of-pocket expenses by country
Proportion of people with public insurance that buy private insurance
Total healthcare expenditures by country
Proportion of people who do not seek medical aid because of costs
Costs for routine doctor visits by country
Prescription drug and screening costs
And yet I believe that many still hold to the idea that the US offers “the best healthcare system in the world.”
Quite a few conservative voices are raised in an outcry about contraception coverage under the Affordable Care Act, which requires companies with more than 50 employees to provide health insurance coverage that includes, among other things, contraceptive services. NOTE: There is no requirement that any individual actually use such services: that is left up to the personal religious convictions of the individual. Businesses, however, hate to pay money, so some are saying that they should not be required to pay for insurance that includes contraceptive coverage because they (the business owners) don’t believe in it. In other words, the business owners want to impose their own religious views on their employees, which I think is wrong.
So a question to ask those espousing such a view: “Do you believe that a large business owned by Christian Scientists should be allowed not to offer healthcare insurance at all, since the owners do not believe in medical services in general?”
UPDATE: Emily Baxter has an interesting post at ThinkProgress on the general topic of healthcare insurance and religious liberty: Despite The Fights Over Religious Liberty, Obamacare Doesn’t Have To Be ‘Girl Versus God’
Though some GOP arguments certainly seem like wrecks of one sort or another. Kevin Drum tries to set the record straight at Mother Jones:
Here’s the astonishing statement that started this kerfuffle:
Kevin Drum responds:
One of the most maddening aspects of the debate over Obamacare isn’t simply the fact that conservatives dislike it, but the fact that they seem unable even to understand what the point is. Via Ed Kilgore, here is Georgia state insurance commissioner Ralph Hudgens—surely a guy who should understand what insurance is and how it works—comparing pre-existing condition requirements to having a car wreck:
A pre-existing condition would be then you calling up your insurance agent and saying, “I’d like to get collision insurance coverage on my car.” And your insurance agent says, “You’ve never had that before, why would you want it now?” And you say, “Well I just had a wreck, it was my fault, and I want the insurance company to pay for the repairs to my car.” And that’s the exact same thing on pre-existing insurance.
Well, sure, it’s the exact same thing except for the fact that it has nothing in common whatsoever. In fact, this is basically a defense of the individual mandate, though Hudgens doesn’t seem to understand that either.
People with pre-existing conditions aren’t folks trying to scam the system. They’re just people who got sick. And Republicans simply have no realistic plan for allowing them access to affordable health care. This is a problem for the GOP, because unlike the $100-a-plate crowd that tittered at Hudgens’ story, most people understand that pre-existing conditions can happen to anyone. That’s why Obamacare’s requirement for community rating—i.e., for insurance companies to cover people with pre-existing conditions at the same price as anyone else—is so popular. What most people don’t quite understand is that this is what produces the rest of Obamacare too. If insurance companies have to cover people with pre-existing conditions, they’ll go out of business unless they cover everyone else too. That way the entire insurance pool covers the small number who get seriously sick in any given year. So you have to have an individual mandate. But lots of people can’t afford insurance. So if you have an individual mandate, you have to have subsidies for low-income workers. And with that, you have community rating, the individual mandate, and subsidies. And that’s about 90 percent of what Obamacare is.
It’s one thing to oppose Obamacare. But Republicans have no realistic alternative. They can blather away about tort reform and HSAs forever, but even low-information voters dimly understand that it’s just blather. Either you’re going to cover sick people or you aren’t. And if you do, you’re going to end up with something that has most of the same features of Obamacare. Smarter Republicans understand this perfectly well, which is why they dance around the issue so manically. They know that their plans don’t actually provide health coverage for much of anyone at all. Dimmer Republicans like Hudgens don’t have a clue, so they just tell dumb stories to well-heeled crowds. I’m not really sure which is worse.
This amounts to fraud. Read and think about what this reveals about the GOP. And let’s wait for the news stories that will be coming out just about this time next year, when every heart-tugging talk show segment in the land will feature stories of 20-somethings whose lives have been ruined because they were convinced not to get health insurance, that going uninsured would be a good idea. “And now, here I am…” <breaks down in sobs>
Talk shows won’t be able to resist because those stories will resonate with the audience, particularly with those able to pat themselves on the back for being smart enough to have healthcare insurance.
But read at the link. Unfortunately, believable.
Interesting article by R.J. Eskow in Salon:
You don’t have to be an unqualified fan of the Affordable Care Act to recognize the lunacy of most Republican objections to it. From “death panels” to “a loss of liberty,” there’s only one consistent through-line to most of their objections: They come from Republicans, they’re directed at a Democratic president, and they’re irrational.
The president’s self-imposed deadline for fixing the website has arrived and, while it’s still far from perfect, the complaints are likely to become broader once again. The Republicans may not realize it, but that way lies danger.
More than once, Democrats have made the mistake of taking victory laps for a plan with very real problems. But the Republicans are setting traps for themselves – traps they may find it difficult to escape, especially if Democrats are shrewd enough to take advantage of them.
This shortsightedness already wounded them once, in the 2012 election, when candidate Mitt Romney was forced to attack a program that was nearly identical to the one thatGov. Mitt Romney implemented in Massachusetts. It looked absurd – because it was. Romney’s campaign was probably always a lost cause, but that didn’t help.
For the Republicans, there’s more where that came from.
The trouble starts with their gleeful rubbing of hands over the Healthcare.gov rollout. Gloating about the website is unwise for a couple of reasons. First, the website’s design and implementation was conducted by a private government contractor, CGI Global, not by government employees. There are many lessons to be learned from the website’s problems, but one of them clearly seems to be this: The privatization of government services, a key goal for the Republican Party, can work very poorly.
Accounts of the Obamacare implementation read like a how-to manual in inept contracting with outside corporations, and the administration deserves to take a hit for that. But the problem isn’t that government created the website. A larger part of the problem lies in the fact that it used a private contractor to do the job.
Worse, the administration chose to use a company whose specialty was not healthcare administration but “government contracting.” The fact that this is now an industry of its own, and one with enormous growth, shows just how far the privatization trend has come on the federal level.
That’s a problem. Professional government contractors know how to game the government procurement system for maximum profits, and those profit margins are added to the cost for taxpayers.
CGI Global, the all-purpose government contractor that handled the website, is a case in point. Even though the Obama administration has made a point of saying government should end no-bid contracts, this project – the most important of Obama’s presidency – was offered on a no-bid contract.
As someone who once led a company that contracted with government agencies, I can tell you that somebody “worked the system” extremely well on this one. Unfortunately, the “system” works much better for the contractors than it does for the public. Every time Republicans crow about the website’s problems, another thought should be implanting itself in the public’s mind: privatizing government services is a very bad idea.
The challenge for Republicans runs even deeper than that. They’ve been mocking the very concept behind the Obamacare exchanges. It’s a concept that made the rollout extremely difficult. The idea was that government would create an electronic “marketplace” where people could comparison-shop for health insurance. This, we were told, would keep costs down by employing market forces and competition.
This also happens to be an excellent way to describe the Republicans’ plan for Medicare. The description is still up at Rep. Paul Ryan’s website:
Beginning in 2024, for those workers born in 1959 or later, Medicare would offer them a choice of private plans competing alongside traditional fee-for-service option(sic) on a newly created Medicare Exchange (emphasis ours) … The Medicare Exchange would provide all seniors with a competitive marketplace where they could chose a plan the same way members of Congress do.
Every time the Republicans tell horror stories or make fun of the ACA’s exchange, they’re telling people that their own plan for Medicare is going to turn the most popular, cost-effective and successful health plan in the country into a tragedy – or a joke.
They’re also sabotaging their own arguments for privatizing Social Security. The plan that George W. Bush proposed in 2005 called upon the government to administer a portfolio of private investment plans on behalf of retirees. There’s still talk of reviving this GOP proposal. Rep. Paul Ryan, leading House Republican and 2012 vice-presidential candidate, continues to push a privatization scheme that even the Bush administration described as “irresponsible.”
As Obamacare goes, so goes the Social Security privatization plan.
There’s a reason why their negative characterizations of Obamacare match their own proposals so closely. As many people know, the Affordable Care Act began its life as a right-wing proposal meant to blunt the drive toward healthcare reform during the Clinton administration. Republicans loved the idea back then. They loved it when Gov. Arnold Schwarzenegger proposed something similar in California. And they loved it when future presidential candidate Mitt Romney implemented it in Massachusetts.
That’s why they’re in such a trap now. Their attacks have already trashed the credibility of the Heritage Foundation, which was a principal architect of the plan back in the Clinton years. The Heritage Foundation’s Robert Moffit brought ridicule on himself and his organization when he wrote that the ACA’s individual mandate was “an Unconstitutional Violation of Personal Liberty” that “Strikes at the Heart of American Federalism,” adding that “It is an assertion of federal power that is inherently at odds with the original vision of the Framers.”
In fact, most experts agree that the idea of the individual mandate originated with the Heritage Foundation itself in a 1989 paper that proposed that the government “mandate all households to obtain adequate insurance.” The paper by Stuart M. Butler argues that:
Many states now require passengers to wear seatbelts for their own protection. Many others require anybody driving a car to have liability insurance. But neither the federal government nor any state requires all households to protect themselves from the potentially catastrophic costs of a serious injury or illness.
The paper continues, “Under the Heritage plan, there would be such a requirement.” And in case there is still any doubt about whose plan contains this individual mandate proposal, the section of the document containing these words is titled “The Heritage Plan.”
Then there’s the issue on which Republicans have scored most heavily . . .
“Doesn’t Eat, Doesn’t Pray, Doesn’t Love” begins:
The question of whether for-profit companies can claim a religious identity, one that exempts them from obeying a generally applicable law, is fully worthy of the attention the Supreme Court is about to give it. But to the extent that much of the commentary about the challenges to the Affordable Care Act’s contraception-coverage insurance mandate frames the issue as a debate about the rights of corporations – as a next step beyond Citizens United’s expansion of corporate free speech – I think it misses the point. What really makes these cases so rich, and the reason the court’s intervention will dramatically raise the temperature of the current term, lies elsewhere.
The religious-based challenges that have flooded the federal courts from coast to coast – more than 70 of them, of which the Supreme Court agreed on Tuesday to hear two – aren’t about the day-in, day-out stuff of jurisprudence under the First Amendment’s Free Exercise Clause: Sabbath observance, employment rights, tax exemptions. They are about sex.
As such, the cases open a new front in an old war. I don’t mean the overblown “war on religion” that some Catholic leaders have accused the Obama administration of waging. Nor do I mean the “war on women” that was such an effective charge last year against a bevy of egregiously foot-in-mouth Republican politicians.
I mean that this is the culture war redux – a war not on religion or on women but on modernity.
All culture wars are that, of course: the old culture in a goal-line stance against a new way of organizing society, a new culture struggling to be born. Usually, that’s pretty obvious. This time, somehow, it seems less so, maybe because the battle is being fought in the complex language of law, namely a 20-year-old law called the Religious Freedom Restoration Act.
This tendentiously named statute, aimed at overturning a 1990 Supreme Court decision that cast a skeptical eye on claims to religious exemptions from ordinary laws, provides that the government “shall not substantially burden a person’s exercise of religion” unless the burden serves a “compelling” government interest and is the “least restrictive means” of doing so.
What’s a substantial burden? What governmental interest is sufficiently compelling? And with particular respect to the two new Supreme Court cases, is a for-profit corporation a “person” that can engage in religious exercise? . . .
Excellent article from Neil Irwin, combining some statements from Pope Francis and some interesting charts. Take a look at this one, since the US healthcare system (“Best in the world!!” ™) is in the news a lot:
The X axis is the health spending per capita. The US is very far to the right: we spend more per person than any other nation.
The Y axis is the quality of care received, as measured by outcomes. Look at all those nations with better quality of healthcare—i.e., all those higher than the US in the chart.
We have a bad system, but perhaps with the Affordable Care Act it will get better. Who knows, at some point the US might even have healthcare as good as that offered by other nations.
Paul Krugman points out the successes the Affordable Care Act has already achieved. He begins:
The law establishing Obamacare was officially titled the Patient Protection and Affordable Care Act. And the “affordable” bit wasn’t just about subsidizing premiums. It was also supposed to be about “bending the curve” — slowing the seemingly inexorable rise in health costs.
Much of the Beltway establishment scoffed at the promise of cost savings. The prevalent attitude in Washington is that reform isn’t real unless the little people suffer; serious savings are supposed to come from things like raising the Medicare age (which the Congressional Budget Office recently concluded would, in fact, hardly save any money) and throwing millions of Americans off Medicaid. True, a 2011 letter signed by hundreds of health and labor economists pointed out that “the Affordable Care Act contains essentially every cost-containment provision policy analysts have considered effective in reducing the rate of medical spending.” But such expert views were largely ignored.
So, how’s it going? The health exchanges are off to a famously rocky start, but many, though by no means all, of the cost-control measures have already kicked in. Has the curve been bent?
The answer, amazingly, is yes. In fact, the slowdown in health costs has been dramatic.
O.K., the obligatory caveats. First of all, we don’t know how long the good news will last. Health costs in the United States slowed dramatically in the 1990s (although not this dramatically), probably thanks to the rise of health maintenance organizations, but cost growth picked up again after 2000. Second, we don’t know for sure how much of the good news is because of the Affordable Care Act.
Still, the facts are striking. Since 2010, when the act was passed, real health spending per capita — that is, total spending adjusted for overall inflation and population growth — has risen less than a third as rapidly as its long-term average. Real spending per Medicare recipient hasn’t risen at all; real spending per Medicaid beneficiary has actually fallen slightly.
What could account for this good news? One obvious answer is . . .
We’ll be reading more and more of these as people complete their searches and sign up. Michael Hiltzik writes in the LA Times:
Last summer Ellen Holzman and Meredith Vezina, a married gay couple in San Diego County, got kicked off their long-term Kaiser health plan, for which they’d been paying more than $1,300 a month. The cause wasn’t the Affordable Care Act, as far as they knew. They’d been living outside Kaiser’s service area, and the health plan had decided to tighten its rules.
That’s when they discovered the chilly hazards of dependence on the individual health insurance market. When they applied for a replacement policy with Anthem Blue Cross of California, Ellen, 59, disclosed that she might have carpal tunnel syndrome. She wasn’t sure–her condition was still being diagnosed by Kaiser when her coverage ended. But the possibility was enough to scare Anthem. “They said, ‘We will not insure you because you have a pre-existing condition,’” Holzman recalls.
But they were lucky, thanks to Obamacare. Through Covered California, the state’s individual insurance marketplace, they’ve found a plan through Sharp Healthcare that will cover them both for a total premium of $142 a month, after a government subsidy based on their income. They’ll have a higher deductible than Kaiser’s but lower co-pays. But their possible savings will be impressive.
More important than that was knowing that they couldn’t be turned down for coverage come Jan. 1. “We felt we didn’t have to panic, or worry,” Holzman says. “If not for the Affordable Care Act, our ability to get insurance would be very limited, if we could get it at all.”
Holzman and Vezina are exactly the type of people Obamacare is designed to help–indeed, rescue from the cold, hard world of individual health insurance of the past. That was a world where even an undiagnosed condition might render you uninsurable. Where your insurance could be canceled after you got sick or had an accident. Where your financial health was at risk as much as your physical well-being.
These are the stories you’re not hearing amid the pumped-up panic over canceled individual policies and premium shocks–many of which stories are certainly true, but the noise being made about them leads people to think they’re more common than they are.
We’ve compiled several alternative examples for this post. They’re anecdotes, sure, just like the anecdotes you’ve been seeing and reading about people learning they’ll be paying more for coverage next year.
The difference is that Americans learning that they’ll be eligible for coverage perhaps for the first time, or at sharply lower cost, are far more typical of the individual insurance market. Two-thirds of the 30 million Americans who will be eligible for individual coverage next year are uninsured today, whether because they can’t afford it now or because they’re barred by pre-existing condition limitations, which will no longer be legal. And more than three-quarters will be eligible for subsidies that will cut their premium costs and even co-pays and deductibles substantially.
Let’s hear from a few more of them.
David Shevlino, 51, is an artist in Delaware. Between the COBRA policy that extends the coverage his wife, Kathy, received at a former job and the bare-bones policy that covers himself and their 15-year-old son, they’ve been laying out $1,000 a month in premiums. Next year they’ll pay $650 a month, after the government subsidy, for a plan through Blue Cross of Delaware that covers the entire family and provides many services that have been excluded up to now.
That makes a big difference, especially for Kathy, who is still dealing with injuries she suffered in a cycling accident and that would have made her uninsurable once her COBRA ran out less than a year from now. “She had already been turned down by Aetna and Blue Cross, the very company that will now insure her,” Shevlino says. “This is a really significant thing–to me, the fact that insurance companies could turn you down didn’t make sense in terms of what healthcare is supposed to be for.”
And Judith Silverstein, 49, a Californian who was diagnosed with multiple sclerosis in 2007. Her family helps her pay the $750 monthly cost of her existing plan–which she only had because of federal law requiring that insurers who provide employer-based insurance continue to offer coverage if the employer goes out of business, as hers did. Next year she’ll get a subsidy that will get her a good “silver” level plan for $50.
For Silverstein that coverage is indispensable. Her case is relatively mild, but MS is a progressive condition that typically has made its sufferers pariahs of the individual insurance market in the past. “I researched the options,” she says. “Nobody’s going to sell you insurance in the individual market if you have MS.” But these customers can’t be excluded or saddled with big premium markups any more.
It’s not only recipients of subsidies who are benefiting. Jason Noble, 44, who has his own property management firm in Southern California, found a gold plan that will . . .
As Sarah Kliff points out, the following 5 statements are all FALSE:
1. Young adults are uninformed about the health-care law.
2. They don’t want health insurance.
3. They don’t need health insurance.
4. Young people will face steep premiums in the insurance exchanges.
5. Young people aren’t signing up for Obamacare yet.
Not one of the 5 numbered states is true. Ms. Kliff explains why.
Medicare Part D (prescription drug benefit) had a very rocky roll-out and the law was poorly drafted, leaving a famous “donut hold” in the coverage: in go through the year, a person using the benefit will find that for a portion of the year prescriptions were not covered. But in time things got fixed, and now people scream that the politicians had better keep their government hands off Medicare…
Ezra Klein interviews the Mark McClellan in the Wonkblog:
In the months before Obamacare officially launched, the White House health-care team talked often about everything they were doing to make sure Obamacare didn’t become the next Medicare Part D.
Fast forward a few months, and the White House health team is desperately hoping Obamacare becomes the next Medicare Part D.
Medicare Part D is the Medicare Prescription Drug Benefit. It was passed by the Bush administration in 2003 and launched in 2006. The launch, to say the least, didn’t go well.
Seniors were confused by the new options. Some showed up at pharmacies only to find their benefits didn’t work, or the plan they thought they signed up for wasn’t the one they got. The initial enrollment push was a disaster, with far fewer seniors signing up than expected. Two months in, then-Majority Leader John Boehner called it “horrendous.”
But the law recovered. Today, Medicare Part D is widely considered a success. More than 90 percent of seniors are satisfied with the program. Republicans point to it as a model for their future reforms. Democrats expanded it as part of the Affordable Care Act.
This is exactly what the White House is hoping happens with Obamacare.
I asked Mark McClellan, who led the Centers for Medicare & Medicaid Services during Part D’s implementation, whether that was realistic. His answers didn’t foretell a pleasant 2014 for the Obama administration. But they suggested that many critics have written the law off far too early.
Even if HealthCare.gov is repaired, McClellan warned that the law’s problems aren’t anywhere near over. Part D’s worst trials came when people actually began attempting to use their insurance. Obamacare hasn’t even reached that juncture yet — and, worryingly, its sign-up process has been more troubled and more disruptive than Part D’s.
Come January there will be people who had their plans canceled by Obamacare but didn’t or couldn’t sign up for new insurance. There will be people who signed up for new insurance but their application got lost in the tubes. Some of these people will be sick, and interruptions to their care will be dangerous — not to mention widely publicized.
“There’s is a 100 percent chance that this will happen to a nontrivial number of people,” McClellan, who’s now at the Brookings Institution, said. “So the Obama administration needs some kind of plan in place for resolving those cases as rapidly as possible and making sure they get the care they need.”
As of now, McClellan said, enrollment data isn’t worth much. “It is way too early to draw definitive conclusions about ultimate enrollment numbers or whether it’ll be skewed to older, sicker people,” he said.
The Medicare Part D experience was that sign-up was slow at the outset and then rocketed upward in the spring of 2006, toward the end of open enrollment. “By that point, every senior had heard about this program or knew people in it. And everyone was familiar with the delayed enrollment penalty. Those things together led to a big bump in enrollment for people who were procrastinating. But they decided to sign up before the end of open enrollment,” McClellan said.
The White House has been explicitly comforting itself by looking to the enrollment patterns of Medicare Part D. But McClellan isn’t certain they apply. For one thing, . . .
This report by Jenny Gold in the Washington Post gives one hope for US healthcare:
For years, Phil Bretthauer was one of the most expensive patients at Unity Point Health in Fort Dodge, a small town in western Iowa. The 70-year-old was frequently in and out of the hospital with heart attacks, COPD and prostate cancer.
“I always keep thinking, there’s something else coming,” says Bretthauer. “If it’s going to happen, it’s going to happen to me.”
His primary care physician, Dr. Lincoln Wallace, was worried about the same thing.
“It’s a demoralizing position to be in to watch a guy like Phil go out the door and to anticipate that he’ll have some event that will likely either threaten his life or end up in the end of his life, and you have little or no way to stop it from coming,” says Wallace.
But this year, Unity Point – which includes multiple hospitals and doctor practices in Iowa — decided to do something to stop the expensive cycle of illness and readmission for patients like Bretthauer. The hospital signed on to become an accountable care organization, a Medicare program created by the Affordable Care Act that economists say could be a pathway to the holy grail of health care—providing better care at a lower cost.
Here’s how it works: a group of doctors and hospitals get together to form a network responsible for taking care of a group of Medicare patients—in this case, about 9,000 Iowans. If the network can prove it’s keeping those patients healthier and spending less money to do so, it gets to keep some of the savings. The ACO can then use that money to do things Medicare doesn’t usually cover—like reaching out more to patients at home. But if the ACO does not succeed, it may face a financial penalty.
ACOs have become one of the most talked about new ideas in Obamacare, touted as a way to help fix an inefficient payment system that rewards more, not better, care. About 4 million Medicare beneficiaries are now in an ACO, and more than 428 hospitals have signed up for either the Medicare program or a private ACO. An estimated 14 percent of the U.S. population is now being served by an ACO.
‘Now, I Have Some Way To Get Care To Them’
Wallace, who is not only Bretthauer’s physician but is also medical director of Unity Point’s ACO, in charge of managing other doctors in the program, believes the ACO has dramatically changed some patients’ care.“Now, if I have someone with multi-organ system stuff or I know that they’re alone, I have some way to get care to them. And we can only do that because our system is able to figure out a way to make it work financially,” he says.
One of the most important aspects is coordinating care for patients among primary care doctors, specialists and other providers.
Wallace started by identifying the patients, like Bretthauer, who were sickest and costing the most. At the time, Bretthauer had recently spent three weeks in the hospital after a heart attack, followed by another two weeks in a rehab facility. When he finally got home to his apartment, he was sick, alone, and depressed.
“I was just so down. I didn’t have anything to do. I’d get up in the morning and sit in this chair for eight hours,” Bretthauer recalls.
Wallace formed a team to care for Bretthauer, made up of doctors, nurses and home health workers.
At the center is home health nurse Tammy Bennett, who visits Bretthauer at his apartment every week or so to check in on him and go over all 17 of his medications.
“He needs to know why he’s taking it, what he’s taking, and we need to make sure we’re all on the same page. And if there are any changes, I notify the doctor,” explains Bennett. During a recent visit, Bennett discovered that Bretthauer was accidentally double-dosing on one of his medications.
When Bennett can’t be there, a telemonitor at Bretthauer’s apartment collects and transmits his vital signs. This allows Unity Point to know exactly what’s going on at any given moment and make changes, possibly averting an emergency room visit.
And Bretthauer says he is much more engaged in his health now. “I feel protected. If something goes wrong, I call them, they get involved. It makes me feel safe,” he says.
Team Work Throughout The System
Unity Point’s expanded focus on monitoring and data collection extends beyond the home and into the hospital. With the help of an electronic medical record system, the hospital now collects data on each of their physicians to monitor how they’re doing compared to their peers.
“We know what each guys per member per month costs are. I can even drill it down in terms of age, diagnoses, how many people are doing well with their cholesterol control, their diabetes control, their immunization rates,” says Dr. Wallace.
And if a doctor isn’t doing so well, Wallace approaches them with the facts and some potential solutions. Usually they adjust, he says.
But there are some things that can’t be quantified. Earlier this year, Phil was hospitalized for major depression. When he got out, he was worried he’d be back to sitting in that chair, eight hours a day. Nurse Bennett knew she had to do something to keep him from slipping back into a depression.
“Tammy asked me what do you like to do? And I said well I’ve announced at a NASCAR track, and I was involved in baseball,” says Bretthauer. So Bennett helped him get a gig announcing at the Little League games six nights a week.
And when baseball season ended, she helped him volunteer at the rehab facility where he’d been a patient just a year before. Bretthauer visits the facility few times a week now—spending time with residents and his favorite: calling the Bingo games.
Bretthauer says being part of Unity Point’s new efforts has been a lifesaver. And as for the hospital, its care really has gotten better. Patients, including Bretthauer, are healthier and aren’t coming to the hospital as often.
And while the hospital system has not saved enough money to get a bonus just from Medicare yet, they’re hopeful for next year.