Archive for the ‘Healthcare’ Category
Texas is quite solidly in the grip of the GOP, which even now is closing down all the abortion clinics in the state—a highly dangerous step from the point of view of public health. Back-alley abortions are dangerous, and it’s silly to think that abortions will simply stop. They won’t, as we know from decades of experience. But it’s even worse: read this Texas Observer article by Dr. Rachel Pearson:
The first patient who called me “doctor” died a few winters ago. I met him at the St. Vincent’s Student-Run Free Clinic on Galveston Island. I was a first-year medical student then, and the disease in his body baffled me. His belly was swollen, his eyes were yellow and his blood tests were all awry. It hurt when he swallowed and his urine stank.
I saw him every Thursday afternoon. I would do a physical exam, talk to him, and consult with the doctor. We ran blood counts and wrote a prescription for an antacid—not the best medication, but one you can get for $4 a month. His disease seemed serious, but we couldn’t diagnose him at the free clinic because the tests needed to do so—a CT scan, a biopsy of the liver, a test to look for cancer cells in the fluid in his belly—are beyond our financial reach.
He started calling me “Dr. Rachel.” When his pain got so bad that he couldn’t eat, we decided to send him to the emergency room. It was not an easy decision.
There’s a popular myth that the uninsured—in Texas, that’s 25 percent of us—can always get medical care through emergency rooms. Ted Cruz has argued that it is “much cheaper to provide emergency care than it is to expand Medicaid,” and Rick Perry has claimed that Texans prefer the ER system. The myth is based on a 1986 federal law called the Emergency Medical Treatment and Labor Act (EMTALA), which states that hospitals with emergency rooms have to accept and stabilize patients who are in labor or who have an acute medical condition that threatens life or limb. That word “stabilize” is key: Hospital ERs don’t have to treat you. They just have to patch you up to the point where you’re not actively dying. Also, hospitals charge for ER care, and usually send patients to collections when they cannot pay.
My patient went to the ER, but didn’t get treatment. Although he was obviously sick, it wasn’t an emergency that threatened life or limb. He came back to St. Vincent’s, where I went through my routine: conversation, vital signs, physical exam. We laughed a lot, even though we both knew it was a bad situation.
One night, a friend called to say that my patient was in the hospital. He’d finally gotten so anemic that he couldn’t catch his breath, and the University of Texas Medical Branch (UTMB), where I am a student, took him in. My friend emailed me the results of his CT scans: There was cancer in his kidney, his liver and his lungs. It must have been spreading over the weeks that he’d been coming into St. Vincent’s.
I went to visit him that night. “There’s my doctor!” he called out when he saw me. I sat next to him, and he explained that he was waiting to call his sister until they told him whether or not the cancer was “bad.”
“It might be one of those real treatable kinds of cancers,” he said. I nodded uncomfortably. We talked for a while, and when I left he said, “Well now you know where I am, so you can come visit me.”
I never came back. I was too ashamed, and too early in my training to even recognize why I felt that way. After all, I had done everything I could—what did I have to feel ashamed of?
UTMB sent him to hospice, and he died at home a few months later. I read his obituary in the Galveston County Daily News.
The shame has stuck with me through my medical training—not only from my first patient, but from many more. I am now a director of the free clinic. It’s a volunteer position. I love my patients, and I love being able to help many who need primary care: blood pressure control, pap smears, diabetes management. We even do some specialty care. But the free clinic is also where some people learn that there is no hope for the chemotherapy or surgery that they need but can’t afford. When UTMB refuses to treat them, it falls to us to tell them that they will die of diseases that are, in fact, treatable.
St. Vincent’s is the primary care provider for more than 2,000 patients across Southeast Texas. Our catchment area is a strip of coastal plain strung with barrier islands. Drive inland and you start to see live oaks; go toward the coast and the oil refineries loom up over neighborhoods. The most polluting refinery in the nation is here, in Texas City. Our patients are factory workers, laborers, laid-off healthcare workers, the people behind the counters of seafood restaurants. . .
However, the Affordable Care Act will help a lot once it’s up and running—and it will not only improve the nation’s health (because millions and millions will at last be able to get healthcare), it will save money. Look at the Congressional Budget Office calculations of Medicare and Medicaid costs over the past few years (Aug 2010, Aug 2011, Aug 2012, May 2013):
The chart is from a WaPo article by Sarah Kliff, which explains that this decline is probably structural, not cyclical.
But the US has a lot of catching up to do. I urge you to look at the charts in Sarah Kliff’s article comparing US healthcare expenditures and outcomes with those of other countries. We are doing a very poor job. Click that link and see.
I have an acquaintance who strongly opposes the Affordable Care Act, much less a universal single-payer system as used in more advanced countries, because providing healthcare to the poor will “create dependency.” Better that they die, apparently.
Ezra Klein has a good column in the Washington Post:
Hurricane Katrina killed at least 1,833 people and damaged more than $80 billion worth of property. It was one of the deadliest, costliest storms ever to hit the United States.
Meanwhile, the Affordable Care Act’s Web site isn’t working very well yet. So of course the media is asking whether “this is Obama’s Hurricane Katrina.” I look forward to future coverage in this vein: “Is the failure of immigration reform Obama’s 1906 San Francisco Earthquake?” “Are the 2014 sequestration cuts Obama’s 1918 Influenza?”
The interest in comparing HealthCare.Gov to a lethal natural disaster is all the odder because the Bush years actually offer a ready analogue to Obamacare: Medicare Part D.Like Obamacare, Medicare Part D was a massive health-care expansion. Like Obamacare, it was administratively complex. Like Obamacare, the Web site didn’t work on launch. Like Obamacare, people who were supposed to be benefitting from the law found their plans upended and the supposedly superior alternatives inaccessible. Like Obamacare, the early months were, in the words of then-Majority Leader John Boehner, “horrendous.”
Obamacare has been live for about six weeks. At this point in Medicare Part D’s life, here’s what the coverage looked like. Let’s start with NPR:
Many health care professional and policy experts have complained about how complicated the Medicare Part D maze is for millions of elderly and disabled people. That may explain why many people still haven’t signed up for the benefits. Out of the 43 million people in Medicare, only about 10 percent have signed up on their own. About 10 million people were automatically enrolled. They could be dually eligible for Medicaid and Medicare, and may even be receiving coverage from a former employer. Still the latest report from the Kaiser Family Foundation, says enrollment numbers are 15 million people below government predictions.
The Washington Post also focused on the mounting enrollment disaster:
A $400 million campaign by the Bush administration to enroll low-income seniors in prescription drug coverage that would cost them just a few dollars per prescription has signed up 1.4 million people, a fraction of the 8 million eligible for the new coverage.
At this rate, by some calculations, the government is on track to spend about $250 for each person it enrolls, and even then it would have only 2 million poor senior citizens taking advantage of what is perhaps the most generous government benefit available today.
The New York Times reported that the new law might cost the GOP support among the elderly:
Older voters, a critical component of Republican Congressional victories for more than a decade, could end up being a major vulnerability for the party in this year’s midterm elections, according to strategists in both parties. Paradoxically, one reason is the new Medicare drug benefit, which was intended to cement their loyalty.
During next week’s Congressional recess, Democrats are set to begin a major new campaign to highlight what Representative Nancy Pelosi of California, the Democratic leader, describes as “this disastrous Republican Medicare prescription drug plan.”
This zoom-out from the NYT will sound familiar to anyone following the coverage around Obamacare:
The Medicare Prescription Drug, Improvement, and Modernization Act … was an effort to blend a classic big government program from the Great Society with the conservative, market-oriented philosophy of the Republicans in power.
It was supposed to be one of the great domestic policy achievements of the Bush presidency.
But today, as state and federal officials struggle to carry out the program, they face widespread complaints from beneficiaries, advocates, pharmacists, lawmakers and others that it is too complex, too cumbersome, too hard to navigate. Congressional committees are holding hearings on problems in the rollout of the plan, which began Jan. 1, and debate has already begun over how to change it.
Michael Kinsley was unsparing in The Washington Post: . . .
Continue reading. It’s pretty entertaining and shows how overblown are the current difficulties with Healthcare.gov. What is happening is undesirable, but anyone who’s worked in software development has seen this very familiar movie many times.
The NY Times has a strong editorial on the terrible state of US health care in general:
Even as Americans struggle with the changes required by health care reform, an international survey released last week by the Commonwealth Fund, a research organization, shows why change is so necessary.
The report found that by virtually all measures of cost, access to care and ease of dealing with insurance problems, Americans fared poorly compared with people in other advanced countries. The survey covered 20,000 adults in the United States and 10 other industrial nations — Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland and Britain, all of which put in place universal or near-universal health coverage decades ago. The United States spends far more than any of these countries on a per capita basis and as a percent of the national economy.
For that, it gets meager results. Some 37 percent of American adults went without recommended care, did not see a doctor when sick or failed to fill prescriptions in the past year because of costs, compared with 4 percent in Britain and 6 percent in Sweden. Nearly a quarter of American adults could not pay medical bills or had serious problems paying them compared with less than 13 percent in France and 7 percent or less in five other countries. Even Americans who were insured for the entire year were more likely than adults abroad to forgo care because of costs, an indication of how skimpy some insurance policies are.
When Americans got sick, they had to wait longer than people in most of the other countries to get help. Fewer than half were able to get same-day or next-day appointments with a doctor or nurse; one in four had to wait six days or longer. (Only Canada fared worse on both counts.) But Americans got quicker access to specialists than adults in all but two other countries.
The complexity of the American insurance system is also an issue. Some 32 percent of consumers spent a lot of time on insurance paperwork or in disputes with their insurer over denials of payment for services they thought were covered. . .
Extremely interesting datapoint: A Louisiana Republican backing Obamacare defeats his rival who ran against Obamacare
Josh Israel writes at ThinkProgress:
Louisiana voters elected Republican Vance McAllister in a runoff to fill the state’s vacant Fifth District U.S. House seat on Saturday. McAllister, a businessman who embraced the expansion of Medicaid available to the state under the Affordable Care Act, defeated a Republican party favorite who called for full Obamacare repeal.
In a district won by Mitt Romney with 61 percent of the vote in 2012, two Republicans were the top vote-getters in a 14-candidate October primary. McAllister, who received nearly 60 percent of the vote in Saturday’s special election, criticized much of the Affordable Care Act, but also criticized Gov. Bobby Jindal’s (R) decision to dismantle charity hospitals in the state, and to reject its Medicaid expansion, which would expand the qualifications for Medicaid recipients and extend healthcare coverage to hundreds of thousands of uninsured Louisianans. “Our governor and Sen. Riser right here have gutted [heath care] to the core and privatized it.”
McAllister’s top opponent, State Senator Neil Riser (R), received support from House Republican Leader Eric Cantor (R-VA), three of the four other Louisiana Republican Congressmen, the National Rifle Association, FreedomWorks and, more tacitly, Gov. Jindal. Riser ran ads saying that he would go to Washington to balance the budget and stop Obamacare — not make friends — andslammed McAllister for ” attempting to redefine himself and stand with President Obama.”
According to President Obama, 265,000 Lousianans would benefit from the Medicaid expansion. According to Jindal’s own Department of Health and Hospitals, the billions of dollars in federal payments available to the state would allow about 272,000 of the roughly 633,000 uninsured adults in the state to get subsidized health insurance on the exchange. But citing potential future costs, Jindal has rejected the expansion, saying “We will not allow President Obama to bully Louisiana into accepting an expansion of Obamacare.”
Very interesting post at Mother Jones by Kevin Drum:
Here’s an email from a reader in California with an interesting wrinkle on the rate shock debate:
I’m self employed, with individual health insurance coverage, and my family is one of those whose current health insurance policy is being canceled and whose premium will rise once we purchase insurance on the CA exchange. But it’s not as simple as that. We signed up for our current policy in November 2011 (therefore no grandfathering) and the premium was substantially lower than the policy we had prior to that. In hindsight, I’m guessing that the premium for that newly introduced plan was so low because the insurance company knew it would have to be canceled in 2014. So, they weren’t going to incur a lot of losses or have to make provisions for a long claims tail.
The premium for our new insurance, purchased from the exchange, is going to be about what our original (pre-2011) policy premiums would have been now, allowing for the usual annual premium increases. So, yes, we’re having to move from cheaper to more expensive insurance. On the other hand, it’s very likely that the cheaper policy would never have been available in the first place without the ACA’s 2014 deadline for such plans. Of course, the insurance company didn’t clarify back in 2011 that this policy had a limited lifespan and would have to be replaced in 2014 with a new one.
I wonder if this is at all common?
Do you believe that insurance companies would do such a thing? I think they’d do it in a heartbeat. It would be considered good marketing: a brief window when extremely low rates can be offered, to pull people in from other policies—not just other policies that we hold, we can scoop them up from competitors: a large new-customer pool. Then, when 2014 comes, we’ll raise the prices. We will lose some, but quite a few will just accept our reason (“Obamacare”), shrug their shoulders, and continue with us. Some will actually look around a bit, but other companies will have rates in the same ballpark, so some will stick by inertia. Altogether, sounds like a net gain for the company with little downside risk.
The company has a long and sordid record of project failure, which makes one wonder why the Obama Administration selected them as lead developer. Jerry Markon and Alice Crites write in the Washington Post:
The lead contractor on the dysfunctional Web site for the Affordable Care Act is filled with executives from a company that mishandled at least 20 other government IT projects, including a flawed effort to automate retirement benefits for millions of federal workers, documents and interviews show.
CGI Federal, the main Web site developer, entered the U.S. government market a decade ago when its parent company purchased American Management Systems, a Fairfax County contractor that was coming off a series of troubled projects. CGI moved into AMS’s custom-made building off Interstate 66, changed the sign outside and kept the core of employees, who now populate the upper ranks of CGI Federal.
They include CGI Federal’s current and past presidents, the company’s chief technology officer, its vice president for federal health care and its health IT leader, according to company and other records. More than 100 former AMS employees are now senior executives or consultants working for CGI in the Washington area.
A top CGI official said this week that the company is “extremely proud” of its acquisition of AMS. Lorne Gorber, CGI’s senior vice president for global communications, said CGI had been aware of the AMS “trip-ups” but has transformed the AMS culture over the past decade. “Anyone at CGI who came from AMS would not be able to find any similarities in how they work today to how they worked a decade ago,’’ Gorber said.
He said that CGI’s overall government contracting work remains high quality and that the company “delivers 95 percent of its projects on time and on budget.’’
A year before CGI Group acquired AMS in 2004, AMS settled a lawsuit brought by the head of the Federal Retirement Thrift Investment Board, which had hired the company to upgrade the agency’s computer system. AMS had gone $60 million over budget and virtually all of the computer code it wrote turned out to be useless, according to a report by a U.S. Senate committee.
The thrift board work was only one in a series of troubled projects involving AMS at the federal level and in at least 12 states, according to government audit reports, interviews and press accounts. AMS-built computer systems sent Philadelphia school district paychecks to dead people, shipped military parts to the wrong places for the Defense Logistics Agency and made 380,000 programming errors for the Wisconsin revenue department, forcing counties to repay millions of dollars in incorrectly calculated sales taxes.
Lawrence Stiffler, who was director of automated systems for the thrift board at the time and a 25-year veteran of IT contracting for the federal government, said AMS was highly unreliable. “You couldn’t count on them to deliver anything,’’ he said. . .
Continue reading. The problems with Healthcare.gov seem very much like self-inflicted damage from the Obama Administration.
I recall Timothy Leary taking LSD trips with prisoners. He thought that LSD would enable them to remold some aspects of their personality—break old patterns and get new insights—in an effort to reduce recidivism. I don’t recall how the research came out, but the recent findings about marijuana’s effect in “rebooting” repetitive patterns and its observed effects on memory (see this post) might offer a therapeutic approach to interrupting the patterns of thought of PTSD.
Vanessa Walz writes at Ladybud.com:
After Staff Sargent Mike Whiter returned home from serving his country, he tried to kill himself three times.
Whiter served in the US Marines for 11 years, including combat tours in Kosovo and Iraq. After his medical discharge, Whiter sought help from the Veterans Administration for his Post Traumatic Stress Disorder (PTSD) as well as his physical injuries.“They put me on 36 different medications in 6 years,” recalls Whiter. “I was on methadone and morphine, benzos, klonopin, xanax, SSRIs…You name a drug, I’ve been on it. I couldn’t sleep, I was having nightmares, I couldn’t leave my house – I was afraid to leave my house.”
Whiter believes that prescription drugs, particularly SSRIs, are contributing to veteran suicides. “SSRIs have suicide listed as a side effect,” Whiter explains. “And they’re giving these pills to people who are already suicidal.”
According to a study released by the Department of Veterans Affairs in February of 2013, 22 veterans take their own lives every day – one suicide every 65 minutes. A 2013 survey by the Iraq and Afghanistan Veterans of America showed that 30% of service members have considered or attempted suicide, and 45% reported that they know an Iraq or Afghanistan veteran who has attempted suicide. In recent years, there have been significantly more US veteran and military deaths by suicide than in combat.
HOPE FOR VETERANS
Mike Whiter’s life today is very different than it was a few years ago. After learning about medical marijuana and PTSD on the Discovery Channel, Whiter believed it might help him.
Since he started using marijuana, Whiter has been able to stop taking all of his prescription medications. No more sleepless nights, no more flashbacks, no more isolation in his home – in fact, Whiter is now the co-director of Philadelphia NORMLand the founder of Pennsylvania Veterans for Medical Marijuana. He has been a featured speaker at numerous public events and rallies, unimaginable during the time he suffered from crippling social anxiety due to his PTSD.
“Marijuana saved my life,” Whiter says. “And when I say that, I’m not exaggerating at all. Those medications would have killed me if I hadn’t taken my own life first. The medications that the VA prescribes are killing veterans.”
In addition to relieving his PTSD symptoms, Whiter credits marijuana for . . .
A “loser” is someone on the individual market who finds that under Obamacare, even using the exchanges, they will have to pay more for less coverage. (Those who get health insurance through their employer, which is a majority, will not experience this—it’s an artifact of the old individual-health-insurance market (pre-Obamacare) in which companies could skim off the cream of applicants (young people in perfect health living nonhazardous lives) and simply refuse to issue insurance to anyone with a “pre-existing condition.” Thus the premiums could be low. But now people who actually are probably going to need health insurance can join, so rates rise to a level that reflects an actual cross-section of the population rather than a carefully screened low-risk group.
At any rate, TPM’s Josh Marshall received the following from TPM reader BW:
Since it’s been estimated that about 3% of the US population will end up “losers” under Obamacare, I thought I’d write in and give you my perspective as a 3-percenter. However, I suspect that I belong to a smaller subset of the 3%, that being people who find it appallingly self-indulgent and shamefully self-pitying to think of ourselves as losers.
Having insurance, even crappy insurance, in the individual market means we are almost by definition, healthy and relatively young. If we were not, we wouldn’t be able to get coverage of any kind in the non-group market. If our ACA-compliant replacement policy costs us more, it’s likely because we’re too affluent to qualify for subsidies.
It takes a remarkable degree of self-absorption and sense of self-entitlement to be healthy, young(ish) and affluent—and yet consider oneself a “loser.” It’s a label I reject out of shame (no matter how much the lazy, superficial MSM want to fixate on me and my “plight”) NOT because there’s anything shameful about being a loser; the shame is in thinking oneself a loser when one is actually fortunate.
I live in Louisiana where 400,000 working poor people will continue to go without health care because one man, Gov. Bobby Jindal, decided letting them have Medicaid wouldn’t be good for his future ambitions. Those 400,000 are the losers. And while my healthcare.gov application has been stuck for a month now at the “View Eligibility Results” stage, where instead of my results I see a blank screen when I click the button, I know I will get better health insurance than the bare-bones individual policy I have now, even if I end up having to pick up the phone, or heaven forbid, send in paper. I will pay significantly more, but after years of being one serious illness from financial ruin, I will finally have security. And not only that; every time I pay my new premium, I am paying into a system that makes it possible for my fellow Americans who have not been as lucky as me—people who really have been losers pre-ACA—to finally get affordable health care.
I was fortunate before Obamacare, and now I am an Obamacare winner. Now if the media would just help more of the public understand how lucky us 3-percenters actually are, perhaps the public would start to recoil at the absurdity of the outrage being whipped up on our behalf, and we could start focusing on how to help the real losers: the working poor in refusenik states.
David Dagan has a good piece in Wonkblog about Sen. Mike Lee’s interest in prison reform:
The federal prison population has more than doubled over the past 20 years, even as crime rates have plunged. Many people think that’s unjust. There is also growing agreement that it is unsafe.
Dozens of former federal prosecutors have signed on to a letter that declares: “Maintaining the status quo in federal sentencing policy threatens public safety.” It’s one of at least three such statements issued by prosecutors in recent months; federal judges and the U.S. Sentencing Commission have also called for changes.
The chief problem, as Brad Plumer has noted, is that the U.S. Bureau of Prisons is chewing up more and more of the federal law-enforcement budget, putting us on a course where punishing past crimes will be prioritized over preventing and solving future ones.
That’s true even though we’re already skimping on prison spending, relative to the need. The surge of inmates has choked federal lockups to 136 percent of capacity, and that figure is on track to hit 155 percent within a decade, according to a new reportfrom the Urban Institute. Playing sardines like this is dangerous to both inmates and guards. It also limits the rehabilitative programming that can prevent prisoners from returning to crime after their release.
To make things worse, medium- and maximum-security facilities are at 145 and 151 percent of capacity, respectively. Since they house a tougher population, these are precisely the facilities where congestion is most likely to erupt into violence.
The Senate Judiciary Committee will consider the beginnings of a fix in coming weeks when it takes up two sentencing-reform bills whose sponsors include the firebrand conservatives Rand Paul (R-Ky.) and Mike Lee (R-Utah) (in keeping with the movement’s new approach to prisons).
By allowing judges to depart from mandatory-minimum sentences under certain conditions, both bills essentially turn such sentences from requirements into recommendations. The measure Paul has championed does this for all mandatory minimums; the Lee bill simply expands a provision that already allows for judicial discretion in some drug cases. But the impact of both measures will be muted by the fact that judges rarely depart from sentencing recommendations in the first place, according to the Urban Institute.
The think tank’s report estimates the impact of various reform proposals in bed-years, which represent one year in prison for one person. The researchers project that the Paul reform would save 81,000 bed-years over the course of a decade; Lee’s bill would save 53,000. That’s a lot, but not enough to put a major dent in the prison population.
This is where the Lee bill, whose other sponsors are Democrats Dick Durbin (Ill.) and Patrick Leahy (Vt.), goes further. It includes a provision to . . .
And here’s a particularly grim article by Josh Eidelson in Salon:
A new report alleges illegal and deadly mistreatment of Arizona inmates whose medical care the state contracted out to the country’s largest private prison health care provider.
The report, released last week by the American Friends Service Committee, a progressive Quaker group, comes as an American Civil Liberties Union lawsuit against the Arizona Department of Corrections awaits an appeals court ruling over the state’s challenge to its class action status. The ACLU alleges “grossly inadequate” care that creates “grave danger” for inmates, including “critically ill” people who were told to “be patient” or “pray” for healing, or that “it’s all in your head.”
Shortly before that lawsuit was filed in March 2013, the state contracted with its current for-profit health provider, Corizon, to replace the departed company Wexford. But the AFSC charges that “Correspondence from prisoners; analysis of medical records, autopsy reports, and investigations; and interviews with anonymous prison staff and outside experts indicate that, if anything, things have gotten worse.” Among the allegations: “delays and denials of care, lack of timely emergency treatment, failure to provide medication and medical devices, low staffing levels, failure to provide care and protection from infectious disease, denial of specialty care and referrals, and insufficient health treatment…”
Asked about the report, Corizon sent a statement saying that since March, it has “increased the number and skill level of our healthcare staff with the goal of continually improving patient outcomes.” Corizon said that its facilities are accredited and subject to internal audits, and that “ADC inmate patients receive care that meets their healthcare needs and satisfies constitutional requirements.” It added that “As with any large healthcare provider, litigation does arise from time to time. However, the vast majority of lawsuits filed against Corizon are without merit and are dismissed or settled with no findings of wrongdoing.” The Arizona Governor’s office did not immediately respond to an early morning Wednesday inquiry.
In 2011 and 2012, the deaths of thirty-seven total inmates were reported in the Arizona Republic. In contrast, writes the AFSC, fifty people have died in custody in the first two-thirds of this year. Last year, the Arizona Republic charged that “Arizona’s prison system has two death rows”: Those “officially sentenced to death” and those who “die as victims of prison violence, neglect and mistreatment.”
The AFSC report includes a series of case studies drawn from media reports and individuals’ accounts. The Arizona Capitol Times reported that a death-row inmate was diagnosed with throat cancer, “but his disease went unknown to him and untreated for seven more months.” A prisoner’s mother, a registered nurse, told AFSC that her son had lost his visitation and phone privileges for alleged “refusal” to provide urine for drug-testing, when the real and well-documented issue was his diagnosed post-chemotherapy bladder conditions. Staff at Tempe St. Luke’s Hospital recorded that a patient who had been discharged back to the Tucson complex “was supposed to follow up [with] pathology and receive a PET scan; unfortunately none of that workup was done at this time. The patients says that he request [nut] no oncology consults ever been performed at this time either…it is felt that the patient does have cancerous etiology and does need to receive further workup.” . . .
I find the Arizona situation shocking. The state officials seem depraved in their indifference. Still, for-profit healthcare has a strong tendency to be poor, especially when there’s a local monopoly (only one provider realistically available): more profits to be made that way.
Steve Benen writes at MSNBC:
For reporters covering Capitol Hill, there are two phrases that should immediately raise red flags when put in the same sentence: “partial transcript” and “House Oversight Committee.”
Republicans on this committee got into quite a bit of trouble in this area during the Clinton era, and now that Rep. Darrell Issa (R-Calif.) holds the gavel, reporters have been fed half-truths through “partial transcripts” over and over again.
And yet, some keep falling for the same trick. Last night, it was CBS News.
CBS News has learned that the project manager in charge of building the federal health care website was apparently kept in the dark about serious failures in the website’s security…. The project manager testified to congressional investigators behind closed doors, but CBS News has obtained the first look at a partial transcript of his testimony.
Henry Chao, HealthCare.gov’s chief project manager at the Centers for Medicare and Medicaid Services (CMS), gave nine hours of closed-door testimony to the House Oversight Committee in advance of this week’s hearing. In excerpts CBS News has obtained, Chao was asked about a memo that outlined important security risks discovered in the insurance system.
Based on the “partial transcript” from Issa’s committee, Chao didn’t know about a Sept. 3 memo on website problems identified by another official at the Centers for Medicare and Medicaid Services. Confronted with the document, the partial transcript shows Chao saying, “I just want to say that I haven’t seen this before.”
The CBS report sounds troubling, right? Probably, at least until one picks up the phone to ask Democrats on the committee whether the CBS report is accurate
I talked to a Democratic staffer this morning about the partial transcript and the aide said Issa’s staff “basically sandbagged this witness with a document he had never seen before and then failed to inform him that it has nothing to do with parts of the website that launched on October 1. In fact, it relates to a function of the website that is not currently active and won’t be until the spring of 2014. Rather than seeking out the truth, this press release tries to scare the public by capitalizing on confusion caused by the Chairman’s own staff.”
Oh. So, when Republicans and CBS suggest the project manager in charge of building the federal health care website was apparently kept in the dark about serious failures in the website’s security, they’re leaving out pretty much every relevant detail that points in a more accurate direction.
The Democratic staffer added that even when this part of the website is active, it “will not submit or share personally identifiable information,” but rather, will only include “insurance information plan data.”
Let’s say this again: beware of partial transcripts from Issa’s office. They keep pulling this trick; there’s no reason anyone should keep falling for it.
The report does not say whether the gullible CBS reporter was Lara Logan or not.
Individual health insurance policies were, basically, a racket, as described by Ezra Klein in the Washington Post:
Last night, NBC’s Chuck Todd asked President Obama about the people losing their health insurance despite his promise that “anyone who likes their plan can keep it.” (See the video and read the transcript here.)
“I am sorry that they are finding themselves in this situation based on assurances they got from me,” Obama replied.
The answer is a bit of a dodge. People aren’t finding themselves in this situation based on the president’s promises. They’re finding themselves in this situation based on his policy. And Obama isn’t apologizing for the policy.
“Before the law was passed, a lot of these plans, people thought they had insurance coverage,” he said. “And then they’d find out that they had huge out of pocket expenses. Or women were being charged more than men. If you had preexisting conditions, you just couldn’t get it at all.”
Obama was wrong to promise that everyone who liked their insurance could keep it. For a small minority of Americans, that flatly isn’t true. But the real sin would’ve been leaving the individual insurance market alone.
The individual market — which serves five percent of the population, and which is where the disruptions are happening — is a horror show. It’s a market where healthy people benefit from systematic discrimination against the sick, where young people benefit from systematic discrimination against the old, where men benefit from systematic discrimination against women, and where insurers benefit from systematic discrimination against the uninformed.
The result, all too often, is a market where the people who need insurance most can’t get it, and the people who do get insurance find it doesn’t cover them when it’s most necessary. All that is why the individual market shows much lower levels of satisfaction than, well, every other insurance market:
Graphic by Jon Cohn
Those numbers, of course, don’t include the people who couldn’t get insurance because they were deemed too sick. Consumer Reports put it unusually bluntly:
Individual insurance is a nightmare for consumers: more costly than the equivalent job-based coverage, and for those in less-than-perfect health, unaffordable at best and unavailable at worst. Moreover, the lack of effective consumer protections in most states allows insurers to sell plans with ‘affordable’ premiums whose skimpy coverage can leave people who get very sick with the added burden of ruinous medical debt.
Jonathan Cohn puts a human face on it:
One from my files was about a South Floridian mother of two named Jacqueline Reuss. She had what she thought was a comprehensive policy, but it didn’t cover the tests her doctors ordered when they found a growth and feared it was ovarian cancer. The reason? Her insurer decided, belatedly, that a previous episode of “dysfunctional uterine bleeding”—basically, an irregular menstrual period—was a pre-existing condition that disqualified her from coverage for future gynecological problems. She was fine medically. The growth was benign. But she had a $15,000 bill (on top of her other medical expenses) and no way to get new insurance.
This is a market that desperately needs to be fixed. And Obamacare goes a way toward fixing it. It basically makes the individual market more like the group markets. That means that the sick don’t get charged more than the well, and the old aren’t charged more than three times as much as the young, and women aren’t charged more than men, and insurance plans that don’t actually cover you when you get sick no longer exist. But the transition disrupts today’s arrangements. . .
As this excellent report by Charles Ornstein in ProPublica makes clear, the change in the healthcare landscape, regardless of the number of winners, will indeed produce some losers. As the article states (in part—I urge you to read the whole thing):
“In a few cases, we are able to find coverage for them that is less expensive, but in most cases, we’re not because, in sort of pure economic terms, they are people who benefited from the current system … Now that the market rules are changing, there will be different people who benefit and different people who don’t.”
“There’s an aspect of market disruption here that I think was not clear to people,” Stenrud acknowledged. “In many respects it has been theory rather than practice for the first three years of the law; folks are seeing the breadth of change that we’re talking about here.”
That’s little comfort to Hammack. He’s written to California’s senators and his representative, House Minority Leader Nancy Pelosi, D-Calif., asking for help.
“We believe that the Act is good for health care, the economy, & the future of our nation. However, ACA options for middle income individuals ages 59 & 60 are unaffordable. We’re learning that many others are similarly affected. In that spirit we ask that you fix this, for all of our sakes,” he and Brothers wrote.
Consumer advocate Anthony Wright said it’s important to remember the way the insurance market worked before the act was passed, when insurers could deny coverage based on pre-existing conditions. “It’s impossible to know what the world would have looked like for these folks in the absence of the law,” said Wright, executive director of the group Health Access.
“We certainly had an individual market, especially in California which was the Wild Wild West, where there was huge price increases, cancellations, a range of other practices.
“That doesn’t mean that there were certain people who lucked out in the old system, who wound up in a group with a relatively healthy risk mix and thus lower premiums,” he added. “The question is: Is health insurance something where people get a rate based on the luck of the draw or do we have something where we have some standards where people who live in the same community, of the same age, with the same benefit package are treated equally?”
Wright said discussions should focus on how to provide consumers like Hammack with assistance if they barely miss qualifying for subsidies.
Interesting article by Charles Ornstein in ProPublica:
This weekend brought more than a modicum of clarity to what happened behind the scenes in the run-up to the Oct. 1 launch of Healthcare.gov.
In a devastating story, Amy Goldstein and Juliet Eilperin of The Washington Post dissected how politics trumped policy when it came to the Affordable Care Act. In two key paragraphs, they wrote:
Based on interviews with more than two dozen current and former administration officials and outsiders who worked alongside them, the project was hampered by the White House’s political sensitivity to Republican hatred of the law — sensitivity so intense that the president’s aides ordered that some work be slowed down or remain secret for fear of feeding the opposition. Inside the Department of Health and Human Services’ Centers for Medicare and Medicaid, the main agency responsible for the exchanges, there was no single administrator whose full-time job was to manage the project. Republicans also made clear they would block funding, while some outside IT companies that were hired to build the Web site, HealthCare.gov, performed poorly.
These interwoven strands ultimately caused the exchange not to be ready by its Oct. 1 start date. It was not ready even though, on the balmy Sunday evening of March 21, 2010, hours after the bill had been enacted, the president had stood on the Truman Balcony for a champagne toast with his weary staff and put them on notice: They needed to get started on carrying out the law the very next morning. It was not ready even though, for months beginning last spring, the president emphasized the exchange’s central importance during regular staff meetings to monitor progress. No matter which aspects of the sprawling law had been that day’s focus, the official said, Obama invariably ended the meeting the same way: “All of that is well and good, but if the Web site doesn’t work, nothing else matters.”
The Post also posted online a May 2010 letter written by David Cutler, a Harvard professor and health adviser to Obama’s 2008 campaign, to Larry Summers, director of the White House’s National Economic Council. In it, Cutler wrote:
My general view is that the early implementation efforts are far short of what it will take to implement reform successfully. For health reform to be successful, the relevant people need a vision about health system transformation and the managerial ability to carry out that vision. The President has sketched out such a vision. However, I do not believe the relevant members of the Administration understand the President’s vision or have the capability to carry it out.
Another piece worth a read: “What’s Really Obstructing Obamacare? GOP Resisters,” by Michael Tomasky of Newsweek/Daily Beast. Tomasky writes that while media reports have focused on the problems of Healthcare.gov, not enough attention has been paid to the efforts by Republicans to obstruct the law. He wrote:
All across the country, Republican governors and insurance commissioners have actively and directly blocked efforts to make the law work. In August, the Obama administration announced that it had awarded contracts to 105 “navigators” to help guide people through their new predicaments and options. There were local health-care providers, community groups, Planned Parenthood outposts, and even business groups. Again—people and groups given the job, under an existing federal law, to help people understand that law.
What has happened, predictably, is that in at least 17 states where Republicans are in charge, a variety of roadblocks has been thrown in front of these folks. In Indiana, they were required to pay fees of $175. In Florida, which under Governor Rick Scott (who knows a thing or two about how to game the health-care system, you may recall) has been probably the most aggressive state of all here, the health department ruled that local public-health offices can’t have navigators on their premises (interesting, because local public health offices tend to be where uninsured people hang out). In West Virginia, Utah, Pennsylvania, and other states, grantees have said no thanks and returned the dough after statewide GOP elected officials started getting in their faces and asking lots of questions about how they operate and what they planned to do. Tennessee issued “emergency rules” requiring their employees to be fingerprinted and undergo background checks.
America, 2013: No background checks to buy assault weapons. But you damn well better not try to enroll someone in health care.
I suspect in the weeks ahead, we will see more reporting on both story lines: how the administration mismanaged the rollout of the law and how Republicans have tried to ensure its failure. But let’s not lose sight of consumers, whose lives will be directly affected by the act and what’s happening now.
One problem, of course, is the lack of qualifications to Obama’s promise, “If you like your healthcare plan, you can keep it,” which required one more phrase, “if your insurer continues to offer it.”
It’s the lack of that phrase that raises people’s ire as insurance companies cancel the junk healthcare insurance policies that are no longer legal (e.g., pays only doctor visits, not hospital stays; requires $40 co-pay for doctor visits; no prescription coverage; annual cap on covered expenses at $2,000, lifetime cap at $6,000—but the premiums are really low. I think you can see why. (Somehow I remember Woody Allen’s gag in Annie Hall: “The food at this resort is terrible,” says one, and the other responds, “Yes, and such small portions, too.”
Ezra Klein takes a look at the tradeoffs in this informative column in Wonkblog at the Washington Post:
Health-care consultant Bob Laszewski buys insurance on the individual market in Maryland. His plan’s benefits are excellent. “I can access every provider in the national Blue Cross network––about every doc and hospital in America––without a referral and without higher deductibles and co-pays,” he writes.
And there’s no catch. “My plan covers about everything,” he continues. “Never had a procedure for either my wife or myself turned down. Wellness benefits are without a deductible. It covers mental health, drugs, maternity, anything I can think of.”
But his plan is ending. The replacements all have tighter networks, higher deductibles, and higher premiums. And Laszewski isn’t alone. Many Americans who currently buy insurance on the individual markets are seeing their plans canceled and finding the replacement plans have higher premiums or stingier benefits. For them, President Obama’s promise that “if you like your plan, you can keep it,” is proving a cruel hoax.
These cancellations are the direct and inevitable result of Obamacare’s most popular promises: That it would put an end to discrimination based on preexisting conditions, that it would limit discrimination against the old, and that it would make sure your health insurance actually cover you if you got sick.
That sounded good every time the president said it. But part of the reason it sounded so good is that the people benefiting from this discrimination didn’t know they were benefiting from it. But people in the individual market right now are paying less because of discrimination against the old and sick. When that discrimination ends, a lot of them will end up paying more.
I don’t have any special knowledge of Laszewski’s plan. But the likely explanation for why his rate is going up is reasonably simple: Sick people will be able to join his plan, too.
A plan like the one Laszewski has is extremely attractive to anyone who is sick, or thinks they might one day get sick. So insurers tend to discriminate for those plans aggressively. That’s not to say no one who joins the plans ever gets sick. They do, and they’re happy to have such excellent coverage when that day comes. But the premiums are much lower because the insurer is keeping out the people who their actuarial models say will need the plan most.
The Affordable Care Act changes all that. Insurers in Maryland can no longer turn people away because they’re likely to get sick. That means they have to assume that the average applicant in a plan like Bob’s is about to get a lot sicker — and that means they have to raise the premium. To return to the health-care trilemma, Laszewski’s plan just went from here: . . .
Insurance companies have obvious financial reasons for wanting to sell their policies only to those unlikely to need them, and to refuse to sell to those who are likely to need insurance. But that’s not the direction we want. The next step would be simply to mail to the insurance company a check every month, in return for which you get a “thank you” postcard. No insurance need change hands, since they are selling only to those who are very unlikely to use it. As Klein points out:
That’s bad for Laszewski, who also makes too much money to qualify for subsidies. But it’s good for the people who couldn’t get into the plan previously. Laszewski’s low(er) premiums were a function of the fact that they literally couldn’t buy the insurance. Now they can. The previous system was better for Laszewski and terrible for them. The new system is worse for Laszewski but vastly better for them.
Sarah Kliff adds more detail to the picture with this article, on what we now know about Obamacare shoppers. Well worth the click, with a variety of graphs and charts.
And Arit John has an intriguing article at the Atlantic Wire: “Don’t Let Your For-Profit Insurer Pick Your New Healthcare Plan“.
UPDATE: Consumers Reports debunks one of the “rate shock” horror stories: “That Florida woman’s canceled Blue Cross policy? It’s junk insurance. – She can get a real plan for only $165 a month“:
Did you recently get a notice saying that your insurance company is canceling your policy because it doesn’t meet the new health law’s higher standards? Thousands of people are, and many are angry about it. But before you rush to judgement, it might not be as bad as it seems.
Conisder the case of Diane Barrette, a 56-year-old woman from Winter Haven, Fla. Her story was featured in this CBS News report and endlessly echoed on the Internet. She was upset because Blue Cross Blue Shield of Florida was canceling her $54-a-month “GoBlue plan 91” and offering to replace it with a $591-a-month “Blue Options Essential plan.”
Sounds terrible—except that Barrette’s expiring policy is a textbook example of a junk plan that isn’t real health insurance at all. If she had ever tried to use it for anything more than an occasional doctor visit or inexpensive prescription, she would have ended up with tens or hundreds of thousands of dollars of medical debt.
Here are some of the gory details. (You can see the rest for yourself on this complete plan summary from the insurance company.)
- The plan pays only the first $50 of doctor visits, leaving Ms. Barrette to pay the rest. Specialist visits can cost several hundred dollars.
- Only the first $15 of a prescription is covered. Some prescriptions can cost hundreds or even thousands of dollars a month
- The plan only pays for hospitalization for “complications of pregnancy,” which are unlikely given Ms. Barrette’s age and in any event only the first $50 is covered.
- It pays $50 for a mammogram that can cost several hundred dollars, and only pays $50 apiece for advanced imaging tests such as MRIs and CT scans and then only when used for osteoporosis screening.
“She’s paying $650 a year to be uninsured,” Karen Pollitz, an insurance expert at the nonprofit Kaiser Family Foundation, said. “I have to assume that she never really had to make much of a claim under this policy. She would have lost the house she’s sitting in if something serious had happened. I don’t know if she knows that.”
In fact, had Blue Cross Blue Shield allowed her to keep the plan, she would have been fined for going uninsured in 2014. Limited plans such as these are considered “excepted benefits” that don’t fulfill the new obligation to have health coverage.
Okay, but can’t we be outraged that Ms. Barrette will have to fork over $591 a month for a replacement plan? Actually, no, because she has other and better options than the costly plan Blue Cross Blue Shield wants to put her in. She get real insurance that covers all essential health benefits for well under $200 a month. . .
Dylan Scott writes at TPM DC:
Donna received the letter canceling her insurance plan on Sept. 16. Her insurance company, LifeWise of Washington, told her that they’d identified a new plan for her. If she did nothing, she’d be covered.
A 56-year-old Seattle resident with a 57-year-old husband and 15-year-old daughter, Donna had been looking forward to the savings that the Affordable Care Act had to offer.
But that’s not what she found. Instead, she’d be paying an additional $300 a month for coverage. The letter made no mention of the health insurance marketplace that would soon open in Washington, where she could shop for competitive plans, and only an oblique reference to financial help that she might qualify for, if she made the effort to call and find out.
Otherwise, she’d be automatically rolled over to a new plan — and, as the letter said, “If you’re happy with this plan, do nothing.”
If Donna had done nothing, she would have ended up spending about $1,000 more a month for insurance than she will now that she went to the marketplace, picked the best plan for her family and accessed tax credits at the heart of the health care reform law.
“The info that we were sent by LifeWise was totally bogus. Why the heck did they try to screw us?” Donna said. “People who are afraid of the ACA should be much more afraid of the insurance companies who will exploit their fear and end up overcharging them.”
Donna is not alone.
Across the country, insurance companies have sent misleading letters to consumers, trying to lock them into the companies’ own, sometimes more expensive health insurance plans rather than let them shop for insurance and tax credits on the Obamacare marketplaces — which could lead to people like Donna spending thousands more for insurance than the law intended. In some cases, mentions of the marketplace in those letters are relegated to a mere footnote, which can be easily overlooked.
The extreme lengths to which some insurance companies are going to hold on to existing customers at higher price, as the Affordable Care Act fundamentally re-orders the individual insurance market, has caught the attention of state insurance regulators.
The insurance companies argue that it’s simply capitalism at work. But regulators don’t see it that way. By warning customers that their health insurance plans are being canceled as a result of Obamacare and urging them to secure new insurance plans before the Obamacare launched on Oct. 1, these insurers put their customers at risk of enrolling in plans that were not as good or as affordable as what they could buy on the marketplaces.
TPM has confirmed two specific examples where companies contacted their customers prior to the marketplace’s Oct. 1 opening and pushed them to renew their health coverage at a higher price than they would pay through the marketplace. State regulators identified the schemes, but they weren’t necessarily able to stop them. . .
Very interesting after-action report, looking at contributing factors to HealthCare.gov’s abortive launch. Amy Goldstein and Julian Eisperin report in the Washington Post:
In May 2010, two months after the Affordable Care Act squeaked through Congress, President Obama’s top economic aides were getting worried. Larry Summers, director of the White House’s National Economic Council, and Peter Orszag, head of the Office of Management and Budget, had just received a pointed four-page memo from a trusted outside health adviser. It warned that no one in the administration was “up to the task” of overseeing the construction of an insurance exchange and other intricacies of translating the 2,000-page statute into reality.
Summers, Orszag and their staffs agreed. For weeks that spring, a tug of war played out inside the White House, according to five people familiar with the episode. On one side, members of the economic team and Obama health-care adviser Zeke Emanuel lobbied for the president to appoint an outside health reform “czar” with expertise in business, insurance and technology. On the other, the president’s top health aides — who had shepherded the legislation through its tortuous path on Capitol Hill and knew its every detail — argued that they could handle the job.
In the end, the economic team never had a chance: The president had already made up his mind, according to a White House official who spoke on the condition of anonymity in order to be candid. Obama wanted his health policy team — led by Nancy-Ann DeParle, director of the White House Office of Health Reform — to be in charge of the law’s arduous implementation. Since the day the bill became law, the official said, the president believed that “if you were to design a person in the lab to implement health care, it would be Nancy-Ann.”
Three and a half years later, such insularity — in that decision and others that would follow — has emerged as a central factor in the disastrous rollout of the new federal health insurance marketplace, casting doubt on the administration’s capacity to carry out such a complex undertaking.
“They were running the biggest start-up in the world, and they didn’t have anyone who had run a start-up, or even run a business,” said David Cutler, a Harvard professor and health adviser to Obama’s 2008 campaign, who was not the individual who provided the memo to The Washington Post but confirmed he was the author. “It’s very hard to think of a situation where the people best at getting legislation passed are best at implementing it. They are a different set of skills.”
The White House’s leadership of the immense project — building new health insurance marketplaces for an estimated 24 million Americans without coverage — is one of several key reasons that the president’s signature domestic policy achievement has become a self-inflicted injury for the administration.
Based on interviews with more than two dozen current and former administration officials and outsiders who worked alongside them, the project was hampered by the White House’s political sensitivity to Republican hatred of the law — sensitivity so intense that the president’s aides ordered that some work be slowed down or remain secret for fear of feeding the opposition. Inside the Department of Health and Human Services’ Centers for Medicare and Medicaid, the main agency responsible for the exchanges, there was no single administrator whose full-time job was to manage the project. Republicans also made clear they would block funding, while some outside IT companies that were hired to build the Web site, HealthCare.gov, performed poorly. . .
This topic interests me because I’ve worked on quite a few software projects, some of which did have launch problems, though no so severe as HealthCare.gov (which is probably more complex than the systems on which I worked).
It’s actually operational—not sign-up, I think, but health-plan comparisons. Read about it here.
This does not apply to those who have health insurance through their employer or Medicare or Medicaid, which is the bulk of the population. It applies on to the individual market, currently about 5% of the population, but with the Affordable Care Act, it’s likely that 10% of the population will now have health insurance on the individual market: the number of people with healthcare insurance will double. (Some conservatives, particularly in the South, really hate this.)
Sarah Kliff explains in the Washington Post‘s Wonkblog:
So these insurance cancellation notices. I hear a lot about them. What’s the deal?
Let’s start with the very basics here. About 15 million people purchase health insurance policies on the individual market. That’s about 5 percent of the population. When they do so, they typically purchase a 12-month contract with an insurance company. And when that contract runs out, both the individual and the insurance plan have an escape hatch. The individual can decide to no longer purchase the plan — and the insurance company can decide to no longer offer the plan.
Most individuals don’t stay in the individual market very long: One study, published in the journal Health Affairs, found that 17 percent of individual market subscribers purchased the same plan for two straight years or longer.
There are some restrictions on how insurance companies can terminate products. HIPAA, a health law passed in the 1990s, does require that insurance companies offer subscribers the opportunity to renew their policy, so long as they continue to pay monthly premiums. If they want to discontinue a subscriber’s policy, the insurance plan must provide 90 days notice and “the option to purchase any other individual health insurance coverage currently being offered by the issuer for individuals in that market.”
And these are the notices that insurance plans are sending out right now, to hundreds of thousands of subscribers: notices saying that they do not plan to offer the policy anymore, and information about what policies will be available.
So why is this happening right now?
Some — or maybe even most — of the plans offered on the individual insurance market right now don’t meet certain requirements in the health-care law. They may not offer preventive care without co-payment, for example, or leave out coverage of maternity care, one of the health-care law’s 10 essential benefits.
Some of these plans have stuck around for a little bit. The health law allowed . . .