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Health Care Thoughts: Obamacare Fail

by  Tom aka Rusty Rustbelt

Health Care Thoughts: Obamacare Fail

The Obama administration has delayed a key portion of the program, the 50+ regulations for employers on providing insurance and on the quality of insurance provided. So why the delay?

1) The administration could not explain its’ own rules and definitions, especially on seasonal workers

2) The proposed reporting and data collection system was a mess
3) The proposed enforcement system was still in its’ infancy, also see #2
4) The restaurant and retail sector told the administration what this would do to employment and hours
5) The 2014 election is looming already

Complexity is the enemy of smooth implementation.

(Interesting political theory among morning talking heads. The Democratic leaders intended to fix and improve ACA in conference committee, but the election of Scott Brown in Massachusetts made that unnecessary, so the unpolished version was passed.)

 

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Sequester Impact: 1 In 7 Seniors Struggle With Hunger

Crooks and Liars Diane Sweet writes about the impact the Sequester is having on something I used to do when working part time at an assisted care and nuring home in Bensonville, Illinois while pursuing my first BA. “Meals on Wheels” would bring a meal a day to the elderly. Since some were apartment-bound with no way to get to a store; potentially, this was their only meal for the day. Often times, I was also the only face they might see that day. In My Datsun 510 (college transportation), I would make a dozen or so stops when I did this. I can vouch for the gratitude I received from making the deliveries.

While Social Security has kept many afloat in today’s economy, 15% of the elderly still live in poverty as determined by the supplemental measurement.

65 and older poverty

As Diane Sweet points out, the Sequester has only made it worst for seniors who depend on this and other programs to make ends meet and to bring them the simplest of things . . . a meal and a face at the door.

Sequester Impact: 1 In 7 Seniors Struggle With Hunger

sequestercuts

Sequester cuts will total $1.2 trillion through fiscal year 2021. This year there is a 5.3 percent cut, totaling $85 billion. The cuts are indiscriminate and will impact nearly every federal program. Here are some of the ways this year’s cut is affecting food and hunger programs:

Meals for needy seniors lost in programs like Meals on Wheels (MOW): 4 million

Savings from cut of 4 million meals: $10 million

Rise in Medicaid costs due to cut of 4 million meals: $489 million

Net cost to U.S. federal budget due to cut of 4 million meals: $479 million

Loss of senior meals, California: 750,000

Loss of senior breakfasts, Palm Beach County, Fla.: 240 daily

Loss of senior meals in group dining facilities, Detroit suburbs and several counties: 86,000

Loss of home-delivered and group dining senior meals, La Crosse County, Wis.: 6,000

Ellie Hollander, president and CEO of the Meals on Wheels Association of America: “The real impact of sequester is that our programs don’t have the ability to expand to meet the growing need. We should be investing in these programs to ensure our seniors have the nutritious meals they need to remain healthy and independent.”

Patricia Hoeft, director of senior center nutrition, the Mid-East Area Agency on Aging (Missouri): “How do I decide which 300 seniors aren’t going to eat that day?”

Meals on Wheels recipient, home delivery program, La Crosse County, Wis.: “These meals are sometimes the only meal that I have a day. I don’t drive, so I have to rely on others to get around to doctors’ appointments. I only get $16 a month for food.”

References:

“Sequester Impact: 1 In 7 Seniors Struggle With Hunger” Diane Sweet Crooks and Liars
“Hunger and the Sequester, By the Numbers” Bill Moyers “What Really Matters”
“A State-by-State Snapshot of Poverty Among Seniors: Findings From Analysis of the Supplemental Poverty Measure” The Henry J Kaiser Family Foundation

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Medicaid Expansion in Michigan

States refusing to expand Medicaid to 133% of FPL has repercussions for those making less than 100% FPL. The PPACA was intended to setup State Exchanges where people could buy healthcare insurance and if they had an income beyond 133% FPL (Federal Poverty Level). Subsidies in the form of a tax credit would be given to each participant (sent to insurance carrier) based on their income. Remember, I said the PPACA was designed for those with incomes >133% FPL? While those with incomes >100% FPL can get subsidized healthcare insurance in the Exchanges, those with incomes <100% FPL can not get subsidized healthcare insurance in the exchanges and they would be covered by Medicaid. The states threatening to not expand Medicaid will leave a hole in healthcare insurance coverage. If the states do not expand Medicaid for single and childless married adults and expand it for married adults with children with incomes <100% FPL, they will not be able to get subsidized coverage on the exchanges either. Many state legislatures are not mentioning this to the constituency in the hope they can blame it on the PPACA, President Obama, and the Democrats. Here is how it is playing out in the State of Michigan . . . “the expanded program would cover as many as 450,000 Michiganders, according to projections. Michiagn State Senator Hune said there is evidence that about half of those in the expanded income category already have coverage of some kind” Press and Argus local newspaper. Michigan State Senator John Hune (my district) is worried about adding 450,000 more uninsured people to Medicaid if they expand it under the PPACA . I could understand the concern if:

• It was not funded. The Medicaid expansion is fully funded up to 100% for the first 3 years and gradually drops to 90% in 2020. The 90% still exceeds the unenhanced Federal Government Medicaid funding of 66% presently given to Michigan for Medicaid. Federal Medical Assistance Percentage (FMAP) for Medicaid and Multiplier, State Health Facts, The Henry J. Kaiser Foundation.

• The State of Michigan already covered adults with and without children up to 100% of FPL. Michigan does not cover up to 100% of FPL for any adult. Jobless Adults with children are covered under Medicaid if they are <37% of FPL. Working adults with children are granted Medicaid coverage at <64% of FPL. Single adults were once covered at <35% FPL if jobless and <45% FPL if working. The program is closed for single adults and married childless adults. Adult Income Eligibility Limits at Application as a Percent of the Federal Poverty Level (FPL), January 2013 The Henry J. Kaiser Foundation.

Recently, the Republican dominated Michigan State Senate went on vacation rather than voting, leaving the PPACA Medicaid Expansion issue to be decided upon when they return in Fall. State of Michigan Senator Hune’s reasoning was the lack of time (two days) to decipher the Medicaid Expansion. Now this happened in an automotive state where people who work in the automotive industry usually end up losing vacation and holiday time when a production line shuts down or a shipment needs to go out. Myself, I have faced such issues when managing a $200 million/year warehouse for a major Tier One. We hung around until the issue was resolved. This is also happening 2 years after the PPACA has passed, been decided as constitutional by SCOTUS, and rolled out piece meal. So why can’t they give up a couple of days and give it a yes or no vote?

The Republican dominated Michigan State Senate and “other opponents” to the PPACA are not acknowledging the resulting hole in coverage which the PPACA will not cover. Those people who do not have an income of at least 100% FPL will not be eligible for PPACA subsidies in the State Insurance Exchanges. For example, a working women with one child making $10,000 per year is at 64% of FPL and is ineligible for a subsidy to assist in paying the ~$4,900 insurance premium levied from the State Insurance Exchange. Pre-SCOTUS PPACA June 2012 decision, the Federal Government could force states to expand the Medicaid coverage by withholding funding already allocated to states for Medicaid. Since the 5-4 majority SCOTUS ruling, SCOTUS determined the Federal Government and Congress can not force states to expand Medicaid. Using the Kaiser Interactive Subsidy Chart, one can see in the chart below, the working Michiganders caught between 36% of FPL and 100% of FPL would not be eligible for PPACA Subsidies in the eventual Michigan Healthcare Insurance Exchange.

Subsidy1

So why is Michigan State Senator John Hune so concerned about the addition of these Michiganders to Medicaid when there is no other comprehensive coverage for those with income < 100% FPL; secondly, the funding is at 100%, drops to 90% in 2020, thirdly it is a net gain for Michigan; and finally Medicaid improves upon what they may now have (telemarketed mini-meds) and would result in healthier workers? Perhaps, Senator Hune is attempting to appease a Tea Party constituency as his reasoning otherwise lacks common sense. Missing out on the funding for additional Medicaid coverage is only one aspect of the issue as there other gains to be realized from expanding. Michigan’s Economy Will Benefit from Expanding Medicaid, Families USA and Michigan Consumers for Healthcare points to a host of other benefits Michigan will forgo if it does not expand Medicaid.

• In 2016, the new federal dollars would support approximately 18,000 new jobs across all sectors of Michigan’s economy, a 0.32 percent increase over the number of current jobs in the state. This is not limited to health care jobs. Because of the multiplier effect (described above), jobs would be created in a wide range of business sectors throughout the state.

• The increased federal funding and jobs created are projected to increase economic activity in Michigan by nearly $2.1 billion starting in 2016.

• From 2013 through 2022, the Medicaid Expansion could save Michigan ~$350 million in uncompensated cost, as more people would be insured. This would offset the decreased percentage in 3 years.

• Hospitals also absorb uninsured healthcare costs. It is estimated another $317 million could be saved with the Medicaid expansion.

• In 2008, the costs of uncompensated care increased family health insurance premiums by an estimated $1,017.

• Increased state revenue from more people working.

• In this conservative get a job or get out of the state of Michigan, insured constituents would be healthier and more productive in jobs.

Solely because of politics, the Republican held Senate in Michigan is stonewalling the Medicaid Expansion at the expense of thousands (6,000 in Livingston County alone) of their constituents. Again as taken by Henry J. Kaiser Foundation, there are 1.9 million people in Michigan who have incomes <100% FPL who would not be eligible for subsidies on the PPACA State Insurance Exchange. Only adults with children are eligible today for Medicaid and only if their income is a much lower percentage than 100% FPL.

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The PPACA Sky is Falling . . .

Chicken Little

Quelle Surprise, The White House Administration has decided to give “some” companies with >50 employees a one year extension in order to prepare and comply with the PPACA mandate. Given the amount of resistance the PPACA has received from the states in preparing for it and the House of Representatives, this delay should come as no surprise at all. While everyone has rushed into the fray claiming it is proof the PPACA is failing, the delay impacts a fraction of the employers with >50 employees. 94 – 96% of the ~200,000 employers who fall into this qualification already offer comprehensive healthcare insurance. The delay was to allow the 4 to 6% of the employers (8,000 to 12,000 employers) time to decide what they will offer. Former health policy administrator Ezekiel Emanual had this to say as reported by Bloomberg Health-Law Employer Mandate Delayed by U.S. Until 2015:

“Former White House health policy adviser Ezekiel Emanuel, now vice provost at the University of Pennsylvania, said today on MSNBC’s Morning Joe that the delay of implementation of the employer mandate will impact a limited number of companies. ‘I actually don’t think this is that big a deal,’ he said.

‘The provision only applies to employers who have 50 or more employees’, Emanuel said. He estimated that there are 200,000 total employers in the U.S. impacted and that “94 percent already offer health insurance” to employees.

‘We need to look for 2020 rather than moment to moment for changes in the system,’ Emanuel said.

Obama has confronted opposition from Republicans at every turn of the law, which passed Congress with only Democratic votes and was later challenged before the U.S. Supreme Court.

Only 16 states have agreed to set up the new exchanges, or marketplaces to sell insurance to people who don’t get it at work. Twenty-four states have refused to expand Medicaid, as called for under the law, according to Kathleen Sebelius, Obama’s secretary of health and human services.

Congressional Republicans, who have vowed to try to repeal the law, have refused Obama’s requests for about $1 billion more to help enact the statute and ensure it runs smoothly. Instead, they’ve started multiple investigations into the implementation.

Nor is this the first time Obama has been forced to scale back the law’s features. In March, the administration said small businesses wouldn’t be able to give their workers a choice of health plans in exchanges set up just for them. In January, a plan to create new nonprofit insurers in states was curtailed after Congress capped funding for the companies.”

Reports of companies limiting workers to 30 hours per week to avoid offering them healthcare insurance has been in the news with food chains and WalMart leading the way. It does not quite work that way as reported by Maggie Mahar at Health Beat Blog; The Employer Mandate is Postponed: What Does This Mean For Obamacare? Is Ezra Klein Right–Should the Employer Mandate Be Repealed?. Maggie goes on to say:

As I explained in a recent post, what the critics don’t seem to understand is that the ACA requires that employers offer health benefits if they have “30-time full-time employees or full-time equivalents.” Two workers who put in 15 hours a week equal one full-time equivalent. In other words, the government doesn’t count heads, it counts hours. To figure out how many “full-time employees and full-time equivalents” a business owner has, the government will add up the hours that all of his employees work, and then divide by 30.

The employer who cuts 12 of his 40 full-time employees to part time, and hires another 12 part-time employees to fill in the holes in his work schedule will wind up with 28 full-time workers and twelve “full-time equivalents.”

He will not have to insure the part-time workers, but he will be required to offer benefits to the 28 who actually work 30 hours a week.

As far as WalMart, people are already complaining about the lack of stocked shelving and service. This plays into the hands of WalMart competitors such as Target and Costco who appear to have their employees well being in mind. Should the Employer Mandate be removed. Some interesting commentary from Maggie Mahar. In 2009, Ezra Klein argued against the employer mandate and recently the same argument surfaced again.

“Again he quotes CBPP: ‘The employer mandate and penalties ‘would likely influence employer decisions about which of their employees to let go when they trim their workforces to cut costs, such as during a recession’ Workers from low-income families would cost the firm significantly more.’

Yesterday Klein repeated the argument, writing that ‘Eliminating” the employer mandate, or at least utterly overhauling it is probably the right thing to do.’

Maggie: I disagree. I admire both Klein’s Wonkblog and the CBPP, and applaud most of what each have written about health care reform. But in this case the argument is based on the false assumption that employers will choose to pay a penalty of $2,000 to $3,000 per employee rather than provide insurance. What both Klein and CBPP overlook is what Klein himself has explained in the past:

‘People simply misunderstand why employers offer health-care benefits. They’re not doing it as a favor to employees. . . Employers offer health insurance because employees demand it. If you’re an employer who doesn’t offer insurance and your competitors do, you’ll lose out on the most talented workers. An employer who stopped offering health benefits would see his best employees immediately start looking for other jobs.’

Research also shows the health benefits improve productivity and reduce absenteeism. As I pointed out: not long ago:: “This explains why 95% of employers with more than 30 workers offer insurance.”

The sky has a long way to fall before it hits your head. Do not be fooled by the commentary lacking substance. The habitual naysayers and pols are having a field day with this revision in implementation when the problem is only a small portion of the total. Most employers are ready to go forward.

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Health Care Thoughts: Obamacare Meets Immigration Reform

by Tom aka Rusty Rustbelt

Health Care Thoughts: Obamacare Meets Immigration Reform

With the passage of the Senate version of immigration reform we have some details to ponder.

Illegals who become “provisional” for up to 13 years will not qualify for some Obamacare credits and subsidies.

Workers who receive “unaffordable” insurance coverage from employers will be available for Obamacare subsidies, and the employer penalized up to $3,000. Provisional aliens would not be qualified for the subsidies, which could give provisionals up to a $3,000 cost advantage over U. S. workers.

Whether this was intended or just thoughtless drafting remains to be seen.

And of course, the Senate bill is just a starting point in a long hot political debate, so this may become nothing at all.

 

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Health Care Thoughts: California Assembly Bill 880 (pending

by Tom aka Rusty Rustbelt

Health Care Thoughts: California Assembly Bill 880 (pending)

It was a no brainer to predict Obamacare would have a major impact on restaurant and retail employers, especially in the throes of a weak economy. The composition of the work forces and often slim margins guarantee problems.

Darden Corp. (Red Lobster and Olive Garden) is infamous for whining and threatening layoffs, and of course Wal-Mart is well know as the “evil empire” of employers (the ACA part-time employment provision is often referred to as the “Wal-Mart loophole).

A clear result of Obamacare was for employers to consider cutting as many employees as possible under 30 hours. In California this would make many employees of corporate giants eligible for Medi-Cal, and California politicians are not happy, thus the pending legislation.

Employers with more than 500 employees would pay a penalty (possibly $6,000 or more per year) to the state treasury for every employee on Medi-Cal. This appears to apply to seasonal workers, although the commentaries I have read are rather murky on the details. More research to follow. This could have a major impact on seasonal agricultural employment.

It occurs to me one solution would be to reduce the number of part-time employees and just make the full-time employees work harder. I’m not certain that is what the Assembly intends.

Stay tuned, this is a giant laboratory.

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Health Care Thoughts: Cap per Procedure

by Tom aka Rusty Rustbelt

Health Care Thoughts: Cap per Procedure

Some employer health plans are experimenting with a cap-per-procedure system, allowing $X for a certain procedure and forcing employees to pay any difference.

This is not as harsh for employees as it first sounds, as the plans are using this as leverage to cap fees from providers, in effect pre-negotiating the fees within the employee cap. This is directed mostly at hospitals, which have wildly differing charge-masters.

This could be favorable for lower cost providers, and we were using this strategy for ambulatory surgery centers a decade ago (ASCs generally have lower prices and better patient satisfaction).

Experimentation is good, but this is gonna be a wild ride for the next few years.

HT: NYT 6/24/13

 

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Health Care Thoughts: Tenet Buys Vanguard, Wave of the Future?

by Tom aka Rusty Rustbelt

Health Care Thoughts: Tenet Buys Vanguard, Wave of the Future?

The three most frequently used words in health care strategy today are:

Integration – more providers employed by hospitals, networks and corporate providers

Consolidation – networks and corporate providers getting larger
Alignment – trying to develop business models that make sense for front line providers in these behemoth organizations, now and in the future

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Obamacare – Fear – Mongers Poison Minds; Hatred Blinds

Maggie Mahar at Health Beat Blog Obamacare – Fear – Mongers Poison Minds; Hatred Blinds” writes about the confusion about, the anger at, and the mischaracterization of the PPACA by every day people, medical workers, and politicians. Having myself presented the facts to rebut assumptions and fallacies, I find her comments interesting and on the money. Most who nit-pick on the PPACA have no obtainable and immediate alternatives in hand to replace the PPACA leaving a return to what was in place previous to its passage. The healthcare industry and Congress has done nothing to improve the situation pre-PPACA. There is no evidence they would move forward with a better alternative to the PPACA if it was repealed.

Maggie’s words:

Judith Mayer Lynn, uninsured and battling breast cancer, should be a fan of the Affordable Care Act1. Instead, Bloomberg reports, she know little about it. When Bloomberg interviewed the 56-year-old she was unaware of subsidies in the law that will help people like her buy coverage in 2014,. “Lynn didn’t know the Affordable Care Act requires insurers to pay for prescription drugs, hospital stays and other services she has spent the last two years scrimping to afford. Nor did she realize she can no longer be denied a policy due to her illness”.

When told of the benefits, “Lynn remained unconvinced, skeptical of insurers and government alike. ‘It’s a joke,’ she said. ‘There’s going to be loopholes in all of these provisions.1’”

If you showed Lynn the list of “essential benefits” that insurers will have to include in the policies they sell to people like her, could you persuade her to read the list—and explain where she saw the holes? Probably not, as her mind is closed to a discussion. In an interview at an Access to Healthcare office in Las Vegas, Lynn said she was unaware of those benefits — and didn’t trust Obama to produce them anyway.

The Poison: Hatred

Perhaps, I should not be surprised. We live in a nation where in 2009, a U.S. Congressman felt free to shout out “You Lie” during a televised presidential speech to a joint session of Congress2. (President Obama had just said that the legislation would not mandate coverage for undocumented immigrants. This is, of course, correct. South Carolina Rep. Joe Wilson (R) later apologized.)

Yet that did not stop another Congressional Republican from calling out the President earlier this month. In a scathing speech on the floor of the House3, Rep. Jim Bridenstine (R-OK) derided President Obama as a “dishonest, incompetent, vengeful liar” who lacks a “moral compass.” Bridenstine cited HHS Secretary Kathleen Sebelius’ efforts to promote enrollment in the Affordable Care Act as one reason President Obama is “not fit to lead.” Bridenstine did not apologize. Instead the next day, he told a talk show host that he had “gotten great encouragement” for his remarks from fellow Republicans. I have followed U.S. politics for many years. Never have I seen a president so hated — not Nixon, not LBJ at the height of the War in Vietnam.

Politicians Are Not Alone in Teaching Americans Not to Trust Obamacare

Lynn recalls one of her surgeons telling her that he was leaving the business because the health-care law dictates what he can charge patients1. This the Bloomberg article notes is “something the legislation doesn’t do.“ Why would a surgeon claim that the Affordable Care Act will be setting his rates? Presumably, he reads newspapers. How could he be so uninformed?

“There is a lot of distrust,” Sherri Rice, chief executive officer at Access to Healthcare explains. When her nonprofit group began asking members about the ACA last month, about half knew little about its provisions and another quarter were “furious” about it, she told Bloomberg. Such anger makes it difficult to think clearly—or take in information. This may explain why Lynn’s surgeon thinks that under the ACA he will be told what he can charge patients. Perhaps he too is so “furious” that the facts don’t register. Hatred blinds.

Educating the Public

The Brookings Institute’s Henry J. Aaron is one of many who blames the Obama administration for not doing a better job of educating the public. “We haven’t seen a lot of energy from the administration on public education. They ceded the field to those who were largely hostile to the bill to frame it in the public’s mind1.”

“Framing”

Aaron is right that Obamacare’s opponents have “framed” the issue. They have outspent supporters by 5-to-1 on TV ads, according to advertising analyst Kantar Media1. But their idea of “framing” is to define an idea with a catchphrase. If some facts do not fit into the frame, they are ignored explains linguistics professor George Lakoff. The “frame” becomes a lens through which conservatives invite us to see policy issues. For example, Laskoff observes, the phrase “tax relief” creates a context, signaling that taxes are bad and this is why we need “relief.” “Obamacare” is, itself a frame, which suggests that the Affordable Care Act will create a “nanny-state,” with the president becoming a national nanny who will tell us what we must do.

When you are lying, repetition is important. (Goebbels used this technique to his advantage) Laskoff points to a speech by Rick Santorum where he repeatedly refers to the President “not listening to the voice of the American people” (14 times) “because he knows better than you” (5 times)4, and is using the Government to run your lives by taking away your “rights” (10 times), and “freedoms.”(12 times “Death panel” became one of the most successful frames. Conservatives favor sound bites that are short, snappy and click shut like a box. Like advertising slogans, they are designed to make people stop thinking.

More, progressive formulations encourage thought. Often, they raise questions5: is health care a “right”, a “privilege”, or a “moral responsibility”—something that, we as a civilized society, we owe to each other? “Individual responsibility” is a phrase that conservatives favor. Each of us is responsible for ourselves, period. By contrast, “shared responsibility” opens the mind to consider the possibility5 that employers, employees, government, and the health care industry itself should share in funding universal healthcare.

Television Ads

It is difficult to explain Obamacare in a one-minute TV ad because health care reform turns on the details–thousands of details. And often, these are interlocking details: you cannot understand one without understanding the next paragraph in the legislation. For example: If you are self-employed, unemployed or work for an employer who does not offer benefits you will be able to purchase your own coverage in the Exchanges — marketplaces where insures will be regulated and will not be able to charge you more if you suffer from a pre-existing condition. If you earn less than $46000, you will be eligible for a government subsidy in the form of a tax credit that will help you pay the premium.

That is just one fact—and it I took me a full paragraph to convey a fairly accurate basic description of who will be eligible for a tax credit.

The definition also raises questions. For example, a reader might well ask; If I have to wait until I get a tax credit (when I pay my 2014 taxes in April of 2015) how will I pay the premiums on my insurance at the beginning of 2014? The answer is that the IRS will forward the money to your insurer in 2014, estimating how large your subsidy should be based on your 2013 income. Then when you file your 2013 taxes in 2014, you and the government will settle. If your 2014 income turned out to be lower than expected, the government may have underestimated your subsidy, and will owe you money. If, on the other hand, you earned more than expected, the subsidy may have been larger than it should have been, and you will owe the government money. To me this sounds fair; but, it doesn’t fit into a sound bite. I spent two paragraphs explaining it.

If a reader were skimming a newspaper story he might not take in those two paragraphs — especially if he already had heard conservatives “frame” the idea that you might own the government money as a “tax credit trap.” The phrase suggests that the tax credit is a trick leaving many Americans with what redstate.com calls “surprise tax bills5” in the spring of 2015.

Suddenly the tax credit does not sound like such a good deal – unless you took the time to read the full explanation.

In October, the Public Will Need a Crash Course in Obamacare

Let us return to the idea to the idea that the Obama administration has done a poor job of educating the public. “For the last couple of years, the Obama administration has done too little to explain what was in the law, and to mobilize support,1” says Henry Aaron. Bloomberg observes that in April of 2013 U.S. health secretary Kathleen Sebelius “offered a different take on timing: “’It didn’t make sense for the U.S. to contact the uninsured long before they can actually sign up for coverage1.’”

I think Sebelius may well be right. Americans are not interested in poring over the many details of Obamacare when it seems a distant possibility. (Polls show that Conservative diatribes have convinced many that the law already was repealed.) People will be much more interested in listening to the facts about the ACA in October, when it is becomes clear that the law is a reality, and that they are faced with a decision. Should I sign up for insurance? Right now Republicans are telling them that, under reform coverage will be unaffordable. Often they throw out numbers like “30% increases.” Here the fear-mongers are speculating about the cost of insurance premiums in the Exchanges where individuals buy their own insurance. But keep in mind, only a small minority of Americans will purchase coverage in these Exchanges

The majority of Americans work for large companies and are offered tax benefits at work. The Congressional Budget Office tells us that Obamacare will have a “negligible” effect on their premiums6.

As for premiums in the individual Exchanges, today Democrats cannot tell you exactly how much your coverage will cost if you buy your own insurance in 2014. This makes it difficult to rebut claims that costs will skyrocket. Everything will depend on your age, your sex, your income, where you live—and how insurers decide to price their products. They will be competing for market share, and will be trying to calculate how to price their product to attract young, healthy customers.

Premiums in the Exchanges: Much Will Depend On Where You Live

In states like New York, insurers now have to follow rules that are very similar to the regulations in the Affordable Care Act. As a result, it is unlikely that individuals buying their own insurance will have to pay more than they do today. In fact, they will probably pay less because in the Insurance Exchanges they will be part of a large group, and thus the insurer’s administrative costs will be lower. In addition, if an individual earns less than $46,000 he will be eligible for a government subsidy, which will slash his premiums.

On the other hand if the customer is a healthy 30-year-old male who lives in a state where insurers are allowed to charge women three times as much as they would charge a man for exactly the same policy and where they charge someone suffering from a pre-existing condition four times as much; the 30-year old man who is purchasing insurance in the Exchange may well be asked to shell out significantly more than he does today. This is because, under reform, he, his sister, and his mother (who suffers from diabetes) will find themselves on a level playing field: Insurers will not be able to gouge his sister or his mother.

(Put that way, reform doesn’t sound so bad does it? Even a progressive can use words such as “gouge” and “level playing field” to “frame” the issue.) Then again, consider how many words I needed to explain the variables that will determine whether your premiums will go up or down in the Exchanges.
It is much, much easier just to scream “sticker shock.”

In October, the Administration Will be Able to Offer Specifics

In the fall, progressives will have an easier task. They will be able to say: “Here in North Carolina an individual will be able to choose from a menu of five plans that range in price from $____to $____a year. Here are the details on the co-pays and deductibles. You will notice that in the plans where premiums are lower, co-pays are higher. In all of these plans your total out-of-pocket spending will be- capped at $6500 a year — no matter which plan you choose, or how much care you need.”

Armed with this information, reform’s supporters will be able to answer the false claims that you are hearing today. (This is why the fear mongers are now becoming louder and more hysterical—as we approach October they know their days are numbered.) “Enroll America” also will point out that: “different plans use different provider networks—you will find a list of their networks here. Some plans charge more because they think that you will pay more for their networks of hospitals and doctors. But they may be wrong: some customers will choose one of the less expensive plans.”

In October, progressives will put premiums in the contexct of subsidies, explaining that “If you are single and earn X, you will receive a government subsidy of $______ . If you are a 40-year-old couple with one child earning Z, you will receive a tax credit of $_____.” When Obamacare’s supporters have hard numbers, and can spell out what reform will mean for YOU and your family, uninsured, self-employed and unemployed Americans will be much more eager to learn about the details of healthcare reform. This is when they will be ready for a crash course in Obamacare.

Educating the Public: Reaching Out at the Right Time

As Joanne Peters, an HHS spokeswoman told Bloomberg: “Our outreach will kick into high gear this summer leading into the fall1, when we’ll be talking to Americans across the country to prepare them to enroll in coverage beginning October 1. Our deliberative tactics build on the lessons we’ve learned, including reaching people with the right message at the right time, when it’s time for them to act.”

“You want outreach and communications with real intensity in the six months when people can go online and sign up1,” adds Tara McGuinness a White House spokeswoman, referring to the open enrollment period that begins in October 2013 and runs through March 2014. In six months, “Enroll America” should be able to get the facts out there to most of the people who, at that point, will want to hear more about how “Obamacare” might help them. Granted, reformers still will have to contend with the conservative crusade to poison our minds by planting seeds of suspicion. This campaign has been going on since 2009. That’s four years of misinformation and outright lies.

Nevertheless in October of 2014, when “Enroll America” has the facts on pricing, I am hopeful that mainstream journalists will at last feel able and willing to call misinformation what it is: “a lie.”

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Welfare Reform Kills II

Earlier I noted the research of Peter Muennig, Zohn Rosen and Elizabeth Ty Wilde which proves (at all standard confidence intervals) that welfare reform killed people.  I was alarmed that almost nobody but the must read Bill Gardner noticed this research.  Now Dylan Matthews has a long excellent post on the research and other evidence that anti poverty programs save lives.

This should transform the political debate entirely.  I expect it to have almost no effect.  But the best of the blogosphere is doing its best.

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