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More On the Real Reason Healthcare Insurance Companies Are Now Encouraging Obamacare Enrollment

In light of some of the comments to my post yesterday arguing that that the real reason that healthcare insurance companies are now madly encouraging Obamacare enrollment is fear of a pro-public-option or pro-single-payer political juggernaut, I want to make clear that by single-payer I do not mean Medicare-for-all.   Single-payer would be, in essence, “the public option” extended to everyone rather than limited to the 5% of Americans who have private healthcare insurance through the non-group (i.e., non-employer-provided) market.  It is not tax-funded identical-for-all healthcare insurance, which is what Medicare is.  I do think that eventually this country will have Medicare-for-all-type healthcare insurance, but not in the near term.  If single-payer works well, then of course that would be the longterm solution, with no need for Medicare-for-all.

I also want to make a point about federalism as it relates to the ACA insurance-market exchanges and, especially, to Medicaid and, for that matter, to any other federal social-safety-network program.  I said in my post yesterday what I think is obvious: that federalism has been a disaster for Obamacare.  But I want to point out that the only reason that Medicaid works under current pre-Obamacare Medicaid is that that program came into being and was effectuated before the hard-right turn of the Republican Party.  Ditto for food stamps.  The really weird, but successful, argument by rightwing governors and state attorneys general to the Supreme Court in the ACA litigation on the Medicaid-expansion provision in the ACA is that, well, y’know, now that traditional Medicaid has been a part of each state’s law for decades, and is popular, it would be politically impossible for state legislators to end that program–the result under the ACA as the statute was written, if a state refused to agree to the ACA Medicaid expansion.  This, they argued–successfully!–meant that the ACA was effectively coercive of state  legislators and therefore infringed upon state sovereignty.  On that “ground,” the Supreme Court struck down that part of the Medicaid portion of the ACA.

That’s also known as the  conservatives-having-their-cake-and-eating-it-to theory of constitutional law.  The argument was so deeply hubristic that its actual success is stunning and outrageous.  But I have no idea why anyone would think that federalism must be a part of a national healthcare insurance law. It does not.

As for whether or not the public will catch on that the main problems with the Obamacare-exchanges-and-private-policies part of the Act is a failure of the healthcare insurance market and of the healthcare market itself–a question that several commenters raised–well, that was what my post was about.  Yes, the public will catch on, once the Dems have a smart, committed, knowledgeable and articulate spokesperson with a high enough national profile to educate them about it.  I expect that that will happen fairly soon.

Finally, although this should be the subject of a separate post, a hallmark of the current Supreme Court is how many really weird, outlandish rightwing arguments the current conservative-legal-movement five-member majority have made the law of the 50-state-soverign-lands.  As I said in an ignored post here last weekend, the Court’s neo-federalism-on-steroids jurisprudence has quietly but profoundly and thoroughly upended federal-in-relation-to-state constitutional law as it had existed since the post-Civil War era. This is a deeply dangerous juggernaut.

I wish more readers would read that post.  It does deal with really important stuff. Honestly.

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The Real Reason Healthcare Insurance Companies Are Now Encouraging Obamacare Enrollment: Fear of a pro-public-option or pro-single-payer political juggernaut

I’ve expected this for some time, and here it is: The Wall Street Journal reports that insurance companies are set to unleash hundreds of millions of dollars in advertising to entice potential customers on to the exchanges created by Obamacare. As the Journal puts it: Insurers … are capitalizing on an unprecedented opportunity in a shifting health-care market. Some seven million Americans are expected to buy health coverage on the new consumer exchanges, where people can compare insurance plans side by side.

— Greg Sargent, Washington Post, this morning

Sargent goes on to say that these plans were long in the works but were delayed because of the dysfunction of the federal website.  I assume that’s accurate, but elsewhere in Sargent’s column, in the form of two new polls are hints of why this project has taken on real urgency.  One poll, by Pew, published today in USA Today, shows a dramatic drop in support for Obama and Obamacare among 18- to 29-year-olds, results similar to those in another recent poll.  Undoubtedly, although this won’t occur to most pundits, this drop reflects fallout from the Snowden revelations and also anger at Obama’s less-than-progressive (and certainly less-than-energetic) agenda.  But there also is this: Only 41% of members of this age group approve of “his signature health care policy, while 54% disapprove.”

But also there is this, from the other poll released this morning, taken for the Associated Press:

In the survey, nearly half of those with job-based or other private coverage say their policies will be changing next year – mostly for the worse. Nearly 4 in 5 (77 percent) blame the changes on the Affordable Care Act, even though the trend toward leaner coverage predates the law’s passage.

Sixty-nine percent say their premiums will be going up, while 59 percent say annual deductibles or copayments are increasing.

Each time I read something of that sort I am struck momentarily by dismay that Obama has failed to tell the public, as often as is necessary to halt the effect of the disinformation, which as it happens is coming mainly from employers and … insurance companies.  Something along the lines of: Gosh, folks, listening to these people, you’d almost think that your employee contributions, co-pays and deductibles had remained steady and fine until the fall of 2013.  Maybe a few statistics would drive home the point.

But we are after all talking about Obama, not, say, a normal president.  And Obama just doesn’t do refutations, much less refutations citing actual statistics.

But one of these days a genuine progressive who has been fighting in the congressional trenches for progressive legislation–Sherrod Brown, I hope, or maybe Jeff Merkley–will show signs of interest in running for president in 2016.  And–who knows?–the press might even begin paying attention to what he (Elizabeth Warren is not going to run) says.  And what he says will include specific refutations to employer and insurance company claims that Obamacare is to blame for what Obamacare is not to blame for.  And then he’ll propose … the public option or even single-payer, leaving Obamacare in place until one of these now-quite-real options begins.  And this time there will not be an absurdly long four-year delay before implementation.

I expect that the experience with Obamacare as sabotaged by Republican state legislators and governors and unremitting campaigns of disinformation, and by shortsighted insurance carriers engaged in their own campaign of deception and trickery toward their current premium holders, will make possible (in fact, likely) what was not possible when Obamacare was being drafted and negotiated.

Republicans and, almost certainly, nearly all mainstream pundits see the 2014 and 2016 political debate as between Obamacare repeal and Obamacare “fixes”.  They don’t consider that the public will recognize a failure of Obamacare for what it is: a failure of “federalism” and, like the pre-Obamacare system, a failure also of the free market regarding healthcare.  And they certainly don’t consider that many , many of the people who have turned against Obamacare now in large part because of the gamesmanship of employers and insurance companies–young people, and employees who’ve seen their employer-based insurance benefit deteriorate annually in key respects–are likely to elect candidates who propose to change the system dramatically, to add a public option or to convert the system to single-payer.  They now know, after all, that the system really can be dramatically changed.

Employers would benefit from single-payer, if not from a public option, so they’re concerted scapegoating of Obamacare might serve their interest.  But the insurance companies are drastically overplaying their hand.  The Democrats have no competent spokesperson right now; that’s certainly true.  But that is temporary; they likely soon will.  Once this epiphany occurs to the insurance industry, they might start reining in their members in order to give Obamacare some chance to succeed.  By then, though, it may well be too late, and the previously impossible will be on its way to fruition.

UPDATE: In light of some of the comments to this post, I want to make clear that by single-payer I do not mean Medicare-for-all.   Single-payer would be, in essence, “the public option” extended to everyone rather than limited to the 5% of people who have private healthcare insurance through the non-group (i.e., non-employer-provided) market.  It is not tax-funded identical-for-all healthcare insurance, which is what Medicare is.  I do think that eventually this country will have Medicare-for-all-type healthcare insurance, but not in the nearterm.  If single-payer works well, then of course that would be the longterm solution, with no need for Medicare-for-all.

I also want to make a point, in light of EMichael’s comment, about federalism as it relates to Medicaid and, for that matter, any other federal social-safety-network program.  Federalism has been a disaster for Obamacare, and the only reason it works under current pre-Obamacare Medicaid is that that program came into being and was effectuated before the hard-right turn of the Republican Party.  The really weird but successful argument by rightwing governors and state attorneys general to the Supreme Court in the ACA litigation on the Medicaid-expansion provision in the ACA is that, well, y’know, now that traditional Medicaid has been a part of each state’s law for decades, and is popular, it would be politically impossible for state legislators to end that program–the result under the ACA as the statute was written, if a state refused to agree to the ACA Medicaid expansion.  This, they argued–successfully!–meant that the ACA was effectively coercive of state  legislators and therefore infringed upon state sovereignty.  On that “ground,” the Supreme Court struck down that part of the Medicaid portion of the ACA.

That’s also known as the  conservatives-having-their-cake-and-eating-it-to theory of constitutional law.  The argument was so deeply hubristic that its actual success is stunning and outrageous.  But I have no idea why anyone would think that federalism must be a part of a national healthcare insurance law. It does not.

As for whether or not the public will catch on that the main problems with the Obamacare-exchanges-and-private-policies part of the Act is a failure of the healthcare insurance market and of the healthcare market itself–a question that several commenters raised–well, that was what my post was about.  Yes, the public will catch on, once the Dems have a smart, committed, knowledgeable and articulate spokesperson with a high enough national profile to educate them about it.  I expect that that will happen fairly soon.

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Sunday Reading

Emerging Strategy for the DEMS; Karoli at Crooks and Liars, Dems Strategy on Extending Unemployment Insurance  Dems will leverage their votes to pass the Farm Bill for an extension of Unemployment . “Now that Congress is set to leave town even as unemployment benefits for 1.3 million Americans are set to expire just after Christmas, is there any chance that Democrats can still prevail on Republicans to agree to extend them? Dems who are pushing for an extension have hatched a new plan to do just that: Once Congress returns, they will refuse to support the reauthorization of the farm bill — which will almost certainly need Dem support to pass the House — unless Republicans agree to restart unemployment benefits with the farm bill’s savings.”  I guess two can play that game.

She Did It for the Kids. “Fox News host Megyn Kelly on Friday lashed out at critics who she said had accused her and Fox News of being racist because she insisted that Santa Claus and Jesus Christ had to be white men. For all you kids watching at home, Santa just is white,” Kelly said at the time. “But this person is just arguing that maybe we should also have a black Santa. But Santa is what he is.

Just because it makes you feel uncomfortable doesn’t mean it has to change, you know?” she added. “I mean, Jesus was a white man too. He was a historical figure, that’s a verifiable fact, as is Santa — I just want the kids watching to know that.” So is the verifiable fact both Jesus and Santa Claus are white men or historical figures? Megyn Kelly won’t back down   David’s Feed

PPACA Website Adventures: Next stop, the call center. I got the power cord to my phone, plugged it in along with my headphones so I could be hands-free, and started dialing. First try, I got the “call back later, we’re too busy” recording. So I waited awhile and tried again. Big mistake. I should have just kept dialing.

It took a total of nine tries to get into the queue, but I did finally hit the magic “Press 1 for English” message. I did so, and settled into the wait, hoping against all hope that I wouldn’t get dumped from the queue like I had on two other occasions.

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Next Year, Will Your Employer’s Insurance Cover 62 Services and Products with No Co-Pay or Deductible? How Much Will You Save? Maggie Mahar Health Beat Blog

Under the ACA,  some 62 preventive services and products will be free (in the past much of the preventative medicine was charged to patient on a non-negotiated rate. Today, they are financed through regulations applied to the insurance industry): no copays and the deductible will not apply. The list includes vision checks for children, birth control, and more than a dozen vaccines.

This rule will hold true not just for plans sold in the exchanges, but for most employer-sponsored plans. Under Obamacare, they, too, must offer preventive care without cost-sharing – unless they are “grandfathered.” (Grandfathered plans are policies that existed before the ACA was passed in 2010, and that have not made substantial changes to benefits or cost-sharing since then.)

This year, just 36 percent of Americans who have health benefits at work are enrolled in a grandfathered plan,, down from 48 percent in 2012 and 56 percent in 2011. Each year, more plans will lose their grandfathered status.

The ACA’s list of preventive services and products covers most of the reasons that many of us visit a physician – for blood pressure checks, cholesterol checks, flu shots, mammograms, tetanus shots, Pap smears or colorectal cancer screening.

Some of us go to the doctor because we want help losing weight, or quitting smoking. Counseling and smoking cessation products – including nicotine patches – all make the list.

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Mainstream Journalism As Just Another “Ism.” (The fallacy of the belief that the modern mainstream media has actual standards)

(Reuters) – Employers tried the carrot, then a small stick. Now they are turning to bigger cudgels.

For years they encouraged workers to improve their health and productivity with free screenings, discounted gym memberships and gift cards to lose weight. More recently, a small number charged smokers slightly higher premiums to get them to quit.

Results for these plans were lackluster, and healthcare costs continued to soar. So companies are taking advantage of new rules under President Barack Obama’s healthcare overhaul in 2014 to punish smokers and overweight workers.

—  How your company is watching your waistline, Kathleen Kingsbury, Reuters, Nov. 13, 2013

May I suggest that Ms. Kingsbury’s employer, Reuters, use a cudgel to get her and her editor to actually think about whether what they offer their news-media subscribers doesn’t contradict itself within the very same piece?  (Reuters is what was known for a century or so as a newswire service and is now just known as a news service; like the AP and UPI, it was historically, and now still mainly, a news-gathering service that publishes only through major-media outlets that subscribe to its services.  Such as Yahoo News, which is where I read it three weeks ago.  Thus, the reference to “their news-media subscribers.”  Okay, okay, I’m a journalism pedant.  I even know that Reuters is pronounced Royters, not Rooters, and that unlike AP and the old UPI it is a British import.  Thanks, Dad!)

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Congressional Republicans Acknowledge That Republican Governors and State Legislators Are Death Panelists. Seriously.

Pam Renshaw had just crashed her four-wheeler into a bonfire in rural Folkston, Georgia, and her skin was getting seared in the flames. Her boyfriend, Billy Chavis, pulled her away and struggled to dial 911 before driving her to the nearest place he could think of for medical attention: an ambulance station more than 20 miles away.

The local public hospital, 9 miles from the crash, had closed six weeks earlier because of budget shortfalls resulting from Obamacare and Georgia’s decision not to expand Medicaid. The ambulances Chavis sought were taking other patients to the next closest hospital. It took two hours before Renshaw, in pain from second- and third-degree burns on almost half her body, was flown to a hospital in Florida.

So began a Nov. 25 article by Toluse Olorunnia on Bloomberg News.  I read the article that day and have thought about it off-and-on since then.  The article goes on to report that several public hospitals closed this year and that many more, public and private, including the world-reknowned Cleveland Clinic, Vanderbilt University Medical Center and Indiana University Health, are “seeking cost savings in areas such as cancer treatment, mental health and infant care.” Nationwide, hospitals have reduced their staffs by at least 5,000 since June.

And as it turns out, although the Bloomberg article did not mention it, some hospitals are reducing their primary-care physician residency positions significantly, including a reduction of 50 such residency positions in the northeastern Tennessee congressional district of Rep. Phil Roe, who himself is a physician.  He also is a Republican.  “It is basically because the law has cut reimbursements for hospitals,” Roe told Politico staffers Seung Min Kim and Jennifer Haberkorn, as they report in a Dec. 3 article titled “New Obamacare weapon for GOP: Doctors”. “They have to find savings somewhere,” Roe said.

The Bloomberg article is titled “Obamacare Cutbacks Shut Hospitals Where Medicaid Went Unexpanded.”  Most of the hospitals in question have large numbers of uninsured patients.  And nearly all of the hospitals are in states whose Republican governors and legislatures have refused to adopt the expanded Medicaid provision in the ACA and are opting instead to see hospitals close or drastically reduce services, resident-physician positions and other staff positions that until now had been paid for by, um, the federal government’s Medicaid funding.  The ACA switches that funding from the current Medicaid program to the expanded Medicaid program that Republican governors and Republican-controlled state legislatures have refused.

I’m sort of waiting for the Dems to, maybe, point out this interesting irony whenever a Republican claims that Obamacare is prohibiting hospitals from from continuing to fund what in fact the federal government, via that Republican doormat Medicaid, actually was funding.  Not Obama himself, of course, because it would require him to actually explain something that he probably thinks is complicated; other Dems, though.  Maybe soon?

Then again, it looks like another Republican congressman, Texas Rep. Michael Burgess, who also is a physician, has hit upon the solution at least to one problem: the shortage of primary-care physicians.  “Many families are now learning that they may not just lose their plan,” he said recently. “But if they like their doctor, they may lose their doctor, too. They may lose their doctor in part because there is already a shortage of primary-care physicians. Many of these plans will now be paying doctors less — so many doctors, whose waiting rooms are already full, have chosen not to participate in the new plans.”

Yep.  Eliminating doctors who accept healthcare insurance should take care of that crowded-waiting-room problem. The doctors who have chosen not to participate in the new plans probably will have available chairs in their waiting rooms, without even moving to larger office space.  And they’ll have available appointment slots, without expanding their workweek.

As a pyrophobic since the age of eight, when I met a lovely elderly gentleman, a neighbor of my best friend, who was a severe-burns victim, I dearly wish Ms. Renshaw well.  But the additional agony she endured because of the recent closure of the only hospital within ambulance distance was neither the fault of Obamacare nor of the federal government that wingnuts rail about.  The recently-closed hospital and others like it throughout the rural South and Plains states would have been closed decades ago, were it not for the federal government, Lyndon Baines Johnson, Democratic congressional majorities … and Medicaid.

Because of the seriousness of this matter, I won’t try to put a pithy ending to this post.  I’ll just say that the current crop of Republican politicians, national and state-level, are death panelists–and that it’s past time for the mainstream media, Democratic elected officials, and, yes, Obama himself, to explain that to the public.  Each time that a Koch puppet-as-pol, or some columnist for the Washington Post, tells the public that hospital closures and a reduction in physicians and in hospital staff and services is the result of Obamacare, the Dems–including those who are running against Republican incumbents–need to point to, say, Kentucky, which with the exception of the small border it shares with Illinois is completely surrounded by Medicaid-expansion refuseniks.  As in, “Soooo, Rep. Roe.  Seems your state is really missin’ the ole Medicaid assistance that kept your hospitals open, fully staffed, and in the black. What’s the problem there? I mean, in that state just north of your border the hospitals seem to be doin’ just fine under the new system.” A nice ad campaign, with the name of the respective Republican officeholder in each state legislative and congressional district, can’t be all that expensive, can it?

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The Antidisestablishmentarianism Theory of Obamacare Illegality. (The ACA has a (dis)establishment clause! Who knew?) [Updated.]

A federal judge in the District of Columbia will hear oral arguments on Tuesday in one of several cases brought by states including Indiana and Oklahoma, along with business owners and individual consumers, who say that the law does not grant the Internal Revenue Service authority to provide tax credits or subsidies to people who buy insurance through the federal exchange. …

The subsidy cases, if successful, would strike at the foundation of the law. Subsidies and tax credits, which could be available to millions of low- and middle-income Americans, are central to Mr. Obama’s promise of affordable care. In drafting the law, Congress wrote that such financial help would be available to people enrolled “through an exchange established by the state” under the law.

A New Wave of Challenges to Health Law, Sheryl Gay Stolberg, New York Times, today

Hmm.  Okay, let me take a crack at this.  The law gives each state the option of running its own exchange or instead allowing the federal government to run an exchange for the state–an operation that must be done separately for each state, because each state has its own insurance companies offering different policies than other states, and subject to state insurance laws and state agency oversight.

The law doesn’t say “through an exchange run by the state” under the law; it says “through an exchange established by the state” under the law.  The states know their options.  Fourteen of them chose to establish an exchange by setting one up and running it.  The rest have chosen to establish an exchange by delegating to the federal government the job of setting up and running the exchange for the state.

The law itself, in other words, by requiring that each state choose one of two mechanisms to establish an exchange–directly or instead by delegation to the federal government–required every state to have (i.e., to establish) an exchange.  The tax credit, or subsidy, provision of the statute does not limit tax credits (subsidies) to people who live in states that choose to physically set up and run the state’s exchange itself.  It provides that benefit to people regardless of their state of residence, because by operation of law–specifically, by operation of that law–states can establish their exchanges by delegating to the federal government the physical setting up and running of the exchange.

Depends, in other words, on what the meaning of established is.  Or, more accurately, on what Congress intended the meaning of “established” to be.  And I’ve just told you what that is.  Surely, the federal courts understand the concept of contracting out a tech job.  Thirty-three states have chosen to contract out this job to the federal government.  Except, of course, that the contract was not negotiated but instead compelled by law.

Voila!  The antidisestablishmentarianism theory is disestablished.  The tax credits/subsidies clause in the ACA applies even to you, Red State denizens who qualify financially.  Congratulations.  I mean, my condolences.

But also in the article is this jaw-dropper, a quote from Jonathan Adler, a law professor at Case Western Reserve University and one of the two proud creators of the ACA disestablishment-clause hypothesis:

Among critics of the law there is a feeling that the law doesn’t have the same legitimacy as a law that passed with bipartisan support.

Let me take a crack at this, too.  This will only take a moment: I don’t recall the provision in the Constitution that classifies laws duly enacted without bipartisan support illegitimate.  But I do wish the Dems had remembered that Article or Amendment in 2001 when Congress enacted the first set of tax cuts for the wealthy, without bipartisan support.  Not that it would have mattered, though.  I mean, who knew that when the Supreme Court put George W. Bush in office via an opinion that said its legal reasoning would apply to that case only, the five justices in the majority also meant that the clause in the Constitution that delegitimizes laws enacted without bipartisan support doesn’t apply to laws enacted by only Republicans?   But you can bet it doesn’t.

Adler’s partner in theory development is a Cato Institute “health policy scholar” Michael F. Cannon, and the Times article gets a quote from him too.  Not to be outdone in the outragousness department by his compadre, Mr. Cannon thusly described the Strategic Airwaves Command plan developed immediately after the ACA was signed into illegitimate law:

After the A.C.A. was enacted and after the president signed it, a lot of people — me included — decided that we weren’t going to take this lying down, and we were going to try to block it and ultimately either get the Supreme Court to overturn it or Congress to repeal it.

Mr. Cannon will testify today at a televised House committee hearing about his and Professor Adler’s theory.  The professor must have a scheduling conflict, because he apparently is not on today’s witness list.  But presumably Mr. Cannon, scholar that he is, can cite the legal authority for the proposition that laws aren’t legitimate unless enacted with bipartisan support if it’s a Democratic rather than a Republican majority that voted for the bill.  He’s not a lawyer, but he does work for the Cato Institute.  Which, as the Times article notes, is libertarian-leaning.  As opposed to, say, democratic-leaning.  But not as opposed to fascist-leaning.  Which the current Republican Party, egged on by its corporate-funded puppetmasters, is.

What’s next from the libertarian crowd?  Polling places only in gated communities? Damn! I shouldn’t suggest it, should I?  Oh, well; they’d have thought of it on their own soon enough. That’s why Cato is called a think tank.

UPDATE: Reader Jack writes in the Comments thread:  “The relationship between Cato and the Ayn Rand Institute (ARI) improved with the nomination of Cato’s new president John A. Allison IV in 2012. He is a former ARI board member and is reported to be an “ardent devotee” of Rand who has promoted reading her books to colleges nationwide.” Wiki

Also, “….but so intense is Allison’s devotion to Rand’s work that he has waged a campaign to make college students read it, using the power of the BB&T Charitable Foundation and millions of dollars in donations to schools to achieve his goal.” Jane Mayer,”

It does seem to me that the mainstream media should stop referring to Cato as a libertarian think tank now that that organization is simply an arm of the Koch brothers’ propaganda machine.

ALSO: Here’s a report on the argument yesterday afternoon in the case.

SECOND UPDATE: An exchange between reader EMichael and me in the Comments thread:

  • EMichael
    December 4, 2013 9:28 am

    Hard to figure out whether to laugh or cry.

    Fairly humorous that one half of the GOP’s healthcare reform platform is to stop the ambulance chasers via tort reform while using the same ambulance chasers to stop the Dem healthcare reform.

    The sad part is that there are judges who will not just laugh at these people and throw them out of his courtroom.

  • Beverly Mann
    December 4, 2013 1:37 pm

    Yup, EM. There’s a cadre of lawyers who have made this their specialty: tortious-interference-with-Obamacare. It’s apparently quite lucrative.


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Was the Nov. 30 Deadline the Make-or-Break Moment for Obamacare? No . . .

Somewhere in the future months, one of us is going to have to eat crow here on the success of the PPACA. The Republicans, Teabaggers, Healthcare Insurance Companies, Gerrymandered Republican Districts, ALEC, Koch Bros, etc. are working their hardest to make this much needed change in how people gain coverage fail. Meanwhile healthcare insurance companies are scamming the public with the cancellation of policies they should have never written after 2010 and are increasing policy premiums in spite of the MLR. Its the PPACA’s fault . . .

In my own state of Michigan, 315,000 people, a minority of the 9 million voters, have signed a petition to force women who want abortion coverage to seek a rider to their policy independent of PPACA coverage. Given that the state has refused to set up a state exchange and has used the Federal Exchange adding to the overloading of it, I wonder how the Federal Government will weigh in on this silliness. This petition is dangerous as it will not be put to vote on the November 2014 ballot. Instead, it will go to the Republican controlled legislature to decide whether it becomes law of not and bypass the Republican governor who vetoed a similar bill. Michigan has quite a few laws which beg for Federal review. Most recently, The state Attorney General decided he would not review juveniles sentenced to life imprisonment without parole claiming it only applies to future trials. Huh????

Maggie Mahar does a good review of the current PPACA deadline which warrants greater acknowledgement.

Was the Nov. 30 Deadline the Make-or-Break Moment for Obamacare? No . . .

Why March 31 is Far More Important –Particularly for Younger Americans 

The media has described November 30 as the administration’s “self-imposed” enrollment deadline, but conservatives—and the media itself—insisted on a date, demanding, over and over again, that the administration answer the “$400 million question”:

How long will it take to fix the Federal Exchange?

Ultimately, Jeffrey Zients, the Obama administration’s new health-care website, promised the site would be “generally operational” for “the vast majority of users” by the end of November.”  No one quite knew what that meant. But immediately, the media turned the November 30 deadline into a headline. On November 28,CNN declared:  “A moment of truth approaches for President Barack Obama’s signature health care reforms with Saturday’s self-imposed deadline to get the website to work properly for most users.”

Reuters chimed in: “President Barack Obama’s healthcare law is facing its biggest test this weekend since its disastrous October 1 launch . . .  If the website does not work on Saturday’s deadline, that could turn off millions of uninsured Americans, especially young and healthy consumers whose participation in the new insurance exchanges are critical.”

Where, I wondered, is Reuters getting its information? From Fox News?

Younger Americans Are Not as Intimidated by Website Snags

There is absolutely no reason to think that 20-something and 30-somethings are more frustrated with the technical glitches than anyone else. There is, in fact, every reason to think that young Americans are not nearly as bothered by software bugs.

First, keep in mind that most Millennials haven’t even tried to sign up. This is because they are not as anxious as older, sicker Americans about securing insurance.

But when they do go to the website, a twenty-something is likely to have an easier time than a 50-something when trying to work his way around glitches. Unlike many of their elders, Millennials solve software snags every day – at home, at work, at school. Twenty-five-year-olds who have grappled with Windows 8 will not be daunted–or surprised—by a few bugs.  For many younger Americans working through such problems is almost intuitive.

This also helps explain why, despite the sustained bad-news blitz, a CNN poll released just last week shows 18-34-year-olds overwhelmingly believe the president’s healthcare law will work: “Seven in 10 younger Americans think the current problems faced by Obamacare will eventually be fixed. Senior citizens are split, and most people between 35 and 65 years old think that the system is permanently broken,” said CNN Polling Director Keating Holland. . (So much for 35-65 year boomers. Some of the folks in my generation are getting grumpy).

The Success of Reform Turns On the Health of Those Who Sign Up

Keep in mind that 18-34-year-olds are needed to make the Exchanges work. As Ezra Klein pointed out recently, what matters most is not the absolute number of Americans who join the Exchanges this first year, but who they are. He explains:  “Back in July, when Sarah Kliff and I asked the White House how they defined ‘success’ in 2014, they always defined it as a function of the mix of people in the exchanges  . . . rather than the number of people in the exchanges . . . More wasn’t necessarily better. Twenty million enrollees would be a disaster if only 1 million of them were young and healthy. . .

“If they got 10 million people to sign up, about 3.9 million had to be young and healthy. If they got 4 million to sign up, success would mean making sure 1.5 million were young and healthy.. . . so long as the ratio was right, the premiums will remain low, and so when people eventually come to buy insurance, they can get a good deal, and they’ll want to sign up.”

In other words, it doesn’t matter whether 7 million or 5 million Americans join the Exchange this year. If enough 20 and 30-something’s join the risk pool, this will ensure that premiums are as low in 2015–or even lower– than they were in in 2014. This is the scenario that reform’s opponents fear most..

Many Young Americans Will Wait Until March

Those who argue that reform is a “failure” because October and November enrollments remain low emphasize that if potential Obamacare customers haven’t signed up by the end of November they will have only 23 shopping days left if they want be covered by January 1.

But many hale and hardy 20-somethings don’t really care whether they are insured by the first of the year. They just want to avoid forking over $95 because they  decided to ignore the mandate that they purchase coverage. In that case, they have until March 31. That is when open enrollment ends—and when the penalty kicks in for those who decide not to buy insurance.

What Happened When Massachusetts Mandated That Its Citizens Buy Healthcare?

Massachusetts’ experience suggests that, for young healthy Americans—the folks we need to keep premiums at reasonable levels– March 31 is the most important deadline

In Massachusetts enrollment in Commonwealth Care began in March of 2007. The state mandated that  but the state’s citizens wouldn’t have to pay a $291 penalty if they purchased insurance by November of 2007.A study published in the New England Journal of Medicine shows just how important that November deadline was.

Researchers began by separating enrollees into two groups—those who were healthy when the joined Commonwealth Care, and those who were not.  Using claims data from the first year that these patients were part of Commonwealth Care, they measured the health mix of the population who had enrolled from March 2007 through June 2008, looking at average age, average monthly health care expenditures, and the proportion of enrollees suffering from a chronic illness. We identified patients as having a chronic illness if within the first 12 months after enrollment they had an office visit at which a diagnosis of hypertension, high cholesterol level, diabetes, asthma, arthritis, an affective disorder, or gastritis was recorded

The chart below reveals the enormous spike in the number of healthy applicants joining the program in November–just in time to dodge the penalty. That month, there was a much smaller increase in the number of chronically ill people signing up for insurance. Many already had purchased insurance.

< a href="">NEJM Commonwealth Care enrollees

The chart also shows that the number of healthy applicants continued to outpace sicker applicants for another six months. Clearly the mandate made a huge difference in ensuring that younger customers joined the pool. I suspect that over the next four months, we’ll see the same pattern nationwide.. I don’t expect to see most Millennials scrambling to buy insurance in December. Very likely, the bigger spike will come in March. This is why MIT’s Jon Guber an architect of Massachusetts Reform, plan calls the October and November Obamacare enrollment figures “basically meaningless”:

Look, when we opened our system in Massachusetts the first month the people could pay premiums and enroll, 123 people enrolled,” Gruber points out  ”By the end of the year, it was 36,000. That meant we got .3 percent of the people the first month. By that standard the federal government did great, 1.3 percent of the people the first month. It’s too early to say anything useful. The real deadline we have to focus on is March of next year.” 

I agree. When we look at who has signed up at the end March, we will be able to assess how well reform is doing—and how likely it is that premiums will rise in 2015.

Was the November 30 Deadline the Make – or – Break Moment for Obamacare?  No  .  .  .  Maggie Mahar; Economist, The Healthbeat Blog

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Oh, Stop, Matthew Yglesias. And COUNTLESS Pundits Like you.

That’s an enormous lowering of expectations, and a reminder to liberals about the formidable barriers to further expansion of the welfare state. The public has long been skeptical of the political system’s practical ability to do the things progressives say they want to do. A health care website that comes in months late, over budget, and still lacking full functionality confirms all those fears when it was initially meant to debunk them. And that’s true whether or not it in some sense “works.”

— Matthew Yglesias, Has Already Failed: Website problems won’t stop Obamacare, but they’ve already wrecked progressives’ ambitions. Slate, today

Yglesias was discussing the Obama administration’s statement yesterday that is now working reasonable well in its capacity to handle log-ons.  The update, Yglesias said, tacitly acknowledged  that “‘t]he government, according to the people who run the government, shouldn’t be expected to do things well.”

That’s right, Matt.  What liberals have always wanted was a healthcare insurance website that works the way Amazon’s does.  They never really much cared whether healthcare insurance, and healthcare itself, was available to people who have a preexisting medical condition and don’t have an employer that provides group insurance, or who just plain can’t afford huge premiums. They just used that as a pretext to get the Amazon-like website, or to try to.

The government shouldn’t be expected to do things well.  If, by “things,” you mean websites.

Just wondering whether I’m the only one who is really, really tired of the punditry’s asinine conflation of means and ends–or, more specifically, of a website’s operations and access to medical insurance and medical care.  I doubt that I am.  I think it’s just that big-name pundits tend to conflate form and substance, because, well, that’s what big-name pundits do.

What a dumb blog post.  Yglesias’s, on Slate; not mine, here.


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Insurers’ Latest Dodge to Not Cover You when You Need It: The Incredible Shrinking Network

Today’s must-read Seattle Times article by Carol M. Ostrom and Amy Snow Landa (interactive graphic here and comparison table here) prompts me to write about a huge problem with American health insurance that I’ve been banging against quite personally in recent months.

Excerpts below give an idea what an important article this is. My thoughts:

Insurers are actively eliminating must-have hospitals from their networks, while imposing unlimited out-of-pocket charges for out-of-network services. If the provider you need (a pediatric or major-trauma hospital for instance) isn’t in your insurer’s network, you could face financial ruin even though you’re insured.

I’ve been deep in the individual health-insurance shopping game recently, shopping for myself in Washington State and for my 22-year-old daughter in Illinois. I even built a web app to compare total costs of different health plans, because there’s really no way to compare them without such a tool.

It’s incredibly complex, with all sorts of interacting variables to evaluate. I can’t imagine how someone without my analytical skills (and time to use them) could even begin to do a good job of it — protect themselves effectively and suss out the best deals to do so. Most would have to throw up their hands and throw a dart.

To be a smart shopper in this market, you have to be very smart, and have lots of time on your hands.

That pretty much describes me — the Republicans’ dream shopper, out there driving down insurance prices by comparing and carefully evaluating all the competition and choosing the best deal.

But even I have been completely flummoxed by one big issue: how do I evaluate the networks of providers offered under different insurers and plans? Sure, I can look to see if my doctor’s covered. Great. Big deal. But what if I have a major auto accident? Is Harborview (Seattle’s top-flight regional trauma center) covered? How about Children’s Hospital, our pediatric mecca? (Not an issue for me these days, but…) The Swedish Hospital system? (Top-rated for ER intake times, the place I would go for a medium emergency.) Seattle Cancer Care Alliance? (This is the outfit you’re gonna want if you face that horror.)

One and only one insurer in Seattle covers all those providers in-network. Most cover none of them.

Ostrom and Landa have done the legwork for us here in Seattle. If you’re elsewhere…sure: you can evaluate this — by going to every single insurer’s site, figuring out which of their often-multiple networks a particular plan supports, then successively searching those networks for all the possible providers using their little web tool, one provider after another, one insurer after another, and building yourself a table.

It’s basically like playing Battleship.

Realistic? Even if you could predict, in advance, what providers you might need someday (and you’re savvy enough to know which providers in town are important), we’re talking hours of work to check whether each plan covers them.

Here are the crux paras from Ostrom and Landa’s article:

The Seattle Times asked the seven insurance companies selling individual policies in the exchange in King, Pierce and Snohomish counties to list their in-network hospitals.

The results show that only one — Community Health Plan of Washington — includes Seattle Cancer Care Alliance, which offers treatment for some of the most complex cancer cases in the region.

Four of the seven insurers do not include the University of Washington Medical Center or the UW’s Harborview Medical Center — which has the state’s only Level 1 trauma center and burn unit.

Community Health includes every major hospital in King, Pierce and Snohomish counties, but is the only exchange insurer that does.

By contrast, Premera and its subsidiary, LifeWise Health Plan of Washington, include many major hospitals, but not the largest Seattle-area hospitals in the two major medical systems — Swedish and UW Medicine.

Let’s be very clear here: Premera and  Lifewise, two of the state’s biggest insurers, provide in-network coverage for none of the important hospitals I listed above. Not Children’s (pediatric). Not Harborview (major trauma).

Meanwhile many, most, or all of their plans have no limit on your out-of-pocket costs for out-of-network providers. If you have a serious illness or injury, you could be financially ruined even though you’ve got insurance.

This part really, really pisses me off:

Coordinated Care CEO Dr. Jay Fathi said the company would use “single-case agreements,” which he likened to an invoice or a bill. The hospital sends the bill to the insurer, who pays it, a system he said functions “fairly smoothly.”

Children’s officials say such agreements are quite rare and are generally limited to patients who are out of network because they live outside the local area. Resorting to single-case agreements, they said, would likely delay care for patients.

In other words, “Trust us. We’ll cover you if you need it.” (Yeah, and I’ve got a bridge for sale.)

This also points out that exposure to out-of-network charges, traditionally much more of a problem in rural counties, has now come home to urban dwellers. Seattle has traditionally been seen as a really great place to get sick — great providers with ample access.

That’s no longer true if you’re buying individual health insurance.

Cross-posted at Asymptosis.

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