“Turning The Health Care Corner”: The Health Care Talking Points That “Everyone Knows” To Be True Are Due For An Update
Political journalism is sometimes criticized, fairly, for its “pack” mentality. Major news organizations wait for the conventional wisdom to organically take shape, and then the players stick to their scripts, reinforcing an agreed upon consensus. In practically no time at all, there are certain political facts that “everyone knows” to be true.
But soon after, that gets dull, the conventional wisdom invites skeptics, and contrarian instincts kick in. Maybe, the political world starts to wonder, those truths that “everyone knows” aren’t so true after all.
For the last several weeks, the consensus in establishment circles was that the Affordable Care Act’s open-enrollment period was not only a disaster, but a catastrophe that would destroy Obama’s presidency, the Democratic Party, the American health care system, and the very idea of progressive governance. Pundits could hardly contain their analogies – this was Obama’s Katrina, Obama’s Iraq, Obama’s Watergate, Obama’s Iran-Contra, and even Obama’s Bay of Pigs.
But the funny thing about narratives is that they’re sometimes fleeting. Ezra Klein suggests today that “Obamacare” may finally be “turning the corner.”
There are increasing reports that HealthCare.Gov is working better – perhaps much better – for consumers than it was a few short weeks ago. “Consumer advocates say it is becoming easier for people to sign up for coverage,” report Sandhya Somashekhar and Amy Goldstein in the Washington Post. “The truth is, the system is getting stronger as it recovers from its disastrous launch,” writes Sam Baker in the National Journal. Applying “was no problem at all, with no delays,” says Paul Krugman.
Reports from inside the health care bureaucracy are also turning towards optimism. People who knew the Web site was going to be a mess on Oct. 1st are, for the first time, beginning to think HealthCare.Gov might work. Data backs them up: By mid-November, the pace of enrollment in the federal exchanges had doubled from what it was in October.
The Obama administration is certainly acting like they believe the site has turned the corner. Somashekhar and Goldstein report that they’re “moving on to the outreach phase, which had taken a back seat as they grappled with the faulty Web site. Next week, the White House will host an insurance-oriented ‘youth summit’ aimed at people ages 18 to 35, an age group whose participation in the health-care law will be critical to its success.”
Why didn’t the White House do this sooner? Because officials didn’t much see the point in directing people to a website that didn’t work. If they’re increasing the website, it’s the result of greater optimism.
Perusing the news this morning, there are more than a few compelling pieces along these lines. The L.A. Times has a terrific article, for example, on “the Obamacare success stories you haven’t been hearing about.” NPR today highlighted some Californians who received cancelation notices – and are thrilled with the results. National Journal made the case yesterday that Obama not only can recover from the troubled rollout; he already has.
Moreover, Greg Sargent has a great piece noting that for all the talk about health care crushing Democrats, there’s a credible argument that the Republican position “is actually a political liability of its own.”
Yes, some of these pieces were written by center-left observers who may be predisposed to hope “Obamacare” succeeds, but note that we weren’t seeing any of these kinds of reports a few weeks ago when the feeding frenzy got underway. On the contrary, Ezra, Greg, and others were openly critical of the administration’s obvious mistakes and missteps as they unfolded.
The conventional wisdom won’t change quickly or easily, but you can almost see the consensus shifting in real time. There are some important issues the administration still needs to address, and failure very much remains an option. For that matter, if it’s a mistake to exaggerate the importance of every piece of bad ACA news, the law’s defenders must be equally cautious about exaggerating the importance of every positive development, too.
But for those stuck in the “Obamacare is and will remain a disaster” story, it’s time for a reality check. The system is improving, enrollment is increasing, more consumers are smiling, horror stories are failing, and health costs are shrinking.
The health care talking points that “everyone knows” to be true are due for an update.
By: Steve Benen, The Maddow Blog, November 26, 2013
“Many Rivers To Cross”: What To Get Rush Limbaugh And Other Racism Deniers For Christmas
Oh, hey, Jonah Goldberg and Elisabeth Hasselbeck and Rush Limbaugh, and all you right-wingers trying to whitesplain racism to Oprah Winfrey: The finale of “The African Americans: Many Rivers to Cross” is on PBS tonight and I’m sure you won’t want to miss it.
You guys know the guy behind it, Henry Louis Gates Jr. Well, OK, you probably only know one thing about him: that he was the Harvard professor arrested by a Cambridge cop in 2009 after having trouble getting into his own house — arrested even after he’d proven he lived there. It took a beer summit with President Obama and Vice President Biden to make things sort of OK.
I wrote at the time about how Obama’s wading into the Gates controversy – he simply told the truth, that the police had acted “stupidly” in detaining and booking the Harvard professor in his own home – had “blackened” him for many white people. It coincided with a sudden plunge in the president’s approval rating among white voters, from the 60s down to the 40s, and he never really recovered.
Yet Gates was a terrible choice to play Angry Black Man, because he’s always been someone who’s treated white people as though they deserve the benefit of the doubt. Melissa Harris-Perry argued in the Nation at the time, “Gates is invested in black life, black history, black art, and black literature, but he has managed to achieve a largely post-political and even substantially post-racial existence.” Which is what made his arrest so shocking.
“Many Rivers to Cross” seems the ideal way for whites, even conservatives, to cross over to understand the enduring legacy of slavery (even you, Sarah Palin) and Jim Crow and the persistence of racism in the age of Obama. Gates doesn’t interview Oprah, but in the finale he does talk to the most illustrious black Republican of our time, former Secretary of State Colin Powell, who gets teary talking about Obama’s victory. “I cried,” Powell confesses to Gates, and Gates gets choked up too.
Oh, I forgot: Colin Powell used to prove the Republican Party wasn’t racist; then he endorsed Barack Obama, and now you guys hate Colin Powell, and think he’s a racist.
Still, Gates does a lot of sly things to make everyone comfortable crossing these rivers with him. He’s kind of literally company, as we see him walk on a cane down roads and riverbeds where unspeakable racial tragedies took place. You’d be safe with him, Jonah Goldberg, strolling down a path that led to the savage quelling of a slave rebellion or a bridge where a Detroit race riot erupted. He admits his own fears. Gates walks Ruby Bridges back to the elementary school she integrated. “Ruby, were you scared?” he asks. “I would have been terrified.”
Yet he also shows how African-American achievement has always coexisted with African-American oppression, which would be a bracing corrective to the ignorance of insisting the ascendance of Barack Obama and Oprah Winfrey mean racism is behind us. Oprah even has an American capitalist antecedent in Sarah Breedlove/Madame C.J. Walker, who was the first African-American millionaire, male or female (though Walker got rich marketing to black women where Oprah ministers to all of us).
Gates introduces us to black strivers and titans and culture heroes, from Walker to Don Cornelius to Vernon Jordan to Questlove; black meccas from St. Augustine, Fla., to Tulsa, Okla., to Detroit, all while telling the story of how far we still have to travel to equality. He shows how white Americans have always been able to love (and appropriate) black culture without giving up their racism. I’m not saying nothing has changed, nor is Gates, but the notion that Oprah’s own popularity disproves her charge of racism is itself disproven by American history.
I probably know more than the average white person about African-American history, which only ensures that I know less than I think I do. And I learned so much from “Many Rivers,” I am sorry to see it end. One thing I haven’t seen anyone say about it: There’s a gender balance that’s rare in history documentaries that aren’t about women’s history. I watched Episode 4 online back to back with “Lincoln at Gettysburg,” which I loved, but which only featured one female scholar, the great Melissa Harris-Perry.
Gates features dozens, from Annette Gordon-Reed and Thavolia Glymph to Michelle Alexander and Isabel Wilkerson. And he focused on the transformative stories and ideas of black women, from Walker to Rosa Parks, Ella Baker, Diane Nash, Charlayne Hunter-Gault, Grace Lee Boggs (including my friend and mentor Angela Glover Blackwell of PolicyLink, where I’m on the board — but I was writing this piece already before I learned that).
I know Goldberg and Limbaugh and Hasselbeck and the other racism deniers aren’t likely to watch “Many Rivers.” And I know it’s simplistic to think a documentary, however artful, can change the minds of partisans who make a good living denying our history, but I can dream. I’d still try to sneak the whole series into the Christmas stocking of your racism-denying but “cultured” relatives this holiday season.
By: Joan Walsh, Editor at Large, Salon, November 26, 2013
“Expanding Conservative Religious Fanaticism”: The Contraception Mandate Cases Aren’t Really About Contraception
Earlier today, the Supreme Court announced that it would hear not one, but two challenges to the Obama administration’s contraception mandate; they’ll be heard together in an action-packed hour of oral arguments sometime in the spring. Both cases deal with conservatives’ ever-growing penchant for anthropomorphizing corporations—this time, the justices will decide whether companies can be exempted from the mandate to provide birth control at no cost to employees because of the owners’ religious beliefs.
Oddly enough, neither of the business owners involved are Catholic, even though the first objections to the contraception mandate were raised by Catholic leaders, who didn’t want religiously affiliated hospitals and schools to provide birth control, which the Catholic hierarchy considers taboo. One case—Sebelius v. Hobby Lobby Stores, documented extensively for the Prospect by Sarah Posner earlier this summer—deals with an arts-and-crafts chain owned by evangelical Christians. The other—Conestoga Wood Specialties v. Sebelius—hones in on a smaller, Mennonite-owned cabinet door manufacturer.
Neither of the plaintiffs’ arguments mention doctrinal objections to contraception. That’s because Protestants, unlike Catholics, don’t believe that birth control is immoral. In fact, the denominations’ divergent views on the two issues created a kind of intra-Christian culture war throughout much of the twentieth century. Haunted, in part, by neo-Malthusian fears about the world’s rapid descent into overpopulation, the Church of England officially moderated its stance on contraception in 1930. Over the course of the following decade, most American Protestant denominations followed suit. The Mennonite Church does not have an official stance on birth control.
In the 1970s, the “Masters and Johnson of Christianity,” Ed and Gaye Wheat, published Intended for Pleasure, a bestselling Christian sex manual with a chapter on “planning and achieving parenthood,” with extensive information about artificial contraceptive methods. Alfred Mohler, the president of the Southern Baptist Theological Seminary, observed in 2006 that although the “birth control revolution…let loose a firestorm of sexual promiscuity,” it also “offered thoughtful and careful couples an opportunity to enjoy the joys and fulfillments of the marital act without remaining at all times equally open to pregnancy.” A Guttmacher Institute report released in 2011 revealed that three-quarters of Protestant American women were using some form of artificial birth control.
When evangelical Christians decided to throw in their lot alongside the Catholic hospitals and schools seeking an exemption from the contraceptive mandate, their argument was, to put it mildly, a stretch. When Wheaton College, an evangelical liberal arts school in Illinois, asked the Obama administration for an emergency injunction against the contraception mandate last year, it emerged that the college was not eligible because it had “inadvertently” been including emergency contraception in its student health plan.
It should also be noted that neither of the cases that will appear before the Supreme Court are founded on sound science; both allege that emergency contraception—and, in the Hobby Lobby case, the IUD—is a form of abortion. This relies on the notion that pregnancy begins when the egg is fertilized—not, as the medical community contends, when a fertilized egg implants in the uterine wall. This means that regardless of what the Supreme Court decides, the facts of the case will be based on junk science, not theology. The Catholic Church, whether you agree with it or not, has consistently maintained that birth control is a fundamental evil. Protestant attempts to overturn the contraception mandate aren’t about theological objections to birth control—they’re an effort to dramatically expand religious freedom rights for conservative Christians.
By: Amelia Thomson-DeVeaux, The American Prospect, November 26, 2013
“A Reminder Of The Essential Truth”: You Might Lose Your Doctor, But Don’t Blame Obamacare
Obamacare critics on the right think they have a new issue. They are calling it “provider shock.” Thanks to the new health care law, these conservatives say, insurance companies are limiting beneficiaries to small groups of doctors and hospitals. As a result, people who depend on these professionals and institutions will have to seek treatment elsewhere—and, inevitably, get substandard care.
When conservatives make these arguments, I imagine they have in mind stories like this one, from the Los Angeles Times:
In a major shift in health-care benefits likely to be followed by others, PacifiCare Health Systems Inc. today will unveil an HMO that will limit members’ choices to a relatively small network of doctors and hospitals. … members who enroll in the plan, called Value Network, will have available to them about one-third of the hospitals and one-half of the doctors of a standard HMO. Altogether, there are 300 hospitals and 250 medical groups in California. Value Network members who use providers outside the slimmed-down network generally will have to foot the bills.
If you’re a fellow health policy geek, then you may have guessed the punch line. This article isn’t from 2013. It’s from 2002. And it’s a reminder of the essential truth here. Insurance companies have been using limited provider networks for a long time. It’s how they conducted business before Obamacare came along and, for better or worse, it’s how they’ll conduct business now that Obamacare is law.
Maybe a little history would put this issue in its proper context. Once upon a time, most insurance carriers would pay for care provided by pretty much any person or facility with a license. But that got expensive and, by the 1980s, insurers responded by reducing what they would pay for services—and then limiting beneficiaries to networks of doctors and hospitals willing to accept these lower fees.
The change was not particularly popular. At the time, Americans were not accustomed to such restrictions on where they got their medical care. In response to the consumer and political backlash—a backlash that providers happily supported—insurers started offering plans with looser restrictions. Mostly these were preferred provider organizations (PPOs), which allowed beneficiaries to seek care out of network as long as they were willing to pay more for each visit and service. But provider restrictions never went away entirely and frequently negotiations over the terms led to very public disputes, as Paul Fronstin, from the Employment Benefit Research Institute, pointed out via e-mail:
There have been numerous stories over the last decade of usually health plans dropping a large provider group because the provider group wouldn’t accept the rates, or less-usually a provider group walking away from a health plan because it didn’t like the terms. Often the two would come to terms after some period of continued negotiation once the contract expired and the news hit the fan, so to speak.
More recently insurers have shown renewed interest in tighter networks, sometimes through what’s known as “tiered network” plans that operate as a sort of hybrid between HMOs and PPOs. (These plans allow people to get care out of network, but only at much higher out-of-pocket costs than more traditional PPOs would require.) And it appears the Obamacare exchanges have lots of these plans.
While I haven’t seen definitive nationwide data, a report from the Center for Healthcare Transformation and Research found that, on Michigan’s new exchange, the majority of options are “limited or network plans.” In California, where narrow networks have gotten a great deal of media attention, the plans Blue Shield is offering will allow access to just 36 percent of the physicians available in Blue Cross employer plans, according to the L.A. Times. And when McKinsey and Company surveyed 16 state exchanges earlier in the year, it found that about half the plans had narrow networks, according to an article in Modern Healthcare magazine.
But Obamacare’s relationship to this trend is more complicated than it might seem. On the one hand, the law has introduced volatility into the insurance market, potentially emboldening insurers who were contemplating tightening networks already. As Karen Pollitz, a senior fellow at the Kaiser Family Foundation, explained via e-mail:
Without question, some insurers took this opportunity—when things are changing and so the old ways of doing business could be shaken up—to offer new, tighter, cheaper network designs. And probably without a clear idea as to what impact it might have on patients. Also without question, some hospitals and doctor groups took this opportunity to take a tougher bargaining stance and demand higher payments from insurers to join their networks, betting the insurers couldn’t live without them, and the insurers called their bluff. It’s not obvious providers knew clearly what the patient impact would be, either.
With Obamacare, and its requirement of selling policies to anybody willing to buy them, insurers also worry about adverse selection. Previously, they were willing to offer plans without provider restrictions, but only to people unlikely to use either outpatient or inpatient services much. Now insurers have to sell plans to anybody, regardless of pre-existing conditions or risk of illness. In other words, they can’t restrict wide-open access to the people least likely to use it. Faced with this reality, some insurers are bound to raise premiums for those plans—or to stop offering them altogether. That’s why some people who buy these plans now would have to pay more for them next year. (Basically, this is just another form of rate shock, about which you’ve read so much already.)
Still, according to nearly every source inside and outside the industry I’ve consulted, the primary reason carriers are offering so many small-network plans in the exchanges is that they believe consumers want them. Their marketing research suggests that, when forced to choose between paying higher premiums for wider networks or lower premiums for narrower networks, the majority of people will go for the cheaper insurance. The one survey I’ve seen on this question, by Morning Consult, suggests the carriers may be right: In that survey, nearly 60 percent of respondents said they’d opt for plans with fewer provider choices if it meant saving on premiums.
Larry Levitt, senior vice president of the Kaiser Family Foundation, summarizes the situation this way:
The main way insurers control costs is by negotiating and selectively contracting with doctors and hospitals. That’s been the case for decades. The only real connection to the Affordable Care Act is that the health reform law is making insurers compete for customers more aggressively.
As it happens, the narrower networks might be a good fit for many consumers, both financially and medically. Totally lost in this debate is the fact that many experts believe our health care system pays the providers of medical care way too much money. That’s particularly true of hospitals, whose obtuse and frequently unjustified prices were the subject of Steve Brill’s celebrated Time magazine article earlier this year. Sometimes high prices correlate with high quality, but sometimes they don’t. And particularly when it comes to more routine care, a community hospital is not just adequate but maybe even preferable to a teaching hospital that specializes in the hardest-to-treat cases.
Of course, the converse is also true. A few people have those hardest-to-treat cases. They are the ones who are better off at a place like Cedars-Sinai or the Mayo Clinic—or who need to maintain long-term relationships with professionals, rather than switching every time plans alter their networks. They are also the people whom, ideally, health insurance should do the most to assist.
But it’s not as if most people in this situation have unfettered access to such doctors and hospitals today. And Obamacare has provisions designed to help them. Most of the exchanges seem to include more traditional PPOs. They are expensive, but they are available to anybody—including people who, because of pre-existing conditions, previously had absolutely no way to buy them. (There are also subsidies that some people can use to offset the cost.) In addition, the Affordable Care Act has a “network adequacy” requirement that, in theory, requires all plans to include hospitals that provide specialty services like pediatric cancer treatment. The law even creates an external appeals process, through which people with private insurance can seek medically appropriate care they believe their carriers cannot (or will not) provide.
There’s a good case for strengthening these two provisions, which are relatively weak, or for taking other steps to help people who depend upon the most advanced hospitals and/or a set of familiar providers. The federal government could, for example, offer more financial incentives for the creation of Accountable Care Organizations, which are closed-network groups of providers designed to deliver the same kind of high-quality, low-cost care you find today at places like Kaiser Permanente, Geisinger Health System, and Group Health of Puget Sound. More states could set hospital rates, as Maryland already does, effectively taking price negotiation out of the market and subjecting it instead to regulation. Or there’s the most radical solution of all: Simply junking private insurance and creating a single-payer system, which would operate more or less like Medicare and would, in practice, mean access to most physicians and virtually every hospital.
None of these things are likely to happen anytime soon. They involve greater government regulation of health insurance, which would be fine with most Obamacare supporters but anathema to the law’s critics. That’s one irony of this latest controversy, as Jonathan Chait pointed out on Monday. Market forces, not government, and the main reason insurers are introducing tighter networks. Yet the people objecting to the result are the same ones who say they love markets.
By: Jonathan Cohn, The New Republic, November 26, 2013
“With Blood On Their Hands”: Neocons Fail Negotiation 101 Yet Again
If you want to know how the neoconservatives who brought us the Iraq War are reacting to the interim deal to freeze Iran’s nuclear program, the best way is to head over to the website of the Weekly Standard, where you can witness their wailing chagrin that the Obama administration doesn’t share their hunger for yet another Middle East war. All five of the featured articles on the site concern Iran, including editor Bill Kristol’s “No Deal” (illustrated with twinned photos of Bibi Netanyahu and Abraham Lincoln, believe it or not), one titled “Don’t Trust, Can’t Verify,” and “Abject Surrender By the United States” by the always measured John Bolton.
These people would be simply ridiculous if they didn’t already have so much blood on their hands from Iraq, and the idea that anyone would listen to them after what happened a decade ago tells you a lot about how Washington operates. But there is something important to understand in the arguments conservatives are making about Iran. Their essential position is that now that Iran has finally agreed to negotiate, we must “keep the pressure on” by not negotiating until they offer, to use Bolton’s words, an actual abject surrender. We should not just maintain but increase sanctions, to make them understand that they’ll get nothing and like it. The only way to get future concessions from Iran is to maximize their pain now.
You’ll recall how much progress the Bush administration made in getting Iran to pull back its nuclear development with this approach (none). It seems pretty clear that the neocons understand about as much about negotiating as my dog does about delayed gratification. So let me suggest that an easing of sanctions now is exactly what could get them to agree to more concessions at the end of the interim agreement’s period of six months. The reason is that what we’ve done is give the Iranians not only something to gain, but something to lose.
You may be familiar with the theory of loss aversion, which states that we tend to fear losses more than we are eager for gains. The pain of losing ten dollars you have is greater than the pleasure of gaining ten you don’t yet have. According to Daniel Kahneman, who pioneered the theory with his late colleague Amos Tversky, the “loss aversion ratio” in experiments is usually around two to one. For instance, if I offer you a bet in which you’ll lose $100 if you’re wrong, I’ll probably have to offer you $200 if you win in order to induce you to take the bet. Loss aversion has been demonstrated in a large number of experiments in a wide variety of contexts.
But as Bob Dylan said, when you got nothing, you got nothing to lose, which brings us back to Iran. Sanctions have by all accounts had a devastating effect on the Iranian economy. What conservatives would like to offer Iran is continued economic misery, in the hopes that a little more of that will get them to do what we want, i.e. dismantle their nuclear program. But under this new agreement, they’ll get a bit of temporary relief. Money will flow in to their economy, easing some of that misery. It might not be actual prosperity, but things will be better than they are now. The Iranian public will be pleased about the improved economy, likely making the regime feel more politically secure. Then at the end of the agreement’s time frame in six months, the country as a whole and the government in particular will have something to lose. The western powers will be able to say to them: Things are going better for you now. If you don’t take the next step in dismantling the nuclear program, we’ll reimpose the sanctions, and you’ll squander what you’ve gained.
Obviously, there are many other variables at play—the need to save face, the desire to be considered a world power, and so on. But if this agreement gives the Iranians something to lose, it might be just the thing to induce them to give up more later.
Or we could just listen to the neocons and start another war. Because that always works out well.
By: Paul Waldman, Contributing Editor, The American Prospect, November 26, 2013
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