“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
“California, Here We Come?”: If Obamacare Can Work For 38 Million People In California, It Can Work For America
It goes without saying that the rollout of Obamacare was an epic disaster. But what kind of disaster was it? Was it a failure of management, messing up the initial implementation of a fundamentally sound policy? Or was it a demonstration that the Affordable Care Act is inherently unworkable?
We know what each side of the partisan divide wants you to believe. The Obama administration is telling the public that everything will eventually be fixed, and urging Congressional Democrats to keep their nerve. Republicans, on the other hand, are declaring the program an irredeemable failure, which must be scrapped and replaced with … well, they don’t really want to replace it with anything.
At a time like this, you really want a controlled experiment. What would happen if we unveiled a program that looked like Obamacare, in a place that looked like America, but with competent project management that produced a working website?
Well, your wish is granted. Ladies and gentlemen, I give you California.
Now, California isn’t the only place where Obamacare is looking pretty good. A number of states that are running their own online health exchanges instead of relying on HealthCare.gov are doing well. Kentucky’s Kynect is a huge success; so is Access Health CT in Connecticut. New York is doing O.K. And we shouldn’t forget that Massachusetts has had an Obamacare-like program since 2006, put into effect by a guy named Mitt Romney.
California is, however, an especially useful test case. First of all, it’s huge: if a system can work for 38 million people, it can work for America as a whole. Also, it’s hard to argue that California has had any special advantages other than that of having a government that actually wants to help the uninsured. When Massachusetts put Romneycare into effect, it already had a relatively low number of uninsured residents. California, however, came into health reform with 22 percent of its nonelderly population uninsured, compared with a national average of 18 percent.
Finally, the California authorities have been especially forthcoming with data tracking the progress of enrollment. And the numbers are increasingly encouraging.
For one thing, enrollment is surging. At this point, more than 10,000 applications are being completed per day, putting the state well on track to meet its overall targets for 2014 coverage. Just imagine, by the way, how different press coverage would be right now if Obama officials had produced a comparable success, and around 100,000 people a day were signing up nationwide.
Equally important is the information on who is enrolling. To work as planned, health reform has to produce a balanced risk pool — that is, it must sign up young, healthy Americans as well as their older, less healthy compatriots. And so far, so good: in October, 22.5 percent of California enrollees were between the ages of 18 and 34, slightly above that group’s share of the population.
What we have in California, then, is a proof of concept. Yes, Obamacare is workable — in fact, done right, it works just fine.
The bad news, of course, is that most Americans aren’t lucky enough to live in states in which Obamacare has, in fact, been done right. They’re stuck either with HealthCare.gov or with one of the state exchanges, like Oregon’s, that have similar or worse problems. Will they ever get to experience successful health reform?
The answer is, probably yes. There won’t be a moment when the clouds suddenly lift, but the exchanges are gradually getting better — a point inadvertently illustrated a few days ago by John Boehner, the speaker of the House. Mr. Boehner staged a publicity stunt in which he tried to sign up on the D.C. health exchange, then triumphantly posted an entry on his blog declaring that he had been unsuccessful. At the bottom of his post, however, is a postscript admitting that the health exchange had called back “a few hours later,” and that he is now enrolled.
And maybe the transaction would have proceeded faster if Mr. Boehner’s office hadn’t, according to the D.C. exchange, put its agent — who was calling to help finish the enrollment — on hold for 35 minutes, listening to “lots of patriotic hold music.”
There will also probably be growing use of workarounds — for example, encouraging people to go directly to insurers. This will temporarily defeat one of the purposes of the exchanges, which was to make price comparisons easy, but it will be good enough as a short-term patch. And one shouldn’t forget that the insurance industry has a big financial stake in the success of Obamacare, and will soon be pitching in with big efforts to sign people up.
Again, Obamacare’s rollout was a disaster. But in California we can see what health reform will look like, beyond the glitches. And it’s going to work.
By: Paul Krugman, Op-Ed Columnist, The New York Times, November 24, 2013
“With Every Waking Moment”: Republicans Seeing The World Through An ACA Lens
On Saturday night, for the first time in a generation, the West and Iran reached a diplomatic breakthrough. Love the deal or hate it, the agreement on Iran’s nuclear program was a historic development with sweeping international implications.
Senate Minority Whip John Cornyn (R-Texas), an 11-year veteran of the institution and the second most powerful Republican in the chamber, immediately turned to Twitter: “Amazing what WH will do to distract attention from O-care.”
I kept waiting for the “just kidding, folks” follow-up, which never came. The Republican leader wasn’t mocking the caricature of unhinged GOP lawmakers; he’d become the caricature of unhinged GOP lawmakers. Indeed, as the notoriety of Cornyn’s message spread, he added, “Isn’t it true that WH are masters of distraction?”
It’s unsettling, of course, when powerful congressional leaders approach foreign policy with all the seriousness of a right-wing blog’s comments section, but it was even more disappointing when CBS’s Bob Schieffer asked House Majority Whip Kevin McCarthy (R-Calif.) on “Face the Nation” yesterday:
“You know, I was on airplanes this weekend, and more than one person I was talking to about this whole deal pending with Iran, and they were saying, this might be a diversionary tactic by the administration, which is desperately looking for good news. Would you put it in that category yet?”
Why lend credence to such silly conspiracy theories? The international diplomacy, involving major world powers, involved months of behind-the-scenes talks. Why would any serious person perceive this as a domestic political ploy, intended to “distract” or “divert” attention from a health care website that’s slowly improving?
The answer, I suspect, is that Republicans and much of the political establishment has become preoccupied with the Affordable Care Act in ways that are hard to defend.
Late last week, for example, National Review’s Jonathan Strong published an interesting piece, explaining why the Republican response to the “nuclear option” was muted: “Harry Reid may have detonated a nuclear bomb, but Senate Republicans don’t want a war if it would distract from the disastrous Obamacare rollout, senior GOP aides say.”
As hard as this may be to believe, many Capitol Hill Republicans believe Senate Democrats rebelled against obstructionism, not to improve the confirmation process, but to shift the focus from “Obamacare” and bait Republicans into a big fight that has nothing to do with health care.
Naturally, then, when months of diplomacy resulted in a deal with Iran, Republicans once more assumed this, too, must relate to the health care law – because “Obamacare” is the prism through which all light shines.
The obsession has reached farcical levels and it’s well past time for a reality-check. To think that every development, everywhere, is some kind of ploy related to health.gov is to lose all sense of reason. Democrats are heavily invested in improving Americans’ health care security, but it doesn’t dominate their every waking moment.
I don’t seriously expect Republicans to end their crusade against moderate health care law first championed by Mitt Romney, but a little perspective is clearly in order.
By: Steve Benen, The Maddow Blog, November 25, 2013
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