“The ‘Wingnut Hole’ Measured”: 5 Million Without Insurance Thanks To GOP Refusal
Because of the decision on Obamacare by the Supreme Court, which left the decision to expand Medicaid (a key part of Obamacare) up to the individual states, most Republican-controlled states refused said expansion, leaving substantial portions of the citizenry in the lurch.
Ed Kilgore has been calling this the “wingnut hole,” and many have been speculating about its size. How many Americans will go without health insurance simply because the GOP dislikes the president? Well, happy 2014, dear readers: initial estimates are in, and we have 5 million lucky winners!
About 5 million people will be without health care next year that they would have gotten simply if they lived somewhere else in America. . . . The court effectively left it up to states to decide whether to open Medicaid, the federal-state program for the poor and disabled, to more people, primarily poor working adults without children. . . .
Twenty-five states declined. That leaves 4.8 million people in those states without the health care coverage that their peers elsewhere are getting through the expansion of Medicaid, according to a Kaiser Family Foundation estimate. More than one-fifth of them live in Texas alone, Kaiser’s analysis found.
That’s approximately the combined population of Delaware, Vermont, the District of Columbia, North Dakota, South Dakota, Wyoming and Alaska. Or alternatively, either Alabama, South Carolina, Colorado or the whole of Norway alone.
The Supreme Court decision was doubly unfortunate, because Republican states tend to be poorer than average and contain a disproportionate number of potential beneficiaries who are losing out. Obamacare, by virtue of distributing benefits downward, was aimed at those very people; it never occurred to the law’s architects that the vagaries of politics and law might give states a way out, and so they didn’t design a backup coverage mechanism.
Some refusenik states, like Iowa, might go forward with an Obamacare-instead-of-Medicaid expansion, but most probably will do nothing. Prospects are bad enough that health-care industry groups have basically given up trying to push through the expansion by lobbying and are just biding their time until conditions are more favorable.
It’s worth remembering that the federal government will pay 100 percent of the cost of the Medicaid expansion through 2016 and 90 percent of the cost afterward. It could very well work out that refusenik states will not even save money because of additional spending on the uninsured in emergency rooms and elsewhere.
But regardless of the pitiful sums involved, make no mistake: This action is utterly gratuitous. Combined with the probable coming Republican refusal to extend unemployment benefits that George wrote about this morning, this is a particularly stiff kick in the teeth to the United States’ most vulnerable citizens to usher in the new year.
By: Ryan Cooper, The Plum Line, The Washington Post, December 31, 2013
“Call It A Comeback”: More Than 9 Million Americans Have Health Insurance Through Obamacare
You don’t get much credit for fixing something that should have worked in the first place, but the Obama administration has avoided a major catastrophe by delivering on its promise to fix HealthCare.gov for most Americans.
After two months of barely functioning, the federal online health care exchanges delivered, racking up 975,000 enrollments in the month of December. That brings the total number of people who have picked a plan through an exchange since October 1 to about two million. The administration reached about two-thirds of its goal of enrolling 3.3 million by the end of 2013 after being fully operational one-third of the time. And it turns out most of the enrollments came during the one-week extension the White House gave itself after the initial problems with the site became apparent.
Four million people have qualified for Medicaid, according to ACASignups.net. Another 3.1 million young adults are covered by their parents’ health insurance, thanks to a provision in the Affordable Care Act (ACA).
This means over nine million people have gained coverage through the ACA since it first became law.
That number could easily shrink or grow as insurers report on how many people purchased ACA-compliant policies directly through them. It’s also unclear how many canceled policies were replaced by plans purchased through the exchanges.
Looking at the rate of enrollments for Medicare Part D, president of health research firm Avalere Health Dan Mendelson believes that the administration can hit its goal of seven million enrollments by the close of open enrollment on March 31.
“Where they are, with about two million enrolled, if they continue to enroll at the present rate, and there’s a little acceleration at the end, they could get to seven million,” Mendelson told the Washington Post‘s Sarah Kliff.
However, Republicans are still predicting doom for the president’s signature legislative accomplishment, suggesting that the disastrous rollout of the exchanges is just the beginning of the problems.
“Just about everyone on the right is still living in October, the annus horribilis of Obamacare (yes, I know it was just a month, and I don’t care), and is waiting to move in for the kill after the whole thing collapses,” The New York Times‘ Paul Krugman wrote.
Republicans are assuming that the estimated 3 percent of Americans who will be paying more under the law along with disruptions of relationships with doctors will overwhelm both the news of millions gaining coverage and Republican states denying Medicaid expansion to five million working people.
Predictions of Obamacare’s death made sense when it seemed a very real possibility that HealthCare.gov could not be fixed.
Now that those predictions have been proven wrong, the law will have a chance to be judged on its merits.
By: Jason Satler, The National Memo, December 30, 2013
“Things Are Looking A Lot Better”: We Don’t Know If Obamacare Is Working Well, But We Know It’s Working
Obamacare got off to a lousy start. But things are looking a lot better now.
Nearly a million people signed up for private health plans via healthcare.gov in December, according to statistics the Obama Administration released on Sunday morning. That pushed the total number of sign-ups for the year to 1.1 million. Combined with the totals that states are likely to report by year’s end, it probably means more than 2 million people have signed up for private health insurance though the Affordable Care Act’s marketplaces. That doesn’t count several million who enrolled in Medicaid, the newly expanded federal-state program that provides insurance to low-income people.
The official enrollment number doesn’t tell us many things. It doesn’t tell us whether these people getting private (or public) coverage had insurance previously—or, if they had insurance, how much they were paying for it. It doesn’t tell us how many of these people have actually paid premiums, which is essential for coverage to take effect. It doesn’t tell us whether insurers have proper data on these people or what kind of access and protection the new coverage will give. It doesn’t tell us how many of the enrollees are in relatively good health or how many are in relatively poor health—or how that mix will affect insurance prices going forward.
In addition, the numbers do not appear to match the Administration’s own targets. According to internal projections, later reported by the Associated Press, officials expected more than 3.3 million enrollments by year’s end, with about 1.8 million of those coming through the federal website.
For all of those reasons, and a few others, it’s premature to say Obamacare is meeting expectations.
But those internal enrollment targets don’t include people who signed up for coverage directly through insurers. And while lower-than-predicted enrollment could be a sign consumers don’t like the new policies, they could also represent the lingering effects of the site’s technical problems. The internal projections were never particularly scientific: Administration officials extrapolated them from the Congressional Budget Office’s projection of overall private plan enrollment in 2014 (about 7 million) and with necessarily imperfect data from prior programs. “What’s important now is that the systems are mostly functioning so that anyone who wants to get coverage can,” says Larry Levitt, senior vice president at the Kaiser Family Foundation. “The outreach campaigns and advertising by insurers likely haven’t peaked yet, so I wouldn’t be at all surprised if enrollment in March is even bigger than December.”
MIT economist Jonathan Gruber, an architect of reforms, has a similarly nuanced take. “Given the technical problems at the start, and given that the important deadline is March 31, what matters right now is the trend in enrollment. In terms of overall enrollment, the trend looks quite good,” Gruber says. “What matters more is the mix in terms of the health of those enrolling, and we won’t have a clear answer on that until we see 2015 rates from insurers.”
While we wait to see more numbers—and parse the meaning of the numbers we have—we do know a few things for sure.
We know, first and foremost, that healthcare.gov is a (mostly) functioning website. This was no sure thing even a few weeks ago. At the end of November, when officials announced that they had met their goal of constructing a website that worked well for most customers, they were cautious to warn about future problems. Partly that was because their previous predictions of success proved so unbelievably wrong. And partly that was because they feared a late surge of customers would overwhelm the site’s capacity, threatening a whole new period of chaos. But the system held up just fine, as the high enrollment numbers indicate.
More important, we know that many of the people getting insurance are very, very happy to have it. In the fall, when insurers began sending notices of rate increases and plan cancellations, all we heard about was people unhappy with—and in many cases angry about—their new options. Now, however, we are increasingly hearing stories about people who are saving money and, in some cases, getting access to health care they’ve desperately needed for a long time.
Here two examples, culled from a new story by Lena Sun and Amy Goldstein in the Washington Post:
Adam Peterson’s life is about to change. For the first time in years, he is planning to do things he could not have imagined. He intends to have surgery to remove his gallbladder, an operation he needs to avoid another trip to the emergency room. And he’s looking forward to running a marathon in mid-January along the California coast without constant anxiety about what might happen if he gets injured.
These plans are possible, says Peterson, who turned 50 this year and co-manages a financial services firm in Champaign, Ill., because of a piece of plastic the size of a credit card that arrived in the mail the other day: a health insurance card. …
Dan Munstock knows this. A 62-year-old retiree in Greenville, Tenn., he hasn’t had insurance since he left his job as a crisis counselor in Miami six years ago. He lives on Social Security income of less than $15,000 a year. Although he does not know of any major ailments, he would like a checkup because, he said, “you can seem fine until the day you drop over with something.”
Like thousands of other Americans, Munstock ran into technical problems with the federal Web site before managing to pick a health plan Dec. 1. He qualified for a federal subsidy to help him afford the insurance, so he has to pay just $87.57 a month toward his premium. After his welcome packet from Blue Cross Blue Shield of Tennessee arrived in the mail, Munstock was so eager to finish the process of enrolling and getting an insurance card that he picked up the phone to pay the first premium instead of using the mail.
“It felt really good,” he said. Paying toward his own insurance, he said, gives him “a certain dignity,” a feeling that he is not “one of the takers.” The next day, he called the doctor’s office. His appointment for a physical is Jan. 2. …
Like the stories of rate hikes and plan cancellations, anecdotes of people gaining insurance or saving money will frequently prove more complicated than they seem at first blush. Some people will discover they owe more out-of-pocket costs than they imagined, because of high deductibles and co-payments. Some won’t be able to see the doctors they want, because plans have limited networks of providers. Some will haggle with insurers over particular bills or services. And that’s not to mention the many other trade-offs in the law—like higher taxes on the wealthy, cuts to various industry groups, higher premiums for some people buying their own coverage, and other steps that made possible the law’s expansion of health insurance.
But nobody ever promised that Obamacare would solve all of the health care system’s ills—or that it would come without costs of its own. The goal has always been to make insurance more widely available, so that more people had access to care and protection from crippling medical bills, while beginning the difficult work of reengineering medical care to make it more efficient. The new enrollment numbers should give us new reason to think it will.
By: Jonathan Cohn, The New Republic, December 29, 2013
“More Bark Than Bite”: Tomorrow’s Obamacare Controversy, Today
If past is precedent, Republicans on the House Oversight Committee will soon release a draft memo they requested and received from the Health and Human Services Department just before most Washingtonians decamped for the Christmas holiday.
At first glance, the memo, obtained by National Journal, looks very bad for the Obama administration. In the Sept. 24 document, a top information security officer for the agency overseeing the Obamacare insurance exchanges warns that the marketplace “does not reasonably meet … security requirements” and that “there is also no confidence that Personal Identifiable Information (PII) will be protected.” Teresa Fryer, the chief information security officer at the Centers for Medicare and Medicaid Service, continues: The federal marketplace will likely “not be ready to securely support the Affordable Care Act … by October 1, 2013.”
It plays right into the Republican narrative about HealthCare.gov: The administration knew the website would not be ready by the launch date but went ahead with it anyway. And the site may still not be adequately protecting consumers’ information.
But, in context, the draft memo becomes much less exciting.
On the Friday before Christmas, Rep. Darrell Issa, the chairman of the House Oversight Committee, released a partial transcript from an interview conducted by the panel’s staff with Fryer. That partial transcript, shared with ABC and CBS, suggested that Fryer warned the administration that there were two findings of serious vulnerabilities in the system.
However, when Democrats on the Oversight Committee released parts of the transcript omitted from Issa’s version, Fryer’s comments looked far less explosive, and ABC updated its story to reflect the change. It turns out that by Sept. 27, a few days after Fryer raised her concerns about the security at launch, extensive new security measures were added.
As she told the committee’s investigators, “The added protections that we have put into place in accordance with the risk decision memo … are best practices above and beyond what is usually recommended.” She went on to describe her confidence in the three-level security system and to note that there have been “no successful breaches [or] security incidents.”
Which brings us back to the draft memo we obtained. We should note that it was just a draft, and was never sent or reviewed by more senior officers in the chain of command, and was written three days before the mitigation strategies went into effect. She later told Oversight Committee investigators that her earlier recommendation against giving the go-ahead to launch the site—the “authority to operate,” as it’s called—did not take into account the mitigation strategies laid out in the Sept. 27 Authority to Operate memo.
The investigators asked Tony Trenkle, then-CMS’ top information executive, this: “So as long as the mitigation strategy described in the [ATO] memo was carried out, you considered that it was, it would be sufficient to mitigate the risks described in the memo?” He responded, “Yes.”
She added that she was “satisfied” with the current security testing, and that she did not object when another CMS information security officer decided to move ahead with the launch. Again, she stated: “All systems are susceptible to attacks. There have been no successful attempts.”
As the Los Angeles Times‘ Pulitzer Prize-winning business columnist Michael Hiltzik noted, “Issa has absolutely no evidence” to support his broader claims that the system’s deep vulnerabilities put all kinds of consumers’ government data at risk, and that CMS moved ahead anyway to avoid embarrassing the White House.
Of course, sleight of hand with opaque bureaucratic documents is nothing new for Issa, but the potential to dissuade Americans from obtaining health insurance through the federal exchanges because of trumped up security fears has pushed relations between the committee chair and the administration to a new low. It’s one thing to say without evidence that the administration is corrupt, but it’s another to tell Americans that their Social Security number is at risk when there’s nothing to suggest that’s true.
But perhaps we can head off another round of this farce by putting out Fryer’s memo before Issa does—in its full context.
By: Alex Seitz-Wald, The National Journal, December 24, 2013
“We Invent, Experiment, And Fix What Has To Be Fixed”: Why You Shouldn’t Succumb To Defeatism About The Affordable Care Act
Whatever happened to American can-do optimism? Even before the Affordable Care Act covers its first beneficiary, the nattering nabobs of negativism are out in full force.
“Tens of millions more Americans will lose their coverage and find that new ObamaCare plans have higher premiums, larger deductibles, and fewer doctors,” predicts Republican operative Karl Rove. “Enrollment numbers will be smaller than projected and budget outlays will be higher.”
Rove is joined by a chorus of conservative Cassandra’s, from Fox News to the editorial pages of the Wall Street Journal, all warning that the new law will be a disaster.
Robert Laszewski, president of Health Policy and Strategy Associates, anticipates a shortage of doctors. “There just aren’t going to be enough of them.”
Professor John Cochrane of the University of Chicago predicts the individual mandate will “unravel” when “we see how sick the people are who signed up on exchanges, and if our government really is going to penalize voters for not buying health insurance.”
The round-the-clock nay-saying is having an effect. Support for the law has plummeted to 35 percent of those questioned in a recent CNN poll, a 5-point drop in less than a month. Sixty-two percent now say they oppose the law, up four points from November.
Even liberal-leaning commentators are openly worrying. On ABC’s “This Week,” Cokie Roberts responded to my view that the law eventually would prove popular by warning of “a whole other wave of reaction against it” if employers start dropping their insurance.
Some congressional Democrats are getting cold feet. West Virginia Senator Joe Manchin recently fretted that “if it’s so much more expensive than what we anticipated and if the coverage is not as good as what we had, you’ve got a complete meltdown.”
Get a grip.
If the past is any guide, some fixes will probably be necessary – but so what? Our current healthcare system is the real disaster — the most expensive and least effective among all developed countries, according Bloomberg’s recent ranking. We’d be collectively insane if we didn’t try to overhaul it.
But we won’t get it perfect immediately. What needs fixing can be fixed. And over time we can learn how to do it better.
If enrollments are lower than anticipated, the proper response is to keep at it until larger numbers are enrolled. CHIP, the Children’s Health Insurance Program, got off to a slow start in 1998. The Congressional Research Service reported “general disappointment … with low enrollment rates early in the program.” CHIP didn’t reach its target level of enrollment for five years. Now it enrolls nearly ninety percent of all eligible children.
Richard Nixon’s Supplemental Security Income program of 1974 – designed to standardize welfare benefits to the poor — was widely scorned at the time, and many states were reluctant to sign up. Even two years after its launch, only about half of eligible recipients had enrolled. Today, more than 8 million Americans are covered.
If mistakes are made implementing the Affordable Care Act, the appropriate response is to fix them. When George W. Bush’s Medicare Part D drug benefit was launched, large numbers of low-income seniors had to be switched from Medicaid. Many needed their prescriptions filled before the switch had been completed, causing loud complaints. The website for the plan initially malfunctioned. Pharmacies got the wrong information. Other complications led even Republican Representative John Boehner to call it “horrendous.” But the transition was managed, and Medicare Part D is now a firm fixture in the Medicare firmament.
If young people don’t sign up for the Affordable Care Act in sufficient numbers and costs rise too fast, other ways can be found to encourage their enrollment and control costs. If there aren’t enough doctors initially, medical staffs can be utilized more efficiently. If employers begin to drop their own insurance, incentives can be altered so they don’t.
Why be defeatist before we begin? Even Social Security — the most popular of all government programs — had problems when it was launched in 1935. A full year later, Alf Landon, the Republican presidential candidate, called it “a fraud on the workingman.” Former President Herbert Hoover said it would imprison the elderly in the equivalent of “a national zoo.” Americans were slow to sign up. Not until the 1970s did Social Security cover most working-age Americans.
As Alexis de Tocqueville recognized as early as the 1830s, what distinguishes America is our pragmatism, resilience, and optimism. We invent, experiment, and fix what has to be fixed.
Of course there will be problems implementing the Affordable Care Act. But if we’re determined to create a system that’s cheaper and more effective at keeping Americans healthy than the one we have now – and, in truth, we have no choice – we have every chance of succeeding.
By: Robert Reich, The Robert Reich Blog, December 27, 2013
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