“Are The Obamacare Clouds Breaking?”: Love It Or Hate It, Obamacare Is Here To Stay
This morning, I was listening to NPR—because yeah, I’m an effete pointy-headed liberal and that’s how I roll—and I heard a story about people in California who got insurance cancellation notices, but then wound up getting better coverage and couldn’t be happier about it. And the other day there was this story in The Washington Post about droves of poor people in rural Kentucky getting insurance for the first time in their lives—free, through Medicaid—because of the Affordable Care Act. In other words, after spending weeks telling the tales of people losing their health coverage (who in truth could get other health coverage), the media are finally putting at least some attention on the people who are benefiting from the ACA.
And encouraging news seems to be breaking out all over. Ezra Klein and Evan Soltas ask, “Is Obamacare Turning the Corner?”, noting that Healthcare.gov seems to be working pretty well, at least on the front end. States with well-functioning web sites like New York and California are meeting or exceeding their enrollment targets. Steve Benen concurs on the corner-turning interpretation. Kevin Drum argues that “Getting Obamacare to the end zone wasn’t easy, and Obama almost fumbled the ball at the one-yard line, but he’s finally won. There’s nothing left for conservatives to do. Love it or hate it, Obamacare is here to stay.”
That isn’t to say that there aren’t lots of problems left to be sorted out. Nor is it to say that the media are done with Obamacare “horror” stories. For instance, last night, NBC News aired this story about employers moving to more modest plans to avoid the “Cadillac tax” on high-cost health plans, complete with disgruntled employees. The piece didn’t bother to explore why an employer might choose a plan for 2014 based on a tax that doesn’t take effect until 2018, other than including a quote from a health-industry consultant claiming that employers “are going to have to get ready for it now,” which makes no sense at all. Think there might be a story there about companies making a decision to scale back benefits and save money but just blaming it on Obamacare? Maybe?
Anyhow, it does appear that we’re starting to edge toward a more balanced media discussion of the successes and failures of this law. I’ll stick to the prediction I’ve made for some time, that the law will be fine. When that December 1 deadline for fixing the website comes, reporters will find that it’s not perfect, but it’s pretty good. In the medium term, the law will do a lot of good for a lot of people, but it won’t transform America into a health care paradise, nor will it drag us into a nightmare of communist oppression. It will have problems, most of which will get sorted out. And the political impact? That will probably be something of a wash as well. Republicans will still be able to go to their conservative constituents and say, “I fought against Obamacare!” as proof of their right-wing bona fides. Democrats will still be able to go to their constituents and say they made it so nobody would get rejected for insurance because of a pre-existing condition. Eventually, Republicans will find something else to shout about.
And who knows, maybe these kinds of problems getting fixed will create a new narrative of success around the ACA: Despite terrible obstacles and mistakes, the administration found its way and delivered for the American people, redeeming liberalism in the process! Weirder things have happened.
By: Paul Waldman, Contributing Editor, The American Prospect, November 26, 2013
“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
“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
“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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