“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
“Obscuring The Bigger Picture”: The Republican Tempest Over The Affordable Care Act Diverts Attention From Three Large Truths
Having failed to defeat the Affordable Care Act in Congress, to beat it back in the last election, to repeal it despite more than eighty votes in the House, to stop it in the federal courts, to get enough votes in the Supreme Court to overrule it, and to gut it with outright extortion (closing the government and threatening to default on the nation’s debts unless it was repealed), Republicans are now down to their last ploy.
They are hell-bent on destroying the Affordable Care Act in Americans’ minds.
A document circulating among House Republicans (reported by the New York Times) instructs them to repeat the following themes and stories continuously: “Because of Obamacare, I Lost My Insurance.” “Obamacare Increases Health Care Costs.” “The Exchanges May Not Be Secure, Putting Personal Information at Risk.”
Every Republican in Washington has been programmed to use the word “disaster” whenever mentioning the Act, always refer to it as Obamacare, and demand its repeal.
Republican wordsmiths know they can count on Fox News and right-wing yell radio to amplify and intensify all of this in continuous loops of elaboration and outrage, repeated so often as to infect peoples’ minds like purulent pustules.
The idea is to make the Act so detestable it becomes the fearsome centerpiece of the midterm elections of 2014 — putting enough Democrats on the defensive they join in seeking its repeal or at least in amending it in ways that gut it (such as allowing insurers to sell whatever policies they want as long as they want, or delaying it further).
Admittedly, the President provided Republicans ammunition by botching the Act’s roll-out. Why wasn’t HealthCare.gov up and running smoothly October 1? Partly because the Administration didn’t anticipate that almost every Republican governor would refuse to set up a state exchange, thereby loading even more responsibility on an already over-worked and underfunded Department of Health and Human Services.
Why didn’t Obama’s advisors anticipate that some policies would be cancelled (after all, the Act sets higher standards than many policies offered) and therefore his “you can keep their old insurance” promise would become a target? Likely because they knew all policies were “grandfathered” for a year, didn’t anticipate how many insurers would cancel right away, and understood that only 5 percent of policyholders received insurance independent of an employer anyway.
But there’s really no good excuse. The White House should have anticipated the Republican attack machine.
The real problem is now. The President and other Democrats aren’t meeting the Republican barrage with three larger truths that show the pettiness of the attack:
The wreck of private insurance. Ours has been the only healthcare system in the world designed to avoid sick people. For-profit insurers have spent billions finding and marketing their policies to healthy people – young adults, people at low risk of expensive diseases, groups of professionals – while rejecting people with preexisting conditions, otherwise debilitated, or at high risk of heart disease, diabetes, and cancer. And have routinely dropped coverage of policy holders who become seriously sick or disabled. What else would you expect from corporations seeking to maximize profits?
But the social consequences have been devastating. We have ended up with the most expensive healthcare system in the world (finding and marketing to healthy people is expensive, corporate executives are expensive, profits adequate to satisfy shareholders are expensive), combined with the worst health outcomes of all rich countries — highest rates of infant mortality, shortest life spans, largest portions of populations never seeing a doctor and receiving no preventive care, most expensive uses of emergency rooms.
We could not and cannot continue with this travesty of a healthcare system.
The Affordable Care Act is a modest solution. It still relies on private insurers — merely setting minimum standards and “exchanges” where customers can compare policies, requiring insurers to take people with preexisting conditions and not abandon those who get seriously sick, and helping low-income people afford coverage.
A single-payer system would have been preferable. Most other rich countries do it this way. It could have been grafted on to Social Security and Medicare, paid for through payroll taxes, expanded to lower-income families through Medicaid. It would have been simple and efficient. (It’s no coincidence that the Act’s Medicaid expansion has been easy and rapid in states that chose to accept it.)
But Republicans were dead set against this. They wouldn’t even abide a “public option” to buy into something resembling Medicare. In the end, they wouldn’t even go along with the Affordable Care Act, which was based on Republican ideas in the first place. (From Richard Nixon’s healthcare plan through the musings of the Heritage Foundation, Republicans for years urged that everything be kept in the hands of private insurers but the government set minimum standards, create state-based insurance exchanges, and require everyone to sign up).
The moral imperative. Even a clunky compromise like the ACA between a national system of health insurance and a for-profit insurance market depends, fundamentally, on a social compact in which those who are healthier and richer are willing to help those who are sicker and poorer. Such a social compact defines a society.
The other day I heard a young man say he’d rather pay a penalty than buy health insurance under the Act because, in his words, “why should I pay for the sick and the old?” The answer is he has a responsibility to do so, as a member the same society they inhabit.
The Act also depends on richer people paying higher taxes to finance health insurance for lower-income people. Starting this year, a healthcare surtax of 3.8 percent is applied to capital gains and dividend income of individuals earning more than $200,000 and a nine-tenths of 1 percent healthcare tax to wages over $200,000 or couples over $250,000. Together, the two taxes will raise an estimated $317.7 billion over 10 years, according to the Joint Committee on Taxation.
Here again, the justification is plain: We are becoming a vastly unequal society in which most of the economic gains are going to the top. It’s only just that those with higher incomes bear some responsibility for maintaining the health of Americans who are less fortunate.
This is a profoundly moral argument about who we are and what we owe each other as Americans. But Democrats have failed to make it, perhaps because they’re reluctant to admit that the Act involves any redistribution at all.
Redistribution has become so unfashionable it’s easier to say everyone comes out ahead. And everyone does come out ahead in the long term: Even the best-off will gain from a healthier and more productive workforce, and will save money from preventive care that reduces the number of destitute people using emergency rooms when they become seriously ill.
But there would be no reason to reform and extend health insurance to begin with if we did not have moral obligations to one another as members of the same society.
The initial problems with the website and the President’s ill-advised remark about everyone being able to keep their old policies are real. But they’re trifling compared to the wreckage of the current system, the modest but important step toward reform embodied in the Act, and the moral imperative at the core of the Act and of our society.
The Republicans have created a tempest out of trivialities. It is incumbent on Democrats — from the President on down — to show Americans the larger picture, and do so again and again.
By: Robert Reich, The Robert Reich Blog, November 22, 2013
“When Ideology Collides With Reality”: Irrational Republican Exuberance Over Obamacare’s Problems
In these days of hyper-polarization, some readers may wonder why I always treat with great respect the findings and analysis of conservative number-cruncher Sean Trende of RealClearPolitics. I don’t always agree with what he says, but he’s willing to say uncomfortable things to people on his side of the barricades when data and history so indicate, as he did in a column today pouring ice water on the popular conservative idea that a collapse of Obamacare would lead to some sort of “existential crisis” for liberalism or “the welfare state.”
I’ve said before that our press corps suffers from histrionic personality disorder, and this is but the latest example. Wasn’t it just weeks ago that we were told the government shutdown could cost Republicans the House? But elections and the ideological orientation of the country don’t turn on such immediate, short-term events. The arc of history is long. Both parties, and both ideologies, have plenty of wins ahead of them, and neither is likely to suffer a knockout blow.
Let’s start by observing that we’re barely 50 days into Obamacare’s launch. While the program is clearly in much graver political danger than was the case a month ago, it’s still unclear that the ship won’t eventually be righted. Maybe the so-called “young invincibles” will sign up in droves, or maybe they won’t and the program will go into a death spiral. We just don’t know yet.
But even if the Affordable Care Act does collapse, I’m not sure that the liberal project will be kneecapped, much less destroyed. Americans have very short memories, and the pendulum will swing back quickly if Republicans mess up their next opportunity to govern.
Trende then goes through a long series of historical examples (dating back to 1890) of big political calamities for one party or the other that was followed in relatively short order, and sometimes almost instantly, by a big recovery, often because the other party over-estimated its advantages and overreached. And he notes that even in specific policy areas a misstep or defeat doesn’t necessarily take issues off the table:
Even the last failed attempt at health care reform, in the early 1990s, didn’t actually spell the end of reform efforts for the next two decades, as many suggest. It just proceeded incrementally, with some fairly significant steps. Congress in 1996 passed the Kennedy-Kassebaum bill, which established health insurance portability. The following year, Republicans helped to establish the State Children’s Health Insurance Program, which today provides health care for almost 8 million children. In 2001, before the 9/11 attacks, Congress was consumed with a debate over the Patient’s Bill of Rights, with the only major disagreement involving whether plaintiffs should be able to collect punitive damages while suing their HMO.
Sean even suggests an Obamacare “disaster” could produce an even more ambitious Democratic health care initiative:
[E]ven if Obamacare does collapse, the most liberal aspects of the American health care system — Medicare and Medicaid — will still be around. Democrats have already been pretty straightforward about what their “Plan B” will be: Medicare/Medicaid for all. Both programs are still very popular, and the Democratic standard-bearer in 2016 would almost certainly campaign on expanding them, perhaps to those over 55 for Medicare and under 25 for Medicaid. I’m not sure that would be a losing issue, even with an Obamacare collapse. In 10 years, I think it’d be a winner.
That is indeed the “silver lining” that a lot of single payer advocates have been seeing in the troubles involving the Obamacare exchanges, which are complex and hard to administer in no small part because of their reliance on a managed competition model many liberals never favored in the first place.
Trende thinks the major lesson here is that the ideological clash of ideas that activists often perceive in political events just isn’t shared by that many voters:
The American electorate is not intensely ideological, and is more motivated by things such as the state of the economy, whether there is peace abroad (or whether we’re winning a war), and whether the president is suffering from a major scandal.
I would agree in part, but would go further to say that today’s radicalized Republican Party has goals that have never commanded a majority of the electorate, and are even less likely to do so in the future. It is capable of making big gains when Democrats screw up, but is determined to risk them immediately to pursue an unpopular agenda. If the worst (or from their point of view, the best) happens and conservatives gain the power to implement that agenda, then the odds are extremely high they will, as Trende puts it, “mess up their next opportunity to govern.” And in that respect, ideology really does matter–when it collides with reality.
By: Ed Kilgore, Contributing Writer, Washington Monthly Political Animal, November 20, 2013
“Intentionally Obscuring The Obvious”: Five Things Every American Needs To Know About Health Care Reform
“Discover the obvious,” Jonathan Cohn said on Monday.
Cohn is one of the nation’s foremost health care journalists and the keynote speaker of the journalism portion of “Hearsay or Fact: A Symposium on the Communication of the Affordable Care Act,” hosted by the Center for Healthcare Research and Transformation.
A senior editor at The New Republic and author of Sick: The Untold Story of America’s Health Care Crisis—and the People Who Pay the Price, Cohn decided to use his time to give five rules about reporting on the Affordable Care Act (ACA). His first rule was an admission that people who follow the everyday tribulations related to Obamacare — like wonks in every field — often assume they don’t need to report on “the obvious” and thus fail to report on the issues that matter most to the public.
He pointed to the success of fellow panelist Stephen Brill’s Time magazine cover story “Bitter Pill: Why Medical Bills Are Killing Us” that illuminated the outrageous variation in medical prices and profits from one hospital and one patient to the next, a well-known fact to experts that came as a shock to many Americans.
What’s obvious to everyone about the debate over Obamacare is that the public is confused. Nearly two-thirds of Americans didn’t know in late September that the health care exchanges were opening on October 1 and 67 percent of the uninsured said “they don’t have enough information about the law to know how it will impact their families,” according to the Kaiser Health Tracking Poll. The uninsured, of course, make up this law’s key demographic. They are the people this law is designed to help most, and their participation in the health care marketplaces will determine if the law is a success.
Why are people so confused? Much of what should be “obvious” has become obscured — intentionally.
Democrats passed the ACA with only Democratic votes — and Joe Lieberman. Republicans have responded with an unprecedented effort to scare voters, starve implementation and sabotage the law, an effort that helped doom the launch of Healthcare.gov, which the White House has to own as a greater act of self-sabotage than anything Republicans could have pulled off themselves.
The political battle over the law has overwhelmed any pertinent policy discussion. So it’s no wonder that people can’t even agree on the basic premises that made health reform necessary and an improvement over the current system, with 56 percent of Americans saying they’ve heard more about the politics and the controversies of the law than any discussion of its practical impact.
Here are five “obvious” premises that every American needs to understand so we can begin to have a rational debate on health care reform.
Before The ACA, America’s Health Care System Was Already ‘Socialized’
You should know by now that the United States spends more than any country on health care, even though approximately 50 million citizens have no insurance whatsoever. This is how we ended up with the 46th most efficient health care system in the world.
The Affordable Care Act attempts to fix this in a number of ways, including health care exchanges, subsidies, Medicaid expansion and regulation.
Since 2011, the government has set how much insurance companies have to spend on actual care – 80-85 percent depending on their size — and the minimum standard for the policies they can offer, among several other regulations. So even though private insurers remain in business and the government hasn’t taken control of the medical industry as it has in the United Kingdom, Republicans argue that it’s “a government takeover” of the health care system. Based on this standard, health care has been “taken over” by the government and even “socialized” for decades.
Since 1965, Americans over 65 and under the poverty level were guaranteed basic care, though it took until 1982 before the last state, Arizona, accepted Medicaid. This left America with a single-payer system, with a giant hole mostly made up of Americans under 65 with jobs, and their families.
In 1986, President Ronald Reagan signed a bill that tried to plug that hole — the Emergency Medical Treatment and Active Labor Act. This law states that any hospital that accepts any federal funds — which basically every hospital in America does — cannot turn away any patient, regardless of his or her ability to pay. As this bill provides no reimbursement for this care, the costs of those who can’t pay get passed on to those who can.
In 1996, Congress passed and President Clinton signed the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which mandated guaranteed renewability for all health insurance plans, requiring that an insurer has to offer you renewals of your policy without charging you any more based on any new information it has about your health.
These are three of the key “government takeovers” that helped lead to the broken health care system that we are now attempting to fix, while maintaining a private insurance industry.
The ACA clearly isn’t a one-size-fits-all solution, health economist Thomas Buchmueller pointed out at Monday’s symposium.
That would be a two-page bill that said, more or less, “Everyone is now on Medicare.”
Rich People Get Their Health Care Subsidized By Taxpayers
Single payer is a simple, proven system that would insure all Americans, save lives and cut costs. And it will likely never happen in America as long as the filibuster exists in the Senate. Still, liberals will not stop offering this ideal solution whenever Republicans complain about costs or cancellations.
The right has its own fantasy solution that is about as improbable as single payer: getting rid of the tax exclusion of premiums for employer-sponsored insurance.
As a result of an accident of history, employers and employees do not have to pay taxes on costs of health insurance policies.
Conservatives hate this. “We call the tax exclusion for ESI a tax ‘break,’ but when you think about it, it operates more like a tax hike,” writes the Cato Institute’s director of health policy Michael F. Cannon, another symposium participant. “It coerces workers into handing control over $11,000 of their earnings to their employers, who then choose the workers’ health plans for them.”
John McCain campaigned for president on ending this “tax break,” which costs taxpayers more than the costs of all the subsidies and Medicaid expansion in the ACA, according to symposium participant Dr. John Z. Ayanian. This will never happen because it would be far more disruptive than Medicare for All and — unlike effective single-payer systems around the globe — it has never been proven to work, anywhere.
As a result, taxpayers will continue to help subsidize takers like Ted Cruz, whose family’s $40,000-a-year insurance policy from Goldman Sachs entitles them to a subsidy large enough to put a family of four on Medicaid, though the Cruzes are clearly able to afford their own health insurance.
Republican Arguments Against Obamacare Are Opportunistic And Contradictory
Republicans fought the passage of the ACA by conjuring images of “death panels” pulling the plug on grandma and a “government takeover” that would destroy America.
The problem with these warnings was that approximately 80 percent of Americans get their health insurance through their employers. Most of these people haven’t and likely won’t notice much of a change in their coverage whatsoever, unless they’ve gone in for preventive or reproductive health care and discovered that they didn’t have to pay a co-pay for it.
That’s why Mitt Romney’s continual assertion that President Obama was embracing “European” solutions never made sense to most Americans.
Republicans didn’t seize on the president’s now-disproven promise “If you like your insurance, you can keep it” until late 2013, though it was clear that it never jibed with his other promise to make sure insurance policies met minimum standards.
Now their fixation on cancellation notices boxes them in, in two ways. First, it ignores that their plot to repeal Obamacare would result in as many as 137 million cancellation notices. Second, right-wing policy proposals would force cancellations that target far more than the estimated 5 percent of Americans who are having their plans changed by the ACA.
“Even if free-market health care reformers were able to pass the plan of their dreams — which would involve tweaking the tax code to end the bias in favor of employer-sponsored insurance — it would likely mean a lot of people would get dropped from their current plans,” the Washington Examiner’s Philip A. Klein notes.
The Republicans’ advantage is that they’re so stuck on the “repeal” part of “repeal and replace” that they’ve never actually passed an ACA replacement. Their rhetoric, and the fact that the only real conservative alternative to single payer requires an individual mandate, means any plan they pass would likely end up generating the same criticisms they’re lobbing at the ACA.
We Can’t Go Back To The Pre-Obamacare Health System
Dr. Ayanian pointed out that though the ACA may not be embraced by a majority of the American public, three key policies have: young people staying on their parents’ plans until age 26, closing the Medicare Part D prescription-drug donut hole, and the ending of concerns about pre-existing conditions.
The Republican Study Committee Obamacare replacement plan, which the House has not voted on, provided pre-existing conditions protections, but only for those who are already insured.
The Washington Post’s Jonathan Bernstein puts it simply — repeal “is dead”:
No one is ever going to kick young adults off their parents’ insurance (or change the law so that insurance companies are allowed to do it). No one is going to bring back the various limitations in pre-ACA insurance policies. Some trimming of the new Medicaid rolls might be possible. But no one — no politician who has to face reelection, at least – is going to just toss all those people off their insurance with nothing to replace it.
Beyond all this is simply the Humpty Dumpty-ness of the situation: The old system has been slowly pushed off the wall for three years now, and by this point it’s really beyond repair, whatever the merits or politics of the situation. Garance Franke-Ruta captured some of this in making the point that delaying things would be impractical at this point, but it really goes beyond that. Too many people have already done too many things to make a full reversal even remotely plausible.
Before the ACA became law, millions of Americans lost their insurance, rates were rising faster than the rate of inflation and the federal government was absorbing more and more health care costs. Repealing it would be a nightmare in that it would reveal a broken health care system badly in need of some type of fix.
Republicans Are Hurting Themselves, Their States And The Working Poor To ‘Punish’ Obama
Because the Supreme Court gave them the chance to do it, about two dozen — all Republican — states have completely rejected the Medicaid expansion in the ACA, even though the government will cover 100 percent of the costs of the expansion for the first three years. States could then opt out of the coverage or continue it with the feds’ contribution decreasing to 90 percent by 2020.
Medicaid expansion should be a huge transfer of wealth from rich blue states to poorer red states, as most of America’s public assistance programs are. Instead Texas, with the largest uninsured population in the nation, has rejected expansion, but will still contribute to helping to insure Californians.
By rejecting Medicaid expansion, just four states – Florida, Texas, Georgia, and North Carolina — will leave 5 million poor people with jobs uninsured. This will result in more emergency room visits that the uninsured cannot afford, and higher rates for the insured in those states.
By: Jason Sattler, The National Memo, November 5, 2013
“Let’s Take A Step Back”: Despite Crappy Journalism, Things That Are Still True About Health Care
It’s been a pretty intense month on the health-care front, what with the beginning of open enrollment for the new exchanges giving rise to lots of disingenuous fulminating from Republicans, not to mention a whole lot of crappy journalism. Any time a story dominates the news for a couple of weeks, there’s a temptation to believe that what’s happening now will change everything. So I thought it might be a good idea to take a step back and remind ourselves about some things that are still true about the Affordable Care Act and still true about health care in America.
Over the long term, the problems with Healthcare.gov won’t have much of an effect on the success or failure of the law.
Yes, it has been a huge screw-up, with both the administration and the contractors sharing responsibility. Yes, it has caused a lot of people trying to sign up for new insurance a lot of hassle. But it’s the thing everybody’s focused on now in part because it’s the only thing happening with the law, until January 1st when a whole bunch of the law’s other provisions also go into effect. The problems with the web site are finite and fixable, and five years from now all this will seem like a minor footnote in the whole story.
Even if everything works perfectly with the ACA, we’re going to have a very expensive system for a long time.
The law did many things to try to “bend the cost curve,” including things like rewarding hospitals for reducing their readmission rates so there isn’t such an incentive to just pile on the procedures. But the fundamental fact is that America’s health-care system is far and away the most expensive in the world—nearly twice as expensive as the average for OECD countries—and it will still be very expensive for the foreseeable future.
There are many reasons why, but what they come down to is that there are lots of actors—insurance companies, hospitals, doctors, device makers—who make ungodly amounts of money off our health-care system, and unwinding all their influence and the points at which costs get driven up is unfathomably complicated. Other countries’ systems were designed by asking how good care can be delivered to everyone at a cost the country can afford; our system, outside of the government parts like Medicare, was basically designed by asking how to make sure everybody except patients can make as much money as possible. At its heart, the ACA doesn’t question that fundamental premise. So the curve may bend, but it won’t bend too sharply, and it’s starting from a very high place.
The expansion of Medicaid is the most significant thing the law did to help uninsured Americans.
It’s easy to forget, with all this talk about people on the individual insurance market, that they make up a small portion of the country. The most meaningful part of the ACA was always its expansion of Medicaid, promising to finally give insurance to millions of Americans who can’t afford it. So far, people signing up for Medicaid are significantly outnumbering those signing up for new private insurance, which isn’t surprising, especially given Healthcare.gov’s problems. And every time a poor family signs up for Medicaid, it’s cause for celebration—they’ll be healthier and more secure, they’ll be more productive at work, and the whole community benefits.
The Republican sabotage campaign against the ACA is unprecedented in American history. You can’t blame every problem the law has or will have on Republican sabotage, but this isn’t hyperbole. It truly is something we’ve never seen (here’s a recap). The only thing that comes close is efforts in the South to resist the school desegregation mandated by Brown v. Board of Education. That isn’t an excuse for any failures of the Obama administration, but it has made everything harder.
Republicans criticizing the ACA have no idea what they’d do to improve the health-care system. If you ask them, they’ll say, “Um … tort reform?” There are a very small number of conservative health-care wonks out there (like the people who came up with the plan that became Romneycare which became Obamacare!), but their ideas are laughably small-bore. Republicans are essentially satisfied with the pre-ACA status quo, with 50 million uninsured Americans and skyrocketing costs. That doesn’t necessarily mean that any particular critique they make of the ACA is wrong by definition, but it’s good to keep in mind.
There’s still no good reason your job should determine your health coverage. The linking of health insurance and employment is an historical accident. When wages were frozen in World War II, companies began offering insurance as a way to attract better workers, unions began demanding it as part of contracts, and today around 80 percent of American get their coverage through their job. One of the best things the ACA does is eliminate the “job lock” this produces, by making it illegal for insurance companies to deny coverage based on pre-existing conditions. Now you can quit your job to start that business you’ve dreamed of without worrying about whether you can get insurance. But the link between employment and insurance is just one more layer of complication that makes our health care system such an absurd kludge. Which leads to…
A single-payer-plus system would have made this whole thing simpler. Conservatives may roll their eyes and say, “Are you still going on about that?” but it’s something we should indeed keep talking about. The Affordable Care Act brings us to a system that is much better than what we have now, but still far worse than what it could be. I’ll continue to reiterate that we could have a system that satisfies the desires of both liberals and conservatives, insures everyone, and does it without all the layers of complication we suffer through now. If we wanted to, we could transition over time to a system like they have in France, with a basic, government-provided single-payer plan that covers every citizen, combined with a market for supplemental private insurance. That would give us the universal coverage and security liberals like, the ability to buy as much insurance as you want from a private company that conservatives like, and the efficiency and cost savings we all ought to like.
Would that be a big change? Sure. But it’s essentially what America’s seniors already have, and it has been very successful. They have their government plan so there are virtually no uninsured seniors, and they can buy Medigap coverage to give them extra benefits.
The ACA could make it easier to transition to a system where all Americans enjoy the same privilege. The exchange marketplace could be transitioned to become the place everyone buys supplemental insurance. We now have a system where a significant chunk of the population—the elderly and poor—are on government plans, and you could widen their availability in both directions (down in age and up in income) and unify the benefits.
That’s a long-term project, but it could be the next big health-care reform (in 20 years or so). Obviously, the most important priority in the next year or two is implementing the ACA and determining what’s working and what isn’t so it can be tweaked and improved. But we shouldn’t forget about what comes next.
By: Paul Waldman, Contributing Editor, The American Prospect, November 1, 2013
Share This Blog
Unknown Feed- An error has occurred; the feed is probably down. Try again later.
mykeystrokes.com 