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“Can We Please Get A Grip?”: Having The Backbone To Set Minimum Standards For Health Insurance

Democrats are showing once again they have the backbones of banana slugs.

The Affordable Care Act was meant to hold insurers to a higher standards. So it stands to reason that some insurers will have to cancel their lousy sub-standard policies.

But spineless Democrats (including my old boss Bill Clinton) are caving in to the Republican-fueled outrage that the President “misled” Americans into thinking they could keep their old lousy policies — and are now urging the White House to forget the new standards and let people keep what they had before.

And some congressional Republicans are all too eager to join them, and allow insurers to offer whatever crap they were offering before — exposing families to more than $12,700 in out-of-pocket expenses, canceling policies of people who get seriously sick, failing to cover prescription drugs, and so on.

Can we please get a grip? Whenever industry standards are lifted — a higher minimum wage, safer workplaces, non-toxic foods and drugs, safer cars — people no longer have the “freedom” to contract for the sub-standard goods and services.

But that freedom is usually a mirage because big businesses have most of the power and average people don’t have much of a choice. This has been especially the case with health insurance, which is why minimum standards here are essential.

Yes, the President might have spelled this out a bit more clearly beforehand, explaining that 95 percent of us aren’t in the private insurance market to begin with and won’t be affected, and that most of the 2 percent who lose their lousy policies and have to take better and more expensive ones will be subsidized.

But right now the President needs all the political support he can muster to hold insurers’ feet to the fire. Democrats should stand firm for a change.


By: Robert Reich, The Robert Reich Blog, November 15, 2013

November 18, 2013 Posted by | Affordable Care Act, Democrats | , , , , , , | 1 Comment

“Medicaid Matters”: Where Is The Outrage Over GOP Governors Cutting Off Lower-Income Americans From Access To Medicaid

E.J. Dionne Jr. raises an argument in his column this morning that’s been getting short shrift by too much of the political world lately: Medicaid expansion matters, and far too many state Republican policymakers are blocking it for no reason.

“President Obama apologized last week after all the criticisms of what’s happening in the individual insurance market,” Dionne explained. “But where is the outrage over governors and legislators flatly cutting off so many lower-income Americans from access to Medicaid? The Urban Institute estimates that 6 million to 7 million people will be deprived of coverage in states that are refusing to accept the expansion.”

The recent disruption in the health care marketplace certainly matters, and the Obama administration has a lot of work to do to put things right. But if we’re going to talk about policymakers who need to apologize and show some semblance of regret, can we at least start to have a conversation about those keeping millions of struggling Americans from having access to coverage, largely out of partisan spite?

Jonathan Cohn published a good piece on this earlier:

Today it’s a few hundred thousand people. By next year, it will be at least a few million. Their health insurance status is changing dramatically: What they have in 2014 and beyond will look nothing like what they had in 2013 and before. For many of these people, the difference will be hundreds or even thousands of dollars a year. In a few cases, it may be the difference between life and death.

You probably think I’m talking about the people getting cancellation notices about their private insurance policies. I’m not. I’m talking about the people getting Medicaid. Both stories are consequences of the Affordable Care Act. But one is getting way, way more attention than the other.

There’s been an obvious preoccupation – on Capitol Hill, with Beltway media, etc. – with website dysfunction and cancelation notices, while Medicaid expansion, which arguably affects a larger group of people, has been routinely overlooked.

Maybe it’s because Washington is “wired” for Republicans and it’s the right’s complaints that have been driving the recent conversation. Perhaps it’s the result of Medicaid beneficiaries lacking the kind of political capital that keeps their plight on the political world’s front-burner. Maybe it’s a matter of timeliness, with implementation disruption seeming “new” in ways Medicaid is not. Perhaps it’s a combination of things.

Regardless, by my standards, this is a genuine scandal. The administration’s missteps are real, but they’re not deliberate. “Red” states rejecting Medicaid expansion because of some misguided contempt for “Obamacare” are leaving struggling families behind on purpose. The callousness is outrageous.

Cohn concluded, “”Should the president have been more candid about the impact his plan would have on people buying their own coverage? Yes. Should we pay attention to those people, particularly when they must now pay more for equivalent coverage? Definitely. Should this put extra pressure on the administration and some states to fix their websites? You bet. But that’s not the only Obamacare news right now. The law is making life better for a great many people – and would help even more if only Republican lawmakers would relent.”


By: Steve Benen, The Maddow Blog, November 11, 2013

November 13, 2013 Posted by | Affordable Care Act, Medicaid, Obamacare | , , , , , , | Leave a comment

“This Is How Obamacare Works”: Listen Up Dipsticks, You Can’t Fix Health Insurance Without Changing Health Insurance

Bill Clinton has been one of Obamacare’s most effective advocates—the “Secretary of Explaining Things,” as President Obama famously called him. But in a new interview already getting attention and sure to get more, Clinton didn’t explain things very well. He made a statement that’s likely to create some misimpressions about the possibilities of health care reform, while giving the administration and its allies yet another political headache. But maybe it’s also an opportunity to have a serious conversation about the law’s tradeoffs—the one that should have happened a while ago.

In the interview, with Ozy Media, the former president fielded a question about the health care law. “The big lesson,” he said, “is that we’re better off with this law without it.” He went on to put the technological problems of into some perspective: Medicare Part D had similar problems, he noted, “and they fixed it.” And he made a plea with Republican lawmakers to stop blocking the expansion of Medicaid. Fine, fine, and fine.

But then Clinton made news. He said that some young people facing higher premiums under the new system should have the right to keep their old plans, even if it requires a change in the law. Clinton framed it carefully: He said specifically he had in mind only those young people whose incomes were higher than four times the poverty line, making them ineligible for subsidies. (That’s about $45,000 for a single adult.) But he also suggested it was a matter of principle, because those people had heard the vow that they could keep their plans: “I personally believe, even if it takes a change to the law, the president should honor the commitment the federal government made to those people and let them keep what they got.”

Clinton’s statement makes it seem as if there is some simple way to let people keep their current plans—to avoid any disruption in the existing non-group market while still delivering the law’s benefits. As readers of this space know, no such magic solution exists. Broadly speaking, the Affordable Care Act seeks to make two sets of changes to what’s called the “non-group” market. It establishes a minimum set of benefits, which means everything from covering “essential” services to eliminating annual or lifetime limits on payments. At the same time, the law prohibits insurers from discriminating among customers: They can’t charge higher prices, withhold benefits, or deny coverage altogether to people who represent medical risks. They have to take everybody, varying price only for age (within a three-to-one ratio) and for tobacco use.

If you buy your own insurance now, it probably doesn’t live up to these standards. For starters, it probably isn’t as comprehensive as you think. It may not cover prescription drugs, for example, or it might leave out rehabilitative services and mental health. It might expose you to out-of-pocket expenses greater than $6,350 (if you have a single person’s policy) or a $12,700 (if you have a family policy). Until three years ago, when Obamacare’s first regulations went into effect, it was even possible the insurer could yank it retroactively—a process known as “rescission”—if you got sick and the carrier scrubbed your medical records for some previous sign of illness, maybe even one you didn’t know you had.

In addition, unless you live in a handful of states, the premiums you are paying come from insurers who knew, going in, they wouldn’t have to cover people who represent high medical risks. If the policy is affordable, that’s because the insurer figured you were pretty healthy and unlikely to have big medical bills. If you’ve had the policy for a while, and prices haven’t gone way up, that’s because the insurer is still making money from this arrangement—which means, overall, the people in this plan aren’t very sick. Until now, insurers have been able to hike premiums on plans that start to lose healthy customers, and they keep doing so until they become unaffordable—leaving those remaining subscribers unable to find new policies at affordable rates.

The Affordable Care Act includes a so-called grandfather clause. That allows insurers to keep renewing plans, without changes or benefits and prices, as long as they were available before March 2010, when the Affordable Care Act became law. But the non-group market is volatile: Very few people stay on plans for more than two years anyway. And the grandfather clause is narrow, by design: If insurers made even modest changes, the protection goes away. Those plans are subject to the new regulations that take effect in January. As a result, the majority of people who buy insurance on their own are learning they can’t have what they had before, even though Obama promised everybody they could. Either their premiums are going up, as insurers accommodate the new regulations, or the plans are disappearing altogether. In those cases, people have to find new plans. And the sticker price of what they’ll find is higher than what they pay now.

This is not a glitch or an accident. This is the way health care reform is supposed to work. And it’s important to put these changes into context. For one thing, it’s a small number of people relative to the population as a whole. The vast majority of Americans get coverage through employers or a large government program like Medicare. These changes don’t really affect them. The law also anticipates these changes by, among other things, offering tax credits that discount the premiums—in many cases, by thousands of dollars. (Other provisions of the law, like a limit on insurance company profits and overhead, should restrain prices more.) As a result, many people buying coverage on their own will be paying less money for benefits that are as good, if not better, than what they have now.

But there are real people who must pay more and, in some cases, put up with less. Some of them are people walking around with junk insurance, the kind are practically worthless because they pay out so little. Some of them are young people, particularly young men, whom insurers have coveted and wooed with absurdly low premiums—and make too much money to qualify for substantial subsidies. And some of them are reasonably affluent, healthy people with generous, open-ended policies that are hard to find even through employers. Insurers kept selling them because they could restrict enrollment to healthy people. Absent that ability, insurers are canceling them or raising premiums so high only the truly rich can pay for them.

Those people are the ones everybody is hearing about now, partly because they are a compelling, sometimes well-connected group—and partly because, absent a well-functioning website, stories of people benefitting from the law’s changes aren’t competing for attention. It’s impossible to know how big this group is. The data on existing coverage just isn’t that good. The anecdotes are frequently, although not always, more complicated than they seem at first blush. It’s probably one to two percent of the population, which doesn’t sound like much—except that, in a country of 300 million, that’s 3 to 6 million people. Most experts I trust think they represent a minority of people buying coverage on their own, but nobody can say with certainty.

Is that a worthwhile tradeoff for reform? Obviously that’s a matter of opinion. The fact that some people—even a small, relatively affluent group—are giving up something they had makes their plight (genuinely) more sympathetic. They are right to feel burned, since Obama did not make clear his promise might not apply to them. And there’s a principled argument about whether people should be responsible for services they’re unlikely to use presently, whether it’s fifty-something year olds paying for maternity care or twenty-something year olds paying for cardiac stress tests.

But the principle of broad-risk sharing—of the healthy subsidizing the sick, of the young subsidizing the old, and everybody paying for services like pediatrics and maternity care—is one built into the insurance most Americans already have. Employers, after all, don’t charge employees different premiums because of their age or gender. What’s more, the people with good, affordable coverage in the old non-group market were the beneficiaries of a system that marginalized many more. They were paying relatively cheap rates for insurance only because insurers trusted they were unlikely to get sick. Of course, some of them did get sick. And when it happened, many made an unpleasant discovery: The policies they carried left them exposed to huge bills. Giving up these plans isn’t merely an act of altruism. It’s also an act of enlightened self-interest.

Oddly, Clinton himself recognized this: In his soliloquy, he mentioned that a young man he met was upset at having to pay more for a plan—even though the young man knew it would help him more if he got sick. As Clinton surely knows, the whole point of reform—not just the pricing and benefit requirements, but also the individual mandate, which Clinton has repeatedly endorsed—is that people need to take steps to protect themselves against future hardship.

Rhetorically, Clinton’s statement actually isn’t that different from what Obama said in his interview with NBC’s Chuck Todd the other night—that he’d like to find a way to let more people keep their coverage. But it wouldn’t be easy to do. Attempting to rewrite the grandfather clause, so that it applies to more existing plans, could cause insurers to raise prices in 2014 for 2015. It’s also not clear that insurers could or would quickly renew existing policies at existing prices. Clinton mentioned specifically that something should be done only for those people facing higher prices—another echo of Obama’s statement. But distinguishing between groups wouldn’t be easy.

Maybe there’s some muddled, half-solution that will ease the transition without causing real damage. Or maybe there’s some brilliant administrative or legislative fix the experts can’t see. But absent an infusion of extra money—say, to create some kind of transitional assistance fund—any effort to slow changes to the non-group market might not just stop the bad things from happening. It might also stop the good. The latter might outweigh the former, by quite a lot.

You wouldn’t know it from all the press, but Obamacare actually disrupts very little relative to what it accomplishes. The problem is that eliminating disruption altogether simply isn’t possible. You can’t fix health insurance without changing health insurance. And there are bound to be some people for whom that change isn’t good. Those trade-offs should be clear. Maybe now they are.


By: Jonathan Cohn, The New Republic, November 12, 2013

November 13, 2013 Posted by | Affordable Care Act, Obamacare | , , , , , , , | 1 Comment

“A Market Of Systematic Discrimination”: President Obama Shouldn’t Apologize For Blowing Up The Terrible Individual Market

Last night, NBC’s Chuck Todd asked President Obama about the people losing their health insurance despite his promise that “anyone who likes their plan can keep it.” (See the video and read the transcript here.)

“I am sorry that they are finding themselves in this situation based on assurances they got from me,” Obama replied.

The answer is a bit of a dodge. People aren’t finding themselves in this situation based on the president’s promises. They’re finding themselves in this situation based on his policy. And Obama isn’t apologizing for the policy.

“Before the law was passed, a lot of these plans, people thought they had insurance coverage,” he said. “And then they’d find out that they had huge out of pocket expenses. Or women were being charged more than men. If you had preexisting conditions, you just couldn’t get it at all.”

Obama was wrong to promise that everyone who liked their insurance could keep it. For a small minority of Americans, that flatly isn’t true. But the real sin would’ve been leaving the individual insurance market alone.

The individual market — which serves five percent of the population, and which is where the disruptions are happening — is a horror show. It’s a market where healthy people benefit from systematic discrimination against the sick, where young people benefit from systematic discrimination against the old, where men benefit from systematic discrimination against women, and where insurers benefit from systematic discrimination against the uninformed.

The result, all too often, is a market where the people who need insurance most can’t get it, and the people who do get insurance find it doesn’t cover them when it’s most necessary. All that is why the individual market shows much lower levels of satisfaction than, well, every other insurance market:

(Graph by Jon Cohn)

Those numbers, of course, don’t include the people who couldn’t get insurance because they were deemed too sick. Consumer Reports put it unusually bluntly:

Individual insurance is a nightmare for consumers: more costly than the equivalent job-based coverage, and for those in less-than-perfect health, unaffordable at best and unavailable at worst. Moreover, the lack of effective consumer protections in most states allows insurers to sell plans with ‘affordable’ premiums whose skimpy coverage can leave people who get very sick with the added burden of ruinous medical debt.

Jonathan Cohn puts a human face on it:

One from my files was about a South Floridian mother of two named Jacqueline Reuss. She had what she thought was a comprehensive policy, but it didn’t cover the tests her doctors ordered when they found a growth and feared it was ovarian cancer. The reason? Her insurer decided, belatedly, that a previous episode of “dysfunctional uterine bleeding”—basically, an irregular menstrual period—was a pre-existing condition that disqualified her from coverage for future gynecological problems. She was fine medically. The growth was benign. But she had a $15,000 bill (on top of her other medical expenses) and no way to get new insurance.

This is a market that desperately needs to be fixed. And Obamacare goes a way toward fixing it. It basically makes the individual market more like the group markets. That means that the sick don’t get charged more than the well, and the old aren’t charged more than three times as much as the young, and women aren’t charged more than men, and insurance plans that don’t actually cover you when you get sick no longer exist. But the transition disrupts today’s arrangements.

(Interestingly, recent Republican plans have focused on disrupting the employer market by ending, limiting, or restructuring the tax exclusion for employer-based plans. There’s an extremely good case to be made that that needs to be done, but it means much more disruption for a much larger number of people. Obamacare’s focus on disrupting the individual market — and only the individual market — is a more modest approach to health-care reform.)

There’s been an outpouring of sympathy for the people in the individual market who will see their plans changed. As well there should be. Some of them will be better off, but some won’t be.

But, worryingly, the impassioned defense of the beneficiaries of the status quo isn’t leavened with sympathy for the people suffering now. The people who can’t buy health insurance for any price, or can’t get it at a price they can afford, or do get it only to find themselves bankrupted by medical expenses anyway have been left out of the sudden outpouring of concern.

If people have a better way to fix the individual market — one that has no losers — then it’s time for them to propose it. But it’s very strange to sympathize with the people who’ve benefited from the noxious practices of the individual market while dismissing the sick people who’ve been victimized by it.

Obama is rightly taking flack for making a promise he wasn’t going to keep, and he’s right to apologize for it. But he shouldn’t apologize for blowing up the individual market. It needed to be done.


By: Ezra Klein and Evan Soltas, WonkBook, The Washington Post, November

November 10, 2013 Posted by | Affordable Care Act, Health Insurance Companies, Obamacare | , , , , | 1 Comment

“This Is Why We Need Obamacare”: Life And Death Is When You Need Care And Can’t Afford To Get It

The biggest health care crisis in America right now is not the inexcusably messy rollout of Obamacare.

No, far more serious is the kind of catastrophe facing people like Richard Streeter, 47, a truck driver and recreational vehicle repairman in Eugene, Ore. His problem isn’t Obamacare, but a tumor in his colon that may kill him because Obamacare didn’t come quite soon enough.

Streeter had health insurance for decades, but beginning in 2008 his employer no longer offered it as an option. He says he tried to buy individual health insurance but, as a lifelong smoker in his late 40s, couldn’t find anything affordable — so he took a terrible chance and did without.

At the beginning of this year, Streeter began to notice blood in his bowel movements and discomfort in his rectum. Because he didn’t have health insurance, he put off going to the doctor and reassured himself it was just irritation from sitting too many hours.

“I thought it was driving a truck and being on your keister all day,” he told me. Finally, the pain became excruciating, and he went to a cut-rate clinic where a doctor, without examining him, suggested it might be hemorrhoids.

By September, Streeter couldn’t stand the pain any longer. He went to another doctor, who suggested a colonoscopy. The cheapest provider he could find was Dr. J. Scott Gibson, a softhearted gastroenterologist who told him that if he didn’t have insurance he would do it for $300 down and $300 more whenever he had the money.

Streeter made the 100-mile drive to Dr. Gibson’s office in McMinnville, Ore. — and received devastating news. Dr. Gibson had found advanced colon cancer.

“It was heartbreaking to see the pain on his face,” Dr. Gibson told me. “It got me very angry with people who insist that Obamacare is a train wreck, when the real train wreck is what people are experiencing every day because they can’t afford care.”

Dr. Gibson says that Streeter is the second patient he has had this year who put off getting medical attention because of lack of health insurance and now has advanced colon cancer.

So, to those Republicans protesting Obamacare: You’re right that there are appalling problems with the website, but they will be fixed. Likewise, you’re right that President Obama misled voters when he said that everyone could keep their insurance plan because that’s now manifestly not true (although they will be able to get new and better plans, sometimes for less money).

But how about showing empathy also for a far larger and more desperate group: The nearly 50 million Americans without insurance who play health care Russian roulette as a result. FamiliesUSA, a health care advocacy group that supports Obamacare, estimated last year that an American dies every 20 minutes for lack of insurance.

It has been a year since my college roommate, Scott Androes, died of prostate cancer, in part because he didn’t have insurance and thus didn’t see a doctor promptly. Scott fully acknowledged that he had made a terrible mistake in economizing on insurance, but, in a civilized country, is this a mistake that people should die from?

“Website problems are a nuisance,” Dr. Gibson said. “Life and death is when you need care and can’t afford to get it.”

The Institute of Medicine and the National Research Council this year ranked the United States health care system last or near last in several categories among 17 countries studied. The Commonwealth Fund put the United States dead last of seven industrialized countries in health care performance. And Bloomberg journalists ranked the United States health care system No. 46 in efficiency worldwide, behind Romania and Iran.

The reason is simple: While some Americans get superb care, tens of millions without insurance get marginal care. That’s one reason life expectancy is relatively low in America, and child mortality is twice as high as in some European countries. Now that’s a scandal.

Yet about half the states are refusing to expand Medicaid to cover more uninsured people — because they don’t trust Obamacare and want it to fail. The result will be more catastrophes like Streeter’s.

“I am tired of being the messenger of death,” said Dr. Gibson. “Sometimes it’s unavoidable. But when people come in who might have been saved if they could have afforded care early on, then to have to tell them that they have a potentially fatal illness — I’m very tired of that.”

Streeter met with a radiologist on Thursday and is bracing for an arduous and impoverishing battle with the cancer. There’s just one bright spot: He signed up for health care insurance under Obamacare, to take effect on Jan. 1.

For him, the tragedy isn’t that the Obamacare rollout has been full of glitches, but that it may have come too late to save his life.


By: Nicholas D. Kristof, Op-Ed Contributor, The New York Times, November 2, 2013

November 8, 2013 Posted by | Affordable Care Act, Obamacare | , , , , , | 2 Comments

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