“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
“The Uproar Over Insurance “Cancellation” Letters”: Offering Terrible Products To Desperate People Is No Longer Acceptable
Kathleen Sebelius, the Health and Human Services secretary, took a lot of grief this morning from Republicans on the House Energy and Commerce Committee who were outraged that some people’s individual insurance policies had been “cancelled” because of health care reform.
Some of the rants bordered on the comical. Cory Gardner, Republican of Colorado, brandished his “cancellation” letter and demanded that Ms. Sebelius nullify the health law for all residents of his congressional district.
Most lawmakers mentioned President Obama’s unfortunate blanket statement that all Americans would be allowed to keep their insurance policies if they liked them. He failed to make an exception for inadequate policies that don’t meet the new minimum standards.
But in between lashings, Ms. Sebelius managed to make an important point. Yes, some people will be forced to upgrade their policies, she said. But that’s preferable to the status quo before the passage of the Affordable Care Act, when insurers could cancel policies on a whim.
“The individual market in Kansas and anywhere in the country has never had consumer protections,” she testified at the hearing. “People are on their own. They could be locked out, priced out, dumped out. And that happened each and every day. So this will finally provide the kind of protections that we all enjoy in our health care plans.”
A true cancellation is when someone gets a letter saying that she’s losing her insurance and cannot renew. That was common practice in the individual market for people with expensive conditions. Under the new law, no one will ever get a letter like that again. They cannot be turned down for insurance.
The so-called cancellation letters waved around at yesterday’s hearing were simply notices that policies would have to be upgraded or changed. Some of those old policies were so full of holes that they didn’t include hospitalization, or maternity care, or coverage of other serious conditions.
Republicans were apparently furious that government would dare intrude on an insurance company’s freedom to offer a terrible product to desperate people.
“Some people like to drive a Ford, not a Ferrari,” said Marsha Blackburn of Tennessee. “And some people like to drink out of a red Solo cup, not a crystal stem. You’re taking away their choice.”
Luckily, a comprehensive and affordable insurance policy is no longer a Ferrari; it is now a basic right. In the face of absurd comments and analogies like this one, Ms. Sebelius never lost her cool in three-and-a-half hours of testimony, perhaps because she knows that once the computer problems and the bellowing die down, the country will be far better off.
By: David Firestone, Editors Blog, The New York Times, October 30, 2013
“Obamacare Witch Hunt”: Republican Halloween Witch Trials About Obamacare Avoid The Facts
Watch out for the hobgoblins! The knives are out. The hearings are on. The charges are flying. Obamacare is on the hot seat … again!
The sad result is that as we get these unconfirmed anecdotes, these stories about problems with insurance companies, these people who face hardship supposedly because of Obamacare, few Republicans think back to pre-2010. Then the costs of health care were skyrocketing – from $1,000 per person in 1980 to about $3,000 in 1990 to $4,000 in 2000 to nearly $8,000 before the Affordable Care Act was passed. The next highest nation for cost: Norway at $5,352.
According to the Commonwealth Fund, 49.9 million Americans were without health insurance in 2009, up 13 million from 2000. Houston, we have a problem.
And remember the stories of pre-existing conditions? Getting kicked off your health insurance or unable to get coverage? How about caps on your care? Or huge deductibles, especially for women? Horror story after horror story.
The facts are clear: 17 million Americans had pre-existing conditions; 34 percent lacked coverage for mental health; 62 percent lacked maternity coverage.
How soon we forget the problems that the ACA was written to solve. Right now, only 5 percent of Americans are covered by individual plans – if you had your plan prior to 2010, you are grandfathered in and can keep it. If the insurance companies want to kick you off they have to alter your plan, but they can no longer kick you off because of a pre-existing condition or because you cost them too much.
Most of these individual plans are renewed yearly and, according to current figures, 48 percent of those with individual plans would get a tax credit under the Affordable Care Act. The average “rebate” would be $5,500, not exactly chump change. Nearly half of those who believe they are suffering sticker shock from their insurance companies would get better coverage for less money.
So, before more and more people are dragged up before Republican-led congressional committees and berated, maybe it is time to get the facts. Maybe it is also time to work to fix what problems may exist and to offer solutions and not engage in more Salem-like witch trials just before Halloween.
By: Peter Fenn, U. S. News and World Report, October 30, 2013
“Getting Better Coverage”: Obamacare “Sticker Shock”? What Under-Insured Think They Have Versus What They Actually Have
In a comment on resurgent talk of “sticker shock” for premiums on insurance bought through the Obamacare exchanges, Kevin Drum makes two points that are important to keep in mind. The first is that the number of people likely to see a major increase in net insurance costs–in excess of the subsidies they may qualify for–is not as large as you might think:
This probably doesn’t describe a huge demographic—people who are just barely above the subsidy threshold and currently have individual coverage and are young enough to see premium increases—but there’s no question they exist.
Those who do fit into this relatively narrow band of people will typically get better coverage for their additional dollars, but they may not appreciate it just yet. Kevin points to a woman quoted in an L.A. Times article on “sticker shock” as illustrative:
“Fullerton resident Jennifer Harris thought she had a great deal, paying $98 a month for an individual plan through Health Net Inc. She got a rude surprise this month when the company said it would cancel her policy at the end of this year. Her current plan does not conform with the new federal rules, which require more generous levels of coverage.
“Now Harris, a self-employed lawyer, must shop for replacement insurance. The cheapest plan she has found will cost her $238 a month. She and her husband don’t qualify for federal premium subsidies because they earn too much money, about $80,000 a year combined.
“‘It doesn’t seem right to make the middle class pay so much more in order to give health insurance to everybody else,” said Harris, who is three months pregnant. “This increase is simply not affordable.'”
I don’t know for sure how this plays out in the real world, but I’d be shocked if Harris’s $98 plan covers expenses related to pregnancy. If it does, the out-of-pocket max is probably astronomical. A bronze plan under Obamacare is still no picnic, but I’m willing to bet it covers a whole lot more of Harris’s maternity expenses than her current plan. In other words, there’s a pretty good chance that she’ll make up for her extra annual expense of $1,700 by sometime around, oh, April or so.
And even if she doesn’t, she now has insurance that will protect her from unforeseen medical conditions and out-of-pocket expenses even if they don’t occur. It is sometimes forgotten that every kind of insurance involves the potential of “excessive” premiums if you get lucky and don’t need it.
But more basically, the politics of Obamacare will indeed be affected by the attitudes of people who do or don’t view their enhanced insurance as having value, and do or don’t think they’re just shelling out dollars to “give health insurance to everybody else.”
By: Ed Kilgore, Contributing Writer, Washington Monthly Political Animal, October 28, 2013
“More Of The Same”: Keeping Alive A Flawed And Self-Destructive Strategy, The GOP Fights On Against Obamacare At Its Own Peril
In the wake of the public uproar over the government shutdown, Democratic hopes for recapturing control of the House of Representatives next year have risen sharply. The party needs to pick up 17 seats, and the main question is whether the current furor against the Republicans will remain until the midterm elections of November 2014.
The House Republicans and their tea party allies, unbowed by their failure to defund President Obama’s Affordable Care Act, have signaled that they have just begun to fight. They have seized on his administration’s inexplicable botching of the law’s rollout to breathe new life into their efforts to kill “Obamacare.”
In so doing, however, they may be keeping alive the flawed and self-destructive strategy that took the country to the brink of financial default. Public opinion polls cited a record plunge in Republican popularity during the government shutdown, attesting to how poorly the tea party scheme to strangle Obamacare in its crib played on Main Street.
House Speaker John Boehner, still nursing the political wounds suffered for trying to appease the get-Obama caucus in the House, told the still-faithful on Wednesday, “We’ve got the whole threat of Obamacare continuing to hang over our economy like a wet blanket.”
Boehner may or may not be proved correct in that view. However, his observation suggests he and his caucus have no intention of getting off the track that led them over a cliff in the executive-branch shutdown, a fiasco for which the GOP gets primary blame.
Much will depend on whether the Obama administration can recover from the amateur hour of the law’s initial implementation and begin to deliver health insurance to the millions of Americans without it. The president seems to have taken his head out of the clouds over the technological screw-up by calling in more experts to straighten out the mess.
Contrary to its foes’ insistence that the law is Public Enemy No. 1, the uninsured public showed unexpectedly heavy interest in enrolling, or at least to exploring whether insurance offered under Obamacare would be good for them and their families. The jury is still out, much as it was on Social Security and Medicare when these programs were first enacted amid even louder laments of “socialism” and “socialized medicine.”
In any event, if the administration manages to overcome the law’s growing pains, the Democrats will have at least a chance to gain new political support among beneficiaries. Many of them are of income levels and ethnicities customarily inclined to vote for the party of Franklin D. Roosevelt and his breakthrough New Deal.
Meanwhile, exertions to keep the flame burning against Obamacare among the House Republicans and their self-appointed leader from the other side of the Capitol, Sen. Ted Cruz of Texas, could be a blessing in disguise to Democrats pointing to next year’s congressional elections.
Their fund-raising arms are experiencing an usual upswing compared to the Republican cash solicitors. The Democrats will be targeting key House GOP incumbents up for re-election in admittedly strong conservative districts who have benefited from gerrymandering. At the same time, moderate Republicans in Congress are starting to band together to purge the tea party influence in their ranks.
The heavy hit on the Republican brand has been emphatically underscored by the post-shutdown polls. The question is whether voters fed up with the party’s increasingly sharp turn to ultraconservatism, one not seen since the days of Barry Goldwater, will remain turned off at voting time a year from now.
By then, Obamacare may or may not be a principal catalyst for decision-making at the ballot box, pro or con, on midterm election day. The same polls also indicate that Americans still worry much more about the state of the economy and, particularly, high unemployment than about the state of federally subsidized health insurance.
But for now, the House Republicans’ reply to all the criticism of their stand against Obamacare is a promise of more of the same, along with hope that the law will indeed collapse, helping them recover from the severe political damage they have inflicted upon themselves.
By: Jules Witcover, The Chicago Tribune, October 25, 2013
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