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The only statement anyone has found in the legislative history that addresses this point comes from the Act’s lead author, who affirmed that Congress did intend to withhold tax credits in federal Exchanges. During a September 23, 2009, mark-up of his bill, which ultimately became the PPACA, Senate Finance Committee chairman Max Baucus (D-MT) refused to consider a Republican amendment regarding medical malpractice on the grounds it fell outside the Committee’s jurisdiction. Sen. John Ensign (R-NV) protested, asking how Baucus’ bill could do other things that lie outside the Committee’s jurisdiction, like direct states to create Exchanges. Baucus responded the bill creates tax credits, which are within its jurisdiction, and makes eligibility for those tax credits conditional on states creating Exchanges. Conditional necessarily means that Baucus intended to withhold tax credits in states that did not create their own Exchanges.
Cash medical practice or, in the phrase favored by leftists critics, “Concierge Medicine,” seems to be growing.
Becker is shifting to a new style of practice, sometimes called concierge or retainer medicine. With the help of a company that has been helping physicians make such shifts for over 13 years, he will cease caring for a total of 2,500 patients and instead cut back to about 600. These patients will pay an annual fee of $1,650. In exchange, they will receive a two-hour annual visit with a complete physical exam, same-day appointments, 24-hour physician phone access, and personalized, web-based resources to promote wellness.
The article suggest that all these doctors choosing to drop insurance and Medicare are primary care. Many are but I know orthopedists and even general surgeons who are dropping all insurance.
The concierge model of practice is growing, and it is estimated that more than 4,000 U.S. physicians have adopted some variation of it. Most are general internists, with family practitioners second. It is attractive to physicians because they are relieved of much of the pressure to move patients through quickly, and they can devote more time to prevention and wellness.
In one session, almost half the group of 160 gynaecologists responded that the woman’s chance of having cancer was nine in 10. Only 21% said that the figure was one in 10 – which is the correct answer. That’s a worse result than if the doctors had been answering at random.
The fact that 90% of women with breast cancer get a positive result from a mammogram doesn’t mean that 90% of women with positive results have breast cancer. The high false alarm rate, combined with the disease’s prevalence of 1%, means that roughly nine out of 10 women with a worrying mammogram don’t actually have breast cancer.
It’s a maths puzzle many of us would struggle with. That’s because, Gigerenzer says, setting probabilities out as percentages, although standard practice, is confusing. He campaigns for risks to be expressed using numbers of people instead, and if possible diagrams.
Graphic showing “false positives” in mammogram tests
Even so, Gigerenzer says, it’s surprising how few specialists understand the risk a woman with a positive mammogram result is facing – and worrying too. “We can only imagine how much anxiety those innumerate doctors instil in women,” he says. Research suggests that months after a mammogram false alarm, up to a quarter of women are still affected by the process on a daily basis.
Survival rates are another source of confusion for doctors, not to mention journalists, politicians and patients. These are not, as you might assume, simply the opposite of mortality rates – the proportion of the general population who die from a disease. They describe the health outcomes of people who have been diagnosed with a disease, over a period of time – often five years from the point of diagnosis. They don’t tell us about whether patients die from the disease afterwards.
The linked article is worth reading despite its implicit pro-NHS boosterism. See also this. The poor education in statistical analysis of doctors, lawyers, journalists and members of other influential groups in our society is a significant problem.
Come on. Who do you think calls himself “an expert in ethics?” Would you? Would I? Of course not. Anybody with a trace of common sense and humility understands that no mere son of Adam can possible be considered competent in ethics, let alone an expert. Isn’t the next article up about Native American torture? And then there’s the one on terrorists murdering five-month olds? No sane member of the H. sapiens species would consider it plausible that any one of us could be a mini-Christ, prepared to judge right from wrong, separate the sheep from the goats.
So, ipso facto, who are the “ethicists?” They are those who lack genuine empathy, humility, or any deep awareness of the challege and subtlety of moral judgment. They are the narcissists, the borderline personalities, the grandiose who imagine themselves fit to be the stewards of God. In another age, they would join the Inquisition.
Living in Madison, I associate with a larger than typical number of lefties, liberals, and others who lean to the left of the political spectrum. Oddly, being a leftist seems to be associated with anti-science and other oddities.
When at parties and having discussions with locals, I always stay out of politics. I always shift the subject. Most of the people I deal with are extremely nice, good folks, but they are true believers, and nothing I say will do anything but make situations uncomfortable. But one subject I never hold back is not getting your kids vaccinated. My wife always cringes if it comes up because she knows the bazooka is coming out.
I use the big words too, like “bullshit”, “nonsense” and interesting catch phrases like “have you ever seen a child with whooping cough?” or “I hope your kids don’t get measles because mine won’t”. It does fall on deaf ears, but with the anti-vaccers (is that a word?) I don’t care.
Separately, my wife, while not a squishy leftist, does have a soft spot for marketing buzzwords like “organic”, “natural” etc. She typically spends more money than need be to offer food choices to my kids that are pesticide free, purchases “safer” chemicals and does other things like that – things that I offer to you are probably nonsensical. However, I have chosen not to “die on that hill”. Besides denting my wallet a bit, I don’t think that it is harming anything, so I let it go. I don’t have many complaints about my wife and I am probably way ahead of most husbands in that department (she puts up with me so that pretty much overrides any of my tiny complaints).
But. Lice. Several years ago, both of my children got lice from school. Fortunately (?) I lost my hair a long time ago so was not in the loop, but my wife was mortified. I will never forget the moment – she said (and I am almost quoting) “get down to Walgreens and get the nastiest, strongest chemical you can find and get back here and help me with this”. I almost fell over and stumbled out to the car in a daze, wondering how my wife could have made such a radical change in the five minutes since my kids came home from school.
But I did learn something. When the excrement hits the air conditioning, people want this crap solved. Now.
Back to the anti vaccination folks.
Everything is great and works until it doesn’t. Today I note this story about a famous anti-vaccination group, the Amish. Funny how one’s religion doesn’t seem that important when your kids contract a terrible disease. All of a sudden, vaccines look pretty good.
More than 135 people crowded into a local woodworking business Thursday where nurses used up every available dose of vaccine — and then ordered 300 doses more, said Pam Palm, a spokeswoman for the Knox County, Ohio, Health Department.
“Not getting immunizations has been the way the Amish have felt in the past, but they certainly have responded in this situation,” Palm said.
The outbreak was detected this week when four unvaccinated Amish community members showed evidence of measles infection following a March trip to the Philippines to offer humanitarian aid to typhoon victims. More than 20,000 people have caught measles in the Philippines and at least 50 have died in a severe ongoing outbreak.
I think this might be a good example of stated preferences vs. revealed preferences. Revealed in a most uncomfortable manner. I assume most of my left leaning friends here in the Madison area would do the exact same thing in the circumstances.
My wife, while succumbing to some of the marketing for organic and natural products, thankfully didn’t fall for the vaccine scares that were prevalent when our children were born.
I think if anyone were going to a third world place that was under duress (like the typhoon ravaged Philippines) that they would be REQUIRED to get boosters for measles, cholera, and whatever else I could think of. And why wouldn’t you anyways? But I guess that is my Midwestern common sense sneaking through again, and heck, what do I know.
I do know this. Kids with measles = parents getting measles vaccines for everyone.
The CMS has a new contractor for Obamacare, not just the web site. The previous contractor, CGI Federal, has been replaced rather suddenly.
“Accenture, one of the world’s largest consulting firms, has extensive experience with computer systems on the state level and built California’s large new health-insurance exchange. But it has not done substantial work on any Health and Human Services Department program.
“The administration’s decision to end the contract with CGI reflects lingering unease over the performance of HealthCare.gov even as officials have touted recent improvements and the rising numbers of Americans who have used the marketplace to sign up for health coverage that took effect Jan. 1.”
David has a good idea. I often read the archives of my personal blog to see how I did in forecasting the future or understanding the present. A major concern of mine is, of course, health care and what is happening. When I retired from surgery after my own back surgery, I spent a year at Dartmouth Medical School’s center for study of health care. My purpose was to indulge an old hobby. How do we measure quality in health care ? I had served for years on the board of a company called California Medical Review, Inc. It was the official Medicare review organization for California. For a while I was the chair of the Data Committee. It seems to have gone downhill since I was there. First, it changed its name in an attempt to get more business from private sources. Then it lost the Medicare contract.
Lumetra, which lost a huge Medicare contract last November, is changing its name and its business model as it seeks to replace more than $20 million in lost revenue.
The San Francisco-based nonprofit’s revenue will shrink this year from $28 million last fiscal year, ending in March 2009, to a projected $4.5 million, CEO Linda Sawyer told the Business Times early this week.
That’s in large part because it’s no longer a Medicare quality improvement contractor, formerly its main line of work. And in fact, the 25-year-old company’s revenue has been plummeting since fiscal 2007, when it hit $47 million.
Beginning Jan. 1, 2015, the Affordable Care Act no longer will provide federal grants to fund state health exchanges. In addition, California law prohibits using the state’s general fund to pay for the exchange.
Anyway, for what it is worth, here are the links to the 2013 health posts.
1. The problem with Obamacare is that it fundamentally changes the relationship of government to the people. The change is wholly malign. There is no way to operate the Obamacare system and also force the government to respect the people’s rights. Obamacare will, at every step, increase the risk at which government holds our rights.
We’re already seeing that with the roll-out, which has promptly violated the president’s best-known and most categorical promises – an indication of his complete lack of respect for us – as well as the people’s rights to decide what to do with their own property (in this case, their earnings), and to execute private contracts according to their own preferences.
What matters about Obamacare is that it has forced so many people to do so many things involuntarily. It will continue to do so. Obamacare is about government force, about limiting people’s options, and about constraining the people to do or not do certain things. That’s what government is about, which is why it’s what Obamacare is about. Government is incapable of being about anything else.
The public debate right now treats the Obamacare fiasco as if the central proposition is that taking over one-sixth of the economy is a technological challenge. The reality that matters is that government taking over the network of human decisions involved in “health care” is a moral outrage. Doing that is applying the model of regulatory force to a vast complex of human questions that have no universal, “right” answers. We might as well let the government tell us what to eat, what to wear, where to live, and what God to believe in – and if Obamacare stands, our government will eventually do just that.
Quite frankly, I think the advice to Republicans to simply stand silent and “let Obamacare implode” is foolish. There is no hope of Obamacare imploding. It’s not a malformed bomb, governed by physical principles. It’s a man-made political arrangement. Its defenders will keep moving the goalposts and changing the rules to keep it on the field. It will get all the overtime it needs. The only way to defeat Obamacare is to actually counter it with a plan and a principled argument.
It has taken a long time, but the price of hearing aids is in the process of falling dramatically. How has this happened? Technological innovation, of course, but there is more. There’s no shortage of technological innovation in U.S. health care. However, because third-party payers, that is, health insurers and governments, determine prices, there is no mechanism for customers to signal value to providers.
This is not the case for hearing aids: Although some states have mandated insurance coverage for hearing aids, this is usually limited to disabled children. The big market for hearing aids is seniors, and Medicare does not cover hearing aids.
This is another case of a phenomenon observed elsewhere by NCPA Senior Fellow Devon Herrick: Where patients pay directly for medical care, prices fall like they do in every other market.
Visited the orthopedist today with someone who recently decided, in part because of uncertainty about the future of the medical system, to go ahead with elective joint-replacement surgery. The orthopedist said that he had three other patients today who want to do the same thing and expressed the same reason. His surgical schedule is booked into January. I suspect we will start to hear many more such anecdotes.
What can be done is Congress creating a new option in the form of a national health insurance charter under which insurers could design new low-cost policies free of mandated benefits imposed by ObamaCare and the 50 states that many of those losing their individual policies today surely would find attractive.
What’s the first thing the new nationally chartered insurers would do? Rush out cheap, high-deductible policies, allaying some of the resentment that the ObamaCare mandate provokes among the young, healthy and footloose affluent.
These folks could buy the minimalist coverage that (for various reasons) makes sense for them. They wouldn’t be forced to buy excessive coverage they don’t need to subsidize the old and sick.
Who knows ? Maybe Jenkins reads this blog. It’s so obvious that the solution should be apparent even to Democrats.
The revelation came out of questioning of Mr. Chao by Rep. Cory Gardner (R., Colo.). Gardner was trying to figure out how much of the IT infrastructure around the federal insurance exchange had been completed. “Well, how much do we have to build today, still? What do we need to build? 50 percent? 40 percent? 30 percent?” Chao replied, “I think it’s just an approximation—we’re probably sitting between 60 and 70 percent because we still have to build…”
Gardner replied, incredulously, “Wait, 60 or 70 percent that needs to be built, still?” Chao did not contradict Gardner, adding, “because we still have to build the payment systems to make payments to insurers in January.”
If the ability to pay the insurance companies is not yet written, how can anybody sign up ?
Gardner, a fourth time: “But the entire system is 60 to 70 percent away from being complete.” Chao: “There’s the back office systems, the accounting systems, the payment systems…they still need to be done.”
Gardner asked a fifth time: “Of those 60 to 70 percent of systems that are still being built, how are they going to be tested?”
I don’t want to wear out my welcome with posts but this is a topic that has interested me for many years. When I retired from practice, I spent a year at Dartmouth trying to learn how we can improve health care delivery and reduce cost without reducing quality.
The Obamacare web site now has lost its happy photo of the Obamacare girl. The fact that she is a non-citizen seems appropriate. The web site is supposed to be fixed by November 30. Will that happen ? Well, maybe not.
On Friday, the man tasked with the digital fixes said the site “remains a long way from where it needs to be” as more and more problems emerge.
“As we put new fixes in, volume is increasing, exposing new storage capacity and software application issues,” Jeff Zients told reporters on a conference call.
And at Tuesday’s White House Press Briefing, Press Secretary Jay Carney again said there was “more work to be done” on repairing HealthCare.gov.
Carney, along with Zients and other administration officials, have repeatedly said the November 30 deadline is to get the health care website working for a “vast majority” of Americans looking to enroll in the Obamacare exchanges.
So, what happens December 2, the Monday after the “glitches” are fixed ? First, they won’t be fixed. The contractor that designed the program, not just the web site, has a terrible record.
The American life insurance system was established in the mid-1700s. The earliest forms of health insurance, however, did not emerge until 1850, when the Franklin Health Assurance Company of Massachusetts began providing accident insurance, to cover injuries related to railroad and steamboat travel. From this, sickness insurance covering all kinds of illnesses and injuries soon evolved, but the first modern health insurance plans were not formed until 1930.
The Baylor program for school teachers was the first in 1929.
Medical insurance took stride in 1929 when Dr. Justin Ford Kimball, an administrator at Baylor University Hospital in Dallas, Texas, realized that many schoolteachers were not paying their medical bills. In response to this problem, he developed the Baylor Plan – teachers were to pay 50 cents per month in exchange for the guarantee that they could receive medical services for up to 21 days of any one year.
In those days, the concern was lost wages more than hospital care.
In 1939, the American Hospital Association (AHA) first used the name Blue Cross to designate health care plans that met their standards. These plans merged to form Blue Cross under the AHA in 1960. Considered nonprofit organizations, the Blue Cross plans were exempted from paying taxes, enabling them to maintain low premiums. Pre-paid plans covering physician and surgeon services, including the California Physicians’ Service in 1939, also emerged around this time. These physician-sponsored plans combined into Blue Shield in 1946 and Blue Cross and Blue Shield merged into one company in 1971.
The modern insurance plans were very recent in origin. I was there for much of it. The commercial insurers fought the status of Blue Cross, which was not required to have reserves. Blue Cross asserted that it promised hospital care, not payment, so reserves were not necessary.
The 1940s and 1950s also saw the proliferation of employee benefit plans, and the included health insurance packages became more and more comprehensive as strong unions negotiated for additional benefits. During the Second World War, companies competing for labor had limited ability to use wages to attract employees due to wartime wage controls, so they began to compete through health insurance packages. The companies’ healthcare expenses were exempted from income tax, and the resulting trend is largely responsible for the workplace’s present role as the main supplier of health insurance.
From the first, commercial insurers focused on employer plans while Blue Cross and Blue Shield (which was founded by the California Medical Association to pay doctor bills) were individual plans.
In 1954, Social Security coverage included disability benefits for the first time, and in 1965, Medicare and Medicaid programs were introduced, in part because of the Democratic majority in Congress. In the 1970s and 1980s, more expensive medical technology and flaws in the health care system led to higher costs for health insurance companies. Responding to higher costs, employee benefit plans changed into managed care plans, and Health Maintenance Organizations (HMOs) emerged. Managed care plans are unique in that they involve a particular network of healthcare providers that have been verified for healthcare quality and that have agreements with the insurer about price and related issues. HMOs were originally primarily nonprofit, but they were quickly replaced by commercial interests, and managed care only succeeded in temporarily slowing the growth of healthcare costs.
Two major changes came in the 1970s. In 1978, the federal government established what were called Professional Standards Review Organizations or PSRO. All doctors had to receive training in how to do these reviews and it was immediately apparent that cost was the only consideration, not quality of care.
I decided to educate myself and took a course from an organization called “The American Board of Quality Assurance and Utilization Review Physicians. I took the exam and passed, then attended the annual meeting. This was about 1986. People I met at that meeting informed me that the exams were graded by throwing them up in the air. Any that landed balancing on one edge were flunked. Nonetheless, the experience was valuable because I could see what was coming.
I was president of the Orange County Medical Association that year and had served for eight years on the Commission on Legislation of the CMA, now called The Council on Legislation. This gave me an opportunity to meet many legislators, many state level and some federal. The impression they made on me was that few knew anything about medicine and most were not very intelligent.
It’s kind of complicated so I will summarize. You are screwed !
There are accusations that insurance companies are using this to drop high risk subscribers. Maybe that is true but it is the consequence of ignorant people designing Obamacare. Did these guys ever set up a new business ? As Casey Stengel once said to the Mets , “”Can’t anybody here play this game?”
We are also told that “in all the furor, people forget how terrible many of the soon-to-be-abandoned policies were. Some had deductibles as high as $10,000 or $25,000 and required large co-pays after that, and some didn’t cover hospital care.” Never mind that we have seen cancellations of insurance policies with deductibles much lower, and customers forced to purchase replacement policies with higher deductibles, and with premium increases of 100%, if not higher.
Then there is this argument.
Why can’t people opt out of mental health coverage if there is not a reasonable chance that they will need that coverage? Why can’t they get mental health coverage when it is needed? After all, pre-existing conditions can no longer be denied, so in the event that mental health coverage is needed down the line, it can be obtained and the insurance companies cannot deny people who already have pre-existing mental health conditions. The Times assures us that over-coverage–and the high premiums that come with it–is “one price of moving toward universal coverage with comprehensive benefits.” They don’t explain why having unnecessary coverage is a step towards social justice, but as we saw from the beginning of this intelligence-insulting, repulsively dishonest op-ed, the New York Times is less about explaining, and more about covering up a disastrous rollout with disastrous policy consequences for the country.
Peggy Noonan, who has frustrated me with her obtuseness at times, gets it now.
Politically where are we right now, at this moment?
We have a huge piece of U.S. economic and social change that debuted a month ago as a program. The program dealt with something personal, even intimate: your health, the care of your body, the medicines you choose to take or procedures you get. It was hugely controversial from day one. It took all the political oxygen from the room. It failed to garner even one vote from the opposition when it was passed. It gave rise to a significant opposition movement, the town hall uprisings, which later produced the tea party. It caused unrest. In fact, it seemed not to answer a problem but cause it. I called ObamaCare, at the time of its passage, a catastrophic victory—one won at too great cost, with too much political bloodshed, and at the end what would you get? Barren terrain. A thing not worth fighting for.
So the program debuts and it’s a resounding, famous, fantastical flop. The first weeks of the news coverage are about how the websites don’t work, can you believe we paid for this, do you believe they had more than three years and produced this public joke of a program, this embarrassment?
She assumed that it wasn’t worth it if it worked !
The problem now is not the delivery system of the program, it’s the program itself. Not the computer screen but what’s inside the program. This is something you can’t get the IT guy in to fix.
They said if you liked your insurance you could keep your insurance—but that’s not true. It was never true! They said if you liked your doctor you could keep your doctor—but that’s not true. It was never true! They said they would cover everyone who needed it, and instead people who had coverage are losing it—millions of them! They said they would make insurance less expensive—but it’s more expensive! Premium shock, deductible shock. They said don’t worry, your health information will be secure, but instead the whole setup looks like a hacker’s holiday. Bad guys are apparently already going for your private information.
My profession is much in the news at the moment, so I thought I would pass along such insights as I have from my career, mostly from a multibillion-dollar debacle which I and several thousand others worked on for a few years around the turn of the millennium. I will not name my employer, not that anyone with a passing familiarity with me doesn’t know who it is; nor will I name the project, although knowing the employer and the general timeframe will give you that pretty quickly too.
We spent, I believe, $4 billion, and garnered a total of 4,000 customers over the lifetime of the product, which was not aimed at large organizations which would be likely to spend millions on it, but at consumers and small businesses which would spend thousands on it, and that amount spread out over a period of several years. From an economic transparency standpoint, therefore, it would have been better to select 4,000 people at random around the country and cut them checks for $1 million apiece. Also much faster. But that wouldn’t have kept me and lots of others employed, learning whatever it is we learn from a colossally failed project.
So, a few things to keep in mind about a certain spectacularly problematic and topical IT effort:
Large numbers of reasonably bright and very hard-working people, who have up until that point been creating significant wealth, can unite in a complete flop. Past performance is no guarantee, and all that. Because even reasonably bright, hard-working people can suffer from failures of imagination, tendencies to wishful thinking, and cultural failure in general.
Morale has got to be rock-bottom for anybody with any degree of self-awareness working on this thing. My relevant moment was around the end of ’99 when it was announced, with great fanfare, at a large (200+ in attendance) meeting to review progress and next steps, that we had gotten a single order through the system. It had taken various people eight hours to finish the order. As of that date, we were projecting that we would be doing 1,600 orders a day in eight months. To get an idea of our actual peak rate, note the abovementioned cumulative figure of 4,000 over the multi-year lifespan of the project.
Root cause analysis is all very well, but there are probably at least three or four fundamental problems, any one of which would have crippled the effort. As you may infer from the previous bullet point, back-office systems was one of them on that project. Others which were equally problematic included exposure to the software upgrade schedule of an irreplaceable vendor who was not at all beholden to us to produce anything by any particular date, and physical access to certain of our competitors’ facilities, which they were legally required to allow us into exactly two (2) days per year. See also “cultural failure,” above; most of us were residing and working in what is one of the most livable cities in the world in many ways, but Silicon Valley it ain’t.
Not to overlook the obvious, there is a significant danger that the well-advertised difficulties of the website in question will become a smokescreen for the fundamental contradictions of the legislation itself. The overall program cannot work unless large numbers of people act in a counter-incentived (possibly not a word, but I’m groping for something analogous to “counterintuitive”) fashion which might politely be termed “selfless” – and do so in the near future. What we seem likely to hear, however, is that it would have worked if only certain IT architectural decisions had been better made.
This thing would be a case study for the next couple of decades if it weren’t going to be overshadowed by physically calamitous events, which I frankly expect. In another decade, Gen-X managers and Millennial line workers, inspired by Boomers, all of them much better at things than they are now, “will be in a position to guide the nation, and perhaps the world, across several painful thresholds,” to quote a relevant passage from Strauss and Howe. But getting there is going to be a matter of selection pressures, with plenty of casualties. The day will come when we long for a challenge as easy as reorganizing health care with a deadline a few weeks away.
UPDATE: I posted this as much for myself as for others to read. Today, Peggy Noonan weighs in. In case this is behind the paywall, here is her conclusion.
Even though it’s huge, and those who are reporting the story every day are, by and large, seasoned and have seen a few things, no one seems to know how it will end. Because it’s new territory. Does anyone believe the whole technological side can be fixed quickly? No. The president may eventually accept a brief delay in implementation—it is almost unbelievable that he will not—but does anyone think that the economics of the ACA, the content as set out and expressed on the sites, will flow smoothly, coherently, and fully satisfy the objectives of expanding health-insurance coverage while lowering its cost? You might believe that, but early reports of sticker shock, high deductibles and cancelled coverage are not promising. Does anyone think the president will back off and delay the program for enough time not only to get the technological side going but seriously improve the economics? No. So we’re not only in the middle of a political disaster, we’re in the middle of a mystery. What happens if this whole thing continues not to work? What do we do then?
This is the Titanic, folks.
I have watched the failed rollout of Obamacare this past three weeks and wondered where it was going. I have some suspicions. There is a lot of talk about delaying the individual mandate, as Obama did with the employer mandate. Megan McArdle has a post on this today. I think it is too late to fix or delay Obamacare.
With Nov. 1 storming toward us and the health insurance exchanges still not working, we face the daunting possibility that people may not be able to sign up for January, or maybe even for 2014. The possibility of a total breakdown — the dreaded insurance death spiral — is heading straight for us. The “wait and see if they can’t get it together” option no longer seems viable; we have to acknowledge that these problems are much more than little glitches, and figure out what to do about them.
Am I exaggerating? I know it sounds apocalyptic, but really, I’m not. As Yuval Levin has pointed out, what we’re experiencing now is the worst-case scenario for the insurance markets: It is not impossible to buy insurance, but merely very difficult. If it were impossible, then we could all just agree to move to Plan B. And if it were as easy as everyone expected, well, we’d see if the whole thing worked. But what we have now is a situation where only the extremely persistent can successfully complete an application. And who is likely to be extremely persistent?
Very sick people.
People between 55 and 65, the age band at which insurance is quite expensive. (I was surprised to find out that turning 40 doesn’t increase your premiums that much; the big boosts are in the 50s and 60s.)
Very poor people, who will be shunted to Medicaid (if their state has expanded it) or will probably go without insurance.
Levin points out: It is now increasingly obvious to them that this is simply not how things work, that building a website like this is a matter of exceedingly complex programming and not “design,” and that the problems that plague the federal exchanges (and some state exchanges) are much more severe and fundamental than anything they imagined possible. That doesn’t mean they can’t be fixed, of course, and perhaps even fixed relatively quickly, but it means that at the very least the opening weeks (and quite possibly months) of the Obamacare exchanges will be very different from what either the administration or its critics expected.
The insurance industry is already reacting to Obamacare and this will quickly become irreversible. This article is from September.
IBM, Time Warner, and now Walgreens have made headlines over the past two weeks by announcing that they plan to move retirees (IBM, Time Warner) and current employees (Walgreens) into private health insurance exchanges with defined contributions from employers.
The article calls it “maybe a good thing” but that supposes the exchanges will function. What if they don’t for a year or more ? What will health care look like in November 2014 ?
What happens next — as we’ve seen in states such as New York that have guaranteed issue, no ability to price to the customer’s health, and a generous mandated-benefits package — is that when the price increases hit, some of those who did buy insurance the first year reluctantly decide to drop it. Usually, those are the healthiest people. Which means that the average cost of treatment for the people remaining in the pool rises, because the average person in that pool is now sicker. So premiums go up again . . . until it’s so expensive to buy insurance that almost no one does.
Will that be apparent a year from now ? I’m sure the administration, and the Democrats, will do almost anything to avoid that. What can they do ? They’ve already ignored the law to delay the employer mandates. It’s too late to delay the individual mandate because individual policies are being cancelled right now.
My sentiments on the whole drug question have been influenced by some experience with the medical aspect of the problem. Drugs are slipping out of any control due to developments in synthetic variations of older substances that stimulate brain chemistry, sometimes in unknown ways. The traditional drugs, if we can use that term, are also slipping out of control with Mexican drug wars replacing the Columbian cartels even more violent than their predecessors.
What about marijuana ? It is widely used by the younger generation and, while I do think there are some harmful consequences, especially in potential schizophrenics, the fact is that the laws are widely ignored and do little good and much harm. First, what about the link to psychosis ?
Epidemiological studies suggest that Cannabis use during adolescence confers an increased risk for developing psychotic symptoms later in life. However, despite their interest, the epidemiological data are not conclusive, due to their heterogeneity; thus modeling the adolescent phase in animals is useful for investigating the impact of Cannabis use on deviations of adolescent brain development that might confer a vulnerability to later psychotic disorders. Although scant, preclinical data seem to support the presence of impaired social behaviors, cognitive and sensorimotor gating deficits as well as psychotic-like signs in adult rodents after adolescent cannabinoid exposure, clearly suggesting that this exposure may trigger a complex behavioral phenotype closely resembling a schizophrenia-like disorder. Similar treatments performed at adulthood were not able to produce such phenotype, thus pointing to a vulnerability of the adolescent brain towards cannabinoid exposure.
As Obamacare looks more and more as though it will collapse, there are some alternatives beginning to appear. Several years ago, I suggested using the French system as a model. At the time, the French system was funded by payroll deduction, a source affected by high unemployment, and used a national negotiated fee schedule which was optional for doctors and patients. The charges had to be disclosed prior to treatment and the patient had the option of paying more for his/her choice of physician. Privately owned hospitals competed with government hospitals and patient satisfaction was the highest in Europe.
French taxpayers fund a state health insurer, “Assurance Maladie,” proportionally to their income, and patients get treatment even if they can’t pay for it. France spends 11% of national output on health services, compared with 17% in the U.S., and routinely outranks the U.S. in infant mortality and some other health measures.
The problem is that Assurance Maladie has been in the red since 1989. This year the annual shortfall is expected to reach €9.4 billion ($13.5 billion), and €15 billion in 2010, or roughly 10% of its budget.
This may be due to several factors. The French economy is in terrible shape with high unemployment. More of the funding for the health plan is coming from general revenues. This was not how it was supposed to work. It was payroll funded, much as the German system is, with a wider source than individual employers. This allows mobility for employees and allows employers to distribute risk among a larger pool. Germany allows other funding sources such as towns and states. I think it is still a good model for us but, with the passage of Obamacare, it will take a generation before another large reform would be viable. Obamacare must stand or fall first and I think it will fall but, as in most government programs, it takes years before the sponsors will admit defeat.
1. The government should offer every individual the same, uniform, fixed-dollar subsidy, whether used for employer-provided or individual insurance. For everyone with private health insurance, the subsidy would be realized in the form of lower taxes by way of a tax credit. The credit would be refundable, so that it would be available to individuals with no tax liability.
2. Where would the federal government get the money to fund this proposal?
We could begin with the $300 billion in tax subsidies the government already “spends” to subsidize private insurance. Add to that the money federal, state and local governments are spending on indigent care. For the remainder, the federal government could make certain tax benefits conditional on proof of insurance. For example, the $1,000 child tax credit could be made conditional on proof of insurance for a child.10 For middle-income families, a portion of the standard deduction could be made conditional on proof of insurance for adults. For lower-income families, part of the Earned Income Tax Credit could be conditioned on obtaining health coverage.
3. If the individual chose to be uninsured, the unclaimed tax relief would be sent to a safety net agency providing health care to the indigent in the community where the person lives, so that it would be available there in case he generates medical bills he cannot pay from his own resources. The result would be a system under which the uninsured as a group effectively pay for their own care, without any individual or employer mandate. By the very act of turning down the tax credit for health insurance in choosing not to insure, uninsured individuals would pay extra taxes equal to the average amount of the free care given annually to the uninsured. The subsidies for the insurance purchased by the insured would then effectively be funded by the reduction in expected free care the insured would have consumed if uninsured. [See Figures II and III.]
The paper goes on to explain the proposal The trouble is that this is another major reform and I see no chance for it in the foreseeable future.
Stuck in a doctor’s waiting room where I’ve been sitting for an hour and will be sitting another hour at least.
A large TV monitor is playing and replaying the same annoying loop of fluffy health programs and ads that I’ve seen many times on successive visits to this office. Sound volume is loud and inescapable. I ask the receptionist if it’s possible to lower the volume. She says she has no control. I ask if it’s possible to turn the thing off, isn’t that an on/off switch? She says: no, believe me, we’d like to, the switch doesn’t work. I try pressing the switch. Nothing happens.
I assume that CNN (which produced the show) is paying the doctors to keep this damn machine running in their waiting room, and that one of the terms of the deal is that the machine won’t be turned down or off. And the advertisers are paying CNN. Good deal for them, and for the doctors — they aren’t likely to lose patients over such a nuisance. But this is really an abusive business model and I hope that it falls out of favor.
UPDATE: The LCD’s power cord is routed through conduit and wired into a junction box, so there is no easy way to pull the plug.
Much of what medical researchers conclude in their studies is misleading, exaggerated, or flat-out wrong. So why are doctors—to a striking extent—still drawing upon misinformation in their everyday practice?
The arguments presented in this article seem like a good if somewhat long presentation of the general problem, and could be applied in many fields besides medicine. (Note that the comments on the article rapidly become an argument about global warming.) The same problems are also seen in the work of bloggers, journalists and “experts” who specialize in popular health, finance, relationship and other topics and have created entire advice industries out of appeals to the authority of often poorly designed studies. The world would be a better place if students of medicine, law and journalism were forced to study basic statistics and experimental design. Anecdote is not necessarily invalid; study results are not necessarily correct and are often wrong or misleading.
None of this is news, and good researchers understand the problems. However, not all researchers are competent, a few are dishonest and the research funding system and academic careerism unintentionally create incentives that make the problem worse.
(Thanks to Madhu Dahiya for her thoughtful comments.)
Last week was a week for the conspiracy theories. First, we had Benghazi and the hearings which interviewed career State Department officers, most of whom probably vote for Democrats. The fact that they were ordered not to talk to Congressmen and denied any attempt at help when under attack, even from as close as Tripoli, invites speculation about motive. Peggy Noonan, a little unusually, hits this one out of the park.
Since it is behind a pay wall, I’ll quote a few bits.
What happened in Benghazi last Sept. 11 and 12 was terrible in every way. The genesis of the scandal? It looks to me like this:
The Obama White House sees every event as a political event. Really, every event, even an attack on a consulate and the killing of an ambassador.
Because of that, it could not tolerate the idea that the armed assault on the Benghazi consulate was a premeditated act of Islamist terrorism. That would carry a whole world of unhappy political implications, and demand certain actions. And the American presidential election was only eight weeks away. They wanted this problem to go away, or at least to bleed the meaning from it.
At the age of 21, Danielle Fong cofounded LightSail Energy, a venture focused on energy storage via compressed air, with heat generated by the compression recovered for later use. Investors include Peter Thiel, Khosla Ventures, and Bill Gates. (GE and RWE of Germany are also developing a compressed-air-based energy storage technology that they call ADELE…it will be interesting to see how these two alternative approaches play out.)
A New York University student has developed a new substance for wound closure, which may be able to replace bandages in many cases. Any comments, Michael K?
This issue has to be handled carefully by reform proponents. Otherwise leftist pols, in tacit collaboration with tech lobbyists who want to be paid to create an automated version of the current system, with reduced costs based on fewer workers and worse (rationed) service, may frame the issue as NHS-style single-payer vs. greedy doctors. Therefore it’s important to argue that the right kinds of reforms might greatly improve the quality of medical care AND the patient’s experience, as well as reduce costs. Mead doesn’t quite make this case.
Currently one sees increased reliance (in the USA) on nurses and physician’s assistants to do things that physicians formerly did. This makes sense to some extent but there is a limit to the amount of skilled work that can be shifted away from physicians without degrading quality of care. The Obama model is to cut costs by overworking a smaller number of physicians while shifting as much work as possible to less-well-paid workers, making patients wait longer, reducing quality of care overall and expecting people to put up with it. The better alternative would lower costs and improve care by using technology to increase productivity.
The Obama model is hostile to the high-tech alternative because 1) the Obama people don’t have a clue about either economics or medicine and 2) high-tech reforms would contribute to decentralization and individual control of medicine, and Obamaism rejects decentralization and individual control on principle.
The Queen has fallen ill, gastroenteritis to be specific. She has been taken to King Edward VII hospital in London. This hospital bills itself as the leading private hospital in London.
Why is she not staying at an NHS hospital? Gastroenteritis is not particularly complicated or unusual and should be well within the capabilities of any decent hospital facility of the most rudimentary type.
The Queen of England’s main role is to provide an example, a symbol. She is doing so today with the choice of her hospital. But is anybody paying attention?