What We Know and Don’t Know about ObamaCare

It’s not what you know. It’s what you don’t know that counts. You may know the present, but you don’t know the future.

So spoke Doug Badger, retired White House and Senate advisor and now senior fellow at the Galen Institute, a non-profit think tank, in Part I and Part II of a Galen Institute report.

Part 1 – What We Know Is.

1. Fewer are uninsured. We don’t know how many exactly but it’s in the 10.5 million to 17.6 million range.

2. Most newly insured people have gained coverage through Medicaid, not the exchanges. In all, 97% of net increase was accomplished by Medicaid.

3. ObamaCare is good deal for uninsured with pre-existing conditions and those with incomes of 200% below federal poverty line ($23,540 for individuals and $40,180 for family of 3). 86% of these receive federal subsidies.

4. Subsides can land you in trouble with the government. Premiums subsidies vary with incomes. If your income goes up by $1000, you have to pay hundreds more dollars for insurance. If you misrepresent your income increase or don’t report it, the government cuts off your subsidies.

5. ObamaCare is bad for most uninsured with incomes great than 200% of federal poverty line. You are not eligible for subsidies, and you enroll in an ObamaCare plan, it will cost you much more than paying $695 for not having a plan. Increased premiums and deductibles and out of pocket expenses will cost you a bundle. If you are in the lower middle class, you may have the uneasy feeling you are being taken for a ride.

6. Premiums are going up. How much depends on where you live and your plan, silver, good, platinum. For silver plans, the most popular, the increase averages 7.5%, but is spikes in certain states 34% in Maryland, 36% in Tennessee. 52% in New Mexico. That’s the bad news. The good news is that only 14% of enrolled in healthcare.gov are paying their own premiums without government assistance.

PART 2 – What We Don’t Know.

1. Can insurers make money in exchanges without corporate welfare. Probably not. Insurers lost $2.9 billion in 2014. Despite $10 billion in federal bailout “reinsurance,” insurers lost $2.5 billion in individual markets in 2014, $162 for each person insured.

2. Will more states expand Medicaid? So far 20 states have resisted Medicaid expansion. No one knows how many jump on Medicaid bandwagon. Most of unexpanded have Republican governors.

3. Will exchange enrollment continues to underperform? HHS projects 10 million will enroll in exchanges in 2016, far below original estimates of 24.8 million by HHS, 23.1 million by Urban Institute, and 27 million by RAND. What’s gone wrong? Distrust of government, and fact that most uninsured are young and healthy and don’t want expensive coverage.

4. How will ObamaCare affect 2016 elections? No one knows, of course, but ObamaCare changes are coming. ObamaCare is good for most of the poor, and bad for many in the middle class. Insurers are losing money, nearly half of insurance co-ops have gone under.

Whether 2016 will be the year ObamaCare holds its ground or implodes politically depends on the electorate.

Media Bias

I’m anxiously awaiting the appearance of Carly Florina.
On The View to discuss bias of the mainstream media.

I‘ve read Daniel Goldberg’s book on CBS bias,
How Dan Rather et al were too left and pious.

Limbaugh, Hannity, and Levin may be too conservative,
Fox News may be serving as right wing preservative.

But as I weigh scales of being conservative or liberal,
I try not to be overly, obviously, or viscerally critical,

And I keep in mind the words of Sir William Gilbert.

Who said of one’s politics never be too overt:

“ I often think it’comical

How nature always does contrive

That every boy and every gal,

That’s born in the world alive,

Is either a little Liberal.

Or else a little Conservative!”

Source: The Mikado, 1885, Act I

Information Technology Moves the World But It Doesn’t Integrate It

Give me a place where to stand, and I will move the earth.

Archimedes, 287-212 B.C.

The greatest migration in the history of the earth is underway, and its lever and trigger is the cell phone.

There are now more refugees – 60 million, than any time in recorded history (Rod Norland, “Mass Migration Crisis, And It May Get Worse, Millions More Poised to Flee Turmoil at Home,” New York Times, November 1, 2015).

When immigrants' boats wash upon European beaches, refugees immediately reach into their pockets or socks or under their belts, to retrieve their cell phones, which are often encased in waterproof packets. They call home, tell relatives they’re safe, say things are better here, and here’s what you have to go to get here, thus setting the stage for millions more to come.

Cell phones, the IT technology they represent, are literally the lever moving the world’s people. Immigrants are coming from everywhere to Europe – Iraq, Afghanistan, Yemen, Eretria, Libya, Egypt, West Africa, even Haiti.

They are fleeing persecution, poverty, strife, religious intolerance, dictatorships, and war. Their preferred destination is Western Europe , with its generous social welfare programs, which, for the moment at least, are overwhelmed, thanks to their fabled largesse.

But it's one thing to receive, process, house, and feed the terrorized hordes. It's another to afford their care and to integrate them into society.

IT is great for reaching millions, even billions, through the Internet, iphones, and personal computers. It's not so good at sorting out the information, and leveraging it for efficiency and for the common good. Compassion has its costs and consequences – such as loss of national identity.

In the U.S. in health care, we are finding out how hard it is to integrate the data and new information across “the continuum of care,” from birth until death.

IT creates often unfathomable issues - how to pay for IT systems, how to make sure data is accurate, how to implement it with disrupting patient-doctor relationships, how to assure the information is “unhackable,” how to protect personal security and privacy, how to guarantee the various systems are interoperable.

George Halvorsen, CEO of Kaiser once told me his organization had pledged $4 billion so that every Kaiser clinician would have every Kaiser patient electronic health information at their fingertips.

This pledge is a good thing. It's an example of IT power for the good. The reasoning goes, you can never have too much good information.

But even good information isn't simple to implement, or to make its various components and systems mesh. Or to make IT data and information understandable to patients or other audiences you seek to reach and influence.

ObamaCare, with its vast audiences and its healthcare.gov website, which tries to integrate information from other federal IT systems, has learned this lesson the hard way, with its disastrous launch and its subsequence lurches into inoperability.

So has the VA information system, “Once cutting edge, the Veteran Health Information and Technology Architecture (VistA) electronic health record (HER) has been stagnant for a decade, and clinicians are frustrated with the lack of integration and mobility compared to commercial systems.”

The VA system inflates costs, lacks interoperability, and isn't properly integrated with other Department of Defense systems. ("Reforming the Veterans Health Adminitration - Beyond Palliation of Symptoms NEJM, October 29, 2015).

The iphone is a powerful lever and starting point in the IT revolution for immigrants and some patients and physicians. Individual interconnections are wonderful as Facebook and Twitter billionaires will attest. But access to IT is just the beginning. It's just the start of the end of the beginning.

Obama Administration to Scrape Bottom of Barrel to Sign Up Uninsured

When ObamaCare’s third enrollment period starts on November 1, an army of ObamaCare “navigators” and”advocates” will be out there, beating the ObamaCare and Medicaid drums and scouring the bottom of social barrels in search of new enrollees.

Navigators and advocates will be at work on fishing piers and villages in Maine, public libraries in rural Iowa, insurer-run retail malls in Minnesota, churches everywhere, and prisons in Florida.

In Florida, federally funded navigators will visit prisons to explain to prisoners how they can sign up for ObamaCare when they are discharged in 2 months. Navigators will fish for enrollees in Maine, and elsewhere, in community clinics, at community colleges, even at 4H clubs so children can persuade their parents to sign on.

ObamaCare advocates will visits bars and college hangouts to persuade ObamaCare holdouts to sign on the dotted line, join the ranks of Medicaid, or face $695 penalties.

Many of the remaining 30 million uninsured, don’t have computers with which to sign on; don’t see the need for coverage; regard themselves as healthy and invincible; believe ObamaCare plans are too expensive, as many are with their rising premiums; think they have better and more fun ways to spend their money; are reluctant to become wards of the Medicaid state; or are simply unaware the compassionate federal government can’t wait to subsidize them if they are eligible, which is, in itself , an unfathomable story.

In any event, it’s roll-out-the-barrel and turn-the barrel - upside-down time to see who resides at the bottom. The government hopes to sign up 10 million by the end of 2016, either in ObamaCare plans or in Medicaid, just in time to declare victory before the election. It’s going to be barrel of funds.

A Place for Smallness in Health Care


Small Is Beautiful: Economics As If People Matter

Ernest Friedrich Schumacher (1911-1977), Title of His Book (1973)

In most last blog, “Bigness Begets Bigness in Health Care”, I wrote how health care businesses are caught in the grips of massive consolidation, triggered by the rise of big government.

In this post, I wish to stress small can be beautiful too. Smallness in health care is occurring simultaneousily with Bigness in health care.

It is useful to compare things great and small. Each has its virtues. In his 2015 book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, Robert Wachter, MD, described this binary problem well, “Medicine is at once an enormous business and an exquisitely human endeavor.”

A human endeavor health care is indeed. Health care is about our health, from birth to death. It’s about sickness and wellness. It’s about patients-doctor interaction. It's about economics - spending your money and other people’s money. It’s about fairness and waste, and the blend of the two when spending other people’s money in government health programs. With centralized care, more people are covered but anything goes, and humanity get lost in the regulatory blizzard. It’s about the need for more efficiency, which Big Business and Big Government, never seem to deliver.

But in the end, it’s also about privacy, confidentially, and hand holding. People are seeking kindness, listening skills, and bedside manners among physicians. And in these realms, smallness not bigness matters.

Physicians are beginning to buck the trend towards bigness by retreating into something called direct primary care, or its off-shoot concierge medicine.
By doing so, they are trying to preserve their autonomy and patient and doctor relationships.

Physicians are paring down, the number of patients they see each year, from 2000 to 3000 or more to 500 to 1000, in order to cut through the bureaucracies and regulations that have engulfed medicine and to what they are trained to do, engage with patients.

Physicians are cutting their practice overheads and costs to patients by not accepting patients covered by third parties, by not being slaves to time consumed by data and coding entry and documentation for insurers and government.

They are delivering bundled prices for a variety of services in their offices, including routine tests and minor surgical procedures.

They are telling patients precisely what to expect for their money by posting prices in advance in their offices and on the web.

They are offering same day scheduling.

They are giving out their cell phone numbers. and they are answering patient emails.

They are spending more time with patients, addressing their concerns, listening carefully to their complaints, explaining what it takes to stay healthy, and unraveling the intricacies of treatment and payment and government policies.

They are being more personal, for medicine is a very personal business.

Health care is a big business, but it’s a small business too

Bigness Begets Bigness in Health Care

Business is business!
And business must grow

Doctor Seuss, The Lorax>

To survive in today’s health care’s business climate, you have to get bigger, so bigger you get.

To grow bigger faster, you merge or acquire other health care businesses, so health care mergers and acquisitions are at an all time high, comprising 24% of total U.S. merger and acquisition deals.

• Drug stores – Walgreens has agreed to buy Rite Aid for $9.4 billion to create a chain of 12,700 stores. That leaves 2 huge drug store rivals - Walgreens-Rite Aid with 12,700 stores, 459,000 employees, 46.5% market share: CVS with 7,800 stores, 217,800 employees, and 30.8% market share.

• Health insurers- The proposed Aetna-Humana and Anthem-Cigna deals . along with UnitedHealth would leave three insurance giants in its wake, each with more than $100 billion in revenues.


• Pharma and Biotech - Valeant Pharmaceuticals and others have struck more than $240 billion in merger and acquisition deals in the last year. Pzizer may grow even bigger by moving to Ireland to form its headquarters to escape U.S corporate taxes, the highest in the world.

• Hospitals - Hospitals are acquiring and merging with other hospitals at an accelerating rate, converting themselves into large integrated systems with multiple hospitals, multiple outlets, and dominant state and regional integrated systems.

What is the cause of this massive trend toward bigness of these segments of the health care industry?

Response to big government is one answer. Under Obama and Obamacare, health care has grown into a centrally controlled massive business enterprise. Medicare, Medicaid, ObamaCare, and the VA now cover 150 million Americans, nearly half the population, and CMS (Medicare and Medicaid) set the fees and the codes and regulate the activities of the private sector.

Health care has become a $3 trillion yearly business. To protect themselves against government and contract with huge government agencies, health care participants must become big themselves - to cope with regulations, to remain profitable, to install costly information technologies, to hire expert managers, to mobilize specialists with their expertise in creating profitable hospital lines of business, and to cushion against loss.

Government bigness begets health system bigness. Bigness begets bigness, money begets money, and organizations beget counter-organizations.

Not that bigness begets efficiency or effectiveness. The VA is a prime example of the badness of bigness. The VA is the biggest health system in the United States, with 9.1 million enrollees, 20,000 physicians, 1600 facilities, 288,000 employees, and an annual budget of $59 billion.

“Yet everybody – veterans, the government, the public at large, and physicians – agree the VA is one big mess. An independent blue ribbon panel of experts, conducted by the Institute of Medicine, concluded “ VHA systems for patient scheduling, staff hiring, supply-chain management, billing, and claims management are stagnant and have more limited capabilities than their private sector equivalents.”

Bigness begets higher costs. Premiums are rising under ObamaCare health exchange plans. Thirty percent of 30% of Medicare recipients’ costs are set to rise 52%. Fees for hospital-acquired practices may double. Fees for common procedures in regions with a high concentration of large group practices are higher than those of small or single practices.

Where does this leave private physicians? In a lurch, frankly. Physicians as a whole as yet have no cohesive national organization representing their business interests. Only 15% belong to the AMA. Their numbers are fractured into 300,000 primary care and 600,000 specialists, each with its own set of priorities.

Movement towards a large physician organization is growing among physician organizations- such as the United Physicians and Surgeons Association, Physicians4patientcare, SERMO, and the Physicians Foundation- to unify physicians, but the movement is still young. Meanwhile, in response to organizational bigness, physicians are retiring early, going to work for hospitals, serving as temporary locum tenens practitioners, entering concierge practices, forming big physician groups, and creating specialty, disease, and urgicare, and other focused centers, to ease the pain of bigness and to cope with its consequences.

Health care is big deal, and it’s begetting even bigger deals.