March 31, 2014

Tentative Conclusions about ObamaCare

Let us hear the conclusion of the matter.

Ecclesiastics, 12:13

O most lame and impotent conclusion!

Shakespeare (1564-1616), Othello

Every book needs a conclusion.   Yet  6 months after ObamaCare’s abortive launch, October 1, 2013,  I have reached no definitive conclusion, foregone or woebegone, on this last day of open enrollment.

The 6 months started disastrously and ended inconclusively.  CBS declared ObamaCare  a “work in progress.”  I would characterize it as a “work in redress,” meaning the Obama administration is still trying to get it right enough to pass political muster.

Again and again, in the course of reprinting 195 daily blog posts that make up this book,  I have said ObamaCare’s future hangs on a single thread – the November 2014 midterm elections.  Like a  tattered sweater, ObamaCare may unravel if voters pull away that thread. 

But even after November, no matter what the outcome, we won’t know if ObamaCare  has passed the ultimate tests – lives saved, diseases prevented or cured,  health of people restored.  These are imponderables you cannot hang  numbers on.  Historians may reach general conclusions.   These conclusions will be imperfect and a matter of opinion.

Consequently, in this, the second of my ObamaCare triology, I have leapt to no conclusions.  

Politics is the mother of health reform. Politics depends on trust in government, emotional and financial security, demographic well-being, economic growth, and a nation’s cultural underpinnings.   Some of these factors are lacking under the present administration.  People have little confidence in the direction of the country.

It has been said health reform is too serious a matter to be left to politicians, or, for that matter, to physicians.   Only 15% of a nation’s health depends on medical care.  The rest depends on poverty, education, family cohesion,  and behavioral choices.   

 Let the people decide what manner of health reform suits them best and what they will accept.   The survival or thrival of ObamaCare comes down  to  matters of  peace of mind,  personal freedom, and perennial elections. 

Richard L. Reece, MD,

March 31, 2014

The Latest  Health Care Polls and the American Creed

A good place to start to remember we are pro-democracy and anti-government. It comes down to ideas that are essentially anti-authority and tend toward self-regulation. It there were an American creed, it might begin.

The American Creed

One, Government is best that governs least.

Two, majority rule.

Three, equality of opportunity.

Garry Orren, a professor of political science at Brandeis, who polls for the New York Times and Washington Post

The average of the latest national polls, as compiled by Real Clear Politics, are:  Oppose 52.1%, Favor 38.6%,  Oppose/Favor  + 13.5%

What do these numbers say about our Creed?

Our government doesn’t govern least, agreed?

On health care, the majority doesn’t rule,

When you add up those in the voter pool.

And as for equal opportunity, 

All must be equal in the community.

Tweet:   Under Obama health law, America’s creed has become - government is best that governs most, minority rules,  and equality of results, no opportunity, counts most

And Who Shall Pay for the Sick?

The sick are the greatest danger for the healthy.

Friedrich Wilhelm Nietzsche (1844-1900), Genealogy of Morals (1887)

How sick they are will factor into next year’s prices.

Shad Terhune,  “Insurers Already Calculating 2015 Premiums as ObamaCare Kicks In”, Los Angeles Times, March 30, 2014

“As California goes, so goes the nation.”   Like most clichés, this one  contains a grain of truth.   More than 1 of 9 Americans live there.   As John Naisbitt observed in Megatrends (1982),  many national trends start there. With 1.1 million enrollees there,  California  leads the nation, with more 1 of 6 of those nationwide signing on the health plan bottom-line.   More Hispanics, the nation’s leading source of the uninsured,  reside there than any other state.   California bears health reform watching.

Already actuaries in California are hard at work.  They are figuring out next year’s rates. They are analyzing claims to see how many enrollees are sick,  for the sick will determine premiums for the healthy.   The sick will determine the level of “sticker shock” for the rest of us.   The sick will determine the degree of “adverse selection.”  The sick may determine the results of the 2014 November election, for premiums for 2015 must be announced in May, three months  before those elections.

If the premiums are low or minimal (less than 10%, preferably 5%), it will bode well for ObamaCare.   If premiums are in the double digits (20% or more),  as Wellpoint, Inc., predicts,  ObamaCare and the health exchanges are in trouble. A “death spiral” of ObamaCare with unaffordable premiums and deductibles may ensue. 

 

Robert Laszewski, a nationally recognized health care consultant, says , “If rates in California increase by 20%," enrollment will go down and any healthy people will bail." Excessive bailing, accompanied by penalties for not enrolling, will not be received well with voters.

Those concerns are one reason the Covered California exchange, insurers and health-law supporters are struggling  to persuade young and healthy people to enroll before Monday's deadline. The goal is to get  a balanced mix of policyholders and keep monthly premiums down.   

As matters now stand, about 30% of the young (18-34), have signed on.  The goal is 40%.  But the young are said to be inveterate procrastinators. They never do today what they could have done yesterday.    On Monday, March 31,  for the young, today arrives.  The  young will have their last opportunity to enroll.  Perhaps then they will recognize that federal subsidies make a bad deal a good deal.

And who shall pay for the sick?  The rest of us, that's who.  That's the way  it has always been and always will be. 

The only questions: How much?  How high the premiums for the healthy? How high the hidden costs to taxpayers?

Tweet: With 2 days to go before open enrollment deadline, all eyes are on California, to see how high premiums might go and how many of enrollees are the sick or the healthy young

Ten Useful Ways of Looking at ObamaCare Numbers

Calculated over decades to come the number of lives saved is likely to total in the thousands, if not the millions. And that will be the true test of the Affordable Care Act as a historical accomplishment for Barack Obama and his administration.

John Irving, “Numbers We’d Rather Be Talking About, “ The Health Care Blog,  March 29, 2014

John Irving,  executive editor of The Health Care Blog, perhaps the most widely read of the health care blogs, has provided 10 ways of looking at those health care numbers everybody will be commenting on as the  first six months of ObamaCare enrollment comes to a close on March 31. 

Irving concludes that, in the long run,  will be a good thing, resulting in thousands, if not millions, of lives saved.   He comments,

“You can forget the nonsense we’ve been hearing about Obamacare costing the lives of thousands of Americans by taking their health coverage away from them.  There is a difference between losing your coverage temporarily because the system is in transition and losing  it and knowing that you’ll never be able to get it back. Ever.”

In other words,  all this talk about the negative effects of ObamaCare is  temporary  and people who lost their coverage will get it back.  

I do not share Irving’s confidence.

Here are Irving’s 10 numbers he says we should be looking at.  The words describing these numbers are Irving’s, not mine.

One, FUDs The number of people who are innocently living their lives thinking they have bought health insurance, but who, for one reason or another,  be it technical glitch, bureaucratic incompetence or technicality – are going to wake up one morning not long from now and discover that they do not have health insurance.

Two, 404s : The number of people  applications lost in the system,  either as a result of the Healthcare.gov fiasco or because their application is sitting forgotten on somebody’s desk somewhere or in a laptop. 

Three, CANCELS The number of people who had their insurance plans cancelled by insurers on the grounds that they did not meet the standards set by the Affordable Care Act.

Four, UNCANCELS: The number of people who had their plans cancelled by the health insurers only to have them declared “uncancelled” by the Obama administration or their state. 

Five, BUMPS: The number of people who have been “bumped” out of network and are being forced to change doctors.  What’s going on? In gamification terms, bumps make things more exciting. In real life, they suck.  Getting bumped off a flight is annoying, getting bumped in the health care system is potentially life-threatening.

Six, PRE-EXs: The number we should talking about is the number of people who’ve signed up for insurance under Obamacare who would have never been able to buy insurance under the old, evil healthcare system that discriminated against people with previously existing conditions like cancer, high blood pressure and HIV/AIDS.

Seven, NETWORKS and DOCS: Once we figure out how many people have signed up for Obamacare we’re going to have to figure out what they bought. What kind of coverage is Obamacare providing? We won’t understand the new healthcare system we’ve built until we’ve mapped and understood the networks that are organizing under the new rules. How many docs and hospitals are participating in each? 

Eight, YOUNG ADULTS: Based on early reports, there is reason to think this number was looking like it was going to be a lot lower than the administration wanted it to be, a fact which terrified the people at health plan responsible for managing risk. 

Nine, TRUE ENROLLMENT: Yes. Yes. We know. If you’ve heard it once you’ve heard it a hundred times. The number of signups doesn’t mean anything.  The QHPs the White House is talking about aren’t real. They are a proxy. What matters is true enrollment: the number of people who were able to successfully sign up and pay their first premium.  

Ten, LIVES SAVED: As we speak Nate Silver or a smart person who looks and sounds a lot like Nate Silver is sitting at a computer in a darkened room somewhere trying to come up with a reliable quantification of the number of lives the Affordable Care Act has saved and will save by shielding people from the barbaric US healthcare system.  

Thoughtful Discussion

In the course of his thoughtful discussion of the significance of these numbers,  Irving says some of these numbers are difficult to quantify.  Some we will never know.  What counts is whether ObamaCare  will save lives over the long term.  That is a  hard number to know at this point. Perhaps good intentions will prevail.  Perhaps the unforeseen negative consequences will trump good intentions. 

Tweet:   John Irving, executive editor of The Health Care Blog,  has provided 10 useful insights into what ObamaCare enrollment numbers mean.