Friday, January 20, 2017

Health care

What's coming with Trump and the Republican congress in terms of health care? I don't know.  As usual he speaks out of both sides of his mouth and probably has no understanding of it at all. Not that Obama understood it when he was pushing for it, but, I doubt Trump has ever really talked about it with anyone who knew the basic plan.  

I still look for some signs that the ACA was a good law and I can't find it, other than for the obvious - some people getting free or actually affordable health care who could not before benefit from it and society benefits from that too.  I've asked a number of people who I think have a clue (that is, not your average person who reads newspaper articles) who support it and I'm still not persuaded by them. It seems to me the following "facts" are true. Correct me with a reference to something I can read (and, um, understand) please: 

- Insurance coverage today is just a few percentage points greater than the pre-recession baseline.

- DHS predicts that less than half the number of people the CBO predicted to be in exchange based plans were actually covered as of last March.

- The large majority of the people signing up will be older and sicker than your average person.

- Premiums, deductibles and co-pays for plans are sky rocketing for many (not everyone - and mine are reasonable - I generally benefit from the law; nevertheless, I am also generally against it). The basis for increases being a "one time correction" is not deductive reasoning but a prediction like any other. And it doesn't seem to include tax increases like the huge Cadillac tax in 2020.

- In 2016, health care costs rose by the greatest percentage since 1984.

- The Commonwealth Fund (which is pro-ACA) analysis found that the CBO initially overestimated exchange enrollment by 30 percent, its costs by 28 percent, and underestimated Medicaid enrollment by about 14 percent. If the CBO has understated the problems and costs, we could be in trouble, because most of the employment issues that will arise were predicted to be coming post 2016.

- About 3/4 of those without insurance still say they cannot afford it.

- Only 5 of the 23 co-ops remain, all failing within 3 years. Of the remaining ones, all posted losses in 2015 and of the few that had gains in 2016, they have to make health risk adjustment payments under the ACA and at least one is suing over it.

- Almost one of three U.S. counties now has a single insurer offering plans.

- Some proponents of the plans are suggesting that we have to double funding. If it is successful, why?

- Last Gallup poll I see, from 8/2016, only 11% of Americans were very positive about ACA and 23% more somewhat positive against 30% somewhat negative and 24% very negative. Asked generally, it is 51 to 44% negative. 29% to 18% thought the law hurt them.

- A  Kaiser Family Foundation poll in 2015 showed of politically independent doctors, 58-42% were negative about it (partisan doctors were pretty much like their political groups). I will add that anecdotally, I haven't spoken to a doctor or nurse that told me they liked it. 

- There is no indication that the "tinkering" that was said to be necessary has helped any of the above.

- A WaPo (generally pro-Obama) article claimed that Republicans are falsely claiming double counting to find Medicare A viable. Here's how they defend it:

"(Note: Some Republicans have argued that the administration “double-counted” the savings from Medicare in order to fund Obamacare. For complicated reasons we've explained before this is an acceptable government accounting practice that both parties have used to calculate the solvency of Medicare. A strong case can be made that there is no double-counting going on at all. It’s simply a case of looking at the same money in different ways. In other words, it is not double counting, but counting different things.)" It could be that I'm just biased but that sounds awfully weak to me.

None of the above includes the usual criticisms about the mandate, unfair waiver provisions, subsidies actually paid for by income redistribution, the admitted lies (you can keep your doctor, your health care plan, etc.) or the political sausage making that led to passage. 

One thing that was clear to me since it was passed. Once you give protection to those with pre-existing conditions and those 26 and under living at home, you are not going to get re-elected by taking it away. I have also thought they were laudable goals if we can find an affordable way to do it (not the way it's being done). Contrary to what I hear, it seems that the Republicans do have a plan or plans. I can't tell you if they are good plans at all. Not being a fan of big government plans in general, I doubt it. We also know that given the huge infrastructure of the ACA, there is not going to be repeal without a replacement.

I don't mind writing these posts without having answers. But I've always floated one on this topic - that we should make a special tax credit (not deduction - credits are better) for those who will pay other people's health care - either one to one - A gives to B or to some type of exchange, that is, A gives to a gov't agency or co-operative earmarked only for health care for those who can't afford it. Perhaps it might even be better than a dollar for a dollar. The usual criticism I hear when I float this is that it cannot possibly pay for the entire health care system. Of course, I never suggested it could. But, I wonder if it would not only pay for those without coverage, but if we would actually have to limit it so that it did not drown out other charitable giving.

I heard another one that makes sense and I am looking for criticism of it. Steven I. Weissman,  who claims to be a former president of a Miami Hospital (which one he doesn't say, but from what I can find online he is a lawyer who ran a acute care facility for a while - doesn't mean it is not a good idea), has a petition on change.org entitled "end predatory healthcare pricing," which calls for an end to hospitals charging different prices depending on what health insurance you have or worse, if you have none. He claims, and I'm not sure that is true, that it is the only service you buy where this happens (I know that is not true of my own profession where attorneys sometimes change price based on who the client is, charging less to those who can afford less or who has referred them, etc.). I think it is largely true. I have twice experienced a medical professional - in one case a doctor and in another case a lab, seek to charge me many times what they would charge an insurance company. Since I hadn't contracted with them (and didn't know they were separate entities servicing me - long stories) I refused to pay more than an insurance company would pay, which was obviously reasonable compensation. He also points out it will end the burden of having a doctor in or out of networks, as they won't be able to vary the price.

I'm not sure what value either his idea or mine will have, but, they are good ideas that will not take a tremendous government network to run. Some people feel that is necessary these days. You'd have to convince me and I haven't been convinced at all.

I had the usual big-government-controlling-our-little-lives nightmare the other day. I am on Obamacare in NY. You don't have a choice if you aren't in a business that has a plan. The plan itself is not bad at all and I do not complain about the cost, which is reasonable. But, I do realize that this is because of other people paying more and everyone paying more taxes and I'm  generally against my having a benefit at other people's expense that isn't available to everyone - and it's not. Someone said to me a couple of year's ago, so you can't complain about Obamacare because you have it. This is a little bit like someone telling you that you can't complain after a shotgun wedding. I didn't have a choice. In NY, you are either on a business plan or you are on an exchange plan. There are no other options.

In any event, my plan, a platinum plan, has automatic re-enrollment. At the end of 2015 after a barrage of emails, I reluctantly took the time to re-enroll, only to be told, as expected, it had happened automatically already. 

This year, I did the same thing - went online to re-enroll after being told I would have no insurance, only to get a response that I was already re-enrolled.

So, I paid my premium before the end of the month as always. It cleared a few days later, meaning it was deposited by my health care company. I also got an email from them in the new year. But, when I went to use it, I was told by my pharmacist it was cancelled. 

So, of course, I called the next day. Well, the agent responded, you were re-enrolled automatically, but . . . the exchange cancelled that plan on 12/31/16 - New Years Eve. Didn't you get an email? No, I said, I just read all my emails.  You have a new plan and it is going to cost you only $31 and change. Okay, I say, first, thanks to everyone for the warning. Great system you all have. Second, there is no way in the world I am going to have to pay only $31. They are going to end up sending me a bill for thousands in a few months. So, I was told to call the exchange.

And I did. Yes, my plan was cancelled as of 12/31. No reason given, but I presume it was not cost effective like so many of them.  They wanted to put me on a cheaper plan. My problem was, I did not think my doctor would accept it - many don't - and that would mean the entire health care organization which has all my med records available for my review and which includes some specialists rather important to me, also would not be available to me. Second, I'm not taking the $31 even though - wow - because first, it would be reprehensible and second, I'm sure I will eventually pay for it. After assuring me that is all I owed per month, after one of the many holds I was put on, she came back and said - oh, maybe you are right. We have you down as having no income last year. I ask, why is that? She answers, because you haven't filed a tax return. Maybe, I say, that is because like most people, I do not file a tax return on New Years Day. We worked it out, and, of course, I have to pay hundreds of dollars a month (still good) but not remotely close to $31 a month.

And, one more thing, I almost forgot - my insurance company - they have been holding on to an over payment from 2015 they forget to tell me about. Frankly, I remember when it happened and it was their fault, but it took so long, I actually forgot about it (no surprise for me really).  That's roughly $555. Then I inquired about the $612 I sent for my premium just before they cancelled me. Oh, sorry, I was told, but since they changed your plan (without telling me), there is a new account number and we won't see your premium, even though we have it. But, we will give it back - in another 6 weeks (I'm sure meaning - if I don't forget). 

And since I wrote that last paragraph, I have yet another surprise. It turns out that not only am I going to be on the very same plan I was on that they terminated because it was supposedly cancelled (no one even understands what I mean when I tell them this at the insurance company because it makes no sense), but it turns out for the month of January, I am on a different plan altogether with a different ID no., but I have my regular doctor listed for primary care physician. BUT - they kicked him off for the new old plan in Feb., even though it is the same plan. Now, I can change it back to him, but, not until Feb., when I will have the old ID number. Get it? I don't. But, what choice do we have?

Bureaucracies have always been heavy to dance with and health care will always be expensive. And I'm sure if the Kingdom of Heaven came tomorrow there would be a software glitch - or ten, and Russia would hack it. Things do take time to work. 

The system should be changed.  I'm for the gov't assisting to standardize record keeping so we can actually have all our healthcare records permanently available. I have always been for a system that allows insurance of pre-existing conditions and like everyone I know, even the most dread haters of Obamacare, I'd like everyone who can be insured and wants to be insured - to be insured. But, the system we have doesn't work. Maybe some of those things are not affordable, period, and are a sacrifice that will have benefits in other ways.

Do I think the Republicans are going to fix it? No. But, maybe it can be improved a little. We will let go for here the whole problem with the federal government controlling healthcare because that ship has sailed. The Republicans obviously think it is a good idea too, just that they can do it better. Regular people will not believe it.

Of course, regular people will not be deciding the fate of the ACA or healthcare. It will be politicians. So . . . .

8 comments:

  1. A few notes from your friendly neighborhood health economist/nephew in multiple comments because this stupid website has a limit of 4,000 characters.

    "Insurance coverage today is just a few percentage points greater than the pre-recession baseline."

    The uninsured rate is about 6 p.p lower than it was before the healthcare law took effect. About 20 million people in the U.S. Who were previously uninsured now have coverage (20 million people is nothing to sneeze at!). This is the biggest drop in the uninsured rate since the creation of Medicare and Medicaid and is a result of 1) those less than age 26 staying on their parents insurance 2) an expansion of medicaid to all individuals less than 133% of the federal poverty line ($32,319/year for a family of four) in states that chose to expand medicaid and 3) the exchanges.
    http://www.gallup.com/poll/193556/uninsured-rate-remains-historical-low.aspx
    https://www.hhs.gov/about/news/2016/03/03/20-million-people-have-gained-health-insurance-coverage-because-affordable-care-act-new-estimates

    "DHS predicts that less than half the number of people the CBO predicted to be in exchange based plans were off actually covered as of last March."

    What is DHS? DHS usually refers to the department of homeland security. Anyway—yes the pre-law CBO estimates were off as they were making predictions in the dark (they didn’t know how people would react). Now that we have actual data being fed into CBOs models (and they have an incredibly sophisticated microsimulation model that they are using now), their current estimates and predictions are quite good.

    "The large majority of the people signing up will be older and sicker than your average person."

    I assume here you are referring to the ACA exchanges. First, yes, the population is older and sicker than the average person. Partly, that was the point of the ACA exchanges. Prior to the ACA, sick people were unable to obtain health insurances due to pre-existing conditions. Having said that, those on the ACA exchanges are as a whole are not entered old/sick people—it also includes a lot of self employed people, those who work part time jobs and are not eligible for benefits, and those that work for small firms that do not offer health insurance.

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  2. A few notes from your friendly neighborhood health economist/nephew in multiple comments because this stupid website has a limit of 4,000 characters.

    "Premiums, deductibles and co-pays for plans are sky rocketing for many (not everyone - and mine are reasonable - I generally benefit from the law; nevertheless, I am also generally against it). The basis for increases being a "one time correction" is not deductive reasoning but a prediction like any other. And it doesn't seem to include tax increases like the huge Cadillac tax in 2020."

    I’ll take the end first. There is no way this or any other Congress will allow the cadillac tax to take effect. Not worth talking about (IMO). Now for the other issues. And I want to divide this into a few groups.

    Group 1 (Those on the exchanges) about 5% of US pop: Lets start with the number 5% of americans are currently enrolled in a plan on the exchanges. Now to premiums and other cost sharing (co pays and deductibles). Premiums are on the rise especially in the past year. I believe this was a one time correction because the insurers now understand what the mkt looks like (older and sicker than they initially thought) and this was the first years they were allowed to fully adjust their premiums. Even though premiums are skyrocketing, most people are not paying them—83% of exchange enrollees receive premium subsidies from the government. You can make an argument that the taxes on high income earners than pay for these subsidies are an inefficient reallocation of resources (that’s an ideological debate that I think is fair to have). However, its not fair to say that these high premiums are affecting most people—because most people are receiving subsidies and not paying these sky high premiums. Second, deductibles and copays. Again, these are very high. But again, +60% of enrollees receive cost sharing subsidies (between 133% and 200% of FPL) that bring their deductibles close to zero. Most people receiving these subsides don’t even realize they are getting them because they are automatically integrated into the plan search tools that run the exchanges.

    Group 2 (Those in the employer sponsored mkt) about 50% of US pop: Premiums grew only 3% 2015-2016 in this market. This growth rate is FAR lower than it was before the ACA. Deductibles continue to rise in the employer sponsored market but, at least to me, it doesn’t look like this has anything to do with the ACA and just existing trends.

    http://kff.org/health-costs/report/2016-employer-health-benefits-survey/view/exhibits/
    http://kff.org/report-section/ehbs-2016-summary-of-findings/

    Group 3 (Those on medicaid and medicare) about 35% of US pop: I don’t think we need to discuss here because their cost sharing is flat.

    "In 2016, health care costs rose by the greatest percentage since 1984."

    Where did this number come from? In inflation adjusted dollars, costs grew at a rate of 6.5% between 1983-1992 and 3% post-aca 2010-2014. It has ticked up a bit (due to the coverage expansions—not in a per person way) but is still 5.8% in 2015

    http://content.healthaffairs.org/content/early/2016/11/22/hlthaff.2016.1330
    https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/HistoricalNHEPaper.pdf

    "The Commonwealth Fund (which is pro-ACA) analysis found that the CBO initially overestimated exchange enrollment by 30 percent, its costs by 28 percent, and underestimated Medicaid enrollment by about 14 percent. If the CBO has understated the problems and costs, we could be in trouble, because most of the employment issues that will arise were predicted to be coming post 2016"

    We could, but like I said above, the CBO was shooting in the dark. They have a lot of good actual data they are using now. To the second point, I see a lot of evidence that has shown that the ACA has no effect on employment.
    http://content.healthaffairs.org/content/35/1/111

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  3. A few notes from your friendly neighborhood health economist/nephew in multiple comments because this stupid website has a limit of 4,000 characters.

    "About 3/4 of those without insurance still say they cannot afford it."

    I assume those is supposed to say “with" and not “without"? This is a complicated problem—health care is expensive, even with insurance. I see no evidence that suggests repealing the ACA would make it cheaper. Alternatively, I see a lot of evidence that repeal would make it more expensive for many people.

    "Only 5 of the 23 co-ops remain, all failing within 3 years. Of the remaining ones, all posted losses in 2015 and of the few that had gains in 2016, they have to make health risk adjustment payments under the ACA and at least one is suing over it."

    I’m not sure what this means.

    "Almost one of three U.S. counties now has a single insurer offering plans."

    Are you talking about ACA exchange plans? Or the ESI mkt? Anyways, I’m always pro more ways to insert competition into any market. I think we should be focused on ways to do that in the current system—I don’t see any evidence that suggests blowing up the system would increase competition.

    "Some proponents of the plans are suggesting that we have to double funding. If it is successful, why?"

    I haven’t heard this from any reasonable people (Bernie Sanders does not count as a reasonable person).

    "Last Gallup poll I see, from 8/2016, only 11% of Americans were very positive about ACA and 23% more somewhat positive against 30% somewhat negative and 24% very negative. Asked generally, it is 51 to 44% negative. 29% to 18% thought the law hurt them."

    Though the view is negative—almost no one wants it fully repealed either. http://www.npr.org/sections/health-shots/2017/01/06/508379529/poll-most-americans-say-dont-repeal-obamacare-without-a-replacement

    "A Kaiser Family Foundation poll in 2015 showed of politically independent doctors, 58-42% were negative about it (partisan doctors were pretty much like their political groups). I will add that anecdotally, I haven't spoken to a doctor or nurse that told me they liked it."

    Most recent data I’ve seen shows primary care doctors split down the middle (48/52 favorable/unfavorable) but only 15% want to see it repealed. Its easy to complain about the status quo, but, like democracy, its the worst system, except for all of the others.
    http://www.nejm.org/doi/full/10.1056/NEJMp1700144?

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  4. You ask what is DHS (in that context)? Nothing, I think. My computer does a lot of things I don't understand, like moving my cursor around the screen, highlighting and grabbing things, then putting the words elsewhere, often without my seeing it (sometimes I do see it happening - so I know in general). And then my editor (me) hits "send" before he should because I'm tired. Its always embarrassing. The sentence should start with "Less than . . . ." Normally, I go back and edit my mistakes after the fact (because it's my blog and I can), but if someone comments on it, I'm stuck with it. So it is there forever. The commenter known as Bear used to mercilessly correct my mistakes, but I always felt if he found less than three errors it was a great triumph and was happy he'd do it. No idea if he reads anymore. Welcome to my world and thanks for your comment.

    As to the CBO, I agree with you, mostly. I'm not knocking their reports. I am opposed to how they are used. I read CBO reports occasionally. They take great care, particularly early on, to qualify everything they write. What happens though is that politicians and the media generalize their findings, ignore their reservations and qualifications, to support a political narrative. Often it is used to defend legislation as it was the ACA. Later, when estimate prove inaccurate (whatever the reason), we need to ask, why then do we base legislation on what we can't know is accurate - over and over again? If we look at what we now know as opposed to what they estimated, it doesn't bode well for the future if the law is not changed.

    As to your comment re: not sneezing at the numbers of people now signed up, I didn't sneeze. I said that obviously it was good for those people and society in general to have more people covered. I would be happy if everyone was covered just like I'd be happy if we could stamp out violence throughout our country and world. The question is always how do you do it without bankrupting yourself and making things worse for everyone?

    You did not comment on the fact that the co-ops have and are still folding, or that the prices are still rising (greatly), etc. My belief is that many people feel that covering poor people is more important than wealthy people buying new cars or going to Cabo. Most of us accept reasonable progressive taxation - though it is wrong to call it "fair." I just think if a law doesn't work (and despite the rhetoric the ACA has never worked), we'd better do something else. Pres. Obama's legacy just doesn't matter. I'm generally opposed to huge gov't plans that take over everything because they usually don't work.

    Anyway, thanks for your contribution.

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  5. So, I belatedly posted Matt's two other comments after I commented on the first one I saw. Sorry, Matt, I thought my email just repeated the first one (because it does that sometimes).

    Generally, other than your stats regarding whether health care costs, I don't see that much disagreement on facts. I can't debate all your comments in a comment myself, but I'll agree there is a policy debate about the good or badness of some people paying for other people that we don't need to have now. It is SOP anyway. The question is now always - to what degree? I think my friend Don, who often comments here, would say - 0 - and Bernie Sanders towards the other end, but, most people don't really mind progressive tax rates - they just think they pay too much. As for the Cadillac tax, I agree, congress will squelch it. But, that's not an answer to the problem of - where does the money that was supposed to come from the Cadillac tax come from? Another reason the ACA is not sustainable.

    With regard to your comment that you think costs will go up with repeal, I don't see what that means in the real world. The Republicans, now in charge, have said for years that it can't be repealed without being replaced and Trump and Price have both said that too. It is one of the insidious things about the ACA. Many Dem politicians said that this is just a step towards Single Payor and a few even said (I can't remember who now, but I watch C-Span) that the act is designed to show that it must fail and single payor is the only option. Once millions of people get insurance (and we agree, that's standing alone, a good thing) it becomes politically impossible to take it away without changing a lot of things.

    It's your field, at least sort of. What's your plan? How do we keep or expand coverage and pay for it? Your answer might be - more taxes. Certainly a lot of people have said that - some suggest doubling what there already is.

    If professionally, it's not wise to put your thoughts on things like that in writing, I get it. This is actually a public forum, although lightly traveled.

    Thanks again for commenting.

    ReplyDelete
  6. Your suggestion of allowing tax credits for health care contributions is a good; but basically it's a charitable contribution. There are programs out there like MediShare that already do things like that. Interestingly, it is not allowed in Montana.
    Anytime I hear anything from the CBO (which is always prefaced by Non-partisan) I cringe. They are required to include assumptions provided to them whether they have any gounding in reality or not. ASSUME that tax revenues increase 80,000% in the next 5 years blah blah. What needs to be done in this regard is for the government to adopt and exclusively use Generally Accepted Accounting Principles. This would help (but probably not eliminate) BS accounting. Also no more 10 year projections. They are useless in this system with elections every 2 years.
    I would prefer to see health insurance entirely removed from employment. Employers don't provide home owners insurance and shouldn't be involved in health insurance. Allow any group of people to form a group and shop anywhere from any company for a plan.
    In looking at medical procedure the only ones that have decreased in price are the ones that are not covered by insurance such as LASIK and certain cosmetic procedures. Seems there has to be a connection. If health insurance was more along the line of catastrophic coverage and not routine coverage certain prices for routine matters would decrease or at least stabilize as competition took effect. Also, let people tailor their coverage specifically to their needs and no add ons that are mandatory.
    Ratings and premiums must be allowed to be realistic. A company cannot provide a service on an ongoing basis if it is required to provide those services at a continual loss.

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  7. Unreal. I was just going to comment "ZZZzzzzzzzzz..." for what was for me the most boring post of yours EVER. Then, low and behold, the most intelligent and lively section of comments your blog has ever gotten. Just goes to show, what the hell do I know? Good job, Frodo.

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  8. I think there was a compliment to someone there. Probably not to me.

    ReplyDelete

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I started this blog in September, 2006. Mostly, it is where I can talk about things that interest me, which I otherwise don't get to do all that much, about some remarkable people who should not be forgotten, philosophy and theories (like Don Foster's on who wrote A Visit From St. Nicholas and my own on whether Santa is mostly derived from a Norse god) and analysis of issues that concern me. Often it is about books. I try to quote accurately and to say when I am paraphrasing (more and more). Sometimes I blow the first name of even very famous people, often entertainers. I'm much better at history, but once in a while I see I have written something I later learned was not true. Sometimes I fix them, sometimes not. My worst mistake was writing that Beethoven went blind, when he actually went deaf. Feel free to point out an error. I either leave in the mistake, or, if I clean it up, the comment pointing it out. From time to time I do clean up grammar in old posts as, over time I have become more conventional in my grammar, and I very often write these when I am falling asleep and just make dumb mistakes. It be nice to have an editor, but . . . .