The Implementation Continues

People made quite an ordeal about the “2,000 page” health reform legislation. I don’t suppose these people had any idea how many more pages of regulations would be drafted as a direct result of the law. Fortunately, Timothy Jost has been writing a series over on the Health Affairs blog that provides a nice overview of implementation as it happens. He provides a good bit of detail, but if you want to be informed, this is the way to do it. Here are a couple of links on medical loss ratios and the new insurance exchanges, but you’ll also find links to his posts on other topics in an editorial note on those pages. Enjoy!

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Happy Thanksgiving!

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Repeal…..and Then?

Demands like this one for health reform to be repealed continue, but with at least one recent poll showing that repeal is less popular than you might think, and some solid data on cost as a barrier to access in this country, the Republicans have an interesting road ahead of them.

The system we had before health reform became law was simply not working. I think we can all agree on that. A significant number of people oppose “Obamacare.” I can understand that. But repeal doesn’t really solve the problem. Sure, if you think that health reform has or will actually make our system worse than it was before, it seems prudent to undo the legislation, but that brings us back to square one–a system that wasn’t working well for most Americans.

Repeal must only be the first step, to be followed by a far more important next step: How do we improve the health care system? In other words, if “Obamacare” isn’t a step in the right direction, what pray tell, is? This is the area where I’ve not seen much in the way of developed proposals. Sure, John Boehner announced a plan that would eliminate the individual mandate while preserving the new ban on pre-existing condition exclusions, but that only makes for good politics and terrible policy.

When one element of reform is popular and another element is unpopular, it makes people happy when you tell them that you’re going to keep the popular element and get rid of the unpopular one. The problem is that the two elements were purposefully designed to work in concert, according to economic theory and human behavior, to avoid some rather disastrous consequences. Unfortunately, most people don’t think through these types of things, preferring to stop analyzing the situation once they feel happy.

The result of this particular promise would be skyrocketing insurance costs. Why? Because many people would choose not to buy insurance until after they got sick. After all, they wouldn’t be required to buy it when they didn’t need it, and they wouldn’t be prevented from buying it just as soon as they needed it. This practice would undermine the entire principle of risk-pooling and uncertainty upon which the insurance industry rests. As a result, most of the people who bought insurance would be sick, and that would make coverage wildly expensive. John Boehner knows this, but he doesn’t talk about it on television because it wouldn’t be popular.

So, I’d like to see some substance. Call for repeal if you like, but show me your alternative plan for reform. That is, unless you think the system is doing just fine, in which case I’d love to see some data to support that assertion. Either way, I want to hear an explanation grounded in evidence, not just a collection of bullet points that cater to people’s feelings.

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Yet Another Quick Overview of Health Reforms Being Implemented

As I’ve said recently, my writing is tapering off for a little while. But this is an informative overview of some of the recently implemented components of health reform. Worth looking at if you want to understand things a little better.

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A Glimpse of Health Reform on Facebook

I’m headed out of town this week. So, I thought I’d give you a pretty substantial blog post, because this may be all you get from me for a while. Here it is………..

I watched this video via Facebook a few days ago:

Then I decided to set my status update on Facebook to read:

“So is ‘Obamacare’ fascist, socialist, communist, or Hitler? Words have actual meanings.”

That set off the following “discussion” in the comments on my page:

Michael: it’s libertarian fascism, or maybe conservative communism? No, wait, I think it is Hitler socialism, or at least socialist demublicratic right-left centrism?

Omar: unconstitutional

Michael: Please, explain this “unconstitutional” claim…

Omar: http://www.politico.com/blogs/bensmith/1010/Lawsuit_against_health_care_bill_will_be_heard.html

Michael: The comments on this are interesting. Seems like our gov’t, including our founding fathers, have been making mandates since America’s founding, such as “An Act for the Relief of Sick and Disabled Seamen” and “The Militia Act”

Omar: This the first time the federal government requires someone to purchase something. That doesn’t sit right with me.

Brad: To be accurate, they don’t require you to purchase something. They do charge you a penalty for not purchasing something. It’s not quite the same thing. You are still completely free not to have insurance if you choose. You just can’t pass the cost of that choice onto the rest of the American people like you could pre-reform. It would be more accurate to say the government has required you to spend money–but even that isn’t entirely true, because their are exemptions for things like religious objections.

Omar: If you think penalizing someone; for not doing something; isn’t requiring them to do it. Then your a fool or trying to fool others.

Michael: Omar, I’m not sure that’s true. It isn’t the first time we have to buy into something, which would be core to the argument being made in the case. “An Act for the Relief of Sick and Disabled Seamen” of 1871 required sailors to buy insurance……, via deductions from their pay checks. “The Militia Act” of 1792 required all men over 18 to be in a militia, which required the purchase of weapons and ammo. Also, every pay period, Medicare, Medicaid and Social Security are deducted from our pay checks. Also, city, state and federal taxes? I think the judge will find that in practice, i.e the reading of the laws as the have been being read, the gov’t has been and continues to require people to to pay into programs, to pay for things and/or to pay penalty for not paying into a program.

Omar: Ok let me rephrase. This is the first time the federal government will require EVERYONE to purchase something. Woman wont have to buy a weapon, non saliors don’t have to buy that insurance. You are only required to pay taxes; if you make mo…ney.

As far as states and local governments; if their Constitution lets them mandate it, like Massachusetts; then that is fine with me.

Michael: Everyone the US gov’t considered a full citizen in 1792 (only men) was required to purchase something (weapons/ammo). I think this and health care are very silimar. And again, everyone has to pay into Medicare, Medicaid and Social Security. How are those programs different?

Omar: Not everyone has to pay it. The bum on the corner asking for money doesn’t pay those taxes. But he will be penalized cause he doesn’t have health insurance.

Not everyone works in our society. You aren’t forced to work, thus not forced to pay… those taxes.

Omar: And are people still required to join the militia? I know I haven’t joined them. Using a bad law for justification for another bad law doesn’t work for me.

Michael: And still, you think the gov’t requiring everyone it considered citizens in 1792 to join a militia and buy weapons is not comparable?

Omar: Yeah it is comparable; in the fact we aren’t required join a militia anymore shows that bad laws are passed and later gone away with? Or am I wrong am I still required to join the militia by law?

Michael: We don’t have militias anymore, since the development of a strong standing army. It’s not that it was a “bad law” that went away. Anyways, let’s see what the judge says…

Lindsey: Hitlerian fasciosociocommunism. Definitely.

Catherine: Wow, I didn’t know it was THAT bad to try and make sure that every human being has a health care plan…

Michael: Catherine: It’s horrid, we need that money and those sick people to fight foreign wars!

Omar: The idea is great; but just cause the overall idea is a really good one, doesn’t mean what is in the bill is good.

Devil is in the details. Like why is gold purchases over a certain amount of money be required to use a 1099, in a health car…e bill???

Catherine: Well, maybe the bill would have been better had we let the people working on it do their job instead of wanting to compromise everything! But then again, what do I know, I’m just another one of those scary european leftist persons…

Kimberly: http://www.youtube.com/watch?v=i2e-86eOIT0

Socialist!

Michael: Omar, the idea of universal health care is everyone has to participate, and everyone pays in. I’m not sure you would be happy with this bill under any circumstances, since it has to have provisions that include everyone in the system…

Omar: I like the idea of choice. I can choice to have it, which I do. Or I can choice to not have it; like people I know. Don’t force me to do it, even if I would want to.

Then again I am Pro choice; you think more Pro choice people would dislike …the mandate.

Michael: The principle that makes universal health care work is that everyone pays in, and everyone uses the system. A single payer plan was watered down by the GOP and Big Insurance to what we ended up with. You can’t find a universal health care plan without some sort of mandate to include everyone. otherwise, the rich just opt out and the system cant survive.

Omar: Then universal health care is unamerican. Goes against freedom of choice.

So, I guess it is socialism.

Michael: ‎”universal health care is unamerican.” sigh. i guess it’s American to let poor people and minorities to live sickly and die young?

Omar: No, it’s American to donate $$ to causes that help them.

Michael: I love that conservative principle: rely on the charity of others, but don’t rush to make that charity happen, therefor starving any public welfare program and ending up back at square one, sick and dying people. You really think community …clinics surviving by the thread of their pants and other starved non profits have any way to take on the care of 60+ million uninsured Americans? Where is this amazing charity we have that makes these clinics not starve? Oh, wait, it doesn’t exist. This charity concept is great in theory, but in practice is an excuse to shut down public assistance.

Omar: I work for a non profit organization that consist of 2 hospitals and many clinics. We depend mostly on donations. That is a reality.

Michael: And you don’t get federal or state funding? I bet you do! Almost all direct providers in America do. That is how they survive.

Omar: Of course we do, but without rich people donating, this organization would exist.
That is the middle ground. Government and private organizations working together to provide the best health care we can. Not a government take over of our hea…lth care, aka universal health care.

Omar: err wouldn’t exist, typo.

Kimberly: Quick pick up all the sick and dieing off the street it’s unsightly I see them everywhere it’s like a 3rd world country! If you can make it to a hospital or call 911 a patient can be treated simple as that and guess what u don’t even have to pay- really. It’s the minority forcing the majority to buy into a system they just don’t want that was made clear Nov2. Sorry it’s the truth.

Brad: Man, people really don’t understand how EMTALA works. Nor do they grasp basic economic principles–like “there’s no such thing as a free lunch”–all that free ER care gets passed on to the rest of us. That’s health economics 101. The electi…on results show two things: 1. Turnout was disproportionately whiter and older than in 2008. 2. The economy still sucks. While it has leveled off, and there has been some job creation, it hasn’t been enough. When the economy isn’t good, when people are out of work, they vote the people in power out. Happens every time. Of course, yes, there are the Medicare beneficiaries who hate government involvement in their health care, but don’t want less Medicare. Hypocrites.

Omar: Brad I would say they don’t like the ineffective government involvement. Tf government was as effective as it promised, then they wouldn’t complain.

Fact- Medicare- pays for ever prosthetic other than for breast Cancer Survivors.

Fix the syst…em, don’t create a new mess.

Kimberly : Wow Brad I’m stumped Healthcare is not FREE?

Brad: But Omar, the health reform law specifically gets rid of the inefficiencies in Medicare (like paying extra for Medicare Advantage). If they just wanted it to be more efficient, seems they’d be all for that.

Brad: ‎@ KG, I thought Republicans favored individual responsibility. If so, they ought to favor a system that puts the burden of coverage on the individual, rather than letting them show up at an ER for care that is paid for by the rest of us. Then again, EMTALA doesn’t equal care without payment in the way people often suggest.

Omar: Southeast Georgia Health System is going to have the 204th CyberKnife in the world. In Jan 2011 it will be completed.Who paid for it, rich people’s donations.

If it was the government funded it would take 3 years.

Brad: And yet, nothing in the new law prevents rich people from making donations.

Kimberly: My point Brad was not a single person who walks in the er is turned down for care. I like your choice of words “burden”.

Omar: It puts government insurance Vs private insurance. Government insurance will be slow, long lines, but sustainable cause they have the government backing.

Private insurance will be more effective, but can’t compete with a system that has gov…ernment backing.

This will force out private insurance companies and bring us into a single payer system. I feel that is the way it is intended.

Brad: It doesn’t put government insurance vs. private insurance. Before reform there was private insurance, Medicare, Medicaid, SCHIP, and CHAMPUS. After reform there is private insurance, Medicare, Medicaid, SCHIP and CHAMPUS. There is no public option. If anything, this will help the private insurance industry. Why do you think they aren’t urging repeal? They stand to win big depending on the regs that come out.

Omar: Doesn’t it create a publicly subsidized “marketplace” to shop for insurance?

Brad: By the “marketplace” I assume you are referring to the exchange. Yes, it creates that. Those are all private insurance products however. It’s basically likely to be a website to help with comparison shopping. Think of it like Travelocity or Expedia for health insurance. Is more transparency and competition suddenly a bad thing?

Omar: No, but if it is publicly subsidized, it give people the advantage of switching to a publicly subsidized insurance plan. Which will be an unfair competition.

Am I wrong about the subsidies?

Brad: There are subsidies, but they are not tied to particular products. Basically, if your income is low enough, you just qualify for Medicaid. Then, if your income is too high for Medicaid, you qualify for a subsidy, which gradually phases out as your income increases. However, you can use the subsidy to purchase any coverage you wish. Making sense?

Omar: Time will tell.

But this debate is good.

Erica: @ Omar “Not everyone has to pay it. The bum on the corner asking for money doesn’t pay those taxes. But he will be penalized cause he doesn’t have health insurance.”

BTW – the bum on the street that doesn’t pay taxes – or anyone who is poo…r enough to not pay taxes – would not be penalized for not having health insurance. They – poor men without children – also are probably eligible for Medicaid after 2014 – for the very first time.

Just sayin’

Omar: So Erica, it is ok to penalize people for how much they make? Did you help write our tax system? lol.
Erica: The point is that he won’t be penalized. Those of us that can and do afford health insurance are already being penalized for those that currently choose not to because our premiums are higher to cover the care of those that are ‘self-pay.’ THAT is NOT okay. AND no, I don’t think I am either smart or stupid enough to write our current tax code.

Alisha: I was curious what status could possibly have 52 comments and I am really surprised that I was so enthralled and ended up reading all 52! Awesome discussion

Brad: So, FB peeps, I’ve been having a hard time coming up with material for my blog. Do I have your permission to post this discussion? Let me know.

Omar: Fine by me.

Erica: Sure. Thanks, Brad

Omar: Just fuzz out our last names. =)

Brad’s Thoughts: It is abundantly clear from this discussion that people remain passionately pro and anti-health reform. It is also abundantly clear that many of the points the group opposed to health reform are making (at least on Facebook) are incorrect. Unfortunately, for many, being passionate often precludes being open to new information. Thanks to those who later came to bat for me. I can’t take them all on by myself.

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Midterm Reflections

Now that the midterm elections are a little more than a week behind us, I wanted to take a moment to reflect on what the results mean. Here it is in a nutshell: People are unhappy. Of course, that begs the question, “Why are people unhappy?” Conservative pundits would have you believe that people are unhappy with the policies of the Obama administration and that the election served as a referendum on these “failed” policies. They look to these election results as necessary and sufficient proof that the American people are tired of being ignored and decided to take their country back. The thing is, if that’s true, then just two years ago, a majority of Americans decided to give their country away enthusiastically. If that sounds ridiculous, it’s because it is.

Elections are driven as much by turnout as they are by other factors, and in midterm elections, voters from the minority party tend to turn out disproportionately. The data clearly show that this happened. By comparison to 2008, voters in 2010 were significantly older and whiter, and the older and whiter demographic tends to vote Republican. Compound that by adding in a languishing economy, and people are desperate to get things fixed. They don’t trust government to solve their problems, and yet, when the economy has problems, they look to a change in government leadership to solve their problems. That is the first paradox among many.

Another paradox is the Republican stance on health reform. They don’t like the intrusive government involvement in the health care system that they call “Obamacare.” Then again, they want to preserve Medicare, the government health insurance program for the elderly and disabled. Apparently government involvement in health care is terrible except when it isn’t. Of course, this paradoxical policy position is readily explained by politics. Remember how the people who voted Republican and who turned out in droves tended to be older? Well, those people love Medicare. Many of them don’t know–or conveniently choose to ignore–that it’s a government program, but they love it. Never mind that Medicare–if extended to the rest of the population–would literally be a single payer system. Never mind that Medicare represents some rather wasteful government spending. Scaring old people translates into votes.

So what happens now? Republicans will put on a show of trying to repeal health reform, which will fail, but be symbolic nonetheless. Then they’ll probably work hard to try and derail implementation of the program, and if they’re successful, here’s what happens:

• The Democrats’ plan looks like a failure (despite never having a real chance)
• Health care costs continue to skyrocket
• More and more Americans lose their insurance coverage
• The nation grows sicker and less competitive
• We get taken over by China

Okay, so that last point is a bit extreme, but it could happen.

It’s going to be a bumpy ride, no doubt. How exactly it all plays out remains to be seen. But if the Republican plan to eliminate the individual mandate while preserving the ban on pre-existing condition exclusions actually becomes reality, get ready to take out a home equity loan when you need to go to the doctor. Oh, you rent? Well, then, just don’t get sick, okay? Because you’ll never be able to afford it.

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Young Adults Smoke A LOT

The folks at Slate have a nifty interactive map that lets you look at smoking rates in the United States. You can look at it state-by-state by age or county-by-county. You can also look at who smokes daily versus who smokes “sometimes.” On the whole, regular smokers appear to be a dying breed. But, take a look at the state level map for the 18-35 year old age group who smoke on occasion. You’ll have to click a few buttons to get there, but the difference is impressive. Apparently a lot of young adults are smoking–just not on a daily basis. That can still be habit forming. And, given that the older population seems to be smoking less, I’d consider buying stock in Nicorette if I were you, because some serious quitting seems to be going on in people’s late 20s and early 30s.

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The Worst Interpretation of Research I’ve Ever Seen

I was perusing “The Health Care Blog” and just read this entry from John Goodman, President of the National Center for Policy Analysis. Now, it’s no secret that he’s conservative, but that doesn’t excuse the way he tries to argue that lacking insurance doesn’t make people any worse off.

Goodman says:

“As I wrote at my blog the other day, the Centers for Disease Control (CDC) discovery that Hispanics (one-third of whom are uninsured) have a life expectancy that is 2 1/2 years longer than whites (90% of whom have health insurance) makes mincemeat out of the oft-repeated idea that the uninsured get less health care and die earlier than everyone else.”

Of course, later he says:

“Now if we did research at the NCPA the way Families USA does research, we would be claiming that lack of insurance actually makes people live longer!”

Yes, let’s not go too far in our interpretation of his misinterpretation. He is not saying that lacking insurance makes you live longer, he’s just saying that lacking insurance doesn’t shorten your life. And how does he reach this conclusion? Because Hispanics live longer, on average, than non-Hispanic whites, despite Hispanics being more than 3 times more likely than non-Hispanic whites to be uninsured. Really?! It couldn’t possibly be that the difference in life expectancy is due to other factors like diet, lifestyle, genetics, could it? It couldn’t possibly be the case that if more Hispanics were insured, the gap in life expectancy between them and non-Hispanic whites would grow even wider, could it? In both cases, the answer is a resounding “OF COURSE IT COULD!”

The statistics from the CDC that Goodman sites are not flawed. His interpretation of them is, however. The only way to state, with certainty, that being uninsured doesn’t matter, is to identify two groups who are identical in every respect except for their insurance status, and follow them over the course of their life time. That is not what these data do. Goodman has simply overstepped, misinterpreted data to push a policy agenda, and hoped that everyone who read his post would be too slow to see his slight of hand. Sorry, Mr. Goodman. You didn’t fool me.

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The Well-Informed American Public

If a picture is worth a thousand words, this video is priceless.

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"Figures Don’t Lie….

….but liars do figure.” We all have things our parents said repeatedly as we were growing up. Things that they said well before we were old enough to understand what they meant, and kept saying long after we got their point. The “lying figures” one was/is one of my Dad’s favorites. I have to admit, it’s clever, and it explains the successful coexistence of MSNBC and Fox News. After all, they can’t both be right, but they can make themselves look like it. Facts are facts, right?

But if that’s the case, how can it be that we’re constantly bombarded by conflicting reports in the media about our health? You know what I’m talking about: One day it’s the “Incredible, Edible Egg” and the next day it’s a ticking cholesterol time-bomb. Coffee is good for you and wards off certain diseases, except when it is bad for you and causes other diseases. Wine? Same thing. What’s going on here? Should you be eating eggs, drinking coffee and sipping wine for breakfast, or will doing so guarantee an early death? The answer, according to my Magic 8 Ball is “Uncertain.”

There are two primary reasons for this. First, as a mostly wonderful article in The Atlantic points out, much of scientific research suffers from substantial bias. Second, the media isn’t trained to rate the quality of the science. Journalists and reporters focus on headlines. If a study says “Eggs are great! Yay, eggs!” it will probably make the news. Ditto the finding “Eggs increase stroke risk by 200%.” (As an aside, almost every news item that tries to report such percentages does so incorrectly–at least according to anecdotal evidence.)

Given these two factors, you really shouldn’t put a lot of emphasis on a single study. In other words, eat eggs or don’t eat eggs, but don’t base how many eggs you eat on a study that Katie Couric told you about last night on the news. For a more elaborate explanation of this, you really should read the Atlantic article.

Now, all of this may have some of you thinking: “Well, then we’re really headed for trouble with all of this comparative effectiveness research!” And you’d potentially be right, if decisions were based on a single study. Fortunately, there are researchers out there doing “systematic reviews” and “meta-analysis” that look at all the studies that have been done, identify gaps in knowledge, evaluate the quality of the various studies, and their respective findings to arrive at a triangulated version of the truth–which is much more likely to be accurate than any single study, because outliers will be identified as such. (If you’re not familiar with outliers, might I suggest Malcolm Gladwell’s book Outliers: The Story of Success?) This is the one area where the Atlantic article falls flat. It acts as though all of published science is biased and therefore nearly meaningless, when in fact there are substantial efforts (e.g., The Cochrane Collaboration) underway to evaluate the evidence and reach more meaningful conclusions.

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