After Trumpcare, Medicare Part M

Here’s a thought: as soon as we defeat Trumpcare, Democrats in both houses introduce Medicare Part M (for Middle-Aged), covering people ages 50-64.

A. It’s good politics:

1. These are the people who were going to be hit the hardest by Trumpcare premium increases. Offer them a better deal and they’ll support us–and people this age vote!

2. It sounds more moderate than Medicare for All, while also making a solid step closer to single-payer, which the Republicans have managed to make sound like pie-in-the-sky socialism with a side order of end-of-the-world.

B. It’s good policy:

1. These are the sickest people in the Obamacare exchanges–move them out of the pools and premiums go down.

2. BUT they’re healthier than most people now on Medicare: put them into that risk pool and the premiums go down there, too.

DON’T believe Trump when he says Obamacare is collapsing.

DON’T believe pundits who say the Democrats have no platform/positions: this plus increased minimum wage plus let’s get out of Afghanistan is platform a-plenty.

The cure for what ails the VA

The cure for what ails the VA:

If you have a sclerotic hospital system on which everyone else has given up, the solution is Dr. Ramanathan Raju, currently the head of the public hospital system in New York but previously chief executive of the Cook County Health and Hospitals System.  No one in Chicago public life gets an A-plus from everyone, but doctors, politicians and journalists alike agree that Dr. Raju took a failing system and turned it around: re-imagining its role in a changed health care landscape while dealing with its day-to-day personnel and quality issues. The improvement has been dramatic and rapid: though Dr. Raju was only in place for two years (much to our dismay), the improvement in the Cook County public health system is obvious to all.

Hire Dr. Raju to fix the V.A.  He’s never met a bureaucracy he couldn’t tame.

(I don’t know him personally and certainly have not solicited his permission to recommend him.  In fact, he was eager to return to his family in New York, which would probably not welcome his leaving again for Washington–but, when duty calls . . . )

ACA geography in blue and red

The huge variance between states in the takeup of private insurance policies under ACA.

As you all know, December was an excellent month for the ACA exchanges, federal and state. The official HHS totals at 28 December were 2.15 million for market policies, 1.58 million for Medicaid/SCHIP. Charles Gaba’s running total for all new ACA coverage – including the mass Medicaid baptisms by transfers from state schemes, private policies contracted outside the exchanges, and under-26es added to their parents’ policies – stands at a round 10 million today.

The HHS report rightly ignores the puerile talking point that the private policies aren’t all paid up. So what? Why should anybody shop with great difficulty for medical insurance, choose a policy, and abandon it at the till at the last minute like an excess packet of cornflakes?

It does go in detail into the demographics, as a high takeup by healthier young people will be crucial to the actuarial viability of the plan. I’ve nothing to add on this issue to the full commentary of others. Matt Yglesias’ worries were answered, to my mind conclusively, by Kevin Drum, Sarah Kliff and Josh Marshall. Short take: the ranking expert at Kaiser says the takeup by under-35s is currently at the minimum for viability, with modest premium increases, and on past experience and by common sense the proportion will rise. Above all, the insurance industry is silent. If there were a real risk of a death spiral, they’d be screaming blue murder.

Instead, let’s take a look at the political and social geography. Here is Gaba’s table of the takeup of market policies by state as of 13 January, as a proportion of the uninsured. Continue reading “ACA geography in blue and red”

You want health insurance with terrible customer service? Forget Obamacare–try Blue Cross Blue Shield of Illinois

There’s not much more to my post than the headline: I’ve just concluded my sixth phone call with BCBS of Illinois (having been hung up on the first five times by an automated phone tree which sends you directly to an automated service-satisfaction survey without first giving you any service to be satisfied about). This means I spent the better–or worse–part of two hours trying to find out why BCBS sent me a bill for my January premium I’d already paid on-line.

I went straight to Blue Cross to buy health insurance because I don’t qualify for a subsidy and didn’t see any reason to grapple with–or burden– But every time you hear that payments made on the government Website might not be transferring properly to the insurers, please remember that payments made on the Blue Cross Website suffer from the same disability. And while there’s a live chat on which at least connects you to a person who can explain the problem, Blue Cross has made sure to keep its product completely untouched by human hands. I finally got through by calling corporate headquarters and explaining first to the corporate operator and then to local customer service and then finally to national customer service (after local stayed on the line with me for ten minutes to assure that national actually picked up) that a bill dated 12/12 should have included an electronic payment made on 12/2, and that no, the bill and my payment hadn’t “crossed in the mail.” In the words of the great Eric Clapton, “How many times must I explain myself ‘fore I can talk to the boss?” though by “Forever Man” I doubt he meant “man with whom you have to stay on hold forever.”

In short (I know, other people’s customer service nightmares are a bore while one’s own is fascinating), everyone who complains about the f***-ups of Obamacare ought to take a second a remember the last time s/he had to deal with a private insurer. In fact, the worst thing about the Affordable Care Act is that it leaves the insurance companies in the picture, and us to their continued tender mercies.

The first million: reality check

One good big prediction, two poor lesser ones.

On November 28 I welcomed the first million enrolees under ACA, whether to marketplace policies or Medicaid/SCHIP. The post was based on the fragmentary data available at the time, brought together in Charles “brainwrap” Gaba’s invaluable running spreadsheet, with some extra tweaks and guesswork by me.

HHS has just released its ACA enrolment report to 30 November. It even has a chart! Heavens to Betsy! Here’s the rare bird (click for better resolution):

HHS Nov chart

How did I do?

  • My headline number: one million.
  • HHS:  “Number of Persons who have Selected a Marketplace Plan or had a Medicaid/CHIP Determination or Assessment: 1.2 million”.

My point. But on the more detailed predictions, I didn’t do nearly so well. Continue reading “The first million: reality check”

The Health Care Seed

“And then, one day, health care for all came up.
Just as the Little President had known it would.”

Arthur Applbaum sends the following.


The Health Care Seed
With apologies to Ruth Krauss and Crockett Johnson

health care seed

A Little President planted a health care seed.

The Speaker said, “I’m afraid they won’t sign up.”
The Senate Minority Leader said, “I’m afraid they can’t sign up.”
And the Supreme Court Justice said, “They shan’t sign up.”

Every day the Little President pulled up the bugs
around the seed and sprinkled the ground with facts.
But no one signed up.
And no one signed up.
Everyone kept saying “No one signed up!”
But he still pulled up the bugs around it every day
and sprinkled the ground with facts.

And then, one day,
health care for all came up.
Just as the Little President had known it would.


Those of an earlier vintage may wish to substitute

The Little That Could.

Healthgov.snfu? No.

The numbers show that is working.

The HHS has released its first detailed statistical report on ACA online applications processed in the first month (October 1 – November 2).
Their summary:ACA marketplace
The split of the 846,184 completed applications between states running their own marketplaces and those relying on is 326,623 (39%) to 519,561 (61%). Some of the other eligibility indicators have similar ratios. However, of the 106,185 individuals who have selected a marketplace plan, it’s 79,391 (75%) to 26,794 (25%). This no doubt reflects the much worse start of the federal site.

The tables exclude all those who have tried to make an application and failed to complete it because of software or administrative snafus. If you read the despairing comments on the hhs blog – a sounding board for the lost without any responses – some unfortunate citizens have been trying since October 1. The best advice seems to be to abandon a jammed application and try again: with paranoid care, a new email address and a virgin browser. On the other side, the report does not include the first fortnight in November, when by all accounts the federal website was working much better than in October. is still far from Amazon’s smoothness, as Zients’ team readily admits. The claim that it’s an irremediably broken system is b/s. Healthgov has determined 886,015 Americans as eligible for a marketplace insurance plan or Medicaid. A broken system, as opposed to an unacceptably buggy, unfriendly, maddening one, could not possibly have done this.

It still of course has a long way to go. The 106,185 who have selected an insurance plan represent 1.5% of the estimated total of the eligible – a slightly better rate, as the report cattily notes, to the early take up of Romneycare in Massachusetts in 2007.

Please look at the HHS report before commenting.
Update 18 November
A different thought. One of the surprises in the website enrollment is the large proportion found eligible for Medicaid or CHIP: 396,261. ACA did expand eligibility for Medicaid (outside the neo-Confederacy), so many of these were not eligible before. But I wonder: how many may have been, but did not apply out of ignorance or fear of stigma? The great thing with universal health care (which ACA isn’t quite, but near) is that it’s a right, so there’s no shame in claiming it.

Obamacare Deception: Insurers (and maybe others) Need a Nice Letter from the FTC

Via Kevin Drum, Paul Waldman presents a truly epic post demonstrating that many insurers’ claims that rates are going up because of the Affordable Care Act are misleading and deceptive.  The press seems to have been duped into thinking that thousands of people are seeing their rates go up because insurers are telling them so.  But in fact, Waldman writes, many of the so-called Obamacare victims will actually benefit from the law.

What’s happening, according to Waldman, is a classic insurer bait-and-switch:

I want to talk about the thing that spawns some of these phony Obamacare victim stories: the letters that insurers are sending to people in the individual market….There’s something fishy going on here, not just from the reporters, but from the insurance companies. It’s time somebody did a detailed investigation of these letters to find out just what they’re telling their customers.

….If the woman I discussed from that NBC story is any indication, what the insurance company is offering is something much more expensive, even though they might have something cheaper available. They may be taking the opportunity to try to shunt people into higher-priced plans. It’s as though you get a letter from your car dealer saying, “That 2010 Toyota Corolla you’re leasing has been recalled. We can supply you with a Toyota Avalon for twice the price.” They’re not telling you that you can also get a 2013 Toyota Corolla for something like what you’re paying now.

I’m not sure that’s what’s happening, and it may be happening only with some insurers but not others. But with hundreds of thousands of these letters going out and frightening people into thinking they have no choice but to sign up for a much more expensive plan, it’s definitely something someone should look into. Like, say, giant news organizations with lots of money and resources.

If what Waldman says is true, that is indeed grotesque behavior, and one that the press should be investigating instead of getting their stories from the Republican National Committee.

But there is another thing.  It also violates century-old federal law.  The press isn’t the only institutioin that should be looking into this.

Section 5 of the Federal Trade Commission Act (15 USC 45) prohibits ‘‘unfair or deceptive acts or practices in or affecting commerce.’’  This is not an obscure law; it has been enforced for decades, despite conservative objections and more recent attempts by deceptive businesses to have it declared unconstitutional.  Any insurer claiming that a consumer must purchase a more expensive policy than what it also offered, and certainly claiming that a consumer must do so because of the Affordable Care Act, is violating the Federal Trade Commission Act.  This is not a close call.

When an insurer tells a consumer that his or her rates are going up because of the Affordable Care Act, and that is not the cause of the increase, it violates federal law.  This is also not a close call, although there is some ambiguity if the insurer can show that it had a reasonable belief that the ACA was the cause.  Insurers, however, know very well why their prices are going up.  Any insurer who says, “Gosh, we raised prices but we really didn’t know why, but we thought it was the ACA,” is essentially admitting that it doesn’t know what it is doing.  These claims should be treated with skepticism.

The trickier question is what happens when someone’s employer claims to its workers that their contributions to their insurance are going up because of the ACA.  Suppose Hobby Lobby (assuming it provides coverage) writes a letter to its employees telling them that they have to pay more because of Evil Kenyan Marxist Islamist Obama.  It knows that this is nonsense: it just wants to make its employees hate Obama as much as it does.  There are two questions here.  First, is this communication “in” or does it “affect commerce.”  If employees could change or alter their health plans because of it, then I would say yes.  If it is simple right-wing agitprop, I’m not so sure.  Second, at some point deception turns into a First Amendment issue.  If you couldn’t deceive people, then that would shut down the entire Republican media strategy over health care.  This is one reason why the connection with commerce is so important.

In any event, the Federal Trade Commission might want to send a letter to insurers participating in the exchange.  We are watching you.  Do not deceive people about this law.

Do you want to know the future?

That is the big question being considered in this long read about the direct-to-consumer genetics firm 23andme and one mother’s struggle to make sense of (and peace with) a $99 genetic profile she got of her 5 year old adopted daughter. I was interviewed for this story because of my work on the use of genetic markers as potential risk adjustor/underwriting variables for private long term care insurance and the fact that the author’s daughter was found to have the e4/e4 variant of APOE-4 which confers increased risk of Alzheimer’s disease.

The author of the story (it is published under a pseudonym) and I talked for a long time, and her anxiety about her daughter getting Alzheimer’s disease was palpable, a result to which she had locked onto. My advice to her was this:

But I appreciate the advice from Duke’s Don Taylor most. “It’s possible the best thing you can do is burn that damn report and never think of it again,” he said. “I’m just talking now as a parent. Do not wreck yourself about your 5-year-old getting Alzheimer’s. Worry more about the fact that when she’s a teenager she might be driving around in cars with drunk boys.”

It is not that AD is not a terrible disease, and goodness knows our nation’s long term care system is messed up, but you can only worry about so many things at once. There must be good uses of such genetic profiles, but it seems easier to get it wrong than right. And coming up with a coherent long term system is not important because a given person is at increased risk of AD, but because we know for certain that many of use now alive will contract the disease, it is just not clear who.

cross posted at freeforall.

Ross Douthat on health care cost containment and innovation

“Trickle-down” is not the only way to finance health-care innovation.

Ross Douthat’s essay against “Medicaid for all” – which boils down to opposition to any form of health-care cost control other than loading the cost on the patients – drew praise from, inter alia, Rich Yeselson:

Millian. You fairly explicated your interlocutors’ best arguments before astutely rebutting them. A model essay.

Agreed as to the format: when Douthat is finished, you know what he wants, why he wants it, and what the stakes are.  In particular, he is frank in saying that his preferred alternative would continue to create great financial stress for the non-rich when they get sick.

Douthat makes two strong points:

1. It’s easy to waste money on health care that could be better spent on something else.

2. The much-maligned U.S. healthcare system does, or at least pays for, a massive amount of health-care innovation; the competing systems spend less money in part by free-riding. Cost controls here could slow innovation worldwide, at a high price in avoidable suffering. (This is the drum Megan McArdle keeps pounding.)

To #1, I would reply that lots of consumer spending is “wasted;” see Robert Frank’s Luxury Fever.  Both the intra-personal hedonic treadmill and the interpersonal process of Veblenian competitive expenditure greatly reduce the marginal welfare gain of a dollar moved from health-care spending to something else consumers (have been persuaded by marketers that they) want. I don’t think we have any reason to think that the marginal healthcare dollar buys less happiness than the marginal dollar spent on anything else; the opposite might easily be the case.

#2 – innovation – is a much more troubling point for fans of cost containment. But it’s a convincing point only if there’s no alternative to unchecked spending on healthcare for the rich as a means of financing innovation. Right now the National Institutes of Health spend approximately 1% of total (public-plus-private) healthcare costs. It’s hard for me to believe that we couldn’t save 10% in healthcare costs, put half of that into more research – thus sextupling the research budget – and get back much more innovation than we’d lose. (And that’s ignoring the possibility that we might ask other rich countries to contribute something to the process.)

Is there any reason to think that patents are really the right way to finance the development of new pharmaceuticals, imaging devices, and medical equipment? Seems radically implausible to me, given prizes and publicly financed development of innovations which are then put into the public domain as alternatives.

Even if the rest of Douthat’s argument were more convincing than I find it, his casual acceptance of widespread financial stress as an acceptable side-effect of an approach whose benefits  – as he admits – are mostly speculative, strikes me as somewhat hard-hearted.  Increasing inequality has made financial stress much more common than it used to be, even in the face of rising GDP per capita. Financial stress is bad for health, and even for effective IQ. It seems to me that the presumption against financial-stress-increasing policy choices ought to be fairly overwhelming.

All of that said, Yeselson (and Chris Hayes) are right. It’s good to have a conservative writer whom it’s possible to engage in serious policy debate.