Rick Altice on the challenges of correctional care (and related matters)

When I was a doctoral student, I wrote a desk-jockey dissertation. I analyzed a gigantic dataset to examine informal economic transfers within low-income families. Then I took a Yale postdoc. One of the first people I met there was Dr. Frederick Altice, who was a key investigator and clinician providing care to HIV-infected prisoners and drug users at the community health care van, a needle-exchange-based health services targeting street drug users. This was the mid-1990s and New Haven was an epicenter for HIV among drug users. It was a pretty awful time for the city. At least New Haven had intrepid people like Rick who worked to limit the public health harms and the human suffering.

One of my first times out, a woman stepped on the van to get some care. She was a sex worker and a person who injected drugs. Within the close quarters of that van, many of the other people waiting gave her a little extra room. She was very grimy, probably homeless.  Rick called her over. He pulled out an apple, and split it with his penknife. He handed her one piece, and said, “Why don’t you share this with me?”  As they ate together, he conducted a beautiful clinical interview that explored her incredible range of serious health problems.

I interviewed Rick today at Wonkblog. We talked about a range of pertinent issues in correctional care. If anything, Rick understates the challenge. Connecticut is quite unusual in providing generous Medicaid to many low-income adults who would be uninsured in other states. 

More here.

How North Carolina could (sorta) have universal coverage by 2016

Could North Carolina became the first State to achieve universal health insurance coverage? A student asked me recently what it would take financially to do so, and how it could most simply and quickly be done. Here is a quick estimate.

Using the Kaiser Family Foundations numbers, in 2016 there will be 1,216,000 uninsured persons in North Carolina if the Affordable Care Act were repealed. If implemented, they estimate that in 2016 398,000 persons will be covered by private insurance bought in exchanges who would otherwise be uninsured, and 377,000 (1) who otherwise would be uninsured will be covered by Medicaid if North Carolina undertakes expansion.

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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–healthcare.gov. 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 Healthcare.gov 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 first million

Welcome to the first million Americans getting health coverage under ACA.

the doctor is inThere’s one group of Americans who have a special reason to celebrate Thanksgiving: the million who now have medical insurance for the first time, thanks to Barack Obama and the Affordable Care Act.

I’ll justify the number after the jump. For now: welcome to civilisation.

I know, I know: ACA doesn’t create a fully universal system, it’s complicated and kludgy compared to single payer, the federal website was launched as leaky as a sieve and is being repaired as it goes, it’s uncertain whether ACA will rein in healthcare costs, there are over 30 million more uninsured to go, yadda yadda. We’ll be talking about these problems many times. For now, Americans should celebrate a milestone.

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How do we get to a million?

Continue reading “The first million”

The health care carrot starts to come up

Ezra Klein and Evan Soltas report that Healthcare.gov is “improving reasonably quickly” and “might well work tolerably early in December.”

Ezra Klein and Evan Soltas, Tuesday morning:

It’s clear that HealthCare.Gov is improving — and, at this point, it’s improving reasonably quickly. It won’t work perfectly by the end of November but it might well work tolerably early in December. A political system that’s become overwhelmingly oriented towards pessimism on Obamacare will have to adjust as the system’s technological infrastructure improves.

Just as Arthur Applbaum promised.

How much subsidy should each person get for health insurance?

For all the bubble and boil the past 4.5 years on health reform, there are basic questions that have not been asked clearly, much less answered. An important one is how much subsidy should people get from government for their health insurance?

The table below is a quick estimate of the per capita subsidy that different groups now receive, or will receive in health exchanges under the ACA. The magnitudes range from a maximum of $10,720 per capita for Medicare, to none for the uninsured or persons purchasing health insurance in the individual market currently, or in exchanges in the future if they make above 400% of poverty. Most people get some government subsidy for their health insurance.

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A simple health reform deal

I wrote the essence of what is below on October 31 at my home blog but forgot to post it here due to sugar haze. Since then, a few bubbles of a supposed shift toward the GOP wanting to tweak the ACA instead of arguing for a repeal that will never come. I agree that it seems unlikely that Republicans will actually vote for something of substance based on past experiences, but of course I have been prattling away about health reform deals for quite a while, the eternal optimist and all that (actually I just think eventually reality will intervene).

Here is simple deal that could provide Republicans with some political gains (we got rid of the individual mandate!) and help the ACA’s risk pooling ability in policy terms, which should be the biggest short, medium and long term policy goal for the Democrats; successful policy should pay political dividends for them down the road as well. A starter deal could also get Republicans rolling on laying out and fixing specific problems with the ACA, saving them from having to “start over” after a repeal that is not likely to ever come…..and eventually the ACA could become the entire nation’s health reform law.

  • For 2014, make some amount of the premium paid by individuals buying coverage in the exchanges who are above 400% of poverty (and thus get no tax credit) tax deductible. This will then give everyone with insurance some federal subsidy (Medicare and Medicaid directly, those with employer sponsored health insurance lots via the tax exclusion of the amount paid by an employer, those receiving exchange subsidies directly, based on their income, and then those buying who are above 400% of poverty getting some benefit from the deduction). Long run we need to reduce tax preferenced spending, so maybe the “pay for” could be bringing forward the cadillac tax or more directly capping the tax exclusion….and slowly turning down the very high tax subsidy of cadillac ESI and searching for the “goldilocks” level of subsidy at some point in the future. A slow “boil the frog a little at the time” approach is likely the only way out of what Paul Starr calls “the policy trap” of many liking their insurance and especially the subsidy they get via employer sponsored coverage; the political difficulty of ending/limiting the tax preference of ESI–the essence of all conservative notions of health reform–is what Ramesh Ponnuru is worrying about here.
  • For 2015, replace the individual mandate with the auto-enroll provisions envisioned by Rep. Paul Ryan’s Patients’ Choice Act. Strong auto-enroll policies enacted while allowing an opt out (presumably with some consequences, correct Libertarians?) could actually pool risk better than the weak individual mandate we now have. We will also have to develop a default insurance option to make auto-enroll work, which is the one thing I would add to the ACA if I could do just one thing.

There are also stories about the administration touting a fix to address the “you can keep it” thing, but it is unclear to me what could be done. Work with me people.