From the Start, Signs of Trouble at Health Portal
By ROBERT PEAR, SHARON LaFRANIERE and IAN AUSTEN.
WASHINGTON — In March, Henry Chao, the chief digital architect for the Obama administration’s new online insurance marketplace, told industry executives that he was deeply worried about the Web site’s debut. “Let’s just make sure it’s not a third-world experience,” he told them.
Two weeks after the rollout, few would say his hopes were realized.
For the past 12 days, a system costing more than $400 million and billed as a one-stop click-and-go hub for citizens seeking health insurance has thwarted the efforts of millions to simply log in. The growing national outcry has deeply embarrassed the White House, which has refused to say how many people have enrolled through the federal exchange.
Even some supporters of the Affordable Care Act worry that the flaws in the system, if not quickly fixed, could threaten the fiscal health of the insurance initiative, which depends on throngs of customers to spread the risk and keep prices low.
“These are not glitches,” said an insurance executive who has participated in many conference calls on the federal exchange. Like many people interviewed for this article, the executive spoke on the condition of anonymity, saying he did not wish to alienate the federal officials with whom he works. “The extent of the problems is pretty enormous. At the end of our calls, people say, ‘It’s awful, just awful.’ ”
Interviews with two dozen contractors, current and former government officials, insurance executives and consumer advocates, as well as an examination of confidential administration documents, point to a series of missteps — financial, technical and managerial — that led to the troubles.
Politics made things worse. To avoid giving ammunition to Republicans opposed to the project, the administration put off issuing several major rules until after last November’s elections. The Republican-controlled House blocked funds. More than 30 states refused to set up their own exchanges, requiring the federal government to vastly expand its project in unexpected ways.
The stakes rose even higher when Congressional opponents forced a government shutdown in the latest fight over the health care law, which will require most Americans to have health insurance. Administration officials dug in their heels, repeatedly insisting that the project was on track despite evidence to the contrary.
Dr. Donald M. Berwick, the administrator of the federal Centers for Medicare and Medicaid Services in 2010 and 2011, said the time and budgetary pressures were a constant worry. “The staff was heroic and dedicated, but we did not have enough money, and we all knew that,” he said in an interview on Friday.
From the Start, Signs of Trouble at Health Portal
By ROBERT PEAR, SHARON LaFRANIERE and IAN AUSTEN.
WASHINGTON — In March, Henry Chao, the chief digital architect for the Obama administration’s new online insurance marketplace, told industry executives that he was deeply worried about the Web site’s debut. “Let’s just make sure it’s not a third-world experience,” he told them.
Two weeks after the rollout, few would say his hopes were realized.
For the past 12 days, a system costing more than $400 million and billed as a one-stop click-and-go hub for citizens seeking health insurance has thwarted the efforts of millions to simply log in. The growing national outcry has deeply embarrassed the White House, which has refused to say how many people have enrolled through the federal exchange.
Even some supporters of the Affordable Care Act worry that the flaws in the system, if not quickly fixed, could threaten the fiscal health of the insurance initiative, which depends on throngs of customers to spread the risk and keep prices low.
“These are not glitches,” said an insurance executive who has participated in many conference calls on the federal exchange. Like many people interviewed for this article, the executive spoke on the condition of anonymity, saying he did not wish to alienate the federal officials with whom he works. “The extent of the problems is pretty enormous. At the end of our calls, people say, ‘It’s awful, just awful.’ ”
Interviews with two dozen contractors, current and former government officials, insurance executives and consumer advocates, as well as an examination of confidential administration documents, point to a series of missteps — financial, technical and managerial — that led to the troubles.
Politics made things worse. To avoid giving ammunition to Republicans opposed to the project, the administration put off issuing several major rules until after last November’s elections. The Republican-controlled House blocked funds. More than 30 states refused to set up their own exchanges, requiring the federal government to vastly expand its project in unexpected ways.
The stakes rose even higher when Congressional opponents forced a government shutdown in the latest fight over the health care law, which will require most Americans to have health insurance. Administration officials dug in their heels, repeatedly insisting that the project was on track despite evidence to the contrary.
Dr. Donald M. Berwick, the administrator of the federal Centers for Medicare and Medicaid Services in 2010 and 2011, said the time and budgetary pressures were a constant worry. “The staff was heroic and dedicated, but we did not have enough money, and we all knew that,” he said in an interview on Friday.
The Soaring Cost of a Simple Breath
By ELISABETH ROSENTHAL
OAKLAND, Calif. — The kitchen counter in the home of the Hayes family is scattered with the inhalers, sprays and bottles of pills that have allowed Hannah, 13, and her sister, Abby, 10, to excel at dance and gymnastics despite a horrific pollen season that has set off asthma attacks, leaving the girls struggling to breathe.
Asthma — the most common chronic disease that affects Americans of all ages, about 40 million people — can usually be well controlled with drugs. But being able to afford prescription medications in the United States often requires top-notch insurance or plenty of disposable income, and time to hunt for deals and bargains.
The arsenal of medicines in the Hayeses’ kitchen helps explain why. Pulmicort, a steroid inhaler, generally retails for over $175 in the United States, while pharmacists in Britain buy the identical product for about $20 and dispense it free of charge to asthma patients. Albuterol, one of the oldest asthma medicines, typically costs $50 to $100 per inhaler in the United States, but it was less than $15 a decade ago, before it was repatented.
“The one that really blew my mind was the nasal spray,” said Robin Levi, Hannah and Abby’s mother, referring to her $80 co-payment for Rhinocort Aqua, a prescription drug that was selling for more than $250 a month in Oakland pharmacies last year but costs under $7 in Europe, where it is available over the counter.
The Centers for Disease Control and Prevention puts the annual cost of asthma in the United States at more than $56 billion, including millions of potentially avoidable hospital visits and more than 3,300 deaths, many involving patients who skimped on medicines or did without.
“The thing is that asthma is so fixable,” said Dr. Elaine Davenport, who works in Oakland’s Breathmobile, a mobile asthma clinic whose patients often cannot afford high prescription costs. “All people need is medicine and education.”
With its high prescription prices, the United States spends far more per capita on medicines than other developed countries. Drugs account for 10 percent of the country’s $2.7 trillion annual health bill, even though the average American takes fewer prescription medicines than people in France or Canada, said Gerard Anderson, who studies medical pricing at the Bloomberg School of Public Health at Johns Hopkins University.
Americans also use more generic medications than patients in any other developed country. The growth of generics has led to cheap pharmacy specials — under $7 a month — for some treatments for high cholesterol and high blood pressure, as well as the popular sleeping pill Ambien.
But many generics are still expensive, even if insurers are paying the bulk of the bill. Generic Augmentin, one of the most common antibiotics, retails for $80 to $120 for a 10-day prescription ($400 for the brand-name version). Generic Concerta, a mainstay of treating attention deficit disorder, retails for $75 to $150 per month, even with pharmacy discount coupons. For some conditions, including asthma, there are few generics available.
While the United States is famous for break-the-bank cancer drugs, the high price of many commonly used medications contributes heavily to health care costs and certainly causes more widespread anguish, since many insurance policies offer only partial coverage for medicines.
In 2012, generics increased in price an average of 5.3 percent, and brand-name medicines by more than 25 percent, according to a recent study by the Health Care Cost Institute, reflecting the sky-high prices of some newer drugs for cancer and immune diseases.
Obamacare flunks first test
As institutions go, the federal government has never been keen to admit mistakes. From the tragic internment of Japanese-Americans during World War II to the ridiculous 1981 school lunch rule declaring condiments (yes, ketchup) as vegetables, the first response to criticism is usually a rush to the microphones to mount a stern defense. Sometimes circling the wagons works, and sometimes it doesn’t. In 1989, a gaggle of furious senior citizens chased Ways and Means Chairman Dan Rostenkowski down the street, berating him over the newly implemented Medicare Catastrophic Insurance Program. Two months later the House voted overwhelmingly to repeal the law.
For Obamacare, however, no such fate looms in immediate view. Despite the widespread meltdown of federal online insurance exchanges — with sky-high failure rates, frustrated consumers, and even a high-profile Obamacare advocate who failed to enroll successfully — the White House plowed ahead. True to form, rather than acknowledge fundamental flaws within the law’s design, Kathleen Sebelius, once governor of Kansas and now secretary of Health and Human Services, was sent to the ramparts — or, rather, “The Daily Show” — to defend the indefensible. Someone had to do it.
Anyone who thinks this disaster derives from a lack of time or money is on another planet. The Affordable Care Act was signed into law by President Obama more than three years ago. This timeframe only underscores the ineptitude of the bureaucrats now entrusted with managing the largest and most intrusive federal program in history. As for cash, it appears that HHS spent over $600 million for the online system —more than it took to get Facebook started. Aside from the governmentwide sequester, Republicans have been singularly unsuccessful in starving Obamacare of funds for implementation.
No, this is a disaster of Obama’s own making, and it’s due to what the outgoing Social Security administrator calls “plain old incompetence and arrogance.” But it is not just about websites crashing. Obama signed into law a mammoth document passed in haste by the Senate on Christmas Eve with the expectation that a House-Senate conference would fix the dozens of drafting mistakes they knew were buried in the draft. That conference never came. With Ted Kennedy’s passing, Senate Democrats lost their supermajority, and the deeply flawed text was rammed through the House by a razor-thin margin without a single correction.
As a result, the White House has issued a flurry of waivers and exceptions to a law they say is “working.” In other cases, they’ve simply ignored the law altogether. Last year, as a preelection ploy, HHS used $8 billion to delay Medicare Advantage cuts that were mandated by the Affordable Care Act. This year, Obama has signed off on a raft of waivers — delaying the employer mandate, eliminating caps on out-of-pocket expenses, and postponing the enforcement of eligibility standards for subsidies.
That’s right, America, we’re rolling out Obamacare on the honor system.
Are these executive actions even legal? For most of the dozens of deadlines that have been missed, the law says “shall” — not “if you feel like it.” That stretch of the law isn’t Sebelius’s worry right now. On “The Daily Show,” her only weapons were a few talking points, a practiced tone of compassion, and some Kansan can-do spirit. That’s when she ran into the Jon Stewart buzz saw.
Stewart is at his best not when carrying on about ideology, but when mocking overly inflated institutions: politicians, Hollywood, the media. In a world of Capitol hearings where congressmen can’t articulate a question and bills that compete to attain the most compassionate and innocuous sounding names, a Cabinet secretary who’s oblivious to a train wreck is an easy mark.
Sebelius stammered, she evaded, she ignored the host’s questions. She claimed with a straight face that “we don’t know how many people have signed up online.” Stewart is no right-winger — he even supports a single-payer system — but he picked Sebelius apart, contradiction by contradiction. “If employers get an exemption from the law, why not individuals?” She offered more: more evasions, more compassion, more can-do spirit, which he met with a scathing rhetorical question asked on behalf of a frustrated country: “Am I a stupid man?”
The secretary and the president appear to think so. Yes, the government will fix the software bugs — that’s not the point. The website disaster is just a symptom of a deeply flawed law and the inevitable incompetence of the massive bureaucracy needed to carry it out. They have about 60 days to turn this mess around. Or at least create something worth defending.
Medical loans can add to the pain
NEW YORK —Gannon, 78, was staggered. She said she could not afford it. And her insurance would pay only a small portion. But she was barely out of the chair, her mouth still sore, when her dentist’s office held out a solution: a special line of credit to help cover her bill. Before she knew it, Gannon recalled, the office manager was taking down her financial details.
But what seemed like just what the doctor ordered has turned into a quagmire. Her loan ensured that the dentist, Dr. Dan A. Knellinger, would be paid in full upfront. But for Gannon, the price was steep: an annual interest rate of about 23 percent, with a 33 percent penalty rate kicking in if she missed a payment.
She said Knellinger’s office subsequently suggested another form of financing, a medical credit card, to pay for more work. Now, her minimum monthly dental bill, roughly $214 all told, is eating up a third of her Social Security check. If she is late, she faces a penalty of about $50.
“I am worried that I will be paying for this until I die,” says Gannon, who lives in Dunedin, Fla. Knellinger, who works out of Palm Harbor, Fla., did not respond to requests for comment.
In dentists’ and doctors’ offices, hearing aid centers and pain clinics, US health care is forging a lucrative alliance with US finance. A growing number of health care professionals are urging patients to pay for treatment not covered by their insurance plans with credit cards and lines of credit that can be arranged quickly in the provider’s office.
The cards and loans, first marketed about a decade ago for cosmetic surgery and other elective procedures, are now proliferating among older Americans, who often face large out-of-pocket expenses for basic care that is not covered by Medicare or private insurance.
The American Medical Association and the American Dental Association have no formal policy on the cards, but some practitioners refuse to use them, saying they threaten to exploit the traditional relationship between provider and patient. Doctors, dentists, and others have a financial incentive to recommend the financing because it encourages patients to opt for procedures and products they might otherwise forgo. It also ensures that providers get paid upfront — a fact that financial services companies promote.
http://www.bostonglobe.com/business/2013/10/13/scrutiny-grows-more-doctors-offer-credit-services-patients/HmrFzOl3Ybgf5L41zLHMdM/story.html?s_campaign=email_BG_TodaysHeadline
Obamacare: The Rest of the Story
By BILL KELLER
Unless you’ve been bamboozled by the frantic fictions of the right wing, you know that the Affordable Care Act, familiarly known as Obamacare, has begun to accomplish its first goal: enrolling millions of uninsured Americans, many of whom have been living one medical emergency away from the poorhouse. You realize those computer failures that have hampered sign-ups in the early days — to the smug delight of the critics — confirm that there is enormous popular demand. You have probably figured out that the real mission of the Republican extortionists and their big-money backers was to scuttle the law before most Americans recognized it as a godsend and rendered it politically untouchable.
What you may not know is that the Affordable Care Act is also beginning, with little fanfare, to accomplish its second great goal: to promote reforms to our overpriced, underperforming health care system. Irony of ironies, the people who ought to be most vigorously applauding this success story are Republicans, because it is being done not by government decree but almost entirely with market incentives.
Using mainly the marketplace clout of Medicare and some seed money, the new law has spurred innovation and efficiency. And while those new insurance exchanges that are now lurching into business will touch roughly 1 in 10 Americans (the rest of us are already covered by private employer plans or by government programs like Medicare), these systemic reforms potentially touch every patient, every taxpayer.
“This is the 90 percent of the story that doesn’t make the headlines,” said Sam Glick, who follows health care reform for the Oliver Wyman consulting firm.
Since the Affordable Care Act was signed three years ago, more than 370 innovative medical practices, called accountable care organizations, have sprung up across the country, with 150 more in the works. At these centers, Medicare or private insurers reward doctors financially when their patients require fewer hospital stays, emergency room visits and surgeries — exactly the opposite of what doctors have traditionally been paid to do. The more money the organization saves, the more money its participating providers share. And the best way to save costs (which is, happily, also the best way to keep patients alive) is to catch problems before they explode into emergencies.
Thus the accountable care organizations have become the Silicon Valley of preventive care, laboratories of invention driven by the entrepreneurial energy of start-ups.
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