ACA’s bungled rollout aside, government health insurance works
Posted Oct. 17, 2013, at 5:59 a.m.
The lead story in the Oct. 13 New York Times details the ongoing problems of the Affordable Care Act’s websites intended to facilitate access by individuals to the law’s hallmark online health insurance marketplaces. Those problems continue.
To summarize, many of the state-run and all of the 36 federally run websites are currently experiencing significant problems providing access to the exchanges, and nobody seems willing or able to predict when they will be fixed. This failure to launch President Barack Obama’s signature domestic achievement is hugely embarrassing for the administration, and will undoubtedly provide a great deal of fodder for late-night comedians. It will also provide an almost unlimited source of talking points for tea partiers and other government-haters, who will cite this unfolding fiasco as more evidence that “government can’t get anything right.”
That would be incorrect.
In 1965 and the years following, I witnessed the implementation of Medicare, which enrolled 19 million beneficiaries almost seamlessly in less than a year, despite the formidable opposition of Southern hospitals wary of its requirements that they desegregate their wards. As I wrote last month, the problem with the ACA is not that the federal government is involved, but that literally thousands of private insurers have their fingers in the cookie jar, resulting in a law that is much too complicated for what it needs to accomplish, and too complex for anybody to administer efficiently and effectively.
Together, Medicare and Social Security — both run by the federal government — have been successfully providing access to private health care and income security for millions of seniors and the disabled for almost 50 years. They have been a major factor in keeping seniors in our country out of poverty.
Both programs are overwhelmingly popular with doctors, patients, the general public and most politicians. Medicare is also much more successful than private, for-profit insurance in holding down the prices paid for medical services and products and overhead costs — 6 percent compared with 20 percent or more. But Medicare is still not doing nearly enough to control costs.
It is estimated that there is at least $750 billion worth of waste in the U.S. health care system.
Politics is the only credible reason for retaining the complex and confusing web of private insurance plans in a health care system that aspires to cover everybody. In order to gain congressional approval, the ACA had to first accommodate the interests of the corporate medical-industrial complex, putting the interests of the American people in a distant second place. Congress’ approval rating now hovers around five percent.
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Shutdown over, Congress turns to Obamacare “train wreck”
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| With the shutdown over and a default averted, Washington has another train wreck to sift through: the Obamacare rollout. Republican critics have plenty to investigate, starting with the $400 million website that doesn’t work and the federal contractor that built it, while asking a more fundamental question: Will it be fixed in time for people to get health coverage early next year. The Obama administration hasn’t answered many questions but Democrats are anxious, worried that it may take weeks, if not months to fix the bugs — while opponents say “I told you so.” Republicans got so caught up with the shutdown — triggered by their effort to stop Obamacare — that they barely focused on the messy rollout. Now they’re set to have a field day with hearings. (PHOTOS: 25 unforgettable Obamacare quotes) Here’s a look at the four key questions as a new blame game unfolds on Obamacare: The “glitches” That’s the polite term the administration has adopted for the website woes that have made Healthcare.gov essentially unusable for most Americans. While some people have gotten all the way through and enrolled, most have been blocked by blank screens, error messages or account log-ins that won’t work at some point along the way. According to the administration, millions of people have visited the site — but officials won’t say how many have taken the first step of creating an account, or the final step of purchasing a health plan. Republicans will try to ferret out who is to blame as they draw attention to the massive problems. Key GOP leaders, including Rep. Darrell Issa (R-Calif.), chairman of the Government Oversight and Reform Committee, Rep. Fred Upton (R-Mich.), chairman of the Energy and Commerce Committee and Sen. Lamar Alexander (R-Tenn.), ranking member of the HELP Committee have fired off oversight letters to HHS and pledged to investigate. (Also on POLITICO: Web brokers on standby, waiting to sell Obamacare plans) “HealthCare.gov is an unmitigated, $400 million disaster,” said Rep. Phil Gingrey (R-Ga.).” Deadlines have been repeatedly missed. The databases that store sensitive medical and financial information aren’t secure. Those attempting to enroll in health care exchanges have been unable to do so due to technical ‘glitches.’ Worse still, these same individuals will be slapped with a penalty tax for being uninsured. If the federal government is unable to manage this website, how can they possibly manage our country’s health care system?” Also expect finger-pointing and demands for heads to roll. Some Republicans have already called for HHS Secretary Kathleen Sebelius to step down or be fired. But the White House is standing by her. “The secretary does have the full confidence of the president,” press secretary Jay Carney said Tuesday. http://dyn.politico.com/printstory.cfm?uuid=741068BD-2B39-4AD3-A1D0-CF31C9BADD16 |
latimes.com
Op-Ed
A healthcare history lesson for the GOP
Democrats have already compromised by abandoning the goal of a single-payer system. It's the Republicans' turn to play fair.
By Jane Mansbridge
October 15, 2013
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Two different narratives have been at play in Washington lately to explain what caused the government shutdown. In the first, House Republicans are to blame for trying to hold Democrats and the president hostage over a law that was duly passed by Congress. In the other, Democrats are to blame for their rigid refusal to compromise on Obamacare.
But there's a part of the story that seemingly has been lost in history: Democrats have already compromised on healthcare reform by adopting Obama/RomneyCare in the first place.
Fundamentally — and infuriatingly for the Democratic base — Obamacare is inherently a compromise because it is a health insurance reform law rather than an overhaul of the structure of our nation's healthcare system. A significant contingent of Democratic voters and activists has always supported a single-payer healthcare system, in which the government, not private insurance companies, covers healthcare costs for all Americans (think Medicare for all).
This would have been a fundamental transition from our current system, in which most people receive healthcare insurance through their employers (which causes big problems for those who lose their jobs or don't qualify for employer-sponsored healthcare). It is also the approach taken by most other modern democracies around the world, including Canada and much of Western Europe, which have both lower mortality rates and lower costs. Instead of having a huge variety of individual companies, with each collecting a middleman's fee, a single-payer system reaps huge benefits in simplicity and quality control.
Yet the single-payer system had already been compromised away when the final 2009-10 healthcare negotiations began. The deep opposition of some Americans to expanding government presented an insurmountable obstacle to adopting this rational, efficient and humane approach to insuring the health of the people of the nation. Recognizing this political reality, many Democrats compromised, even those who considered the single-payer approach to be by far the best policy.
Instead of pushing for single payer, they rallied around another approach: the "public option." The public option would have preserved the current employer-based system of private health insurance coverage while providing a government-run healthcare insurance alternative as well as a safety net for the uninsured. Importantly, it would have also injected much-needed competition into an environment where private insurance plans are increasingly consolidated.
Still, this compromise of abandoning a single-payer system for a public option was not enough for Republicans and some conservative Democrats. Even though a public option was included in both the House and Senate versions of healthcare reform, politics prevailed and yet another huge concession was made. Instead of a single-payer system or even a public option for those who chose it, Democrats went along with the Obama compromise of adopting RomneyCare, the old Republican plan signed into law by Mitt Romney when he was governor of Massachusetts.
This plan builds on the existing system of insurers and insurance plans and was explicitly designed to mimic previous Republican plans in order to assure passage in Congress. Notably, it includes the "individual mandate," which 19 Republicans first proposed in 1993 as a legislative alternative to President Clinton's healthcare reform bill. Today, Republicans attack the individual mandate as unconstitutional.
For many Democrats, these compromises have been hard to swallow. Frustration still lingers among liberals over the abandonment of the single-payer system. In surveys on healthcare, 11% of Americans oppose the administration's health plan because it does not go far enough. Among Democratic activists, that percentage is far higher.
The Democratic base has reason on its side in favoring a single-payer system. But in politics, reason is often not enough. When others feel strongly on the other side, the best thing for the nation is often compromise. Hence, the Democratic Party reluctantly adopted RomneyCare, a.k.a. Obamacare, to get Republican approval.
Despite all these compromises and concessions, House Republicans still forced a government shutdown. Having coerced the Democrats into adopting a Republican health insurance reform plan, they then accused the administration of refusing to compromise. What kind of shell game is this?
The Democrats have compromised over and over again. Now it's the Republicans' turn to play fair.
Jane Mansbridge is a professor at Harvard University's Kennedy School and a member of the Scholars Strategy Network.
http://www.latimes.com/opinion/commentary/la-oe-mansbridge-obamacare-democrats-single-payer-20131015,0,2882836,print.story
Report: 25,000 Mainers fall into Obamacare coverage gap
Posted Oct. 16, 2013, at 2:59 p.m.
About 25,000 poor and uninsured Mainers will miss out on health insurance under the Affordable Care Act because the state refused to expand Medicaid, according to a national study released Wednesday by the Kaiser Family Foundation.
Those individuals fall into the “coverage gap,” a health reform law no-man’s land encompassing nearly 5.2 million Americans who live in many Republican-led states, including Maine, that don’t plan to expand Medicaid to cover more low-income residents. Adults who fall into the gap earn too much to qualify for existing Medicaid programs but too little to qualify for federal financial help to buy private health insurance in the new marketplaces set up under the law.
The architects of the law intended for the Medicaid expansion to cover more low-income Americans, while federal subsidies available through the marketplaces would make coverage more affordable for those with higher incomes. But a June 2012 Supreme Court ruling made the expansion of Medicaid optional for states. Maine, along with 26 other states, opted out.
That left a big and unexpected loophole.
The ACA, or “Obamacare,” would have set a national eligibility level for Medicaid of 138 percent of the federal poverty level, or $15,856 for an individual and $26,951 for a family of three. Tax credits are available through the marketplaces to those earning from 100 percent to 400 percent of the poverty level — or $11,490-$45,960 for an individual, and $19,530-$78,120 for a family of three.
Health advocates are now attempting to explain to many low-income individuals that they’re, counterintuitively, too poor to get subsidies.
In Maine, 24,390 people fall into the coverage gap, and many are likely to remain without health insurance, according to the Kaiser analysis.
John, a 60-year-old man who lives in the Rangeley area, said he’s one of them.
“I feel left out, like I’ve been thrown under the bus,” he said.
John has an intestinal condition called ulcerative colitis that interferes with his ability to work, but he’s not on disability. He survives on his savings and income from a small rental property, he said. He has relied on the state’s Dirigo Health insurance program in the past, but Dirigo will phase out at the end of the year.
He can’t understand why Gov. Paul LePage has resisted the expansion and refused federal money to fund it.
Under the ACA, the federal government has pledged to cover states’ Medicaid expansion costs completely for the first three years and then scale down funding to 90 percent over the course of several years.
“I think it should have been accepted, there’s money there that’s already [assigned] to the state of Maine for this,” said John, who asked that only his first name be used out of fear of political reprisal. “It’s crazy to dismiss it and throw it away. I don’t know what the point is.”
‘Obamacare is a bit like the astronaut on top of the rocket’
By Ezra Klein,
Robert Laszewski is president of Health Policy and Strategy Associates, a policy and marketplace consulting firm that has him working closely with many in the heath industry as they try to navigate the Affordable Care Act, as well as the author of the excellent Health Care Policy and Marketplace Review blog. As such, he has a unique view on how the rollout looks from the industry side. We spoke on Monday. A lightly edited transcript of our conversation follows.
Ezra Klein: You wrote about how the problems on the back-end of the insurance portals, in the way they communicate with the systems of actual insurers, might be as bad or worse than the front-end traffic problems. What are you worried about, exactly?
Bob Laszewski: What I’m worried about is that when people go to their doctor in January they may walk in, and the doctor and hospital won’t find them in the insurer’s computer system or their bank account won’t be appropriately debited or they’ll be signed up for the wrong plan. I’m worried about all these things. Now, we have a few weeks to get this straightened out. But only a few weeks.
EK: Tell me what you’re hearing from the insurance industry that has you concerned.
BL: The insurance industry is literally receiving a handful of new enrollments from the 36 Obama administration-run exchanges. It’s really 20 or 30 or 40 each day through last week. And a good share of those enrollments are problematic. One insurance company told me, “we got an enrollment from John Doe. Then five minutes later we got a message from CMS disenrolling him. Then we got another message re-enrolling him.” On and on, up to 10 times. So insurers aren’t really sure if the enrollments they’ve got are enrollments they should have.
And remember, the insurers have automated all this. They don’t have a clerk sending out a welcome letter and an enrollment card. So if you just let the computer run, it could theoretically issue a welcome letter, a cancellation letter, a welcome letter, a cancellation letter, etc. Now, they’re not doing this right now because it’s all screwed up. They can manage a few dozen per day by hand. But when you’re talking about thousands or tens of thousands or hundreds of thousands, it becomes completely unmanageable.
EK: What do you think went wrong in the design of the federal insurance marketplace. The Obama administration put a lot of focus on this. They knew how important it was. But what they built has, thus far, performed disastrously.
BL: I think they trusted their subcontractors. There’s an astronaut joke that an astronaut is a guy sitting on top of a rocket assembled by the lowest bidders. Obamacare is a bit like the astronaut on top of the rocket. As I understand it, some of these were no-bid contracts, like CGI.
So I think some of the problem is the Obama administration never brought in heavyweight IT people to oversee this. Are there no Democrats in Silicon Valley? Kathleen Sebelius was the governor of Kansas. Mary Tavenner is a nurse and health policy person. Their senior people had no information technology background. And they’re listening to the consultants! There’s an old joke in the insurance industry that you don’t get very far if you bet your career on promises the IT department is making. And these people didn’t just bet their career on it. They bet Obama’s signature project on it!
Something to compare with is they really brought in the A-team from the campaign to promote Obamacare. They have a heck of a team to go out and communicate it when it’s up and running. It’s the best people. But there were no heavyweights brought in to manage the IT.
This project is one of the single biggest IT projects in American history. When Amazon.com and Facebook started they came up as a small company and came up slowly. This had to become prime time on day one. And this business about building it for 50,000 people? You have 50 million people uninsured and 19 million in the individual market and a few hundred million who aren’t eligible for Obamacare but have been hearing about it for years! Did they not think a few of those would go take a look? I think it gets back to oversight. It was a lack of oversight on the part of the Obama administration. They needed to bring in the same kind of heavyweights in IT that the Obama administration brought in to sell this from the campaign.
EK: You said a few minutes ago that they really only have a few weeks to fix this before they run into serious problems for the law. Is anything you’re hearing from the insurance side convincing you that the system is improving that quickly?
Search Tools Wanting on Many Exchanges
By ABBY GOODNOUGH
SHELBYVILLE, Ky. — As he was trying to sign up for health insurance through Kentucky’s new online exchange this month, Kenny Wheeler hit a wall.
Mr. Wheeler, an independent sales representative with a neuromuscular disorder, had succeeded where many in other states had failed, getting through a thicket of log-in pages. But when he tried to find out whether two health plans he liked would pay for his medications or let him keep his current doctors, he could not.
He called one doctor on the spot, but the receptionist could not tell him whether the practice was in the new plan networks. Nor could Mr. Wheeler, 61, get quick answers from the insurers themselves. Exasperated, he put off completing his application.
Since the new health insurance exchanges opened for business on Oct. 1, millions of people who have visited the online sites have been unable to enroll because of technical problems and software glitches. But many people who are getting through the log-in process are encountering a different set of problems when they try to determine whether policies sold through the exchanges will provide the doctors, hospitals or drugs they need.
Most of the 15 exchanges run by states and the District of Columbia do not have provider directories or search tools on their Web sites — at least not yet — so customers cannot easily check which doctors and hospitals are included in a particular plan’s network. Most allow customers to search for providers by linking to the insurers’ Web sites, but the information is not always accurate or easy to navigate, health care experts say.
At this stage, even many doctors are uncertain about whether they are contracted with exchange plans from state to state because the plans — and even some of the insurers — are so new.
“I’ve had to do all this legwork on my own,” Mr. Wheeler said.
Ellen Boyd, 62, of Torrington, Conn., said she had tried to check whether her doctors were in a plan offered on her state’s exchange by clicking a link that took her to the insurer’s Web site. But it appeared that she had to go ahead and buy a plan before being able to check which providers were in its network, she said.
“I thought I would be able to go to the Web site and pop in a name and get a yes or no answer,” said Ms. Boyd, who has osteoporosis and ulcerative colitis and wants to stick with her current doctors. “It makes your hair hurt, I’ll tell you.”
Are Republican factions facing irreconcilable differences?
Despite talk of unity, the GOP's rift seems only to have widened in response to conservatives' anti-Obamacare strategy, which involved a government shutdown and a refusal to raise the debt ceiling.
By Michael A. Memoli and Brian Bennett
7:04 PM PDT, October 16, 2013
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WASHINGTON — In a closed-door meeting on Wednesday, House Majority Leader Eric Cantor (R-Va.) listed the beliefs he said united Republicans, urging them not to "confuse tactics with principles."
"The differences between us are dwarfed by the differences we have with the Democratic Party," he declared.
But in the Capitol's halls, as bruised and defeated Republicans discussed what had befallen them, those internal divisions seemed only to widen.
"It's pretty hard when we have a circle of 20 people who stand up every day and say, 'Can we surrender today, Mr. Speaker?'" said Rep. Tim Huelskamp (R-Kan.), referring to moderate Republicans in the House.
Rep. Charlie Dent (R-Pa.), one of those centrists, countered that he was merely a "truth teller."
"Some people have a hard time when others state the obvious," he said, noting that Republicans cannot enact major legislation without support from Democrats, who control the Senate. "We might as well accept that reality and deal with it."
The 16-day government shutdown drew to a close Wednesday night as the House prepared to approve a Senate-passed budget compromise. But even as Congress was ending the shutdown and averting the prospect of the government defaulting on its debts, the volume of political recriminations was growing.
Republicans had initiated the confrontation last month hoping to block or delay President Obama's healthcare law. Having failed in that effort and with their internal divisions vividly exposed, they spent Wednesday in a furious round of finger-pointing in both chambers.
"Everybody is frustrated. We got to put Humpty Dumpty back together again," said Rep. Fred Upton (R-Mich.).
House Speaker John A. Boehner (R-Ohio), who has been unable to unite his troops, did not appear in danger of losing his post, in part because no challenger has stepped forward to try to take the job.
But relations between the party's moderates and tea party conservatives are raw. Both sides — but particularly tea party conservatives and advocacy groups — have threatened to try to stage primary challenges to unseat incumbents.
http://www.latimes.com/nation/la-na-gop-divisions-20131017,0,5685681,print.story
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