I didn’t find much value added by James Antle’s post at The National Interest on how Jonathan Gruber may continue to influence the PPACA. Except this very succinct characterization of the PPACA:
Obamacare is largely a Medicaid expansion plus churn between old health-insurance plans and new Obamacare-compliant ones, so far achieving modest gains in coverage at the cost of higher premiums and reduced access for many.
It’s hard to imagine the stupid American voter would be enamored of this, if smart people like Jonathan Gruber had deigned to explain it to them at the time.
That’s something that Mickey Kaus has been complaining about since 2009. It’s hard for the popularity of the PPACA to increase because most Americans don’t benefit by it or see themselves as ever being benefited by it. Sure, it’s popular among those receiving subsidies. Free beer is always popular. But the number of Americans receiving subsidies under the PPACA is actually pretty small.
I also suspect that the popularity of the PPACA will actually dwindle as the reality of its operation becomes clearer. At this point all indications point to a different sort of “death spiral” than has been predicted taking hold with consumers trying to control their premium payments by re-enrolling in plans with lower premiums but higher out-of-pocket expenses.
My concern about this is more related to the run-on economic effects. Money spent on healthcare insurance premiums can’t be spent on food, rent, clothing, or automobiles.
It will remain popular among those who are sick and were unable to obtain insurance before it existed. I think it will be interesting to see if its other second order effects, i.e. people who can now get health care are able to work, outweigh your concerns. However, either way I can’t lose, in the short run. If the ACA is repealed we can stop worrying about cutting costs.
Steve
True, some people who were without health insurance now have an insurance card. Supposedly, though, 35% of those not having HC are even interested in applying for it through the PPACA. Even having an insurance card, however, does not guarantee you the quality, range of options, or expediency of health services you may want Furthermore, most people enrolled in the exchanges are subsidized by the government. Others have eased into HC through medicaid expansion. And then there are those left out of the savings loop, by having higher premiums and deductibles, making them wonder why they even bother with health insurance, when they get so little satisfaction back from it.
I am also not convinced that the current slight decreases recently noted in HC costs are due to the fair or prudent way this bill was written. Rather, I think the recession and fiscal difficulties have discouraged many from seeking health care. And, with the high deductibles, self-pays via concierge medical services growing, out-of-pocket payment is more frequently used than before. As stated before, the physicians I’ve used this past year do not accept any insurance anymore. Such a trend of physicians refusing to cooperate with government or any insurance payments, IMO, is only going to increase, along with a greater patient backlog for those who are involved in Obamacare exchanges. In fact This Fall, The Physicians Foundation released it’s 2014 Survey of American Physicians, with an assessment of Obamacare as follows:
Then you have what will be the final impact of this HC law yet to be felt by the people — the delayed employer mandates, the higher reassessed premium rates in many states (not all), greater penalties for those not applying for health insurance — all deliberately postponed until the law could first distribute it’s popular goodies to people before the hammer came down on the realities yet to be manifested by many because of this bill.
[Shrug] These social insurance things take a generation or more to shake down. Social Security itself, and Medicare, were pretty paltry things when they were young, far from the mainstay of existence they have since become for elderly Americans.
As for the blight of socialism that weakens our moral fiber and destroyed our willingness to work and endure and all that … I find myself contemplating all those pretty pictures economists draw showing that working and middle class wages have stayed pretty flat for the past thirty years, even while the country as a whole continues to prosper. When I was a wee little kid, back in Truman and Eisenhower days, the books all said that people got richer proportionately as the economy grew, because That Was How Capitalism Worked. And now they don’t, because it isn’t true anymore. Instead, our political and business leaders have shifted us to a society in which many many ordinary people with ordinary jobs simply cannot make a satisfactory living without some kind of government assistence — EITC, Food Stamps, SS Disability, etc. No one thinks this is wonderful, but it’s what we’ve got and it’s not going to improve until conservatives get past pretending that some mighty act of will can restore the golden age of the 1920’s. Really rebuilding American society is going to take an effort on the scale of World War II. I don’t see that happening soon. [/shrug]
I’m not sure the comparison between the PPACA and Social Security, in particular, are very close. Social Security had bipartisan support, was never actually unpopular, and Franklin Roosevelt was elected to the presidency four times. Most people imagine that they’ll get old. Relatively few imagine that they’ll become poor, that they’ll be sick, or that they’ll be unable to get healthcare insurance.
“The survey’s top-line finding: Of the 20,000 doctors surveyed, almost 50 percent stated that Obamacare deserves either a “D†or an “F.†Only a quarter of physicians graded it as either an “A†or a “B.—
I can address that. Most docs have no idea what is in Obamacare. They have never read any of it. However, they do have a general sense of who it aims to reduce costs. Of the several ways you can costs in medicine, there are two that are very common. One is to put the provider at risk. In this scenario providers get a set fee of some sort, and then try to reduce spending by not using all of that fee.Think bundled payments as an example. This is largely what Obamacare does. The other common way is to put the patient at risk, i.e. high deductibles or co-pays. This is what is usually meant by letting the market reduce costs. It has long been the preferred approach by conservatives. (This is grossly simplified and plans from both parties often use some of each of these approaches.)
Not surprisingly, most physicians would rather see the patient put at risk. It certainly makes life a little simpler for them. In the long run, I am not sure it matters that much, if they are mostly worried about income. Both methods will cut income, if they work.
And, to come clean, if Obamacare goes away and we go back to the way we have been doing things, several of my projects go down the drain. Once we go back to a revenue centered model we will again be focused on doing as much work as possible rather than controlling costs while emphasizing quality.
Steve
Just to remind people of my views, I think that the prospects for this being an effective way of reducing total healthcare costs at least while maintaining decent standards of public health have been greatly exaggerated. There have been studies that have shown what I think is pretty obvious: that people will economize on their own healthcare spending when they have incentives to do so. To the best of my knowledge no one has ever produced a study that has suggested that people generally economize on unnecessary healthcare while continuing to spend on necessary healthcare.
However, steve, what is your evidence that the PPACA largely puts providers at risk? I think that it does both and over time the greater part of any savings is likely to fall on patients rather than providers. That’s what changing from Gold to Silver to Bronze Plans (or even, putatively, creating a Copper Plan) does and that is widely predicted to occur during the present open enrollment.
Looks like we’ll be needing Obamafood and Obamahomes so that we can afford other necessities of life that Obamacare precludes our buying. Maybe Obamasex, too, for the disadvantaged.
“To the best of my knowledge no one has ever produced a study that has suggested that people generally economize on unnecessary healthcare while continuing to spend on necessary healthcare.”
Correct. Such studies as exist suggest they are more likely to eliminate necessary care resulting in higher spending in the long run.
“However, steve, what is your evidence that the PPACA largely puts providers at risk? ”
Well first, I will concede that with all of the changes going on, some of what CMS is doing gets lumped in with Obamacare when it is a separate program. For purposes of this discussion, it is sort of irrelevant since docs conflate the two together. That said, Bundled payments are becoming more and more common for Medicare patients. At present, I think we have about 50 different procedures/diagnoses where payment is bundled. They have cut payments for medicare Advantage plans. The push for ACOs is an ACA program and those are set up to put providers at risk. All of these things are dictated by the ACA.
On the patient side, the ACA does not directly dictate that people HAVE to sign up for high deductible plans. It sets up exchanges and lets the insurance companies compete. However, knowing that the way insurance companies will lower costs and compete is by adjusting deductibles (and networks) they did have the foresight to require insurance companies to compete with similar plans in terms of out of pocket costs.
I suppose you can argue about whether there is actually more provider risk or patient risk in terms of total dollars at risk (I don’t know), but my point is that from the POV of providers, it looks as though they are bearing more of the risk.
Steve
The healthcare industry is nothing more than hustlers and scammers. They intentionally mix emergency room and routine doctor decisions. It should be very easy to price shop for an X-ray, MRI, bloodwork, etc. for a routine doctor visit. There is no life threatening condition.
All the studies that prove the world will come to an end have been done by whom? Disinterested parties or hustlers and scammers?
When my wife got health insurance, the doctor ordered $3,000 worth of bloodwork, and he did not even flinch when he did it. If the insurance had not paid for it, I would have questioned every penny, but then, he would have never taken her.
There is no way to justify $3,000 for doing bloodwork. If it was not covered by insurance, it would be substantially less, and he would have only ordered the tests absolutely necessary.
If healthcare is so vital, it should be nationalized. The medical personnel should be drafted into a Medical Corps. They should be paid the same as the military, and they should be required to live in medical base housing. We would see how fast they change their tune.
…”but my point is that from the POV of providers, it looks as though they are bearing more of the risk.”
Here is where I agree with Steve. After all, HC providers are the ones participating in fiscally unknown territories, based on medical models guidelines set up by the relatively new ACO and MSSP programs, under complex and changing ACA guidelines. Consequently, IMO, they are the ones having the greatest up front risks.
Even though, inherent in most new programs, is the expectation that there will be degrees of uncertainty and fallibility, the fact that government departments select and oversee components of care leaves hospitals, physicians and care providers financially liable and at the mercy of “unexpected” mistakes and flaws created under said government management. For example , who takes the hit if a particular health episode is inaccurately assessed, another health episode overlaps the current one, a patient doesn’t follow a doctor’s protocol, or other unexpected variables and circumstances arise? These interceptions create care outliers, that can skew bundled payment plans, having them veer off standards of care practices and outcomes normally seen in other similar health episodes.
As a side comment: As of late September Healthcare Informatics writes that three more ACO participants have dropped out of the original 32 in the start-up stages — bringing the current number of ACO’s down to 19. Some of the reasons given in exiting the program were noted as being “financially detrimental,” or simply not meeting annual benchmarks established by the group.
“Even though, inherent in most new programs, is the expectation that there will be degrees of uncertainty and fallibility, the fact that government departments select and oversee components of care leaves hospitals, physicians and care providers financially liable and at the mercy of “unexpected†mistakes and flaws created under said government management.”
I hope you don’t actually believe this kind of stuff as this in no way describes the way we practice. You should also realize that if you eliminate risk for providers it limits their incentives to minimize bad outcomes and complications as they will still get paid. Remember that the protocol* for reducing central line complications has a nearly 100% success rate. Yet, most hospitals did not adopt it until it was “required” by CMS. Note that this was not driven by private insurers.
Steve
*This protocol basically requires that you wash your hands, wear a gown and gloves and fully drape the patient. Very minimal costs, maybe $6 per patient, yet was actively resisted as it does take an additional two minutes.
Of course it wasn’t. By and large insurers’ earnings are proportional to premiums and premiums are proportional to reimbursements. It’s in insurers’ interests for costs to rise.
You should also realize that if you eliminate risk for providers it limits their incentives to minimize bad outcomes and complications as they will still get paid.
Steve, I never said anything about a carte blanche elimination of risks for providers. However, health care providers should not be needlessly hamstrung with a labyrinth of rules, regulations, paperwork, and bureaucratic protocols that stress bottom-line numbers more than personalized patient care. Such a cost-analysis emphasis puts a strain on many doctor-patient relationships, discouraging a more hands-on approach, in lieu of their involvement with more time-consuming complexities that go hand-in-hand with the ACA.
Furthermore, there was also no mention of eliminating risk factors dealing with common sense or updated protocols — like what has been stressed by The Nurse’s Association directed at Ebola precautions, nor the ones cited by you regarding reduction of central line complications. Some examples of unforeseen or extended risks in a medical event, that often can’t be predicted, is what I was referencing. These unaccounted for dynamics are what can put damaging holes into those tidy bundled payment plans. For instance, if a physician is too cost-constrained, there is always the possibility that quality of care will yield to keeping diagnostic work-ups, etc. within the perimeters of “normal” care allotted for these conditions. This then will present higher risks to patients with abnormal circumstances. If the doctor, however, chooses to go outside the box of care stipulated via government guidelines, then the risk of insufficient payment may be on him.
Why not entertain tort reform in reducing some frivolous, unnecessary medical costs? Or….experiment with another way to cut insurance costs that will also increase health coverage to those without it, by allowing people to buy health insurance across state lines?
Such ideas have been suggested by more conservative types. However, tort reform, making health insurance more competitive, even expanding HSAs to those who might benefit from them, are derided by the liberal elites who consistently feel that the only viable healthcare reform options are the ones included in the all-encompassing ACA pill.
ObamaCare popularity falls to new low as second enrollment period begins. http://www.politico.com/story/2014/11/poll-obamacare-approval-112948.html. Advocates noted that “the American people are stupid, that’s settled science. ”
Obamacare architect Dr Gruber was unavailable for comment but tweeted ” eff you, I got my cash.”
This William Voegeli piece is a perfect place setting showcasing the current state of political discourse with a “Gruberized” public — Liberal Bulls***.
At the end Voegeli sums up much of the lacy idealism espoused by liberalism in stark realistic terms, much like a black/white photograph can emphasize and outline images and contours, rather than gauzy or distracting colors manage to do.
*very description of the PPACA.
@jan
Conservatives have their own bullshit, but they tend to be polite and use soap. (Did I mention I hate hippies?)
Liberals get away with it because they know how conservatives think, and they think the same way. They want all the same things you want, but they can call you names and slander you because you fear losing those things. They do not really want the crap they spout. They believe that “all animals are equal, but some animals are more equal.” They are more equal.
I would give them national healthcare but not single payer. I would give them a national healthcare system of clinics and hospitals, and there would be no other options. All other medical practices would be outlawed. Let the rich liberals rub shoulders with the poor at the local clinic.
There would be laws passed outlawing medical procedures done outside of the US, and this would just be the start. By the time I was finished, the liberals would be clamoring for free-market capitalism, and they would make you look like a socialist. Hell, you would need to slow them down on their mad dash to laissez-faire capitalism.