Tuesday, December 24, 2013

Obamacare After Obama

In These Times

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A woman navigates HealthCare.gov.

Obamacare After Obama


The Affordable Care Act’s issues will be far from resolved by 2016.

BY Achy Obejas

Whoever settles in at the White House in 2017 will likely need a plan to revise certain aspects of the law that we can already see as problematic.

Just when it looked as if the roll-out of the Affordable Care Act (ACA) couldn’t be any worse, the president himself stepped right in it. By extending the time that people could stay on health plans that don’t comply with the ACA—those that need to be phased out so that the ACA insurance exchanges have a balanced mix of healthy and sick subscribers—Barack Obama perpetuated one more of the law’s problems into the future. And in doing so, he’s guaranteed we’ll still be discussing fundamental issues about the ACA in the 2016 presidential election.

Like most complex laws, the ACA has built-in lags in enacting particular features. When it was signed by the president in 2010, certain things quickly went into effect, including allowing young people to stay on their parents’ insurance until they turned 26 and prohibiting the denial of health insurance to children with preexisting  conditions.

But other aspects of the law, such as the health exchanges and the fine for not purchasing insurance, were delayed until this year and next. What this means, though, is that each new phase provides a new opportunity to criticize and adjust the law.

In the disastrous first two months of the healthcare website, only about 16 percent of the administration’s target 800,000 sign-ups found their way through the HealthCare.gov maze. Add to this Obama’s new suggested “fix”—delaying the phase-out of noncompliant private individual health plans, thus compelling fewer people into the exchanges—and the timeline to get the exchanges working as designed gets pushed into 2015, right as the presidential campaign heats up. Obama’s proposed fix is particularly messy because it requires state-by-state approval from both the state’s insurance regulator and the insurance companies that have already canceled thousands of these plans. Chaos is inevitable.

Not surprisingly, polls suggest that support for the ACA has dropped. According to a November 2013 CBS poll, 43 percent of Americans want to repeal the law.

Thankfully, even the GOP’s Tea Party, anti-Obamacare potential 2016 candidates—Sens. Rand Paul, Ted Cruz and Marco Rubio—will have a hard time leading that charge. More than half of states have embraced the ACA’s Medicaid expansion for low-income people, including New Jersey, where Gov. Chris Christie—another likely GOP presidential aspirant—signed on. That means that Paul, Cruz and Rubio can go nuclear on the ACA during the GOP primaries, but anyone supporting Christie is going to hold their fire. And if Christie wins the GOP nomination, the ACA war is over—not because he loves it, but because he’s smart enough to accept it.

Eight GOP governors, including Terry Brandstad of Iowa—an early primary state—have signed up for the Medicaid expansion, and three have built their own state exchanges. Assuming a Paul, Rubio or Cruz becomes president, it would be a logistical nightmare for him to get these govs to step back. How do you make people give up their private plans and buy new ones, and then take them away? Roughly 129 million Americans have pre-existing conditions, and their only hope for healthcare is the ACA.

But that won’t make it any easier for potential Democratic presidential contenders like Hillary Clinton, though the ACA is much closer to her health plan than the one Obama campaigned on. The fact is, the ACA roll-out is so plagued that no one but Obama is going to claim ownership.

The White House and Senate Majority leader Harry Reid are refusing to support any legislation—no matter who proposes it—that would alter the law. That is the best way to keep it from getting gutted. But whoever settles in at the White House in 2017 will likely need a plan to revise certain aspects of the law that we can already see as problematic.

None of this should make ACA supporters panic, no matter how loud or hysterical the critique gets. Consider that Social Security, originally passed in 1935, was still being amended as late as the 1970s, when a cost-of-living mechanism was added to the original law. It’s unlikely that we’ll be talking about the ACA for even half that long, but we won’t be anywhere near over it by 2016, or possibly even 2020.

Achy Obejas, a Havana-born member of the In These Times Board of Editors, is the author of Ruins (Akashic 2009, akashicbooks.com) and Aguas & Otros Cuentos (Editorial Letras Cubanas, 2009). A former staff writer for the Chicago Tribune, she is also the translator, into Spanish, of Junot Diaz's Pulitzer Prize-winning This Is How You Lose Her. She is currently the Distinguished Visiting Writer at Mills College, Oakland, Calif.

'Sticker Shock' over Obamacare Bolsters Single-Payer Argument





New reporting by AP underscores systemic problems with healthcare system based on for-profit insurance model

 

 
- Jon Queally, staff writer 
 
 
As the political uproar surrounding the Affordable Care Act has played out over recent months, one single fact remains: the private insurance model—on which the law widely known as Obamacare is based—is more complicated, more expensive, and provides less coverage than a simple, "everybody in/nobody out," single-payer model that almost every other advanced country in the world enjoys.




And even within the debate about whether or not Obamacare is a "step forward" or a "step back" for healthcare delivery in the U.S., what's become increasingly clear—as was predicted by progressive critics of the Obamacare model—is that though portions of the law undoubtedly improve the kinds of coverage that some people receive, others are still excluded from the system entirely and among those who are now purchasing insurance for the first time in their lives many will face "sticker shock" at the high premiums or out-sized deductibles.

As new reporting by the Associated Press highlights:
As a key enrollment deadline hits Monday, many people without health insurance have been sizing up policies on the new government health care marketplace and making what seems like a logical choice: They're picking the cheapest one.
Increasingly, experts in health insurance are becoming concerned that many of these first-time buyers will be in for a shock when they get medical care next year and discover they're on the hook for most of the initial cost.
The prospect of sticker shock after Jan. 1, when those who sign up for policies now can begin getting coverage, is seen as a looming problem for a new national system that has been plagued by trouble since the new marketplaces went online in the states in October.
What the AP goes on to describe is how the economic hardships that most middle- and low-income Americans experience on a daily basis compel them to choose insurance policies with the lowest monthly premium, but don't realize that the huge deductibles attached to those plans mean that they may have huge medical bills to pay before their coverage kicks in.

In addition, because the state-level exchanges from which participants in Obamacare must purchase their plans are so complicated, many consumers—especially those with little experience navigating the private insurance marketplace—won't possess the technical or financial savvy to calculate the best plan for themselves or their family.

"I am so deeply clueless about all of this," said 29-year-old Adrienne Matzen, an actor in Chicago, told the AP. She's been  mostly without insurance since she turned 21, but must now figure out how to receive coverage she can afford while living with two chronic illnesses and earning less than $20,000 a year.

Someone like Matzen—who ultimately may or may not be individually better off under the ACA—exemplifies why the overall system is still so far from the ideal that progressive critics of Obamacare say is possible.  The choices available to her  depend on the state she lives in, her ability to navigate the choices, and a host of other complex factors.

As the AP reports: "The complexities of insurance are eye-glazing even for those who have it. Only 14 percent of American adults with insurance understand deductibles, according to one recent study."

On the other hand, a single-payer or Medicare-For-All approach, according to its proponents, would cut out both the complexity and an enormous part of the expense that has historically plagued private insurance industry and will remain under Obamacare.

This summer, Gerald Friedman, a professor of economics at the UMass Amherst, released a study showing that a single-payer system like the one described in Rep. John Conyers' HR 676 could save as much as $592 billion a year in U.S. healthcare costs.

According to his fiscal assessment, those savings would be more than enough to cover all 44 million people the government estimates will be uninsured in the coming year while also improving the existing coverage for everyone else. “Paradoxically, by expanding Medicare to everyone we’d end up saving billions of dollars annually,” Friedman said of his findings. “We’d be safeguarding Medicare’s fiscal integrity while enhancing the nation’s health for the long term.”

And as Dr. Steffie Woolhandler, a spokeswoman for Physicians for a National Health Program, recently explained on Democracy Now!:
[Single payer/Medicare for all] means you would get a card the day you’re born, and you’d keep it your entire life. It would entitle you to medical care, all needed medical care, without co-payments, without deductibles. And because it’s such a simple system, like Social Security, there would be very low administrative expenses. We would save about $400 billion, which would allow us to afford the system. I mean, I just want to remind you that when Medicare was rolled out in 1966, it was rolled out in six months using index cards. So if you have a simple system, you do not have to have all this expense and all this complexity and work.
______________________________________

Why Are Americans Spending More on Healthcare Than Any Other Nation, While Getting Lower-Quality Care?


  Books  


 
 

An excerpt from the new book, 'The American Health Care Paradox.'





 
Photo Credit: Shutterstock.com/Ricardo Reitmeyer



 
 
The following is an excerpt from Dr. Elizabeth H. Bradley and Lauren A. Taylor's new book, The American Health Care Paradox: Why Spending More is Getting Us Less (Perseus Books, 2013).

Joe is a twenty-eight-year-old man with type 1 diabetes, living in the United States. He lacks permanent housing and has been staying in a friend’s condemned, boarded-up house. To avoid being seen there, Joe enters through the marshlands behind the house. His shoes are full of holes, but he cannot afford to replace them. Joe’s diet has similarly suffered from his lack of income; he some- times goes several days without fresh food, which negatively af- fects his diabetes. Also, after a lifetime of poor insulin control, he is starting to lose circulation in his feet. Last year, Joe had two toes removed on his right foot to save his life (hospital cost: $7,132). Still, neuropathy continues to cause him decreased sensitivity in and increased risk of trauma to his feet. The doctor he last saw emphasized the importance of keeping his feet dry, getting proper nutrition, and taking his costly insulin as prescribed, all of which Joe is eager to do. Since that appointment, Joe has been diligent in taking his insulin, but dry feet and proper nutrition remain dif- ficult to achieve due to his living conditions and unemployment. His doctor has already raised the issue of having to have more toes removed on his left foot (cost: $14,430), and without immediate changes, Joe will need to have a below-the-knee amputation in the years ahead (cost: $17,347) and will likely need a wheelchair (cost: $1,042). The estimated cost of his medical expenses will top $30,000, paid by a state medical assistance program that is funded by taxpayers. Amid a system marked by the most advanced medical treatment in the world, Joe is dying a slow, painful, and expensive death. A decent pair of shoes costs $50.
We begin with the true story of a young man living in the United States.

While that story may sound like the basis of a Hollywood plot, we encountered similar stories throughout our research on the American health care system. It goes without saying that Joe needs more than a good pair of shoes to improve his health; he also needs accessible shelter and nutritious food. But the cost of these interventions still pale compared with $30,000 in medical treatment he is currently on track to accrue in the coming years. Furthermore, shelter, food, and shoes might enable him to return to work and not suffer a lifetime dependent on a wheelchair. Joe, and many others like him, illustrate how inadequate attention to social services and supports can lead to exorbitant health care expenses. We confront the consequences of this imbalance experienced by people across the income spectrum. Joe’s is one story, which, replicated across the country, begins to unravel the paradox that has perplexed policymakers for decades: How is it that the United States spends more per capita than any other nation on health care, while Americans fare worse in many measures of health?



According to the 2013 Institute of Medicine report Shorter Lives, Poorer Health, Americans have lower life expectancy and higher rates of infant mortality, low birth weight, injuries and homicides, adolescent pregnancy and sexually transmitted diseases, HIV/AIDS, drug-related deaths, obesity, diabetes, heart disease, chronic lung disease, and disability than people in other industrialized countries. Furthermore, racial and economic disparities fail to explain this national health disadvantage in the United States. Americans who are white, insured, college educated, and upper income have poorer health than do their counterparts in other industrialized countries. Although the Institute of Medicine report was circulated as news, the “spend more, get less” paradox it documented has been recognized for decades. As early as 1971, Nathan Glazer, a sociologist at Harvard University who worked on President Lyndon Johnson’s Model Cities Program, used the term paradoxto describe American health care. In his article published in The Public Interest, Glazer pointed out that while the American population increased 17 percent between 1955 and 1965, medical personnel increased 63 percent with no improvement in general health of the population. More recently, Dartmouth economist Jonathan Skinner used the term to demonstrate that between 1986 and 2005, the geographic regions with the largest increases in Medicare spending were not the ones with the largest survival gains.

Researchers, policymakers, and practitioners have offered a number of rationales for this paradox mostly related to the design and financing of the health care system. Pundits of various political views have laid blame on greedy insurance companies, inefficient and wasteful hospitals and government programs, and skyrocketing costs of pharmaceutical drugs. These assertions can be supported with data but do not fully explain why spending more on health care is getting Americans less health.

We propose a different explanation, based on compelling data gathered over years of research. Inadequate attention to and investment in services that address the broader determinants of health is the unnamed culprit behind why the United States spends so much on health care but continues to lag behind in health outcomes.

The idea that Americans spend more and get less when it comes to health care is frustrating to a populace long steeped in the virtues and benefits of capitalism. The American spirit resists the thought that the nation may not be getting value for money. The situation is upsetting not only because it connotes waste in the system, but because it provides evidence of the United States’ falling behind its peer, industrialized countries—spending more but not being any healthier for it. The United States ranks top out of thirty-four nations in national spending on health care as a percentage of GDP. Data from countries in the Organisation for Economic Co-operation and Development (OECD) from 2009 puts US health care spending at $7,960 per person, while most others spend less than $4,000 per capita (see Figure 1.1) and rank above the United States in multiple measures of health.



[Source: OECD, Health at a Glance 2011 (Paris, France: OECD Publishing, 2011).]


Most of the health care spending finances hospitals, physicians, and clinics. According to 2010 data from the Centers for Medicare & Medicaid Services, it is allocated as follows: approximately 31 percent is for hospital care; 20 percent, for physician and clinic services; 10 percent, for prescription drugs; 7 percent, for dental and other professionals; 7 percent, for government administration; 6 percent is for investment (structures, equipment, and noncommercial research); 6 percent is for nursing home and other long-term care; and 14 percent is for other medical costs including home health care (3 percent), government public health activities (3 percent), other medical products (3 percent), and other health, residential, and personal care (5 percent).
This piece was published with permission from Perseus Books.

 
Dr. Elizabeth Bradley is professor of public health at Yale, faculty director of its Global Health Leadership Institute, and master at Branford College. She was previously director of the health management program and co-director of the Robert Wood Johnson Clinical Scholars Program at Yale and served as hospital administrator at Massachusetts General Hospital. She lives in New Haven, Connecticut.

Lauren Taylor studies public health and medical ethics at Harvard Divinity School, where she is a Presidential Scholar. She was formerly a program manager at the Yale Global Health Leadership Institute. She now lives in Boston.


Thursday, December 19, 2013

Americans Are Paying for Health Care with More Than Money




Americans now spend close to $3 trillion a year for health care, around 18 percent of our GDP. That works out to almost $9,000 per person in Maine, almost twice as much per person as the average for other wealthy nations that provide health care for all their people.





Not only do we pay more, but we pay in far more ways than any other country. Some are obvious. They include health insurance premiums, “out of pocket” co-pays and deductibles, and payments for health care products and services that are not covered by insurance. Out-of-pocket payments are increasing every year as insurers shift more of the rising costs to their customers and employers to their employees.

We also pay in ways that are not so obvious. We all pay federal, state and local taxes to support programs such as Medicare and Medicaid, health care for federal, state and local employees, military personnel, the Veterans Affairs and many others. Since employment-related health insurance is tax exempt, we also pay around $250 billion a year in the form of lost tax revenues, that is then made up by higher taxes on all of us.

Other ways we pay are almost invisible, but we feel them anyway. Workers no longer bargain for increased wages or better working conditions. In a weak economy, any small gains they have made in total compensation have been more than consumed by increases in health care costs. As a result, real wages are declining.

At a recent national health care conference I attended, there was a panel discussion about the effects health care costs on a small central Maine town. Employee health care costs have risen dramatically over recent years. Benefits for the town’s 11 employees now total $18,000 each for a total of almost $200,000. This has forced severe cutbacks in other services such as road maintenance, public safety, libraries, education, and (ironically) emergency medical services. Diminished public services and a deteriorating quality of life is one more way we pay for our health care.

This should come as no surprise. During the past sixty years or so Americans have generously poured money into our health care system through thousands of channels that are individually difficult and collectively impossible to control.

Since Americans view health care as a business, we’ve allowed our health care system to become populated by thousands of profit seeking companies (some nominally nonprofit), each trying to maximize profits and competing for a larger share of an ever-growing pie. Many of these private businesses are heavily subsidized by tax-supported health care programs and tax breaks. So far, we have been unwilling to put any effective restraints around the growth of this huge pot of gold.

This is not a failure of capitalism or corporations, They are simply doing what they are supposed to do — create wealth for their owners. It’s a massive failure of public policy. It’s the fault of all of us, including our political leaders, for failing to put any meaningful constraints around our health care system to keep it affordable for everybody.

The result has been the creation of a gargantuan medical-industrial complex that has become the pac-man of public and private budgets. It is riddled with inefficiency and waste including unjustifiably high prices and excessive use of lucrative services and products, many of them without demonstrated value or downright harmful,.

The Affordable Care Act begins to make some timid efforts at addressing this problem. Nobody I know thinks they will be sufficient. After seven years of “RomneyCare” (after which the Affordable Care Act was patterned), Massachusetts now has almost everybody insured, but it has the highest health care costs of any state in the country. Some public figures there are beginning to suggest moving toward a statewide single-payer system.

As I’ve written before, the market forces the ACA is trying to harness have not, will not and cannot solve this problem. As most other wealthy countries have done, we need to channel the many existing health care revenue streams together into a single funnel with a publicly managed flow-control valve, and then muster the political will to use it. That is what our neighbors in Vermont are now in the process of trying to do.
As one Canadian conference participant put it, “It breaks my heart to see Americans destroying your schools, libraries and public safety to pay for health care.”

It breaks my heart, too. We can do a lot better.
Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all, and a member of Physicians for a National Health Program.

Saturday, December 7, 2013

Universal healthcare is the patriotic thing to do


SALON



Colin Meloy: Universal healthcare is the patriotic thing to do

The Decembrists' frontman on his first CD, his tribute to the Kinks -- and the Affordable Care Act VIDEO



Topics: The Weekly Feed
Colin Meloy: Universal healthcare is the patriotic thing to do


Tuesday, December 3, 2013

The Real Fix for Obamacare's Flaws: Medicare for All






There's no reason to rollback the progress the ACA has made. But we should go all the way and dump the for-profit system

 

 
 

(Image by National Nurses United, Medicare for All campaign)




Lost amidst the well-chronicled travails of the Affordable Care Act rollout are the long term effects of people struggling to get the health coverage they need without going bankrupt.

If that sounds familiar, it's because that's been the main story line of the US healthcare system for several decades. Sadly, little has changed.

Still, with all the ACA's highly publicized snafus, and less discussed systemic flaws, there's no reason to welcome the cynical efforts to repeal or defund the law by politicians whose only alternative is more of the same callous, existing market-based healthcare system.

US nurses oppose the rollback and appreciate that several million Americans who are now uninsured may finally get coverage, principally through the expansion of Medicaid, or access to private insurance they've been denied because of their prior health status.

At the same time, nurses will never stop campaigning for a fundamental transformation to a more humane single-payer, expanded Medicare for all system not based on ability to pay and obeisance to the policy confines of insurance claims adjustors.

Website delays – the most unwelcome news for computer acolytes since the tech boom crashed – are not the biggest problem with the ACA, as will become increasingly apparent long after the signup headaches are a distant memory.

What prompted the ACA was a rapidly escalating healthcare nightmare, seen in 50 million uninsured, medical bills plunging millions into un-payable debt or bankruptcy, long delays in access to care, and record numbers skipping needed treatment due to cost.

The main culprit was our profit-focused system, with rising profiteering by a massive health care industry, and an increasing number of employers dropping coverage or just dumping more costs onto workers.
The ACA tackles some of the most egregious inequities: lack of access for many of the working poor who will now be eligible for Medicaid or subsidies to offset some of their costs for buying private insurance through the exchanges, a crackdown on several especially notorious insurance abuses, and encouragement of preventive care.

But the law actually further entrenches the insurance-based system through the requirement that uncovered individuals buy private insurance. It's also chock full of loopholes.

Some consumers who have made it through the website labyrinth have found confusing choices among plans which vary widely in both premium and out of pocket costs even with the subsidies, a pass through of public funds to the private insurers.

The minimum benefits are also somewhat illusory. Insurance companies have decades of experience at gaming the system and warehouses full of experts to design ways to limit coverage options.

The ACA allows insurers to cherry pick healthier enrollees by the way benefit packages are designed, and as a Washington Post article noted on 21 November, consumers are discovering insurers are restricting their choice of doctors and excluding many top ranked hospitals from their approved "network".

The wide disparity between the healthcare you need, what your policy will cover, and what the insurer will actually pay for remains.

Far less reported is what registered nurses increasingly see – financial incentives within the ACA for hospitals to prematurely push patients out of hospitals to cheaper, less regulated settings or back to their homes. It also encourages shifting more care delivery from nurses and doctors to robots and other technology that undermines individual patient care, and that may work no better than the dysfunctional ACA websites.

Is there an alternative? Most other developed nations have discovered it, a single-payer or national healthcare system.

Without the imperative of prioritizing profits over care, Medicare for all streamlines the administrative waste and complex insurance billing operations endemic to private insurance. That waste is a major reason why the US has more than double the per capita cost of healthcare of other developed nations, yet lower life expectancies than many.

Medicare for all eliminates the multi-tiered health plans that plague both the individual and group insurance markets that are tied to the girth of your wallet not your need for care. Class, gender, and racial disparities in access and quality of care vanish under Medicare for all.

It's beyond time that we stop vilifying government and perpetuating a corporatized healthcare system that has abandoned so many. We can, with a system of Medicare for all, we can cut healthcare costs and promote a much more humane society.

Rose Ann DeMoro
Rose Ann DeMoro is executive director of the 185,000-member National Nurses United, the nation’s largest union and professional association of nurses, and a national vice president of the AFL-CIO. Follow Rose Ann DeMoro on Twitter: www.twitter.com/NationalNurses

Thursday, November 21, 2013

Healthcare.gov and the Gulf Between Planning and Reality

Healthcare.gov and the Gulf Between Planning and Reality


Back in the mid-1990s, I did a lot of web work for traditional media. That often meant figuring out what the client was already doing on the web, and how it was going, so I’d find the techies in the company, and ask them what they were doing, and how it was going. Then I’d tell management what I’d learned. This always struck me as a waste of my time and their money; I was like an overpaid bike messenger, moving information from one part of the firm to another. I didn’t understand the job I was doing until one meeting at a magazine company.

The thing that made this meeting unusual was that one of their programmers had been invited to attend, so management could explain their web strategy to him. After the executives thanked me for explaining what I’d learned from log files given me by their own employees just days before, the programmer leaned forward and said “You know, we have all that information downstairs, but nobody’s ever asked us for it.”

I remember thinking “Oh, finally!” I figured the executives would be relieved this information was in-house, delighted that their own people were on it, maybe even mad at me for charging an exorbitant markup on local knowledge. Then I saw the look on their faces as they considered the programmer’s offer. The look wasn’t delight, or even relief, but contempt. The situation suddenly came clear: I was getting paid to save management from the distasteful act of listening to their own employees. 

In the early days of print, you had to understand the tech to run the organization. (Ben Franklin, the man who made America a media hothouse, called himself Printer.) But in the 19th century, the printing press became domesticated. Printers were no longer senior figures — they became blue-collar workers. And the executive suite no longer interacted with them much, except during contract negotiations.

This might have been nothing more than a previously hard job becoming easier, Hallelujah. But most print companies took it further. Talking to the people who understood the technology became demeaning, something to be avoided. Information was to move from management to workers, not vice-versa (a pattern that later came to other kinds of media businesses as well.) By the time the web came around and understanding the technology mattered again, many media executives hadn’t just lost the habit of talking with their own technically adept employees, they’d actively suppressed it.

I’d long forgotten about that meeting and those looks of contempt (I stopped building websites before most people started) until the launch of Healthcare.gov.

* * *
 
For the first couple of weeks after the launch, I assumed any difficulties in the Federal insurance market were caused by unexpected early interest, and that once the initial crush ebbed, all would be well. The sinking feeling that all would not be well started with this disillusioning paragraph about what had happened when a staff member at the Centers for Medicare & Medicaid Services, the department responsible for Healthcare.gov, warned about difficulties with the site back in March. In response, his superiors told him…
[...] in effect, that failure was not an option, according to people who have spoken with him. Nor was rolling out the system in stages or on a smaller scale, as companies like Google typically do so that problems can more easily and quietly be fixed. Former government officials say the White House, which was calling the shots, feared that any backtracking would further embolden Republican critics who were trying to repeal the health care law.
The idea that “failure is not an option” is a fantasy version of how non-engineers should motivate engineers. That sentiment was invented by a screenwriter, riffing on an after-the-fact observation about Apollo 13; no one said it at the time. (If you ever say it, wash your mouth out with soap. If anyone ever says it to you, run.) Even NASA’s vaunted moonshot, so often referred to as the best of government innovation, tested with dozens of unmanned missions first, several of which failed outright.

Failure is always an option. Engineers work as hard as they do because they understand the risk of failure. And for anything it might have meant in its screenplay version, here that sentiment means the opposite; the unnamed executives were saying “Addressing the possibility of failure is not an option.”

* * *
 
The management question, when trying anything new, is “When does reality trump planning?” For the officials overseeing Healthcare.gov, the preferred answer was “Never.” Every time there was a chance to create some sort of public experimentation, or even just some clarity about its methods and goals, the imperative was to deny the opposition anything to criticize.

At the time, this probably seemed like a way of avoiding early failures. But the project’s managers weren’t avoiding those failures. They were saving them up. The actual site is worse—far worse—for not having early and aggressive testing. Even accepting the crassest possible political rationale for denying opponents a target, avoiding all public review before launch has given those opponents more to complain about than any amount of ongoing trial and error would have.

In his most recent press conference about the problems with the site, the President ruefully compared his campaigns’ use of technology with Healthcare.gov:
And I think it’s fair to say that we have a pretty good track record of working with folks on technology and IT from our campaign, where, both in 2008 and 2012, we did a pretty darn good job on that. [...] If you’re doing it at the federal government level, you know, you’re going through, you know, 40 pages of specs and this and that and the other and there’s all kinds of law involved. And it makes it more difficult — it’s part of the reason why chronically federal IT programs are over budget, behind schedule.
It’s certainly true that Federal IT is chronically challenged by its own processes. But the problem with Healthcare.gov was not timeline or budget. The problem was that the site did not work, and the administration decided to launch it anyway.

This is not just a hiring problem, or a procurement problem. This is a management problem, and a cultural problem. The preferred method for implementing large technology projects in Washington is to write the plans up front, break them into increasingly detailed specifications, then build what the specifications call for. It’s often called the waterfall method, because on a timeline the project cascades from planning, at the top left of the chart, down to implementation, on the bottom right.

Like all organizational models, waterfall is mainly a theory of collaboration. By putting the most serious planning at the beginning, with subsequent work derived from the plan, the waterfall method amounts to a pledge by all parties not to learn anything while doing the actual work. Instead, waterfall insists that the participants will understand best how things should work before accumulating any real-world experience, and that planners will always know more than workers.

This is a perfect fit for a culture that communicates in the deontic language of legislation. It is also a dreadful way to make new technology. If there is no room for learning by doing, early mistakes will resist correction. If the people with real technical knowledge can’t deliver bad news up the chain, potential failures get embedded rather than uprooted as the work goes on.

At the same press conference, the President also noted the degree to which he had been kept in the dark:
OK. On the website, I was not informed directly that the website would not be working the way it was supposed to. Had I been informed, I wouldn’t be going out saying “Boy, this is going to be great.” You know, I’m accused of a lot of things, but I don’t think I’m stupid enough to go around saying, this is going to be like shopping on Amazon or Travelocity, a week before the website opens, if I thought that it wasn’t going to work.
Healthcare.gov is a half-billion dollar site that was unable to complete even a thousand enrollments a day at launch, and for weeks afterwards. As we now know, programmers, stakeholders, and testers all expressed reservations about Healthcare.gov’s ability to do what it was supposed to do. Yet no one who understood the problems was able to tell the President. Worse, every senior political figure—every one—who could have bridged the gap between knowledgeable employees and the President decided not to.

And so it was that, even on launch day, the President was allowed to make things worse for himself and his signature program by bragging about the already-failing site and inviting people to log in and use something that mostly wouldn’t work. Whatever happens to government procurement or hiring (and we should all hope those things get better) a culture that prefers deluding the boss over delivering bad news isn’t well equipped to try new things.

* * *
 
With a site this complex, things were never going to work perfectly the first day, whatever management thought they were procuring. Yet none of the engineers with a grasp of this particular reality could successfully convince the political appointees to adopt the obvious response: “Since the site won’t work for everyone anyway, let’s decide what tests to run on the initial uses we can support, and use what we learn to improve.”

In this context, testing does not just mean “Checking to see what works and what doesn’t.” Even the Healthcare.gov team did some testing; it was late and desultory, but at least it was there. (The testers recommended delaying launch until the problems were fixed. This did not happen.) Testing means seeing what works and what doesn’t, and acting on that knowledge, even if that means contradicting management’s deeply held assumptions or goals. In well run organizations, information runs from the top down and from the bottom up.

One of the great descriptions of what real testing looks like comes from Valve software, in a piece detailing the making of its game Half-Life. After designing a game that was only sort of good, the team at Valve revamped its process, including constant testing:
This [testing] was also a sure way to settle any design arguments. It became obvious that any personal opinion you had given really didn’t mean anything, at least not until the next test. Just because you were sure something was going to be fun didn’t make it so; the testers could still show up and demonstrate just how wrong you really were.
“Any personal opinion you had given really didn’t mean anything.” So it is in the government; an insistence that something must work is worthless if it actually doesn’t.

An effective test is an exercise in humility; it’s only useful in a culture where desirability is not confused with likelihood. For a test to change things, everyone has to understand that their opinion, and their boss’s opinion, matters less than what actually works and what doesn’t. (An organization that isn’t learning from its users decided it doesn’t want to learn from its users.)

Given examples of technological success from commercial firms, a common response is that the government has special constraints, and thus cannot develop projects piecemeal, test with citizens, or learn from its mistakes in public. I was up at the Kennedy School a month after the launch, talking about technical leadership and Healthcare.gov, when one of the audience members made just this point, proposing that the difficult launch was unavoidable, because the government simply couldn’t have tested bits of the project over time.

That observation illustrates the gulf between planning and reality in political circles. It is hard for policy people to imagine that Healthcare.gov could have had a phased rollout, even while it is having one.

At launch, on October 1, only a tiny fraction of potential users could actually try the service. They generated concrete errors. Those errors were handed to a team whose job was to improve the site, already public but only partially working. The resulting improvements are incremental, and put in place over a period of months. That is a phased rollout, just one conducted in the worst possible way.

The vision of “technology” as something you can buy according to a plan, then have delivered as if it were coming off a truck, flatters and relieves managers who have no idea and no interest in how this stuff works, but it’s also a breeding ground for disaster. The mismatch between technical competence and executive authority is at least as bad in government now as it was in media companies in the 1990s, but with much more at stake.

* * *

Tom Steinberg, in his remembrance of his brilliant colleague Chris Lightfoot, said this about Lightfoot’s view of government and technology:
[W]hat he fundamentally had right was the understanding that you could no longer run a country properly if the elites don’t understand technology in the same way they grasp economics or ideology or propaganda. His analysis and predictions about what would happens if elites couldn’t learn were savage and depressingly accurate.
Now, and from now on, government will interact with its citizens via the internet, in increasingly important ways. This is a non-partisan issue; whichever party is in the White House will build and launch new forms of public service online. Unfortunately for us, the last new technology the government adopted for interacting with citizens was the fax; our senior political figures have little habit of talking to their own technically adept employees.

If I had to design a litmus test for whether our political class grasps the internet, I would look for just one signal: Can anyone with authority over a new project articulate the tradeoff between features, quality, and time?

When a project cannot meet all three goals—a situation Healthcare.gov was clearly in by March—something will give. If you want certain features at a certain level of quality, you’d better be able to move the deadline. If you want overall quality by a certain deadline, you’d better be able to delay or drop features. And if you have a fixed feature list and deadline, quality will suffer.

Intoning “Failure is not an option” will be at best useless, and at worst harmful. There is no “Suddenly Go Faster” button, no way you can throw in money or additional developers as a late-stage accelerant; money is not directly tradable for either quality or speed, and adding more programmers to a late project makes it later. You can slip deadlines, reduce features, or, as a last resort, just launch and see what breaks.

Denying this tradeoff doesn’t prevent it from happening. If no one with authority over the project understands that, the tradeoff is likely to mean sacrificing quality by default. That just happened to this administration’s signature policy goal. It will happen again, as long politicians can be allowed to imagine that if you just plan hard enough, you can ignore reality. It will happen again, as long as department heads imagine that complex technology can be procured like pencils. It will happen again as long as management regards listening to the people who understand the technology as a distasteful act.


The Biggest Problem With Obamacare’s Rollout Is Being Caused Intentionally by Republicans






 

The Biggest Problem With Obamacare’s Rollout Is Being Caused Intentionally by Republicans





The media have been buzzing with stories — many of them wildly exaggerated — of people facing higher premiums as a result of Obamacare. But there’s a story about rates you may not have heard: According to Jonathan Gruber, a leading health care wonk at MIT, all private insurance premiums in the 25 red states that are refusing to expand their Medicaid programs will be 15 percent higher as a direct result of that decision.

But those numbers don’t capture the human cost. The reality is that conservatives are complaining about insurance policies being cancelled and the ACA’s error-plagued exchanges at the same time as they actively work to keep millions of poor Americans from gaining coverage under the law’s Medicaid expansion.

The victims of Obamacare’s implementation problems being hit the hardest, by far, are those whose incomes fall between the federal poverty line and the eligibility cutoffs in those 25 states rejecting Medicaid expansion. Not only will they be left uncovered, they won’t even be eligible for the generous subsidies that people earning slightly more than they do can use to buy insurance. It’s brutally unfair. The Kaiser Family Foundation estimates that 4.8 million poor adults may fall into that coverage gap — about twice the number of people expected to pay more for their insurance when their substandard policies are cancelled.


And it gets worse. In 40 states, adults without children are ineligible for Medicaid regardless of their income level. In 30 states, the parents of children who qualify for Medicaid may not be eligible themselves. All of these people would be covered under Medicaid’s expansion, but they’re being left high and dry in the 25 states who have rejected expansion. And while the problems plaguing healthcare.gov result from mismanagement and a contracting boondoggle, those red state lawmakers who refuse to expand Medicaid are inflicting this harm intentionally, based solely on their ideology.

In other words, they’re actively working to maintain America’s shamefully high rate of uninsured. And that comes with deadly consequences. Because, in this country, we do ‘let ‘em die’ – we let the poor and the uninsured die from treatable illnesses every day.

Last week, the Texas Observer ran a heartbreaking essay by Rachel Pearson, who recalled being a young medical student volunteering at a free clinic in Galveston, Texas. Pearson had a patient – a poor, uninsured patient — who was obviously very sick. But Pearson couldn’t properly diagnose his ailment with the resources available to the clinic. When his pain became severe, she sent him to an emergency room, but the personnel there refused to treat him because his symptoms weren’t an immediate threat to “life or limb.” As time passed, his condition deteriorated until he began having difficulty breathing. It was only then that an emergency room finally admitted him and diagnosed the cancer that had metastasized throughout his body. “It must have been spreading over the weeks that he’d been coming [into the clinic],” she wrote. He died a few months later. “The shame has stuck with me through my medical training — not only from my first patient, but from many more,” wrote Pearson, who now heads the clinic.

A 2009 study published in the American Journal of Public Health linked 45,000 deaths every year to the uninsured, even “after taking into account education, income, and many other factors, including smoking, drinking and obesity.” The lead researcher of the study, Andrew Wilper of the University of Washington School of Medicine, told the Harvard Gazette, “We doctors have many new ways to prevent deaths from hypertension, diabetes and heart disease — but only if patients can get into our offices and afford their medications.”

This is the real-world backdrop for our fierce debates over Obamacare. Yet Republicans’ answer to the uninsured crisis is to claim that having no coverage at all is better than being enrolled in Medicaid. And that’s why conservatives have no legitimate leg to stand on in griping about the program’s flaws, no matter how deep they run. Because when it comes to health care, the American conservative movement has nothing constructive to offer to fix the problem of getting more people health insurance — they can only whistle past the graveyard.

Here’s the sum total of what conservatives propose to fix our health care system. “Tort reform” remains popular; the argument is that malpractice suits drive up insurance premiums and make health care less affordable for the rest of us. But according to a 2009 study by the Congressional Budget Office, the total cost — “malpractice insurance premiums together with settlements, awards and administrative costs not covered by insurance” — makes up just two percent of our health care costs, and Republican proposals to limit payouts would reduce the cost of American health care by just one-fifth of one percent. When the CBO included the indirect effects — doctors performing defensive medicine to ward off lawsuits — they concluded that tort reform would only reduce health care spending by half of one percent. It’s an empty proposal that has more to do with dinging trial lawyers, who tend to support Democratic campaigns, than with improving our health care system.

Allowing insurance companies to sell policies across state lines is another reform proposed reform. Conservatives argue that more competition would lead to lower insurance costs. The problem here is quite simple: The US faces sky-high costs for health care goods and services — we pay more for everything from primary care visits to prescription drugs to surgeries thanpeople in other wealthy countries. Insurance costs reflect health care costs, and interstate insurance sales wouldn’t touch the underlying problem. Rather, it would create a race to the bottom, with insurance companies setting up shop in states with the least consumer protections so they could fleece their customers with impunity. None of this would expand coverage to the uninsured, improve care or bring down costs in any meaningful way.

Today’s conservative movement would only offer assistance to those who are already getting help from the public sector. But ironically, Paul Ryan’s Medicaid proposal would restructure the system so it looks like Obamacare. His plan, passed with an overwhelming majority of Republican votes in the House, would offer seniors vouchers to purchase private insurance on an online exchange. But the value of Ryan’s vouchers would only increase a bit faster than the rate of overall economic growth, which is projected to be far slower than the growth in health care costs. Over time, the vouchers would lose value, and the scheme would simply shift costs onto the backs of seniors.

For the poor, Ryan’s plan would have a similar effect. Rather than the federal government sharing the actual costs of Medicaid as they grow, Ryan would turn the program into a block grant to the states that would increase with inflation and population growth. In real-world terms, this would cut spending on health care for the poor by about a third by 2023, according to analysis by the Center on Budget and Policy Priorities.

There are only two ideas conservatives support that might help the tens of millions of Americans priced out of decent health care. In theory, they support community health centers like the one Rachel Pearson runs in Texas. (Although in practice, Paul Ryan’s budget imposes deep cuts on America’s 8,500 community clinics.) The other is to provide the poor with vouchers to purchase insurance on the private market. The idea has been embraced by some conservative intellectuals, but it hasn’t been offered as a legislative proposal. It has, however, been enacted in Arkansas under the Affordable Care Act and other states are considering following suit.

This is all today’s right has to offer.

Liberals like to point out that the Affordable Care Act was modeled on a conservative, market-friendly approach to reducing the number of uninsured – a plan born at the Heritage Foundation and championed by such conservative luminaries as Newt Gingrich.

But that’s only half true. It was a Republican plan 20 years ago, when conservatives still expressed an interest in governing responsibly. Today’s tea party-dominated movement sees health insurance as something that fosters dependency on the government, and must therefore be limited to those who can afford it themselves or get it from their employers.

Liberals have every reason to be dismayed over the maddeningly problematic launch of the Affordable Care Act’s exchanges because their preferred route to expanding coverage – building on the popular and already functional Medicare system – would have avoided many of the problems plaguing this overly complex, public-private scheme. But conservatives, serving up only red-meat rhetoric about government takeovers and litigation run amok, have nothing real to offer in terms of solutions. As such, in a rational world they should have nothing to say about Obamacare’s rocky rollout.
 
Joshua Holland is a senior digital producer for BillMoyers.com. He’s the author of The Fifteen Biggest Lies About the Economy (and Everything Else the Right Doesn’t Want You to Know about Taxes, Jobs and Corporate America) (Wiley: 2010), and host of Politics and Reality Radio. Follow him on Twitter or drop him an email at hollandj [at] moyersmedia [dot] com.

WATCH: Bernie Sanders Nails Why Republican Attacks on Obamacare Are Just a Distraction


  News & Politics  


WATCH: Bernie Sanders Nails Why Republican Attacks on Obamacare Are Just a Distraction

And he does it in under three minutes.
Senator Bernie Sanders of Vermont went on Chris Hayes' program recently and summed up quite eloquently and concisely how bankrupt the Republican attacks on Obamacare are. "Our Republican friends, who have nothing to say about healthcare, are able to harp on the one thing the president said and show it again and again and claim he lied," Sanders said. But it's all a distraction, from what's reall important, which is the lamentable and inexcusable state of healthcare coverage in this country. Yes, the president could have been more nuanced in explaining to Americans that their junk insurance would get replaced by something better. "But in the long run," Sanders said, "you have to get away from inadequate, junk insurance programs and provide real healthcare."

Watch for yourself:

Wednesday, November 20, 2013

Obama Administration Maps Out Detour Around HealthCare.gov




business



Obama Administration Maps Out Detour Around HealthCare.gov

Posted:   |  Updated: 11/20/2013 11:00 am EST




Tuesday, November 19, 2013

Obamacare Is Either The Product Of Criminals Or A Conspiracy To Destroy The Corrupt American Healthcare System




Obamacare Is Either The Product Of Mentally Retarded Criminals Or A Conspiracy To Destroy The American Healthcare System

October 15, 2013


Source: Lee Rogers, Blacklisted News


The on-going disaster of the Affordable Care Act otherwise known as Obamacare is undoubtedly the most poorly planned implementation of any government program in American history. This law which forces people to buy health insurance or face a fine is one of the dumbest ideas ever conceived but it is the implementation of it that has been even dumber. The implementation has been so horrible that one has to question if this was done intentionally to plunge the entire healthcare system into chaos. This might sound counterintuitive but it really isn’t. The reason for the Obama regime to do something like this is that it would give them the pretext to justify a complete government takeover of America’s healthcare system. This would be presented as the false solution to a problem that they created in the first place. If this wasn’t part of a broader conspiracy, the only other explanation for the piss poor implementation is that the Obama regime put mentally retarded criminals in charge of its drafting, planning and execution.





There are so many facets to this but the Affordable Care Act should really be called the Unaffordable Care Act because it is actually increasing the cost for existing insurance policies. The amount of regulations, taxes and fees the law requires insurance companies to comply with forces them to pass on additional costs to customers. Both individuals and businesses have been severely impacted by this. Since the law has gone into effect it has caused businesses to hire more part time workers and less full time workers. This is because the law only forces businesses to provide health insurance for full time workers but not part time workers. By mandating that businesses shell out more money to provide health insurance for full time workers it discourages them from bringing on more full time help. Many businesses simply can’t afford these additional costs and especially not with Obamacare dramatically increasing the cost of health insurance.

Simply put, any law that forces a business or an individual to buy a product or face consequences is morally wrong. Now that there is a precedent for this type of insanity it is anybody’s best guess as to what they will force people to buy next. What if the government required every individual in America to purchase a battery operated masturbation device in order to subsidize dildo manufacturers? Besides dildo manufacturers and mentally ill perverts, would anybody really be happy about this? It is the same concept with Obamacare as the only people who are happy with this law are insurance providers and mentally ill people. Whether or not they are also perverts could be debated but it would not be surprising if that were indeed the case. The stock prices of health insurance providers have risen substantially as Obamacare has been rolled out. This has undoubtedly made the people running these operations very happy as it is forcibly increasing their customer base.
Perhaps the most ridiculous aspect of the Obamacare implementation is healthcare.gov the web site that is supposed to allow people to sign up for health insurance through the newly mandated exchanges. The site has been completely non-functional since its launch a few weeks ago. A CNN reporter who recently tried to enroll in an insurance plan through healthcare.gov has been unable to do so despite trying continuously for two straight weeks. At an Obamacare enrollment event with Health and Human Services Secretary Kathleen Sebelius present, staff members failed to get one person to enroll properly. In fact, it has been virtually impossible to find anyone who has been able to successfully enroll in an insurance policy through the site. To add insult to injury, check out the Sebelius interview on The Daily Show in which she tries but utterly fails to put a positive spin on the situation. It is painful to watch.

Although an exact cost of the site is unknown, it has been estimated by various news outlets that it has cost the federal government many millions of dollars to build. Digital Trends has estimated the cost to be roughly around $500 million dollars. This is an obscene amount of money for a web site that doesn’t work. Information technology experts who have analyzed the site have been extremely critical of how it was put together. Some have criticized the poor architecture where as others have commented on how the site seems to have been rushed and thrown together. If that weren’t bad enough the site appears to also have a number of major security flaws. Considering the amount of sensitive information the site is supposed to process the security flaws represent a potential gold mine for identity thieves. At this point the only thing preventing hackers from stealing data appears to be the fact that the system is so broke that it even makes hacking it difficult. One would think that somebody would have been smart enough to delay the Obamacare implementation until the site was ready but it should be clear by now that common sense is something that does not exist within the Obama regime.

The on-going debacle with the site alone should have resulted in a number of people getting fired. It is completely ridiculous that Sebelius who is ultimately responsible for the Obamacare roll out still has a job. In fact it doesn’t appear as if Obama has fired anybody over what should be a major embarrassment to his regime. This is supposed to be Obama’s signature achievement as our dear leader and many are viewing it as an abject failure. What makes this even more comical is the fact that Obama recently fired several top military generals over comparatively trivial issues. Obama has continued to express confidence in Sebelius despite everything that has happened which raises a number of questions. This actually gives credence to the possibility that they engineered Obamacare to fail. This would at least explain why Sebelius and others have not been fired because if this were the case she did exactly what she was supposed to do.

It is also possible that healthcare.gov is just designed to collect personal information from people so they can be harassed by the Internal Revenue Service and other draconian government entities at a later date. Admittedly this is speculation but considering how horrible the site launch has gone, it is something that must be considered. The site does appear to at least be successfully collecting data from some people but has been entirely unsuccessful at enrolling people in insurance plans.

Another problem with Obamacare is the fact that it is one of the most complex laws ever written and there is no way that any single human being will ever have a full understanding of it. In fact current U.S. House Minority Leader Nancy Pelosi once famously remarked that they needed to pass the Obamacare bill in order for people to see what’s in it. What sort of insane person would support something that they haven’t read let alone understand? Unfortunately this is the type of mental illness we are dealing with from the people who mindlessly support Obamacare. If you were to try and read the law, the actual text is over 2,000 pages and the associated regulations are 30 times longer than the law. Who the hell has time to sort through all of that shit? The complexity of Obamacare is a big reason why the implementation has gone so horribly wrong and this is proven with everything we are seeing unfold. Only criminals who sought to benefit special interests in the insurance industry or a bunch of mentally ill morons would have crafted a law such as this. Take your pick but it is most likely that it was a combination of both.

There is no question that Obamacare is a complete and total failure if you believe that this was meant to provide affordable health insurance to all Americans. It has in fact done the opposite and raised the cost of health insurance making it unaffordable for many Americans. The official site for Obamacare is so screwed up that even after a couple of weeks people still cannot properly enroll in an insurance plan. We actually have the federal government requiring people to buy a product on a site that doesn’t work, and if you don’t buy the product you will be fined. This is such bull shit. In a sane world Obama would be removed from office for incompetence on just this issue alone. Of course he would have been impeached earlier for many other high crimes and offenses he has already committed during his time in office.

None the less, this failure is so ridiculously obvious that we have to consider this to be part of a larger agenda to intentionally destroy America’s healthcare system so the government can take it over. Only time will tell, but what is really sad is that there are still people who are defending and promoting Obamacare. Why on earth would anybody continue to do this? It is undeniable that these people have to be mentally ill and should seek treatment immediately. It is too bad that Obamacare will probably prevent them from getting this treatment so for the time being these people should be avoided at all costs. After all, those who use this type of thought process and avoid using common sense and logic to form opinions are extremely dangerous to themselves and others.