Obamacare After Obama

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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

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

Published on Monday, December 23, 2013 by Common Dreams

 

'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.

______________________________________

This work is licensed under a Creative Commons Attribution-Share Alike 3.0 License.

  Books  

Perseus Books / By Elizabeth H. Bradley, Lauren A. Taylor

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

 

 

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

 

Photo Credit: Shutterstock.com/Ricardo Reitmeyer

December 6, 2013  |  

 

 

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.

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Americans Are Paying for Health Care with More Than Money

Published on Thursday, December 19, 2013 by Bangor Daily News (Maine)

Americans Are Paying for Health Care with More Than Money

 

by Philip Caper

 

 

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.

© 2013 The Bangor Daily News

 

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.

Universal healthcare is the patriotic thing to do

SALON

Saturday, Dec 7, 2013 2:00 PM UTC

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

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

Published on Tuesday, December 3, 2013 by The Guardian

 

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

 

by Rose Ann DeMoro

 

 

(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.

© 2013 Guardian News and Media

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