Trump

Trump

Dear (Quite Possibly) President Trump

33

Even the most ardent of Obamacare supporters are now forced to admit that the law has hit a rough patch this year. The opposition to Obamacare is positively gloating with self-congratulatory “I told you so” assessments of the supposedly dire situation. Defenders of the cause are counteracting with the customary deluge of charts and graphs to prove unequivocally that Obamacare is actually turning out better than they expected. Integrity and honesty being in short supply on both sides of this quandary, chances are excellent that no matter what happens next, the American people will lose big time, unless….

How the “Public Option” Became Just Another Fuzzy Buzzword

4

In an earlier post, I criticized managed care proponents for promoting concepts defined only by the aspirations of their proponents.  HMO, ACO, “medical home,” and “patient-centered this and that” are examples.

The “public option” (PO) is the latest example of a buzzword defined only by the aspirations of its proponents. The PO, first introduced to the public a decade ago by Jacob Hacker, Democratic presidential candidates and advocates of what would become the Affordable Care Act, has been revived by Democrats over the last five months. [1] Hacker, Hillary Clinton, Barack Obama and others say a PO would reduce premium inflation. But they refuse to define the PO, which makes it impossible to determine whether it could survive, much less reduce premium inflation. It’s not even clear whether proponents are proposing a PO open to all Americans or just to those who shop on the state exchanges established by the Affordable Care Act. The best they can do is say the PO will be “like Medicare.” That’s not a definition. That’s an aspiration.

Premium Hikes in the Exchanges: Not Good News, But Not the End of Obamacare Either

4

OK.  Yes, this is bad.  The Obama administration is being disingenuous if it tries to spin it any other way.   And, as has been clear for several months, this hands Hillary a “nasty” issue (pun intended). 

The “this,” of course, is the administration’s announcement on Oct. 24—after weeks of speculation and anticipation—that premiums in the exchanges will rise by an average 22% for 2017 coverage (if both state- and federally-run exchanges are included in the count.)

Despite the fact that tax subsidies will significantly soften the blow for the vast majority of people buying health insurance in the exchanges, millions of families will still be adversely affected.  

Specifically, about 2 million people who will buy coverage through the exchanges in 2017 will not get subsidies because their incomes are too high.  You could argue: hey, they can afford it.  But it’s still a pretty big hit when your monthly premium goes from $500 a month to $625.   

Huge ACA Rate Hikes in 100
Words or Less

2

ACA permits people to sign up even if they are already sick. Real insurance cannot work that way.

Imagine an Accountable Fire Insurance Act that required insurers to sell you fire insurance after your home had burned. Homeowner insurance rates would skyrocket. Anyone who carefully read the ACA would see that coming.

The big insurers knew this would happen but played along in the beginning to avoid attracting political fire.

When 75% of Americans get a taxpayer subsidy under ACA, it isn’t really insurance but more of an income redistribution mechanism…for better for worse.

There it is, 97 words.

Will Clinton Take Another Look at Value-based Healthcare?

1

Paul Keckley“Value” is the most important concept in healthcare today. But it’s problematic.

Futurists say our system is transitioning from volume to value. Device and drug manufacturers tout the value of their products. It even found its way into Wednesday night’s Presidential debate when frontrunner Hillary Clinton answered Chris Wallace’s query Medicare’s long-term viability with the following reply: “We’ve got to get costs down, increase value, emphasize wellness. I have a plan for doing that.”

Value is defined as “a fair exchange in return for a thing” (Dictionary.com). Per Webster’s, it is a “fair return in goods, services, or money for something exchanged; worth in money; usefulness, or importance in comparison with something else.”  In essence, it is the relationship between what something costs and the benefits that accrue to its purchaser. Transactions between buyers and sellers based on the purchaser’s deduction of what something costs and the benefits derived are the basis for value-based economics. They’re aided by rating services like Consumer Reports that provide useful methods for making selections: the current issue covers SUVs, coffee makers, nut butters and gas/electric ranges.  Very straightforward. Side by side.

Don’t Surrender

31

flying cadeuciiIndependent physicians are at the beginning of a challenging movement as we fight to stay relevant and solvent during the transition of health care from independence to “regulation without representation”.   In 1773, British Parliament passed the Tea Act with the objective to help the struggling British East India Company survive. Opposition to the Act resulted in the return of delivered tea back to Britain.  Boston left the ships carrying tea in port and on December 16, 1773, colonists in disguise swarmed aboard three tea-laden ships and dumped their cargo into the harbor.  The seeds were planted for the Revolutionary War. 

Is the ACA Merely a Step Towards Single-Payer “Medicare-for-All?”

4

A recent commentary in the Wall Street Journal announced, “Obamacare’s meltdown has arrived.” Over the years I’ve heard conspiracy theories that the Affordable Care Act was designed to fail, as a means to nudge a reluctant nation one step closer to a single-payer, Medicare-for-All health care system.

Bernie Sanders famously advocated for single-payer during his campaign.  In 2011, the Vermont legislature passed a bill to create a single-payer initiative. Green Mountain Care was abandoned in 2014 by Vermont’s governor — a Democrat — as being too costly. Despite an 11.5 percent payroll and a sliding-scale income tax of up to 9.5 percent, Green Mountain Care was projected to run deficits by 2020.   

A similar single-payer initiative is now taking place in Colorado. Amendment 69, known as ColoradoCare, would create a taxpayer-funded health insurer. ColoradoCare would be available to nearly all Colorado residents, including Medicaid enrollees. Federal programs, such as Medicare, TRICARE and the VA would remain in place, however.

Open Enrollment 2016… Can the Exchanges Be Saved? And Other Trending Questions

13

It’s open enrollment season—the annual period in which tens of millions of consumers wallow in the misery of health insurance choices and costs.  So, let’s pause to reflect on the status of things—enrollment-wise—with employer coverage, Medicare, and the exchanges. 

In particular, do consumers have better tools these days to help them choose insurance plans? 

For people with employer-based coverage—about 150 million Americans—things are okay and stable, but not great. The latest report from the Kaiser Family Foundation, released last month and based on a detailed survey of 1,900 employers (small, mid-size and large), indicates that premiums rose on average a modest 3% in 2016—to just over $18,000 for family coverage.  Workers paid 29% of that. 

A similarly small increase in premiums has prevailed for several years and is expected again for 2017. 

Almost all firms with 50 or more employees offer health benefits and the vast majority claim their coverage meets the ACA’s requirements for value and affordability.  Overall, 56% of employers offer health benefits because hundreds of thousands of small firms either choose not to offer it or can’t afford it—especially the smallest Mom and Pop shops.

There’s a Story Behind the “Craziest Thing in the World”

7

screen-shot-2016-10-04-at-12-39-26-pmIs he on or off message — or what?  We are taking about Bill Clinton, who said in a speech today/yesterday that small business folks and individuals were “getting killed” by Obamacare….with “premiums doubled and their coverage cut in half.”  

“The people who are getting killed in this deal are the small businesspeople and individuals who make just a little too much to get in on these subsidies,” Clinton said. He added that for many people, Obamacare’s changes have meant “their premiums doubled and their coverage [was] cut in half.”

Ouch.  But then he went on to say that one solution is to allow Americans to buy into Medicare, as Hillary has proposed.   We’re not sure if she’d be pissed or pleased with these remarks.  Perhaps not bad to let Bill signal her awareness that things with the exchanges are not good, and that she might be open to bigger changes in the program than she’s owned up to so far.

Fail to Scale: Why Great Ideas In Healthcare Don’t Thrive Everywhere

4

In the world of fine wine, it is well known that some types of wine grapes grow only in very specific climates and ecologies. The concept borrowed from the French is “terroir” (ter-WAHR). Terroir explains why the finest champagne grapes grow only in a small district in northeastern France, characterized by rolling hills and a chalky limestone subsoil that provides a steady level of moisture and imparts a mineral note to the wine’s flavor.

Health policy advocates have sought for generations to propagate promising forms of health care organization across the country. Yet one finds repeatedly that some forms of organization that prosper in one part of the country fail to thrive in others. Is it possible that the concept of terroir also applies in health care?

The Case Of Kaiser Permanente

Kaiser Permanente’s health plans would be a great example. Kaiser has been a darling of health policy advocates such as Alain Enthoven, Paul Ellwood, and others because of its integrated structure, global risk, and salaried employment model of physician practice. Yet, despite repeated federal interventions, beginning with the Health Maintenance Organization Act of 1973, Kaiser only recently exceeded 10 million in enrollment for the first time in its 71 year history. Moreover, 82 percent of that enrollment is in two states—Oregon and California—where Kaiser originated. The percentage of Kaiser’s enrollment that derives from its origin states is basically unchanged in a decade.