OP-ED

2014 A Healthcare Odyssey

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It might have been the best of times. It could have been the worst of times. But 2014 turned out to be the most mediocre of times. Here’s a recap.

Why did Sebelius resign?

Never make a promise to your kids that you can’t keep. And never project the number of people who will sign up for the exchanges and change your mind, unless you are the CBO. If you have read about the problem of uninsured in the US you might have considered CBO’s original projection that seven million people will sign up on the exchanges within six months of open enrollment a tad conservative. Weren’t there millions and millions, forty million apparently, gagging for healthcare coverage?

The CBO revised the projection to six million in February with the projection date of March 31st coming tantalizingly close. Towards the end of March you could hear the cheers of “roll baby, enroll” getting louder.

On April Fools’ Day, the ACA remained intact, the country had not descended in to civil war and some eight million had signed up for Obamacare.

Well done CBO! I predict the world population will increase by at least 5 million by 2020. I’ll revise my predictions on December 31st, 2019.

Shortly thereafter, the secretary of Health, Kathleen Sebelius resigned. The left claimed it was because Obamacare was such a success. The right claimed it was because Obamacare was an unmitigated disaster. The one thing both sides seemed to agree on was that she had indeed resigned.

Ebolarization of America

A virus divides. Divides a nation, I mean. Yes, I know viruses divide, or multiply, or whatever. But I’m talking about another type of division: polarization.

How has the Ebola virus, which is still ravaging Western Africa and has a case fatality rate of somewhere around 50 % (that is it kills half the people who contract it) become a variable for Nate Silver’s model for likely outcome of presidential elections?

Don’t believe me? Ask a person three questions. A) Is our fear of Ebola rational? B) Should flights from Western Africa be banned? C) Should asymptomatic healthcare workers who have volunteered in Ebola-stricken areas be quarantined?

The answer predicts a) vote for Hillary Clinton in 2016, b) belief in Anthropogenic Global Warming and c) fear of anti-bacterial soap.

Why? Because the virus originates in Africa. It presents a cover to express one’s prejudices and insecurities.

It all started off with a Tweet from Donald Trump. True to form, it was primal, uncultured and unhelpful but stimulated a lot of work at Huffington Post.

“The U.S. cannot allow EBOLA infected people back. People that go to faraway places to help out are great-but must suffer the consequences!”

Then the isolationists got all excited.

Then the progressives stepped in.

Want flights from Africa banned? Want workers quarantined? Fear Ebola more than cancer, guns, anti-bacterial soap and vending machines? It must be because you are dumb, xenophobic and racist, as this piece in Vox alleges about Canada’s ban on visas.

Canadians xenophobic! Bleeding heart liberal Canada! What a load of blithering codswallop.

USA has been lucky. If public figures, public institutions and the bi-hemispheric media operate on Id, they could stifle efforts to contain an epidemic if a foreign virus gets out of control. It would scant matter the provenance of the virus; whether Iceland, New Delhi or Sierra Leone.

To state the obvious: viruses have neither a race nor religion. Viruses don’t play favorites. But I’m still wondering whether Ebola would vote GOP or Democrat.

Landmark study debunks assumption

The year started icily with results of the Oregon Health Insurance Experiment (OHIE) which showed that expanding Medicaid in Oregon increased utilization of the emergency department. That is people on Medicaid are more likely to use the emergency department than the uninsured.

Big deal? Aren’t your “so what” neurons yawning with paralytic boredom?

Actually, it was a big deal, at least for Michael Cannon and many on the right. The ACA, seemingly not content with the ontological value of expanding insurance, posited a theory. I think it was a theory although these days the line between theory, wishful thinking and science is blurred. Let’s call it an assumption.

The assumption was that the uninsured use the emergency department because they don’t have primary care. They don’t have PCPs because they don’t have insurance. This raises healthcare costs for all. Expand insurance and they will see a PCP, who will treat disease at an early and treatable stage, which will reduce use of emergency departments, which will reduce healthcare costs.

Meaning expanding insurance reduces healthcare costs. Compassion saves costs. This sort of economics induces spasms of self-righteous raptures. “It’s scientific to be kind, stupid.”

Except the OHIE showed the opposite – ED use goes up. Which means that the assumption, and train of assumptions that made the proto-assumption, needs to be revisited. Which makes one wonder: why not just say that expanding insurance is good for its own sake and worth the money? Why ruin kindness with dodgy return of investment calculations unadjusted for inflation?

Halbig

I don’t know anything about the 1024 species of genus Rhododendron. I am mercifully also spared knowledge of constitutional law. But, to paraphrase Potter Stewart, I know lunacy when I see it.

Halbig versus Burwell is the sort of lawsuit Lewis Carroll might have written about in a world separated by a rabbit hole. That it was contested is parody. That it was found in favor of plaintiffs by DC Court of Appeals is lunacy. That it will be heard before SCOTUS means the Supreme Court has run out of DVDs from France.

According to the plaintiffs, citizens who bought insurance through exchanges in states where the Federal government runs the exchange do not qualify for subsidies. But in states with state-run exchanges they do qualify for subsidies. The IRS subsidies, which have been available to all, are illegal. Why? Because the Affordable Care Act (ACA) states that subsidies are available to those “enrolled in an exchange established by the state…”

What a tongue twister! Try saying it quickly.

Charitably, this is waterboarding of semantics. Or rationalism’s knock-out punch to common sense. But a more primal question is why? Why would the ACA jeopardize itself? Subsidies are essential for the individual marketplace to survive, which is the core of the ACA.

Because, say the detractors, the government wanted a stick to whip the states, red states to be precise, into developing their own exchanges. Why didn’t they use the stick? That’s the point – say both sides!

The conspiracy theory was confirmed by Jonathan Gruber, the chief intellectual architect of the ACA, who was Romneyed*. He later Grubered** the statement.

If the ACA collapses because SCOTUS finds for Halbig it would be like, depending on your political affiliations, nailing Al Capone for tax evasions or the local pastor for lying about his golf handicap. The law deserves a better epitaph.

The right will achieve a pyrrhic victory. They’ll have to present an alternative to the ACA. They might find that alternative eerily similar to the ACA.

Pareto strikes at the heart of Vermont

Vermont, the bluer than thou state, the bluest of blue failed to pass a single payer.

The governor did the math. The cost of a single payer system was dangerously close to the net revenue of the state.

Time to reflect. Single payer wasn’t defeated by Sarah Palin, the rhetoric of Death Panels, Koch Brothers, Rupert Murdoch or the 1 %.  It was defeated by arithmetic. Simple math, addition and subtraction, not calculus.

Of course, the math could have been different. The universal coverage could have entailed a lower actuarial value than the platinum plus actuarial value the Vermonters presently enjoy. “Let them all have cake” could have also been achieved by higher taxes. But that wouldn’t have been a Pareto improvement. And non-Pareto improvements risk losing votes, even from bluer than thou, bluest of blue, people. Or, as fellow Tweep @JediMD pithily said “Marie Antoinette would have lost chandeliers.”

So single payer advocates, including some who visit this site, instead of blaming GOP for lack of single payer time to take a good hard look at the mirror. The fault dear Brutus lies with us, not Koch brothers.

Strange Morality and Stranger Economics of Medicaid

Imagine a visiting alien, Neocon (No Econ) from Planet Dearth taking a look at Medicaid. Planet Dearth is just like planet Earth, except there is a dearth of Ivy League institutes and economists.

He might record the following conversation.

Government: “we care about the health of poor people. Why don’t you see more of them? They have coverage. It’s called Medicaid.”

Primary Care Physician: “sorry but you pay us too little and impose too much paperwork.”

Government: “ok, let’s see what we can do. Remember we care about poor people. I know. Let’s cut your rates by 40 %. “

Neocon might wonder: “WTF! I thought we had it bad on Dearth.”

I admit that I’m a simpleton. I’m sure there is some nuance to the Medicaid pay cuts for 2015. Perhaps Vox might be able to explain and entertain me with fine post hoc rationalization and how this is a part of the larger plan to solve inequality.

Now for the moment you have been waiting for. The awards for 2014.

Book of the Year

Jonathan Bush’s “Where does it hurt”

An amalgam of realistic frustration (the problems) and unfettered optimism (the solutions). Bush identifies the key warts in the system. Not so sure about his prescriptions.

Research Paper of the Year

Jena et al. showed that when cardiologists are away at meetings patients live longer. Beautiful study confirming that we are not just on the asymptote of diminishing returns, we are in the realm of negative marginal returns. The challenge is how do we rack back? And, no, more meetings for cardiologists is not the right answer.

Quote of the Year

Joint first place.

Nassim Nicholas Taleb for “Empiricism of Idiots.” The tendency to rationalize fear as a function of numerator/ denominator. To believe that one should be more frightful of cancer (higher numerator) than Ebola. But the action lies in the asymmetry of error, which could, in the case of Ebola mean a very large numerator and a very small denominator.

Jonathan Gruber for “speak-o- you know like a typo.” Self-evidently brilliant.

And now, drum roll….. 

Healthcare’s Person of the Year

MIT economist and architect of the ACA, Jonathan Gruber.

The man, the myth, the legend. The sheer chutzpah. The brutal honesty. He is my Tyler Durden. America needs more people like him to speak plainly and off the cuff.

For Gruber might achieve what no body before him has achieved: getting the country to have a responsible, adult conversation about healthcare.

Prediction for 2015

Much like 2014 with a bolder journey to status quo, more navel gazing and a proliferation of start-ups trying to put meaning to meaningful use.

Wishing you all a happy and prosperous 2015.

Footnotes

*Romneyed: videotaped at moment of extreme honesty.

** Grubered: extreme contextualization of a statement which might later be misconstrued as meaning what it literally means. You have to be there at the precise moment the statement was uttered. If you miss it by even a nanosecond you could misunderstand the context. This should not be confused for “denial.”

 

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Matthew Holt@BobbyGvegasSaurabh JhaPeter1Perry Recent comment authors
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Matthew Holt
Editor

Nicely done Saurabh, we’re all way down the Rabbit hole. It’ll be ironic that Texas et al will take the Medicaid money just at the same time that Halbig will win out and to get coverage in the red states you’ll have to go from being nearly poor to destitute—the opposite of how it is now!

Saurabh Jha
Guest
Saurabh Jha

Thank you Matthew and happy 2015.

I have faith in Justice Roberts and his ability to surprise us with a rhetorical rabbit from the hat. One that would checkmate Cato with their own libertarian principles.

Were I GOP, I’d be praying that SCOTUS finds for Burwell. They have a great opportunity to show magnanimity by improving the ACA rather than blasting it to smithereens.

Peter1
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Peter1

“Bleeding heart liberal Canada!” There are Conservatives in Canada and they are now in power in Ottawa. Canadian Conservatives like to emulate Conservative Americans and support American policies. Harper is the lap dog of the U.S. “expanding Medicaid in Oregon increased utilization of the emergency department.” It’s hard to break long time habits. Did anyone look to see if those Medicaid patients could find a PCP that would accept Medicaid payments? Would your comment mean that giving access to health care for previously uninsured is bad policy? “So single payer advocates, including some who visit this site, instead of blaming… Read more »

Saurabh Jha
Guest
Saurabh Jha

Peter, how wonderful it is to get your attention! “Would your comment mean that giving access to health care for previously uninsured is bad policy?” Peter, did you miss this? “why not just say that expanding insurance is good for its own sake and worth the money? Why ruin kindness with dodgy return of investment calculations unadjusted for inflation?” “Did anyone look to see if those Medicaid patients could find a PCP that would accept Medicaid payments?” Which, of course, will be remedied by reducing rates by 40 %! Oh you bleeding hearts, how you affirm your care for the… Read more »

Peter1
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Peter1

“How long will you continue to blame corporations? Can’t you see, the problem is the people!” Given that corporate lobbyists write much of the legislation and legislators don’t read the bills given that they spend many hours dialing for dollars, and that the approval rating for congress is at historic lows your comment is naive at best. As for Vermont, the Governor actually won a narrow victory campaigning for single-pay. He finally shelved the legislation (not voted down) when he could not find a way for Vermont to afford it – assuming it was based on existing costs. He won… Read more »

Saurabh Jha
Guest
Saurabh Jha

Agree about the bit about utopia.

Actuarial value of proposed SP was pretty high. Certainly not bronze

Saurabh Jha
Guest
Saurabh Jha

“There are Conservatives in Canada and they are now in power in Ottawa. Canadian Conservatives like to emulate Conservative Americans and support American policies. Harper is the lap dog of the U.S.” Thanks for confirming that. Which is my point. Journalism during Ebola has been largely about templating one’s own bugbears which, in this instance, happens to be the author’s evident discomfiture of the type of government in Canada. It will be left to future historians to describe the Ebola epidemic as the time when science reporting in the US dipped below the level of the gutter, and the dangers… Read more »

@BobbyGvegas
Guest

““There are Conservatives in Canada and they are now in power in Ottawa.” __ Our Too-Big-To-Fail banks and hedge funds are now way long on leveraged oil patch lending and energy futures derivatives. The unanticipated, continuing deep plunge of crude prices worldwide (I paid $1.949 a gallon for gas last week in Tennessee while on Holiday) means that the Wall Street Big Dogs are terribly exposed, just like they were with crap mortgage securities last time around. Everyone was assuming intractably rising 3 digit crude. Congress’s recent last-minute removal of key restrictions on taxpayer liability for bailouts means that we… Read more »

Saurabh Jha
Guest
Saurabh Jha

Sounds apocalyptic! Happy 2015!

Perry
Guest
Perry

“Government: “ok, let’s see what we can do. Remember we care about poor people. I know. Let’s cut your rates by 40 %. “

This is where it seems the illusion of medical coverage trumps the reality.

@drsxr
Guest

Great article.
“Let them have chandeliers”. Will tuck that away for future reference.

Senor
Guest
Senor

Nice article.

In regards to Ebola—I believe that if Ebola had originated in a European nation (let’s say Germany), travel bans to and from Germany would have been more likely to be put into place by the USA and other countries.

Dr. Vader
Guest
Dr. Vader

If I could upvote, I would upvote