Tag: The ACA

Round One of the Obamacare Exchange Hearings. Angry Republicans 6 Contractors 0.

Oct 24, 2013• 7

By Charles Ornstein

Today’s House Energy and Commerce Committee hearing/grilling of the contractors behind Healthcare.gov brought a lot of defenses and fingerpointing, but little clarity of when the website will be fixed.

Still, here are some of the more-memorable quotes. The sources are below each.

“I will not yield to this monkey court,” Rep. Frank Pallone (D-N.J.) said when Republican lawmakers tried to talk about online privacy fears. -Politico

“This is not about blame. It’s about accountability,” said Rep. Fred Upton (R., Mich.), chairman of the House Energy and Commerce Committee. “We still don’t know the real picture, as the administration appears allergic to transparency.” – WSJ.com

“CMS [the Centers for Medicare and Medicaid Services] had the ultimate decision to go live or not go live,” said Cheryl Campbell, senior vice president of CGI Federal, the lead federal contractor on the project. “At CGI we were not in position to make that decision. We were there to support the client. It’s not our position to tell clients whether to go live or not go live.” — Washington Post

“Amazon and eBay don’t crash the week before Christmas,” said Rep. Anna Eshoo of California, a Democrat. “ProFlowers doesn’t crash on Valentine’s Day.” – NBC News

“Three weeks after the Web site went live, we are still hearing reports of significant problems. These problems need to be fixed, and they need to be fixed fast,” said Representative Diana DeGette, Democrat of Colorado. -New York Times

“We understand the frustration many people have felt since healthcare.gov was launched. We have been and remain accountable for the performance of our tools and our work product,” said Andrew Slavitt, the group executive vice president for Optum/QSSI, a contractor on the project. – ABC News

Meanwhile, HHS officials may be regretting their decision to give Healthcare.gov visitors the ability to post comments to the site. ProPublica reporters reviewed over 500 comments posted at https://www.healthcare.gov/connect/.

A sampling:

Wrongly Listed As Jailed

“Website said my wife and I were ineligible due to current incarceration. We have never been arrested in our lives, both 63!!!!!!!!!!!!!!!!!!!!!!!,” Fred wrote on Oct. 21.

Health Problems Made Worse

“I have a pre-existing condition …. a-fib…..and actually had an attack after getting frustrated with this confusing mess,” Bill wrote on Oct. 22. (A-fib refers to atrial fibrillation, an abnormal heartbeat.)

Daughter is Not a Daughter Anymore

“I am having difficulty with my account,” Joanna wrote on Oct. 22. “It appears that my daughter was added twice so that I now have two daughters with the same name and social security number. I am unable to delete one of them. Also, the drop down menu that relates to what relationship someone is to another is faulty. I choose that my husband is the father of our daughter and that my daughter is a dependant [sic] to me and my husband. What it actually shows though is that my daughter is a stepdaughter to her father and that my daughter is now both my husband and I’s parent. “

Healthcare.com Would Have Worked Better

Oct 20, 2013• 21

By J.D. Kleinke

Is this any way to build a railroad?

By now you’ve heard that the “Obamacare exchanges” did not launch on October 1 so much as stumble out into public view, barely able to crawl.

Three weeks later, the federal version — “healthcare.gov,” which is actually the same exchange re-deployed 36 times in 36 states — is still barely able to crawl. By contrast, most of the 15 exchanges operated by individual states and the District of Columbia are working more or less fine, for varying reasons we will explore in a moment.

Why the epic fail for healthcare.gov, estimated to have generated a health insurance enrollment rate of less than one-half of one percent among nearly 10 million visitors? Information technologists have identified lunk-headed flaws in its overall design, while pointing to the way the Federal government rolled it out, all at once, all across the nation — as if it were a campaign commercial and not one of the most complex undertakings in the history of e-commerce.

Which would be for good reason: the federal exchange is a campaign commercial, one the Administration had no choice but to broadcast after its opponents went to war on every front against implementation of the Affordable Care Act.

The architects of the ACA expected that states would build their own exchanges. The federal exchange was supposed to be a failsafe — a fallback for a few straggler states unable to build their own in time for the October 1 launch. For the rest, healthcare.gov was supposed to do two things: point people to their state’s exchange; and handle the very complicated task of querying tax and other federal databases to verify people’s eligibility.

Instead, it found itself saddled with the entire e-commerce job for 36 refusenik states.

Should the Obamacare Exchanges Be Shut Down?

Oct 19, 2013• 36

By Robert Laszewski

My sense is that the biggest reason Obamacare is now in trouble is because of the top-secret way in which the administration has handled the rollout. If they had developed the computer system in a transparent way, the marketplace would have told them long ago this would not work.

No one outside the inner circle at the Department of Health and Human Services has any idea what’s really going on behind the Wizard’s curtain. Hasn’t for months. Doesn’t now.

So any technical advice any of us could give would be, to say the least, uninformed.

If I were on the inside, and it were up to me, the first thing I would do is bring in a group of heavyweight information technology experts to tell me just what was really going on. The administration cannot trust the people who have been working on this because they told them to launch this mess on October 1 and almost three weeks in there has been no improvement on the website or in the backroom––they no longer have credibility.

I would ask those experts to very quickly answer three questions:

Can this thing be fixed on the fly––as the administration appears to be trying to do?
If it can’t be fixed on the fly––and three weeks into this that sure looks doubtful––then can it be taken down for one or two months with a high degree of confidence it can be brought back up in time to enroll people sooner rather than later?
If the first two options are not possible, just how long will the computer system have to be shutdown before Obamacare can be launched in a way that there can be confidence it will work smoothly?

Then I would take their advice.

State Surveillance Endangers the Affordable Care Act: A Case Study

Oct 18, 2013• 10

By Adrian Gropper, MD

… and a call to action. This case study is based on my meeting with the Center for Health Information and Analysis (CHIA) in my home state. CHIA is an all payers claims database, a massive collection of diagnoses, locations, dates and prices for all of your health services across all of your providers and insurers. Whether it’s claims or health records, almost every state and many private clearing houses are setting up to monitor you.

Your information can be used by business to manipulate prices for maximum profit, or by you to inform your choice of health insurance plans and health care providers.

Unfortunately, business can get your information but you can’t. This reflects an industry strategy to obstruct the market-based features of the Affordable Care Act. I hope you will take this case study, edit it, and file it with the Attorney General and Governor in your state to ask for your data as a consumer protection issue. That’s what I’m about to do.

My state is #1! Go Massachusetts! My state is #1 in health care costs. It’s also #1 in implementing a health insurance exchange (Romneycare 2006) and a leader in state surveillance with the 2012 cost containment law known as Chapter 224. Chapter 224 mandates various state surveillance mechanisms including a health information exchange that monitors encounters and an all payer claims database called “the center”.

The cost containment law also includes some consumer protections. Line 1909 states:

“To the maximum extent feasible, the center shall also make data available to health care consumers, on a timely basis and in an easily readable and understandable format, data on health care services they have personally received.”

Although the state surveillance is in place, and the price fixing that keeps us #1 is ongoing, the consumer protection part of the law is not implemented. So, I took the opportunity to meet with the executive director of CHIA and their chief legal counsel and get the scoop on why the state is not following the law. To paraphrase their explanation: “It’s too hard.”

Why PCORI Should Be Very Wary of Studying Medical Devices

Oct 18, 2013• 7

By Peter Ubel, MD

In the New York Times on Thursday, October 17, Topher Spiro wrote an important op-ed expressing why we need to hold onto the medical device tax that helps pay for parts of the Affordable Care Act. Spiro backs up his argument by pointing out how profitable the device industry is. To his argument I would also add the fact that this will provide the industry with more paying customers. Certainly it can afford to pay the taxes.

But I diverge from Spiro on a proposal he floated near the end of his piece:

“To complement these efforts, the new Patient-Centered Outcomes Research Institute [PCORI], a non-governmental body created by the Affordable Care Act, should pay for research that compares the effectiveness of devices so physicians can make informed choices. (Three years into its existence, the institute has initiated few, if any, studies of medical devices.”

Listen to me PCORI. Don’t follow this advice, unless you plan not to survive to celebrate your fourth birthday.

Consider what happened to the Agency for Healthcare Policy Research (AHCPR), when it tried to help physicians figure out the best way to treat low back pain. AHCPR was created as a stand-alone research institute, akin to the NIH, but one that would focus not on the basic science of treating disease, but instead on evaluating how well existing treatments worked.

A Pragmatic Fix for Healthcare.gov & the HIXs

Oct 18, 2013• 24

By Matthew Holt

By now even those of us who originally thought that we were seeing minor teething troubles are no longer deluding ourselves. Healthcare.gov, the federal health insurance exchanges (HIXs), and many of the state HIXs are in deep trouble.

One summary of many articles about this is up at ProPublica. But now that the House Republicans have stopped trying to destroy the country and themselves, attention will turn quickly to this problem, and–much worse–beyond the politics, there is now only eight or so weeks to get ready for actual enrollments for Jan 1, once you take out Thanksgiving and the Christmas holiday. Getting ten or twenty million new customers on board, not to mention the small businesses who want to move from their current insurance onto the exchanges, seems like an impossible task.

But, if we can muster the will, there may be a solution. (And yes, I want it to work, faut de mieux). Quietly last summer two private online insurance brokers, eHealth which runs the eHealthInsurance.com site, and GetInsured, struck deals with HHS which allowed them to enroll individuals in plans that qualify for the mandate under the ACA, and more importantly, connect with the “Health Exchange Data Hub” that figures out whether the enrollee qualifies for a subsidy (theoretically by connecting to the IRS).

That part of the transaction, though, could be done by attestation and dealt with later. In other words, someone buying health insurance could state what their income will be in 2014 (or was in 2013) and if it ends up varying dramatically on their 1040 then in 2015 they will pay or receive the difference. Essentially this is something all Americans recognize–the IRS asks you for more or gives you a tax refund well after the fact, and H&R Block and their competitors make a business of giving you the refund right away (and of course charge you for the privilege).

That is important because what seems to be crippling the HIXs right now is not the back end, it’s the front end. (Go to this Reddit thread for lots more deeply technical conversation about that). Showing people options, comparing plans, setting up accounts–that’s all standard web stuff and most of the HIXs can’t do it. Those private brokers have both smoothly done this for years and at least the two I mentioned have built comparative tools for the new insurance plans. (Both were demoed at Health 2.0 on October 1).

So why can’t we put prominent links to eHealthInsurance.com and GetInsured on the Healthcare.gov site and move people over there? Continue reading…

My Personal Affordable Care Act–A Manifesto

Oct 17, 2013• 43

By Vik Khanna

The Founding Fathers had one. Karl Marx had one. Bertrand Russell and Albert Einstein had one. And, now I have one: a manifesto, declaring my intent to live my life with as little interaction as possible with the US health care system by doing what the Affordable Care Act (ACA) tells me by omission I do not need to do: take responsibility for myself.

This is my Personal Affordable Care Act.

My manifesto is an algorithm for thriving in spite of the government’s naked and absurd attempt to define health as something that begins in the clinic. My goal is to make myself and my family as scarce as possible within the health care system.

The ACA is a collective solution to the mass failure of individual will. Our transformation into an information culture actually worsened the malady. We are so conditioned to success at the speed of a search engine that, like the person who aspires to retire early, but refuses to save, we’ve forgotten to manage the fundamentals.

First, that every healthy lifestyle decision you make today, from diet and exercise to outlook and mood, requires thought and an exertion of will. Even in the age of Google, volition matters, and choosing not just wisely, but strategically, is an option available to most people.

Second, despite revolutionary democratization of medical information, we still don’t do our homework. Americans visit physicians 3 times per year on average, and the number one reason for the visits is “cough.” Really? You need to go to the doctor for a cough? Unless you have a fever, chest discomfort, bloody sputum, or the cough lasts for weeks and keeps you up at night, it is almost certainly viral or related to an allergen and self-limited.

The Federal Shutdown is Over. The Health Care Fight is Just Getting Started. Here’s What May Happen Next…

Oct 17, 2013• 2

By Dan Diamond

Social security numbers allegedly passed around in clear sight. Page after page of unworkable code. And no clarity on when it will all be fixed.

Just another day of trying to log in to healthcare.gov.

Two weeks after its launch, the federal health insurance exchange is a “failure,” says the Washington Post‘s Ezra Klein. Some officials deserve to be fired, according to Robert Gibbs, who until February 2011 was one of President Obama’s closest advisers.

And those are the Affordable Care Act’s supporters.

Even the president conceded on Tuesday that healthcare.gov had “way more glitches than I think are acceptable.”

Those glitches could take months — or even years — to fix, according to reports. But there’s a key deadline looming: Jan. 1, 2014, when the ACA’s individual mandate takes effect.

Under the mandate, millions of Americans who were expected to use the exchanges to obtain health insurance will face fines if they haven’t purchased coverage by Feb. 15, raising the question of whether the mandate or other Obamacare provisions should be postponed — an uncomfortable position for an administration already trying to implement a politically divisive law.

But at this late date, what parts of the ACA can legally be delayed?

“In a sense, all of it,” Timothy Jost, a Washington & Lee law professor, told me. But “there’d be a high political price to pay. And delay could result in litigation.”

Jost was among several experts who spoke with me about the health insurance exchanges’ bumpy rollout, the ripple effects for the mandate and other provisions, and what it could all mean for implementing the ACA.

What Agencies Can and Can’t Do
When considering a delay to Obamacare, it’s important to understand the difference between statutory and discretionary deadlines.

For example, the ACA’s language directly calls for many mandatory deadlines — like rolling out the individual mandate or implementing a slew of insurance market reforms on Jan. 1, 2014.

But the agencies also have had considerable leeway on how they’ve chosen to apply the law — like choosing an Oct. 1 launch date for the exchanges, a deadline that retrospectively seems ambitious.

How Naïve Can Democrats Get?

Oct 14, 2013• 41

By Uwe Reinhardt

Beholding David H. Howard’s rendering of the crazy-quilt of financial sources that have been tapped by the designers of the Affordable Care Act of 2010 (hereafter ACA ’10) to finance the new entitlements they put in place – a little nuisance tax here, a little nuisance cut in other federal spending there – reminds me once more of the sincere, indeed touching, naiveté with which Democrats tend to go about enacting new entitlements.

It is a totally counterproductive and inelegant approach. To be sure, none of the added taxes or spending cuts in the bill seriously disrupt anyone; but they do spread a little pain all around. Therefore, it seems almost deliberately designed to maximize opposition to it from many quarters.

It also leads to acute embarrassments, such as having to postpone by a year (and perhaps more years) the unseemly penalty imposed on employers with 50 or more employees each working 40 your or more etc etc, even at the appearance of having broken the law – or so we are told.

When will the Democrats ever learn?

And from whom might they learn?

From the Republicans, of course.

Dream back to the good old days – 2003 – when the Bush Administration and the Republican Congress pushed through, with deft parliamentary maneuvering and some arms twisting, H.R. 1 (2003), the Medicare Prescription Drug, Improvement, and Modernization Act – hereafter the MMA ’03.

Of Course, Then There’s The Fact That You May Be Better Off Waiting To Buy Coverage, Anyway …

Oct 13, 2013• 3

By Trudy Lieberman

Will all the White House messages, the stream of breathless Twitter updates on the number of hits and enrollments, and the press hype surrounding opening day send the uninsured public into panic mode? Will they prompt buyers to consider only the premium and click to enroll ASAP? And why not? For weeks the administration, state exchange officials and supporters of the Affordable Care Act have been telling the public how cheap premiums will be — much cheaper than expected.

A Pennsylvania woman told me she was chomping at the bit to enroll because she was eager to dump her policy from Aetna for a cheaper model from Blue Cross. Never mind that she had no idea whether the coverage was better, the same, or worse.

A Nebraska woman heard there was a worksheet to fill out and it had to be completed by October 1. It was first-come-first-served, an agent had told her.

If cheap premiums were the only thing shoppers had to consider, this sense of urgency might be fine. But it’s not. Here’s the problem.

Selecting a health insurance policy is fraught with potential missteps and misunderstandings. As the Nebraska woman told me, “You’re walking into a chasm of uncertainty. It’s like shopping for a used car. You don’t know if you’re getting a lemon,” a lemon you’re stuck with until the next open enrollment.

For consumers, the key advice right now is: don’t rush into anything. Tuesday, October 1st marked the first day of a six-month open enrollment period, not the last. Coverage doesn’t even begin until January 1, 2014, so there’s no need to buy the first policy you see. If you do want coverage on January 1, the deadline for enrolling is Dec 15.