Hope and Exchange

ObamaCare is due to land in a mere 10 months—about 300 days—and the Administration is not even close to ready, so naturally the political and media classes are attacking the Governors and state legislators who decline to help out. Mostly Republicans, they're facing a torrent of abuse in Washington and pressure from health lobbies at home.

But the real story is that Democrats are reaping the GOP buy-in they earned. Liberals wanted government to re-engineer the entire health-care system and rammed the Affordable Care Act through on a party-line vote, not stopping to wonder whether it would work. Now that implementation is proving to be harder than advertised, they're blaming the states for not making their jobs easier.

Editorial board member Joe Rago on HHS's extended deadline for states to implement health exchanges under ObamaCare and why many Republicans governors are refusing to.

The current rumpus is over ObamaCare's "exchanges," the bureaucracies that will regulate the design and sale of insurance and where 30 million people (and likely far more) will sign up for subsidized coverage. States were supposed to tell the Health and Human Services Department if they were going to set up and run an exchange by October, but HHS delayed the deadline to November, and then again at the 11th hour to December.

Sixteen states have already said they won't participate. Another 11 are undecided, while only 17 have committed to doing the work on their own. Six have opted for a "hybrid" federal-state model. That means HHS will probably be responsible for fallback federal exchanges in full or in part in as many as 25 or 30 states.

The opposition isn't so much political as practical. Or rather, the vast logistical and technical undertaking to build an exchange helps explain why so many Governors resisted ObamaCare in the first place.

States have regulated the small business and individual insurance markets for decades (some well, others less so). Now they're supposed to toss everything out for a complex Washington rewrite, which is still being rewritten. The exchanges will also help enforce the individual mandate and premium increases. They'll also have to spend a ton of money. Ohio estimates it will cost $63 million to set up an exchange and $43 million to run annually, based on a KPMG study.

Getty Images Health and Human Services Secretary Kathleen Sebelius

Most spending will go to information technology, in an era when many states still run Medicaid using paper forms and pneumatic tubes. These systems are supposed to allow consumers to review health plans online (or in person and by mail and fax), pick one and then ping HHS and the Internal Revenue Service to determine who is eligible for what subsidies. Private businesses spend years developing and refining such consumer software. States need to fund call centers to field queries and even hire "navigators" to actively encourage people to enroll.

The main problem is that states are being conscripted as federal contractors. HHS has declined to reveal basic operational details except to make clear that state-based exchanges won't really be run by the states. "No matter which option is chosen," as Scott Walker put it, "Wisconsin taxpayers will not have meaningful control over the health-care policies and services sold to Wisconsin residents."

So if things don't work voters will blame the Governors for decisions made in Washington. And when it turns out that ObamaCare's costs are underestimated and its benefits exaggerated, they'll have enabled an entitlement that many of their constituents oppose. The wonder is that any GOP leaders—ahem, Chris Christie and Rick Scott—are still playing Hamlet.

Partly that may be due to the insurance and provider lobbies, especially the hospitals. They're furious that states might spoil the deals they cut with the White House and frantic for new revenue, which will only flow with the subsidies. (Note that health industry stocks rallied on President Obama's re-election.) They're also generally more powerful at the local level and favor state-run exchanges as easier to manipulate. But Governors who give in are setting themselves up as political fall guys, just as the insurers will be when premiums inevitably spike.

We suggested at first that states could try to spin straw into gold, ignore HHS and try to adopt a marginally less destructive approach. One state that tried is Utah, which built an impartial insurance clearinghouse in 2009 based on "defined contribution, consumer choice, and free markets," as Governor Gary Herbert put it in a November letter to HHS.

Now he's asking Washington to accept "Utah's version of a health insurance exchange," even though it clearly does not comply with Affordable Care Act provisions. HHS claims it is trying to be flexible, so this will be a useful test.

But the main reason HHS and ObamaCare partisans are trashing the state hold-outs is that the federal government isn't any better equipped to make the plan a success. HHS's reputation as one of the most dysfunctional agencies is notorious. To take one example, an ObamaCare-mandated update to a major computer network called the System for Electronic Rate and Form Filing, which governs insurance approvals, has been delayed by months.

HHS's bandwidth is likely to be fried and its personnel overloaded by the workload of 25 exchanges or even 16. And the effort will be complicated by the serious legal questions and eventual lawsuits about the statutory authority of a federal exchange to dispense subsidies at all.

The Affordable Care Act barely passed and then barely survived Supreme Court review and the 2012 election. Now the entitlement is hurtling toward a truth-in-advertising moment and liberals are terrified that it won't produce the results they promised. That was always likely given the central planning architecture of ObamaCare, but now the likes of Mr. Walker are declining to do their work for them and depriving them of scapegoats.

The day after ObamaCare passed, we invoked the "Pottery Barn" rule that Colin Powell once applied to Iraq: You break it, you own it. Washington is about to break it, and the states are saying they won't be accomplices.

Printed in The Wall Street Journal, page 16 A version of this article appeared November 28, 2012, on page A14 in the U.S. edition of The Wall Street Journal, with the headline: Hope and Exchange.

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How Will Medicaid Enrollees Fare Under ObamaCare?

How Will Medicaid Enrollees Fare Under Obamacare? | Psychology Today (function(d, s, id) { var js, fjs = d.getElementsByTagName(s)[0]; if (d.getElementById(id)) return; js = d.createElement(s); js.id = id; js.src = "//connect.facebook.net/en_US/all.js#xfbml=1&appId=220580041311284"; fjs.parentNode.insertBefore(js, fjs); }(document, 'script', 'facebook-jssdk')); In sticking with the safe choice, a person places himself at the mercy of the circumstances. Neel Burton, M.D. Studies of women reluctant to ask for pay raises show that, deep down, they feel undeserving. Susan Krauss Whitbourne, Ph.D. Why does the holiday suicide myth persist in the face of evidence to the contrary? Elana Premack Sandler, L.C.S.W., M.P.H Gift exchanges involve mental math that far surpasses that covered in college-level calculus. Camille S. Johnson The final letting go of adolescence for both parents and teenagers must be forgiveness. Carl E. Pickhardt, Ph.D. HomeFind a TherapistFindFind a Therapist
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SiblingsRecently Diagnosed?Diagnosis DictionaryMagazineCurrent IssueCustomer ServiceSubscribeRenewGive a GiftArchiveTestsPsych BasicsExpertsIndex of BlogsOur ExpertsPublic SpeakersMedia Interviews Curing the Healthcare Crisis Empowering patients and caregivers by John C. Goodman, Ph.D. How Will Medicaid Enrollees Fare Under Obamacare? Access to care will likely go from bad to worse. Published on December 17, 2012 by John C. Goodman, Ph.D. in Curing the Healthcare Crisis

In 2014, the nation is expected to start insuring about 32 million uninsured people. About half will enroll in Medicaid directly; and if the Massachusetts precedent is followed, most of the remainder will be in heavily subsidized private plans that pay little more than Medicaid rates.[1]

That raises an important question: How good is Medicaid? Will the people who enroll in it and in private plans that function like Medicaid get more care, or better care, than they would have gotten without health reform? I will begin this series by evaluating the evidence to answer that question. Then, I will propose three alternatives: (1) abolish Medicaid altogether and integrate the beneficiaries into the private health insurance system; (2) allow Medicaid to be a competing health plan, rather than a plan that sequesters poor people; or (3) replace much of Medicaid outpatient spending on the nonelderly, nondisabled with a health stamp program. (For more details, please see my book Priceless: Curing the Healthcare Crisis.)

The 32 million newly insured citizens may not get more healthcare. They may even get less care. Even if they do get more, odds are that low-income families as a group will get less care than if there had never been a health reform bill in the first place. The reason: As we have seen, the same bill that insures 32 million new people also will force middle- and upper-middle-income families to have more generous coverage than they now have. As these more generously insured people attempt to acquire more medical services they will almost certainly out-bid people paying Medicaid rates for doctor services and hospital beds. To make matters worse, the health reform bill did nothing to increase the supply side of the market to meet the increased demand.

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The Effects of Underpaying Physicians

On paper Medicaid is attractive. It promises coverage for most medical services with no premium and usually no out-of-pocket payments. But Medicaid pays physicians only about 60 percent as much as private insurers pay, and many Medicaid patients have difficulty finding doctors who will see them. Increasingly, physicians are dropping out of the Medicaid program, declining to see new Medicaid patients or limiting Medicaid patients to a small percentage of their practice.[2] As a result, the patients turn to much costlier settings, such as hospital clinics and emergency rooms.

One study found that children were denied appointments 60 percent of the time when a caller reported Medicaid-CHIP as their coverage. By contrast, only 11 percent were denied an appointment when the caller reported private insurance. Of those who were able to obtain an appointment as Medicaid patients, the average wait was twenty-two days longer than those with private insurance.[3] Another study found that even the uninsured have an easier time making doctors’ appointments than Medicaid enrollees.[4]

Although Medicaid rates for physicians are typically lower than what physicians receive from the private sector in every state,[5] the payment gap varies from one state to the next. New York state pays only about $30 for a comprehensive eye exam for a new patient, while Mississippi reimburses a physician $106 for the same service. Texas and Florida pay $63.55 and $66.90, respectively.

Access to Primary Care

About 30 percent of doctors do not accept any Medicaid patients, and among those who do, many limit the number they will treat. One survey found two-thirds of Medicaid patients were unable to obtain an appointment for urgent outpatient care.6 In three-fourths of the cases, the reason was the provider did not accept Medicaid. Among general practitioners who will accept Medicaid, thelowest figures are 30 percent (Los Angeles), 40 percent (Miami) and 50 percent (Dallas and Houston).[7]

Access to Specialists

People enrolled in Medicaid and CHIP also experience difficulty finding specialists who will treat them for the low fees Medicaid pays.[8] A Government Accountability Office (GAO) report discovered that children enrolled in Medicaid or CHIP were one-third more likely to report problems accessing specialty care than children enrolled private health plans.[9] One survey[10] finds that:

In Dallas and Philadelphia, only 8 percent of cardiologists accept Medicaid patients; in Los Angeles, it’s only 11 percent.In both Dallas and New York City, only 14 percent of OB/GYN specialists will see Medicaid patients; the figure is 28 percent in Miami and 33 percent in Denver.

Use of the Emergency Room

According to a recent report, between 1997 and 2007 the total number of annual hospital emergency room (ER) visits doubled, mostly due to the increased frequency of use by adults with Medicaid coverage.[11] Medicaid enrollees account for more than one-fourth of all ER visits in the United States.[12]

Poor access to care is part of the problem. In our next installment, we will look at another aspect: quality of care under Medicaid. Problems with access to care and with quality of care support the case for reforming Medicaid.

Notes:

Robert Steinbrook, “Healthcare Reform in Massachusetts—Expanding Coverage, Escalating Costs,” New­ England­ Journal­ of­ Medicine­ 358 (2008): 2757–2760, http:// www.nejm.org/doi/full/10.1056/NEJMp0804277. Ben Storrow, “State’s Health-Care Coverage Gets Mixed Grades, Daily Hampshire Gazette, February 8, 2010.Kevin Sack, “As Medicaid Payments Shrink, Patients Are Abandoned,” New­ York ­Times, March 15, 2010, http://www.nytimes.com/2010/03/16/health/ policy/16medicaid.html.Joanna Bisgaier and Karen V. Rhodes, “Auditing Access to Specialty Care for Children with Public Insurance,” New­ England­ Journal­ of­ Medicine 364 (2011): 2324–2333.Brent R. Asplin et al., “Insurance Status and Access to Urgent Ambulatory Care Follow-up Appointments,” Journal ­of ­the­ American­ Medical­ Association 294 (2005): 1248–1254, doi: 10.1001.John C. Goodman et al., “Medicaid Empire: Why New York Spends So Much on Healthcare for the Poor and Near Poor and How the System Can Be Reformed,” National Center for Policy Analysis, Policy Report No. 284 (2006): 27, http://www .ncpa.org/pdfs/st284.pdf#page=27.Brent R. Asplin et al., “Insurance Status and Access to Urgent Ambulatory Care Follow-up Appointments,” Journal­of­the­American­Medical­Association 294 (2005): 1248–1254. doi: 10.1001/jama.294.10.1248.Merritt Hawkins & Associates, “2009 Survey of Physician Appointment Wait Times.”Ron Shinkman, “Kids in Medicaid, CHIP Have Trouble Accessing Specialty Care,” Fierce ­Healthcare, April 6, 2011, http://www.fiercehealthcare.com/story/gao-medicaid-chip-shortchanging-children/2011-04-07.“Medicaid and CHIP Information on Children’s Access to Care,” Government Accountability Office, GAO-10-293R, April 5, 2011, http://www.gao.gov/new.items/d11293r.pdf.Merritt Hawkins & Associates, “2009 Survey of Physician Appointment Wait Times.”Ning Tang, John Stein, Renee Y. Hsia, Judith H Maselli and Ralph Gonzales, “Trends and Characteristics of US Emergency Department Visits, 1997?2007,” Journal­ of­ the­ American­Medical Association 304 (2010): 664?670. doi: 10.1001/jama.2010.1112.Linda Gorman, “Medicaid Block Grants and Consumer-Directed Healthcare,” National Center for Policy Analysis, Issue Brief No. 102, September 15, 2011.

Tweet Have a comment? Start the discussion here! Tags: beneficiaries, doctor services, health insurance, health insurance system, health plan, health reform, healthcare crisis, hospital beds, low income families, medicaid, medicaid rates, medical services, middle income families, odds, physicians, pocket payments, private health insurance, private plans, remainder, stamp program Previous Post Liability-by-Contract: A Reform That Would Help Patients Next Post How Bad Is Care Under Medicaid? Subscribe to Curing the Healthcare Crisis Subscribe via RSS

John C. Goodman, Ph.D. is Research Fellow at The Independent Institute; President in National Center for Policy Analysis, & author of Priceless: Curing the Healthcare Crisis.

more... Curing the Healthcare CrisisRecent Posts Fraud, abuse, and perverse incentives are all too common. In some cases relying on Medicaid may be worse than having no insurance at all. Access to care will likely go from bad to worse. The right kind of malpractice reform would lower costs and benefit consumers. Liability-by-contract would create strong incentives for quality healthcare More of Curing the Healthcare Crisis blog Most Popular Most ReadMost Emailed 1 Porn Stars and Evolutionary Psychology
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2012 in review: Top U.S. stories [VIDEO]

A look back at the stories that dominated the U.S. headlines in 2012.

Sorry, I could not read the content fromt this page.

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Pre-Debate, New York Times Defends Obama from 'Bad Hand' Dealt by Bush

On Wednesday, New York Times political reporters Jackie Calmes (pictured) and John Harwood offered a pre-debate fact-check which predictably leaned in Obama's favor (and blamed former President Bush): "A Closer Look at Assertions the 2 Sides Have Made on Economic Issues."

The first presidential debate is likely to focus on economic issues as President Obama and Mitt Romney clash over the size and role of government. Here are some topics that could come up.

DEBT Mr. Romney blames Mr. Obama for annual trillion-dollar deficits adding to what is now a $16 trillion national debt.

Nonpartisan analysts agree that Mr. Obama inherited a bad hand: the 2009 deficit was a projected $1.2 trillion when he took office because of Bush-era policies and an economic crisis that slashed tax collections and increased spending for jobless aid and other safety-net programs. He has added $1.4 trillion in stimulus spending and tax cuts, and he has continued the Bush policies that Democrats blame for the swing from surpluses to deficits: income tax cuts, a Medicare drug benefit and war operations.

But Mr. Obama’s health care law, rather than adding $1 trillion to deficits as Mr. Romney says, includes offsetting cost savings and tax increases. And Mr. Obama proposes tax increases on the wealthy and spending cuts.

Calmes has asserted that claim before. Yet there is immense skepticism that Congress will stick to reducing payments to Medicare, among other things required that would make Obama-care actually reduce the deficit. The House Budget Committee (chaired by Paul Ryan) accuses the White House of using "gimmicks and double-counting," which the CBO is required to take at face value. And conservative economists have predicted Obama-care will add to the deficit.

Mr. Romney’s claim that Mr. Obama has taken $716 billion from Medicare benefits to pay for the health care law has been widely debunked. The cuts would affect those providing health care, not beneficiaries. The health law, in fact, expanded Medicare benefits. Mr. Ryan included identical savings in Republican budgets he passed in the House.

Does the Times truly believe that cuts to health care providers will not affect health care for patients at all?

Clay Waters is the director of Times Watch, an MRC project tracking the New York Times. Click here to follow Clay Waters on Twitter.

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Murdered Woman’s Family Sues For Greater Online Gun Control

Jitka Vesel

On December 12, 2012, the family of shooting victim Jitka Vesel sued the online gun market Armslist.com for the wrongful death of their loved one, who had been shot about 12 times in a parking lot in Illinois, by a gunman who had illegally obtained his weapon on the website.

Vesel’s brother hopes that lawmakers — like those named to the President’s gun violence prevention task force, created in the wake of the shooting at Sandy Hook Elementary — will address illegal online gun sales as they talk about measures to curb gun killings. Armslist does not require its buyers or sellers to give identification, and is not legally required to administer background checks:

“Armslist matches buyers and sellers solely based on Armslist’s mandatory drop-down menus that steer illegal buyers to illegal sellers,” Vesely said. “Armslist’s development of content thus materially contributes to the illegality of the gun sales it promotes.”

Jitka Vesel, 36, was shot 11 to 12 times by Smirnov in the parking lot of the Czechoslovak Heritage Museum in Oak Brook, Illinois, a Chicago suburb. Smirnov, a Canadian resident, had stalked her after she rebuffed his romantic overtures, according to Vesely. Smirnov, now serving a life prison sentence without parole, paid an extra $200 for the gun that had been listed for $400 because he couldn’t buy it legally, according to the complaint.

Background checks have indeed been part of the post-Newtown conversation about needed gun control measures; the President’s spokesperson floated the idea of closing the so-called ‘gun show loophole,’ which allows private sellers to distribute firearms without any checks on the purchaser. The Brady Campaign has found that, in some studies, “63 percent of private sellers sold guns to purchasers who stated they probably could not pass a background check.” Few lawmakers have addressed the idea of online black markets for gun sales, or websites like Armslist.com that do not have proper protections to ensure guns are not being sold to criminals.

Flawed federal laws also limit the ability of Vesel’s relatives to acquire evidence against Armslist in their civil suit. Several federal laws, known collectively as the Tiahrt Amendments, prevent trace data linking guns used in crime to previous owners and sellers from being used in civil proceedings.

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Merry Christmas: a (partial) list of Obamacare taxes, fees

Starting in 2014, President Barack Obama’s health care law will expand coverage to some 30 million uninsured people. At the same time, insurers no longer will be allowed to turn away those in poor health, and virtually every American will be required to have health insurance — through an employer or a government program or by buying it on their own.

For the vast majority of people, the health care law won’t mean sending more money to the Internal Revenue Service. But the wealthiest 2 percent of Americans will take the biggest hit, starting next year.

And roughly 20 million people eventually will benefit from tax credits that start in 2014 to help them pay insurance premiums.

A look at some of the major taxes and fees, estimated to total nearly $700 billion over 10 years.

— Upper-income households. Starting Jan. 1, individuals making more than $200,000 per year, and couples making more than $250,000 will face a 0.9 percent Medicare tax increase on wages above those threshold amounts. They’ll also face an additional 3.8 percent tax on investment income. Together these are the biggest tax increase in the health care law.

— Employer penalties. Starting in 2014, companies with 50 or more employees that do not offer coverage will face penalties if at least one of their employees receives government-subsidized coverage. The penalty is $2,000 per employee, but a company’s first 30 workers don’t count toward the total.

— Health care industries. Insurers, drug companies and medical device manufacturers face new fees and taxes. Companies that make medical equipment sold chiefly through doctors and hospitals, such as pacemakers, artificial hips and coronary stents, will pay a 2.3 percent excise tax on their sales, expected to total $1.7 billion in its first year, 2013. They’re trying to get it repealed.

The insurance industry faces an annual fee that starts at $8 billion in its first year, 2014.

Pharmaceutical companies that make or import brand-name drugs are already paying fees; they totaled $2.5 billion in 2011, their first year.

— People who don’t get health insurance. Nearly 6 million people who don’t get health insurance will face tax penalties starting in 2014. The fines are estimated to raise $6.9 billion in 2016. Average penalty in that year: about $1,200.

— Indoor tanning devotees. The 10 percent sales tax on indoor tanning sessions took effect in 2010. It’s expected to raise $1.5 billion over 10 years.

The 28 million people who visit tanning booths and beds each year — most of them are women under 30, according to the Journal of the American Academy of Dermatology — are already paying.

Tanning salons were singled out because of strong medical evidence that exposure to ultraviolet lights increases the risk of skin cancer.

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Friedman: GOP Denial Is Destroying The Party And The Nation

The political obsessions of the Republican base — from denying global warming to defending assault weapons to opposing any tax increases under any conditions, to resisting any immigration reform — are making it impossible to be a Republican moderate, said Carville. And without more Republican moderates, there is no way to strike the kind of centrist bargains that have been at the heart of American progress — that got us where we are and are essential for where we need to go.

That’s NY Times columnist Tom Friedman in his latest column, “Send in the Clowns.” He notes:

… if Republicans continue to be led around by, and live in fear of, a base that denies global warming after Hurricane Sandy and refuses to ban assault weapons after Sandy Hook — a base that would rather see every American’s taxes rise rather than increase taxes on millionaires — the party has no future. It can’t win with a base that is at war with math, physics, human biology, economics and common-sense gun laws all at the same time.

Nor can we stop catastrophic climate change without a Congress that will support strong action. The fossil-fuel-funded Tea Party is apparently content destroy the GOP, the nation’s future, and the climate — though not necessarily in that order.

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