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ObamaCare Clusterfuck: Lessons on exchanges from the Swiss and the Dutch

Quoting the Health Affairs abstract* of an article by Ewout van Ginneken, Katherine Swartz, and Philip Van der Wees:

We review the Swiss and Dutch experience with exchanges and offer specific lessons for the US exchanges. First, risk-adjustment mechanisms—which provide premium adjustments intended to compensate health plans for enrolling people expected to have high medical costs—need to be sophisticated and continually updated. Second, it is important to determine why people eligible for coverage don’t enroll and to craft responses that will overcome enrollment barriers. Third, applying for subsidies must be simple. Fourth, insurers will need bargaining power similar to that of providers to create a level playing field for negotiating about prices and quality of services, and interim cost containment measures may be necessary. Fifth and finally, insurers and consumers alike will need meaningful information about providers’ costs and quality of care so they can become prudent purchasers of health services, since managed competition among health plans by itself will not substantially drive down health costs.

Oh, ha ha ha. You mean we're going through all this agony to set up a marketplace and the cost curve won't get bent? Reach me my pearls, because I'm heading for the fainting couch!** But even more interesting, look at the criteria for successful health exchanges; is ObamaCare on track for fulfilling any of them?

1. "[R]isk-adjustment mechanisms... need to be sophisticated and continually updated." If this is even on the radar, I have yet to hear of it. Readers? We haven't even got the Federal data hub up and running, let alone wired up to "continually updated" risk adjustment mechanisms. And the 17 states that are creating their own exchanges; where are they in this picture?

2. "[D]etermine why people eligible for coverage don’t enroll and to craft responses that will overcome enrollment barriers." HHS is explicitly not going to market to the "vulnerable and disengaged."

3. "[A]pplying for subsidies must be simple." Under ObamaCare, your subsidy is a tax credit. So you take money out of the coffee can on the kitchen table right away, and then wait 'til next April to see how it all worked out. What could be simpler? The application for subsidy is 26 pages long and subject to perjury. If your income changes after your initial eligibility determination, you could be hit with a tax bill. Routing customers to Medicaid vs. exchange subsidies is complex, and one state has already punted on it.I don't think applying for subsidies is simple at all.

4. "[I]nsurers will need bargaining power similar to that of providers....". Good news here! ObamaCare was drafted by Liz Fowler, a WellPoint VP, and I think it's safe to say that that she took care of her industry's bargaining power before she waltzed back through the revolving door. Anyhow, Obama says that now government and the insurance companies are "joined at the hip." So that's alright then.

5. "[I]nsurers and consumers alike will need meaningful information about providers’ costs and quality of care." No sign of that. The navigators might do that, but provider costs aren't part of their job description. Anyhow, ObamaCare "cares" about insurance, not health. The exchanges are selling out Gold, Silver, Loser Bronze** insurance plans, not health plans.

Bottom line here is that even if you accept the need for the complex rentier-friendly neo-liberal leechery of Obama's Rube Goldberg-style*** health insurance bailout, ObamaCare is still a Clusterfuck.

And naturally, single payer would make all this nonsense go away. People would be eligible, as citizens, for health care, and we wouldn't be coding a massive kludge to subsidize people's care in a system that's designed to deny them care in the first place, as a business model. So thanks, progressives, for taking single payer "off the table" while you were running interference for ObamaCare in 2009.****

NOTE * Because who can afford to purchase the full PDF from a journal?

NOTE ** Such a transparent attempt to upsell citizens consumers, built right into the law. I mean, c'mon. Find me the guy who buys his condoms small, mkay?

NOTE *** For those who came in late, here's a Rube Goldberg device:

NOTE **** Incidentally, Obama himself admits he gets as much mail for single payer as he gets against ObamaCare. So it's not like he's unaware of single payer; he actively opposes it.

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