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ObamaCare Clusterfuck: Narrow networks and high deductibles aren't bugs. They're features

Interesting article from Trudy Rubin in CJR:

But it was a Dec. 18 Bloomberg View op-ed by Aaron Carroll, a professor of pediatrics at the University of Indiana and blogger at The Incidental Economist, that put the Great Cost Shift [on to your shoulders; what Obama calls "skin in the game"] most squarely on the table. Carroll dove right into the number one market-based solution—the high deductibles and other out-of-pocket costs consumers face as a trade-off for cheaper premiums. And he acknowledged the famous (in policy circles) RAND study from the 1970s, a randomized controlled trial that “showed that people who have plans with high out-of-pocket costs spend significantly less on health care.” This is the core justification for the cost-sharing shift.

OK. Very good to know, though it sure would be nice to know who, exactly, is in those "policy circles"; I'd guess a ton of Flexians.

There’s just one problem. As Carroll reminded readers, “that study didn’t just find that people respond to higher costs; it also showed that they sometimes respond by making bad decisions.” They couldn’t discriminate between necessary and unnecessary care. He concludes that trying to reduce overall costs with increased cost-sharing “might actually do harm.”

But "harm" to rent extraction, and what else matters?

Carroll strengthens his argument with several links to write-ups of research. There’s also a more recent RAND study—one the press largely failed to cover—that examined the relationship between high deductibles and healthcare spending and showed similar results to the first study. People in plans with deductibles of $1000 or more spent less on healthcare and consumed fewer services. But the cutbacks weren’t responsive to the details of the plans: patients with high-deductible plans used fewer preventive services, even though those services usually weren’t subject to the deductible. That meant, for example, fewer immunizations for children.

Meaning higher mortality among the poors, and greater profits later on with aftercare for those who catch the diseases immunization would prevent! It's a two-fer!

One way to look at this: shifting costs to patients might reduce overall spending, but it’s not clear it’s a good way to get better value for what we spend [although it's an excellent way to extract rents]. That’s not even getting into questions about fairness to chronically ill patients who really don’t have a choice to consume fewer healthcare services.

Right. And so what?

And we shouldn’t forget the report just about a year ago from the National Association of Insurance Commissioners, in the context of a debate over shifting costs to Medicare patients, that concluded: “We were unable to find evidence in peer-reviewed studies or managed care practices that would be the basis for nominal cost sharing to encourage the use of appropriate physicians’ services.”

"Appropriate" in what sense? Why not just optimize for profit and have done with it? Profit, we can measure! (It's the old neo-liberal scheme of "Pick the metric, and the nudging will follow!")

In his op-ed, Carroll takes his argument in a political direction, pointing out the contradictions in newfound Republican complaints about high deductibles in “Obamacare” plans—it was conservative think tanks, after all, that pushed these plans for years as a solution to the cost conundrum. Undoubtedly, reporters will track the politics of the Great Cost Shift as it surfaces as an election issue for the 2014 midterms.

But the more challenging and arguably more relevant story is how consumers who bear the burden of the shift respond—and how their responses affect both their health and the healthcare system. Will spending go down? Will there be side effects? Is this another form of rationing care by price? And is that the choice the public prefers? There’s plenty to explore here.

Well, hopefully they'll respond not as "consumers," but as citizens!

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Alexa's picture
Submitted by Alexa on

Carroll is being facetiousl

Naturally Repubs will make hay out of Dems sticking it to the American People!

I've heard one of the Heritage Foundation "dudes" whose initial policy was supposed to be the basis for RomneyCare and ObamaCare.

Their version was not one with "comprehensive" policies--all were bronze-type plans.

I don't believe that they were subsidized, IIRC.

That's the reason for HSA's.

Unfortunately, I believe that the "horse is out of the barn."

Now that the SCOTUS has upheld the "individual mandate" tax, I can't imagine that within my lifetime (if ever), lawmakers will actually have the gumption to pass a single-payer plan.

If one reads the ACA, it becomes very apparent that much of our "entire" public health systems, as well as the private insurance market AND employer-sponsored health plans have been radically changed in so many aspects that it would NOW take another gargantula legislative effort to UNDO this fiasco called the ACA.

Does anyone really believe that there are any lawmakers up to that task? (I mean really?)


Submitted by lambert on

... but it can be replaced! That, I am convinced, is doable. It does require delegitimizing a big part of the Democratic Party, but they are doing a great job of that.

Alexa's picture
Submitted by Alexa on

and have been calling for "repeal and replacement" of the ACA for almost a year.

But, until and unless "liberal activists" turn around, and I mean soon, the Democratic Party's plans (straight from the pages of the Fiscal Commission's proposal) to pass a massive and major "overhaul" of the federal personal and corporate income tax system--there will NOT be the funding available to finance MFA.

Heck, they claim that there's not the funds for this now. Just wait until they lower corporate tax rates to 25%.

And, even worse, achieve lowering the marginal tax rates on "the wealthy" to anywhere from 23% (I believe that this is about the "low ball" rate from B-S) to 30% (Buffet Rule).

We haven't even begun to see "entitlement cuts"--and they are being made to PAY FOR THESE TAX CUTS!

It's no secret--it's in "The Moment Of Truth."

(I really do appreciate any efforts toward obtaining MFA. But unless we can stop the tax overhaul, I simply cannot see this as a serious possibility, any time soon.)

BTW, heard earlier on Sunday Talk Show that we've so far missed the 7 million target by 5.9 million.

It will be interesting to see how Dems spin this!

Submitted by lambert on

... among the usual suspects to the effect that "single payer is impossible." Of course, they're lying, and if it were truly impossible they wouldn't even bother to say anything. So we are gettting to them, and that is good.

* * *

To the larger point, I think sequencing like that is like trying to play 11-dimensional chess. We really have two interacting goals: (1) MFA and (2) progressive taxation (not, as MMT teaches, to "pay for" any programs, since taxes do not fund spending, but to prevent the rich from buying the State with their loose cash, and to prevent the development of an aristocracy of inherited wealth). So advocate for policy first, last, and always IMNSHO.

Alexa's picture
Submitted by Alexa on

not an "impossibility"--just not plausible, any time soon.

Honestly, I'm not sure which "usual suspects" that you're referring to (Krugman, etc.?).

But I don't think that any of them fear, or are even the least bit concerned about, the influence of the Dem Party Base.

By defending the ACA--and trying to "put lipstick on a pig," they are simply trying sell the ACA in an attempt to positively engage and energize the Dem Party base for the midterms, and beyond.

Turnout for midterm election has been historically low for the Dem Party (as you know).

Many pundits are predicting pickups for Repubs in the House and Senate.

A few believe that Repubs will regain the Senate--more seem to think that they will fall short by a couple of seat, but make gains.

So I interpret the tamping down of single-payer efforts, partly, just the usual DNC/DLC/Dem Party propaganda.

BTW, I hope that I can get some of the DLC founder's video clips up in the next month or so.

You could call his interview a sort of "victory tour."

Again, unless someone can throw out the neoliberals in both parties--especially in the Democratic Party, since they have TOTAL control of the Party, unlike Repubs who actually have a (Tea Party) Populist Base that has to be reckoned with, I cannot see any advances in the passage of MFA.

But maybe I'm wrong. If I am, "it will be a relief, not a regret."


Submitted by lambert on

... is to constantly point out the suckitude of ObamaCare (which many of them will experience for themselves in any case).

Of course I'm not starry-eyed about prospects, but everything is impossible until it isn't. Meanwhile, I don't see any reason to propagate narratives of powerlessness that don't work in my interest; there are many others who are very well paid to do that, so the "wise fools" do what they are paid to do.

Adding, again, that if the Kleins of this world were feeling no pressure, they would be silent on single payer. But they are not silent; they deploy the "not politically feasible" card instead. Ergo, they feel pressure. I see no reason to take the pressure off them by reinforcing their narrative.

Alexa's picture
Submitted by Alexa on

pointing out some weaknesses of the ACA won't propagate a narrative of powerlessness.

Certainly, this is not my goal.

I approach this and other policy issues as an "Independent"--since the 2004 Democratic Party debacle that led to Democratic Party candidates Kerry and Gephardt (who was a DLC founder)--"joining hands" to defeat a non-DLC candidate.

So my engagement in the political process is both policy- and ideologically-driven (for good or ill), as opposed to party-driven. Although for years, I was pretty much a Yellow Dog Democrat.

I am truly convinced that until we the Democratic Party of its neoliberal ideology (including "plucking the vine" of all corporatist Dems)--many of the issues and goals that liberals care about, are unattainable.

I don't think "Little Ezra" is feeling a whole lot of pressure from the Left. A casual reading of most progressive blogs--to its credit, excluding Corrente--pretty much demonstrates that most bloggers are "afraid not to vote for Dems," no matter how much they are used and abused. (Not to say that this pertains to you, Lambert.)

And the Democratic Establishment reads blogs and knows this, as well.

They are simply trying to get "the Left" to quit giving fodder to the Repubs (and some of the Dem talking heads may actually fear the Right) to use against the ACA--because they fear (and rightfully so) that this may harm them in 2014 and 2016.

When I post the "gloating" videos regarding the DLC takeover of the Dem Party, I think (or hope) that my opinions expressed will make a little more sense.

Listening to C-Span has really been an eye-opener.

The PtB in both legacy parties truly have no sense of shame. And their manipulation of their respective Party bases, knows no bounds.

[I keep swearing that I'm going to quit watching--but I'm hooked, LOL!]

Submitted by Dromaius on

South Carolina and Missouri are on the fast track to neuter Obamacare. In SC at least, the plan is to reimburse citizens for any penalties they pay for not carrying insurance. Other ickynesses are also in the works, such as neutering people's abilities to get subsidies, etc.

Google South Carolina and Obamacare, or Missouri and Obamacare. The links are to right wing sites, but the facts are true.

I would not be at all surprised to see other Republican states following suit. Of course, the effective goal is to make things worse for us, not better.

Alexa's picture
Submitted by Alexa on

I'll take your word for it, Dromaius.

It goes back to what I said earlier--Repubs won't repeal the ACA--just neuter it.

There are several pieces at the Heritage Foundation website that lay out their "original" proposed "individual mandate" plan.

It was a basically CDHP.

And I've not read it in a while, but I don't believe that they intended to subsidize the program.

But Dems should have known that it was always possible, once they passed the individual mandate, that Republicans would gain power--an "absolute," eventually--and either diminish or strip the subsidies out of the program.

Which was one of several reasons that our regional coalition was against the individual mandate from the get-go!

Of course, according to one of the DLC Founders, the only option other than "socialized medicine," was the individual mandate.

My question is: "When did MFA as we know it in the US, become socialized medicine?"


Alexa's picture
Submitted by Alexa on

It was mentioned on Sunday Talk Shows that Republican Senator Ron Johnson (WI) recently conceded that "the ACA is no longer a piece of paper that can be repealed."

He has an excellent point--especially since it has been woven into ALL of our public health care programs AND the private insurance market, both individual private and employer-sponsored insurance.

But the real point of his statement, IMHO, is that many (corporatist/mainstream) Republicans are NOT interested in repealing the ACA--and never have been.

Just as DLC/corporatist Dems "manipulate" the Dem Base, so do Repub politicians.

Most of what we hear from Republicans (aside from a few Tea Partiers) is for the benefit of their conservative base--just talking points and "BS."

I don't believe for a minute that the ACA will be "overturned" if Repubs were to take power in 2016.

Subsidies might be diminished--or cut out entirely--but ideologically, just like the business-friendly conservative SCOTUS--the Republican Party has accepted that this is "the law of the land." (and secretly applaud it)

Why would either legacy party overturn this authoritarian legislation?

The ACA was a master stroke for neoliberals in both parties!

Submitted by Dromaius on

My right wing brother actually said last night that he wished we had socialized medicine. He claimed that Obamacare was supposed to be socialized medicine. I reminded him of the several times I told him that his right wing talk radio buddies were lying about that notion.

I should mention that this conversation took place when I called to update my advance directive with him, for January 1, 2014 when I run "naked" with no medical (not health) insurance. I have added to my directive that if I am unconscious during an emergency, I do not even want emergency care that will incur high expense (an amount which I've named, and used the term "usual and customary" to describe)....and that, my friends, is what "health care" means to me. Future employers can use medical bankruptcy to determine eligibility for hire. I figure I'm better off dead than unemployable.

Alexa's picture
Submitted by Alexa on

Oh, there will be some Repubs in favor--no doubt.

Mr. A and I know more than a few VERY Republican small business owners who DO want a single-payer system.

But, just as the ultra conservative (but business frirendly) SCOTUS allowed the "individual mandate" tax (and they are supposedly avidly anti-tax), many mainstream, business-friendly corporatist Republicans WANT the ACA, for the same reasons as our DLC/Corporatist Dems have fought tooth and nail for it--to pander to big and small business!

The heck with what "the little people" think or want!

Even both of our Republican Senators support the ACA. It is really mostly the loud but boisterous Tea Party Repub lawmakers who purport to be against the ACA.

And again, much of this is to pander to the Repub Base that they are terrified of (due to primarying).

Of course, this is just my take . . .

Submitted by lambert on

I've had success framing single payer as "something a 'small State' should do" (and the State should be smaller, because it's grotequely swollen imperial apparatus should be shrunken drastically).

"Just think of it as consolidating the back office operations to maximize purchasing power -- and putting doctors back in charge of practicing medicine."

Submitted by lambert on

... they'd be advocating tax resistance (which the law prepares for, in fact, by saying that the IRS can't put a lien on you for not paying the ObamaCare penalty).

So they aren't serious.

Submitted by cg.eye on

If people who barely earn enough to cover expenses per paycheck are forced into high-deductible plans, where are they going to find the money to cover basic medical expenses before the deductible kicks in? It's like McDonald's giving advice on tipping the help -- a feature of their now-defunct website most likely designed for their middle-managers -- when the majority of their employees qualify for public assistance.

Under high-deductible plans, preventative care -- not screening, care -- is still out of reach. With the bonus of the 1% calling the insured lazy, shiftless, etc. for not taking care of themselves, it's a formula for slow-motion domestic ethnic cleansing.