It Could Be Worse
October 22, 2013 4:49 AM   Subscribe

I signed up for an account on Healthcare.gov last week. It wasn’t the smoothest process, but I was able to create an account. Some parts are slow; sometimes you have to reload a page to make progress. But it’s starting to work. It will be fixed, because it has to be. And now that the launch and inevitable crash has finally happened, in a way the worst is over. Real-world traffic is providing programmers all the debugging data that they could ever want, and “all bugs are shallow with the president watching,” as Paul Ford writes in Bloomberg Businessweek, paraphrasing the open-source-software advocate Eric Raymond’s assertion that “with enough eyeballs, all bugs are shallow.” -- Rusty Foster in The New Yorker
posted by jim in austin (585 comments total) 18 users marked this as a favorite
 
MeFi's own!
posted by jquinby at 4:57 AM on October 22, 2013 [5 favorites]


"It could be worse" is like my own personal motto. That's what gets me out of bed in the morning. That, and "This too shall pass."
posted by RedOrGreen at 5:05 AM on October 22, 2013 [14 favorites]


Not to worry...The RNC is on it. I'm sure they have nothing but the best interests of the American people in-mind.
posted by Thorzdad at 5:07 AM on October 22, 2013


Dave Weigel had a great idea the other day. Obama should fire Sebelius and hire the guy who successfully implemented a similar program in Massachusetts.
posted by (Arsenio) Hall and (Warren) Oates at 5:09 AM on October 22, 2013 [3 favorites]


How Politics Set The Stage For The Obamacare Website Meltdown

I also heard it mentioned on NPR this morning (but can't find a link to it) that a large number of visitors to healthcare.gov are actually just window-shopping; i.e. people who already have insurance but want to check out the alternatives available to them now. So this strikes me as more evidence that the problems with healthcare.gov stem from it being more popular than expected.
posted by TedW at 5:13 AM on October 22, 2013 [6 favorites]


"It could be worse" is like my own personal motto. That's what gets me out of bed in the morning. That, and "This too shall pass."

If you just take the step to "The nature of life is to be unsatisfactory" and "All things are transient," you are almost at Buddhism!
posted by GenjiandProust at 5:20 AM on October 22, 2013 [26 favorites]


the biggest contractor, CGI Federal, was awarded its $94 million contract in December 2011. But the government was so slow in issuing specifications that the firm did not start writing software code until this spring…. As late as the last week of September, officials were still changing features of the Web site.

Which makes it like every single software project that I've ever worked on. Often with similar outcomes.
posted by octothorpe at 5:21 AM on October 22, 2013 [41 favorites]


"The president's statements in support of [Secretary of Health and Human Services Kathleen] Sebelius seem awfully, eerily similar to George W. Bush saying [ to then-FEMA director Mike Brown] 'Brownie, you're doing a heckuva job' during Katrina. And to say this is rollout is much different than Hurricane Katrina, they're very similar." - Rep. Tim Huelskamp (R - KS),

I try to be an openminded person, but why Republicans keep shooting themselves in the foot by saying things like this, I will never know.
posted by roomthreeseventeen at 5:23 AM on October 22, 2013 [5 favorites]


If the main contractor CGI Federal was a competent organization run by ethical people - or even an organization solely focusing on its own preservation and reputation - they would have walked away from this contract as even inexperienced developers could have foreseen the train wreck before the train even left the station. But CGI are solely in the business of making money and if they have to defraud taxpayers out of a couple of billions then so be it.

I bet the next scandal involving CGI Federal and Healthcare.gov will be about outrageous consulting and support fees that will cost taxpayers hundreds of millions of dollars. Pretty standard business practice when BigCorp does IT consultancy.
posted by Foci for Analysis at 5:24 AM on October 22, 2013 [6 favorites]


I try to be an openminded person, but why Republicans keep shooting themselves in the foot by saying things like this, I will never know.

Lack of gun control. That, and some notable members being fucking stupid and intellectually dishonest.
posted by MuffinMan at 5:26 AM on October 22, 2013 [10 favorites]


As late as the last week of September, officials were still changing features of the Web site.

That almost sounds like heaven, submitting final changes three weeks before launch, instead of three weeks after.
posted by Brandon Blatcher at 5:26 AM on October 22, 2013 [11 favorites]


"It could be worse" is like my own personal motto.

A friend's comment, on finding his basement flooded with 5 feet of water after an unusual storm, chest freezer floating on its side, still humming as TV dinners bobbed around it like paparazzi, the furnace, water heater, washer and dryer all ruined, was "It's just more work."
posted by jon1270 at 5:29 AM on October 22, 2013 [11 favorites]


I ignored the website for the first couple of weeks - I figured it would be mobbed. A brand-new super-controversial website? I'm sure there were thousands of people just wanting to take a look.

I finally created my account a couple nights ago, around 11:00pm Eastern. It took about five minutes.

I wonder how long it will continue being a GOP talking point: Remember when you went to the Obamacare website and it was real slow? FOR A FEW DAYS? BACHMAN 2016!

But I'll always remember that the GOP alternative to Obamacare was: Fuck you. We're shutting down the government. Can't afford a doctor? Fuck you, get rich.
posted by Cookiebastard at 5:31 AM on October 22, 2013 [118 favorites]


So this strikes me as more evidence that the problems with healthcare.gov stem from it being more popular than expected.

It was a website that was going to have massive load on day one. Those almost never go well. There are websites that handle massive load just fine, all of them *grew* to that load, and I'm pretty sure all of them had massive code rewrites, including complete re-implementations, to handle the increasing load.

Basically, the healthcare exchange opened to Slashdot levels of load, and it wasn't ready. Of course, it was also the usual outsourcing leading to finger-pointing nightmare, but that's another issue. But it's rare for anything but a government based site to get this sort of opening anymore. Commercial sites get soft opens, beta periods, and so forth. I can't think of another site that had to open to the levels of load that healthcare.gov had to open with.

Big Load is a hard problem, and everyone things they have the answer. Then they meet their particular version of Big Load, and they realize that they don't know. Then they hire someone who has. Then that person realizes that while they understand how to handle their Big Load, this Big Load is very different.

But there is a general rule. If you're using SQL, you're probably screwed. You can do big load with SQL, but only with superbly built data models and superb code. If your website developers are building your data model, you're almost certainly going to lose.
posted by eriko at 5:31 AM on October 22, 2013 [29 favorites]


The funny bit (for some definition of 'funny') is that the entire exercise of shutting things down was to derail AHCA, but plenty of hay could have been made on the rockiness of the opening weeks of enrollment. Instead, the shutdown grabbed the headlines and the bugs are slowly getting ironed out, sort of. The GOP has once again demonstrated flawless execution in stepping on its own dick.
posted by jquinby at 5:34 AM on October 22, 2013 [7 favorites]


Which makes it like every single software project that I've ever worked on. Often with similar outcomes.

As someone on my twitter feed wrote, keep all the client emails lest, "We didn't ask for that" be a terminal client mind-change.
posted by Slackermagee at 5:35 AM on October 22, 2013 [2 favorites]


But there is a general rule. If you're using SQL, you're probably screwed. You can do big load with SQL, but only with superbly built data models and superb code. If your website developers are building your data model, you're almost certainly going to lose.

This pretty much sums it up perfectly. I do really wonder how strenuous of a "load" test they did on this prior to go-live.
posted by playertobenamedlater at 5:38 AM on October 22, 2013


Slackermagee: "As someone on my twitter feed wrote, keep all the client emails lest, "We didn't ask for that" be a terminal client mind-change."

I did a short contract stint at GE a few years back and learned very quickly that whoever has the most complete paper trail wins. Soon as our group came under the gun for missed milestones during a proverbial come-to-Jesus meeting, our lead pulled out the paper trail and absolutely eviscerated the GE folks, point by point, complaint by complaint. It was supremely delicious.
posted by jquinby at 5:39 AM on October 22, 2013 [12 favorites]


The site is poorly laid out. I had to spend hours to find the link to report an Undesirable to the DeathPanel.
posted by dr_dank at 5:39 AM on October 22, 2013 [42 favorites]


"with enough eyeballs, all bugs are shallow"

By the way, this is one of the many fallacies of software development. The assumption behind it is all eyes are perfectly competent, given enough time, therefore, with enough eyes, you'll find enough eyes that are competent enough in a short time to spot all the bugs.

In fact, research shows that the rate of bug discover doesn't scale linearly with the number of reviewers. The first few reviewers will find the most bugs, each additional one finds fewer and fewer -- and, of course, every hour someone is reviewing code for bugs is an hour you are not creating code. And, of course, since the number of eyes that understand a given bit of code (and thus, could spot the bug) is finite, it is then provable that a bug may be too deep to spot until a test case is presented.

This is why functional teams only have a couple of people doing this. The point of writing software isn't discovering bugs, it's writing software.
posted by eriko at 5:41 AM on October 22, 2013 [10 favorites]


This pretty much sums it up perfectly.

I suspect the load went...

1+1+1+1+100000000000000SYSTEM HALTED
posted by eriko at 5:41 AM on October 22, 2013 [2 favorites]


It will be fixed, because it has to be.

That's the epitaph of many a failed project. The fact that something is necessary doesn't mean it is possible.
posted by Chocolate Pickle at 5:42 AM on October 22, 2013 [2 favorites]


On September 11, 2001, the F.B.I. was still using a computer system that couldn’t store or display pictures; entering data was time-consuming and awkward, and retrieving it even more so.

If Edward Snowdon's revelations are accurate, it seems like they fixed all that pretty quickly and there is no reason to think that throwing a few billion taxpayer dollars at Healthcare.gov won't result in the same improvement.

But Obama should be happy for the technical glitches. Overjoyed. Because the real test isn't if people who need healthcare sign up - the real test is if tens of millions of young, healthy people who don't need healthcare sign up - before the threatened penalties kick in. Right? Obama needs a few hundred healthy people to sign up along with every pre-existing condition otherwise the system explodes in a financial melt-down. When this does not happen - what 25 year old wants to make an extra car payment every month? - Obama will be happy to blame it on technical problems.

If the technical problems are all solved by 2016 the IRS will have millions of young people facing fines and penalties and Democrats are going to own that problem 100%.
posted by three blind mice at 5:42 AM on October 22, 2013 [1 favorite]


I was admittedly one of the early rubberneckers who persisted until I finally got on. My immediate reactions were: "Throw more hardware at it.", "Victims of their own success." and "I don't even want to know what kind of arcane data and hardware deep in the federal bowels they're having to access with this thing."
posted by jim in austin at 5:49 AM on October 22, 2013 [2 favorites]


The Daily Show with Jon Stewart: glitch
posted by Mister Bijou at 5:51 AM on October 22, 2013 [2 favorites]


I was sad to see that the contractors used open source code called DataTables after stripping off the required licensing information.

Guys, guys, come on. Using other people's software when it's better than what you could write yourself is sensible and is awesome, but trying to act like you didn't is shameful (at best).
posted by wenestvedt at 5:56 AM on October 22, 2013 [6 favorites]


When this does not happen - what 25 year old wants to make an extra car payment every month?

You still have to pay the fee.
posted by vacapinta at 5:56 AM on October 22, 2013




When this does not happen - what 25 year old wants to make an extra car payment every month?

Were you ever in your life 25? A car payment for real healthcare? Shit, yeah! It's when it costs a rent payment and covers next to nothing and you're going to be kicked off the first time you get really sick or hurt that 25 year olds decide to do without.

I mean, hellfire, you ever actually, you know, talk to a fit and strong 20-something? Their friends are all fit and strong, and they know people who have had horrific fucking injuries. Fit and strong people have risk profiles that tend toward broken bones, torn tendons and muscles, abrasions, contusions, concussions and that thing with the shoulder that never goes away since they pushed that bench-press or fell off their fixie or slipped on the rock wall or dove for the catch. Everyone knows someone who got sent to the ER, and how much it put them on the hook for.

So, the mythical 25 year old who eschews signing up for healthcare is a completely fit and healthy male couch potato who's never been worried by a serious bout of the flu. Not a terribly large demographic, I'm afraid.
posted by Slap*Happy at 6:03 AM on October 22, 2013 [28 favorites]


I was a young and healthy 25 year old at one point and I would have jumped at the opportunity to purchase affordable health insurance. My girlfriend and I got married around then largely so that I could get on her job's policy and that didn't really turn out well.
posted by octothorpe at 6:04 AM on October 22, 2013 [8 favorites]


what 25 year old wants to make an extra car payment every month?

"According to the survey, a large majority of California’s eligible uninsured1 – eight in ten – do feel they need health insurance coverage. Even seven in ten (72 percent) of the youngest uninsured Californians – those ages 19 to 25 – say they need health insurance."

Emphasis mine. Disclaimer: I work for this place, but not on the policy or polling side.
posted by rtha at 6:04 AM on October 22, 2013 [7 favorites]


New York Times:
One major problem slowing repairs, people close to the program say, is that the Centers for Medicare and Medicaid Services, the federal agency in charge of the exchange, is responsible for making sure that the separately designed databases and pieces of software from 55 contractors work together. It is not common for a federal agency to assume that role, and numerous people involved in the project said the agency did not have the expertise to do the job and did not fully understand what it entailed.

...

According to one specialist, the Web site contains about 500 million lines of software code. By comparison, a large bank’s computer system is typically about one-fifth that size.
posted by BobbyVan at 6:05 AM on October 22, 2013 [2 favorites]




I walked through the application with my SO. Early in the process we hit a couple seeming dead ends where everything just hung up. After repeated attempts, we did get through. It's not the smoothest or most intuitive system, but as someone I work with noted, have you tried buying insurance on an insurance company website recently? In terms of process design, it's certainly no easier. Part of it is just that many people have not had that experience, so there's no direct comparison.

But I also think it's prone to user error. Some of the "submit" buttons, as I recall, weren't that obvious, and the form field entries were a little tricky too. I was hoping that libraries or community groups were organizing an effort to assist people in signing up, because I think a ton of the problem might just be due to user error meeting a clunky and somewhat confusing interface. Though it's clear there are technical problems, too.
posted by Miko at 6:09 AM on October 22, 2013 [2 favorites]


> "It could be worse" is like my own personal motto.

A friend's comment, on finding his basement flooded with 5 feet of water after an unusual storm, chest freezer floating on its side, still humming as TV dinners bobbed around it like paparazzi, the furnace, water heater, washer and dryer all ruined, was "It's just more work."


Daniel Radcliffe's father would always tell him, if he ever was grumbling about work, that "well, at least you're not working down in a mine."
posted by EmpressCallipygos at 6:21 AM on October 22, 2013 [5 favorites]


These young people you speak of? Are any sexually active females?

In my early career as a young woman who was having the sex, even during the time I was getting the pill for free as a guinea pig, heathcare was important to me.
posted by Lesser Shrew at 6:29 AM on October 22, 2013 [15 favorites]


My phrase is "Life is hard." It serves me well as a catch-all.
posted by Pope Guilty at 6:30 AM on October 22, 2013


It could be worse!
posted by Chocolate Pickle at 6:31 AM on October 22, 2013


Dave Weigel had a great idea the other day. Obama should fire Sebelius and hire the guy who successfully implemented a similar program in Massachusetts.

Part of the problem, I think, is that this system has to interface with every other state exchange's system, unless the state (like mine) doesn't have its exchange site up yet. I don't know enough about the site to know what it's doing, but that's a lot of interfaces to widely distributed external systems. That's not an easy thing.

Also, there have been some weird comments in the press from some of the folks doing the work on the site. As TPM recently covered, a NYTimes article quoted one of the "specialists" as saying as many as 5 million lines of code need to be rewritten to get the system working properly. (That's a highly suspect number, but even more suspicious, the "specialist" apparently went on to claim the codebase for the site was 500 million lines of code--which would make it larger by a factor of ten than most operating systems and is quite obviously a bullshit number; for comparison, I think Windows XP is only like 35 million lines of code.) The contractors may not be playing straight.
posted by saulgoodman at 6:32 AM on October 22, 2013 [10 favorites]


I am 26 y.o. uninsured male, I need insurance. I commute by bike and I am terrified of what would happen if I get in an accident before Jan. 1.
posted by wikipedia brown boy detective at 6:33 AM on October 22, 2013 [8 favorites]


If your website developers are building your data model, you're almost certainly going to lose.

+1...alas, the newb script kiddies with whom I am accursed...
posted by j_curiouser at 6:39 AM on October 22, 2013


I've been working in public school IT for 15 years. This is typical of top down tech decision making. Top brass gets sold crap tech with literally no support. It all collapses and all the main decision makers are exempt from accepting responsibility. No one gets fired, everyone gets raises...
posted by judson at 6:45 AM on October 22, 2013 [6 favorites]


I also heard it mentioned on NPR this morning (but can't find a link to it)
posted by jon1270 at 6:45 AM on October 22, 2013


The One Disheartening Number That Suggests HealthCare.gov Will Not Be Fixed Anytime Soon
OK, so the site is gargantuan, as measured by lines of code. These numbers are clearly meant to underscore the enormity of the task at hand in building (and fixing) a site the size of Healthcare.gov. But the software developers I’ve talked to see it a little differently. If the site really contains 500 million lines of code, they say, that’s a strong hint that the programmers involved are doing something wrong. (Microsoft’s Windows Vista operating system, by the way, contained some 50 million lines of code, and was criticized for being slow and bloated at that.) And if they’re using the number of lines of code as a metric for progress and project scope, that may be indicative of serious dysfunction in the process.

Dan Check, Slate’s vice president for technology, puts it this way: “If you contract something out and get 500 million lines of code back, there’s no way it’s going to work correctly.”

Why? Because as Jeff Atwood, co-founder of the coding question-and-answer site Stack Overflow, wrote in 2006: “Here's the single most important decision you can make on your software project if you want it to be successful: keep it small. Small may not accomplish much, but the odds of outright failure—a disturbingly common outcome for most software projects—(are) low.”

Sure, big projects require more code than small ones. But my programmer friends tell me a number like 500 million suggests the Healthcare.gov contractors may be writing their own code in many places where they'd be better off relying on open-source external libraries. They may also be solving problems via copy-and-paste rather than more elegant programming techniques such as inheritance or polymorphism.
posted by BobbyVan at 6:53 AM on October 22, 2013 [1 favorite]


How Republicans Became Accidental Champions of Obamacare
Yes, it is awfully rich that Republicans and conservative commentators, after doing their utmost to undermine the Affordable Care Act these past few years, are now carping about the serious flaws in the Web sites set up to process applications for health insurance coverage. While the administration bears responsibility for the technological problems, there is no question that odds for success would have been greater if it had not been denied the funding it needed to set up such a complex new system, if it had not had to handle the new insurance exchanges in so many states that refused to build their own, and if it had not had to delay stages of the exchange construction to avoid political opposition. Then there’s the larger fact that the administration went with such a complex approach to expanding coverage precisely because of the political (and industry) opposition to the far simpler solution of Medicare-for-all single-payer coverage.
[...]
As many others have noted, Republicans and conservatives (other than a few not particularly vociferous policy wonks who now say they are rooting for Obamacare because it beats the alternative and that guy in Massachusetts who provided the model for the ACA) have never had developed a serious plan for this problem because so many of them do not see it as a problem. That they have now shifted toward seizing on the kinks in Obamacare should for this reason be taken as a sign of progress. Despite themselves and without fully realizing it, Republicans are perilously on the verge of becoming advocates for expanded health care coverage.
posted by zombieflanders at 7:02 AM on October 22, 2013 [1 favorite]


the IRS will have millions of young people facing fines and penalties and Democrats are going to own that problem 100%.

That's not a problem, that's the system working as it was intended to work. The fines will eat a portion of their refunds, or else they'll have to pay additional money to the IRS, which is something that happens to tens of millions of Americans every year. Why is this supposed to be different?

When I was 26 I got sick, and the health insurance I purchased through my graduate school covered nothing. I was on the hook for hundreds of dollars that I didn't have, and this was AFTER paying hundreds of dollars for worthless "coverage." I would've taken a real insurance policy at age 26 in a heartbeat, if I had the least idea of how to get one.
posted by 1adam12 at 7:02 AM on October 22, 2013 [6 favorites]


Yeah, I kept hearing the "oh noes, young people won't sign up, all is lost!" and as others have said, that doesn't remind me of any young people I knew.

Lots of young people may not use healthcare much, but many of them have seen their parents suffer for the lack of it, or older brothers and sisters. My parents suffered a medical bankruptcy while I was in college; my father had heart trouble, couldn't get coverage, then had a heart attack and died uninsured. My mom had to declare bankruptcy (which I think you can't even do now, right?) due to medical bills, which is a great thing to have to do while mourning your spouse of 35 years, let me tell you.

Lots of young people still start families, or have chronic health conditions, or disabilities, or are sexually active. Most of them are not so stupid they don't know what happens when things go wrong and you have no medical coverage.

I got through my uninsured 20s by keeping my fingers crossed and hoping for the best. I was lucky. I would much rather have had affordable insurance.
posted by emjaybee at 7:06 AM on October 22, 2013 [3 favorites]


what 25 year old wants to make an extra car payment every month?

the IRS will have millions of young people facing fines and penalties and Democrats are going to own that problem 100%.


Two new polls have good news for Obamacare
- Americans are confused about whether the insurance exchanges are working. The Pew poll found that 46 percent of Americans know the online insurance portals aren't working well. But 29 percent think they're working fairly or very well. And 25 percent don't know. So a majority of Americans either don't know how the exchanges are working or think everything is going fine. Given that the exchanges are working quite badly, that's good news for the law.

- People who use the exchanges like them. About one-in-seven Americans say they have tried using the exchanges. 56 percent found them easy to use. Three out of five people who've tried the exchanges were just curious about them.

- The uninsured want insurance. 65 percent of the uninsured say they plan to get insurance within the next six months. Those numbers are reflected in the visits to HealthCare.gov: Among the insured, 12 percent have visited the exchanges, and 19 percent plan to. Among the uninsured, 22 percent have visited the exchanges and 42 percent plan to. That's great news for the law. It's much easier to sign up people who want insurance than to sign up people who don't.

- A majority want the law to keep going. Obviously the 46 percent who approve of Obamacare in the Washington Post/ABC News poll want to see it implemented. But so do many of those who disapprove of the law. The result is that 66 percent want to see the law implemented.
posted by zombieflanders at 7:08 AM on October 22, 2013 [1 favorite]


I have healthcare through my job, and you know what? One of the main reasons I- as a dumb young person who totally doesn't have any awareness of her own mortality- would never have been willing to quit this job is because I am terrified of being uninsured. I'm not about to walk out the door on January 1st or anything, but now I know that I COULD do that and not have to be afraid of making the choice between a horrible untreated illness or life-long penury. So that's pretty cool.
posted by showbiz_liz at 7:15 AM on October 22, 2013 [17 favorites]


So a lot of the Republican's criticisms of the website seem to be a variation of Woody Allen's "The food is terrible—and such small portions!”. On the one hand they've been arguing that nobody wants this but at the same time, they're bashing the president because the website can't handle the crush of all the people who do want it.
posted by octothorpe at 7:17 AM on October 22, 2013 [10 favorites]


...because I am terrified of being uninsured...

Made even more terrifying if you checked what COBRA coverage would set you back...
posted by jim in austin at 7:21 AM on October 22, 2013 [2 favorites]


I wonder what Republicans would have said if the site had spent the resources to support a one-time spike in traffic. Something about wasting money overbuilding the system, no doubt.

The bigger the project, the more likely it is to have issues. I was part of the MassHealth rollout, and getting everything to work together was a nightmare. It's always fun when you ask for a report and get a printout generated from COBOL.

On top of that, you have myriad laws around data privacy and security. These laws generally don't keep up with technology; we pretty much had to chose from pre-certified vendors, and getting new vendors approved was a year-long process.

Anyway, Big IT is hard, and Big IT on government is even harder. There's nothing surprising or even extraordinarily incompetent about this rollout. Which is perhaps the most depressing part of the story.
posted by snickerdoodle at 7:22 AM on October 22, 2013 [7 favorites]


those who disapprove of the law...66 percent want to see the law implemented

This is the perfect encapsulation of two-faced conservative policy rhetoric
posted by Reasonably Everything Happens at 7:26 AM on October 22, 2013


the open-source-software advocate [me!]

Just wants to point out the scrubbing of Copyright notice. Which I'm rather sure violates law. Lets see how gutless the GPL (and the 3 clause BSD) licence is and the lack of action taken when Copyright is violated.

The company makes the software available to anyone under two open-source licenses, but says the licensing requires that the code contain a copyright notice. The copyright is in the opening lines of the software, an example of which can be found on SpryMedia’s website, but TWS says it’s not anywhere in Healthcare.gov’s code:

I've not read the 10,000 plus pages of the ACA but I wonder what other rights have been taken from Citizens. CAN-SPAM as an example does not allow natural born citizens to sue, only Corporations. Thus no non-lawyer is afforded the use of the courts to effect redress.
posted by rough ashlar at 7:30 AM on October 22, 2013


the codebase for the site was 500 million lines of code--which would make it larger by a factor of ten than most operating systems and is quite obviously a bullshit number

Yep. Although It's probably an accurate number if you include the entire software stack that it takes to run the site. I mean, any website probably takes millions of lines of code to run, if you include the website itself, the server software, the database, the operating system, device drivers, BIOS, microcode... I seriously wonder if that's where the number comes from.

"500 million lines of code!!!1! (of which we only wrote like 10,000 lines and it's where all the problems are)"
posted by Kadin2048 at 7:31 AM on October 22, 2013 [5 favorites]


Commercial sites get soft opens, beta periods, and so forth. I can't think of another site that had to open to the levels of load that healthcare.gov had to open with.

This is all 20/20 hindsight, but it seems like they could have designed slow-rollout to allow for testing and the like, at least for some portions of the system. Like, they could have allowed 100, then later 1000 people per day, or some other reasonable number, create accounts, verify their identities, and so some of that other preliminary stuff. Squash a lot of bugs and slowly ramp things up.

That wouldn't have allowed a true end-to-end ramp-up but it would have allowed more of a ramp-up of some parts of the system they had a lot of trouble with early on.

Still, I agree that this isn't an easy problem and if they have it fully operational and relatively glitch-free by even, say, November 15th that should be considered about par for the course.
posted by flug at 7:31 AM on October 22, 2013


There's nothing surprising or even extraordinarily incompetent about this rollout. Which is perhaps the most depressing part of the story.

yep - 'regular' incompetent.

I would bet that, for every significant issue, there is at least one email in the system from a senior-ish software engineer saying, "I really, really advise you not to do it that way."

I advise any curious journalist to quit going to the PR guys and execs, and start finding some mid/sen engineers who know the real story. And publish those emails.
posted by j_curiouser at 7:35 AM on October 22, 2013 [4 favorites]


I seriously wonder if that's where the number comes from.

I agree. 500 million smack of an ass-pull number. But if one includes the software stack of the site plus the software stack of each and every other firm that interfaces with, well....now I can understand how the number was obtained. I'd just like to see the "proof of work" used to arrive at the number.

"500 million lines of code!!!1! (of which we only wrote like 10,000 lines and it's where all the problems are)"

Other than when someone else made a mistake in their code or documentation and you did it right.
posted by rough ashlar at 7:35 AM on October 22, 2013


If they had tried to do a slow roll-out, the same people who screamed about "rationing healthcare [i.e., death panels]" would have screamed about "rationing access to healthcare."

That said, I would have tried to do a state-by-state roll-out or something -- anything -- besides their "big bang"approach.
posted by wenestvedt at 7:35 AM on October 22, 2013 [2 favorites]


Just wanted to chime in and reiterate that COBRA is ridiculous. My SO and I paid over $17,000 in the year and a half she was unemployed. As someone with a job (read: insurance) and is aware of exactly how much my company pays towards my healthcare, it would have taken me almost 10 years to hit that number... but with COBRA we did it in 18 months.
posted by Blue_Villain at 7:35 AM on October 22, 2013 [2 favorites]


Yep. Although It's probably an accurate number if you include the entire software stack that it takes to run the site.

It obviously interfaces with a lot of other federal government systems--the IRS, whatever they are using to verify your identity, maybe immigration, and who knows what else. Plus it interfaces with all the various states that have their own healthcare exchanges. And all the various insurance company systems.

My guess is someone made an estimate of all the various systems the exchange depends on, adding up a whole bunch of estimated line number totals.

I mean, 500 million is a nice big round number, some kind of ballpark estimate, not output from wc -l . . .
posted by flug at 7:39 AM on October 22, 2013 [1 favorite]


Well, Healthcare.gov is coming along better than the Collaborative Media Foundation, I'll give it that.
posted by entropicamericana at 7:39 AM on October 22, 2013 [2 favorites]


I have had healthcare through my job since May of 1997, when I was a young dumb person well aware of my morality. They were self-insured, and several people reported to me that they had not been given raises one year because they had been told, explicitly, that their medical expenses that year had been too high (had a baby, emergency gallbladder surgery). At that point I had nothing to lose and taped my review - I got a dollar an hour raise. I told my coworkers that, and it turned out they were all making at least a dollar less than me except the guy who had just had twins (and he got a raise - he was on his wife's insurance) and my manager.

Most of them left within a few months of my leaving, even with 5+ years working there.

Next job insurance started right away! No gap! Yay! I stayed a few years, things started looking iffy, so I quit. Time to pay Cobra. $1000s range. Talked to BCBS. $250 a month for basic insurance, $500 or so more a month to include pregnancy. I honestly don't remember what I did, probably the $250 and tripled up on birth control (thank you, Planned Parenthood). One of my co workers stayed on, was hospitalized for emergency surgery and recovery, and found out after the fact the company had recently stopped paying health insurance coverage while telling the employees they were paying it.

Next job I kept for a double handful of years, more or less, popped out my babies. Laid off in the Great Recession, paid Cobra, then went on shitty insurance through my spouse.

Now I have supercalifragilistic insurance again. Yay! I got a call out of the blue the other day for a new position with some old co workers making 35% more than than I make now.

My first inclination was to turn it down, because I'd have to be a contractor for six months and I didn't want to have to be without decent health insurance. Now maybe I wouldn't have to - but I think (I'd have to research) I could go ACA all the way and then get on full time and back to supercalifragilistic coverage again. If not, well, I could survive six months on shitty spouse insurance, I expect.
posted by tilde at 7:40 AM on October 22, 2013 [4 favorites]


How much have the US Taxpayers spent to get this non working site? At this rate the HHS Secretary can only count hits and accounts rather than enrollees? Sure, you should be angry and be able to answer simple John Stewart questions. A typical government production aiming for Mars at whatever the costs, but if this were a rocket launch it would be cancelled and scrubbed a long time ago. Throw more money at the problem and feed the Republicans budget I told you so wackjobs until some type of accountability is shown, which I'm sure will result in a resignation before March.
posted by brent at 7:42 AM on October 22, 2013


But there is a general rule. If you're using SQL, you're probably screwed

Huh. So what SHOULD one use?
posted by shothotbot at 7:46 AM on October 22, 2013 [1 favorite]


The Washington Post has a good piece today on the testing leading to the troubled launch of healthcare.gov.
Days before the launch of President Obama’s online health ­insurance marketplace, government officials and contractors tested a key part of the Web site to see whether it could handle tens of thousands of consumers at the same time. It crashed after a simulation in which just a few hundred people tried to log on simultaneously.

Despite the failed test, federal health officials plowed ahead.

When the Web site went live Oct. 1, it locked up shortly after midnight as about 2,000 users attempted to complete the first step, according to two people familiar with the project.

...

The Centers for Medicare and Medicaid Services (CMS), the federal agency in charge of running the health insurance exchange in 36 states, invited about 10 insurers to give advice and help test the Web site.

About a month before the exchange opened, this testing group urged agency officials not to launch it nationwide because it was still riddled with problems, according to an insurance IT executive who was close to the rollout.

“We discussed . . . is there a way to do a pilot — by state, by geographic region?” the executive said.

It was clear at the time, the executive said, that the CMS was still dealing with the way the exchange handled enrollment, federal subsidies and the security of consumers’ personal information, such as income.

One key problem, according to a person close to the project, was that the agency assumed the role of managing the 55 contractors involved and had not ensured that all the pieces were working together.

Some key testing of the system did not take place until the week before launch, according to this person. As late as Sept. 26, there had been no tests to determine whether a consumer could complete the process from beginning to end: create an account, determine eligibility for federal subsidies and sign up for a health insurance plan, according to two sources familiar with the project.


(of which we only wrote like 10,000 lines and it's where all the problems are)

FWIW, in the same New York Times article:
One specialist said that as many as five million lines of software code may need to be rewritten before the Web site runs properly.
posted by BobbyVan at 7:47 AM on October 22, 2013 [4 favorites]


These young people you speak of? Are any sexually active females?

For hetero ladies who aren't relying on condoms as contraception, yeah, this. Last I checked birth control is only free (thanks Obama) with a perscription AND insurance (and without can run to a few hundred a year, depending). And in most cases,* you're not going to get that perscription without seeing a doctor first. Generally at least yearly. Not Getting Pregnant, it turns out, is kindof expensive and almost worth the cost of healthcare by itself.

*long live planned parenthood
posted by likeatoaster at 7:48 AM on October 22, 2013 [12 favorites]


How much have the US Taxpayers spent to get this non working site? At this rate the HHS Secretary can only count hits and accounts rather than enrollees? Sure, you should be angry and be able to answer simple John Stewart questions.

But public officials are not accountable - esp. once one gets a couple of levels down from the head in a bureaucracy.

So what SHOULD one use?

If you hate SQL, something else. RavenDB is popular with the "NoSQL" crowd. But something like Name, age, smoking, State et al are fine for SQL unless the If you're using SQL, you're probably screwed wants to explain exactly HOW their statement is correct.
posted by rough ashlar at 7:51 AM on October 22, 2013 [3 favorites]


In my early career as a young woman who was having the sex, even during the time I was getting the pill for free as a guinea pig, heathcare was important to me

This. For me, the Pill:

$900/year without insurance
$420 with.

That's just the script cost, and that's from before copays were ruled out. That doesn't include the the annual appointment you need to have to keep your prescription active ($120 without insurance, $20 copay with), the annual Pap smear ($150 without insurance, $20 with), and any followups for complications/abnormal Paps/colposcopies, of which I had a couple. Then, too, a lot of people need fairly frequent GYN consultations to adjust/adapt their birth control method, whether it's checking to adjust dose or medication mix, or trying other approaches like the IUD or implants. Also, if you do end up pregnant, no matter what you decide to do you're going to want medical access at a controlled rate. Even with the massive improvements Obamacare has offered in coverage for women, it's still kind of a no-brainer for sexually active women.
posted by Miko at 7:52 AM on October 22, 2013 [2 favorites]


Just wanted to chime in and reiterate that COBRA is ridiculous. My SO and I paid over $17,000 in the year and a half she was unemployed. As someone with a job (read: insurance) and is aware of exactly how much my company pays towards my healthcare, it would have taken me almost 10 years to hit that number... but with COBRA we did it in 18 months.
The cost of COBRA premiums are exactly the cost of the premium. (Well, they can be 2% higher to cover admin costs, but that's not much)

So I think you mean to say that health insurance in the US is ridiculous, not that COBRA is ridiculous. Also, if you are paying less than $100 a month for healthcare insurance, it's almost certain that your employer is additionally paying 2-5x that on your behalf without you knowing it.

This is one of the terrible things about hiding health insurance behind the employer tax deduction, because the insane costs and insane cost rises over the past decades are completely hidden.
posted by Llama-Lime at 7:52 AM on October 22, 2013 [5 favorites]


Y'know, just one of the NSA data centers probably has enough horsepower to nip this little load problem in the bud.
posted by jason_steakums at 7:53 AM on October 22, 2013 [2 favorites]


So what SHOULD one use?

A rigorous approach to scaling.
posted by j_curiouser at 7:56 AM on October 22, 2013


Y'know, just one of the NSA data centers probably has enough horsepower to nip this little load problem in the bud.

I wouldn't be so sure.
posted by ghharr at 7:56 AM on October 22, 2013


This is one of the terrible things about hiding health insurance behind the employer tax deduction, because the insane costs and insane cost rises over the past decades are completely hidden.

Might not be that hidden. I worked for larger companies, and they sent a packet of benefits home every year that explicitly laid out all they were paying 'for' me - their half of taxes that weren't Federal Income Tax, short term disability, life insurance, the small stock grants, a portion of the ESPP, and 75% of my health care with the implication that when I want to whine about how "little" I am paid, I have to keep those benefits in mind as part of the TCP.
posted by tilde at 7:58 AM on October 22, 2013 [1 favorite]


Y'know, just one of the NSA data centers probably has enough horsepower to nip this little load problem in the bud.

For certain values of fire and bud

Oh, is Medical Marijuana covered by the Silver plan?
posted by rough ashlar at 8:00 AM on October 22, 2013


... One of the main reasons I- as a dumb young person who totally doesn't have any awareness of her own mortality- would never have been willing to quit this job is because I am terrified of being uninsured. I'm not about to walk out the door on January 1st or anything, but now I know that I COULD do that and not have to be afraid of making the choice between a horrible untreated illness or life-long penury. So that's pretty cool.

I've been watching the debate in your country, and it's astonishing that I haven't seen this mentioned very often - and yet it's the most radical and subversive part of the whole plan. It breaks the chains between employer and employed, and gives workers more freedom. It will increase the velocity of of the labour market and raise wages - employers will have to offer more to keep their best people, and stop depending on the horror of being uninsured to shackle people to their jobs. All of the talking heads on your news keep blasting off about edge cases - the young uninsured, the poor, people who have been screwed by pre-existing conditions - but the subterranean rumble of workers who are slowly realizing that there's been a deep shift in their relationship to their employers... maybe it's just too big to see.
posted by Mary Ellen Carter at 8:04 AM on October 22, 2013 [60 favorites]


You would think that Republicans and all their "Entrepreneurs are awesome long live small business job creators!" would be all over something that disconnects being insured from being employed by someone else, since it gives people a lot more freedom at lower risk to start small businesses and employ people. But no.
posted by rtha at 8:11 AM on October 22, 2013 [8 favorites]


It breaks the chains between employer and employed, and gives workers more freedom.

I think that's certainly true. There are actually two main thing stopping me from, I don't know, attempting a freelance career or going off to do seasonal farm work or working part time and volunteering part time, or what-have-you: fear of not having health insurance, and student loan payments. Both of these factors limit my options and mobility, and that's the case for a lot of people I know. (If you're from a very poor family, you're obviously limited in a different and more severe way, but more and more, Americans have been systematically robbed of their ability to move up from such circumstances. Once you can possibly afford to, you must go to college and you must have health insurance, and then you're stuck...)
posted by showbiz_liz at 8:15 AM on October 22, 2013 [5 favorites]


You would think that Republicans and all their "Entrepreneurs are awesome long live small business job creators!" would be all over something that disconnects being insured from being employed by someone else, since it gives people a lot more freedom at lower risk to start small businesses and employ people. But no.

Technically, they do. Or, they did, since Obamacare, individual mandate and all, is their health care plan from 1996 and Romney's from 10 years later. But, y'know, Kenyan soshulust MOOSLEM and whatnot.
posted by zombieflanders at 8:26 AM on October 22, 2013 [2 favorites]


rtha: "You would think that Republicans and all their "Entrepreneurs are awesome long live small business job creators!" would be all over something that disconnects being insured from being employed by someone else, since it gives people a lot more freedom at lower risk to start small businesses and employ people. But no."

Yeah but they're against anything that gives workers more relative power. You can abuse the heck out of your workforce if they're tied to their workplace by their company provided health insurance.
posted by octothorpe at 8:26 AM on October 22, 2013 [10 favorites]


If you have a problem with SQL performance, and you're not doing totally stupid joins to get data out of a fundamentally broken data model, (I'm looking at you wordpress.. ) you just need more horsepower, and your vendor will be OVERJOYED to make that happen for you.

That said, ALL OF THIS COULD HAVE BEEN AVOIDED simply by

(1) Making every healthcare provider use the VA's VistA system. It works, it's paid for, and did I mention that it works?

(2) While we're at it, just submit all the bills to the treasury. That works too.

(3) And it's a whole lot easier if you just load everyone into the system. So we might as well go with Universal Healthcare and end all the bullshit once and for all..

See, even now we have options.
posted by mikelieman at 8:27 AM on October 22, 2013 [12 favorites]


I am waiting for Oregon to get its exchange together so I can sign up already.
posted by curious nu at 8:27 AM on October 22, 2013


I've never written code, but was not surprised at all that healthcare.gov has had problems. Getting that site up and running would be a big, difficult job even under the best of circumstances, which, given the political opposition, some states not creating their own exchanges, various compromises and kludges built into the law, etc., this was not.

I'm reasonably optimistic they'll eventually be able to make the system functional, for some definition of "functional," but it may take them a while to get it sorted out. In the meantime, at least some people are already seeing benefit from the ACA, and IMO that's an unalloyed good.
posted by Nat "King" Cole Porter Wagoner at 8:33 AM on October 22, 2013


If Edward Snowdon's revelations are accurate, it seems like they fixed all [the FBI computer system] pretty quickly and there is no reason to think that throwing a few billion taxpayer dollars at Healthcare.gov won't result in the same improvement.

I'm not sure what particular Snowden revelation you're referring to, but I'm pretty sure the system in question at the FBI was the "Virtual Case File" (VCF) project, and it was abandoned in 2005 as a complete failure.

It's practically legendary in some circles. They dumped about $170 million into it between 2000 and 2005, and in the end got nothing.

I know people who worked on various aspects of it -- honestly, if you do IT work in the DC area it's hard not to know someone who worked on some part of it -- and it's still an open question in my mind whose fault the ultimate failure really was. The FBI apparently changed requirements constantly, never letting the developers finish anything before changing their minds again; on the other hand, progress was ridiculously, stupidly slow for the amount of money being spent, and it wouldn't surprise me at all if the contractors overstuffed the project with warm bodies to keep the revenue flowing.

I don't believe that any of the code created for VCF was reused in the follow-on effort ("Sentinel"); it was a total writeoff.

Failure, as the saying goes, is always an option.
posted by Kadin2048 at 8:39 AM on October 22, 2013 [1 favorite]


You would think that Republicans and all their "Entrepreneurs are awesome long live small business job creators!" would be all over something that disconnects being insured from being employed by someone else,

They do! Here's an excerpt from a recent paper written by scholars from AEI and the Heritage Foundation.
In the context of employer plans, this approach would mean moving away from the unlimited tax break that is conferred on employer-paid premiums, and instead providing directly to workers a fixed tax credit that would offset the cost of enrollment in the private insurance plans of their choice. Workers selecting more expensive insurance plans would pay for the added premiums out of their own pockets. Those choosing low-premium, high-value plans would pocket the savings, enabling them to offset additional health expenses if they wished to do so. This system would not only be more efficient: It would also be a far more equitable way to provide health benefits through the tax code. American taxpayers would get a break for health coverage as individuals, irrespective of their employment status or the generosity of the health plan provided by their employers.
Republican budget documents introduced by Paul Ryan have also included support for replacing the employer-based health insurance tax credit with individual subsidies as recently as 2010.
Upend Employer-Based Health Care

The Roadmap would eliminate the tax exclusion for employer-provided health insurance, a core foundation upon which which the modern system is built. It would be replaced with a refundable tax credit of $2,300 per adult and $5,700 per family to buy insurance on the market.

More than half of all American workers are on employer-based plans, according to 2010 Census data, and rolling back the tax break would ratchet up business costs and jeopardize coverage for those workers. On the flipside, the tax treatment of employer-based plans has been criticized across ideologies as unfair to individuals who don't receive coverage via their job and a cause of runaway medical cost inflation.

This part of the plan did not make it into his subsequent 2011 and 2012 budgets.
posted by BobbyVan at 8:40 AM on October 22, 2013 [1 favorite]


we might as well go with Universal Healthcare and end all the bullshit once and for all..

Completely agree with you, but we couldn't go there because it's SOCIALISM. If you read about the history of how the UK developed the NHS, it was basically this - expanding an existing system to gradually cover more and more of the population. Smart.
posted by Miko at 8:40 AM on October 22, 2013 [4 favorites]


This recent NPR piece called a lot of that "small business" rhetoric into question, as well. They don't mean it, it's just a way to pull our heartstrings to create better conditions for the big businesses who are lining their pockets.
posted by Miko at 8:41 AM on October 22, 2013 [5 favorites]


The cost of COBRA premiums are exactly the cost of the premium.

I guess, not really though.

It's the cost of the premiums for that particular policy where there is no competition or regulation in the market. The insurance company can charge whatever they want as long as [place of employment] decides to pay for it. So if the [place of previous employment] opted for a Cadillac plan, then that's what you pay for in COBRA. Alternatively, if [place of previous employment] opted for a budget plan, then again, that's what you pay for in COBRA.

You either sign up for whatever ridiculous plan your previous employer opted for, without whatever benefits the executive team got out of that deal... or you sign up for individual coverage that loses out on being a group policy and thus the benefit of shared risk.

So as an ex-employee there is no "choice" in the matter. You either get lucky, or you can't really afford insurance. As a platform for funding healthcare in an entire country, this is the opposite of good. Whereas under the ACA and the local markets you still gain the benefits of shared risk (read: affordable payments) and still maintain the ability to choose whether you want the bare bones, the Cadillac, or somewhere in between. All without being sworn to whatever plan a company you no longer are affiliated with chose.
posted by Blue_Villain at 8:54 AM on October 22, 2013


They do! Here's an excerpt from a recent paper written by scholars from AEI and the Heritage Foundation.

GOP’s “repeal and replace”—curbing tax exclusions for employer-based coverage
Providing workers with a fixed tax credit to buy outside coverage will only improve the system if workers enjoy secure access to properly regulated coverage, within a framework that ensured everyone reliable access to affordable coverage with due protections for individuals with high expected treatment costs.

In other words, this path requires something like the new exchanges established under the Affordable Care Act. For reasons I will discuss later, I’m not confident that Capretta and Moffit would create the robust exchanges that their policies require.

Austin Frakt, among others, has argued that conservatives should embrace ACA, which is as much a step toward their preferred market-based reforms as they are likely to get. On the substance, ACA actually is the bipartisan compromise many political moderates had hoped for in comprehensive health reform.
posted by zombieflanders at 8:55 AM on October 22, 2013 [2 favorites]


Also, if you do end up pregnant, no matter what you decide to do you're going to want medical access at a controlled rate. Even with the massive improvements Obamacare has offered in coverage for women, it's still kind of a no-brainer for sexually active women.

Just adding to this. A little more than two years ago, my wife was eight months pregnant. Her pregnancy had been going really smoothly, but then she developed severe pre-eclampsia, which ended in an emergency c-section delivery and a (mercifully short) NICU stay for our son. Without insurance, the cost would have been more than $40,000. (We received so many different bills over the following year that I can't recall exactly how much we paid and how much our insurance paid. $40,000 is almost certainly an underestimate, but even so, it's a pretty big number.)

Even an uncomplicated birth is likely to have delivery costs around $10,000 according to WebMD.

And that doesn't take into account all the costs of having a miniature human around after the delivery is over. I guess what I'm saying is: Birth control is a BIG DEAL.
posted by Jonathan Livengood at 8:57 AM on October 22, 2013 [1 favorite]


rtha:
You would think that Republicans and all their "Entrepreneurs are awesome long live small business job creators!" would be all over something that disconnects being insured from being employed by someone else, since it gives people a lot more freedom at lower risk to start small businesses and employ people. But no.
They had a bill that was sitting around before the health care debate began, the HAA, or Wyden-Bennett Act. Decoupling health care from employment was a major feature. It had a lot of Republican support but when the time came and things began moving in terms of actually taking action on heath care all the R support disappeared. Because they wanted to be able to focus on just screaming, "No!" more effectively. Or something. I don't know, I don't understand the GOP anymore.
posted by charred husk at 8:59 AM on October 22, 2013 [3 favorites]


I've been watching the debate in your country, and it's astonishing that I haven't seen this mentioned very often - and yet it's the most radical and subversive part of the whole plan. It breaks the chains between employer and employed, and gives workers more freedom.

Back when I used to get into political arguments with old high school classmates on Facebook (I know better now), the one and only time I scored a point with a libertarian classmate about health care was when I mentioned this. He actually said something like "Hmm, that's actually a really good point I hadn't thought about before." I was floored.
posted by misskaz at 9:01 AM on October 22, 2013


A lot of those "small" businesses, especially those with around 50 workers, are going to be tempted to misclassify their employees as independent contractors to avoid covering them under the ACA, something the IRS and Department of Labor take a dim view of. There are pretty severe penalties for doing so.
posted by Biblio at 9:01 AM on October 22, 2013


Oh, and I never knew this about Wyden-Bennett:
In a July 1, 2009 interview, Obama said he agreed "with '90 percent' of Wyden's thinking" but called HAA "radical"; according to The Oregonian:[11]
The president said his discussions with Wyden are similar to those with people who advocate a single-payer system. In theory, those plans work, he said. "The problem is, we have evolved partly by accident into an employer-based system." A "radical restructuring" would meet "significant political resistance," Obama said, and "families who are currently relatively satisfied with their insurance but are worried about rising costs ... would get real nervous about a wholesale change."
posted by charred husk at 9:02 AM on October 22, 2013 [2 favorites]


According to one specialist, the Web site contains about 500 million lines of software code.

Ah, yes, the Anonymous Source. Now give us a Rasmussen poll.

I've posted before how I've never been a fan of this Heritage-based, Republican-championed, Romney-implemented law. Forcing us to use the corrupt health insurance system that has been fucking us over for decades is unconscionable. Still, I was hoping the guys who ran circles around the Romney campaign would make the exchanges work, but it turns out we were victim of that other delicious idiocy that Republicans have perfected since the Reagan years, the corrupt public / private contract system. So now we have a system that feeds right into the "500 million lines of code" idiocy, and all the other conservative idiocy and lies.*

Anyway, I was going to post my exchange story, but now I'm too depressed and angry. Luckily my current insurance is good until the end of July, at which point I'll just go to one of the insurance companies' websites (I don't qualify for subsidies, thanks Corbett) directly. Fuck this whole world.


*Or my brother-in-law's dumbass, "Everyone's going to find out they have a $2,000 deductible!" comment. Guess what, buddy, I haven't had a deductible that low in a decade.
posted by dirigibleman at 9:07 AM on October 22, 2013 [2 favorites]


What's heartening to me, despite my reservations about this system rather than single-payer, is how scared the Republicans are of it. I mean, we here on the left grouse about keeping the insurance companies, etc. etc., but even this ugly, patched-together compromise that gives workers a tiny bit more power (while still allowing insurers to make bank) makes Republicans shit their pants and shut down government.

They know that to people who have nothing, even a little something is going to be appealing, and a whole lot of Americans have nothing. Remember those stories about free health clinics in poor areas where people stood in lines for days to finally get a medical problem looked at? That's what a lot of Americans are going through, right now; a lot of them, in fact, are poor whites, a demographic the Republicans have traditionally been good at corralling. But now Obama and the Democrats have given those people a big gift.

Not to mention all the less-poor folks who might not normally bother to vote but are now going to have a reason to like the Democrats, because again, even crappy coverage is better than none.

I do think that at least some of the Koch-funded resistance is about corporations not wanting employees to feel more empowered to leave crappy jobs with insurance, I just think that most of our media pundits haven't had to worry about that kind of thing in so long they never think about it. Which is one of the many problems of our media/pundit class.
posted by emjaybee at 9:18 AM on October 22, 2013 [9 favorites]


Of course, Obamacare could be worse. For example, it could be the GOP's current approval rating.
posted by obscure simpsons reference at 9:19 AM on October 22, 2013 [1 favorite]


It took me two weeks for the site to finally work for me and let me get to the point of being able to compare possible plans, and discover they were all, even with a subsidy, worse than what I was getting with my current private insurer.

I'm glad the site is getting fixed, and I'm thrilled that thousands- millions- of people who never had healthcare will be able to get it now. But that doesn't mean I "lose" the right to point out it was a shitty site with a shitty launch that provided me after a long waste of time and energy with a bunch of really shitty product options. And yet when I noted this on Twitter, I got the usual kneejerk response from fellow liberals to shut up and stop whining.

That the site exists is good. The site is also a piece of shit. These two statements can exist simultaneously and I feel no betrayal of any political principles. I've always been fascinated with how Progressives strive to encourage people to expect better things from their government, and then get really pissy when those people are upset that they didn't get it.
posted by XQUZYPHYR at 9:20 AM on October 22, 2013 [8 favorites]


The very concept of a deductible has always struck me as just kinda... evil. Am I crazy here? I was sort of shocked to see that even the gold level plans had deductibles on the NY exchange, only platinum seemed to be totally free of them.
posted by showbiz_liz at 9:21 AM on October 22, 2013


This is all 20/20 hindsight, but it seems like they could have designed slow-rollout to allow for testing and the like, at least for some portions of the system. Like, they could have allowed 100, then later 1000 people per day, or some other reasonable number, create accounts, verify their identities, and so some of that other preliminary stuff. Squash a lot of bugs and slowly ramp things up.

I have been working to try and get healthcare through my state's (Washington) exchange for a couple weeks now. The support person assigned to my ticket said that they would have LOVED to do a slow rollout, but that it was literally prohibited by the law. In her view, the right thing to do would have been to do a 2-week advance launch to the DSHS clients who are losing their insurance on 10/30 and who have no other options. That would have been a sub-population with a true, pressing need to be bumped to the front of the line, as well as being a more heterogeneous population in terms of special healthcare needs, subsidy qualifications, language, and levels of computer familiarity. It would have been a GREAT idea, except for the part where it would have been a Federal law violation.
posted by KathrynT at 9:24 AM on October 22, 2013 [3 favorites]


This is just a good day and nothing can detract from it. I love this short speech from NHS founder Aneurin Bevan: "I am proud about the National Health Service. It's a piece of real Socialism. It's a piece of real Christianity too..."
posted by vacapinta at 9:24 AM on October 22, 2013 [1 favorite]


they were all, even with a subsidy, worse than what I was getting with my current private insurer.

Does your employer pay any percentage of your premium?
posted by KathrynT at 9:25 AM on October 22, 2013 [2 favorites]


I love this short speech from NHS founder Aneurin Bevan: "I am proud about the National Health Service. It's a piece of real Socialism. It's a piece of real Christianity too..."

Pfft, right. Like Jesus was into taking care of the poor and healing the sick.
posted by entropicamericana at 9:27 AM on October 22, 2013 [2 favorites]


That the site exists is good. The site is also a piece of shit. These two statements can exist simultaneously and I feel no betrayal of any political principles. I've always been fascinated with how Progressives strive to encourage people to expect better things from their government, and then get really pissy when those people are upset that they didn't get it.

I should note that this is far from universal:

Five thoughts on the Obamacare disaster (Ezra Klein & Sarah Kliff @ WaPo's Wonkblog)

Take this, conservatives: Criticism only makes Obamacare stronger! (Brian Beutler @ Salon)

Why Liberals Admit Obamacare’s Failures While Conservatives Refuse to Concede Its Successes (Jonathan Chait @ NYMag)
posted by zombieflanders at 9:29 AM on October 22, 2013


It took me two weeks for the site to finally work for me and let me get to the point of being able to compare possible plans, and discover they were all, even with a subsidy, worse than what I was getting with my current private insurer.

Keep an eye on your mail. One of my friends just got a friendly note from their insurance provider, letting them know that their current individual plan (purchased on the open market) was going away. I didn't read the actual letter but apparently it blamed the ACA.

I'm not sure if that's because their current plan didn't meet the new minimum standards or what.
posted by Kadin2048 at 9:45 AM on October 22, 2013 [1 favorite]




I'm curious what sort of development methodology was used (waterfall, Scrum, etc.). My guess is that with so many different contractors, there was no unified methodology. Scaling something like Scrum (with constant customer involvement, adaption to change, and delivered working code every 4 weeks or less) to this size project is tough but doable. The concept of waiting to start coding until *all* the requirements are complete is CRAZY and is software development from like 1990. Make a list of functionality you know you'll need, rank it, and start coding the first thing. Show the customer something that works (even a plain form where you type in an SSN and some date is displayed - anything), get feedback, rinse and repeat. Obviously you'd know a lot of requirements up front, but a basic rule of large projects is you will never know all the requirements up front. Change during a long project is 100% assured. Choose a methodology that accepts change rather than one that fears it.

I've worked on (much smaller) projects that lasted (for example) a year and underwent huge changes throughout, but when using Scrum we always had real working software for some features almost right away, and had a staging server where the client could go poke at it as needed, give their own demos, etc.

With multiple teams they each show working pieces early on and deliver their pieces to the other teams and the customer periodically. So if there's a team that's just the "security team", they should be able to pick encryption methods and libraries early on and show an app that takes a form of say 5 fields of input application data and stores it in a bare-bones Application table in encrypted form. Then build on that ...

Heck, maybe they did things iteratively like this but I bet not.

The health exchange is a beast of a project though I'm sure. I hope it smooths out and isn't fundamentally flawed.
posted by freecellwizard at 10:34 AM on October 22, 2013 [1 favorite]


So, my state's new health insurance website appears to be working OK -- but the news is reporting that a shockingly low number of people have actually signed up for plans.

If you try it, you realize quickly that that's because everyone with an income below $45k/yr is directed to submit a complicated benefits application to find out whether they qualify for Medicaid or any subsidies. Apparently, processing all those applications takes time, and the state Medicaid office is seeing at least six to nine times the application volume they're accustomed to. No word that I've seen on whether they've been able to increase staffing to ease this bottleneck, but I'm optimistic they'll get it sorted out in time.

FWIW, the cheapest plans in my ZIP code are both cheaper than I could find on the individual market last year and, OMG, actually required to cover something. Which individual insurance never was much good on before.
posted by asperity at 10:38 AM on October 22, 2013 [1 favorite]


My favorite thing about the launch of the website is that now the rest of the country gets to experience something like the WoW launch all over again, and I am heartened to see that exactly the same arguments on all sides get made in the real world as in gamer land.
posted by Errant at 10:44 AM on October 22, 2013 [6 favorites]


Just thinking about the chaotic tangle of APIs for all those state exchange, insurance company and government department systems that this thing needs to interact with and all the different data formats they must spit out makes me shudder. Middleware hell.
posted by jason_steakums at 10:44 AM on October 22, 2013 [4 favorites]


I am imagining some kinda ISO-something or something adopted from the DoD back in the 80s.

Gotta have a full spec, in a binder, before you write one line of code and the target platform is the posix layer of NT 5 on some kind of archaic ruggedized 386 mini-tower.

Probably wanted the site to be ISO 9001 and EAL-7 certified.

Good thing it is just code.

Now they just need to find that one person with no life and an overpowering need for a pat of the back from some low level functionary to put in the mental effort to fix it while everyone else shrugs and goes home at 5.
posted by Ad hominem at 10:48 AM on October 22, 2013


Okay, just did healthcare.gov - the identity verification reminds me of when I got my credit checked with a weird question about an employer from 1993 and a type of insurance product I never bought.

I just enrolled us in healthcare through work for about a Silverish Plan (hard to tell as there is SKUing going on of course). Keeping that in mind, a comparable plan through the HCA site from the same provider seems to be about double the price - so cheaper than I thought. I don't know how much my employer pays for my insurance, I didn't read the notice this year.

I think (hope) the next benefit from working for employers involves the ability to negotiate a higher take-home pay in return for not taking insurance through them. I don't see it happening because 1 - there's no way to guarantee someone not having a life event or whatever and wanting/needing to move to employer insurance and then they have that *and* higher pay. I can see most employers being relieved of health care costs and not doing anything else about it. Although if you could designate base salary and healthcare allowance that might be a fairish way to do it - compensate people who use employer paid insurance and non employer paid insurance somewhat equally. Gets sticky though for putting singles versus married/dependent folks ... but like I said, I don't see that happening.

My current employer doesn't give us any level of "free" health insurance for the solo user, but I/we have worked for those in the past. Kind of a headache when it came to insurance - 'free' bronzeish insurance (some provided free silver) meant that we had mounds of paperwork to deal with for primary and secondary insurance coverage if we wanted to try to gap cover crappy insurance with medium or higher insurance.
posted by tilde at 10:50 AM on October 22, 2013


Just had a thought: people are throwing around a huge number describing how many lines of code the site has. We also know they used at least one piece of open source software without attribution.

Is it possible that the code line count is being massively inflated because they're using open source software? For instance, here's a simple example for a small web site: run it on a Windows server, and all the source is closed, so the server software is in binary form and would be exempted from the code line count...but run it on a Linux server that you compiled the code for yourself, and you'd still have the uncompiled code lines, so that would be included in the code line count.

Even if we're only talking about the software (non-OS) side of things, the same argument could be made for everything open source that they leveraged...especially if they're doing it without attribution, so there'd be no easy way to identify and separate out the open source stuff.

If true, then the number of lines of code being quoted is insanely inaccurate.
posted by davejay at 10:53 AM on October 22, 2013 [2 favorites]


Just thinking about the chaotic tangle of APIs for all those state exchange,

See... I know this is a problem, but I don't know WHY this is a problem.

Establish X number of mandatory fields that have to be parsed in a specific format; name, address1, address2, city, state, zip, SS, sex, annual income, etc. and then just have everything else be a free text field.

Then you just dismantle the banks that are too big to fail and have all of those newly-unemployed car-sales credit-guys review the apps and use their existing systems to work with the customers.

THERE IS NO DOWNSIDE TO THIS.
posted by Blue_Villain at 10:59 AM on October 22, 2013 [1 favorite]


I got one of those ominous "Your current plan is going away! Stay tuned" letters from my employer's insurer. Our enrollment is next month, I think. No idea whether that is good, bad, or indifferent. Our company is too big to stop offering insurance, so that's not it. I hope it's actually going to be better, but I would never assume that till I see it.
posted by emjaybee at 11:00 AM on October 22, 2013 [1 favorite]


Windows 7 contains 40 million lines of code. I am guessing that includes a lot of userspace stuff too.

The 3.3 Linux Kernel contains 15 million lines of code.

Fedora 9 contained 204,500,946 lines of code.

That means they claim to have written the equivalent of more that 2 Linux distributions.

There is no way. And even if they were including 2 different linux distributions,all that code is out of their scope. So claims they need to rewrite 500 million lines of code is total nonsense.

First step is to figure out why they are claiming it is 500 million lines of code.
posted by Ad hominem at 11:16 AM on October 22, 2013 [10 favorites]


Just thinking about the chaotic tangle of APIs for all those state exchange,
See... I know this is a problem, but I don't know WHY this is a problem.

Establish X number of mandatory fields that have to be parsed in a specific format; name, address1, address2, city, state, zip, SS, sex, annual income, etc. and then just have everything else be a free text field.

Then you just dismantle the banks that are too big to fail and have all of those newly-unemployed car-sales credit-guys review the apps and use their existing systems to work with the customers.

THERE IS NO DOWNSIDE TO THIS.
I have written APIs to that spec. HELL NO.

1. Name - prefix, suffix, middle names, maiden name
2. Address - county, ZIP+4
3. Annual income - job? Social Security? Pension? SSI? Dependency payments? Annuities? Guess or based on last filed income tax statement?
4. Etc - Marital status? Relation to other applicants? Responsibility for financial matters of other applicants? Racial makeup? Phone numbers? Types of phones? Security questions and answers? Current insurance status?

** Free Text Fields Must Die. **
posted by tilde at 11:23 AM on October 22, 2013 [4 favorites]


First step is to figure out why they are claiming it is 500 million lines of code.

By "they", you mean one anonymous source in the NY Times article, right?
posted by maudlin at 11:24 AM on October 22, 2013 [1 favorite]


So claims they need to rewrite 500 million lines of code is total nonsense.

The (anonymous) claim is that "as many as five million lines of software code may need to be rewritten."
posted by BobbyVan at 11:26 AM on October 22, 2013


Apparently my state's exchange is humming along just great, despite using some of the same contractors as the federal exchange. Of course, it only has to deal with (probably less than) 1/50th of the traffic. They also chose to allow users to check for eligibility without creating an account, which I suspect made a much more significant difference than is pointed out in the article. Is there any solid reason to require an account first?
posted by dilettante at 11:27 AM on October 22, 2013 [1 favorite]


Just thinking about the chaotic tangle of APIs for all those state exchange, insurance company and government department systems

I would be willing to be that some of those systems don't even have APIs, certainly not secure web service APIs. Getting the info for the health care site probably also required people responsible for those other systems to write new code.
posted by freecellwizard at 11:27 AM on October 22, 2013 [1 favorite]


By "they", you mean one anonymous source in the NY Times article, right?

According to one specialist, the Web site contains about 500 million lines of software code.

You are right. First step is finding that specialist and making sure they don't get to touch the code.

The (anonymous) claim is that "as many as five million lines of software code may need to be rewritten."

Ok Ok, I still don't buy it.
posted by Ad hominem at 11:29 AM on October 22, 2013 [2 favorites]


I would be willing to be that some of those systems don't even have APIs, certainly not secure web service APIs. Getting the info for the health care site probably also required people responsible for those other systems to write new code.

Oh no doubt. I'm certain that at multiple points in the mix you'll find a vital piece of legacy hardware that's just a dusty old Dell in a closet that only communicates over RS-232, that only one person in the office is confident enough to restart when it goes down.
posted by jason_steakums at 11:34 AM on October 22, 2013 [3 favorites]


> "seven in ten (72 percent) of the youngest uninsured Californians – those ages 19 to 25 – say they need health insurance"

Generation Opportunity is trying to change that. Their spokesperson on On the Media:
Our goal with this campaign is to educate young Americans. Our experience with young people across the country has been that they think they are compelled to buy insurance, no matter what. The law very clearly gives them the ability to pay a small penalty and buy health insurance that is actually gonna be cheaper and a better deal for them.
What insurance would be cheaper (even with ACA penalty added)? My guess is catastrophic care. I had that between a full time job where they discouraged COBRA and graduate school. A 2 month window and I managed to have an ambulance & ER -worthy bike accident. That insurance was nearly worthless. Didn't help at all for the broken tooth, though I guess if I'd broken a bone it would have been better.
posted by morganw at 11:45 AM on October 22, 2013


I'm curious what sort of development methodology was used

Marketing: Agile!
Management: MIL-STD 498
Trenches: Code & Fix
posted by j_curiouser at 11:46 AM on October 22, 2013 [3 favorites]


I don't know how much my employer pays for my insurance ...

Look at your tax return from 2012. Your W-2 should be attached. Box 12, Code DD is the amount of money spent on your health insurance in 2012. This amount includes both the employer part and the employee contribution, that is, the total premium for your company health insurance.

Companies with less than 250 employees were exempted from including this information on the W-2 for 2012, but will be required in 2013.
posted by JackFlash at 11:51 AM on October 22, 2013 [4 favorites]


The Tale of the Terrible, Glitch-Filled Health Care Law Rollout
Of course, the computer glitches didn't help: "During the first few days of enrollment, people had trouble logging onto [the] website because of heavy traffic." Because of all the problems, less than a month after its rollout, at least one senator from the president's own party wrote to officials in charge of the website, saying, "I am writing to express my concern with serious problems brought to my attention relating website. [People] have reported that the pricing information of plans listed on the website is inaccurate and misleading...A discrepancy of thousands of dollars is more than just a 'glitch'...This sort of problem could greatly hinder successful implementation of the [new health care law] by undermining consumer confidence in the program."

A Democratic Congressman wrote to the president after a month into the sign-up to complain that "only 500,000 of 40 million eligible [people] have signed up so far. This low participation number is not surprising. After all, the fledgling program has been plagued by mishaps and misinformation." He was also frustrated that Congress was doing nothing to help fix the problems.

Things got so bad that even a governor who supported the law was frustrated that only "700 of the 100,000 applications [from his state] that have been submitted" had even been processed. He also noted that the Department of Health and Human Services promised that the "glitches" were fixed, even if users still had difficulties with the website. Among those glitches were "computer file transfers" that caused people to have to resubmit applications that were processed incorrectly.

Medical professionals were also upset with the program. "It's a nightmare," said one. "It will be a disaster" if the problems are not fixed, said another.

Let's just show the cards here. If you haven't figured it out, this is all about the sign-up period for what was the then-new Medicare prescription drug program, Part D.
[...]
The bill was passed in December 2003. In November 2004, there was a vote to raise the debt ceiling. You know what didn't happen? The Democrats in the Senate didn't hold the debt ceiling hostage because the act was confusing and unpopular - remember, it passed the House only because of bribery and threats by Tom DeLay. They didn't try to undermine it or sabotage it. No, they tried to make it better, with Republicans refusing to do so.
posted by zombieflanders at 11:54 AM on October 22, 2013 [3 favorites]


Obama should fire Sebelius and hire the guy who successfully implemented a similar program in Massachusetts.


I wouldn't say MA has a done an awesome job though either. Shit works, but it's very confusing, mostly because of all the different parts that sound vaguely the same: MassHealth, Commonwealth Care, Health Connection, etc. And get ready spend an afternoon on hold if you have a question. Now I just visit the local office at the local hospital when I need to reapply or something. They know exactly what buttons to press.

That said, I am a freelancer with affordable insurance, and that is such a huge win and stress relief that it makes all the hassle completely worthwhile.
posted by Camofrog at 11:56 AM on October 22, 2013 [1 favorite]


Folks might have been unfamiliar or have forgotten the roll out of Medicare Part D, prescription drug insurance, in 2006. It was a much simpler system without the eligibility verification and subsidy complexities of the ACA. Yet it was a total nightmare. I had to help several elderly people sign up and it required weeks of evenings just to sort out the plan offerings and figure out the various formularies to get people signed up.

Yet today, the system works very smoothly and there are about 25 million participants. I assume the ACA system will be refined and work as well by next year.

What makes the ACA exchanges so complicated is that it is a private insurance system shoehorned into an existing complicated system.

First and most important, they have to verify that you are eligible for using the exchanges. To do this, they have to verify that you aren't already covered under a qualifying plan from your employer. This is to prevent the exchanges from cannibalizing employer plans and making them more expensive.

Then they have to verify that you are not an undocumented immigrant.

Next, they have to verify your income and family size. This is to determine first, whether your income is so low that you do not qualify for the exchanges, but instead must use the Medicaid system. Then, if you are not eligible for Medicaid, they must determine if you are eligible for an exchange plan with subsidies.

It is all of these checking and verification steps that are causing the slow down. Presentation of plan options and actual sign up is relatively simple.
posted by JackFlash at 12:09 PM on October 22, 2013 [6 favorites]


The (anonymous) claim is that "as many as five million lines of software code may need to be rewritten."

I suppose that sentence can mentally be extended with "..., or as few as one, there's no way to be sure without auditing the code itself and reviewing the bug reports exhaustively."
posted by davejay at 12:34 PM on October 22, 2013 [2 favorites]


"Out first mistake was writing it in LOGO. But that little turtle was too cute!"
posted by charred husk at 12:40 PM on October 22, 2013 [5 favorites]


I don't know how much my employer pays for my insurance
Look at your tax return from 2012. Your W-2 should be attached. Box 12, Code DD is the amount of money spent on your health insurance in 2012. This amount includes both the employer part and the employee contribution, that is, the total premium for your company health insurance.

Ah! Great, found it in the online payroll system. Looks like for every $2 in premiums I paid over, they paid $3. I was on superfantastimaticgorical version EPO but I switched to a mid-range PPO for 2014 to include more family members. About the same premium for me, and oddly, the exact same co-pays. But I have a deductible now, and put in an FSA plan to help with that.
posted by tilde at 12:40 PM on October 22, 2013 [1 favorite]


Is Obamacare in a Death Spiral?
As Yuval Levin has pointed out, what we’re experiencing now is the worst-case scenario for the insurance markets: It is not impossible to buy insurance, but merely very difficult. If it were impossible, then we could all just agree to move to Plan B. And if it were as easy as everyone expected, well, we’d see if the whole thing worked. But what we have now is a situation where only the extremely persistent can successfully complete an application. And who is likely to be extremely persistent?

1. Very sick people.
2. People between 55 and 65, the age band at which insurance is quite expensive. (I was surprised to find out that turning 40 doesn’t increase your premiums that much; the big boosts are in the 50s and 60s.)
3. Very poor people, who will be shunted to Medicaid (if their state has expanded it) or will probably go without insurance.

Insurance that is only sold to these groups is going to be very, very expensive. Not the first year -- President Barack Obama was in the Rose Garden just this morning, touting the fantastic cost savings available to the old and sick people whom Obamacare was already helping. But if those are the only people who sign up, insurers will lose a bunch of money on these policies. And then next year, they’ll ask for a lot more money.

What happens next -- as we’ve seen in states such as New York that have guaranteed issue, no ability to price to the customer’s health, and a generous mandated-benefits package -- is that when the price increases hit, some of those who did buy insurance the first year reluctantly decide to drop it. Usually, those are the healthiest people. Which means that the average cost of treatment for the people remaining in the pool rises, because the average person in that pool is now sicker. So premiums go up again . . . until it’s so expensive to buy insurance that almost no one does.
posted by BobbyVan at 1:16 PM on October 22, 2013 [1 favorite]


And who is likely to be extremely persistent?

What's the deal with these ivory tower conservative elites?

Show me the polling data. Otherwise, it's just more thumb-sitting. Polling data says he's wrong. Plus, he's intuitively wrong. Sickness and injury is a constant worry for people of all ages and health. It sure as hell was for me in my 20's. Otherwise they wouldn't sign up for the company health plan, and I don't see many people saving a few bucks by opting out of that at work, regardless of age.
posted by Slap*Happy at 1:24 PM on October 22, 2013 [6 favorites]


Is Obamacare in a Death Spiral?

Welp, I guess we'll just have to go to single-payer, then.
posted by entropicamericana at 1:27 PM on October 22, 2013 [4 favorites]


The support person assigned to my ticket said that they would have LOVED to do a slow rollout, but that it was literally prohibited by the law.

I'm not surprised that they couldn't sign anyone up for any policies before the date. But I'm surprised that they couldn't do ANYTHING at all. The web site has a ton of preliminary steps that could have been opened to the public, that all would have fallen well short of offering any actual health care plan. For example, allow people to create their login account. Or enter their own and their family's information, social security numbers, income. Then go through the verify identity steps. And so on.

I mean, does federal law actually prohibit them from opening up a web site that does nothing but allow you to create a login account? Does nothing but allow you to verify your identity?

Maybe--I haven't taken the time to review the law with my team of lawyers--but I find it hard to believe.

This wouldn't have allowed any live end-to-end testing but they would have been a lot better off on Day 1 if even the account creation system had worked well. Certainly you could have done a slow roll-out of that element?
posted by flug at 1:29 PM on October 22, 2013 [3 favorites]


I like the ACA and generally support Obama's policies, but I think this web site rollout was unbelievably incompetent. You TEST software before releasing it -- at my company we have more than twice as many testers as developers. You'd have one team building test networks that can simulate thousands of users, one team doing usability testing, one team doing functional testing, another doing security testing. And that's on top of unit tests that the developers write themselves. These kinds of scaling problems are tricky but very well understood by competent people with some expertise in the field. I have no idea why the administration allowed their star achievement to be tarnished by a shoddy web site.
posted by miyabo at 1:32 PM on October 22, 2013


Is Obamacare in a Death Spiral?

Oh, McArglebargle, glibertarian extraordinaire. So willing to lie on cue, so consistently wrong on everything, including Obamacare from the very beginning.

Case in point:
What happens next -- as we’ve seen in states such as New York that have guaranteed issue, no ability to price to the customer’s health, and a generous mandated-benefits package -- is that when the price increases hit, some of those who did buy insurance the first year reluctantly decide to drop it. Usually, those are the healthiest people. Which means that the average cost of treatment for the people remaining in the pool rises, because the average person in that pool is now sicker. So premiums go up again
Oh, really? Let's see what NY was really all about:

Here’s why health insurance premiums are tumbling in New York (emphasis mine)
A headline about the health care law driving down premiums, by this level of magnitude, is a rarity. But it shouldn't be shocking: New York has, for two decades now, had the highest individual market premiums in the country. A lot of it seems to trace back to a law passed in 1993, which required insurance plans to accept all applicants, regardless of how sick or healthy they were. That law did not, however, require everyone to sign up, as the Affordable Care Act does.

New York has, for 20 years now, been a long-running experiment in what happens to universal coverage without an individual mandate. It's the type of law the country would have if House Republicans succeeded in delaying the individual mandate, as they will vote to do this afternoon. The result: a small insurance market with very high insurance premiums.


For years New York has had one of the most heavily regulated insurance markets in the country. The 1993 reforms not only required insurers to accept all customers; they also mandated that insurers charge everyone the exact same price. Young or old, healthy or sick, it doesn't matter in New York: Everyone gets the same deal.

This is great for someone who is sick and old who, in other states, might get charged a sky high rate or rejected altogether. It's not great though for the young and healthy, who end up footing a bigger chunk of the bill for all those more expensive beneficiaries.
posted by zombieflanders at 1:47 PM on October 22, 2013 [7 favorites]


BobbyVan, okay, now we know you are just trolling. Nobody links to Ms. McArgle Bargle unless it is to point and laugh at the glibness of her ignorance. I mean, nobody even wastes the time to rebut her stupid stuff anymore.
posted by JackFlash at 1:58 PM on October 22, 2013 [5 favorites]


I sort of admire his tenacity at this point, idk.
posted by elizardbits at 2:06 PM on October 22, 2013 [3 favorites]


Damn, if only there were a pre-existing federal program that all of the states and healthcare providers were already plugged into that we could just increase funding for instead of funneling money through hundreds of private insurers.
posted by tonycpsu at 2:44 PM on October 22, 2013 [8 favorites]


Damn, if only there were a pre-existing federal program that all of the states and healthcare providers were already plugged into that we could just increase funding for instead of funneling money through hundreds of private insurers.

Instructions unclear: expanded Office of Weights and Measures scope of authority to cover every citizen.
posted by jason_steakums at 2:50 PM on October 22, 2013 [2 favorites]


jason_steakums: " Instructions unclear: expanded Office of Weights and Measures scope of authority to cover every citizen."

Neat trick considering no such agency exists in 2013!
posted by tonycpsu at 2:53 PM on October 22, 2013 [1 favorite]


(That's all under NIST now.)
posted by tonycpsu at 2:53 PM on October 22, 2013


David Auerbach on 5/500 miiiiilllllion lines of code:
But while the numbers in the Times article don’t tell us much about the healthcare.gov codebase itself, they do tell us something about the “specialist” sources that inform the article. The sources are not programmers, because programmers would not speak in terms of lines of code with no further context. We hear that “disarray has distinguished the project” in part because government “officials modified hardware and software requirements for the exchange seven times.” The officials probably modified them 70 times—requirements for any software project are constantly in flux, and it’s expected that project managers and software engineers will adapt. Modifications alone do not signal a project in disarray. ...

I have no idea who the Times’ sources were, but they sure sound like employees of CGI Federal. Because they almost certainly aren’t programmers, I’d guess they are probably mid- or high-level managers who are trying to salvage CGI Federal’s reputation. They may well be “specialists,” but their specialty is more likely the art of procuring government contracts.

This is to be expected. What’s less expected is that such anonymous sources would be treated with this degree of credulity by national reporters who lack technical understanding of their subject matter and are thus more likely to parrot whatever a “specialist” tells them. The Times has a great tech reporter, Natasha Singer, who has done well-informed work on consumer profiling, taking little for granted. They should put her on this story.
Auerbach is no Pollyanna about the state of Healthcare.gov, BTW.
posted by maudlin at 3:19 PM on October 22, 2013 [7 favorites]


Neat trick considering no such agency exists in 2013!

Damn you, facts!
posted by jason_steakums at 3:52 PM on October 22, 2013 [1 favorite]


So all of FreeBSD has around 5M lines of code. I'm finding it hard to buy that a website, no matter how complex, could have 100 times that.
posted by octothorpe at 3:53 PM on October 22, 2013


I'm finding it hard to buy that a website, no matter how complex, could have 100 times that.

If you have a government contract and get paid by the line of code, you'll get 500 million. Kinda like how $10,000 of LP gas cost 26 million (Iraq war - the 26 mil was delivery charges)
posted by rough ashlar at 4:01 PM on October 22, 2013


One of the main reasons I- as a dumb young person who totally doesn't have any awareness of her own mortality- would never have been willing to quit this job is because I am terrified of being uninsured.

So in one fell swoop, Obamacare is also increasing social mobility (AKA "the American Dream") by giving people a genuine ability to better their lot when opportunity knocks, instead of being trapped where they are.

Clearly this must be stopped at all costs.
posted by anonymisc at 4:03 PM on October 22, 2013 [4 favorites]


If you have a government contract and get paid by the line of code, you'll get 500 million. Kinda like how $10,000 of LP gas cost 26 million (Iraq war - the 26 mil was delivery charges)

This is not how government IT contracts work, especially since contracts are awarded before work can begin.
posted by zombieflanders at 4:05 PM on October 22, 2013 [2 favorites]


According to VS Code Analytics the "web" portion of my largest project is 64,184 lines this includes the usual code for user roles, membership, authentication, presentation, bells and whistles like oauth.

The backend worker processes that handle the heavy lifting are 217,500 lines.

So lets say 300k total.

On disk, including junk like images,config files, documentation, installers, it is 1.3 GB

It takes long enough to build that I try to build only a few times a day and doing a full get from TFS takes like 5 minutes, mostly due to network speed, but still.

Even if they managed to generate 500m lines of code, WTF kind of source control do they use or build environments. I mean it must be the largest piece of software ever written.

It is so out of proportion it would be like building a plane with a 10 mile wingspan or a building 100 miles tall.

They should get these people working on a space elevator or something.
posted by Ad hominem at 4:20 PM on October 22, 2013 [3 favorites]


No no no, they misheard the source: 500 million lines of coke. They pulled an awful lot of all-nighters to hit deadline.
posted by jason_steakums at 4:27 PM on October 22, 2013 [8 favorites]


This is not how government IT contracts work, especially since contracts are awarded before work can begin.

I worked with some military-contractor-type folks at one point who did indeed try to come up with estimates of code size before the work had started, and then staff up teams by number of lines of code to write. Yes this is insane and I hope they didn't do it on this project, but it is not outside the realm of possibility.
posted by miyabo at 4:44 PM on October 22, 2013


Yeah, I'm 24. I no longer had health insurance when I moved out of my home state for college, so I bought it from my university-- very expensive, but if I hadn't had it, I wouldn't have had surgery two years ago that's made my life significantly easier (and which I never would have anticipated in advance). After college, I moved home so I could have health insurance again (from my state, because I was low-income), but job opportunities were so bad there that I just got in a financially fucked-up state where I couldn't afford anything. I held my breath and moved to a better city where I actually found a good job, but it'll be another few months before I have health insurance again and I'm still holding my breath.

Health insurance is such a big deal to young people. Young people get sick, they want to go to the doctor, they want to know about birth control, they want to cure that infected toenail, they want treatment for their depression, &c. They don't want to spend thousands of dollars they don't have on it. Not that that means people in their 20s are always on top of their game about these things, but man, every friend I have who doesn't still have insurance through their parents walks a tightrope. One of them got a chipped tooth and had to borrow $1000 from a rich friend to have it fixed before it just sat in her mouth and died. It's incredibly obvious how important health insurance is if you don't have it even for a little while.
posted by stoneandstar at 5:24 PM on October 22, 2013


As a firm believer in Workfare instead of Welfare, I think we should have got the banking industry to build it for free in return for all that bailout money.
posted by George_Spiggott at 5:37 PM on October 22, 2013 [5 favorites]


"You may have noticed that all the Nigerian e-mail scammers have become a lot less active lately," Ted Cruz joked to constituents in Texas. "They all have been hired to run the Obamacare website." Hey, nice Africa joke there, Cruz! Subtle!
posted by Cookiebastard at 6:24 PM on October 22, 2013


JackFlash,

Seriously! I read your comment ...

BobbyVan, okay, now we know you are just trolling. Nobody links to Ms. McArgle Bargle unless it is to point and laugh at the glibness of her ignorance. I mean, nobody even wastes the time to rebut her stupid stuff anymore.

... and I thought, "Surely Thomas Levenson is still taking time to tell us all why McArdle is wrong about everything!?!" But no. He hasn't written about her since June!
posted by Jonathan Livengood at 8:33 PM on October 22, 2013


The horror ... the horror ...
The House Energy and Commerce Committee asked John McAfee, the tech security guru who went on the lam in Central America last year under suspicion of murder, to examine the troubled rollout of Obamacare's online insurance website, according to CNBC.

The consultation never occured, but that didn't stop McAfee from sharing his thoughts with noted right-wing conspiracy theorist Alex Jones in an interview posted Tuesday on Jones's website.

"My advice would be: Throw it away, and start over," McAfee said. "You cannot fix the system that's there. It is impossible, the way it is architected, any good programmer will tell you, it's just not going to work... It will never work the way that it is."
For added WTF, here's Maddow's long piece on McAfee, including an appearance from Frank Rich.
posted by maudlin at 9:53 PM on October 22, 2013


That said, I would have tried to do a state-by-state roll-out or something -- anything -- besides their "big bang"approach.

This sounds attractive, but a) you're dealing with a legal requirement here that mandated that people got access to the sites at a specific date (as the law mandates mandatory insurance from 2014-01-01) and b) you're not avoiding complexity this way, just spreading the pain over a longer period.

Both politically and from an IT implementation point of view it makes sense to do it all at once and get it over with; experiences learns that with big, complex projects like this errors and congestion are unavoidable, but that they get solved quicker when the system goes live than by keeping it in testing.

If only because a lot of the errors and gaps can only be found by bringing it live.
posted by MartinWisse at 11:51 PM on October 22, 2013 [1 favorite]


Obamacare trouble tickets? I dunno. WORKSFORME

And it looks pretty damned snazzy, too...

Does anyone have any CURRENT open issues? Man, putting their bugzilla online would really be cool, but the risk of private info leaking it probably too great.
posted by mikelieman at 3:40 AM on October 23, 2013 [1 favorite]


"My advice would be: Throw it away, and start over," McAfee said. "You cannot fix the system that's there. It is impossible, the way it is architected, any good programmer will tell you, it's just not going to work... It will never work the way that it is."

We don't even know within a factor of 100 how many SLOC there are, how the hell would he know how the thing is architected?
posted by octothorpe at 4:37 AM on October 23, 2013


I know that anyone who counts LOC doesn't know anything about development.
posted by mikelieman at 5:44 AM on October 23, 2013 [4 favorites]


Obamacare rollout is awful. GOP’s position is a lot worse. (emphasis in original)
Bottom line: Republicans just don’t envision the federal government playing an ambitious oversight role in regulating the health system — or spending the money necessary – in service of the goal of expanding coverage to tens of millions of uninsured.

But Republicans are going further than just arguing their position. They are actively trying to prevent people from enjoying the benefits of the law, to try to make it fail. As Ron Fournier notes, while there are serious questions about the failures of the Obamacare rollout, that doesn’t diminish the fact that multiple GOP governors, by opting out of the Medicaid expansion for purely political reasons, are acting against the interests of millions of their own constituents. The GOP’s commitment to full repeal has led it to refuse to participate in bipartisan fixes that even GOP-aligned constituencies want. Republicans’ current criticism of the law’s rollout is also of a piece with this larger stance. As Brian Beutler observes:
If you’re a reporter or a news junkie or a constituent, you should be absolutely clear that these people don’t want Healthcare.gov to work and are making wild, unsupportable claims to discourage people from becoming insured.
We can keep two ideas in our heads at the same time. The first: Obamacare’s rollout is awful and demands accountability. The second: GOP criticism of the rollout is deeply incoherent and indicative of a larger refusal — one that has gone on for years — to participate seriously in the basic governing necessary to solve this pressing national problem.
posted by zombieflanders at 6:25 AM on October 23, 2013


mikelieman: "I know that anyone who counts LOC doesn't know anything about development."

SLOC count can be an interesting metric if looked at within a specific context and combined with other metrics but yeah, not very useful in general. I was just pointing out that we don't know anything about the internals of the project so we're just guessing at what's wrong.
posted by octothorpe at 6:38 AM on October 23, 2013


Hey, nice Africa joke there, Cruz! Subtle!

Eh, he's just trying to make up for having blown his best chance to trash the site because he was too busy dicking around with the government itself.

It's just a sign he's desperate. That makes me happy in my pants a bit.
posted by EmpressCallipygos at 7:10 AM on October 23, 2013 [1 favorite]


Protip: Make sure you uncheck the box that says "Automatic referral to death panel on 60th birthday" before you submit. Sneaky bastards!
posted by Renoroc at 7:11 AM on October 23, 2013 [2 favorites]


CBS News: HealthCare.gov pricing feature can be off the mark
The administration announced it would provide a new "shop and browse" feature Sunday, but it's not giving consumers the real picture. In some cases, people could end up paying double of what they see on the website, CBS News' Jan Crawford reported Wednesday on "CBS This Morning."

...

Prices for everyone in the 49-or-under group are based on what a 27-year-old would pay. In the 50-or-older group, prices are based on what a 50-year-old would pay.

CBS News ran the numbers for a 48-year-old in Charlotte, N.C., ineligible for subsidies. According to HealthCare.gov, she would pay $231 a month, but the actual plan on Blue Cross and Blue Shield of North Carolina's website costs $360, more than 50 percent higher. The difference: Blue Cross and Blue Shield requests your birthday before providing more accurate estimates.

The numbers for older Americans are even more striking. A 62-year-old in Charlotte looking for the same basic plan would get a price estimate on the government website of $394. The actual price is $634.
posted by BobbyVan at 7:11 AM on October 23, 2013


It's almost as if choosing a state where the GOP is deliberately sabotaging Obamacare (beyond the sabotage from the federal GOP) may not be the best benchmark:
Participating in a state-based exchange would have allowed the state to create more opportunities for competition, as the N.C. Rate Bureau does for auto insurance companies. “With a state-based exchange, we would’ve been in control over discussions that would’ve incentivized companies to participate,” Goodwin said.

More competition, of course, could have resulted in better pricing and insurance choices, as it has with the 166 companies participating in auto insurance in the state. With Obamacare, only two companies are participating in the N.C. exchange, leaving North Carolinians with an average of 22 qualified health care plans to choose from, less than half the national average.

Don’t know what the best option is for you? Again, the legislature has made things more difficult, turning down a $27 million federal grant for outreach regarding the Affordable Care Act. Goodwin estimates in the next six months alone, tens of thousands of calls will come into state offices with questions about Obamacare, but state law requires his employees to forward people to the feds if they start asking for help with enrollment.

The grant also would’ve helped his office proactively meet at least some of the uncertainty and misinformation surrounding Obamacare. “I had two emails this morning,” he said. “To me that’s frustrating, because it’s going to cost individuals and families money.”
posted by zombieflanders at 7:30 AM on October 23, 2013 [3 favorites]


JackFlash: "Nobody links to Ms. McArgle Bargle unless it is to point and laugh at the glibness of her ignorance. I mean, nobody even wastes the time to rebut her stupid stuff anymore."

Actually, even her editors couldn't ignore her innumeracy in that piece (via).
posted by tonycpsu at 7:35 AM on October 23, 2013 [1 favorite]


It's almost as if choosing a state where the GOP is deliberately sabotaging Obamacare (beyond the sabotage from the federal GOP) may not be the best benchmark:

That's immaterial. Healthcare.gov asks visitors specifically which state (and county) they reside in before providing the estimates.
posted by BobbyVan at 8:08 AM on October 23, 2013


We may be in trouble with this thing. Looking at the source, the contractors seem to be hobbyists or college undergrads building their first website. Really--check out the login page's source. It's a mess.

The exchange is like a perfect storm of everything that can go wrong in a software development project: It's politicized and high-profile, the contract managers seem to have just thrown warm bodies at the problem indiscriminately as if they were building the Great Pyramids instead of complex software, and it involves back-end integration with who knows how many other Federal and State systems. When even one stakeholder doesn't buy in, you get problems. In this case, there's not only lack of buy-in among some stakeholders, but actual hostility, so some level of initial failure is basically guaranteed.

That's immaterial. Healthcare.gov asks visitors specifically which state (and county) they reside in before providing the estimates.

I'm guessing you're not a developer here if you think you've demonstrated how this is "immaterial."
posted by saulgoodman at 8:17 AM on October 23, 2013 [2 favorites]


That's immaterial. Healthcare.gov asks visitors specifically which state (and county) they reside in before providing the estimates.

Not really. Remember that the biggest problems are with the back-end interactions between the federal site and databases of the individual states and insurers. States with their own exchanges seem to come off really well, while those without, not so much. It was...interesting that CBS chose one of the worst states in terms of implementation, then went and interviewed someone from a state with not only an exchange, but an apparently effective interaction with Healthcare.gov, yet didn't bother to ask if the information Healthcare.gov was giving for their state was accurate.
posted by zombieflanders at 8:22 AM on October 23, 2013


Not really. Remember that the biggest problems are with the back-end interactions between the federal site and databases of the individual states and insurers.

This disparity has nothing to do with "back-end" interactions between the different states. It has to do with Healthcare.gov misleading customers by providing only two age cohorts (49 and under; 50 and over), when there is a great deal of variation within the cohorts. Healthcare.gov compounds its error when it informs customers that their final rates might be lower -- but not that they might be higher.
posted by BobbyVan at 8:25 AM on October 23, 2013


We really don't know enough to say. Healthcare.org might depend on web services hosted by the other exchanges or something to perform its calculations of cost and benefit. We can't assume any operations on state-level information are performed within the boundaries of the Federal site. The data might be owned and served up by the state exchange systems, on the backend, for all we know.
posted by saulgoodman at 8:48 AM on October 23, 2013


But the front-end does seem to have problems of its own.
posted by saulgoodman at 8:49 AM on October 23, 2013


That's fair, saulgoodman, but the more fundamental issue is that it's impossible to provide reasonably accurate estimates with only two age cohorts.

If there's an architectural reason to lump all users into the >50 and <50 categories (i.e., a more granular division leads to breakage), the site should either provide a price range or -- at the very least -- a prominent disclaimer that the final rate could be significantly higher.
posted by BobbyVan at 8:53 AM on October 23, 2013


CBS News: HealthCare.gov pricing feature can be off the mark

This is not the actual pricing of health plans. It is only an estimate given to window shoppers who are not logged in and have not provided the detailed information necessary to give an actual price.

The estimates are based on this table which provides the unsubsidized price for a 27-year-old and a 50-year-old.

The ACA requires that there be no more than a 3:1 increase in price going from a 21-year-old to a 64-year-old. You can see a sample table for age variation here. It is not a linear. It rises more steeply as you get older because medical costs generally increase as you get older. Prices are fairly flat from 21 to 30, double by age 52 and triple by age 64.

So it is CBS News that is misleading. Its headline implies that people are being incorrectly charged when they are only talking about a window-shopping estimator which does not include precise age corrections. It also does not include possible subsidized prices because it doesn't know your family size or income. When you log in and provide all of your detailed information, the prices shown are your actual, correct prices.
posted by JackFlash at 9:09 AM on October 23, 2013 [9 favorites]


Thanks for those excellent clarifications, JackFlash!
posted by saulgoodman at 9:19 AM on October 23, 2013


So? Obamacare-2.0 is going to totally fucking rock?
posted by mikelieman at 9:20 AM on October 23, 2013


But there is a general rule. If you're using SQL, you're probably screwed.

I beg to differ. I know that nosql is all the rage now, but I think a lot of people who advocate for it don't have a good understanding of what's involved in building a scalable database with proper data integrity. What I'm seeing now is that nosql developers are reinventing a lot of wheels as they discover all the issues that database researchers and developers have spent a lot of time working on over the years.

If your website developers are building your data model, you're almost certainly going to lose.

I think that's the problem right there. Building a good data model (sql or nosql) for a huge system like this takes an experienced database developer, but all too many web site developers don't appreciate that.
posted by klausness at 9:25 AM on October 23, 2013 [3 favorites]


But there is a general rule. If you're using SQL, you're probably screwed.

If you're using SQL wrong, you're probably screwed. But that's always been true.

When you use it right, it effectively takes care of enforcing a lot of your most critical business rules merely by virtue of how the data is modeled and provides mechanisms for reading and manipulating data that are way more efficient and well-optimized than you're likely to have time to develop by other means. I'm still a big fan of relational database-driven architectural design for enterprise systems. RDBMSs provide a really solid foundation to build on if you understand how they work well enough. If you don't, well, then yeah, you're probably screwed. Same as it ever was.
posted by saulgoodman at 9:35 AM on October 23, 2013


By the way, for anyone having trouble getting into the exchanges for real pricing, ValuePenquin has done a pretty good job of aggregating data. I have checked their data for a couple of states and they are within about $15 to $25/month for their estimates. It looks like what they have done is use a quote for a 21-year-old for each plan and then applied an estimate of the age variation.
posted by JackFlash at 9:53 AM on October 23, 2013 [1 favorite]


This is not the actual pricing of health plans. It is only an estimate given to window shoppers who are not logged in and have not provided the detailed information necessary to give an actual price... So it is CBS News that is misleading.

First paragraph of CBS report: "A new online feature can dramatically underestimate the cost of insurance." (emphasis mine)

The estimates are based on this table which provides the unsubsidized price for a 27-year-old and a 50-year-old.

I'm guessing you didn't discover that bit of information by going through the "shop and browse" process...
posted by BobbyVan at 9:56 AM on October 23, 2013


Ezra Klein: ‘HealthCare.gov is in de facto shutdown’
posted by BobbyVan at 11:23 AM on October 23, 2013


Mike Konczal: What Kind of Problem is the ACA Rollout for Liberalism?
However, the smarter conservatives who are thinking several moves ahead (e.g. Ross Douthat) understand that this failed rollout is a significant problem for conservatives. Because if all the problems are driven by means-testing, state-level decisions and privatization of social insurance, the fact that the core conservative plan for social insurance is focused like a laser beam on means-testing, block-granting and privatization is a rather large problem. As Ezra Klein notes, "Paul Ryan's health-care plan -- and his Medicare plan -- would also require the government to run online insurance marketplaces." Additionally, the Medicaid expansion is working well where it is being implemented, and the ACA is perhaps even bending the cost curve of Medicare, the two paths forward that conservatives don't want to take.
posted by tonycpsu at 12:46 PM on October 23, 2013


Matt Yglesias: What Do Conservatives Like About Health Care in Singapore?
— Singapore has "multiple tiers of protection to ensure that no Singaporean is denied access to basic healthcare because of affordability issues."
— "The first tier of protection is provided by heavy Government subsidies of up to 80% of the total bill in acute public hospital wards, which all Singaporeans can access."
— "The second tier of protection is provided by Medisave, a compulsory individual medical savings account scheme ...
— As best I can tell, these Medisave accounts are deposited into the Central Provident Fund, a government-run investment pool, rather than constituting private savings as we would understand them.
— "The third level of protection is provided by MediShield, a low cost catastrophic medical insurance scheme" supplemented by private insurance called Integrated Shield plans and "Singaporeans must subscribe to the basic MediShield product before they can purchase the add-on private Integrated Shield Plans."
— "Finally, Medifund is a medical endowment fund set up by the Government to act as the ultimate safety net for needy Singaporean patients who cannot afford to pay their medical bills despite heavy subsidies, Medisave and MediShield."

None of this sounds to me like anything American conservatives favor. As in, there is no legislation that's been championed by major Republican leaders that would do any of these things and, in general, none of these measures comports with conservative aversion to government spending and regulation. And, yes, providers are regulated by a couple of entities.
posted by tonycpsu at 12:50 PM on October 23, 2013




BobbyVan: "Marketwatch: Obamacare mandate may be delayed -- Official says deadline to have insurance could be postponed"

What a dishonest headline.
The Administration, however, has recognized that there's a "disconnect" between the actual and effective deadlines, as the deadline to have health insurance under the ACA is currently six weeks earlier than the deadline to buy it. Now, the Administration is working to revise its current policies making sure the two deadlines line up with each other, says the HHS official. Official word on a possible new deadline will come shortly, the official adds.
In other words, they're making the theoretical deadline line up with the actual deadline. Some delay!
posted by tonycpsu at 1:29 PM on October 23, 2013 [4 favorites]




FYI, if the linked articles with names like "10 things Obamacare won’t tell you" and "What if Obamacare works?" weren't a tip-off, MarketWatch is a News Corp. company with a history of muddying the waters on Obamacare (among other things).
posted by zombieflanders at 2:04 PM on October 23, 2013 [3 favorites]


I'm thinking Harry Reid will tell Joe to go use his bill for target practice.
posted by tonycpsu at 2:11 PM on October 23, 2013


Roll Call: Sen. Joe Manchin III, D-W.Va., in a preliminary move that could jam his own politically vulnerable colleagues, is working on a bill to delay the individual mandate by a year, his office confirmed Wednesday.

Joe Manchin wants to delay the individual mandate? I'm shocked, shocked I tell you:

Joe Manchin's Mandate-Panic Does Not Mean the End of Obamacare
Well, the problem is that Manchin has been swinging a dull ax at the mandate for nearly three years. In early 2011 he joined three Democrats also looking at a 2012 re-election campaign and mulled a delay of the unpopular tax. "I’ve always had a concern and a problem with the mandate, that we were forcing it, basically saying by the law of the land you have to buy the product," he told reporters then. His allies at the time were Nebraska Sen. Ben Nelson, who's since retired (and been replaced by Republican Deb Fischer), as well as Missouri Sen. Claire McCaskill and Montana Sen. Jon Tester.

The politics have changed since then. Tester and McCaskill won't face re-election again until 2018; they have made no new noise about tweaking Obamacare.* Of the four "red state" Democrats seeking re-election in 2014—Mary Landrieu, Mark Begich, Kay Hagan, and Mark Pryor—the first two have dismissed talk of adding Obamacare tweaks to the debt limit, and only the last of them has a first-tier GOP challenger. Manchin would need to pull along all of these Democrats to prevent the rest of the party from amending the debt limit bill to stop a delay of the mandate.
posted by zombieflanders at 2:11 PM on October 23, 2013 [1 favorite]


Shocker from Fox News! I Was an ObamaCare Guinea Pig.

So scary. I'll look first and report back -- oh.
I signed up. I saved. And so will millions of Americans.
Setup. That has to be a setup. I'll keep going:
For a few days, I couldn’t do anything at all on the website.

Then for a day or so I could “log-in” but not complete registration. And then for a day, I could answer the questions to complete my registration but not actually complete the process.

On one occasion, I got so frustrated at the stalled exchange website that I actually shook my computer.
Yeah, that's more like it. I hope you were hugging your stress-reducing Ezra Klein doll, honey.
But finally, early on the first Saturday morning following the launch of the exchange site — probably because the rest of the state (unlike my five-year-old) was still asleep -- I was able to log-in and complete my registration and check out all my options for insurance.

There were literally 50 plans that were better than my current insurance -- both with lower premiums, lower out-of-pocket costs and better coverage. And there were ten plans with a higher premium than my current insurance, but with lower deductibles.

So -- and here’s an important point -- the reason that more people haven’t signed up for coverage yet is probably that, just like me, they needed to take some time (and first, find some time!) to weigh all the options.
Yeah, but did you actually save any money? Was it worth it?
Within a week, I had settled on a “gold” plan offered by Empire Blue Cross Blue Shield. ... This option will cost my family $931 per month — $408 per year less than my previous crappy plan and a $5,000 savings in deductibles. A big win for me and my family financially and in terms of what’s covered.

Plus in the past, I spent several days looking for and comparing insurance options. Under ObamaCare, even with the slow and sticky website, I spent a total of four hours — to save over $5,400. That kind of return on investment would make Warren Buffett drool.
OK, the image of drooling Warren Buffett reassures me. This really is Fox and not a spoof site. Whew!
posted by maudlin at 3:08 PM on October 23, 2013 [2 favorites]


FYI, if the linked articles with names like "10 things Obamacare won’t tell you" and "What if Obamacare works?" weren't a tip-off, MarketWatch is a News Corp. company with a history of muddying the waters on Obamacare (among other things).

Or you could look at who is posting them.
posted by winna at 3:35 PM on October 23, 2013


Does your employer pay any percentage of your premium?

I'm not the commenter you are responding to, but it is undeniable that there are going to be some people for whom health care is either more expensive or worse under Obamacare. I'm one of them, for example. And I say that as a supporter of health care reform.

Well, "worse" is subjective I guess. The network of doctors and hospitals I have access to is considerably smaller. Given that I'd rather pay somewhat more for a better plan with a wider network (such as the plan I have until the end of this year) but am not able to get such a plan under the ACA I feel justified in claiming my health care will be getting worse. At the least it will be more restrictive and the hospitals they will cover are worse than the ones covered now.

Things can be complicated, they don't have to be 100% good or 100% bad.
posted by Justinian at 4:32 PM on October 23, 2013


Here’s how the White House just tweaked Obamacare
"As we understand the interaction between these rules, an uninsured taxpayer eligible for the tax credits must have coverage effective by March 1, 2014 to avoid the penalties," Haile wrote on Oct. 8. "To ensure that they have coverage effective on March 1st, taxpayers must enroll in their qualified health plans and pay their premiums by mid-February."

The Associated Press reported on Haile's memo the next day and the White House confirmed that, as the regulations were written, shoppers would need to purchase coverage by mid-February to avoid the fine.

What the administration is doing today is probably best described as a tweak to the individual mandate: They are allowing anyone who purchases coverage during open enrollment (up through March 31) to not face a tax penalty for those three months they spent uncovered. This is only true for people who buy coverage through the marketplace.

How much this change had to do with HealthCare.gov's technical problems isn't totally clear. On the one hand, it certainly helps alleviate some of the time pressures on the administration if it can give shoppers six additional weeks to purchase coverage. On the other, it's easy to see this change getting made in any situation. It's confusing to have two separate deadlines, one when the individual mandate kicks in and another when shopping ends. Either way, now those two dates are the same. The mandate kicks in and open enrollment ends for exchange shoppers on March 31.
posted by zombieflanders at 5:04 PM on October 23, 2013 [1 favorite]


Yeah, that's a pretty minor tweak which would have been a good idea even in the absence of website problems.
posted by Justinian at 5:09 PM on October 23, 2013


I'm going to try the site again. My state hasn't got an exchange running. So we'll see how it goes this time. (Last time, I got put on hold.)
posted by saulgoodman at 7:29 PM on October 23, 2013


Does anyone have any CURRENT open issues?

Since you asked:

I was able to setup my account on healthcare.gov a couple of weeks ago, but I'm unable to complete my application. The first time, I answered all the questions and verified my identity, but when it returned me to the "My Applications & Coverage" page, it said my application was "In Progress." When I click on the application, it says it's incomplete, so I go through and fill in the missing answers, get to the end, electronically sign it, and get kicked back to the "My Applications & Coverage" page, where the application is once again incomplete.

I've tried five or six times, and every time the missing answers are different. Sometimes my wife's SSN becomes my SSN. Sometimes the answers to earlier questions aren't even saved long enough to get to the "review and sign" stage. Of course, there's no non-linear way to edit the application, so if I go back to the first step to type in my address for the millionth time, I have to go through the entire application again.

Also, at the top of the screen there's a line saying "You have a notice available about your identity verification.." (yes, with two periods), but nowhere to click to view the notice. For some reason, this un-clickable notice feels even more frustrating than the incompletable application.
posted by bradf at 8:02 PM on October 23, 2013


Hey, it's working decently well for me now, actually. Some pages are a little clunky, and when I initially tried to submit an application, it churned for quite a while, but everything worked fine after that, and it looks like we could save nearly $400 a month without any subsidies at all on a Silver plan, and $300 or so on a gold plan... Hmm... I'm starting to not mind that the site isn't flawless...
posted by saulgoodman at 8:07 PM on October 23, 2013


Also, at the top of the screen there's a line saying "You have a notice available about your identity verification.." (yes, with two periods), but nowhere to click to view the notice. For some reason, this un-clickable notice feels even more frustrating than the incompletable application.
posted by bradf at 11:02 PM


Have you called them? 1-800-318-2596
posted by mikelieman at 4:41 AM on October 24, 2013


I just got a note that the limited-care plan offered by my temp agency is ending on New Year's Day. If my agency doesn't come up with something else, I may be doing this.
posted by EmpressCallipygos at 4:43 AM on October 24, 2013


Things are getting a bit heated at today's ACA hearing.
posted by tonycpsu at 8:16 AM on October 24, 2013 [2 favorites]


Looking at the source, the contractors seem to be hobbyists or college undergrads building their first website. Really--check out the login page's source. It's a mess.

To expand a little on my own previous comment above, a colleague of mine showed me the older source for the login page and it looked terrible and the file size seemed unnecessarily large (and there were lots of weird working comments), but it looks like they've either cleaned things up a bit or that code was bogus. There's still an awful lot going on there for such a simple function, but then, web pages are getting more bloated in general these days...
posted by saulgoodman at 9:07 AM on October 24, 2013


Things are getting a bit heated at today's ACA hearing.

Apparently nothing about the 834s, just being fucking morons who don't know what HIPAA is and inventing conspiracy theories, then?

I remember how these tactics worked so well for them when it came to Benghazi Benghazi BENGHAZI and the IRS "scandal." I mean, we did end up with President Romney and a GOP supermajority with a soaring favorability rating, right?
posted by zombieflanders at 9:26 AM on October 24, 2013 [3 favorites]


From the woman who put together the CFPB's web services:

9 Things You Should Know Before Debating HealthCare.gov, From Someone Who Actually Launched a Successful Government Website
Over the summer of 2010, I had coffee with Eugene Huang. Eugene worked in the White House as a Senior Advisor to the US CTO and had been recently appointed as the acting CTO at a new federal agency called the Consumer Financial Protection Bureau. He asked me: What would you do if you had the opportunity to make digital and tech work in government?

My response was threefold:
1. Never build a website that's too big to fail; instead, start small.
2. Let's do open source when possible (preferably always).
3. Let's have in house strategy, design, and tech.
None of this was particularly revolutionary in the private sector, however many government agencies at that time (and currently) outsource their technical capabilities to the point where the vision and strategy is out of house. Not only that, fixing a typo on a website can take 24 hours. My conversation with Eugene laid the foundation for what became our technology and digital team, as well as approach to digital services. Here's how we did it.

[tl;dr: Start small, have a vision, fix federal hiring and procurement. And stop putting website requirements in legislation.]
posted by zombieflanders at 10:02 AM on October 24, 2013 [3 favorites]


CBS News: Some Democrats suggest extending, delaying Obamacare enrollment
Frustrated by the troubled rollout of the healthcare exchanges, a handful of Democrats are floating the idea of delaying the open enrollment period for the Affordable Care Act exchanges in order to allow users more time to sign up for insurance and avoid being hit by tax penalties.

As the law stands, open enrollment on the exchanges will end on March 31. For the first year that taxpayers do not sign up for insurance for 2014, they will have to pay a penalty of $95 or up to one percent of income. The next year that fine increases to $325, and it eventually rises to $695 by 2016.
posted by BobbyVan at 10:33 AM on October 24, 2013


I feel like this is your version of "Surely this..."
posted by jason_steakums at 10:42 AM on October 24, 2013


What is it with these reporters that use "delaying" when what they mean is "extending"? Shaheen does not say "delay":

"Given the existing problems with the website, I urge you to consider extending open enrollment beyond the current end date of March 31, 2014. Allowing extra time for consumers is critically important so they have the opportunity to become familiar with the website, survey their options and enroll," Shaheen wrote.

posted by rtha at 10:57 AM on October 24, 2013


Fellow Lefties, Please Stop Trying to Reassure Us with Logic
You really think saying "Fix the website!" now is going to prevent Republicans from turning around and saying "Destroy the program!" later? You really think what drives right-wing rage is logic?
...
Right-wingers are the folks who wave signs saying "KEEP GOVERNMENT OUT OF MY MEDICARE." Right-wingers are people who believe that being pro-gay is inextricably linked to being pro-sharia. Right-wingers are people who considered opposition to NSA spying treasonous in the Bush years and consider NSA spying itself to be treasonous now.

Logic doesn't enter into this. It's all about passion.
...
No, they're not switching tactics. They're just doing what they did (or tried to do) during the shutdown: like sharks, they're heading wherever they think they detect blood in the water. They thought it was the moment just before implementation began; now they think it's the rollout of the portal. Once the portal is fixed, it'll be something else. The nature of what they're doing never changes. It's always a feeding frenzy.
posted by tonycpsu at 10:59 AM on October 24, 2013


Washington Examiner (conservative publication): CareFirst says 76,000 customers will lose current coverage due to Obamacare
CareFirst BlueCross BlueShield is being forced to cancel plans that currently cover 76,000 individuals in Virginia, Maryland, and Washington, D.C., due to changes made by President Obama's health care law, the company told the Washington Examiner today.

That represents more than 40 percent of the 177,000 individuals covered by CareFirst in the states.

Though Obama famously promised that those who liked their health care coverage could keep it under his program, in reality the health care law imposes a raft of new regulations on insurance policies starting Jan. 1 that are forcing insurers across the country to terminate existing plans.

In theory, rules were supposed to allow pre-existing plans to be "grandfathered in," but they were written so narrowly as to leave out many plans.

"Of the 177,000 individuals under age 65 who are covered by CareFirst, about 76,000 of them are in a non-grandfathered plan – a plan that will not comply with the guidelines imposed by the Affordable Care Act at their time of renewal this year or next," CareFirst said in an email in response to an inquiry by the Examiner.

posted by BobbyVan at 11:27 AM on October 24, 2013


Who's to blame in BobbyVan's Florida Blue coverage loss scandal? Straight from the trenches here in Florida, it turns out to be Florida Blue, not Obamacare.

But don't worry! The latest from Florida Blue: though we're canceling 300k policies, we're giving 'migrating' options.

Hope they get it all sorted amicably because Florida Blue's who I'm eying for a new exchange plan if we decide to go that route.
posted by saulgoodman at 11:52 AM on October 24, 2013


I don't know that "blame" is a useful metric for cases like this. Blue Shield California is cancelling lots of their individual plans out here as well (like mine) and pushing everyone onto the exchanges. Are they required to do that under Obamacare? No, they could grandfather the plans in. But is it an absolutely forseeable and inevitable result of Obamacare? Yes it is because they make more money by pushing the less profitable plans onto the exchanges.

So who is to blame? The company which makes the rational decision to maximize their profits or the law which gives them incentive to do it? Both, probably, which is why I don't think "blame" is, as I said, useful.
posted by Justinian at 12:00 PM on October 24, 2013 [3 favorites]


Yes, and I agree, but the press and the public seem to disagree. Between them, they barely ever find a situation in which blame isn't chief among their concerns.
posted by saulgoodman at 12:03 PM on October 24, 2013


All the coverage on the subject here in Florida has been about who to blame, at least.
posted by saulgoodman at 12:04 PM on October 24, 2013


Though Obama famously promised that those who liked their health care coverage could keep it under his program, in reality the health care law imposes a raft of new regulations on insurance policies starting Jan. 1 that are forcing insurers across the country to terminate existing plans.

In theory, rules were supposed to allow pre-existing plans to be "grandfathered in," but they were written so narrowly as to leave out many plans.


Interesting that he didn't mention what these rules were. Like, say, plans that wouldn't cover pre-existing conditions.

Also from that article:

It continued, "These individuals in Maryland, Washington, D.C., and portions of Northern Virginia will be required by the health law to purchase a new ACA-compliant health plan. This phenomenon is not unique to CareFirst and its members, but rather a result of industrywide changes in accordance with new ACA health plan standards."

While individuals in Maryland and Virginia will have the option of shopping for new plans either on the Obamacare exchanges or the individual market, D.C. residents who get cancellation notices will be forced to purchase insurance on the exchange.


What they presumably failed to disclose (at least, I hope Klein isn't deliberately omitting info) is that they're doing it because Carefirst has a stranglehold on the DC-area health care market that Obamacare and the exchanges are looking to break. Nor do they disclose that in Maryland, they've been asking for price hikes six times that of their competitors like Aetna.
posted by zombieflanders at 12:07 PM on October 24, 2013 [2 favorites]


You can tell conservatives are desperate when they're looking for gotchas that were rendered moot four years ago:
"When I say `If you have your plan and you like it,... or you have a doctor and you like your doctor, that you don't have to change plans,'” the president said after we asked him about this, "what I'm saying is the government is not going to make you change plans under health reform."

Importantly, the government might create circumstances - say, a public health care option that is less expensive since profit is not a concern and overhead is lower - where you might find your business forcing you into that public plan.

Pressed by Diane Sawyer in an interview that same day, the president acknowledged this, saying, "I can't pass a law that says, 'I'm sorry, employers, you can never make changes to the health care plans that you provide your employees.' What I can say is that the government is not going to force you to, your employer or you to join a government plan, for example. If you're happy with it, and your employer's happy with it, keep it."
Importantly, Obama was talking about employer-based plans, not individual plans, and he admitted early on that the law doesn't allow the government to force the hands of private insurers. Somehow, I doubt conservatives would approve of the jackboot of government stomping on the necks of insurance companies and forcing them to continue to offer the exact same plans forever, even if they're not profitable, yet we're now supposed to believe that these companies choosing to cancel the less-profitable plans is Obama's fault.

But, as mentioned above, logic need not apply -- there's blood in the water.
posted by tonycpsu at 12:09 PM on October 24, 2013 [1 favorite]


Did you see my comment? Sure, the law isn't requiring insurers to cancel these plans. But it sets up a new regulatory and market framework in which the insurers would be stupid not to cancel the plans. Surely if you pass a law making something inevitable you can reasonably be said to share responsibility for it.

If a law was passed saying that anyone who pours gatorade over tonycpsu's head gets $500 but does not require anyone to pour gatorade over your head we can still say the lawmakers and the gatorade pourers both share responsibility?
posted by Justinian at 12:15 PM on October 24, 2013


Justinian: "Did you see my comment? Sure, the law isn't requiring insurers to cancel these plans. But it sets up a new regulatory and market framework in which the insurers would be stupid not to cancel the plans. Surely if you pass a law making something inevitable you can reasonably be said to share responsibility for it."

Yes, I saw your comment, and even favorited it because I agree that blame isn't useful here. Obama made a claim that is factually true but misleading, while his opponents are trying to seize on that misleading claim even though he wasn't talking about the individual insurance market, and even though he backed away from it and admitted that the ACA might create incentives that would cause employers to change plans.
posted by tonycpsu at 12:23 PM on October 24, 2013


zombieflanders' "9 things ..." link by the person who ran the CPFB web site project is worth a read. The bit where they turned the 20+ complaint form into this web form is great. Clean and simple.
posted by freecellwizard at 12:25 PM on October 24, 2013


Yes, I saw your comment, and even favorited it

Oh, carry on then. You are a wise man.
posted by Justinian at 12:26 PM on October 24, 2013




...aka a Category 5 Blamestorm.
posted by jquinby at 1:44 PM on October 24, 2013


Well, the reality is, this thing did have a roll-out deadline determined in advance by a political process rather than sound project planning, and for all the people saying this could have been done better open-source, that's simply not true when you consider all the closed source and proprietary data systems involved in the integration effort. Even with the best developers in the world on the job, I suspect it wouldn't have had a "successful" release.

But what matters now is the site is working for a lot of people. I've had success using it to do what it's supposed to do, and it wasn't so slow as to be painful (just a little slower than I might have liked at certain points).

As much as people are saying "typical government cock-up" this and that, the fact is the very internet they're using to complain is a pretty good example of a successful large-scale Federal project that succeeded beyond most people's expectations and I'd hesitate to pin the blame entirely on management incompetence. The tricky thing with government projects, often, is that the development deadlines are determined in advance without any regard for the actual work to be done. Politics not sound planning drives a lot of the development decisions. In fact, big everything on day one system deployments like this have a terrible track record in both the private and public sectors.

Software development is not remotely like conventional real-world construction in at least one crucial respect: There's a rapidly diminishing productivity curve when you just throw more people at the project expecting to speed up development. Coordinating people and managing the work they're doing very quickly adds so much overhead to the project that development suffers. People really need to stop thinking of software development in terms of construction metaphors. It's not the same thing. Not even remotely.
posted by saulgoodman at 2:38 PM on October 24, 2013 [5 favorites]


All that said, I just ran into a broken piece: the eligibility report. I couldn't view it. It just came up as a blank page, but otherwise, the rest seems to be working.

Whoa! One of the plans I was offered includes dental and eye care for the kids for nothing. That's nuts. Some of the emergency services are more expensive under this plan because the deductible applies to them (something like six grand per person), but most of the routine stuff is basically free and it costs $300 less a month than my premium work plan. And there's lots of other free goodies in the plan. I'm supposed to reenlist in my work plan tomorrow morning (my renewal form is actually a day overdue, but I've been in touch with the front office). Maybe I just shouldn't?
posted by saulgoodman at 9:28 PM on October 24, 2013


Whoa! One of the plans I was offered includes dental and eye care for the kids for nothing.

Y'know, I've always wondered - why is dental care, of all things, an add-on with health insurance? It's a straight up health concern.
posted by jason_steakums at 9:42 PM on October 24, 2013


Check the provider network, saulgoodman. That's where they're getting me. The prices and such were great, the provider list was significantly worse.
posted by Justinian at 12:36 AM on October 25, 2013


All that said, I just ran into a broken piece: the eligibility report. I couldn't view it. It just came up as a blank page, but otherwise, the rest seems to be working.

Whoa! One of the plans I was offered...


You got farther than I have. The blank eligibility page is as far as mine goes for now; I can't see any specific plans at all.

In principle I am very much pro-ACA and I think Republican rhetoric on this has generally been asinine, but the website is shockingly, inexcusably bad.
posted by jon1270 at 5:14 AM on October 25, 2013 [1 favorite]


I realized after a couple of tries that you don't actually need to be able to view the eligibility report to move on to the enroll step. It's not the most inuitive UI though, as
It's not clear how you move into the next step. Also, the "live" chat seems to be manned by chat bots.

Justinian: thing is, my son's going to need braces so that orthodontics coverage could save us a ton potentially... Network isn't a huge concern. Tallahassee's pretty small and doesn't offer that many options too start with.
posted by saulgoodman at 5:36 AM on October 25, 2013


It's not the most inuitive UI though, as It's not clear how you move into the next step.

No, it's much worse than an unintuitive UI. In my case, for now and for several attempts since yesterday afternoon, there is simply no way to advance in the process. Links don't work. They go to blank pages, or time out, or produce gibberish error messages, and pretty much nothing else.
posted by jon1270 at 6:13 AM on October 25, 2013


CBS News: Medicaid enrollment spike a threat to Obamacare structure?
The disastrous rollout of HealthCare.gov may have another serious problem: A CBS News analysis shows that in many of the 15 state-based health insurance exchanges more people are enrolling in Medicaid rather than buying private health insurance. And if that trend continues, there's concern there won't be enough healthy people buying health insurance for the system to work.
posted by BobbyVan at 6:51 AM on October 25, 2013


A CBS News analysis shows that in many of the 15 state-based health insurance exchanges more people are enrolling in Medicaid rather than buying private health insurance. And if that trend continues, there's concern there won't be enough healthy people buying health insurance for the system to work.

Huh? This strikes me as an extraordinarily dumb idea for CBS to be floating.
posted by jon1270 at 7:08 AM on October 25, 2013


CBS News has confirmed that in Washington, of the more than 35,000 people newly enrolled, 87 percent signed up for Medicaid. In Kentucky, out of 26,000 new enrollments, 82 percent are in Medicaid. And in New York, of 37,000 enrollments, Medicaid accounts for 64 percent. And there are similar stories across the country in nearly half of the states that run their own exchanges.

Medicaid experts say they're not sure why they're seeing the lopsided enrollment numbers, but point out it's easier to enroll in Medicaid than private insurance.


Who the hell are these "Medicaid experts" they're talking to? I can't tell if it's morons or axe-grinders, but in either case maybe it's because, I don't know...WA, KY, and NY are all states participating in the Medicaid expansion? Dollars to donuts the rest of the states they weirdly chose not to identify are all expansion participants as well.

This is why I'm completely not surprised that actual NY insurance experts characterize it much differently:
State officials and private insurance executives say they anticipated the higher Medicaid enrollment under the health care law, and the state budget plan enacted this year projects higher federal reimbursement rates to make up for more people moving into Medicaid.
[...]
Leslie S. Moran, senior vice president at the New York Health Plan Association, which represents many of the private companies involved in the state’s program under the health care law, said the state and industry have been having regular teleconferences to settle issues that have arisen.

“We’ve had a real good relationship and therefore an ability to flag problems very quickly and work to make sure they get fixed very quickly,” she said.
[...]
Moran said that many of those new Medicaid enrollees who thought they were signing up for one of the private insurance plans under “Obamacare” are an easier population to reach with word about the new system because they likely are already receiving some sort of assistance, such as food stamps.

“Part of the Affordable Care Act was to expand eligibility of Medicaid and to capture people eligible for Medicaid but who were not already in that program,” she said.
And WA is on the same page:
State officials say they are pleased with the high number of Medicaid enrollments. About two-thirds of those who have enrolled in Medicaid coverage are low-income adults who are newly eligible because of the state’s Medicaid expansion in 2014.

An additional 56,000 Washington residents have completed applications that are only missing the first premium payment, which is not due until December 23. That figure is an increase of nearly 20,000 over the week before.

Most people who have completed applications – or nearly 40,000 of the 56,000 total applicants – are members of households in which at least one member is enrolling in a private health plan while at least one other member qualifies for Medicaid coverage.
[...]
The latest figures are “really good news,” said Exchange spokeswoman Bethany Frey. “We’re still off to a really strong start.”
posted by zombieflanders at 7:43 AM on October 25, 2013 [4 favorites]


Well shit. Now the site won't let me do anything, and I need to figure out if I can get a better deal on my kids' coverage that includes dental today before I miss my open enrollment deadline at work. Damn. So annoying.
posted by saulgoodman at 7:59 AM on October 25, 2013




When I login and try to view my account profile to see previous plans I've saved, view other options, etc., I just get a blank, broken-looking screen when it works at all to let me login (which isn't often). Damn. I really thought I might be able to save some money, but at this rate, I think I'll just have to keep the kids on the work plan until next year.
posted by saulgoodman at 8:09 AM on October 25, 2013


It also loses track of the fact I've already logged in if I navigate back to the home page. Yeesh. What a cluster.
posted by saulgoodman at 8:10 AM on October 25, 2013


It's behaving like a site that hasn't completed development testing.
posted by saulgoodman at 8:11 AM on October 25, 2013 [1 favorite]


And I keep seeing random javascript function calls displayed on the screen instead of the rendered content that's supposed to display (like "$FfeUserTool.GetFFEUserPrincipal().GetFirstName()" where it's supposed to say "Hi Steven!"). Sheesh. I bet this site is susceptible to all sorts of script-kiddie attacks, too, judging from the care that went into it.
posted by saulgoodman at 8:17 AM on October 25, 2013


Yeah. I give up. I can view "My Applications and Coverage" at all. Can't even shop for a plan, the minimum the site's supposed to do. Very disappointing.
posted by saulgoodman at 8:20 AM on October 25, 2013


Ezra Klein: Sorry liberals, Obamacare’s problems go much deeper than the Web site (Note in particular Klein's endorsement of a point made by Megan McArdle above.)
The problem is precisely that the people who really need insurance will be patient and persistent. The people who don't need insurance as badly may not be. And if that happens, then in year two, costs are going to rise sharply for those sicker, older people left in the exchanges. And Republicans who see Obamacare's problems as a path to success in 2014 won't even think about expanding Medicaid.
posted by BobbyVan at 9:01 AM on October 25, 2013


Note in particular Klein's endorsement of a point made by Megan McArdle above

Not exactly. She was saying all insurance everywhere would go up, Klein is talking about what looks to be the federal exchanges. She was wrong because she failed to take into account the individual mandate, as Klein's compatriot Sarah Kliff pointed out. Kliff, perhaps not coincidentally, also wrote an article this morning talking about the state exchanges. Of particular note is this bit:
Connecticut doesn't have the highest enrollment numbers, with just under 4,000 people signing up for private plans and the state Medicaid program, know as HUSKY. They have, however, had one of the smoothest launches -- and are putting out the most detailed statistics about who is signing up for coverage.

Only in Connecticut, for example, do we know that about one-third of the new enrollees are under 35. We know that about half are purchasing mid-level silver plans, with the rest divided between the bronze and gold offerings. We know which carriers they are buying from, too. This data is important to how well the marketplace works: Keeping premiums low depends in no small part in getting young people to sign up. In Connecticut we know that, at least right now, that's happening.
posted by zombieflanders at 9:42 AM on October 25, 2013 [2 favorites]




Also, related:

A Chart That Will Help Dispel Your Obamacare Hysteria
The main reason for low enrollment will be that people don't sign up for health insurance programs right away. They wait until the last minute. This is true of public insurance and this is true of private insurance. And while you've heard people (including me) say this for months, this is one of those cases when numbers tell the story better than words. And there are some numbers very few people have seen.

The numbers are from Massachusetts, the state whose health reforms became the template for the Affordable Care Act’s coverage expansion. The place to look is within what’s known as the “Commonwealth Care” program, which is where people getting private insurance subsidies shopped for plans—in other words, an analogous structure to the new federally run exchanges.

Raw statistics on enrollment are already in circulation. They show that the majority people didn’t sign up right away and a the biggest rush came at the end, when people realized they would owe a financial penalty for going without insurance. But even the raw numbers don’t fully capture the timing of enrollment, because they include large numbers of people whom Massachusetts officials automatically transferred from a “free care” pool the state had operated previously. If you want to get a real sense of enrollment patterns among people choosing to shop and buy plans, it’s better to exclude the people getting free care. (In the Massachusetts plan, that would mean people who ended up enrolling in what were called “Type I” and, with some exceptions, “Type IIA” plans.)

Jonathan Gruber, the MIT economist who was an architect of the Massachusetts health reforms, has provided me with those numbers. The results? Of the 36,167 people who eventually enrolled in premium-charging plans from Commonwealth Care, 123 signed up in the first month. That’s right—one hundred and twenty-three, or about 0.3 percent. Over the first two months, the number was a bit larger—2,289. But that’s still just 6.3 percent.
posted by zombieflanders at 10:07 AM on October 25, 2013 [2 favorites]


Is there any truth to this new MarketWatch story: Court Could Block Obamacare Subsidies in 34 States? Are the courts potentially going to be meddling in this process too now? If so, forget ever being able to develop anything sound for the job because the requirements are going to turn into jello from here out.

And how the hell does it possibly serve the public interest in any way to have the courts block the Federal government from giving people money to help them afford healthcare coverage?

There are so many bad faith actors in the political machinery intent on making this not work, it'll be a miracle if it works out for anyone. What a shame. Further proof that Republicans don't even want their own policies to work if there's a risk they'll accidentally give working people more economic freedom.
posted by saulgoodman at 11:01 AM on October 25, 2013


Justinian: thing is, my son's going to need braces so that orthodontics coverage could save us a ton potentially...

DENTAL PLAN. Lisa needs braces! DENTAL PLAN. Lisa needs braces! DENTAL PLAN. Lisa needs braces!

All these years and it gets stuck in my head every friggin' time.
posted by Justinian at 11:20 AM on October 25, 2013


Is there any truth to this new MarketWatch story: Court Could Block Obamacare Subsidies in 34 States? Are the courts potentially going to be meddling in this process too now? If so, forget ever being able to develop anything sound for the job because the requirements are going to turn into jello from here out.

Kind of:

Judge allows anti-Obamacare suit to proceed
The reason that so many Americans have ended up having to purchase from federal-run exchanges is because, with few exceptions, Republican-run states have refused to set up their own exchanges as acts of defiancy against what they see as the tyranny of Obamacare–a law they have railed against repeatedly. Republican attempts to sabotage the law’s implementation is part of what helped set up this challenge to the law in the first place. Most of the states have refused to set up exchanges, but that decision tracks closely with which party is in control.

Just because the judge allowed the lawsuit to proceed, however, doesn’t mean that it will succeed. Judge Friedman also refused a request by the plaintiffs to prevent the feds from issuing subsidies to individuals in federal-run exchanges, which means implementation will go forward unaltered while the lawsuit is considered.

Wydra also points out that under a legal concept called the Chevron doctrine, courts are obliged to defer to a “reasonable interpretation” of the law by a government agency empowered by Congress to carry out said law. Whatever your view on the merits of the plaintffs’ case, she says, the Internal Revenue Service’s view that everyone in an exchange is entitled to the subsidies, is a reasonable one.

That is, unless you think of the law as designed to cause untold suffering to all in its path.
FWIW, this seems like the kind of thing to make it almost but not quite to SCOTUS, and even if it did, my guess is that would be unlikely to be overturned based on what we heard out of NFIB v. Sebelius. Legal experts of MeFi, what say you?

*nudges Justinian*
posted by zombieflanders at 11:25 AM on October 25, 2013 [1 favorite]


If you need some Goths conquered I'm your guy but I'm no legal expert.
posted by Justinian at 11:33 AM on October 25, 2013 [1 favorite]


I'll take it.

I coulda sworn you were the one commentating on the SCOTUS decision...
posted by zombieflanders at 11:36 AM on October 25, 2013


You're probably thinking of the Zimmerman trial. But that was strictly amateur analysis EVEN IF I WAS PROVEN ABSOLUTELY CORRECT. Errr, sorry got a little carried away.
posted by Justinian at 11:41 AM on October 25, 2013


But since you asked, I think the claim is frivolous and will be going nowhere. And I stayed in a Holiday Inn Express last night.

no i didnt
posted by Justinian at 12:07 PM on October 25, 2013 [3 favorites]


Gizmodo: Why the U.S. Government Needs a "Digital Core"
What gov.uk did that was so brilliant is that the team focused on 25 of the top 50 transactions that citizens make with their government and decided to make those transactions painless. So instead of having hundreds of different sites to visit whenever you have to pay money or register something with the government, you can do it all at once, with one account. Imagine that. Instead of a labyrinthine mess of federal sites for every different purpose—or more frustratingly, the absence of online infrastructure at all in some cases—the U.S. builds one website that serves as a one-stop shop to pay your taxes, get a passport, register your business, and, yes, buy health care.

Not that this kind of tech-centric culture can't still be a reality. We have an Office of E-Government & Information Technology. We have a Digital Government Strategy. We even have a Chief Technology Officer for the U.S. His name is Todd Park and he was appointed in 2012. Before that he served as one of the “entrepreneurs-in-residence,” in the Health and Human Services department, and before that he was the co-founder of two massive healthcare startups: Athenahealth and Castlight. He's done a lot of pretty sweet things, like hold an annual "health datapalooza" where entrepreneurs presented projects using open data from the government with the goal of improving care in the U.S.

But! Park's role is kind of irrelevant if he doesn't have the right team and structure to back him up.

Bracken points to some potential bright spots in the US: the Presidential Innovation Fellows, a group of private, nonprofit and academic leaders who advise government officials, and the appointment of Jen Pahkla, founder of Code for America, who is serving a year in the new role of Deputy U.S. Chief Technology Officer for Government Innovation. According to a blog post by Pahlka, the 10 fellows for 2013 are working on some pretty big and important projects, including MyUSA, which seems to be an effort similar to gov.uk. But these need to be addressed by a full-service, full-time, in-house team... not just fellows who come and go every year.
posted by zombieflanders at 1:14 PM on October 25, 2013 [3 favorites]


Re: a "Digital Core", I've been thinking lately it would be kind of rad if the Federal Govt had kind of a clearinghouse for working with open source developers who want to donate time and code. Like, if someone had a great idea for a piece of software that streamlines interaction with a certain government service, there should be an official channel for them to go through if they wish to donate a proof of concept or something. Some cultivated software repos of open source software that helps private entities meet government regulations would be great, too (for example, FCC regulations on broadcasters closed captioning online video, to take an example from my own industry, or even the real basics like compliant tax filing software). Like a one stop shopping kind of thing where you can feel safe that the software would actually get you compliance, because it's been verified by the regulatory agencies in question.
posted by jason_steakums at 2:44 PM on October 25, 2013


One thing that has not been commented on yet - did the contractors remove the copyright notice as a way to pad the bill for development to the Government?
posted by rough ashlar at 5:58 AM on October 26, 2013




I'm hoping that you posted that so that we could point and laugh at that. "Young Americans had options before ObamaCare"? We're supposed to take a site that calls the ACA ObamaCare seriously?
posted by octothorpe at 6:13 PM on October 27, 2013 [3 favorites]


Seriously, what a fearmongering, cynical pile of crap. I love how it uses all this revolutionary, generational-resentment language to....support the kinds of policies that continue making wealthy older people better off at the expense of the young. The good news is if you've got two brain cells to rub together, you can smell it for what it is from a long way off.
posted by Miko at 9:10 PM on October 27, 2013 [3 favorites]


Umm, you realize most residents don't actually file tax returns in most western countries, right zombieflanders and jason_steakums? Your employer and the revenue service figure it out, like they do for your estimated taxes in the U.S., except they monitor the accuracy and keep it correct. You need to notify the revenue service about certain types of side income or investment income.

Republicans have opposed any measures to simplify the U.S. tax system, like pre-printing the expected default values onto simple tax returns. Accountants opposed that too. I doubt they'd want government services simplified either.
posted by jeffburdges at 1:08 AM on October 28, 2013


OptOut.org: "We all know a bad deal when we see it"

Three reasons why Obamacare is bad for you


OptOut.org, so trustworthy and classy...oh, wait:

Right-Wing Ad Equates Obamacare and Rape: A creepy new ad suggests if you sign up for Obamacare, you'll be raped by a scary Uncle Sam clown.
The ad is somewhat reminiscent of this Burger King commercial that involved a guy waking up with a scary clown king in his bed, but the political message is less abstract. In this case, the message is that the government is trying to forcibly rape women with a blunt metal instrument[...]There's also a video aimed at college men in which the creepy Uncle Sam clown materializes out from under some near-child's exam chair to presumably fondle his prostate. Because that is what doctors do, right?

The videos, as Yahoo's Chris Moody tell us, are part of a much larger effort to persuade college kids not to sign up for the health coverage mandated by President Obama's new law, the enrollment period for which begins Oct. 1. The law relies heavily on the involvement of the young and healthy, who subsidize the old and sick.

Generation Opportunity will tour 20 college campuses later this month to spread this message, doing all the "cool kid" college activities, such as playing Cornhole and attending college-football tailgate parties, and passing out beer koozies that read "opt out." It'll be setting up stands alongside pro-Obamacare groups like Enroll America, passing out pizza and "literature," and trying to get kids to sign a pledge promising not to sign up for insurance under the new law.

Because nothing says cool like not having health care coverage, and maybe, if these ads succeed in scaring women out of the annual Pap exams they need, a diagnosis of cervical cancer.
posted by zombieflanders at 6:41 AM on October 28, 2013 [2 favorites]




I'm imagining the training for Generation Opportunity speakers includes timing how fast they can whip a chair around backwards to sit down and "just rap about this with you" and drilling them until they can turn a cap's bill backwards to no greater than 5 o'clock and no less than 3 o'clock with their eyes closed.
posted by jason_steakums at 7:28 AM on October 28, 2013


"And, remember, kids! Poochie says: 'Opt out of Obamacare!'"
posted by tonycpsu at 7:31 AM on October 28, 2013 [1 favorite]


How Kentucky Built The Country's Best Obamacare Website
From that point forward, Kentucky's game plan for a successful website launch could be read as a counterpoint to the mistakes that the Obama administration made in building its own website. The recipe for success in Kentucky was: A pared-down website engineered to perform the basic functions well and a concerted effort to test it as frequently as possible to work out glitches before the Oct. 1 launch.
...
Testing was undertaken throughout every step of the process, said Carrie Banahan, kynect's executive director, and it was crucial because it allowed state officials to identify problems early in the process. She laid out the timeline like this: From January 2013 to March, they developed the system; from April to June, they built it; from July to September, they tested it.

That stands in stark contrast to the picture painted by federal contractors at last week's hearing on HealthCare.gov, which underwent testing only in the two weeks before launch.
...
From a design standpoint, Kentucky made the conscious choice to stick to the basics, rather than seeking to blow users away with a state-of-the-art consumer interface.
...
"It's not glitzy, but it's very efficient," Banahan added.
Let's hear it for the laboratories of democracy!
posted by tonycpsu at 7:52 AM on October 28, 2013 [1 favorite]


"And, remember, kids! Poochie says: 'Opt out of Obamacare!'"

"Life without health insurance is a real slam dunk!" *throws ball of paper towards wastebasket, misses*

"The only mandate we need is a mandate for more beer, right bro?" *awkwardly alternates between an attempted fist bump, handshake and hug*

In my mind the speaker looks like Paul Ryan wearing Mitt Romney's mom jeans with a backwards cap.
posted by jason_steakums at 7:56 AM on October 28, 2013 [1 favorite]


Poll: Bad press is increasing interest in Obamacare
The poll found 51 percent of all those surveyed -- Democrats and Republicans alike -- say the House Republican attacks and troubled launch of the Obamacare website have made them more interested in the new medical insurance plan. Only 4 percent say they're less interested.

The poll was conducted between Oct. 17 and 20, immediately after the government shutdown and while media attention was shifting to the many technical problems with the Healthcare.gov website.

Interest in the plan is especially high among younger people who are needed to make the plan's economics work. Nearly 60 percent of so-called "young invincibles" age 18 to 29 said they wanted to know more about the ACA. Because people this age use less healthcare than other groups, their insurance payments help subsidize the healthcare costs of others.

All the media attention also seems to have made up for what has been considered a lackluster effort by the government to make people aware of the ACA. Around 64 percent of the uninsured said they were now curious about it, the highest rate of any group in the survey.
posted by zombieflanders at 2:25 PM on October 28, 2013


Intentionally screwing up the web site in order to get the word out. Now *that's* playing the long game!
posted by tonycpsu at 3:05 PM on October 28, 2013


NBC News: Obama admin. knew millions could not keep their health insurance
President Obama repeatedly assured Americans that after the Affordable Care Act became law, people who liked their health insurance would be able to keep it. But millions of Americans are getting or are about to get cancellation letters for their health insurance under Obamacare, say experts, and the Obama administration has known that for at least three years.

Four sources deeply involved in the Affordable Care Act tell NBC NEWS that 50 to 75 percent of the 14 million consumers who buy their insurance individually can expect to receive a “cancellation” letter or the equivalent over the next year because their existing policies don’t meet the standards mandated by the new health care law. One expert predicts that number could reach as high as 80 percent. And all say that many of those forced to buy pricier new policies will experience “sticker shock.”
posted by BobbyVan at 3:25 PM on October 28, 2013 [1 favorite]


Taking Obama's statement of "if you like your health care, you can keep your health care" as meaning that nobody's health care was ever going to change ever is a load of disingenuous horseshit. Our private plan that we bought in 2010 has changed every year, every year offering less coverage for more money. This is the first year we'll actually be getting a better deal. What, did you think the government was going to force health insurance companies to never change a plan?
posted by KathrynT at 3:43 PM on October 28, 2013 [7 favorites]


The Shocking Facts About Obamacare Sticker Shock
Indeed, Harris’ $98 premium is the result of the very kind of medical underwriting that allowed insurers to charge relatively healthy people a lot less for insurance and exclude sicker people altogether. Those practices are outlawed by reform. Insurers will no longer keep sicker people form signing up for insurance or charge older people more than three times the rates of younger and healthier applicants and offer benefits in 10 broad categories of coverage. Since many insurers are anticipating more sicker people to sign up for care and are now offering more benefits, premiums are comparatively higher, though competition among plans has shown to lower rates.

But ultimately, the decision over whether to cancel coverage is that of insurers. They have the option of incorporating the new minimum standards into their plans (to ensure compliance), though some may still cancel policies in an effort to shed some of the sickest and costliest beneficiaries or push people into different plans.

During an appearance on NBC’s Meet The Press on Sunday, Pat Geraghty, CEO of Florida Blue, put it this way, “[W]e’re not cutting people, we’re actually transitioning people. What we’ve been doing is informing folks that their plan doesn’t meet the test of the essential health benefits, therefore they have a choice of many options that we make available through the exchange.

“And, in fact, with subsidy, many people will be getting better plans at a lesser cost. So this really is a transition. And in fact, the 300,000 figure is the entire year. So it’s really 40,000 people for January 1, and we’re walking them through that transition,” he added.
posted by zombieflanders at 4:25 PM on October 28, 2013


Remarks of President Barack Obama – As Prepared for Delivery

American Medical Association

Chicago, Illinois

June 15, 2009
And that means that no matter how we reform health care, we will keep this promise: If you like your doctor, you will be able to keep your doctor. Period. If you like your health care plan, you will be able to keep your health care plan. Period. No one will take it away. No matter what.
posted by BobbyVan at 5:40 PM on October 28, 2013




About 20x more true than the agenda you're trying to push.
posted by Llama-Lime at 6:13 PM on October 28, 2013


Honest question in response, Bobbyvan:

Did you read the article that zombieflanders posted, or the comment that KathrynT just made?
posted by EmpressCallipygos at 6:14 PM on October 28, 2013


Honest question: is this tweet by Valerie Jarrett true?

Strictly speaking, yes. From the ThinkProgress article I linked to (emphasis mine):
It’s hard to know exactly how many Americans will find themselves in this situation, but approximately half a million policyholders across the country have received cancellation letters from insurers, undermining President Obama’s promise that you can keep the coverage you have and save thousands of dollars doing so.

So what gives?

Under the law, policies in existence before the law went into effect on March 23, 2010, are exempt from the new minimum benefit requirements absent major changes. But some of the individual plans issued since, still offer skimpy benefits, very high out-of-pocket spending or have annual and lifetime limits. They’re designed to attract younger and healthier beneficiaries — who rarely use the coverage they purchase at those attractively low premium rates — but don’t provide comprehensive insurance should one actually fall ill or need to use care.
What's happening a lot now seems to be that insurance companies are (in their usual super-shady way) cancelling unprofitable or non-compliant plans--or in what appears to be the case for several companies, pure dickish spite--and jacking up prices, then blaming mean ole Obamacare for their assholery.
posted by zombieflanders at 6:24 PM on October 28, 2013 [5 favorites]


Because I'm such a nice guy, I'll go ahead and post CBS News' latest fearmongering (complete with breaking news from 2010!) so BobbyVan can sleep in:

Obamacare: More than 2 million people getting booted from existing health insurance plans

OOOH scary! Halloween, y'all!
There have been estimates about hundreds of thousands of people losing coverage, CBS News' Jan Crawford reported on "CBS This Morning." CBS News has reached out to insurance companies across the country to determine some of the real numbers -- and this is just the tip of the iceberg, Crawford said.
Thanks, Jan, for going the extra mile and talking to insurance companies, who have no bias against Obamacare whatsoever.
It's an unexpected reality of Obamacare being told through anecdotes in local papers and on social media. But the hard numbers reveal the evidence is far more than anecdotal. CBS News has confirmed with insurance companies across the country that more than two million people are getting notices they no longer can keep their existing plans. In California, there are 279,000; in Michigan, 140,000; Florida, 300,000; and in New Jersey, 800,000. And those numbers are certain to go even higher. Some companies who tell CBS News they've sent letters won't say how many.
Note the many subtexts here. There's the "unexpected reality" of something that happened three years ago (more on that later), the TWO MILLION cancelled plans because Obama personally hates you, and the oh-so-sad insurance companies who are just too heartbroken to share hard data or explain what's actually going on. Cue the Timberlake, folks.
Industry experts like Larry Levitt, of the Kaiser Family Foundation, say the insurance companies have no choice. "What we're seeing now is reality coming into play," he said.
Note: KFF has actually been a relatively straight player on Obamacare, which is evidenced by the rest of the article, but the framing here and in the following bit makes it seem like Obama is a dictator. I'm willing to bet Levitt's full interview was a wee bit less doom-and-gloom than she puts it.
Obamacare forces them to drop many of their plans that don't meet the law's 10 minimum standards, including maternity care, emergency visits, mental health treatment and even pediatric dental care.
Holy shit, what a monster! Obama's forcing those innocent, vulnerable little insurance companies to include preventative health care for common conditions in their health plans. Wait, no, that's just me being sarcastic, you can't actually make that out to be horr--
That means consumers have to sign on to new plans even if they don't want or need the more generous coverage. Industry experts say about half the people getting the letters will pay more -- and half will pay less, thanks to taxpayer subsidies. Levitt said, "The winners outnumber the losers here, but because of all the website problems, it's hard to find out who the winners are because they don't even know it themselves."
Bravo, Jan Crawford. It took you eight paragraphs to get to the point where your sensationalist headline and lede are proven to be wildly misleading. I mean, c'mon, insurance companies are being "generous" here by cancelling plans because they very begrudgingly have to offer basic fucking health care? And in what I'm sure will come as a huge shock, she never once mentions either that the insurance companies have had three and a half years to come up with compliant plans; or that cancelling plans instead of modifying them to meet barebones, minimal coverage is all the fault of the companies rather than Herr Chairman Supreme Leader Obama. The American press, everyone!
posted by zombieflanders at 5:53 AM on October 29, 2013 [4 favorites]


Because I'm such a nice guy, I'll go ahead and post CBS News' latest fearmongering (complete with breaking news from 2010!) so BobbyVan can sleep in:

[Hits snooze button.]

posted by BobbyVan at 7:20 AM on October 29, 2013 [4 favorites]


Why normal debate about Obamacare is impossible
But the GOP outrage about Americans supposedly “losing” coverage is largely just more of the same old misdirection. It’s a subset of a larger Republican refusal to have an actual debate about the law’s tradeoffs — one in which the law’s benefits for millions of Americans are also reckoned with in a serious way.

On the substance of this argument, Igor Volsky has a good response, noting that these Americans aren’t “losing” coverage at all:
Individuals receiving cancellation notices will have a choice of enrolling in subsidized insurance in the exchanges and will probably end up paying less for more coverage. Those who don’t qualify for the tax credits will be paying more for comprehensive insurance that will be there for them when they become sick (and could actually end up spending less for health care since more services will now be covered). They will also no longer be part of a system in which the young and healthy are offered cheap insurance premiums because their sick neighbors are priced out or denied coverage. That, after all, is the whole point of reform.
But many foes of Obamacare refuse to grapple seriously with the basic tradeoff at the core of the law. For a fair look at whether this tradeoff is “worth it,” see Jonathan Cohn.

While it is too soon to assess the true dimensions of this tradeoff, the debate over it is entirely legitimate. It is the policy debate we should be having. But some Obamacare foes don’t even acknowledge that the law involves a tradeoff at all. Only the law’s downsides, and not the millions who stand to gain — many old, poor or sick — must be acknowledged.

As the Post’s Glenn Kessler argued in debunking some of Ted Cruz’s rhetoric about “millions” losing from Obamacare: “The full impact of the health-care law will not be known for years, and there are bound to be winners and losers in any major change in social policy…he does not allow at all for the possibility that millions of people are benefiting from the law — and that quite likely the number of winners from the law is larger than the losers.”
posted by zombieflanders at 7:23 AM on October 29, 2013


Immediately before your quoted section, zombieflanders, Greg Sargent makes this admission:
Critics of the law are right to ask whether it is having an adverse impact on these millions of Americans. And the White House could have been clearer in laying the groundwork for this political argument: It wasn’t sufficient to say people who like their plans will be able to keep it, which is narrowly untrue.
A discussion about the law's tradeoffs is worthwhile. But you can't say you want a "normal debate" over Obamacare when this is how the plan was sold to the public.
Q. I like my current insurance coverage. Will I have to change plans?

A. No, you will not have to change plans. For those who have insurance now, nothing will change under the Obama plan – except that you will pay less.
posted by BobbyVan at 7:51 AM on October 29, 2013 [2 favorites]


Immediately before your quoted section, zombieflanders, Greg Sargent makes this admission

The "narrowly untrue" and my response to the Valerie Jarrett tweet are related. The problem is less what Obama said and more what the insurance companies are doing. The NBC and CBS reports are just gobbling up whatever's being thrown at them by the insurance industry without bothering to do even cursory fact-checking or balanced reporting.

A discussion about the law's tradeoffs is worthwhile. But you can't say you want a "normal debate" over Obamacare when this is how the plan was sold to the public.

I don't agree at all. What Sargent says, and what I wholeheartedly agree with, is that this has become about how Obama is the liar and how Everything (Obamacare) Is Bad and Nothing Is Good. That's not what occurred, and the fact that the GOP is just flat-out lying about it, rooting for horrible things to happen because Black President, and pretending Medicare Part D issues--which I should again note were addressed by the Democrats as issues to be fixed rather than repealed and replaced--never happened, is really shitty and disgusting. Getting assists via shoddy and one-sided reporting isn't a plus, either.
posted by zombieflanders at 8:06 AM on October 29, 2013 [1 favorite]




Ugh.. NPR is reporting 'both sides' about insurers discontinuing policies that were crappy and replacing them with ones that actually cover people. While I appreciate that they tried to tell both sides they're still headlining the whole thing as the 'messy rollout'.
posted by localhuman at 3:11 PM on October 29, 2013




Wow, the WSJ is a sad embarrassment of its former self.
posted by octothorpe at 5:36 PM on October 29, 2013 [1 favorite]


Not that I didn't think that already but this is really a low point for them.
posted by octothorpe at 5:59 PM on October 29, 2013 [1 favorite]


localhuman: "they're still headlining the whole thing as the 'messy rollout'."

Actually, I wouldn't argue with that characterization. We won't get to better outcomes by denying the existence of what's obviously been a horribly managed effort as far as public relations and information technology are concerned.

In fact, I'd argue that it's essential for the media to highlight the places where the executive branch has dropped the ball, but it's also important that they point out that the problem would be even worse if the GOP were in charge, because their alternative (to the extent that they have one) would be the elimination of Medicare and Medicaid, with everyone being forced into the equivalent of ACA's insurance exchanges. Imagine how horribly the website would be crashing if we had a hundred million or so more people trying to enroll!

Would also be cool if the media could maybe reiterate that the assholes complaining about how a government program isn't working were last seen shutting the entire government down for over two weeks.
posted by tonycpsu at 6:59 PM on October 29, 2013 [2 favorites]


the assholes complaining about how a government program isn't working were last seen shutting the entire government down for over two weeks

This. For God's sake, this.
posted by GrammarMoses at 7:10 AM on October 30, 2013 [1 favorite]


Will You Lose Your Insurance By January? The Oct. 31 Deadline Insurers, Obama and the Media Aren't Telling You About
Moreover, the administration and its progressive allies -- and I consider myself one -- aren't facing up to the PR disaster emerging from both the balky healthcare.gov website and how millions of people are facing cancelled coverage they now have. No matter how it's explained away or packaged, the prospect of dropped coverage impacting possibly millions of people simply doesn't square with repeated assurances from Obama and his allies that, essentially, no one would lose their current coverage. Most of the people offering reassurances that finding new plans on the exchanges isn't such a big deal are salaried employees of organizations, news outlets and companies that pay for their insurance; they might feel otherwise if they had to search for comparable plans that provide coverage for themselves and their families as the January 1 deadline approaches. It also could directly hurt many of the independent, freelance workers, influential creative people and self-starting tech and small-businesses entrepreneurs who could serve as a loyal base for Democrats in the years to come, but who may feel betrayed by what appear to be some broken promises on health care by President Obama.
posted by BobbyVan at 10:07 AM on October 30, 2013


CNN: Security hole found in Obamacare website
The Obamacare website has more than annoying bugs. A cybersecurity expert found a way to hack into users' accounts.

Until the Department of Health fixed the security hole last week, anyone could easily reset your Healthcare.gov password without your knowledge and potentially hijack your account.

The glitch was discovered last week by Ben Simo, a software tester in Arizona. Simo found that gaining access to people's accounts was frighteningly simple. You could have:

- guessed an existing user name, and the website would have confirmed it exists.

- claimed you forgot your password, and the site would have reset it.

- viewed the site's unencrypted source code in any browser to find the password reset code.

- plugged in the user name and reset code, and the website would have displayed a person's three security questions (your oldest niece's first name, name of favorite pet, date of wedding anniversary, etc.).

- answered the security questions wrong, and the website would have spit out the account owner's email address -- again, unencrypted.

Armed with the account holder's email address, a person with malicious intent could easily track down their target on social media, where they'd likely discover the answers to those security questions.
posted by BobbyVan at 10:22 AM on October 30, 2013


Will You Lose Your Insurance By January? The Oct. 31 Deadline Insurers, Obama and the Media Aren't Telling You About

It's as yet unverified, and would probably be wildly illegal:

If Insurers Are Using Obamacare to Trick Their Customers Into Expensive Plans, They Need a Nice Letter from the FTC
[W]ith hundreds of thousands of these letters going out and frightening people into thinking they have no choice but to sign up for a much more expensive plan, it’s definitely something someone should look into. Like, say, giant news organizations with lots of money and resources.

If what Waldman says is true, that is indeed grotesque behavior, and one that the press should be investigating instead of getting their stories from the Republican National Committee.

But there is another thing. It also violates century-old federal law. The press isn’t the only institution that should be looking into this.

Section 5 of the Federal Trade Commission Act (15 USC 45) prohibits ‘‘unfair or deceptive acts or practices in or affecting commerce.’’ This is not an obscure law; it has been enforced for decades, despite conservative objections and more recent attempts by deceptive businesses to have it declared unconstitutional. Any insurer claiming that a consumer must purchase a more expensive policy than what it also offered, and certainly claiming that a consumer must do so because of the Affordable Care Act, is violating the Federal Trade Commission Act. This is not a close call.
Are All Those Insurance Company Cancellation Letters Too Good to Check?
It's true that there are some people who are going to end up paying more for coverage under Obamacare than they're paying now. But Waldman is right: there's something very fishy about these letters. Over the past three years, insurance companies have swapped their plans around so fast and so often that virtually no one today has a plan more than a couple of years old—something that seems an awful lot like a deliberate effort to evade Obamacare's original intent that most individual policies would be grandfathered and therefore remain available to existing customers who wanted to keep them.1 Now, having engineered a situation where most current policies aren't grandfathered, millions of people are getting letters canceling their existing plans and being told that the replacement is far more expensive.

I'm not sure what's going on here, but there's at least one lesson in this for the press: never take these letters at face value. If you find someone who's going to end up paying more thanks to Obamacare, fair enough. Run with the story.2 But first, you'd better perform the due diligence to find out what a comparable plan really costs. That means getting income and coverage details from the subject of your story and then doing a detailed search of the local exchange to find out what's on offer. We're not seeing enough of that.

1-Plans in existence before March 23, 2010, are grandfathered, which makes them exempt from most of the new requirements of Obamacare. However, if your insurance company switched you into a "better" plan after that date, it's not grandfathered and can be canceled at any time.

2-Of course, it would be nice if you also ran some stories about people who are benefiting from Obamacare, especially since they probably outnumber the other folks by 100:1 or so.
“Rate shock”: The GOP’s shameful new Obamacare lie
Some people who receive these notices will be pleasantly surprised to find that the most similar new plan offered by their current provider is actually cheaper than their old one. Others will be told that a similar plan will cost more. What they won’t be told, because insurers don’t want to downsell or advertise for their competitors, is that they’re likely to find a different plan available through their state exchange that’s closer to the same price or cheaper. If they can’t find a cheaper one, then there’s a decent chance that federal subsidies will reduce their out-of-pocket costs. It’s only the remainder — and it’s likely to be a small remainder — that genuinely will have no choice but to either pay more money (in some cases significantly more) or pay a fine and go without coverage.

That remainder will be higher than it needs to be if people are discouraged from shopping around. Healthcare.gov isn’t helping in that regard. Neither are insurers or the conservatives who are pretending to care about rate shock.

And that’s really the point I was making on Monday. Conservatives only care about these problems insofar as they can be used to trash or undermine the law in its entirety. That’s why they never, ever mention any of the millions of people who will or are already benefiting from the law. If they did, they’d have to entertain solutions to these problems that don’t essentially kick a tent pole out from underneath the system.
posted by zombieflanders at 11:06 AM on October 30, 2013 [5 favorites]


I'm not sure what's going on here, but there's at least one lesson in this for the press: never take these letters at face value. If you find someone who's going to end up paying more thanks to Obamacare, fair enough. Run with the story.2 But first, you'd better perform the due diligence to find out what a comparable plan really costs.

The problem is that people are no longer allowed to have a comparable plan - that's why the rates are going up in the first place. You can't have your cheap plan that was only good for healthy single people anymore, for example, because all plans are required to include pediatric dental care and maternity benefits. So it's an apples and oranges thing. You're not being kicked off your old plan - your old plan is gone, never to rise (legally) again unless the law changes.
posted by corb at 12:48 PM on October 30, 2013


Well, the health insurers COULD HAVE easily just sent out an amendment to the policies bringing their coverage up to the required minimum legal limits, right?
posted by mikelieman at 12:57 PM on October 30, 2013 [1 favorite]


The problem is that people are no longer allowed to have a comparable plan - that's why the rates are going up in the first place. You can't have your cheap plan that was only good for healthy single people anymore, for example, because all plans are required to include pediatric dental care and maternity benefits. So it's an apples and oranges thing. You're not being kicked off your old plan - your old plan is gone, never to rise (legally) again unless the law changes.

Did you even read the rest of the article you're quoting? This is how it's supposed to work.

The article even says that in the original piece it's quoting (emphasis in original):
....If the woman I discussed from that NBC story is any indication, what the insurance company is offering is something much more expensive, even though they might have something cheaper available. They may be taking the opportunity to try to shunt people into higher-priced plans. It's as though you get a letter from your car dealer saying, "That 2010 Toyota Corolla you're leasing has been recalled. We can supply you with a Toyota Avalon for twice the price." They're not telling you that you can also get a 2013 Toyota Corolla for something like what you're paying now.
I'm not sure that's what's happening, and it may be happening only with some insurers but not others. But with hundreds of thousands of these letters going out and frightening people into thinking they have no choice but to sign up for a much more expensive plan, it's definitely something someone should look into. Like, say, giant news organizations with lots of money and resources.

It's true that there are some people who are going to end up paying more for coverage under Obamacare than they're paying now. But Waldman is right: there's something very fishy about these letters. Over the past three years, insurance companies have swapped their plans around so fast and so often that virtually no one today has a plan more than a couple of years old—something that seems an awful lot like a deliberate effort to evade Obamacare's original intent that most individual policies would be grandfathered and therefore remain available to existing customers who wanted to keep them.
posted by zombieflanders at 1:01 PM on October 30, 2013


The problem is that people are no longer allowed to have a comparable plan - that's why the rates are going up in the first place.

It's not like this is new. Long before the ACA was ever a twinkle in anyone's eye, insurance companies could change your plan or up or rates very nearly at will. State insurance commissioners got to play whack-a-mole with insurance companies in their states who were always trying to pull this kind of thing in unlawful or barely legal ways. Anthem Blue Cross in California has been under investigation almost constantly for years, been found to improperly drop coverage from individual policy holders, announced it was going to raise rates by as much as 40% (after its parent company announced a nearly $3 billion quarterly profit!), etc.
posted by rtha at 1:02 PM on October 30, 2013 [1 favorite]


corb: "The problem is that people are no longer allowed to have a comparable plan - that's why the rates are going up in the first place."

I explained in the other thread why you can't get a comparable plan. TL;DR: people who choose to underinsure themselves require taxpayers to bail them out when their shitty plan stops paying.

corb: " for example, because all plans are required to include pediatric dental care and maternity benefits"

Are you seriously resorting to concern trolling about the comparatively minuscule expenditures of pediatric dental and maternity benefits not applying to everyone? Because the last time I checked, my employer doesn't offer a separate health plan for women or lesbian couples that excludes coverage for treatment of prostate cancer. Pooling risk means pooling people with all sorts of conditions that may apply more to them than to others. Insurance companies aren't generally going to bother with plans that exclude these things, because the cost of covering those specific things in relation to the overall cost of the coverage is a rounding error, to the point that it's not worth the expenditure in marketing / customer service resources to cater to such a small segment of the population that would care to exclude these things.
posted by tonycpsu at 1:03 PM on October 30, 2013 [6 favorites]


Politifact: Valerie Jarrett says 'nothing in Obamacare forces people out of their health plans.'
Our ruling

Jarrett said it was a "fact" that "nothing in Obamacare forces people out of their health plans."

Saying there’s "nothing" in the law that forces people out of their health plans is a pretty extreme claim -- one that implies that insurers who pull the plug on non-Obamacare-compliant plans are acting in some sort of government-free vacuum. Even if it’s technically true that the insurer pulls the plug on a plan, the insurer will only be doing this because the law itself and its implementing regulations have created a context in which, sooner or later, old-fashioned plans will inevitably pass into oblivion -- as the law always intended. We rate the statement False.
posted by BobbyVan at 1:37 PM on October 30, 2013


Of course, the part just before that said that grandfathered plans had already been decreasing well before the exchanges opened, and that the regulations are enforcing better guaranteed coverage.
posted by zombieflanders at 1:56 PM on October 30, 2013


Ms. Jarrett could have been honest and said that. She chose to write something false instead.
posted by BobbyVan at 2:02 PM on October 30, 2013


Also from Politifact: ‘If you like your health insurance, you can keep it’
Obama’s statement had a reasonable point: His health care law does take pains to allow Americans to keep their health plan, especially people who get their insurance through work.

But most people have never been able to keep their insurance through thick and thin. Even before the law took effect, a substantial number of policyholders were forced to switch plans every year. Figures from the nonpartisan Congressional Budget Office suggested that the law could increase that rate, not reduce it, even if Americans on balance benefit from the law’s provisions mandating comprehensive coverage.
[...]
We ran through the numbers and found that the individual market accounts for about 6 percent of Americans who now have health care. The health care law requires those policies to offer comprehensive coverage, and that means some of the old policies are no longer allowed.

Experts told us there is no precise data to determine how many people will be forced to change health care plans, but they generally agreed the number will be small this year. We rated Axelrod’s statement Mostly True.
[...]
U.S. Sen. Marco Rubio, R-Fla., said on Fox News that when you put those two things together, people getting cancellation notices from their insurers won’t be able to buy health insurance.
[...]
Rubio is right about the people getting cancellation letters, but the letters also state that consumers will have "continuous health care coverage" and assigned them a particular plan, or gave them the option to contact Florida Blue and choose another plan.

So their coverage is not dependent on being able to buy insurance through healthcare.gov, the government’s online marketplace. We rated his statement Mostly False.
posted by zombieflanders at 2:03 PM on October 30, 2013 [1 favorite]


Ms. Jarrett could have been honest and said that. She chose to write something false instead.

We can keep on playing this game until the thread runs out. The fact of the matter is that the lies being told by Obamacare opponents are both more numerous and much worse, and the glee that they're expressing should be appalling to everyone. It's especially galling after three and a half years of deliberate sabotage of the law and its foundations, up to and including a government shutdown and billions of dollars of damage to the country committed entirely by a single party.
posted by zombieflanders at 2:06 PM on October 30, 2013 [6 favorites]


I think part of the problem with the ACA/Obamacare (which I thought was only for right-wingers but now I see used by lefties so who knows what the good term is) is that, like so many other things going on right now, it's a proxy war, and because it's a proxy war, no one is really having honest conversations about it.

The ACA will probably have a larger good impact on a larger group of people than it will have a bad impact on a smaller group of people. But it's difficult to really assess it and talk about it, because everything's political. It does have a negative affect on a smaller group of people, but it feels, in some circles at least, like anyone who says that must be denied - not because it's untrue, but because it's an attack on something that is standing in for all the policy ideals and desires. It's a standin for socialized health care, even though it is in no way socialized health care, but this weird Frankenstein monster patched together. And on the other side, in other circles, there's this sense that you can't admit that the ACA benefits anyone, because to do so would be to give up the fight.

It has good qualities and bad qualities, and people will choose to listen to one or the other, but it doesn't have to be an angel or a devil situation.

TL;DR: people who choose to underinsure themselves require taxpayers to bail them out when their shitty plan stops paying.

This is true, but only very recently - in the 80s when it became mandated that hospitals start treating everyone who walked in the door. It would also be just as easy to design a law that allowed people to opt out of coverage and sign a waiver saying they will not accept treatment they can't pay for.
posted by corb at 4:03 PM on October 30, 2013 [1 favorite]


So then hospitals will just let uninsured patients bleed to death because they've signed some stupid waiver? That's a great solution.
posted by octothorpe at 4:13 PM on October 30, 2013 [1 favorite]


House Republicans demand an ACA briefing with the President. Most don't bother to show up.

"Fortunately for House Republicans, extreme bouts of self-righteous indignation are covered by Obamacare," Pelosi spokesman Drew Hammill said in a statement.
posted by dirigibleman at 4:20 PM on October 30, 2013 [3 favorites]


I think part of the problem with the ACA/Obamacare (which I thought was only for right-wingers but now I see used by lefties so who knows what the good term is) is that, like so many other things going on right now, it's a proxy war, and because it's a proxy war, no one is really having honest conversations about it.

The ACA will probably have a larger good impact on a larger group of people than it will have a bad impact on a smaller group of people. But it's difficult to really assess it and talk about it, because everything's political. It does have a negative affect on a smaller group of people, but it feels, in some circles at least, like anyone who says that must be denied - not because it's untrue, but because it's an attack on something that is standing in for all the policy ideals and desires. It's a standin for socialized health care, even though it is in no way socialized health care, but this weird Frankenstein monster patched together. And on the other side, in other circles, there's this sense that you can't admit that the ACA benefits anyone, because to do so would be to give up the fight.

It has good qualities and bad qualities, and people will choose to listen to one or the other, but it doesn't have to be an angel or a devil situation.


I made several comments that point out this exact dichotomy upthread, including yesterday and today, and they're worth checking out. The problem is, at least in the public sphere (elected officials and the media in particular), this has largely been confined to one side. And on the other, the criticisms reach this absolute fever pitch and become ever more fantastical, and are talked about by more powerful people.

Take, for instance, Medicare Part D, which was basically a mirror image of Obamacare politically. It wasn't popular with Democrats, passed with minimal votes from the opposition, and was roundly criticized after it went into effect. But the Democrats didn't try and repeal it 42 times, the shut down the government, threaten to destroy the world's economy, and sabotage it for three and a half years just because they didn't get their way. Instead, they offered reforms that, in the end, seem to have made it a better program for everyone.

This is true, but only very recently - in the 80s when it became mandated that hospitals start treating everyone who walked in the door.

Yes, thanks to Reagan and conservatives, who then proceeded to offer that solution en masse (including the most recent presidential candidates) as their alternative health care vision apart from a brief period in the mid-90s when they offered up Heritagecare Bennettcare Romneycare Obamacare.
posted by zombieflanders at 4:36 PM on October 30, 2013 [1 favorite]


Up is down: Fox News' Greta Van Sustren debunks CBS's story on the Florida woman whose losing her "insurance".

I put "insurance" in quotes, because what Florida Blue was selling her was not insurance, it was a scam. I'm on record as not being wild about Obamacare, but if your outrage is that companies like Florida Blue can't keep scamming $50 / month from people like Ms. Barrette, then you are an asshole. This is exactly the sort of thing I mean when I talk about conservative idiocy and lies getting in the way of honest debate about the ACA.

(This also exposes another conservative lie. Clearly the mainstream media has a very conservative bias, not a liberal one.)
posted by dirigibleman at 5:20 PM on October 30, 2013 [5 favorites]


Medicare Part D is not comparable to the ACA because it's a voluntary benefit. Seniors weren't required to participate.
posted by BobbyVan at 6:34 PM on October 30, 2013


Seriously, these sub-$100/mo premium plans you can get on the individual market or from crappy part-time/temp employers aren't worth the paper they're printed on, much less the premiums you pay. They allow you to say you have insurance, and that's about it -- they're more a method of enabling consumer fraud than a method of ensuring access to healthcare.

While I'm sure not every individual will be in a better position come January, those of us in that low-end segment of the market are going to be much better off.
posted by asperity at 6:36 PM on October 30, 2013


Medicare Part D is not comparable to the ACA because it's a voluntary benefit. Seniors weren't required to participate.

The original comment was that it was a mirror image of ACA politically You know. Like ACA's evil twin, with all its parts on the wrong side, like a reflection in the mirror. And also that seemingly random word, "politically," has a function in that particular construction.
posted by saulgoodman at 6:44 PM on October 30, 2013 [1 favorite]


My only goddamn complaint about the whole thing right now is why is the press suddenly acting like all the right wingers in government and the private sector haven't been doing their level best to sabotage this thing since the beginning? (Well, that and the fact I wasn't able to sign up online and save my family the $400 bucks a month I would have saved on the exchange. Okay--all right, I'm bummed single-payer seems like such a non-starter politically, too.)

Is that the new political normal now? You're expected to be able to work public policy miracles when nearly half the population have been reduced to drooling medieval morons who recite scriptures by cant while spending more of their time pillorying people for their fashion or other personal choices online than actually dreaming about anything beautiful or sacred?

America has utterly lost its vision for the future and it's vision of itself as anything more than a glorified whorehouse for the well-to-do.

And it's all--absolutely every last bit of it--due to the party most responsible for making the ACA rollout such a trainwreck. And no, I don't mean the "Democrat" party.
posted by saulgoodman at 6:51 PM on October 30, 2013 [7 favorites]


The condescension isn't really necessary. I understood the original comment and think any "reflection" is pale at best. None of the legitimate criticisms of Part D come close - in terms of political potency - to requiring *all* Americans to purchase a product from a private company or else face increasingly severe tax penalties. Part D was an unfunded political giveaway for seniors and drug companies. That's pretty good politics!
posted by BobbyVan at 6:54 PM on October 30, 2013


Which, of course, completely missed the point I was making about how the GOP has used and continues to use Obamacare to turn completely unrelated battles into potential economic terrorism, give up on doing their fucking job entirely for the purpose of media soundbites, and cynically pandering to an increasingly unhinged yet numerically shrinking minority for the political equivalent of shits and giggles (see also: IRS "scandal," BENHAZIWHARRGARBL, etc). All of which was done while simultaneously sabotaging Obamacare and every single other attempt at governance of the last three years even when it was in pursuit of GOP goals from pre-2009. Which means that people claim "both sides do it," equally, all the time when it's not even remotely close to being true.
posted by zombieflanders at 7:13 PM on October 30, 2013 [7 favorites]


Your ideas deserve condescension.
posted by saulgoodman at 8:12 PM on October 30, 2013 [1 favorite]


Sorry. I'm having a bad day. But sometimes I get tired of mincing words.
posted by saulgoodman at 8:16 PM on October 30, 2013


Does anyone have any CURRENT open issues?

I was able to fill out my application for my husband and I, but it won't let us shop for our plans in New York State. I've been told by tech support that this has something to do with the fact that I--and not my husband--am medicaid eligible because I'm pregnant, and they're not offering any medicaid sign-ups until an unspecified date in December. Which wouldn't bother me, except, you know, I'm pregnant, and so it makes it all feel pretty urgent. I'm also really unsure of that 37,000 number, if a high percentage is medicaid sign-ups but they're not actually offering any medicaid-managed plans yet.
posted by PhoBWanKenobi at 6:52 AM on October 31, 2013


Thank you for that. It sorta-confirms my "Why didn't we just roll out universal medicare and be done with it?" opinion.
posted by mikelieman at 7:08 AM on October 31, 2013 [1 favorite]


I made several comments that point out this exact dichotomy upthread, including yesterday and today, and they're worth checking out. The problem is, at least in the public sphere (elected officials and the media in particular), this has largely been confined to one side. And on the other, the criticisms reach this absolute fever pitch and become ever more fantastical, and are talked about by more powerful people.

You did, though I will note - possibly as a result of what sources you see come into your feeds - they are largely anti-Republican voices. I don't see many Democratic voices frankly admitting that some people will, in fact, be worse off under the ACA. And they will - demonstrably they will. In fact, it will be much worse off for those who are already doing relatively well by health insurance.
Actually, even the average health plan costs more than the Cadillac thresholds mandated by Obamacare - about $10,522 per employee, according to the Society for Human Resource Management. (The law includes premiums paid by both the employer and the employee.) At that price, employers would pay a 40 percent tax on the $322 difference—about $130. For a company with 10,000 employees, that equates to a $1,300,000 tax bill....

The intent of the tax is to force consumers with the best health plans to have to pay more costs out of pocket, which, in theory, would force them to make more cost-conscious decisions when it comes to expensive tests and frequent doctor’s visits.
If you have a company that's been offering very generous health care, it will now cost them twice as much to offer that health care - which incentivizes them to give great health care less, rather than more.
posted by corb at 7:22 AM on October 31, 2013


Also, to note, this isn't just a left/right thing:
“It’s extremely misleading,” said Anders Lindall, AFSCME Council 31 spokesman in Chicago. “Far from being excessive, our plans are reliable, strong and safe.

“The tax punishes workers who have made sacrifices in pay to trade off for health security for their families. We shouldn’t impose a negative incentive against strong health plans.”

“Proponents assert people are overinsured, and that to control health spending the thing to do is increase peoples’ deductibles and copays, and that will get people to tell their doctors they don’t need as much health care,” said Tom Leibfried, national AFL-CIO legislative representative. “But there’s not a lot of evidence that increasing what people pay out of pocket slows health spending.”
posted by corb at 7:35 AM on October 31, 2013


I'm so old, I can remember when the conservative critique of government-subsidized health programs was that the poor people didn't have enough "skin in the game" (in the form of a personal responsibility to pay for a portion of their care), and therefore didn't have enough incentive to "shop around" for the best deal.

But I guess when the people being forced to do their homework and look for better deals are the ones with superior coverage already, suddenly making them pay a larger share of the cost is a problem.

And yes, many of the people with "cadillac" plans are Democratic-leaning union members who've taken health benefits in lieu of salary, and unions were not happy about accepting this tax. But at some point, when we're all paying for a service like healthcare that's costing more and more to deliver, we all have to sacrifice, and the unions, as they often do, sucked it up and took one for the team.
posted by tonycpsu at 7:36 AM on October 31, 2013 [2 favorites]


You did, though I will note - possibly as a result of what sources you see come into your feeds - they are largely anti-Republican voices.

It's almost as if they had many valid reasons for criticizing them.

I don't see many Democratic voices frankly admitting that some people will, in fact, be worse off under the ACA.

And yet, you just said that "this isn't just a left/right thing." Which is it?

Of course, the claim that "many Democratic voices" never said this isn't true. Even apart from the many, many criticisms from the left regarding coverage during the Congressional debates and votes, many left-of-center commentators have pointed out that Obamacare is essentially a "kludge" that in the end, is not perfect but is massively better than the status quo. Take special note of the example made of Denmark in that link:
Take a look at the Netherlands, as Matt Steinglass does here. Their health care system is well thought of, and it's remarkably similar to Obamacare: a public-private system that relies on private health insurers, public funding, and an individual mandate. As Steinglass points out, the Dutch system has some features that make it simpler than Obamacare, but it also has some features that make it more complex. But these are mostly nits. In the end, the Dutch system is really quite similar to Obamacare. And it works fine.

I'd submit that a big part of the reason for this is path dependence: the Dutch system is one that replaced an older single-payer system. In other words, they went in exactly the opposite direction from the one Konczal recommends. But it worked OK because the Dutch universally approved of national healthcare already and were universally covered by it. I assume that the details of the new system were contentious, but they were contentious primarily at a technocratic level. Nobody was fighting the basic idea of providing health care for all. That meant the new program could be rolled out on a reasonable schedule and without any big surprises or massive resistance.

Obamacare doesn't have that luxury. It's fighting not only technical issues, but also massive cultural and political resistance. This is what makes the rollout so hard.
Which brings me to the next point, the one made by the posts that I linked to, which is that conservatives just absolutely refuse to admit any good whatsoever is being done. It's fine to talk about loss of coverage for a small minority as a bad thing, as many on the left have done. It's not at all to completely deny not only that the overall impact will be positive (possibly much moreso), but that there is nothing good ever to come out of it, and that it is literally worse than Hitler. Thus, lies about Obamacare being "job killing," the idea of "death panels," and all of the various other truth-bending and flat-out lies that are being spread.
posted by zombieflanders at 7:49 AM on October 31, 2013 [1 favorite]


And yet, you just said that "this isn't just a left/right thing." Which is it?

My apologies, I should have been clearer - my contention is that the objective fact that some people will be worse off under the ACA is not a left/right thing, because union representatives who are not supposed, at least, to be overtly political other than "What is good for my boys", are criticizing it.

But the Democratic voices that you're talking about aren't talking about the individual people who will be worse off - they're talking about implementation problems, which will, honestly, be fixed eventually and not a long term thing. They're not talking about people having worse coverage as a bad thing - they're talking about it as a positive thing.

It's not at all to completely deny not only that the overall impact will be positive

The utilitarian overall impact, at least in the short term, will likely be positive. I'm not sure how the funding for it will go in the future, and am concerned it will raise taxation, but that's a long-range critique that can be leveled of most government programs. However, the impact for some people's constituents will not be positive.

The Hitler thing is ridiculous, but bears no more seriousness than when MoveOn did the Bush/Hitler ad. Every political cycle, there's going to be a lot of people saying that X person is like or worse than Hitler, mostly, I think, because they're not active on the internet and thus don't know they're Godwinning.

The idea of death panels is hyperbolic, but not untrue persay - though it's not an Obama thing, and has very little to do with the ACA other than that it's a very expensive program. Every time you have some kind of terminal illness, someone makes a decision somewhere or has already made a decision somewhere at what point they will stop paying for your care. Every insurance program that exists now has already made that determination. Some insurance companies place that bar higher than others. The threat is that if single-payer had gone through, the government would be the insurer, and thus there wouldn't be any options, no hope of grabbing the brass ring of another health care plan. The problem is that people don't understand that that was a single-payer/monopoly threat, not an overall ACA threat.

tl;dr: People say stupid shit all the time, some more than others. Who everyone thinks is saying the more stupid shit is largely going to depend on their bias. The problem is people not saying intelligent and objective shit, and that's a problem that affects both sides, possibly as a result of the nature of the political system.
posted by corb at 8:06 AM on October 31, 2013


The Hitler thing is ridiculous, but bears no more seriousness than when MoveOn did the Bush/Hitler ad

Oh Jesus Christ, MoveOn didn't make a Bush/Hitler ad and you know that. They had a contest and someone submitted that ad that MoveOn quickly deleted.
posted by octothorpe at 8:40 AM on October 31, 2013 [4 favorites]


But the Democratic voices that you're talking about aren't talking about the individual people who will be worse off - they're talking about implementation problems, which will, honestly, be fixed eventually and not a long term thing. They're not talking about people having worse coverage as a bad thing - they're talking about it as a positive thing.

That's some serious twisting of words there. They are, in fact talking about the individual people who will be worse off. They're talking about the overall outcome of Obamacare being a positive thing, and to take that out of context so as to portray them as being glad that a small minority people have worse coverage is just weird and disturbing. To claim that Democratic sources are never saying that there will be some people worse off is untrue. It's just that, for whatever reason, you discount them just because they point out that most will be better off and the overall outcome will be positive.

The Hitler thing is ridiculous, but bears no more seriousness than when MoveOn did the Bush/Hitler ad yt . Every political cycle, there's going to be a lot of people saying that X person is like or worse than Hitler, mostly, I think, because they're not active on the internet and thus don't know they're Godwinning.

No, it bears much more seriousness, because it's not just random trolls on or off the internet, it's the people who are responsible for helping run the country. Conservatives in every level of government have used Hitler, slavery, terrorism, and murder, among many other analogies, as a way to describe a plan that would have had their support before a black dude with a funny name put it up for a vote.

tl;dr: People say stupid shit all the time, some more than others. Who everyone thinks is saying the more stupid shit is largely going to depend on their bias. The problem is people not saying intelligent and objective shit, and that's a problem that affects both sides, possibly as a result of the nature of the political system.

Enough with the "both sides do it nonsense." In our current political climate, the amount of stupid (and racist, and sexist, and homophobic, and just generally horrible) shit being said largely ends up coming from the conservatives. In the sphere of the media and elected officials, it's overwhelmingly coming from them.
posted by zombieflanders at 8:41 AM on October 31, 2013 [1 favorite]


More on how stupid the both-sides-are-bad false equivalency nonsense is, seeing as how Republicans either just don't give a shit about helping, or are are looking for spiteful retribution:

The Republican Health-Care Plan: Repeal and Cackle
The Wall Street Journal editorial page, Philip Klein, and Ross Douthat, among others, argue that the tumult in the individual market shows the failure of Obama’s regulatory vision. The old, lightly regulated system encouraged insurers to pick up healthy customers and do everything to avoid covering people who might incur high costs — people with preexisting conditions, women of childbearing age, and so on. This system was much more ideologically congenial to the right, as it allowed the “makers” to enjoy the financial fruits of their good health without having to cross-subsidize the “takers.” And they see the tumult as vindication of the conservative belief in a lightly regulated system, with less comprehensive coverage, and less shifting of resources from the healthy to the sick. “[A]n overwhelming majority of Americans,” argues Klein, “were happy with their coverage.”

That is not true. People in the individual market are far less satisfied than people in either the employer-based market or in public insurance plans, as Jonathan Cohn notes: The employer-based health-insurance system is much more popular than the individual market. It’s also much more redistributive. The 25-year-old male in the loading dock has to pay the same premiums as the diabetic 60-year-old in accounting. Is this injustice an important part of the political discourse? How often do you hear people complain about it?

Every iteration of an alternative conservative health-care proposal would impose far more disruption on the status quo than would Obamacare. Most conservative plans involve drastically curtailing the tax deduction for employer-based insurance. That would create cancellation notices for many times the number of people currently seeing them. Even the more modest plans to scale back Obama’s regulation of the individual market would run the GOP into a political minefield. Which regulations do they want to strip away? Discrimination against people with preexisting conditions? Discrimination against potentially pregnant women? Mental-health parity? Every single one of those changes creates millions of angry potential victims.

This is exactly why the actual Republican Party health-care plan is not repeal and replace, but repeal and cackle. Republicans are on strong ground exploiting fear of change. They have understood perfectly well that they must avoid having to defend a different set of changes to the status quo. They have kept their various replace ideas safely to the side for exactly that reason.
posted by zombieflanders at 8:58 AM on October 31, 2013


Alex Pareene @ Salon: Obamacare is a Mess, and Liberals Need to Fix it
First of all, yes, Brian Beutler is totally correct, the people using these stories for political gain are over-hyping the problem, disingenuous, and wholly uninterested in the principle of universal healthcare. That’s a given. In most instances, the policies being canceled are terrible fake policies that don’t cover anything. Generally, the policies now available to these people will offer superior coverage. Many of the people whose policies were canceled will qualify for subsidies to buy better coverage. It’s also quite possible — maybe probable — that insurance companies are intentionally trying to upsell people on plans that will cost more out of pocket than other plans available on the exchanges. We know all this, because we read all the smart liberal bloggers. Most Americans don’t! For most Americans, Obamacare is, so far, canceled plans and a nonworking website.
...
And not just the news outlets that political elites pay attention to. People with canceled plan letters and “rate shock” horror stories will be featured on local news broadcasts across the country, with even less context and explanation that you’ll find on the national news, because local TV news is pretty uniformly terrible. And they’ll keep getting featured, because there are simply going to be a ton of people who get their policies canceled and then get asked to pay more. Sarah Kliff estimates 7-12 million people. That’s a fraction of the total population, and many of these people may now qualify for Medicaid or subsidies, but that’s still a lot of people deeply frustrated by “Obamacare” right as it begins it much-publicized roll-out.

All of that is exactly why this is a dumb way to give people health insurance. This is a program that, by design, is going to annoy literally millions of Americans immediately. It will improve most of those people’s lives, but it will do so in a way that feels as coercive as possible. It didn’t have to be that way! No one is ever annoyed that they qualify for Medicare or Medicaid. People may hate paying the taxes that fund those programs, but people always appreciate direct benefits.
...
Democrats created this mess for themselves. Conservative Democrats are responsible for many of the programs flaws, and, perversely, their attempts to shield themselves from public outrage ended up creating a law that will lead to more public outrage than a more government-oriented program would’ve. But the program was designed by moderate and even liberal Democrats. They were working to appease the conservatives, yes, but we should have long since learned that a conservative Congressional Democrat will only ever agree to something if you promise to make it a little bit, or a lot worse. In other words, the ask should’ve been bigger.
posted by tonycpsu at 9:48 AM on October 31, 2013


The idea of death panels is hyperbolic, but not untrue persay...The threat is that if single-payer had gone through, the government would be the insurer, and thus there wouldn't be any options, no hope of grabbing the brass ring of another health care plan...

First, per se.

Second, a big difference is that the government's decisions and actions would be made within the framework of public policy, over which the citizens can have an influence. When insurers make these decisions - and yes, they do - we have no voice in them. We don't vote for the CEOs of insurance companies, can't expel them when their policies are cruelly exclusive or inadequate to the need, and can't work for legislation to change their internal criteria. If we've been essentially sentenced to death by a refusal to cover, it's totally unlikely there's any "brass ring" coming from another insurer - and there's nothing we can do about that; it's a purely economic decision on their parts to exclude whomever they want.

This is the difference between democratic governments and autocratic private corporations - in one of them, individual people are empowered; in the other, they are irrelevant except as profitmaking products.
posted by Miko at 12:04 PM on October 31, 2013 [3 favorites]


corb: "because all plans are required to include ... maternity benefits"

You know, when I read this yesterday, I figured this was the latest chain-email-friendly wingnut talking point that was going around the Internets, but I had no idea that it had made it all the way to "GOP Congressperson using it in a Congressional hearing" status. But, here we are:
Republicans want to make women pay more for insurance again

But let’s examine the demographic politics of Ellmers’ snide inquisition. The Affordable Care Act’s requirement that insurers cover maternity care is a major manifestation of its broader prohibition against gender rating. Before Obamacare, it made sense actuarially for insurers to charge women more than men for coverage on the individual market. The fact that women, rather than men, incur maternity costs was a big part of their justification, though women were also generally charged more for equivalent coverage. By prohibiting the practice, Obamacare doesn’t just strike a blow for moral reasoning. It effectuates a billion-dollar transfer of wealth from men to women.

By undertaking to foist the costs of maternity care back onto women alone, Ellmers was proposing, perhaps unwittingly, to transfer all of that wealth from women back to men. Take her point to its logical conclusion and she was also arguing for absolving anyone who’s genetically insulated from certain medical expenses from paying a penny to treat others who aren’t so lucky. Born with a harmful BRCA mutation? Then the cost of financing breast cancer treatment should be entirely on you and your unfortunate peers. Got the Huntington’s disease gene? Buh-bye!
posted by tonycpsu at 12:20 PM on October 31, 2013 [4 favorites]


I think the main difference here is that there are some people who think insurance should be a joint endeavour/public good, where everyone pays to ensure that everyone gets health care - kind of like a deliberately collaborative practice - while others think insurance is either a employment benefit or a gamble. If it's a public good - and mind, I think most people who think collective insurance is a public good would probably prefer a non-insurance scheme - then it makes sense that healthy people will pay for sick. If it's an employment benefit, then allowing it to be flexible for different employers makes sense. If it's a gamble, where the insurer is the bookie, then of course it makes sense that different situations are going to be rated at different payments. Like life insurance - you're paying a certain amount, betting that the peace of mind and payout to your family will be worth the payments. They're betting that you will pay them more money than they will have to pay if you die.

The problem is that the two are trying to talk to each other as though they have the same shared ideals of what insurance should be. And yes, both sides are arguing that the other side is immoral for having those views - but in reality, it seems a competing case of values and dreams. I'm not sure there's actually a compromise.
posted by corb at 12:30 PM on October 31, 2013


Under our non-ACA system, healthy people already paid for sick people, although in less direct (but ultimately more expensive) ways than pooling risk via health insurance.

But getting people to recognize that is almost impossible.
posted by rtha at 12:37 PM on October 31, 2013 [2 favorites]


The problem is that the two are trying to talk to each other as though they have the same shared ideals of what insurance should be. And yes, both sides are arguing that the other side is immoral for having those views - but in reality, it seems a competing case of values and dreams. I'm not sure there's actually a compromise.

Probably because having the argument about insurance rather than healthcare is part of the problem. The US has both the highest per-capita spending and costs in relation to the economy on healthcare, but is pretty far down in the rankings for pretty much every health statistic, if not entirely across the board.
posted by zombieflanders at 12:55 PM on October 31, 2013 [1 favorite]


corb: "I think the main difference here is that there are some people who think insurance should be a joint endeavour/public good, where everyone pays to ensure that everyone gets health care - kind of like a deliberately collaborative practice - while others think insurance is either a employment benefit or a gamble."

No, that's not how the sides break down at all.

I'll grant you that there is a tiny minority of libertarian-minded zealots yourself who actually believe that health insurance should be a straight actuarial gamble, with those who lose being on their own, unable to get care at the ER. The true believers among this group would like to phase out Medicare, Medicaid, and Social Security, and if you take them at their word, would gladly die in the street if their personal resources to prolong their lives ran out.

But to call this group a "side" in this debate is ridiculous. This is a viewpoint that's over-represented on the Internet, one whose actual number of devotees could comfortably fit in a high school auditorium once you subtract the ones who will gladly draw benefits they claimed to hate once they need them.

In reality, the two sides in this debate are the ACA essentially as it is, and the status quo pre-ACA. Even the Republicans' plans for Medicare and Medicaid involved ACA-like exchange-and-subsidize schemes.

There is no measurable popular support for anything approaching your idea of people being on their own if they run out of coverage, so stop trying to make it sound like there is.
posted by tonycpsu at 12:57 PM on October 31, 2013 [2 favorites]


Republicans want to make women pay more for insurance again

Republicans are really working hard at convincing women to never vote for them again. Have they noticed the gender gap in the polls in Virgina?
posted by octothorpe at 12:57 PM on October 31, 2013


The problem is that the two are trying to talk to each other as though they have the same shared ideals of what insurance should be.

At the individual level, people generally do have the same ideals: that when they get sick or need procedures, they will be able to meet the direct cost to them.

When no players entering the deal expect to take the risk of losing out, it's not really gambling.
posted by Miko at 12:59 PM on October 31, 2013 [2 favorites]


Obamacare’s Three Per Cent
Gruber summarized his stats: ninety-seven per cent of Americans are either left alone or are clear winners, while three per cent are arguably losers. “We have to as a society be able to accept that,” he said. “Don’t get me wrong, that’s a shame, but no law in the history of America makes everyone better off.”
I guess we can count the fact that our resident one-percenter apologists are now carrying water for a full three percent of the population as progress.
posted by tonycpsu at 12:59 PM on October 31, 2013


Probably because having the argument about insurance rather than healthcare is part of the problem.

I think you're right - I think it's one of those situations where everyone's fighting about different things and making it worse on all sides with everything they touch.

I think if the government had, say, health care clinics that they allowed all Americans to go to, I might think it would be too expensive in the long run or I might not, but I wouldn't be mortally offended in the same way as I am over the idea of doctors having to work for free or of people being mandated to buy insurance or people having to pay excise taxes. Even though I know that's my tax money. Because it's about different ideals. I understand that that might upset some people with an R next to their name, but I think that'd be fine. I'd want it balanced with the rest of the budget, but as long as there were no new taxes for it, it wouldn't particularly bother me.

But that's not what's being sold - and probably because they couldn't get it passed. So this weird crony-capitalism-meets-socialism Frankenstein monster has been created that suits no one, but everyone thinks it's a first step towards either heaven or hell.
posted by corb at 1:13 PM on October 31, 2013


corb: "the idea of doctors having to work for free"

[citation needed]

At least your concern for males paying for maternity care is founded on a situation that actually does exist, even if it's not an actual problem in the way you say it is. But where does this idea that doctors are or will ever have to work for free? Even in the UK, with single payer and a national healthcare provider, doctors make more than a comfortable living.

Admit it -- you're really just throwing shit on the wall and seeing what sticks at this point, aren't you?
posted by tonycpsu at 2:26 PM on October 31, 2013


If a male doesn't pay for maternity care, does he get any parental rights at all?

I would suggest that "NO". If a male wants to be a freeloader and not pay for the birth of children, then why should he get any input into raising them?

I guess if you prove that you've been castrated or something, you can get a tax credit.
posted by mikelieman at 2:30 PM on October 31, 2013 [1 favorite]


If "doctors working for free" were an actual thing instead of made-up bullshit fearmongering, I'm pretty sure the AMA would have had something to say about it, and I can't find anything where they have.
posted by rtha at 3:45 PM on October 31, 2013 [1 favorite]


Ugh. This is one of those things where I'm not even sure that it will stem the tide of attempted "gotcha" conversation, but essentially: if a doctor is forced to treat patients that walk in their door, whether or not they are able to pay, they are working for free. This is not a specific ACA thing, but not everything has to be a specific ACA thing when talking about the problems with healthcare or health insurance or how the government creates rules to attempt to find the good.
posted by corb at 6:49 PM on October 31, 2013


corb: "This is one of those things where I'm not even sure that it will stem the tide of attempted "gotcha" conversation, but essentially: if a doctor is forced to treat patients that walk in their door, whether or not they are able to pay, they are working for free."

It's not a "gotcha" when someone asks you to clarify a statement in which you're using a definition of the phrase "working for free" that virtually nobody else on the planet shares, so don't try to make this out like you're being treated unfairly here. If doctors are getting compensated for their services (whether it's out of the patient's pocket, out of a private insurance company's pocket, or from other citizens by way of the federal treasury) then they are not "working for free" by any reasonable definition of the term. Just because the check comes from someone other than the patient doesn't mean it's illegitimate.

If doctors get paid, they're not working for free. This is not a controversial use of the English language. I welcome opposing viewpoints, but don't chastise me for asking words to be used correctly.
posted by tonycpsu at 7:53 PM on October 31, 2013 [9 favorites]


Another Obamacare horror story debunked (via):
Her current plan, from Anthem Blue Cross, is a catastrophic coverage plan for which she pays $293 a month as an individual policyholder. It requires her to pay a deductible of $5,000 a year and limits her out-of-pocket costs to $8,500 a year. Her plan also limits her to two doctor visits a year, for which she shoulders a copay of $40 each. After that, she pays the whole cost of subsequent visits... at her age, she's eligible for a good "silver" plan for $333 a month after the subsidy -- $40 a month more than she's paying now. But the plan is much better than her current plan -- the deductible is $2,000, not $5,000. The maximum out-of-pocket expense is $6,350, not $8,500. Her co-pays would be $45 for a primary care visit and $65 for a specialty visit -- but all visits would be covered, not just two.
posted by tonycpsu at 8:04 PM on October 31, 2013


if a doctor is forced to treat patients that walk in their door, whether or not they are able to pay, they are working for free

Good thing then that this is something you completely made up and is not actually happening anywhere except in your fevered imagination.
posted by Miko at 8:28 PM on October 31, 2013 [2 favorites]


I can never tell if the world that Libertarians want to exist is more horrible than their fantasies about the world that actually exists.
posted by Pope Guilty at 9:12 PM on October 31, 2013 [4 favorites]


It's pretty much performance art.
posted by Miko at 9:18 PM on October 31, 2013


if a doctor is forced to treat patients that walk in their door

Simple answer: they aren't.

I assume you're thinking of the requirement that hospital ERs treat anyone who walks in, at least until they're stabilized, if they accept medicare or medicaid money.

But the hospitals and physicians are being paid, even for the patients who can't pay. Their payment is simple: access to medicare and medicaid patients. Any (private) hospital is free to reject medicare and medicaid patients at any time, and thereby remove the requirement to treat all comers in their ER, but virtually uniformly they have made the business decision not to.

And, frankly, this sort of indirect payment is common enough in the business world. It's not far from Wal-Mart's insistence on cost reduction or quality increase every year, for which the supplier is uncompensated. The supplier's payment for doing the very real work to provide the savings/quality is continued access to Wal-Mart. So insisting that this is some sort of horrible imposition, instead of the federal government acting like any other large economic entity, won't fly.
posted by ROU_Xenophobe at 10:05 PM on October 31, 2013 [3 favorites]


It's also common in universities, nonprofits, museums, arts organizations, etc. When a granting organization assumes the payment for program fees or admission fees, we still get paid. When we offer a free day to local community members, in order to strengthen goodwill and the chance of repeat visitation from them, we still get paid. It's true, having a variety of payment methodologies, including in-kind, is a completely normal part of a complex revenue model.
posted by Miko at 5:35 AM on November 1, 2013


If doctors are getting compensated for their services (whether it's out of the patient's pocket, out of a private insurance company's pocket, or from other citizens by way of the federal treasury) then they are not "working for free" by any reasonable definition of the term.

As far as I understand it - and please correct me, if you have data that contradicts this - the Emergency Medical Treatment and Active Labor Act does not, in fact, fund the requirement to treat everyone. According to the American College of Emergency Room Physicians, 55% of emergency room care goes unpaid (They're an advocacy group, so their numbers may be slightly inflated, but it's still significant)

It could be argued that the ACA does away with that problem by requiring everyone to have health insurance, but they are not, in fact, guaranteeing that full compensation will be rendered. Insurers decide how much they will pay for each service, and so they are not reimbursed at the level that they actually bill, but are forced to accept what the insurance chooses to provide. They can go after the patient, but are not allowed, even if they are aware and the patient is aware that they cannot pay, to refuse care. In addition, it allows patients to sue the hospital and doctors if they are turned away or released before they are stabilized, even if that would take significant treatment, as well as the punitory fines of $50,000 for each case.

The idea that this only applies to hospitals who accept Medicare patients ignores the fact that Medicare is mandatory and enrollment automatic in this country if you are collecting Social Security. It's definitely a strong-arm. It's not the only strong-arm Congress has done, trying to work things that they would not normally have authority to do into the commerce clause, but it's certainly a mighty one.
posted by corb at 6:49 AM on November 1, 2013


CNN: Senate Democrats supported rule that led to insurance cancellations
Washington (CNN) - Senate Democrats voted unanimously three years ago to support the Obamacare rule that is largely responsible for some of the health insurance cancellation letters that are going out.

In September 2010, Senate Republicans brought a resolution to the floor to block implementation of the grandfather rule, warning that it would result in canceled policies and violate President Barack Obama’s promise that people could keep their insurance if they liked it.
posted by BobbyVan at 7:18 AM on November 1, 2013


That's a complete misunderstanding of how medical billing works. The rates are often pre-negotiated between the hospital and the insurer - the hospital has an incentive to offer lower costs so the insurer will make them a preferred provider. But if no negotiation takes place, the insurer may well pay the list price for the procedure. There is no ultimatum.

I'd rather the negotiation takes place between large powerful companies and large powerful hospitals, than between sick individuals and large powerful hospitals.
posted by miyabo at 7:25 AM on November 1, 2013


if a doctor is forced to treat patients

The idea that this only applies to hospitals who accept Medicare patients ignores the fact that Medicare is mandatory and enrollment automatic in this country if you are collecting Social Security. It's definitely a strong-arm.


"Forced" and "strong arm" imply threats of physical violence or control, neither of which are employed here. Maybe you'd find the terms 'conditional' and 'incentive' useful?
posted by jon1270 at 7:31 AM on November 1, 2013


Medical care facilities' budgets aren't built completely on fee-for-service models and haven't been for decades - so it's ridiculous to say people "don't get paid" when clients aren't paying directly, regardless of what other things you believe about whether people should be allowed to die to allow hospitals to refuse treatment. It's not a simple cash-in, service-out model, so it really is disingenuous to pretend as though it is for argument's sake.
posted by Miko at 8:24 AM on November 1, 2013 [2 favorites]


corb: "As far as I understand it - and please correct me, if you have data that contradicts this - the Emergency Medical Treatment and Active Labor Act does not, in fact, fund the requirement to treat everyone."

Healthcare providers use a catch-all category of "uncompensated care" to describe care that isn't paid for by the patient or an insurer, even if they receive government payment for it later through some kind of state or federal subsidy. This vernacular allows them to claim that about 6% of their operating costs go to uncompensated care, which sounds like a lot.

However, according to Kaiser's most recent figures, the total amount classified as uncompensated care was $57 billion in 2008, but they were reimbursed by federal, state, and local government funds to the tune of $42.9 billion (75%), meaning the hospitals actually only provided $14.1 billion in free care nationwide. So the 6% figure is really 1.5%.

So, strictly speaking, yes, there is some "free" healthcare given out to people who can never pay, a small portion of which is never reimbursed to the hospitals. You can call this small fraction of their operating expenses free care, but you're simply lying when you say doctors are working for free. Is the Subway clerk working for free when they make the second sub for a buy one get one deal? Is a bartender working for free when they hand out a free drink to a regular who tips well? You're really embarrassing yourself with this kind of logic.
posted by tonycpsu at 8:29 AM on November 1, 2013 [6 favorites]


The National Association of Public Hospitals compiles regular reports of how "uncompensated" care is funded (latest one available online is from 2010). They use the term "unreimbursed" care, because they are in fact compensated for it, relying on non-Medicaid/Medicare federal, state, municipal, private grant and other funding sources to make up the shortfall. Those sources in fact made up 56% of "safety net" hospital funding that year.
posted by Miko at 8:38 AM on November 1, 2013 [1 favorite]


Here's something more along the forced-fee-for-service model: it's not something that has actually taken place to my knowledge, but it was a real bill submitted in Massachusetts, which can be viewed in some ways as a tester for the ACA, since Romney's plan and the ACA had such similarities in many ways - thus a possible eventual political position and one it is reasonable to oppose. One doctor writes for the Examiner his opinions about it, calling it "enslavement."
Massachusetts Senate Bill No. 2170 proposes that physician's reimbursement be determined by the state and physicians must accept all patients in the state with an "Affordable Health Plan". Physicians will not be able to set their own fees. It would compel doctors to accept specific patients, predominately from the small business community, with an insurance plan that will pay them at rates of Medicare plus 10 percent before they could become a licensed doctor in the state.
posted by corb at 8:57 AM on November 1, 2013


Yeah, all those poor doctors in the UK and Canada and wherever else they're paid a salary: slaves! It's tragic.

And go figure: That bill had the support of....insurance companies!
posted by rtha at 9:07 AM on November 1, 2013 [1 favorite]


I'm sorry, what? One of those is a position piece from a far-right think tank who is currently notorius for being the climate-change denier guys with funding from sketchy sources, which makes me question their credentials on pretty much everything. The other is an editorial from a crank who believes all fraud comes from the government, despite the fact that, as of 2011, fraud rates in private insurance were twice that of government-run insurance. The fact that he's writing for a far-right media source, is a white Republican complaining about enslavement, and repeatedly cites his for-profit work as primary sources only adds to the dubiousness of his knowledge base.

Do you have anything that's not birther levels of credibility/e-mail chain woo on a bill that never happened, which has nothing to do with the original point you made?
posted by zombieflanders at 9:20 AM on November 1, 2013 [2 favorites]


corb:"enslavement"

Enslavement.

You, of all people, dropping that particular turd into the punch bowl.

Have you no decency, madam?
posted by tonycpsu at 9:29 AM on November 1, 2013


Like on the one hand this is a predictable and contemptibly vile conversation but on the other hand the excellent refutations being made that are actually based in logic and fact and reason are really stellar, and I thank you all for your valuable work.
posted by elizardbits at 9:34 AM on November 1, 2013


One doctor writes for the Examiner his opinions about it, calling it "enslavement."

It's horrible that his owners kidnapped him, strapped him to a boat, and forced him to become a doctor and treat people with life-threatening emergencies instead of letting them die. Hopefully he'll someday be sold to a nice candy maker, or something.

Shameless.
posted by dirigibleman at 9:38 AM on November 1, 2013 [2 favorites]


zombieflanders: The "real bill" link is to the actual text if you want to avoid the other two. I can try to dig up what other newspapers thought at the time, if you want - I was at the point where reading search results was depressing, so I wanted to go with what I had.

If you don't think that this is a thing that ever had a shot of passing, or would definitely not pass federally, I'd certainly be interested in why you think so. For me, seeing stuff like that, it definitely seems like a real possibility. What do you do when doctors don't want to accept insurance plans with low reimbursements, and people can't get care because of that? How long does it take before people create ways to ensure that they can get care, even if it means riding over the doctor's wishes?
posted by corb at 9:40 AM on November 1, 2013


If you don't think that this is a thing that ever had a shot of passing, or would definitely not pass federally, I'd certainly be interested in why you think so.

It had so little chance of passing nationally that single-payer was off the table completely before the debate about what would become the ACA ever began. We "can't" have something like that here because socialism is bad. It's so bad that it's worse than letting people who can't afford medical care just die.

As for how long it would take before we create ways to make sure people get the care they need while doctors get pay? In this country, apparently forever. Other nations seem to have managed to have a less fucked-up and immoral system, all without their entire doctor population fleeing.
posted by rtha at 9:56 AM on November 1, 2013


The idea that this only applies to hospitals who accept Medicare patients ignores the fact that Medicare is mandatory

I like how obviously deceptive this statement is. Of course medicare isn't "mandatory" in the sense relevant to this discussion, since neither physicians nor hospitals are required to accept it. But I'll go ahead and call it "mandatory" anyway, when I've been talking about free care being "mandatory," because there's another totally irrelevant sense in which medicare is mandatory to nearly all workers.

Again: neither physicians nor hospitals are required to accept medicare or medicaid, and you can find real-world examples of physicians and hospitals that don't. All a hospital has to do to avoid the ER requirements is stop accepting medicare and medicaid; that they've overwhelmingly chosen not to do that is because the package deal is good business. All a physician has to do to avoid it is not be an ER physician at a medicare/medicaid participating hospital.
posted by ROU_Xenophobe at 10:14 AM on November 1, 2013 [2 favorites]


Yeah, all those poor doctors in the UK and Canada and wherever else they're paid a salary: slaves! It's tragic.


I get paid a salary; not what some of my colleagues in private practice earn, but still quite generous. And it is a predictable amount each month which makes planning and budgeting easier. Physicans who complain about being paid a salary under any kind of national health care system tend to be greedy whiners who are overly concerned with keeping up with the bankers and other overpaid 1%ers who live in their gated communities.
posted by TedW at 11:53 AM on November 1, 2013 [3 favorites]


Yeah, pity those destitute doctors in socialized healthcare systems. Since none of their patients are paying, them, they're working for free!
posted by tonycpsu at 12:02 PM on November 1, 2013


How long does it take before people create ways to ensure that they can get care

Seems like the ACA is kinda people creating ways to ensure they can get care. Working with the art of the possible, and all.
posted by Miko at 12:42 PM on November 1, 2013


The "real bill" link is to the actual text if you want to avoid the other two. I can try to dig up what other newspapers thought at the time

Also, I cannot for the life of me understand what something that was not even enacted has to do with anything pertinent to this conversation.

Frankly, if socialized medicine would drive people out of health care who were otherwise only in it for the money, and attracts people motivated by something more intrinsic than status and wealth, I'm prepared to take that as largely a really good thing.

However, let's note that it's not even on the table right now. We might get there someday, but we aren't there now. Right now, we've got a plan that was developed as a profound compromise so that the people can get the basic services they need while (perhaps unwisely) not putting a parasitic but powerful and exceedingly profitable industry out of business.
posted by Miko at 12:51 PM on November 1, 2013


The one thing I'm getting tired of is people on the left, particularly the MSNBC types like Chris Hayes or Lawrence O'Donnell insisting that if I think I prefer my old health insurance to my new Obamacare plan it's because I didn't understand my old insurance and had junk insurance and my new stuff is better and I haven't done the research and I'm confused by right wing shills.

No, I really do understand my old plan and my new plan. And it's not just the right wing types that aren't telling you the whole story. Now, on balance the lefty guys are telling you more of the truth. They aren't outright lying to you. But how often have you heard those guys talking about provider networks rather than rates and benefits? Not very often. Why?

Because that's where the catch is. And there's always a catch because there is no free lunch.

My new plan is, as I've mentioned before, better coverage (lower deductible and out of pocket) for the same price. Those guys on TV would thus tell me I'm benefiting. But I'm not. Because they get that great coverage and good price by strictly limiting the providers in the network. Particularly hospitals and medical facilities. My old plan did not to anything like the same extent. So, no, I'm not misinformed. I apparently understand what's happening better than Hayes or Maddow or O'Donnell. Who, don't get me wrong, are generally doing the lord's work fighting back against bullshit. But I resent being told I'm confused when I am not. I just realize that price is not the only important metric.

Background: My biggest problem with Obamacare is that it isn't single payer. I'm not criticizing Obamacare per se, just the people defending it quasi-honestly. And I do wish I could, like Obama promised (and he did promise), have kept my old plan. Which I preferred.
posted by Justinian at 5:39 PM on November 1, 2013 [4 favorites]


Yeah, it's important that lefties not fall into the trap of swallowing whatever talking points are handed down from on high. If your experience is typical, it's definitely something that should be talked about as a potential drawback for some people.

Still, I'm curious as to whether your experience of ending up with a plan that has a smaller network is typical, or perhaps something related to regional/local factors that don't reflect on the ACA in general. Were there other options that let you keep a bigger network at a higher cost, or with higher deductibles? I'm not trying to be condescending here, just trying to understand how you weighted the plan cost, network size, and out-of-pocket cost variables in your decision.

Clearly, there are people who would pay more for access to a larger network, so it would surprise me if they're not making that option available, and if they're not, I'd expect them to offer those options in the future. Might this just be a case of the insurers being very conservative in the number of plans they offer until they have data on what the demand for each is?
posted by tonycpsu at 6:45 PM on November 1, 2013


Were there other options that let you keep a bigger network at a higher cost, or with higher deductibles? I'm not trying to be condescending here, just trying to understand how you weighted the plan cost, network size, and out-of-pocket cost variables in your decision.

Not significantly. There are a couple of bronze plans that have a marginally larger network; my theory is that because they cover so much less of the visits to the doctors/hospitals they are willing to let you go to a more expensive place. Because you're coughing up most of the dough. But none of the gold/platinum plans (and this is in California where there are 12 companies competing which I believe is the second or third most in the country) have wide networks. That's how they offer great benefits at a reasonable price. By limiting the facilities you can be treated at to the cheaper ones.

I live two blocks from Cedars-Sinai hospital. Now, I'll admit it was probably a little much to hope I could find a plan which would cover treatment there even though it is a great hospital. Because it's also, I think, the single most expensive hospital in the entire country. But they won't cover the Miracle Mile medical center. Or... well you get the point. It looks to me like they essentially compiled a list of medical facilities sorted by cost and drew a line at like the 55th or 60th percentile and said "Okay, we'll cover any facilities below this line and no facilities above this line". Which is great for keeping costs low but means the highest quality treatment becomes unavailable as well as giving no regard to proximity or the like.

I concede the relationship between quality and price when it comes to hospitals isn't exactly 1-1, but there is certainly a correlation. You don't get the highest quality care for the cheapest cost. You can probably get decent care for a decent cost but I'd be perfectly willing to pay more per month for a network which included more expensive and better hospitals. And, in fact, have been doing so.

Actually that's not true; I've been paying the same per month... but I've been willing to accept a higher deductible and a higher maximum yearly out of pocket cost. Lawrence O'Donnell would sneer and say that I'm confused because I'm SAVING MONEY FOR BETTER COVERAGE!!!!11!1!1eleven but he can kiss my butt.
posted by Justinian at 11:39 PM on November 1, 2013 [1 favorite]


. It looks to me like they essentially compiled a list of medical facilities sorted by cost and drew a line at like the 55th or 60th percentile and said "Okay, we'll cover any facilities below this line and no facilities above this line". Which is great for keeping costs low but means the highest quality treatment becomes unavailable as well as giving no regard to proximity or the like.

I don't understand. Are you saying that no one in the state can buy coverage that includes those hospitals in the network?
posted by Miko at 4:38 AM on November 2, 2013


It might actually be the case that no individual plan on the exchange has those hospitals in-network, even if some employer plans do. However much things should improve for the anonymous Average Person on the individual market, they still can't negotiate the deals that Calpers/UC/CSU can.
posted by ROU_Xenophobe at 9:01 AM on November 2, 2013 [1 favorite]


That does make sense when you factor in the employer plans, yes. I see.
posted by Miko at 9:33 AM on November 2, 2013


Thanks for the explanation, Justinian. Your point that these details matter is an important one, and if your experience is typical, it would be irresponsible for pundits to not acknowledge that some people that count as "winners" in the straight expected value proposition sense might be losing out on particular components of their original plans that they valued.

With respect to liberal pundits: I can't stand to watch Lawrence O'Donnell anymore, but I think Chris Hayes in particular has been very fair in his coverage of the ACA's fits and starts. I do think there's a certain amount of "grading against the curve" going on, where a progressive commentator will point out that a problem exists, but will compare it to Medicare Part D or the slow RomneyCare rollout, or explain that the Rube Goldberg cost control mechanisms aren't what progressives wanted in the first place, but of course these explanations/excuses (depending on your point of view) are cold comfort for people who have to deal with the law as it is today.

The outstanding question is whether your experience is in fact typical, or is perhaps just a temporary condition that the insurers will remedy by providing plans with larger networks that include the particular providers you seem to value more highly. I find it hard to believe they wouldn't expand their options to satisfy the demand for service at these facilities assuming they're fairly priced for the quality of care they deliver.
posted by tonycpsu at 10:40 AM on November 2, 2013


The outstanding question is whether your experience is in fact typical,

I do think it may be a bit of an outlier. It may just be that the insurers did not craft a premium plan for the individual market that included some of your wished-for facilities in the network because that will be quite a costly plan, and so very, very few people are in a position to, or would, buy it. I understand that you would, but I think that is probably very unusual, and offering it to a very tiny market may not have been deemed worth the administrative cost.
posted by Miko at 12:24 PM on November 2, 2013


I have no doubt that's the case. I was only whining complaining about being labelled as confused by many liberal pundits because I don't think my new plan is better than my old plan in every way.
posted by Justinian at 1:04 PM on November 2, 2013


Karen Finney is on MSNBC talking about how people are confused by their junk policies. Sigh.
posted by Justinian at 1:36 PM on November 2, 2013 [1 favorite]


I'm not your doctor, Justinian, but my recommendation is to taper off your MSNBC usage in favor of an hour or so of Fox News every day, just to re-set your ideological instrumentation.
posted by tonycpsu at 1:55 PM on November 2, 2013


That seems extreme. Couldn't I simply stab myself in the face with an icepick instead?
posted by Justinian at 3:37 PM on November 2, 2013 [1 favorite]


This "inside baseball" account of the White House's management of the ACA corroborates what a lot of liberals have feared for a long time, which is that President Obama's conciliatory, conflict-averse nature combined with unanimous, unyielding GOP opposition likely had a significant negative impact on the implementation of the law.
(Include standard disclaimer about anonymous sources, grinding of axes, failure's orphan status, etc.):
HealthCare.gov: How political fear was pitted against technical needs

Based on interviews with more than two dozen current and former administration officials and outsiders who worked alongside them, the project was hampered by the White House's political sensitivity to Republican hatred of the law - sensitivity so intense that the president's aides ordered that some work be slowed down or remain secret for fear of feeding the opposition.

[...]

Soon, however, it became evident that the office - with more than 200 people - would not survive on its own. It lacked tools, such as the ability to award grants and outside contracts, that were vital to its mission, said Richard Foster, Medicare's chief actuary for nearly two decades before he retired early this year. So the office, with a slightly new name, moved in early 2011 into the Centers for Medicare and Medicaid Services (CMS), a large agency spread among locations in the District, Bethesda and Baltimore.

The move had a political rationale, as well. Tucked within a large bureaucracy, some administration officials believed, the new Center for Consumer Information and Insurance Oversight would be better insulated from the efforts of House Republicans, who were looking for ways to undermine the law. But the most basic reason was financial: Although the statute provided plenty of money to help states build their own insurance exchanges, it included no money for the development of a federal exchange - and Republicans would block any funding attempts. According to one former administration official, Sebelius simply could not scrounge together enough money to keep a group of people developing the exchanges working directly under her.

Bureaucratic as this move may sound, it was fateful, according to current and former administration officials. It meant that the work of designing the federal health exchange - and of helping states that wanted to build their own - became fragmented. Technical staff, for instance, were separated from those assigned to write the necessary policies and regulations. The Medicaid center's chief operating officer, a longtime career staffer named Michelle Snyder, nominally oversaw the various pieces, but, as one former administration official put it: "Implementing the exchange was one of 39 things she did. There wasn't a person who said, `My job is the seamless implementation of the Affordable Care Act.' "

[...]

From the beginning, the administration worked in a venomous political climate. "You're basically trying to build a complicated building in a war zone, because the Republicans are lobbing bombs at us," the White House official said.

White House officials contend that the political sensitivities did not influence the substance or pace of the work. But others who were involved say otherwise.

According to two former officials, CMS staff members struggled at "multiple meetings" during the spring of 2011 to persuade White House officials for permission to publish diagrams known as "concepts of operation," which they believed were necessary to show states what a federal exchange would look like. The two officials said the White House was reluctant because the diagrams were complex, and they feared that the Republicans might reprise a tactic from the 1990s of then-Sen. Bob Dole (R-Kan.), who mockingly brandished intricate charts created by a task force led by first lady Hillary Clinton.

In the end, one of the former officials said, the White House quashed the diagrams, telling CMS, instead, to praise early work on those state exchanges that matched the hidden federal thinking.

[...]

So that September, when the administration issued the "scope of work" for the largest IT contract, the specifications skirted the question - saying only that "CMS will not know for certain how many states will apply" to run their own insurance exchanges.

After the contract was awarded to CGI Federal, the administration kept giving states more and more time to decide whether to build their own exchanges; White House officials hoped that more would become willing after the 2012 election. So the technical work was held up. "The dynamic was you'd have [CMS's leaders] going to the White House saying, `We've got to get this process going,' " one former official recalled. "There would be pushback from the White House."

[...]

Such delays were "a singularly bad decision," said Foster, the former Medicare chief actuary. "It's the president's most significant domestic policy achievement," he said, and the very aides who had pushed the law through Congress were risking bad implementation "for a short-term political gain."
posted by tonycpsu at 9:03 AM on November 3, 2013 [1 favorite]


Great, now Nancy Pelosi is telling me I'm wrong about my own life. Thanks, Nancy.
posted by Justinian at 1:11 PM on November 3, 2013 [1 favorite]


Wall Street Journal: Aides Debated Obama Health-Care Coverage Promise
One former senior administration official said that as the law was being crafted by the White House and lawmakers, some White House policy advisers objected to the breadth of Mr. Obama's "keep your plan'' promise. They were overruled by political aides, the former official said. The White House said it was unaware of the objections.
You Also Can't Keep Your Doctor: I had great cancer doctors and health insurance. My plan was cancelled. Now I worry how long I'll live.
Everyone now is clamoring about Affordable Care Act winners and losers. I am one of the losers.

My grievance is not political; all my energies are directed to enjoying life and staying alive, and I have no time for politics. For almost seven years I have fought and survived stage-4 gallbladder cancer, with a five-year survival rate of less than 2% after diagnosis. I am a determined fighter and extremely lucky. But this luck may have just run out: My affordable, lifesaving medical insurance policy has been canceled effective Dec. 31.

My choice is to get coverage through the government health exchange and lose access to my cancer doctors, or pay much more for insurance outside the exchange (the quotes average 40% to 50% more) for the privilege of starting over with an unfamiliar insurance company and impaired benefits.
posted by BobbyVan at 7:01 AM on November 4, 2013 [1 favorite]


The Real Reason That The Cancer Patient Writing In Today’s Wall Street Journal Lost Her Insurance
Get that? The company packed its bags and dumped its beneficiaries because it wants its competitors to swallow the first wave of sicker enrollees only to re-enter the market later and profit from the healthy people who still haven’t signed up for coverage.

Sundby is losing her coverage and her doctors because of a business decision her insurer made within the competitive dynamics of California’s health care market. She’ll now have to enroll in a new plan that offers tighter networks of providers as a way to control health care costs and offer lower premiums. Eleven insurers are participating in Covered California and for the first time they won’t be able to deny coverage to Sundby or any other cancer patients.
posted by tonycpsu at 7:10 AM on November 4, 2013 [3 favorites]


Special Investigation: How Insurers Are Hiding Obamacare Benefits From Customers
Across the country, insurance companies have sent misleading letters to consumers, trying to lock them into the companies' own, sometimes more expensive health insurance plans rather than let them shop for insurance and tax credits on the Obamacare marketplaces -- which could lead to people like Donna spending thousands more for insurance than the law intended. In some cases, mentions of the marketplace in those letters are relegated to a mere footnote, which can be easily overlooked.

The extreme lengths to which some insurance companies are going to hold on to existing customers at higher price, as the Affordable Care Act fundamentally re-orders the individual insurance market, has caught the attention of state insurance regulators.

The insurance companies argue that it's simply capitalism at work. But regulators don't see it that way. By warning customers that their health insurance plans are being canceled as a result of Obamacare and urging them to secure new insurance plans before the Obamacare launched on Oct. 1, these insurers put their customers at risk of enrolling in plans that were not as good or as affordable as what they could buy on the marketplaces.

TPM has confirmed two specific examples where companies contacted their customers prior to the marketplace's Oct. 1 opening and pushed them to renew their health coverage at a higher price than they would pay through the marketplace. State regulators identified the schemes, but they weren't necessarily able to stop them.

It's not yet clear how widespread this practice became in the months leading up to the marketplace's opening -- or how many Americans will end up paying more than they should be for health coverage. But misleading letters have been sent out in at least four states across the country, and one offending carrier, Humana, is a company with a national reach.
posted by zombieflanders at 7:13 AM on November 4, 2013


Get that? The company packed its bags and dumped its beneficiaries because it wants its competitors to swallow the first wave of sicker enrollees only to re-enter the market later and profit from the healthy people who still haven’t signed up for coverage.

Get that? The ACA is providing companies a business incentive to drop its sickest and most expensive enrollees, but don't blame the ACA!
posted by BobbyVan at 7:24 AM on November 4, 2013 [1 favorite]


No, the ACA didn't provide those business incentives, they've been there the entire time and are blaming them on it. FTFA (emphasis mine):
But Sundby shouldn’t blame reform — United Healthcare dropped her coverage because they’ve struggled to compete in California’s individual health care market for years and didn’t want to pay for sicker patients like Sundby.

The company, which only had 8,000 individual policy holders in California out of the two million who participate in the market, announced (along with a second insurer, Aetna) that it would be pulling out of the individual market in May. The company could not compete with Anthem Blue Cross, Blue Shield of California and Kaiser Permanente, who control more than 80 percent of the individual market. “Over the years, it has become more difficult to administer these plans in a cost-effective way for our members,” UnitedHealth spokeswoman Cheryl Randolph explained. “We will continue to keep a major presence in California, focusing instead on large and small employers.”

The two insurers were also operating at a tax disadvantage in the state. As California Insurance Commissioner Dave Jones explained, “One of the factors I believe contributed to this decision….is the special tax break that California law gives to Anthem Blue Cross and Blue Shield, which has allowed and continues to allow those two companies to avoid paying $100 million in state taxes a year.” “Aetna and United Healthcare don’t get the special tax break provided to Anthem Blue Cross and Blue Shield, and so they faced a major competitive disadvantage in California.”
But, hey, the free market speaks and we must listen, no?
posted by zombieflanders at 7:34 AM on November 4, 2013 [3 favorites]


There is also the question of how many other people in Ms. Sundby's situation couldn't afford individual plans in the first place under the old rules where plans were free to deny coverage for pre-existing conditions. Would be nice for the Democrats to return fire with some op-eds from some folks who were shunned by the individual insurance market but can now afford coverage.
posted by tonycpsu at 7:43 AM on November 4, 2013


Would be nice for the Democrats to return fire with some op-eds from some folks who were shunned by the individual insurance market but can now afford coverage.

My husband was diagnosed with autoimmune arthritis after we purchased our individual plan. When the ACA was up for review, we got a letter from our insurance company pointing out that autoimmune arthritis was a disqualifying condition for continued coverage under their pre-ACA rules, and we "might want to shop for other plans to avoid a break in coverage" depending on how SCOTUS ruled. The implication being that if the ACA was overturned, they would drop him IMMEDIATELY.

Hell, before the ACA, we wouldn't have been able to insure my infant son on the private market, since he had been to the hospital for croup 3 times in his first year of life. That alone would have disqualified him.
posted by KathrynT at 10:35 AM on November 4, 2013 [5 favorites]


Got an op-ed in you, KathrynT?
posted by Miko at 10:46 AM on November 4, 2013 [1 favorite]


One of the things I don't understand is the Republican plan if they did repeal Obamacare. They usually claim they only want to get rid of the individual mandate and not the "good" provisions like the elimination of pre-existing conditions clauses but so far as I can tell they have never actually explained how you forbid denying coverage based on pre-existing conditions in the absence of the individual mandate.

Yeah, yeah, they don't actually have such a plan and it's all for show. But, really, do they not care about pre-existing conditions? Or what?
posted by Justinian at 11:10 AM on November 4, 2013


I don't understand is the Republican plan if they did repeal Obamacare

Actual plan: "Go now and die in what way seems best to you."
posted by ROU_Xenophobe at 11:19 AM on November 4, 2013 [5 favorites]


CBS News: HealthCare.gov ducked final security requirements before launch
CBS News analysis found that the deadline for final security plans slipped three times from May 6 to July 16. Security assessments to be finished June 7 slid to August 16 and then August 23. The final, required top-to-bottom security tests never got done.

The House Oversight Committee released an Obama administration memo that shows four days before the launch, the government took an unusual step. It granted itself a waiver to launch the website with "a level of uncertainty ... deemed as a high (security) risk."
New York Times: Strategic Move Exempts Health Law From Broader U.S. Statute
WASHINGTON — The Affordable Care Act is the biggest new health care program in decades, but the Obama administration has ruled that neither the federal insurance exchange nor the federal subsidies paid to insurance companies on behalf of low-income people are “federal health care programs.”

The surprise decision, disclosed last week, exempts subsidized health insurance from a law that bans rebates, kickbacks, bribes and certain other financial arrangements in federal health programs, stripping law enforcement of a powerful tool used to fight fraud in other health care programs, like Medicare.

...

The federal government has forbidden the use of drug coupons in Medicare and other federal health programs, saying they amount to a classic kickback scheme, with drug companies paying consumers to use their products.

Mark Merritt, the president of the Pharmaceutical Care Management Association, which represents benefit managers like Express Scripts and CVS Caremark, expressed a similar concern. “The coupons steer consumers away from lower-cost alternatives to more expensive drugs, increasing costs to insurers and to the government,” he said.
posted by BobbyVan at 5:19 AM on November 5, 2013


dirigibleman: "Up is down: Fox News' Greta Van Sustren debunks CBS's story on the Florida woman whose losing her "insurance"."

Roger Ailes must have received a bad batch of mind control medication this month.

Juan Williams: Insurance cancelled? Don't blame Obama or the ACA, blame America's insurance companies
But some people losing their current policies [and being offered better coverage] are going to have to pay a higher price. Taking crocodile tears to a new level, ObamaCare opponents are now rushing to their defense and calling the president a liar.

These critics include Republican politicians who did not vote for ObamaCare; these are Republican governors who refuse to set up exchanges to reach their own citizens; these are people oppose expanding Medicaid to help poor people getting better health care; these are people who have never put any proposal on the table as an alternative fix for the nation’s costly health care system that leaves tens of millions with inadequate medical coverage and tens of millions more totally uninsured.

The fact is if you are one of the estimated 2 million Americans whose health insurance plans may have been cancelled this month, you should not be blaming President Obama or the Affordable Care Act.

You should be blaming your insurance company because they have not been providing you with coverage that meets the minimum basic standards for health care.

Let me put it more bluntly: your insurance companies have been taking advantage of you and the Affordable Care Act puts in place consumer protection and tells them to stop abusing people.
posted by tonycpsu at 7:44 AM on November 6, 2013


ProPublica: Loyal Obama Supporters, Canceled by Obamacare
The couple — Lee, 60, and JoEllen, 59 — have been paying $550 a month for their health coverage — a plan that offers solid coverage, not one of the skimpy plans Obama has criticized. But recently, Kaiser informed them the plan would be canceled at the end of the year because it did not meet the requirements of the Affordable Care Act. The couple would need to find another one. The cost would be around double what they pay now, but the benefits would be worse.

...

“We’re not changing our views because of this situation, but it hurt to hear Obama saying, just the other day, that if our plan has been dropped it’s because it wasn’t any good, and our costs would go up only slightly,” he said. “We’re gratified that the press is on the case, but frustrated that the stewards of the ACA don’t seem to have heard.”
posted by BobbyVan at 8:32 AM on November 6, 2013




I'm really on the fence on "you can keep it." He certainly wasn't literally correct when he said those things. I do wonder if he realized how many nonconfirming plans there were out there that would not be grandfathered. I mean, there's part of me that is bothered about the overliteralness of calling this a "lie." You can keep your plan...if they still offer your plan and your plan is still legal. It's like, you can keep your digital cable plan, too, until they change the plan, and as long as it's still legal. And you can keep your phone contract, until they change the terms. You're dealing with a private company, and if they stop offering a product, you can't keep it. They did stop offering it because the law is intended to replace it with better plans - but they won't be the same plan. In short, it's complicated, but he probably shouldn't have made a sweeping promise like that.
posted by Miko at 9:21 AM on November 6, 2013 [1 favorite]


I called Kaiser Permanente and spoke to spokesman Chris Stenrud, who used to work for the U.S. Department of Health and Human Services. He told me that this was indeed a good plan. Patients in the plan, known as 40/4000, were remarkably healthy, had low medical costs and had not seen their premiums increase in years. “Our actuaries still aren’t entirely sure why that was,” he said.

It's not mentioned in that article what their plan was actually missing just that "it did not meet the requirements of the Affordable Care Act". It sounds like Kaiser realized they were undercharging some customers with that plan and are using the Affordable Care Act as an excuse to discontinue the plan rather than slightly raise the cost of that plan to include whatever it was the plans were missing.

It really sucks that that couple lost their plan, but if the insurance market was such that they had to be lucky to get such a good plan in the first place then that system needed to be changed.
posted by Green With You at 9:25 AM on November 6, 2013 [3 favorites]




GOP’s latest, desperate Obamacare strategy: Try to confuse Americans!
Many of the people receiving cancellation notices or experiencing rate shock will eventually find that they’re pretty happy with their new options. But when that happens, their human interest value collapses, as does their usefulness toward the end of undermining Obamacare. So what are the odds, do you suppose, that Republicans are providing this kind of information to their constituents themselves?

The ugly subtext to stories like these — which proliferate so rapidly, but then turn out upon closer inspection to be less black-and-white than originally depicted — is that Republicans are fostering and nurturing constituent confusion.

#YOURSTORY is a manifestation of that strategy. A site like #YOURSTORY could be just as easily used to field inquiries and respond to troubled constituents with useful information. Instead it’ll be used as a crowdsourcing tool for anti-Obamacare opportunists.

The existence of a campaign like this suggests that the universe of individual Republicans who are refusing to help constituents navigate the Affordable Care Act is larger than we know. And we know it exists[...]The strategic logic here is perverse, but there is a logic to it.

Millions of people are getting cancellation notices from their insurers. Most of those people will be pretty happy with the new system — if they’re made aware of and guided through it by conscientious public servants. The conundrum for conservatives is that once enough people are enrolled in Obamacare, its constituency will be too large for them to support repealing it without offering some alternative that also expands coverage to millions and millions of people. Which is to say, Republicans would be working against their own public policy ambitions if they did right by people receiving these letters. So they’re using them as pawns instead.
posted by zombieflanders at 10:22 AM on November 6, 2013


Single-payer looking good enough yet?
posted by Miko at 12:13 PM on November 6, 2013 [6 favorites]


There's NOTHING Obama can say or do which won't be used as an excuse to beat the guy up. Period. Juan Williams is right on the nose on this. The cancelled policies? They the reason we have regulation, and while you might say that you don't mind being taken advantage of, often so does a beaten wife...

That doesn't stop the police from hauling off her abuser, does it? No. Nor should it.
posted by mikelieman at 12:48 PM on November 6, 2013


The Hill: Sebelius: ‘Possible’ for felon to become an ObamaCare navigator
“So a convicted felon could be a navigator and could acquire sensitive personal information?” Cornyn asked.

“That is possible,” Sebelius said.
posted by BobbyVan at 1:43 PM on November 6, 2013


It's not like being a felon means you're going to steal identities or some shit like that. Christ on toast, Bobby.
posted by rtha at 2:07 PM on November 6, 2013 [8 favorites]


Ah, here comes the GOP feeding the Alex Jones nuttery in their ongoing quest to be vindictive assholes. There are tons of places where convicted felons can work and that have access to more privacy data than Healthcare.gov. Hell, it doesn't even have HIPAA-protected data on it, as Joe Barton found out last week.

But anyway, just a quick reminder that the GOP has been sabotaging the Navigators because they don't want anyone to help people:
In Georgia, Insurance Commissioner Ralph Hudgens boasted in a speech two months ago about a new state law that requires navigators to be licensed by his office. "Let me tell you what we're doing: Everything in our power to be an obstructionist," Hudgens said to cheers.

Amanda Ptashkin, the outreach and advocacy director for Georgians for a Healthy Future and a navigator herself, says she and other navigators had to go through a time-consuming process to get certified, first by the federal government, which requires 20 hours of training, and then by the state. The state's regulations required fingerprints, passing a background check, an affidavit of citizenship, getting a driver's license photo taken, paying a $50 fee, more training, taking a test, and waiting. When the exchanges opened on Oct. 1, only four or five navigators in the state had made it through the process. Almost a month later, they're up to 45 and things are working more or less smoothly, but it's difficult to coordinate efforts in the absence of state involvement. "It's unfortunate that we don't have leadership on the state level to help inform consumers," Ptashkin said.

To pro-Obamacare advocates like Ethan Rome, the executive director of Health Care for America Now, attacking the administration over problems with HealthCare.gov while also obstructing the work of the navigators in the states is "jaw-dropping, turbo-charged hypocrisy." "These people who say they want to fix the website aren't actually interested in helping people take advantage of the benefits of the ACA," Rome says.

"If you're one of these congressional Republicans, and you care deeply about how the website functions, here's my question: How many small businesses did you help get a tax credit? Because if the answer is zero, then just go home and don't ever come back to Washington," Rome adds.

At least four health care groups from Ohio to Texas have declined or returned hundreds of thousands of dollars in federal grant money in the face of state regulations. Meanwhile, navigators in Wisconsin say onerous regulations prevented them from getting to work sooner.

Some states like Indiana are making navigators pay as much as $175 for licensing, while Missouri and others states have passed laws limiting what kind of advice navigators can give to consumers, which advocate say has a chilling effect on their work. A lawsuit in Tennessee successfully challenged a similar law that authorized a $1,000 fine for violations. In Florida, navigators are barred from doing their work on the grounds of country health departments while state regulators held up licenses.
It's also worth noting that they GOP didn't say word one about this when it was their health legislation:
Before there were navigators, there was the Senior Health Insurance Assistance Program, which helps seniors navigate the Medicare Part D perscription-drug program. "It's what the navigator program was based on," says Keith, "and you just don't have these same kind of requirements on SHIPS as we see on navigators. And then you look at the list of states and you wonder, what's going on here?"
Also:

Who Are Obamacare Navigators And Will They Steal Your Identity?
Because health insurance prices are no longer based on health, Navigators will not ask you about health information. This is a good thing.

So what keeps Navigators from stealing your private information and your identity? Thirteen Republican Attorney Generals wrote a letter to the Department of Health and Human Services about their concerns. These Attorney Generals must not know the content of the Affordable Care Act, as Section 4302 outlines how data is used and protected. The requirements are the same as HIPAA, and for those who have ever accessed the health care system and needed information, you will realize the rules are very stringent. Section 1411 sets the fine for improper use and disclosure of information at $25,000. And identity theft is a federal crime regardless of where the thief obtained the information.
posted by zombieflanders at 2:16 PM on November 6, 2013 [2 favorites]


BTW, on that list of places where a felon can get a job, it includes (among others), Allstate Insurance, Blue Cross/Blue Shield, and First Health Group. I assume John Cornyn's subpoenas of them are going out as well?
posted by zombieflanders at 2:24 PM on November 6, 2013 [4 favorites]


Things are going better than I thought if this is the best that DrudgeBot and the GOP can do.
posted by tonycpsu at 3:03 PM on November 6, 2013 [3 favorites]



...
PolitiFact: Barack Obama says that what he'd said was you could keep your plan 'if it hasn’t changed since the law passed' [Spoiler: Pants on Fire]
posted by BobbyVan at 4:04 PM

The Atlantic: The Hidden Marriage Penalty in Obamacare -- Childless couples and empty nesters pay more. Much more.
posted by BobbyVan 18 hours ago


Thanks for pointing these things out, BobbyVan. Obamacare is not perfect but it is a good start and by pointing out the imperfections, hopefully we can all continue to improve it until it rises to the level enjoyed by the rest of the enlightened world.
posted by vacapinta at 4:07 AM on November 7, 2013 [1 favorite]


The problem is that almost everybody he's quoting is most emphatically not looking to improve it.

A petty rant: Republicans are the real lying liars on Obamacare
If you imagine a spectrum between the pre-Obamacare status quo, and the kind of job-destroying “socialism” that the rest of the first world somehow endures, Obamacare is probably about 80 or 90 percent of the way toward the former.

When the final numbers are in, and next year’s numbers, and the numbers the year after that, Obama’s claim will look much closer to the truth than the socialism accusation, but reporters won’t pepper Republican press secretaries with questions about why their bosses warned of a coming dystopia that never actually came. Just like the right’s been given a complete pass for feigning concern for people whose coverage has been canceled, when their own reform proposals are an order of magnitude more disruptive.

This raises an interesting philosophical question about the moral differences between lies told in the service of creating something, lies told in the service of trying (but failing) to prevent it, and lies told in support of alternatives that will never come to pass.

But as far as political credibility is concerned the distinction is moot. These are all just lies, even if each is rooted in the fact that people have different and contentious views of the greater good.

Lying is bad. People shouldn’t lie. But on this score, just ask yourself whose descriptions of Obamacare were closer to reality: Obama’s or the Republican Party’s? It’s not even a close call.
posted by zombieflanders at 7:14 AM on November 7, 2013


Washington Post Fact Checker: The White House effort to blame insurance companies for lost plans [Spoiler: Three Pinocchios]
Blaming the insurance companies can only go so far. First of all, the administration wrote the rules that set the conditions under which plans lose their grandfathered status. But more important, the law has an effective date so far in the past that it virtually guaranteed that the vast majority of people currently in the individual market would end up with a notice saying they needed to buy insurance on the Obamacare exchanges.

The administration’s effort to pin the blame on insurance companies is a classic case of misdirection. Between 75 and 95 percent of the problem stems from the effective date, but the White House chooses to keep the focus elsewhere.
posted by BobbyVan at 7:57 AM on November 7, 2013


BobbyVan: The Dark Homunculus
posted by charred husk at 8:16 AM on November 7, 2013 [4 favorites]


Washington Post Fact Checker: The White House effort to blame insurance companies for lost plans [Spoiler: Three Pinocchios]

We've been over this before. The TL;DR is: insurance companies change their plans all the time (and a minority of existing plans were around before the grandfather rule), the vast majority of people currently in the individual market will be getting better or cheaper plans (often both), and the subsidies enhance affordability.
posted by zombieflanders at 8:21 AM on November 7, 2013


Avik Roy: 49-State Analysis: Obamacare To Increase Individual-Market Premiums By Average Of 41%
One of the fundamental flaws of the Affordable Care Act is that, despite its name, it makes health insurance more expensive. Today, the Manhattan Institute released the most comprehensive analysis yet conducted of premiums under Obamacare for people who shop for coverage on their own. Here’s what we learned. In the average state, Obamacare will increase underlying premiums by 41 percent. As we have long expected, the steepest hikes will be imposed on the healthy, the young, and the male. And Obamacare’s taxpayer-funded subsidies will primarily benefit those nearing retirement—people who, unlike the young, have had their whole lives to save for their health-care needs.
posted by BobbyVan at 8:33 AM on November 7, 2013 [1 favorite]


For the curious, the huge, crippling flaw that makes the study BobbyVan cites so wrong as to be dishonest is that what they did was look for the cheapest pre-ACA plans they could find (which obviously are going to cover very little) and compared them to the cheapest ACA plans, which provide actual no-shit health insurance.

So, yes, if you really wanted to pay an insurance company lots of money for essentially nothing, you'll be out of luck, because now they have to provide meaningful health insurance instead of diddly-fuck.
posted by ROU_Xenophobe at 8:49 AM on November 7, 2013 [6 favorites]


But until Obamacare it was my right as an American to pay huge sums of money for diddly-fuck! Where are my freedoms?!??:!eleven
posted by rtha at 8:52 AM on November 7, 2013 [1 favorite]


Jesus Christ, Avik Roy? That fucking hack?

Let's click through to the methodology page:
"Our pre-ACA dataset consists of the five least expensive plans (by monthly premium) for the most populous zip code in every county." To cover a significant age range we collected rates for 27, 40, and 64-year old male and female non-smokers. We adjusted these rates to take into account those who are denied health insurance coverage as well as those who receive a surcharge. Using the "denial rate" and "surcharge rate" from the federal government's repository, we assumed that those who are surcharged pay 75 percent more and those who are denied, find insurance elsewhere at three times the original rate.
I just did this for my age range in my zip code, which happens to be the most populous in my county (Allegheny County, PA.) The plans available are listed here. The pre-ACA "average" from Roy's absurd "5 cheapest plans" methodology is $105, while the actual average of all 14 plans available is $166, representing an increase of 37%.

Then there's the fact that these are base rates, not including surcharges. On nearly every one of the non-HMO plans, it says 49% of people paid surcharges not included in those base rates. Also, more than a quarter of applicants are turned down. None of these caveats apply to ACA plans.

It gets worse if you look at places with even more plan choices pre-ACA, like my old zip code in Philly. 26 plans, with Avik's "methodology' using a hard-coded cutoff of the 5 cheapest plans which don't cover anything and have ridiculously high out-of-pocket costs and annual caps.

It's like these assholes aren't even trying.
posted by tonycpsu at 9:02 AM on November 7, 2013 [1 favorite]


What, you mean an article in a magazine hostile to Obamacare written by a conservative hostile to Obamacare citing statistics from a libertarian thinktank hostile to Obamacare is fudging the numbers on Obamacare? I'm gobsmacked!
posted by zombieflanders at 9:03 AM on November 7, 2013


I certainly can't vouch for Roy's methodology, having not looked into the statistics myself.

But isn't he arguing that even when you account for the more expensive insurance (3x more expensive, in Roy's estimation) purchased by those denied coverage, as well as the surcharge (75%), individual insurance post ACA is *still* much more expensive? It seems to me that Roy is himself taking the artificially low pre-ACA "base rate" and increasing it to account for denials and surcharges, before doing the post-ACA comparision.
posted by BobbyVan at 9:23 AM on November 7, 2013


He pulled the weights out of his ass, so any numbers derived from those weights can only be as good as or worse than his wild-ass guess.

Why would we believe that higher-risk applicants would be able to simply pay three times those very low rates to get anything approaching adequate coverage in the pre-ACA marketplace? There are a lot of patients that insurers won't go near no matter what they're able to pay, because it's simply not worth their time to create and market these plans. I know the number three sounds good, but what's the justification for it? Same goes for the 75% for surcharges.
posted by tonycpsu at 9:37 AM on November 7, 2013


This probably isn't an apples-to-apples comparison, but it does provide some basis for the 3x figure.

According to this 2009 article in Modern Healthcare, "the average annual deductible of [state high-risk insurance pools, which provide coverage to uninsured individuals who cannot qualify for private insurance, usually because of a pre-existing medical condition] last year was nearly $1,600 -- about three times that of an average employer-sponsored plan."
posted by BobbyVan at 9:52 AM on November 7, 2013


It's definitely not apples-to-apples, because state high-risk pools are heavily subsidized in most states.
posted by tonycpsu at 9:57 AM on November 7, 2013


But isn't he arguing that even when you account for the more expensive insurance (3x more expensive, in Roy's estimation) purchased by those denied coverage, as well as the surcharge (75%), individual insurance post ACA is *still* much more expensive?

Yes, that is what he is arguing.

He is wrong because he's not comparing like for like, he's comparing catastrophic-only massive-deductible plans that provide very little coverage (ie had limits low enough that they would probably not actually cover a single catastrophic injury or illness) to bronze-level ACA plans that provide meaningful coverage.

He's also wrong because he's assuming that a 27 year old with pre-existing late-stage cancer, or who's nonambulatory after a stroke, or has some other horrifyingly expensive condition could buy individual coverage in NC for $240 a month. This is how pants-crappingly stupid this study is.

The only way in which the ACA has made health insurance more expensive is that it's no longer legal to offer scam plans that charge lots of money for almost no benefits.
posted by ROU_Xenophobe at 10:39 AM on November 7, 2013 [6 favorites]






BobbyVan: The Dark Homunculus

I better look into some warding spells. Does Obamacare cover those?
posted by homunculus at 7:45 PM on November 7, 2013


You can still use your existing arcane traditions if they cover preexisting curses and they ensure that 80% of your magickal energies go directly towards your spellcraft.
posted by jason_steakums at 8:09 PM on November 7, 2013 [3 favorites]


Jon Stewart Tears Apart Obama, Fox News ‘Motherf*ckers’ for Lying About Obamacare

Jon Stewart buying into the framing of the issue and not pointing out that it's the insurance companies choosing to discontinue the policies, the disingenuous little shit.
posted by Pope Guilty at 8:50 PM on November 7, 2013


I suspect this is just one of the many DDOS tools created for October 1st targeting the healthcare.gov site.

IF the GOP hired Russian Hackers to Denial-of-Service attack the Healthcare.Gov site, is that treasonous or would it be more accurate to call it seditious? And if those Russian Hackers are also working with Islamic Terrorist Groups, that means that YOUR DONATION TO THE GOP PROVIDES MATERIAL SUPPORT TO TERRORISTS.

If you donated to any GOP candidates at this point, you're on the NSA Watch List.
posted by mikelieman at 2:20 AM on November 8, 2013


IF the GOP hired Russian Hackers...

Busted.
posted by BobbyVan at 7:40 AM on November 8, 2013


Pretty damn comfortable 41-year-old Dylan Ratigan used to pay $170 a month for a catastrophic plan because as a pretty damn comfortable 41-year-old guy he's immortal, psychic, or has enough ready cash on hand to pay for all the costs of say, getting treated for cancer.

Apparently his new plan (magically cancelled by "Obamacare", not his insurance company) will cost him $600 a month. He is sad and angry.
posted by maudlin at 10:45 AM on November 8, 2013 [2 favorites]


Christ, what an asshole. Like everyone pulling this "LOOK AT ME, OBAMACARE STOLE MY BIKE!" routine, I bet he hasn't even glanced at the options available to him on the ACA exchanges. I'd also love to know what the annual / lifetime caps were on his bargain-bin catastrophic plan.
posted by tonycpsu at 11:01 AM on November 8, 2013


Polls: Obamacare's Troubled Rollout Has Not Changed Public Opinion
Consider Gallup's findings released last week. In a poll conducted Oct. 26-28 -- weeks after the troubled website HealthCare.gov went live on Oct. 1 -- 44 percent of Americans said they approved of the law while 47 percent said they disapproved.

Those numbers differ only slightly from Gallup's poll conducted Oct. 18-20, which found 45 percent approving of the law and 50 percent disapproving.

Both polls actually indicated a minor bump in support since August, when Gallup showed 41 percent approving of the law and 49 percent disapproving.

Gallup isn't the only pollster to show such consistency. A CNN poll that was conducted Oct. 18-20 showed a big majority -- 56 percent -- opposed to the health care law. But that's a negligible change from CNN's poll in September that showed 57 percent opposed. And support even ticked up slightly during that span, from 38 percent to 41 percent.

The Kaiser Family Foundation, which tracks public opinion on the law every month, showed 43 percent with an unfavorable opinion of Obamacare in mid-September, while 39 percent said they had a favorable opinion of the law. Kaiser's survey conducted Oct. 17-23 showed essentially the same: 44 percent opposed, 38 percent in support.

The Washington Post/ABC News poll that was conducted Oct. 17-20 found 46 percent in support of the law and 49 percent opposed. A September WaPo/ABC survey showed 42 percent supporting Obamacare and 52 percent opposing.

A Reuters/Ipsos web survey conducted during the month of October actually found support for the Affordable Care Act inching up from 44 percent in September to 47 percent with opposition dipping from 56 percent to 53 percent. Among uninsured respondents, Reuters/Ipsos showed support rising from 37 percent to 44 percent, with opposition dropping from 63 percent to 56 percent.

The stability of the numbers suggests that the embarrassing rollout has done little to exacerbate the law's popularity. Opposition to the Affordable Care Act remains fairly widespread -- just as it has been since President Barack Obama signed it into law in 2010.
posted by zombieflanders at 11:10 AM on November 8, 2013 [1 favorite]


Interesting, zombieflanders. Public disapproval seems to be directed more at President Obama personally.

Pew Research:
Obama also gets negative ratings on health care policy (37% approve, 59% disapprove). In January, views of Obama’s handling of health care policy were mixed (45% approved, 47% disapproved).
posted by BobbyVan at 12:40 PM on November 8, 2013


Obama also gets negative ratings on health care policy (37% approve, 59% disapprove).

I'm sure this disapproval is a combination of people who think the law goes too far, and people who are pissed we don't have single payer yet.
posted by showbiz_liz at 12:47 PM on November 8, 2013


It hardly matters. The ratings will come up again as people get familiar with it, get their insurance, and the system gets better.
posted by Miko at 1:20 PM on November 8, 2013


Interesting, zombieflanders. Public disapproval seems to be directed more at President Obama personally.

Well, most people who get their news from right-wing sources aren't likely to do much fact-checking, so it's no surprise they'd also be wrong about basic civics.
posted by EmpressCallipygos at 3:29 PM on November 8, 2013 [1 favorite]


I'm becoming more convinced that they made a serious error by wimping out on the penalties for not signing up.
posted by Justinian at 3:29 PM on November 8, 2013


New York Times: Daring to Complain About Obamacare
Along with the smug insureds, President Obama doesn’t care much about the relatively small percentage of us with canceled coverage and no viable replacement. He keeps apologizing while maintaining that it’s for the good of the country, a vast improvement “over all.”

And the “over all” might agree. But the self-employed middle class is being sacrificed at the altar of politically correct rhetoric, with nobody helping to ensure our health, fiscal or otherwise, because it’s trendy to cheer for the underdog. Embracing the noble cause is all very well — as long as yours isn’t the “fortunate” family that loses its access to comprehensive, affordable health care while the rest of the nation gets it.

The truly noble act here is being performed by my friend Nicole, who keeps posting Obamacare fiasco stories on my Facebook page, despite being conspicuously ignored, except for my single “like.” It’s the lone “like” that falls in the forest, the click nobody wants to hear.
posted by BobbyVan at 7:58 AM on November 11, 2013 [1 favorite]


Man, that NYT article is a nasty piece of work, and I say that as someone who has a bunch of pretty big complaints about the implementation of the ACA (including the fact that my husband and I still can't sign up for coverage, and will have to during a narrow two week window in December which they assure us will go off without a hitch but I'm not so sure.)
posted by PhoBWanKenobi at 8:22 AM on November 11, 2013


I wonder if she wrote a whiny op-ed in 2010, when Anthem jacked rates on individual policy holders in California by as much as 40%, after raising them almost 70% the year before.

Also, apparently yet another person who doesn't understand that insurance is risk-pooling and that is a reason why yes, you are going to pay for benefits you will never use.
posted by rtha at 8:26 AM on November 11, 2013 [6 favorites]


rtha, don't bother. Logic doesn't work on Dittoheads.
posted by EmpressCallipygos at 8:29 AM on November 11, 2013


At least that op-ed supports my hypothesis that people who unironically use the terms "politically correct" or "politically incorrect" stopped thinking a long time ago.
posted by maudlin at 8:54 AM on November 11, 2013 [1 favorite]


The truly noble act here is being performed by my friend Nicole, who keeps posting Obamacare fiasco stories on my Facebook page, despite being conspicuously ignored, except for my single “like.” It’s the lone “like” that falls in the forest, the click nobody wants to hear.

LIKE IF U WANT 2 SPEAK TRUTH 2 POWER
posted by jason_steakums at 8:55 AM on November 11, 2013


Why Isn't Everyone More Worried about Me?
Written by Lori Gottlieb, a Los Angeles psychotherapist and author, it relates how she got a cancellation letter from Anthem Blue Cross and was offered a plan for $5,400 more a year, then had a frustrating phone call with the company. Did she go to the California health exchange and find out what sorts of deals would be available to her? Apparently not. She took Anthem at their word—you can always trust insurance companies, after all!—then took to Facebook, where she "vented about the call and wrote that the president should be protecting the middle class, not making our lives substantially harder."

And here's where our story takes a shocking turn. Instead of expressing what she felt was the appropriate sympathy, those 1,037 people on Facebook she thought were her friends but turned out just to be "friends" had the nerve to point out that the Affordable Care Act will help millions of previously uninsured and uninsurable people get coverage. Gottlieb was disgusted with these people she termed the "smug insureds." And none of them even "liked" her post!
[...]
How terribly smug, to think that the fate of millions of poor people who will now get insurance is as important as the suffering of this one person who might have to pay more for comprehensive coverage, and also happens to have access to The New York Times where she can air her grievances! If only it weren't so "trendy to cheer for the underdog."

It's one thing to feel your own problems more acutely than those of other people, even millions of other people, even many whose problems make yours look trivial by comparison. We all do that, and we could barely function if we didn't. It's quite another thing to expect that other people will see your problems as more important than those of millions. I sprained my ankle a few weeks ago, and I'll admit that in the time since I've given more thought to my ankle's recovery than I have to the 660,000 people who die every year from malaria. But if I asked you why you aren't thinking more about my ankle than you are about malaria, you'd wonder if it was my brain that I had sprained.
posted by zombieflanders at 9:05 AM on November 11, 2013 [3 favorites]


‘Let Todd Work’
House Oversight Committee Chairman Darrell Issa (R-Calif.) is eager to hold a hearing on the Affordable Care Act’s website, getting answers directly from Todd Park, the White House’s chief technology officer. No problem, Park said last week, agreeing to testify the first week in December – after he’s done with the next round of tech fixes.

For reasons no one has been able to explain, Issa has said that’s not good enough. Late Friday, the far-right committee chairman subpoenaed Park, insisting that he stop working on fixing the website and start talking to lawmakers about why the website isn’t working. If that seems nonsensical on its face, welcome to the world of House Republican policymaking.

Indeed, this is the first time in quite a while that I can think of a committee reaching out to a potential witness, the witness agreeing to testify, and then having the committee subpoena him anyway, just for the sake of doing so.

An interesting group has rallied to Park’s defense.
A group of technology experts has a message for Rep. Darrell Issa, the Republican Oversight Committee chairman who last week disregarded the White House’s insistence that U.S. technology chief Todd Park is too busy to testify about his efforts to repair HealthCare.gov.

“Let Todd Work,” the group proclaims on a website launched after Issa issued a subpoena for Park to appear before his panel on Wednesday.
The site has a long way to go before it could fairly be characterized as viral, but it’s a compelling pitch from a credible group of industry tech experts. LetToddWork.org argues that “instead of continuing to fix Healthcare.gov (a mess he did not make), Mr. Park has to spend his hours preparing for his testimony…. No matter what side of the aisle you sit on, Todd is one of the good guys. Let him do his job.”
posted by zombieflanders at 9:17 AM on November 11, 2013 [2 favorites]


zombieflanders: " How terribly smug, to think that the fate of millions of poor people who will now get insurance is as important as the suffering of this one person who might have to pay more for comprehensive coverage, and also happens to have access to The New York Times where she can air her grievances! If only it weren't so "trendy to cheer for the underdog.""

And who, importantly, doesn't seem to have actually shopped the exchange for a better deal. It literally never occurs to these people that the whole reason their prices are going up is because they were being sold a pile of shit by the very same companies that will happily sell them better plans, probably at a lower price through the exchange because they're suddenly required to actually deliver something of value.
posted by tonycpsu at 9:51 AM on November 11, 2013 [3 favorites]


Heh, indeed!
As a bonus, I enjoyed the bit where she rails against the “smug insureds” on Facebook who ask why she doesn’t “marry the guy I’m dating. How romantic: ‘I didn’t marry you just to save money, honey. I married you for your provider network.’” Yes, clearly her Facebook friends were expressing their sincere views and not making fun of dumb arguments Gottleib has written whole books defending or anything.
posted by tonycpsu at 10:02 AM on November 11, 2013


Salon: Worrying signs for Obamacare: Plan B needed for Healthcare.gov
A working website would limit the political consequences the canceled plans are causing, but it’s in many ways a distinct problem. Republicans would be using the cancellations as impetus to undermine the law even if Healthcare.gov were functioning as well as Amazon. The administration is looking for an administrative remedy for cancellation letter recipients, but there’s no obvious solution that wouldn’t require congressional action, and Republicans would block congressional action — such as extending subsidies — that actually addresses the problem without undermining the law. In other words, Obama is facing a political nightmare, and we’re not even at the point of contemplating the damage Republicans will inflict if the site isn’t working by the end of the month.

Democrats in Congress will then face increasing pressure to agree to a GOP plan to delay the individual mandate penalty for a year — an approach intended to use Healthcare.gov’s collapse to pull the rug out from underneath well-functioning markets in states with their own exchanges.

The administration may have the authority it needs to circumvent Congress here — extend the open enrollment period and provide hardship exemptions from the penalty to people in states without functioning marketplaces. But it would have to be prepared to admit failure first.

Now obviously Obama shouldn’t contemplate doing any of this if the site really will be working by the end of the month. But if and when it becomes clear to administration officials that it won’t be ready, they’ll need to announce the failure and the workaround more or less simultaneously. The absence of a plan B would create a vacuum for congressional saboteurs, and Democrats would probably get sucked into it. Opposing all proposed solutions won’t be sustainable. And at that point Obama would have to entertain the prospect of allowing Republicans to inflict lasting damage upon his signature achievement.
posted by BobbyVan at 10:33 AM on November 11, 2013


As we have long expected, the steepest hikes will be imposed on the healthy, the young, and the male. And Obamacare’s taxpayer-funded subsidies will primarily benefit those nearing retirement—people who, unlike the young, have had their whole lives to save for their health-care needs.

Remind me again why the loudest objectors to this plan are the old people with failing health? And don't tell me it is because they are just looking out for the young because I will laugh in your face and possibly spit in your eye.
posted by entropicamericana at 10:41 AM on November 11, 2013


Because old people want you to keep your damn dirty government hands off their Medicare!

Miko asked this a while back but since I found out the definitive answer yesterday: I don't understand. Are you saying that no one in the state can buy coverage that includes those hospitals in the network?

Specifically with regards to Cedars-Sinai, the hospital roughly three blocks from where I live, there is one California individual plan which includes Cedars in-network. It is a "catastrophic only" plan with massive deductibles and thus not worth the paper it is printed on to the vast majority of people. So practically speaking, no, you can't buy coverage which includes this hospital on the individual market. Many other nearby hospitals are similar though it is hard to say for sure because last time I checked the website was still unable to tell you which plans include which hospitals in-network.

The website stuff is very amateur hour.
posted by Justinian at 12:12 PM on November 11, 2013


Troubled Obamacare website enrolled fewer than 50,000 in Oct -WSJ
(Reuters) - Fewer than 50,000 Americans were able to sign up for new Obamacare health insurance plans through the error-plagued HealthCare.gov website serving 36 states, falling far short of the federal government's target, the Wall Street Journal reported on Monday.

Citing two people familiar with the matter, the Journal reported that the number represented sign-ups since the October 1 launch of new insurance marketplaces under President Barack Obama's healthcare reform.

"We cannot confirm these numbers," said Erin Shields Britt, a spokeswoman for the U.S. Department of Health and Human Services, in a statement. "More generally, we have always anticipated that initial enrollment numbers would be low and increase over time."

If accurate, the numbers fall far short of government expectations for nearly 500,000 sign-ups for HealthCare.gov in October.

The Obama administration is due to release national enrollment numbers sometime this week.
posted by BobbyVan at 2:02 PM on November 11, 2013


Sarah Kliff: States have hit 3 percent of Obamacare sign-up goals. That’s actually not a disaster!
Is 3 percent a good total for the first month of open enrollment? That's a bit hard to know, given that this is the country's national take at expanding private health coverage to millions of Americans. On the one hand, if the expectation was for enrollment to continue apace, this would be horrible news.

That is, luckily for the administration, not the expectation. Most health policy experts predict that enrollment will move faster in November and December, as we get closer to the Dec.15 enrollment deadline for January coverage. Massachusetts, as the White House points out pretty much any chance it gets, only had 0.3 percent of its first year-enrollment in the first month. This is not to say that the Avalere data predicts 70 million enrollees in year one -- we don't have enough uninsured people to make that happen -- but that 3 percent enrollment in month one is probably not doom.
posted by zombieflanders at 2:12 PM on November 11, 2013


Just for bobbyvan:

Paula poundstone on the ACA web site issues.
Most of us agreed that we loved the idea of people with pre-existing health problems being able to receive coverage. It is simply not possible that technical challenges with the website could cause voters to turn off on that idea.

Anybody who has ever used a computer knows, that privilege goes hand-in-hand with frustration. Why would we give up on the affordable health care law because of that?

If we were ordering something from Amazon, we'd keep trying for months. Heck, if we were having cable installed, we'd take the day off work to wait for the cable man. We're no strangers to struggling with websites. Why would that make us give up on a law that makes some insurance policies provide preventative medicine with no co-payments?
posted by EmpressCallipygos at 5:14 PM on November 11, 2013 [2 favorites]




I see you favorited my comment, bobbyvan. I'm glad you agree with Paula Poundstone, in that the problems with the web site are actually not a good reason to abandon ACA or consider it a failure.

If that's your position, then I have to wonder why you are posting so many of these doomsaying articles. Next time, could you possibly provide some of your own commentary so as to elucidate your own thought process? Because if you liked what I posted then I'm having a hard time squaring it with the things you've been posting.
posted by EmpressCallipygos at 4:40 AM on November 12, 2013 [1 favorite]


So practically speaking, no, you can't buy coverage which includes this hospital on the individual market.

So, I find this really interesting. I suppose it means that the hospital is only doing the minimum possible to check the required legal boxes of the ACA and contenting itself with the employer-provided market and white-glove plans. I think that's a shame, but at the same time, did you have access to non-emergency doctors and programs within this hospital before? It seems to me that if employer plans run through brokers have always been their market, perhaps they've just always been their market. Does this represent a true change in access, or does it just make it more clear why you can't use it?
posted by Miko at 6:04 AM on November 12, 2013


Bill Clinton: Health Care Law Should Be Changed To Allow People To Keep Their Plans
Former President Bill Clinton said Tuesday that the health care law should be changed if necessary to allow people to keep their health care plans that have been cancelled as a result of the implementation of Obamacare.

"I personally believe, even if it takes changing the law, the president should honor the commitment the federal government made to those people and let them keep what they got," Clinton told OZY TV. Clinton preceded his comments by saying that the country is better off with the Affordable Care Act. The former president also recounted a story where a man he met had his individual plan canceled because of Obamacare, and his insurer offered a plan with twice the premiums, but his copays and deductibles were much lower.
posted by BobbyVan at 8:01 AM on November 12, 2013 [1 favorite]


I suppose it means that the hospital is only doing the minimum possible to check the required legal boxes of the ACA and contenting itself with the employer-provided market and white-glove plans.

At least here in Seattle, that's not always by the hospital's choice. Seattle Children's Hospital is suing to try and get in-network on more plans than they're currently on.
posted by KathrynT at 8:24 AM on November 12, 2013


"I personally believe, even if it takes changing the law, the president should honor the commitment the federal government made to those people and let them keep what they got," Clinton told OZY TV.

Does he even have the power to make the companies do this? Wouldn't it mean allowing plans that exclude people for pre-existing conditions to continue?
posted by Miko at 8:40 AM on November 12, 2013 [1 favorite]


Insurers say they are trying to balance the need to offer adequate networks of providers with market demand for affordable health insurance.

Can someone parse this for me? Is this insurers' effort to "balance" an effort to preserve profit?
posted by Miko at 8:42 AM on November 12, 2013


Bill Clinton Wants You to Keep Your Plan, Won’t Say How
How could you change the law to do this? It would be really, really hard. The main rationale for Obamacare is that the individual-health-care market is dysfunctional. Most people who can’t get group insurance — either through their job or through a government-financed plan, like Medicare — can’t get any insurance at all. Insurers have to make sure they don’t attract sick customers, so they either attach hidden conditions to their insurance to protect against covering expensive care, or else limit their policies to very healthy people. That’s why people with individual insurance are much less satisfied than people with group-based insurance.

It is true that some of those very healthy people can get cheap insurance, as long as they remain healthy. But insurance requires spreading risk from the healthy to the sick. That’s how employer insurance works, and people like that kind of insurance much more. The math is also inescapable. If insurance companies have to charge sick people less than it costs to cover their medical expenses, then the money needs to come from somewhere. Obamacare furnishes some of that money through tax credits, some of it through Medicaid expansions, but a portion comes from higher premiums to people who are healthy.

If you want to make sure every healthy person paying low rates in the individual market right now can keep their plan, then you have two choices. One is to abolish Obamacare altogether, which means making it impossible for people with preexisting conditions to get affordable insurance. Clinton doesn’t want to do that — he continues to endorse the law. The second is to come up with some other source of funding to compensate insurance companies for their losses. Clinton doesn’t say where that money would come from.
posted by zombieflanders at 9:04 AM on November 12, 2013 [1 favorite]


Washington Post (Greg Sargent): Dems to White House: Fix Obamacare, and fast
This Friday, House Republicans are expected to vote on a proposal — championed by GOP Rep. Fred Upton — that would allow insurance companies the option of continuing all existing health plans for a year, in response to the loss of plans that has taken place despite Obama’s vow otherwise. The White House points out that this will undermine the law.

Dem leadership aides have predicted that some House Dems will vote for the plan. And CNN’s Dana Bash stirred up chatter today when she Tweeted that “lots” of House Dems will vote for it if the White House has not put forth its own fix by the end of the week — in effect giving the White House a deadline. Obviously, “a lot” of Dems voting for this proposal would constitute another major Obamacare headache.

House Democratic leaders are privately warning rank and file Dems that a vote for this bill – and other anti-Obamacare legislation – could alienate leading Democratic donors heading into 2014, a source familiar with internal discussions tells me. “Votes against the Affordable Care Act are going to turn off a lot of these top national progressive donors,” the source said in characterizing the arguments.

...

The big picture remains the same: All that will really matter is whether the policy works over the long haul. But jittery Democrats are not in a big picture mood right now, and the new Quinnipiac poll finding Obama at his lowest approval rating ever is not going to make them any more inclined to take the long view. So they are telling the White House in no uncertain terms that a fix is a must, and fast.
posted by BobbyVan at 1:29 PM on November 12, 2013


Does he even have the power to make the companies do this? Wouldn't it mean allowing plans that exclude people for pre-existing conditions to continue?

Yeah. It doesn't make sense. The companies are the ones canceling the policies, rather than bringing them into compliance. I don't see how this can be forced without giving the Feds more explicit authority over insurance companies.

Not sure what Clinton's up to here. I feel like Clinton's always been a little too eager to appease conservatives, even though there's never really any upside to it. I wonder if this isn't really just more of the same bad policy judgment that went into Clinton's welfare reform on display.
posted by saulgoodman at 2:02 PM on November 12, 2013


Can someone parse this for me? Is this insurers' effort to "balance" an effort to preserve profit?

That depends on your point of view. Some hospitals and providers are more expensive than others. If you include the more expensive hospitals in your network your premiums have to be higher than if you don't; that's just math. So I'm not sure how to address the question. The insurers would argue that it's an attempt to keep premiums lower which helps consumers. But, sure, you could say that they should offer more expensive hospitals in-network and simply eat the extra cost. But you could make that argument about anything. You could say that insurers should offer full coverage with no copay and no out of pocket expenses to every provider in the state and any attempt not to do so is an effort to "preserve profit". But is that really fair?

So the answer isn't yes or no. It depends on many data points, not all of which we necessarily have access to.
posted by Justinian at 2:20 PM on November 12, 2013


I see you favorited my comment, bobbyvan. I'm glad you agree with Paula Poundstone

All else aside, favoriting a comment is not and has never been an indication of agreement with the comment's content, and certainly not a particular political position. It doesn't matter who is doing it.
posted by Kadin2048 at 2:26 PM on November 12, 2013 [2 favorites]


Miko: I think that's a shame, but at the same time, did you have access to non-emergency doctors and programs within this hospital before? It seems to me that if employer plans run through brokers have always been their market, perhaps they've just always been their market. Does this represent a true change in access, or does it just make it more clear why you can't use it?

My current plan which is being cancelled does include coverage at Cedars-Sinai. So it absolutely represents a change in access. Restricting the provider network so more expensive doctors aren't covered is exactly how they provide the new plans at a reasonable price! You don't get something for nothing. To be clear, it's not just Cedars. It's almost any hospital or facility which is somewhat more expensive than average. They were covered under my old plan and not covered under the new plan. Cedars just happens to be a couple blocks away. I hope I don't ever need an ambulance or anything, it'll be tough to convince them to drive me somewhere a couple miles away in LA traffic rather than the 3 blocks to Cedars.
posted by Justinian at 2:28 PM on November 12, 2013 [1 favorite]


This new Quinnipiac Poll is bad for President Obama on pretty much every level. But the numbers on the Affordable Care Act are particularly bad:
Only 19 percent of American voters say the quality of care they and their families receive will improve in the next year because of the Affordable Care Act (ACA), while 43 percent say it will get worse and 33 percent say ACA won't affect their health care.

Voters oppose the ACA 55 - 39 percent, with men opposed 59 - 37 percent and women opposed 51 - 41 percent.

American voters are divided 46 - 47 percent on whether Obama "knowingly deceived" the public when he said people could keep their existing health insurance plans if they wished.

Voters also support 73 - 20 percent extending the March 31, 2014 deadline for signing up for coverage without facing a penalty.
posted by BobbyVan at 2:29 PM on November 12, 2013


Profiting off of providing vital medical services should be illegal anyway. It's knowledge-based extortion, functionally and ethically the same as refusing to offer life-saving assistance to someone in immediate danger.
posted by saulgoodman at 2:33 PM on November 12, 2013


quoting myself because that's how I roll: It's almost any hospital or facility which is somewhat more expensive than average. They were covered under my old plan and not covered under the new plan.

I have realized I am assuming everyone sees the catch here when it isn't obvious and I should have laid it out. The cost of medical treatment, doctors, and facilities is correlated with the cost of living of the area in which those facilities are located. Since the area in which I live has a relatively very high cost of living, all of the local facilities are expensive.

So you see the problem? None of the plans I can get will cover almost any of the local facilities because they are expensive. They are expensive because I live in an expensive area. So I won't be able to seek treatment in my neighborhood, I'll have to drive somewhere. Not a huge distance in the grand scheme of things but, really, I should be able to obtain insurance which covers my local hospitals and doctors. Like I have now.
posted by Justinian at 2:38 PM on November 12, 2013 [1 favorite]


Talking Points Memo: Feinstein Signs On To Landrieu Bill That Addresses Insurance Cancellations
Sen. Dianne Feinstein (D-CA) announced Tuesday that she would co-sponsor Sen. Mary Landrieu's (D-LA) bill that allows people with existing individual plans to keep their insurance indefinitely.

"This bill provides a simple fix to a complex problem," Feinstein said in a statement. "This bill will extend the grandfather date for individual insurance plans so that individuals who have insurance policies they like can keep them indefinitely, unless the individual chooses another plan or the insurer stops providing health insurance in the individual market."

Thousands of people with insurance plans in the individual market have recieved cancellation notices because their plans are no longer compliant under the new health care law's minimum benefit requirements.
More on the Landrieu bill (also from Talking Points Memo):
Landrieu -- who faces a potentially tough re-election battle next year -- announced legislation Thursday to let people on the individual market keep their current insurance policy for as long as they continue paying their premiums. This would apply to plans that fail to provide "essential health benefits" or meet the law's standard for "grandfathered" policies that can continue, and would thus be canceled or replaced.

Part of the problem is that this would unwind Obamacare's guarantees of quality coverage and affordable prices, which were the basis of two important -- and popular -- market reforms under Obamacare: community rating (insurers cannot charge sick people more) and guaranteed issue (insurers cannot deny coverage to anyone).

"If what she's saying is you can keep your health plan forever if you like it, that basically repeals the market reforms," Jost said. "You're continuing to allow people to buy a defective product. You're segmenting the risk pool again with respect for coverage. Does that mean you can say you'll cover physical health without mental health? Does that mean you don't have to cover maternity coverage? ... The whole idea here is we're trying to create a community -- a system based on mutual aid rather than everybody paying for exactly the care that they are likely to need in the next few moments."

Landrieu's plan could also disrupt the premiums set by insurers because a chunk of their expected customers would no longer be enrolling in the marketplaces. "Mechanically that's very difficult," Jost said. "It basically denies people the community-rating advantages that were the whole reason -- or one of the reasons -- for the law in the first place. ... So you're just moving the problem down the road a bit, but in the meantime it really messes over the insurance companies because they've written their premiums based on knowing who their pool would be, and that's based on knowing what sorts of people would sign up early on."

Brad Dayspring, a spokesman for the Senate GOP's electoral arm, boasted to TPM that "Landrieu is championing legislation to destroy Obamacare."
posted by BobbyVan at 2:47 PM on November 12, 2013


Yeah, that plan is DOA. There is no fix for this "problem" except to ride out the political complications.
posted by Justinian at 2:50 PM on November 12, 2013


Roll Call: Hoyer ‘Not Closed’ to Voting for Upton Obamacare Bill
Just minutes before the White House slammed a House GOP bill aimed at President Barack Obama’s “if you like it, you can keep it” promise regarding health care plans, the No. 2 House Democrat said he was open to supporting the proposed change to the Affordable Care Act.

House Minority Whip Steny H. Hoyer’s willingness to consider voting for the bill, scheduled for floor consideration on Friday, underscores the difficulty many Democrats face in wanting to deal with the dust-up over health insurance policy cancellations while still supporting the president.

“I don’t know what I’m gonna do on the Upton bill,” the Maryland Democrat said at a Tuesday briefing with reporters when discussing legislation sponsored by Energy and Commerce Chairman Fred Upton, R-Mich.

Hoyer noted that he was “inclined not to be for the Upton bill at this time,” but he emphasized that he was “not closed to the option,” and would “reserve judgment” until he had seen the legislative text, which is reportedly undergoing some tweaks.

“I agree that people who purchased their policies prior to [the law's enactment date] ought to be able to keep their policies,” he said.

Upton’s bill would allow individuals to keep their health insurance plans regardless of whether they comport with the new standards of the 2010 health care law. Though Obama assured the American people that no one would have to give up their preferred policies, many people are finding that their policies are being canceled as the law goes into effect because the plans they currently have don’t line up with requirements under the new law.
posted by BobbyVan at 3:04 PM on November 12, 2013


There is nothing wrong with profiting off knowledge, medical or otherwise. And there is no such thing as knowledge-based extortion because knowledge is always relatively easily acquired and hard to monopolize. It's wrong to dominate markets by artificially limiting access like the insurance companies and AMA do though.
posted by jeffburdges at 3:11 PM on November 12, 2013


really, I should be able to obtain insurance which covers my local hospitals and doctors.

Well, it sure would be nice, but I'm not sure it should be a given. My dad's VA insurance only works at VA hospitals, for instance, so he goes an hour to have appointments. And if you don't have insurance and need to schedule surgery, you do it at a public hospital, even if it's not nearby. If you have to use an ambulance, then I would expect just like in the past you call your provider on the way, or as soon as you can, and get pre-approval and they take you to the closest place anyway, and then they transfer you to in-network care once you're stable.

I mean, I understand why you would want to use your local hospital, but as long as we are married to this system designed to preserve business for insurance companies, there's no reason to expect they will want to develop something to market to you. I don't mean to sound unsympathetic, but it looks like that's the breaks. I'm sorry you don't get to keep your doctors.
posted by Miko at 4:05 PM on November 12, 2013


(No reason other than what Obama said, of course. It wasn't an accurate representation and what rankles is that his staff must have known this).
posted by Miko at 4:13 PM on November 12, 2013


Perhaps I misspoke when I said "I should be able to obtain insurance which covers...". What I meant was "I should be able to obtain care at my local hospitals and doctors". If it takes overthrowing the insurance paradigm in favor of single payer then that's what we should do.
posted by Justinian at 4:16 PM on November 12, 2013


Actually mandatory private insurance works in countries who actually regulate their insurers, and who have a stronger tradition of financial institutions behaving themselves, like Germany. We're too corrupt in the English speaking world probably.
posted by jeffburdges at 4:25 PM on November 12, 2013


"I should be able to obtain care at my local hospitals and doctors".

As I noted, that's an ideal - an optimal condition and one not a lot of people have as things stand - which I think is easy to overlook.

I do think we'd have to have single payer to eliminate that problem - even then, though, I'd still fully expect hospitals t specialize. You might not go to the same place for cancer treatment as you would for eye surgery as you would for delivering babies, etc.
posted by Miko at 4:40 PM on November 12, 2013


In some states, it's a criminal offense not to help someone whose life is in immediate danger if you have the ability to help. How is a business model built on denying access to lifesaving help when it isn't personally profitable ethical in light of these more basic ethical and legal standards. Now granted, not every medical procedure is immediately a matter of life or death, but viewed more long term, many if not most are. Our ethics are inconsistent if it's okay to withhold vital medical assistance for profit.
posted by saulgoodman at 4:49 PM on November 12, 2013


And I mean for profit, not for revenue, but for actual profit in the technical sense.
posted by saulgoodman at 4:50 PM on November 12, 2013


That's not really at issue. As you note, turning people away from emergent care is usually not permissible. It's after the emergent care that they can (and do) move you to a different facility. I think Justinian isn't talking about "using" this hospital for emergent care, but for its other services - hospitalists, planned surgeries, etc. If you're having an emergency, you generally go to the nearest place, even now, and even if you have no insurance at all.
posted by Miko at 6:00 PM on November 12, 2013


Just checked: emergency care represents less than 2 percent of all health care costs, but
About half of all emergency services go uncompensated, according to Centers for Medicare & Medicaid Services (CMS).The typical ER treats 1 in 5 patients without insurance or a clear method for reimbursement. The CDC reported that 19 percent of all emergency patients in 2009 were uninsured.
and just 13.3% of emergency visits result in admission.

So even with the low rate of return on emergency care, it has been treating well over a third of Americans every year, but still represents a small portion of hospital and healthcare business in general. Given those stats, emergent care visits are definitely not the make-or-break for hospitals in deciding whether to contract with providers.
posted by Miko at 6:04 PM on November 12, 2013 [1 favorite]


I'd naively hope the law distinguished between individuals and organizations there, saulgoodman. Individuals should be under some ethical and legal obligations to render aid, mostly just notifying authorities. An individual should not imho be obligated to perform medical procedures like say CPR merely because they know it, well CPR comes with liabilities in particular. An organization otoh is a legal entity set up to perform particular tasks so regulations could reasonably require that the organization perform said tasks anyways. In principle, I've no problem with a cardiologist refusing to work on non-paying customers, well individuals are allowed to be assholes, but that might prevent a hospital from hiring him given their legal obligations.

Apparently all the laws actually distinguishes between on-duty personnel and off-duty or lay people, which approximates the organization vs. individual divide fairly well. Our asshole cardiologist is actually compelled to sign up for giving free care when he gets hired though, but not when he learned the skills of course. Actually, Vermont requires you “give reasonable assistance” in the event they witness another human being in “grave physical harm,” which includes CPR, but the penalty for failure to provide aid is only a $100 fine. Anyway, there is no obligation to perform CPR merely because you know it outside Vermont.
posted by jeffburdges at 6:08 PM on November 12, 2013


If it's unethical to actively threaten someone's life for profit, then it's unethical to passively threaten someone's life for profit (through threat of inaction). In other words, denying someone nonemergency care that would extend and improve the quality of their lives is just as unethical as denying them care for an immediately life threatening condition. Denying someone routine medication for a chronic illness is unethical, too, regardless of the timescales involved. The mere addition of time and distance doesn't change the fundamental ethical concerns.
posted by saulgoodman at 6:13 PM on November 12, 2013


I'm addressing the ethical principles involved, not necessarily the law, obviously, but the ethical case seems pretty straightforward. And as for it mattering whether it's an individual or an organization, why should it? When criminal organizations extort money, it's still extortion just as surely as when an individual does it.
posted by saulgoodman at 6:16 PM on November 12, 2013


denying someone nonemergency care that would extend and improve the quality of their lives is just as unethical

Well, who would you have cause of action against here? If you're non-emergent, the number of people who are "denying" you care is everybody.

You're not that far from saying that denying someone routine food for chronic need of food is unethical. You and I are both "denying" food from countless people in such a case. When you remove time and distance, you are a total ethical criminal just as much as bureaucrat at Kaiser Permanente is, because of all the lifesaving or life-enhancing things you could be doing at this minute, and aren't.

It might be an ethically appealing proposition, but it's not pragmatic and so doesn't make a good framework for moral decisionmaking.

I'm content to say that we want to have universal healthcare because it improves everyone's standard of living - it is a clear good, has good economic implications and enhances individual freedom. I don't think we need to find a way to justify it through strained moral reasoning. We don't need a villian to prosecute before we identify a potential good.
posted by Miko at 9:28 PM on November 12, 2013


It's unethical to compel a person to work, saulgoodman, that's called slavery.

An individual cannot ever take on an ethical obligation, and should not ever be given a legal obligation, by acquiring knowledge. It doesn't matter if they're the only person in the world that understands your life threatening illness.

An organization can be subject to compulsions because an organization exists for a specific purpose and it cannot compel its workers to work either. An individual is not some tool that exists for a specific purpose.

In truth, all knowledge is relatively cheaply acquired, so individuals cannot actually overcharge for intellectual work, unless an organization employs market or governmental power to artificially limit competition.

Also, an organization can become large enough to control market power, but no individual can become that powerful, especially not through merely possessing knowledge.

There are civic activities, like testifying, voting, and jury duty, that act as extremely limited exceptions to the "no compulsory work" principle, but (a) they cannot keep you too long, (b) they're ideally required to pay you, and (c) you can always protest by doing the job badly, like always voting for acquittal. All those "individuals must render aid" laws cannot keep you too long either and cannot require that you do the job properly.
posted by jeffburdges at 12:34 AM on November 13, 2013 [1 favorite]


My state (MN) outlaws all for profit health care. Every provider and insurer is a non-profit organization, with the public service requirements that come with that. Incidentally it works extremely well, with the best outcomes in the country on many measures.

Are you saying doctors are slaves here? Because you can be quite well paid without making a legal profit.
posted by miyabo at 5:56 AM on November 13, 2013 [2 favorites]


Washington Post (Greg Sargent): The Morning Plum: Dems struggle to maintain unity as Obamacare woes mount
Signs are everywhere this morning of the mounting pressure on the White House — much of it from Democrats — to produce some kind of administrative fix for those who are losing their health coverage due to Obamacare. The New York Times reports this morning that administration officials are continuing to refuse to detail the fixes they are considering, except to reiterate that they oppose the House GOP’s own ”fix” to the problem, which will be voted on this week.

That GOP proposal — the “Keep Your Health Plan Act,” which is championed by Rep. Fred Upton — would allow insurers to continue to offer coverage for all of 2014 outside the exchanges. Democrats and outside observers say the bill would undermine the law’s protections, sow public confusion and undermine the exchanges.

A senior Democratic aide tells me opposition to the Upton plan will be increasingly difficult to maintain among House Dems if the administration doesn’t offer a workable fix of its own. The aide adds the need to maintain House Dem opposition has been made more urgent by another problem: Senate Dems (the latest being Dianne Feinstein) supporting their own politically expedient “fixes” that could also undermine the law.

“Now that Feinstein has broken off, that makes it even more important that House Democrats stay together as much as possible — to keep Senate Ds from caving,” the senior Dem aide says. But the aide adds, in a reference to this week’s House action: ”We need an administrative fix that works before the vote.”
posted by BobbyVan at 6:52 AM on November 13, 2013


because of all the lifesaving or life-enhancing things you could be doing at this minute, and aren't.

No, because I don't have sufficient resources or opportunity to personally provide food and care to all the people in the world who might be starving or dying of treatable diseases. Big organizations and governments potentially do. But it's not even that they just don't provide for everyone they potentially could in our system--it's even worse than that. Instead, for profit-companies actively exploit their ability to provide needed food, medicine and other resources for the maximum profit possible (since as profit-seeking entities, that's their goal). That's extortion only on a larger scale than the more obvious forms if you believe that life is a fundamental right rather than a privilege.
posted by saulgoodman at 6:54 AM on November 13, 2013


That GOP proposal — the “Keep Your Health Plan Act,” which is championed by Rep. Fred Upton — would allow insurers to continue to offer coverage for all of 2014 outside the exchanges. Democrats and outside observers say the bill would undermine the law’s protections, sow public confusion and undermine the exchanges.

From the link in the article for that paragraph:

House Bill to Expand “Grandfathering” of Individual-Market Plans Would Raise Premiums in Insurance Marketplaces and Undermine Market Reforms
The Upton bill is intended to address the problem of “non-renewal” or “cancellation” notices that some insurers recently sent to existing enrollees in individual-insurance-market plans, as well as the difficulties that people are currently experiencing in enrolling through the new marketplaces. It is important to note, however, that in many cases, insurers that decided to discontinue certain plans for 2014 were not required to do so under the Affordable Care Act but made a business decision to take such action. In some cases, insurers chose not to renew grandfathered plans that they could have continued. In others, insurers could have continued people’s 2013 coverage until various points in 2014 (when a person would have to join a new, ACA-compliant plan) but instead ended the old coverage to coincide with the open enrollment period for ACA-compliant plans.

Also, while some states required insurers to discontinue pre-ACA individual-market plans at the end of 2013 and offer new plans in 2014 that complied with the new standards, in most states, insurers had the option of “early renewal” of their existing individual-market plans, which would have permitted the plans to continue covering enrollees until the end of 2014. Some insurers chose not to take advantage of this option, however, and sent enrollees non-renewal notices.

The Upton bill does not directly address the non-renewal issue. It gives insurers the option to extend some or all of their pre-ACA plans but does not require them to do so. People who received notices that their plans will not be available in 2014 would not necessarily get a different outcome if this legislation is enacted.

The ACA already permits people to remain enrolled in grandfathered individual-market plans, as long as they were enrolled in such plans when the ACA was enacted and the plans have not changed significantly since. The Upton bill would vastly expand the number of people enrolled in individual-market plans that do not comply with ACA requirements. It would push forward the date when a person’s plan is eligible for grandfathered status by nearly three years from 2010 to the beginning of 2013. This means that grandfathered status would be extended to plans made available after health reform was enacted, as well as to plans that have undergone major changes and no longer resemble the plans offered before health reform was enacted. Moreover, it would open all these plans to enrollment by new customers, not just people who were already enrolled in the individual market prior to health reform.

As a result, under the Upton bill, insurers offering existing individual-market plans outside of the insurance marketplaces in 2014 could continue to reject people with health problems and charge sicker and older people far higher premiums than younger and healthier people must pay. This would deter sick people from enrolling in plans outside of the marketplaces while enticing younger, healthier people to choose them instead of marketplace plans. In contrast, plans offered through the marketplaces would have to comply fully with ACA requirements — for example, they must take all applicants regardless of pre-existing medical conditions and cannot charge higher premiums based on people’s health status.
posted by zombieflanders at 7:00 AM on November 13, 2013 [1 favorite]


In other words, this is conservatives telling 95% of Americans "fuck you and your health." The laughing and gloating isn't mentioned, but is fairly obvious.
posted by zombieflanders at 7:01 AM on November 13, 2013


Sen. Mary Landrieu (D-Louisiana): BREAKING: @SenJeffMerkley [D-Oregon] joins growing coalition supporting my targeted bill to keep promise of #ACA & allow ppl to keep their insurance

See above for more information on the Landrieu bill.
posted by BobbyVan at 7:13 AM on November 13, 2013


We're attacking saulgoodman's twisted arguments, miyabo, because the arguments themselves completely devalue individual liberties. There is nothing wrong with forbidding for-profit insurers or hospitals like MN does because that's not compelling an individual.

I'm frankly appalled by saulgoodman's assertion that it should not matter if you compel an individual or an organization to provide care, obviously that makes all the difference. An organization is a a legal entity for a given purpose created with the government's assent, but the government has no substantial rights over an individual's time.

As an aside, If American doctors had guarded their private time more jealously, like by never accepting pagers, then today we'd simply have more doctors, maybe with slightly lower salaries and smaller medical school tuitions.

In fact, there are apparently for-profit health care providers in MN, just not for-profit hospitals. I've seemingly found a couple for-profit eye clinics, perhaps regular doctor's practices operate as for-profit entities too.
posted by jeffburdges at 7:28 AM on November 13, 2013


We're attacking saulgoodman's twisted arguments, miyabo, because the arguments themselves completely devalue individual liberties.

What's twisted about it? It's a long established principle in ethics that passively doing harm through inaction when you have the ability to help someone is ethically wrong. That's all I'm saying--well, that, and it's obviously even more despicable to extort money from someone in return for needed help you could provide. There's not even one twist required to make the argument.
posted by saulgoodman at 7:32 AM on November 13, 2013


Erick Erickson: It’s a Trap!
Senator Mary Landrieu has written legislation in the United States Senate that the Democrats love. It mandates insurance companies have to keep people on their present insurance. The GOP is supposedly against mandates and against government forcing private businesses and individuals into contracts they don’t want.

Here’s what is going to happen.

The House, with the help of a good number of Democrats, will pass the Upton plan and send it to the Senate. Harry Reid will substitute the Landrieu plan and send it back to the House. The House will be forced to either vote for the Landrieu plan or be characterized as siding with insurance companies against people.

In one fell swoop, the Democrats will have the GOP on record saving Mary Landrieu’s re-election in Louisiana by casting her as the one who saved Americans’ health care plans, and also getting on record as really being in favor of fixing Obamacare with the use of mandates.

The GOP is walking right into the trap.
TL;DR: BobbyVan quoting Greg Sargent, me quoting Erick Erickson, dogs and cats living together, mass hysteria.
posted by zombieflanders at 7:33 AM on November 13, 2013 [1 favorite]


Just to make it clear I'm not inventing the commonplace idea that the law has long recognized that failing to help a person in need when you have the ability can constitute a "crime of omission," here's a cite:
For example if a person passing by a pool saw a child drowning in it and there is no other sources present to rescue him from drowning and that person passes by that pool and leaving the child to die, he commits omission.
If you think I'm twisting the argument, explain where there's a twist. The only difference between a kid drowning in a pool and a man or women dying gradually of a treatable disorder is that one situation unfolds over a longer span of time.

What's twisted is to suggest that the underlying ethical problem is somehow a fundamentally different one just because one form of dying might take longer than another.
posted by saulgoodman at 7:44 AM on November 13, 2013


That's funny, zombieflanders. Grover Norquist's Americans for Tax Reform has also come out against the Landrieu plan.

I disagree with Erickson on the tactics here. Landrieu gets points for introducing a bill whether Republicans join her or not. And neither bill stands a chance: President Obama would veto them both!

I see this as yet another Plan B-type moment for the GOP. They can shoot the moon on the Upton plan, which fails in the Senate... or they can take a less-ideal Landrieu bill (assuming Reid lets it onto the floor), send it to the President and force him to veto it.

Even that scenario is unlikely, however, as the White House will probably come up with *something* to compensate the people who are losing their plans. I'd imagine Democrats would propose a new subsidy to make people who have lost plans whole, and it would be paid for by raising taxes on someone unpopular (high frequency traders, oil companies).

Outcome: Party line vote, status quo remains, website slowly gets fixed, IRS winks and nods and doesn't really go after people who don't get insurance by the deadline, and this all gets litigated again in 2014.
posted by BobbyVan at 7:47 AM on November 13, 2013 [2 favorites]


So I think the interesting thing here is that the doom predictions are, in fact, accurate - because the doom predictions were never about people who were already suffering. The doom predictions were never about people with pre existing conditions and no employer health plan. Those people were already, as many ACA supporters say, screwed. It could not get much worse for them, because they were already in a bad place.

Doom predictions were about exactly the people suffering now - middle class or upper middle class people with relatively good employer purchased (or occasionally individually purchased) health plans. And those plans, though it isn't always politically convenient to admit, were actually pretty good. They paid for very good doctors, for private beds in good hospitals, for waiting rooms that were pretty and quiet and not overcrowded, where doctors are paid well enough not to have to rush through patients, and can have a more holistic view of health. For birthing centers and inpatient care without someone impatiently tapping their watch.

The ACA, however, is not only not concerned for those people, it is building everyone else's care off of their backs. By overtaxing "cadillac care" that lets people get great care when they want it without worrying about co-pays or deductibles, they are making it more expensive for everyone - and thus, less likely to be offered. Under the ACA, this is a feature, not a bug. They don't want people consuming cushy health care, because they fear it drives up overall costs.

The ACA provides everyone mediocre health care. For those who used to receive subpar healthcare, this is a step up. But for those who had great healthcare, this is very clearly a step down.
posted by corb at 7:53 AM on November 13, 2013


Not for me, corb. I've still got the same old platinum work plan I always had, and I am square dead-center middle class according to every measure.
posted by saulgoodman at 7:55 AM on November 13, 2013


So I think the interesting thing here is that the doom predictions are, in fact, accurate - because the doom predictions were never about people who were already suffering.

If by "doom-saying" you mean "baseless, completely false scare-mongering," then sure. The only thing that would doom this is GOP and conservative sabotage (ongoing since 2010) with the help of any Democrat enablers. The policy of the law as it stands now is an overwhelming public good.

The ACA, however, is not only not concerned for those people, it is building everyone else's care off of their backs. By overtaxing "cadillac care" that lets people get great care when they want it without worrying about co-pays or deductibles, they are making it more expensive for everyone - and thus, less likely to be offered. Under the ACA, this is a feature, not a bug. They don't want people consuming cushy health care, because they fear it drives up overall costs.

Apart from some chatter back in 2010, this hasn't been an overriding concern of either supporters or opponents. Most plans--cushy or not--are basically staying the same as they are now, especially for the vast majority of people with employer- or government-provided health care, which comprise about 80% of Americans (see below).

The ACA provides everyone mediocre health care. For those who used to receive subpar healthcare, this is a step up. But for those who had great healthcare, this is very clearly a step down.

Nope, not even close to being right:
Gruber broke down the A.C.A. “winners” and “losers” for me. About eighty per cent of Americans are more or less left alone by the health-care act—largely people who have health insurance through their employers. About fourteen per cent of Americans are clear winners: they are currently uninsured and will have access to an affordable insurance policy under the A.C.A.

But much of the current controversy involves the six per cent of Americans who buy their own health care on the individual market, which the A.C.A. has dramatically reformed. Gruber argued that half of these people (three per cent of all Americans) will have little change to their polices. “They have to buy new plans, but they will be pretty similar to what they had before,” he said. “It will essentially be relabeling.”

The other half, however, also three per cent of the population, will have to buy a new product that complies with the A.C.A.’s more stringent requirements for individual plans. A significant portion of these roughly nine million Americans will be forced to buy a new insurance policy with higher premiums than they currently pay. The primary reason for the increased cost is that the A.C.A. bans any plan that would require a people who get sick to pay medical fees greater than six thousand dollars per year. In other words, this was a deliberate policy decision that the White House and Congress made to raise the quality—and thus the premiums—of insurance policies at the bottom end of the individual market.
posted by zombieflanders at 8:10 AM on November 13, 2013


corb: "Doom predictions were about exactly the people suffering now"

A handful of middle class (or, in many cases, upper class who wants to be described as middle class for the purposes of an op-ed) people getting a letters from their insurance company telling them should buy a more expensive plan, even though there are often comparable plans available on the exchanges for less? DOOM AND SUFFERING.

Millions of people not having an access to health insurance at all? Hey, whaddya gonna do?

corb: "And those plans, though it isn't always politically convenient to admit, were actually pretty good. They paid for very good doctors, for private beds in good hospitals, for waiting rooms that were pretty and quiet and not overcrowded, where doctors are paid well enough not to have to rush through patients, and can have a more holistic view of health. For birthing centers and inpatient care without someone impatiently tapping their watch."

This is pure, unadulterated bullshit. It's still legal to offer plans that have every single one of the features you talk about here. The ACA imposes no restrictions on network sizes, pay for doctors, or how "holistic" a view of health the providers take. Any decisions to offer or not offer these plans post-ACA are purely made for profit reasons, not due to any kind of regulatory burden imposed by the ACA.

But, hey, to anyone else who thinks doctors work for free if a single patient doesn't pay the full sticker price, I'm sure your logic makes perfect sense!
posted by tonycpsu at 8:11 AM on November 13, 2013 [4 favorites]


I've still got the same old platinum work plan I always had, and I am square dead-center middle class according to every measure.

Your company may have just made a decision to eat the additional 'cadillac' taxes itself without passing them on to you. Many won't. (Mine didn't, because they're a bag of assholes a well-run corporation devoted to maximizing shareholder returns.)

In the long run, absent a dramatic tightening in the labor market, there's no reason for companies not to pass additional costs through to employees. Not like employees are going to do anything about it.
posted by Kadin2048 at 8:16 AM on November 13, 2013 [1 favorite]


So then the status quo is better?
posted by zombieflanders at 8:23 AM on November 13, 2013


Sure, it's still legal to do all of those things, but they face a punitive tax burden designed to discourage them- just like no one is going to jail if they fail to buy health insurance, but they will face a tax penalty.

Zombieflanders - do you think that employers are likely to continue to eat the higher taxes themselves rather than passing them along or offering less generous coverage? I understand you view the ACA as a net good, but that doesn't mean it's not sucking for some, even as it helps others.

That is, by the by, one of the things some people view as "socialism" - not the governmental system itself, but the idea that it's okay to bring some people down, as long as others are being raised up, as long as more of the latter is happening than the former. There may not have been a lot of public criticism on these grounds, but it's what I've heard talked about a lot, at least.
posted by corb at 8:26 AM on November 13, 2013


Any "crime of omission" you've cited constitutes only immediate short term commitments, saulgoodman, actually only relatively unskilled ones, except for the Vermont CPR thing I cited.

It's tantamount to slavery to compel an individual to carry out extended or dangerous labors without reasonable compensation. An individual always has the right to say "fuck this I quit", although not necessarily during their shift, an emergency, etc.

It's perfectly fine to compel an existing organization to pay employees to do their existing jobs because that organization is a legal entity that exists as the state's assent.
posted by jeffburdges at 8:30 AM on November 13, 2013


do you think that employers are likely to continue to eat the higher taxes themselves rather than passing them along or offering less generous coverage? I understand you view the ACA as a net good, but that doesn't mean it's not sucking for some, even as it helps others

For the most part, yes. But the doom-saying was never about that. It was about government takeovers, death panels, crushing tax increases, and a whole manner of other things. What you're talking about is a new wrinkle on an old story, wildly overblown into doom-saying.

That is, by the by, one of the things some people view as "socialism" - not the governmental system itself, but the idea that it's okay to bring some people down, as long as others are being raised up, as long as more of the latter is happening than the former. There may not have been a lot of public criticism on these grounds, but it's what I've heard talked about a lot, at least.

Then those people have no idea what socialism is. This is market capitalism at work, after all. Remember, the only people bringing anyone down are the insurance companies. They're the ones who could change the rates on their Cadillac plans, they're the ones holding up the most inefficient health care system in the world, and they're the ones hiking premiums and cancelling plans regardless of whether the law requires them to. Of course, these same people worried about that definition of socialism and railing against Obamacare are making an extremely strong case for health care like that in Scandanavian countries, the UK, and much of the EU. They would be loath to admit it, obviously, but that's their problem.
posted by zombieflanders at 8:41 AM on November 13, 2013 [3 favorites]


o, because I don't have sufficient resources or opportunity to personally provide food and care to all the people in the world who might be starving or dying of treatable diseases.

What is your moral defense for having much more resources or opportunity than one individual other person? Why are you allowed to have those things and not, say, a person I identify for you from Meriden, CT?

You don't need to be able to save the world, in your construct. Just one other person. I suspect you have control of enough resources to save one starving person. Why aren't you?
posted by Miko at 8:42 AM on November 13, 2013


Is this to be an empathy test?
posted by BobbyVan at 8:57 AM on November 13, 2013 [1 favorite]


corb: "Sure, it's still legal to do all of those things, but they face a punitive tax burden designed to discourage them- just like no one is going to jail if they fail to buy health insurance, but they will face a tax penalty."

The Cadillac tax is not designed to, and will not, prevent doctors from being paid. Provider compensation is completely orthogonal to the specific services that are covered. Providers who specialize in the kinds of treatment covered only by Cadillac plans may look to shift their focus or lower their prices on those treatments, but overall, providers will be getting more insured patients which means more demand for their services, which means they will make their money. The "very good doctors" you speak of may have to start treating more than just the people who can afford the Cadillac plans, but that's a feature, not a bug.

corb: "That is, by the by, one of the things some people view as "socialism" - not the governmental system itself, but the idea that it's okay to bring some people down, as long as others are being raised up, as long as more of the latter is happening than the former."

zombieflanders gets it right here -- the doomsaying has been scaled back as people have realized that Obama isn't actually coming to personally kill their grandma, to the point where we're now required to believe that one wealthy person who might have to pay more is as much of or more of a tragedy than the millions who don't get care.

You are right that socialism demands some sacrifices by those with more means to those with less, but the amount of actual socialism here is minuscule -- we're talking about people having their coverage for acupuncture and massages covered by private sector insurers possibly cost a bit more so that others can afford to get cancer screenings. I wouldn't expect a serial apologist for the wealthy and privileged to think that tradeoff is worthwhile, but most Americans do.

And, yes, the Cadillac costs will be passed on to consumers. That's the point. Because employer-provided insurance is tax exempt, the incentive is to lard up these plans with things that don't improve health outcomes. I'd prefer that employment and health insurance were disassociated entirely, but until that happens, something needed to be done to keep people from exploiting this loophole.
posted by tonycpsu at 8:59 AM on November 13, 2013


Your company may have just made a decision to eat the additional 'cadillac' taxes itself without passing them on to you.

Nah, actually we were informed that we managed to get the plan again this year for a slightly smaller increase in monthly premiums than in previous years. We did see a small increase in employee premium contributions in the latest enrollment period, as usual, but even according to the benefits management company (which had been telegraphing skepticism about ACA previously) the company got a better deal this year than in previous years (specifically, our premium contributions didn't increase as much as they usually do even without our employer making up the gap).

The biggest risk here has always been that because our system has been such an inconsistent patchwork all along there definitely will be individual cases that come out worse off, and those will no doubt be exploited for all the political mileage they can be by the critics.
posted by saulgoodman at 9:16 AM on November 13, 2013 [4 favorites]


What is your moral defense for having much more resources or opportunity than one individual other person? Why are you allowed to have those things and not, say, a person I identify for you from Meriden, CT?

I'm not defending my right to have just enough resources to keep myself alive while denying others that right, so I don't get your point. Unlike a government or gigantic health care conglomerate, there is exactly zero chance I have the personal resources or knowledge skills to save even one other person from dying from a long-term medical condition much less everyone. That's irrelevant.

Explicitly, my claim is that it's unethical to withhold care from people when you have it to give, so I'm not sure what these objections are supposed to mean. I can't perform cancer surgery. I can't even afford to pay for someone else to perform cancer surgery. But its the ethics of a business model that expressly seeks to maximize profit by having the capability to provide life-saving help to people but denying that help to anyone who can't pay the ransom that I'm questioning.
posted by saulgoodman at 9:30 AM on November 13, 2013


the A.C.A. bans any plan that would require a people who get sick to pay medical fees greater than six thousand dollars per year. In other words, this was a deliberate policy decision that the White House and Congress made to raise the quality—and thus the premiums—of insurance policies at the bottom end of the individual market.

Six thousand? That seems awfully low. I'm not entirely comfortable with the government choosing this number for everybody.

Your company may have just made a decision to eat the additional 'cadillac' taxes itself without passing them on to you. Many won't.

The 'cadillac' tax doesn't take place until 2018. Some insurers claim they are cutting benefits to adjust for it now, but this seems dubious to me. Health insurance premiums have been skyrocketing over the last few years sans ACA. I don't quite see why there is a need for a 'cadillac' tax. Maybe it would make more sense to tax employee provided health care over a certain amount as regular income.

Your health plan changing? Employers, insurers largely to blame

The United Parcel Service UPS will no longer cover employees’ spouses on the company health plan.

I'm a little concerned about the mandatory mental health care requirement. I hope it will be an overall benefit, but I'm a little skeptical of the "mental health" industry - the situation seems ripe for fraud considering mental health diagnosis is so subjective. There was an article the other day claiming that adding healthy young people to the insurance pool won't necessarily help out as much as thought since so many of them are suffering from "undiagnosed" mental health issues. Perhaps it is a good time to invest in SSRI manufacturers.

I guess the important thing is to get as many people as possible enrolled in the next year and try to fix the major problems that emerge, but that is going to be very difficult with the confederates taking over the Republican party. Hopefully ACA works out well enough that President Christie will be inclined to patch it rather than dump it.
posted by Golden Eternity at 9:33 AM on November 13, 2013


saulgoodman: What if your liver produced a rare enzyme that could cure cancer? But only your liver made it, and it couldn't be recreated in a lab. You're a generous person and volunteer one day a month for a painful procedure to extract that enzyme that can cure five people. But there are thousands of people dying of cancer every day, and their friends/families want you to "volunteer" more days. You decide to start charging people for your special enzyme. That's unfair, people claim in response. Mobs start forming, the media surrounds your house, PR campaigns get started asking you to save this person or that person. Eventually you're arrested for some bullshit crime and forced to undergo the treatments in perpetuity. Hundreds of lives get saved but you're basically a prisoner. Fair?
posted by BobbyVan at 9:43 AM on November 13, 2013 [1 favorite]


Conservative Health Reform Will Also Make People Lose Their Insurance Plans
Instead of transferring resources from the healthy to the sick and causing certain classes of bad plans to vanish, the conservative proposal would transfer resources from the sick to the healthy and cause certain classes of good plans to vanish. Paul Ryan's 2009 health care plan would rescind the tax subsidy for employed-provided insurance, which obviously would cause many of us with employer-provided insurance to lose our plans. And again, that's not a downside to Ryan's plan (John McCain ran on a similar health care proposal in 2008); it's the whole point—Republicans think the subsidy cause people to be overinsured and to overconsumer health care services.

The impact is different because the parties disagree about important questions of value and public policy. But both proposals disrupt the status quo because both reform proposals are proposals to reform health insurance. Now one absolutely fascinating aspect of American life is that while left-wing wonks and right-wing wonks both passionately want to reform the health care system, most indications are that the voters actually don't. The bulk of the electorate clings rather fiercely and rather perversely to a status quo that, objectively speaking, delivers average health care outcomes at spectacular cost. This is why you end up with both Republicans and Democrats talking about their proposals in ways that radically understate the amount of change that these proposals would actually entail.
posted by zombieflanders at 9:46 AM on November 13, 2013


Let me turn this Cadillac tax question around a bit.

The total revenue raised from the tax in the next ten years, is estimated by the CBO to be $57 billion. Since the tax doesn't begin until 2018, let's divide that number by 5 instead of 10, so we'll say it raises an average of $11 billion per year.

The employer insurance tax exemption, on the other hand, is the largest tax expenditure at $300 billion per year, larger even than the home mortgage interest deduction, and 27 times larger than the amount that would be raised by the Cadillac tax.

Unless we want to borrow more, the costs of government programs have to be financed through tax increases or a reduction in these tax expenditures. All other things being equal, I think most people, even conservatives, would like to see the tax expenditures that go to non-productive things be eliminated before the ones that go to productive things. We can argue about what's productive and what isn't, but if you're going to complain about the Cadillac tax, then you need to be explicit about where else you'd go to raise the $11 billion a year to replace the tax should it be repealed.
posted by tonycpsu at 9:47 AM on November 13, 2013


BobbyVan, there are no random people who the ACA is putting into prison for an accident of their birth, so I think maybe you're full of shit right now.
posted by kagredon at 9:49 AM on November 13, 2013 [3 favorites]


we're talking about people having their coverage for acupuncture and massages covered by private sector insurers possibly cost a bit more so that others can afford to get cancer screenings

Minimizing the downsides of the ACA is likely to come around and bite you in the ass eventually; the effects we've seen so far are not "acupuncture and massages" but relatively healthy, young people paying startlingly more than they were previously paying for coverage. Particularly if they were on catastrophic HDPPs.

And I know the typical pro-ACA response is to say "well, those plans were worthless anyway", but that's not how many people viewed them. Some people may have had HDPPs because that's all they could get, but other people had them because that's really all they wanted. The same way that some people have $5k deductibles and some have $50 deductibles on their car insurance, there's a range of risk tolerance when it comes to health insurance.

If you were, say, a guy in his 20s or early 30s with no significant current health complaints, looking to have a policy that would keep you from being absolutely bankrupted if you took a corner too fast on your motorcycle, some of the now-banned HDPPs -- the ones that didn't have absurd annual or lifetime caps (which did exist) -- were a reasonably good deal. Maybe not for everyone, and certainly not for those who bought them unaware of what they covered and what they didn't, but for some people they were fine.

Supporters of the ACA have continually minimized the impact of the changes, which seems dishonest. You can certainly still be in favor of the ACA while acknowledging that, absolutely by design, some people end up taking a bath. But pretending that it's just louche bourgeois with their acupuncturists and massage therapists is right out of the RNC playbook.
posted by Kadin2048 at 9:50 AM on November 13, 2013 [1 favorite]


> Six thousand? That seems awfully low. I'm not entirely comfortable with the government choosing this number for everybody.

Is it that it's regulated by the government? Were/are you okay with insurance companies being the ones to choose the number? Because that's the system we have now.

> do you think that employers are likely to continue to eat the higher taxes themselves rather than passing them along or offering less generous coverage?

They have been passing the higher costs of coverage on to their employees all along, plus offering less generous coverage. The ACA did not make this suddenly be possible. See, for example, Exhibit 6.2.
posted by rtha at 9:52 AM on November 13, 2013


It's telling you have to over-fit your scenario so much to get it to lead to the point you're going for, BobbyVan, but I'll bite: I'm not saying you or anyone else is obligated to sacrifice your own life and well being to save someone else. I'm explicitly talking about seeking to maximize profit in return for doling out life-saving care and have been since the start of this digression.
posted by saulgoodman at 9:55 AM on November 13, 2013


BobbyVan, there are no random people who...

No shit. In case you didn't notice, saulgoodman was making a philosophical point about the ethics of the compulsory delivery of life-saving medical care. A couple of other people objected to it. I'm offering a thought experiment to flesh out his position a bit more.
posted by BobbyVan at 9:55 AM on November 13, 2013


Kadin2048: "Minimizing the downsides of the ACA is likely to come around and bite you in the ass eventually"

I'm doing no such thing, and have, in fact, acknowledged that, by design, there will be some losers so that there can be many more winners. But the part of my post you quoted is true. The Cadillac tax threshold is $10k per person or $27k per family. It affects very few people, and mostly plans that are, as I said, including things that people wouldn't normally pay so much for were it not for the fact that the employer insurance exemption makes it in the employer and employees' interests to make sure as much of the employee's compensation is categorized as an exempt healthcare expense instead of a taxable salary expense.

On the high-deductible catastrophic plans: these still exist. They're called bronze plans. Nobody's making you buy higher-end plans that cover more. The plans that aren't available now are ones that also had yearly/lifetime maximums that meant they didn't actually cover you in the event of a catastrophe. Nobody is better off buying these, and the actuaries knew this, which is why they lobbied against the bill so hard.
posted by tonycpsu at 9:58 AM on November 13, 2013


The fact that you compare imprisonment and loss of bodily autonomy to be a loss of liberty on par with paying a slightly higher marginal tax rate reveals a deep and disturbing faultline in your moral calculus.

Let's flip around this outlandish and stupid hypothetical, shall we? What if your liver produced a rare enzyme that didn't work properly, making you very ill? You're a hardworking person who works a fulltime job, with no insurance. You decide to ask that people wealthier than you give a small portion of their money, which would still leave them with more than enough to have a comfortable living, so that you can afford the healthcare you require without going broke. That's unfair, people claim in response. Mobs start forming, the media surrounds your house, PR campaigns get started asking you to give back money to this person or that person. Eventually you die. Hundreds of dollars are saved, but you're basically dead. Fair?
posted by kagredon at 10:08 AM on November 13, 2013 [2 favorites]


And also, "in case you didn't notice": saulgoodman made it pretty clear in the comment that you linked that he is not interested in getting into an argument about whether you're morally obligated to go full-on George Price, and more interested in talking about whether we should continue to support a system that exploits the weak, poor, and ill purely for profit:
But its the ethics of a business model that expressly seeks to maximize profit by having the capability to provide life-saving help to people but denying that help to anyone who can't pay the ransom that I'm questioning.
posted by kagredon at 10:22 AM on November 13, 2013


It's always nice to have a discussion with people who think they've identified a "a deep and disturbing faultline in your moral calculus." But to answer the question, I'm generally in favor of modest redistribution schemes when it comes to health care. So yes, I would be in favor of the wealthier paying slightly higher marginal taxes to support the health care necessities of the poor, including this person with the bum liver.

And I take the point that saulgoodman was making about finances vs. "bodily submission." I was being a little extreme/colorful at the end, so probably should have left it at this. Should the person with the rare, cancer curing enzyme be allowed to sell it on the open market?
posted by BobbyVan at 10:31 AM on November 13, 2013


BobbyVan: "Should the person with the rare, cancer curing enzyme be allowed to sell it on the open market?"
Edward R. Murrow: Who owns the patent on this vaccine?

Jonas Salk: Well, the people, I would say. There is no patent. Could you patent the sun?
posted by tonycpsu at 10:34 AM on November 13, 2013


And, yes, I know in your hypothetical edge case only the hypothetical person's liver can produce the enzyme. In that case, it's his/her body, so they can do what they want. The most likely outcome is the government offers a large sum for a sample so they can try synthesize and mass produce it. I'm okay with that.
posted by tonycpsu at 10:37 AM on November 13, 2013


Is that the most likely outcome or would he patent it and sell the rights to drug companies for a large royalty?


Edward R. Murrow: Who owns the patent on this vaccine?

Jonas Salk: Well, the people, I would say. There is no patent. Could you patent the sun?


It's hard for me to believe that medicine would advance at as fast a rate in today's world without patents and open markets and profit motive or whatever. If it comes to providing vaccines to people who can't afford them, removing the incentives for private enterprise to create new drugs may not be the best way to do it. I think patent law for drugs should just be made as reasonable and fair as possible, and the health care industry should have regulations to prevent massive profit taking and exploitation on critical health care. Maybe in the midst of a catastrophic epidemic there should be some kind of imminent domain law where government could take over production of a vaccine if necessary.
posted by Golden Eternity at 11:06 AM on November 13, 2013 [1 favorite]


Likewise nice to have a discussion with someone who failed to make any convincing points about the main point of the thread, and so settles for derailing it into a freshman level philosophy class.
posted by kagredon at 11:16 AM on November 13, 2013 [2 favorites]


Yeah, Libertarian types generally prefer to operate in the world of hypotheticals, as their philosophy comes crashing down at first contact with the enemy known as reality.
posted by tonycpsu at 11:17 AM on November 13, 2013 [1 favorite]


Do you really think something of value is gained by disparaging people of a certain political philosophy, that isn't even being discussed in the thread?
posted by corb at 11:28 AM on November 13, 2013 [1 favorite]


The anti-ACA argument is explicitly libertarian, and the derail into the liver enzyme hypothetical is being invoked as a basis for an inductive case against state intervention. To say that a discussion of the contradictions of libertarian philosophy when it encounters real-world problems isn't on the table would be like me advocating for single payer, but pretending there aren't problems that come with the territory in countries that have more progressive taxation and redistributive mechanisms to pay for their more socialized health systems.
posted by tonycpsu at 11:39 AM on November 13, 2013 [2 favorites]


Edge cases make for shitty public policy and boring same-old hand-wavey discussions. But mostly they make for shitty public policy, especially health policy.
posted by rtha at 11:41 AM on November 13, 2013 [1 favorite]


If it comes to providing vaccines to people who can't afford them, removing the incentives for private enterprise to create new drugs may not be the best way to do it.

Actually, you might have missed it, but the economics have failed us quite spectacularly when it comes to providing incentives for new antibiotic and vaccines production. There was a big thread about this on the blue only recently. The economic incentives for curing people and keeping them healthy are not nearly as strong as those for keeping people in treatment and dependent on expensive proprietary drugs indefinitely. The economic incentives don't work because the research that goes into developing cures costs more than the returns (curing people is significantly less profitable than keeping them alive but sick).
posted by saulgoodman at 11:41 AM on November 13, 2013 [3 favorites]


saulgoodman : Explicitly, my claim is that it's unethical to withhold care from people when you have it to give, so I'm not sure what these objections are supposed to mean.

What if you'd rather not incur liability by breaking a rib? Very normal when CPR is performed properly. What if you'd really rather be home for your spouse's birthday rather than spending 8 more hours in surgery, but the next shift's cardiologist loses far more patients?

saulgoodman : I'm explicitly talking about seeking to maximize profit in return for doling out life-saving care and have been since the start of this digression.

An organization is a financial entity so it cannot sacrifice anything beyond assets. Assets are usually fair game when lives are endangered, that's fine.

An individual is sacrificing their time which holds whatever value they place upon it. Just because they sold x hours earlier does not give you the right to claim y hours now.

Individuals aren't even really trying to maximize profit in the first place They're balancing their time, standard of living, reputation, social status, enjoying the game, personal ethics, etc. It's not "for-profit" to want to help your kids at a particular moment. Yet, you refuse to concede that individuals should not be compelled to provide care, outside say shifts they've already begun.
posted by jeffburdges at 11:53 AM on November 13, 2013 [1 favorite]


Labor costs are not accounted for as profits but as expenses. Doctors or anyone else who performs a service expecting to be made whole for their time has nothing to do with maximizing profits. And you know that.
posted by saulgoodman at 11:59 AM on November 13, 2013 [1 favorite]




I would suggest that the individual motivation of the people doing the research themselves has always been a bigger driver than mere profit.
posted by mikelieman at 12:03 PM on November 13, 2013


Or let's look at it another way. Let's say I'm a highly paid executive who earns approximately $100,000 a minute.

If it would take five minutes of my time to save the child drowning in a pool (the example from the legal blog I cited earlier about what constitutes a crime of omission), are you seriously arguing that it would be ethical of me to refuse to spend that five minutes of my time saving the drowning child? Or that it would be ethical of me to then slap a lien against the child's family for $500,000?

Our culture is too concerned with what the rules are and not concerned enough with what's right.
posted by saulgoodman at 12:04 PM on November 13, 2013


the economics have failed us quite spectacularly

Compared to what alternative economics?
We’ve done a lot with antibiotic development since the very first antibiotics were discovered. We have antibiotics that are very nontoxic. They’re very safe to give. They’re very, very targeted at the bacteria. …

They kill bacteria, and they don’t do much harm to the host, to the human cells, and that’s great. It makes them drugs that are easy to use. It makes them drugs that are nontoxic to use.

We’ve over time developed antibiotics that got around a lot of the weapons that the bacteria had to become resistant, so we were really ahead of the game for a long time. We were quickly developing new antibiotics. When bacteria developed resistance, we always had a new antibiotic waiting in the wings, and we had new therapy that we had to offer.
[...]
…There’s probably a variety of factors that have contributed to the fact that we don’t have new antibiotics. One might be that we developed a lot of the antibiotics that were easy, if you will, to develop. …

There are some people who say we sort of picked all the low-hanging fruit, and then it got really hard to develop new antibiotics.

Another reality is there’s not much money to be made in making new antibiotics, so we saw a lot of drug companies who left the field of antibiotic development because of this combination of factors, that it was getting really hard to discover, to develop new antibiotics, and you don’t make a lot of money in selling these drugs, so the market really wasn’t there.
It seems that 'the economics' were working quite well for a long time, and may still be working to a large extent, but perhaps a big "capital allocation" problem still exists.

If patents are big part of what does attract any investment in new vaccines and antibiotics and it is true that we aren't doing enough to develop new antibiotics and vaccines because there is not enough money in it, then reducing the value of patents would seem to make the situation worse.

I would suggest that the individual motivation of the people doing the research themselves has always been a bigger driver than mere profit.

But I suspect that a large amount of the money that is required to develop new vaccines does not just go to researchers, but to buy equipment, setup labs, etc. I'm sure too much of this money is wasted on corporate profit, but most likely a lot of it is just needed to get the work done for a reasonable price. Perhaps the government could seed investment money or help setup labs or something. Or maybe Bill Gates and Warren Buffet could help out.
posted by Golden Eternity at 12:24 PM on November 13, 2013 [1 favorite]


there is exactly zero chance I have the personal resources or knowledge skills to save even one other person from dying from a long-term medical condition much less everyone

So, you have both kidneys?

I'm kind of being pedantic, I know, but I think that we don't need to wander down this path because it's unproductive. I understand your anger that companies aren't more humanitarian, but...they're companies. We have decided to let healthcare be a business rather than a public service. I don't personally agree with the decision, but this is a natural outflow of that.

Right now, we are engaged in an attempt to be sure that no one is denied coverage. That's good. Whether any one individual, organization, or hospital is required to provide coverage because it's closest/cheapest/most convenient or whatever is not the same question. Similar coverage from another purveyor is the equivalent.
posted by Miko at 12:25 PM on November 13, 2013 [1 favorite]


Ideally, your executive's employer broke labor laws by docking him the $500,000, but regardless five mins costs little real time.

I'm fine with the doctor doing an operation his hospital loses money on so long as the hospital is still paying his time. Now if he loses money when the hospital loses money then may he needs to renegotiate his contract.

I'm not fine with a police officer forcing an off-duty nurse to deliver CPR, thereby incurring liability outside her employer's insurance. Indemnify her until she wants to do it anyways.

I'm not fine with a doctor being told he must work an extra 8 hour shift because otherwise this person might die. Just hire more fucking doctors.

We're not arguing such different real world scenarios, but your original arguments dangerously discounted individual liberties.
posted by jeffburdges at 12:28 PM on November 13, 2013 [1 favorite]


I'm still struck that everyone is arguing about paying for healthcare WHILE we're burning dollars on bullshit like the F-35 can't-fighter program -- and by doing things like killing that turkey frees up money to make this entire discussion moot.
posted by mikelieman at 12:29 PM on November 13, 2013 [3 favorites]


I'm fine with the doctor doing an operation his hospital loses money on so long as the hospital is still paying his time

The loss leader is a perfectly acceptable business model - works everywhere from Starbucks to restaurants to Wal-Mart to tuition...
posted by Miko at 12:30 PM on November 13, 2013


Consider that we don't worry about the profitability of the Army and Marines. So why do we worry about the profitability of doctors and hospitals?
posted by mikelieman at 12:32 PM on November 13, 2013


It's not a black and white debate.

Clearly we all could do more to help the world. Saving one life from malaria costs $2,500. We could probably all save at least one life a year if we really wanted to do so.

On the other hand, a lot of people are making a truly staggering amount of money in America off the suffering of others, and this seems like a reasonable thing to want to end.

The medical profession is not a private industry -- it is subject to extremely tight regulatory requirements that in many cases have enormously benefited physicians and their employers by restricting the supply of care. It is perfectly reasonable for us as a society to ask them to contribute more in return.
posted by miyabo at 12:41 PM on November 13, 2013 [2 favorites]


Well, quibbling some more, the "medical profession" isn't an industry at all, public or private -- it's a profession which is in demand in the health care industry -- which is an industry. Participation in that industry as it is has benefited physicians in some ways, mainly financial, and in other ways has harmed the actual practice of medicine. IN any case, doctors aren't the only ones delivering health care, and often not even the ones with primary responsibility for health outcomes.

But I am fully in support of your general thesis. I just don't think we even need to go to ethical extremes to get there. Sure, this industry has been taking us to the cleaners for a couple of decades. They can certainly be expected to choke it back a little, especially since we just gave them a massive gift in the form of a client pool.
posted by Miko at 2:05 PM on November 13, 2013 [1 favorite]


We do worry about profitability from the military, at least the "we" with any power do, mikelieman, just try cutting any pointless defense contract.
posted by jeffburdges at 1:08 AM on November 14, 2013 [1 favorite]


Wall Street Journal: Ponnuru and Levin: A Conservative Alternative to ObamaCare [Paywalled: Link goes to Google headline search]
The outlines of such reforms have been apparent for years. The key is to enable all Americans to purchase coverage and to approach health care as consumers: with an interest in quality and an eye on cost.

The first step of a plan to replace ObamaCare should be a flat and universal tax benefit for coverage. Today's tax exclusion for employer-provided health coverage should be capped so that people would not get a bigger tax break by buying more extensive and expensive insurance. The result would be to make employees more cost-conscious; and competition for their favor would make insurance cheaper.

That tax break would also be available—ideally as a refundable credit sufficient at least for the purchase of catastrophic coverage—to people who do not have access to employer coverage. This would enable people who now choose not to buy insurance to get catastrophic coverage with no premium costs. It also would give those who want more-comprehensive coverage in the individual market the same advantage that people with employer plans get.

Medicaid could be converted into a means-based addition to that credit, allowing the poor to buy into the same insurance market as more affluent people—and so give them access to better health care than they can get now.

All those with continuous coverage, which everyone could afford thanks to the new tax treatment, would be protected from price spikes or plan cancellations if they got sick. This guarantee would provide a strong incentive to buy coverage, without the coercion of the individual mandate. People who have pre-existing conditions when the new rules take effect would be able to buy coverage through subsidized, high-risk pools.

By making at least catastrophic coverage available to all, and by giving people such incentives to obtain it, this approach could cover more people than ObamaCare was ever projected to reach, and at a significantly lower cost.
posted by BobbyVan at 6:16 AM on November 14, 2013


Politico: Obama to propose admin fix
Trying to quell a growing rebellion from members of his own party, President Barack Obama will announce an administrative fix Thursday to Obamacare to ensure Americans who like their insurance can keep it by permitting current plans to continue into the coming year.

The president’s proposal would allow insurers to offer plans in 2014 that were previously slated to sunset this year, but require the companies to let consumers know how — if at all — their policies don’t comply with the minimum benefits of the Affordable Care Act, according to a source briefed on the proposal.

There is also expected to be some adjustment to risk pools to offset the change, a source said.

...

Though there will be relief among some corners of Congress that the White House has offered a solution, even the rollout of a White House’s proposed fix to Obamacare itself has been bumpy. Senate leaders weren’t even briefed on what the fix will entail ahead of time, sources said.

“Yes, one is coming,” said one exasperated aide about a proposed fix. “You’d think they’d want to tell us first.”

Some Democrats indicated Thursday that they aren’t on board with an administrative fix and are insisting that any changes must be done through legislation.

At a closed-door caucus meeting, Rep. Bill Pascrell (D-NJ) said he would support a GOP bill on the cancellations Friday.
posted by BobbyVan at 7:42 AM on November 14, 2013


I guess these assholes don't remember 2010.
Democrats can't run from Obamacare. They shouldn't try.

Take a look at this list:
John Adler (NJ), Jason Altmire (Blue Dog-PA), Mike Arcuri (Blue Dog-NY), John Barrow (Blue Dog-GA), Marion Berry (Blue Dog-AR), Dan Boren (Blue Dog-OK), Rick Boucher (VA), Bobby Bright (Blue Dog-AL), Gene Chandler (Blue Dog-KY), Travis Childers (Blue Dog-MS), Artur Davis (AL), Lincoln Davis (Blue Dog-TN), Chet Edwards (TX), Stephanie Herseth Sandlin (Blue Dog-SD), Tim Holden (Blue Dog-PA), Larry Kissell (NC), Frank Kratovil (Blue Dog-MD), Lipinksi, Jr (IL), Stephen Lynch (MA), Jim Marshall (Blue Dog-GA), Jim Matheson (Blue Dog-UT), Mike McIntyre (Blue Dog-NC), Michael McMahon (NY), Charlie Melancon (Blue Dog-LA), Walt Minnick (Blue Dog-ID), Glenn Nye (Blue Dog-VA), Collin Peterson (Blue Dog-MN), Mike Ross (Blue Dog-AR), Heath Shuler (Blue Dog-NC), Ike Skelton (MO), Zack Space (Blue Dog-OH), John Tanner (Blue Dog-TN), Gene Taylor (Blue Dog-MS), and Harry Teague (NM).
That's a list of all the Democrats who voted against Obamacare in 2009. Afterwards a number of them looked at the polls and decided they needed to spend more time with their families and "retired." Their seats were won by Republicans. Davis and Melancon decided to run for higher office (and lost.) Altmire and Holden lost their jobs through Democratic primaries in 2012 --- and voting against Obamacare was an issue in both campaigns. As for the rest, with the exception of Barrow, Lipinski, Matheson, McIntyre, and Peterson, every last one of the remaining Blue Dogs on that list lost his seat in 2010 to a Republican. Voting against Obamacare didn't help them one little bit. And voting against it again by going along with more GOP sabotage won't help any Democrats in 2014 either.

Democrats cannot run away from this. They shouldn't even try. In fact, if they're worried about keeping their seats they need to convince their constituents to hang in there and explain to them how the reforms will end up being a net plus for them in the long run. Every Democrat in the country has Obamacare wrapped around them very tightly whether they like it or not. So they'd better do everything in their power to make sure it works.
I understand that politics often trumps policy, but this is bad politics, too. It's depressing that "I welcome their hatred" has become "Thank you sir, may I have another?"
posted by tonycpsu at 7:59 AM on November 14, 2013 [3 favorites]


I involuntarily make a growling sound whenever I see Altmire's name in print. The man lied to my face in person saying that he would support universal healthcare and I spent six months of evenings sitting in a dingy office in Springdale, PA making phone calls for his campaign because I thought that he'd follow through with that.
posted by octothorpe at 8:07 AM on November 14, 2013 [1 favorite]


Obama Dares Insurance Companies to Put Up or Shut Up
The White House on Thursday will announce a plan for allowing insurance companies to continue offering existing individual insurance policies even if they fall short of the coverage standards set by the 2010 health-care law, a Democratic official briefed on the plan said.

....The plan, which the official said could be implemented without passing legislation, would allow insurance companies to extend "substandard'' plans in 2014 only if they are already in existence. Unlike the House bill, the administration plan wouldn't allow insurance companies to offer such plans to new customers.
Here's my guess: this is primarily a put-up-or-shut-up move from Obama, not a plan designed to really fix the problem of canceled policies. I base this on two things.

First, I think insurance companies are mostly allowed to do this already. Second, I think that most of the canceled policies have been canceled because insurance companies wanted to cancel them. They were designed in the first place to entice buyers away from their old grandfathered policies, and insurance companies did this explicitly so that they would be free to cancel them when 2014 rolled around. This allowed insurers to replace them with more expensive policies without taking any heat for it. They could just blame it on Obamacare.

This is just speculation on my part, so don't take it to the bank. But I think Obama's main goal here is to remove this handy excuse. He's basically daring insurers to go ahead and reissue the old policies. If they don't do it, it means that Obamacare was never really responsible for the cancellations in the first place. And if the insurers see that their bluff is being called and decide they don't want to take the PR hit, then the old policies get reissued and everyone is happy. It's a win-win for Obama.
posted by zombieflanders at 8:49 AM on November 14, 2013


I do not share K-Drum's optimism. There are just too many opportunities to obfuscate the reality of whether they're offering the same plans they're now canceling, or offering ones with the same names but vastly different features. The complexity of the insurance system provides so much cover for them to claim Obamacare moved their cheese, and Democrats (including Obama) have shown they have no appetite for patiently talking to voters in these nuanced terms.

The simplicity of the current media narrative will undermine any attempts to split the baby on this. I'd love to be proven wrong, but this backpedaling isn't going to satisfy the media's hunger for a "Democrats in disarray" storyline.
posted by tonycpsu at 8:58 AM on November 14, 2013


I fully expect ACA to die a death by a thousand cuts and the Democrats to snatch defeat from the jaws of a marginal victory.
posted by entropicamericana at 9:58 AM on November 14, 2013 [2 favorites]


I fully expect ACA to die a death by a thousand cuts and the Democrats to snatch defeat from the jaws of a marginal victory.

Then again, the GOP was also supposed to easily take back the Senate in 2010 and 2012, repeal Obamacare, and venerate the bones of Reagan on a dias made of platinum in the entrance to the Capitol, and they haven't managed to do that. Since apparently the administrative fix takes the cancellations off the table until after the 2014 elections, it's not unlikely that they'll have a legitimate rape/not a witch/Obama wants to enslave whitey moment to get the press all hot and bothered.
posted by zombieflanders at 10:18 AM on November 14, 2013


Oddly, I was referring to the recent concessions like the administrative fix and the postponement of provisions like the one that sets limits on the costs of health care, giving some insurers the option to raise prices until 2015 and the requirement that businesses provide their workers with health insurance or face fines. Give 'em an inch and they'll take a mile.
posted by entropicamericana at 10:23 AM on November 14, 2013 [1 favorite]


Give 'em an inch and they'll take a mile.

Or as Dave Weigel puts it:
But I don't think that's the point. Whatever Obama does, it won't restore all the canceled plans. Republicans (and anyone who's talked to any insurer, ever) know this is not the case. After this week, Republicans will be able to react to any new stories about canceled plans by pointing out that, hey, they wanted to fix this, but the president arrogantly refused them and went with his own plan.
The ball is basically in the media's court on this one until the website problems are fixed. Most of these cancelled plan stories can't withstand even a cursory investigation of the facts, much less the amount of scrutiny you'd expect from the nation's paper of record, yet the press can't help themselves, and the NYT knows if they don't run it, someone else will.

Meanwhile, the metric ACA supporters would be able to use to balance these stories out -- the number of new enrollments in the exchanges -- are kept down by the technical SNAFUs and uncertainty about what the next concession is going to be. Why would people want to sign up while Obama keeps tinkering with it to appease members of Congress who will just keep moving the goalposts? There are successes, of course -- states that implemented their own exchanges are doing as well or better than Massachusetts did with their launch -- but that's a level of nuance the press wants no part of when they have an army of people willing to pass themselves off as a rugged individualist, working class hero being kept down by the jackboot of Obamacare for an click-baity op-ed.

I feel like Obama's got the game theory on this all wrong. You had to make concessions on the bill itself to get to 60 votes in the Senate, but it takes 67 to override a veto, along with almost 300 in the House. I'd be shocked if they had a whip count for any of these legislative options that could hit those thresholds, and if they do, well, you go down swinging, but at least you put up a fight and show your base something.
posted by tonycpsu at 10:48 AM on November 14, 2013 [2 favorites]


Medicaid could be converted into a means-based addition to that credit

No.
posted by mikelieman at 10:53 AM on November 14, 2013


Yeah, if they're asking for that, they might as well have asked for Obama to come to their houses and fix them up a sandwich.
posted by tonycpsu at 10:55 AM on November 14, 2013


I feel like Obama's got the game theory on this all wrong. You had to make concessions on the bill itself to get to 60 votes in the Senate, but it takes 67 to override a veto, along with almost 300 in the House. I'd be shocked if they had a whip count for any of these legislative options that could hit those thresholds, and if they do, well, you go down swinging, but at least you put up a fight and show your base something.

True. Maybe he knows (or thinks he knows) that the site will up by Dec 1, in which case the media loses interest, the GOP does something stupid like shut down the government again, and he breathes easy. Or not, we go into mid-January with the site still broken, a bunch of financial hoopla going on, and we can likely say Obamacare is more or less dead in the water. All the more reasonable pundits have basically said it hinges on the site, and if that issue disappears then so does the media's shiny objects. AFAIK that stance hasn't changed since mid-October.
posted by zombieflanders at 10:56 AM on November 14, 2013


So, what happens when ACA supporters try to fight back against the cancelled coverage stories with a testimonial from someone who has been helped by the ACA?

This.
Hannity and His Crew Carefully Tee Up healthcare.gov Model So Coulter Can Slut-Bait Her
HANNITY: All right. What's your reaction to that?
COULTER: I feel sorry for this poor woman.
HANNITY: Me, too.
COULTER: Adriana's going to have to make a sex tape next week to get her reputation back.
HANNITY: Oh, stop....
You need to watch the clip if you want to understand where the blame lies here. Yes, it lies with Coulter, who's as vile as always. But watch the way the segment is structured. The "sex tape" line isn't just one in a flurry of Coulter one-liners -- Hannity and his staff clearly built the segment around it.
...
Oh, but I forgot: Obamacare is so horrible that it's perfectly fair to go on national television and tell two million viewers that a woman who had nothing to do with its creation or implementation ought to try making a porno, just because she has a tangential connection to the law.
At this point, there's really no difference between the vile anonymous comment section of your local newspaper website and what gets broadcast in prime time on the most popular cable news channel.
posted by tonycpsu at 12:15 PM on November 14, 2013 [2 favorites]


State rebuts Obama plan to allow old health insurance policies
OLYMPIA, Wash. -- Just hours after President Obama announced changes to his health care law to give insurance companies the option to keep offering consumers plans that would otherwise be canceled, Washington state Insurance Commissioner Mike Kreidler says those changes will not be allowed in our state.

Kreidler says Thursday he has "serious concerns" about how Obama's proposal would be implemented and its potential impact on the overall stability of the state's health insurance market.

"I do not believe his proposal is a good deal for the state of Washington," Kreidler said in a statement announcing his decision. "In the interest of keeping the consumer protections, we have enacted and ensuring that we keep health insurance costs down for all consumers, we are staying the course. We will not be allowing insurance companies to extend their policies. I believe this is in the best interest of the health insurance market in Washington."
posted by BobbyVan at 12:22 PM on November 14, 2013 [1 favorite]


Good on Mr. Kreidler, and good for the citizens of Washington.

Meanwhile, the predictable reaction from the insurers and state regulators.

Heckuva job, Barack.
posted by tonycpsu at 12:29 PM on November 14, 2013


Well, the more President Obama's plan looks to be a non-starter, the more pressure there will be on politically vulnerable Democrats to support a stronger legislative fix.
posted by BobbyVan at 1:17 PM on November 14, 2013


Zombieflanders, have you even looked at the cost of platinum these days? In these tough economic times we all must make sacrifices. A silver dias is good enough.
posted by corb at 1:23 PM on November 14, 2013


BobbyVan: "Well, the more President Obama's plan looks to be a non-starter, the more pressure there will be on politically vulnerable Democrats to support a stronger legislative fix."

Great! Let those assholes own it if they can somehow overcome the 2/3 veto threshold.
posted by tonycpsu at 1:44 PM on November 14, 2013


How The President Plans To Fix Obamacare

My favorites:
Enrollees allowed to keep preexisting medical conditions

As a preventive measure, each American receives free raw steak to reduce swelling on shiners

Meeting insurance companies halfway by letting them cancel health care plans for only the sickest patients

Offering easy-to-follow instructions on how to snap your own neck in the event that you are diagnosed with cancer and lost your insurance
posted by tonycpsu at 1:49 PM on November 14, 2013


Great! Let those assholes own it if they can somehow overcome the 2/3 veto threshold.

And that's assuming Reid even lets it come to a vote in the first place. Even if it passes, it's DOA in the House and the Upton bill is DOA in the Senate, because each believe the other's is a trap. So we're back at square one. No one is happy, equilibrium is restored!
posted by zombieflanders at 1:52 PM on November 14, 2013


Talking Points Memo: Many Senate Dems Unsatisfied With Obama's Obamacare Fix
Senate Democrats up for re-election in 2014 weren't satisfied Thursday with President Barack Obama's one-year administrative fix for insurance cancellations under Obamacare and demanded a legislative solution to go further.

"The president's announcement this morning was a great first step and we will probably need legislation to make it stick," said Sen. Mary Landrieu (D-LA), who has proposed legislation with five other Democrats to force insurance companies to let people keep their policies permanently if they want to.

Liberal Sen. Jeff Merkley (D-OR), who has co-sponsored Landrieu's bill, told TPM that Obama's move "doesn't go as far as I'd like it to go but it's a step in the right direction."

Sen. Kay Hagan (D-NC) also called the move "a step in the right direction" but likewise declared that "a one-year fix is not enough, and we need to do more."

Sen. Mark Begich (D-AK) told TPM he prefers a bill by Sen. Mark Udall (D-CO) to let people keep their insurance plans for two years. He added shortly after on CNN, "I think we have to move forward on the legislative plan." Obama's plan, he said, "is only as far as I can see, only a year long. I think, again, I think it's not enough, but it's a step."

"It's a step in the right direction and I'm not going to comment further on it," Sen. Jeanne Shaheen (D-NH), who backs Udall's bill, told TPM before entering a Democratic caucus meeting.
posted by BobbyVan at 2:10 PM on November 14, 2013


On a more serious note, it's puzzling as to why AHIP (and NAIC to a certain extent) are making a fuss around the administrative fix yet seem to be mum on the legislative fixes, or the fixes that they themselves hint about. I can get why AHIP doesn't want to talk about normal plan churn, because admitting that the actual amount of affected consumers is so small (between 0.5% and 1.5%) undercuts their message, but that's going to be key to any fix. It'll be interesting to see what they say whatever passes its respective chamber.
posted by zombieflanders at 2:13 PM on November 14, 2013




The backlash to the Obamacare fix has already started
One thing you quickly learn covering the NAIC is that it has a wing of really progressive, liberal insurance commissioners, about five or six regulators who regularly work together. Kreidler is without a doubt part of that camp and one of the most liberal insurance regulators in the country.

It does feel a bit weird to have one of the most liberal regulators be the first out of the gate to oppose Obama. At the same time, it also makes sense: What Kreidler is doing is a full-throated defense of the Affordable Care Act.

The whole reason insurance policies are getting cancelled right now is because the Affordable Care Act wanted these plans – which have less robust benefit packages – to go out of business.

That's why Washington is among a handful of largely Democrat-led states that specifically bar insurers from offering "early renewals": Plans that start in December 2013 and dodge health law requirements. This includes some really big states, too, like California and New York.

"I encourage anyone who is shopping for new health plans – whether you’ve been uninsured or have received a cancellation notice from your insurer – to look at all of your options," Kreidler continues. "Don’t just take what your insurance company says."
That last part, by the way, is something that the administrative fix mandates, i.e. the cancellation letters now have to say what the new plans offer and why the old ones were cancelled. I'm not sure if this is already mandated by the WA and OR insurance commissions, nor if it's something that gets tossed if they don't want to comply with the other mandates. That might make a difference in the reporting.

But probably not.
posted by zombieflanders at 2:34 PM on November 14, 2013


Someone tell me I'm wrong please but my pessimism is growing. Now I fear we're headed for a worst case scenario where lots of people get tossed into the individual markets but either through over-optimism about signups, bureaucratic incompetence, or political malfeasance we end up with a death-spiral of spiking premiums. 'Cause that looks like where we're heading with all the talk about "fixing" Obamacare by sabotaging the risk pools.
posted by Justinian at 8:16 PM on November 14, 2013 [1 favorite]


Jonathan Gruber, who worked on both the RomneyCare plan in Massachusetts and the ACA, doesn't seem too concerned about it. I'm more disappointed with Obama on the politics of his concessions than I am worried about it being an existential threat to the system. It's just not a good sign when you're almost six years into your presidency and haven't figured out that nothing you do is going to make your political enemies be any nicer to you.
posted by tonycpsu at 9:41 PM on November 14, 2013 [4 favorites]


Jonathan Cohn has a good article on why what's going on right now is not going to cause death spirals. Basically, the law has a bunch of stuff built into it (the big one is the "risk corridors") that was made expressly to mitigate this through 2015 or even 2016. The policy is relatively sound, even in the face of the sabotage that's been thrown at it. If the website is fixed soon, it likely won't even matter much in 2014, let alone past that. Say what you will about how the bill being a half-measure on all accounts (I agree!), but it does seem to have been written well enough to have a general idea on what could go wrong and how to deal with it over the short- and mid-term.
posted by zombieflanders at 4:24 AM on November 15, 2013 [2 favorites]


Wall Street Journal: Ponnuru and Levin: A Conservative Alternative to ObamaCare

Counterpoint:

Conservatives Confident America Rejecting Obamacare, Ready for Every-Man-for-Himself Care (emphasis in original)
The Republican plan is to move as many people as possible from the kind of insurance they like to the kind of insurance they hate. Obama's plan is to make unpopular individual health insurance more like the popular employer-based health insurance, with lots of cross-subsidies from healthy to sick. The conservative plans propose to make popular employer insurance more like the unpopular individual market.

The right’s dilemma grows more acute when you move from the general to the particular. Their argument is that Obama forces healthy people to pay higher premiums to pay for a bunch of crap they don’t want or need. Karl Rove argues in his Wall Street Journal column that Obamacare forces people to pay for “expensive and often unnecessary provisions.” And what provisions are these? Where is the medical equivalent of Bridge to Nowhere or scientific research on animals that Republicans love to mock? The problem turns out to be a requirement that “every policy offer a wide range of benefits including mental health and addiction treatment, and maternity care (even for single men or women past childbearing age), and cover 100% of the cost of an array of preventive services.”

This is a morally bizarre conception of what health insurance means. Most of us don’t need mental-health or addiction treatment. Some of us do. Some of us who don’t currently need mental-health treatment might potentially need it one day. You could have a system in which only people who need mental-health treatment pay for mental-health insurance, but then it wouldn’t be insurance anymore. It would be a system in which you pay for a doctor out of pocket.

More comical still is Rove’s denunciation of the Obamacare requirement that insurance provide free preventative services. Here’s the list of preventative services covered under the law. It’s a bunch of screening tests and vaccines. These things may not completely pay for themselves, but they’re highly cost-effective – a small, cheap early intervention can often prevent a costly, painful one later. The Department of Health and Human Resources estimates they would add 1.5 percent to the cost of premiums. Is that an outrageous sum to prevent a fair amount of pain and suffering?

I suppose one could, if inclined toward a certain libertarian mind-set, defend on moral grounds Rove’s belief that mothers alone should bear the cost of giving birth, rather than forcing the rest of us to foot the bill. But is this an argument Republicans have any chance of winning? Their plan is literally to run against motherhood.
posted by zombieflanders at 6:14 AM on November 15, 2013 [1 favorite]




I believe in government.

I'm furious about Obamacare's incompetent rollout.

But, actually, what haunted progressives for decades was Democrats' inability to pass healthcare reform. They've done that. In a couple of years, nobody's going to remember that healthcare.gov went tits-up for a month or two, but they'll remember that we started caring for our uninsured instead of letting them get so sick that their only recourse was an emergency room visit that we were paying for anyway.

123 people enrolled in RomneyCare's first month. It seems to have weathered the storm. So will the ACA.
posted by tonycpsu at 7:57 AM on November 15, 2013 [9 favorites]


lots of cross-subsidies from healthy to sick.

One thing that bugs me about this continued framing (and journalists using it, too) is that these categories are not fixed, and that's the entire point. At any moment, any one of us could cross the healthy/sick divide.

I've never seen anyone go from the pro side to the con side of this issue faster than a laid-off executive whose COBRA ends and then gets cancer, or a "young invincible" who has a serious ski accident. And the like.
posted by Miko at 9:58 AM on November 15, 2013 [4 favorites]


Nobody Drowned From Obamacare
No, actually, it's not. When you all cocked up the response to Hurricane Katrina, thousands and thousands of people died unnecessarily. When you all went out of your way to dismantle FEMA, which had been one of the crown jewels of the previous administration, and then handed the remnants over to the failed CEO of a luxury show-horse organization, thousands and thousands of people actually died. They were not inconvenienced for a spell by a botch of a website. They were really, most sincerely dead.
posted by tonycpsu at 10:41 AM on November 15, 2013 [1 favorite]


The Canonical List of Obama's Katrinas
Check the date on that last one. I love it -- Obama is such a terrible president that he had his first Katrina even before he officially became his party's nominee.

But yes -- the health care rollout may seem worse than other Obama crises, but we have definitely heard this kind of talk[ ]before.
posted by tonycpsu at 11:39 AM on November 15, 2013 [1 favorite]


From the Charles Pierce piece tonycpsu linked above:
First of all, nobody's "raising" those questions except opportunistic yahoos on the Republican side and -- as we shall see -- career apparatchiks formerly in the employ of C-Plus Augustus, many of whom have spent the past five years trying to pretend that they weren't part of the worst presidency ever.

I just have to say "C-Plus Augustus" is probably the best nickname ever for Obama's predecessor.
posted by TedW at 11:43 AM on November 15, 2013 [1 favorite]


An Obamacare "Loser" Speaks Out ... About Not Being an Entitled Douche
Since it’s been estimated that about 3% of the US population will end up “losers” under Obamacare, I thought I’d write in and give you my perspective as a 3-percenter. However, I suspect that I belong to a smaller subset of the 3%, that being people who find it appallingly self-indulgent and shamefully self-pitying to think of ourselves as losers.

Having insurance, even crappy insurance, in the individual market means we are almost by definition, healthy and relatively young. If we were not, we wouldn’t be able to get coverage of any kind in the non-group market. If our ACA-compliant replacement policy costs us more, it’s likely because we’re too affluent to qualify for subsidies.

It takes a remarkable degree of self-absorption and sense of self-entitlement to be healthy, young(ish) and affluent—and yet consider oneself a “loser.” It’s a label I reject out of shame (no matter how much the lazy, superficial MSM want to fixate on me and my “plight”) NOT because there’s anything shameful about being a loser; the shame is in thinking oneself a loser when one is actually fortunate.
posted by tonycpsu at 11:45 AM on November 15, 2013 [4 favorites]


Washington Post: Obama’s ratings tumble after health-care flaws
The flawed rollout of the Affordable Care Act has pushed President Obama to the lowest point of his presidency, with dwindling faith in his competence and in many of the personal attributes that have buoyed him in the past, according to a new Washington Post-ABC News poll.

Opposition to the new health-care law also hit a record high in the survey, with 57 percent saying they oppose the president’s most significant domestic initiative. Forty-six percent say they are strongly against it. Just a month ago, as the enrollment period was beginning, the public was almost evenly divided in its assessments of the law.

Disapproval of Obama’s handling of the health-care law’s rollout stands at 63 percent, with a majority saying they strongly disapprove. Last month, 53 percent disapproved.
NBC News: Insurers, state officials say cancellation of health care policies just as they predicted
Several insurance industry officials and state insurance commissioners expressed frustration Friday, saying they were “baffled” by President Barack Obama’s assertion that the cancellation of millions of insurance policies occurred because a key provision of the Affordable Care Act didn’t work as expected. The administration was warned three years ago that regulations would have exactly that effect, they said.

They said the widespread cancellations in the individual health insurance market — roughly 5 million and counting -- are in line with what was projected under regulations drawn up by the administration in 2010, requirements that both insurers and businesses objected to at the time. Cancellations also are occurring in the small group market, which covers businesses with between two and 50 employees, they noted.

...

In comments filed in August and December 2010, America’s Health Insurance Plans -- a trade group representing 1,300 insurance plans — urged the administration to “reconsider” grandfathering rules because they were too stringent to allow many to keep their policies.

In the first round of comments, AHIP stated that under the administration’s proposed regulations, “The percentage of individual market policies losing grandfathered status … will likely exceed the 40-67 percent range” and warned that could cause “disruptions” for those who wish to keep their policies.
Sen. Marco Rubio (R-FL): No Bailouts for ObamaCare
Buried deep in the Department of Health and Human Services' press release that accompanied the president's Nov. 14 speech was this sentence: "Though this transitional policy was not anticipated by health insurance issuers when setting rates for 2014, the risk corridor program should help ameliorate unanticipated changes in premium revenue. We intend to explore ways to modify the risk corridor program final rules to provide additional assistance."

Risk corridors are generally used to mitigate an insurer's pricing risk. Under ObamaCare, risk corridors were established for the law's first three years as a safety-net for insurers who experience financial losses. While risk corridors can protect taxpayers when they are budget-neutral, ObamaCare's risk corridors are designed in such an open-ended manner that the president's action now exposes taxpayers to a bailout of the health-insurance industry if and when the law fails.

Subsequent regulatory rulings have made clear that the administration views this risk-corridor authority as a blank check, requiring no further consultation or approval by Congress. A final rule handed down in March by HHS and the Centers for Medicare and Medicaid Services states: "Regardless of the balance of payments and receipts, HHS will remit payments as required under section 1342 of the Affordable Care Act."

...

As the people's representatives, the U.S. Congress should completely eliminate the possibility of a bailout of insurance companies. On Tuesday I am introducing legislation that would eliminate the risk corridor provision, ensuring that no taxpayer-funded bailout of the health insurance industry will ever occur under ObamaCare. If this disaster of a law cannot survive without a bailout rescue valve, it is yet another reason why it should be repealed.
posted by BobbyVan at 5:50 AM on November 19, 2013 [1 favorite]


Most Americans Oppose Obamacare Repeal Despite Rollout Troubles
[T]he survey did not find these doubts about the law translating into surging demand to undo it. Reprising a question first asked in July, the survey recorded a close split when respondents were asked to choose among three options for what Congress "should do now about the health care law."

Thirty-eight percent of those polled said Congress should "repeal the law so it is not implemented at all," while 35 percent said lawmakers should "wait and see how things go before making any changes." Another 23 percent said Congress should "provide more money to ensure it is implemented effectively" (the remaining 5 percent had no opinion).

Notwithstanding all the tumult surrounding the law's rocky implementation, those numbers changed little from July, when 36 percent supported repeal, 30 percent wanted Congress to wait and see, and 27 percent wanted lawmakers to provide more funds for implementation.

Just like the question of the law's ultimate impact, this choice divided the country along familiar lines. What's more, the new results showed striking stability since last July for almost all major subgroups.

Since last July's poll, support for repeal has oscillated only slightly (or not at all) for self-identified Democrats (9 percent now, unchanged since July) and independents (40 percent now compared with 41 percent then); whites (48 percent versus 44 percent) and nonwhites (unchanged at 16 percent); young adults under 30 (unchanged at 26 percent) and seniors (42 percent now versus 40 percent then). The survey recorded a somewhat bigger shift toward repeal among whites without a college degree (up to 53 percent from 46 percent last summer) and self-identified Republicans (74 percent now, from 65 percent last summer). But whites with at least a four-year college degree remained essentially unchanged, with 36 percent now backing repeal, compared with 39 percent in July.

Indeed, like the question over the law's eventual impact, this measure found clear signs of doubt among the key elements of the modern Democratic coalition, but no indication that they are rushing to abandon health reform
Rubio Trolls Obamacare With Bill To Repeal 'Bailout' Provision
The program, which legislation mandates to sunset at the end of 2016, is one of several Obamacare provisions -- along with a reinsurance program and risk adjustment program -- aimed at combating adverse selection and prevent some insurers from spiking premiums during the first few years of the Obamacare exchanges.

"This is yet another feature of Obamacare that's designed to minimize any disruption caused to insurance markets," said Jon Gruber, an economist at MIT and architect of Obamacare who supports the law. "The risk corridor is pretty wide so you have to make a lot of money or lose a lots of money for it to kick in. I think repealing it would essentially add uncertainty. Insurers are conservative folks. They don't like uncertainty. They're going to raise their prices."
[...]
"Repeal could save money," Dan Mendelson, a former top health official for the Clinton White House who now runs the consulting firm Avalere Health. "The risk corridors are funded by the government for plans that lose too much money. For plans that make too much money, they will make payments to HHS. There's no requirement for the risk corridors to balance out, so it's possible that the program would be a net cost to taxpayers if, in total, plans lose more money than they make within the program."

But Mendelson thinks Rubio's proposal is a bad idea. "This is a nice way to destabilize the commercial offerings in the exchanges," he said. "It's basically a repeal strategy."

Gruber said Rubio was merely "trolling" Obamacare supporters. He noted that a provision similar to the risk corridors was included in Medicare Part D. "This is classic right-wing ideology," he said. "It's just trying to do what they can to repeal it."
posted by zombieflanders at 5:56 AM on November 19, 2013


Kaiser Health News: Doctors Complain They Will Be Paid Less By Exchange Plans
Many doctors are disturbed they will be paid less -- often a lot less -- to care for the millions of patients projected to buy coverage through the health law’s new insurance marketplaces.

Some have complained to medical associations, including those in New York, California, Connecticut, Texas and Georgia, saying the discounted rates could lead to a two-tiered system in which fewer doctors participate, potentially making it harder for consumers to get the care they need.

“As it is, there is a shortage of primary care physicians in the country, and they don’t have enough time to see all the patients who are calling them,” said Peter Cunningham, a senior fellow at the nonpartisan Center for Studying Health System Change in Washington D.C.

If providers are paid less, “are [enrollees] going to have difficulty getting physicians to accept them as patients?”
posted by BobbyVan at 6:24 AM on November 20, 2013 [1 favorite]


Doctors Fire up the Obamacare Waaambulance
Medical doctors are highly paid professionals. They earn more money—a lot more money—than your average American. What's more, American doctors get paid more than doctors in any other country. Given how much of health care is financed either directly (Medicare, Medicaid, Veterans Affairs, public-sector workers) or indirectly (tax subsidy for employer-provided insurance) by the federal government, it's natural to make restraining doctors' income part of any program for making health care more affordable. So when you read stories about doctors whining that Affordable Care Act exchange plans don't pay them enough, please throw up a little in your mouth and proceed to ignore the doctors' complaints. The only practical reason to worry about low compensation for doctors in the ACA exchanges is it may cause them to boycott exchange patients. If that happens, the solution is to reduce doctors' payment rates elsewhere in the system. If we ever reach the point where American doctors have been squeezed so badly that they start fleeing north of the border to get higher pay in Canada, then we've squeezed too hard. Until that happens, forget about it.

But also spare a thought for the journalists. The Affordable Care Act is a big deal. ACA implementation is a big deal. People should write stories about how much doctors get paid in ACA plans. But people who write stories on this subject without noting the yawning pay gap between American doctors and doctors in Canada, France, Germany, etc. are doing their readers a disservice.
Why Are American Doctors Paid So Damn Much?
If Econ 101 is to be believed, higher pay should produce more doctors. And yet, even though the United States pays doctors far more than any other country on the globe, we're in the bottom third. We have more doctors per capita than poorish countries like Mexico and Poland, but far fewer than Belgium and Britain and Germany—all of which pay doctors considerably less than we do here. So what's going on?

As Matt says, the basic answer is that U.S. doctors operate as a cartel. They artificially limit their own ranks, which drives up their compensation:
What we really ought to be doing is working to further pressure the incomes of doctors through supply-side reforms. That means letting nurse-practitioners treat patients without kicking a slice upstairs to an M.D., letting more doctors immigrate to the United States, and it means opening more medical schools. Common sense says that since the population both grows and ages over time, there should be more people admitted to medical school today than were thirty years ago. But that's not the case. Instead we produce roughly the same number of new doctors, admissions standards have gotten tougher, and doctors have become scarcer.
This is yet another reason not to shed too many tears for doctors. They've basically brought this on themselves. If the market were allowed to produce as many doctors as there's demand for, they'd already be getting paid less. Right now they're enjoying the substantial rents that come from squeezing their own supply, and they've fought like lemmings for decades to keep it that way. You can hardly blame for that, but there's no reason the rest of us should put up with it. It's time to fight back.
posted by zombieflanders at 9:31 AM on November 20, 2013 [7 favorites]


ACA slows growth in health costs
According to a new report published by Jason Furman, chairman of the White House Council of Economic Advisers, over the last three years – the period since “Obamacare” became the law of the land – per capita health care spending has grown at a rate of 1.3%. “This is the lowest rate on record for any three-year period and less than one-third the long-term historical average stretching back to 1965,” Furman noted.

Moreover, thanks to health care reform, inflation for health care goods and services is “currently running at just 1 percent on a year-over-year basis, the lowest level since January 1962.”

How do we know the Affordable Care Act deserves credit, and this isn’t just a cyclical shift, or a reduction resulting from weak economic growth?
“The fact that the health cost slowdown has persisted so long even as the economy is recovering, the fact that it is reflected in health care prices – not just utilization or coverage, and the fact that it has also shown up in Medicare – which is more insulated from economic trends, all imply that the current slowdown is the result of more than just the recession and its aftermath,” the report stated. “Rather, the slowdown appears to reflect ‘structural’ changes in the United States health care system, a conclusion consistent with a substantial body of recent research.”

The ACA is a contributing factor because it includes reductions in Medicare overpayment to private insurers and medical providers, and incentives for hospitals and doctors to improve their quality of care, the report stated.

“Recent research implies that reforms to Medicare will have ‘spillover effects’ that reduce costs and improve quality system-wide,” the report stated. “Accounting for ‘spillovers’ implies that the ACA’s effect on health care price inflation may be much larger than previously understood.”
In terms of the real-world impact, this means more affordable care for consumers and more savings in government spending.

In other words, it’s the sort of thing Republicans should be pretty happy about – which generally means they’ll ignore the news and/or issue a press release declaring the opposite, assuming no one will know the difference.
posted by zombieflanders at 1:45 PM on November 20, 2013 [1 favorite]


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