Nov. 20th, 2013

A short list of the shoes yet to drop as the ACA disaster unfolds over the next year…

1) The millions who had their individual and small-group insurance cancelled will largely fail to find a substitute, and the stories of what happens to the unlucky ones who then suffer a medical catastrophe will dwarf what we have seen so far. Punishing the responsible and hard-working is several orders of magnitude more harmful politically.

2) When people try to use their new ACA plans, many will discover how limited their new provider networks are, and in many cases (especially in rural areas) the network doctors will be far away and overcrowded with new patients. More news stories.

3) Remember that health outcomes for those covered by Medicaid are not statistically better than for those who are uninsured or underinsured. But the number of doctors taking Medicaid patients will not have grown much, while the expansion will send many more patients their way -- how will this work?

4) Loss of freedom to move. In the 80s I was covered by one of the best HMOs in the country, the Harvard Community Health Plan. It and Kaiser were the models for the HMO movement, which cut costs by managing care and restricting the service networks to employed doctors and their own hospitals. In return you paid a much lower premium. But if you left the service area, you could only get emergency services covered - the model was that you would return "home" ASAP for any real treatment. *This is the ACA model* -- the HMOs were politically trashed for their restrictions, and now suddenly the HMO menu of confined geographies, limited hospitals, and gatekeepers for specialists is back, at vastly inflated premiums. As some pointed out in 2010, the public has always hated having to deal with insurance companies, and with the Feds taking on the mantle of People's Insurance, expect the public to begin to hate the Feds.

5) Now that we can see how it is going to work, it's obvious that both subsidies and costs of the new system are not especially well targeted. The well-off with pre-existing conditions get a huge subsidy even though they may not need it, while the middle class just above subsidy range may pay a huge hidden tax for their insurance despite barely having $100 a month to spare. Some people who truly needed help benefit, but that is almost an accident compared to the side-effects to everyone else.

6) Yet to come: security issues. Currently the law allows subsidies only for those using the exchanges (and there are lawsuits about the provision of subsidies to those using the Federal exchange, which is not explicitly authorized by the text of the law.) So to get a subsidy you *must* use the exchanges, yet security experts unanimously agree the Federal exchange, at least, is full of security flaws. The stories of hackers gaining access to private user data for identity theft are on the way.

7) Payment problems: the IT people now say that 40-60% of the backend work on the Federal exchange has yet to be done, with no plan to forward the subsidies to the insurers until January. No one knows how flawed the data being sent to the insurance companies is, or if insurance companies will refuse to cover those whose payments fail to arrive by the due date. More stories will come of this when people are refused service after they thought they had signed up.

We enjoyed Andrew Sullivan when he was plugging marriage equality 20 years ago. He has flip-flopped and evolved into an apologist for the powerful and his religious impulses, pontificating on economics and policy he barely understands based one whether the "right people" hold certain views. His habit of first-naming his cool-kid friends ("Ezra") is pretentious and he jumped the shark quite some time ago. Presumably when elections upend the current order he will find a new set of cool kids to suck up to.

The next article is a pretty good roadmap of the way to go if Dems and Reps are to come together to rescue the ACA before we hear about the thousands of people who formerly had insurance but now will be bankrupted by a minor brush with a hospital:

This is what it looks like when the less in tune part of the population discovers they've been lied to:

The following link is about a woman who lives in WA state, which has been lauded as having the best of the state exchanges. She wrote to Obama about her new low-cost health plan, and Obama spoke about her as a success story. Now she discovers the state's exchange miscalculated her subsidy, and her correctly unsubsidized premium is so high she still won't be able to afford insurance. Yay! BTW, Oregon's $300 million exchange still has not enrolled a single person…

Internally, Democrats are fighting over how to respond to the ACA disaster. They correctly see electoral repudiation on the horizon. Much whistling in the dark by the usual apologists, but privately they know the situation is grim.

The lawlessness of trying to patch problems without getting legislative help:

Public turns against the whole idea of federal responsibility for healthcare:

The end of youth enthusiasm for Hope and Change:

And another swan song for the Blue Model:



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