Sunday, September 21, 2014

Elisabeth Rosenthal exposes hospitals as free-billing zones

I stand back in awe from the healthcare reporting of The New York Times' Elisabeth Rosenthal, who since June 2013 has been exposing in front-page blockbuster after blockbuster the rampant greed and depraved price-gouging endemic to the US healthcare system. Her nine-part "paying till it hurts" series, indexed here, is worthy of a Pulitzer. It should galvanize the country as Silent Spring or The Other America did.

Rosenthal's latest exposes many hospital ORs as free-billing zones in which an array of doctors, physical therapists and other service providers can insinuate themselves in a procedure without the patient's prior knowledge or consent, whether they're in the patient's insurance network or not -- and then relentlessly pursue either the insurer or the patient or both for their exorbitant billings.

The most egregious example Rosenthal spotlights is when neurosurgeons or orthopedists call in out-of-network surgeons to assist -- who bill at out-of-network rates, to the tune of $117,000 in the headline case.  Then there's the smaller-scale gouging:
Unexpected fees are routinely generated outside the operating room as well. On the wards, a dermatologist may be called in to examine a rash and perform an expensive biopsy. The person in scrubs who walks a patient to a bathroom for the first time after hip surgery may turn out to be a physical therapist billing $400.
Rosenthal's fully-documented examples will make you afraid ever to set foot in a hospital -- unless perhaps you're on Medicare with full-bore Medigap insurance. A few policy takeaways from this tale of systemic depravity:

Thursday, September 18, 2014

If you answer the first question wrong on healthcare.gov, no soup(sidy) for you

Back in April, when the ACA's extended open season was finally over, surveys conducted by McKinsey & Co. and PerryUndem (for EnrollAmerica) indicated that most of the still-uninsured were eligible for ACA subsidies (or Medicaid, in expansion states) but didn't know it. In fact, McKinsey found that two thirds of subsidy-eligible respondents who visited healthcare.gov but did not enroll were not aware of their eligibility -- and so had no idea how much health insurance would actually cost them.

I have an article up at The New Republic (my first there) examining why so many of the uninsured remain unaware of what the ACA has to offer them. In all fairness, the first answer must be that knowledge penetration takes time -- the CBO always projected a 3 to 4-year path to full takeup.

Sunday, September 14, 2014

Two questions about Obama's thinking about ISIS

Peter Baker has a purported insider's view of Obama's thinking about the ISIS crisis™, based on interviews with 10 people present at two recent dinners the president held with foreign policy experts and journalists. Like most such exercises, it's not particularly revealing (with one exception noted at bottom), as the president is putting best foot forward with his guests and the guests assess him through a partisan prism (Richard Haas is respectfully negative, Jane Harman equivocally positive).  

I was struck, though, by two questions Obama's not-so-private exegesis left unanswered. I don't doubt that he has considered these questions in depth, but he has not seen fit to address them directly.

The first concerns his decision to ramp up aid to "moderate" Syrian rebels and support them with air strikes as appropriate.

Wednesday, September 10, 2014

Obama phones it in

In press conferences on Aug. 28, Sept. 3 and Sept. 5, and in a Meet the Press interview on Sept. 7, Obama provided considerable detail about the way he plans to "degrade and ultimately destroy" ISIS. Key themes, cumulatively elaborated over the four sessions, were that 1) The U.S. would not act precipitously in Syria; 2) Obama would not "Americanize" struggle -- U.S. military support would be calibrated to Sunni political action; and 3) the effort would build methodically and take considerable time.

Earlier today I traced these themes through all four of these quite recent Q&As because I assumed that they would serve as prelude to tonight's speech, which would distill them and continue to bring them into sharper focus. But the speech didn't do that. It was the comic book version -- the barest outline. It did not grapple with how the U.S. can build capacity to fight ISIS and foster the beginnings of viable government in Syria, an effort that Obama previously more or less rejected as futile -- and which he did address at least partially on 9/5 and 9/7, suggesting that the difference is greater motive and pressure on nearby Sunni nations to act in concert. He didn't provide any detail as to what degree of Congressional buy-in he considers necessary or unnecessary.  He held up U.S. efforts against al Qaeda affiliates in Yemen and Somalia as models, rather than his fight against core al Qaeda, seemingly to minimize the threat, though ISIS arguably has more capacity now than bin Laden's group ever did.

No, Obama is not plunging neck-deep in the Big Muddy

"We don't have a strategy yet." Those words of Obama's in an Aug. 28 press conference so flipped out the foreign policy establishment and media that no one heard heard what Obama was saying.

A translation: The conditions are not yet in place for significant U.S. military action against ISIS in Syria. Our efforts now are concentrated on beginning to create such conditions.

Those who fear that Obama is poised to plunge neck-deep in the Syrian muddy (here's to you, Mr. Sullivan) might look again at how he has elaborated this point repeatedly  -- in press conferences on Sept. 3 and Sept. 5, and in his Meet the Press interview with Chuck Todd that aired Sept. 7.

Here's how he put it on Aug. 28:

Tuesday, September 09, 2014

The Republicans' ACA shell game

The most credible rap against the Affordable Care Act is that it raises the cost of insurance bought in the individual market for people who have no preexisting conditions and earn too much to qualify for subsidies.

That is true. Hence all the "rate shock" stories bruited by the GOP last fall.  Most of those stories did not survive scrutiny, because the GOP went for dramatic hardship cases, and most true hardship cases qualify for subsidized coverage.  Those truly dinged by the law were more like a couple with two children profiled by the New York Times earning about $100,000 per year and a single 50-something man earning just under $50,000 profiled in the same article -- folks on the wrong side of the subsidy cliff.*

Somewhere between one and five million people suffered at least short-term financial harm of this sort. Their numbers are now dwarfed by the 6-7 million people getting subsidized private plan coverage, the 7 million-odd added to the Medicaid rolls, and the 2-3 million under age 26 who gained coverage on their parents' plans.

The law as a whole remains unpopular -- because Republicans have been relentlessly smearing it for five years, because the individual mandate has always been an unpopular concept, because healthcare.gov dysfunction imprinted "train wreck" perceptions before the problems were patched and signups surged, and because astounding numbers of the still-uninsured still don't know that they qualify for subsidized coverage.

Nevertheless, reality has seeped in enough to sap the strength of the Republican attack.  And as the intensity of that attack has diminished, its policy core has shrunk to a simple line that masks a core evasion. Here's one iteration, as expressed to Talking Points Memo's Sahil Kapur:
"Ensuring that people with preexisting conditions have access to coverage has long been a popular policy, and one where there is bipartisan agreement. It's the the entirety of ObamaCare that remains EXTREMELY unpopular," Brad Dayspring, a spokesman for the Senate GOP's campaign arm, told TPM in an email.

Sunday, September 07, 2014

Question for Obama: Why is arming a "moderate" Syrian opposition no longer a "fantasy"?

Back in January Obama suggested to David Remnick that trying to arm and shape a "moderate" opposition to Assad was futile:
... I asked Obama if he was haunted by Syria, and, though the mask of his equipoise rarely slips, an indignant expression crossed his face. “I am haunted by what’s happened,” he said. “I am not haunted by my decision not to engage in another Middle Eastern war. It is very difficult to imagine a scenario in which our involvement in Syria would have led to a better outcome, short of us being willing to undertake an effort in size and scope similar to what we did in Iraq. And when I hear people suggesting that somehow if we had just financed and armed the opposition earlier, that somehow Assad would be gone by now and we’d have a peaceful transition, it’s magical thinking.

“It’s not as if we didn’t discuss this extensively down in the Situation Room. It’s not as if we did not solicit—and continue to solicit—opinions from a wide range of folks. Very early in this process, I actually asked the C.I.A. to analyze examples of America financing and supplying arms to an insurgency in a country that actually worked out well. And they couldn’t come up with much. We have looked at this from every angle. 
More recently, he told members of Congress that the notion that the U.S. could have conjured an effective moderate opposition was "a fantasy."  Now, though, as he told Chuck Todd in an interview airing today, his nascent strategy in Syria depends on building such an opposition. When Todd challenged him as to how ISIS could be defeated in Syria without U.S. troops, here was his response:

Friday, September 05, 2014

Contain, degrade, destroy ISIS? It's a timeline

[Update 9/5, 12:15 p.m. ET: in a press conference in Wales that just ended, Obama added "ultimately" at least thrice to the phrase "degrade and ultimately destroy" and variants, reinforcing the 'timeline' theme below.]

I'm not qualified to assess the efficacy of Obama's past or current conduct of policy with respect to Syria and Iraq. But I am well attuned to Obama's rhetoric and the thinking it reflects. On that basis, I can tell you that the media angst over whether he's signaled intent to contain, degrade or destroy ISIS is a lot of hooey.

Current U.S. policy, as Obama has described it and to the extent it can be disclosed, is pretty straightforward. U.S. air power will contain ISIS, and begin to degrade its warmaking capacity, while regional actors get their act together, with the help of U.S. prodding and incentives. To the extent that they do so, efforts will escalate to destroy ISIS.

Contain, degrade and destroy are stages in a process, timeline uncertain and dependent on strategic goals such as winning Sunni Iraqi buy-in to the new government and getting Gulf states to act in concert in finding viable Syrian opposition to back (while also, I would guess, working to leverage and to some extent covertly coordinate with warfare against ISIS conducted by Iran and Syria).

It's true that Obama's rhetoric has served to temper more overheated pronouncements by Biden, Kerry and others. And there was a real division between Powers' denunciation of the Russian invasion of Ukraine and Obama's refusal to call it that. But his own rhetoric with respect to Iraq, Syria and ISIS can be cast as  inconsistent or conflicted only if you break apart the implicit and contingent timeline he's outlined with the help of various verbs.