Bette in Spokane has some genuine pain (probably. Or maybe not...see updates)

[multiple updates, through 2/3/14]

Yes, the brief "ACA victim" story that Rep. Kathy McMorris Rodgers (R-Wa) inserted in her response to the State of the Union address was cherry-picked and misleading. The pain that the ACA inflicted on the couple in question was exaggerated. But it was probably real. They are in the relatively small subset of Americans who may fare worse under the ACA than under the pre-ACA status quo.

Here is the tale that Rodgers told:

Not long ago I got a letter from Bette in Spokane, who hoped the President’s health care law would save her money – but found out instead that her premiums were going up nearly $700 a month.

Reporter David Wasson of the Spokesman-Review tracked Bette down and learned that she is hostile to the ACA ("I wouldn't go on that Obama website at all") and did not check out her options on the exchange. The $700 difference was between the plan she and her husband carried in 2013 and the plan their insurance company offered in replacement. Here are the basics:

Did communism keep the west in the pink?

Thomas Edsall relays* the core ideas of a book by French economist Thomas Piketty, Capital in the 21st Century, that is causing a stir among economists. According to Picketty, the broad sharing of wealth and shrinking of economic equality in the developed world in the middle of the twentieth century was an historical anomaly:

There are a number of key arguments in Piketty's book. One is that the six-decade period of growing equality in western nations - starting roughly with the onset of World War I and extending into the early 1970s - was unique and highly unlikely to be repeated. That period, Piketty suggests, represented an exception to the more deeply rooted pattern of growing inequality.

According to Piketty, those halcyon six decades were the result of two world  wars and the Great Depression. The owners of capital - those at the top of the pyramid of wealth and income - absorbed a series of devastating blows. These included the loss of credibility and authority as markets crashed;physical destruction of capital throughout Europe in both World War I and World War II; the raising of tax rates, especially on high incomes, to finance the wars; high rates of inflation that eroded the assets of creditors; the nationalization of major industries in both England and France; and the appropriation of industries and property in post-colonial countries.

As we hyperventilate, a quiet healthcare revolution?

Healthcare wonks were understandably a-twitter yesterday over the unveiling of the first substantive "repeal and replace" legislation -- a bill from Senators Coburn, Burr and Hatch that would re-remake the individual insurance market, semi block-grant Medicaid and take a big bit out of the employer's health insurance tax deduction.

The bill is important. Some of its core provisions could be enacted within the framework of the ACA. Some of those provisions -- e.g., replacing the individual mandate with a combination of continuous-coverage protection and default auto-enrollment -- are palatable to some progressives, and others -- capping the employer's tax deduction at 65% of the cost of an average plan -- might be downright attractive to them.  Others, not so much. But as a framework for possible compromise with ACA proponents -- e.g.,  if, say, Democrats have the Senate and Republicans the House and presidency in 2017 -- it has potential.

Under the radar, meanwhile, are two bipartisan efforts that could potentially have a more profound impact on healthcare costs, and therefore on healthcare delivery, as well as on the nation's long-term fiscal outlook.  Both are attempts to move government payment for health services away from fee-for-service. Both seek to foster a combination of coordinated care and pay-for-performance (as do pilot programs in the ACA).  Significantly, amazingly, this potentially revolutionary effort has not yet taken on strong partisan markings.

The most recent effort on this front bears the imprimatur of Congress's most creative and informed healthcare legislator, Senator Ron Wyden (D-Ore.), in concert with Sen. Johnny Isakson, (R-Ga.); Rep. Erik Paulsen (R-Minn.); and Rep. Peter Welch (D-Vt.). The bill, the Better Care, Lower Cost Act of 2014, hones in on the sickest Medicare patients, a small percentage of whom account for the majority of costs.  Modern Healthcare's Andis Robeznieks explains:

For Ezra Klein, the past isn't past. It's news.

New York Times media columnist David Carr, delving into why Ezra Klein could not find a home for his new venture at the Washington Post, cites Henry Blodget in a claim that digital media is different in kind from print media, and builds up to this:

Great digital journalists consume and produce content at the same time, constantly publishing what they are reading and hearing.

Klein himself, however, describes the mission of the new venture as doing exactly the opposite:

Early last year, Melissa Bell, Matt Yglesias and I began wrestling with a question that had bugged all of us for a long time: why hadn't the Internet made the news better at delivering crucial context alongside new information?

This year, we're founding a new publication at Vox Media in order to do something about it.

New information is not always — and perhaps not even usually — the most important information for understanding a topic. The overriding focus on the new made sense when the dominant technology was newsprint: limited space forces hard choices. You can't print a newspaper telling readers everything they need to know about the world, day after day. But you can print a newspaper telling them what they need to know about what happened on Monday. The constraint of newness was crucial.

If Republicans win it all, what will they do to the ACA?

I want to make a foray into reporting and ask some healthcare wonks what they think Republicans will do to the Affordable Care Act if they win both houses of Congress and the presidency by 2016.

While Republicans gleefully anticipate the ACA's implosion, ACA supporters assure themselves that repeal is a dead dream, as the ACA has already provided insurance to millions and rewritten coverage rules (e.g., guaranteed issue) in ways that will be impossible to take away. That may be true. But it does seem to me that Republicans in control of Congress and the presidency could ruin the law without repealing it outright.  They could do so out of a combination of antipathy to a law that (colloquially) bears Obama's name and sincere belief in principles such as consumer choice and deregulation.

Obama's permission structures

Steve Rosen, "a former AIPAC foreign policy chief known for his hawkishness on Iran," gave the Obama administration a backhanded compliment that sheds some interesting light on complaints that "no one fears" Obama.  Regarding AIPAC's heavy-handed backing of the Kirk-Menendez Iran sanctions bill that the administration is dead-set against, JTA's Ron Kampeas reports:

“AIPAC puts a premium on bipartisan consensus and maintaining communication with the White House,” said Rosen, who was fired by AIPAC in 2005 after being investigated in a government leak probe, though the resulting charges were dismissed and he later sued AIPAC unsuccessfully for damages.

Rosen noted AIPAC’s forthcoming policy conference in March; such conferences routinely feature a top administration official — the president or  vice president, the secretary of state or defense. At least one of these failing to appear “would be devastating to AIPAC’s image of bipartisanship,” he said.

Facto or factoid?

Austin Frakt has started a Twitter string, partly prompted by an exchange with me, that has me troubled about the name of my blog, which was a casual accident.

The substantive discussion was about whether policy outcomes eventually settle policy debates (Frakt is skeptical). The Twitter shorthand is "fact or factoid?"  That brought me back to what I thought I was doing in naming this blog.

I opened a space on Blogspot called xpostfactoid in 2004 and put up a handlful of entries about the Kerry campaign. It sat fallow until 2007, when Obama appeared on the horizon. The name was, I think one of those spontaneous puns that please the finder and then aren't given much thought.  But it did later take on a significance to me that I'm now thinking was founded on a double error.

What Avik Roy won't tell you about healthcare in Switzerland and Singapore

Avik Roy so despises the Affordable Care Act that he wants it to swallow Medicare and Medicaid.

According to Roy's latest sketch of a conservative plan to offer universal health insurance, Medicare and Medicaid are the chief culprit in the United States' uniquely expensive healthcare system -- notwithstanding that they pay less per procedure than private insurers and patients, and that most experiments in alternatives to fee-for-service payment are located within them.

In Roy's free-market healthcare vision, Medicare and Medicaid patients would be transitioned onto deregulated health insurance exchanges, where insurers would be free to offer even skimpier insurance than the current exchange bronze plans, designed to cover just 60% of average patient costs. They might also be free to expand the ACA's age-rating, which limits the ratio of older patients' premiums to young patients' to 3-to-1, and be freed from offering the ACA's minimum essential benefits.

To flesh out this vision, Roy touts the virtues of his two favorite national systems: those of Singapore, which features mandatory individual health savings accounts (HSAs), and  Switzerland, in which everyone buys insurance on private exchanges (subsidized for about a third of the population). But as is his wont, Roy fails to mention the feature that enables each of these systems work: strong government influence over pricing.

Take first Roy's sketch of Switzerland's free market system:

Love vs. reason, or Martin Luther King vs. Steven Pinker

[reposted, in honor of Martin Luther King Day]

To read the shorter Steven Pinker -- one of the many compressed versions of the ideas developed over 800 pages in The Better Angels of Our Nature: Why Violence Has Declined that he has published in newspapers and magazines or offered in interviews -- you might think that the driving force behind the dramatic reduction in violence over the course of human history was an expansion of empathy, the ability to enter into the feelings and sufferings of other. And so it is, to a degree. Pinker attributes the growth of empathy in large part to the development of commerce, which requires interaction, and printing, which helped expand the circle of literacy and, ultimately, the range of human experience that the literate absorb.

But fairly late in his argument, Pinker subordinates empathy to reason as a driver of the "rights revolution" -- the growing expansion of categories of people (and to a degree, now, animals) whom it becomes taboo to subject to violence of various kinds, including second class citizenship. It's reason that expands the circle:

What really has expanded is not so much a circle of empathy as a circle of rights--a commitment that other living things, no matter how distant or dissimilar, be safe from harm and exploitation. Empathy has surely been historically important in setting off epiphanies of concern for members of overlooked groups. But the epiphanies are not enough For empathy to matter, it must goad changes in policies and norms that determine how the people in those groups are treated...abstract moral argumentation is also necessary to overcome  the built-in strictures on empathy. The ultimate goal should be policies and norms that become second nature and render empathy unnecessary. Empathy, like love, is in fact not all you need (Location 13,110). 

"Empathy, like love..." But empathy is not love, not as theologians and moral philosophers -- for example, Martin Luther King -- have defined the latter. Love is bigger than empathy. In King's formulation, it encompasses something like the reason that Pinker places higher on the (social) evolutionary scale.

Toward the end, Obama still seeking beginnings

Much as I admire both David Remnick and Barack Obama, I did not find Remnick's new 17,000-word profile of the president particularly illuminating [update: not so for the outtakes Remnick published a few days later].  Remnick asked some tough questions but did not push back much on the answers. That allowed Obama to be Obama, splitting differences, embracing complexities and balancing opposites, without really enabling him to defend his record with much vigor.

On the other hand, Obama being Obama is always interesting to me, and I did find a couple of his dicta revealing in the way they reiterated and updated old habits of mind and speech. Here's one:

I will measure myself at the end of my Presidency in large part by whether I began the process of rebuilding the middle class and the ladders into the middle class, and reversing the trend toward economic bifurcation in this society.”

"Began to" is Obama's signature way of hedging his goals, which he has always cast in terms of new beginnings rather than completed revolutions.  It's his vaunted "long game" from the other end of the telescope. Not for the first time, I'm driven back to his in his 100th-day press conference:

Most early ACA signups so far were previously insured. Is that bad?

The Wall Street Journal is today trumpeting a study by McKinsey and other insurer broker-supplied data suggesting that the vast majority of ACA signups to date were already insured:

Only 11% of consumers who bought new coverage under the law were previously uninsured, according to a McKinsey & Co. survey of consumers thought to be eligible for the health-law marketplaces. The result is based on a sampling of 4,563 consumers performed between November and January, of whom 389 had enrolled in new insurance....

Health Markets Inc., an insurance agency that enrolled around 7,500 people in exchange plans, said 65% of its enrollees had prior coverage. Around 10% were dropping out of employer coverage, either because the employer stopped offering its plan or because they could qualify for subsidies on the marketplaces. Fifteen percent had previous individual plans canceled, and 40% decided to switch into coverage bought through an exchange from previous individual plans.

Near the end of the article, reporters Christopher Weaver and Anna Wilde Mathews offer key contextualizing information, brought into focus by Kaiser's ubiquitous Larry Levitt:

It isn't surprising that some percent of new purchasers of private health insurance are people who had insurance before. About 66% of people buying new individual health plans in early 2011 were covered by employer-backed plans in late 2010, according to a Kaiser Family Foundation analysis of federal survey data prepared for The Wall Street Journal. About 20% of enrollees in early 2011 were previously uninsured, the analysis found.

There is "massive churn in the individual market, and always has been," said Larry Levitt, senior vice president at Kaiser. "It wouldn't surprise me if many [health-law enrollees] were insured in the last year," he said, but "that doesn't mean they wouldn't have ended up uninsured if not for the exchanges."

A few further thoughts about these stats, to the extent that they're an accurate reflection of the market thus far:

Tweet of the century

This is, like, the most satisfying thought ever:

I have just realised that uteruses are technically 3D printers.
— Helen Lewis (@helenlewis) January 17, 2014

Hats off, Helen Lewis, whoever you are.

Visions of dysfunction

In a longer than usual read of the Times front section this morning, three tales abruptly coalesced in my mind as markers of U.S. political dysfunction.

First up, we have Republicans blocking the U.S. from fulfilling a core international commitment - a major adjustment to a changing world -- and the administration failing to go to the mat for the country's credibility:

The Senate on Thursday gave final approval to a $1.1 trillion spending bill for the current fiscal year, leaving behind what might have been the Obama administration’s best chance to overhaul the International Monetary Fund and meet its obligations to the world’s other economic powers.

Does Robert Gates know what's in Menendez-Kirk?

In interviews following the publication of his new book, Duty: Memoirs of a Secretary at War, Robert Gates appears to oppose legislation that would impose new sanctions on Iran.  But it's not entirely clear that he knows what's in the Menendez-Kirk bill that's currently been endorsed by 59 senators. Or rather, he does not direct his rather vague criticism at the actual provisions of that bill -- which, its proponents would argue, does exactly what Gates is calling for.

Gates told the Wall Street Journal*:

I think that the Senate's effort to pass additional sanctions now, that would become effective now, is a serious mistake, but unlike the administration, I would support the Senate, or Congress, voting additional sanctions, but that would be triggered only with the failure of the negotiations, so that it lets the Iranians know that if this negotiation doesn't work it's not just going back to the way things were at the beginning of the negotiations -- it will be worse for them.  So I think it strengthens the president's hand. We worry all the time about strengthening hardliners on the opposite side of the table. Maybe we oughtta tell the other side of the table that they oughtta worry about some of our hardliners (my transcript).

The summary of Menendez-Kirk circulated on Capitol Hill claims:

The bill does not violate the Joint Plan of Action.  New sanctions would only be imposed if Iran violates the interim agreement or does not reach a final agreement regarding its nuclear program.

Gates, the un-Rumsfeld

Back in December 2008, I thought I saw a subtext in one of the core themes in Gates' writings about Pentagon procurement:

Gates: Have the army you'll go to war with

Defense Secretary Robert Gates' precis of the Pentagon's new National Defense Strategy in Foreign Affairs, A Balanced Strategy, can be read as an extended inversion of Donald Rumsfeld's fatalistic "you go to war with the army you have." Gates' mantra: have the army you'll go to war with. Here as in many speeches, he spotlights the imperative to reform the Pentagon bureaucracy so that it responds more swiftly to the immediate needs of soldiers in the field -- and can think past ingrained assumptions about what kinds of conflict the U.S. needs to prepare for in the future. Hence his subtitle: "Reprogramming the Pentagon for a New Age."

Five years later, no sooner did I crack open (okay, conjure on-screen) Gates' new memoir when I came across the same inversion of Rumsfeld's infamous mantra, this time in Gates' own voice. At the outset, elaborating on his book's title, Duty: Memoirs of a Secretary at War, Gates enumerates several "wars" he had to fight in office, ending with this:

And finally, there was my bureaucratic war with the Department of Defense and the military services, aimed at transforming a department organized to plan for war into one that could wage war, changing the military forces we had into the military forces we needed to succeed (Kindle locations 52-54).

That "war," in Gates telling, emanated from what seems to be the book's core autobiographical claim: that Gates was driven by, indeed obsessed with, safeguarding the welfare of the troops that Bush's bungling (he doesn't put it that way, but the substantive indictment is clear) put and kept in harm's way.  Some of what he did on the troops' behalf is compressed by Fred Kaplan in a remarkable review of Gates' book:

The enemies of the ACA are failing

A couple of days ago, I noted that while the state-run Affordable Care Act exchanges were collectively outperforming HealthCare.gov, that apparent performance gap had been exaggerated by the lag in reporting by states relying on the Federal exchange. Since HealthCare.gov was barely functioning until early December, and some health exchanges were working well much earlier, I noted that the gap should continue to close as new numbers came in.

Today, HHS released state-by-state exchange signup numbers through 12/28. HealthCare.gov states are indeed catching up.  The fourteen states running their own exchanges, along with Washington D.C. (also running its own), encompass just about about one third of the U.S. population (slightly over 100 million people). Their 956,000 signups as of 12/28 comprised about 44% of the total of 2,152,000 signed up on the exchanges.(Honestly, I should have noted a ratio close to this in the prior post, as HHS has for some time claimed about a million signups on HealthCare.gov that it hadn't yet ascribed to specific states.)

Just what has a single mother of three lost in Wisconsin's Medicaid "expansion"?

Today's New York Times has an illuminating contrast of how one-party rule is changing life in the "twinned cities" of Duluth, MN (Democratic) and Superior, WI (Republican). The article's finale focuses on how the Affordable Care Act affects people in Minnesota, which runs its own exchange and is implementing "an expansion of the state’s already far-reaching Medicaid system," and Wisconsin, which declined to run its own exchange and has just won federal approval for a conditional Medicaid expansion, which will offer Medicaid to childless adults earning less than 100% of the Federal Poverty Level (FPL) while at the same time ending existing Medicaid coverage for adults who earn more than 100% FPL*, pushing them onto the exchanges**.

Times reporter Monica Davey found a single mother of three in Superior, WI in the latter category, newly booted off Medicaid because she earns over 100% FPL. Her situation is doubly ironic, in that she works for a nonprofit that serving homeless people -- including helping them sign up for Medicaid -- but is herself a Republican and supporter of Scott Brown Walker. That is perhaps why she has not fully checked out her own options -- which have indeed been worsened by Walker's some win/some lose Medicaid shift, but not as badly as she may think.  The Times article did not delve very deeply into her options  -- so we'll fill in the gap below. Here's the situation:

States on Healthcare.gov have closed the signup gap a bit with states running their own exchanges

A week ago (Jan. 6), Theda Skocpol  crunched state-by-state ACA signup numbers tracked by Charles Gaba and concluded, not surprisingly, that takeup was far higher in states trying to make the law work than in states ignoring or actively impeding the exchanges (not to mention the Medicaid expansion).

That conclusion was not surprising, but the statistics were badly skewed by wide discrepancies in the timeliness of the states' reporting.  HealthCare.gov was barely functional until early December, but the majority of states reliant on HealthCare.gov had posted signup figures only through 11/30 at the time of Skocpol's report.  Almost none had yet tallied the rush of signups immediately preceding and following the 12/23 deadline (later extended) for buyers seeking to obtain coverage effective January 1.  A much-reproduced chart accompanying Skocpol's report showed states relying on HealthCare.gov with anemic exchange takeup rates -- ranging, in various breakouts, from 3% to 6.3% of first-year CBO projections for each state. In contrast, Skocpol showed the 14 states running their own exchanges (and accepting the Medicaid expansion) with a collective exchange takeup rate of 37.2% of CBO projections. (Skocpol gave a rather unsatisfactory account of how the reporting gap should be handled on Charles Gaba's blog, here.)

In the intervening week, seven states relying on HealthCare.gov have updated their signup numbers at least through December 23: Delaware Idaho, Iowa, Nebraska, New Mexico, South Dakota, Wyoming.* Collectively, according to my tote-up, they have reached 16.9% of CBO projections -- 41,186 out of 244,000.

In contrast, the 14 states and District of Columbia running their own exchanges have by my count reached 32.9% of CBO projections -- 1,036,131 out of 3,143,000 projected. (I don't know where the discrepancy with Skocpol's 37.2% comes from; D.C., which she may have omitted, has a 36% takeup rate). Moreover, the Healthcare.gov states' reporting still chronologically lags that of the self-operating states: most of the latter have numbers updated into the first week of January, while most of the HealthCare.gov numbers I've cited date from the last week of December.

A CHIP off the old block in the ACA

Test-driving HealthCare.gov  in various locales, I was a bit surprised to learn that in New Jersey, the kids (under age 19) in a family of four with an income of  $75,000 would be eligible for the Children's Health Insurance Program (CHIP).

Probing for the break point, I found that if the same family earned $82,424, the kids would still be in CHIP. At $82,425 they would not.  The exchange would offer a subsidized plan for the whole family.

The cost difference for the family is negligible. Because families are subsidized so that premiums equal a fixed percentage of the family income, the subsidy for the family just over the CHIP line grows to cover the difference. The subsidy for the $82,235 family in Essex County is $616 per month, while for the CHIP-eligible family earning a dollar less, it's $297. Net result: their premiums for identical silver plans are within a couple of dollars of each other (in Essex County, $654--$655 for the benchmark second cheapest plan). 

CHIP eligibility is not tied to the ACA Medicaid expansion, and every state has its own eligibility break point. In New York, it's 400% of the Federal Poverty Level (FPL). In Texas, it's 200%. In New Jersey, oddly left blank on this otherwise useful map, it's 350% (the FPL for a family of four was $23,550 in 2013). Exchange shoppers in states that have opted out of the Medicaid expansion may nonetheless swell the CHIP rolls a bit -- though only if those shoppers had previously failed to take advantage of their kids' CHIP eligibility.

The ACA's pre-existing condition

Ezra Klein is that rare interviewer whose questions are determined almost as much by what his interlocutor just said as by what he's got planned.  That often includes teasing out real or apparent contradictions between two statements in the interview. So it was in this exchange between Klein and healthcare consultant/ACA critic Robert Laszewski:

K: That brings up two issues. The first is the individual mandate, which begins this year but is a much bigger penalty in year two, and then even bigger in year three. So one question here is how well that works.

RL: I have an interesting answer for that. I think the mandate is almost worthless because the word is getting around that they can’t really collect it. And by year three, it’s really a lot of money. I think there’ll be real pressure to just get rid of it. I don’t think you can force people to buy this insurance. If they don’t want it there’ll be a political groundswell to get rid of it. So in my mind the individual mandate is kind of irrelevant to this.

Writhing out of narrow networks in a medical seller's market

In a recent post, I voiced some unease about the "narrow networks" offered by a majority of plans on the ACA exchanges. According to a McKinsey study cited by the WSJ, 70% of silver plans are "ultranarrow" (offering access to five or fewer hospitals) or "narrow" (offering access to thirteen or fewer hospitals). Doctor rosters are similarly trimmed.  These networks reflect insurers' relative lack of pricing power versus providers.  As Ezra Klein highlights in a column spotlighting the missing link in U.S. healthcare reform, "It’s health-care providers -- not insurers -- who have too much power in the U.S. system."  That's because the U.S. is the only wealthy country in which government does not effectively set prices.

Insurers are thus retailing overly expensive care.  You can't blame them for trying to cut out the most expensive providers in our most-expensive-in-the-world market.  In that prior post, I highlighted one alternative that many employer-sponsored (or funded) plans provide:

Gates' America, no longer pearly

Here is Robert Gates' final word on Congress in his 1996 memoir, From the Shadows:

In the final analysis, though, for all its obstructionism, criticism, and complicating actions, Congress approved the weapons programs, covert actions, arms control agreements, and other measures requested by Presidents to pursue— and control— the struggle with the Soviets. Congressional continuity was, in fact, a reflection of the broad consensus of the American people. And this enduring broad public support was the great underlying strength of the United States in the long struggle with the Soviet Union.

The obstructionism and complicating role of Congress, however, did have a useful function. I sat in the Situation Room in secret meetings for nearly twenty years under five Presidents, and all I can say is that some awfully crazy schemes might well have been approved had everyone present not known and expected hard questions, debate, and criticism from the Hill. And when, on a few occasions, Congress was kept in the dark, and such schemes did proceed, it was nearly always to the lasting regret of the Presidents involved. Working with the Congress was never easy for Presidents, but then, under the Constitution, it wasn’t supposed to be. I saw too many in the White House forget that (p 559).

And here is Robert Gates in an excerpt from his new memoir Duty: Memoirs of a Secretary at War I, due out Jan. 14:

Remember "googol"?

Apropos of nothing except an attic clean-out: it makes me feel old to realize that I wrote this (for kids) before Google existed.  Accidentally dated...

Math Lesson

A googol's a number designed to boggle--

a "1" with a hundred zeros in train--

do you think there have been, since the world began,

a googol drops of rain?

Or might there be, on any beach

a googol grains of sand?

Or in God's mind, on a given day

a googol actions planned?                              

The name came from Kasner, the mathematician

(though legend has it his son supplied it):

What did he do with it after he named it?

He thought about it and multiplied it,

leaving us with the Googolplex--

which all the world's mathematical heroes,

writing together, year by year

could never supply with all its zeroes.

Googolplex! Ten to the googol power--

more zeroes than the eye can see.

The power of googol--what does that mean?

It means a lot to me.

A country struggling to share too-high healthcare costs

Jonathan Cohn today posted a roundup of eight health care experts' prognoses for the Affordable Care Act. Among them is Sean Parnell, author of the book and blog The Self-Pay Patient, information sources for those forced to pay all or most or a good portion of their medical expenses out of pocket. Regardless of whether the ACA "succeeds" or "fails," this part of Parnell's forecast is a near-certainty and worth noting:

There will be more Americans who pay directly for more of their health care. The ACA is projected by the Congressional Budget Office to leave 30 million people uninsured, and tens of millions more will get high-deductible plans through exchanges or their employers. These self-pay patients will demand price transparency and discounts for paying in full at the time of treatment, and innovative entrepreneurs will step up to cater to them while ignoring the traditional third-party payment system.

Many have pointed out the irony of Republicans excoriating the ACA for offering high-deductible plans, which conservatives have long touted as a means to promote patient responsibility and cost control. Some reforms intended to make patients weigh costs could be effective if they include the information required to make an informed choice -- e.g., incentives to choose providers with high performance ratings and transparent pricing -- or reference pricing, where the use of a plan-preferred specialist is fully covered, while patients pay the difference if they want a more expensive provider. 

apolitical xpostfactoid

No one is political all the time. Looking back at 2013's posts, I note that about I seem to indulge in a post that doesn't directly engage the policy or politics of the day a bit more than once a month.  Below, a handful that I'd hope might engage at least a handful of readers. A somewhat longer list after the jump. Happy New Year!

A companion list to The Atlantic's "50 Greatest Inventions" 10/25
A Pooh guide to blogging 7/15
Poor infrastructure breeds its own etiquette 6/2
Kierkegaard, Julian, Obama 5/5
As God gave him to see the right  3/4