The ACA saved his life. Its subsidies saved his finances. Its enemies almost killed him

The Philadelphia Inquirer's Robert Calandra has a great story about a death's-door ACA conversion experience for a certain Dean Angstadt:

"I don't read what the Democrats have to say about it because I think they're full of it," he told his friend Bob Leinhauser, who suggested he sign up.
That refrain changed this year when a faulty aortic valve almost felled Angstadt. Suddenly, he was facing a choice: Buy a health plan, through a law he despised, that would pay the lion's share of the cost of the life-saving surgery - or die. He chose the former.

Read more at http://www.philly.com/philly/health/healthcare-exchange/20140427_Hs1obamacare27xxxxxxxxx.html#E8pxpMvPEBLcEwee.99

"I don't read what the Democrats have to say about it because I think they're full of it," he told his friend Bob Leinhauser, who suggested he sign up.
That refrain changed this year when a faulty aortic valve almost felled Angstadt. Suddenly, he was facing a choice: Buy a health plan, through a law he despised, that would pay the lion's share of the cost of the life-saving surgery - or die. He chose the former.

Read more at http://www.philly.com/philly/health/healthcare-exchange/20140427_Hs1obamacare27xxxxxxxxx.html#E8pxpMvPEBLcEwee.99

 He's a self-employed, self-sufficient logger who has cleared his own path for most of his 57 years, never expecting help from anyone. And even though he'd been uninsured since 2009, he especially wanted nothing to do with the Affordable Care Act.

"I don't read what the Democrats have to say about it because I think they're full of it," he told his friend Bob Leinhauser, who suggested he sign up.

That refrain changed this year when a faulty aortic valve almost felled Angstadt. Suddenly, he was facing a choice: Buy a health plan, through a law he despised, that would pay the lion's share of the cost of the life-saving surgery - or die. He chose the former.

Angstadt's conversion was complete almost immediately following his online signup for a private plan in late January. ", "All of a sudden, I'm getting notification from Highmark, and I got my card, and it was actually all legitimate," he said. "I could have done backflips if I was in better shape."

At that point in the story I did wonder whether this jubilation would be tempered when the gentleman had a full accounting of his share of out-of-pocket costs. ACA plans tend toward high deductibles -- an average of almost $3,000 for silver plans, which is the level he chose -- and out-of-pocket maximums that often hit the allowable per-person limit of $6,350.

Attention, Mitch McConnell: More than half of Kentucky is a high-risk pool

As highlighted in my previous post, in the recent NYT/Kaiser poll of attitudes toward the ACA in four red states, an astounding 57-60% of respondents reported that someone in their household has a pre-existing condition. In Kentucky, the number was 60%.

That fact throws into stark relief Mitch McConnell's response when asked what he would do for terminally ill Kentuckians who would lose their new insurance if the ACA is repealed, as he has demanded it must be:

There are a lot of people like that, of course, who are losing what they had before, who were insured through the high-risk pool, who are losing what they had before.The way that should’ve been handled was state-based high-risk pools. Not at the federal level. Because for every one of those, you’ve got somebody who was insured and through a state-based high-risk pool, who lost their situation because they were wiped out Dec. 31 of 2013. So I’m worried about those people.

As the Louisville Eccentric Observer, an alt-weekly, points out*, the state's high risk pool covered fewer than 4,000 people in 2013 --  less than one hundredth of the 413,000 who obtained insurance this year via Kynect, the state's  ACA exchange. Ah, Mitch might respond, but not all of those 400,000 would need a high-risk pool. True -- just most of them (or else would pay through the nose for private insurance).

More than half the families in four deep red states have a member with a pre-existing condition

Remember the rate-shocked -- those folks who received cancellation notices on their insurance policies last fall and who were faced with steep rate hikes as the Affordable Care Act took full effect? They exist, for sure. But there are probably fewer of them than earlier estimates indicate.  And there can't be a lot of them in four red states spotlighted in the Times/Kaiser poll released this week.

The people in those states -- Arkansas, Kentucky, Louisiana and North Carolina -- disapprove of the ACA by margins ranging from 31 points (AR. 62-29)  to 16 points (NC, 54-38), according to the poll. At the same time, however, majorities in each state, ranging from 57-60%, reported that someone in their household has a pre-existing condition. Think about that for a moment.

Red state attitudes toward the ACA: like America's, but more so

Update, 4/25:  see next post re the high rate of pre-existing conditions reported by respondents to this poll.

A New York Times/Kaiser Family Foundation poll released yesterday probes perceptions of the Affordable Care Act in four red states, Arkansas, Kentucky, Louisiana and North Carolina. * In all of these states, Obama's approval rating is in the 30s, and the ACA is also deep underwater, with approval/disapproval percentages ranging from 29/62  in Arizona to 38/54 in North Carolina.*

Those overall judgments, stoked by five years of relentless Republican denunciations and a barrage of negative advertising in recent months, are stark.  And yet, the underlying attitudes revealed in the poll's internals are strikingly congruent in key respects to the attitudes toward prospective healthcare reform recorded nationally in a Kaiser poll conducted in December 2008, when approval for a president-elect who had campaigned on a national healthcare overhaul was sky-high. 

In both polls, majorities opposed simply maintaining the pre-ACA status quo -- doing little or nothing to expand coverage in 2008, repealing the ACA today. In both, majorities favored government action to make health insurance available to people who could not get it from their employers. In both, majorities supported expanding Medicaid.  Yet in both, majorities rejected the notion that it was the federal government's responsibility to make affordable healthcare coverage available to all Americans.

Bringing a fire extinguisher to a flood

A few days ago,  a friend sent me a 297-word graduation speech by economics Nobel laureate Thomas Sargent, delivered in 2007, that's been making the rounds. The speech consists of twelve precepts, delivered with economists' economy, that have been hailed as a distillation of "everything you need to know about economics," as Ezra Klein -- too fond of such sweeping overstatement since launching Vox -- put it.

The piece rubbed me the wrong way, not because its precepts are not true, but because their uber-message seems out of step with our slow-growth, post-meltdown, austerity-hog-tied economy. The upshot, as Josh Barro summarizes it this morning, is that there's no free lunch. The two bullet points that bugged me in particular  were these:

4. Everyone responds to incentives, including people you want to help. That
is why social safety nets don't always end up working as intended.

5. There are tradeoffs between equality and efficiency.

To take the second first: sure. But as we've learned in the last few years, there's also tradeoffs between inequality and efficiency. When the top 1% grab 95% of the fruits of growth, they tend to 1) use their outsized capital unproductively, increasing their rents, 2) hollow out their customer base, and 3) extend their control over the political system, eroding checks on their own power and ensuring their further corruption.

In December 2008, support for ACA linchpins was broad and shallow

As the Affordable Care Act's first open enrollment season wraps up with a major surge, the law's implementation remains as polarized as public opinion and party rhetoric. States that ran their own exchanges and accepted the Medicaid expansion reduced their uninsured populations by three times as much as states that abstained on both counts, according to Gallup polling. California and Connecticut reached 175% of the CBO's projection for first-year private plan signups; Oklahoma, just 28%, according to Charles Gaba's spreadsheet. Meanwhile, as Obama declared, "the repeal debate is and should be over” and “the Affordable Care Act is working," Republicans geared up once again to make repeal and denigration of the law the centerpiece of their election strategy.

At this juncture, after five years of political mortal combat, it's instructive to look back at Americans' reactions when first confronted with the proposed core provisions of the ACA. The Kaiser Family Foundation probed opinions about those measures back in December 2008, polling over 1600 adults (thanks, Larry Levitt). By that point, the prospective law's outlines were clear, as all three Democratic candidates had proposed similar healthcare reform plans.

At first blush, respondents were enthusiastic about the mechanisms for expanding private-market health insurance: requiring employers to cover employees, and requiring individuals to buy affordable coverage. When asked to consider potential consequences of those mandates, however, respondents turned ambivalent.  The poll results might have been read to provide cover to Democrats to move forward. But they also pointed to multiple entry points for Republicans to exploit the pending legislation's tough tradeoffs.

Liberal Dem, Conservative Doc

As a front-page blogger at Daily Kos and creator of the site's popular Daily Pundit Roundup, Dr. Greg Dworkin (f.k.a.DemFromCT, now blogging under his real name) is a high-profile political liberal.  On Twitter, he is an enthusiastic if scrupulously evidence-based proponent of the Affordable Care Act, defending the efforts it embodies to extend access, control costs and improve quality in healthcare delivery.

As a pediatric pulmonary physician with nearly 25 years in private practice, however, Dr. Dworkin spontaneously describes his approach to systemic change in the medical delivery system as "conservative."  He is not hostile to concepts such as coordinated care, bundled payments or risk-based payment -- in fact he has adapted to many changes along these lines over the course of years. He just sees innovations on this front as incremental and experimental -- and to be judged on the basis of evidence that's not in yet.

Dr. Dworkin's thinking about healthcare reform is also, to a degree, conservative in a more political sense. While he sees no clear benefit as yet from reforms in the way doctors and hospitals are paid, he does witness patients growing ever more cost-conscious as health plan deductibles rise and prescription drug coverage grows more restrictive. In a recent discussion of what healthcare reform looks like from the physician's point of view, he placed more emphasis on the effect of newfound cost-consciousness in patients than on changing incentives for doctors.

As with bundled payments, he said, the advent of consumer cost-consciousness is "a process that's been happening for a long time -- it predates and goes in parallel with the Affordable Care Act."

Program note

Blogging has been slower here because I'm working on two reported pieces. One, which I'll post tomorrow morning, is an interview with  Dr.Greg Dworkin, pediatric pulmonary physician and headline Daily Kos blogger, exploring what efforts to control healthcare costs look like from a physician's standpoint. While obviously politically liberal, Dr. Dworkin, like most doctors, is an empiricist and therefore "conservative" in the sense of requiring evidence before crediting any given reform measure.

Happy Easter, everyone. I gather it's all about "chocolate eggs and Jesus risen," as C.S. Lewis once heard a 4 year-old murmuring to himself.  In metro New York this year, it's also all about glorious sunshine and refreshingly cool breezes.  So here's to worshiping outside.

Racism in service of plutocracy: Beutler's response to Chait

Jonathan Chait's two-front argument that 1) the Republican policy platform has deep roots in slavery and racism, but 2) Democrats are too quick to ascribe racism to individual conservatives, their policy positions and utterances, angered a lot of progressives, who see false equivalence as well as neglect of the real effects of conservative policies on African Americans and other minorities.

On the false equivalence front, Brian Beutler argues that Chait has mischaracterized progressives' case that the Republican gestalt is racist:

Tell me your ACA-shopping story

Always fair-minded, Jonathan Cohn pauses in his celebration of lower-than-forecast ACA premiums (as highlighted by the latest CBO update) to acknowledge:

In the transition from the old system, in which insurers could charge higher prices to the sick or avoid them altogether, to a new system, in which everybody pays the same price regardless of pre-existing condition, some young and healthy people must now pay more for their individual policies

The "and" in "young and healthy" is interesting, because, as the conjunction suggests if you look twice, it's not just the young who are paying more under ACA rules. Some if not most healthy older buyers who were in the individual market in 2013 are now paying more -- that is, if no one sharing the insurance has a preexisting condition.*

If you're in the individual market and you're paying more for your insurance in 2014 than you did in 2013, I'd like to speak to you (or, for that matter, if you're unsubsidized and paying less or about the same).  I'd like some detail about what your prior policy covered vs. what your current one does -- what were the tradeoffs. (I wrote up two such stories last month, and I'd like to do more.)

Cognitive dissonance on Passover

I suffer from it, as recounted in this June 2011 post:

Jeffrey Goldberg, Excommunicator

Jeffrey Goldberg has ignited a blog conflagration with an attack on Allison Benedikt's coming-of-age tale of her progressive disillusionment with the gung-ho Zionism she sucked up in summer camp. I found Benedikt's  narrative riveting, and Goldberg's critique smotheringly self-righteous.

Goldberg asks of Benedikt: "Does she ever try to answer for herself why Israel exists? Or is she happy to subcontract out her thinking about the most important questions facing Jews first to her camp counselors, and then to her husband?"  It's true that Benedikt's stances on the issues are barely sketched in, but that in itself suggests neither a lack of thought nor of due diligence. Her focus is on how her changing perceptions registered emotionally, not on the data points that caused them. Hers is not a policy piece; it's a chronicle about how she navigated the family mania for Israel -- and later, her husband's antipathy toward the country -- over the course of a decade and a half or so. Benedikt's response to Goldberg makes this point better than I can.

I want to focus on Goldberg's most poisonous charge -- which he saves for last. I think it reveals more about him than about Benedikt:

And then there is a whole set of other questions:  Does she ask herself whether she has a responsibility to make Israel a better, more humane, place? Does she question herself about the consequences of abandoning Israel? Does she think about the sin of the wicked son in the Passover story, and how that sin might echo in her own life? 

Abandoning Israel? Goldberg seems to have derived that idea from Benedikt's kicker at the close. Let's take a look:

Why the South doth prevail (and why to some extent it didn't)

A 1957 essay by William F. Buckley, Why the South Must Prevail, was making the rounds on Twitter last night (thanks to Erik Kleefeld). In it, Buckley pretends to some regard for the ultimate welfare of Southern "negroes" but asserts that Southern whites have the right to preserve their cultural superiority by denying their black neighbors the right to vote --because  "the claims of civilization supersede those of universal suffrage."

That is, southern whites don't want to integrate and so pollute their...culture, so they have the right to keep "negroes" from voting to force them to do.  How can a minority claim to speak for "civilization"? "[T]he White community is so entitled because, for the time being, it is the advanced race."

People well-versed in Buckley's oeuvre and career, and in the legislative civil rights battles of the of the late 50s, will doubtless weigh in with appropriate context and analysis. Lacking more than passing familiarity with the latter and interest in the former, I still think it's worthwhile to note a couple of points that struck me, coming to this cold.

The moral (and economic and social) equivalent of war, revisited

William James' prescient 1910 essay The Moral Equivalent of War was written in part as a rebuttal to pre-World War I theorizing about the role of war in human society that to post-world-war eyes look rather shocking:

Other militarists are more complex and more moral in their considerations. The Philosophie des Krieges, by S. R. Steinmetz is good example. War, according to this author, is an ordeal instituted by God, who weighs the nations in its balance. It is the essential form of the State, and the only function in which peoples can employ all their powers at once and convergently. No victory is possible save as the resultant of a totality of virtues, no defeat for which some vice or weakness is not responsible. Fidelity, cohesiveness, tenacity, heroism, conscience, education, inventiveness, economy, wealth, physical health and vigor — there isn't a moral or intellectual point of superiority that doesn't tell, when God holds his assizes and hurls the peoples upon one another.

James did not dismiss such views out of hand. Asserting, "The war-party is assuredly right in affirming and reaffirming that the martial virtues, although originally gain by the race through war, are absolute and permanent human goods," he wondered how humanity might martial those virtues in less destructive ways. And as I noted in The Moral Equivalent of Warmongering, Steinmetz's sentiments maintain a persistent half-life in in common attitudes, expressed via boomer-bashing and other (eternal) moralizing that excoriates those who have concerned themselves mainly with peacetime pursuits.

Today it's not acceptable to suggest that war is a consummation devoutly to be wished. But Ian Morris, in War! What is it Good For?* has updated the argument that war has so far been a major spur of human development -- not only technological, a reality impossible to ignore -- but social and political as well.  In effect, it seems Morris argues (I haven't read the book yet -- excuse the blogger's license) that war has taught us peace. From David Crane's review in The Spectator:

Chait channels Obama

When I read Jonathan Chait's extended argument that a) many Republican policies have deep roots in slavery and racism, but b) for liberals to assume that advocacy of core conservative policies is itself a marker of racism is illegitimate, my immediate thought was that Chait was echoing Obama:

@xpostfactoid1  Apr 7@jonathanchait Hey, didn't Obama say that in March 2008? http://www.huffingtonpost.com/2008/03/18/obama-race-speech-read-th_n_92077.html …

In a followup post, Chait himself notes that Obama had more recently stolen his fire -- in an interview with David Remnick published this past January:

“There is a historic connection between some of the arguments that we have politically and the history of race in our country, and sometimes it’s hard to disentangle those issues,” he went on. “You can be somebody who, for very legitimate reasons, worries about the power of the federal government — that it’s distant, that it’s bureaucratic, that it’s not accountable — and as a consequence you think that more power should reside in the hands of state governments. But what’s also true, obviously, is that philosophy is wrapped up in the history of states’ rights in the context of the civil-rights movement and the Civil War and Calhoun. There’s a pretty long history there. And so I think it’s important for progressives not to dismiss out of hand arguments against my Presidency or the Democratic Party or Bill Clinton or anybody just because there’s some overlap between those criticisms and the criticisms that traditionally were directed against those who were trying to bring about greater equality for African-Americans. The flip side is I think it’s important for conservatives to recognize and answer some of the problems that are posed by that history ...”

That is in fact a pretty exact match with Chait's thesis, as Chait asserts. But like almost everything Obama says -- in fact like almost everything most of us say -- it was close kin to prior pronouncements.  Here's what I had flashed back to, from Obama's great speech on race in the immediate wake of the Jeremiah Wright controversy. After recounting the roots of African American anger, Obama pivoted, in his on-the-one-hand-on-the-other manner:

Some notes on the RAND survey

RAND has released its latest survey results on the health insurance status of American adults aged 18-64, spotlighting changes in health insurance enrollment since 2013. The results are based on survey responses from 2,425 people -- and since RAND surveys its panel monthly, it is able to track changes in health insurance status, pegging sometimes quite wide margins of error for each finding. The top line is that an estimated 9.3 million more people had health care coverage in March 2014 than in September 2013 (albeit plus or minus 3.5 million). That is, as Adrianna McIntyre frames it, "the uninsured rate among 18-64 year old adults in the United States fell by 23 percent—from 20.5 percent to 15.8 percent."

Adrianna also spotlights the report's biggest surprise: that the bulk of the increase comes from an estimated 8.2 million people gaining employer-sponsored insurance (ESI). RAND speculates that "some" of these people "may have taken up an employer plan as a result of the individual mandate; others may have newly found a job."  RAND found that only about 1.4 million people gained coverage from the new exchanges, as only about a third of the 3.9 million they found gaining coverage through the exchanges were previously uninsured.

A few thoughts and questions in response to the RAND findings are outlined below. My own confirmation bias may be at work, but I suspect that more than one third of ACA private plan signups were previously uninsured, for reasons outlined mainly in point #5.

This subsidized health insurance was brought to you by...?

Urging caution in response to current ACA signup stats and polling results, Jonathan Bernstein reiterates his  favorite question with regard to the political fallout:

How many of those in the exchanges, in expanded Medicaid, and newly eligible for their parents’ insurance plans are aware that they are covered by Obamacare? I’ve consistently guessed that a large number of people wouldn't make the connection, but we still have no data.

I have always found the possibility that some people would sign up for coverage made available through the ACA without knowing that the ACA (or "Obamacare") was responsible fascinating and challenging. Sometimes Bernstein emphasizes that over time -- say, five years from now -- a lot of people who buy Qualified Health Plans or sign up for Medicaid on Healthcare.gov or the state exchanges won't know that their options originated with the new law. That seems easier to credit than that a significant percentage, if not a majority, of this year's signups would not know that "Obamacare" was the source of their coverage.

Regarding awareness among this year's signups, a few thoughts:

1. It takes a village:  Drew Altman, President of the Kaiser Family Foundation, points out that in California, which spent more on ACA outreach than all the federal exchange states combined, relatively few of the uninsured signed up on their own:

"How politics makes us stupid": Ezra Klein's hypothesis, Chait's case study

Serendipity. On one sunny Sunday, Jonathan Chair purported to explain the controlling dynamic in U.S. politics. And Ezra Klein purported to explain the controlling dynamic in politics, period. Their hypotheses are congruent.

Klein deployed social science research from a team led by Yale law professor Dan Kahan demonstrating that all of us actively resist evidence that challenges our assumptions. In matters of passion and identity, we almost literally can't see contrary evidence. Exhibit A is an experiment in which people who had already demonstrated their ability to use math to arrive at a counterintuitive conclusion disabled that capacity when it threatened to undermine a political conviction.

In Kahan's experiment, people who had previously parsed data about the effectiveness of a skin cream were shown similarly presented data about the effectiveness of gun control. And, lo:

For pharma and medical device makers, U.S. is The Big Rock Candy Mountain

The New York Times' Elisabeth Rosenthal is out with another front-page chapter in her incomparable epic detailing the dysfunction of the U.S. healthcare system. She's spotlighted (1, 2, 3) price-gouging by various physician specialties, hospitals, and now medical device makers and pharma.

Rosenthal focuses mainly on diabetes treatment. It really has improved radically over the past two decades, with ever-more sophisticated insulin pumps and accouterments, and synthetic human insulin.  But near-monopoly pricing power -- unmitigated, in the U.S. alone, by strong government pushback -- forces many patients to buy more sophisticated treatment than they need, at astronomical markups. As is de rigeur in Rosenthal's pieces, the contrast with other wealthy countries hurts most. The contrast with the U.K. highlights strengths and, to a lesser extent, weaknesses of a system that contrasts starkly with our own:

In Britain, each hospital negotiates for pumps for its patients, getting prices that are typically less than half those in the United States, Dr. Pickup said. The vial of insulin analogue that Ms. Hayley gets for $200 at an American pharmacy is typically bought by British pharmacists for under $30 and dispensed free....

Chewing the Israeli spider to catch the Iranian fly

Times reporter Jodi Rudoren's analysis of the near-breakdown in Israeli-Palestinian talks relays a strong conviction that the talks are going nowhere. But process for process's sake is not necessarily pure insanity:

...keeping the Palestinian track alive helps prevent Mr. Netanyahu and his allies in the United States Congress from taking steps that could threaten diplomacy with Tehran.

True, Rudoren also alleges the converse, in a roundup of supremely cynical rationales for keeping the talks going:

[The talks]are a critical confidence-builder in Israel’s strained relationship with Washington, providing Mr. Netanyahu with access and leverage to press his case on Iran.

But better a Netanyahu whispering darkly of eternal Iranian perfidy than going before the U.S. Congress to denounce a "bad deal" to thunderous bipartisan applause.

The health insurance market is an ocean, endlessly churning

Long, long ago, back on March 22, I noted of the ACA signup count that it ain't over when it's over. Medicaid enrollment, including those newly eligible under the ACA expansion, is open all year. And in this interval between open enrollment periods, many people will become eligible for a two-month "special enrollment period" if they experience a "qualifying event" such as job loss, divorce, marriage (if, say, one of the couple has no income), or childbirth. I also noted with some wonder how fluid health insurance markets are: according to an estimate by healthcare scholars Rick Curtis and John Graves, less than half the people who will be eligible for ACA enrollment at the end of 2014 will have been eligible a year prior. [Update, 4/4: Graves has just made the case anew with Jonathan Gruber.]

Today's news brought several further snapshots of this fluidity. The LA Times' Chad Terhune noted another large category of pending special enrollments -- college graduates:

it's estimated that several hundred thousand more Californians could qualify for a special enrollment period as college students graduate, families move and workers change jobs.

In the short term, also in California, extended enrollment for those who started but could not complete applications before 3/31 is going to be huge, reports Marketwatch's Russ Britt:

Quote of the decade

... that came very early in the decade, 1/28/10*. Remember when Scott Brown won his Senate seat, Democrats were running around like chickens with their heads cut off, Obama's trumpet was still uncertain, and Nancy Pelosi said this?

You go through the gate. If the gate's closed, you go over the fence. If the fence is too high, we'll pole vault in. If that doesn't work, we'll parachute in. But we're going to get health care reform passed for the American people.

 That, ducks, is leadership. Followed through with a whip job for the ages.


* Yeah, yeah, that was the last decade, technically. And?

Where Obama's placation ended

In honor of the ACA's end-of-open season rush, a repost. 

Sunday, April 18, 2010

Garry Wills, summing up David Remnick's portrayal of Obama in The Bridge: The Life and Rise of Barack Obama, is close to right, and yet so very wrong, as he segues to his own judgment:

Obama’s strategy everywhere before entering the White House was one of omnidirectional placation. It had always worked. Why should he abandon, at this point, a method of such proved effectiveness? Yet success at winning acceptance may not be what is called for in a leader moving through a time of peril. To disarm fears of change (the first African-­American presidency is, in itself, a big jolt of change), Obama has stressed continuity. Though he first became known as a critic of the war in Iraq, he has kept aspects or offshoots of Bush’s war on terror — possible future “renditions” (kidnappings on foreign soil), trials of suspected terrorists in military tribunals, no investigations of torture, an expanded Afghan commitment, though he promised to avoid “a dumb war.” He appointed as his vice president and secretary of state people who voted for the Iraq war, and as secretary of defense and presiding generals people who conducted or defended that war.