That high deductible ain't ineluctible

Dulce et decorum est to highlight the plight of low-income ACA shoppers who choose sky-high-deductible Bronze plans on the ACA exchanges. In some states, there are far too many of them.

But if you're going to do this, for God's sake bring into the narrative the Cost Sharing Reduction subsidies that attach to silver plans for low-income buyers, reducing deductibles and copays. For some buyers, the higher (though subsidized) silver premiums are a hard swallow.  But the story is incomplete if you don't lay out the choice. 

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."