Healthcare access in the U.S.: 2022 in review

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It's been a year of crosscurrents in the healthcare industry -- and of reporters exposing those crosscurrents, often with a ten- or twenty-year look-back. We have seen fantastic investigative reporting on hospitals unleashing hellhounds on indebted patients; hospital systems disinvesting in low income neighborhoods and shifting resources to wealthy ones; private equity degrading and pillaging selected healthcare industry segments (1, 2); hospitals prioritizing VIPs in the emergency room; and insurers finding synergies in what used to be conflicts. Provider consolidation continues apace; Medicare Advantage threatens to swallow fee-for-service Medicare, while its profit-maximizing methods are introduced into fee-for-service Medicare; and MA gaming of risk adjustment goes as yet unchecked, or rather inadequately checked. As for our response to Covid (oy), it’s not really my bailiwick, but see the note at bottom.

On the upside, the federal government got its first toehold in negotiating prescription drug prices; a national prohibition on most medical balance-billing went into effect; the FTC under Lina Khan challenged four hospital mergers; with federal prompting, the number of states providing or soon to provide a year of post-partum Medicaid enrollment rose to 34; CMS proposed a rule designed to smooth Medicaid enrollment on multiple fronts, including limiting renewals (and so, disenrollments) to once every twelve months; the ARPA boosts to ACA premium subsidies were extended through 2025, and marketplace enrollment is on track for a second consecutive year of double-digit growth; and the uninsured rate is at an all-time low (though threatened by the pending end of the moratorium on Medicaid disenrollments).

As in past years, xpostfactoid (and my writings elsewhere) focused mainly on the ACA marketplace, with some forays into Medicaid and Medicare, particularly on the causes and impact of Medicare Advantage’s accelerating gains in market share. As always, I closely examined ACA enrollment patterns, with special attention to the complexities that lead enrollees to suboptimal outcomes.

Below, a few posts from 2022 that went over biggest with…me. I’ve limited selections to the period before I ported xpostfactoid to Substack in late September, as the posts on that site are readily skimmed.

At The American Prospect
How the Texas Legislature Learned to Stop Worrying and Love the ACA Marketplace - 4/21/22
Ground zero for rooted reflexive hostility to the Affordable Care Act is Texas. Or was. While the state still wriggles, writhes and resists expanding Medicaid — which would cut its uninsured rate in half — this year the state legislature unanimously passed legislation that massively boosts subsidies in the ACA marketplace — with the cost borne entirely by the federal government. An amazing tale of bipartisan comity in…Texas.

At healthinsurance.org
Silver, Bronze, or Gold? Choosing a Metal Level in the ACA Marketplace - 4/25/22
The ACA marketplace purports to associate metal level with value. But Cost Sharing Reduction subsidies, which attach only to silver plans, make a hash of purported metal value. So, a guide to marketplace shopping in different income brackets. Relatedly…
Applying for ACA coverage? Know the ropes (between income levels) - 11/28/22
Understanding how small differences in projected income can have a large impact on your health plan costs can be key to obtaining affordable coverage.

At xpostfactoid 

In New Mexico, a Midas Touch has a double edge - 2/9/22
A look at the downside as well as the much bigger upside of a market in which gold plans are cheaper than silver.

In ACA marketplace in 2022, too much underinsurance (bronze plan selection) at low incomes - 3/23/22
In March 2022, the American Rescue Plan made silver plans with strong CSR free-to-low-cost at incomes up to 200% of the Federal Poverty Level. In 2022, too many low income enrollees bought bronze plans.

11 states where high-income marketplace enrollees went for cheap gold plans - 3/28/22
A look at markets where gold plans cost less than benchmark silver

The high-income surge in ACA marketplace enrollment - 4/7/22
ARPA’s removal of the income cap on ACA premium subsidies had its effect.

Is avoiding overpayment of Medicare Advantage plans beyond U.S. government capacity? - 6/3/22
A dive mainly into MedPAC complaints and proposals. See also “To whose advantage is Medicare Advantage? Parts 1 and 2 (here on Substack).

Average weighted actuarial value in the ACA marketplace - 7/20/22
It’s considerably lower than the average in employer-sponsored insurance, and down somewhat from 2016, thanks mainly to silver loading.

U.S. uninsured rate hits an all-time low - 8/3/22
I’d been expecting such a finding for about a year.

Democrats have twelve years of healthcare accomplishment to run on - 8/31/22
They do, really.
——

* Note: On the pandemic front, I am no expert, but I credit those who accuse the U.S. of having failed miserably to institute policies and messaging that would reduce Covid infections and fatalities, make resumption of normal activities safer, protect workers, and ease the stress on healthcare systems. Accordingly the U.S. has the highest Covid deaths per 100,000 ratio among peer nations. I lament failures to mandate paid sick leave and workplace safety measures; facilitate, incentivize, and in some cases mandate vaccine boosters; make rapid tests and N-95 masks widely available and free or close to free; institute widespread indoor air quality control; mandate indoor masking when cases spike; provide effective, unified, up-to-date public health messaging; and facilitate equitable global vaccine distribution. Above all, to my mind, the failure to appropriate fresh funds to fight Covid and prepare for future pandemics is unfathomable. You can blame Republicans for blocking requested funding, but neither Democrats in Congress nor the Biden administration fought hard enough to overcome resistance when they might.

On the plus side, legislation providing economic relief led to a near-miraculous economic recovery from the pandemic’s initial shock and prevented a surge in the uninsured rate. And the swift development of effective vaccines was miraculous. 

2017: A year of healthcare combat

2017 was the fourth year in which xpostfactoid focused mostly on healthcare access -- and more specifically, on ACA implementation (and, this year, on de-implementation, threatened and actual).

It was a year of intense combat (to be continued...) and high drama, and I participated not only via writing, but as an advocate in New Jersey working to help ward off ACA repeal, and as a Certified Application Counselor during Open Enrollment.

Below is a look back at a few posts, roughly one per month, that I hope might have contributed something to our understanding of where we've been and where we're headed in the struggle toward (or away from) universal healthcare access. These include:

• Statistical measures of the extent to which Republican repeal-and-replace bills (AHCA, BCRA) would reduce subsidies to low income Americans (and relatedly, at the contrasting structure and aims of Democratic and Republican healthcare spending cuts).

• Previewing the paradoxical effects of Trump's cutoff of federal reimbursements for Cost Sharing Reduction subsidies, then spotlighting the actual effects in counties where marketplace enrollment is heaviest.

• Snapshots of who's benefited most (1, 2) and who's been left out (1,2,3) by ACA offerings.

• A couple of passes (1, 2) at my vision of how U.S. healthcare might most plausibly and profitably evolve.

Here they are in chronological order, earliest first:

Late Days of Empire Edition: Health Wonk Review

We're addled on many fronts here in Trumpville, and this week's Health Wonk Review reflects that. We have snapshots of a country that continues to trail its peers in population health measures; an opioid vendor looking to short-circuit potential tobacco industry-level liability; an individual market for health insurance offering unaffordable plans to many of the unsubsidized, and freakish bargains to some of the subsidized; and, for a little futuristic relief, a human resources tech vendor that may chain healthcare data to a block, where it shall remain unaltered forever and ever.

At Workers' Comp Insider, Tom Lynch  looks at what the U.S. gets for spending 41% more on health care than our wealthy nation peers in the OECD and 81% more than the entire 35-nation OECD average. Spoiler: not much. We're "sort of like a big-market baseball team spending gazillions more for players than any other team, only to finish out of the running."

At Managed Care Matters, Joe Paduda notes that Purdue Pharma is trying to strike a deal to resolve all state claims relating to opioids. He warns:

"X" is for ten: An anniversary for xpostfactoid

Over the weekend, it dawned on me that xpostfactoid's tenth anniversary was coming up. I checked, and indeed, I started blogging continuously on October 10, 2007, after a couple of false starts.

The thought made me rather sad, in that the blog started as Obama came into full focus and is tied up with my hopes of political and national renewal that gained steam throughout 2008  -- as first the seeming miracle of Obama's nomination drive came to fulfillment and then the wonder of the United States electing an African American whose rhetoric and thought was imprinted with Lincoln's took hold. And look where we are now -- in danger of turning that legacy, if not the whole world, to ashes after electing a lifelong fraudster and vicious demagogue, someone an emotionally grounded six-year-old would run from screaming.

But the blog's first posts from fall 2007 feel strangely contemporary. Back then, in the Later Bush Era, I wondered whether American democracy had lost its ability to self-correct -- precisely the capability that Obama spent the next nine years spotlighting as the nation's defining virtue. If you'll indulge a pair of early snippets:

Facing the Facebook music

I'm a Twitter addict who doesn't much like Facebook. I've been uncomfortable reaching out to healthcare tweeps on my personal Facebook page, or to anyone I don't know personally. Yet I've read that Facebook is a far more potent vehicle for reaching potential readers than any other social media platform. Ergo, I'm giving it a whirl via an xpostfactoid Facebook page, where I'll, um, post posts -- my own, and others that seem worth highlighting/discussing.  Hope you'll give it a look, and a like (or share). If anyone has any suggestions as to how to make it something other than a blog duplicate, I'm all ears.

Update: I think I'm going to like posting/kibitzing on healthcare news of the day on this page. 

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.

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

xpostfactoid at 5

Today is xpostfactoid's fifth birthday as a continuous blog, after a couple of false starts.  Since the blog's heart, for better or wooly-headed worse, has always rested in close reads of Obama' rhetoric, may I commend you to yesterday's post,  The credo of a community organizer?

My not-most-read posts of 2011

As Kevin Drum notes today, all the cool kids (himself now included) are putting up their most-viewed blog posts of the year. Well, you know how we uncool kids cope: with variations on a theme.  My most-read posts have all been boosted by links from my more-trafficked friends in the blogosphere. What I'd like to do here is pull out of storage a few posts that I could have wished had grazed a few more eyeballs.

First, recent readers may have noted how stimulated I've been by Steven Pinker's The Better Angels of Our Nature: Why Violence has Declined.  I've kept up a kind of response journal, in which I've oscillated between enthusiastic assent and various doubts and caveats. Why a running annotated read, instead of a finished review?  Well, I'm impatient, and it's a long book. But also: whatever you think about humanity's prospects, and whatever the weaknesses in Pinker's historiography, this is a book that changes the way you view history and the moment we're living in as you read. I keep viewing other things I read, and age-old musings, in light of it. I hope there's some value in recording this process. So here are the posts, earliest first:

The bettering angels of our nature
Better angels in the news
Religion helped develop our better angels
How our better angels' wings might be clipped
Better angels leave their kitchens in Cairo
Can humanity lead itself out to pasture?
Better dead than red, revisited
Better Angels in Super Hornets

Here are a few more posts, mostly nonpolitical, that I'd like to give a second chance:


The best liar in the field
A president confesses error and defends democracy
Rat race or fluid human dance?
Prophets of the new millennium
Five questions for Obama
Jeffrey Goldberg, excommunicator
Slo-mo grow on the plateau: Tyler Cowen's general theory of American malaise
About those free-range little Krugmans and Manzis
Ruth Marcus's false "false false choice" charge
MIA in the latest Jane Eyre

Thanks for reading! Stay tuned in 2012.

Some comparisons are obvious...

of course, of course. But still, this echo gave me a bit of a chill.  One passage in my rebuttal of Drew Westen's attack on Obama bounced around the web quite a bit, e.g., in the LA Times online:

Sprung, blogging at Xpostfactoid, compared Obama's challengers on the left to Martin Luther King Jr.'s critics during the civil rights era. "Let's not forget that many African Americans at times regarded King as an appeasing sellout, much as many progressives now see Obama as one," Sprung wrote. "The Panthers and the Nation of Islam were more satisfying to many. King called out his adversaries, but he never shrank from engaging with them. Neither has Obama — though the results have not always been what his base could have wished."

Obama, of course, quotes King all the time, and is not shy about identifying with him or Lincoln (and damn the obvious "Mr Obama, you're no..." rejoinders).  As in Iowa yesterday:

"I think that we forget when [Martin Luther King Jr.] was alive there was nobody who was more vilified, nobody who was more controversial, nobody who was more despairing at times. There was a decade that followed the great successes of Birmingham and Selma in which he was just struggling, fighting the good fight, and scorned, and many folks angry.  But what he understood, what kept him going, was that the arc of moral universe is long but it bends towards justice.  But it doesn’t bend on its own.  It bends because all of us are putting our hand on the arc and we are bending it in that direction.  And it takes time.  And it's hard work.  And there are frustrations."

Charles M. Schulz, Palin prophet

Forgive me for repeating myself, dear reader, but compare:

a.) From the Anchorage Daily News, 2/19/11, reporting the leaked contents of a book manuscript by former Palin aide Frank Bailey:

The manuscript opens with an account of Palin sending Bailey a message saying "I hate this damn job" shortly before she resigned as Alaska's governor in July 2009, less than three years into her four-year term.

b) xpostfactoid, 7/4/09, Why she did it:

The year of Obama

Yesterday was xpostfactoid's first birthday (discounting a couple of false starts). It's been an attempt, as the bio at right suggests, to fathom "how democracy works, how it malfunctions and self-corrects." Self-corrects is the operative word: the capacity to "throw the bums out" is what gives governance in functioning democracies the crooked straightness of a good walking stick.

About ten years ago, while reading a Stephen Ambrose's biography of Eisenhower, it occurred to me that the electorate is smarter than I am -- in fact, smarter than any of us. A lifelong Democrat, I realized that the country would not be better off if Democrats always won. Eisenhower, notwithstanding the immoral and destructive coups he authorized in Iran and Guatemala and his abdication on civil rights, was a prudent steward, an able cold warrior, and a constant brake on the military-industrial complex he decried at the end of his tenure. Reagan too has my respect, though I loathe much of what he did to the Federal government's capacity to protect and further social welfare. He did not "win the Cold War," but he did engage Gorbachev with just the right progression from toughness to negotiation to trust. He stepped back and let the Soviet Union unravel itself, providing the right incentives for glasnost and the unwinding of empire.

I had some family evidence of the way democracy works. My paternal grandparents, lifelong Democrats, voted for Reagan in 1980. My father couldn't bring himself to do it, but he voted for John Anderson. Carter's was a failed presidency. Americans recognized it, as they've now recognized Bush's failure. A little late for my taste, but there were reasons for that, beginning with Monica Lewinsky, running through a kink in the Constitution (Nov. 2000), a national trauma (9/11) and a bonding over the year following with a wartime president that was almost but not quite undone by his folly in Iraq.

At the same time, I've wondered through the Bush years whether American democracy retains and will continue to retain the capacity for self-correction. Given the horrendous governance of the Bush team, it's been possible to imagine that a combination of curbs on civil liberties, deregulation, lobbyist empowerment, gerrymandering, media degeneration and advanced political marketing could eventually foreclose the possibility of a peaceful transfer of power -- a truly contested election. 2006 provided major reassurance. Democracy in America is not dead yet. But I still think it's on the endangered list.

The greatest danger to American democracy is the Bush Administration's assault on civil liberties. We've barely noticed, but the Bill of Rights has been gutted. The Administration has successfully asserted the right to deem anyone it wishes an "enemy combatant," hold such people indefinitely, and torture them at will. This has been done to American citizens. Just this week, meanwhile, we learned that peaceful protestors against the death penalty were classified as terrorists by the Maryland State Police. Americans have largely accepted and even embraced this disinheritance. Only a bare majority tells pollsters that torture is wrong--a smaller majority than in any developed democracy, smaller even than in China. This past primary season, the Republican candidates for President were vying do outdo each other in their fervent support of torture and suspension of habeas. McCain, the best of that lot on this crucial front, betrayed his own prior opposition to torture, first by agreeing to loopholes in the Military Commissions Act of 2006, then by voting against a provision that would have ended the CIA's exemption from the prohibition against torture in the armed services.

As of now, the executive branch of the federal government can assert absolute control over the corpus of anyone it wants. Habent corpus - they have the body. If we don't change course, the executive may widen the scope of those over whom it asserts such control at any time -- say, after the next major terrorist attack. McCain will not roll back executive power. It's not even certain that Obama will do it. On this front he's right: it's not about him, it's about us. Lovers of liberty will have to be ready on day 1 to hold his feet to the fire.

Despite these dangers, and all the viciousness of various phases of the presidential campaign, this election season has also been a time of tremendous hope. For me, the (first) year of xpostfactoid will forever be the Year of Obama. I have wrestled with "naivetephobia" -- the fear of looking foolish, and later recognizing the folly, of buying into a presidential candidate's calls for renewal embodied in...himself ("it's not about me, it's about you," is at best a paradox). But Obama is right on this point: we have had great leaders before at times of great peril. We have made great changes -- abolishing slavery, building the core citizen protections of the New Deal, enacting civil rights legislation and making it stick.

For those of us who have dared (sorry!) to hope for great things from Obama, the Lincoln parallel is the great repressed reference point. The New Yorker, in an extraordinary endorsement essay, obliquely invoked this charged analogy:

Obama has returned eloquence to its essential place in American politics. The choice between experience and eloquence is a false one––something that Lincoln, out of office after a single term in Congress, proved in his own campaign of political and national renewal. Obama’s “mere” speeches on everything from the economy and foreign affairs to race have been at the center of his campaign and its success; if he wins, his eloquence will be central to his ability to govern.

Like Lincoln, Obama rose to national prominence by sheer force of intellect as evidenced in speeches. Exactly contrary to what his critics claim, his speeches are effective not because of soaring empty rhetoric but because his calls for renewal are underpinned by a clearly articulated reading of American history and an equally explicit enumeration of the priorities that his policy proposals are designed to advance.

Those priorities are to restore "fairness" in our tax code, roll back rising income inequality, and revive effective regulation; to invest in projects essential to prosperity in the next century (alternative energy, universal healthcare, education); to reduce the power of lobbyists and change the tenor of political discourse; to recenter our antiterror efforts on Afghanistan/Pakistan; and to re-establish diplomatic engagement and nonmilitary aid as pillars of our foreign policy. He spells them out repeatedly, and he has won over what looks to be a majority of Americans with this multi-pronged pitch. That's not to say that Obama's campaign is free of hokum and pandering. But the outlines of what he aims to accomplish are clear.

If this blog has any value, it's mainly in the year-long attempt to listen to Obama, to highlight the internal logic of his metapolitics, his foreign policy, his economics, and his political strategy. If he wins and is immediately whipsawed by events, if he proves as feckless as Carter or as slippery as Clinton, the blog will serve to remind only myself (who else will read back?) of my own folly. If he does indeed prove to be a transformational president, an instrument of democratic self-correction and American renewal, I'll be proud to have tuned in early.

Pause, refresh: Obama's core case against Clinton

After several weeks' full immersion in what Obama calls the "silly season" of our politics, it's clarifying to look afresh at the core of Obama's case for himself rather than Clinton. Here's how he put it on April 22 in Evansville, Indiana, after congratulating Clinton on her win in the PA primary:

We can be a party that says there's no problem with taking money from Washington lobbyists - from oil lobbyists and drug lobbyists and insurance lobbyists. We can pretend that they represent real Americans and look the other way when they use their money and influence to stop us from reforming health care or investing in renewable energy for yet another four years.

Or this time, we can recognize that you can't be the champion of working Americans if you're funded by the lobbyists who drown out their voices. We can do what we've done in this campaign, and say that we won't take a dime of their money. We can do what I did in Illinois, and in Washington, and bring both parties together to rein in their power so we can take our government back. It's our choice.

We can be a party that thinks the only way to look tough on national security is to talk, and act, and vote like George Bush and John McCain. We can use fear as a tactic, and the threat of terrorism to scare up votes.

Or we can decide that real strength is asking the tough questions before we send our troops to fight. We can see the threats we face for what they are - a call to rally all Americans and all the world against the common challenges of the 21st century - terrorism and nuclear weapons; climate change and poverty; genocide and disease. That's what it takes to keep us safe in the world. That's the real legacy of Roosevelt and Kennedy and Truman.

We can be a party that says and does whatever it takes to win the next election. We can calculate and poll-test our positions and tell everyone exactly what they want to hear.

Or we can be the party that doesn't just focus on how to win but why we should. We can tell everyone what they need to hear about the challenges we face. We can seek to regain not just an office, but the trust of the American people that their leaders in Washington will tell them the truth. That's the choice in this election.

Three interlocking points here. First, metapolitics: we can't change our policies until we change our political process. On one level, "Washington is broken, we need an outsider" is the oldest schtick in our politics. But Obama has done something about it, almost singlehandedly. He's refused lobbyist money, and pac money, and opened the floodgates of small donations. He's changed political funding forever. We tend to forget what a tremendous accomplishment this is. His argument is simple: change the money flow, and you'll change our politics. Why should we believe he can do this? Because he's accomplished part one already.

The second point is also simple, but true: I opposed this war from the start. I offer a clean contrast with McCain. Clinton can reduce this difference to "a speech he gave in 2002," but the fact is that Obama spoke out repeatedly against the war from October 2002 through to the day of invasion, March 20, 2003, and beyond. And the contrast has bite because there's resonance to the charge that Hillary supported the war primarily to preserve her own political viability. Why else would she neglect to read the NIE before voting to authorize force? Why else would she rally round in early 2003 when Bush "rushed to war" precisely as she warned him against doing in her Oct 10, 2002 speech supporting the resolution authorizing force?

Finally, there's the "truthiness"argument, which Obama grafted onto his "change our politics" argument back in January, when he first started calling the Clintons out for distorting his record -- and suggesting that these Rovian tactics undermine voter trust. Here's how he put it in the Jan. 22 CNN debate:

there's a set of assertions made by Senator Clinton, as well as her husband, that are not factually accurate. And I think that part of what the people are looking for right now is somebody who's going to solve problems and not resort to the same typical politics that we've seen in Washington...the larger reason that I think this debate is important is because we do have to trust our leaders and what they say. That is important, because if we can't, then we're not going to be able to mobilize the American people behind bringing about changes in health care reform, bringing about changes in how we're going to put people back to work, changing our trade laws. And consistency matters. Truthfulness during campaigns makes a difference.

In yesterday's Washington Post, Clinton's new chief strategist Geoff Garin tried to cast this three-pronged critique, which Obama has stuck to and sharpened for months, as a character attack. What it is in truth is a penetrating critique of Clinton's campaign and of her decisions and actions while in office. The attack is on "character" only insofar as Clinton's campaign and tenure in office express her character. Obama never suggests that Clinton is a bad person. He does argue explicitly that she is enmeshed in those elements of the political process he's trying to change. The attack also remains in bounds -- not violating Ronald Reagan's 11th Commandment -- because Obama states repeatedly that Clinton will make a far better President than McCain (or Bush).

There may be 80% overlap in Obama and Clinton's written policy proposals. But the differences outlined above are real, and they're fundamental. The Obama campaign remains on focus.

Related posts:
Obama endorses Hillary!
Changing 'the rules' on Clinton
Debunked! Obama spanks the Clinton Kids again
Truth and Transformation
Obama Praises Clinton, and Buries Him
Obama: Man, those Clinton Kids are Something