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

Good news: HealthCare.gov's shop-only feature is now all you could wish

In the darkest days of HealthCare.gov's dysfunction, I was preoccupied for a time by the partial workarounds enabled by third-party informational sites like ValuePenguin and HealthSherpa. ValuePenguin in particular offered (and still offers) a near-complete and accurate substitute for the informational functions of HealthCare.gov: it will calculate your subsidy and show you all available plans, accurately priced, with plan summaries.

HealthCare.gov at first, famously, had no pre sign-in informational feature allowing users to scope out options if they could not register, as most couldn't. When that feature was hurriedly added, it at first referred people to the Kaiser subsidy calculator, rather than incorporating its own subsidy calculation. It also gave out misinformation, at least for me in New Jersey: failing to query about age, the site quoted prices at a middle-range age without disclosing that it was doing so. In my case, the quoted prices were half to two-thirds of the actual prices, which I found on ValuePenguin and confirmed with the insurers.

The Wall Street Journal's narrow view of narrow networks

I have see-sawed back and forth between respect for the Wall Street Journal's healthcare reporters and intimations that WSJ coverage of the Affordable Care Act has been skewed toward the negative.

Today's front-page story by Timothy Martin on the prevalence of "narrow networks" in plans offered on the ACA exchanges certainly emphasizes the negative -- without adequate context, in my view.

First, consider the broader context. News this weekend was full of "ACA signup surge" headlines: 1.1 million people have enrolled in plans via HealthCare.gov, and about 2 million overall have enrolled in ACA plans when state exchange totals (not yet fully tallied for the pre-Christmas surge) are added in.  That's well off original projections but signals a significant recovery and acceleration. Today's front-page Journal story is the first since these numbers came in, and mentions them only in passing.

Fair enough, perhaps. The story is about "narrow networks" -- ACA plans that exclude access to many doctors and hospitals within the coverage area. The narrative is built on a McKinsey study finding that 70% of silver plans offered on the ACA exchanges are "narrow" or "ultranarrow" as defined by the study: offering access to fewer than 14 hospitals.

The ACA is killing off a college plague: junk student insurance

One type of junk health insurance that the ACA is doing away with is the kind of crappy policy that many colleges used to push on their students. (There is one loophole extended to Jan. 1, 2015, explained below.)  BusinessWeek exposed this scam in 2008:

More than half of the insurance plans recommended by colleges offer benefits of $30,000 or less, according to a survey published in March by the General Accounting Office, an arm of Congress. Many plans have further limits that prevent payout of even modest maximums. While two-thirds of the country's more than 17 million college students have coverage from a parent's employer or their own job, many of the rest may be vulnerable if they suffer a serious illness or accident. With premiums and restrictions increasing under employer-provided plans, a growing number of parents are shifting children to college-sponsored coverage. But "when a student gets gravely sick, $30,000 in benefits is unrealistically low," says Alan Sager, a professor at Boston University's School of Public Health.

Free market visionary foresees healthcare apocalypse

Free market fundamentalist John H. Cochrane gave himself a Christmas gift on the Wall Street Journal op-ed page on Dec.25, allowing himself to anticipate the Affordable Care Act's certain imminent demise. Then, like a Left Behind acolyte imagining the apocalypse, he moved on to a vision of the new healthcare heaven and earth (liberally adorned with those free market halos, stock tickers):

We need to permit the Southwest Airlines, LUV -0.18% Wal-Mart, WMT +0.42% Amazon.com AMZN +0.95% and Apples of the world to bring to health care the same dramatic improvements in price, quality, variety, technology and efficiency that they brought to air travel, retail and electronics. We'll know we are there when prices are on hospital websites, cash customers get discounts, and new hospitals and insurers swamp your inbox with attractive offers and great service. 

The Affordable Care Act bets instead that more regulation, price controls, effectiveness panels, and "accountable care" organizations will force efficiency, innovation, quality and service from the top down. Has this ever worked? Did we get smartphones by government pressure on the 1960s AT&T T +0.30% phone monopoly? Did effectiveness panels force United Airlines and American Airlines to cut costs, and push TWA and Pan Am out of business? Did the post office invent FedEx, FDX +1.01% UPS and email? How about public schools or the last 20 or more health-care "cost control" ideas? 

An all-too-hidden benefit in ACA insurance

Eugene R. Anderson, a pioneer in insurance coverage litigation for policyholders for whose firm I've long worked, was fond of saying that insurance is a unique product. You pay up front, and you get what you pay for much later, if ever.

That's less true of health insurance than of most other forms of insurance, since we all need some healthcare in most years. But it's true of high-deductible health insurance.  And that may prove a problem for public perception of the Affordable Care Act.

What subsidy cliff? Jared Bernstein and Dean Baker defend the Affordable Care Act

I spent my last post peering over the edge at various points of the Affordable Care Act's subsidy cliff -- the income cutoff beyond which shoppers for health insurance are ineligible for subsidies.  I was prompted by a New York Times article spotlighting  who stand to lose most by this cutoff: middle aged and older, with incomes just over the line. In brief: if you're 27 and single, premium subsidies fade out gradually. If you earn one dollar more than the subsidizable limit, it may cost you $100 per year. If you're 55 and looking to cover a family of four, however, that extra dollar may cost you almost $9000 in subsidies.

While I had a couple of quibbles with the Times article, I thought it was fair.  The subsidy cliff is a real design flaw. A pair of 55 year-olds covering a 23 year-old son or daughter in New Jersey with an income of $79k shouldn't have to pay $1300/month for rather crappy insurance, which is what they would pay in Essex County, NJ.

I was somewhat taken aback, then, to discover that the fiery Dean Baker and the more mild-mannered Jared Bernstein both took rather furious issue with the Times article (by Katie Thomas, Reed Abelson, and Jo Craven McGinty). Baker's rhetoric is harsher than Bernstein's, but I think he does have a point. Bernstein's rebuttal strikes me as more of a reflex partisan pushback.* Take his opening salvo:

The ACA's subsidy cliff for older buyers

The New York Times quite rightly highlights* the plight of older ACA exchange shoppers who fall over the "subsidy cliff"  -- that is, earn just enough to be ineligible for premium subsides but are subject to high premium prices because they're older.

The article's poster family is in the worst possible situation as far as the ACA is concerned: 50-something couple, two kids, no employer-based insurance, and an income just over the subsidy line. You could say they're not representative, because they're worst-placed -- but that, in a way, was the point. Winners and losers should not be separated by $1000 in annual income.

There is a serious flaw in the ACA subsidy formula. If you're young and single, subsidies taper gradually. If you're 50something, they fall to zero abruptly.  If you're fiftysomething with kids, they fall very abruptly. That's because premium prices (and thus subsidies) are higher for older adults, and subsidies (if you qualify) rise with each additional person covered by the plan. If there's three or four or five of you, and you don't qualify, you lose effectively three or four or five subsidies. It's primarily age that carves the cliff, though -- especially for two older adults.

Self-employed? That pre-ACA health insurance deduction is still there...

Self-employed and seeking health insurance? Call an accountant.

Everyone who's paying attention knows that shoppers on the ACA exchanges are eligible for premium subsidies if their income is under 400% of the Federal Poverty Level  (FPL) and the benchmark silver plan in their area would cost them more than 9.5% of their income (for young people in states with low premiums, subsidies may fade out somewhere under 300% FPL).

Equally important for those who qualify are additional subsidies to reduce deductibles and maximum yearly out-of-pocket costs. As I pointed out in a prior post, these subsidies have hard break points: they bump up at income levels of $17,235 and $22,980 and phase out at $28,775. Since self-employed "profit from business" is notably malleable, and since retirement contributions come off the Modified Adjusted Gross Income (MAGI) used to calculate subsidy eligibility, the low income self-employed are well advised to keep an eye on those break points.

There is in fact a third dip for the low-income self-employed -- and a longstanding major benefit for those with higher incomes. It's the self-employment health insurance deduction. If you're self-employed and buying insurance for yourself and/or your family on the individual market, you can deduct the full cost of the insurance from your MAGI. That is, if your self-employment income exceeds the cost of insurance after various other deductions:

If only Obama would say what he's never stopped saying. If only he would do what he's done.

Perhaps inevitably, at every political stress point liberals knock themselves out urging Obama to say precisely the things he's been saying nonstop since he first appeared on our horizon. The latest to succumb to the temptation is Michael Tomasky:

...politically I don’t think fairness is enough. Average Americans care about fairness, but not really all that much. People who have incomes comfortably above the median but who still aren’t rich are going to suspect that fairness means something is coming out of their hide. What they do care about, though, is growth. Everybody from Bill Gates to his janitor wants the economy to grow. So the case for these programs that Obama needs to make consistently going forward is not the case for their fairness, but the case that these policies, and not tax cuts for the wealthy or more draconian domestic budget cuts or less regulation, will promote growth.

Yup, if only Obama would say something like "in America, our prosperity has always risen from the bottom-up" and make the case that prosperity is not sustainable when inequality is rising. As he did in Raleigh, NH in June 2008:

We've done this because in America, our prosperity has always risen from the bottom-up. From the earliest days of our founding, it has been the hard work and ingenuity of our people that's served as the wellspring of our economic strength. That's why we built a system of free public high schools when we transitioned from a nation of farms to a nation of factories. That's why we sent my grandfather's generation to college, and declared a minimum wage for our workers, and promised to live in dignity after they retire through the creation of Social Security. That's why we've invested in the science and research that have led to new discoveries and entire new industries. And that's what this country will do again when I am President of the United States.

 And in Georgetown in April 2009:

The long and the short of income inequality

Ezra Klein made a splash a few days ago by arguing that Obama is wrong to call rising inequality the defining challenge of our time, asserting that jobs should take precedence: "Growth simply isn't producing enough jobs. This is a more severe and more urgent problem than inequality.

Today, Paul Krugman counters that inequality that the president was right -- first because stagnant incomes may have contributed to the debt crisis and are now depressing consumer demand, but more fundamentally, because the wealthiest have converted their disproportionate economic power into disproportionate political power, corrupting the country's ability to address its policy challenges.  The  the super-0rich, Krugman charges, triggered the financial meltdown by building a bipartisan consensus for financial regulation -- and have crippled the recovery by demanding austerity.

Klein's binary choice between addressing unemployment or austerity seems fundamentally mistaken to me, I would supplement Krugman's analysis with research by Peter Turchin (thanks, T. Greer), who has identified very long-term cycles of expanding and contracting inequality, and tied them chiefly to the supply of labor:

Young, self-employed and seeking health insurance via the ACA exchanges? See an accountant

A good number of Americans who will be shopping for health insurance on the ACA exchanges are self-employed.  A 2007 Commonwealth Fund study found that 34% of buyers on the individual market for health insurance were self-employed (p.3). In 2012, about 15 million Americans were self-employed.

Doubtless many of the younger Americans subject to "rate shock" on the ACA exchanges are self-employed and earning enough to qualify for only small subsidies or none at all. For those who have not learned to max out on allowable deductions to reduce their taxable income -- e.g., everything from paper clips to home office space to computers, auto expenses and retirement fund contributions  -- the ACA adds new incentives -- in some cases powerful ones.

The ACA offers subsidies not only for premiums but for deductibles and maximum out-of-pocket (OOP) expenses. While the premium subsidies shrink at a steady rate per $1000 of income (and fade gradually to zero for a single young person), the break points for deductibles and OOP are sharper.  At some break points, a $1000 difference in reported income can mean a difference of thousands in medical expenses covered in a given year.

In which Ezra Klein shorts Avik Roy

ACA supporters are naturally ticked off that conservatives are now carping at the high deductibles and out-of-pocket maximums in many ACA insurance plans, most notably the bronze ones. Ditto for "narrow networks" -- a limited choice among doctors and hospitals.  The Dish has a precis of complaints from Jonathan Chait, Jonathan Cohn, Kevin Drum and Ezra Klein. Here's Ezra:

What's confusing about this line of attack is that high-deductible health-care plans -- more commonly known as "health savings accounts" -- were, before Obamacare, a core tenet of Republican health-care policy thinking. In fact, one of the major criticisms of Obamacare was that it would somehow kill those plans off. "Obamacare may be fatal for your HSA," warned the Heritage Foundation on 2010. "Health Savings Accounts Under Attack" blared Red State....

Obama's pledge that "if you like your doctor, you can keep your doctor" is also under fire. The issue here is that insurers entering the competitive health marketplaces are tightening their networks in order to cut costs and improve quality. It's worked: Premiums in the marketplaces are far lower than was expected when Obamacare passed.

 This, too, is a success for a longtime conservative health-policy idea..."Narrow networks are not some cruel attempt to limit patient choice foisted upon us by the insurance industry," write economists David Dranove and Craig Garthwaite. "Instead, these plans may provide our best opportunity for harnessing market forces to lower prices."

Fair enough. However, when Klein asks his old healthcare sparring partner Avik Roy to explain the apparent hypocrisy, he lampoons Roy's response without engaging its substance, which is perfectly consistent with Roy's longstanding attack line against the ACA. There are, I believe, internal contradictions in that attack line, and Klein has dealt with them elsewhere. But not here:

The End of the End of History?

In The Origins of Political Order, Francis Fukuyama casts the history of the state as the history of the sovereign power's struggle to neutralize powerful subjects' (or citizens') biological imperative to pass their advantages on to their children  -- that is, the sovereign's attempts to neutralize the force of kinship ties, which are the means of building rival power centers. Sovereigns have come up with various ingenious means of checking the encroaching power of hereditary local elites, such as an exam-based civil service (China) or an imported elite slave class (Mamluk and Ottoman empires). The most successful and enduring of such means has been democracy, enabled by (and evolving from) rule of law and a strong state, wherein the majority retains the power to periodically trim or slap back back entrenched privilege.  Hence Fukuyama's faith, famously professed in The End of History, that a kind of Darwinian pressure of global competition would lead all states to embrace liberal democratic capitalism.

Recent years have dented that faith, however, as Fukuyama has come to fear that that other Darwinian pull -- of elites to pass their privilege to their offspring -- might batter down the walls of commonwealth.  Here's how he puts it in an article previewing his next book, Political Order and Political Decay, due out in September 2014:

Obama's Mandela: man of interior action

Some time ago, after James Fallows wrote that Obama's speeches are often memorable at the ideas level, but rarely at the phrase level, I responded:

Re that strange absence of memorable phrases: it's not just balanced by one strength, it's book-ended between two: conceptual complexity/coherence on the macro side, and cadence on the sub-micro. At least in 2007/2008, less so now, Obama's speeches were musical, hinging on repeat phrases (yes we can) and on the simplest of rhetorical devices, various forms of parallel structure, e.g. anaphora, the repetition of beginning words (also a lot of parallel phrasings in series -- "A man touched down on the moon, a wall came down in Berlin" etc.).  It was no accident that Will.i.am was able to set one of his speeches to music to some effect.

I heard this kind of music in Obama's eulogy for Mandela. It was a speech of strong cadences that gave shape to the speaker's thought. At his best, Obama is a prose poet, and today he was Mandela's poet.

Poet, not novelist. At the outset, Obama set himself a problem:

WSJ hits ACA from the left

Good reporters at the Wall Street Journal continue to bust the ACA's chops.  The likes of Louise Radnofsky, Amy Schatz, Timothy Martin and now Leslie Scism, who's been covering insurance for at least 15 years (and is also a news editor), are not going to get their facts wrong. But it remains fair to wonder whether the Murdoch-era news editorial regime is shaping the stories' emphasis [UPDATE: I have spoken to someone at the Journal, whose word I trust, who assures me that editors area not imposing a political agenda on reporters. I regret speculating about motive without information.]

Today, Scism and Martin spotlight something that has in truth troubled me as I explore offerings on HealthCare.gov and ValuePenguin:  the prevalence of high deductibles, particularly in bronze plans:

As enrollment picks up on the HealthCare.gov website, many people with modest incomes are encountering a troubling element of the federal health law: deductibles so steep they may not be able to afford the portion of medical expenses that insurance doesn't cover.
The average individual deductible for what is called a bronze plan on the exchange—the lowest-priced coverage—is $5,081 a year, according to a new report on insurance offerings in 34 of the 36 states that rely on the federally run online marketplace.

An early proponent of leading from behind

was Nelson Mandela, according to the New York Times obit (by Bill Keller):

In his autobiography, Mr. Mandela recalled eavesdropping on the endless consensus-seeking deliberations of the tribal council and noticing that the chief worked “like a shepherd.” 

“He stays behind the flock,” he continued, “letting the most nimble go out ahead, whereupon the others follow, not realizing that all along they are being directed from behind.” 

That would often be his own style as leader and president.

[Update via Smartypants, citing Mandela's biographer Richard Stengel: Mandela used the term directly:

Mandela loved to reminisce about his boyhood and his lazy afternoons herding cattle. "You know," he would say, "you can only lead them from behind." He would then raise his eyebrows to make sure I got the analogy.

[Update 2: Note that the original association of Obama with "leading from behind," in Ryan Lizza's New Yorker analysis of his foreign policy, incorporates the shepherding metaphor (and in Mandela's case, experience):

Nonetheless, Obama may be moving toward something resembling a doctrine. One of his advisers described the President’s actions in Libya as “leading from behind.” That’s not a slogan designed for signs at the 2012 Democratic Convention, but it does accurately describe the balance that Obama now seems to be finding. It’s a different definition of leadership than America is known for, and it comes from two unspoken beliefs: that the relative power of the U.S. is declining, as rivals like China rise, and that the U.S. is reviled in many parts of the world. Pursuing our interests and spreading our ideals thus requires stealth and modesty as well as military strength. “It’s so at odds with the John Wayne expectation for what America is in the world,” the adviser said. “But it’s necessary for shepherding us through this phase.”

The Times obit also stresses Mandela's supreme self-confidence:

Obama portrays a nation at risk in bid to reset national agenda

Obama gave a great speech today, focused on reversing rising income inequality, which he called "the defining challenge of our time." It's been a dispiriting autumn, and as Obama's returned to the bully pulpit in recent days I've thought that maybe I'm past getting keyed up as he cranks up the rhetoric.  But he didn't do that. He offered new thinking and reframed our political discourse. He expanded and refocused the narrative he's been developing throughout his political career.

The outlines of that narrative were familiar. Throughout its history, the United States has thrived because it's periodically widened the circles of opportunity, extended the means to pursue happiness to previously excluded groups, made new investments in shared prosperity. Around 1980, though, the country took a wrong turn, and the American dream is fraying.  As president, he will channel popularly willed recommitment to shared prosperity.

This time around, though, there were several differences. The stylized, compressed precis of U.S. history that's an Obama speech staple was focused more sharply on economic turning points.  The wrong turn of the last 30-plus years was ascribed in large part to global economic forces, in a sense depoliticized. The faith that political action will right the ship was tempered by a warning that rising inequality, unchecked, could take us to a point of no return.

Finally, an economic argument that sustainable prosperity depends on reversing the widening wealth gap was more fleshed out than ever before. I have never read a presidential speech that cited as many economic studies.  Those studies and a battery of stats were deployed to make several key points: that inequality is at an historic high point; that the U.S. lags other wealthy countries in economic mobility; that those born in poverty in the U.S. today are likely to remain locked in; that poverty is not just a "minority" problem but touches more than half of Americans at some point in their lives; and that rising inequality is a drag on growth.

About that "toothless" Dodd-Frank reform...

Dodd-Frank is widely written off as meek, weak and watered down by relentless bank lobbying.  Perhaps it is in many respects. But the long-unfinalized and tortuously complex Volcker Rule, largely eliminating the banks' proprietary trading and in-house hedge and private equity funds, has already had significant effect, as the WSJ's Scott Patterson recounts:

Regulators aren't expected to start strictly enforcing the Volcker rule until 2015, giving banks some breathing room. Because the rule was widely anticipated, most banks already have done away with operations focused on proprietary trading, or making bets with their own money.

For example, Goldman shut down in 2010 its Principal Strategies in-house trading unit, partly as a response to the looming Volcker rule. Last month, Goldman Chairman and Chief Executive Lloyd C. Blankfein outlined other steps being taken by the New York company to comply with the Volcker rule, including "winding down our hedge-fund investments."

Moreover, the relative hawks in the contentious five-agency rule-writing process, most notably outgoing CFTC Chair Gary Gensler, seem to have in large part prevailed on key issues in the rule's pending finalization next week:

Against gratitude

[repost]

Okay, not really. But I am personally uncomfortable with overt expressions of gratitude, and while I think this is mainly an emotional limitation on my part, there may be at least the ghost of a reasonable caveat in it.

As a teenager, I took a slightly unsavory pleasure in the science fiction of Robert Heinlein.  He not only entertained but also influenced and repelled me. He once wrote (through a character) that there was something sick at the heart of German civilization, and whether that's true or not, I think that the sickness he condemned clings to him, in a kind of gleeful authoritarianism. At the same time, some fragments of his cracker barrel wisdom stayed with me. One of his quirks, voiced by various favored characters, is an aversion to gratitude. As I recall at this distance, he cast it as a power play of the weak, a form of toadying, or guilt masquerading as love.  I think he's wrong to reduce gratitude to those impulses, though gratitude is certainly alloyed with them.  In a similar vein, though, he ridiculed worship, asking why an omniscient, omnibenevolent  God would require the saccharine praise of human beings. That was the question that really stuck with me. It gets at the heart of gratitude, since worship is mainly an expression of gratitude to God.

Such gratitude is -- should be -- a spontaneous expression of love. That's how those who voice it understand it.  But why does it express itself in "saccharine" praise?  In a Thanksgiving post, Andrew Sullivan's Dish suggested an answer:

A caveat for Ezra Klein

[updated, with a rather large caveat to the caveat...]

..who has a cogent set of questions about how well HealthCare.gov will be working as of Dec. 1 and going forward.  On one key question I think there's a moderating factor:

9. Where the Dec.1 deadline really matters is for people who've already had their plans canceled and who need to be able to sign up for a new one in time for it to start on Jan.  1. If the Web site isn't working smoothly for these people in the next week or so it'll be an utter disaster when 2014 comes and many of these people find themselves uninsured and some get sick.

Most people subject to policy cancellations in the individual market are probably not eligible for subsidies, since they've already found insurance affordable. That means they don't really need HealthCare.gov.  They can easily get complete information about their options on ValuePenguin and then sign up directly with an insurer. [UPDATE: I'm afraid my premise here is severely compromised; William Ocasio reminds me that a recent Families USA study found that 71% of those currently in the individual market are below 400% of the Federal Poverty Level, and thus potentially eligible for subsidies. In practice, though, many people above about 270% FPL are not subsidy-eligible -- you only get a subsidy if the full cost of the benchmark silver plan exeeds a benchmark percentage of your income, and plan prices vary pretty widely from market to market. Still, probably more than half of those subject to cancellation are in fact eligible for at least some subsidy.]

Those who have received policy cancellations and are eligible for subsidies will need to get a subsidy application processed by hook or crook (that is, by online, phone or print application to the federal government) by Jan. 1. If they can't, I would imagine that some kind of retroactive subsidy payment will have to be worked out, after a lot of angst. For what it's worth, the subsidy-eligible probably won't be subject to rate shock, unless they're at the very top end of the scale, where the subsidy can shrink to near nothing.

Related:
Bypassing HealthCare.gov, cont.
Who needs HealthCare.gov?

"People analytics" should lead to better pay in all jobs

Anyone who reads Don Peck's deep dive into new advances in "the algorithmic assessment of workers' potential might be in varying degrees excited and disturbed by new means of predicting, assessing and improving performance. My chief reaction went in a different direction. The tests potentially highlight the huge performance differential in any type of work -- and hence, the value of good performance:

Teri Morse, the vice president for recruiting at Xerox Services, oversees hiring for the company’s 150 U.S. call and customer-care centers, which employ about 45,000 workers. When I spoke with her in July, she told me that as recently as 2010, Xerox had filled these positions through interviews and a few basic assessments conducted in the office—a typing test, for instance. Hiring managers would typically look for work experience in a similar role, but otherwise would just use their best judgment in evaluating candidates. In 2010, however, Xerox switched to an online evaluation that incorporates personality testing, cognitive-skill assessment,

Just what is the United States retreating from?

I have a problem with the way Mark Landler frames recent Obama administration diplomatic activity -- the scheduling of a Syrian peace conference as well as the interim agreeement with Iran:

At one level, the flurry of diplomatic activity reflects the definitive end of the post-Sept. 11 world, dominated by two major wars and a battle against Islamic terrorism that drew the United States into Afghanistan and still keeps its Predator drones flying over Pakistan and Yemen. 

But it also reflects a broader scaling-back of the use of American muscle, not least in the Middle East, as well as a willingness to deal with foreign governments as they are rather than to push for new leaders that better embody American values. “Regime change,” in Iran or even Syria, is out; cutting deals with former adversaries is in.

To call these initiatives "a broader scaling-back of the use of American muscle" seems to me a distortion of historical US foreign policy norms. Regarding Iran: when has the U.S. ever imposed military muscle to halt another country's (professedly peaceful) nuclear program?  It is only the bluster of the neocons -- the crew who blundered into Baghdad -- and of a Congress always eager to show fealty to Netanyahu that makes a preemptive strike at Iran seem like a kind of default response to that country's nuclear program.

Bypassing HealthCare.gov, cont

In prior posts, most recently here, I have explored the possibility that shoppers for health insurance on the ACA exchanges might bypass the still-balky HealthCare.gov with the help of information-only comparison sites ValuePenguin and HealthSherpa. Customers ineligible for a federal subsidy can already easily get all the information they need on these sites and then enroll directly with an insurer. For those whose incomes entitle them to subsidies, however, the subsidy application has been the roadblock, as it must be submitted directly to the federal government, either through HealthCare.gov or via phone or print application.

That may be about to change. Kaiser Health News' Julie Appleby reports, "Insurers and the Obama administration are testing fixes to healthcare.gov designed to allow insurers and web-based brokers to directly enroll consumers who qualify for subsidies under the health law."  It appears, though that the fixes require insurers themselves to route the customer's application through HealthCare.gov -- that is, in the 36 states that have forced the federal government to run their exchanges.  Direct insurer processing of the subsidy application is still only an ask:

C.S. Lewis: Joymongerer, democrat by default, less repressive than many of his critics, amateur philosopher

In honor of the 50th anniversary of C.S. Lewis' death on November 22, anappreciation that I agree with in toto:

I think Lewis was so compelling because, first, he was incomparable at evoking "joy" as he defined it. Whatever idea and yearning for "heaven" I ever had came from Narnia. Second, I think he had an intuitive -- not theoretical -- grasp of psychology -- he was one of those people who reads his own mind so well, he knows a good deal about how all human minds (and wills and emotions) work.The bickering of the children in The Magician's Nephew, Eustace's redemption in Dawn Treader, the seeds of human hatred elucidated by Screwtape -- and above all, the parental love turned to jealous gall in Till We Have Faces -- his greatest imaginative leap and rendition of the romance of the soul --have a kind of easy, intimate verity that give his spiritual dramas life.

At the same time, when it came to doctrine and apologetics, I think he was an unwitting sophist -- an honest sophist, if that makes any sense, because he fooled himself first...

Red states' ACA exchanges: lab or slab?

Austin Frakt has launched a multi-post-and-tweet campaign arguing that the Affordable Care Act is an essentially conservative chassis amenable to conservative reform, and that conservative healthcare wonks should be aiming to mend it, not end it. (Subtext: they'd be doing just that  if they were not playing for Team GOP.)

The penultimate post in the series dangles conservative wonk-bait via a list of potential reforms in ascending order of disruptiveness to the current ACA structure, e.g., paring back essential benefits and allowing more catastrophic plans on the exchanges (not so disruptive) and creating high risk pools or universal zero- or low-premium catastrophic insurance (very disruptive).  But how to move GOP lawmakers and their think tank supporters off their "repeal and replace" schtick and onto a "revise and reform" track?

Frakt's most recent post suggests an answer by misdirection:

My conclusion is that the ACA is far more amenable to more conservative reforms than to more liberal ones. Of course, this could change. A public option could be added, for example. But, having had that political fight recently, I doubt it will. The most likely pathway leftward (in the sense of toward single payer) would be if the ACA failed in a sense that could be interpreted as market failure.

In fact, I do expect the ACA to fail in some states, but not in the ones that are most likely to adopt a state-level single payer program. Exchanges may fail where support for and enrollment into them is discouraged by political leaders and other institutions. Ironically, this is more likely to happen in states whose leaders are more ideologically supportive of market-based approaches.

If some state exchanges fail, and Republicans do not at that time control presidency, Senate and House, then what? Looking back at GOP state governments' refusal to run their own ACA exchanges, Jonathan Bernstein offers a might-have-been that's also, it seems to me, a may-be-yet:

Imagine if, right now, there were only a handful of states in the federal exchange, and some of the more aggressive and innovative conservative governors were running their own exchanges...suppose that several Republican governors had pushed for a deal in which they would implement Obamacare, including setting up exchanges in their states, if and only if they were given waivers and allowed to try some conservative policy ideas. The pressure would have been intense on the administration to allow at least some of them. After all, the administration never wanted to build all those different state exchanges in the first place. And certainly the president didn’t want obstruction verging on sabotage from Republicans across the board, as is de rigueur now. In order to get some Republican buy-in, there’s a very good chance Obama would have been extremely willing to cut deals, even if liberals would have been appalled at the results for the affected states.

Recall also that back in 2011 Obama supported legislation that would have moved the starting line for state waivers enabling alternative means of reaching near-universal coverage from 2017 to 2014 -- and further, that the administration has proven receptive to rather radical, privatized variations of the Medicaid expansion.

In short, O'Barkis is willing.  Too bad Republican governors and legislatures are more interested in sabotage than in genuine conservative policy innovation.  If and when, however, they're stuck with the corpse of a state exchange (or one on life support), and the ACA is still the law of the land, Republican governors may cook up some fetching Frankenstein monsters of their own. 

Who needs HealthCare.gov?

[updated and corrected 11/22, per notes at bottom]

HealthCare.gov may be obsolete before it's fixed.

Purely informational comparison shop sites ValuePenguin and HealthSherpa provide all the information that's supposed to be available on HealthCare.gov: price quotes incorporating the user's location, income,  age and family composition for all insurers available to that user on the exchange. ValuePenguin provides plan details.  (Shopping without a login or completed application is also possible on HealthCare.gov, but there are limitations and inaccuracies.*)

The missing link has been the subsidy application. That has had to be done through HealthCare.gov, or through phone or print applications, both of which can be started by calling the number posted on HealthCare.gov.  That application is the black box from which it's unclear how soon a completed application will emerge. As I've noted before, some insurers at least will take an application for a specific plan from a user who's started a subsidy application with the government, but that's a two-track and perhaps unsettling process

Now, though, the government is poised to let the insurers -- and online brokers, which also enable some comparison shopping -- take the subsidy application, according to HuffPost's Jeffrey Young:

Now these insurance issuers and brokers are about to get what they want. The Centers for Medicare and Medicaid Services is close to providing insurers with the technological capability to also take subsidy applications, as well as sell plans to customers, spokeswoman Julie Bataille said during a conference call with reporters Tuesday. ..

Online brokers eHealth, Go Health and about 30 others also will soon have this capability, Bataille said. "We believe that they are on track to begin their transactions as soon as possible. This is something that, obviously, they will make determinations about individually as they see how their system is interacting with ours, and they make their own assessments about the fixes necessary for them to begin their work." 

[Update: fixes currently being tested  have the insurers route their customers' subsidy applications through healthcare.gov.  It remains unlikely that insurers will gain direct access to the federal data hub that enables subsidy determinations.] 

The brokers could be a useful intermediary for some. eHealth  offers comparison shopping, with plan details for each posted choice, though in many locations it's far from covering all options on the exchanges. Within its own universe, however, eHealth will make your subsidy estimate, give you price quotes incorporating that estimate, hold information for any plan you select and notify you when enrollment is available on eHealth -- that is, when the site can initiate the subsidy application. A user should check their choices against ValuePenguin or HealthSherpa, however (I have found ValuePenguin's price quotes to be more accurate than HealthSherpa's in New Jersey).

If you want to eliminate the middleman, once the government allows third parties to process the subsidy application, you can use a non-transactional comparison site like ValuePenguin and then apply directly through the insurer offering the plan you choose. Many (I suspect most) insurers on the exchanges provide plan summaries online and enable online applications.

Once the government does outsource the subsidy application process, who needs HealthCare.gov? Its front end, that is. All that really matters is the back end: whether an application can be processed accurately in reasonable time. That of course is the rub, and allowing third parties to initiate subsidy applications won't make the technological challenge* go away. But perhaps the insurers and brokers will be able to expedite the process on behalf of their prospective customers -- and enable a smooth shopping process. If insurers and brokers can take the complete application, all the government needs to do on the front end is refer users to functioning online brokers and the informational sites.

At present, those who are not eligible for subsidies can easily make an informed choice from among policies available on the exchanges and complete the transaction through the insurer or an online broker.

One caveat: "informed" choice is a relative term. Online (and print brochure) plan summaries are not insurance contracts, which are complex, though less prone to booby-trapping than before ACA coverage rules took effect. If I were buying on the exchanges (as I might, next year), I might still seek the advice of a real live human broker to scope out how the co-pays, deductibles etc. might play out.

* You can comparison shop on HealthCare.gov without filling out an application. But subsidy information won't be incorporated in the price quote (they refer you to the Kaiser calculator for that). And the price quotes I got for my wife and I in New Jersey did not take our age into account and so were way off.

** Not to mention the yet-unbuilt systems to process subsidy payments to insurers.

Update, 11/21: just recalled that eHealth has been somewhat notorious for poor customer service:  it gets two out of five stars on epinions.com, and Rick Ungar spotlighted some customer horror stories when Avik Roy used the site to spotlight rate shock. Among the complaints: signing up at one price, getting enrolled at another. That should not be possible under the ACA. But the experiences do highlight possible pitfalls to using a middleman. Of course HealthCare.gov and the state websites should function at the least, in William Ocasio's  phrasing, as "public options to private marketplaces."   The point here is that complete effective workarounds while HealthCare.gov is still balky may soon be imminent, and that private online gateways may remain an important part of the landscape.

Update 2, 11/22: An earlier version of this post assumed that one could effectively ACA shop on eHealth. Prompted by the Anon comment below, I further tested eHealth and found that in many locations it does not include most of the plans available on the exchanges. I have amended the post accordingly. For the record, here is the original lead paragraph:

Online health insurance brokers like eHealth and purely informational comparison shop sites ValuePenguin and HealthSherpa provide all the information that's supposed to be available on HealthCare.gov: price quotes incorporating the user's location, income,  age and family composition for all insurers available to that user on the exchange. eHealth and ValuePenguin provide plan details. eHealth will make your subsidy estimate, give you price quotes incorporating that estimate, and, for now, hold the the plans you select in a kind of provisional shopping cart. [Update: management/healthcare scholar William Ocasio of Northwestern tweets that eHealth omits some insurers. So results should be checked against ValuePenguin or other brokers.] 

Low-tech glitches on HealthCare.gov

I get that fixing HealthCare.gov dysfunction is a massively complex tech project.  But there are informational flaws on the site -- sins of omission and commission -- that would be easy to fix. I've encountered two.

For the first, call me stupid. There's a hole either in my tech savvy or my reading about ACA implementation -- or both.  But stupidity is rarely rare, and the designers of heatlhcare.gov should have anticipated my need for one really basic piece of information.

From October 1 to November 15, I tried to create a login at healthcare.gov at least 40 times.  For perhaps too long, I assumed that my failure was just the core failure of the site. Gradually, recently, it dawned that whatever the site's functional failures, most people by now could at least log in -- and were encountering further glitches when they tried to complete applications (see comments on this HHS posting). So I went on live chat and quickly learned the cause of failure: if you've blocked access to pop-ups, you have to turn off the pop-up blocker. I did so, and lo, my login is created.

Status quo Sunday at the New York Times

I had the oddest sense of deja vu while reading Ross Douthat's column about the Affordable Care Act today immediately after reading Tom Friedman's column about Israel. 

Both were sleight-of-hand defenses of a status quo: an Israel continuously extended on theft of land and a welfare state in statsis that Douthat would not have adapt to mitigate new problems of wealth distribution and risk transfer.

Friedman's column is a mealy-mouthed plug for a book by Haaretz columnist Ari Shavit, which may well be better than Friedman's characterization.  It begins with an even-handedness trope: a plea to view "the real Israel, not the fantasy, do-no-wrong Israel peddled by its most besotted supporters or the do-no-right colonial monster portrayed by its most savage critics." Fair enough. But the column sanitizes the colonial reality, flashing briefly on a bloodless freeze-frame of expelled refugees in 1948 rather than engaging with the continuing and accelerating gobbling of the West Bank.  It then devolves into que sera piety: Palestinians should suck it up and get on with their lives. And by the way, the failure of two-state negotiations is all their fault: