Thursday, March 15, 2012

NanoCare Update

The Congressional Budget Office, as you may recall from yesterday's post, warned that a couple million fewer people than originally intended would be covered under the Affordable Care Act (ACA). The CBO today revised that figure yet again, and the outlook is even grimmer: it now predicts, in what it called a "worst case scenario" that 20 million people may actually lose their employer-based coverage in the next decade as a direct result of the legislation.

Then again, three million more people could be covered. Nobody really knows, because all the estimates are based on the future state of the economy, the political state of the states administering the programs and exchanges, and the fact that this is all a great big guessing game based on suppositions and theories and what-ifs. In other words, whether or not we receive medical coverage will still be pretty much dependent on the vagaries of the semi-regulated free market. How sick is that?

Here is the CBO techno-speak in its second press release in 24 hours:
Despite the care and effort that CBO and JCT (Joint Committee on Taxation) have devoted to modeling the health insurance system and the provisions of the ACA, there is clearly a tremendous amount of uncertainty about how employers and employees will respond to the set of opportunities and incentives under that legislation. In response to questions from Members of Congress, CBO and JCT have prepared an analysis showing how the effects of the ACA on health insurance coverage would differ under alternative assumptions about the behavior of employers.
Ohhhh-kay -- whether or not workers get health care will depend not only on the future economy, but also on their employers' mood and behavior on any given day. Hmmm. I guess the bosses are destined to turn into Scrooges, because last year the CBO forecast that only a million poor slobs would lose health insurance through their crapola jobs. They were only wrong by a factor of several hundred percentage points.

The White House is scrambling to contain the damage, dismissing the new CBO report as "what's a few million uncovered people in the grand scheme of things?"  And besides, if fewer people are covered, the budget can be balanced and the deficit cured. Letting sick people stay sick will save the taxpayers a bundle! I wish I were kidding about this tone-deafness, but I'm not. Here's the official line from the Obama Administration blog:
This suggests that taxpayers will save $50 billion more, on net, through 2021 and Americans will pay even less for private insurance than CBO previously projected – which is good news..... the bottom line is clear: the Affordable Care Act will reduce our deficit, control health care costs, and make health care more affordable.
Naturally, the vast majority of people expected to lose their employment-based coverage will be low-wage workers. According to the CBO, of the 11 million poorly-paid individuals to have benefits cut, three million of them will qualify for Medicaid. And then it's always possible that employers who drop or threaten to drop their employee health plans will get "incentivized" to provide at least a modicum of subsidized coverage. The Hill has more.

Math was never my strong suit, so I confess I do not understand all the number crunching and the convoluted prognostications. But then, I suspect, neither do the so-called experts.

Medicare for All, though, where everyone pays a progressive tax based on income? That is eminently understandable, and equitable to boot. 


The Black Swan said...

I posted this in the previous NanoCare comments, but I thought I would repost since it has been buried.

This is what it is like to be uninsured in America and experience a catastrophic injury.

I thought I would share a recent experience I have had with our HealthCare System. I am in my 20's and was on my parents insurance policy until I turned 26. I was in school and unemployed and did not sign up for my own health insurance. The cheapest plans for catastrophic care start at around $89/month and have deductibles around $5000. This is a lot of money when you are a poor student. Unlucky for me, I broke my leg over the winter. My total medical bills are around $80,000. This includes surgery and 3 nights in the hospital, plus an ER visit, physical therapy and medications. I could have gone and had this surgery done in Spain for $12,000 plus airfare! Trust me on this, I priced it out and contacted surgeons over there. Not that I would want to travel with this injury, but it is insane that the same treatment and procedure in Spain is 1/7th the cost! Think about that for a minute.

Now I am lucky, or not, that my financial destitution qualifies me for all sorts of charity care and with a little luck I will get almost all of my medical bills written off. Because of this injury I have also had to drop out of school, and the financial hardship will delay my return if not end it once and for all. It all depends on the level of charity I receive. My injury has also prevented me from returning to the workforce and without a college degree... and with this economy...

Take what you want from this story. I just thought I would put it out there to let people know just how outrageously expensive medical care is. They may have put my leg back together, but the financial cost could ruin me for life.

Now imagine the millions of uninsured who will be forced into situations like mine, whenever they or members of their family get ill or injured.

There is no option but single-payer Medicare for all. Anything else is pillaging the ill for the benefit of billion dollar corporations.

Denis Neville said...

That news will further stoke fears and resentments. What a holy mess!

And this news, “The richest get richer,” even more anger.

“The vast majority will see their incomes go on eroding slowly while those at the top enjoy an ever-larger share of national income and wealth. The inevitable result will be economic, political and social instability – not a pretty picture for anyone.”

Speaking of instability…

@ Zee, DW2000, Valerie, all

When talking about Nazi fascism, there is the tendency to focus on its images of “mass hysteria,” such as Kristallnacht, the Reichstag fire, etc., to the exclusion of the day to day lives and complicity of ordinary Germans. Nazi Germany could never have grown without the participation of ordinary people, even conventionally good people. The Nazis would never have come to power without the passive, and also active, consent of Germany’s elites. Nazi excesses also required wide complicity among police, judges, lawyers, military officers, businessmen, and religious leaders and the daily choices they made in the acceptance of what they perceived to be lesser evil, or simply by looking away. Many Germans were appalled by Kristallnacht, but such feelings were only of a brief duration. There were no judicial nor government inquiries. It was because of individual and institutional acquiescence that the militant minority Nazis were able to seize power in a previously highly civilized country.

In 1933, the German writer Thomas Mann wrote that he had “witnessed a revolution of a kind never seen before, without underlying ideas, against ideas, against everything nobler, better, decent, against freedom, truth and justice. Common scum have taken power, accompanied by vast rejoicing on the part of the masses.”

Alexis de Tocqueville, who was a great admirer of the United States, expressed his concern about the majority’s power in a democracy to impose conformity. He wrote, “The kind of oppression with which democratic peoples are threatened will resemble nothing that had preceded it in the world: our contemporaries would not find its image in their memories. I myself seek in vain an expression that exactly reproduces the idea that I form of it for myself and that contains it; the old words despotism and tyranny are not suitable. The thing is new, therefore I must try to define it, since I cannot name it.”

“I walked across the snowy plain of the Tiergarten — a smashed statue here, a newly planted sapling there; the Brandenburger Tor, with its red flag flapping against the blue winter sky; and on the horizon, the great ribs of a gutted railway station, like the skeleton of a whale. In the morning light it was all as raw and frank as the voice of history which tells you not to fool yourself; this can happen to any city, to anyone, to you.” - Christopher Isherwood, Down There on a Visit

James F Traynor said...

Ah, Karen! Medicare for all. A shimmering dream gone abornin'. We'll have to kill them all to realize it. It's not that is doesn't make eminent sense. It does and they fear it even more than the idea of Scandinavia. They anoint themselves with garlic and violently wave crosses at the very idea.

John in Lafayette said...

Even leaving the morality out of it, Medicare for all makes sense from a strict dollars and cents standpoint.

Right now in America there are, in essence, three groups of people when it comes to paying for medical care. There are those who are too expensive to insure profitably (the elderly and the military), those who are too poor to afford private insurance, and those who are young enough, healthy enough, and profitable enough to insure through private insurance.

What we've done in this country is we've allowed private insurers to insure those who don't need medical care and are, therefore, profitable, while also allowing them to pawn off those who aren't profitable on the people who also happen to be paying for their own insurance (otherwise known as the middle class).

And because the poor receive medical care only when their problems become acute, their care actually costs the taxpayers more than it would if we provided them full coverage.

But here's the thing: When we compare the cost of Medicare, Medicaid, and VA insurance to the cost of private insurance for the healthiest among us, we find that, on a per-patient basis, private insurance for the healthiest of us is also the most expensive.

So if we took everyone who pays for private insurance and put them on Medicare today, the total number of dollars spent paying for medical care in this country would decline dramatically.

And we also realize that the only reason we don't put everyone on Medicare today is to protect the profits of the insurance companies and to protect the monopoly that is the AMA. It's unconscionable, really.

Suzan said...

Think we could get an ongoing strategy started so that in every public place where health care is discussed someone in the audience asks right off the bat:

"So how many high-income people will lose their health care under the Obama plan?"

And then follow up with the latest number of the rest of us who will.

Yes, it will be used against Obama by his detractors (no matter how they embraced his choices earlier).

But wasn't that the risk he took when he embraced so many of their ideas in his "compromise?"


dreamsamelia said...

@Black Swan--stories like yours put a lot more ooomph into our raucous cries of "Medicare for All" as these years of street protest drag on. (and on). ...
Although I found it interesting that a friend who is a doctor, whose father was a doctor, says he thinks we should go back to the pre-Medicare days, because his Dad literally had a jar in the front room where indigent patients could pay what they could or nothing at all. There was no "billing office" nor secretary nor even a nurse. It was the most basic fee-for-service you could get.

The problem now is the hospitals are renovating themselves like hotels, paying executives the same staggering salaries the rest of the corporate world gets, and investing in ultra expensive equipment, which then has to be over-prescribed in order to pay for it, while the patients are the guinea pigs for the not-well-studied longitudinal effects of all these gamma knives, MRIs, CTs, etc.
Our belief in all this technology is, on a primitive level, every bit as superstitious as the bloodletting which was "state of the art" medicine in George Washington's day--today, as then, condoned with broad professional consensus of the "latest evidence-based medicine," which cannot clearly see its own biases.

And it is more founded on an irrational greed than on true health. Why, dear Gaia, should a broken leg cost $80,000? It didn't cost that much for the slaves, who somehow had to get by or die. And we can just blithely mention "68 lives were lost building Hetch Hetchy Dam" (in Yosemite). Or quote the latest civilian casualties in our latest war zones--in other words, the way we accept deaths in war, and as a cost of doing business, and the way we accepted slave labor in this country, while shoving the Native Americans off land they had borrowed for millennia(while we claim to own into perpetuity!), all suggest we don't fundamentally care about people's health in this country. Instead it is another scheme for our paid for politicians to continue to siphon unconscionable sums from the 99% to the 1%, who are demented in thinking they need anything else. The truly sick in our society are the 1% who think hoarding resources for themselves while people die or go broke for lack of healthcare is acceptable.

But community is our strongest defense against the 1%, short of creating justice broadly today, here, now, on this earth. The slaves, too, coped by using the ancestors to see "the long arc of history." Those of us who can clearly see the pitiable fallacies of the 1% who keep perpetrating their ruinous greed on billions of people and the natural world literally do have each other--and the clear-eyed vision of the Times comments and blogs will carry us through to a better day.

The Black Swan said...

When I was a kid my family went on vacation in Greece and I got a really bad ear infection. Saw the village doctor that day and got prescription antibiotics and painkillers. Total Cost was around 50 euros! This time around my ER visit plus a CT scan was $4500! When Hospitals and Doctors are charging this much, our insurance premiums go up. This prices out millions of people. There is no reason for these costs other than unmitigated Greed. The ACA will not change this. It will still leave those poor souls being pillaged by insurance companies, paying ridiculous prices for every medical procedure. I have a few friends in Chinese Medicine, who are horrified by the US medical system. It is not just about insuring everyone, price control needs to be a big part of the deal.

Kat said...

Amelia, you hit the nail on the head. Especially with this statement:
Our belief in all this technology is, on a primitive level, every bit as superstitious as the bloodletting which was "state of the art" medicine in George Washington's day--today, as then, condoned with broad professional consensus of the "latest evidence-based medicine," which cannot clearly see its own biases.
I know that our for profit insurance companies deserve our wrath, but our hospital systems should have some blame thrown their way too. I am tired of all the marketing-- whether it is yet another ad on the radio, a full page ad in the NYT, or one of the more stealthy press releases that are disguised as a news story in the local paper or on the local news.
Hospitals may be non profit in that they don't pay income taxes, but for the most part they act like a profit making entity in all other ways-- with administrators and executives and revenue generating physicians doing well for themselves. Yes, they give out some charity care and don't forget to remind you that they do it-- but they do forget to remind you that these are the rules that they agree to abide by in exchange for their exemption from income taxes.
So, we have a consumer driven model of health care. We certainly overpromise what technology can accomplish. And we convince perfectly well persons that their body is some ticking time bomb-- you're going to get a heart attack! Cancer lurks just around the corner! Pharma and medical device makers are happy to play along. I think they've been successful if my experience with various family members and friends or many NYT commenters is tells us something about the general population.
In the meantime, someone like Black Swan is left to cobble together some charity care.
Our health care system in general seems more and more to me to be a scheme to distribute wealth upward.

Zee said...

@Black Swan--

I absolutely agree with you that "There is no option but single-payer Medicare for all. Anything else is pillaging the ill for the benefit of billion dollar corporations."

But single-payer is still off in the future for both you and this country.

I am glad that you have been able to find a charity—or charities—to cover part of the cost of repairing your broken leg, with some hope that the rest of it will simply be written off. But perhaps the following can be of help to you, or to other readers of this forum who find themselves in a similar situation.

It seems not to be common knowledge, but the ridiculous “rack rates” for hospitals and other providers can often be “negotiated down” by uninsured patients. I can't guarantee that your hospital will help you out in this way for your remaining costs, but it can't hurt to ask.

Note that neither the articles below or I am advocating that you hire a “service” to do your negotiating for you. The disadvantages of doing this are enumerated in one of the articles below.

But hospitals prefer to be paid something rather than nothing at all, so it can't hurt to ask, and then do your own negotiating.

Moreover, one need not even be indigent or low-income to negotiate favorable time payments. Last year both Mrs. Zee and I had expensive trips to the emergency room. In my case, the e-room visit was followed up with an MRI and an expensive spinal injection. These expenses put a significant crimp in our budget. Mrs. Zee was able to negotiate time payment plans to the various providers with only a few 'phone calls, easing our budget crunch significantly.

Again, hospitals prefer to be paid rather than not paid, so why shouldn't you ask for time payments, too?

Now, take this last suggestion with a really big grain of salt. Mrs. Zee, who used to be in health care, seems to recall that if asked, hospitals cannot charge more than their lowest fee negotiated with inurance companies. Perhaps this is something worth investigating.

@Kat and @Anne Lavoie, I know that you are both nurses. Do you have any familiarity with the suggestions that I've offered above?

Any reasons not to ask?

Kat said...

I don't really have much experience from the payment side of things. I do know that hospitals are willing to take payments on time and these can be quite low. I also know that for the truly indigent (without medicaid), costs are often eaten by the hospital. It was never my experience to see someone kicked out for not paying. Hospitals still make a lot of money.
I know this is only my experience, and I should not generalize but I did get frustrated with the dire predictions "people are going to die if we don't pass this health care reform!" I see health care sucking a bigger and bigger part of our social welfare spending. There is little to rein in the costs-- as Valerie pointed out evidence based medicine and comparative effectiveness research are not some magical panacea.
I once had a patient with a condition which was exacerbated by heat. He was in the hospital, kind of just hanging out. Talking to him, it became clear that what he really needed was some a/c at home and he would be fine. No money for that-- but he could have a room for over a week!

Karen Garcia said...

Hospitals don't kick sick people out, but if you can't pay and don't qualify for Medicaid and own your own home, they will slap a lien on it. At least that's what happened to me many years ago.
The reason people die for lack of insurance is that they delay care, knowing that going to the hospital will bankrupt them. That is, if they even qualify for bankruptcy any more. Congress made that a lot harder too.
And yes, you can haggle with hospitals over your bill. Insurance companies barter for reduced rates when they negotiate contracts with hospitals. Uninsured people are always billed at a higher rate as a matter of course.

Kat said...

You're right. You are stuck if you don't qualify for medicaid, or you are totally indigent. Some people, if they have plenty of time can comb through their bills and negotiate but this is hardly an answer for everyone.
I do think the bankruptcy reform bill was really awful. I remember wondering where the outrage was at the time. It is unconscionable that people lose their house because they had the misfortune to be sick. A repeal of that law would have been far preferable to the stupid ACA.