ACA Report Card from The Economist

A mixed report, of course, but as a summary in one place I thought it was useful.  I have read The Economist’s copyright policy and am not reprinting anything from that mag here.  However, I am linking:

http://www.economist.com/node/21618904/print

If It Saves One Life

This is something I’ve been thinking about for a long time.  I doubt any of the rest of you are interested in this phenomenon but I’ve found it to be very true in my own experience.  Once tragedy strikes, especially one we believe could have been prevented, we tend to change our minds about numerous things.  That old saying “if it saves one life it’s worth it”, which the guy quoted below actually says at the end of his testimony, and most of us know is not a very legitimate tool to use to bring about change, suddenly has meaning.

When I think back to the Health Care debate and why it was so important to me, Daniel’s story about his sister’s death, matched my own perception of that debate at the time because of my niece’s death.  During the years I fought for health care reform I met hundreds of people whose stories were similar to my own.  And honestly, they weren’t all hot-headed progressives (and I’m not either although I do get hot-headed about health care inefficiencies).  Most of them were simply hard working Americans who had a terrible story to tell about a health care system that had failed.

I think this is one of the reasons so many of the provisions in the ACA are popular while the bill itself isn’t.  Some of us can imagine what it would be like to not have these new regulations or know someone who is benefiting from them now.  And so even though the bill is a mess in so many ways, they’re grateful for it in other ways.  It’s interesting to me that the polling is so skewed.

Anyway, my point really is just that while I really am not impressed with the bill that became the ACA, either during it’s development or now, I still can’t help but be grateful that someone elses family won’t have to suffer the same terrible loss that we suffered.  That brings it down to the most personal level which is exactly what Daniels is talking about.  This is when, right or wrong, people look to their government for help…………………most of us don’t really have anywhere else to go to find the same kind of resolution to an injustice.  If the ACA had been in effect at the end of 2007 chances are very likely my niece would be alive today………………that’s a really life altering scenario to think about.

There’s a part of me that wishes things were different because I know it’s not necessarily fair to the rest of you who make it through life without this kind of event or are able to separate your logical and principled selves from needing or desiring any kind of assistance yourself.  The idea that a man like Daniel, could now be attempting to influence a debate about background checks tells me all I need to know about reality.

WASHINGTON — Elvin Daniel, 56, is a card-carrying member of the National Rifle Association, an avid hunter and a self-described “constitutional conservative” from a small town in Illinois. He became an unlikely witness for the Democrats on Wednesday at the first-ever Senate Judiciary Committee hearing on gun violence against women.

Daniel choked back tears at the hearing as he recounted the story of his sister, Zina, who was shot and killed by her estranged ex-husband in 2012. After her ex slashed her tires and physically threatened her, Zina had obtained a restraining order against him, which should have prohibited him under federal law from buying a gun. But he was able to purchase a gun online, where private sellers are not required to conduct background checks.

“Now I’m helping to care for my two nieces who lost their mother and who will have to grow up without her,” Daniel told the committee. “I’m here today for Zina and for the stories like Zina’s that happen every day because of the serious gap in our gun laws that continue to put women’s lives in danger.”

American women account for 84 percent of all female gun victims in the developed world, and more than a quarter of female homicide victims in the U.S. are killed by an intimate partner.

The two bills being considered in the Senate, introduced by Sens. Amy Klobuchar (D-Minn.) and Richard Blumenthal (D-Conn.), would strengthen federal gun prohibitions for convicted domestic abusers and those deemed by a judge to be a physical threat to a woman. Klobuchar’s bill would include physically abusive dating partners and convicted stalkers in the category of persons who are prohibited from buying or possessing a gun. Blumenthal’s bill would ban guns for those who have been issued a temporary restraining order by a judge for domestic violence.

All the provisions being discussed are supported by a majority of Americans, according to a recent HuffPost/YouGov poll. But gun limits are difficult for Congress to pass, even when they are broadly supported by voters, due to the strong opposition of the well-funded and well-organized gun rights lobby. A popular bill that would have closed gaping holes in the federal background checks system fell just short last year of the 60 votes it needed to overcome a Republican filibuster.

The NRA is already fighting Klobuchar’s bill, claiming that it “manipulates emotionally compelling issues such as ‘domestic violence’ and ‘stalking’ simply to cast as wide a net as possible for federal firearm prohibitions.”

“If we can save just one life, that would be worth everything we’re going through,” Daniel said. “And I know we can save more than one life.”

Daniel’s Testimony and More is from Huffingpost which I realize is a very partisan source.  I read about it somewhere else but now can’t find the source.  At least it’s not Reuter’s Scott…………………LOL

Here’s a little less partisan one but still not the one I was looking for.

Open Thread – Monday (Edited)

I’m still working but took a break this afternoon to do a little reading. I’m trying to finish Unbroken but I’m not there yet. Next weekend is the book review………..hint, hint. I’ve also been working on our taxes, that’s right we filed an extension (just like the Romneys), but I have even less money now than I did in April to pay what we still owe……………yikes. And we finally got the rest of the parts we needed to finish our big export order to Taiwan, which we’re trying to get out the door (that’s money in the bank). Anyway, I did read a couple of interesting pieces during my breaks this weekend that might spark a little conversation.

Last week Nova linked this piece from the Atlantic about why liberals shouldn’t vote for Obama. It was interesting but didn’t sway me. I’d already explored all of the issues and decided I’m going to vote for him anyway. The most important issue for me is health care reform and even though he didn’t get the bill I wanted I’ve decided repealing the ACA is too big of a threat for me to not support him.

One of the issues discussed was our drone policy, particularly in Pakistan.

Obama terrorizes innocent Pakistanis on an almost daily basis. The drone war he is waging in North Waziristan isn’t “precise” or “surgical” as he would have Americans believe. It kills hundreds of innocents, including children. And for thousands of more innocents who live in the targeted communities, the drone war makes their lives into a nightmare worthy of dystopian novels. People are always afraid. Women cower in their homes. Children are kept out of school. The stress they endure gives them psychiatric disorders. Men are driven crazy by an inability to sleep as drones buzz overhead 24 hours a day, a deadly strike possible at any moment. At worst, this policy creates more terrorists than it kills; at best, America is ruining the lives of thousands of innocent people and killing hundreds of innocents for a small increase in safety from terrorists. It is a cowardly, immoral, and illegal policy, deliberately cloaked in opportunistic secrecy. And Democrats who believe that it is the most moral of all responsible policy alternatives are as misinformed and blinded by partisanship as any conservative ideologue.

Then today I saw these charts and thought what the hell? I haven’t had the time to look into where exactly the information came from but according to them there have been exactly zero civilian deaths in Pakistan due to drone strikes this year. Can that be true?

This piece, “Is Karl Rove Losing It?”, is a pretty interesting take on Karl Rove and the author wonders if he really has as much power as he thinks he does. It’s probably just wishful thinking, those of us on the left aren’t too fond of the guy.

Karl Rove is back as GOP party boss, but this time it’s clear that even the best-laid plans of the savviest political strategists often go awry.

That became obvious earlier this week, on Sept. 25, when Missouri senatorial candidate Todd Akin reaffirmed that he was staying in the race in defiance of Rove, who had demanded Akin’s withdrawal and yanked American Crossroads’ millions from his campaign after Akin touted the prophylactic character of “legitimate rape.”

When pulling the super PAC dough didn’t faze the stubborn Missouri Tea Partyer, Rove went ballistic. “We should sink Todd Akin,” he declared , according to Bloomberg Businessweek. “If he’s found mysteriously murdered, don’t look for my whereabouts!”

Rove’s remarks did more than just reopen the schism between the GOP establishment he embodies and the Tea Party, which has begun to see him as a ruthless party boss. It also showed that the Republicans have another serious problem in addition to Mitt Romney’s disastrous candidacy: Karl Christian Rove.

And lastly this one suggests three reasons why Romney isn’t doing better than he is. I do realize it’s not over though…..believe me.

1. His stand on the auto bailout “Let Detroit Go Bankrupt” has hurt him in states like Ohio.

2. He probably lost Florida when he chose Ryan as his running mate as the majority of seniors apparently don’t like their plans for Medicare…………even if they were excluded from the cuts.

3. His lack of connection with ordinary Americans exemplified by his 47% comments.

Flip Flopper in Chief?

I just don’t see how someone with so many different opinions or statements on one subject can realistically believe he can or even should be President.

A quote from Romney’s book “No Apology”;

After about a year of looking at data — and not making much progress — we had a collective epiphany of sorts, an obvious one, as important observations often are: the people in Massachusetts who didn’t have health insurance were, in fact, already receiving health care. Under federal law, hospitals had to stabilize and treat people who arrived at their emergency rooms with acute conditions. And our state’s hospitals were offering even more assistance than the federal government required. That meant that someone was already paying for the cost of treating people who didn’t have health insurance. If we could get our hands on that money, and therefore redirect it to help the uninsured buy insurance instead and obtain treatment in the way that the vast majority of individuals did — before acute conditions developed — the cost of insuring everyone in the state might not be as expensive as I had feared.

It’s not as if this interview with Glenn Beck was while he was in college, it was in 2007.

When they show up at the hospital, they get care. They get free care paid for by you and me. If that’s not a form of socialism, I don’t know what is,” he said at the time. “So my plan did something quite different. It said, you know what? If people can afford to buy insurance … or if they can pay their own way, then they either buy that insurance or pay their own way, but they no longer look to government to hand out free care. And that, in my opinion, is ultimate conservativism.

And in a 2010 interview on Morning Joe he was asked if he believed in universal health coverage and said;

Oh sure. Look, it doesn’t make a lot of sense for us to have millions and millions of people who have no health insurance and yet who can go to the emergency room and get entirely free care for which they have no responsibility, particularly if they are people who have sufficient means to pay their own way.

And then surprise of surprises last night on 60 Minutes he reversed course.

“Well, we do provide care for people who don’t have insurance,” he said in an interview with Scott Pelley of CBS’s “60 Minutes” that aired Sunday night. “If someone has a heart attack, they don’t sit in their apartment and die. We pick them up in an ambulance, and take them to the hospital, and give them care. And different states have different ways of providing for that care.”

h/t Sam Stein & Amanda Terkel

My oldest daughter finally convinced one of her friends to apply for the CA PCIP enacted as part of the ACA. Her friend Sara completely lost the ability to speak and also lost control of many motor skills while in graduate school about three years ago. Her medical insurance expired as she was forced to quit school and was also unemployable. Luckily, her partner was able to support the two of them, but just barely. Sara was unable to purchase health insurance and had no medical diagnosis so was also denied disability.

She has spent the last three years in emergency rooms and trying to get care and a diagnosis through the health department but most tests were denied and no one seemed able to make a diagnosis even though she has gone down hill dramatically in the past three years. At one point the state sent her to a mental health expert as they thought she was making herself sick or something. She now walks with the help of a walker, can no longer drive and barely leaves the house as it’s too much effort.

About a month ago she received her insurance through PCIP and was finally able to see both a GP and the neurologist he sent her to and now has a likely diagnosis and even medication to improve her condition. Her tests were ordered on an emergency status and she was diagnosed with PLS a very rare (only 500 cases in the US) and degenerative form of ALS (Lou Gehrig’s) that is not as deadly or rapidly progressive. There are treatments and while it is debilitating it isn’t a death sentence and can be mitigated while improving her quality of life.

We had a similar experience with our niece who died in 2008. We waited a very long time for her insurance company to approve the tests she needed but the approval never came. Instead she received a notice that her insurance had been terminated. We couldn’t get in to see a neurologist until we could prove we had the money to pay for whatever tests and treatment she might need. We converted our IRA’s to cash and put our rental house on the market but we were too late. While I was on the way to bring her home from Albuquerque to see the neurologist I’d found to treat her she had a seizure and died.

Mitt Romney can’t even seem to figure out if we have an obligation to help people in these circumstances or not.

Bundled Payments are Hard

One of the big issues in breaking down siloed care is how to “bundle” a payment. Providers balk unless you “risk adjust”: basically account for variations among patients. Without a risk-adjusted payment, a few high-cost patients are going to wipe out any savings. So, what to risk adjust? That’s the big question. In it’s simplest form, you either pay more to help adjust for provider risk or limit those involved in the demonstration. Exclude “risky” patients from bundling. I think that defeats the whole point.

Quoting from a behind the paywall trade pub:

Bundling is still experimental — and an accurate method is difficult to determine in the abstract — CMS may want to consider a combination of pre-payment risk adjustment that could be reconciled after the fact in order to account for high-cost patients, says Paul Van de Water of the Center on Budget and Policy Priorities. This would give doctors more security in participating in bundling, Van de Water said, as risk adjustment is never going to completely account for outliers.

Other options include flagging particular codes, such as for diabetes, so you know who is “riskier.” But that’s still pretty crude and it’s tough to get an accurate picture just on claims data.

Still others want “the medical, social, and personal patient factors that are beyond a provider’s control, such as poor nutrition, tobacco and alcohol use, and non-compliance with treatment recommendations ….
and geography, right down to neighborhoods people live in, also needs to be taken into account. This account for underserved areas. And they’re talking block-by-block.

This is hopelessly complex. But bundled payments are a big part of the “savings” in the ACA.

What’s Next

The PPACA extends the current system to more people to increase coverage, but doesn’t fundamentally reform health care at the delivery level. As such, it will not succeed in bending the cost curve to make the growth rate of health care spending sustainable. The interesting question now is what path it takes when it inevitably collapses. I see one of two options: 
 
1. “Individual Market Based” – Some combination of Ron Wyden’s and Paul Ryan’s reforms are enacted eliminating the employer based tax preferences and replacing them with individual tax credits, thus eliminating the already tenuous “firewall” between the exchanges and the employer based system.  
 
Medicare and Medicaid (and potentially TriCare) are voucherized and integrated into the existing subsidy system in the exchanges so that all health insurance is purchased by individuals in the exchange system with varying levels of subsidies and tax credits based on age and income. About as close to “Free Market” as you are likely to get. 
 
2. “Single Payer (sort of)”. Medicaid for all is enacted replacing the exchange system entirely with a universal minimal standard insurance package provided by the government. Coverage and reimbursement is dictated by a more robust version of the Medicare Payment Advisory board that strictly limits name brand drugs and other expensive treatments in favor of generics and applies similar cost/benefit analysis to approved procedures (and reimbursement rates). The ability to see specialists without a referral or otherwise go “out of network” is curtailed, as are end of life procedures.  
 
In parallel with the public system, private insurance and medical care remain to provide enhanced care for those who can afford it.  
 
Eventually, the public system comes to resemble public schools vs private schools as taxpayers who opt for the private system are not receptive to tax increases to maintain and improve a public system that they themselves do not participate in, thus regulating the public system to a second tier level of care, much like Medicaid is today.

SCOTUS Decision (Open Thread)

So today is the day. I thought we could just use an open thread for comments as the decision and opinions come in.  Anyone have a link to that liveblog we can add here?

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