Goodman starts with a zinger. The point was universal coverage. "Four years later, not even the White House pretends that this goal will be realized."
The best parts, to me: After noticing that families near 14% of the poverty level get about $8,000 in medicaid benefits, or about $11,000 worth of subsidies on exchanges,
the employees of a hotel who earn pretty much the same wage ... will be forced to have an expensive family plan... the ObamaCare mandate amounts to about a $10,000 burden on these businesses and by extension their employees.This leads to a novel (to me) economic effect.
As businesses discover that almost everyone who earns less than the average wage gets a better deal ...in the exchange or from Medicaid, and that most people who earn more than the average wage get a better deal if insurance is provided at work, trends already evident will accelerate. Higher-income workers will tend to congregate in firms that provide insurance. Lower-income workers will tend to work for firms that don't. But efficient production requires that firm size and composition be determined by economic factors, not health-insurance subsidies.And John is prescient on just why exchange policies seem to be pretty awful:
Under ObamaCare, insurers are required to charge the same premium to everyone, regardless of health status, and they are required to accept anyone who applies. This means... they have strong incentives to attract the healthy (on whom they make a profit) and avoid the sick (on whom they incur losses).
The result has been a race to the bottom in access and quality of care. To keep premiums as low as possible, the insurers are offering very narrow networks, often leaving out the best doctors and the best hospitals.He has some nice alternatives, including
giving everyone the same universal tax credit for health insurance would be a good start. More easily accessible health savings accounts for people in high-deductible plans is another good idea.
Every provision in ObamaCare that encourages employers either not to hire people or to reduce their hours should go. Everything in the law that prevents employers from providing individually owned health insurance that travels from job to job should go. And everything that makes HealthCare.gov more complicated than eHealth (a 10-year-old private online exchange) should go.By contrast, I was interested that Emanuel, an architect of the law, was so weak in its defense.
Look at access to care. According to Gallup, the percentage of uninsured Americans declined from 18% in the middle of 2013 to 15.9% in the first quarter of 2014..Interesting that pro and con opeds start with essentially the same opening sentence! The glass is indeed 85% empty. Ezekiel passes on the canard that health insurance is "access to care."
But most important, recall that the idea was not simply to expand Medicaid and high-subsidy insurance. "Free health care for all" would have produced a lot of people signing up. That's not the measure of success.
A very interesting paragraph:
Look at quality. In 2010, as part of the Affordable Care Act, the federal government launched the Partnership for Patients, a push to reduce infections and other preventable errors and injuries that occur in hospitals through financial incentives. The results have been dramatic. In three years, avoidable central line infections have dropped 41%. Ventilator-induced pneumonias have dropped 55%. Unnecessary, elective C-sections have dropped more than 50%. Hospitals are also getting better at preventing falls, which have declined more than 11%. Overall, the Partnership for Patients has prevented roughly 15,000 deaths, averted hundreds of thousands of injuries, and saved more than $4 billion.This was news to me. And astonishing. After all these years of complaining that doctors are too careful because of out-of-control liability, it took a Federal program to get doctors to wash their hands and prevent falls?
Even if it did, though, this point has nothing to do with the ACA, exchanges, and the rest! The government could easily have passed this magical program without touching health insurance. This is like saying we should fly to Hong Kong first class because the snacks on the plane are good.
He mentions the recent slowdown in costs. But he concedes there was a recession, and that took place before the ACA set in. No need to restart that fight. We'll see if the ACA really ends up being cheap.
But Emanuel concedes all is not right and needs some pretty radical fixing.
Step one would be to operate the exchanges like a cutting-edge e-commerce website, not a traditional government program. ...The challenge is more than getting the sites to work faster and more reliably. The challenge is to get them to run like Zappos or REI, with a relentless focus on improving the insurance offerings, attracting customers, and facilitating an easy, informative shopping experience.I just love this paragraph. It's written in a strange new voice that takes over policy discussions -- the regulatory passive. "to operate..getting the sites to work... to get them to run...." Just who is going to do all this toing? News flash: the ACA is a "government program," and it's run by Health and Human Services? When did government programs ever not operate like, well, government programs? When did any government program relentlessly "focus on improving the insurance offerings, attracting customers, and facilitating an easy, informative shopping experience." Try the Post Office some day. But no,
..there must be constant improvement. And it can probably occur only with a 21st-century, private-sector management structure—one that empowers a CEO, probably with health-insurance experience, and a team of tech-savvy management specialists, to run the entire operation.
Ah, just bring in a czar to command the operation.
Step two would be to change the way doctors and hospitals are paid as quickly and efficiently as possible. In order to control costs and improve quality, there needs to be a transformation in the way care is delivered. There needs to be continuous monitoring of patients in order to intervene early to prevent acute exacerbations of chronic illnesses. And when patients do get sick, there needs to be a greater focus on treating them outside of the hospital so the care they receive is safer, more efficient and lower-cost.
That wonderful regulatory passive again. "to change... there needs to be a transformation... there needs to be monitoring...there needs to be a greater focus." Who prey tell is going to do all this stuff? Why are they going to do it? Who is going to pay for it?
Interestingly, the bottom line ends up not being so different from Goodman. Government programs act like government programs -- for example following arcane procurement rules -- because, by Federal Law they have to run like government programs. And those laws aren't silly, they were put in place because otherwise people steal.
There is a place filled with "CEOs with health-insurance experience and teams of tech-savvy specialists." There is a place where "big transformations in the way " services "are delivered" happens. There is a place that "private-sector efficiency "happens. It's called "the private sector." Really, Emanuel has without realizing it written a pretty effective piece for deregulation of the whole mess.
And, though his closing paragraph praises the law, consider the closing sentence
Now is not the time for autopilot. Lawmakers need to enhance the exchanges and more rapidly adopt alternatives to the fee-for-service payment system.This actually calls for legislative and regulatory changes no smaller than what Goodman calls for!
Emanuel should not get away with the misleading claim that levels of uninsured have fallen. The Gallup surveys he references do show rates declining from mid-2013 to 12 2014, but they also show rates climbing between the signing of ObamaCare in 2010 and last summer. At best, he might claim that ObamaCare caused rates to rose and now have reversed some of the increase.
ReplyDeleteThe bad incentives that this law creates (and we'll see how much they really bare out) need to be weighed against the very real benefit that far fewer Americans now need to worry that a sudden health problem will cause financial ruin. As we know from the Oregon Medicaid study, this provides real increases in wellbeing.
ReplyDelete"far fewer Americans now need to worry that a sudden health problem will cause financial ruin"
ReplyDeletePlease demonstrate.
Good summary of these, and thanks for calling attention to the 'regulatory passive' language often used in policy pieces. I've often thought that ardent advocates of massive, wide ranging govt projects should spend one week working at places like the government office in the marvelous WP story linked below; it would provide some perspective on what can realistically be achieved by passing laws. Many in DC seem to equate passing laws with making things happen, having little interest in the quotidian details of implementation, with the ACA being a current, obvious prominent example. While this administration is certainly not the first to buy into the myth of 'passing law = result', the current administration showed an almost complete lack of interest in implementation of the ACA, and was 'surprised' that the website did not work, etc.
ReplyDeletehttp://www.washingtonpost.com/sf/national/2014/03/22/sinkhole-of-bureaucracy/?hpid=z1
I wonder how many readers are surprised at this, Professor Cochrane's most recent post on the health care debate. To make sure we understand correctly he thoughtfully provides helpful paragraph by paragraph exegesis. (Don't even think of calling it politically motivated "spin.") And thankfully, of course, we can rest assured if there were any information which ran counter to his preconceptions, it would find straightforward, evenhanded presentation here.
ReplyDeleteFor a contrasting approach, on the specific issue of enrollments, readers might take look at Charles Gaba's ACASignups.net. Right now the conclusion is that between 12 and 16 million people have coverage who didn't two years ago. Such a disaster.
I wonder how many readers are surprised at this, Professor Cochrane's most recent post on the health care debate. To make sure we understand correctly he thoughtfully provides helpful paragraph by paragraph exegesis. (Don't even think of calling it politically motivated "spin.") And thankfully, of course, we can rest assured if there were any information which ran counter to his preconceptions, it would find straightforward, evenhanded presentation here.
For a contrasting approach, on the specific issue of enrollments, readers might take look at Charles Gaba's ACASignups.net. Right now the conclusion is that between 12 and 16 million people have coverage who didn't two years ago. What a disaster.
It's probably too late for anyone to read this except for Professor Grumpy but I wanted to address the side issue of what "got doctors to wash their hands". It was money. Medicare will not pay for treatment of hospital-acquired infections. One person in 25 who is admitted to the hospital will develop an infection. It roughly quintuples the length of stay and the cost. Going forward, hospitals will eat that cost. It used to be a money-maker. Hospital infection rates will also be published on the Internet, so the old technique of "public shaming" has been resurrected. Perhaps dirty hospitals will have to paint a large scarlet letter on their facades.
ReplyDeleteTherefore, there has been a major push by the hospitals to reduce infections. The name badges at one hospital say "Ask me if I washed my hands" at the bottom. Despite these and other exhortations hospital staff (not just doctors) have an estimated 50% compliance rate with hand washing. As an aside, doctors are the only people I know who wash their hands BEFORE they use the rest room.
The other problem is colonization of equipment, clothes, and furniture. There are news stories about the germs found on stethoscope heads, forbidding doctors to wear neckties, etc.
You can't wash doorknobs, telephone handsets, and light switches after every use. Ditto for keyboards and mice, which everyone touches now that electronic records are de rigeur. The next time you use the rest room count how many different surfaces you touch. There are recommendations that stethoscope heads be cleaned every day. I don't know how they came up with that number. Do you feel good about being patient #27 if the stethoscope was last cleaned before patient #1 this morning? Has anyone ever documented disease transmission by a stethoscope? No, but we'll make up some rules anyway because like ObamaCare and all sorts of ridiculous laws regulations they sound like good ideas that should be inflicted on people without any evidence of efficacy.
After a patient is discharged their room is subjected to a process with the unfortunate name "terminal cleaning". This usually entails fogging the room with something like peroxide or placing UV lights in the room to sanitize it. Unfortunately the bugs start growing again as soon as you turn off the equipment.
ECRI has declared antimicrobial copper to be a top priority in 2014. A 2013 study published in the Journal of Infection Control and Hospital Epidemiology showed that replacing only 6 surfaces in a hospital room reduced infections by more than half. The great thing about copper is that you don't have to nag people to use it. You just put it on doorknobs, light switches, bed rails, etc and let it do its work passively 24/7.
The slow adoption of antimicrobial copper is extremely frustrating. This is a passive continuous technology. Passive continuous technologies like clean water, reduced air pollution, food safety regulations and vaccinations have prevented more death and disease than any 100 wonder drugs combined. In 1900 the top killers were infectious diseases such as pneumonia, TB, and dysentery. Children died of whooping cough and diphtheria and were crippled by polio. It wasn't drugs that wiped out these diseases. It was passive continuous public health measures. That's where the focus needs to be. Nobody has to remind you to use the sewer system.
/rant off