Tag Archives: obamacare

Billions Left on the Table

North Carolina is one of the states that didn’t expand its Medicaid program after the passage Obamacare. According to this little item from the Wonkblog there are a BUNCH of states that are reconsidering their decisions to opt out:

Money talks: Medicaid expansion makes headway in Republican states. “Two things have led to a change of heart for some Republican politicians. Most of the 27 states that are already expanding the program have begun to reap billions in federal subsidies for insurers, hospitals and healthcare providers, putting politicians elsewhere under intense pressure to follow suit. As demonstrated by Pennsylvania’s deal with Washington, the Obama administration has also proved willing to accept tweaks that give the private sector a greater role in providing healthcare and place new responsibilities on beneficiaries. All of that has got as many as nine states talking to the administration about potential expansion terms.” David Morgan in Reuters.

According to the Reuters article referenced above, North Carolina is one of the states looking at what it can do:

Some states with Republican governors, such as Indiana, are negotiating with Washington for agreements that could pass political muster with conservatives back home. Others such as North Carolina, South Dakota and Wyoming are exploring options.

One of the reasons that North Carolina’s leaders said they didn’t want to opt for expansion is that they feared the Feds wouldn’t pick up the vast majority of the cost as they’d promised (I’m paraphrasing). Now that they’re seeing what kind of money they’re leaving on the table they seem to be second guessing their decision, but they’re likely going to slow-play their hand because things might change in November.

According to the Reuters article if the Democrats lose control of the Senate then the wave of Republican states reconsidering their Medicaid expansions might ebb. Here’s the irony for North Carolina Republicans, many of whom might benefit from Medicaid expansion: on this particular issue they might be better off if Dem. Senator Kay Hagan wins reelection. And if you think the only Republicans who might benefit are those who are eligible for Medicaid then you’re forgetting all the Republicans who work in the health care industry. Just look at the projections for Pennsylvania:

A study by the RAND Corp predicted a $3 billion economic boost and the creation of 35,000 jobs – big advantages for a state that has struggled for decades to make up for jobs lost from the decline of the coal and steel industries.

Unfortunately for the Democrats this kind of issue is far too complex to make an effective campaign tactic. After all, this is a country full of people who said things like “Keep the government’s hands off my Medicare” when Obamacare was being debated. You can’t possibly expect them to back a candidate out of enlightened self interest when they don’t even know what their self interest is.

North Carolina’s $51 Billion Gamble

Brad DeLong has some thoughts about Obamacare and here in NC this one bites:

The willingness of state-level Republican politicians to hurt their own people–those eligible for the Medicaid expansion, those who would benefit from a little insurance counseling to figure out how to take advantage of subsidies, those hospitals who need the Medicaid expansion to balance their finances, those doctors who would ultimately receive the subsidy dollars–is, as John Gruber says, “awesome in its evilness”. The federal government has raised the money, and all the state has to do in order to get it spent is to say “yes”. Especially in contrast with the extraordinary efforts state-level politicians routinely go through in order to attract other spending into their state, whether a BMW plant or a Social Security processing center, this demonstrates an extraordinary contempt for a large tranche of their own citizens. And when I reflect that a good third of that tranche reliably pull the lever for the Republican Party year after year…

To that point, here’s some encouraging news about North Carolina’s non-participation in Medicaid expansion:

North Carolina’s decision not to expand Medicaid coverage as part of Obamacare will cost the state nearly $51 billion in federal funding and reimbursements by 2022, according to research funded by theRobert Wood Johnson Foundation

It notes that North Carolina stands to lose $39.6 billion in federal funding between 2013 and 2022…

“States are literally leaving billions of dollars on the table that would support their hospitals and stimulate the rest of their economies,” says Kathy Hempstead of the Robert Wood Johnson Foundation.

The report notes that for every $1 a state invests in Medicaid, it will receive $13.41 in federal funds.

And here’s the real kicker:

The decision not to expand Medicaid coverage will leave 6.7 million U.S. residents uninsured in 2016. That includes 414,000 people in North Carolina.

Of course Obamacare isn’t perfect and Medicaid isn’t the end-all, be-all of health care insurance — DeLong himself says in his thoughts about Obamacare that “Where the Medicaid expansion has been allowed to take effect, it has taken effect. People are going to the doctor more, people are finding doctors to go to, and the only minus is one that we already knew: that Medicaid is not a terribly good way to spend our money in treating people with chronic conditions” — but it is still a better option than nothing and an improvement over the Emergency Room as primary care provider system that we’ve had.

What’s truly frightening to consider is where we’ll go from here. Without the funds our doctors and hospitals will be missing out on literally billions of dollars of reimbursement, almost 1/2 million citizens will be uninsured and will continue to use the emergency room as their primary caregiver, the hospitals will have to eat the cost and downward we spiral.

Measuring Success

There are many ways to measure success and/or failure, and it’s important to keep that in mind when you assess hot-button issues. For instance, this article in the Greensboro News & Record about Obamacare’s affect on insurance coverage in North Carolina:

In North Carolina, 16.7 percent of residents are now uninsured, compared with 19.6 percent before the onset of the ACA, according to a study conducted by the social network WalletHub.

 

North Carolina ranked 33 among states for its number of uninsured residents.

The Tar Heel state also ranked fourth among states with the most net new private insurance enrollees per capita.

WalletHub used data from the Kaiser Family Foundation, the Centers for Medicare & Medicaid Services, the U.S. Department of Health and Human Services and the Census Bureau to make its projections.

Those who supported Obamacare will likely tout this statistic as proof that Obamacare is working. On the other hand, those opposed to Obamacare can ask the question, “But at what cost?” That’s the crux of the issue: we can all probably agree that more people having health insurance is a good thing, but we’d probably have lots of heated debate over how much to pay for it, how to pay for it and how to structure the program. Does the phrase “socialized health care” ring any bells.

Quite frankly I think it’s far too early in the process to declare Obamacare a success or failure, but I’d say these numbers show a positive trend towards getting more people health insurance coverage. Long term who knows whether or not Obamacare will be a net success, but at a minimum we’ve seen thousands of North Carolinians moved off the roles of the uninsured and that’s a step in the right direction.

 

Health Care Rights

Have you heard about the SCOTUS decision in the Hobby Lobby case? If you live in American and haven’t heard about it then you might live in a cave, but here’s the gist of it:

The U.S. Supreme Court has upheld a decision whereby closely-held companies can request exemptions the Patient Protection and Affordable Care Act (ACA) coverage provision for some contraceptives because of the corporations’ founding family’s religious beliefs…

Much of the controversy over today’s decision derives from the fact that Hobby Lobby and Conestoga are not in the business of conducting religious services or overseas humanitarian missions as their primary business. They are for-profit companies. The ruling allows the corporations to refuse coverage because of the religious beliefs of individual leaders.

Beyond selectively singling-out women’s reproductive care, the decision raises the question of whether corporate leadership elsewhere might refuse coverage of other drugs due to religious beliefs.

A lot of the reaction I’ve seen online has focused on a couple of points: the weirdness of bestowing religious rights on closely held corporations using the argument that the corporation is an extension of the owners (that’s simplistic but I think gets to the heart of it); that the religious rights of the corporation/owners trumps the reproductive rights of their female employees.

I’d like to focus on the second point for a minute because I think the argument is a bit off and, quite frankly, misses the larger point. While it is regrettable that employers like Hobby Lobby would refuse to pay for insurance that covers all of their female employees’ contraceptive choices it doesn’t mean that those same employees can’t go out and get those contraceptives if they’re willing to pay for it themselves. Thus they aren’t denying them anything, they’re just not paying for it. That might seem like semantics, but I think it’s important because what it exposes is that corporate health insurance in this country is not a right for anyone.

Health insurance as we know it came into being in the World War II era as an incentive companies used to attract and retain employees who were in short supply at the time. As such, health insurance was never a “right” but was a benefit that came to be so commonplace that most employees started to view it as a right. Then something funny happened – companies realized they could shift the cost of health insurance back to employees and not suffer too many dire consequences and so they starting jacking up premiums and co-pays or simply doing away with health insurance all together. The result is a growing percentage of our population without access to health insurance, which means they forego preventive care and rely on ERs when they get sick, helping drive up health care costs for everyone.

The Clinton administration’s effort to deal with the rising health care problem twenty years ago was a notorious failure. ObamaCare started out as an ambitious plan to provide health care coverage for everyone, fought the “socialized medicine” stigma, went through a negotiation phase involving the health insurance cabal that resulted in the imperfect system being fought out in the courts today. You’d be hard pressed to find anyone happy with the system, except maybe for the millions of people who had NO access to health insurance pre-Obamacare and now at least have the option to buy it.

Long story short, while it’s easy to get hung up on the reproductive and religious rights arguments raised by the Hobby Lobby case, it would be a mistake to limit the scope of the conversation. The bigger question is why we can spend so much time and energy talking about our religious rights, women’s reproductive rights, our right to bear arms, etc. but we never seem to debate whether we should have a fundamental right to affordable, adequate health care and whether or not relying on private companies to provide it is the best way to approach it.

Health Insurance – Caveat Emptor

One of the problems with buying health insurance is that it's one of the most complicated purchase any one of us will make in any given year. With the advent of Obamacare scores of people will be buying insurance on an open market for the first time – versus opting from a limited set of options from an employer – and that means the complexity of the process will have an ever greater impact in the coming years. That's what makes this story on Planet Money so scary:

Any day now — assuming the government manages to fix HealthCare.gov — millions of people will start shopping for health insurance.

Will those shoppers know what they're doing? More to the point, if you're one of those shoppers, will you know what you're doing?

Here's a quick quiz, courtesy of economists George Loewenstein and Saurabh Bhargava, who study what people know (and what they think they know) about health insurance. The economists have used longer versions of these quizzes in their research…

While the share of people who answered each question correctly varied, the vast majority of people who took the quizzes got at least something wrong.

And this isn't just some academic artifact: Bhargava and Loewenstein are leading an ongoing study of some 50,000 real-world choices that people make when shopping for insurance — and found that 65 percent of the time, people choose plans that are more expensive than other options but don't provide more benefits.

You should go take the quiz. You might be surprises at how much you think you know that you really don't.

The Red State ACA Donut Holes

North Carolina, like many states controlled by Republicans, opted out of the Medicaid-expansion component of the Affordable Care Act. A New York Times article explores the practical effect it's having on those states' citizens:

A sweeping national effort to extend health coverage to millions of Americans will leave out two-thirds of the poor blacks and single mothers and more than half of the low-wage workers who do not have insurance, the very kinds of people that the program was intended to help, according to an analysis of census data by The New York Times.

Because they live in states largely controlled by Republicans that have declined to participate in a vast expansion of Medicaid, the medical insurance program for the poor, they are among the eight million Americans who are impoverished, uninsured and ineligible for help. The federal government will pay for the expansion through 2016 and no less than 90 percent of costs in later years.

Those excluded will be stranded without insurance, stuck between people with slightly higher incomes who will qualify for federal subsidies on the new health exchanges that went live this week, and those who are poor enough to qualify for Medicaid in its current form, which has income ceilings as low as $11 a day in some states…

The 26 states that have rejected the Medicaid expansion are home to about half of the country’s population, but about 68 percent of poor, uninsured blacks and single mothers. About 60 percent of the country’s uninsured working poor are in those states. Among those excluded are about 435,000 cashiers, 341,000 cooks and 253,000 nurses’ aides.

“The irony is that these states that are rejecting Medicaid expansion — many of them Southern — are the very places where the concentration of poverty and lack of health insurance are the most acute,” said Dr. H. Jack Geiger, a founder of the community health center model. “It is their populations that have the highest burden of illness and costs to the entire health care system.”

We're going to be hearing a LOT about the ACA, aka Obamacare, rollout over the next few months. The program opened for enrollment on Tuesday (Oct 1) with a start date set for January and the traffic to the website was heavy enough that it slowed to a crawl.  Like any new program, especially one of this scale, there will be issues but it will be interesting to see if the overall benefits outweigh the problems enough that people will eventually say "Keep the government's hands off my ACA!"

If that does happen it will be with folks like the self-employed who couldn't get on a regular insurance plan that was anywhere near affordable, the employees working for small employers who stopped offering health insurance long ago because they couldn't afford to provide coverage and weren't legally required to, and the folks with preexisting conditions who couldn't get any coverage no matter how much they were willing to spend. Sadly it seems that a huge chunk of the working poor will fall in the "not poor enough" donut hole created by states' refusal to expand Medicaid and won't have access to a program that was most definitely intended for them.

As you can likely tell I'm one of those who is truly hoping that ACA is a step in the right direction for our country. I don't believe it's a silver bullet or that it truly fixes anything, but I'm hoping that it's a step in the direction of a comprehensive, effective reform of our health care system. It's still way too early to see what the end result of ACA is going to be, but quite frankly it would be hard to go backwards from where we've been in the recent past so I'm pretty confident it will be a net benefit for society. On the other hand I seriously doubt it's enough on its own and I hope we continue to look for ways to make sure the neediest have some form of health coverage without bankrupting the rest of us in the process.

Living in the Land of the Suicide Caucus

The 80 Republican representatives who signed the letter sent to House Speaker John Boehner urging the course of action that has led to the government shutdown were dubbed The Suicide Caucus by none other than conservative columnist Charles Krauthammer. Who are they and where are they from? Let's see:

On August 21st, Congressman Mark Meadows sent a letter to John Boehner. Meadows is a former restaurant owner and Sunday-school Bible teacher from North Carolina…

Meadows was not pleased with how Boehner and his fellow Republican leaders in the House were approaching the September fight over spending. The annual appropriations to fund the government were scheduled to run out on October 1st, and much of it would stop operating unless Congress passed a new law. Meadows wanted Boehner to use the threat of a government shutdown to defund Obamacare, a course Boehner had publicly ruled out…

Before Meadows sent off his letter to Boehner, he circulated it among his colleagues, and with the help of the conservative group FreedomWorks, as well as some heavy campaigning by Senators Ted Cruz, Marco Rubio, and Mike Lee, seventy-nine like-minded House Republicans from districts very similar to Meadows’s added their signatures.

Here's a map showing the 80 districts. I live smack dab in the middle of the heaviest concentration:

SuicidePactDistricts

But are they really suicidal? Actually they're acting rationally if you look at where they're coming from:

In one sense, these eighty members are acting rationally. They seem to be pushing policies that are representative of what their constituents back home want. But even within the broader Republican Party, they represent a minority view, at least at the level of tactics (almost all Republicans want to defund Obamacare, even if they disagree about using the issue to threaten a government shutdown).

Most folks here in the land of the Suicide Caucus despise "libruls" and distrust the government intensely. What would be interesting to see is how they would react if their reps got their way and shrank government programs drastically. Most folks don't realize all the programs the government is behind – "Keep the government's hands off my Medicare! – so would they put two and two together and blame their representative for their lost money/service? Probably not.