December 1st has come and gone and somehow the media has largely overlooked the November 30th deadline for massive improvements to Obamacare. I suppose that is only because there hasn't been a disaster to report. Per the progress report at http://www.hhs.gov/digitalstrategy/blog/2013/12/operational-progress-report.html the system is now capable of processing 50,000 people simultaneously, 800,000 per day, with less than a 1% error rate and 90+% uptime (downtime for fix installs and testing).
Of course Republican leaders, always concerned about the little guy, point to the error rate of 1% which can only be described as an abject failure. Then you have those Republicans on the Sunday talk shows bemoaning the complete lack of medical record security in the system. This last point is of special interest as, because there is no screening for preconditions in the application process, there is no medical history put on the website by consumers to be "stolen".
If there is any question about the political slant of the US main stream media a good study would be the number of stories about the the Obamacare website the first week of December vs the first week of October. I would argue a truly helpful, informative media would be in full promotion mode alerting people if they wanted to apply now was the time because the federal system is up on its feet and working. Not perfect, but then neither was Windows 7 (or its many, many precursors).
Last word isn't written on this, and no doubt the intro was badly botched. Apparently they set themselves a rather impossible task for the federal site. Less is sometimes indeed more, Bauhaus was right! They should have kept it simple, but of course this is greatly aided with the benefit of hindsight. And there is quite a bit of stuff the president shouldn't have said or promised.
Diagnosis for Healthcare.gov: Unrealistic Technology Expectations
The website for the Affordable Care Act was doomed by an inordinately complex setup that tried to link disparate databases in real time.
By David Talbot on December 2, 2013
Why It Matters
Millions of Americans lack health insurance and are expected to use healthcare.gov to enroll.
The fiasco with the $600 million federal health insurance website wasn’t all bureaucratic. Forcing slow and disparate databases run by government and insurance companies to work together in real time—and then launching the service all at once—would have challenged even technology wunderkinds.
In particular, the project was doomed by a relatively late decision that required applicants to open an account and let the site verify their identity, residence, and income before they could browse for insurance. That meant the site would have to interface in real-time with databases maintained by the Internal Revenue Service and other agencies.
“You could put 100 Google engineers on it, and it’s not going to fix [the fact] that the scope of the project is flawed or fix the IRS system if it’s slow,” says John Halamka, chief information officer of Beth Israel Deaconess Medical Center in Boston. “You don’t want to query 10 downstream systems and be reliant on their performance, because you are only going to be as good as the slowest one.”
This problem did not plague many of the health-care exchanges at the state level. For example, the Massachusetts system lets you shop for insurance anonymously, and even apply for an insurance policy without setting up an account. Identity confirmation is done later, before the policy becomes effective. Similarly, the exchange in Kentucky—which, like the federal website, went live on October 1—didn’t require users to set up an account or verify their identity before enrolling.
The New York state exchange does require people to verify their identity and set up an account before enrollment, but the state had planned for this and had ID systems in place, says Greg DeBor, managing director at Manatt Health Solutions, which assisted the state with policy and design matters related to the exchange.
These state and federal websites are the key to the implementation of the Affordable Care Act, often called Obamacare. The law calls for state-specific health insurance exchanges—websites where people can compare prices and purchase private health insurance or determine if they are eligible for Medicaid. If states do not set up their own exchanges—34 did not—their residents must use the federal government’s site, healthcare.gov, which crashed and was widely inaccessible after it went live on October 1.
On September 26, President Obama hinted of no problems and compared healthcare.gov to popular e-commerce sites. “Now, this is real simple,” he said. “It’s a website where you can compare and purchase affordable health insurance plans side by side the same way you shop for a plane ticket on Kayak, same way you shop for a TV on Amazon. You just go on, and you start looking, and here are all the options.”
But beyond the president’s cluelessness about the looming problems, his analogy fails because on both Amazon and Kayak, you can dive in and start shopping without the website first having to query numerous federal databases. E-commerce sites also are willing to postpone certain details. For example, Amazon will immediately send you an e-mail to confirm your purchase and then later send you one with a UPS tracking number, after it’s made the link to a UPS database.
In contrast, the federal site took on complications that would befuddle even the best technologists. “The scope of ‘we will provide all the functionality for 34 states, and linkage to 1,000 insurance companies, and an online real-time marketplace’ was probably too big to accomplish given the time available,” Halamka says.
DeBor says the technological challenge was exacerbated by the administration’s demand that every element of the hugely complex site be ready at once. “The requirements [for the site] came out very late, and they were all predicated on everything being ready at once. With those two things, it made it hard for anybody to deliver on this,” he said. “It was the ‘big bang’ approach: we have to do everything and have everything ready on October 1.”
But fixes are possible, and are slowly underway. The Center for Medicare and Medicaid Services, which oversees the site, is adding storage capacity to speed application processing. And the agency has been implementing dozens of software upgrades to do things like make databases work together better and to fix issues that only became evident after the October 1 “big bang.”
The administration was predicting that the site could handle 50,000 visitors at a time by the Thanksgiving weekend, when its self-imposed December 1 deadline for site fixes arrived. Even so, it delayed a marketing campaign to avoid a crush of new users—which could still paralyze the site.
Americans spend more than 17 percent of GDP on health care; other high income industrial democracies spend only about 11 percent. The 6 percent difference in our $17 trillion economy amounts to $1 trillion.
The excess in the United States is primarily attributable to a more expensive mix of procedures and services, higher prices paid to drug companies and physicians, and inefficiencies in the financing of health care. There are undoubtedly cultural differences between the United States and other countries, but it is also true that Swedes differ from Italians, Germans from French, and the English from all of the above.
What these countries have in common that distinguishes their health care systems from the American is universal insurance for basic care, a larger share of government in financing health care (typically about 75 percent of the total versus 50 percent in the United States), and more aggressive control of expenditures.
Americans spend more than 17 percent of GDP on health care; other high income industrial democracies spend only about 11 percent. The 6 percent difference in our $17 trillion economy amounts to $1 trillion.
The excess in the United States is primarily attributable to a more expensive mix of procedures and services, higher prices paid to drug companies and physicians, and inefficiencies in the financing of health care. There are undoubtedly cultural differences between the United States and other countries, but it is also true that Swedes differ from Italians, Germans from French, and the English from all of the above.
What these countries have in common that distinguishes their health care systems from the American is universal insurance for basic care, a larger share of government in financing health care (typically about 75 percent of the total versus 50 percent in the United States), and more aggressive control of expenditures.
I was at a retirement planning seminar last night and after the speaker asked if anyone was signed up for the ACA he started to say "I bet you're glad you didn't". That's when two hands went up in the audience. The couple said they had, the process was simple and they saved a lot of money even while their new plan had a lower deductible and better coverage. Not the result the presenter evidently was fishing for.
It seems young people signups have been coming along and while the original goal for the end of March likely won't quite be reached the program will be close. That is amazing given the bad start and all of the demonization directed towards Obamacare.
On a tangential note, you left off the cost of paperwork as a reason why American health care costs are so high. I know at least one strong Republican that sits on a board with me who is now starting to lament a single payer system wasn't adopted. He's been having had to deal with the wide array of issues necessary to implement our insurance plan.
What did Churchill say? You can count on Americans to get it right after they've exhausted all other possibilities?
I have to say, Art, while I understand that ACA is far from perfect (which healthcare system is?), and that there are losers from the law (as there are losers from any insurance. Fire insurance is basically redistribute funds from those not suffering fires to those that do, etc.)
But I'm still as baffled by the sheer volume of hostility it receives, given that:
- It's a conservative idea (from Heritage, no less)
- It's been implemented relatively successfully by a former conservative presidential candidate in Massachusetts
- It isn't socialist medicine (both hospitals and insurance companies are private)
- The status quo is clearly VERY suboptimal (much more expensive than anywhere else whilst leaving tens of millions uninsured)
- There is a wealth of evidence that quite a few other countries are doing substantially better whilst being cheaper at the same time.
I'm sure I could make this list a lot longer if I thought about it for 5 more minutes but it's really depressing. US politics has become so tribal that it's hard to distinguish fact from fiction.
03-15-2014, 10:24 AM (This post was last modified: 03-15-2014, 10:25 AM by ArtM72.)
(03-15-2014, 10:04 AM)admin Wrote: I have to say, Art, while I understand that ACA is far from perfect (which healthcare system is?), and that there are losers from the law (as there are losers from any insurance. Fire insurance is basically redistribute funds from those not suffering fires to those that do, etc.) But I'm still as baffled by the sheer volume of hostility it receives, given that: - It's a conservative idea (from Heritage, no less) - It's been implemented relatively successfully by a former conservative presidential candidate in Massachusetts - It isn't socialist medicine (both hospitals and insurance companies are private) - The status quo is clearly VERY suboptimal (much more expensive than anywhere else whilst leaving tens of millions uninsured) - There is a wealth of evidence that quite a few other countries are doing substantially better whilst being cheaper at the same time. I'm sure I could make this list a lot longer if I thought about it for 5 more minutes but it's really depressing. US politics has become so tribal that it's hard to distinguish fact from fiction.
We have a major subculture where belief is all that is necessary to determine truth. Pair that with active deception and blind advocacy and your national decision making structure ends up a little...er... deficient.
So let's talk about my new policy under Obamacare. For one, my premiums have declined by half. Before selecting my plan, I did my homework (a critical component for purchasing a good policy). I made sure that my doctors accepted the insurance and that my specific drugs, treatments and tests would be covered. So far, I've used my new plan many times and it's working.
That said, there are huge gaps that must be addressed, like high deductibles and maximum annual out-of-pocket costs. Many Americans aren't eligible to purchase off the health care exchanges at all. But instead of talking about how to strengthen Obamacare, most Republicans and some pundits find it far sexier to call for a complete repeal. Their near gloating over flaws and failures is disturbing. Let's be clear. Those of us on Obamacare are not lazy, unwilling to work, looking for a free handout, or sitting at home abusing our bodies. Like all Americans, we simply need health insurance. Because without it, we die needlessly.
The linchpin of the program is the attempt to make sure that all Americans have health insurance, via the individual mandate. But Obamacare is a market mechanism, in that health insurers and health care providers remain private and compete against each other.
As has been pointed out countless times, this was originally a conservative approach, designed to work via the marketplace: The alternative is to have the government either (i) directly provide the health insurance (a “single payer” system, as in Canada; or under US Medicare for that matter) or (ii) directly provide the health care itself (”socialized medicine,” as in the UK; or the US Veterans Administration hospitals). The new approach was proposed in conservative think tanks such as the Heritage Foundation. It was enacted in Massachusetts by Republican Governor Mitt Romney.
The administration announced last week that only 1.08 million people ages 18 to 34 had signed up for Obamacare by the end of February, or about 25 percent of total enrollees. If the proportion doesn’t improve significantly, the result likely will be fatal for the Affordable Care Act. The administration had said it needed 40 percent of registrants in the health insurance exchanges to be young adults, or about 2.7 million of the expected 7 million total.
Early in his new book, “Reinventing American Health Care,” Ezekiel Emanuel pictures the late senator Arlen Specter (Pa.) holding up an incomprehensible chart of the U.S. health-care system — in 1993. What Emanuel calls the “interconnected weirdness” of our health-care system has only gotten weirder since.
Yet what he does is enormously helpful: He sorts it all out and gives us a clear and straightforward accounting of a system that is anything but. Emanuel starts at the beginning (1790, to be exact) and progresses logically to the present, through the development, political wrangling and legal journey of the Affordable Care Act (ACA). Then he hurtles into cheerily optimistic projections about the future — perhaps more than a tad more optimistic than his own accounting of the past would warrant.
His review of how our health-care system got this way is a depressing reminder of forces that have little to do with health care and nothing to do with health.
As the clock ticks down to the end of open enrollment for health coverage, one thing is becoming clearer: what the final demographics will look like. Demographics matter a lot because they will help determine whether the health insurance market goes into a death spiral (or requires hefty federal subsidies to keep it from doing so). Young healthy people, and a lot of them, are needed to keep the market stable and premiums low. As we head into the final few weeks, we have a pretty good idea of how many young healthy people there will be, and the answer is: a whole lot fewer than the health-care wonks were expecting.
But wait a minute! I hear you cry. We don’t know any such thing! After all, everyone expects a lot of young healthy people to wait until the last minute! Are you saying they’re wrong?
Not exactly. I too expect the demographics of March enrollment to skew younger than prior months. But at this point, unless that enrollment is truly massive, I don’t think that will be enough.
To see why, let’s start with some basic numbers. As of March 1, 4,242,325 people had selected a plan on one of the exchanges; 1,075,990 of them, or just a smidge over 25 percent, were young adults ages 18 to 35 -- that critical demographic that the exchanges need to enroll. Previous projections had been for 40 percent.
It’s true that in Massachusetts, the young showed up relatively late to the party:
However, at this point, with one month to go, the youth contingent would have to be truly massive to get near the 38.5 percent that was originally projected.
Just how massive depends on the total number of signups in March. But to get some perspective, it’s not even mathematically possible for youth signups to get to 40 percent of total signups unless we get at least 912,174 more people to sign up in March -- and then, it’s only possible if every single one of those people, including covered family members, is between the ages of 18 to 35.
This is, if course, not likely. Thankfully, as the number of signups rises, the percentage of them that needs to be young adults falls. But even if we assume 3.5 million people sign up in March -- theoretically possible, but not what anyone I’m aware of is projecting -- 55 percent of them would have to be young to pull the demographics back in line.
A lower target -- say, 33 percent -- would be easier to achieve. We could hit that even if the signups in March are less than 50 percent young adults . . . as long as at least 2 million people sign up. That’s about 10 percent higher than the December numbers -- certainly doable, but I don’t know if I’d call it the most likely scenario.
How much does this matter? Well, a team from the Kaiser Family Foundation calculated that if enrollment were only 33 percent young, costs would exceed premiums by about 1.1 percent; if it were 25 percent (i.e. if it doesn’t change much), costs would exceed premiums by about 2.4 percent.
However, Seth Chandler, a law professor who specializes in health and insurance law, disputes that calculation. And as far as I can tell, it's only looking at age -- that is, we’re assuming that if we get fewer young people, we get fewer of every kind of young people.
But what if what we’re witnessing is the broad operation of adverse selection -- older and sicker people buying while the young and healthy stay away? The first place that would show up in the data would be . . . a disproportionately low number of young people, particularly young men. Which is exactly what we do see. This explanation seems more likely to me than the alternative.
So are we definitely due for a death spiral?
No. For one thing, that 38.5 percent number doesn’t come from the insurers; it comes from the government. The government has been talking to insurers, but it isn’t running their actuarial models. If the insurers assumed a worse demographic mix than the government analysts, then we may not need so many young people to keep the markets sound.
Insurers also want this to work, so they may be willing to take losses for a few years to keep premiums low -- especially if the government funnels money to them through the risk-corridor program.
What this does tell us, however, is that it is now probably impossible to achieve the demographic mix that the government has been forecasting. And keeping it from happening may well prove very expensive for the federal government.
Few notes:
Few alarms, if any, from the insurance industry suggest their models are less stringent, but they could just be relaxed because of the corridor.
The cost overruns (1.1% if only 33% are young, 2.4% if only 25% are young) don't sound like a death spiral.
There are years to fix it as insurance companies also want this to work. People who don't sign up have to pay a fine.
03-23-2014, 12:27 AM (This post was last modified: 03-23-2014, 12:37 AM by admin.)
U.S. consumers eligible for Obamacare health plans could see double-digit price hikes next year in states that fail to draw large numbers of enrollees for 2014, including some states that have been hostile to the healthcare law, according to insurance industry officials and analysts.
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, its lowest point in five years. At least 12 million Americans have now received coverage directly through a provision of the law. Roughly 3.1 million young adults under the age of 26 are now covered under their parents' plan. Another 4.5 million low-income individuals and families are now eligible for Medicaid, despite the 19 states that opted out of expanding the program and the six that still can't decide what to do. Finally, more than five million Americans have selected a private insurance plan on an exchange, a figure robust enough to ensure the exchanges will be a stable way for Americans to get health coverage for a long time to come.
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.
Most importantly, look at costs. For the past five decades, health-care costs have grown more than 2% faster than the overall economy. But over the past three years, the rate of growth has slowed so that it's now about even with the overall economy. This is a potentially revolutionary success. There is no question that part of this slowdown is due to lingering effects of the Great Recession and other factors, such as changes in insurance design. But changes induced by the health-care law have doubtlessly helped sustain, and perhaps accelerated, this trend. Competitive bidding lowered prices for hospital beds, walkers and other durable medical equipment 40%. Excessive payments to Medicare managed-care plans, hospitals and home health-care agencies were reduced. Providers are forming new accountable care organizations, which are providing high-quality, efficient care by reducing unnecessary tests and treatments, keeping patients healthy, and obviating the need for expensive hospital services. As a result, since the Affordable Care Act was passed, Medicare beneficiaries have seen almost no rise in their premiums for Part B and prescription drug plans. And in the private market, health-insurance premiums have moderated. In the exchanges, premiums have been below the nonpartisan Congressional Budget Office estimates by roughly 16%.
"And in the private market, health-insurance premiums have moderated. In the exchanges, premiums have been below the nonpartisan Congressional Budget Office estimates by roughly 16%."
That's something we don't hear on the news.
Planet money did a spot recently about LaCrosse, WI where, according to a Dartmouth study Medicare costs were the lowest in the nation. One key to the reason for that is the focus of the study, LaCrosse's peoples' nearly 100% adoption of advanced health care directives, compared to about 30% nationally. Here's the link. It really is important for everyone to read/listen to if you do not yet have an advanced health care directive (aka "living will").
