Saturday, November 9, 2013

Obamacare: Making Lemonade

Responding to:
J. F. Wharam and Others
N Engl J Med 369:1481, October 17, 2013

The authors point out the real and predictable failings of a market-based health care system: it costs too much (duh).  And they suggest more market-based reforms to fix the problems of unaffordably high deductibles and co-pays in the Obamacare health insurance exchanges (premiums could be lower too).  California is perfectly poised to leverage the situation by taking the obvious next step towards a single payer system (a goal for 2017): authorize the elected Insurance Commissioner to set the prices of the health insurance plans. The legislation's been introduced and almost passed several times.  The Exchanges have already whittled down the insurance plans to only a few left standing, and set compulsory enrollment, and standardized benefits. Chopping their rates and profits gets pretty close to the role health insurance plans already now play in Medicare, as third party administrators.  


  1. .The Affordable Care Act is not good enough....
    • it is ensuring that health care will come to us as a profit-driven commodity, where health care expense is treated as a business loss.
    • It protects the unhealthy connection of health care coming from employment, which accounts for how 49% of Americans receive their health care.
    • And it maintains a class-based access to health care.
    Give us all a single-payer, non-profit national health care system, separated from employment, universal and affordable for all!
    The national single payer movement should be leading the charge! Si se puede!!
    There are significant funding problems for a state-based system according to this video taken at the recent PNHP annual conference. Bringing Medicare beneficiaries into a CA system would take an act of Congress to release the federal monies.
    Furthermore, it’s a mistake to put our hopes in 2017 after witnessing the abandonment of SB 810 by State Senator Mark Leno and the two sitting DEM majority leaders in the CA Senate (President pro Tem Darryl Steinberg) and CA Assembly (speaker John Perez) along with a sitting DEM governor Brown.
    Go to Maplight and you will find these two leaders have both being rewarded over the years for keeping single payer.SB 810 away from any serious action. It's been a warm-fuzzy for them to ‘support’ for their Progressive supporters, but knowing full well it wouldn't pass under Schwarzenegger and even taken out of the legislative arena recently by Mark Leno.
    Click on any amount and it will list the names of organizations, corps and individuals giving them money.
    Darryl Steinberg (taking $$ from 4 parts of Health industry)
    John Perez: (also taking $$ from four parts)
    Mark Leno (also taking $$ from two parts)
    Furthermore, before using the increasingly, insurance-based Medicare as a mode, l there needs to be major improvement. Few are aware of the increasing intrusion of Insurance and Pharma since its 'modernization' in 2003. For an example, every month Medicare (CMS) sends Advantage Plans a monthly capitated amount for each beneficiary, whether they have used it or not. Under the Affordable Care Act, these rates were supposed to be decreased approx. 3%to help fund the ACA. At the last moment, they were INCREASED 2%.
    In CA, depending on the county, this can be anywhere from $800-$900+ each, every month.
    Go to "2014 MA Rate Book [ZIP, 108KB]" at link below and you will get the file that shows the capitation rates by state and county for the entire US. Rates vary from $700-1000+ across the country.
    To understand the columns and amounts:
    Medicare Advantage plans are rated by stars, so the columns represent:
    County name,
    Risk Parts A & B 5-Star,
    Risk Parts A & B 4.5-Star,
    Risk Parts A & B 4-Star,
    Risk Parts A & B 3.5-Star,
    Risk Parts A & B 3-Star,
    Risk Parts A & B <=2.5-Star,
    ESRD (End Stage Renal disease needing dialysis or transplant to survive) Parts A & B
    Medicare needs another modernization and this time according to HR 676. Medicare Part B would see Medicare paying 100%, instead of the 80/20 split it has now, which sends beneficiaries to Advantage or Medigap plans.
    Part D plans would also be eliminated and drugs would be purchased by the government.
    Si se puede!!

  2. Good point! This will expose to many newcomers (and an eager media) some of the true inequities of the private market: in order to pay less up front, you pay more when you need care. And this will hit low income consumers most, since they're the ones most likely to select the lowest premium plans on the exchanges. Of course before they might not have had ANY coverge, but that's likely to be overshadowed.

    Right now, the ACA deserves our support as the most significant step forward in a long, long time (at least in my 25+ years of working on health care reform) However, in my humble opinion, once the ACA is firmly established and accepted, it's time to push for more reforms.