Wednesday, August 24, 2016

Plumbing The Mind Of Obamacare's True Believer

I had the occasion to read two Sarah Kliff pieces on Vox in as many days, and while I can't recommend them for overall content, I do read them as a certain "tell" as to how Obamacare true believers are processing the late news that Aetna will be exiting most exchanges, representing eleven states, as well as Humana paring back its participation from 15 to 11 states. This was no surprise given Aetna warned the Department of Justice that blocking its proposed merger with Humana would result in it exiting Obamacare exchanges.

Kliff is not entirely delusional, as these grafs attest:
The marketplaces' failures to attract a robust group of health plans to many areas suggests that Obamacare’s insurance expansion is on the path to looking like other safety net programs we know, offering limited services to a predominantly low-income population.

"The exchange population — 85 percent of which qualifies for financial assistance — looks a lot like the Medicaid population," says Michael Adelberg, who previously served as the administration’s acting director of the exchange policy. "And with it, we’re seeing the start of the ‘Medicaid-ization’ of exchange plans: narrow networks with no frills."
Which is largely to say, the Medicaid expansion has been a "success", to the extent it has signed new people eligible under the new guidelines. However,
All available evidence suggests that the law is helping these people gain access to medical services that were previously out of reach — and there isn’t much reason to think this will change. Even when there are large premium spikes, more than 80 percent of marketplace enrollees have subsidies that ensure their monthly fees remain affordable.
So, recapping,
  1. Subsidies pasting over skyrocketing premiums are Jim dandy, i.e. if someone else pays the freight, the problem of absurd costs no longer exists, Q.E.D.
  2. This is true no matter how many insurers exist in these markets. 
The second point is the more important one, because if the number of providers goes to zero, the subsidy will not matter. This elemental fact is apparently lost on her. Kliff is likewise completely baffled by the bureaucratic monster she otherwise endorses (emboldening mine, as usual):
It is the considerable burden our fragmented system puts on patients to coordinate their own care.

I'm not talking about the work of managing one's health, the work that diabetics do to monitor their blood sugar or the healthy eating choices a doctor might recommend for an overweight patient. This can be a significant burden in its own right.

What I didn't understand was the burden patients face in managing the health care system: a massive web of doctors, insurers, pharmacies, and other siloed actors that seem intent on not talking with one another. That unenviable task gets left to the patient, the secret glue that holds the system together.
Kliff naively believes that a cobbled-together system of shreds and patches and bureaucratic fumbling will do otherwise, especially when the payer is some combination of state and private entities. In that case, the most important person in this equation is always the payer, with the beneficiary coming in second, -ish. "Glue" is what we do to unfortunate race horses.

Update: Comes this Vox podcast starting Matt Yglesias, Ezra Klein, and Sarah Kliff in which they gabble on about how Obamacare isn't failing somehow (h/t Catherine Siena). The chirpy, twee tone about collapsing numbers of providers (and, what they don't mention, rising costs) reminds me of teenagers who broke a window without getting caught. No remorse, no apologies, no regrets; their earnest intentions, apparently, are enough.

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