Search Results For Obamacare Can Work?

Obamacare Can Work? Ctd

Andrew Sullivan —  May 30 2013 @ 7:37pm

Ezra Klein and Evan Soltas discourage putting too much stock in the recent polling on Obamacare and state-level premium projections:

[A]ll these numbers are simply guesses. Really. That’s it. California’s numbers are guesses. Maryland’s numbers are guesses. Oregon’s numbers are guesses. Vermont’s numbers are just guesses. Everyone is just guessing. … We’re covering those guesses in the press. When they come in low, we say it’s good news for Obamacare. When they come in high, we say it’s bad news for Obamacare. But we don’t really know whether the guesses are right or wrong either.

Even more interesting is what happens in year two. By then, insurers will know who signed up and how much their care actually cost. But at that point, their pricing won’t really be up to them. The law’s medical loss ratio rules require insurers in the exchanges to spend at least 80 percent of premiums on actual health care. If the care costs less than that, insurers have to send consumers a rebate — something many have already had to do.

Aaron Carroll wonders if political maneuvering based on these “guesses” will come back to haunt Republicans actively opposed to implementation:

[T]he gambit of those opposing Obamacare seems to be a full throated and all-out-effort to show that Obamacare doesn’t work. The danger, though, is that it might.

 The jury is still out, of course. But it’s important to recognize that full-out opposition to reform like this is somewhat novel in American politics. No one knows what such a strategy will bring in the long run.

Many thought passing the Affordable Care Act would be President Obama’s “Waterloo.” It wasn’t. In fact,  some have argued that the flat out refusal to negotiate in the law’s passage cost opponents the chance to get a final product more to their liking. Things are shaping up similarly now. If, a year from now, it appears that exchanges are working out in states that embraced them, and that the Medicaid expansion is succeeding in states that allowed it, then it may turn out that refusing to bend may have instead caused the opposition to break.

Obamacare Can Work? Ctd

Andrew Sullivan —  May 29 2013 @ 9:27am

Despite the recent announcement of low premiums for Californians under Obamacare, Sarah Kliff isn’t celebrating yet:

California’s health-care marketplace isn’t like those being set up elsewhere in the country. When California created the country’s first-ever health insurance exchange, way back in November 2010, it made a very significant policy decision. The state decided that it would act as an “active purchaser” that would select a small number of health plans allowed to sell on the California exchange. Health plans would have to do more than meet a set of requirements in the Affordable Care Act. They would need to be selected by the California exchange’s board to compete in the marketplace. …

In an active purchaser exchange, health plans know that they’re competing against others for the chance to access millions of customers with tax subsidies. That could easily effect the bids that they submit, the ones they hope will get them into the new marketplace. That’s the dynamic in California, but not in most other states. That makes it a bit difficult to generalize what the state’s insurance rates say about what will happen elsewhere, where this downward pressure doesn’t exist.

Lanhee Chen, Romney’s former policy director, argues that the California’s rates aren’t as favorable as they first appear:

The only way Covered California’s experts arrive at their conclusion [that individual health insurance premiums in 2014 may be less than they are today] is to compare apples to oranges — that is, comparing next year’s individual premiums to this year’s small employer premiums.

They’re making this particular comparison, they explain, because they believe that the marketplace for individually purchased insurance will look like the marketplace for small employer-purchased insurance next year. For example, the state already requires insurers to issue policies to all comers in the small employer market. Premiums are therefore higher today for small employers than for individuals purchasing coverage on their own.

What this means, however, is that Covered California is creating for itself a very favorable and already higher baseline from which to compare next year’s individual health insurance premiums. That’s how they’re able to create the appearance that Obamacare’s reforms will lower individual premiums.

Meanwhile, Yglesias thinks Obamacare’s Cadillac tax on high-cost healthcare plans is beginning to pay off:

Conservative ACA critics in their scorched earth campaign against Obamacare have been insisting that this, like every promising cost-control measure in the law, is doomed to failure and/or will never be implemented. The story today about actual employer and insurer response to the Cadillac tax indicates that, no, it is beginning to have an impact. Note that this is not the first piece of good news about health care spending aggregates, and that by and large we should expect the press’ understandable and inevitable negativity bias to underestimate Obamacare.

Cohn argues that this is a tax conservatives should support. Previous Dish on California’s low ACA premiums here and here.

Obamacare Can Work? Ctd

Andrew Sullivan —  May 24 2013 @ 1:59pm

Yesterday California announced premium rates for its healthcare exchanges. Sarah Kliff points out that the premiums are lower than many estimates:

Health insurers will charge 25-year-olds between $142 and $190 per month for a bare-bones health plan in Los Angeles. A 40-year-old in San Francisco who wants a top-of-the-line plan would receive a bill between $451 and $525. Downgrade to a less robust option, and premiums fall as low as $221. These premium rates, released Thursday, help answer one of the biggest questions about Obamacare: How much health insurance will cost. They do so in California, the state with 7.1 million uninsured residents, more than any other place in the country.

It’s also worth noting that, thanks to Obamacare’s subsidies for the poor, many will pay less than the already low sticker prices. In case you missed it, Jonathan Cohn weighed in this morning in a must-read. Ezra notes how California is a vital test:

It’s not just the largest state in the nation. It’s also one of the states most committed to implementing Obamacare effectively. Under Gov. Arnold Schwarzenegger — remember how that really happened? — California was the first state to begin building its insurance exchanges. The state’s outreach efforts are unparalleled. Its insurance regulators are working hard to bring in good plans and make sure they’re playing fair. If California can’t make the law work, perhaps no one can. But if California can make the law work, it shows that others can, too.

Elspeth Reeve adds that other states have had similar experiences:

We’ve see this happen in other states. Earlier this month, rate proposals released by insurance companies in Washington state showed some people’s premiums would actually go down. Premera Blue Cross had estimated that premiums would rise about 50 percent to 70 percent. When Oregon released proposed health care premiums online in May, two insurers requested the chance to adjust their rates — to make them lower. Why is this happening? “The premiums and participation in California, Oregon, Washington and other states show that insurers want to compete for the new enrollees in this market,” the Kaiser Family Foundation’s Gary Claxton told The New Republic. The glories of the free market.

Let us now praise the Heritage Foundation, that Marxist-Leninist den that originally came up with the idea of healthcare exchanges.

Obamacare Can Work?

Andrew Sullivan —  May 24 2013 @ 12:50pm

Good news from California.

President Obama Visits Boston To Talk About Health Care

The latest reader thread we want to highlight centers on your personal experiences with the ACA – mostly good, some just okay, a few terrible. Read the whole collection here. Several more of your stories are below, aired for the first time:

I’m 43 and was laid off last year from one of the major banks.  I fell off a ladder about five years ago and ended up having four surgeries to get it all straight.  Besides that, I’ve got ADD and generic meds, but no other major health issues.  I was pretty surprised to be denied coverage by a few companies when trying to get it myself last year.  When Obamacare activated, I was surprised that I got subsidies as a member of the upper-middle class and able to get affordable coverage while looking for a job.  When I did get a contract job, I looked into health coverage.  What the contract company was offering was over twice what I was paying on my own!  The benefits weren’t even that different.  I kept my plan through healthcare.gov and am very happy for it.  For an income around $100k, I figured I’d make sacrifices for the greater good, but I’m actually seeing benefits.

Another reader:

My extended family’s Obamacare success stories come with a huge helping of Republican epistemic closure.

First, the successes.  My 52-year-old brother retired early from working in a manufacturing plant for 30 years and started his own small business.  His house is paid for and he is extremely frugal, so his business provides a comfortable yet modest living.  However, he could not afford to purchase insurance just for himself before Obamacare, so he went uninsured.  Now he pays $53 a month for a plan that is very similar to what his girlfriend has through her employer.  Success!

My niece was able to stay on her parents insurance while she went to grad school for nursing.  Success!

My cousin has a 24-year-old son with spina bifida.  With that preexisting condition, it would have been almost impossible (and unaffordable) to find insurance to cover him once he was off his parents’ policy.  Now with the law restricting insurance companies from denying coverage for preexisting conditions, he will be able to enter the workforce with no worries about his coverage.  Success!

Now the epistemic closure part.  Even with all of these personal examples, my extremely Republican parents have been brainwashed by Fox and still think Obamacare is the worst thing ever to happen to this country.  They are convinced that their Medicare will be taken away and they won’t be able to find any doctors.  They are convinced that President Obama just wants to take all of their money and give it to poor people.  I have stopped trying to educate them with facts and real examples because it is no fun beating my head against a brick wall!

Another:

I am a surgical specialist.  My politics would be RINO, but in this day and age, I vote “not Republican”, as I do not believe the party can be trusted with power nor to govern.

ACA is basically a Rorschach test for partisans.  I’m personally for it as a first step towards a better system, so maybe I’m biased.  I see someone every week who now has healthcare who didn’t before.  Unfortunately, these are often neglected issues that would have been better managed in the past, but at least they have a way now to get care.  I also may be unique because I am uninsurable outside of a group plan due to a personal history of blood clots.  I was turned down by every single insurer despite being fit, no other health issues, and a lifetime risk of clotting again of 8% with no medications or 3% with Coumadin, 10.00/3 month supply.

I practice in a blue-collar area with plenty of uninsured and I’ve watched my income plummet with the economic downturn.  I found that about 1/2 of my head-and-neck cancer patients were uninsured and I had to eat the cost of their treatment – no more; this year so far everyone has had insurance.  Medicaid doesn’t pay much, but it is better than nothing.  The homeless guy I operated on last week came in with his tongue cancer small enough that it hasn’t spread to the neck and his surgery should be all he needs.  That saves the cost and morbidity of radiation therapy.  Sure, he is being paid for by the state, but the cost was much less than what it would have been had he hit the ER in a few months with metastatic disease.

I also had a guy follow up today who is no longer insured since losing his job recently. My right-wing office manager of course blames Obamacare.  I had a gentleman last year who was in the union but for some reason hadn’t been working. He had refused working a certain job since it would have been on a concrete floor, which is hard on his back.  I don’t know the other details, but he had opted to not get his Cobra, and being a 62-year-old smoker and drinker, he has some risks.  He tried to buy Cobra, but he was 20 months out – and of course, he blamed Obamacare for his inability to get Cobra. I don’t bring politics into the mix, but the only reasons he’ll ever get insurance again is because of government programs.  Good luck finding a private insurer who would touch him.

Those who love purely private medicine should ask how would a 78-year-old diabetic with heart disease gets insurance, and what would be the cost?  How does someone with MS get health insurance on the private market if they are single and unable to work?   Look at dental care. (This is healthcare, but that’s another argument.)  A sizable percentage of the population has untreated dental disease.   One-half of my on-call weekends are spent dealing with neck abscesses related to dental infections.  Many of these people are uninsured. And the classic story is they had dental work done, had to pay a bunch of money in cash, developed an abscess, were treated with oral penicillin, got worse and were sent to the ER, where the rest of us treat for free.

I see at least one case a week where the ACA has helped someone get insurance and I have yet to see a case where it hurt.  I am sure there are 25-year-olds who didn’t have insurance and who didn’t have a healthcare issue who are financially hurt, but the fact is, statistically, some of them do get sick, injured, etc … and not having coverage is not acceptable to society who has to eat the cost.  Believe me, I’ve fixed dozens of facial fractures on young men with motorcycles, fast cars, or big mouths who didn’t have insurance.

I also do not understand the greed of many.  I have colleagues who makes 3X what I make yet they feel they are being screwed.  I make a very good living and it bothers me that I see people who are poor and have to do without basic care.  I do not think that everyone should make the same amount of money, and I feel my work is worth more than most, but I also grew up lower middle-class and I can’t fathom not caring that hard working people or children unfortunate to be born to bad parents suffer needlessly.

But another dissents from the others, quoting me:

I’m not sure that “Obamacare is as big a liability for Obama this fall as the Iraq War was for Bush in 2006″, but I do think it will potentially be used as a HUGE negative, even for many who voted for him and other Dems in the past few elections. And I believe that if the Democrats do not quickly grab hold of the reins and prepare well and cleverly and early on to counter what will be the number one issue to beat about the head and shoulders of our candidates, we will most definitely lose the Senate and eventually the presidency. Why? Because many of those hardest hit by the worst unintended effects of Obamacare are middle-class independent and Democratic voters.  And they are feeling betrayed and pissed and afraid for their financial safety.

Most of us who supported health care reform did so out of a sense of empathy and fairness; we were tired of seeing so many people going without decent health care, were angry hearing the nightmare insurance stories in which children were denied cancer treatment, in which the mentally disabled and chronically ill and employed but uninsured got all their care through emergency room visits. We wanted our kids covered longer because college is costlier and taking more time to complete, much less find employment after graduation.  We were tired of having our local communities and hospitals and ERs having to foot the bill for the low-income uninsured, for being forced to absorb the costs of long-neglected conditions that ended up being hundreds, thousand and even hundreds of thousands of dollars when decent primary care could have prevented the illness. We thought it was not only stupid financially; it was morally wrong and wanted to find a way to fix it, smartly.

What we all really wanted, whether we knew it or not, was a single-payer/public option that was affordable and spread out the risk nationwide to make all of our out of pocket costs go down. Instead we got the worst possible “free market” solution they could dream up in DC. 

Far too many of us in the middle class – those of us with one or two job incomes and employer provided health insurance – have been financially REAMED by Obamacare – by the tax changes; by the way this law has been manipulated by our employers and insurance companies to pass on their costs to the individual; by the increase in costs and reduction in benefits in an economy that is stagnant and in which most of us haven’t had a raise in years.  Too many people who supported reform, who voted D, who out here are making moderate incomes and dealing with the competing financial demands of raising families, paying for college costs, helping their elderly parents and now desperately trying to save for their retirements (there are no pensions anymore, don’t forget) are being hurt financially by this law, and unfairly so. And – whether I agree with this or not – it’s all being blamed on Obama and the ACA.

Example: I work as an RN at a medium-sized corporate hospital that offers our employees a really shitty BCBS plan. We staff nurses averaging about $50-60K/yr in earnings and many of them are single parents. I am blessed to be able to opt out due to my spouse having coverage (excellent coverage) as a federal employee, but my friends do not.  Over the past two years, they have seen their deductibles jump to $6000K/yr or more, with co-insurance of 20-30% or more pharmaceutical “co-pays” have jumped to ridiculous levels.

This winter several of my co-workers had to pay almost $60 for a generic albuterol inhaler during their recovery from the various flu-bugs we all got. My coworker’s 12 year-old daughter has juvenile diabetes and she pays hundreds out of pocket monthly for her insulin and supplies. Remember that $5000/family tax-free flexible health savings account we all could sign up for in the past? You know, the one where you set an annual amount to divide up like a loan and put into an account that will advance you the money up to your elective limit for health costs?  Well, “Thanks to Obamacare” it’s been cut to $2500, and believe me that goes fast. One of my coworkers had to take both her small children in for abscessed tonsillectomies and it cost her $3500 dollars, out of pocket,  on our hospital’s wonderful BCBS plan. 

I’ve seen more formerly uninsured people get covered, which is fantastic, but now my hardworking peers approaching middle adulthood with diabetes, hypertension, chronic autoimmune disorders like lupus, funny moles on their skin, obstructive sleep apnea, depression and a whole host of health issue are JUST NOT GOING TO THE DOCTOR ANYMORE.  If it’s not free or catastrophic, they’re crossing their fingers and hoping a trip to the health food store or some meditation will fix their problem.

Yes, they get the low-cost, required “essentials and annual freebies”, but in general, too many of us had better out-of-pocket costs before Obamacare (and even then we were sometimes stretched to pay those).  Since we’re insured by our employers, we don’t meet the stringent numbers to qualify for subsidies on the exchanges, so even if we wanted to opt out and buy there, we’d pay even more in premiums than we do now. I am exuberant that my kids can stay on our health insurance until they’re 26, and that my 29-year-old son would have insurance right now after not having any for four years if he had not finally found a job with it as a benefit.

And I won’t even tell you ALL the ways business is blaming Obamacare so that they can ruthlessly make cutes, refuse raises, and generally squeeze out profit and then dump the hurt on their employees.  At our hospital, ACA is blamed SPECIFICALLY for the layoffs and cost cuts that are hurting the quality of care and safety we offer our patients. They have forced on us increased nurse-to-patient ratios and cuts to CNA caregivers, which has resulted in poor outcomes and even a few serious harms to patients.

Physicians at our hospital are miserable, and spend less time on patients and more time trying to learn and use our electronic medical system . It’s clunky, out-of-date and creates serious errors, but because corporate is cashing in on CMS bonuses in reimbursements by implementing electronic medical records now, they are more concerned about their bottom line than doing it well. So they refuse to purchase better software and the doctors yell and insult and dodge putting in orders (which means WE have to step away from the bedside to do it for them.  Worse, they take their business elsewhere down the road, which in turn results in days off for us due to fewer patients in our unit.

Patients are unhappy and give us poor “Patient Satisfaction Scores” because no one answers their call lights fast enough, so they wet their pants, their food sucks and their rooms are dirty longer than they used to be and the equipment looks like something donated to a Third World hospital in Africa, so they don’t trust it.  My CCU is an oasis of relative safety, mostly due to Medicare reimbursement rules about ratio’s and standards of care, but we are struggling every day and stretched way too thin, and we all worry about the looming “sentinel incident” around the corner that hurts or kills a patient and costs us our license.  Would YOU like your nurse to be distracted from your open-heart surgery recovery because she has to leave your bedside to answer the phone, buzz in visitors, deliver food trays, enter medical orders for cranky doctors, answer call lights for water for other patients, and cant get your emergency cardiac iv’s because her computer system has crashed once again? I don’t think so.  

Anyway, this is just a long, frustrated, but hopefully insightful, rant about the day-to-day NEGATIVE impact of ACA has been, and why it will be a big challenge to overcome in the next two election cycles. I really wish we had more focus on THESE kinds of issues and how they will be remedied, and fast because it scares the SHIT out of me that we’ll end up getting an entirely radical Republican national government if we don’t. And there’s no Meep Meep if that happens.

Update from a reader:

Your allegedly sympathetic but frustrated RN asserted that “because of Obamacare,” Health Savings Account minimums have been “cut” to $2,500, and folks can’t sign up for robust HSA accounts anymore. Well, I knew that was bull as soon as I read it because I have an HSA for my kids and me, to which I contribute $4,000 annually. So I Googled the issue. The IRS issues the annual HSA minimums and maximums, which I don’t see has anything to do with “Obamacare” – have a look.

So this RN is using the HSA minimum and representing that as the maximum that “Obamacare” appears to allow. The truth is, anyone with dependents could sign up for as much as $6,550 in HSA contributions in 2014! (That figure is verified here.) And it’s going up another $100 for 2015.

Another:

The respondent discussing HSA limits as quoted by the IRS is discussing a health savings account, which has different limits and is continuable through successive years, as opposed to the Flexible Spending Account as discussed by the RN. The FSA is a tax-differed method to pay for out-of-pocket expenses for health plans without high deductibles. FSAs expire at the end of each year, with any unspent money evaporating. So, in a sense, they are both right, but talking about different beasts.

(Photo by Yoon S. Byun/The Boston Globe via Getty Images)

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It’s an uplifting story that also makes you want to despair of government. Three 20-year-old programmers from San Francisco have set up a website – thehealthsherpa.com – that already does a huge amount of the work that the government website cannot effectively handle yet. No, you can’t enroll in Obamacare on it, but you can quickly see your options. What a concept! Available information! Money quote:

“They got it completely backwards in terms of what people want up front,” said Liang. He added: “They want prices and benefits, so that they could make the decision.” Liang showed CBS News how it worked. “You come to our website and you put in your zip code — in this case a California zip code. You hit ‘find plans,’ and you immediately see the exchange plans that are available for that zip code.”

It didn’t work for me, because they don’t have New York or DC plans yet in their system (California is their strong suit). But I did get instant access to both states’ exchange sites – no clogged system at all:

Using information buried in the government’s own website built by high-priced government contractors, they found a simpler way to present it to users. “That’s the great thing about having such a small team,” said Kalogeropoulos. “You sit around a table and say, ‘Okay, how does this work?’ There’s no coordination meetings, there’s no planning sessions. It’s like, ‘Well, let’s read the document and let’s implement this.'”

They’re busy updating and adding new features, like calculations for the various tax subsidies, as the video shows. So why not use this site or encourage other young geeks to set up similar ones outside the government just to convey information that is currently buried in healthcare.gov? You can then use that information to call up an insurance company or broker or navigator and buy your insurance. Then ask yourself: how did three 20 year-olds manage this in weeks while the feds had three years and fucked it up so bad it seems like an episode of computer Hell?

One reason is small scale. It reminds me of the difference working for the Dish as an independent, small group of peers rather than embedded in a larger media organization. If we have an idea, we execute it. Before, we’d have to run it up endless ladders, wait for approvals, get last-minute delays, persuade some busy guy to help us, lobby for resources, and on and on. Now I just click my fingers and say: “Get on it, Special Teams!” and we have House ads. Well, not quite like that. But we never want to grow too much for exactly these reasons. In technology and creativity, smaller is better.

We know Obama has the skills to do this. He did it in both campaigns to stunning effect. But then he was out of government, out of all those cumbersome contracting rules, able to be more nimble. Why, one wonders, did he not fight the entrenched ways of doing things and innovate more aggressively? Why did he not focus on this in ways that were not simply urging his officials to make sure they got it right?

Mike Konczal blames Obamacare’s technical problems on the law’s design. He contrasts Obamacare’s form of social insurance, which he labels “Category A,” with previous forms of social insurance, such as Medicare and Social Security, which he labels “Category B”:

What we often refer to as Category A can be viewed as a “neoliberal” approach to social insurance, heavy on social_insurance_categoryprivate provisioning and means-testing. This term often obscures more than it helps, but think of it as a plan for reworking the entire logic of government to simply act as an enabler to market activities, with perhaps some coordinated charity to individuals most in need.

This contrasts with the Category B grouping, which we associate with the New Deal and the Great Society. This approach creates a universal floor so that individuals don’t experience basic welfare goods as commodities to buy and sell themselves. This is a continuum rather than a hard line, of course, but readers will note that Social Security and Medicare are more in Category B category rather than Category A. My man Franklin Delano Roosevelt may not have known about JavaScript and agile programming, but he knew a few things about the public provisioning of social insurance, and he realized the second category, while conceptually more work for the government, can eliminate a lot of unnecessary administrative problems.

Drum pushes back:

If I had my way, we’d have a fairly simple, universal, single-payer health care system in the United States. It would work better; provide broader coverage; and probably be cheaper than what we have now. But countries like Switzerland and the Netherlands demonstrate that an Obamacare-like system can work reasonably well too.

Konczal is certainly right to mock conservatives who don’t seem to understand that Obamacare is fundamentally a pretty conservative design for national health care—which means that if it fails, it will hardly be a failure of old-school liberalism—but I think he goes too far when he tries to blame the rollout problems on that design. There was never any realistic hope of wiping out the entire private insurance industry and instituting a single-payer system anyway, which makes this all a bit academic, but even if Obamacare is a second-best design, it’s still one that other countries have shown can be implemented effectively. I imagine that, over time, the same will be true here.

Douthat complicates Konczal’s argument:

If the Obamacare exchanges are a mess and the individual market is facing cost spirals, then conservatives are going to face some understandable skepticism (more even than usual!) from voters if they talk up the virtues of free market health care and the individual marketplace in 2016 and beyond. But in principle, the distinction between Obamacare’s approach to health policy and the conservative version of means-testing, block-granting, and competitive marketplaces is clear enough. That’s because while Obamacare may be using neoliberal rather than New Deal-style means, it’s still chasing essentially left-of-center ends: It seeks a level of universality and comprehensiveness that conservatives don’t think is necessarily worth pursuing. And it’s that quest, those goals, that require the complicated mandate-regulate-subsidize combination that could undo the individual marketplace if the enrollment isn’t where it needs to be and the subsidies and fines and regulations aren’t successfully fine-tuned.

In other words, pace Konczal, the potential problems with Obamacare aren’t necessarily “driven by means-testing, state-level decisions and privatization of social insurance.” They’re driven by the law’s attempt to employ these (notionally) decentralized means while still seeking essentially centralized ends.

Reihan thinks health reform should have had a default option:

The idea of a default option comes to mind in light of the difficulties facing the new health insurance exchanges. Even in the absence of technical difficulties, I’m starting to wonder why anyone thought that a substantial majority of healthy young people would sign up for coverage, including heavily subsidized coverage. The threat of a penalty is one obvious reason. Yet the Obama administration and its allies have been reluctant to emphasize the punitive dimension of the individual mandate, for obvious political reasons. Rather than using the threat of a penalty to spur enrollment, coverage expansion advocates have emphasized the benefits of insurance, hence the (apparent) reluctance of the architects of the exchanges to expose consumers to the full, unsubsidized cost of the new insurance options.

After diving into the latest Congressional Budget Office projections for Obamacare, Jed Graham predicts an ominous future for the exchanges set up by the law:

CBO projections now not only imply that the subsidized exchange pool will shrink more precipitously, but the average benefit will rise 5.7% a year — faster than the 5% seen last August. This combination of fewer beneficiaries and faster benefit growth implies that low-income and older beneficiaries will make up an increasing share of the insurance pool. ObamaCare subsidies rise with age and decline as incomes rise; falling to zero for households who earn more than 400% of the poverty level. …

CBO’s new forecasts suggest more healthy people will opt not to pay an ever-growing chunk of their income, when they can pay a smaller fine and still get the same coverage at a fixed price when they need it, perhaps with a several months delay. More people who skip coverage will be exempt from the mandate because minimum coverage exceeds the law’s affordability threshold, the CBO noted.

Justin Green sees an easy-to-miss opportunity for Republicans:

Attention Eisenhower conservatives: this might just be your moment to offer reforms to fix ObamaCare. Just maybe. Instead, we’ve got Marco Rubio joining Ted Cruz’s effort to defund ObamaCare. Can such a push work?

Weigel unpacks the reasoning behind what he calls an “empty threat”:

Rubio’s ploy is easy to understand. He’s trying to push through an immigration reform bill that’s anathema to Republicans. His most famous co-sponsors, John McCain and Lindsey Graham, spent yesterday attacking Rand Paul for a filibuster that the base embraced immediately. So he needs to get behind the occasional stunt.

Previous Dish on Holt-Eakin and Roy’s suggestions for improving Obamacare here.

Malcolm Gladwell reviews a book that addresses that question, America’s Bitter Pill:

At the end of [the book, Steven] Brill offers his own solution to the health-care crisis. He wants the big regional health-care systems that dominate many metropolitan areas to expand their reach and to assume the function of insuring patients as well. He talks to Jeffrey Romoff, the C.E.O. of the University of Pittsburgh Medical Center, who is about to try this idea in the Pittsburgh area, and becomes convinced that the same model would work throughout the country. “The [hospital’s] insurance company would not only have every incentive to control the doctors’ and hospitals’ costs, but also the means to do so,” he writes. … A system like this, Brill estimates, based on a few back-of-the-envelope calculations, could slice twenty per cent off the private-sector health-care bill.

It’s at moments like this that Brill’s book becomes problematic. The idea he is describing is called integrated managed care. It has been around for more than half a century—most notably in the form of the Kaiser Permanente Group. Almost ten million Americans are insured through Kaiser, treated by Kaiser doctors, and admitted to Kaiser hospitals. Yet Brill has almost nothing to say about Kaiser, aside from a brief, dismissive mention. It’s as if someone were to write a book about how America really needs a high-end electric-car company that sells its products online without being the least curious about Tesla Motors.

In an interview, Brill spells out his primary complaint about Obamacare:

The basic deal that the Obama administration and the Democrats in the Senate had to make was we’ll get more coverage for people. But we’ll get more coverage for people at the same high prices that allow the drug companies to be so profitable, that allow the non-profit hospitals to be so profitable, that allow the device-makers to be so profitable — and that is the result that is Obamacare.

So the good news is this couple I interviewed in Kentucky who hadn’t had access to doctors in years suddenly had access to health care. The bad news is that you and I and all the other taxpayers are paying the same high prices for that health care that dominated and completely screwed up the system in the first place.

He continues that thought in another interview:

It is great that more people are getting health care, but we cannot continue to be a country where health care prices are 40, 50, 60 percent higher than they are in every other country where the health care results are as good, or better, than ours. It’s unsustainable.

So the only ray of hope I have is that if Obamacare will force changes in the cost structure just because there are going to be so many more people buying health care that it will just have to change the cost structure. That was sort of the implicit expectation that Gov. [Mitt] Romney had in Massachusetts, which is if we enact this plan and give more people health care, then when they have it, we’ll see that we have to do something about the cost and we’ll get the political will together to do that. The question is: Does Washington today, tomorrow, next year, in five years, even in the face of daunting health care costs — will they ever be able to summon the political will to do something about it?

GDP

That’s how Neil Irwin reads the new GDP numbers:

The Commerce Department revised its estimates of first-quarter gross domestic product Wednesday to show that the economy contracted at a 2.9 percent annual rate. A combination of shrinking business inventories, terrible winter weather and a surprise contraction in health care spending drove the first-quarter decline, which is the worst since the first quarter of 2009, when the economy shrank at a 5.4 percent rate.

And that contraction is worse than expected; forecasters had predicted only negative 1.8 percent. Ben Casselman has more:

Last month, I noted that negative quarters are rare outside of recessions. Quarters this bad are even rarer. There have been only two other non-recessionary quarters since World War II when the economy shrank at a rate over 2 percent. Both times, the economy entered a recession the following quarter.

That doesn’t mean we’re about to fall back into a recession. On several other occasions, negative quarters were followed by a strong rebound. Just a few years ago, for example, U.S. GDP fell 1.3 percent in the first quarter of 2011, then bounced back to post a 3.2 percent growth rate in the second quarter.

Then again, it’s worth remembering that we’re notoriously bad at predicting recessions. In fact, we aren’t even very good at knowing when we’re in one. The semi-official arbiters at the National Bureau of Economic Research didn’t identify the most recent recession until December 2008, by which point it had been underway for a year; they didn’t pick up on the 2001 recession until it was over. If we were in a recession now, we might not know it.

But Danielle Kurtzleben isn’t too worried:

Weather accounted for somewhere between 50 and 100 percent of the GDP pullback, says PNC senior economist Gus Faucher. When polar vortexes and multiple feet of snow keep people stuck at home, they just can’t get out to buy groceries or see the doctor. That’s only a temporary hit to the economy — everyone has to go to the doctor and buy food again at some point. …

Broadly speaking, the job market isn’t growing as fast as we’d like it, but it didn’t seem to pull back in the first quarter. And though healthcare helped pull GDP downward in the first quarter, even employment in that industry didn’t appear to take a hit:

Screen_Shot_2014-06-25_at_11.58.51_AM

Danny Vinik details the dip in healthcare spending:

[The new GDP data] may be a case of bad news that’s not so bad – and maybe even good.

The reason why consumer spending fell is that health care spending decreased by 1.4 percent in the first quarter. In fact, in the BEA’s second estimate, health care spending contributed 1.01 percent to the growth rate. Under the third estimate, it subtracted 0.16 percent. In other words, health care spending went from a strong contributor to GDP growth to a detractor from it – all in a quarter when millions of Americans gained health insurance.

Daniel Gross wonders what caused that 0.16 revision:

It could be that people were hoarding medicines and avoiding going to the doctor during the cold weather. Or it could be that many newly insured people delayed going to see the doctor, buying medicine, or having procedures done in January, February, or March until their health-care premiums were fully processed by the state and federal exchanges in April. (Remember, April 1 was the deadline for signups under the Affordable Care Act). It could be that doctors are rationing health care—refusing to schedule appointments. Or it could be that many people are actually paying less for health care because they have insurance—i.e., seeing doctors with a $25 co-pay instead of going to the emergency room.

Clearly, the implementation of Obamacare is disrupting and disturbing the way that health-care services are being priced and consumed. In the first quarter, that led to lower spending—either through lower utilization, or lower prices, or some combination thereof.

Matt O’Brien calls that decline in healthcare spending “good news for our long-term budget, but bad news for our short-term growth”:

Still, this is something of the soft bigotry of a slow recovery’s expectations. The economy should be able to withstand some bad weather and bad inventories without falling back into negative territory. And it should be growing faster now to make up for that slower growth before, if the first quarter really was a blip.

Suderman gets snarky:

At the end of April, when the monthly GDP report found a sluggish, barely growing economy that had expanded by just 0.1 percent in the first quarter of the year, former White House Press Secretary Jay Carney found the good news. Health care spending was up, way up, thanks to Obamacare. The Bureau of Economic Analysis (BEA) had found that health spending had grown by 9.9 percent, the fastest growth of any quarter since 1980. The health law was working—and had saved the economy! … This was a bit rich coming from the same White House that had argued for years that the health law would hold health spending in check.

But now there’s another problem: Health spending appears not to have grown at a record rate during the first quarter of the year. It didn’t grow at all. In fact, it shrank by 1.4 percent, according to a revision released today by the BEA. … Perhaps, however, the White House, in its boundless optimism, will find the upside: The administration can now go back to arguing that Obamacare is working because it’s causing health care spending to shrink.

Matt Phillips looks ahead:

We’ll have to wait until the Census Bureau’s next services survey report in September to see whether medical care usage actually does pick up. That would stand to reason. Government estimates of increased healthcare spending were “probably more early than wrong,” wrote Morgan Stanley economic analysts in research notes. “Coverage has, in fact, expanded significantly this year, and that should support higher healthcare spending.”

Drum isn’t too optimistic:

Everyone is brushing off [the GDP decline] because other economic signals suggest it was a one-off event. And maybe so. But even if it is, it probably knocks about 1 percent off the full-year figure compared to a more normal growth rate of, say, at least 2 percent. The only way it turns out to be a nothingburger is if this number really is an anomaly and the economy makes up for it with supercharged growth for the rest of the year.

I have my doubts about that. I just don’t buy the tired excuse that the Q1 number was weather related. Something happened.

(Chart from Benen)