Mandatory Health Insurance part 3

[nbcrusader]

From the same folks that run Amtrak and the USPS.

Perhaps the non-functioning web site was actually part of the ACA - the bill no one ever read.

[AEON]

Originally Posted by nbcrusader

Perhaps the non-functioning web site was actually part of the ACA - the bill no one ever read.

[Irvine511]

food for thought:

The Truth About the Obamacare Rollout

The feds botched the website. But the states are doing much better.

by Jonathan Cohn | October 18, 2013

The federal government is open and paying its bills, which means you can start looking at the other big story from the past few weeks: The startup of Obamacare’s marketplaces. But to fully appreciate what’s happening, you need a split screen.

On one side is the story you’ve heard so much about. In 36 states, the Department of Health and Human Services (HHS) is operating the new insurance marketplaces, where non-elderly people without employer benefits can buy coverage on their own. This part of the rollout has gone … really badly. Two weeks after the sites went online, people are still have trouble setting up accounts and logging onto the system.

HHS is working feverishly to make improvements and the system's performance has improved incrementally. But people are still getting hung up at the initial stages, which means they never get the chance to apply for financial assistance and shop for plans. A study following web traffic showed a sharp drop-off in users at each successive stage of the online application process, which suggests the system was stopping a lot of people from moving forward. And that’s just the part of the system visible to consumers. Insurers say that the system is producing some incorrect information about the few people who make it through the process—a fixable problem, for sure, but a warning that other flaws may yet lurk undetected.

Administration officials have said they never expected so many initial visitors and that the high demand is a good sign. Both claims are true. But the system quite obviously suffers from serious design flaws. I’ve spoken to about a half-dozen developers in the week and they pointed to some of the same problems that experts in the Wall Street Journal, Washington Post, Kaiser Health News, and Slate identified previously. It's hard to know how much of the second-guessing is accurate. But there's a broad consensus about one early source of trouble. As a story in the Journal explained, the site initially required visitors to create accounts before shopping, because a tool to allow anonymous browsing wasn't ready on time. Establishing an account is among the more complicated tasks the website must perform—it requires sending information back and forth between multiple systems, all through secure channels. The result was a bottleneck.

In fairness, federal officials operated under tremendous political and logistical constraints, the kind few outsiders can grasp. Private developers don't have the same stringent standards for privacy and security, for instance. And given the enormous challenges of trying to integrate so many systems—some new, some old—nobody seriously expected the launch of Obamacare’s federal websites to take place without glitches. But few expected this many problems. And nobody seems quite sure when things will get better.

You can get a sense of what real people visiting the sites are seeing by reading dispatches from Sarah Kliff and Phil Galewitz, two reporters who have spent the last two weeks trying to apply. (Kliff finally succeeded; Galewitz got only as far as the account creation process, and that was after 63 tries.) You could also listen to some of the law’s “navigators”—the official counselors, most of whom work for non-profits, who are advising people on coverage options and how to enroll. Here’s, Vicki Tucci, who works with the Legal Aid Society of Palm Beach County, Florida, and who spoke recently to TNR reporter Mimi Dwyer:

People trying to get insurance have been remarkably patient, which tells you something important about how dysfunctional and frustrating the old insurance market was. In fact, one of the most insightful analyses of Obamacare’s federal site came from John Green, co-producer of Vlogbrothers—who tried applying for insurance via an Obamacare exchange (one the federal government is running for Indiana) and then compared the experience to applying for insurance the old way, via an insurance company website. Even with the delays and server errors, he found, Obamacare was quicker and easier—mostly because, under the old system, he had to reconstruct several years of his medical history down to every exam and test.

But at some point patience will run out—and delays will start to affect who’s signing up for insurance.

So that’s the part of the story you’ve heard. But it’s not the whole story—not by a longshot.

Obamacare’s architects assumed that most states would opt to run their own marketplaces, with federal officials running only a few. The assumption proved wrong:

Pretty much any state with a Republican governor or Republican legislative control said no, adding to the administrative burden on HHS. But 14 states plus the District of Columbia are managing their own markets. Mostly it’s places you would expect—progressive outposts like California, Washington, and New York—where Obama and his policies are most popular. But Kentucky, where a Democratic governor and group of dedicated officials have worked diligently to deliver the law’s benefits, is also on the list.

Some of these states are still having major problems: Hawaii, which relied on the same contractor as HHS, seems to be in the worst shape. But the websites in other states are now running and, while it's difficult to get a precise sense of how each one is operating, most appear to be functioning well. They may have more traditional glitches, like random error messages or delays in certain features. (California had to hold off introducing a tool that allows people to check provider networks online.) And most had trouble on the first day or two. But since that time they've been running more smoothly.

One of those states is Connecticut, where Kevin Counihan, chief executive of Connecticut’s health marketplace, told me last week that

As a result, Obamacare in these places seems to be working more or less like it's supposed to work. Consumers are getting opportunities they never had before—to shop for insurance plans, each one with clearly defined benefits that make true comparisons possible, and to receive substantial financial assistance that provides many with thousands of dollars a year in assistance. And, from the looks of things, people are taking advantage of it. The Advisory Board, which is tracking state figures, says that about 180,000 have completed applications for insurance and, of those, 50,000 have enrolled.

Those figures don't say much about whether Obamacare in these states will meet goals for enrollment. It's way, way too early to make that judgment. But the figures suggest that the technology in these places works. And people using the sites say the same thing. “The system is working well—we can’t complain,” Licelot Miguel, a navigator in New York, told Dwyer. (Miguel emphasized that she was speaking for herself, not on behalf of her organization.) The first day was tough, Miguel said: It seems some browsers weren’t working. But now the slowdowns tend to be human rather than technological, Miguel said, because people need 15 or 20 minutes to choose the right plan. “When you get through to the end, it’s like oooooh. People get excited.”

The success of some (not all) states shouldn’t spare the federal sites from scrutiny. It’s possible, for example, that federal procurement and contracting policies limited HHS to a universe of information technology developers that were good at delivering winning bids—but not so good at making modern websites. It’s also possible that cabinet agencies are not set up to run these kinds of operations well, at least not on such a large scale and under such a strict timeline. In the future, conservatives will cite the early problems of Obamacare's federal websites when they express skepticism of large federal programs. They might be right when they do.

The Obama Administration also has questions to answer. Implementation did not appear to suffer from neglect or indifference. Countless officials, staff, and contractors put in long weeks and long hours. Chief of Staff Denis McDonough told people he spending two hours a day on it. (Presumably he still is.) But a recent New York Times story painted a devastating picture of project management, with officials ignoring internal warnings or refusing to heed them. And it sounds like things got worse in the weeks leading up to October 1, as the likelihood of a severely flawed launch grew. Here’s what I heard from somebody direct knowledge of what was happening behind the scenes:

But if these past two weeks appear to reflect poorly on the federal bureaucracy and the Administration managing it, they shouldn’t reflect poorly on health care reform itself—which, after all, has worked in Massachusetts and seems to be working in the states running their own operations. The success of states like Kentucky and New York and Connecticut and California are important for their own sake: By my count, they constitute about a fourth of the national population. But they are also important for what they show about how the law can work, once the technology piece is in place.

Larry Levitt, a senior vice president of the Kaiser Family Foundation, puts it this way:

One reason it's too early to draw judgments is that the administration still has time. Open enrollment lasts until March 31. To get coverage that will start by January 1, consumers must enroll by the middle of December. The best evidence we have about enrollment patterns comes from a New England Journal of Medicine paper written by economists Amitabh Chandra, Jonathan Gruber, and Robin McKnight. They examined the Massachusetts reforms, during the first year, to see who signed up and when. Most people waited until the last minute—the point at which delay meant incurring financial penalties under the mandate. Relatively speaking, the latecomers were more likely to be young and healthy people, the ones whose support the system needs to function properly. That’s good news, because it suggests the most tentative consumers—the ones least likely to wait out website delays—haven’t started shopping yet.

Massachusetts provides another lesson: Early logistical and technological problems aren’t the end of the world. Stephanie Mencimer recalled the history recently in Mother Jones:

Medicare Part D, the prescription drug benefit that the Bush Administration introduced in 2006, had its own problems at the start. Now the program works seamlessly. “We saw the same kind of challenges in Part D and they sorted themselves out,” Karen Ignagni, the head of America’s Health Insurance Plans (AHIP), told me recently. She would know. One reason the Bush Administration was able to correct the problems of Part D is that groups with a stake in success, like the insurers, lent a hand. Insurers are doing the same thing now—in no small part because the high web traffic suggests a large market of new and enthusiastic buyers. “I can tell you, based on calls and emails and other kinds of contacts, like through brokers, the interest is very high,” Ignagni says. “And we’re seeing enrollment coming through and that’s growing.”

Obamacare is a more ambitious enterprise and, as such, its problems appear to be more significant. And Ignagni, like administration officials, has a rooting interest in the new system's success. (Her members want and need the customers.) But she is absolutely right to make a big deal about the apparent enthusiasm. The architects of Obamacare weren't simply trying to build websites, after all. They were trying to build a whole new health care system. And, up until now, they've been mostly successful. A few million young adults have gotten health insurance through their parents' policies. Hospitals are reducing readmissions, apparently in reaction to the law's new incentives. Setting up insurance marketplaces was always bound to be more complicated, just because it requires reinventing the existing market. But that effort has also achieved more than most people seem to realize. Insurers are offering competitive premiums, lower even than projections had suggested. And it's for a product—comprehensive insurance, available to anybody at uniform prices—that in most places insurers never offered before.

That leaves just one, final challenge: Making sure people can actually buy the insurance, and apply for the federal subsidies, so they can get the security they've craved for so long. It's no minor thing: Given the depth of problems at the federal sites, there's obviously a lot of work to do. And if it's months, rather than weeks, before the federal sites are working, the administration will need to consider other actions—whether it's quickly developing alternative methods of enrollment, extending the open enrollment period beyond March 31, or even offering short-term extensions and exemptions from the mandate in those states where people can't enroll easily. (Dan Diamond and Jonathan Chait discussed those possibilities recently.) But the administration still has plenty of time to get this right, just as some states have already.

Source URL: Obamacare Implementation: What the Feds Got Wrong, States Got Right | New Republic

[deep]

Drudge leads with this and I am sure Fox News will be all over it

Jacksonville-based Florida Blue, the state’s largest health insurer, will be canceling 300,000 individual policies, according to Kaiser Health News.

The company cites costs associated with the new health care law’s requirement that things like maternity and newborn care, mental health, substance abuse services, and emergency services be covered by individual and small market plans.

the headlines should read 300,000 people that were paying premiums for a shit health care policy will no longer be paying too much for an inferior product

[LJT]

I really don't understand American healthcare...I am assuming every aspect of your health you want covered adds more to your insurance? So you want to have babies, so you get maternity cover, but oh maybe you can't afford any mental health cover now, so fuck you and your post-partum depression? or you've got a long term psychiatric illness like schizophrenia so you get mental health cover, but can't afford a lot of other cover, so screw you and any other of the many co-morbidities people have with mental illness?

Btw does this mean you guys don't get maternity pay etc?

[nbcrusader]

Originally Posted by deep

the headlines should read 300,000 people that were paying premiums for a shit health care policy will no longer be paying too much for an inferior product

Nice spin!!

[anitram]

Originally Posted by LJT

Btw does this mean you guys don't get maternity pay etc?

From what I remember when I lived there, the feds guarantee 12 weeks of unpaid leave and some states provide a few more weeks than that. But there is no mandated pay, though employers are free to provide that as an employment benefit.

In Canada you get 52 weeks of paid leave (paid out from employment insurance, which comes in at 55% of your current pay up to a maximum of something like $1700/month) and then you typically get an employer top up added to that which varies from as little as 6 weeks to as long as 6 months in my experience.

[Pearl]

Originally Posted by LJT

I really don't understand American healthcare...I am assuming every aspect of your health you want covered adds more to your insurance? So you want to have babies, so you get maternity cover, but oh maybe you can't afford any mental health cover now, so fuck you and your post-partum depression? or you've got a long term psychiatric illness like schizophrenia so you get mental health cover, but can't afford a lot of other cover, so screw you and any other of the many co-morbidities people have with mental illness?

Btw does this mean you guys don't get maternity pay etc?

Regarding maternity leave, I've never heard anything different from what anitram described. As for mental health, some insurances have limits on how often you can visit a therapist. Its not like you can go every week, depending on your insurance. And I think at one point, you will have to pay in full, probably for the first two or three visits before insurance kicks in. This is based on my experience.

[LJT]

You would think proper maternity leave and pay would be a strong conservative principle as it would make the choice of having a baby easier for a woman to make rather than to have financial matters dictate whether you can or not.

I mean it's an easy thing to spin as being for the family and what not.

On the mental health side of things, if you have a mental health problem that requires you to be in a facility for a period of time, is that covered by the state or does that come from health insurance? I imagine people with severe and enduring mental illness are unlikely to be on any kind of insurance plan? Do they then accrue debt while being treated or does it work some other way?

[nathan1977]

HealthCare.gov pricing feature can be off the mark - CBS News

Industry analysts, such as Jonathan Wu, point to how the website lumps people only into two broad categories: “49 or under” and “50 or older.”

Wu said it’s “incredibly misleading for people that are trying to get a sense of what they’re paying.”

Prices for everyone in the 49-or-under group are based on what a 27-year-old would pay. In the 50-or-older group, prices are based on what a 50-year-old would pay.

CBS News ran the numbers for a 48-year-old in Charlotte, N.C., ineligible for subsidies. According to HealthCare.gov, she would pay $231 a month, but the actual plan on Blue Cross and Blue Shield of North Carolina’s website costs $360, more than 50 percent higher. The difference: Blue Cross and Blue Shield requests your birthday before providing more accurate estimates.

The numbers for older Americans are even more striking. A 62-year-old in Charlotte looking for the same basic plan would get a price estimate on the government website of $394. The actual price is $634.

[AEON]

This whole thing is just an overly-complicated train wreck...as we knew it would be.

The government is very poor at implementing technology. I work with government website teams quite often, and they are getting bottom of the barrel talent and project management.

And Irvine, there is NO WAY this is the most complicated web site history. I've helped implement some supply chain B2B sites that tracked everything to the pebbles of raw materials sitting in a pile in Africa to the to inventory of the finished goods sitting on a shelf - which also included just-in-time manufacturing, demand forecasting, regional sales tracking, marketing campaigns...in one system.

[Diemen]

Originally Posted by AEON

This whole thing is just an overly-complicated train wreck...as we knew it would be.

The government is very poor at implementing technology. I work with government website teams quite often, and they are getting bottom of the barrel talent and project management.

And Irvine, there is NO WAY this is the most complicated web site history. I've helped implement some supply chain B2B sites that tracked everything to the pebbles of raw materials sitting in a pile in Africa to the to inventory of the finished goods sitting on a shelf - which also included just-in-time manufacturing, demand forecasting, regional sales tracking, marketing campaigns...in one system.

I think there's quite possibly a difference in scale (at least regarding necessary bandwidth) between your sites and healthcare.gov.

Not many sites are able to handle the kind of load that healthcare.gov needs to handle. From what I've been reading from the IT world, failures like this are fairly common in new sites that want to be able to handle thousands of hits/minute.

[Diemen]

There's also this:

The classic definition of chutzpah is the child who kills his parents and then asks for leniency because he's an orphan. But in recent weeks, we've begun to see the Washington definition: A party that does everything possible to sabotage a law and then professes fury when the law's launch is rocky.

On Tuesday, Rep. Paul Ryan became the latest Republicans to call for HHS Secretary Kathleen Sebelius to step down because of the Affordable Care Act's troubled launch. "I do believe people should be held accountable," he said.

Okay then.

How about House Republicans who refused to appropriate the money the Department of Health and Human Services said it needed to properly implement Obamacare?

How about Senate Republicans who tried to intimidate Sebelius out of using existing HHS funds to implement Obamacare? "Would you describe the authority under which you believe you have the ability to conduct such transfers?" Sen. Orrin Hatch demanded at one hearing. It's difficult to imagine the size of the disaster if Sebelius hadn't moved those funds.

How about congressional Republicans who refuse to permit the packages of technical fixes and tweaks that laws of this size routinely require?

How about Republican governors who told the Obama administration they absolutely had to be left to build their own health-care exchanges -- you'll remember that the House Democrats' health-care plan included a single, national exchange -- and then refused to build, leaving the construction of 34 insurance marketplaces up to HHS?

How about the coordinated Republican effort to get the law declared unconstitutional -- an effort that ultimately failed, but that stalled implementation as government and industry waited for the uncertainty to resolve?

How about the dozens of Republican governors who refused to take federal dollars to expand Medicaid, leaving about 5.5 million low-income people who'd be eligible for free, federally-funded government insurance to slip through the cracks?

The GOP's strategy hasn't just tried to win elections and repeal Obamacare. They've actively sought to sabotage the implementation of the law. They intimidated the people who were implementing the law. They made clear that problems would be exploited rather than fixed. A few weeks ago, they literally shut down the government because they refused to pass a funding bill that contiained money for Obamacare.

The Obama administration deserves all the criticism it's getting for the poor start of health law and more. Their job was to implement the law effectively -- even if Republicans were standing in their way. So far, it's clear that they weren't able to smoothly surmount both the complexities of the law and the political roadblocks thrown in their path. Who President Obama will ultimately hold accountable -- if anyone -- for the failed launch is an interesting question.

But the GOP's complaints that their plan to undermine the law worked too well and someone has to pay border on the comic. If Republicans believe Sebelius is truly to blame for the law's poor launch, they should be pinning a medal on her.

Wonkbook: The GOP’s Obamacare chutzpah

Implementation was bound to be rocky (note that it was also a rocky start in Massachusetts under Romney). The Obama administration and the teams working towards implementation of the healthcare.gov site clearly underestimated the scope of potential issues, and should be held accountable for that. But let's not pretend that Republicans are actually concerned that the law isn't getting implemented as smoothly as it should.

[AEON]

Originally Posted by Diemen

From what I've been reading from the IT world, failures like this are fairly common in new sites that want to be able to handle thousands of hits/minute.

Which is why such projects go through a development cycle which includes stress testing and possibly a slow, controlled roll-out.

This will be a great example of "what not to do" for IT execs.

[Diemen]

Originally Posted by AEON

Which is why such projects go through a development cycle which includes stress testing and possibly a slow, controlled roll-out.

This will be a great example of "what not to do" for IT execs.

Agreed (though some of the obstacles thrown up by Republican governors certainly would have made an attempt at controlled rollout difficult regardless).

Full disclosure: my original reply a couple posts up to you was going to say "Were your sites designed to handle thousands of hits/minute?" until I realized the punchline: "neither was healthcare.gov."

[Popmartijn]

Originally Posted by Diemen

Implementation was bound to be rocky (note that it was also a rocky start in Massachusetts under Romney). The Obama administration and the teams working towards implementation of the healthcare.gov site clearly underestimated the scope of potential issues, and should be held accountable for that. But let's not pretend that Republicans are actually concerned that the law isn't getting implemented as smoothly as it should.

http://takingnote.blogs.nytimes.com/...ts-for-failure

The rollout is bumpy, and inexcusably so. It appears that the federal exchange Web site wasn’t fully tested until two weeks before it opened. As today’s Times story put it, the online health insurance marketplace “is still limping along after three weeks.”

Lawmakers can and should hold the administration to account. But given that House Republicans have done everything in their power to try to dismantle the Affordable Care Act — including shutting down the entire government — it’s understandable that House Democrats expressed suspicion about their motives.

“I wish I could believe that this hearing is above board, but it’s not,” said Representative Frank Pallone, Democrat of New Jersey. “The Republicans don’t have clean hands coming here. Their effort is obviously not to make this better, but to use the website glitches as an excuse to defund or repeal Obamacare.”

Maybe it's an idea to start holding Republicans accountable for the success of the ACA. If it becomes a success, then votes for them, if not then votes for someone else. Maybe then they'll finally start doing their job.

[AEON]

Originally Posted by Diemen

Agreed (though some of the obstacles thrown up by Republican governors certainly would have made an attempt at controlled rollout difficult regardless).

Full disclosure: my original reply a couple posts up to you was going to say "Were your sites designed to handle thousands of hits/minute?" until I realized the punchline: "neither was healthcare.gov."

You're a good sport. I hope this debacle leads to a simple, single-payer system in the long run. The ACA is way too complex and will create more bureaucracy - which is almost never a good thing. With each layer of middle men, the costs will go up. That's the nature of the beast.

[anitram]

Somebody else already asked this, but how on earth do any of you see single payer happening anytime soon?

The entire Republican Party stands in opposition, while the Tea Party is completely irrational on this point. And you have a number of conservative Democrats who aren't much better.

[AEON]

Originally Posted by anitram

Somebody else already asked this, but how on earth do any of you see single payer happening anytime soon?

.

If we see 8-12 years of Democratic control of the WH and Congress - I can see it happening.

[Diemen]

Originally Posted by AEON

If we see 8-12 years of Democratic control of the WH and Congress - I can see it happening.

I envy your optimism. I think the only way it could happen in the near future is if there is a concerted and successful effort from the "Establishment" Republicans to shut down the Tea Party's current grip on the party and its base. I suppose if the Dems do capitalize on the current national animus towards the Tea Party and ride it to electoral victory in Congress, they could just push ahead and go for single payer anyway, but I shudder at the thought of how much further that would push the level of vitriol from the far right.