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A Surprising Reason Some Still Don’t Like Obamacare

The Affordable Care Act (“Obamacare”) has slowly become more popular as Americans discover that the law has lowered the number of people without health insurance and provided baseline benefits to millions of us (preventive care, youth coverage under parents until age 26, doing away with pre-existing conditions, etc.), without causing massive social or health care disruption.

Critics of the ACA cite ideals like letting the marketplace sort things out, rather than relying on government intervention to do so. Of course, the individual mandate, the requirement to be insured, was scaled back by the late 2017 tax reform law–such that people on the individual insurance market will be able to opt out in 2018 and beyond if they choose without penalty (even though the US Supreme Court ruled in 2012 that the mandate is constitutional).

Recently, a reader sent me a fascinating article about why some evangelical Christians also dislike Obamacare. It’s known as crucicentrism.

Not all evangelicals hold this worldview. According to a source cited in the article, about one quarter of evangelicals espouse this viewpoint.

Still–what does it mean? From the aforementioned article:

To secure a permanent place at God’s side is far more important than any short-lived torment to the body. From this perspective, then, the greatest kindness one can show others is to help them reach the salvation of the Cross.

Such a crucicentrist view on compassion explains puzzling statements by white evangelicals like Mark Green, a Tennessee state senator. “Sickness,” Green told a church group, “is one of the main avenues that bring people to religion.” In the Gospels, he said, “every person who came to Christ came to Christ with a physical need. It was either hunger or a disease.” When the government created the ACA it did a “great injustice” because, Green explained, by helping people regain their health, it had limited “the Christian church’s role” and robbed sick individuals of the opportunity “to come to a saving knowledge of who God is.” People who fell ill would now look “to the government” instead of to God.

In this worldview, suffering is seen as a pathway to faith, which will lead to salvation. And, I presume, better health.

Maybe this shouldn’t be surprising. After all, institutions have always needed members, missions, and money to maintain their existence over millennia.

But I do find this inclination shockingly uncharitable.

What do you think?

Candor and Thoughtfulness

In a first for an occupant of the White House, President Barack Obama has authored a lengthy appraisal of health care reform efforts in the United States in a top-notch medical journal, JAMA. The essay looks in detail at the effects of the Affordable Care Act (“ObamaCare”) thus far on access to health coverage and the trends in health care spending.

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The rate of uninsured over time.

Beside the historic first of a sitting President publishing a significant health care think-piece, what’s notable is the candor with which Obama appraises the ACA — both its successes and failures. He offers a roadmap going forward for how we can further expand coverage and continue to diminish the portion of our spending devoted to health care (both as a government and as individuals, i.e. what we pay out-of-pocket).

The two most impressive achievements of the ACA are the drop in numbers of uninsured Americans (from 16% to 9% of the population) and the slowing of health care inflation. The article is a bit wonky, so here is a key portion of the argument about how the ACA has slowed health care spending:

From 2010 through 2014, mean annual growth in real per-enrollee Medicare spending has actually been negative, down from a mean of 4.7% per year from 2000 through 2005 and 2.4% per year from 2006 to 2010…Similarly, mean real per-enrollee growth in private insurance spending has been 1.1% per year since 2010, compared with a mean of 6.5% from 2000 through 2005 and 3.4% from 2005 to 2010…

As a result, health care spending is likely to be far lower than expected. For example, relative to the projections the Congressional Budget Office (CBO) issued just before I took office, CBO now projects Medicare to spend 20%, or about $160 billion, less in 2019 alone.

What I also find interesting is the ancillary material: Like all JAMA authors, President Obama was required to submit a financial disclosure form to demonstrate no apparent financial conflicts of interest in his presentation of data and policy recommendations. As an attachment to the article, the White House included the President’s annual financial public disclosure statement. A couple of take homes for me: Index Funds. The President sensibly has retirement investments in Vanguard index funds. There’s even information about the mortgage on his Chicago home. If interest rates stay the way they are, he should definitely think about refinancing soon.

Health Care Predictions Re-Visited

Luciano Lozano. 'Be the bonsai.'

Luciano Lozano. ‘Be the bonsai.’

Happy New Year, one and all! I hope that it’s a healthy one for you.

Since we’re here at the beginning of 2016, it’s time again to look at some predictions I made about health care in the U.S way back in 2013 (also revisited a year ago).

  1. Obamacare will move ahead. Despite 2 different hearings before the Supreme Court and dozens of repeal challenges, the Affordable Care Act stands.
  2. Medicine will enter the era of ‘Big Data.’ Anyone seen those TV ads for ‘Optum,’ (to name just one big data player)? We are already here.
  3. Big data will lead to targeted medical marketing. This wasn’t even a prediction. It’s already been happening for years.
  4. Greater price transparency will come to health care. Not really close to cracking this nut, but a lot (a ton!) of attention is now focused this way.
  5. By 2020, all states will have expanded Medicaid. We are already to 30 states plus the District of Columbia. More on the way.
  6. The number of uninsured will be cut in half within four years. Not quite there yet, but the number of uninsured is the lowest since 1972.
  7. The number of NPs and Physician Assistants will continue to grow, as will the field of community health workers. Yes and yes.
  8. We will see the first nationwide health plans. Yes — the key word here is consolidation — insurers, hospitals, etc.
  9. Finally, a continuous doctor-patient relationship will become a luxury that can be purchased. Everything keeps pointing in this direction.

I’m giving myself a solid seven out of nine this year, up one from last year — and the remaining two predictions are also likely to prove true over time.

One area not covered here that will continue to see explosive growth: Telemedicine. It’s the Wild West. Which company will emerge as a market leader? Stay tuned.

Brill’s Content

time-magazine-bitter-pill-coverLegal journalist Steven Brill has a new book out. You may have heard something about it; there’s been extensive coverage of it in the last week or so. It’s called America’s Bitter Pill, a narrative containing a massive set of interviews (>200) with players involved in the passage of the Affordable Care Act, aka Obamacare.

The book’s subtitle, “Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System,” gives you an inkling of his attitude. Brill wrote the book as an outgrowth of a major piece he reported for good ol’ Time magazine in 2013, an article to which the entire issue was devoted. Brill’s Time piece was successful — it got people talking, won a magazine award, and put the term “chargemaster” into our vernacular.

Brill can be acerbic, both in his writing and in interviews. His candor is refreshing. Critics of the new book charge Brill with misinterpreting the significance of some of the statements made by his interview subjects, and for offering flawed policy recommendations based on his reporting.

Nevertheless, what makes “Bitter Pill” special is the fact that Brill himself underwent a major health care scare and lived to tell about it in poignant and funny detail. He had an aortic aneurysm that required open heart surgery, a nearly $200,000 operation. His insurance paid 90% of the cost, but his discussion of the numerous insurance statements (“Explanations of Benefits,” known as EOBs) he received is hilarious. And he gets a rare opportunity: When interviewing the CEO of United Health, the largest private US health insurer [also his insurer], he gets to pull a totally illogical EOB out of his pocket and confront the CEO with it.

Behold: Mr. CEO can’t interpret it, either.

HealthCare Prediction CheckUp

doc-office-aca_wide-403577f90f9f2aa9fdfb92060c1f512825900d1f-s6-c30A while back I made a list of predictions about the world of health care as we entered the Obamacare era.

Let’s see where we stand:

1. “Obamacare will move forward” — in spite of staunch opposition. — Check.

2. Big Data #1 — you’ll be nudged by your doctor or medical home with reminders for preventive care items like flu shots or colonoscopies. — Check minus. This was already happening (e.g. letters reminding women of annual mammogram screenings), but not yet to the extent I foresee.

3. Big data #2 — targeted medical marketing along the lines of Netflix or Amazon, using your prior purchases/preferences. — Nope. I still see this coming. We are at the precipice of a slippery slope.

4. “Patients will be a step closer to becoming true consumers.” What I meant here is that we will see increasing efforts launched to provide price transparency and comparability for health care services, so that patients will actually be able to value shop. — Big proto-check. Big because of a few key efforts — see Elisabeth Rosenthal’s amazing series called “Paying Till it Hurts” in the NY Times, which inspired its own Facebook group and grassroots effort to rein in health costs and bring greater transparency to the ‘market,’ and Steve Brill’s TIME magazine wholly devoted to the mysteries of the ‘chargemaster’ — we are moving quickly in this direction. But only a proto-check because we are nowhere near where we need to be.

5. “More people will get insurance. The 47 million uninsured will be cut in half within four years…” — Check. We are well on the way. See #6.

6. “By 2020, all states will have expanded their Medicaid pools, providing more coverage to the poorest of the poor.” — Nope. But 27 states and the District of Columbia potentially have us near a tipping point. I gave myself some leeway here, and I’m confident we’ll get there.

7. “The number of nurse practitioners and physician assistants will grow dramatically. Nurse practitioners will continue to gain more independence in practice. A new category of health worker will flourish: the community health worker, a lay combination of social worker and medical provider. In particular, community health workers will help with the 5 percent of people who account for half the health care spending in the U.S.” — You betcha.

8. “We will see the rise of the first nationwide health plans. Archaic rules that keep health care local will be modified to eventually allow for consolidation. Like hotel chains, you’ll be able to get health care at the same organization in different cities. The sponsors may be hospitals, say the Cleveland Clinic, or big health insurers, like Aetna. As with hotels and airlines, you’ll have frequent visitor programs, and you’ll be able to amass points toward discounts and perks.” — Not yet. Just you wait. Industry consolidation (i.e. mergers and acquisitions) will continue and drive this.

9. “The traditional doctor-patient relationship in which a single doctor gets to know you over years will become a luxury.” — Check. Just take a look here. Or here.

Generously scoring, that’s six out of nine right so far. Sixty-seven percent is no Nate Silver, but there’s plenty of time still on the clock for the long range bets.

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