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Healthcare.gov may be temperamental and insecure, but it came through in the end

Healthcare.gov , the internet face of "Obamacare" -- a mandatory federally guaranteed public insurance marketplace for the uninsured -- has been troubled to say the least.  Experts suggested security was bad enough that the portal should be shut down for repairs (it never was).  The portal at times was unreachable, and at other times lost registration information midway through enrollment.  In recent months the site's quality and reliability improved somewhat, although some problems on the service and security fronts remain.
 
I. HealthCare.gov Reaches Milestone
 
But the progress was apparently good enough to keep the site from being a deal breaker for Americans.  On Tuesday, President Barack Obama (D) told CBS Corp. (CBS) in a video interview aired on the network's "Evening News":

We admittedly had just a terrible start because the website wasn't working, and despite losing effectively two months, we are going to be reasonably close to that original projection [of 7 million enrollees].



At roughly 4 pm today the administration announced that 7.1 million Americans had enrolled in the program.  

ACA 7.1 million

The White House's press secretary, Jay Carney, states:

We surpassed the 7 million mark with the over 200,000 people who enrolled yesterday in states run by the federal government alone.  When we get numbers in from the rest of the states and people who are trying to sign up by the deadline and are finishing now, even more people will be covered.



The President in a speech said the new regulation didn't fix America's troubled healthcare system, but "it has made [it] a lot better".  While others will disagree with that assessment, the landmark warrants a look back at what exactly "Obamacare" is, how some Americans enrolled in it, and the troubles it has had.
 
II. What is Obamacare and the ACA?
 
It's been four years since The Patient Protection and Affordable Care Act (PPACA) [PDF] passed through Congress and was signed into law by the President.  The bill survived a Supreme Court challenge and multiple efforts to undo or undermine its provisions by House Republicans.
 
A key provision of the bill was the mandate to states to create so-called "healthcare exchanges" -- online portals where citizens can shop for health insurance and be guaranteed the ability to not be denied coverage.  A central federal website -- Healthcare.gov -- guided Americans through the enrollment process, trying (and at times failing) to connect them to their state exchange.
 
Given the massive traffic pressure on Healthcare.gov and state portals, the ACA was intimately tied to the internet and tech space in general.  Indeed the President often leaned on top tech executives and thinkers to try to brainstorm solutions for the program, as it struggled.
 
Healthcare.gov
Healthcare.gov managed to survive the final week of enrollment, by far its busiest week since its disastrous launch.

As of last week only 6 million people had enrolled, leaving the program 1 million short of its target mark.  But an advertising campaign helped to fuel a surge of enrollment requests, which pushed the program to its target in the eleventh hour.
 
The late surge brought in record traffic, both at the U.S. Department of Health and Human Services and The Medicare & Medicaid phone center.  Joanne Peters, a spokeswoman for the DHHS said the volume of visitors and callers set records.
 
But unlike in the disastrous launch of the program last October -- a milestone that also set records -- the centers braced for the surge and handled it relatively well this time, from a technical perspective.  There were relatively few complaints of service outages.
 
Open enrollment closed Tuesday morning, although those who tried to enroll but were stymied by technical glitches should be able to still try again to complete the process.
 
III. A Compromise
 
Many of the ACA's biggest backers will admit the bill is an imperfect compromise.
 
While the bill assures that some "uninsurable" groups both young and old -- e.g. cancer patients, etc. -- get the insurance and treatment they need, its costs are somewhat unevenly distributed.  Older Americans generally will pay the same or sometimes a little less overall versus existing plans.  Out of pocket expenses (e.g. the cost of buying drugs at the pharmacist or paying a part of the doctor's visit bill) may increase somewhat; that increase is almost always offset or surpassed by a decrease in monthly premiums.  
 
Younger Americans, many of whom are uninsured, are forced to enroll in more expensive plans or face modest financial penalties.  Either way costs for younger Americans will tend to rise as costs for older Americans dip.
 
The bill lacks some of the provisions that make healthcare in other socialized insurance schemes more cost-competitive -- namely collective drug buying.
  

HIV treatment
The ACA dropped early proposals for collective drug buying, placating one key opposition group (the corporate pharmaceutical lobby).  [Image Source: Tomorrow Global]

The concession prevented vigorous opposition from the pharmaceutical industry, but it also makes Obamacare one of the more expensive socialized medical plans worldwide in terms of cost versus services.  It also lacks much of the preventive medicine that's offered in Canada and other socialized medical systems, provisions that have been shown to reduce the cost of care.
 
But the bill is also misunderstood somewhat.  Even before the ACA, hospitals and medical centers were mandated to give some level of medical care to uninsured patients in emergency situations.  While the hospitals could try to collect medical bills from these people, bankruptcy or inability to pay often left the public covering the majority of uninsured Americans' health care costs.
 
IV. What Came Before the ACA?  Meet "Reagancare"
 
Perhaps the greatest misunderstanding perpetuated by both parties for image reasons, is the notion that Obamacare is the first program of its kind or the first system of mild socialism/federal regulation on the medical industry.

Before the ACA, there was The Emergency Medical Treatment and Active Labor Act (EMTALA) (USC 42§1395dd), a component of the The Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985.  Signed into law by President Ronald Wilson Reagan, that act offered America's first major institutionalized socialism in the medical care field.

(For those who care, the 99th Congress that passed that law had a Republican-controlled Senate and a Democratic controlled House -- sort of the party mirror image of today's Congress and President.)
Cobra medical care
Under both COBRA/EMTALA and the ACA the federal government took medical marketplaces deeply reliant on federal aid and forced them to become controlled markets, obeying federal mandates and guaranteeing service. [Image Source: West One Mortgages]

Under COBRA/EMTALA (which could be creatively termed "Reagancare") hospitals were forced into a regulated marketplace, in which private competitors offered services to customers, but were forced to live with federal rules -- namely guaranteeing service and limiting abusive practices.  In exchange, the hospitals received federal Medicare funding for participating in this controlled market.
 
Sound familiar?  That "shocking", "revolutionary" socialist Obamacare program wasn't really all that new at all -- it was nearly identical on some levels to the Regan program.  Under the ACA the finer details are of course different from the EMTALA/COBRA, but the motivations and execution from a high level viewpoint are virtually indistinguishable.
 
Under the ACA medical insurers were forced into a regulated marketplace, in which private competitors offered services to customers, but were forced to live with federal rules -- namely guaranteeing service and limiting abusive practices.  In exchange, the insurers received federal Medicare/Medicaid funding for participating in this controlled market.
 
V. "Patient Dumping" -- the Existential Medical Moral Crisis of 1980s, which Reagancare (aka COBRA/EMTALA) Answered
 
Prior to the passage of the COBRA/EMTALA it was rare, but not altogether unheard of for hospitals to engage in so-called "patient dumping" -- literally abandoning patients with treatable, relatively inexpensive emergencies like a heart attack to die if they had no insurance or cash to pay.  
 
Clearly many hospitals and doctors would not do such a coldhearted act, given their religious, ethical, and/or professional convictions.  For example, such an act would seem to clearly violate the Hippocratic Oath that is taken by doctors in the U.S. took.
 
That said, patient dumping did happen, which ostensibly led to President Reagan and the divided Congress to work together to pass the EMTALA and other measures within COBRA to try to prevent the coldhearted tragedy of a medical institution turning away a patient and condemning them to death because they couldn't pay.

Hospital entrance
The EMTALA was an instance of Reagan resorting to mild socialism (heavy regulation) to prevent a seemingly abusive private sector practice -- patient dumping [Image Source: Queller Fisher]

Of course, the cost was government regulation of a private market -- mild socialism.  But President Reagan and Congress were undeterred by that unmentionable elephant in the closet.
 
Thus the EMTALA/COBRA were passed and hospitals that turned away patients for profit risked being shut down by the big federal government.  Like insurers under Obamacare, hospitals weren't exactly thrilled at this notion, but they had little room to argue given that without government aid, most hospitals by the 1980s would likely have been insolvent.  The government was artificially propping them up with taxpayer money and it could pull the plug at any time.  Thus the muffled outcry against the EMTALA/COBRA -- like the ACA -- was like a child crying over their overbearing parent's household rules.  They could whine and throw a tantrum, but at the end of the day they were inescapably reliant on their loving provider, the federal government.
 
Likewise in the current context the ACA arose largely out of the occasional practice of insurance companies refusing coverage for individuals with certain expensive, but treatable conditions such as cancer or brain diseases.  While a hospital could not deny patients emergency treatment, EMTALA did not provide for long-term treatment guarantees -- it was up to the patient and their insurance to provide that.  If they couldn't get insurance, or if their insurance refused to pay for their treatment, they would likely get sicker and die, when they might have been able to be saved.
 
Such cases, much like the patient dumping issue, appear to be relatively rare, but are not unheard of.  They happened frequently enough to convince President Obama and the divided Congress -- basically the mirror image in terms of party control of the White House and Congress under President Reagan -- to legislate new regulation for yet another key component of the medical market.  Here again, the unspoken argument was similar -- the costs of mild socialism and federal regulation were worth it to prevent the relatively rare, but very disturbing and sad tragedies of patients who were denied coverage and died.
 
VI. Both Parties Practice Don't-Ask-Don't-Tell When it Comes to Policy Parallels
 
Neither party over the course of the ACA debate has been overly eager to highlight the similarities of the two programs.  For Obamacare's supporters, mentioning the EMTALA could be viewed as plugging their supposed archrival -- the Reaganists.  And it would dull some of the luster of Obamacare -- a program that was supposedly so unique and revolutionary (although it really wasn't).  It might also highlight how limited and lacking Obamacare was compared to strongly socialist public offerings in the UK and Canada.
 
Obamacare's opponents, likewise, were happy to keep the EMTALA skeleton in the closet, as it threatened to undermine their argument against Obamacare.  After all, if you accept sweeping federal regulation of one key medical market to prevent the medical industry from willfully allowing treatable patients to die, it's hard to make a compelling case against similar regulation to another key medical market for nearly the exact same reason.
 
Hence both parties practice a "don't ask don't tell" sort of philosophy when it comes to what came before Obamacare.  But it's important that the media remind the public of this secret that our politicians want us to forget about.
 
Under the EMTALA, it became illegal for any hospital receiving Medicare federal funding to turn away patients needing emergency treatment.  Other corresponding COBRA provisions brought new regulations to insurers. 
 
Arguably both the EMTALA and ACA are examples of "mildly" socialist federal health care programs that aim to solve the tough question of how to treat (or some would say, whether to treat) those who cannot pay for treatment, or which the free market does not view as profitable to treat.
 
In both cases the socialism is rather "mild" in that these are secondary efforts in comparison to the much larger primary private sector insurance market.

Ronald Reagan signs COBRABefore the ACA, the EMTALA of 1986 -- championed by President Ronald Reagan -- first institutionalized mild socialism into the U.S. medical system. [Image Source: White House Photo]

Some fear that Obamacare might eventually grow into the primary U.S. insurance provider, but it's important to recognize that even under Obamacare it's more a story of regulation than a government takeover. Under Obamacare, new regulations ban insurance companies from engaging in certain practices.  Insurance companies are required to compete in the government ensured state markets that guarantee enrollment.  At the same time citizens are also regulated, as they are penalized financially if they choose not to pay for the enrollment and don't otherwise have insurance.
 
In that regard while the insurance exchanges provision of the ACA is inherently socialist and different in principle to the EMTALA, it's a similar idea to some extent, in that it involves the federal government going in and giving orders to some group of medical businesses, mandating them to provide service to citizens.

VII. What Will Obamacare's Legacy Be?
 
Will Obamacare work out any better than Reagancare?  Is the answer to one troubled federally controlled, regulated, and subsidized healtcare market to tightly regulate another crucial piece of the healthcare economy?

Even among those willing to ask that bold question, the answers are admittedly unclear.

Karen Pollitz, a senior fellow at the Kaiser Family Foundation, told Reuters that achieving the enrollment mark was a metric to look at, but that it would take analysis to figure out exactly what the enrolling population means politically and to the program's future.  Comments Ms. Pollitz:

We still have a lot to learn about what underlies those numbers in terms of who signed up and how many were newly insured people versus switching from other coverage.  We have more to see ... about how many of them actually completed enrollment and how much coverage expansion was accomplished.

At a victory lap of sorts in the White House Rose Garden, President Obama addressed the press stating:

This law is doing what it's supposed to do — it's working.  The debate over repealing this law is over.
 
Obama ACA
Wishful thinking?  President Obama claimed today that the debate over "Obamacare" was "over".
[Image Source: AP]

That statement might be a bit premature.  Even The White House in its follow-up press release acknowledged that the budget plan put forth by House Republicans would repeal the ACA, effectively eliminating Obamacare.  While that bill is unlikely to succeed, Republicans clearly are still trying to capitalize on criticism surrounding the ACA, including the technical debacles generated by healthcare.gov, as well as more technical debates (and at times misinformation) regarding the healthcare exchanges themselves.
 
U.S. House Speaker Rep. John Andrew Boehner (R-Ohio) pledged to beat back the ACA on Tuesday.  But even his rhetoric has softened.  His press release did not explicitly mention a repeal.  In it he writes:

Our drive to stop the train wreck that is the president's health care law will continue.  We will rely on aggressive oversight that highlights the law's massive flaws and smart, targeted strikes that split the legislative coalition the president has relied upon to force his health care law on the American people.

John Boehner
House Speaker John Boehner pledged to continue to fight "Obamacare".
[Image Source: AP]

Whatever side of the fence you're on, Healthcare.gov's staff deserves some credit for somewhat salvaging the trainwreck the internet portal was at its launch last year.  

And for those looking to argue politics, remember this -- Republicans and Democrats alike have both embraced a socialist federal health care solution, ever since President Reagan signed such an agreement into law.  The latest debate simply boils down to the parties' inability to agree on whether to expand on that socialist solution, or leave it as is.  At the end of the day, for now Obamacare is the law of the land -- a young sibling to the aging, troubled child of the 1980s, Reagancare (EMTALA/COBRA).

At the end of the day Obamacare's biggest difference from Reagancare very well may be its shiny coating of digital age, internet services.  That makeover transformed a quiet, elephant in the closet, into a noisy, misunderstood, and heavily criticized federal effort.  But in the end it also showed signs of achieving some degree of success, establishing a legacy of its own -- young and fragile as that legacy may be.

Sources: The White House (official blog), (speech via YouTube), House Speaker John Boehner, USA Today





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