Brad Delong Smackdown Watch

Brad Delong has an impressive set of thoughts on PPACA implementation and a path of the future. I think he is getting one thing significantly wrong as the clues are already emerging:

2.The Republican-Heritage Foundation piece of the bill–the exchanges–appear, to me at least, to be functioning much better than expected. I thought, given the amount of brainpower health insurance companies devoted to gaming the system, that they would have been able to blast large holes through community raining by crafting policies that only an idiot with chronic conditions would sign up for. That has not happened. Yet. But I am now considerably more optimistic about the possibility of providing effective social insurance via a health insurance marketplace dominated by for-profit insurance companies than I once was.

Recently, I wrote about AIDS medications and Gresham’s law applying to health insurance. I think this is the first salvo of the “brainpower health insurance companies devoted to gaming the system” as it is the most obvious target to create policies that are amazingly ugly to people with chronic, expensive conditions.

One of the major challenges for Obamacare is transitioning the health insurance industry from being extremely competent at finding ways to not covering sick people towards finding ways to keep people from getting too sick. The biggest stick in this transition is the massive sea change in underwriting from exclusionary, statistical and experience underwriting to an inclusionary community rating system of underwriting. This change, as we have discussed ad nauseum, allows all people, including those with expensive pre-exisiitng conditions to get insurance. It is why the Exchange risk pools are sicker, on average, than the risk pools of the pre-Exchange underwritten individual insurance markets as those markets kept the sick people who could actually need services out of the market.

Insurers are required to accept and cover HIV patients. They don’t want to. So they are trying to avoid them by being fugly….

relatively inexpensive AIDS mediciation for the first insurance company with this idea would get put on the most expensive formulary where pre-authorizations, high co-insurance and high co-pays apply until the member reaches the out of pocket maximum. This anti-social but rationally based business model should make the plan very unnattractive to individuals with HIV. They will logically look at the market and look for a plan that does not completely fuck them over.

The same logic applies to diabetics, cancer survivors, transplant recipients and other high cost individuals.

And here is where problems emerge. Once one plan in a market decides to make themselves as unattractive as possible, every other plan has to either follow suit in making themselves unattractive or be willing to take on massive health costs as they become the preferred plan for HIV positive individuals.

We’re seeing this with AIDS/HIV patients for two reasons. The first is that this is a population with known high costs that insurers really want to avoid. Secondly, there is a significant network of very effective advocates who are able to identify this as a business strategy of some insurers and scream about it. I would be shocked if other very high cost but very small population diseases are not being “top-tiered/specialty tier for generics” as a risk avoidance strategies, but I have not heard about them.

The policy solution is simple, engage in a regulatory arms race to force insurance companies to compete on providing health coverage and health improvmeent instead of cherry picking good risk and off-loading bad risk to competitors and/or government programs. This will work in most Blue states and some Red states. Insurance companies will probably have a consistent twelve to eighteen month head start on whatever other risk shifting schemes they have, but the threat of regulation, especially goal based regulation instead of explicit rule based regulation should be an effective constraint on these types of behavior. Other states like Florida have a political class that is actively getting off (with neither a safe word nor consent) by inflicting pain on the vulnerable, poor and marginal.

103 replies
  1. 1
    bg says:

    yesterday the copay on my husband’s insulin suddenly went from $50 to $122. When we called the insurer, we were told that the company had changed the drug’s “tier” in the middle of policy year. There is no generic. Since we are not “vulnerable, poor and marginal,” we can manage this. But it looks like they are trying to get rid of us. And since this is Florida, which deregulated health insurance in response to the passage of the ACA, it looks like they will get away with it.

  2. 2
    Brad DeLong says:

    Why, thank you…

    You aren’t surprised at how slowly underwriting-via-fine-tuning-of-the-benefits-package is proceeding?

  3. 3
    Face says:

    All of this becomes a nothingburger after SCOTUS torches the subsidies aspect of the ACA and blows the whole thing up.

  4. 4
    Omnes Omnibus (the first of his name) says:

    @Face: Yep, life is pointless, so we may as well sit in a corner and quiver.

  5. 5
    Richard Mayhew says:

    @Brad DeLong: Beta testing year — I expected some mid-year tuning but the constraint has been uncertainty based on how state regulators will react to it. Some will smack down, others will wash their hands and be told to blame Obamacare for the morning fog much less underwriting manipulation. I expect to see a whole lot more of this in the 2015 plan year as plans will respond to their local regulatory environment plus they have seen if there is a race to the bottom started in 2014.

  6. 6
    Cermet says:

    As someone who does not want private, for profit health care, how in the world can any company take on an significant number of known extremely expensive patients? This screams for Gov single payer.

  7. 7
    Richard Mayhew says:

    @Face: I don’t think the Supremes will for a couple of reasons.

    1) Highly unlikely circuit split once Halbig goes en banc for a re-hearing.

    2) Medicaid expansion had no clearly identified stakeholders and the blame could be attributed to THEM. Taking away state based subsidies places Team Red in a bad position as clearly identified and sympathetic stakeholders now lost a current benefit with two clearly identifiable ways to restore the Obamacare subsidy status quo for Red team politicians — enact a state exchange or pass a three sentance clean-up bill. Fuck-you-ism works better with unsympathetic or non-politically connected victims who have not received anything yet. Telling middle class voters to fuck-off because the politician is too lazy is not a winning message.

  8. 8
    Richard Mayhew says:

    @Cermet: Either single payer or tightly regulated health insurance as a public utility model. Either can work, either does work in the rest of the civilized world.

  9. 9
    Omnes Omnibus (the first of his name) says:

    @Richard Mayhew: I agree with both contentions. If Roberts, acting as a political judge, were going to vote to kill the ACA, the time to do it was the first case before it most of it went into effect.

  10. 10
    catclub says:

    @Richard Mayhew: I agree with your logic, but the length of time that Redstates have resisted the hospitals and health care providers (GOP class) who want Medicaid expansion is impressive (=horrifying). In this environment, killing subsidies is possible. They will just call them all moochers.

  11. 11
    Omnes Omnibus (the first of his name) says:

    @catclub: If it is at the Supreme Court, the decision maker who will matter is Roberts. The four sensible justices will vote to uphold on simple statutory interpretation grounds. Robert as a political judge, I addressed above. And Roberts as judge qua judge is too smart to get caught on the wrong side of something laughably stupid.

  12. 12
    Matt McIrvin says:

    @Richard Mayhew: There’s an active effort afoot by conservatives to convince the DC circuit to not rehear Halbig en banc, on the justification that it’s a breach of unwritten tradition or some such thing. I’m not sure how much chance it has of succeeding.

  13. 13
    JMV Pyro says:

    @Omnes Omnibus (the first of his name):

    Admittedly, I’m not concerned about the exchanges being gutted so much as I am about another Sibelius type decision that upholds the law, but creates another Medicaid gap style loophole that harms even more people.

    I don’t think the Supreme Court will get rid of the federal exchanges, but I wouldn’t put it past them to try and fuck around with them. This is the Roberts Court after all.

  14. 14
    Mnemosyne says:

    @Cermet:

    IMO, “for profit” is really the problematic part of our healthcare system. Many other countries — including Germany and Switzerland — have private insurance companies as their universal system, but those companies are very tightly controlled and regulated by their governments and they are non-profits.

    (In Switzerland, again IIRC, the insurance companies are allowed to have a sideline of supplemental insurance for things like private hospital rooms that they are allowed to make a small, regulated profit on.)

  15. 15
    gene108 says:

    @Cermet:

    As someone who does not want private, for profit health care, how in the world can any company take on an significant number of known extremely expensive patients? This screams for Gov single payer.

    Cherry picking, by for profit health insurance companies, is a form of cost constraint, by the payer of the service.

    Single payer will also have cost constraints, i.e. some things will not be covered or will be covered at such a minimal level, as to be ineffective.

    Medicare and Medicaid are single-payer systems in the U.S.A. and both have things they exclude or do not automatically pay for, even if you feel it is necessary to get more physical therapy sessions, for example or will nit-pick about routing you to an X-ray, when the doctor recommends you get an MRI.

    There’s no perfect system of health care access, where everybody gets everything they want.

    It is what trade-offs are most people willing to live with and accept that is the issue, with any health care system.

    P.S. I’m not trying to say the U.S. system is the best. It sucks. But a lot of people seem to think single-payer will be a cornucopia that will meet everyone’s health care needs, which I do not think is true either.

  16. 16
    Matt McIrvin says:

    @Richard Mayhew: …I just had a very interesting argument on Facebook that supports your second point. It was with a conservative incensed about the ACA individual mandate who used lots of CAPITAL LETTERS.

    The main anecdote he was using to support his outrage was about someone in Georgia who, as it sounded, had fallen into the Medicare-expansion hole and had been told (possibly falsely) that she was still required to buy insurance: insurance that, he claimed, no doctor would take. He didn’t blame the state government; he blamed Obama and the ACA.

    At one point, though, I mentioned Halbig and the possibility that the subsidies might be yanked for people on the federal exchanges. And he actually agreed in an aside that that would be a bad thing to do.

  17. 17
    Omnes Omnibus (the first of his name) says:

    @Matt McIrvin: When there is a 2-1 decision in which the majority is completely off base, the unwritten tradition is that it is reheard en banc.

    @JMV Pyro: In any case, I think the more likely result is the en banc rehearing of Halbig ending in the panel’s decision being reversed. No split in the Circuits, no cert.

  18. 18
    gene108 says:

    @Mnemosyne:

    Many other countries — including Germany and Switzerland — have private insurance companies as their universal system, but those companies are very tightly controlled and regulated by their governments and they are non-profits

    There are bunch of big non-profit insurance carriers in the U.S.A, but they have figured out ways to have both a non-profit arm, which makes gobs of money and a for profit arm, which makes gobs of money.

    Getting the regulations right to make non-profits or for-profits operate, so they are not raking in the dough is key.

  19. 19
    Matt McIrvin says:

    @Omnes Omnibus (the first of his name): But conservatives don’t think the majority in the 2-1 vote was completely off base, they think it was right.

  20. 20
    catclub says:

    @Matt McIrvin: Yes, but the unanimous 4th Circuit decision says it actually was off base, to justify the en banc re-hearing

  21. 21
    Omnes Omnibus (the first of his name) says:

    @Matt McIrvin: Are you talking about conservatives on DC circuit? If not, they have no say in the matter.

  22. 22
    dmsilev says:

    @Omnes Omnibus (the first of his name): What’s the timing on all this? I know the administration requested the en banc hearing last week; how long typically does it take before we know whether the Appeal Court will agree to that? Assuming they do, how long until the hearing and decision? Months, I assume?

  23. 23
    catclub says:

    Doesn’t someone with AIDS/HIV want to buy the GOLD plan, because they know they are going to spend past the deductible anyway? Yes, I have assumed they can afford the Gold plan, but giving the much higher deductible on the silver plan, they work out the same, don;t they?

  24. 24
    Cervantes says:

    @Face:

    I’m trying to imagine a nothingburger.

    No, not seeing it.

    Can you help?

  25. 25
    Cervantes says:

    @Matt McIrvin:

    There’s an active effort afoot by conservatives to convince the DC circuit to not rehear Halbig en banc, on the justification that it’s a breach of unwritten tradition or some such thing. I’m not sure how much chance it has of succeeding.

    Close to zero — but you’re right, one can never be completely sure.

    Say more about that “active effort.”

  26. 26
    Omnes Omnibus (the first of his name) says:

    @dmsilev: the court gave the plaintiffs 15 days to respond to the government’s request of a rehearing. Following that, we will see. I can’t really say how long the process may take.

  27. 27
    Davis X. Machina says:

    @gene108:

    AIlianz has a nice sideline in gap policies, as I have found out. My son’s silver-and-a-bit stateside BC/BS didn’t pass muster from the Canton of Vaud, when he went to uni over there for a year, so we wound up buying one. He couldn’t get the residency permit without it, either.

    Switzerland’s full of corporate relocaters, so it’s probably not a tiny market.

  28. 28
    Omnes Omnibus (the first of his name) says:

    @Cervantes:

    Say more about that “active effort.”

    I am presuming it refers to the spate of op-eds like this.

  29. 29
    Punchy says:

    In any case, I think the more likely result is the en banc rehearing of Halbig ending in the panel’s decision being reversed. No split in the Circuits, no cert.

    Lawyers in a recent TPM article (sorry, cant link) said otherwise to both of your suggys. Said en banc for this case would be unprecedented (and thus unlikely), and SCOTUS’s desire to adjudicate this will be untethered to a split/no split amongst the Circuit Courts, for political reasons.

  30. 30
    MomSense says:

    @Mnemosyne:

    I actually think that highly regulated as well as regulated profit are more important than whether the company is non-profit. I say this because when I look at some of the cost comparisons for procedures and diagnostics, often the non profit hospitals charge a lot more than their for profit counterparts.

  31. 31
    drkrick says:

    @Richard Mayhew:

    Either single payer or tightly regulated health insurance as a public utility model. Either can work, either does work in the rest of the civilized world.

    Fixed.

  32. 32
    Omnes Omnibus (the first of his name) says:

    @Punchy: Was it this? Many of the lawyers making these arguments filed briefs in favor of the plaintiffs/appellants. They are not offering disinterested legal analysis; they are making arguments.

  33. 33
    Cervantes says:

    @JMV Pyro:

    This is the Roberts Court after all.

    The Roberts Court can’t dissolve into the ether soon enough for me, either, but its record is mixed — perhaps more than you think.

  34. 34
    Glocksman says:

    @Omnes Omnibus (the first of his name):

    MEGO (My Eyes Glazed Over) at trying to read that.
    My question to you Counselor would be does Adler make legitimate points or is he merely ‘pounding the table’?

  35. 35
    Cervantes says:

    @gene108: Useful reminder, thanks.

  36. 36
    Cervantes says:

    @Omnes Omnibus (the first of his name):

    No split in the Circuits, no cert.

    Iron-clad?

  37. 37
    Cervantes says:

    @drkrick: Thank you.

  38. 38
    Ella in New Mexico says:

    given the amount of brainpower health insurance companies devoted to gaming the system, that they would have been able to blast large holes through community raining by crafting policies that only an idiot with chronic conditions would sign up for. That has not happened.

    At the risk of repeating myself, YES THEY FUCKING HAVE, AND YES THIS FUCKING HAS HAPPENED.

    Huge deductibles and out-of-pocket limits, combined with “co-insurance” percentages for labs, radiology in/outpatient care + no transparency or accountability for charges made by the medical community = lots of precious bucks coming out of the budgets of the average person but not the insurance companies coffers.

    So much so, people are avoiding needed health care, so their policies end up being “Catastrophic Coverage” plans, whether they wanted one or not. Or, like one of my friend’s who acquired a life threatening aortic valve infection, they have set up a fundraising campaign online to beg for help from friends and family so they can pay his medical bills and keep the electricity on while he recovers.

    Seriously, this was the same thing that happened BEFORE OBAMACARE!!!!!

    Wondrous thing for-profit health care is– it creates jobs!!! At least Go Fund Me and Razoo are making money. Who’da thunk it?

  39. 39
    Omnes Omnibus (the first of his name) says:

    @Glocksman: Adler is a participant in the suit – a peripheral one, but a participant, nonetheless. His op-ed was a legal argument; that is, he emphasized the facts and law favorable to his position and directed attention away from, or ignored, counterarguments. Also, in his piece at Volokh that I linked earlier, he did not bother to disclose his involvement in the case. It isn’t that he is “pounding the table;” it is that he is presenting his side as though it is disinterested commentary.

  40. 40
    Omnes Omnibus (the first of his name) says:

    @Cervantes: Of course not. Nothing ever is. OTOH with no split in the circuits, it is a statutory interpretation case on which 4 of 4 appellate courts that have heard the case agree. This is not the kind of case that the Court usually takes.

  41. 41
    Ella in New Mexico says:

    @Mnemosyne:

    IMO, “for profit” is really the problematic part of our healthcare system. Many other countries — including Germany and Switzerland — have private insurance companies as their universal system, but those companies are very tightly controlled and regulated by their governments and they are non-profits.

    Agreed, but in the US, regardless of how much whining you hear about “Government over-regulation” we don’t regulate for-profit or AND non-profit healthcare anywhere near enough.

    Blue Cross Blue Shield is exhibit one: they suck so very, very much, nationwide, using “reasonable and customary charges”, big deductibles and out of pocket limits, and the power of the “co-insurance cost share” to ream their customers heartlessly.

  42. 42
    raven says:

    @Ella in New Mexico: I’ve been very happy with BCBS for 20 years. so there

  43. 43
    Omnes Omnibus (the first of his name) says:

    @Ella in New Mexico:

    Agreed, but in the US, regardless of how much whining you hear about “Government over-regulation” we don’t regulate for-profit or AND non-profit healthcare anywhere near enough.

    And this is why no sentient person ever saw the ACA as anything but a first step toward a good system. An improvement and a step forward but that is it. IMO, the most important thing the ACA does is to establish the concept that people have a right to healthcare.

  44. 44
    Corner Stone says:

    Whatever one thinks of President Obama, as a public speaker, I’m not sure there has ever been anyone consistently as good. The man gives a good delivery.

    Mildly still on topic as it was about Obama signing the VA Reform bill.

  45. 45
    Omnes Omnibus (the first of his name) says:

    @raven: I had BC/BS when I was clerking. My out of pocket expenses for surgery to repair an ACL, MCL, and meniscus tear were less than $200 – most of that was physical therapy co-pays. Anecdote not data.

  46. 46
    Corner Stone says:

    @Cervantes:

    The Roberts Court can’t dissolve into the ether soon enough for me, either, but its record is mixed — perhaps more than you think.

    Any one or two “good” standouts that come to your top of mind?

  47. 47
    mai naem says:

    @bg: Jeezus, how is this even legal? Wow, you would think that the copays are contractual annually for existing medications. I understand them messing around with new meds.

  48. 48
    raven says:

    @Omnes Omnibus (the first of his name): Same with my bride for her back surgery. I’ll take our personal experience over “data” rants any day.

  49. 49
    Mnemosyne says:

    @Ella in New Mexico:

    You’re stuck in a bad spot because the lower population states don’t have as much bargaining power as the bigger states, so the insurance companies have more control and ability to screw you. Colorado is having a lot of the same problems, from what I’ve heard. Also, Blue Cross is evil.

    I’ll suggest what I always suggest, which is to file an official complaint with your state department of insurance and copy the complaint to HHS. If enough people complain, one or the other agency will need to act, but they won’t know what’s going on unless you make them aware of it.

  50. 50
    Roger Moore says:

    @Matt McIrvin:

    There’s an active effort afoot by conservatives to convince the DC circuit to not rehear Halbig en banc, on the justification that it’s a breach of unwritten tradition or some such thing.

    A nasty, suspicious person might take this as a sign that they know perfectly well that their argument has no merit and will be laughed out of court if it’s ever reheard en banc.

  51. 51
    rikyrah says:

    oh really, Ezra?

    The PRESIDENT is to blame?

    NOT the racist muthaphuckas that met the NIGHT OF HIS INAUGURATION

    and decided…

    during the worst economic downtown of this country since the Great Depression that they would commit

    ECONOMIC TREASON

    against this country because they wanted the Black Man out of the White House..

    No, THEY didn’t break politics…

    The President did?

    G-T-F-O-H

    …………………………………………………………………….

    Liberal MSNBC Host Says Obama Broke “American Politics Even Further”

    Tommy Christopher on August 07, 2014

    Fresh off his weeks-long stint flacking for Paul Ryan’s poverty plan, Vox publisher and All Infill-in host Ezra Klein further dabbled in Beltway view-from-nowhere dumbshittery Wednesday night when he declared, to MSNBC viewers, that President Obama broke politics. He promised to change politics, but instead, he broke them worse than they already were broken. Just listen:

    …..

    “The president didn’t do all of this by fixing American politics. He did this by breaking American politics even further.”

    http://thedailybanter.com/2014.....-politics/

  52. 52
    raven says:

    Looks like we’re fixin to bring a little smoke on ISIS

    WASHINGTON — President Obama is considering airstrikes or airdrops of food and medicine to address a humanitarian crisis among as many as 40,000 religious minorities in Iraq who have been dying of heat and thirst on a mountaintop after death threats from the Islamic State in Iraq and Syria, administration officials said on Thursday.

  53. 53
    Mnemosyne says:

    @Omnes Omnibus (the first of his name):
    @raven:

    Depends on the state. Here in California, Anthem Blue Cross is evil and has been sanctioned by the state multiple times for their shenanigans.

  54. 54
    Cervantes says:

    @Corner Stone:

    Any one or two “good” standouts that come to your top of mind?

    Sure.

    It upheld the PPACA.

    It refused to stop the EPA from regulating the emission of certain greenhouse gases by power plants.

    It struck down an anti-immigrant law in Arizona.

    It recognized that the people we are holding indefinitely and often illegally at Guantánamo do, indeed, have the right to judicial review.

    It required judicial warrants authorizing the searching of cell-phones when people are arrested.

    Some other important things, too — feel free to ask again later if you want elaboration or proper case citations.

  55. 55
    Cervantes says:

    @rikyrah: Could not agree with you more re Ezra Klein’s noxious little emission.

  56. 56
    Omnes Omnibus (the first of his name) says:

    @Mnemosyne: Also depends on the employer. I was working for the federal government. Big risk pool and a customer one probably doesn’t want to lose. What’s a knee reconstruction here or there compared to all those premiums?

  57. 57
    raven says:

    @Mnemosyne: Fine, then let’s be more specific than just BCBS, right?

  58. 58
    burnspbesq says:

    @Matt McIrvin:

    There’s an active effort afoot by conservatives to convince the DC circuit to not rehear Halbig en banc, on the justification that it’s a breach of unwritten tradition or some such thing. I’m not sure how much chance it has of succeeding.

    Which got rudely smacked down almost as soon as it appeared.

    http://balkin.blogspot.com/201.....er-on.html

  59. 59
    Omnes Omnibus (the first of his name) says:

    @burnspbesq: I hadn’t seen that. Thanks.

  60. 60
    Corner Stone says:

    @Cervantes: I had a different evaluation of their mixed ruling on ACA. They left it to go forward but stuck a dagger into it.
    Striking down much of AZ HB 1070 was definitely a “good thing”, as was the habeas ruling for Gitmo detainees.
    No need for citations, thanks.

  61. 61
    Cervantes says:

    @Omnes Omnibus (the first of his name): Agreed, of course, and I would not take it to the bank, either.

  62. 62
    Mnemosyne says:

    @Omnes Omnibus (the first of his name):

    Being the federal government, you guys may well have been self-paying (i.e. BCBS administered the insurance but the feds paid the actual bills). That’s what the Giant Evil Corporation does — Cigna administrates the insurance but the GEC makes the decisions about the formulary, etc.

  63. 63
    Cervantes says:

    @Omnes Omnibus (…): Thanks, I’d seen that Adler piece. And it’s no surprise, obviously, that people like him, who have been pushing the suit all along, are saying what they are saying now. I was just wondering if someone new is speaking up, someone worth looking at.

  64. 64
    Cervantes says:

    @Corner Stone: Sure, especially when it comes to the PPACA ruling, “good” is a relative term.

    As I said, their record is mixed.

    And here’s the enjoyable part of that: Scalia lost many important battles.

  65. 65
    Ella in New Mexico says:

    @raven:

    I’ve been very happy with BCBS for 20 years. so there

    I’m happy for you. Sadly, that’s not the case in general.

    BCBS NM just bought out the Lovelace Health Plan of NM which was outstanding in it’s ability to keep our out-of-pocket costs down for the past 15 years, while still providing excellent network and care options. When they did, they promised they would honor our existing plan until the year’s end. Of course, they are NOT doing that, and are refusing to pay a variety of charges that were covered and often were completely free under our previous plan, necessitating long and drug-out telephone battles to get them to just do what they are being paid to do.

    They pretty much depend on the fact that people are busy or don’t understand their rights and won’t fight every single time. I NEVER had that problem with my former insurance.

    @Mnemosyne: You are absolutely right. And I’m doing that on pretty much a bi-weekly basis right now.

    @raven:
    @Omnes Omnibus (the first of his name):
    I am truly happy for both of you, and you may be lucky enough to have insurance plans that have not reduced their coverage for those medical costs. But in our state, their plans–even for giant pools like Federal or State Employees–have changed significantly, and pretty much now suck. If I were to get outpatient knee arthroscopy today, I’d have to pay $4,000-$5000 bucks for it under BCBS NM’s best plan (barring any additional costs they routinely try to deny due to “reasonable and customary” rules). Under my old plan, it was $250.

  66. 66
    Corner Stone says:

    @raven: Tom Gara:
    “We may have to bomb some folks.”

  67. 67
    Ella in New Mexico says:

    @raven: @Omnes Omnibus (the first of his name): @Mnemosyne:

    Looks like BCBS is a curse word. My response is in moderation. ;-)

  68. 68
    Ella in New Mexico says:

    @raven:

    I’ve been very happy with BCBS for 20 years. so there

    I’m happy for you. Sadly, that’s not the case in general.

    BCBS NM just bought out the Lovelace Health Plan of NM which was outstanding in it’s ability to keep our out-of-pocket costs down for the past 15 years, while still providing excellent network and care options. When they did, they promised they would honor our existing plan until the year’s end. Of course, they are NOT doing that, and are refusing to pay a variety of charges that were covered and often were completely free under our previous plan, necessitating long and drug-out telephone battles to get them to just do what they are being paid to do.

    They pretty much depend on the fact that people are busy or don’t understand their rights and won’t fight every single time. I NEVER had that problem with my former insurance.

    @Mnemosyne: You are absolutely right. And I’m doing that on pretty much a bi-weekly basis right now.

    @raven:
    @Omnes Omnibus (the first of his name):
    I am truly happy for both of you, and you may be lucky enough to have insurance plans that have not reduced their coverage for those medical costs. But in our state, their plans–even for giant pools like Federal or State Employees–have changed significantly, and pretty much now suck. If I were to get outpatient knee arthroscopy today, I’d have to pay $4,000-$5000 bucks for it under BCBS NM’s best plan (barring any additional costs they routinely try to deny due to “reasonable and customary” rules). Under my old plan, it was $250.

  69. 69
    Omnes Omnibus (the first of his name) says:

    @Ella in New Mexico: I wasn’t trying to refute or deny your experience. I was only noting that your experience with the company was not mine. I am sorry that your situation is what it is.

  70. 70
    Cervantes says:

    @Ella in New Mexico:

    @raven:
    @Omnes Omnibus (the first of his name):
    I am truly happy for both of you

    Wait — do they have some good news to share?

  71. 71
    Omnes Omnibus (the first of his name) says:

    @Cervantes: I have seen no one but the usual suspects.

    @Cervantes: No, we just did not have bad experiences while insured by BC/BS. OTOH, I suppose that is good news compared to what others seem to have experienced.

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  73. 73
    Villago Delenda Est says:

    @Cervantes:

    I would not take it to the bank, either.

    Ah, that phrase gives me fond memories of the night of the Colorado primary in 2012, when our local Rmoney shill told us we could take an Rmoney victory in that state to the bank.

    Santorum won the primary.

    UNLIMITED CORPORATE CASH! suffers from a very embarrassing “insufficient funds” notice.

  74. 74
    Ella in New Mexico says:

    @Omnes Omnibus (the first of his name): of course, and thanks.

    @Cervantes:

    Wait — do they have some good news to share?

    Yes! That they are not being fucked by their health insurers. I’d say that’s damned good news. ;-)

  75. 75
    KithKanan says:

    @Mnemosyne: Oh, goodie. My employer just switched over to them from Blue Shield of CA.

    Of course, Blue Shield of CA is also evil, but in this county your choice is pretty much one or the other (literally so on the exchange, effectively so for a small-ish business otherwise).

  76. 76
    Chyron HR says:

    The Republican-Heritage Foundation piece of the bill–the exchanges–appear, to me at least, to be functioning much better than expected.

    Wow, it’s almost like there’s a reason why this “Republican plan” has only ever been passed by Democratic majorities facing unanimous Republican opposition.

  77. 77
    Eric U. says:

    @gene108: a single payer system as funded by our current jerkwater republicans could easily become a real problem. Look at what they did to the VA, and expand that to everyone. Given a rational government, I do think that single payer is the way to go.

  78. 78
    Cervantes says:

    Brad Delong:

    I am now considerably more optimistic about the possibility of providing effective social insurance via a health insurance marketplace dominated by for-profit insurance companies than I once was.

    Well, that’s good … I guess.

    Thanks for your ten points.

    No question: the Republicans were complete jerks even in 1993.

    But as for this:

    And the ACA is something that moderate Republicans are already profoundly unhappy they let themselves be bullied into lining up in opposition to.

    How is this a known?

    And I do agree here:

    But it is not clear what the important connections between the passage of the ACA and the slowing-down of health-care cost inflation have been.

    OK, but since we’re engaged in “big thoughts” and all, what are your best guesses?

    Re your point 4, it can’t be denied.

    And I agree with point 10.

    One other small thing: “awesome in its evilness” is absolutely right but what’s all this about “John” Gruber?

    Thanks again for writing it all out.

  79. 79
    Cervantes says:

    @Ella in New Mexico: Yes, I was just fooling around … so to speak.

  80. 80
    burnspbesq says:

    @Glocksman:

    My question to you Counselor would be does Adler make legitimate points or is he merely ‘pounding the table’?

    The latter, in my view. Adler’s a dick, but he’s smart enough to count votes, and he knows his position is going down in flames if DC rehears Halbig en banc.

  81. 81
    burnspbesq says:

    @Corner Stone:

    Any one or two “good” standouts that come to your top of mind?

    The Roberts Court has been surprisingly good on search-and-seizure issues. Jones, the GPS-tracker case, was a real surprise, and this term’s case on warrantless searches of cell phones was about as good as one could have hoped.

    They’ve also been mostly good on Guantanamo detainess, although they need to step in and smack down the DC Circuit for effectively nullifying Boumediene.

  82. 82
    raven says:

    Just what I need, an 800+ page book about Reagan!

  83. 83
    Villago Delenda Est says:

    @Cervantes:

    No question: the Republicans were complete jerks even in 1993.

    And well before that. They were trending complete jerks starting in 1964, and they got to complete jerk, moving on to full-fledged asshole, in 1980. They have not stopped since. Now outright naked fascism is acceptable as a GOP position…and the vermin of the Village celebrate it.

  84. 84
    Cervantes says:

    @Villago Delenda Est: Well, sure, and I like the spectrum of jerkitude you’ve fashioned for them, and that they, I’m certain, are proud to fulfill — but I was responding to a point Brad made specifically about 1993.

    Looking at the Republicans more generally, I’d have to say that being a real jerk — like being a real racist — requires power — and as the Democrats ruled the House almost without interruption from 1931 to 1994, the Republicans were more like jerk-buds-in-waiting during that period. It’s only after 1994 that they’ve been able to really … blossom.

  85. 85
    Corner Stone says:

    @burnspbesq:

    The Roberts Court has been surprisingly good on search-and-seizure issues.

    Why do you think that is? Is it “correct” interpretation of existing laws, is it political, or some mix? I use the scare quotes as you say one was a “real surprise”.

  86. 86
    Bobby Thomson says:

    @Omnes Omnibus (the first of his name):

    And Roberts as judge qua judge is too smart to get caught on the wrong side of something laughably stupid.

    Cough. Shelby County. Cough.

    Plus with added racism!

  87. 87
    Omnes Omnibus (the first of his name) says:

    @Corner Stone: Part of it is that Scalia is surprising good on search and seizure issues.

  88. 88
    Matt McIrvin says:

    @Cervantes: Executive power counts for a fair bit, especially in foreign policy, and through the 1980s they were winning Presidential elections with huge blowouts–the Democrats couldn’t even touch them. There was a slightly different form of jerkdom that blossomed in that environment.

  89. 89
    Cervantes says:

    @Matt McIrvin:

    There was a slightly different form of jerkdom that blossomed in that environment.

    Sure, and the most painfully victimized there were primarily foreigners in their own lands — and perhaps the best illustration of that is the Boland Amendment and what came after it.

    So just imagine what Reagan and Bush might have done with Gingrich as Speaker and you may well agree with me!

  90. 90
    Bobby Thomson says:

    @Cervantes: Talk about defining deviancy down. OK, they aren’t a Stalinist or Nazi court, but this is the worst Supreme Court since the pre-switch days.

  91. 91
    Cervantes says:

    @Bobby Thomson: Sure, I did not rate the Roberts Court relative to other Supreme Courts we’ve had. I just said its record is mixed, in the sense that I — and probably you — haven’t always disagreed with the majority.

    Luckily, there are other ways to distinguish me — and probably you — from Stalinists and Nazis.

  92. 92
    Corner Stone says:

    @Cervantes: I thoroughly denounce Stalin!

  93. 93
    Cervantes says:

    @Corner Stone: But not Pol Pot, and don’t think it’s gone unnoticed.

  94. 94
    Corner Stone says:

    @Cervantes: Nor broccoli, either. Fuck the haters!

  95. 95
    Davis X. Machina says:

    @raven: Does this count as an invasion? As per Libya? Or not, because up until recently we were already in Iraq?

    I need to keep track, so I know how many times Obama has sold me out…

  96. 96
    Corner Stone says:

    @Davis X. Machina: Should we be bombing some folks over there?

  97. 97
    raven says:

    @Davis X. Machina: Beats me but it seems like 40,000 people are trapped and, as usual, there are few that can do anything about it.

  98. 98
    Omnes Omnibus says:

    @Bobby Thomson: You have a point there. I was thinking in terms of technical side and it is hard to get dumberer that messing up simple rules of statutory construction. OTOH, on the substantive side, saying racism is over is a level of dumb that boggles the mind.

  99. 99
    burnspbesq says:

    @Corner Stone:

    Why do you think that is? Is it “correct” interpretation of existing laws, is it political, or some mix? I use the scare quotes as you say one was a “real surprise”.

    Hell if I know. I’d like to think that Jones is a result of a careful rethinking of what it means to have a reasonable expectation of privacy in our new digital world, but even I am not that much of a Pollyana. Shit happens, I guess, and it’s worth remembering that there is only one former prosecutor on the Court (Alito).

    The cell phone case was easy if you looked at it from the perspective of the policies that have historically been the basis of the search-incident-to-arrest exception to the warrant requirement, I.e., protecting the arresting officer’s safety and preventing the destruction of evanescent evidence. If you’re taking somebody to jail and confiscating their phone, they aren’t wiping it while you’re sitting outside the magistrate’s chambers waiting for your warrant application to be reviewed.

  100. 100
    Cervantes says:

    @raven: On the CSM web-page telling the story of this genocide, under the article proper, there was a poll:

    “Have you watched a horror film in theaters in the past six months?”

  101. 101
    spaps says:

    Richard,

    Will the CMS edge servers for risk adjustment and reinsurance affect practices like these? Insurers will need to be submitting 2014 claims and enrollment data by early December to be compliant, with the window open until 4/30/15.

    Won’t those insurers dumping these high cost patients get punished for having a low risk score and need to transfer funds to those taking on the higher risk?

  102. 102
    Richard Mayhew says:

    @spaps: a bit but there are a couple assumptions being made that argue for assholery:

    A) risk corridor payments only kick in after either 2.5 or 3% miss (at airport without references) and they nevere cover full lost.

    B) risk adjustment payments are fuzzy and a royal pain in the ass to get approved/ cash in bank account for well established/run government programs. A company with high risk will get paid eventually….

    C) hold cash now from low claims payout and pay later is better to mbas than pay big claims now and get uncertain payments later

  103. 103
    Nathanael says:

    Families are fighting back by getting everyone with chronic illnesses onto Medicaid (== reliable treatment for chronic illness) even if it requires divorce.

    Everyone should be put on Medicaid. The exchanges… well, it’s gonna be hard for the regulators to fight this arms race, since the insurance companies are gonna bribe them. Kill the insurance companies and go with Medicaid for everyone.

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