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Sparse networks, quality and tweaking the ACA

The ACA subsidy formula right now is tied solely to the actuarial value of a plan.  Subsidies are based on the second least expensive Silver plan for an individual in a market region before Cost Sharing Reduction subsidies are applied to boost actuarial value.  The government pays a fraction of the cost of what it takes to get a person a 70% policy.  This is a problem because it does not take quality of plans or networks into account.

There are an interesting pair of papers.  The first one is one that Claire McAndrews of Families USA flogs  on her quest to get better network directories and better networks.

We examined physician networks in 34 states offering plans through the federal marketplace during 2015 open enrollment using the rating area (geographic unit for marketplace premiums) containing each state’s most populous county. We analyzed 4 silver plans (the category of plans purchased by 69% of consumers)1: lowest, second lowest, median, and highest premium plans. One plan was excluded for a defective search engine, yielding 135 plans.

Using plans’ online directories between April 12 and 18, 2015, we searched for in-network specialist physicians in obstetrics/gynecology, dermatology, cardiology, psychiatry, oncology, and neurology (largest volume nonsurgical specialties) and endocrinology, rheumatology, and pulmonology (specialties treating common outpatient conditions).4 Accounting for patient travel, we applied a broad and narrow search radius relative to each rating area’s most populous city. Based on directories’ functionality, the broad radius was 160 km (100 miles) or, when unavailable (in 12%), the maximum search radius (typically 80 km [50 miles]). Our narrow search was half the broad radius….

Using the broad and narrow searches, 18 (13.3%; 95% CI, 8.5%-20.3%) and 19 (14.1%; 95% CI, 9.1%-21.1%), respectively, of 135 plans were specialist-deficient plans. Two plans included dermatologists and oncologists in the broad search radius but not the narrow radius. Three plans included endocrinologists in the broad search radius but not the narrow radius….1

Networks without adequate fairly common specialists are low cost products (on average) for two reasons.  The first is the most likely reason that a specialist is excluded from a network is the network is paying below the minimal acceptable rate for a specialist.  This would be an indicator that the network is paying fairly low rates.  Secondly, networks that do not have core specialists will not be attractive to people who know that they need to see a core specialist.  An individual with cancer will not buy a plan that does not have any oncologists in it.  It is a risk dump so deficient networks are engaged in an adverse selection cherry pick.

The other article I found interesting with was an analysis of how people made decisions on quality and price when shopping on Exchange:

We found that consumers were much more likely to select a high-value plan when cost information was summarized instead of detailed, when quality stars were displayed adjacent to cost information, when consumers understood that quality stars signified the quality of medical care, and when high-value plans were highlighted with a check mark or blue ribbon. These approaches, which were equally effective for participants with higher and lower numeracy, can inform the development of future displays of plan information in the exchanges…. 2

It is a good public goal for individuals to choose high quality and affordable plans that meet their needs.

The current design of exchange subsidies does not allow that to happen in most cases and the design of the 1332 waiver program rules minimizes the opportunities for improvement at the state level.  Let’s go below the fold to have a policy discussion:

 

Healthcare.gov is a passive shopper.  It displays whatever is approved without engaging in any quality filtering or consumer choice improvement architecture.  This has led to the opportunity for companies to spam the Exchanges:

A company can offer numerous plans that have minuscule differences in benefit configuration.  Each plan counts as a separate entry in the Silver category, so a company can spam the Exchange with isomorphic plan designs.  If a company is fairly confident that its base configuration is in the running to be either the #1 or #2 lowest priced Silvers, there is minimal marginal cost of slightly tweaking benefit designs by bumping up co-pays or shifting some deductible dollars to co-insurance dollars or otherwise making small marginal and effectively meaningless changes to a plan to spawn mirrors….

We know that most subsidy receiving individuals who are buying on the Exchange are post-subsidy price sensitive.  Owning the #2 Silver and then seeing a large gap between #2 Silver and the first competing Silver means that almost every price sensitive shopper who is healthy (as they don’t need a narrow network) will buy Celtic/Ambetter.  Individuals with known medical conditions are less likely to go to a narrow network plan because they already have relationships with providers that work for them.  It is an attempt to buy healthy membership and dump sicker people to other insurers.

An active shopping Exchange like Covered California does not allow for spamming of the Exchanges.

Molina was not allowed to dominate the second Silver benchmark price point because Covered California is an active purchaser exchange.  Covered California actively chooses the carriers that it allows on the Exchange and then actively minimizes the number of isomorphic representations of the same actuarial value on the exchanges….

The active purchaser model gives consumers meaningful choices.  They can choose a cheap but low quality Molina plan for significant cost savings as it is the #1 Silver with a wide spread between its price and the benchmark Silver price.  Or they can choose a higher quality Silver that is fully subsidized as that high quality Silver is the benchmark Silver.  That decision process falls apart in an active purchaser exchange once there are two MCO based Exchange carriers, but the large gap between the first and second Silver gives consumers significant choices.

States with weak network adequacy regulation and using either Healthcare.gov or a passive buyer state based marketplace will see a race to the bottom on plan quality under the current subsidy attachment system.

Insurers will continue to attempt to pare back their networks while also engaging in risk dumps to other insurers with richer networks at the same actuarial level.  We have been seeing that healthy Exchange buyers are extremely price sensitive and will churn easily if there is a significant gap between prices in Period 1 and Period 2.  This makes sense because most healthy buyers are minimal users of healthcare and if they are subsidized, they don’t have a ton of spare cash lying around.  Plans that capture most of the healthy members in a region will be profitable even if they have to take care of the sick members as well.  If the low cost and low quality plans can also avoid the sick members, they’ll make a mint.

So what are the solutions for passive purchasers and low network adequacy regulation states.

The first solution is a local solution.  States can adapt better network adequacy standards where networks will not be approved unless there are sufficient number of specialists in the network.  This is what Families USA and the National Association of Insurance Commissioners are trying to get with their model network adequacy law.  I like it as a first step but it is still a fairly low bar that they are asking for.  Sparse networks will still be in play with the model act.

The long term solution is reworking the subsidy attachment points.  This will take an act of Congress and a friendly president as the 1332 process’s constraints on federal budget neutrality will prevent most states that run their own Exchanges from substantially changing the subsidy attachment point.  The change would be to have the subsidy attach to the second silver plan of “middle quality” where quality is a definition of network adequacy, care coordination, preventive medicine, and long term improvements.  Low cost and low quality networks would still have a business opportunity to pick up the very healthy and the very young but reasonably decent plans that actually spend money to build a network and engage in care management of sick individuals would have a chance.  This would cost money, and it would cost some real money but it is a plausible ten year goal to get a fix into the ACA.

 

Citations:

1) Dorner, S. C., Jacobs, D. B., & Sommers, B. D. (2015). Adequacy of Outpatient Specialty Care Access in Marketplace Plans Under the Affordable Care Act. Jama, 314(16), 1749. doi:10.1001/jama.2015.9375
2) Greene, J., Hibbard, J. H., & Sacks, R. M. (2016). Summarized Costs, Placement Of Quality Stars, And Other Online Displays Can Help Consumers Select High-Value Health Plans. Health Affairs, 35(4), 671-679. doi:10.1377/hlthaff.2015.1367






52 replies
  1. 1
    Mike J says:

    As always, don’t view a lack of comments as a lack of interest. I think it’s more that we have too much respect for you and view the topic as too important for our usual blog pie fights.

  2. 2
    Alain the site fixer says:

    I’m tweaking a few things including the Social Icons to share posts. So if you see that stuff come and go, don’t be alarmed. I’ll leave it when it works! :)

    And like Mike J said, please don’t take lack of comments to equal lack of interest!

  3. 3
    a hip hop artist from Idaho (fka Bella Q) says:

    I haven’t forgotten to look for some behavioral health information for you, but I haven’t gotten around to it either. Thanks for all your interesting posts.

    Hi Alain!

  4. 4
    Miss Bianca says:

    @Mike J: Seconded. I’m usually too stunned by the wealth of information in an average RM post to even know where to begin to comment.

  5. 5
    MomSense says:

    @Miss Bianca:

    Sometimes it takes a while just to digest the information.

  6. 6

    @Mike J: @Miss Bianca: Both of you, stop, I am blushing.

    I know what I write is not the easiest stuff to engage with. Some of it is targeted at the general Balloon Juice audience, and some of it is targeted at a very narrow but extremely wonky audience who may or may not be regular readers here. This particular piece is mostly targeted at the second group. It is the cost of entry to for a very wonky but fun conversation where the end result might be a slightly better system….

  7. 7
    Miss Bianca says:

    @Richard Mayhew: Well, I don’t know if I fall into the second group (ETA: “if you have to ask…”), but I do know that I ever ran for some sort of state/national office I don’t think I could do much better for advisors than to pick on the brain trust at BJ!

  8. 8

    @Miss Bianca: To fund significant new social spending, just get a swear jar at every Balloon Juice cabinet meeting….

  9. 9
    Miss Bianca says:

    @Richard Mayhew: : ) “A quarter in the jar, Cole! Oh, make that a dollar!”

  10. 10
    Trollhattan says:

    @Miss Bianca:
    “There’s no room!”
    “We need a bigger jar.”

  11. 11
    jl says:

    How about a federal solution? Uniform standard contract to be offered on exchange with higher minimum standard for network design. Coupled with an attack on local provider oligopolies and price differentials. People want fancier stuff, establish separate supplemental coverage insurance policy market. (Go Swiss!)

    i guess that will have to wait until after 2020 and maybe Democratic House and Senate (if we are lucky).

  12. 12
    martian says:

    There’s a lot here to digest, so I probably won’t comment further, but thank you for this. It is helping to clarify some things about my state’s exchange that appeared very random.

  13. 13
    martian says:

    Just wanted to add – I agree with above. Your posts are consistently and remarkably high value. Probably a lot of lurkers like me are just soaking it in.

  14. 14
    amygdala says:

    Are there data, or if not is anyone thinking, about how potential specialist work force changes may affect networks? I’ve worked in on both coasts and can’t think of a place in either of them with an oversupply of endocrinologists or rheumatologists, and there are projections than my own field (neurology) will be in short supply sooner rather than later.

    With current medical students both swamped with educational debt and seemingly more concerned about lifestyle than in the past, I worry about this. Infectious Disease is in a bit of a crisis these days, with rising numbers of unfilled fellowship spots. It’s a time-consuming field that doesn’t pay as well as many others. In an era where we have to use antibiotics wisely and pathogens, old and new, can get around the world quickly, this is troubling.

    The focus, and rightly so, has been on primary care, but there are specialties that will likely be in similar jams soon. Big cities and wealthy suburbs and exurbs may be okay, because doctors like to live there, but rural communities might find themselves in an even worse situation than they are now. I can think of ways to fix this–loan repayment programs targeted to particular specialties or practice settings–but it occurs to me the insurance community has the data to inform those decisions.

    (edited to correct grammatical error)

  15. 15
    Uncle Cosmo says:

    @Mike J:

    As always, don’t view a lack of comments as a lack of interest.

    Really? Really? I beg to differ.

    martian: ” Probably a lot of lurkers like me are just soaking it in.” Really? Really? I’d like to see the stats as to how many viewers made it “below the fold to have a policy discussion.” I’d be shocked! shocked! if it was any more than a dozen. My eyes glazed over in the middle of the first blockquote.

    Not disputing your expertise, Richard, or the significance of your chosen subject. But goddamn the material is dull! (And I know dull. As I used to tell my Stat 101 stoonts, No one but a very few, very twisted people like me do this stuff for fun!)

    Twelve comments in > 2.5 hours, 2 of which actually address the topic at hand. (Now 15 and 4.) My unscientific guess is that an open thread started right now would get twice that in 15 minutes….make that 10. And maybe that ought to be site procedure: Follow a terminally-wonky thread with an open thread fairly quickly, say within 15 minutes. Yeah, maybe it would draw eyes away from this thread, but by your own admission you’re only interested in snagging posters who have the time/interest/expertise to get deep into the weeds.

  16. 16
    raven says:

    @Uncle Cosmo: So don’t fucking read it. NOBODY cares. . . schmuck.

  17. 17
    Kylroy says:

    @jl: Wait, an actual halfway grounded proposal *before* somebody bleating about how this is all stupid and single payer is a panacea? WHAT HAVE YOU DONE TO THE OTHER COMMENTERS?!?

    /sarcasm

    All that said, yeah, these posts are both valuable and difficult to respond to. Probably why we’d always get “SINGLE PAYER ROCKS YOU LOSERS!!!” posts, because it’s an easy retort that doesn’t require the commenter to actually digest any information.

  18. 18
    Uncle Cosmo says:

    @raven: I’d be absolutely pleased not to read it, if there was something else here to read & discuss, but I made my comments to the previous thread & this bit of terminal wonkery has had the screen all to itself for, let’s see, 3 hours & 17 minutes now. Which was the point of my post, which obviously sailed waaaay over your head.

    And just FTR, without pretending to speak for “everybody,” I will say that I don’t give a flying fuck about you or your opinions either.

  19. 19
    raven says:

    @Uncle Cosmo: Who cares?

  20. 20
    a hip hop artist from Idaho (fka Bella Q) says:

    @amygdala: The infectious disease doc shortage will probably cause the most serious public health crisis that workforce problems spur, becuase as you note:

    [Infectious disease is] a time-consuming field that doesn’t pay as well as many others. In an era where we have to use antibiotics wisely (and often do not) and pathogens, old and new, can get around the world quickly, this is troubling.

    [ Parenthical emphasis by Bella Q]

    ETA:
    Seen in garage under local neuro department
    license plate

    APHASIA

  21. 21

    @Uncle Cosmo: I’ll take your suggestion under advisement the next time we have a Balloon Juice editorial meeting and John passes out the assignments…

  22. 22
    Miss Bianca says:

    @amygdala:

    The focus, and rightly so, has been on primary care, but there are specialties that will likely be in similar jams soon. Big cities and wealthy suburbs and exurbs may be okay, because doctors like to live there, but rural communities might find themselves in an even worse situation than they are now. I can think of ways to fix this–loan repayment programs targeted to particular specialties or practice settings–but it occurs to me the insurance community has the data to inform those decisions.

    the elephant in the room, of course (or is there a herd of elephants in the room?) is, as you point out, that the sheer expense of getting a medical education must tend to winnow out specialization in certain areas, both medical and geographical. I find myself wondering whether certain insurance groups might actually start financing students to continue in certain needed specializations for their networks?

  23. 23
    Trollhattan says:

    @amygdala:
    A pretty disturbing post, but also not surprising–just something few of us outside medicine probably ponder.

    Spent about six hours in the car Saturday with my 8th grader and one of her teammates (six hours for a two-hour match, what’s not to love?) and career goals came up. Neither is particularly drawn to medicine, other than the fun stuff they see on the teevee machine, such as being a medical examiner. Quoting: “I’m okay with cutting up dead people, I just don’t want to do it to live people.” Alright, then.

    Mind (caution: dad brag imminent) these are both straight-A students who actually spent time discussing how to prepare for the forthcoming high-school workload and how many hours/evening they were facing and how the heck do they work in soccer practice and still watch “Criminal Minds” AND not get behind at school?

    On the plus side, neither talked up law school, other than maybe if they got to prosecute MURDERERS. My suspicion is we don’t have enough medical school slots for the current, much less the forthcoming needs and should be dealing with this as policy, starting yesterday. But not if they just churn out plastic surgeons and Cheney life-extenders (am pretty sure they’re crafting those, somewhere), then we won’t have the right mix anyway.

  24. 24
    amygdala says:

    @a hip hop artist from Idaho (fka Bella Q): The ID shortage is concerning, to be sure, but I figure rising obesity rates probably have increased demand for the services of endocrinologists. They’re typically front and center for patients whose diabetes is hard to control.

  25. 25
    Kylroy says:

    @Richard Mayhew: I think this whole exchange has demonstrated how nothing pads comment counts like people bitching at each other.

    And seriously Cosmo, you’ll make it a few hours without Balloon Juice catering to your particular interests, I promise. I’m not much interested in cooking, gardening, or PETA-style veganism, but I don’t waste my and others’ time bitching about their presence.

  26. 26
    amygdala says:

    @Miss Bianca: As it turns out, Kaiser plans to open up a medical school. Maybe education medical students needs to be silo’d like this. Not everyone needs to be House, but that remains the predominant model for US medical education. It’s changing–slowly–but perhaps that needs to be forced along. I’m not sure how the incentives should be structured, just that the unintended consequences need to be addressed ruthlessness when identified. Taxpayer dollars should not go to creating more cosmetic plastic surgeons in Beverly Hills, the Upper East Side, etc.

  27. 27
    Mnemosyne says:

    To me, one of the big takeaways is that consumers benefit when the state takes an active interest in making sure insurance companies aren’t going to screw them. Once again, I am proud of my adopted home state.

  28. 28

    @Mnemosyne: can I broaden this slightly… People greatly benefit when local levers of government take an active interest in their residents not getting involuntarily screwed

  29. 29
    Capri says:

    Unfortunately, what drives numbers of physicians is the open slots in residencies, not external need. Some of the most vitally needed specialties, such as gerontology, are the most under served

    What boggles my mind more than anything is that nobody in the human medical field knows what anything actually costs. Insurance companies know what patients are charged, but that’s not the same thing. Human medicine is like the wedding industry, they take advantage of folks who are not price sensitive because they are in a hightened emotional state. And they’ve done it so long with every single thing that you would really have to start from scratch.

    You can buy a test tube rack or a roll of tape for a certain amount of money for use in research or veterinary medicine. Or you can buy the exact same things for 10X that amount from a medical supply source.

  30. 30
    amygdala says:

    @Trollhattan: It wasn’t that long ago that smart kids mostly had law (and hence politics) and the clergy as their major options. Law has really taken a knock in recent years. STEM has generated a lot of opportunites, although maybe that’s leveling off. I would argue the extreme money to be made in finance has been a major net negative for many advanced economies.

    As for medicine, we’re staring right into a physician shortage in the US. Many of us who have taught students and trained residents saw this coming for at least a decade. The AAMC started paying attention as well. In addition to increasing enrollments at existing US medical schools, for the first time in a long time, new allopathic programs are opening up in the US. I’m not sure what, if anything, is happening on the osteopathic side. But I’m hoping they’re increasing throughput, too. Problem is that the long training time for physicians means it takes a decade to see a bump in the numbers, even if the doors to the new med school open today.

    This on top of a longstanding global nursing shortage is trouble. And we need to be careful about poaching docs from parts of the world who need them even more than we do.

  31. 31
    Miss Bianca says:

    @amygdala: Holy crap, it’s a happening thing! Well, that’s one way to keep your insurance group a player as the industry changes.

    ETA: How is the movement toward “non-traditional” medical student recruitment going? I had heard that at least one prestigious med school (Johns Hopkins?) was making an effort to recruit students who hadn’t gone the heavy “math-science” route. If more med schools were willing to do the same – and more innovative ways of financing the education were available – I bet we’d see a lot more people enter the field.

  32. 32
    liberal says:

    @Miss Bianca:

    …the elephant in the room, of course (or is there a herd of elephants in the room?) is, as you point out, that the sheer expense of getting a medical education…

    No, the elephant in the room is the fact that there are so many market failures in the economics of medicine that designing a rational, non-socialist system is hopeless.

  33. 33
    amygdala says:

    @Capri: It’s not just residency slots. Those are in short supply, relative to student demand for them, in neurosurgery and dermatology, for example. There are concerns that neurosurgery will be shortage field in the not-too-distant future. The average neurosurgeon is well into *his* 40s, and there is significant maldistribution. If you live in a big city and need a craniotomy at 3AM, there’s almost certainly a hospital or two that will be able to get that done for you. In a rural community, it can be a roll of the dice.

    The heightened emotional state you referred to applies to physicians as well as to patients. That’s juuuust starting to change, but the idea of doing everything possible and damn the costs is deeply ingrained in American medicine.

  34. 34
    martian says:

    @amygdala: In what way do you think specialist scarcity might affect networks? Might it make some specialists cost prohibitive for some networks?

    I’m in a high density area. Issues my family has are things like, for ex., difficulty getting my daughter’s orthopedic surgeon and my surgical oncologist on the same network along with a laundry list of assorted other specialists. Just not possible, apparently, I think probably for reasons covered by Richard in this post.

    I’m a bit bemused when I hear about concerns over med school debt for young doctors. My cousin is an internist, and she accepted a position with a practice that paid all her debts off. She’s in a fairly rural area, too. I swear, it’s like she goes in for a few days a week and they just pour buckets of money over her. I can believe that her circumstances are rosier than the norm, but is it really unfeasible for new doctors to get at least part of their school debt covered like that?

  35. 35
    Scamp Dog says:

    @Uncle Cosmo: I always read these, but only occasionally make a comment. Although I don’t comment all that much,come to think of it.

    Keep ’em coming, Richard!

  36. 36
    Miss Bianca says:

    @liberal: well, yeah, OK…I’m not going to argue that point. But I have my doubts that the Great Socialist Revolution is coming to A Street Near You! any time soon, so I gotta pick and choose my pachyderms.

  37. 37
    amygdala says:

    @Miss Bianca: Even though I just went straight through, I think nontraditional students are important. They’re a stabilizing influence; 100+ former pre-meds in a confined space can go from mildly anxious to Lord of the Flies in nanoseconds.

    The idea that the US should scrap the current system, which provides relatively accessibility to nontraditional system, for the way physicians are trained in much of Europe has been put forth as making it easier to train more docs. I get the rationale, but, as mentioned, I think the nontraditional students are important. It takes real moxie, for someone who wasn’t a STEM major in college, to take a year of bio, math, and physics, and two years of chemistry, to chase a dream of going to med school.

    An interesting program I learned of recently is a 3-year PhD to MD program at Columbia. It’s for people with biosci PhDs. That degree means that they’ve done all the pre-reqs and other relevant coursework. Obviously it’s not a large-scale solution, but good to know someone’s thinking outside the box.

  38. 38
    Miss Bianca says:

    @amygdala: I’ve entertained fantasies of doing it myself…but I’m getting a bit long in the tooth to be going back to school for essentially a second BA, then on to med school, internship, etc.

  39. 39
    Kylroy says:

    @liberal: And there we go! 32 comments, that’s got to be a new record.

  40. 40
    Capri says:

    @amygdala: I’ve heard that overall dermatology is the hardest specialty to crack, which means the residents who are accepted into derm residencies by and large had the highest grades and highest test scores. With the best of the best becoming dermatologists, it begs the question why more medical breakthroughs aren’t developed by them. Or are they under the radar somehow?

  41. 41
    amygdala says:

    @martian: There are already parts of the country with inadequate neurosurgical coverage or mental health providers. Forget the kind of coverage you have; there just aren’t enough practitioners to do the work. On top of that, in rural communities, the kinds of distances patients have to travel to get to the office can be prohibitive.

    I’m sympathetic to the network issues you deal with. I am increasingly of a mind that the major benefit of a medical degree these days is being able to manage one’s own care more for systems issues than medical knowledge.

    The feds have a number of loan repayment programs. Some, like your cousin’s, are directed toward primary care, underserved communities, or both. There are also programs for researchers. My best friend from med school was an early beneficiary of the former. She had enormous debt, because her parents thought girls should get married rather than go to med school. The program allowed her to pay off her loans despite the lower salaries indigent primary care clinics pay.

    I was in one of the first research-oriented programs. My loans weren’t that bad, but getting rid of most of them early in my career allowed me, like my friend, not to have to worry so much about salary. Even better, my program gets in touch periodically to assess the kind of work that I’m doing. I feel very strongly that programs like this should have that kind of monitoring built in, to see if they’re effective.

    I fear we may be getting into a situation where similar interventions may be necessary to make sure there’s adequate access to trauma care, mental health service, and other fields outside of primary care.

    I should also mention, for the sake of completeness, that the feds also offer what I like to call loan avoidance, specifically military scholarships I know some folks who paid for med school that way.

  42. 42
    amygdala says:

    @Miss Bianca: You don’t necessarily have to have a second BA, “just” the pre-reqs, which, admittedly, can feel like a second BA. I always like to point out that one of my med school classmates was in his early 30s when he graduated, which means he was pushing 40 when he finished his neurosurgery residency and another was 40 when we graduated med school. Howard Dean was a nontraditional student, too.

    Having said that, it is a lot of years. Pretty much all of my late teens to early 30s remain a bit of a blur.

  43. 43
    amygdala says:

    @Capri: Derm is popular because it’s lucrative without the long hours of other many other highly remunerative specialties, such as neurosurgery or cardiothoracic surgery. Ophtho residencies are also highly competitive for similar reasons. Although eye emergencies are more common than dermatologic emergencies, so the eye docs do get called in nights and weekends.

    (edited to correct a spelling error, which I seem to doing a lot today… apologies)

  44. 44
    martian says:

    @amygdala: “I fear we may be getting into a situation where similar interventions may be necessary to make sure there’s adequate access to trauma care, mental health service, and other fields outside of primary care.”

    Would that be so terrible, having some broader program to defray the costs of a medical education? Issues of personal cost and benefit seem to be shaping who is drawn into what fields or even studying medicine at all in some profoundly negative ways. It was a major reason she chose them, and I assume very worth it to them.

    In my cousin’s case, I don’t think it was a federal program that paid off her loans. I’m pretty sure it was the practice that hired her.

  45. 45
    martian says:

    Blah, editing.
    In my cousin’s case, I don’t think it was a federal program that paid off her loans. I’m pretty sure it was the practice that hired her. It was a major reason she chose them, and I assume very worth it to them.

  46. 46

    @amygdala: I need to steal that line of 100 premeds and Lord of the flies

  47. 47
    StellaB says:

    My class in medical school had 15% older students (>30) too. We mostly went into primary care. Older students returning to school is less common in Europe and not necessarily a bad thing. The European model only shaves a year off the training anyway except for some of the internal medicine subspecialties.

    I did taxes for AARP today. The last lady whose taxes I did had an AGI of $10000, dental expenses of $9000, and no insurance (in California). “Somebody told me I didn’t qualify.” You can lead a horse to water….

  48. 48
    amygdala says:

    @martian: Except for making educating and training docs even more expensive, I don’t have a problem with trying to shape the work force to meet population needs. Medicine is only just starting to consider cost as a priority for research; I wish the same were true for medical education. If anything, the increasing touchy-feeliness of med school curricula only makes it more expensive.

    I fear what’ll happen if we don’t have repayment programs, specifically that someone with a survivable head injury won’t pull through because there’s no neurosurgeon or more deaths by suicide because people in acute crisis can’t get timely mental health help. Your cousin’s situation sounds like a bonus program, which practices and hospitals in smaller (usually) communities sometimes use to attract docs. Whatever it takes to get them where they’re needed.

    No judging on my part regarding edits, since I’ve been making typing and other errors all over this thread.

    @Richard Mayhew: Use the line at will, with my compliments (and no requirements whatsoever for citation).

  49. 49
    rikyrah says:

    @Mike J:
    ICAM about the comments. Like so many others, when I say that I have learned more about Obamacare from you than any other source on the internet, I mean it. I don’t even know how Cole found you, but I consider it our good fortune that he did. I am scared of the day that a bigger blog will steal you away 😢.

  50. 50
    Curt says:

    The ACA subsidy formula right now is tied solely to the actuarial value of a plan. Subsidies are based on the second least expensive Silver plan for an individual in a market region before Cost Sharing Reduction subsidies are applied to boost actuarial value. The government pays a fraction of the cost of what it takes to get a person a 70% policy.

    Richard, have you posted here, or could you link to, an explainer about why it was set up this way? I’ve never understood it. All I know is, the plans I can afford are getting worse, the premiums keep going up anyway, and my subsidies aren’t keeping pace to cover those increases. In fact, because I made a little more than expected last year, I now have to repay some of those subsidies in my taxes. Thanks Obama!

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    @rikyrah: I am happy here and not looking to move. I knew a frontpager in meat space and had been a lurker here since 2005. In the summer of 2013 I saw a lot of questions and asked if I could write.

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    But, issues have picked up enough for me to
    assume itt is likely to be a good suggestion to stadt working on my e-mail advertising plan.

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