Third Party Out of Pocket assistance

The Pittsburgh Post Gazette has a nice deep dive into the financial implications of the ACA for hospitals. As expected, more people with insurance means less bad debt and less charity care.

One of the promises made by the Affordable Care Act appears to be coming true: U.S. hospitals spent less on charity care for uninsured and underinsured patients in 2014, the first year of the health care law’s implementation.

The drop in charity care — as well as a stabilization of bad debt expenses — was revealed after the Post-Gazette analyzed federal data from the Centers for Medicare and Medicaid Services, which has been collecting data from about 5,000 general acute care hospitals since 2011 as part of the ACA law.

The Post-Gazette analyzed data on charity care and bad debt for the 4,509 hospitals that reported data all four years. For those hospitals, charity care dropped 13 percent, from 1.81 percent of net patient revenue in 2013 to 1.59 percent in 2014.

They also found that Medicaid expansion was a big driver of the decline as states that expanded Medicaid eligibility saw significantly greater declines in bad debt and charity care. If that holds up, then we should continue declines from 2015 and 2016 as more states expanded Medicaid.

More interesting to me was a discussion about how hospitals, especially non-profits, will use the freed up charity care funds.

Though the tradition has been that people with insurance — even inadequate insurance — would not qualify for hospital charity care, some hospitals are already covering deductibles and co-pays under their charity care policies. For some hospitals that was necessitated by some of the ACA marketplace insurance policies with deductibles as high as $5,000.

Low actuarial value coverage is a problem. But I am not sure where charity care from hospitals comes into play with this equation and what the policy implicatiosn are. I want to walk through two examples of how insurers would react to hospitals paying an individual’s deductible as their reactions differ.

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Tuesday Morning Open Thread: YES SHE DID!

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Late Night/Early Morning Open Thread: All You Can Eat Buffet

Thanks to commenter JCJ for the recommendation, here’s the Brook’s Falls live feed bear cam from Katmai National Park in Alaska. So tune in and watch the grizzlies eat all the salmon they can eat!

Now I’m Back And Not Ashamed To Cry

This was amazing. Accept no substitutes.

(ETA: click back to the beginning to see her whole speech if you missed it).

I was in tears…so very proud to say this woman is the First Lady of the United States of America.

It looks like we could use a fresh DNC thread. Last one looks like comment overload. Carry on…Elizabeth is speaking now.

Open Thread: Goddess Bless the Guardian

They’ve pinned the YouTube livestream. From their liveblog:

Franken says that work by people to register voters in Minnesota is “the reason I am giving this speech here and not into my bathroom mirror.”

He continues:

This week is about passion. Starting Friday morning, it’s all about work. Hard work.

Many of you have jobs. Many of you have families. Ignore them.

Let me tell you something. Kids love it when their parents aren’t home. They love it!

An eight-year-old kid knows how to use a microwave oven. And let me tell you something else. And 8-year-old kid can teach a 4-year-old kid how to use a microwave oven.

It’s a chucklefest…

Right this minute, proud Bernie supporter Sarah Silverman is making a strong pitch for Hillary. I’m hearing lots of cheers, not many boos. (Could just be my ears/speakers.) Hill-a-ry! Hill-a-ry!

Next up: Paul Simon…

Open Thread: Donald Trump’s Foreign Affaires

From the article:

Just weeks after she started preparing opposition research files on Donald Trump’s campaign chairman Paul Manafort last spring, Democratic National Committee consultant Alexandra Chalupa got an alarming message when she logged into her personal Yahoo email account.

“Important action required,” read a pop-up box from a Yahoo security team that is informally known as “the Paranoids.” “We strongly suspect that your account has been the target of state-sponsored actors.”

Chalupa — who had been drafting memos and writing emails about Manafort’s connection to pro-Russian political leaders in Ukraine — quickly alerted top DNC officials. “Since I started digging into Manafort, these messages have been a daily oc­­­­currence on my Yahoo account despite changing my p­­a­ssword often,” she wrote in a May 3 email to Luis Miranda, the DNC’s communications director, which included an attached screengrab of the image of the Yahoo security warning.

“I was freaked out,” Chalupa, who serves as director of “ethnic engagement” for the DNC, told Yahoo News in an interview, noting that she had been in close touch with sources in Kiev, Ukraine, including a number of investigative journalists, who had been providing her with information about Manafort’s political and business dealings in that country and Russia…

Republican party’s first semi-official 2020 presidential candidate ‘Freedom Coalition’ leader asked about credible reports that Trump is being spoon-fed disinformation by Putin, says, ‘Yeah, but wait’ll he finds out what a nasty fella Vlad really is.’

Can you imagine the non-stop BREAKING chyrons if anyone who had so much as taken a selfie with Hillary Clinton said something like this to a reporter?
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A Whiter Shade of Fail

These sweet dears:

The day started early for a group of about 100 people who gathered outside City Hall to rally on behalf of the Equality Coalition, many carrying placards supporting Sanders or slamming the Democratic National Committee.

Cory James, 22, of Flint, Mich., said that while he hadn’t yet given up hope that Sanders could pull a convention “surprise,” he said he could never vote for presumptive nominee Hillary Clinton.

“The Democratic Party doesn’t represent me anymore,” James said. “It represents corporate interests, that’s all.”

Joel Bradshaw, 39, bused down from New York on Friday carrying his “Bernie flag,” anxious to lend his voice to the downtown demonstration.

“If Hillary wants to be queen, we’ll bring the guillotine,” he said.

Bradshaw said he was not advocating violence, only a “loud voice.”

Almost as soon as the Equality Coalition left City Hall on its long march down Broad Street, another large group took its place.

A mix of Sanders supporters, opponents of the U.S. drug war and anti-media activists, the crowd joined in a thunderous chant of “Feel the Bern!” At one point their voices drowned out traffic cop whistles and car horns along the busy traffic circle.

It’s like a less organized Phish concert.

Monday Evening Open Thread: Meanwhile, From the Real Enemy of Our Democracy…

Because not being in the media spotlight for even one day makes the Combover Caligula break out in the cold sweats, like any other junkie. Just imagine how happy Paul Ryan and Reince Preibus must be about Trump threatening to use this information to punish all his enemies! It’ll make finding a viable candidate so much easier in 2020…

Apart from all the poo-flinging monkeys, what’s on the agenda for the evening?

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Democratic National Convention Livestream

Report so far: Some people are being dicks; others aren’t. Open thread!

Bernie Heckled by His Own Delegates

Well, as you’ve probably heard, this happened earlier today:

My first thought was something along the lines of sowing and reaping — if you sit back and bask in your supporters’ adulation for you and antipathy toward your opponent for long enough, if you indulge fantasies that can’t come true, it’s not possible to flip the crowd’s sentiments like a switch, and they may not believe you when you tell them that we don’t, in fact, live in that fantasy world.

So far, at least, hate is trumping the ever-loving fuck outta love at the convention. But Sanders gets some sympathy from an unexpected source:

I don’t take much comfort from the fact that the 1992 convention featured Jerry Brown boo-birds and that Bill Clinton went on to win anyway. Am I wrong in thinking today’s media is an order of magnitude worse than it was back then? That they’ll use the discord to mainstream the Republican freak show in a way they wouldn’t have attempted 25 years ago?

But Giordano knows a lot more about that topic than I do, so maybe he’s right. I hope so. Anyhoo, should be interesting!

Gone, Baby, Gone

The DWS shit-show was getting pretty pathetic:

Democratic National Committee (DNC) Chairwoman Debbie Wasserman Schultz was repeatedly interrupted and booed Monday as she sought to speak to Florida’s convention delegation.

The Florida lawmaker, who will resign after the Democratic National Convention this week after leaked emails showed top members of the DNC working to boost Hillary Clinton‘s presidential primary bid, had to strain her voice to yell over the flurry of protestors who showed up to interrupt her speech.

“We need to make sure we move together in a unified way,” she said over shouts from the crowd.

As she spoke, people stood on chairs holding up signs that said “emails,” “No!” and “Thanks for the ‘help,’ Debbie.”

Others repeatedly shouted: “Shame.”


The Florida congresswoman was defiant, insisting delegates would see more of her.

“You will see me every day between now and Nov. 8 on the campaign trail, and we will lock arms and we will not stand down,” she said.
CLEVELAND, Ohio – Presumptive Democratic nominee Hillary Clinton named U.S. Rep. Marcia L. Fudge as the Permanent Chair of the 2016 Democratic National Convention in Philadelphia this week.
Democratic National Committee Chairwoman Debbie Wasserman Schultz will not be speaking or presiding over this week’s convention at all…
Jesus, what does it take for this tone-deaf fool to take a hint?  Anyone with an ounce of political skill would have seen the writing on the wall and stepped down, but not DWS.

Fuck Everyone and Everything

I am so sick and tired of dealing with everyone’s fucking feelings and this bullshit about being cheated. Not only was Bernie not cheated out of the nomination, it’s all so besides the fucking point. Despite the sporadic few states in which Russia’s favorite fauxgressive Jill Stein and the glibertarian shitshow are on the ballot, this election is a binary construct if you intend to vote.

You vote for Trump or you vote for Clinton. That’s it. Those are the choices. And if you choose not to vote for either or vote for Trump, you are responsible if Trump wins. It’s not on Hillary- she’s making her pitch. The voters decide, and to quote some lyrics, “if you choose not to decide you still have made a choice.”

I don’t understand why people don’t get that elections aren’t about your feels. You look at which candidate is more likely to do things you like and which one is more likely to create World War III, and depending on your level of psychoticism, you choose accordingly. Your feels may impact how involved you get or if you donate or if you are enthusiastic about voting or if you go out and work to elect a candidate, but your feels shouldn’t be shaping your decision.

I was super excited about Obama in 2008. In 2016, I looked at both of the Dems, and said I would support either. I later leaned Clinton because I decided that while I liked what Bernie was shouting about, shouting about shit doesn’t get things done. But either way, I was going to support the Democrat, because the Republican ticket was, no matter who they nominated, would be a Death Star of Suck and we are all Alderaanians now.

TL;DR: Vote for the Democrat or you are to blame for the disaster. Also, FUCK YOU.

Monday Mid-Day Open Thread

Did you see the movie “Boyhood,” starring Ethan Hawke and one of the lesser Arquettes, among others? I thought it was just okay. But there was one piece of dialogue in it that I really loved and haven’t forgotten — it was centered around the boy (Mason) asking his dad about magic:

Mason: Dad, there’s no real magic in the world, right?

Dad: What do you mean?

Mason: You know, like elves and stuff. People just made that up.

Dad: Oh, I don’t know. I mean, what makes you think that elves are any more magical than something like a whale? You know what I mean? What if I told you a story about how underneath the ocean, there was this giant sea mammal that used sonar and sang songs and it was so big that its heart was the size of a car and you could crawl through the arteries? I mean, you’d think that was pretty magical, right?

Well, here’s another real thing that’s magical — Honduran white bats:

honduran white bats

They have white fur, pointy lemon-colored ears and noses, and they live in tents they fashion out of living plants. How cool is that?

Open thread!

Market Segmentation for providers

As part of a very interesting discussion on the underlying ethics of the American health insurance direction, there was an interesting set of tweets that I want to explore some more here:

From a provider point of view, the fragmented payer market is an excellent opportunity for providers to segment the market. I was speaking with a friend of mine whose a neurologist and she said that her office manager routinely juggles a dozen different insurers. She did not pay attention to what the individual insurers paid per product, she just saw the patients who her scheduler put on her schedule.

Below is a hypothetical pricing chart by insurer and product line that a typical doctor could see in the course of day. The numbers are hypothetical but close enough.

Provider Pricing matrix

Yes, this is confusing as hell for the patient as they have no idea what they are getting. It is confusing as hell for the doctor’s back office. It is confusing as hell for the insurance company.

It is also an attempt to segment the market. We talked about provider account receivable preferences before where docs want to fill their schedule first with high paying, no questions asked commercially covered people, then Medicare as they pay fast, then Exchange plans, then CHIP and then finally Medicaid. That was a general statement. Providers or their schedulers will often give the marginal appointment slot to one or two particular commercial payers instead of any and all commercial payers.

The more segmented the market the theoretically ‘efficient’ it is but all of these pricing decisions are amazingly non-transparent so I have no idea how to math out an efficiency argument here.

Monday Morning Open Thread

samwise possessed by spirits major x4

Samwise, via commentor Major Major Major Major, expresses how we all feel right now…

Gail Collins, who’s been covering Clinton for some time, in the NYTimes:

When Clinton is nominated for president later this week in Philadelphia, we’ll be talking about her as the first woman to get a crack at running the country. But she’d also be one of the most famous people ever to get the honor. In America, she’s been part of the backdrop of our lives for nearly a quarter of a century. We’re watching a very familiar face making a brand-new mark on history.

In 2000, when she first ran for the Senate, the fact that New York had never sent a woman to the Senate was an afterthought, given all the other stuff there was to consider. “It was the first time I’d been a candidate and the first time I’d lived in New York,” she recalled in a phone interview. The very idea of that race was incredible — maybe outrageous. And it didn’t begin well. She had trouble with the carpetbagging issue…

Then she turned everything around. Went on an endless “listening tour” of such anti-glamorous, earnest wonkiness that reporters who trailed after her from town to town began to develop nervous tics and drinking issues. But it was the perfect strategy. By the end, she had worn down her aura of outsiderdom. And she seemed to be enjoying herself. While all politicians at her level have stupendously sturdy egos, Clinton does appear to get a certain relief being in venues where the focus is on somebody else.

The thing I remember most about those trips from Oneonta to Cooperstown to Horseheads — besides the tedium — was the intense reaction she got from middle-aged women, who yelled and waved and begged for autographs. They were the ones who remembered what it was like when the newspapers had separate “help wanted” columns for men and women, who needed a male co-signer when they got their first car loans. I suspected that a lot of them, like me, still had credit cards in their husbands’ names because that was just the way things worked when they first began to charge stuff at Macy’s or use American Express.

And there was something else. Hillary Clinton represented the possibility of a second act. The country was full of women who had come of age with the women’s revolution, who had tried to have it all, raising children while having good — but maybe not spectacular — careers. Now there was the about-to-retire first lady, in her new persona, suggesting they might be able to start a whole new episode in life. Driving around through upstate New York, Clinton was in the home territory of Susan B. Anthony and Elizabeth Cady Stanton, who had broken the old rules about staying home, rearing the kids and then retiring to a rocking chair…

… Young women are not universally crazy about the first-woman thing. Some just see her as an imperfect candidate. For others, it’s because the whole gender thing seems like yesterday’s news. “There aren’t as many overt questions about ‘Can a woman do it? Is it something the country is ready for?’ ” Clinton acknowledged.

That’s probably true, and if it is, she deserves a lot of the credit. You can argue the pros and cons of Hillary Clinton’s character, or her potential to change the nation, or her position on trade policy. But you can never take away the fact that she was the one who made the idea of a woman becoming president so normal that many young women are bored by it…

Whatever her defects, she is a candidate with a very long and event-filled history of toughing things out, who finds solace in stupendously hard work and in doing her homework. She’s one of the best-known people on the planet, but she can happily spend a day listening to complaints about watershed pollution or flying halfway around the world to sit through a conference on sustainable development.

When she was still secretary of state, I asked Clinton about another presidential campaign and she waved the idea aside. Her future plans, she said, involved sleeping and exercising and traveling for fun. “It sounds so ordinary, but I haven’t done it for 20 years. I would like to see whether I can get untired,” she said.

She may never find out.