Thursday Evening Open Thread: Tim’s Right About Medicare

From the article:

… “We say to our Republicans that want to privatize Medicare, go try it, make our day,” said Senator Chuck Schumer of New York, the incoming Democratic leader, mustering his best Clint Eastwood/Ronald Reagan impersonation.

Since 1995 — when the newly installed speaker, Newt Gingrich, famously proposed $270 billion in cuts to Medicare and declared the program would “wither on the vine” because of the appeal of Republican-crafted free-market options — Democrats have seen the exceedingly popular but financially strained program as a winning wedge issue…

Now Democrats intend to capitalize on it again, beginning with their approach to the nomination of Representative Tom Price, Republican of Georgia, to lead the Department of Health and Human Services.

Mr. Price is not only a leading proponent of repealing the Obama-era health care law, but he has embraced Republican efforts to move future Medicare users into private insurance programs and raise the eligibility age. He told reporters shortly after the Nov. 8 election that he anticipated Republicans would embark on a substantial Medicare overhaul within the first six to eight months of Donald J. Trump’s presidency.

Senate Democrats intend to press Mr. Price on this subject during his confirmation hearings. They see a wide opening for political gain, given the 57 million older Americans who rely on Medicare — including many white Midwesterners with financial worries who voted for Mr. Trump.

“Good luck to selling that to the voters in Indiana and Ohio that were Democrats and voted for Trump this time,” Senator Sherrod Brown, Democrat of Ohio, said about a Medicare revamp. “They’re going to be fleeing quickly, right?”

A Medicare fight is also a potential political lifeline for Democrats in red states who could be in very tough contests in 2018. Ten Senate Democrats face re-election in states carried by Mr. Trump. One of them, Joe Donnelly of Indiana, has already made it clear that he will brook no overhaul of Medicare and that he intends to vote against Mr. Price’s nomination to the health care agency…

Democrats also noted that Mr. Trump did not campaign on the idea of tinkering with Medicare or its companion entitlement program, Social Security. In fact, his statements about those two cornerstones of American retirement security were that he would not cut them. That difference raises the prospect of a clash with congressional Republicans — particularly House Republicans led by Speaker Paul D. Ryan — who have long pushed for Medicare changes and championed them in House budgets…

So, with a little luck & a lot of skill, we can protect Medicare, scare a bunch of venal Repubs, ding up a particularly bad cabinet member wannabe, drive a wedge between the upcoming President-with-an-asterisk and his GOP ‘partners’, and keep voters’ attention focused for the 2018 elections. Sounds worth some phone calls to me!
Apart from fighting the good fight, what’s on the agenda for the evening?

Not the bumper sticker but the core of the fight

Actuarial value and subsidy level is the core element of the coming fight on Medicare. The delivery mechanism through which that value is transferred is window dressing.

Andrew Sprung outlines what is at stake for Medicare:

what precisely is the Medicare guarantee?

At present, there’s a pretty specific answer: for 95% of seniors, the federal government will pay about 85% of the premiums for insurance that covers a bit more than 80% of the average user’s medical costs. That’s what traditional Medicare does right now, via Parts A, B and D, for those whose incomes are below $85,000 for a single person or $170,000 for a couple.

Put another way, the federal government pays a bit more than two thirds of the average senior’s total medical costs. Low income beneficiaries have all or part of their premiums and out-of-pocket costs paid by Medicaid, though a variety of programs. High income seniors pay higher shares of their premiums, with the percentage stepped up through several income brackets. …..

And here is he is on the ACA:

For 8.8 million current enrollees in the ACA marketplace (as of June 31 30), subsidies cover an average of 73% of the premium for plans with a weighted average actuarial value of 80% (surprise!– thanks to Cost Sharing Reduction (CSR) subsidies, the average AV of plans sold in the marketplace is really that high). On average, then, the ACA marketplace covers about 58% of enrollees’ costs — though that average is very uneven, ranging from over 90% for the lowest-income enrollees to close to zero for the barely subsidy-eligible (and zero for the subsidy-ineligible)*. For another 12 million people whom the ACA rendered eligible for Medicaid, federal and state government cover close to 100% of costs….

Under the charitable assumptions that a typical EPFA(HR2300) subsidy would cover 59% of the premium for a plan with a 60% actuarial value, the premium subsidy would cover 35% of the average enrollee’s medical costs — regardless of whether her income were $17,000 or $17 million.

That is the the essence of the upcoming healthcare fights. Everything else is window dressing or mechanics to shift blame for large benefit cuts.

Network information

Loren is a healthcare wonk. He knows this shit cold and he is right, no one in their right mind would think to call the in-network hospital to see if the anesthesiologist would be in-network if a laboring mother to be needed/wanted an epidural.

As other wonks in the tweet stream noted, the best that he could hope for is the hospital to give him a non-binding informational advisory that their anesthesiologists were or were not in network. And even here, the information is incomplete. Many carriers will offer a number of different networks in the employer and individual markets. Some carriers will tell providers that they are in seven of the twelve networks offered. In those cases, the office manager or the billing clerk might be able to tell an interested patient who is trying to effectively shop for planned care whether or not Dr. Smith is in-network for them. Here the system may not be working but it is not flailing around completely in a fireball of fail.

However not all carriers will do this. Instead they’ll send Dr. Smith seven contract amendments for the seven current networks that they want Dr. Smith in. They will never send him the other five narrow network amendments to sign or reject. So when a patient is trying to conform to the system that we impose on them, the billing manager will honestly say “Yep, we take all plans from Mayhew Insurance….” and three months later as the claim is submitted and everyone expects an in-network charge, the patient gets whacked with an out of network bill.

Our provider information systems are designed to fail in a Kafka-Goldberg-Dilbert menage a trois.

Wednesday Morning Open Thread: Self-Care and Self-Defending


(Matt Davies via

In NYMag, Kat Kinsman has “A Post-Election Action Plan for Anxious People”:

The worst happened. More will happen. All the magical thinking and proactive worrying in the world didn’t prevent the outcome of this election, and letting it attack me from the inside is not a viable solution, not if I want to spend the next few years anywhere other than under my increasingly pilling comforter. So I’ve come up with a coping plan. Maybe it’ll help you, too.

Set a stretch alarm. When I’m in a panic spiral, I’ll find myself in sharp, shocking pain, then realize I’ve been gnarled up in startle position for several hours. Before the election, it got so bad that I set a reminder on my calendar to stand up and breathe deeply a few times a day. It’s painfully easy to forget to do, and the simple (and totally free!) act of drawing in breath can knock me out of a terrible thought loop and help me move forward with purpose.

See friends in person whether you feel up to it or not…
Also, don’t see people you don’t want to…
Step away from the internet…
Get some sleep…
Take meds if you need them…

Pick one cause. You cannot go on every single protest march, make every call, sign every petition, sway every politician. Commit to selecting one cause and making it your big mission, or finding one little thing to do every day. A letter or phone call to a legislator, an hour volunteering, a couple of bucks to a cause, or a check-in on a friend living in a place where they may not feel safe. It might feel small. It will keep you sane.

Read the whole thing, it’s not very long, and Kinsman’s reasoning seems very sound.
Speaking of taking one step at a time: Longtime commentor Jenn suggested we initiate a Friday Progress Open Thread, which seems timely (and doable, for me). Got suggestions as to where each of us individually can make a difference? Want to brag a little on your own progress? Leave a comment here (or email me at annelaurie dot verizon dot net) and I’ll set up the first POT this Friday.

One suggestion, right now: It’s not too late to donate to Foster Campbell, the Democrat in Louisana’s December 10th runoff election.

Apart from all that, what’s on the agenda for the new day?

Recission and the bad old days

Sabrina Corlette is going through all of the conditions that used to be cause for an insurer to either never write a policy or to go back through medical records and rescind a policy once someone got expensive:


An insurer only needs to find a diagnosis once in the medical records to attempt to rescind in the pre-ACA days.  Even if that diagnosis was wrong, if it was in the records and the current set of claims was expensive enough, an insurer could fight for years to throw a person off of coverage.   Gout leaped out at me as it triggered a memory.

About four years ago, I was refereeing an adult soccer tournament.  I like this tournament as I get to see and work with a bunch of really good referees for some pretty good games and we have fun.  I showed up to the fields on  Friday afternoon, did two evening games and then went out with the crew for burgers and a few beers.  The burger was amazing.  Half a pound of beef with some blue cheese crumbles and a couple of local IPA’s.  It is one of the better burgers I’ve had.

Saturday was a full day on the field.  I ran six games, four on the line and two in the middle.  It was hot, it was humid and as the fields got used, the surface got worse.  After the last game, we again went out for a burger, a beer and some no-shit story telling.

Sunday morning I only had two games before I could go home.  First game went fine, Over-23 women who were still in good enough shape to play a full ninety.  I had the middle and in the 87th minute, my left foot tweaked a bit on a divot in the field.  No big deal, I stretched it out at the end of the game and got ready to go to my pre-game for the line I had to run.  This was a men’s open game with mostly former PDL players so it was an up and down game with a well disciplined defensive line that had no problem running a thirty yard sprint trap (bastards).  My left foot was not feeling great.  And then it failed.  I attempted to stop an upfield run, plant hard and change direction to a full sprint to the goal line.  My foot folded in on itself and it hurt like a bastard with eight minutes left.

Thankfully the game was out of reach (3-0).  I hobbled for the rest of the game and then hopped to the referee tent.  A friend of mine is an athletic trainer.  She looked at my foot and said it was either a break or an arch sprain.  I should get an x-ray.  I got into my flip flops and drove the the local urgent care center.

At the urgent care center, I said my left foot near the big toe was in extreme pain.  The clinician asked if I had any red meat or alcohol this week.  Yes, I had two burgers and three beers since Friday night.  “Mr Mayhew, you have gout”  This was within the first two minutes of the examination.  I protested, explained that it was a sports injury and an atheletic trainer thought the problem was either a sprain or a break in the metatarsal.  “Mr. Mayhew, you have gout, here is your scrip and you don’t need an x-ray”

Bull — I made an appointment with my PCP for Monday morning.  He looked at my foot, ordered an X-ray and determined it was a nasty sprain where 6 weeks of PT would be needed.  He saw in my electronic health record that I had not filled the scrip for the gout medication and saw the diagnosis for gout.  He thought it was absurd and ordered a uric acid blood test for me.  I got the results the next day and mine were low-normal.

I had a structural skeletal injury not gout.  The mis-diagnosis did not effect my treatment or recovery.  It did not effect my eligibility for coverage as I am covered through work.  However if I was to go on the pre-ACA underwritten individual insurance market and I ran up $100,000 in claims, that gout diagnosis would be a probable hook for a pre-ACA insurer to rescind my coverage.  I would probably win eventually but I would be fighting for a year or more and running up large legal expenses for a bad diagnosis.

Get mad you sons of bitches

It looks like one of the big stories on election night was low turn-out. Maybe that’s not surprising given that both candidates had low favorability ratings. I’m not sure it’s worth arguing about who’s to blame for this, whether it’s the special snowflake Bernie bro voters or the uninspiring neoliberal shill campaign. (Some of it may be voter suppression but the drop is too big to be explained by that alone.) The bottom line is that it happened, and that we don’t want it to happen again.

So anti-Trump protests, fuck yeah!

Tens of thousands filled the streets in at least 25 US cities overnight — with demonstrations outside Trump’s properties across the country.

Let’s keep the anger and intensity at 11 for four years. The best thing that happened to the Democratic party in my lifetime was the last four years of the Bush administration.

And let’s keep pushing the media to do their fucking jobs. We can’t let them roll over the way they did for W from 2001 to 2004:

I deeply hope that journalists won’t normalize Trump’s behavior, as we started to see in the “Well, I guess Americans just wanted change” narrative on cable news networks as the states started to pile up for him. In fact, as it turned out, his followers wanted to throw the entire government and its values onto the bonfire.

I hope, too, that owners of news organizations are willing to finance court battles, because that seems very likely to be necessary in the months and years ahead. Trump is nothing if not litigious.


If January 2017 isn’t going to herald disaster for press rights — and the citizens served by a free and independent press — we’re going to need some help. We’re going to need some heroes.

Open Thread: Bill Explains It

Y’know, Bill’s the one with the raw political talent (aka ‘charisma’), but I can see that he might actually think the woman he’s loved so long is not only smarter than he is, but liable to end up in the history books as the better President, too.