The ObamaCare Insurance Exchanges: Not Quite Ready for Prime Time

Drum roll please – And with all the drama and thrill of a Fourth of July firework dud, the ObamaCare insurance exchanges officially opened on October 1.

Despite three and a half years of preparation, launches of the much-awaited “healthcare insurance marketplaces” were almost universally fraught with problems.  Multiple states reported near-immediate crashes of their online sites. Visitors to others witnessed a stunning array of error messages, prolonged delays and an inability to complete the forms necessary to register, let alone choose a healthcare plan.

Concerns about privacy, non-encrypted personal data, and poorly trained and minimally screened system “navigators” added to rampant consumer frustration.

All the hype leading up to the October 1^st launch -- followed by a floundering debut -- has resulted in a predictable and rapid loss of interest from the public.  Like attendees at a fireworks grand finale that fails to ignite, consumers quickly become distracted.  They pack up their blankets and folding chairs, and head back to the car.

Recall that the exchanges were designed to function as a sort of “marketplace” for consumers, and to be the gateway to health insurance for people who don't have access to coverage through their employers.  The exchanges are critical because the requirement for everyone to have healthcare insurance – the so-called “individual mandate” – is the sine qua non of the reform legislation.

Many states opted not to embark on the onerous task of creating the online exchanges themselves, deferring instead to the federal government to tackle that challenge.

Unfortunately, the government’s own site performed no better than those in the various states that attempted to build and manage their own. One of the most troubling “glitches” was that many consumers who managed to navigate the initial on-line registration were ultimately “timed out” because they took too long comparing and contrasting plans – One of the core advertised functions of the exchanges.

As a result of vast technology problems, the Obama administration shut down its site for an overhaul and repairs within days of the launch. A visit to the healthcare.gov site reveals that the enrollment functions will be “temporarily unavailable”.

Perhaps they would have been more inclined to delay raising the curtain on the new exchanges had Obama not granted waivers to all of Congress, their staffers, the unions and a host of his supporters.

Despite what many would describe as an abject failure, the Obama administration released a statement describing the October 1^st debut in remarkably favorable terms.

In testament to the administration’s brazenness in spinning a yarn, the release was titled, "Health Insurance Marketplace Open for Business - Week One Success."

According to the statement, "Americans are excited to look at their options for health coverage, with record demand in the first days of the marketplaces".  Consumers have until December 15th to enroll for coverage that they are required by law to have in place by January1, 2014.

Apparently, there’s nothing like the threat of an IRS investigation and a hefty fine to incite “excitement” in a shopping experience.

Unfortunately, the problem with the troubled launch of the exchanges extends far beyond the technicalities of getting people enrolled in healthcare insurance.  

Like it or not, John Q. Public doesn’t have the same “this-is-the-defining-legislation-of-my-tenure” enthusiasm about the Affordable Care Act as President Obama and his omnipotent band of do-gooders in Congress.  In fact, well more than 50% of Americans remain largely critical of the bill and would like to see it delayed, if not fully repealed. 

Furthermore, Americans – particularly the young and healthy whose enrollment is critical to the viability of ObamaCare – don’t have a tolerance for failed technology.  Generations X, Y and Z are fickle; what sounded like a great idea when they voted quickly loses its appeal when signing up requires effort and a time commitment. They have short attention spans and are easily distracted.  Getting them to return to the website after the problems have reportedly been fixed may prove more difficult than predicted, IRS threats not withstanding.

To complicate matters further, many consumers are now realizing that the government’s inability to create and run the on-line exchanges portends an ample threat to its ability to manage something as complex as healthcare.  It’s unlikely that consumers will trust an airline to fly a plane if that airline can’t mange to successfully sell a ticket for the flight.

The Affordable Care Act, lovingly known as ObamaCare, is wrong on just about every level. Ultimately, the bill reflects the arrogance of Liberals who perceive themselves as superior, feel compelled to tell Americans what they need, and then proceed to redefine that “need” as a “right”.  The entire premise is misguided at best, and frankly, with all due respect to Chief Justice Roberts, unconstitutional. 

The vast majority of Americans who already have health insurance are being hit hard with enormous rate increases, skyrocketing deductibles, and huge new taxes and fees as a result of the bill.

The roughly 40% of ObamaCare that is supposed to be funded by cuts in Medicare spending will have a profound impact on doctors and their patients. Access to care will be limited, quality will decrease, and personal choice and privacy will become figments of our past.

Eventually, with enough time and additional taxpayer money, the Obama administration will cobble the insurance exchanges into some semblance of function. Unfortunately, their lack luster debut is nothing more than a harbinger of things to come.

In the words of Congressman Eric Cantor (R-VA), "A dysfunctional website is the least of that law's problems."

Confessions of a Serial Profiler – Avoiding "Security Theater"

I admit it: I believe in profiling.  In fact, I have personally profiled people every single day of my professional life.

It turns out, profiling is a critical component of the practice of medicine.  Without it, a physician would be hard-pressed to make a quick and accurate diagnosis.

Profiling is what allows a physician to categorize a patient based on age, gender, race, and body habitus, as well as dozens of other characteristics.  It is what allows us to scan multiple gigabytes of memory within milliseconds, and to begin both considering and eliminating potential diagnoses.   We immediately assign various “labels” (yes, labels!  Just think of it!):  old/young, male/female, white/black, thin/fat, relaxed/distressed, and so on.  These characteristics, taken together, and considered along with the patient’s complaints and presentation, make a specific set of potential diagnoses most likely.  This is known as the “differential diagnosis”, and sets the course for further examination, testing and treatment.

Profiling is what keeps doctors from ordering pregnancy tests on elderly women and suspecting sickle cell disease in Caucasians.  It removes the concern about Tay-Sachs disease in people who aren’t of eastern European decent, and places gall bladder disease low of the list of concerns in thin, young white males.

This practice is not unique to medicine.  We profile every day, in every walk of life, every time we rely on past experiences to make an informed decision.

“Profiling”” is what results from understanding the statistical likelihood of an occurrence, incorporating salient history, and synthesizing the information to guide our further actions. Frankly, it’s what separates intelligent mammals from lower forms of life.

Why then, when it comes to the most serious threat to our national security – domestic terrorism – would we not want to profile?  Why in the world would we want to avoid calling statistical likelihood and past experience to bear?

Let us not confuse “profiling” with “prejudice”. Profiling is the use of personal characteristics or behavior patterns to make generalizations about an individual that are based on facts.  Prejudice, on the other hand, is a pre-conceived unfavorable opinion or hostile feeling formed beforehand, or without knowledge or reason.

But it’s not as if we don’t know who the likely perpetrators of terrorist acts are.  Repeat after me: “9-11, the Boston bombings, Ft. Hood shootings, and Benghazi massacre were heinous acts of terrorism, perpetrated by radical Muslim extremists.”

Yet in the days immediately following the identification of the two Chechen brothers responsible for the Boston Marathon bombings, President Obama warned us to “avoid jumping to conclusions”.

Eric Holder admonished us to refrain from the assessment that this was, in fact, an act of Islamic terrorism, reaffirming America’s firm commitment to tolerance of all religions

The administration displayed the same reticence to identify acts of terrorism employed by Islamic extremists in the case of the Ft. Hood shootings and the Times Square bomber. Although not on domestic soil, the murderous attack on our consulate in Benghazi is a further case in point.

The militant Islamist movement is alive and well in the United States. Without the fortitude to call it by its proper name and to employ profiling to identify those who would act on its behalf, we contribute significantly to our peril.

At the highest level of our government, there is a pervasive unwillingness to call jihadist efforts what they are.  This is exacerbated by a refusal to actively profile those individuals most likely to engage in terrorism fueled by radical Islamic ideology. As a result, we do not have security in this country; we have “Security Theater”.

To make matters worse, we are subjected to daily infringements on our personal liberties for benefit of this illusion of security.

Hundreds of thousands of times a day in airports across the nation, random American are compelled to discard unopened bottles of water and tubes of toothpaste that exceed the arbitrary 3 oz. size limit.

The system is ridiculously inefficient, results in thousands of lost hours for business travelers, and provides a level of stress and annoyance for pleasure travelers that have undoubtedly translated into a decrease in elective air travel.

While the TSA is busy patting down middle-aged blond women and freckled, redheaded toddlers, they are simultaneously ignoring clear and present security threats.  This isn’t just a stupid game; it’s a dangerous one.

Full body scanners and enhanced pat-downs aren’t making us safer. These are reactive measures devoid of common sense and mired in political correctness.

The Department of Homeland Security is applying “equal opportunity” constructs to the task of identifying potential terrorists.  This would be tantamount to a doctor doing a biopsy on all skin lesions and moles so as not to appear “prejudiced” or discriminatory against the ones that are actually cancerous!

Despite all of the intrusions into the lives of average Americans, Homeland Security has failed to secure the homeland. We have spent Billions of dollars and have ended up with front row seats at “Security Theater”.

Physicians do a patient no good by refusing to identify and call a disease by its proper name.  Diabetes, obesity and cancer become harder to treat if they are given some colloquial moniker in an attempt to make them sound somehow less ominous.

That said, not all breast tumors are malignant.  Physicians rely on a physical exam and diagnostic tests such as mammograms and ultra-sounds to determine which lesions require additional evaluation. There are well-known characteristics based on appearance, size, shape and location that increase the index of suspicion.  That’s why not all breast lumps are subjected to surgical excision. 

Similarly, there are tumors that are not malignant now, but have telltale characteristics that reflect a high risk of becoming cancerous over time.  Those lesions require careful scrutiny and ongoing surveillance.

Tamerlan Tsarnaev, the now dead mastermind of the recent Boston bombings was on the FBI watch-list for years.  He was deemed to be such a security concern that he was actually denied US citizenship.

The government of Saudi Arabia warned U.S. high-level officials at the Department of Homeland Security specifically about Tsarnaev’s Islamist militancy.

Likewise, the Ft Hood shooter, Nadal Hassan, demonstrated clear evidence of risk to become a radical Muslim zealot capable of enacting violence in the name of jihad. 

When physicians fail to profile, identify and act on lesions that are well known to be risks for cancer, it’s called “malpractice”.  What shall we call it when our government does the same?

Defunding ObamaCare: It’s Time to Walk the Walk

Perhaps it’s Stockholm Syndrome – The phenomenon where hostages begin to sympathize with the positions held by their demented and maniacal captors.  That could explain what would compel a conservative leader like John Boehner to abandon his previously held commitment to defunding ObamaCare. But explanation or not, it’s unacceptable.

Early in their tenures, a large number of freshman members of Congress pledged to defund ObamaCare.  They may have hoped that the Supreme Court would ultimately relieve them of their obligation to act by declaring the bill’s individual mandate unconstitutional. Or perhaps they were counting on the GOP regaining the White House and repealing the bill entirely. Regardless, 105 current House Republicans signed a letter last August committing to defund ObamaCare.

House Speaker Boehner, however, recently brought forth and passed a Continuing Resolution (“CR”) that funded the federal government – including ObamaCare -- for the rest of the fiscal year. 

How did that happen? Republicans control the U.S. House of Representatives and therefore the government’s purse strings. They have the authority to write spending bills, yet apparently lack the courage to stand up for the very principles that got them elected.

Make no mistake: ObamaCare is the GOP’s Rubicon.  If we allow the motherload of new entitlements dictated by ObamaCare to go into effect, there will be no retrenching. 

Remember – Obama raided Medicare to the tune of $716 billion in order to pay for ObamaCare. 

Medicare is more than 50 years old.  The vast majority of Americans can’t remember a time when Medicare did not exist.  Immediate major cuts to the program will be both painful and unpopular.  Medicare must be reformed, but it will take time, as people make accommodations and rethink healthcare options for their elder years.

ObamaCare, on the other hand, represents a brand new set of entitlements to which people are not yet wedded.  There isn’t even one generation that has become dependent upon it. There’s still time; we can still unwind this one.

We were repeatedly assured that the ACA wouldn’t “add one dime to the deficit”. In a report requested by Senator Jeff Sessions, however, the Government Accountability Office estimates that in the long term, ObamaCare will actually add more than $6.2 trillion to the ever-widening crevasse (http://www.nationalreview.com/corner/341589/gao-report-obamacare-adds-62-trillion-long-term-deficit-andrew-stiles). That’s a whole lot of dimes added to our children’s tab.  Given the government’s historic under-estimations, the reality is likely to be much, much worse.

The country is mired in $16.6 trillion in national debt. Unemployment rates are already far too high, and even Douglas Elmendorf, Director of the CBO, admits that ObamaCare will reduce employment by more than 800,000 jobs (http://cnsnews.com/news/article/cbo-obamacare-will-kill-800000-jobs-over-decade). The new healthcare law is already driving up the cost of medical coverage for American families while at the same time limiting their access to care. All in all, ObamaCare is like offering the people on the Titanic an “upgraded cabin”.

House Republicans should have taken notes on Rand Paul’s recent 13-hour filibuster on the Senate floor in opposition to John Brennan’s nomination to head the CIA. Paul didn’t worry about being labeled an obstructionist; instead, he fought for his conservative principles. The same sort of impassioned pleas need to take place regarding ObamaCare.  Our elected officials have an obligation to defund or repeal it.

Now governors are in the position of having to make decisions about expanding Medicaid within their states.  Many are falling prey to the promise by the federal government to pay 100% of the cost of a targeted Medicaid expansion for the first two years.  Federal funding will then drop over time.

Our federal government is committing to pay for the states’ Medicaid expansion? The same federal government that can’t pay its bills? The government that borrows more than a third of every dollar it spends from the Chinese?

This has all the makings of an unmitigated disaster.  Like the rest of ObamaCare, it would be exceedingly difficult to dial back a Medicaid expansion after several years when the federal government no longer covers the costs. Once millions more people are enrolled in an entitlement program, history reveals that it is nearly impossible to contract.

Regardless of any hollow funding promises from the federal government, Medicaid expansion is clearly not the best way to stabilize a state’s healthcare system -- one that is already struggling to care for uninsured patients.

The Heritage Foundation predicts that states will incur huge increases in Medicaid costs as the federal contribution drops.  These costs are anticipated to far exceed any savings gained by covering previously uncompensated care.

According to a 2011 Congressional report, the ACA’s Medicaid expansion would cost states at least $118 billion over the next ten years. (http://www.fiercehealthcare.com/press-releases/joint-congressional-committee-report-details-new-health-laws-fiscal-burden-)

To make matters worse, Medicaid serves as a huge disincentive for the poor to find employment, because they disqualify for the program once they begin earning better incomes.

If that weren’t compelling enough, Medicaid has the worst health outcomes of any insurance program in the developed world.

Some form of subsidized private insurance would be a far better option than a Medicaid expansion. Private insurance routinely results in clinically superior outcomes.  It would also serve as an incentive for employment while stimulating the economy through privately generated income.

Any of these more credible and affordable solutions, however, will require the backbone of Republican leadership.

The GOP can make a come back -- But only if the politicians that we sent to Washington on our behalves are willing to stand up for time-tested conservative principles.  They need to muster up the courage, tenacity and profound commitment that brought this country into being. Defunding and dismantling ObamaCare would be a formidable first step.

If, on the other hand, our current leaders are truly suffering from Stockholm Syndrome, then the first step is for others to demonstrate that they need not succumb to the ideological subterfuge of their captors. Witness Rand Paul. One way or another, all syndromes eventually run their course.

Health Insurance Exchanges: Welcome to the Bread Line

With the dust from the November elections settled and the blur of the holidays behind us, Americans are finally starting to focus on the gritty details of the new healthcare law. 

Most people are at least vaguely aware that the core component of ObamaCare is the “individual mandate”: The requirement that every American have health insurance coverage by January of 2014. What is less understood, however, is the vehicle by which this mandate is proposed to occur – Namely, the state “healthcare insurance exchanges”. 

The very term “exchange” is confusing and a misnomer, as it wrongly implies some sort of swap meet or barter system which it is not.  In reality, the “exchanges” were conceived to be a sort of open marketplace where people can shop for, compare and choose a suitable insurance plan that best fits their individual or family healthcare needs. 

The exchanges, we were told, will be replete with a panoply of different options that will be pre-screened to assure that they meet the basic requirements set by the federal government. It all sounds like the platform for a delightful afternoon of window shopping amongst a multitude of different insurance plans, picking and choosing the one that you think will suit you and your loved ones best.  Lots of “shopping”, “comparing”, “choosing” and “options” will occur in the wonderful new world of health insurance exchanges.

The law calls for the exchanges to be up and running by October 1^st of this year. Apparently, the ringmasters in Washington believe that this will provide adequate time for people to educate themselves about their options, shop for, and purchase an appropriate plan prior to the mandate taking effect in 2014.

States were given the choice of setting up their own exchanges, partnering with the federal government to create an exchange, or deferring the entire thing to the federal government. 

It turns out that state governors took those 3 choices seriously – And the majority of them have said they want no part creating or running their state’s exchange. 

If a state decides to take on the task itself, the state is fully responsible for the set up and administration of the program. This includes the provision of adequate customer service, information technology systems for the coordination of healthcare data, and daily administration of the exchange.  Tens of thousands of helpers -- termed “navigators” -- will need to be hired to assist consumers who are likely to be overwhelmed by the exchanges and their myriad choices.   California alone plans to hire and train 21,000 new employees to act as navigators. These and other administrative costs will fall directly to the state if they opt to set up the exchange on their own.

Given the states’ complete lack of input in determining the requirements for the exchanges on the one hand -- and their obligation to enforce the rules and fund the entire implementation and administration on the other -- it is not a surprise that many would choose to opt out.

Furthermore, although there is initially some federal funding (read “tax dollars”) set aside to help states with expenses associated with the exchanges, full financial responsibility transfers to the states after a year.  In other words, states that assume responsibility for running their own exchanges must devise a source of revenue (read “tax dollars”) for running them by 2015. The federal government has been unable to provide any reasonable prediction regarding the cost to implement and operate the exchanges– A detail that makes fiscally responsible governors more than a tad uncomfortable. 

As conservatives predicted, the wildly unpopular healthcare reform bill is a huge unfunded tax liability, and that reality is becoming clearer by the minute. Faced now with the option of establishing exchanges in their states, the majority of governors have therefore chosen to take a pass.

Unfortunately, in what may be the most egregious insult of Obama’s administration, the Democrats force-fed us a massive healthcare reform plan that is entirely predicated on insurance “exchanges”, that they offered to -- but are neither prepared nor capable of --creating. 

As of this writing, 23 states have declared that they will not set up their own state-based exchanges, deferring to the federal government to do it; 19 will handle the task themselves; 6 have opted for a federal-state partnership; and 3 are still undecided. 

The federal government is therefore left with the daunting task of creating online insurance marketplaces for two-thirds of the country.

Apparently, it did not occur to authors of the bill that states might actually take the option to abdicate responsibility for the exchanges to the federal government. Since it is simply not conceivable that the government will be able to design and implement exchanges in as many as 32 states between now and October, we are left to wonder what portions of their grand plan we will be required to following until this is accomplished.

Even if the exchanges become an eventual reality in all states, great questions remain.

With the ability to “shop”, “compare” and “choose” from the advertised host of different “options”, what’s not to like about the exchanges?  For one, the price tag.

The cost of premiums for insurance purchased on the exchanges is expected to significantly exceed the cost of insurance prior to ObamaCare.

The Department of Health and Human Services has determined a generous, comprehensive list of health benefits that must be covered in order for a plan to be “qualified”. ObamaCare classifies four tiers of qualified insurance – Platinum, Gold, Silver and Bronze – which refer to the portion of healthcare costs that are covered under that plan.  Platinum plans will be designed to cover 90% of the actuarial value of HHS’s required “essential health benefits”, while Bronze plans will cover only 60%.

The IRS itself predicts that the cheapest health insurance plan available under ObamaCare in 2016 will cost a family of four $20,000 a year. The $20,000 per year price tag would be for a “Bronze” plan, the lowest level qualified option to avoid paying a penalty.

The extend to which one is eligible for federal subsidies to purchase one of these plans – and the amount of the penalty for failing to comply with the mandate – will be determined by one’s adjusted income reported to the IRS in 2013.

The penalty (determined by the Supreme Court to be a tax) for not having healthcare insurance, starts at $95 per person and increases to $695 per person or 2.5% of income, whichever is greater.  H&R Block estimates that an individual earning $50,000 in taxable income would pay a $400 fine for failure to have insurance, while a family of four with a household income of $100,000 would face an $800 penalty.  Much of the Affordable Care Act is being implemented through the tax code, and these fines would be deducted from any tax refunds that are due.

That dwindling but fortunate group who continue to get their healthcare insurance through their employers (and therefore not via the “exchanges”) are likely to see their salaries drop as employers have to pay more to provide a “qualified” plan for their workers.

And so it goes. The overwhelming structural flaws in the ill-conceived healthcare reform law are about to be revealed on a massive scale. A critical component of the healthcare law – the insurance exchanges – are shaping up to be the unmitigated disaster that could easily have been predicted. Given the massive impact that the Affordable Care Act will have on Americans and our economy, it is unconscionable that Congress did not anticipate and account for the likely unwillingness of states to create the exchanges upon which the rest of the bill is reliant.

Furthermore, even if the government is ultimately able to get the exchanges up and running, they will clearly saddle consumers with higher premiums and questionable choice. States will undoubtedly be obligated to significant increased costs and administrative nightmares.

Suddenly, “shopping” for healthcare insurance at one of the new “exchanges” begins to sound less like the idyllic marketplace experience that Nancy Pelosi has described.  It appears more akin to the Russians “shopping” for bread  -- If one can call standing in an endless line with the entirely uncertain promise of eventually obtaining a stale and overpriced crust, “shopping”.