September 18, 2013

Insurers limiting doctors, hospitals in health insurance market

Comment by Don McCanne of PNHP: These new data on use of narrow provider networks in state insurance exchanges, using Los Angeles County as an example, are important because they show us the extent to which this concept is being applied. Narrow provider networks reduce health care spending by limiting patient access to low cost providers - taking away choice - and by impairing access though supply-side contractions, that is, rationing care by limiting the supply of covered health care providers.

Another table accompanying the Los Angeles Times article (available at the link above) lists premiums for typical policies issued by these insurers for the benchmark silver plans. When comparing premiums with the numbers of physicians in the network, there are several interesting observations. Health Net, with the fewest number of physicians in their network, has the lowest premiums - no surprise. Blue Shield, California's nonprofit Blues plan, has premiums on the lower end though it has a much larger number of physicians than does for-profit Anthem Blue Cross, yet their premiums are similar. The nonprofit seems to be more concerned about patient access whereas the for-profit seems to be concerned more about profits. However, Anthem's EPO (exclusive provider organization) offers a larger choice in providers but extracts a much larger premium for that coverage. Comparing Anthem's two products, it looks like if you want an accessible doctor, you're going to have to pay for that right. Considering that Kaiser is a closed, integrated health system, it does have a fairly decent number of physicians, but it also has the highest premiums. It is likely that Kaiser's premiums are not high because of the number of physicians, but rather they are high to prevent destabilization of their business model by allowing too many new enrollees which might strain their capacity.

Health Net's silver plan premiums are set far enough below the others such that they will be very attractive for shoppers in the insurance exchange. The bronze plans have even lower premiums and will also be attractive. Most shoppers will be relatively healthy and will select their plans based on the premium - not on the physician networks nor on the out-of-pocket costs they would face if major health problems were to develop. Some of these people will become ill or suffer significant injuries. At that time they will discover that their choices of providers are too limited, that access may be impaired because the physicians are too busy or because they are too far away, and that the out-of-pocket expenses to which they are exposed will cause financial hardships.

Leave policy decisions to private insurers and they will always select policies that will advance their business models as opposed to policies that would provide optimal access, quality and affordability for patients. Having cheap premiums is no solution when you can't get a doctor when you need one, and, when you finally do, you're left broke.

Single payer would have avoided all of this, and it still can.

My comment: Underinsurance is why health care bankruptcies are STILL 50% of all bankruptcies sever years after reform.

September 11, 2013

9/11 "alternative" theories and "conspiracies"

The various HOP levels are

--our government is behind 9-11, that is to say MIHOP=Made It Happen On Purpose.
--LIHOP= Let It Happen On Purpose.
--The third option is incompetent negligence due to having other priorities like the missile defense shield boondoggle, cutting taxes for the rich and planning the invasion of Iraq.

Personally, I’m somewhere between negligence and LIHOP, and highly skeptical about the theories presupposing controlled demolition. The reason for this is mainly living in Seattle, witnessing the controlled demolition of the Kingdome, and reading all of the related stories about it at the time. Most of the people reasoning about controlled demolition on 9-11 are working from strictly theoretical calculations—channeling Rene Descartes. Actual professionals who do controlled demolitions channel Francis Bacon; they can’t afford to rely solely on theoretical calculations because they don’t want to die in the process of doing their work. They know they need to do some empirical testing. Several weeks before the final implosion, the demolition crew did an extensive series of test blasts. There is no such thing as a demolition crew that would agree to skip this step, period. No amount of money is worth being killed or maimed.

As the articles widely available in the press at the time explained, the crew could not assume that the plans they were given on the structure of the Kingdome were completely correct. Just because a designer specifies a certain grade of rebar or concrete doesn’t mean that the actual building contains exactly what is specified. Do contractors never pull substitutions because they had a stash of something similar to what was specified on hand? Never make a guess that some less critical areas might get by with concrete to which extra sand was added to save a bit of money? That’s why demolition experts do test blasts—to check their assumptions about material strength in various areas of the building to be demolished.

MIHOP requires far too many things that would have had to go exactly right concurrently. LIHOP explains how foreknowledge doesn’t necessarily require complete information about operational details. This is in fact what the interrogation of Zubaydah (before the torture) indicated.


http://www.time.com/time/magazine/article/0,9171,1101030908-480226,00.html



The fact that I don’t necessarily agree with everyone in the 9-11 truth movement certainly doesn’t mean that I agree with the official stance, which is to deride anyone who suspects that our government hasn’t told us the truth about what they know. To criticize “conspiracy theorists” is to blame the victim instead of taking on the perpetrators. There is a reason why people come up with conspiracy theories—they happen to be a normal and healthy response to the experience of being forbidden access to relevant information and being constantly lied to by the people who do.

The radical therapist Claude Steiner once said that paranoia is actually a heightened state of awareness, in which the paranoid put together narratives that make sense of the only information they have available. He gave an example of a woman he treated who believed that her husband was engaged in several elaborate plots on her life. What Steiner did was to interview the husband, who was disturbed by his wife's narrative. The husband was in fact thinking of having her permanently committed to the funny farm, but he always responded to his wife's questions about what was wrong between them by saying “Nothing, honey.”

That was the crux of the problem. The wife was in a heightened state of awareness and knew only that “Nothing, honey” was a pile of steaming bullshit. Not having access to real information about what was going on in her husband's head, she invented it. Steiner's ultimately successful therapy was simply to convince the husband to stop lying and withholding information. In this case, the husband did not exactly lead the examined life, and was unaware of the harm that social “white lies” can sometimes cause. Being genuinely concerned about his wife, he agreed to try to be more introspective and commit to being honest about his feelings. The wife agreed to acknowledge this effort, and to be more persistent about asking for information instead of automatically assuming the worst. Of course members of our imperial government have no such commitment to making it all better for the rest of us—see the classic Ingrid Berman/Charles Boyer movie Gaslight for a psychological take on their game.

The bottom line here is that it is a basic requirement of sanity to be able to make sense of one's information environment, to be able to put it into a coherent and meaningful picture, and if those people who know what is going on behind closed doors constantly lie to the public and withhold information, the inevitable result is that people will naturally want to fill in the blanks by any means possible. This process is analogous to the effects of sensory deprivation—float in one of those tanks long enough to deprive your brain of sensory input, and it will quickly start inventing some.

Current official explanations of 9-11 are like a picture puzzle with half the pieces missing. Many people have been taking magic markers and extrapolating from what is visible to fill in the missing spaces in an attempt to put together the entire picture. They are constantly ridiculed for this, and opinion makers who wish to be taken seriously always bog the discussion down in disputes about whether or not the colored-in parts really look like the original pieces. Some will be closer approximations than others, of course; a few may well be wildly off. But the really important issue (which remains for the most part unaddressed) is “What in bleeding hell gives our government the right to hide the pieces in the first place?”

Attacking people who are trying to make sense of their information environments with limited data is highly unethical, no matter how nutty their theories may sometimes sound. It's exactly like putting a rape victim on trial for her previous sexual history instead of going after the rapist. Theories may fall anywhere on a continuum from plausible to seriously off-base, just as women's prior sexual histories may vary from none to very experienced. By any objective analysis, some unofficial theories of what happened on 9/11 are prim virgins in high-collared white lace blouses, and some are prancing around in tight red spandex streetwalker outfits. But either way, it just plain should not matter—critics should focus on calling rapists, liars and secret-keepers to account rather than slandering their victims.

“Conspiracy theorists” are commonly dismissed as irrational or unscientific. It's true that scientific training helps people to cope with not having certain and final answers, and that only a minority of the population has such training. However, one important part of scientific training is learning to avoid speculating beyond the data, but this requirement of the scientific process depends critically on the assumption (which is almost always valid) that scientists will present all relevant data and methodology to their research community as accurately and as completely as they can. Since this condition is not currently met by our government (and most certainly not by the 9/11 Commission), it is outrageous to attack as “unscientific” people who express concern about a government that insists on keeping secrets from them, especially when those secrets threaten the foundation of our democracy. The attacks should be directed instead toward those who are keeping what should be publicly available information from them.

How long will the official arbiters of “reality” continue to defend the rapists, the liars, the secret-keepers who conceal information that in a real democracy ought to be made available to the public? If we could spend $40 million investigating a blow job, surely we could spend more than $15 million on finding out what really happened on the day of the worst attack on our soil. I hope that more people will join with those who are demanding honesty and transparency in the public sphere. The urge to be accepted as a real member of the elite class of reality creators, those who claim the right to lie and withhold information on the grounds that they alone are entitled to decide what the public should know, can be very tempting. Any person who gives in to this temptation badly fails our democratic republic. What is tyranny but a system in which rulers assert the right to know everything about their subjects while keeping their own operations strictly undercover?

September 10, 2013

Companies dumping retirees on defined benefit health plans to defined contribution.

Comment by Don McCanne of PNHP: We already knew that employers were canceling retiree coverage in their company-administered health plans and switching to defined contribution approaches which place the risk of future health care increases onto the backs of their retirees. What is new is the acceleration of this shift by large employers who are taking the easy way out by using private insurance exchanges - a new intermediary that adds to the profound administrative waste already inherent in our health care system.

What is next? Sears Holdings and Darden have already adopted these defined contribution approaches for their active employees. When IBM, Time Warner, Caterpillar, DuPont, and the others that are sure to follow find that these new retiree programs are so successful in controlling the employers' costs, how soon will it take them to shift their active employees into these plans? Even the union-negotiated plans are at risk since unions have lost much of their negotiating clout.

Middle-income Americans are already feeling the crunch. They realize that juggling cost-of-living, education expenses, defined contribution retirement funds, housing and transportation, and other costs is becoming much more difficult as the American Dream is being slowly chiseled away. They know that it is happening, but their lack of taking an activist stance seems to suggest that they don't know what to blame it on.

Well, it's pretty obvious. We have a government of, by and for the one percent. Unless the ninety-nine percent wake up, we'll soon see virtual moats around their castles. In fact, just try to get close enough to knock on their doors today, and you'll see what a private police state for the one percent is like.

My comment: People close to retirement age can be charged three times as much for underinsurance with ACA plans.

September 8, 2013

Democratic Party Platform: July 4, 1900

There is a clunker in there approving the Chinese Exclusion Act, but they were pretty sharp in recommending throttling imperialism and corporatism at birth. Too bad they failed.

http://janda.org/politxts/PartyPlatforms/Democratic/dem.900.html

We declare again that all governments instituted among men derive their just powers from the consent of the governed, that any government not based upon the consent of the governed is a tyranny, and that to impose upon any people a government of force is to substitute the methods of imperialism for those of a republic. We hold that the Constitution follows the flag, and denounce the doctrine that an Executive or Congress deriving their existence and their powers from the Constitution can exercise lawful authority beyond it or in violation of it. We assert that no nation can long endure half republic and half empire, and we warn the American people that imperialism abroad will lead quickly and inevitably to despotism at home.

<snip>

We are not opposed to territorial expansion when it takes in desirable territory which can be erected into States in the Union, and whose people are willing and fit to become American citizens. We favor trade expansion by every peaceful and legitimate means. But we are unalterably opposed to seizing or purchasing distant islands to be governed outside the Constitution, and whose people can never become citizens.

We are in favor of extending the Republic's influence among the nations, but we believe that that influence should be extended not by force and violence, but through the persuasive power of a high and honorable example.

The importance of other questions, now pending before the American people is no wise diminished and the Democratic party takes no backward step from its position on them, but the burning issue of imperialism growing out of the Spanish war involves the very existence of the Republic and the destruction of our free institutions. We regard it as the paramount issue of the campaign.

<snip>

We oppose militarism. It means conquest abroad and intimidation and oppression at home. It means the strong arm which has ever been fatal to free institutions. It is what millions of our citizens have fled from in Europe. It will impose upon our peace loving people a large standing army and unnecessary burden of taxation, and will be a constant menace to their liberties. A small standing army and a well-disciplined state militia are amply sufficient in time of peace. This republic has no place for a vast military establishment, a sure forerunner of compulsory military service and conscription. When the nation is in danger the volunteer soldier is his country's best defender. The National Guard of the United States should ever be cherished in the patriotic hearts of a free people. Such organizations are ever an element of strength and safety. For the first time in our history, and coeval with the Philippine conquest, has there been a wholesale departure from our time honored and approved system of volunteer organization. We denounce it as un-American, un-Democratic and un-Republican, and as a subversion of the ancient and fixed principles of a free people.

<snip>

Corporations should be protected in all their rights and their legitimate interests should be respected, but any attempt by corporations to interfere with the public affairs of the people or to control the sovereignty which creates them, should be forbidden under such penalties as will make such attempts impossible.

September 7, 2013

A resolution against war on Syria--feel free to steal for your organization

If you're wondering where I got the information, it's 99% from DU and can be confirmed using Advanced Search.

WHEREAS in 2011 the US and its allies marginalized the Syrian National Council, a group formed with the principles of nonviolence; non-sectarianism; and no foreign military intervention, set up a government-in-exile in Turkey, and recruited, armed and trained violent armed groups to pursue regime change in Syria; and

WHEREAS the US, the UK, France, Turkey, Saudi Arabia and Qatar then began flying in fighters, weapons and equipment to turn the Syrian Spring into a bloody civil war; and

WHEREAS the Saudi-sponsored sectors of the Syrian opposition are advocating ethnic cleansing of Alawites and Christians (“Christians to Beirut; Alawites to the grave”) and have already attacked these minorities; and

WHEREAS during a recent hearing, Secretary of State Kerry was asked which rebel groups had specifically asked for our intervention, and Kerry could not or would not answer; and

WHEREAS a recent academic study of intrastate conflicts shows that attacks like the one being proposed in Syria typically increase civilian casualties by 40 percent; and

WHEREAS it is not entirely clear who was responsible for the use of sarin in Syria with the White House assessment being “the strongest position that the US Intelligence Community can take short of confirmation”; and

WHEREAS the US has no credibility whatsoever making moral assertions about the use of WMD, given its aid to Iraq’s use of chemical weapons against Iran in the 80s and its refusal to join worldwide bans on the use of cluster bombs and depleted uranium (both of which have caused far more casualties than chemical weapons); and

WHEREAS in 2012 the Pentagon estimated that it would take 75,000 ground troops to secure Syria's chemical weapons, and now has no confidence in the efficacy of military strikes against Syria; and

WHEREAS public opinion polling demonstrates that war against Syria is even less popular than Congress; and

WHEREAS neither the Assad regime nor any current dictatorship supported by the US (including Saudi Arabia, home to most of the 9/11 hijackers) has the capacity to make chemical weapons or other WMDs, so that this capacity is instead supplied by the US and other western countries;

THEREFORE BE IT RESOLVED that ________ recommends that President Obama and Congress not approve any military action against Syria; and

THEREFORE BE IT FURTHER RESOLVED that ________ recommends that President Obama and Congress instead embark upon positive solutions to Syria’s civil war, including but not limited to

• massive aid to help the neighboring countries handle the 2 million of Syria's refugees they have already taken in
• putting pressure on countries shipping weapons to either side of the civil war and using what leverage we have with those suppliers to start an arms embargo
• approaching that sector of the Iranian government strongly opposed to the use of chemical weapons due to their experience on the receiving end in the 80s, and encouraging them to put pressure on the Assad government; and

THEREFORE BE IT FINALLY RESOLVED that the ________ send electronic copies of this resolution to President Obama and to our Democratic congressional representatives.

September 6, 2013

The largest health insurers are not participating in most state exchanges

Right. They are only "wary" of those parts that benefit patients.

Comment by Don McCanne of PNHP: UnitedHealthcare, Aetna, and Cigna - three of the largest private insurers in the nation - have decided to not participate in most of the state exchanges being established under Obamacare. Obama and his health care architects had told us that it was better to build on the system we had, expanding the prevalence of private insurance. With this gift of a ready-made market for the private insurers, why are they sneaking away?

America's private insurers have always welcomed the healthy and shunned the sick. The greatest example is the largest insurance market of all - America's workers and their families - not only the largest market in the nation but also the healthiest.

In contrast, the individual and small group markets exposed insurers to greater risks, so they countered by using underwriting to select only the healthy while rejecting those who needed health care. In turn, Obamacare now prohibits selective enrollment - cherry picking and lemon dropping. Insurers rightfully fear that those with greater health care needs will rush into the exchanges, creating high cost risk pools that would price premiums out of the market.

About 31 million people will remain uninsured. They are healthier than average since they will include young invincibles who would rather take a chance, hard working immigrants and their families, many of whom are prohibited from participating, lower-income workers who are exempt because of lack of affordable plans for them, and families with incomes high enough to disqualify them from subsidies yet low enough that they will find the premiums to be unaffordable, especially for plans that still leave them exposed to the out-of-pocket expenses of high deductibles and other cost sharing.

These big insurers aren't dumb. If they are going to sell plans in the exchanges, they want most of these low-cost individuals included in order to dilute the high costs of the sick who will enroll, thereby allowing the insurers to offer competitive premiums. Quite clearly, they are not convinced that will happen.

Will delaying a year result in an influx of some of these healthy individuals into the plans? Look at the list again. Likely some of the previously healthy who develop medical problems will want in. But that will increase the costs of the pools even more, causing the healthier to disenroll because the premiums are driven up further - the classic problem of the death spiral of skyrocketing health insurance premiums.

We should listen to UnitedHealthcare, Aetna, and Cigna. This is a highly flawed method of financing health care. It just doesn't make sense from a business perspective. But also we should give some thought to this ourselves. Does it really make sense to to insert an administratively wasteful insurance intermediary that has found great success in manipulating the markets so that they can welcome the healthy and shun the sick? Medicare Advantage has already proven to us that private insurers will always find a way around risk adjustment and other regulations in order to shift costs away from them and onto taxpayers.

Obama and friends crafted this program to take good care of the insurers while depriving us of a less costly, more efficient and more effective social insurance program - an improved Medicare for all - and yet the insurers are still not satisfied. It's too bad that we are going to have to wait until 2015 and 2016 to see premiums skyrocket and insurers bail out.

What will be our response then? Will we let the insurers continue to cover the healthy while accepting for the rest of us the fact that financial hardship is simply an inevitable consequence of facing serious illness? Based on the lack of public engagement to this date, it seems like that is where we are headed.

My comment: One thing to remember about the general public is that most of them will never get expensively sick. In every age demographic, 15% of its population accounts for 85% of the costs, and 5% for half the costs.