Obamacare and the 2014 election

I will be joining Jim Capretta (a Duke Grad) and AEI fellow from 4-5pm today discussing the role of Obamacare and the election for an online debate/discussion….last week was the first in the series on the issues that will shape the 2014 election. As I think about the topic (how will Obamacare impact the 2014 election?) I think my first answer is that I am unsure. Better think of something else to say. Will work in bar b que and football if need be.

And I realize I have not been blogging much. I have an RO1 due October 5, and a U19 proposal due October 5 on top of the normal chaos of life.

IOM report “Dying in America”

The Institute of Medicine yesterday released its report “Dying in America: Honoring Individual Preferences Near the End of Life.” It is a 500 page report with lots of interesting and relevant information, and it suggests many avenues for improvement. One key theme that comes through is the call for a focus on individual preferences near the end of life. The study that we recently published in the Journal of Clinical Oncology is directly relevant to this conversation.

This report is plainly, and comprehensively written, and I think its publication signals the end of our long, national stupid that began when a proposal in the ACA to pay for advanced care planning was termed “death panels.”

In defense of football

I don’t write to defend domestic violence, drug abuse, denigration of women, or the many other ways in which professional football players misbehave. I don’t write to defend what I consider to be the unjust withholding of money from college players. And I don’t write to defend lack of transparency and not paying for the health needs of players injured while playing.

I do write to defend the game of football, as it was played yesterday in a middle school game in Durham, N.C. I loved playing middle school and high school football, and I now have the privilege of being a volunteer assistant coach with my son’s team, who won the game 14-12. The other team easily could have won and both played well and hard. No parents misbehaved. The refs did a good job. And no one got seriously hurt.

I realize that none of the good outcomes listed above was inevitable.And there are long term worries about head injuries in football, and the finding of a JAMA study in May, 2014 is the most worrying that I have seen–that exposure to football (years playing among college players) is associated with cognitive impairment independent of head injury. If that finding holds up, then it really could be a game changer.

Several people have asked me how I could let my 14 year old son play football given the risks. The simplest answer is that there are obvious risks of playing. However, the counter factual of him not playing football also carries risks, just of a different type. For example, he tends to do better in school during football season. The motivation of “I have to do my work because if my teachers don’t sign off I can’t play and it will hurt my team” is a better school motivator for him than anything else I have found as a dad.

There are also some benefits of football that may not be clear from  afar. My son’s football team is far more integrated racially and on an income basis than is our church or neighborhood. It is good for kids to learn that they can work together toward common goals with people who are different. And football is the consummate team game. Players have to depend upon one another. On one play yesterday that was set up perfectly, one kid missed a block. 10 guys did their job and 1 did not and the play failed terribly. This is a strong life lesson of inter-dependence and also accountability (the film doesn’t lie). Finally, some of the most practical examples of redemption I have experienced have come via football.  I’ll tell you just one.

There is a kid who last year could not run 1 lap around the track because he was so out of shape. He had lots of anger issues and couldn’t be trusted to keep his head in games. This year, he ran extra after practice the first few weeks to try and get in better shape. His improvement in fitness in 1 year is hard to imagine. Yesterday, he played both offense and defense and almost never came out of the game, and I watched him help a younger kid get in the correct position on a few plays. He did not correct with a harsh anger, but as a leader who knew it was in everyone’s best interest for him to help the other kid understand.

None of these good outcomes is inevitable. However, they are possible if football is done in the correct way.

More on working towards a deal

Harold Pollack has an interesting give and take with Avik Roy about Avik’s health reform plan. There have been legitimate criticisms about the details or lack of them and how the gaps would likely have to be filled in, and that is how it goes and why it is so hard to pass any sort of health reform proposal. Many folks thought that I went too easy on Avik’s plan, but they missed my main point. It is not the details of his plan that were the most important, but his frame of acknowledging that the overall structure of the ACA is here to stay, and that continued policy nihilism is a bad strategy. It is inevitable that the ACA will be changed and tweaked over time, and it is better to start the process sooner, rather than later.

These sorts of details noted in the various pieces won’t be “snuck through” a revision of the ACA. The country is paying far more attention to health insurance and health policy than ever before. These issues will be banged out in the open, and both political sides have a stake.

One key issue that needs to be resolved:

  • what is an acceptable out of pocket spending amount from both a policy and cultural perspective?

As Adriana Macintyre noted today on on twitter, deductibles over $1,000 have often been considered to be relatively high, and the presence of deductibles above this level has been trending up for some time.

ScreenHunter_01 Sep. 10 10.47

However, many ACA exchange plans have deductibles much larger than that. There is a lot more “skin in the game” than many think. Is that good? Bad? Acceptable? What is the maximum that should be allowed?

These are the types of questions that will have to be banged out in the next step on health reform.

Stance on Medicaid could cost N.C. $10 Billion

So says a Charlotte Observer/McClatchy analysis that was done in conjunction with Kaiser Family Foundation, the best source of non partisan health policy information around (update: it is actually done with Kaiser Health News, and independent, editorial arm of KFF). They quote me in the story, and here is the plan I put out in January, 2014 to which they refer. Here is a post from last year about the fiscal impacts of States sitting out the Medicaid expansion.

After the 2014 election, the political incentives will begin to align in a way that makes possible a reform plan that will likely include some sort of modified Medicaid expansion in North Carolina.

United to sell ACA plans in North Carolina

There has been word of this for awhile, but this is the most public statement I have seen confirming that United will sell ACA plans in North Carolina next year. Historically, Blue Cross Blue Shield N.C. had over 90% of the individual purchase market in the state. Coventry was the only company that offered plans in addition to BCBS NC in 2014 (and only in around 35 of the 100 counties), but United says they will offer plans this coming year in nearly all 100 counties. 

North Carolina had one of their higher private insurance uptake rates in year one of the ACA. United says they are coming for a share of this (stronger than expected) market.

One of the key questions for any state’s ACA marketplace is how many insurers are going to offer their plans? The plain reality is that a year ago–and for the previous 20–there was really only one game in town for the individual purchase market. At the next ACA open enrollment in November, there will be three choices in at least some N.C. counties, and two is almost all of them.

If you think competition in insurance is good, this is an incremental, positive step.

CBO: 1974, 2014 & 2024

CBO has released a long term budget outlook update. It has more detailed than average discussion of their assumptions about economic growth–an interesting read. They also reduced again their 10 year Medicare spending projections. The continuing deceleration of Medicare spending is the most important policy story that does not get much attention. Still plenty of uncertainty about its etiology and how long it will last, but it is good news (which doesn’t travel fast), that is cooked into the cake so to speak, whatever comes next.

This figure 1-5 (p. 19) comparing the federal budget in 1974, 2014 and 2024 projection from the report caught my eye. The huge growth in Major Health Care Programs is both demographic (the baby boomers) and health care inflation the past 40 years (ACA contributes, but is not the main thing going on; see p. 12, table 1-2). Even as health care inflation has moderated, the baby boomers moving into Medicare (and also Medicaid via long term care expenses) foretells continued growth of the Major Health Care programs bucket in the federal budget. And the increase in Social Security is wholly demographic.

The demographic drivers of this were inevitable in 1974.

ScreenHunter_04 Aug. 27 10.21


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