“When one person suffers it is a tragedy, when millions do, it is a statistic.”

As abhorrent as quoting Josef Stalin might be, the monster was right.

Opponents of Obamacare love to cite specific examples of people “harmed” by PPACA. As we’ve seen, while their “examples” are false, wildly distorted, and/or fake, they are also powerful as few bother to read the follow-up debunking stories.

Amidst all the complaints about Obamacare from individuals “suffering” under their new policies, it is easy to miss out on the big picture..

From a reader (thank you JR) came this – 4 million people with mental health issues will not gain coverage under Obamacare.  They will not have access to Medicaid, because the state legislators and/or governors don’t want to accept federal dollars to expand Medicaid.

These are real people – boys, girls, moms, dads, grandparents, friends, neighbors, sisters, brothers, wives, husbands, classmates.

They are suffering from bi-polar disorders, deep depression, addiction, autism, severe anxiety and panic disorders.  We are talking about seriously ill people, some with disorders similar to the perpetrators of the Newtown Connecticut and Navy Yard shootings; others who, without treatment, will never become productive, fulfilled, tax-paying members of society.  Instead they will be a burden on us all.

There are 11 southern states that have, for reasons of their own have refused to expand Medicaid as of now.  According to the piece in Insurance Broadcasting, “More than 1.1 million uninsured people who have serious mental health and substance abuse conditions live in just two states — Texas (625,000) and Florida (535,000).”

What does this mean for you?

The next time someone tells you what a great country we live in, ask them if this is how great countries treat their most vulnerable citizens.

When state politicians cut their own social support budgets while refusing to help those desperate for help, we become a smaller, meaner, and less-civilized society.

The full report is here.

Looks like the glitches, gremlins, and guffaws are just about over; CMS reported today that enrollment via the exchanges is up to 4 million, an increase of some 700,000 over the last few weeks. That despite the ongoing efforts in some states to hinder enrollment, efforts which include outlawing “Navigators”, refusing to expand Medicaid, and prohibiting or barring various forms of consumer education.

Of course, there have been many, many stories of citizens disappointed/angered/furious with their new health plans.

There’s the one about the Michigan woman with cancer who has to pay more.  Oh, wait, she actually doesn’t; her new plan through Blue Cross Blue Shield cut her monthly premiums almost in half, from $1,100 to $571; that plus the annual-max-out-of-pocket pretty much assures her she’s fine after all.

Whew!

Well, then there’s the woman who claimed “Obamacare raped her future”!  Wow, such inflammatory language!  Especially for one so…uninformed.  Ashley Dionne said her costs would go up by a factor of four, but she didn’t realize she’d likely qualify for Medicaid, which would have cut her monthly premium to, well, nothing.

And who could forget Bette from Spokane! She was socked with a $700-a-month increase!  Uh, well, not…exactly.

Oops.  Turns out Bette never checked the exchange, could have got a much lower price, and the price she was quoted was for a waaaay better plan than the cheap one she had – and that’s why it was more costly.

Huh.  Well, what about those folks in Texas?  You know the one Maggie Mahar wrote about, the poor woman (why are they always women?  why don’t we men get to be victims?) with MS who had her policy canceled and the new one cost – gasp – $1000 a month! The couple with a $20,000 deductible! OUTRAGEOUS!!!

Well, that was not true.  First, no policy for a 27 year old will cost that much.  Next, there are NO $20,000 deductibles.  Finally, the paper that printed this crap never fact-checked the piece, and didn’t print a correction, and the reporter assigned the story was told to “To find people who [had insurance policies that] were cancelled – and having some difficulty.”

There are more horror stories.  But please, before you read and repeat, think.  Does it make sense?  Is it objective?  Who printed/produced it?

What does this mean for you?

Yes, there will be horror stories.

But none as horrible as 50 million of our fellow Americans not covered by insurance.

None as horrible as a loved one with breast cancer who can’t get care.

Now that’s horrible.

Amongst all the noise about the exchanges and enrollment, it is all-but-impossible to separate the BS from the RS  (real scoop).  So, here are a few factoids.

• Overall, enrollment for 2014 continues to lag behind initial projections,which the CBO estimated at 7 million last June, then lowered to 6 million this month.
• A recent analysis indicated some states’ active efforts to hinder enrollment are working, and are partly responsible for the shortfall in enrollment.
  Ed note – In those states, blaming the Administration for low enrollment while doing your best to prevent it yourself is like blaming your mom for your bad grades after you refused to study.
• As of Feb 1, 3.3 million have enrolled via the exchanges.
  • 55% are female
  • 27% are 18-34
  • 31% ar 55-64
  • 82% get some level of subsidy
• CMS may require health insurers selling via the federal exchanges to make sure at least 30 percent of “essential health providers” are in-network in 2015.  This in response to some complaints about networks that are allegedly too narrow.
  Ed note – Which is kind of ridiculous; smaller networks are better at controlling costs and that’s a BIG part of the success criteria for health reform.
• California’s website was recently down for five days due to software problems. Bad timing as a marketing push had just been rolled out.  Nonetheless, private insurers had enrolled about 829,000 members as of a week or so ago. About 86% of CA enrollees benefit from fedreal subsidies.
  • Anthem added 223,640 members
  • Blue Shield gained 213,6467
  • Kaiser increased by 131,448
• The flood of new enrollees are causing some delays in issuing ID cards, with Anthem among those “challenged”.
• Anecdotally, many of the new enrollees appear to be new to insurance as well.  This may indicate a substantial percentage of exchange enrollees were previously uninsured.  
• “Private” exchanges saw a big volume increase in late 2013 and that appears to be continuing into this year.

What’s the net?

Too early to tell.  Looks like things are going much better than late last year – but things were such a horror show that may be “damning with faint praise.”

We will have a much clearer picture in May, after the penalty period comes in to play, premium payment issues are straightened out, and most of the rest of the computer messes are cleaned up.

Okay, deep breath here folks.

There’s no question the Federal Exchange is a mess.  And that’s the polite characterization.

But let’s not get too carried away, because the Federal Exchange is just a small part of PPACA/Obamacare.  In fact, the Exchange impacts just 7% – seven percent! – of the US population.  Thus, it is:

1. Irrelevant for most Americans – specifically the 80% who get their insurance from their employer or are covered by Medicare or already covered by Medicaid.
2. Not operating in 16 states plus DC, and that includes a couple of big ones – California and New York specifically.  In general, those exchanges are doing pretty well. Yes there are significant problems in Hawaii, Maryland and a couple other states, but overall they’re doing fine.
3. Operating in states where 59% of today’s uninsured live.  Sure that’s a lot, but it isn’t everyone, not even close. And, a big chunk of that 59% are not eligible for coverage for various reasons (undocumented, state refused to expand Medicaid, etc.)

And, the Federal Exchange is just one part of Obamacare.

It is a means to an end, and that “end” is covering as many eligible people as possible, while fundamentally changing the competitive marketplace to force insurers to compete based on delivering the best outcomes at the lowest price.

Key components of Obamacare already implemented include:

• Medicaid and CHIP expansion, providing coverage to the growing population of people who don’t make enough money to buy their own coverage, or who work for small companies that don’t provide insurance.  
• Credits to help small businesses buy coverage
• Elimination of medical underwriting, lifetime caps, and coverage of dependents to 26
• Allocation of funds to Comparative Effectiveness Research to promote treatments that actually work.
• Policy changes and funding for new delivery systems and reimbursement arrangements, funding which has generated explosive growth in Accountable Care Organizations and Medical Home-based models.

What does this mean for you?

Eventually, the federal exchange will be fixed.  Meanwhile, our health care “system” is going thru drastic change, change that will, over the long term, improve the health care we get and reduce the cost of that care.  

Of course, there’s going to be some well-deserved political fallout in the interim.

It is increasingly clear that healthcare.gov is not working, and is not getting appreciably better. If it doesn’t get fixed – and I mean REALLY fixed – by the drop-dead date of December 1, the implementation will have to be delayed until it is.

And that may not happen until late next year.

There are two problems – the front end enrollment process, and the back end information distribution process. On the front end, a handful of people are successfully enrolling in health insurance on healthcare.gov but a handful is nowhere near enough to get the program up and running successfully.  However, that’s just as well, and may actually be intentional.

If tens of thousands of people were successfully enrolling every day, the back end – where all the things happen that make health insurance actually work – would not be able to handle the volume.  That is a very polite way of saying it would be an unmitigated disaster.

Once you’re signed up, (among other things) your bank account has to be debited, subsidy calculated and applied (if there is one) and enrollment and eligibility information catalogued and prepared for distribution.  This process relies heavily on an EDI  process using an industry standard known as the “834”.

The problem is that each insurer has their own slightly-different version of the 834, so each health plan’s 834 has to be programmed, tested, and then tested each month to ensure the right data in the right format is getting to the right computer databases.  The best discussion of the issue was on Bob Laszewski’s interview with Daryl Chapman last week. Here’s an excerpt:

 There are lots of data elements and a lot of field variables. Because of this complexity, no one takes a file straight into a production system––too risky. There are variations on the process but every company has some type of validation process. Generally, the 834 goes through an acceptance process, which scans the file and checks for errors. If it passes the data check it uploads to some kind of “model office” where it is tested again and then, if it passes, it goes to production. Although most of that is automatic there are several chances for the file to “error out.” Once in production, the file drives the payment system, claim system, and is the source for the list of doctors and hospitals they need to confirm the person is eligible for benefits.

Files still have lots of opportunity to trigger false reports in each of these systems if they aren’t accurate.

For example, member data is not the same as payment or cash data (member payments in this case come from two sources; the subscriber and the government). Poor quality data can lead to lots of problems trying to reconcile who the health plan was paid for and who they have on their eligibility system. Very few systems ever connect cash to belly-buttons and even fewer have debit and credit carry forward accounting capability making reconciliation on the fly very difficult.

If the member data is a mess then the cash becomes a mess. When the subsidy cash goes to the carrier from the federal government, the carrier doesn’t just get you; they get thousands of member cash files. If there isn’t a match, the claim paying process has to be suspended until people with green eyeshades figure it out.

And out in the world where doctors and hospitals live if the data isn’t clean doctors and hospitals may not treat you if the carrier file doesn’t say you are covered. They may demand payment upfront from the patient until things are straightened out or balance bill if claims aren’t reimbursed. That is a particular problem here because so many of these people will presumably be low-income.

This is where the biggest problem lies, and the hinge on which the success or failure of Obamacare rests.  I do not understand why the Administration doesn’t bite the proverbial bullet and shut down the Exchanges until they are absolutely ready to go.  Sure, there’d be a lot of political fallout, but that would last for a few news cycles, and then they’d be off to some new celebrity scandal.

Instead, the President and his proxies are telling people to get on to the site and sign up.  A site that isn’t working, and is much harder to fix because the White House appears to want to avoid some political damage. That is unconscionable.

What we need now is Lyndon Johnson.  He’d get the right people in the room, beat them mercilessly, make the tough decision and move on.  Instead we have millions of people who desperately want and need health insurance spending hours trying fruitlessly to enroll on a site that is fundamentally broken.

 What does this mean for you?

An aphorism is appropriate – If you don’t have time to do it right in the first place, what makes you think you’ll have time to fix it?

The rollout of the federal Exchanges has been a disaster.

There’s no way to sugar coat it; whether it’s a design, technology, or communications problem (more likely all three), they are NOT working. And yes, there’s a clear management/leadership failure here; the Obama Administration failed twice;

• first – designing the right development process (it appears that among other things, political decisions caused them to hold back on issuing detailed guidance to key stakeholders, i.e. health insurers)
• second – encouraging Americans to use the Exchanges on day One, when they should have known they were not ready.

While the feds and their contractors are working feverishly to fix things on the fly, I’m hearing from my tech expert colleagues that they’d be far better off taking the Exchange off line, fixing the problems, then re-starting it.

Among the issues/problems, there’s:

• a requirement that enrollees enter all their personal info before they can look at and compare plans
• a lack of server capacity to handle the traffic volume
• a lack of communication between the Exchange and the various health plans (this may be the most critical problem over the next few months as folks get cancellation notices from their current insurers and are required to sign up via the Exchanges)
• erstwhile enrollees can’t find out if their doctors are in any of the plans available to them.

HHS bears a lot of responsibility for this, and perhaps Sec. Sibelius should be fired.  However, that would require the President to nominate a new Secretary, and given the hyper-partisan approval process, any new Secretary would face uncertain-at best-chances of approval by the Senate. And yes, President Obama is ultimately responsible, and therefore it is incumbent upon him that this gets fixed now, and gets fixed correctly.

Better to shut down the Exchanges now, get them fixed, test the heck out of them using feedback from early users, and get them back up when they are really ready..

If that requires delaying the mandate for a few months, so be it.

What does this mean for you?

A very big, and very painful, lesson on how not to do big IT projects, and an equally big and painful lesson on the perils of allowing politics to trump common sense.