Looking For Health Care Anecdotes

[LUCKY GUESS: A day later the Spokesman-Review has a chat with the woman I identified.]

In the Republican response to Obama's SOTU Congresswoman McMorris-Rodgers told us this about Obamacare:

Not long ago I got a letter from Bette in Spokane, who hoped the President’s health care law would save her money – but found out instead that her premiums were going up nearly $700 a month.

So what lucky "Bette" is having her switchboard light up this morning? Well, last November Ms. McMorris-Rodgers gave us a bit while discussing the problems with the Affordable Care Act:

It’s about Bette Grenier, who can’t afford the increased payments and is currently uninsured because of Obamacare.

Hmm. Her Joe the Plumber moment is imminent! There is a Bette Grenier in Spokane who heads a roofing contractor firm with ten employees.  And if (IF!!!) this is her little-used Facebook page, she is no fan of Hillary, so maybe she is no fan of Barack.

In any case, a small business owner might well have been in the market for private insurance and may well be looking at higher premiums under Obamacare. There were apparently 290,000 cancellations in Washington State and the state did not pick up onObama 's suggestion that they extend non-compliant plans for another year.

Paul Krugman is deeply interested in this, presumably as long as we can show the Congresswoman to be lying or misinformed:

I’d be interested, by the way, to know the details about the constituent described in the official GOP response, who supposedly faced a $700 a month rise in premiums. What kind of plan did she have? Did that number include subsidies? The ACA is supposed to keep health costs to 8 percent of income, so the only way you could get numbers like that is if the individual (a) had a really bare-bones policy offering hardly any protection and (b) has an income well over $100,000.

As to "an income well over $100,000", I am surprised that such an authority would fail to grasp that for unmarried individuals the subsidies disappear at $46,000. That said, a Silver Plan in Washington for a single mom age 58 (per WhitePages.com) and no kids with no subsidy would be $6,226 per year, which at $519/month is less than the $700/month premium hike we are examining.

So let's give her a hubby and take the income up to $94,300, where subsidies end (still less than $100,000, BTW, but presumably Prof. Krugman has deeper thoughts distracting him).

Now two 58 year olds with two kids are asked to pay $15,556 for a Silver Plan with an annual out-of-pocket maximum of $12,700. Yikes!

And speaking from personal experience, my wife and kids had their non-compliant but quite comprehensive Connecticut plan cancelled for non-compliance (no mental health coverage, which drove us crazy...); a comparable replacement Gold Plan was $600/month more, without subsidies. So personally, I score this anecdote as a "definitely maybe".

It will be interesting to see where the facts lead us. Trust but verify.

SHOW ME THE CLIFFS: Not to get all gloomy and pedantic but the passage from Prof. Krugman excerpted above displays a shocking ignorance of the economics of the ACA subsidies.

As already noted above, subsidies depend on marital status and the number of kids. The claim that they only disappear if "the individual" has "has an income well over $100,000" is only true if "the individual" is also married and has three or more eligible kids.

Per this chart from ObamaCareFacts.com, a single person with no kids loses their eligibility for subsidies at $46,000. And that implies a dramatic subsidy cliff - as the site illustrates, a family of four that is a dollar below the eligibility line ($94,200) can gain $3,550 in subsidies. Earn another dollar, and all of those subsidies disappear. Oops! Not that anyone will finagle their taxes as a consequence. Hmm, Pikkety and Saez will report on declining middle-class reported income, Obama (and Krugman!) will rail about rising inequality - it's a win-win!

But Krugman has embedded a second major misunderstanding:

The ACA is supposed to keep health costs to 8 percent of income...

"Health costs"? Come again? The subsidies are meant to keep premiums at (or near) 8 percent of income. Wait'll he gets a lod of the deductibles and co-pays!

The ObamaCareFacts site refers people to the Kaiser-Permanente subsidy calculator, so here we go: a family of four (non-smokers, national average, mom and dad are forty) earning $55,125 (taken from ObamaCareFacts site as 250% of Federal Poverty Line although Kaiser disputes that):

The premium, pre-subsidy: $9,700. Subsidies of $5,569 per year bring the premium cost down to $4,130 per year. That is 7.5% of $55,125. So far, so good.

However! The fine print, which I recall was initially obfuscated by the ObamaCare website, includes this, on deductibles and co-pays:

Your out-of-pocket maximum for a Silver plan (not including the premium) can be no more than $10,400. Whether you reach this maximum level will depend on the amount of health care services you use. Currently, about one in four people use no health care services in any given year.

If the family does spend $10,400 and hit the out-of-pocket cap I am pretty sure that will represent more than 8% of total income. Hey, insurance is complicated to buy.

Interestingly, Prof. Krugman recently lectured Bret Stephens of the WSJ on an appropriate corrections policy. Let's reprise that here:

Instead, he points to an online post he put out admitting, with a minimum of grace, that using nominal incomes was wrong.

Sorry, but that’s not what I — or, if I may speak for my employer, The New York Times — calls a correction.

What, after all, is the purpose of a correction? If you’ve misinformed your readers, the first order of business is to stop misinforming them; the second, so far as possible, to let those who already got the misinformation know that they were misinformed. So you fix the error in the online version of the article, including an acknowledgement of the error; and you put another acknowledgement of the error in a prominent place, so that those who read it the first time are alerted. In the case of Times columnists, this means an embarrassing but necessary statement at the end of your next column.

I have confidence that Prof. Krugman, with grace and alacrity, will correct these gross misrepresentations about the economics of the ACA subsidies. The impression he is currently promoting is that the subsidy phase-outs only hit the well-off and that total health care costs for a subsidized family are well-contained. Wrong and wrong again.

FROM THE CHAT WITH BETTE: We learn this about her health insurance options:

But the “nearly $700 per month” increase in her premium that McMorris Rodgers cited in Tuesday night’s GOP response to the State of the Union address was based on the priciest option, a $1,200-a-month replacement plan that was pitched by Asuris Northwest to Grenier and her husband, Don.

The carrier also offered a less expensive, $1,052-per-month option in lieu of their soon-to-be-discontinued catastrophic coverage plan.

...

She said she contacted the congresswoman late last year to complain after getting a letter from Asuris Northwest advising that her $552-a-month policy no longer would be offered. She sent the congresswoman’s office a copy of the letter, which included the rate quotes for the suggested replacement policies.

Although the couple’s catastrophic plan had a $10,000 deductible, it included four doctor visits per year at no additional out-of-pocket cost, she said.

The replacement policies offer lower deductibles and broader coverage, she said, but they didn’t include the doctor visits at no extra charge.

No mention of kids, who might well be past the age of 26. As to the notion that her old plan was "catastrophic" with a $10,000 deductible, how would she characterize the Silver plan noted above with a maximum out-of-pocket of $10,400?

But down to cases! Per the Kaiser site, two adults with no subsidy in Washington are looking at a Silver plan costing $12,453 per year. The annual out-of-pocket cap (excluding the premium) is $12,700, so this does not strike me as a lot less catastrophic than their old plan (although we lack information about their old co-pay rate, but they do have the four "free" doctor visits.)

So the old plan was $552/mo; the new one is $1,038/mo. Quelle difference! That is $486/mo., and quite close to the "$1,052-per-month option" mentioned in the story. I have no doubt a Gold Plan costs more, but I doubt the deductibles are comparable.

Since Ms. Grenier did send her Congresslady a letter indicating the cost of her old plan as well as price offers for various replacement alternatives, I would say the heat, if any, is on Ms. McMorris-Rodgers. That said "nearly $500 per month" would have been as useful a sound-bite and essentially accurate.

And Prof. Krugman's objections included this:

We don’t know the particulars here, but many if not most stories of rate shock turn out to involve people who didn’t actually apply for a policy, and therefore never found out what it would really cost.

That seems to be answered. We eagerly await his corrections, clarifications and amplifications. I certainly hope that in the course of noting Ms. McMorris-Rodgers exaggerations he corrects his own over-enthusiams. (My breath is unheld).

 

Comments

[cathyf]

Well its 70 years later and without the "distortion" we would now have 1980 healthcare for the rich and 1970 healthcare for the poor ... but we'd be spending less on it by god and that's something.

I think you are far to optimistic. Suppose the courts had ruled back during WWII that health insurance was not a legitimate business expense. I think that what would have happened in the US is what happened in the rest of the western world -- government-run single-payer systems for expensive treatments, and paying out-of-pocket for little stuff. These government systems would balk at paying for anything new ("experimental" they would intone) and so there would be no funding available for anything new that wasn't cheap enough for people to just pay for. There would be no money to pay for extensive safety testing -- no billion-dollar drugs -- so there would be lots of thalidomide babies from multiple drugs.

And you have no idea just how much all of the other governments of the world wish that it had happened that way and the US was just like them. That the US wasn't providing a huge market for safe, effective, life-saving treatments that are expensive for a few years and then virtually free after that. Then there would be no safe, effective, expensive, proven-by-us treatments that their sheeple want, and no one would know what their governments desperately want to deny them.

[boris]

Cathy, you're probably right ... I was trying to base the argument on the fewest assumptions.

[jimmyk]

several have expressed skepticism that increased spending on medical care results in meaningful advance.

That's hardly tantamount to "Medical advance...who needs it?"

[Janet - the districts lie fallow, while the Capitol gorges itself]

BTW I can't believe anyone thought the uninsured would sign up for Obamacare. The bulk of them just walk into ER's, and always will, and we will always end up paying for them as we always have. The rest pay in cash.

I know! That's what I did. Young, hippie lifestyle, not much money....any extra cash went for margaritas.
I paid cash (on a payment plan) when I had to get my wisdom teeth out...& when my dog got hit by a car & I had a big vet bill.
I covered rent, kept my car going, food, & utilities. I woulda never spent what little extra money I had for health insurance.

[boris]

That's hardly tantamount to "Medical advance...who needs it?"

It's just a composite rendering with a hint of snark. Infer at your own risk.

[boris]

The levels of skepticism expressed here regarding medical advance is inconsistent with my perceptions. Thus I consider it valid to infer the skepticism is to some extent feigned and/or exaggerated.

Seems to me the hyper-sensitivity to a tiny bit of snark is also feigned and/or exaggerated.

Not feeling the sympathy right now ...

[clarice]

GMac, bless you.. Those folks ran thru the weeds for me and I got this resolved..even have a local WF guy who promised to hep me with the rest of the CD cashing in stuff..

[Ignatz]

--They distort the market with their disdain for everyone; by bidding three and one-half million for a Corvette.--

Bidding 3.5 million for a Corvette at an open auction where anyone can bid is the market.

[Ignatz]

--I don't know what effect Ignatz's personal situation plays in his position, ... it certainly affects how I respond to his points. But he did write the following ...

"One last example on the cancer topic to show how little progress has been made in most areas"--

Boris, you're a smart guy so I'm sure you know that nothing in this passage;

Cancer survival rates have doubled in the past 30 years, according to a report released yesterday.

Patients now have a 50 per cent chance of living for five years after diagnosis.

Cancer Research UK, which produced the figures, said earlier detection, screening programmes and better treatment explained the improvements.

is contrary to anything I said and I would think that my pointing out how little progress has been made in so many areas would illustrate that "medical advance...who needs it?" is precisely the opposite of what I'm saying. We do need it but the idea that employer tax breaks is an efficacious way to bring it about seems specious at best.

As to the first point, "earlier detection, screening programmes and better treatment explained the improvements" is pretty much EXACTLY what I said. However, the better treatment especially, but all three to some extent, are isolated to specific types of cancer so that those certain cancers which used to be almost invariably fatal are now in some cases seldom fatal at all. That does not imply that all cancers have doubled survival rates and in fact implies the opposite. Some have rocketed far past a mere doubling while many remain quite intractable.
Lung, pancreatic, brain, liver, colon, esophogeal, etc have not made large advancements either in screening and early detection nor treatment.

It's also important to note that the five year standard is not as useful as it once was and can be very misleading. Decades ago if one made it past five years it generally indicated the cancer was relatively unlikely to return because it had either been cured or killed you by then.
However with life extending therapies it is more common for people to survive the five years and still be fighting the cancer with the ultimate outcome the same. So five year survival can increase dramatically while overall survivability may not increase at all or very little.

Not sure why you would think my wife's experience should effect what are facts, nor how you extrapolated the idea you apparently attributed to me from what I wrote.

[cathyf]

Also, as far as the "medical advances since 40 years ago" argument -- WWII was 70 years ago. After the war, Europe was devastated, with people literally starving and freezing the first winter. For a lot of years, the US boomed while the rest of the world struggled to recover. Our health insurance system funded almost all of that, and it was most important for the first 10-20-30 or so postwar years. Capital has to go where there are possible profits, and without the gazillions of dollars set aside for health care spending we wouldn't have $25,000/year arthritis treatments, $50,000/year AIDS drugs -- or $4/month beta blockers that cost a billion dollars to develop.

[boris]

"contrary to anything I said and I would think that my pointing out how little progress has been made in so many areas"

You wrote "most areas". And I do think it refudiates the intent of your comment to the extent your intent was to contradict my remarks.

IOW if your comment was contrary to mine, then yes, the article supporting my comment would have to be contrary to yours.

Also all I said was your situation affects how I respond to your points.

[Ignatz]

By "most areas" I meant the most common forms of cancer which is an accurate statement.
Early detection and more screening is not for the most part a triumph of medical advancement.
The areas in which significant medical (read chemo and mono clonal antibodies) advancement has occurred is in narrow areas of specific and not usually too common types of cancer.
For most cancers the advances have been small and in most cases fairly insignificant. As I pointed out for 80% of breast cancers the first and second lines of defense are essentially unchanged from forty years ago. There are other lines after that which didn't exist forty years ago but by the time you get to them they are usually palliative not curative and extend things usually by months.

The statistics are skewed by large advancements in small areas and near stasis or insignificant ones in others. And I already pointed out the decreasing usefulness of the five year standard. People who have cancer that has advanced beyond the early stages are still dying of cancer, they're just doing it at six years instead of four.

Stage IV cancer (metastatic cancer) remains a death sentence in nearly all cases, excepting only testicular cancer. That does not seem to me a very significant advance overall.
They are still nowhere near a cure and still cannot even agree on how or where cancer starts; is it a function solely of aberrant stem cells or is it not?

Medical advancement? Faster please.

[boris]

"Early detection and more screening is not for the most part a triumph of medical advancement"

If you had written "Improvements in early detection and screening ... etc" your comment would be laugh out loud ridiculous.

Medical advancement is more than drugs and procedures, it includes research, knowledge, instruments for detecting and screening (closer to my fields) and other electronics and software.

IMO detection and screening counts toward my claim and against your "glass half empty" quibbles.

I personally know two people who survived stage IV. I personally know scientists and engineers working in the Madison Wisconsin area on cancer technology. The company I worked 25 yrs for had a biomedical division (my division was lab instruments).

I am in the glass half full and getting better camp. Don't know where you are coming from but you don't get to sneer for 3 pages then say "faster please".

[chuck it]

Oh, look whose ox is being gored. The vast improvements in healthcare seem to be in billing efficiencies.

After all, why would they want to kill the goose, when keeping it barely alive keeps the gold eggs a'layin.

[clarice]

I'm in the getting better camp, too, Boris, and I think the "better" began when the field was taken over by biochemists and microbiologists and away from surgeons.

[clarice]

BTw, I think a fine book on the subject is "The Emperor of all Maladies", an incredible work by a physician who writes beautifully and clearly.

[clarice]

Should be "G Max"*

[Ignatz]

--Don't know where you are coming from but you don't get to sneer for 3 pages then say "faster please".--

I'm sneering at the patently ridiculous notion that employer provided health insurance has made any significant contribution to advancing healthcare that wouldn't have occurred in its absence, which is where this conversation started.
And I'll continue to sneer at it because it is absurd and unsupportable.

Recognizing something that obvious in no way precludes me from desiring medical advances and neither my arguments nor specific words anywhere suggested anything like that.
If you are of the opinion cancer is on the verge of being cured, be my guest.

--IMO detection and screening counts toward my claim and against your "glass half empty" quibbles.--

I assumed by medical advances you meant significantly more effective drugs and a greater understanding of cancer which leads to significant progress toward a cure. Herding more women into mammograms and sticking more fingers up dudes' arses may be very effective ways of reducing cancer deaths but I wouldn't categorize it as a "medical advance".

And cancers do occasionally spontaneously stop; however go ask an oncologist if Stage IV cancer is curable. That's why they call it terminal cancer; because it isn't.
What are these great advances in detection? They still shove a tube up your arse for colon cancer. They still squeeze your boob in an x ray machine for breast cancer.
MRIs and CT scans have been around for decades. So have most of the protein marker tests.
Those test are continually being refined, but a slightly more targeted or more sensitive test hardly amounts to some big advance.
There is incremental progress at the fringes, and significant progress in some limited areas, but the vast majority of the chemo dispensed for cancer is stuff that has been around for decades and a diagnosis of metastatic cancer is essentially still a death sentence.

And in any event not a shred of credible evidence has been produced supporting the original claim that employer provided healthcare somehow produced any of it.

You can get as cranky as you want, but the facts remain unrefuted. Not sure why it seems something personal with you, but apparently it is, so as others have said, cheers.

[boris]

"I'm sneering at the patently ridiculous notion that employer provided health insurance has made any significant contribution to advancing healthcare that wouldn't have occurred in its absence"

Yes ... sneering at the "patently ridiculous" conclusion treating employee health insurance as a business expense provided more money to the health care system ... "distorting" it as you say ... somehow in unheard of fashion resulted in more research and development than otherwise. What a crazy notion!

To think all those cancer charity events I have donated time to, breast cancer, ovarian cancer, were lying about the value of money donations to fund research were a complete waste because as you say, and I quote for bgate's benefit "patently ridiculous notion that [money] has made any significant contribution to advancing healthcare "

"... and sticking more fingers up dudes' arses ..."

Been a few years ... here in Madison Wisconsin they use something newer ... a blood test ... technology you know. Might be better, might detect earlier ...

"... not a shred of credible evidence has been produced supporting the original claim that employer provided healthcare somehow produced any of it ..."

Nor shred to suggest that money has no effect ...

... it seems something personal with you ...

Says the sneering pot.

[boris]

Lest people think I am "getting cranky" ...

I think I know something about the general subject and have simply defended a reasonable position.

If others escalate the invective and hostility ... hey I like to argue so I just keep up. Does not bother me a bit.

More than a few "discussions" I have been in here result in commenters actually acting as if defending and keeping up with the tone they set ... is something I am doing to them. Don't know for sure but it seems like by getting nasty themselves that is supposed to end the debate on their terms.

Sorry if that is supposed to be how it goes. Not how I role.

[DrJ]

boris,

I've refrained from getting into this, but the PSA test that detects prostate cancer is pretty poor. The (ahem) direct examination method cannot be replaced by it.

My father had prostate cancer that the PSA test did not detect but a finger did. He is alive over thirty years later.

He is not alone.

FWIW, it is very difficult to find good markers early in whatever cancer. To do so you need samples from people who have that cancer. How do you get those samples? You can only get them once a person is diagnosed, and by then rarely is it early stage.

And cancer is not static: it changes with time (duh) so the biomarkers it puts out change with time too. So while it is helpful to have markers from a diagnosed patient, those markers may well not be useful to detect an early-stage cancer.

[srp]

On cancer: Survival rates are a near useless metric for progress in treatment because we detect so many more non-fatal cancers than before. For example, tons of breast cancer "survivors" have pre-cancerous cells that would not have progressed to disease in any case. Ditto prostate cancer. That said, Herceptin is practically a miracle drug in the HER2+ cases--when administered to all but the most dire cases in combo with standard chemo it is extremely effective in preventing reoccurrence. Peter Huber has a book out describing how further progress along these lines will require dismantling the institution of the double-blind clinical trial as the gatekeeper for drug approval.

[boris]

"I've refrained from getting into this ..."

Apparently PSA detects earlier but not all positives require treatment.

So thanks for clearing up that very important detail and I will see that my doctor knows to update his procedures.

Your knowledge and experience on this subject is appreciated more than you know.

[srp]

On Wells Fargo.: Strategy for many years there has been to go high-tech and cut out customer service, manage by the numbers and pressure employees to hit their stretch goals. The latter sometimes leads to bad behavior. When we got our first mortgage ever, our Wells loan officer tried to hold us up at the closing by demanding a higher rarte than we had agreed to. Our escrow agent squashed that, pointing out that we had the loan officer's signature on the approved rate. After the call was completed, the escrow agent said that many Wells officers were pulling this stunt and that it sometimes worked on immigrant borrowers who already had their worldly goods in the moving van at closing.

[DrJ]

The PSA test has a high rate of both false negatives and false positives. It has its uses, but it really is a poor diagnostic. One of these days I intend to look at it in greater detail -- it seems like there is great potential for a better test.

[Darragh McCurragh]

There are some hard and fast actuarial (insurance mathematics) rules as to the "progress" of the "Affordable" (dabble) Care Act: since everyone has to choose a plan and the insurance companies have to take the applicant on (by and large) without "discriminatory" screening (the equivalent to offering insurance after the house went on fire), those with a higher risk or chronic illnesses seek out "gold" and "platinum" policies where there patient contribution is as low as possible. These gold and platinum premiums (true to their name) then go up. The healthier members of the collective, those that do not currently need any insurance in the sense that they have no bills to cover, head for the door and change insurers and/or revert to basic plans (with contributions out of pocket as high as 40%, but that doesn't matter as these people don't pay anything if they don't go to visit a doctor). With these net payers all gone, the "better" plans become insolvent, because you can't raise the premiums much, as the chronically ill tend to be able to afford less than those who just left. These plans are then abandoned by the insurance industry and the state has to pick up the bill. However, even the other plans eventually rise in costs as insurers have to lick their wounds and high member turnover leads to higher safety margins in a premium's calculation, etc. etc. etc. One could of course write a book about it, but this mechanism alone will kill first the "affordable", then the "care" and then some.