Wednesday, April 15, 2015

The candidate?


High Obamacare deductibles actually DEPRIVE people of insurance

The mantra that progressives used to pass ObamaCare was the constant call for “universal coverage.” Everyone, it was argued, should have a health insurance policy, and this goal was considered important enough to force everyone in the country to buy a product whether they wanted it or not.

But focusing on one goal to the exclusion of all others can lead to unexpected pitfalls, and now, as ObamaCare turns five, we are seeing that universal coverage is meaningless without taking into account the price and quality of the – now mandatory – insurance policies.

By now, we’ve all heard about the cancelled policies and the rising premiums, which the administration has tried to justify with the unprovable claim “it would have been worse without ObamaCare.” We’ve heard about the coming doctor shortage, and the declining attendance at medical schools. And we’ve heard about the rising penalties for those who choose not to buy health insurance. But there is one aspect of insurance that has not received enough attention, and that is more devastating to people’s actual access to care than almost anything else: rising deductibles.

The deductible on an insurance policy is the amount you, the customer, have to pay out of pocket before the insurance company starts picking up the tab. Obviously, low deductibles are preferable to high ones, but some people may opt for a higher deductible in exchange for lower monthly premiums. Or at least, they used to back when they actually had a choice.

Under the Affordable Care Act, choice has been discarded in favor of uniformity, and the practical result is the worst of both worlds: higher premiums, and outrageous deductibles all at the same time!

The Kaiser Family Foundation recently released a study showing just how few people are actually able to afford ObamaCare’s deductibles. On average, just 63 percent of non-poor, non-elderly households have enough money to afford a mid-range deductible of $1,200 to $2,400. Most mid-priced ObamaCare plans fall into this category, meaning that more than a third of people who are forced to buy these plans cannot actually afford to use them.

For less well-off individuals, the news gets worse. For higher deductible plans, between $2,500 and $5,000, only 51 percent of households have enough money to pay. This is particularly grim, considering the individual deductible for ObamaCare’s cheapest plan, the Bronze Plan, has been set at an astonishing $5,181 for 2015.

People who opt for the Bronze Plan are not likely to be rolling in cash. These are the people who do not have employer-provided health insurance, and who want to pay as little per month as possible, while gambling that they remain healthy enough to avoid any serious hospital visits. In short, young people and those working temporary or part-time jobs, and not exactly the type to have $5,000 just lying around. Unaffordable insurance might as well be no insurance at all, except, of course, that anyone trying to opt out will be punished with steep penalties from the IRS.

And even without making these kinds of assumptions about Bronze Plan users, the fact that fully half of households cannot afford such high deductibles should be cause for concern for anyone who cares about actually lowering the cost and increasing the quality of medical care, rather than just ticking symbolic “universal coverage” box.

All this reveals what we have known all along. ObamaCare was never about helping people. There is no point in having insurance at all if the deductibles will bankrupt you, and universal coverage becomes a meaningless shibboleth for progressives more concerned with legacies and talking points than with actual governance.

Anyone actually interested in making health care in America better, rather than simply scoring political points, would do well to follow the principles of free markets and patient-centered care. It’s time to dismantle a broken federal bureaucracy, and let doctors go back to serving the interests of patients, not of the government.



The latest Doc Fix will shaft the really sick and the elderly

When the Senate returns from recess this week, it will consider the “Medicare Access and CHIP Reauthorization Act” (MACR). The bill has acquired many names such as “The Doc Fix Fix” and “Budget Buster,” but a more appropriate one is “IPAB-lite.”

IPAB — the Independent Payment Advisory Board — was created as part of Obamacare to cut Medicare expenditures whenever those expenditures grew too quickly. Thankfully, IPAB’s unpopularity has thus far prevented it from getting off the ground. Unfortunately, the changes MACR makes to Medicare’s payment system seem very much along the lines of what IPAB would do. After all, the new payment system within MACR is consistent with IPAB’s mission, incentive structure, and likely outcomes.

IPAB is the sort of grandiose scheme one would expect from social engineers. Its mission includes producing proposals “aimed at extending the solvency of Medicare, lowering Medicare cost-growth, improving health outcomes for beneficiaries, [and] promoting quality and efficiency.” Of course, whether IPAB could achieve such goals is dubious given its incentive structure.

The incentives that IPAB’s board members would face would give them little reason to be concerned about the adverse outcomes of their proposals. IPAB members would likely pay little to no cost if they made decisions that harmed patients. The most they might suffer is public criticism and a resignation before their term is up — assuming, of course, that the consequences of their decisions become apparent before their term expires. Given how long it can sometimes take for policy decisions to be linked directly to bad consequences, IPAB members may be long gone from the board before the consequences of their decisions become apparent. If IPAB members are unaccountable for being wrong, odds are their decisions will have adverse outcomes.

One of the most likely effects of IPAB’s cost-cutting authority is that sicker patients would suffer the most. The reason is that such patients have the hardest time fighting back. More specifically, they have little ability to influence Congress to overturn IPAB’s proposals. Relatively few people become seriously ill each year, not enough to have much impact at the ballot box. Furthermore, people who are ill are generally not engaging in the networking, meetings and other activities necessary to influence Congress. As such, IPAB’s proposals could harm the sick with little political fallout.

The new payment system MACR creates for Medicare is eerily similar to the IPAB model. Dubbed the Merit-Based Incentive Payment System (MIPS), it will reward or penalize physicians who treat Medicare patients based on various metrics. Two of the metrics that MIPS will use to grade physicians are how well physicians’ patients score on quality measures and how many medical resources physicians use to treat patients. Under MIPS, a physician will receive a composite score, between zero and 100, based on how well he meets the MIPS criteria. Each year, the Centers for Medicare and Medicaid Services (CMS) will choose a “threshold” number. If a physician minimizes the use of medical resources while his patients score well on quality measures, he will likely score above that threshold and he will receive a bonus. If he scores below it, he will be penalized with a cut to his Medicare reimbursement.

The intent behind MIPS is consistent with the IPAB mission of lowering Medicare’s cost growth and improving quality. The quality measures and resource use components of MIPS are supposed to promote those goals by rewarding physicians who provide quality care at a lower cost.

But it is unlikely MIPS will achieve those goals without also harming the sickest patients. First, MIPS will be run by people with incentives similar to IPAB. The various metrics and thresholds will be devised by CMS bureaucrats, most of whom will have civil service protection. Thus, it will be all but impossible to fire them, even if MIPS does harm patients. Additionally, CMS will be advised by professional medical organizations on which quality measures to use. They, too, will pay little cost for being wrong since they receive their funding from health-care professionals and not patients.

Second, MIPS will incentivize physicians to avoid the sickest patients. For physicians, the easiest way to have patients who score well on quality measures and limit the use of resources is to treat patients who are only moderately ill. Patients who have their diabetes or their heart conditions under control will generate better scores on quality measures such a blood sugar level or blood pressure. Keeping such patients healthy will involve fewer resources. These factors will increase the chances that a physician gets a bonus on his Medicare fees.

By contrast, sicker patients will score poorly on quality measures. Treating them will require more resources. A sicker caseload likely means a physician will fall below the MIPS threshold and see his Medicare fees cut. In short, the sickest Medicare patients will have a harder time finding physicians who will treat them thanks to MIPS.

Yet it is the sicker patients who are most in need of a physician’s care. Indeed, they are the patients that a program like Medicare is supposed to serve in the first place. When President Lyndon Johnson signed Medicare into law in 1965 he said, “No longer will older Americans be denied the healing miracle of modern medicine.”

Yet the MIPS program could do exactly that, at least for the Medicare patients with the most serious health problems. And changing it will prove exceedingly difficult as the sickest patients lack the political clout necessary to influence Congress

One of the goals of MACR, eliminating the unworkable Sustainable Growth Rate, is a worthy one. Getting rid of this perennial problem, however, should not come by way of a new payment system that will make it harder for sicker patients to obtain physician care. The Senate should remove MIPS. Otherwise, lawmakers risk installing an IPAB-style payment system in Medicare.



Is ISIS Islamic, and Other “Foolish” Debates

“Do they think we are Jewish now? LOL,” responded one ISIS fighter in Syria when asked for his thoughts on the current public debate about whether the Islamic State is actually Islamic. He went on to make an argument, as many of these fighters often do when interviewed, that not only is the Islamic State Islamic but it is the purest and most pristine form of Islam, the kind most in line with what God and His Prophet had intended all along. Another ISIS fighter from South Africa, when asked how he knew that the Islamic State was legitimate, remarked that “I just used my brain.”

“The truth is never endorsed by the masses,” he said. “It’s always the smallest groups that are firm in truth. Migration becomes compulsory when a caliphate is established on the foundations of Sharia Law, and Muslims around the world have no valid excuse to remain amongst the infidels in enemy lands.”

This line of argument by members of the Islamic State and, to be sure, numerous other Salafi-Jihadi movements creates a major dilemma for Muslim communities around the world. How are they supposed to deal with violent movements within their faith, tiny in number but claiming greater religious authenticity, and greater claim to the truth? While this question and the debate surrounding it has been a persistent undercurrent in Western societies since 9/11 at least, the most recent spike in the conversation occurred after Graeme Wood’s cover story in the Atlantic and the numerous responses that followed. It was a welcome conversation, even if, as Wood himself recently noted, the “debate is mostly foolish.”

It is indeed foolish for a few different reasons. Firstly, the debate is largely between an “academic” view of Islam and the divisions within it, peaceful or otherwise, and a normative view of Islam, which seeks to distance the rigid, conservative, and violent forms of the religion from the one practiced by the vast majority of Muslims around the world. To argue that ISIS isn’t “Islamic” in a normative sense is to argue, to some degree, that Salafism isn’t a branch of Islam and that jihad isn’t a noble concept in the religion, arguments that are false and misleading, and severely hinder attempts to understand these movements properly.

While there was some discussion following 9/11 about whether “Al-Qaeda was Islamic”, the debate wasn’t as heated as it is today with the Islamic State. Al-Qaeda was in many ways easier to set aside – they were strange men with beards living in far off caves. When Muslim youth in Western countries join in significant enough numbers, it raises the question of Islamic authenticity more acutely. This happens even though Al-Qaeda and the Islamic State are not all that different in their commitment to violent Salafi theology. The only difference, as Cole Bunzel recently pointed out, is that ISIS practices it “with greater severity.”

Secondly, what has been missing from virtually all the articleswritten on the topic thus far is a sustained analysis of ISIS primary documents and actual interviews with jihadi fighters in Syria and Iraq. Looking at ISIS documents, murals, billboards, media releases, and other publications, as well conducting interviews with fighters themselves, offers the best insight into the sources of inspiration for the group’s ideology, which defies simple characterizations. Most broadly, ISIS’ ideology is based on a narrative that is well-known, that the Muslim world has been in decline due to the lack of a Caliphate under which Muslims can fulfill their faith by living according to Islamic Law. The state of the Muslim world today is contrasted with an idealized period of history – the so-called ‘Golden Age’ of Islam, not only referring to the ‘rightly-guided’ caliphs who immediately succeeded Muhammad but also the Umayyad and Abbasid Caliphates extending through the medieval period that saw the Muslim world further ahead in scientific and human development than the West.

As a result of this projection onto an idealized medieval period, ISIS documents and publications do not adopt a mere ‘back to basic sources’ approach (in this case, the Qur’an and Sunna embodied in the hadith and life of the Prophet). Rather, great emphasis is placed on showing respect for the rulings and opinions of authorities of the four traditional schools of Sunni jurisprudence developed during the medieval period. To be sure, that does not mean no authority is given to modern jihadist thinkers or the Salafi-Wahhabi purist ‘reform’ trend dating back to the 18th century often invoked to describe ISIS’ inspiration.

While statements by Abu Mus’ab al-Zarqawi, Osama bin Laden, Sayyid Qutb, and Wahhabi scholars can all be found in detail in ISIS documents and publications, there are also considerable documents citing opinion from the four schools of Islamic legal tradition. For example, in a statement distributed in the Fallujah area on offering prayers on Eid al-Adha and Eid al-Fitr, three differing categories of opinion are given on whether the prayers are obligatory, citing all four schools to illustrate the range. In other instances, the concept of ijmaa (consensus) among the Ahl al-’Ilm (theologians, jurists etc.) is stressed, such as in a Friday sermon for Ninawa province mosques on the division of the world into the abodes of Islam and disbelief.

One could go on, but it is in the realm of IS fatwas in particular – issued by its Diwan al-Eftaa wa al-Buhuth – where the impressive ability to find opinions from medieval jurists and theologians is laid bare. Many of them are unknown to most of the outside world, including contemporary Muslims. The best example is the fatwa ISIS issued to justify burning alive the Jordanian pilot, deemed an ‘apostate’. Many were quick to say this practice is absolutely condemned in Islam, but ISIS cited Hanafi and Shafi’i jurist opinion to claim it is permissible, including specific citation of a 15th century Egyptian Shafi’i jurist.

Though the Islamic State’s approach can be dismissed as “selective quoting” of tradition, the fact remains that ISIS’ critics can be accused of the same thing. The problem is that with such a huge corpus of Islamic literature and no central infallible authority like the Pope to regulate teachings, many of ISIS’ actions, seen as heinous in this day and age, can find a place within the vastness of Islamic tradition.

We may dismiss such evidence by claiming that ISIS is only citing them in order gain legitimacy and credibility among its followers, but that’s precisely the point: they feel reassured that they have a coherent theological basis in their actions. Of course it is inaccurate to say that ISIS is Islam en bloc, but to label the movement un-Islamic is to take a normative, and ultimately self-defeating, stance. It is an argument which ignores some very basic evidence regarding the movement and its history, and impedes proper understanding of what they believe and where they are heading.



For more blog postings from me, see  TONGUE-TIED, EDUCATION WATCH INTERNATIONAL, GREENIE WATCH,  POLITICAL CORRECTNESS WATCH, AUSTRALIAN POLITICS, and Paralipomena (Occasionally updated) and Coral reef compendium. (Updated as news items come in).  GUN WATCH is now mainly put together by Dean Weingarten. I also put up occasional updates on my Personal blog and each day I gather together my most substantial current writings on A WESTERN HEART.

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