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Harold Pollack: Welcome to another, uh, edition of Curbside Consult.
Aaron Carroll: Thank you. Glad to be here.
Harold Pollack: Maybe we can start by having you introduce yourself.
Aaron Carroll: Sure. I'm Aaron Carroll. I'm a pediatrician and a health services researcher.
I'm a professor of pediatrics at Indiana University School of Medicine, and I am the director
of the Center for Health Policy and Professionalism Research there.
Harold Pollack: And how do you and I know each other?
Aaron Carroll: I guess we've known each other for a number of years now but mostly through
the blogging world. We blog at the Incidental Economist together.
Harold Pollack: So why don't we start talking about the *** at healthcare.gov?
Aaron Carroll: Okay.
Harold Pollack: How bad do you think it is?
Aaron Carroll: Well, that's a good question. It's broad enough that I think it needs to
be broken up a bit. How bad is it for whom? For the administration, it's horrible. It's
shown that they perhaps don't have the managerial expertise to hold this together.
I think it feeds into the argument that government can't do anything right, that they're slow,
that they can't innovate, that they can't get things done on time or on budget. So I
think from the perspective of "How does this look in changing people's minds about the
idea that government can really do comprehensive healthcare," it's terrible.
I think it's terrible for people that are trying to sign up for insurance too. If you've
been waiting to do this, uh, and you're, you're getting on the website and it won't work,
and what you're finding out is wrong, and it's not the correct information, and it's
slowing you down, that's horrible. On the other hand, it's important to remember, none
of the insurance was going to kick in yet.
It all kicks in on January 1, so even if people can't sign up yet, it's not as if they sign
up today versus next month would make any difference in their health at all. Because
none of the coverage would kick in sooner. But [still] you know, it, it's not good. You
certainly wish it would go, would have gone better, uh, and, and we hope that they will
fix it.
Harold Pollack: A couple of things about that. Among supporters of, of healthcare reform--myself
being one--there's been an interesting reaction. I think there, there are a bunch of technocratic
types who are basically saying, how could we improve the way the government does IT?
Aaron Carroll: Mm-hmm (affirmative).
Harold Pollack: They look at healthcare.gov's problems and compare it to (say) cost overruns
in the Pentagon... All of a sudden, Al Gore's Reinventing Government thing doesn't seem
quite as narcolepsy-inducing as it did two months ago.
Aaron Carroll: Right.
Harold Pollack: How do we make this work as a sort of bureaucratic performance issue?
Then there are people on the little bit further left like Mike Konczal who are saying: "Hey,
wait a minute. All these conservatives are saying, this proves something bad about government's
capacity to do stuff. If we had single payer, you'd get on the website, and it would just
say, 'you're covered.' It's really this sort of kludgy public/private effort to get the
market involved that makes everything way more complicated than it needs to be."
Aaron Carroll: Yeah.
Harold Pollack: In fact, if you go to the state of Kentucky...if you go to Massachusetts,
they have an exchange. It's working well, and it's doing what it's supposed to do. We're
all making these global conclusions based on the fact that in the past month, we've
had a really bad website.
Aaron Carroll: Well, you know, and it's also one of those where I've found some of the
attacks to be very shortsighted because many conservative plans to reform Medicare involve
creating exchanges and, getting people to shop online for private plans. So it's basically
everything that, that the Affordable Care Act does, but instead of doing it for 17 or
18 million people right now, we'll do it for everybody on Medicare. And if government can't
get this right, I don't know why there's any expectation that all of a sudden they can
turn around and get that right...
Creating a private exchange is part of many types of healthcare reform that, that appear
from both sides of the aisle. If they can't get this right, it eliminates many of the
options for, for future types of healthcare reform that many people have proposed.
Harold Pollack: What's ... you may know someone named Austin Frakt.
He notes that this whole episode reinforces the incredible status quo bias that we all
have towards our own healthcare, whatever it is ... Once this gets done in place, the
next time anyone wants to really change healthcare, people are going to say, "Hey, wait a minute.
You're messing with my Obamacare."
Aaron Carroll: It's the "get the government hands off my Medicare" problem. it's important
to remember that Medicaid was passed in the 60s, and the last, the last state finally
came on board in [1982]. That was Arizona. Um, they were the first to leap onto Medicaid
or one of the first to leap onto Medicaid expansion from the conservative states this
time around, so you know, it is, it will be fought.
It will be long, and it will be hard, and it may take 20 years as it did with, with
traditional Medicaid but it will be very hard to sort of go backwards once these things
get started. I think the conservative concern is simple: Of this goes into place, it will
be nearly impossible to get rid of it, there's some truth to that. It will be possible to
pare it back, but to rip Medicaid away once the expansion is in place, or to tell millions
of people who have gotten insurance once this truly does get going next year that they're
going to take it away--that's gonna be hard. I think Austin's right. Eventually, we will
have a status quo bias, where this will be the status quo.
Harold Pollack: By the way, in some low-income southern states, you could see 30 or 40% of
working-age adults on Medicaid. That will be just an amazing transformation
Harold Pollack: So just, just to remind people, we're at Curbside Consult. I'm Harold Pollack,
and I'm talking with my friend, Aaron Carroll. Let's shift a little bit over to the media
coverage of the roll out of healthcare.gov. By common consent, there's an epic fail by
the Obama administration in the roll out of the website, uh, but what do you think of
the way the media's covered it?
Aaron Carroll: I'm very cynical about the media.... They're like squirrels. They follow
whatever is flashy and new, and they're zippin' all over the place. I think at the moment,
the narrative is: "Look who's getting screwed, and look how bad it is, and Obamacare was
a big lie, and people are getting hurt by it."
Once those kinds of narratives get built, they get a little bit of momentum behind them,
and all of a sudden, everything's discussed through that lens. This has been a liberal
complaint. I'm sure you can find conservatives who have this exact same complaint about,
for example, the 47% ...
At the moment, they are fixated on finding stories about people who are getting screwed
by Obamacare. It is possible to find these people. I'm sure that there are younger-ish
healthy people who had decent plans that were pretty cheap because they were individually-rated
pretty low, but they're a minority. Vastly more people are going to benefit from the
Affordable Care Act than will be hurt by it, and yet almost all the stories are focusing
on people who are potentially hurt.
Ironically enough, even when we're finding those people, it turns out half of those stories,
if not more, are falling apart, that it turns out that they're not even being accurately
reported, that they might actually be better if they get subsidies or if they, you know,
just searched a bit further or, you know, or it turns out that they actually have chronic
conditions or even pregnancy. Many would actually benefit immensely from the Affordable Care
Act, and they just don't realize it yet. So it's still even hard to find those anecdotes
to, to show how people are being hurt but, but I don't want to get into that.
I always take things from a population level. Are we describing the vast majority of people
or are we describing a small subset and making it sound much worse than it is?
Harold Pollack: A, a couple of points on that. First, it is remarkable to me how every single
piece of anecdata has, has fallen apart on scrutiny. NBC describeda lady in California
and how her policy was cancelled, and then she had to buy one that was ten times more
expensiv. A reported from the L.A. Times called the woman up.While he talked to her, and he
did two really complex things.
First, he actually looked at her old insurance policy, which it turns out doesn't basically
cover anything. As one expert put it, she's paying money almost to be uninsured. Then
the reporter got on the exchange, Covered California, and he says, okay, what could
she get. It turns out that, in fact, she's a winner, not a loser from healthcare reform.
Harold Pollack: About every single story that I've seen has imploded in this way. Sean Hannity
had an episode where he had six people on, and all six of them it turns out that with
the most rudimentary fact checking, all six of the stories just falls apart. These anecdotes
may be totally unrepresentative. Even on their own terms, almost every one of these anecdotes
just turns out to be wrong.
Harold Pollack: By the way, these are not corrected or if they are corrected, the original
error occurs in some massive outlet like NBC or Fox, and the correction appears in the
New Republic or Salon, which of course have smaller reach. So the narrative of fiasco
is perpetuated, while many of the real human tragedies that don't happen to fit this narrative
are completely ignored.
Aaron Carroll: That's right. Well, I mean, yeah, the five million people who are not
getting Medicaid expanded. The millions of people who are going to get Medicaid-that
might be a great story. Or the millions of people who eventually will get some sort of
insurance, almost all of them with subsidies, so that it becomes relatively affordable.
The fact that people had insurance before that had incredibly low annual limits if these
had comprehensive hospital coverage at all.
Harold Pollack: I think it also has something to do with who is benefitting and who not.
One of the sadder aspects of this story is that Medicaid recipients and people who are
not on Medicaid but need to be are a disorganized group of people who are politically marginal
and who check off every box for other-ness in the eyes of the marginal middle class voter.
It is a sad sign of the times that we are just more willing to ignore what's going on,
with, with those folks than we are to ignore other people who have less profound need.
Aaron Carroll: Well, almost anyone who is being screwed by Obamacare falls in the middle
class, almost by definition because they could afford some sort of plan. SNAP nutritional
benefits were just massively cut this weekend, and I don't think it appeared on the Sunday
shows at all, and that was for many, many more millions of people. But they almost all
fall into the very low end of the socioeconomic spectrum.
Harold Pollack: By the way, just for, for our listeners, so SNAP benefits, which is
food stamps and related programs, was just cut by about 5% to about 48 million people.
Aaron Carroll: If we had a 5% tax increase on someone else, they would lose their money...
You know, yes, 5% doesn't sound that big until it affects you. Then all of a sudden, it's
a huge deal that will destroy the economy. Right. If we say, if we said Obamacare was
raising people's health insurance by 5%, people would all lose their minds.