The Hardest Part of Setting Up ObamaCare's Health Exchanges

It's been clear for a while that the most difficult part of building ObamaCare's health exchanges will be setting up the systems to determine benefit eligibility.

As I noted back in Reason's October 2010 issue, the exchanges — whether they are run by the states or the federal government — will have to be able to verify someone's family income as well as a number of other determining factors. And to do that, they'll have to play nice with an array of government I.T. systems. The Washington Post has some additional details on the challenges involved:

After people become aware of benefits, the health exchange faces its biggest challenge: Figuring out who is eligible for what. In many states those who earn less than 133 percent of the Federal Poverty Line are eligible for Medicaid — except if the state has already extended benefits to an even higher level, as 35 states have for children. 

“There may be different family members eligible for different programs,” says Sam Gibbs, vice president of sales at eHealthInsurance. “There needs to be a technology system that can support that activity, and look at multiple programs for multiple people.”

A state can’t figure out how much an individual earns on its own. For that, it needs to ping a federal data hub that does not yet exist.

The federal government recently contracted with the healthcare IT firm QSSI to build that data hub, and they plan to make it available to both the exchanges that states run and those that the federal government sets up. It will determine whether individuals are eligible for Medicaid, subsidies or no benefit at all.

The challenge here is for states, which may have complex Medicaid rules or old computer systems, to actually plug into the federal hub. 

“In many states, the Medicaid system is the best technology that the 1980s could offer,” says Bruce Caswell, who runs the health-services segment of Maximus, a firm that works on large government data systems. “As a consequence, they might have brittle interface capabilities.”

An old Medicaid system, for example, may only have the capacity to send large batches of data each night. That was fine back in the 1980s, when most applications happened by mail. It’s less desirable when you have a law that would like to see real-time application processing. 

These systems are going to have to work with a high degree of accuracy: It's going to be a big problem if the exchanges are routinely assigning people higher or lower subsidies than they qualify for, or doling them out to people who don't qualify for them at all.

Yet that's exactly what researchers worry could happen. A Health Affairs study by a researcher at the Vanderbilt University School of Medicine published earlier this year estimated that, due to the complexities of calculating an individual's income for the purposes of subsidy distribution, a non-trivial number of exchange enrollees are likely to get the wrong subsidy. Incomes fluxuate unexpectedly. The time frames used to judge income are too small. The databases used to verify individual income are incomplete. yet the exchanges are going to have be able to make relatively swift judgements about income levels and subsidy qualifications anyway. 

How are the exchange designers going to manage this? The answer is: It's going to be very, very complicated. So complicated, in fact, that they may not get it done on time. States were originally supposed to inform the federal government this week of their decision to either build an exchange or let the federal government try to do it for them. That deadline has been extended. But it may already be too late. “These are systems that typically take two or three years to build,”  Kevin Walsh, who manages insurance exchange services at Xerox, told the Post. “The last time I looked at the calendar, that’s not what we’re working with.”

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  • John||

    These systems are going to have to work with a high degree of accuracy: It's going to be a big problem if the exchanges are routinely assigning people higher or lower subsidies than they qualify for, or doling them out to people who don't qualify for them at all.

    It is almost as if Top Men don't have the information sufficient to run an economy.

  • robc||

    Thats just crazy talk.

    If that were true, someone would have had some sort of theory about it. Called it something like the information problem or the calculable problem or something.

  • John||

    Surely someone would have written a book pointing this out. Wouldn't you think?

  • robc||

    If such a problem existed, it would have been noticed a long time ago, so that book would be written in some european language, something weird like Austrian or something.

  • geo1113||

    That's because they don't.

  • John||

    Forgot the sarc tags.

  • ||

    Since I don't feel like answering each little post on this because Groovus Cassandra Maximus predicted ALL of what you see (I was only wrong about speed of implemetation), and will continue to see (oh, and need we forget that physician owned hospitals are verboten under ObamneyCare, forgot about that, didn't ya Shriek?) to unfold, by design, and with complete TEAM RED compliance behind the scenes. Yes, I know they voted against it initially, but it was going to pass, and they knew it, and they certainly haven't put up any fight against it when it counted (debt ceiling deal, anyone? Bueller?)

    I am convinced Romney was a fall guy to prevent any pretense of repeal, if he actually happened to win when Hitler started ice skating. I am also convinced Dread Justice Roberts believed, or was convinced "MEDICAL CARE IS A RIGHT!!!" and ruled accordingly to protect this giant abortion of a law. Also, 21 discrete taxes are part of this law, and you folks that wanted EITC and other little goodies to go bye-bye, well they do whenever a family without coverage files their taxes and the per child allowance also decreases. I'm not sure it's worth getting rid that smaller redistribution for a much, much larger one.

    Now, as RC Dean once put it recently and eloquently, I will go "cavort with the Slavic wimminz," and periodically update you people what private practice in centralized medical scheme is like.

  • db||

    Did you ever call into a radio show before you left to say you were leaving the country to avoid professional slavery, as I suggested?

  • R C Dean||

    The smart thing for the Repubs in the House at this point would probably be to give up on repealing OCare, which ain't gonna happen, and instead just vote down any attempt to fix it.

    Its a 100% Democratic program, so let it lock up and fail. Why not? The Repubs will get the blame for problems anyway, and the Dems will get the credit if the Repubs fix it so it kinda works. The only upside for the Repubs is a colossal failure of the whole mess. And for that to happen, all they have to do is . . . nothing at all.

    Prediction: they will botch it.

  • John||

    You are right. They should quietly torpedo any attempts to fix Obamacare. They can't be as blatant about it as you say. But they should just put poison pill stuff in any attempt to fix it. They own the House. So just vote in an Amendment to ban funding to planned parenthood or some other wedge issue the Democrats can't compromise on on any fix.

  • Palin's Buttplug||

    The House will be busy voting on anti-abortion bills for two years. And maybe a wild-hair investigation or two as well.

  • John||

    And meanwhile the country is going to be further falling to shit on Obama's watch. Good luck with that.

    And is Diane Feinstein now an evil Rethuglican?

    http://dailycaller.com/2012/11.....azi-video/

  • Sevo||

    Palin's Buttplug| 11.13.12 @ 11:03AM |#
    "The House will be busy voting on anti-abortion bills for two years. And maybe a wild-hair investigation or two as well."

    Shreek, your obsessions are not shared by many.

  • ||

    The House will be busy voting on anti-abortion bills for two years.

    I was under the impression that "MEDICAL CARE IS NOT A RIGHT" to you, Shriek.

    Surgical and pharmaceutical abortions are discrete medical care and procedures.

    Are you suggesting there is a "RIGHT TO MEDICAL CARE!!!!" now?

  • ||

    But they should just put poison pill stuff in any attempt to fix it.

    Who needs a poison pill when you can quietly kill any such bill in committee by not giving it a hearing?

    Or by taking any such bill, and doing a "gut and replace" and turning them all into Obamacare repeal bills?

  • AlexInCT||

    This is not a good idea, because the failure of Obamacare is the end goal that the people that passed it want anyway. Obamacare is supposed to sabotage the system in such a way that it forces people desperate for care to accept the single payer system that is the end goal of the marxists behind the nationalization of healthcare.

  • Pro Libertate||

    The House leadership should have one canned response to everything initiated by the administration or the Democrats in the House: "No, fuck you, cut spending."

  • John||

    The irony of watching Democrats begging Republicans to help them fix Obama's signature achievement would be fabulous. Sadly, we are probably not living well enough to see it.

  • Pro Libertate||

    "No, fuck you, cut spending."

  • John||

    It would be brilliant. What are the Democrats going to say? The obstructionist Republicans won't help us save America from the evils of Obamacare?

    I don't think there will be any fixes forth coming. That is such a no brianer even Republicans will figure it out. The Dems are stuck with that pile of crap.

  • Pro Libertate||

    The bad news is, so are the rest of us.

  • R C Dean||

    That is such a no brianer even Republicans will figure it out.

    Such optimism.

  • WTF||

    That is such a no brainer even Republicans will figure it out.

    They're called the Stupid Party for a reason.

  • Pro Libertate||

    That's why I'm offering them this canned response, free of charge: "No, fuck you, cut spending."

    If the Democrats actually agree to cut spending a little, then there is an additional response: "Thank you. Now fuck off, cut more spending."

  • ||

    " If the Democrats actually agree to cut spending a little,"

    I'll have what you're having.

  • Pro Libertate||

    It's just a hypothetical. When in doubt, use the standard response: "No, fuck you, cut spending."

  • GW||

    Not gonna work. The dems will blame the Republicans, and supporters of Obamacare will believe them.

    The fact that it's a flawed, bullshit piece of legislation to begin with, that might need "fixes" to work properly, will be a point completely missed by these morons, who literally think that they can be handed something at no cost with the stroke of a pen.

    Obamacare will be such a train wreck that the next "fix" for it will be a single payer system.

  • robc||

    "No, fuck you, cut spending."

    Ive decided what the House should do is just concede, based on one condition, cutting spending.

    Announce that they will pass any budget, any tax cut changes, anything the White House wants along those lines as long as the budget is balance.

    I would even let them target balanced in year 4 (8), but a straight line target for every year between now and then. Choice of cuts are entirely up to the White House.

    Deficit in 2012 was $1.1T.

    So give them target of $800B this year, $500B the next, $200B the third and balanced Obama's final budget.

  • robc||

    As part of this, the House has to refuse to pass anything at all unless the WH agrees.

  • Brett L||

    The House has passed at least one updated budget every year. The Senate hasn't passed anything but CBRs and additions in 3.

  • robc||

    I understand, but passing explicitly Obama's budget (with certain deficit restrictions) would force the Senate's hand.

  • Pro Libertate||

    "No, fuck you, cut spending."

  • ||

    I like your ideas. Do you have a newsletter?

  • Pro Libertate||

    "No, fuck you, cut spending."

  • LTC(ret) John||

    We need T-Shirts and bumper stickers of that.

  • deified||

    I would like to hear this in Eric Cantor's drawl

  • Red Rocks Rockin||

    The smart thing for the Repubs in the House at this point would probably be to give up on repealing OCare, which ain't gonna happen, and instead just vote down any attempt to fix it.

    Any attempt to "fix" Obamacare would be negated by the Plans/Reality Mismatch anyway, so you're probably right.

  • Almanian_||

    We were listening to the Top Arnold Quotes on Youtube this weekend while drinking moonshine and Jim Beam. And beer, now that I think about it.

    Good times...

    Anyway - they quote that seems applicable here is, "GET TO DAH CHOPPAH! NOW!"

  • Spoonman.||

    They opened a new dorm at Cornell, but failed to put the "evacuation plan" sheets of paper in the little plastic slots for them.

    Some genius filled them with a picture of Arnold and "GET TO DA CHOPPAH!"

  • Almanian_||

    #WINNING

  • Fist of Etiquette||

    Does the bureaucracy actually care if the correct benefits get to the right people?

  • John||

    Yes. How do you buy votes if it doesn't go to the right people?

  • Oso Politico||

    'A state can’t figure out how much an individual earns on its own.' - an individual is now just an 'it'? - Reason has left the house for PC Land.

  • R C Dean||

    Yeah, should have gone with "his/her/hir" to really hit all the PC notes.

  • ||

    I use "his" when the gender's unknown. "Their" for singular use gets on my nerves.

  • Pro Libertate||

    That's still good English. Plurals are dumb, "it" is demeaning, "his/her" is clunky. BFD.

  • R C Dean||

    "his/her" is clunky.

    And, of course, micro-aggresses against the transgendered.

  • Pro Libertate||

    Believe it or not, I was thinking the same thing but just couldn't type it. We're so screwed up.

  • Jordan||

    I'm pretty sure that "state" was the antecedent here, not "individual".

  • Pro Libertate||

    Yes, you are correct. Should've noticed that myself.

  • Zeb||

    Reading comprehension not your strongest point?

  • Skyhawk||

    The 'it' in that sentence refers to the state.
    Removing the objective clause makes it easier to see-

    "The state can't 'X' on it's own"

  • Ken Shultz||

    "Due to the complexities of calculating an individual's income for the purposes of subsidy distribution, a non-trivial number of exchange enrollees are likely to get the wrong subsidy. Incomes fluxuate unexpectedly. The time frames used to judge income are too small."

    Why does central planning have to be so hard?

    Why can't they just tax the rich and give me what I want for free?!

  • Palin's Buttplug||

    This seemingly is already being done nationally.

    http://www.nytimes.com/2012/10.....html?_r=1&

    Under the Affordable Care Act, at least one of the nationwide plans must be offered by a nonprofit entity. Insurance experts see an obvious candidate for that role: the Government Employees Health Association, a nonprofit group that covers more than 900,000 federal employees, retirees and dependents, making it the second-largest plan for federal workers, after the Blue Cross and Blue Shield program.

  • R C Dean||

    How is the GEHA offering coverage to government employees in any way analogous to this exchange, Plug?

  • John||

    It is not. But shitting on threads and distracting people is what Shreek does.

  • Palin's Buttplug||

    To be eligible to participate in the multistate program, insurers must be licensed in every state. The Government Employees Health Association recently bought a company that has the licenses it would need.

    GEHA is licensed to operate as a national exchange. Don't you think they are set up to do credit/income verification?

  • John||

    No dipshit. All of their customers work for the government. That makes verifying income a bit easier than it would be with the general public. My God you are fucking stupid.

  • Sevo||

    Hey, s/he's amusing anyhow...

  • WhatAboutBob||

    Crazy old Maurice Palin's Buttplug. He's It's always good for a laugh.

  • R C Dean||

    And GEHA is licensed to operate as an insurance company, which is not the same thing at all as an exchange.

    I think fucking stupid sums it up nicely. Pardon me, sums him/her/hir up nicely.

  • fish||

    Not so stupid John...private employers will be compelled to use their own resources to provide the data gov wants. Private industry pays, government takes! A win/win!

  • John||

    Sounds nice but too many people work in the under ground economy or off the books for that to work.

  • Rasilio||

    Actually no it doesn't and they are not set up to verify income because income is not part of their equation. They merely have to verify eligibility which is determined by being a Federal Employee.

    Verifying income would mean knowing what investment income they had, what 2nd jobs they had, what their spouses employment status was, and a hundred other factors GEHA would have no access to.

  • John||

    Which makes it even less analogous to the exchanges.

  • Ayn Random Variation||

    Notice how it runs away after the talking point it was given was so easily refuted?

  • nicole just can't even!||

    OT: The latest on student loan forgiveness:

    Graduates currently in school or who graduated last May who DO NOT do public service work need not repay more than about 7% of their income toward their federal (that is, federally guaranteed or federally-issued) student loans, for 20 years. After 20 years, all remaining principal and interest is forgiven.
  • ||

    Arithmetic is hard. What could possibly go wrong?

  • nicole just can't even!||

    I'm not willing to do enough math to make myself really angry, but say you make an average of $50k over the period. You're only on the hook for $70k tops. I use $50k because it's roughly the HH average income (though individual income would be used to calculate this). I know a lot of people who took out more than $70k, not counting interest...

  • nicole just can't even!||

    Meanwhile, if I put 7% of my income toward student loan debt, I would pay it off in less than a year. Because I'm a fucking moron.

  • ||

    I paid mine off already.

    Because we're not parasites, we couldn't possibly understand the plight of all those Women's Studies majors who minored in Dingaling-dynasty Chinese literature.

    EDUCATION IS A RIGHT!!!

  • John||

    I still have a few. But not much. I am quite sure the day I pay the last one off, the government will forgive all of them. Everyone who was responsible must be punished and punished severely.

  • robc||

    I paid mine off the first week of each quarter of school BY PAYING THE FUCKING BILL.

    Of course, it was a lot cheaper in 87-91 than today.

  • SugarFree||

    I paid mine off the first week of each quarter of school BY PAYING THE FUCKING BILL.

    1%er monster!

    If 7% is the ceiling, what is the floor?

  • robc||

    I voted for Johnson.

    I am the 1%!

  • ||

    Wait, what? You PAID THE FUCKING BILL?

    What the hell's wrong with you? You're supposed to let the feds magic some money out of Obama's sheer willpower and do it for you.

    You're such a sucker!

  • nicole just can't even!||

    Well I'm glad rob is at least more of a sucker than I am.

  • robc||

    Also, grad school paid me to go to school.

    Ive always found it weird that other people pay lots of money to go to grad school.

  • John||

    Rob. You are nothing but an exploiter. You must be punished.

  • robc||

    You are nothing but an exploiter.

    Yep, me and every other grad student in engineering or science.

  • Mickey Rat||

    So your grad student years involved doing something useful for the university.

  • Spoonman.||

    NASA paid Rice and Rice paid me, but apparently many of the branch UT campuses don't pay their geology grad students a stipend.

    One guy who started the same time I did pretended it was a difficult choice between UTEP and Rice.

  • Lord Humungus||

    I also had no student loans when I graduated. Of course rates, even in '90-'95 were low.

  • Zeb||

    I had mine paid off by the time I was 25. I guess I'm a chump. Though I think they would have been paid by now in any case.

  • RG||

    Took the life insurance money when my father passed away and paid off all student loan and car debt. No fancy vacations or BMWs.

    What was left over got socked away in savings until we used it as a downpayment on our house.

  • ||

    Saving is for prudent people. I say take out lots of credit cards and buy expensive shit until you run out of money.

  • ||

    I know people who took out waaaaayyy more than $70,000.

    It's like these assholes don't understand that the laws of economics apply.

  • nicole just can't even!||

    Well, they were right. At least for a while.

  • ||

    Yeah, the feds are pretty good at conjuring money from thin air.

    That's what the Occutards were fighting for.

  • Auric Demonocles||

    Oh boy, I'm glad that kids a year younger than me get to skip out on a ton of their debt, on top of the reduced interest rates they already have. There's no way they could just pay 12% of their income like I'm doing, to pay it off themselves quickly.

  • ||

    Or you could just, you know, refuse to have anything to do with ObamaCare, and resist it entirely like a handful of states currently are.

    Better yet, follow Missouri's lead and propose a bill criminalizing attempts to enforce any part of the law by any authority, state or federal.

  • John||

    I really think we are going to see massive civil disobedience when the mandate kicks in. People just won't pay the penalty. What is Obama going to do? Throw millions of people in jail for tax evasion?

  • Palin's Buttplug||

    No, you idiot.

    The IRS just won't process a refund to the deadbeats.

  • Palin's Buttplug||

    err, scratch "deadbeats" and replace with "patriots".

  • John||

    The refund only matters if the IRS owes you money dipshit. That is easily solvable changing your withholding so you underpay.

    They will get retards like you. But everyone with an IQ above 80 will easily avoid it.

  • Palin's Buttplug||

    So you changed from "thrown in the slammer" to an easy fix on withholding.

    You are teachable after all.

  • John||

    What are you even talking about? You get more stupid every day. People will avoid that penalty by the millions. It will never be enforced. You just change your withholding so you owe money at the end of the year and then send in your money sans penalty.

    Just because you are retarded doesn't mean everyone else is.

  • Sevo||

    Dipshit, that sound you heard wasn't a jet; it was the point.

  • Restoras||

    I am so stealing this.

  • Ken Shultz||

    They can't throw you in the slammer, but it will still accrue as a penalty and compound with interest over time.

    They can't throw you in jail for it, but they can garnish your wages, seize your assets, close your bank accounts, ruin your credit rating, and harass your employer. They might go after your wife.

    They can do all sorts of things to ruin your life without throwing you in jail for it. And in the end, they'll get the money either through garnishment or attaching your assets anyway. There is no fear out there that the IRS will never get its money. You pay the penalty on your tax form. Anything you don't pay will be collected by the IRS eventually.

    Sure as death and taxes, right?

  • John||

    Sure they can do that. But when you have millions of people who are poor and really don't have the money, is the IRS going to spend their time chasing them down? Doubtful. And if they do, the political backlash will be brutal.

    My guess is that the whole thing becomes a Potemkin village where the government pretends to fine you and people pretend to pay the fine.

  • Ken Shultz||

    They already do all that stuff.

    Most people who go afoul of paying their taxes aren't wealthy people who can afford an accountant and a tax lawyer.

    And the IRS doesn't take people to court to garnish their wages. They just do it. I think you have to sue them to make it stop.

    Your boss gets a notice that so and so's being garnished, and your employer just sends that money to the IRS and takes it out of your paychecks until the amount is paid in full.

    For people living from paycheck to paycheck, that can be devastating. And if they don't pay the fee for year after year? It'll add up over the years and compound with interests, too! That happens to millions of people.

    I don't think that creates a big problem for the IRS. The systems they have now for garnishing people's wages works just fine.

  • John||

    And Ken, when the states refuse to expand medicaide, there will be millions of working poor who can't afford insurance and can't get on medicaide. I doubt the IRS is going to spend much time going after those people.

  • Ken Shultz||

    Now that is going to be an issue.

    I think that was what things like the takedown of Canandadrugs.com was really about.

    The government will work hard over the next few years to deny people any access to healthcare without going through an insurance company. Online pharmacies, for instance, are a lifesaver for the uninsured. The government will try to shut all that down--so that sick people won't have any other access to healthcare.

    I question whether their strategy will work, too. I think you've got a great point there. The uninsured could and probably will still overwhelm the system.

    Requiring people to buy auto insurance sure as hell didn't solve the problem of uninsured motorists. Why would this be any different?

  • GW||

    There's a gap in here somewhere. There are going to be lots of people who make too much to be on Medicaid, but too little to be responsible for paying the fine.

    And besides, unless the IRS steps up their game, the penaltax will be just like owing back taxes: owe them long enough, and Uncle Sam cuts you a deal for pennies on the dollar. People too broke to pay the penaltax are also the same sorts of chaps who will leave a job if and when the Feds start garnishing. Get a job somewhere else, and the cat and mouse game starts all over again.

    And unlike private sector bill collectors, the government bureaucrats don't have an incentive to actually recover the money.

    Can't wait to watch this clusterfuck happen. I'm gonna pop some popcorn.

  • ||

    I honestly think it might not even come to that in several states. Texas, Missouri, and Kentucky look like they're on a firm path to absolute defiance, and dozens of other states are in the process of constructing legislation comprehensively rejecting ObamaCare.

    Let's hope to God it turns out successful.

  • Fatty Bolger||

    The law doesn't even allow for that. I believe it does let them go into your bank account and just take the money, though.

  • John||

    The money has to be there. They will play hell enforcing that thing. Most people who don't have insurance are young and work on the margins anyway. The middle class people from whom those things are easy to enforce already have insurance.

  • Fatty Bolger||

    Yeah, I think the working poor are the hardest hit. They'll lose their refunds, and still won't have insurance.

  • robc||

    I will have insurance that I want, and will owe the penalty, but hopefully wont have to pay it, but even if I do, it will be cheaper than a gold plated policy.

  • Fatty Bolger||

    I think that's what a lot of sole proprietors will do.

  • John||

    Yup. But the refund was their money anyway. If they don't change their withholding to keep from paying the penalty they are shrike level stupid.

  • R C Dean||

    But the refund was their money anyway.

    Pish posh. Surely you know that all money is for make benefit of Greater Obamastan, and that while you may be graciously allowed to use a little of it now and then, its never yours.

  • Adam330||

    Refunds for the working poor are typically EITC adn other refundable credits, so not their money.

  • NoVAHockey||

    working poor are supposed to be caputred in the Medicaid expansion. right now nobody really knows what happens to these people if a state doesn't expand its coverage. there's kind of a no man's land. the law assumes there would be medicaid expansions and doesn't necessarily give subsidies to buy coverage to those people. you'll have a situation where there's poor on medicaid, slightly less poor and priced out, and higher up the scale with a subsidy to buy coverage.

  • Ken Shultz||

    The Medicaid expansion means more hospitals are going to be losing more money on them and, thus, jacking up the cost of care for everyone else in the system.

    Medicaid reimbursement is a pittance.

    It's almost an admission of guilt there, where they know what they're doing is going to jack up the cost of care, so they want to try to insulate the people who won't be able to afford the costs.

    That's probably the second best argument against ObamaCare right there. Medicaid is one of the main reasons the cost structure of the system is so screwed up--and expanding it to cover 17 million more people is just going to increase the proportion of that problem.

  • GW||

    If many doctors are like one of my physician friends, then Obama has another problem: because he's going to stop treating medicaid patients.

    You can certainly be handed your hand during the poker match, but they can't make you sit at the table and play.

  • R C Dean||

    I believe it does let them go into your bank account and just take the money, though.

    Oh, please let the IRS start stripping the rent and food money from thousands of young families living paycheck to paycheck. Please, please, please.

  • Ken Shultz||

    They already do it though!

    It'll just be on a wider scale.

  • Brutus||

    The infuriating thing about that MO Proposition is that we just reelected that bitch McCaskill, the one whose vote made the Proposition necessary. It tells you what a complete fucking unforced error Todd Akin was.

  • The Late P Brooks||

    "No, fuck you, cut spending."

    "But we promised to cut ten dollars of spending if you agreed to one dollar of revenue!"

  • Pro Libertate||

    "No, fuck you, cut spending."

  • R C Dean||

    Promising to cut spending =/= cutting spending. Please try again.

  • ||

    I'm wondering, have our Federal and state governments reached the point where their own dinosaur-like capacity for change will finally be their undoing? It seems like this is an insurmountable obstacle for any implementation.

  • John||

    That is a really good point. The state and locals are so unionized and resistant to any change, that you could never implement much of anything.

  • The Late P Brooks||

    Graduates currently in school or who graduated last May who DO NOT do public service work need not repay more than about 7% of their income toward their federal (that is, federally guaranteed or federally-issued) student loans

    I NEED THAT MONEY FOR MY DATA PLAN!

  • Jordan||

    North Carolina is currently in the process of creating a new Medicaid computer records system. Guess what their self-described "cutting edge" system is written in. COBOL. A dead language. Good luck finding anyone under the age of 50 to maintain that shit-heap. And as you may have guessed, the project is massively over-budget and behind schedule.

  • John||

    The crony who got the contract only knew COBOL. I guess all those guys who are out of work after fixing Y2K can get jobs in North Carolina now.

  • Palin's Buttplug||

    Sounds like it was outsourced to IBM.

  • Brett L||

    I'd love to say that I was shocked, but I'm not. "We got this Big Iron, and we are bygod gonna use it!"

    I knew a guy who saved a college $250k/year in mainframe maintenance contracts by installing a $50k Linux box running an emulator. (It was step one of a larger plan to spend most of that $250k/year over the next several years on getting the million and one little COBOL programs into the 21st century.)

  • Rasilio||

    COBOL?

    Is there anyone even alive that still remembers that language?

  • ||

    Just for perspective, COBOL is 53 years old.

  • R C Dean||

    Probably joined AARP a few years back, then.

  • Brutus||

    The vacuum tubes'll really be humming on that computer when they get it going, no?

  • ||

    We use a ton of it at my company. After decades of use, what are you going to do? Scrap a few million lines of code?

  • Rasilio||

    Um, if you are smart yes.

    You need a plan to migrate those few million lines of code onto modern systems with modern hardware because eventually you're going to have a hardware failure and find no one makes a system capable of running your Cobol files.

  • ||

    All you have to do is keep writing new shells. Then the COBOL just keeps floating along like a boat down a river.

  • Rasilio||

    Yep the bandaid approach.

    Until you get to a point 40 years down the line when you need to make a change and literally can't find anyone who knows what that cobol code does.

    Sure your approach can work for a while, but eventually it will break down and need to be replaced and you can either do that in a planned manner or wait till it is a crisis.

  • Ken Shultz||

    Yeah, I think a lot of that is just to keep compatible with tons of antiquated government systems.

    Who wants to pay to rewrite all of that stuff from scratch? And since they payers are used by so many very different agencies--just in the same state--you're gonna have to get them all to agree to rebuild everything from scratch.

    I used to be a quality control analyst for a company that payers for every state in the country--New York was the worst. You need backward compatibility with things that were written in the mid-70s.

    Crunching payers and grouping patients is so complicated, the programs run on servers that cost in the millions. It's among the most complicated code run, I gotta think it's gotta be up there with nuclear explosion simulations and weather calculations.

  • fish||

    COBOL? That just means it's elegant...like telling jokes in latin.

  • LTC(ret) John||

    CAROLUS: Quid scotum a sotto separat?
    SCOTUS: Haec mensa, rex.


    (CHARLES: What distinguishes an Irishman from a drunkard?
    IRISHMAN: This very table, O king.)

  • LTC(ret) John||

    I forgot to mention the Kings was at the other end of the table than the Irish monk who answered him.

  • NoVAHockey||

    Between this and the resistance to medicaid expansion this thing might never get off the ground. but it will cost a lot to find out.

  • ||

    a non-trivial number of exchange enrollees are likely to get the wrong subsidy

    ANY exchange enrollee getting a subsidy above $0 is getting the wrong subsidy.

  • John||

    And they will fuck up the subsidies. I have a friend in Massachusetts who was between jobs for a while. So he is required by Romneycare to buy insurance. But he is also out of work and doesn't have the money to buy his own. So he gets a subsidy from the state. Sounds okay except that the people who enforce the penalty and the people who give the subsidy work for different state agencies. Of course the state of Mass is always broke and is anywhere from five to six months behind paying the subsidy. Meanwhile, they are right on schedule declaring him a criminal and fining the shit our of him for not having health insurance, that he wouldn't have bought had the state not made it a law that he had to.

  • ||

    Massachusetts is Massachusetts, John. The only thing that can fix it now is the Tzar Bomba.

  • NoVAHockey||

    someone's been playing with that nuke site.

  • ||

    Try aiming at Boston and upping the yield of your theoretical device to 2,000,000 megatons. Awesome.

  • NoVAHockey||

    woah

  • ||

    Why doesn't your friend from Massachusetts move to a different state and leave no forwarding address for the Masshole state government?

  • ||

    The Fugitive Slave Act.

  • LTC(ret) John||

    The comment that WON the year.

  • Ken Shultz||

    That's probably the best argument against the individual mandate right there.

    It's inhumane to sick law enforcement or the IRS on someone who has lost his job and is trying to make ends meet.

    I remember when healthcare reform was supposed to be about helping people who couldn't afford health insurance premiums--some how the solution morphed into using law enforcement or the IRS to harass people who can't afford health insurance premiums.

    That's mean and nasty.

  • John||

    All the mandate does is make poor people and young people who can't afford insurance contribute to the health care system by buying insurance they otherwise wouldn't have bought.

    It is nothing but a giant tax on the working poor.

  • Ken Shultz||

    I guess they figure the working poor are so stupid they'll just vote for the next Obama again, anyway.

    They certainly seem to think ObamaCare benefits them!

  • Surly Chef||

    The problem here is that the CBO estimate of $4500 for a "bronze" plan makes it cheaper to take the penalty from the medicade cut off of 133% of poverty, about 000, all the way up to $175000, at least during the first year. So basically everyone just above the poverty level to those in the lower middle class, will still be without coverage, and will have new taxes.

  • John||

    Exactly Chef. It was nothing but a giant tax increase on the working poor and lower middle class. But most of those people are bitter clingers anyway. Typical white people.

  • Surly Chef||

    I'd say the most annoying part is that liberal friends and coworkers always assume in that in support for Obamacare they are helping me get coverage because I'm in the lower middle class and will be for quite a while, with my career where it is. When confronted with the facts, the just blink and then make a rationalization as to why I owe the system money.

  • Brutus||

    Great story.

    Our future is Brazil, not 1984.

  • fish||

    ...and to think people were upset that Romney lost!

  • DaveAnthony||

    Funny, we had some technocrat consultant jackass at our manufacturing site yesterday bragging about how Massachusetts has "universal health care".

    What he meant was that the state universally puts a gun to it's citizens' heads and says "you must buy this product from a private corporation".

  • Rasilio||

    You know I'd say the upside here was lots of jobs for My field, Software QA, because any attempt to build a system this complex will have more bugs than a roach motel. Unfortunately however they will probably outsource 90% of that work to India, which contrary to popular belief is not cheaper but is significantly less accurate and gives a near 100% guarantee of PHI (Personal health identifying) data theft because it is very hard to test this stuff without live data (not impossible but very few people are able to maufacture test data at that scale and even when they are it is significantly more expensive than just using backups of production data) and it is impossible to prevent someone in India with access to the data from simply walking out of the building with a copy and selling it to the highest bidder.

  • ||

    Don't question the federal government. What are you, a Klansman?

  • The Late P Brooks||

    How are the exchange designers going to manage this? The answer is: It's going to be very, very complicated.

    This is why we need universal free unlimited no-questions-asked health care provided by the government!

  • Rasilio||

    As sad as it is to say that would actually be better than the cluster fuck that Obamacare will turn into.

    That said an even better solution would be to simply outlaw employer provided health insurance and then require everyone to have a HSA (whether they use it or not is up to them) and have the government fund the HSA for the poor and middle class on a sliding scale based on income and family size. At the high end the HSA would be worth $12,000 a year and at the low end it would only be $1000 a year but the person could suppliment with their own pre tax deposits up to $12,000 in total deposits (anything after that is taxed as normal).

    Then let everyone buy whatever health insurance they want, or don't buy any at all because with $12,000 being saved 99% of people would never actually need insurance, they could just pay out of pocket for everything.

    You would also retain a very small Medicare program for those with high cost chronic illnesses.

    You could do this for what we currently spend today on Medicare + Medicaid and end up with something approaching a true free market in health care.

  • John||

    That said an even better solution would be to simply outlaw employer provided health insurance

    Why would you outlaw that? If I want to bargain for that as a benefit to my job, that is between me and my employer. And it makes a lot of sense to buy insurance in big groups because it spreads the risk.

    I don't get Libertarians obsession with employer provided health insurance. Whatever happened to freedom of contract?

  • ||

    I don't get Libertarians obsession with employer provided health insurance.

    Because, John, like with Medicare/Caid (CMS), patients are divorced from cost, simply put. When that happens, costs cannot be controlled. The only way to get the Libertarian pipe dream of no medical/nursing/AHS licensing, no RX requirements (WHICH STATES WILL NEVER, EVER PERMIT FOLKS; and I don't support for a very few drugs, antibiotics specifically), purchasing insurance across state lines, and a truly "fee for service", price negotiated upfront system sans is to disabuse the electorate that medical care is not a "right" demanded at the point of a gun John Q style.

    As COBRA (EMTALA), Sandra Fluke, and TEAM BE RULED by proxy of the electorate, demonstrates, John, this can never, ever happen.

  • John||

    Those are all the problems. But the cure of banning employee provided health insurance is as bad as the disease.

  • ||

    You have heard of "Cutting one's nose to spite his or her face," no?

  • Contrarian P||

    Freedom of contract is fine. I have no problem with you bargaining for employer provided health insurance. What we have a problem with is the system that grants enormous perks to the employer provided system while screwing individuals who want to buy the insurance on their own (i.e. tax benefits, not allowing individuals to bargain collectively, etc).

  • Red Rocks Rockin||

    And it makes a lot of sense to buy insurance in big groups because it spreads the risk

    That's the same claim supporters of Obamacare are saying though.

    "MORE PEOPLE BUYING INSURANCE WILL LOWER HEALTHCARE COSTS BECAUSE OF MORE PEOPLE IN THE POOL! WHY DO YOU HATE THE POOR?!?1!!"

    At this point, healthcare costs will only be lowered structurally if the entire cost-shifitng insurance/government subsidy infrastructure is nuked and we go back to cash.

  • R C Dean||

    I don't get Libertarians obsession with employer provided health insurance.

    If that's all it was, then whatevs.

    But its not. Its tax-favored insurance offered withing the context of massive regulatory capture and hidden subsidy. As it currently exists, and its kinda like unions this way, it has nothing much to do with freedom of contract at all.

  • OldMexican||

    It's been clear for a while that the most difficult part of building ObamaCare's health exchanges will be setting up the systems to determine benefit eligibility.

    That would be: "the most difficult part [...] will be setting up the systems to determine benefit eligibility in a way it does not exclude many in any of the politically-protected groups."

    Now that is a feat to see worth the admission fee!

  • The Late P Brooks||

    healthcare reform was supposed to be about helping people who couldn't afford health insurance premiums--some how the solution morphed into using law enforcement or the IRS to harass people who can't afford health insurance premiums.

    RESISTANCE IS FUTILE

  • rho||

    Lost in all the chatter about enacting insurance exchanges and whatnot is what was supposed to be a key feature of the ACA--namely, controlling costs.

    The only thing harder than setting up these exchanges is figuring out how much a random medical procedure actually costs. If you have insurance, the hospital bills X; if you don't, they bill Y; if you pay in cash, it's X-N; if you're poverty stricken, they bill the government X+N-Z.

    Nobody has a clue how much anything costs because the one thing the free market excels at--setting prices--is not allowed to occur in health care.

    Nobody has a clue how to control costs because we don't know how much anything actually costs. We're going to end up with a weird Frankenstein's monster of cost control through rationing based on the fairy-tale cost structures from insurance billing.

  • R C Dean||

    In hospitals, at least, we can tell you to within a farthing what the actual out-of-pocket cost of damn near everything is, at least under the Medicare conventions for cost reporting.

    The insurers are supposed to be contracting with providers to set up their networks for the plans offered through the exchanges, and those contracts will have the provider reimbursement in them. Theoretically, but . . .

    One of the big problems coming with the exchanges is setting up the networks. Those plans offered through the networks are supposed to be fungible commodities, and no one knows how that will square with different insurers having different networks. How much leverage will providers/insurers have? How good will those networks be? What kind of out-of-network benefit will be required?

    Our problems with micro-managed health insurance are only beginning.

  • ||

    See the beginning of the thread, RC.

  • R C Dean||

    Nice rant, Dr. G. Not sure the Repubs are secretly in bed with the Dems already on this, but if no, they will be soon. Its the nature of the beast: once a big program gets settled in, everybody takes their place at the trough whether they voted for it or against it.

  • The Late P Brooks||

    I don't get Libertarians obsession with employer provided health insurance. Whatever happened to freedom of contract?

    Not this again. Because employer-provided "free" insurance is a HUGE DISTORTION IN THE MARKET.

    Now, if an employer wanted to provide some sort of buyer's club access to an insurance program which the employee then paid for with actual after tax take home pay dollars, I probably would not object (so much).

  • LTC(ret) John||

    My employer does that with dental - they just cut any other subsidy/involvement with it - we can buy through them.

  • Auric Demonocles||

    Hell, I'm fine with the employer paying for the health insurance with pretax dollars, as long as they can also just give the employee the same amount of pretax dollars as a raise and no insurance.

  • John||

    Why does the employer have to do that? He can if he wants to. But it is none of the government's business if he does or not.

  • John||

    Not this again. Because employer-provided "free" insurance is a HUGE DISTORTION IN THE MARKET.

    Tough shit. Sometimes markets get distorted. It is my freedom to contract for whatever benefits I want. If you want to tax that like income, have at it. But you can't tell me what I can and cannot take as compensation.

    You can, but when you do please admit to being the authoritarian statist fuck you claim not to be.

  • Calidissident||

    If the government wasn't actively encouraging this distortion, you'd have a point

  • some guy||

    I can't wait until 2014 rolls around and this whole thing blows up in their faces.

  • R C Dean||

    I'm already doing quite well off of it. Nothing helps the legal profession like fear. Well, fear and uncertainty. Well, fear and uncertainty and high costs.

  • ||

    No ruthless efficiency then.

  • The Late P Brooks||

    It is my freedom to contract for whatever benefits I want.

    Says the government parasite.

  • The Late P Brooks||

    admit to being the authoritarian statist fuck you claim not to be.

    See above.

  • 16th amendment||

    If the feds are going to set up a system this complex, they can surely set up a system to tell states whether someone with social security number xxx-xx-xxxx is dead or alive.

  • attractions guide||

    I will always support Obama...

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