Longevity and Long-Term Care: The Medical Crisis of the 21st Century : Part 2

Throughout the 20th century, most Americans saw “longevity” as a goal. If we took care of our bodies, we reasoned, we could “live longer and better.”

But in the 21st century, I suspect that some of us will learn to fear “longevity” the way we now fear cancer.

This is the second in a series of posts that will explore the anguish that some experience when they live into their late eighties and nineties–and how we, as a society, can address the hardships of “old, old age.”

                                           Senile Dementia   

Thanks to better diets, exercise, and advances in medical knowledge, more and more of us are living to four score and seven. But the downside is that in too many cases, our bodies are out-living our minds. As I note in the post below, since 2011, 40% of the increase in Medicare’s outlays can be attributed to spending on Alzheimer’s patients.

Why is the incidence of Alzheimer’s (AHD) spiraling? Because we are less likely to die of heart disease or strokes, millions of Americans are living long enough to be diagnosed with senile dementia. One could say that longevity is the proximate cause of Alzheimer’s.

Because women live longer than men, they are more likely to fall victim to AHD, the most common form of dementia. If a woman lives into her 60s her risk of being diagnosed with Alzheimer’s at some point over the rest of her life is 1 in 6. By contrast, for breast cancer, her risk is 1 in 13.  By 2050, the number of people age 65 and older suffering from Alzheimer’s may well triple, rising from 5 million to as many as 16 million.

Why then don’t we hear more about this scourge? Because at this point there is little or nothing that doctors can do to stop it. The Mayo Clinic’ website explains: while some drugs can “temporarily improve symptoms of memory loss and problems with thinking and reasoning . . .  these treatments don’t stop the underlying decline and death of brain cells. As more cells die, Alzheimer’s continues to progress.”

Last month Consumer Reports warned that “the overall results” for Alzheimer’s drugs “are far less encouraging than the ads portray. Most people who take them don’t experience a meaningful benefit.

More than half experience side effects. And they’re expensive, costing anywhere from $140 to more than $656 monthly..

Even a small benefit or chance of improvement might be worth it if Alzheimer’s drugs were risk free,” Consumer Reports observed. “But they are not. They can cause side effects such as insomnia, nausea, muscle cramps, diarrhea, and reduced appetite, all of which can be troublesome for people with dementia.” Occasionally, the drugs may cause more serious side effects such as internal bleeding and a slowed heart rate that could be potentially dangerous.

Meanwhile, the average Alzheimer’s patient lives 8 years—and 40% of those years are spent enduring the most severe, late stages of that disease. Some patients linger for 20 years. This is what makes Alzheimer’s so expensive.

                                The Need for Long-Term Care

At this point, we cannot cure senile dementia, but we can reduce the suffering that patients and their families endure by creating the long-term palliative care system that millions of baby-boomers and many of their parents will need. First, this means figuring out how to fund such a system. Medicare pays for some treatments, but it does not cover long-term care.

Up until now relatives have provided much of that care at home, but increasingly, the burden is becoming too great for aging spouses. And even if their children live close to home, daughters as well as sons have jobs that they cannot leave.

Medicaid will pay for nursing home care, but only after the patient and spouse spend down nearly all of their resources. (New laws now make it very difficult families to transfer assets to heirs when they see Alzheimer’s coming.) And even when families exhaust their assets, nursing homes and hospices often do not provide the combination of palliative care and skilled nursing that patients require.

Finally, and most importantly, we need to think about how to ease the path to death. Here, I am not talking about euthanasia. (In a later post, I will address  ”aid in dying” –a.k.a. “physician-assisted suicide”–and explain why some palliative care specialists have had second thoughts about that solution.)

In this post, I am focusing on reducing the fear, the panic, the overtreatment, and the medical flailing about that makes what I have called “the American way of dying” so traumatic. Death always will involve loss and suffering, but it does not have to be impossibly cruel, and it does not have to wreck families.
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A Patient’s Story–How Much Can or Should– Your Doctor Tell You About Potential Risks?

Below a non-fiction story from Pulse: Voices from the Heart of Medicine, “an online magazine of personal experience in health.”  Pulse is both a magazine and an online community that provides a chance for patients, doctors, nurses, social workers to come together, and share their experiences.

The magazine’s founders write: “Despite the large numbers of health magazines and medical journals, few openly describe the emotional and practical realties of health care. We at Pulse believe that our stories and poems have the power to bring us together and promote compassionate health care. “   Pulse was launched by the Department of Family and Social Medicine at Albert Einstein College of Medicine/Montefiore Medical Center in the Bronx, New York, with help from colleagues and friends around the state and around the country (Subscriptions are free: You will find the home page here.

At the end of the story, see my note, asking HealthBeat readers: “What Do You Think: Should the patient have sued the doctor?” Would she even have a case?

                                                    Collateral Damage

By Brenda Scearcy

Dr. Robert’s office felt right to me, with a musical birdsong soundtrack, soft lighting and fresh green tea, and I had my best friend in tow: piece of cake. In this serene atmosphere, I was sure that I’d find out what to do next to finish treating my endometrial cancer.

It’s probably gone now, since my hysterectomy two weeks back, I thought. But let’s play it safe; he’s the gynecological-cancer guru.

Like a general gearing up for combat, Dr. Robert said, “We can beat this. We’ll do a second surgery to remove lymph nodes and omentum–robotically, of course, so your recovery time will be quick. Down the road we’ll definitely do radiation and chemo, and your odds of recurrence will go way down.”

That tone. So assured…

“What’s an omentum?” I asked hesitantly.

“A slab of belly fat deep in the abdomen that can trap cancer cells; we usually recommend its removal if the cancer nearby is aggressive.”

“Side effects?” I asked.

“Not much to speak of. In rare cases, you get a slightly draggy foot from nerve damage.”

My whole psyche was dragging its feet. Did I need this, just after coming through a highly successful surgery?

A month before, I’d sought treatment for a garden-variety fibroid. My primary ob/gyn, Dr. Ann, had offered to remove the fibroid laparoscopically. Beforehand, as part of her usual pre-surgical procedure, she sent a tiny chunk to the lab for a cancer check.

Bingo.

A cancerous fibroid is a whole different ballgame, so Dr. Ann and I went to Plan B–a full hysterectomy and ovary removal.

Immediately after the surgery, Dr. Ann cradled my head in her sweet-smelling arm and whispered affirmations to me, cheek to cheek. Although everything else is erased by anesthesia, I clearly remember the feel of her skin and how fervently she whispered, “You’ll even want to eat–salmon!”

I did heal like a champ, wowed by blissful, oxycodone-induced hallucinations and by seeing my teenage daughter mature as she stepped into her new role as pants-puller-upper.

Call me a flake, but I believed that Dr. Ann’s surgery had removed the cancer. During waking hours, I couldn’t drum up any sincere worry. (But I did have nightly “mares,” always the same: a terrifying man breaking into my house, and I a throttled screamer. On a subconscious level, my fears about cancer were in overdrive.)

My first post-op visit with Dr. Ann, a few days after the surgery, was tremendously reassuring. She showed me the lurid photos she’d taken of my cancerous uterine fibroid, backlit and glowing ruby-red, so I’d finally see my torturer. (I still have a wallet-size photo.) We laughed–hard, which I don’t recommend after abdominal surgery.

Then she went over the lab results with me. The cancer was grade one (not aggressive) and had been relatively contained, with just one other spot on one of the removed ovaries. Dr. Ann told me that this spot was a bit of misplaced endometrial tissue that had sprouted a tumor. It was not ovarian cancer, which is often more aggressive. Welcome news. She poured her heart into reassurances.

But still. “There are other treatments, like lymphectomy, chemo or radiation, that I want you to consider,” she said. A recent cancer survivor herself, she wanted to make sure that I stayed in touch with my inner warrior. She sent me to Dr. Robert.

And Dr. Robert insisted that lymphectomy/omentectomy was the least I should do. According to him, chemo and radiation were necessary insurance against the Big C.

He described the omentum as having little purpose and regaled me with stories of women who were vacuuming the house eighteen hours after their surgeries.

I’d studied ecology in grad school; its principles guide every part of my life. I know that everything is interrelated, and that when you do one thing, it can affect other things in surprising ways. But I wanted to believe that the cancer was behind me.

Also, I was foggy-headed, suffering from cold-turkey estrogen withdrawal after the hysterectomy. So my antennae weren’t up, and my energy for fact-checking Dr. Robert’s claims was nonexistent. And then there were those nightmares….

Ultimately, it came down to this: Dr. Ann recommended that I take Dr. Robert’s advice. He was the expert. Hoping that lymphectomy would seal the deal, I had the surgery.

The immediate after-effects:

(1) Excruciating shoulder pain, referred from my diaphragm, from gas injected during surgery.

(2) Lymphedema, a build-up of fluid caused by lymph-vessel blockage. Within two days, I looked like a sumo wrestler, with lymph pooling around my middle. No clothes fit.

(3) A walnut-sized pocket of lymph in my right belly. One night at supper, my shirt suddenly grew wet as lymph spurted out of one of the operation slits.

(4) Permanent nerve damage and numbness: Dr. Robert had accidentally cut nerves to my left quadriceps, groin and lower belly.

Dr. Robert had mentioned none of these possibilities.

During my hospital stay, I never saw him. Once home, I repeatedly phoned his office, begging for help, but he never called back. Two weeks later, during our only post-op visit, he said the nurse had never told him.

Having removed more than half of my abdominal lymph nodes, Dr. Robert found that they were all cancer-free. My post-op report stated that he’d removed them prophylactically; as I saw it, that was like removing a hip so I wouldn’t break it.

A year later, I found my legs and buttocks swelling up again. At first I thought I’d twisted my ankle, but eventually Dr. Ann enlightened me: I had chronic lymphedema.

She steered me to cancer rehab, where I learned I could improve the symptoms slightly with time-consuming exercises, careful skin care and $135-a-pair pantyhose that squeeze me girdle-tight.

Now I roll a tennis ball around my ankle to break apart the fibrosis caused by lymphedema. I research cheaper pantyhose. And to give myself time to exercise and heave my hips into those leg-hugging hose, I set my alarm forty-five minutes early each morning.

I’ve damaged my knee with the grunting maneuvers required to don the hose. Long walks are temporarily a thing of the past.

The last straw is that I must hand wash these tights nightly–an odious eight-step chore.

Looking back, what astounds me is Dr. Robert’s profound lack of curiosity about his interventions’ potential impact on my daily life. He could have anticipated some of the problems–what symptoms might I develop? How ugly would I feel as a human blimp?–and might at least have warned me about what to expect.

And if I’d known the risks beforehand, I could have asked myself which I would choose: uncertainty about a recurrence, or the tedious gamut of lymphedema care?
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The Next Plague: Alzheimer’s

In the 1970s and 1980s, a plague called AIDS swept through this country. Like a medieval scourge it was mysterious, incurable, and ruthless as it killed those who were far too young to die.

Now, baby-boomers have reason to fear a new scourge: It won’t cut them down in their youth, but if they dodge heart disease and beat cancer they may find themselves trapped in their bodies, watching their minds dissolve.

Did you know that a woman who is now 65 stands a 20% chance of dying of Alzheimer’s? (See Michael Kinsley’s essay in the New Yorker.)

On Bloomberg View Matthew C. Klein has put together a booklet of “visual data” titled: “How Americans Die.” These stunning interactive graphs will startle you. For instance, were you aware that suicide has recently become the leading cause of violent death in the U.S.?

But it is the pages devoted to Alzheimer’s here  and here that stopped me in my tracks.
I turns out that about 40% of the increase in Medicare spending since 2011 can be attributed to greater spending on Alzheimer’s treatment.(We don’t have reliable data on Alzheimer’s spending before that.) And that number is bound to climb.)

The Boomers will be the second generation to die of dementia, but the first to see it coming. 

These charts are terrifying but important. We need to begin thinking about how to cope with Alzheimer’s. Here, The Mayo Clinic outlines “What is On the Horizon for Alzheimer’s.

I’m not optimistic about a cure anytime in the foreseeable future. But we definitely need to think about how to care for the many who will be suffering from this dreadful disease.
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If Democrats Campaign on Obamacare Will They Lose White Votes?

Recently, the New York Times ran a  front-page story reporting that Democrats running for Congress are reluctant to “run on Obamacare.” Instead, they are “running away from it, while Republicans are prospering by demanding its repeal.” The problem, according to the Times, is that discussions of the Affordable Care Act (ACA) tend to focus on “coverage for those of modest means,” and this “has led white voters to see the law as an act of government redistribution to the 15 percent of the population that is uninsured.”

As proof, the paper cites a five-month-old New York Times/CBS News poll showing that “just 17 percent of whites said the health law would help them while 41 percent said it would hurt; among blacks, 42 percent said it would help them while 15 percent predicted it would hurt.”

“Democrats could ultimately see some political benefit” from Obamacare the story acknowledges.  But as candidates prepare for mid-term elections, “they are confronting a vexing reality: Many of those helped by the health care law — notably young people and minorities . . . tend to vote in midterms at lower rates than older and white voters.”

The reporter points to two Democratic candidates in Georgia who are doing their best to distance themselves from reform: “Jason Carter, the grandson of former President Jimmy Carter, who is running for governor, and Michelle Nunn, the daughter of former Senator Sam Nunn, a candidate for the Senate.. . .  They have spoken in public about the law mostly to criticize it, did nothing to promote enrollment for insurance before last month’s deadline and declined interviews to even discuss the law.”

                         Who Benefits From Obamacare?

The Times describes those who will be helped by reform as people “of modest means.” This is a phrase that newspapers such as the New York Times, The Washington Postl and the Wall Street Journal often use to refer to the poor or the lower-middle-class –i.e., not you, dear reader.”  (Try Googling this rather old-fashioned, faintly British phrase, along with the names of these papers, and you will be startled by how often it pops up.)

In this country, we do not like to talk about class. I recall that when I first became a journalist, I was told that if I wanted to write about “the rich” and “the poor,” I should refer to them as “the have’s” and “the have not’s.” Of late, “people of modest means” seems to have become the preferred euphemism for the working-class. That phrase makes it clear that these are plain, hard-working folks, and we respect them– or at least we would if we knew any of them.

What is peculiar about this story is that it overlooks the fact that there are a great many white, middle-aged Americans “of modest means” who now have affordable insurance, thanks to the ACA. Perhaps they don’t read the Times, but they do vote. Why wouldn’t they cast their ballots for candidates that support Obamacare?

As for “government redistribution” of income, the article seems to suggest that middle-class white Americans will be paying more in taxes in order to help “the 15% of the population that is uninsured.”  In fact, only the wealthiest 2% (those earning more than $200,000, $250,000 for couples)  face tax increases that will help fund universal health care for working-class, middle-class and upper-middle-class Americans of all ages and colors.

                       Obamacare Protects the Under-insured   

Moreover, the group that benefits includes not just “the 15% who are uninsured,” but millions of Under-insured Americans who have been trying to get by on cheap policies that did not cover:

brand-name drugs, even if there was no generic substitute;

hospital bills over $2,000;

– chemotherapy;

ambulances;

doctors’ visits while the patient is in the hospital.

                   Subsidies for the Upper-Middle Class

Some readers may be surprised by my claim that the ACA helps not just the middle-class, but many in the “upper-middle-class.”

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Health Care Spending Spikes: Why?

Recent data from the Bureau of Economic Analysis (BEA) reveals that  during the last three months of 2013, spending on health care rose at an annual rate of 5.3%. The trend continued this year, with spending climbing 6.2% on a year-over-year basis in January and 6.7% in February. Now some of Obamacare’s fiercest critics are saying “I told you so.”

“We knew this was coming,” gloats Douglas Holtz-Eakin, John McCain’s former economic adviser. “The question now is whether we can hold spending down.” It’s worth recalling that Holtz-Eakin, who served as CBO director under George W. Bush, has been wrong in the past. When I debated him on the Lou Dobbs show in 2009 he insisted that the ACA would leave us with a “ton of debt.” In fact it has reduced the deficit. And in March of 2013 when testifying before the House Energy and Commerce Committee’s Subcommittee on Health Holtz-Eakin had the chutzpa to declare that “There is anecdotal evidence, of [Exchange] premiums nearing $100,000 in New York.”  This was, of course, utter nonsense.

Still, the surge in spending came as a surprise. Since December of 2007, after adjusting for inflation, health care outlays have been rising by only 2.6%  “The sudden jump has led some some commentators to declare an end to the era of slower health-cost increases, which has lasted for the past several years,” observes former CBO director Peter Orszag observes.  Yet, Orszag notes, “Medicare spending growth is still low, even through last month. Indeed, in the first half of this fiscal year, nominal Medicare spending was only 0.6 percent higher than in the corresponding period a year earlier.”

Why Have Outlays Risen for Those Under 65, But Not for Seniors?

BEA suggests that the jump during the first two months of this year reflects the fact that, thanks to the Affordable Care Act (ACA),  more Americans had comprehensive insurance that gave them access to a wide range of services.

Those who became insured in January and February are the folks who signed up at the very beginning of the enrollment period. No doubt many of them had been postponing needed care for a long time. As soon as they were covered, they began visiting doctors, scheduling elective surgeries, and filling prescriptions. Medicare patients, by contrast, had no reasons to seek more care at the beginning of 2014. Their insurance had not changed.

Going forward, won’t the fact that more Americans are insured mean that health care spending will continue to climb?  ”No”, says  Larry Levitt, a senior vice president at the Kaiser Family Foundation (KFF). This “will be a one-time bump in health spending.”
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How Much Will You Pay for Health Care in 2015? What You Need to Know About Healthcare Inflation-Part 1

 

Probably you have seen headlines like this one: “O-Care premiums to skyrocket.”

The warning, which was posted on The Hill, seemed designed to cheer conservatives distraught by Obamcare’s enrollment numbers. It began by announcing that next year, “premiums will double in some parts of the country. The sticker shock will likely bolster the GOP’s prospects in November and hamper ObamaCare insurance enrollment efforts in 2015.”

Where did the reporter get her information?  The story is based on interviews with “health insurance officials.”

Why would they issue such dire predictions? Perhaps they are trying to soften us up so that when insurance rates rise by “only” 7% to 10%, we’ll be surprised and grateful? (This is just a thought.)

The truth is that there is absolutely no reason to believe the same old, same old, fear-mongers who claim that in 2015, rates will spiral “by 200% to 300%.”

But what about those who predict double-digit hikes?  Wellpoint, the biggest commercial insurer in the Exchanges, recently told Bloomberg that it may ask for “double-digit plus” increases when it proposes 2015 rates sometime next month.

Wellpoint can propose whatever it wishes, but I very much doubt that state regulators would accept such stiff increases. A combination of regulation and competition will keep a lid on premiums both in the Exchanges, and off-Exchange, just as it did this year.

My guess is that, in most states, rates will rise by no more than 2% to 4%. Meanwhile, government subsidies will climb to cover those increases for most who buy policies inside the Exchanges. (This year 80% of shoppers who purchased insurance in the state marketplaces received tax credits to help with premiums.) Folks who purchase coverage off-Exchange won’t receive subsidies, but carriers selling policies to individuals outside the government’s online marketplaces will have to compete with prices inside the Exchanges.

Why am I so optimistic?

The Underlying Cost of Medical Care Is Slowing

Americans have become so accustomed to hearing about “runaway health care inflation” that most do not realize that we have finally “broken the curve” of rising health care costs.

Granted, for most of this century, rates soared: “From 2000 to 2009, health insurance  premiums climbed 84%,” Zeke Emanuel, a former White House healthcare adviser and author of Reinventing American Healthcare: How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System., recently told NBC’s “Meet the Press.”

By contrast, “for the past three years, health care cost growth has dramatically slowed and is just about even with growth in the economy. Some of this is due to lingering effects of the recession in 2008,” he added. “But a part of it is undoubtedly due to the ACA.”

Drew Altman, president of the Kaiser Family Foundation, points out that, despite the aging of the population, ”the Congressional Budget Office projects that Medicare will cost significantly less in the future than previously thought,in part because of the ACA’s changes to Medicare’s payments. “  (As I have explained, those cuts do not reduce benefits, but they do force hospitals to cut waste and provide better value for our Medicare dollars.

Both in the public sector and in the private sector, “Overall health spending is growing at the slowest rate in 50 years,” Altman observes,  (dating back to when the government first started tabulating health expenditures.)”

“The key for the future is not to eradicate premium increases entirely,” Emanuel adds. The goal “is to make sure [that these increases] aren’t Excessive.”

He stresses that there is still much to be done to rein in healthcare spending. But for the moment “the exchanges are stable,” says Emanuel. “Premiums are likely to rise a little but not excessively.”

If you don’t believe Emanuel and Altman, take a look at the graph below, comparing outlays for all medical services (the orange line) to the PCE (personal consumption expenditures–the blue line) from 2009 to 2014. As you can see annual spending on healthcare services is now growing by well under 1% a year. (For a larger version of the graph, click on the link above.)

ifi0rzbQK9cU   bloomberg chart

Bloomberg News used the graph earlier this week, to illustrate a story that lays out some critical and little-known facts:

Prices “for medical services, which make up the biggest share of health care costs, have eased in the past two years. From February 2013 to February 2014 physician fees edged up just “0.2 percent–down from a 1.6 percent rise 2012,” Bloomberg reported, and “the cost of nursing home care rose by only 0.3 percent,” compared with “1.8 percent two years earlier.”

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How Many of Obamacare’s New Enrollees Were Uninsured Last Year? Why It Doesn’t Matter

Charles Gaba, the enrollment guru who has been tracking Obamacare sign-ups since October, now estimates that by April 15, some 17 million Americans will have purchased their own insurance policies either in the Obamacare Exchanges (8 million) or off-Exchange (9 million)

But how many of them were uninsured and how many were simply replacing policies that Obamacare had forced insurers to cancel?  This is the question conservatives ask.  After all they argue, if most of these folks already had coverage, we have just wasted a great deal of time and money moving them from a policy they chose to one that President Obama prefers.

There are two answers to their question. The first is that while we don’t have an exact number as to how many of the new enrollees were uninsured, we do know that, thanks to Obamcare,  the percent of Americans who are “going naked” has declined. New Gallup data shows that the uninsured rate fell from 18.1% in the third quarter of 2013 to 15.6% in the first quarter of 2014.

That said, Gaba offers a second, even better, answer: “It doesn’t really matter.” 

I agree. As he explains:

“It doesn’t matter because every one of those new policieswhether on-exchange or off-exchange; whether it went to someone who didn’t have insurance before, someone who had their old policy cancelled or went to someone who voluntarily made the switch to a new one…which  . . is a LOT of people, by the way…is still a fully ACA-compliant, full-coverage healthcare plan.”

Gaba points out that “the primary point” of his website (ACASignups.net) “is to track how many people are now enrolled in a “QHP certified” plan regardless of whether they had insurance before or not. Some moved from no plan at all to a QHP. Others moved from a ‘junk’ policy to a QHP (some have argued that there aren’t that many of these, but there were still a lot of them). Still others yet (myself included) have moved from a decent plan to a QHP. . . . The point is, they’re all ACA QHPs now.” [his emphasis]

This is critical to understanding the purpose of health care reform. From the beginning the goal of the Patient Protection and Affordable Care Act (PPACA) was not simply to insure the uninsured, but to protect the under-insured by making certain that everyone has comprehensive coverage.  Whether a carrier is peddling policies in a state marketplace or off-exchange all plans now must comply with the ACA’s rules by:

–covering the ten essential benefits

–offering free preventive care, and

–capping how much a patient can be asked to pay out-of-pocket.

In addition, carriers can no longer discriminate against customers suffering from pre-existing conditions by charging them exorbitant premiums, and they cannot set a limit on how much the insurer will pay out, over the course of a year or a lifetime.

The second goal of the Patient Protection and Affordable Care Act is to make sure that the price of such high quality insurance is not beyond reach. Government subsidies help low-income and median-income families, but the only way to make sure that everyone else can afford policies that meet the ACA’s high standards is by asking all of us to share in the cost.

This is why the ACA mandates that everyone purchase insurance. When more people pay into the risk pool, the costs decline for everyone. It is only then that universal coverage becomes possible

 

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Obamacare Enrollment, Including Medicaid, Heads for 14-20 Million

Revised: April 12

Charles Gaba, who has become the go-to-guru for Obamacare enrollment numbers, now predicts that by April 15, 7.09 to 9.75 million Americans will have purchased health insurance in the Exchanges. 

This is in line with the back-of-the-envelope estimate that he offered a week ago: “a nice round 8 million.”  (In parentheses, he suggested:  Perhaps a little higher (1M even?)., and then struck that thought.  “As always,” he noted, “I’ll be more than happy to be proven wrong, as long as I’ve undershot the mark.”

 

To that 7.09 to 9.75 million, he now adds 2.09 million who he is certain have bought comprehensive coverage outside the Exchange, plus an additional 5.7 million who, according to a Rand study published earlier this week, may have signed up  off-Exchange. Finally, Gaba estimates that 5.23 million to 7.29 million Americans have enrolled in Medicaid or CHIP. 

As of April 12, this brings the total number who will have insurance that meets the Affordable Care Acts (ACA’s) high standards to roughly 14 million to 20.2 million.

When Gaba first reported on the Rand report, he acknowledged that Rand’s numbers “were based on a survey” and “surveys include margins of error.”

Gaba has gained his reputation by being meticulous—and cautious. Typically, his estimates have been conservative. Given that track record, I suspect that by April 15, we will find that well over 14 million people have benefited from Obamacare. If pressed, I would guess 17 million.

At this point, you may be wondering: But don’t we need the new enrollees who are purchasing policies off-Exchange to join the state marketplaces in order to spread the cost of coverage among as many people as possible?

The answer is “No.”

A little-known provision in the ACA stipulates that if a carrier sells policies to individuals both in the state marketplace and in the private market, the insurer must view those customers as part of one risk pool, and price their policies accordingly. Together, they will  share the risk of becoming sick, while also sharing the cost of insurance that guarantees everyone access to care. All other things being equal, the larger the pool of people who buy coverage both on and off the Exchanges, the lower the risk– and the lower the cost for all of them.

“All other things being equal” includes whether the new people jumping into that pool are healthy. Recent evidence suggests that the new entrants are, in fact, younger, and as a result, more robust than those who signed up earlier.

In future posts, I’ll take a closer look at that pool, and explore how much you are likely to wind up paying for insurance next year.

 

 

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Obamacare Enrollment Hits 7 Million, Putting Downward Pressure on 2015 Premiums; Word-of-Mouth Spreads the Truth

(Updated March 31)

As the “train wreck” called Obamacare pulls into the station it’s becoming clear that some 7 million Americans are signing up to purchase insurance in the Exchanges. Ten days ago I went out on a limb and predicted that we would hit 7 million, if not by March 31, by early summer. Now it appears that we’ll break through that target by midnight.

Seven million was the Congressional Budget Office’s (CBO’s) initial estimate, but when the roll-out proved rocky, the administration lowered its expectations to 6 million. Reform’s opponents groused that this still was too optimistic, and before long the consensus estimate fell to 4 to 5 million. (Conservatives, who had helped lower the consensus, then accused Democrats of moving the goal-post to make it easier to claim success.) 

                             Younger Americans Join the Pool

Who are these last-minute shoppers? According to the Wall Street Journal,carriers are beginning to report that many are under 40.  Today, more insurers confirmed the trend. This should come as no surprise.

We always knew that people in their 50s and 60s would join the Exchanges first. Healthy 20-somethings and 30-somethings who rarely see a doctor would be in no rush to sign up. Why begin paying premiums before you have to? 

                                          Momentum Builds

Now, younger Americans are  jumping into the pool, and, most importantly, the pace of enrollments is building. Friday, March 28, Charles Gaba, the “numbers Geek” who has correctly predicted earlier enrollment milestones, wrote: “We’re in uncharted territory. . . Things are moving VERY quickly now, and events are quickly overtaking my ability to keep up.”  Yesterday (Saturday, March 29), Gaba hiked his March 31 estimate to 6.7 million, up from 6.22 million earlier in the week.

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Breaking News: As of Today Top Analyst Projects That Well Over 6 Million Will Enroll in Obamacare by March 31

 

Charles Gaba, the  health care guru who has become widely known as the “Nate Silver of Obamacare”. is now projecting that by March 31 6.22 million Americans will have signed up for insurance in the Exchanges. 

And that is what Gaba is projecting today.  I suspect that as we approach the deadline,  enrollments will snowball.

As young people who have signed up talk to those who haven’t, more and more 18-34 year olds will learn about the subsidies that not only  cut premiums, but slash deductibles.

Spread the word: the subsidies are so generous that roughly 6.5 million Americans will be able to buy $0 premium plans. That’s right—the insurance will cost nothing. Half of those 6.6 million will be under 39. 

.7 million anyone?

Keep in mind, after March 31 people can sign up if they experience a “life-changing” event: get married, have a baby, lose a job, get divorced.

A great many of them will be under 40. Young Americans will continue to sign up throughout the summer.

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