Seema Verma is the projected next head of the Center for Medicare and Medicaid Services (CMS). She is a perfectly plausible nominee with views that I will seldom agree with. She is the consultant that led to Indiana to develop the HIP V.1 health savings account based Medicaid build-out that was tweaked to become HIP 2.0 which is the Medicaid expansion waivered for Indiana. I want to highlight something that she wrote in 2008 in Health Affairs:
Already, we see areas we would like to improve. The $1,100 deductible may be too low for those persons with chronic illnesses. We wonder if there should be additional copays for those individuals not paying up to the five percent CMS limit to further encourage appropriate utilization.
What is the logic here? Is this a Willie Sutton moment or is there something else going on?
$1,100 is a significant deductible for anyone. Using the 2017 Acturial Value (AV) Calculator for Platinum, an $1,100 deductible leads to 88% AV coverage assuming no other cost sharing. In 2008, that deductible is probably 75% AV coverage. That is coverage which is less than typical coverage people receive at work, and it is significantly less than the AV that people get on Exchange with Cost Sharing Reduction subsidies. The counterargument is that Healthy Indiana fully funded the deductible so beneficiaries were paying their monthly premiums/HSA contributions but the entire idea of an HSA is to give at least a partial ownership stake for a savings account and make people very reluctant to spend the money.
This reluctance to spend money is a major problem. We know that people are fairly bad shoppers who do not differentiate between high value and low value care all that well. We also know that chronic conditions are where we spend most of our money. We also know that skipping chronic condition maintenance care leads to higher acuity care in the future. Increasing the deductible to cut down on chronic condition spending by decreasing utilization seems to be at best a case of shuffling money around from less maintenance care to more acute care. I’m not understanding this?
I could see a logic saying that alternative payment reforms with two and three way gain sharing or even just straight co-insurance increases so that people are more cost sensitive are plausible pathways to get the same or better care at the same or lower prices, but I really don’t understand the point of increasing the deductible from either a financial or care point of view.
“I could see a logic…”
…but this is a GOP cabinet nominee. The only logic is IGMYFY.
The skill is making it look helpful, then when it is not, go, “See! Government can’t do anything!”
My job at a non-profit wound up getting us a Bronze plan and then a debit card with some money to help meet the high deductible. I guess it winds up cheaper that way for them, and it does work for me.
“further encourage appropriate utilization” – I’m adding that to my collection of modern Orwellian phrases.
I used to know a Seema and a Verma, not a Seema Verma, though.
The only way this is logical is if the goal is cost shifting to the “consumer”.
Better health outcomes, long run cost savings from better management of chronic illnesses, and the increased productivity of people living with chronic illnesses (being able to work because they are healthy enough to work) are not the goals.
These Republicans are cruel and greedy.
I believe the concept in play is adding insult to injury.
The appropriate level of utilization to any Republican is zero. Since the only way for a chronic illness sufferer to utilize healthcare at a zero level is to die, that’s basically the goal. It’s the banality of evil written in a couple of clean sentences.
It was said to me quite explicitly back when I was in grad school and on junk insurance – no deductable, but 20% co-insurance and an annual limit for perscription drugs of *$1500*. They wanted to drive chronically ill people off the plan altogether. If they had no other place to go? Well, they were making a noble sacrifice in order that the undergrads could have cheap insurance. Those were the *exact words* of the insurance rep I spoke to.
They’re quite used to basically condemning people to death for a few additional shekels. That’s your death panels right there.
She is a crook, Mayhew
mai naem mobile
Well for Ms. Verma, $1100 for a deductible is nothing being that she got $3.5M from the State of Indiana for her work on the Medicaid expansion plan. Also too, if it’s Lumpy, you know she’s either a crook, a grifter or completely unqualified for the job,or all of the above.
@mai naem mobile: Where does T find all these fucktards with Indian sounding names?
Paraphrase requote from forever:
Yes I can see why the medical consumer should have more skin in the game and disincentives to use the system since accessing the US medical system, tests, paperwork, phone calls, keeping records of phone calls and appeals is SOOOO much fucking fun.
mai naem mobile
@schrodinger’s cat: it’s not Indian sounding,she is Indian American. She’s a Johns Hopkins grad – I only know this because when she was originally nominated there was a congrats from Johns Hopkins.I’m surprised Lumpy hasn’t hired Avik Roy for something.
@mai naem mobile: He seems to prefer the women, better. Nikki Haley.
@ArchTeryx: Yeah, I think the plan is to encourage underutilization. Some people will end up costing more due to acute care, but that will be balanced out by those who die sooner. Look at all the savings!
@mai naem mobile: I knew a couple of Indian doctors who were completing their residencies from Johns Hopkins when I lived in the DC area in the mid to late oughts.
The purpose is to deny sick people health care.
@mai naem mobile:
Avik Roy for all his faults pointed out that the GOP has become a white supremacist party, that Trump is a hate-monger, and that the GOP is utterly compromised and needs to be replaced with something new. So I am not sure that he is going to be very popular with either the Trump or (formerly) mainstream factions of the party at this point.
Just saw on google news that the Ohio House and Senate passed legislation to ban abortion after 6 weeks.
Boy these Republicans are eager to get abortion back in front of SCOTUS.
Way to go Ohio.
I would say best case from a cost perspective would be less maintenance care leading to people with chronic conditions dying before receiving acute care. You’re assuming that keeping people alive is one of their healthcare goals. Profit is the only Republican goal.
You forget inflicting pain.
Each death needs to be loudly talked about, and the churches that these assholes pharisaically attend picketed and shamed. There should be constant pickets in front of their country clubs, and in front of the gated naighborhoods.
Make it felt.
Can we get a Weathermen GoFundMe started?
@Weaselone: exactly. And to punish poor people for being ppor
@MomSense: I’m not an MD, but it looks like accurately determining gestational age is problematic that early. E.g. PubMed:
Convenient that Ohio’s rule cuts off at 6 weeks while PP services include up to 8 weeks, huh.
Presumably, even if this law is upheld, in most cases it will be impossible to enforce as the drugs would be easily available. But of course, this law should be struck down and should never have been considered in the first place.
(“Why do you think the State should be able to force you to reproduce?”)
Where does he find these people? They enjoy being cruel.
@p.a.: After the last round of insurance handling, which is still not resolved and will probably have to go to repeal, I have declared to Mr WereBear that they want you to just give up and die.
The sicker one is, the less one is able to hack through all the obstacles.
@MomSense: For a couple of terms, my little corner of southwest Ohio succeeded in sending a Democrat to the Statehouse. Then my district was redrawn just enough so that only a Republican could win. Gerrymandering is ruining my State.
India? I hear there’s a lot of people there.
Wikipedia is silent on her origin prior to obtaining her BS from UMd and MS from JHU. Could be an immigrant, could be another anchor baby. So Twittler has no problem with the non-Messican immigrants?
ETA: She doesn’t have much of a presence on Google if this very post is the #6 hit.
@Poopyman: Most Indian immigrants that I know of are firmly in the Democratic column and vote overwhelmingly D* but I guess the 20% IGMFY contingent is very well represented among the Republicans.
*More than 80% went for the O man in 2012.
OT. Seems there is a common thread running thru Der Fuhrer’s picks:
1. retired generals
2. who had policy disagreements with Obama.
Wonder if item two is what makes them so attractive to der fuhrer?
@D58826: Just offered ambassador to China to the governor of Iowa. Perhaps a reward for seizing people’s land by eminent domain and giving the rights to ETP to put the Bakkan pipeline (DAPL) through fields of crops and pasture. Der T is an ETP stockholder.
The cost sharing thing is idiotic.
At the most abstract level, health care is a good unlike most other goods. It’s not like people want unlimited health care—healthy patients don’t bitch about not getting any of that sweet, sweet chemo. People want exactly the amount of health care that will keep them happy, productive, and long-lived (if possible). No more, no less.
Why anyone pays attention to the idiots who push consumer-driven health care saving is beyond me.
@Aleta: I left IA at the age of 17. Dad still bitches about how awful Branstad is.
@MomSense: I don’t get the claim that the thugs on the USSC (after Trump puts his little thumb on the scale) will actually hold back from overturning Roe.
Not only will they do that, they’ll dump their states’ rights bullshit and immediately try to ban abortion at the Federal level.
@Another Scott: What’s going to be really interesting is when the right’s “oh, of course we’ll never prosecute women!!1! Just doctors!!1!” comes up against women doing it themselves using untraceable drug networks.
@Aleta: lates poll – 70% of public not concerned about his business conflicts and the old granny-starver said it isn’t any of Congresses business.
One of the decisions I’ve made in the wake of this election is to restrict my economic activity to blue states as much as humanly possible, which is why I’m now awaiting a shiny new purse from Tom Bihn in Seattle — American made in a blue state.
I’m stuck going to Disneyworld in Florida this spring because that’s the only way the Devil Woman will allow me to see my nieces, but after that, only blue states will see my travel dollars. If red states don’t want my filthy money, I won’t force it on them.
@D58826: What about Bud Light Lime General, I haven’t heard his name yet.
@Mnemosyne: Looks like a school bag! Not that there is anything wrong with that.
That’s just the general website — the actual bag is this one, the Side Kick. I should be able to carry my new Passion Planner plus all of my other necessities without getting too weighed down. And it can convert to a fanny pack if my bad shoulder protests too much!
(Yes, I am now old and broken-down enough to understand the appeal of the fanny pack.)
I would like to see the wording of that poll. If people understood the potential negative impact of the business conflicts, the outcome might be different. This issue has not received enough attention, apart from a few articles in the NYTimes, WAshington Post, and Newsweek.
@Mnemosyne: Heh I carry a backpack when I have to lug my laptop, so I get it. Just teasing. Bags are my weakness, shoes not so much.
@D58826: So over 54% of voters did not vote for Trump but 70% aren’t concerned about his potential conflict of interest?
@schrodinger’s cat: Brahmins will be Brahmins.
@Yutsano: Are you talking of Verma in particular, or Brahmins in general? Or are you calling the GOP Indians, Brahmins. I has a confused.
I’ve seen many people opine that people make “better” choices when they have “skin in the game”. I have no idea where this dumb-donkey quote came from with respect to health care, but it’s out there.
What this leaves out is that *EVERYONE* has “skin” in the health care “game” – THEIR HEALTH.
And the stupidity of it is, there are lots and lots of situations where a person can’t judge risks well. What are the risks of uncontrolled diabetes? They’re *huge* – but they can stay hidden from obvious view for years, and then, once they’re clearly visible, the person may be in need of expensive long term care.
I mean, there are times. I found my depression was less well controlled with generic bupropion; I wanted Wellbutrin XR, not the generic. I’m willing to pay a higher copay for that; I understand that it’s something of a “luxury” from the POV of the insurer (but the difference is well supported anecdotally, and has been shown to be true in some situations). I can see “luxury” copays, especially in cases where a person wants to skip trying the old-standby medication, in favor of the NEW! IMPROVED! drug they saw on a TV ad, that hasn’t shown any advantage over the old-standby. But if they tried old-standby, and it didn’t work, it’s mean to make them pay higher for NEW! IMPROVED! to see if *that* works.
Anyway: to follow on the prior example, if you make diabetes meds and testing supplies expensive, so the patient has “skin in the game” you’re asking for lower standards of care because the person responsible for administering treatment (i.e.: the patient!) might find their preferred options are forbidden, or cost-prohibitive. That isn’t even good for cost control – diabetes often kills slowly and expensively.
@schrodinger’s cat: I thought I knew where I was going with that but my sleep deprived brain has lost it now.
@Yutsano: Actually, Brahmins have been among the most progressive and regressive Indians. Also, the ones to adapt to change (at least in the public sphere) and the ones to resist it (in the private sphere). As a community they revere knowledge more than money. Historically, their worst sin was to keep education out of bounds for most others (lower castes, women etc).
Both Nehru (first Prime Minister and the architect of liberal modern India) and Savarkar (the intellectual guru of the Hindu right and Nehru’s contemporary) were lawyers educated in England and Brahmin by birth.
So its complicated.
The “point of increasing the deductible from either a financial or care point of view” is that they have the fun of hammering those worthless eaters. Right wingers always want to get even, and it’s a curious fact that the people they like to get even with the most are the ones that can’t hit back.
One of my coworkers who’s in recovery with AA keeps threatening to do an intervention if I buy any more bags. ?
Dr. Ronnie James, D.O.
@lowercase steve: Thats what Avik Roy said *last month*. Now, he’s happily back advising the GOP how to gut the ACA/ Medicare. “I can’t stay mad at you!!”
Long time lurker first time poster. So the “we should charge chronically ill people more” hits home for me. I’m chronically ill, have a $1000 deductible, pay $850/mo for insurance with a 20% copay for doctor and specialist visits, and…what? This is not enough? Maybe from their viewpoint. I can’t work, so it’s rather more than too much for me.
I’ve actually needed to cut down on BJ and on social media in general since the election, for the sake of my mental health, but I chanced to see this today. Makes me feel real good about my future.
Adam L Silverman
@owlface: Just saw your comment in moderation, which happens every time someone posts their first comment. You should be good to go now going forward, except when WordPress has one of its regular hiccups and sticks you back in moderation.
We’re glad your here. And I’m sure Richard didn’t mean to bum you out.
@Adam L Silverman: Thanks! No, Richard didn’t bum me out, I value his discussions on health insurance. Just, wow, that’s a hard quote for me to take.