UPDATE: So far, as October 4, there is no evidence that anyone has enrolled in Obamacare. The one person alleged to have done so has now been shown to have been lying and the details he offered to the eager press, were phony. It appears the IT collapse is continuing.
UPDATE #2 There appears to have been 1% or less of applicants who negotiated the maze actually signed up. The web site is closed for the weekend to fix “glitches.” I still suspect it would have been better strategy to allow the October 1 rollout of this mess and focus on the debt ceiling for a potential shutdown.
UPDATE #3: Here is an informed discussion of Obamacare and the IT mess that created it.
To add insult to injury, the administration outsourced the building of this costly contraption to CGI Group, a Canadian firm. CGI, whose U.S. operations are based in Northern Virginia, “just so happened” to increase the number of H-1B visas it requested from 172 in 2011 to 299 in 2012. It seems more than a little likely that the Obamacare project gave jobs to foreigners while needlessly leaving fully dozens or perhaps even hundreds of qualified citizen IT professionals on the unemployment line.
It gets even worse. CGI was “officially terminated in September 2012 by an Ontario government health agency after the firm missed three years of deadlines and failed to deliver the province’s flagship online medical registry.”
Oh well.
The Obamacare exchanges are supposed to open next month. There are major problems with the IT systems but that is what the government says. I have been in favor of health care reform for years and posted some of my thoughts here a few years ago. At the time, I favored something on the lines of the French system which includes private practice, free choice of physician and a good electronic billing system but has a budget limit to keep costs down. Obamacare went the opposite way and has a bloated benefit package to be controlled by rationing of access. Its entire method of financing depends on charging the young more than the cost of their care to subsidize those older or with chronic illness. It also includes a system for rationing of care in the elderly.
How did we get here ? I posted some thoughts on this with a brief history. My book has more and the Paul Starr book is excellent but dated. The tragedy of American health care has been a story of rent seeking. Until after World War II, American doctors were pretty much on a cash basis with patients. Hospital care was a minor component except for surgery and this was of modest cost. Hospitals charged a daily rate and what insurance there was paid for insurable events, like emergency admission and surgery. Childbirth was not covered, except for caesarian section, until I was a medical student in the 1960s. My older three children were delivered before insurance covered delivery and the cost was about $250 per instance for mother and child.
What would work well, I think, is some sort of catastrophic coverage for the young which would not be expensive. A mandate might work here for such things as drivers’ licenses. The French system allows the patient free choice of doctor and allows doctors to charge more than the official fee schedule, so long as the charges are disclosed before care. There are incentives for doctors to accept the fee schedule such as vacations and pensions. In addition, in France medical school is free. I am sure some arrangement could be made for forgiveness of student loans in return for accepting the official fee schedule or service in clinics for the poor.
The French system does not include the insane system of subsidies which will not work and invites corruption. What it does is pay an agreed upon fee schedule for services, much as indemnity style health insurance did 50 years ago. The difference is that, unlike most insurance and Medicare, the doctor can charge extra. It is called “balance billing” and must be disclosed before treatment.
Single payer enthusiasts argue that this will not work as doctors will cheat. They ignore the tremendous incentive for doctors to leave the system and retire or go to cash payment. This is what is happening now. One huge incentive for doctors to quit is the guidelines which have criminal penalties. This is what created the tremendous backlash against the Hillary Clinton program in 1994. Any practice outside the system was to be illegal.
One of the better sources is a blog that has since seemed to close down but which included a lot of information about Obamacare. For the discussion of guidelines, go here. A few highlights.
That question is: Just who are the people writing all those clinical guidelines – the “guidelines” physicians are now expected to follow in every particular in every case, on pain of massive fines, loss of career, and/or incarceration?
DrRich is quick to say that the act of creating clinical guidelines is not inherently evil, and indeed, back in the day when guidelines were merely guidelines (instead of edicts or directives that must be obeyed to the last letter), creating clinical guidelines was a rather noble thing to do.
But today, we have physicians clamoring to become GOD panelists (Government Operatives Deliberating). These aristocrats of medicine will render the rules by which their more inferior fellow physicians, the ones who have actual contact with patients, will live or die. Clearly positions of such authority will be very desirable, and so, as one might predict, they are being vigorously pursued. And we are seeing candidates audition for these panels with efforts ranging from amateurish to ruthless. It puts one in mind of the early-season contestants on “American Idol.”
We see them vociferously extolling, in every public venue they can find, the idea of “fly by wire” medicine, whereby every decision physicians make will be determined not at the bedside but by the best and the brightest experts, acting at a distance. The experts will distribute rules of action based on only the best scientific evidence (“best” being determined by those selfsame experts).
There are two kinds of guidelines that I am familiar with. One type is derived from clinical research done under controls that show statistical significance. They are pretty reliable although variation in patients may make them of limited use. The other type is called “consensus guidelines” and they are derived from panel discussions by “experts” often physicians who have not been in practice for years. I consider them to be of dubious value but they are usually concerned chiefly with cost. Cheaper is better if you believe them.
Some of the coming problems are posted here.
1. The software doesn’t work.
Less than two weeks before the launch of insurance marketplaces created by the federal health overhaul, the government’s software can’t reliably determine how much people need to pay for coverage, according to insurance executives and people familiar with the program.
Government officials and insurers were scrambling to iron out the pricing quirks quickly, according to the people, to avoid alienating the initial wave of consumers.
A series of glitches and delays have left many doubtful that healthcare exchange system that will support ObamacAre will be ready by the scheduled Oct. 1 launch. WSJ’s Christopher Weaver explains.
A failure by consumers to sign up online in the hotly anticipated early days of the “exchanges” is worrisome to insurers, which are counting on enrollees for growth, and to the Obama administration, which made the exchanges a centerpiece of its sweeping health-care legislation.
Of course the government has said that it will “trust” applicants to disclose their true income. That should work well.
Four people familiar with the development of the software that determines how much people would pay for subsidized coverage on the federally run exchanges said it was still miscalculating prices. Tests on the calculator initially scheduled to begin months ago only started this week at some insurers, according to insurance executives and two people familiar with development efforts.
The FBI spent ten years developing new software that is less complicated. A couple of years ago, they gave up and started over. The Air Traffic Control system uses software that is 40 years old.
Oh well, some things just take time.
Already, some requirements in the law, such as a mandate that large employers offer workers insurance and limits on consumers’ annual out-of-pocket spending, have been delayed, with officials citing administrative and technological hurdles.
The big contractors are having problems.
Glitches in technology projects of this scale are “totally to be expected,” said Michael Krigsman, an information-technology consultant who advises companies on IT projects. “On the surface, you’d think this is pretty easy for a website to give you a price, but behind the scenes, the number of variables is very high,” he said.
The calculator application is being developed by the government contractor CGI Group Inc. CGI has won more than $88 million in government contracts to build the exchanges through next March, the largest amount of any contractor, according to the GAO report. Donald Meyer, a public-relations executive representing CGI, declined to comment on behalf of his client.
I wonder how they are related to Obama ? I have serious doubts having seen many health care IT systems up close.
Tags: economics, health care, medicine, Obama