Browsing the archives for the Health Care category.


The Further Adventures of Gov. Sam Brownback

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Health Care, Republican Party

Adding to the rolling disaster that is Kansas, Gov. Brownback somehow decided that raising taxes on HMOs would be just the thing to close the state’s budget gap. This is not going well.

According to The Wichita Eagle, leaders at Aetna are warning lawmakers that if Brownback’s proposal goes into effect the healthcare company would be hit with $12 million in additional taxes and add $206 to an average HMO insurance policy holder’s bill. Brownback’s proposal is currently awaiting approval in a House-Senate conference committee.

Seriously, what was he thinking?

Specifically, Brownback is looking to raise a “privilege fee” on annual HMO premiums which is currently at 1 percent. Brownback wants to raise it to 5.5 percent in order to bring in $136 million in new revenues. The $136 million would then be used to replace $80 million in state funds currently going to Medicaid, according to the Eagle. Kansas officials argue that the tax has to go to all HMO companies that offer Medicaid through Kansas’s KanCare program.

And yes, of course Brownback refused to expand Medicaid through the ACA, which would have taken care of the Medicaid problem without Kansas citizens haven’t to suffer for it. Why would we expect anything else?

On Monday, new Kansas revenue estimates projected a $400 million deficit for the 2016 fiscal year. That deficit is projected to grow to near $500 million if lawmakers don’t pass new insurance taxes.

“Conservatives” seem to think that if they can find some magic formula regarding taxes and budgets that costs will just go away. But some costs don’t go away. You can manage them stupidly or smartly, but they aren’t going away, and shifting who has to pay for stuff is not making the cost go away.

Elsewhere: Be sure to read “I am a cook in the US Senate but I still need food stamps to feed my children” and “Conservative Republicans Alone on Global Warming’s Timing.”

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Does the GOP Fear the Fallout from King v. Burwell? (Updated)

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Congress, Health Care, Obama Administration, Republican Party, Supreme Court

SCOTUS will hear the King v. Burwell case on March 4. This is the case in which it is alleged that states that did not set up their own exchanges under the Affordable Care Act cannot offer federal subsidies to people buying insurance through the federal exchange. The New York Times editorial board says of this,

On Wednesday, the Supreme Court will hear oral arguments in one of the most anticipated cases of the term: King v. Burwell, a marvel of reverse-engineered legal absurdity that, if successful, will tear a huge hole in the Affordable Care Act and eliminate health insurance for millions of lower-income Americans — exactly the opposite of what the law was passed to do.

Even an idiot ought to be able to understand that the primary point of the exchanges is to facilitate people buying individual health policies that can be subsidized. I suspect even some Republicans realize this.

The suit is based on one ambiguously worded sentence in the ACA. In a subsection of the law dealing with tax credits, the ACA describes exchanges “established by the states.” The authors of the bill say this was a vestige of the original assumption that the states would set up their own exchanges. It wasn’t anticipated that so many would refuse to do so. But the Burwell challenge hangs on  those four words — established by the states.

The challengers did not innocently happen upon these words; they went all out in search of anything that might be used to gut the law they had failed to kill off once before, on constitutional grounds, in 2012. Soon after the law passed in 2010, Michael Greve, then chairman of the Competitive Enterprise Institute, which is helping to finance the current suit, said, “This bastard has to be killed as a matter of political hygiene. I do not care how this is done, whether it’s dismembered, whether we drive a stake through its heart, whether we tar and feather it and drive it out of town, whether we strangle it.”

After the challengers found the four-word “glitch,” as they initially called it, they worked backward to fabricate a story that would make it sound intentional. Congress, they claimed, sought to induce states to establish exchanges by threatening a loss of subsidies if they did not. (Not coincidentally, the challengers also traveled state to state urging officials not to set up exchanges, thus helping to create the very “crisis” they now decry.) Of course, if Congress intended to introduce a suicide clause into a major piece of federal legislation, it would have shouted it from the mountaintops and not hidden it in a short phrase deep inside a sub-sub-subsection of the law. So it is no surprise that no one involved in passing or interpreting the law — not state or federal lawmakers, not health care journalists covering it at the time, not even the four justices who dissented in the 2012 decision that upheld the Affordable Care Act — thought that the subsidies would not be available on federal exchanges.

So, the purpose of Burwell is to kill Obamacare, and if SCOTUS decides for the plaintiffs, it might very well succeed. The Kaiser Family Foundation estimates that if the states without their own exchanges lose subsidies, 13,402,890 Americans who ought to be insured by 2016 will lose out. And the entire law could quickly unravel for everyone, as the health insurance industry is thrown into chaos. I understand roughly 9 million people would lose their insurance almost immediately.

The immediate fallout from a decision for the ACA challengers would, therefore, be chaos and devastation, and the long-term consequences potentially even worse. The ripple affect could impact just about everybody, and probably not in a good way.

 This past week Republicans in Congress seemed almost frantic in demanding the Obama Administration reveal their “Plan B” to the world. What will they do to save the ACA if the subsidies are struck down in so many states? And the Administration has said, over and over, there is no Plan B. If the subsidies are lost, there’s not a whole lot that can be done to salvage anything.

But rightie media are not accepting this. The Administration is hiding Plan B. HHS denies it is preparing Plan B. The Administration won’t say it is preparing Plan B. (Actually, it plainly says there isn’t one and none are in the works.) But there must be a Plan B! How could there not be a Plan B? Of course there is a Plan B, and congressional Republicans demand to know what it is.

Smart money says all this posturing is trying to signal the Court that the actual fallout of a decision for the challengers wouldn’t really be that bad; the Administration has a Plan B! Also, when the dominoes start crashing and people find themselves cut off from health care again, they are prepared to point to the White House — See? They should have had a Plan B. It’s their fault.

Republicans also have proposed a Plan B, although no one who knows anything about health care insurance thinks it will work. And a whopping majority — 64 percent — of Americans think that if SCOTUS rules against the subsidies, Congress immediately should step up and reinstate them. Which Republicans in Congress have no intention of doing.

Which makes me think that at least a few Republicans are genuinely nervous that a ruling in their favor could bite them, hard. Deep down, a few of the less demented among them may really want the White House to jump in with a Plan B and save their butts.

Update: Here’s something interesting — a GOP senator is proposing that if the subsidies are struck down, Congress should extend them for 18 months.

The loss of subsidies for millions of people would also put the Obama administration on the offense for the first time to protect its signature healthcare law.

A White House crusade against the GOP would mean a firestorm of accusations that the party is taking away care and endangering lives  – building up for the 2016 election.

To avoid that situation, some Republicans are floating a stopgap that would keep the subsidies in place temporarily.

Sen. Ben Sasse (R-Neb.) promised this week that he would introduce legislation that creates a “temporary model to protect those harmed by ObamaCare” in which people could still receive financial help for their healthcare costs for 18 months after a court decision.

Startin’ to sweat a bit there, dude?

Senate Finance Committee Chairman Orrin Hatch (R-Utah) hinted at a similar proposal earlier in the week, promising “a short-term solution” until a Republican can enter the White House.

By some coincidence, 18 months from the likely date of the decision — end of June, 2015 — would possibly take us just past the 2016 elections.

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More Elusive Than Bigfoot

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Health Care, Obama Administration, Supreme Court

The King v. Burwell case, to be argued in front of the SCOTUS in March, was deliberately crafted to take down the Affordable Care Act. So why is it the crafters couldn’t find better plaintiffs? Jeffrey Toobin writes,

The case is based on the claim that the Obama Administration policy of allowing those who received tax subsidies to buy insurance on the federal exchanges—which cover the thirty-four states that don’t have state-run exchanges—violates the terms of the Affordable Care Act itself. If the plaintiffs succeed in making their case, eight million people are estimated to lose their health insurance, and the A.C.A. itself could subsequently unravel.

But the King case, like any case, can only proceed if the plaintiffs have standing—that is, if they can claim an “injury in fact” from the Obamacare law. Thanks to two recent, excellent pieces of journalism, in Mother Jones and the Wall Street Journal, we now know a great deal about the four plaintiffs. Two are veterans of the Armed Forces and can receive health care through the Department of Veterans Affairs; accordingly, they have no reason to seek the tax subsidies under the law. The other two plaintiffs may make too little money to qualify for the tax subsidies, and, furthermore, one who claimed to be a Virginia resident listed a motel that prohibits long-term stays as her address. In short, the provisions of the Affordable Care Act in question in King v. Burwell may be irrelevant to all four plaintiffs—which would mean that they lack standing to challenge it.

Toobin says that conservative justices for many years have dismissed various challenges from liberals on the grounds that the plaintiffs did not demonstrate the law posed an “injury in fact” on them, and thus they lacked standing.

During the George H. W. Bush Administration, a coalition of environmental and conservation groups sued to stop new federal regulations that limited the application of a section of the Endangered Species Act. Chief Justice Roberts, then the Deputy Solicitor General, persuaded the Supreme Court to throw out the case because the plaintiffs would not suffer direct harm from the new regulations and lacked standing to bring the case. In Lujan v. Defenders of Wildlife, the court held that a “generally available grievance about government—claiming only harm to his and every citizen’s interest in proper application of the Constitution and laws, and seeking relief that no more directly and tangibly benefits him than it does the public at large—does not state an Article III case or controversy.”

I understand they don’t hear cases brought by spotted owls, either. A pity.

The Administration’s lawyers didn’t bring up the issue of standing in their brief, which means they either were asleep at the switch or they’d rather not have the case dismissed in a way that would allow the Right to try again.

This also begs the question of why the Right can’t find better plaintiffs. I occasionally read posts or comments from someone who has a legitimate-sounding story of being worse off because of Obamacare, but somehow the examples the Right chooses to feature never stand up to scrutiny.

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Inaction and Consequences

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Health Care, Obama Administration

There are measles epidemics breaking out around the country, and plenty of people are plenty mad at anti-vaxxers who have weakened our herd immunity and allowed this to happen by not getting their kids immunized. Apparently upscale crunchy suburban parenting requires abstention from vaccines, or else one is a bad parent allowing toxins into children’s bodies. These are college educated people who have persuaded themselves that the risks of the vaccines are greater than the risks from the diseases. I understanding not feeling warm and fuzzy toward the pharmaceutical industry, but this is ridiculous.

I ran into a guy the other day raving about vaccines being a violation of personal sovereignty. To which I thought, how did we get to be such a nation of whiny hothouse orchids that vaccinations are a violation of personal sovereignty? I can understand the small number of people with genuine religious objections, but most anti-vaxxers are objecting on pseudo-science grounds. The long-discredited link between vaccines and autism is still believed, and the link is still being promoted on a lot of websites. Plus there are new scientifically unsupported theories about how the number of vaccines kids are getting is overloading their immune systems, or something.

If vaccines were a brand new thing this fear might be more understandable, but if you’re alive today you probably were vaccinated as a child. Not counting the original, primitive smallpox vaccine of the 1790s — which really was risky — people have been getting vaccinated for all kinds of diseases since the late 19th century. The U.S. issued regulations of recommended vaccine schedules for children and adults in the 1940s. It must have been a state program, but in the 1950s in my public elementary school, the school nurse from time to time lined up everyone in class in alphabetical order and give us our shots right there in school. Nobody was excused.  When I enrolled my kids in public school in the 1980s I had to send their immunization record to the school.

However, after all these years, a substantial number of people have decided that immunizations are (choose as many as apply) a government plot, a scam by the pharmaceutical industry, a threat to our health that for some reason nobody but some celebrities on teevee take seriously, or a harbinger of the One World Order, This is just weird.

Health fads aren’t new at all, but fads about diets have gotten so prevalent they’ve spawned a new term — orthorexia. Suddenly gluten is bad. Suddenly people have to de-tox. Like we didn’t have livers for that. Not that I’m exactly a role model of sensible eating, but I do run into people who are absolutely obsessed with only eating certain foods from a few trusted, and out of the way, sources. It’s like anything sold in a chain grocery store might cause sudden death.

My working theory for at least some of this craziness is that food and health fads have taken the place of religion for some people as a means for protecting themselves and their loved ones for the scary things out there. Prayer has been replaced by colon cleanses.

The measles outbreaks also reminds us that the things we do, or don’t do, really do affect other people in myriad ways. We can go around pretending that our personal choices are just our business, but it’s not always that simple.

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Attempts to Smear Obamacare Getting Lamer

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Health Care

Having run out of cancer patients willing to lie about how Obamacare took away their treatments, the New York Post has found a young man claiming that Obamacare  refused to give him subsidized insurance when he couldn’t afford to pay the full premium. Except …

So there I was: A struggling grad student with no health insurance, and unable to afford unsubsidized ObamaCare plans I’d hardly, if ever, use.

But Uncle Sam was there on his white horse, ready to save my day with . . . Medicaid?

Yes, folks, his state (Illinois, I believe) was ready to sign him up for Medicaid, but because he is eligible for Medicaid he can’t buy other insurance on the exchanges. And apparently he is too special to accept Medicaid. Which I am on myself right now, btw, at the state of New York’s insistence. I got two prescriptions filled last week for just a $1 copay. Works for me.

But let us return to this unfortunate young man, who feels it is beneath him to accept Medicaid, but doesn’t want to pay for the other alternatives available to him.

Reading on, we learn that Precious was 26 years old and in graduate school when he learned the group plan he was on as a student was being discontinued for some bullshit reason, probably because the school administration realized it could save itself some money by dumping the insurance plan and blaming the ACA. But Precious is too special to accept Medicaid, because it would give him cooties, and private plans are more expensive than group plans, and he is being ripped off because he is young and healthy and has to pay more because he’s being dumped into the same risk pool as old, sick people.

Precious then claims his only option was to take short-term insurance which he realizes is a ripoff, but Obamacare gave him no choice. Well, except for Medicaid, but that’s not really an option for someone as special and precious as he is.

My experience perfectly highlights the insanity of the Affordable Care Act. It forced me — a paying, insured, well-educated, healthy American — out of the coverage I’d had, then tried to push me into Medicaid.

The program wouldn’t let me pay more when I offered to pay a higher rate to stay out of Medicaid, and it provided only one other option: paying the highest rate available for insurance I didn’t use once in 2014.

Which means he wouldn’t have used Medicaid, either, so he wouldn’t have gotten cooties after all.

Rather than take the easy route and enroll in Medicaid, I paid my own way with a private plan of my choosing. Now, instead of being rewarded for saving taxpayer money, I’m being punished with a fine of at least $95. What a country!

The punch line is the author’s bio at the end of the article: “Justin Haskins is a writer and editor for The Heartland Institute, a Chicago-based free-market think tank.” I bet he’s read Atlas Shrugged three times.

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New Bullshit Anti-Obamacare Court Decision

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Health Care

When I first saw this headline I felt genuine panic — Court Rules That Subsidies in Obamacare’s Federal Exchange are Illegal, Dealing Huge Legal Blow to Health Law. That’s the headline at Hit & Run, where the Koch-funded libertarians probably are doing cartwheels around their desks. You can look it up if you want to read it.

Here’s the story on Talking Points Memo. The two Republican judges on the three-panel D.C. Circuit Court of Appeals decided that the state insurance exchanges run by the federal government may not offer subsidies, or the tax credits offered by the IRS. The one Democrat called this bullshit.

“This case is about Appellants’ not-so-veiled attempt to gut the Patient Protection and Affordable Care Act,” Edwards wrote in his dissenting opinion. He called said the majority’s reading of the statute amounts to “a poison pill to the insurance markets in the States that did not elect to create their own Exchanges. This surely is not what Congress intended.”

My initial panic was mollified somewhat by the realization this decision does not affect the New York exchange, which is run (somewhat clumsily) by New York. Still, it’s a hell of a mess, and it’s not clear to me if this will go into effect immediately. If so, a lot of people are about to lose the insurance they’ve had for less than a year.

The White House is going to ask the full panel to rule on the decision, which could possibly reverse it.

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Health Care Makes People Healthier! Who Knew?

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Health Care, Obama Administration

A study published in the Annals of Internal Medicine yesterday said that after the 2006 “Romneycare” law went into effect in Massachusetts, mortality rates in Massachusetts dropped by about 3 percent.

The study tallied deaths in Massachusetts from 2001 to 2010 and found that the mortality rate — the number of deaths per 100,000 people — fell by about 3 percent in the four years after the law went into effect. The decline was steepest in counties with the highest proportions of poor and previously uninsured people. In contrast, the mortality rate in a control group of counties similar to Massachusetts in other states was largely unchanged.

A national 3 percent decline in mortality among adults under 65 would mean about 17,000 fewer deaths a year.

There have been a number of estimates of how many people die in the U.S. every year because they lack insurance. I think that’s a hard thing to quantify, and some people (Megan McCardle, actually) denied that access to health care made any difference to mortality rates at all, based on some standard McCardle-style reasoning that makes sense only if you don’t think about it.

The estimates have ranged from a low of 18,000 deaths per year to a high of 45,000 (analysis here), and the new study comes closer to supporting the lower figure. However, I postulate that the effects might be larger in poorer states, especially over a longer period of time (the study only covered 2006-2010). I believe Massachusetts already had lower mortality rates than much of the rest of the country, mostly because it is more affluent overall. Also, it’s going to take a few years before the effects of long years of neglect fade away. But they’re not going to fade so much in “Medicaid gap” states.

See also interesting comments from The Incidental Economist.

Meanwhile Gallup reports that the percentage of uninsured Americans has dropped to the lowest point since they began measuring the percentage of uninsured Americans.

Also meanwhile, some whackjob Republican is comparing Obamacare to the Holocaust. And a majority of Americans still think Obamacare is a failure.

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The Evil Rich

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Health Care

In some states, the poor have been avoiding “Obamacare” because of the political stigma:

Health professionals, state officials, social workers, insurance agents and others trying to make the law work for uninsured Americans say the partisan divisions and attack ads have depressed participation in some places. They say the law has been stigmatized for many who could benefit from it, especially in conservative states like West Virginia that have the poorest, most medically underserved populations but where President Obama and his signature initiative are hugely unpopular.

These are also states with the most competitive Senate and House midterm election campaigns, so the right-wing super PACs have poured millions into advertisements demonizing the ACA and the Democrats who support it. As a result, the poor have been convinced that Obamacare is evil on steroids.

Other problems stymied the introduction of the law, notably the initially dysfunctional federal website. But the political polarization “complicates our efforts to enroll people and to educate people about the Affordable Care Act, there’s no question,” said Perry Bryant, head of the advocacy group West Virginians for Affordable Health Care, based in Charleston, the capital.

“Literally, people thought there would be chips embedded in their bodies if they signed up for Obamacare,” Mr. Bryant said.

Far to the east, at a branch of the Shenandoah Valley Medical System in Martinsburg, Sara R. Koontz, a social worker, said she had heard people express fears about chip implants as well as “death panels” as she sought to enroll uninsured residents. Some told her that they would rather pay a penalty than sign up for insurance, she said, and even people who did enroll paused in their excitement to ask, “Wait — this isn’t that Obamacare, is it?”

The wealthy people spending money to discourage people from getting health insurance get great health care, I’m sure.

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The Real Death Panels

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Health Care, Obama Administration

Health and Human Services Secretary Kathleen Sebelius resigned yesterday, which the Right heralds as a sign of victory. Some guy at the Federalist already is salivating over the grand fight they’re going to have nominating her replacement —

In any case, it appears that this resignation presents Republicans with a golden opportunity to reignite their crusade against Obamacare with Sylvia Burwell’s nomination as a proxy for all the problems with the law. Burwell is a political loyalist and a veteran of the shutdown fight with no record on health care, and will likely be coached to avoid answering questions about specific challenges with implementation at HHS. Senate Republicans actually have an advantage here in the wake of the Nuclear Option’s implementation: they can easily come up with a list of facts they claim the administration has hidden, details kicked aside, statutes ignored, and a host of other challenging questions on accountability over the implementation (and non-implementation) of the law. A list of every question Sebelius has dodged over the past several years would suffice. By demanding answers before the HHS nomination moves forward and refusing to rubber stamp the president’s pick, Republicans could force more vulnerable Democrats to take a vote that ties them both to the Nuclear Option and Obamacare six months before a critical election.

I understand Rachel Maddow was bothered that the resignation stepped on a week of good news about the ACA. But by November, it may not matter. I do not think most folks give a hoo-haw about the nuclear option, and who knows what public opinion of the ACA will be by November? If Republicans grandstand overmuch over the nomination hearings, they risk overplaying their hand, as they are prone to do.

Krugman writes,

When it comes to health reform, Republicans suffer from delusions of disaster. They know, just know, that the Affordable Care Act is doomed to utter failure, so failure is what they see, never mind the facts on the ground.

Thus, on Tuesday, Mitch McConnell, the Senate minority leader, dismissed the push for pay equity as an attempt to “change the subject from the nightmare of Obamacare”; on the same day, the nonpartisan RAND Corporation released a study estimating “a net gain of 9.3 million in the number of American adults with health insurance coverage from September 2013 to mid-March 2014.” Some nightmare. And the overall gain, including children and those who signed up during the late-March enrollment surge, must be considerably larger.

However, we still have the huge injustice of the refusal to expand Medicaid.

What’s amazing about this wave of rejection is that it appears to be motivated by pure spite. The federal government is prepared to pay for Medicaid expansion, so it would cost the states nothing, and would, in fact, provide an inflow of dollars. The health economist Jonathan Gruber, one of the principal architects of health reform — and normally a very mild-mannered guy — recently summed it up: The Medicaid-rejection states “are willing to sacrifice billions of dollars of injections into their economy in order to punish poor people. It really is just almost awesome in its evilness.” Indeed.

And while supposed Obamacare horror stories keep on turning out to be false, it’s already quite easy to find examples of people who died because their states refused to expand Medicaid. According to one recent study, the death toll from Medicaid rejection is likely to run between 7,000 and 17,000 Americans each year.

There’s your death panels, folks. They’re called “Republican governors.”

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Silver Linings

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Health Care

Among other things I’m still messing around trying to get a cheaper health insurance policy through the New York exchange. In December I gave up and paid my old premium for January. (I did finally get a notice from New York about my eligibility, dated December 26, advising me to be sure and sign up by December 23.)

Since I do qualify for a subsidy, there are four or five plans that would save me considerable money on premiums, and I’ve calculated I would still come out ahead even if I end up paying all of the deductible. And if I don’t need much medical care this year I could come out way ahead. Only one of them lists my doctor as a provider, though, and I just need to get hold of someone at my doctor’s office to confirm they are in that network. And no one’s ever there when I call. It’s always something. I’ve got to sign up by tomorrow, I understand, to be covered in February.

There’s still a lot of bitching and moaning about Obamacare in the headlines. Jonathan Cohn writes that the actual enrollment data isn’t that bad.

Ed Kilgore summarizes,

The long-awaited breakdown on the age of young enrollees (defined as under 34) came in at 24%, not catastrophic but well below the target of 40%. But as Cohn points out, the Massachusetts precedent showed that young-uns tend to enroll in this kind of scheme quite late, so let’s wait a while before panicking over the age mix.

Cohn also notes that about 79% of enrollees are qualifying for premium tax credits, a.k.a. purchasing subsidies, which is very much in line with CBO predictions.

The real news to me in his post is which of the coverage levels is proving to be most popular. For 60% of enrollees, it’s the “silver plans,” which are distinguished by protection from really large out-of-pocket costs. Health reforms of all varieties should take notice of that (particularly conservatives who think shifting more health purchasing from insurance to self-payment is the key to controlling costs).

The silver plans are the ones you can get with a subsidy, so that’s probably accounts for a lot of their popularity.

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