Physician Experience vs. Expectation

During the past decade we have witnessed the corporatization of medicine.  Solo private practice physicians in the U.S. are dwindling rapidly in the United States, except perhaps for a few selective specialists and in underserved areas. Some physicians are experimenting with the new "Direct Payment" model or "Concierge Medicine"

Although private solo or small group practices offer autonomy and control, there are disadvantages. Those who join an integrated health system, or become employed by a hospital gain administrative support and the ability to negotiate insurance contracts with more bargaining power than a small provider. However there are serious trade-offs. Physicians who sell their practice to a hospital find that hospitals receive failing grades in their prowess to run medical practices.

This is a relatively new phenomenon and hospital management may improve in the next several years. Kaiser seems to have met the challenge by forming a separate entity for a medical group which then interfaces with the hospital.  The governance structure is distinctly separated.   This allows the providers negotiating power and the abiity to make more decisions for themselves.

There are other issues in making this transition to a group practice.  Cultural clash  and generational difference can also affect the new relationship.

 Modern Health Care presents this case

"Dr. Janet Chipman worked for more than a decade in a busy surgery practice she owned with three other physicians, treating patients and sharing the responsibility of running a multimillion-dollar business. She says she valued the autonomy of private practice, which was a common career path among her peers and one she sought when she finished her training.

"But nearly three years ago, Chipman and her colleagues signed an employment contract with Baptist Health, a Kentucky hospital operator that has doubled its number of employed doctors to 485 in the past three years. They felt that joining a sizable health system would boost their negotiating leverage with health insurers and make it easier to recruit surgeons into the practice. They'd also have more bargaining clout with vendors. And it would be more viable to participate in one of the new alternative payment and delivery models, such as an accountable care organization

Even so, Chipman had plenty of doubts before signing the deal. “The decision was incredibly hard for me personally,” she said. “I came from the culture of having your own practice and your independence.”  

Not so for Dr. Nicole Lee. The first-year fellow in maternal and fetal health at the University of Mississippi will enter the workforce in two years. She expects to go directly into hospital employment. That's because working for a large health system likely will mean less on-call duty, allowing her to balance work and personal life. “If I have a family, they will definitely be my priority,” Lee said. “Being on call every other week is not feasible to me.”

Other factors enter decisiono making processesRegular work hours, enhanced family life
Guaranteed on call coverage
Working for a large health system likely will mean less on-call duty



Younger physicians work ethic has changed, largely bevause of new workoplace rule setting strict liits for work hours, and call schedules, caliing for controls much like the airline industry for pilots to reduce risks of error due to fatigue. When thes physicians enter the workforce they carry over this new ethic in private prctice.

Doctors moving from independent practice to employment may be more autonomous, business-savvy and likely to prioritize work over other obligations. But they also may chafe under bosses and rules. “They're used to setting the rules,” said Dr. T. Clifford Deveny, Catholic Health Initiatives' senior vice president for physician services and clinical integration. “One of the things you give up is that complete independence.” 

Younger doctors may have no experience with or desire to take on demanding call schedules or leadership roles. “They're looking for lifestyle,” said Danise Cooper, manager of physician recruiting specialists for Cejka Search

Thrown together, once-independent physicians and younger doctors may clash over how to share the

workload and rotation duties. In addition, physicians may differ in how they respond to their employer's invitation to participate in quality improvement or strategic efforts. And since physicians may treat one another's patients, some doctors may worry about how their colleagues' work ethic and attitudes and accessibility to patients may reflect on them and influence their patients' satisfaction. 

Cultural discord among doctors can lead to costly turnover. Culture conflict ranked in the top five reasons for turnover among doctors in the most recent retention survey by the American Medical Group Association and Cejka Search. Hospitals lose revenue when doctors depart.


The shift is taking place relatively quickly, and may accelerate even more with the mandates of the Affordable Care Act, as more physicians are saddled with non-medical responsibilities.

Twenty percent of U.S. doctors worked for a hospital in 2012, according to the American Medical Association. That figure rises to 26% if you include doctors in a medical practice partly owned by a hospital. Six years earlier, 16% of doctors were hospital employees..

The growth in direct hospital employment of physicians has accelerated for a variety of reasons, including new payment models offered by public and private insurers that bundle payments for hospitals and doctors for entire episodes of care or establish financial incentives for providers to coordinate care and achieve better outcomes and lower costs. These new models require closer collaboration between hospitals, physicians and other providers, and may be easier to achieve when physician practices are more closely integrated with health systems.

Is Obamacare Unraveling?

By ROBERT LASZEWSKI

Rumors have been circulating in the marketplace all week that the administration was thinking of extending the individual health insurance policies that Obamacare was supposed to have cancelled for as much as three more years.

Those rumors have now come out into the open with Tom Murphy’s AP story on Friday.

He and I agree, and his statement is not a question, rather a rhetorical statement.  It does not take a rocket scientist to analyze what has happened in a very short time.  The initial HBE rollout was and remains a fiasco, which will set the plan back several years. Yes it is possible to enroll if you don't work and can afford to spend over one hour on hold, and/or navigate the HBE websites.  I can only speak to Covered California's health benefit 'Marketplace'.  They should have called it "The Shopping Maul'.  Surely you will feel mauled by the process.  It is a cross between the last day of shopping before Christmas, and 'Black Friday'  

The deadlines were foolish for an unproven system. It was only tested at its launch. Fail Whale there.

FEDERAL HEALTH BENEFIT EXCHANGES: COVERED CALIFORNIA, BREAKING NEWS

Exchange enrollments at 3.3 million, big jump in January

By Paul Demko 

Posted: February 12, 2014 - 5:15 pm ET

Tags: Costs, HealthCare.gov, Insurance

(Story updated at 6:15 p.m. ET)

Nearly 3.3 million individuals signed up for private insurance plans through the state and federal exchanges during the first four months of the open enrollment period, HHS reported Wednesday. The total represents significant growth in January, but is still less than halfway toward the goal of 7 million enrollments by March 31.

State exchanges enrolled 1.4 million individuals through the end of January, while 1.9 million individuals signed up through the federal exchange, according to figures released by the CMS on Wednesday. The federal exchange, in particular, showed momentum in January: Nearly 40% of total enrollments through the federal HealthCare.gov website occurred last month. 

It's very, very encouraging news,” HHS Secreatary Kathleen Sebelius said on a call with reporters Wednesday.  

However the total numbers only show a small part of the enrollment issues.  Demographics vary widely from state to state in terms of age, health, and gender.

“We're seeing a growing population of Americans who are young, healthy and well covered, and these younger Americans are signing up in greater proportions,” Sebelius said.

A significant number of new enrollees are from those who had pre-existing policies cancelled at the end of 2013.

Catastrophic Options

Hardship Exemptions  (Qualifications)

However, in some states exchange customers continue to skew significantly older. In Ohio and Wisconsin, for example, only 21% of enrollees were between the ages of 18 and 34.

A gender discrepancy is also emerging, with women representing 55% of those seeking coverage. In some states, the gender imbalance is even more pronounced. Women account for 60% of signups in Oregon and 62% of exchange customers in Mississippi.

HHS also issued data for the first time on the type of plans being purchased on the exchanges. More than 60% of state and federal exchange customers opted for silver plans, which are designed to cover 70% of medical costs

Last week, the Congressional Budget Office reduced its estimate for how many people will sign up for coverage in 2014 from 7 million to 6 million, due in part to the rocky rollout of the federal exchange and continued problems with some state marketplaces. 

There is still no data available on how many individuals have actually made their first premium payment. Even after enrollment and premium payment it remains to be seen how many will find a suitable provider. Magnifying this issue in California is massive errors in the provider directory listing providers who will not accept Covered California.

A massive  deception has been built into Covered California. Policies called Blue Shield PPO (Silver  Plan) are not ordinary Blue Shield PPO plans.  Not only that but there is a difference between group PPO plans and Individual Family Plans (IFP).

I contacted a wel established medical group (Inland Empire)  (120 providers)  to inquire about their providers enrolled in Covered California. I was told tthey accept the group Blue Shield PPO, but NOT the IFP. 

This will come as a great shock to those enrolled in many Covered California plans.

Precautionary note:  Check with your chosen provider to ascertain if they accept your specific plan under Covered California. Covered Callifornia is a general term and means very little. Be certain to find if the specific plan that was signed up for is truly available.

Many patients will present to the doctor's office and find they do not have a provider.

Important News:  Covered California is updating it's Provider  Directory.  Check with your chosen provider to corroborate their participation.  Urgent Care Centers are also specific to a planBe certain your chosen provider is aa member of the medical staff of your chosen hospital.

The Health Benefit Exchanges say that enrollment can be changed until March 31.2014.  

Note: This article will be updated weekly.

Affordable Care Act..Obama admits "THERE MAY BE STRUCTURAL PROBLEMS.

...Hinges No Longer Squeak, They Are off the Doors....  California today announced the expansion of customer service agents for COVERED CALIFORNIA.

CoveredCA is hiring an additional 350 telephone agents to meet the continuing demand to enroll for Covered California. The California Medical Association also reported; Health Reform and Covered California News

The White House is relaxing the employer mandate again 

The Treasury Department on Monday rolled out more tweaks to the health-care law's requirement that all large employers--those with 50 or more workers--provide insurance coverage to their workers. This is the part of Obamacare was supposed to take effect at the start of 2014, but was delayed by the White House this past summer as the White House was facing significant push back from employers.

Covered California is hiring more workers to fix service problems

California's health insurance exchange is racing to fix persistent service problems before it faces another surge of Obamacare applicants eager to beat a March enrollment deadline. The state is drawing on a $155-million federal grant it received last month to improve service ahead of the March 31 sign-up deadline under the Affordable Care Act. The Obama administration is counting on California to deliver another big wave of enrollment to compensate for a shaky rollout nationwide.

350 workers added to Covered California call lines
Hundreds of customer service representatives will be added to Covered California’s phone lines, to help cut wait times and to enroll more state residents into health care plans before a March deadline, state officials announced Monday

California health exchange pulls doctor directory again

California's health insurance exchange pulled its online doctor directory again after some physicians were wrongly listed as accepting patients' coverage plans, spurring a blame game between insurers and providers. A major error was made in the provider directorty for private insurers Covered California published the incorrect list of providers.  Many have not signed up to be providers under California law.  Covered California requires a different set of rules including unique reimbursement rates. Many providers do not even know they are llisted, and when they present themselves to the MDs office they will find the doctor' office unable to accept them.

For 3 million, 'affordable' health care might not be
The lure used to get uninsured Americans to sign up for health law coverage was the promise of generous premium subsidies.The promise comes with a catch for almost 3 million people earning three to four times the federal poverty rate: They may have to pay up to 9.5% of their income toward that premium before the government subsidy kicks in. That could take a substantial bite from their budgets — potentially as much as $600 a month for a family of three earning $58,590 to $78,120. As a result, some middle-class families may decide health insurance is beyond their reach and pay a penalty rather than buy coverage. 

Faith based and Charitable Funding as An Alternative Solution

Have charitable organizations....faith based religious, and other non-profits furnish health care financing...Keep your health care away from government

Affordable Care Act.......The Missing Link....It is not Australopithecus

Houston, we  have a problem  "Failure to Launch"

Despite a goal of access to health care for all, however the hinge on the door for acccess is squeaking. News such as this are appearing in medical news.

Family Planning Clinics In Calif. Squeezed By Health Law KQED - February 10, 2014 Millions Trapped in Health-Law Coverage Gap Wall Street Journal - February 9, 2014 They quit their jobs, thanks to health-care law Washington Post - February 9, 2014 Enrolling in Covered California is not for the weak of heart, or spirit.  For those who were previously uninsured for a variety of reasons the affordable care act raise spirits with the elimination of the fear of not being able to pay for health care. The current system was not sustainable financially, however health care is available taking away the financial morass of insurance companies, bureaucracy and government.  Neither government, nor insurance companies provide health care. Physiciains, nurses, hospitals and many other providers care for patients. A consequence of the change will be the marked reduction in 'free care'. The old model of those fortunate enough to pay for their own care, and providers and hospitals having deep pockets to finance care for the less priveleged of our society. In order to assure health care and security for all the down side is forfeiting freedom. The tyranny of absolute security is freedom. Some of  us understand the concept and the reason for opposition to the affordable care act.  Others see it as an opportunity   for free health care.   Those whol will receive this generosity are often not only uninsured, but also un-empowered, and have little impact, are passive and do not have resources, nor influence to make changes. The U.S. Constitution (    )  guarrantees the pursuit of life, liberty and the pursuit of happiness.  That statement places us in a conundrum.  Does that mean care to avoid illness, or treatment to keep one alive? This is not some ephemeral abstract thought embodied in our founding document. Other constitutional guarrantees in the past have been manipulated to make change The Affordable Care Act in Californa is known as  'Covered California'.  Patients who sign up are screened for eligibilty based on income and household size. Those who's income is greater than........are required to purchase a subsidized health insurance policy or face a fine.  Some of these policies look nice, offered by stable companies, such as Blue Shield, Healthnet, Anthem and their providers are listed under providers for Covered California.  However with a more in depth search you will find they did not receive contracts and are not providers.  (small details).....this will reduce access to providers (and some hospitals). None of this has been adequatly explained  Some who look forward to using Covered California should call their chosen provider and ask if they are a provider for Covered California.   Many of them are not, and some may not even know if they are signed up for it.

Is Sunday a Day of Rest for Social Media ?

Sunday may or may not be a day of rest in social media, depending upon your lifestyle. If you use Social Media for business it may give you time to prepare your social media stream for later in the week, scheduled by an increasing number of social media add ons, such as Hootsuite, Buffer, Hubspot and others.

Sunday may be a time to socialize about Friday and Saturday's movies, dinners, parties, weddings, and other events.

Social media has been accepted and internalized among young people. Everyone has it and is dong it. The line between social and business is evaporating, just as it has in real life.  More deals go down on the golf course, at the coffee shop, restaurants, and during times of transportation.  It's easy enough to bring along all your digital documents and share them on google + or just 'bluetooth' them across the desk or table. Google drive, dropbox, skydrive, amazon and others all provide shareable storage for free or little charge

Physicians can share medical consults and discuss difficult diagnostic challenges anywhere at the clinic, hospital, operating room or from the automobile (smart) that will be driving itself very soon. Powerpoint, Slideshare, Prezi, offer different and imaginative presentation modes. Since  Youtube was bought by Google the two share log ons and also integrate and synchronize via Google plus.  Google continues to add some private and secure modes for video conferences . They call it "Helpouts".  And for MDs it is  HIPAA compliant which allow patient - provider secure and confidential communications In additon to these open social platforms, there are physician specific sites, such as SERMO, and DOXIMITY

Social has merged with business, and more is coming with wifi remote monitoring, coupled with two way interactive video and/or audio conferencing.  House "calls' have truly been reinvented. and are probbably more functional than the 'black bag " visits of yesteryear.

When it comes down to it, we are all connected socially.  Our responsibility remains to our patents, and no matter`how exciting the technology is, will it help you to deliver care, or is it just a  'toy" ?

Not Running A Hospital, Or What is Wrong at Hadassah ?

Hadassah was the alternate name of Queen Esther,  and is also the name of the American Jewish charitable organization of women, founded by Henrietta Szold in 1912.

Hadassah Medical Organization has fallen on hard times.

Only recently has this news been released. A lack of transparency and poor governance have accumulated to question the solvency of Hadassah Medical Organization, which is now $ 1.5 billion dollars in debt.

Pointing fingers at the past will not change the situation, however all should learn the importance of transparency in governance. There should be no shame at failure, only the lack of willingness to be committed to change.

   

Paul Levy, former CEO of a prominent Boston Medical Center shared with us on his blog, Not Running a 
Hospital. The title is quite an allegory, since he is now retired from hospital leadership. Apparently that is 
what has occured at Hadassah Medical Organization. What can global medical interests do to help?

Small Data

Health care and health reform are being influenced by seemingly unrelated spheres of influence. Many industries are effected by these same interactions in banking, transportation, defense, technology, basic science, education and government.

The age in which we live is both exciting and terrifying. Now that I am a septagenerian I see it is both. And somehow we will survive, grow stronger and thrive.

The catalyst is largely information technology and cyber technology, whether it is functions for gathering data, analytics,pseudo artificial intelligence, or robotics.  All of it is shaped by bits and bytes.  Even the basic materials of the integrated circuit and computer microprocessors will undergo basic changes perhaps away from silicon to carbon or even biological compounds such as the building blocks of DNA, nucleic acids.

Rather than having a simple bit or byte, nucleic acids as we know them, offer 4 different subunits that form a lexicon for building proteins from amino acids.

Big Data is often quoted in health care for analytics, for biological and research discoveries.

We in health care are now being continuously bombarded about the essentiality of gathering more and more information. Our government is underwriting some of the costs and also placing a large burden upon not only physicians but all providers, and hospitals to enter health data into the IT infrastrucure for some future use, some of which is still not defined, and some which is truly unproven.  Despite this billions of dollars have been and will be spent on this endeavor.

There have been some precautionary notes offered from other sectors:

Viewpoint: Why your company should NOT use “Big Data”

The latest trend is “Big Data”. The original concept of Big Data was the concept of using all of the information a company collect that was being thrown away due to costs and capacity constraints. With the rapidly declining cost of storage and retrieval, combined with machine learning, we should be able to find insights in all that ‘garbage data’ and use it to make better decisions in the core business. At least that’s the theory. As far as the basic theory goes it’s all true, but it’s not the full story.

Like a lot of trends, the drive to mastering Big Data has gone a little overboard. Google searches for the term “Big Data” has grown from practically nothing in 2010 to almost 200,000 searches a month by the end of 2013

It has become so ingrained in company cultures that to say you don’t want to use Big Data is a bit like saying you are against data-driven decision making. It would be career suicide to say Big Data is a waste of company time and resources.

The graph below depicts the exponential growth of big data over time.

The details can be found at the original article on ViewPoint

The Sad State of HHS and CMS

Many ask, "Has HHS and CMS bitten off more than it could chew?"

The Failed Whale

Perhaps health.gov should have used the 'Fail Whale' icon for it's failed website. Those of you who were on twitter when it first began would see the 'fail whale' when twitter was overloaded. We don't see this very much anymore.....HHS has inherited the 'Moby Dick" of the Affordable Care Act.  Has anyone seen Ishmael ?

Medicaid & Medicare  Pharmacies Braced for Cuts to Their Medi-Cal Payments LawMakers Reach Deal on Doctor Payments Health Reform News  U.S. lawmakers reach accord on paying doctors for Medicare Los Angeles Times - February 7, 2014 Exchange Mum on Premium Payments California Healthline - February 6, 2014 Aetna Expects to Lose Money on Health-Law Marketplaces Wall Street Journal - February 7, 2014 Obamacare Thrives In San Francisco's Chinatown Kaiser Health News and NPR - February 7, 2014 An interesting evaluation of an ethnic community health plan Ex Microsoft Exec Brings Lists and Whiteboard to Overhaul Obama Website How he wound up with this job...His road to this job was a long one. It began in July -- about 12 weeks before the launch of healthcare.gov -- when Microsoft CEO Steve Ballmer announced a massive reorganization  (their loss, our gain).  DelBene’s process is collaborative and open, his colleagues say -- which is important in his new role. “You can see him evolve his positions as he gets more data. It’s not like he’s established his positions and [listening] is just a formality -- just Kabuki ritual theatre,” says U.S. Chief Technology Officer Todd Park. Todd Park, the U.S. chief technology officer, praises DelBene for listening and being open to new ideas (Photo by Karl Eisenhower/KHN). After finishing up his part of the presentation, he felt a “tingle” at the back of his throat, as though he was going to start coughing. He didn’t want to disturb anyone, so he headed for the door to the hallway -- or so he thought. “I started opening the door to the closet!” he recalls, and there was laughter all around.  “Oh! The new guy!” the president said. The Health Benefit Exchange is a product of how government works. DelBene would never have released a product from Microsoft without assurances it did not have many "bugs.  Perhaps part of our government should be 'privatized' and failures should be penalized........just as it is in the real world.  How long will voters and taxpayers tolerate incompetence while paying the bill ?

Feeling the Pain ? ACO ACA HIX HIE HHS CMS ICD10

We physicians have some difficulty objectively measuring pain.  Even subjectively it becomes a challenge when your patient asks for pain medications.

The standard of medical practice now is to ask, "What is your pain level from 1-10 if 10 would be the worst pain  you have ever felt, and 0 is no pain whatsoeverl.  Even this scale is very subjective and is based upon what that patient considers his worst pain.  That depends on many factors. Patients who have never had any pain would not know what the worst pain would be.  Pain thresholds differ greatly from one patient to ano ther.  Comparing one patient to another with  this metric is meaningless.  Perhaps we should set a standard as labor pains. This standard however would only apply to women.

All of the above acronyms are a feature of health reform, which is not painless. The medical lexicon includes countless three letter or four letter acronyms, which are too lengthy to describe here.

ACO, ICD-10, MU, PCMH, and PQRS are more than just an acronym soup. 

Karen DeSalvo now the head of ONC and a former primary care physician from Louisana is the lady for the job of reducing our pain. (perhaps hypnosis, denial, or retirment would be better than the narcotic of acceptance and/or major revision of how government interacts with healthcare.

Diana Manos of Health IT News describes DeSalvo's background: 

To advance America’s triple aim of improving the experience of care, improving the health of populations, and reducing per capita costs of healthcare, DeSalvo outlined five key goals, which ONC will be focused on over this, the second decade of its work.

They are:

1. Increase end user adoption of health IT
2. Establish standards so the various technologies can speak to each other
3. Provide the right incentives for the market to drive this advancement
4. Make sure personal health information remains private and secure
5. Provide governance and structure for health IT

DeSalvo believes interoperability remains the most important issue as a framework for Health Reform.

Despite more than half a decade of progress, Interoperability appears to have stalled.

Michael Schatzlein MD 

of Asencio Health describes the current status of interoperabillity and it's future in the world of the internet.  It's greatest hope is the present generation of internet enabled patients who will demand interoperability, perhaps at the ballot box if bureaucrats cannot accomplish the goal..  The federal government has already invested billions of dollars of your tax money toward this goal.

Affordable Care Act......The Twilight Zone

 Rod Serling could not have written a better story than that of the rollout of Obamacare. Gazing into the future he saw imaginative and surreal happenings which he shared with all of us. He died at an early age (50) and hopefully so too will Obamacare.

"The Twilight Zone" was a television saga from the 1950s when most things on TV were on black and white, which were appropriate colors for this science fiction anthology.  When one watched this series your frame of reference was always questionable for the things, places and times were not what you were led to believe, and only  at the very end did you find you were following  'The Pied piper'.

After analyzing the Affordable Care Act I was doubtful about it's mechanisms although I was very much in favor of it's end game (to produce an equitable and accessible health care system) as were most physicians.

To say that the Affordable Care Act was well meaning would be a platitude for a destructive and wanton negligent act.  My opinion has become more hardened since October 2013 when this 'great hope' for change went into effect.

My relatively neutral opinion at the time was a precautionary tale, as I hoped I would be incorrect. It has not been, and much worse than I could have imagined.

In additon to the direct effects on the health system, the collateral samge is worse for the economy including employment.  The CBO (Congressional Budget Office) states succinctly ,

"The reduction in CBO’s projections of hours worked represents a decline in the number of full-time-equivalent workers of about 2.0 million in 2017, rising to about 2.5 million in 2024. … CBO estimates that the ACA will reduce the total number of hours worked, on net, by about 1.5 percent to 2.0 percent during the period from 2017 to 2024, almost entirely because workers will choose to supply less labor – given the new taxes and other incentives they will face and the financial benefits some will receive. … In the longer run, some businesses also may decide to reduce their hiring or shift their demand toward part-time hiring – either to stay below the threshold of 50 full-time-equivalent workers or to limit the number of full-time workers that generate penalty payments."

Scott Gotlieb goes on to explain;

As workers transition from part time work (without benefits) to full time work (with health benefits) many workers will actually lose income in the form of the subsidies that they will have to forgo (and the additional fact that lower wage workers, who are in lower tax brackets, won’t benefit as much from the implicit subsidy they will get from the special tax treatment of health benefits that they receive by purchasing their health insurance through their employer). CBO seems to focus mostly on people who are out of the labor force for a period of time and transitioning back to full time work, which suggest its estimates may be low.

CBO states, in reference to these impacts, that the “exchange subsidies effectively constitute a tax on labor supply for a broad range of workers.” CBO focuses mostly on those transitioning to full time work (with benefits). But the same disincentives apply to workers on Obamacare who are already employed full time, and looking to grow their income.

The congressional actuaries go on to state that forgoing Obamacare subsidies and returning to full time work with health benefits (for lower wage and middle class workers) amounts to an average, implicit tax of about 15% paid by each worker. CBO does note that these considerations only affect a segment of the workforce – specifically the middle class and working class who earn annual incomes that put them below 400% of the Federal poverty level (about $95,000 for a family of four). But that represents a large portion of the labor market.

These disincentives can’t be easily fixed – they are baked into the structure of the Obamacare subsidies. A refundable tax credit, similar to the one offered in some conservative plans, sidesteps many of these effects.

Sean Davis has more from the report. And it’s not like the non-partisan CBO is alone in this conclusion: It is consistent with the latest report from the Federal Reserve as well. Whatever the reality of Obamacare’s impact on the percentage of America that is insured or uninsured, it seems clear that they are reducing the number of working hours available and decreasing hiring in professions and positions that are most likely to be filled by the working class … the very people Obamacare was originally intended to help.

-- Benjamin Domenech

All the dynamics that drive up health costs have coalesced in southwestern Georgia, pushing up premiums. Expensive chronic conditions such as obesity and cancer are common among the quarter million people in this region. One hospital system dominates the area, leaving little competition. Only one insurer is offering policies in the online marketplace, and many physicians are not participating, limiting consumer choice.

Until these elements are brought under control, it will be challenging for the Affordable Care Act to fully live up to its name, not just here but in other parts of the country where premiums are high. Other expensive places include rural Nevada, parts of Wisconsin, most of Wyoming, southeastern Mississippi, southwestern Connecticut and Alaska.

Case in point:

But for those earning too much to qualify for federal financial help, the premiums can be overwhelming. A 60-year-old making $47,000 in Albany would have to pay a quarter of her income for the least expensive mid-level “silver” policy, the level most consumers are buying.

Even some people who qualify for federal assistance, such as Stacie Brown, owner of a pottery shop, are balking. The cheapest “bronze” plan for Brown, her husband and son would cost the family $300 a month but not begin paying medical bills until they exceeded the $6,300 individual deductible. The cheapest silver plan would cost $508 a month but not start paying until a $3,000 individual deductible was met. Her son’s pediatrician was not in any of the networks, and that was the one medical service she felt sure her family would use.

Brown ultimately bought a $256-a-month Assurant Health plan for her son, sold outside the marketplace, which covers his pediatrician and unlimited office visits. She and her husband have decided to forgo coverage for themselves, even though they may face a tax penalty of $700.

“I can’t afford the affordable health care,” she said. “I don’t know anyone in this area who can afford it, and I do pretty well in life.”

Source: The Washington Post