• Don Taylor is leaving TIE

    This is my last post at TIE. I am restarting my individual blog freeforall or www.donaldhtaylorjr.com. Here is an RSS feed for all the posts  http://donaldhtaylorjr.wordpress.com/feed/ The twitter account @DonTaylorFFA is a bot that will only send out posts from my blog, and/or you can follow me on twitter @donaldhtaylorjr

    The tag line of freeforall  is “health policy and budget wonkery and the politics of where they meet” which should sound familiar if you have been reading along; I also pay special attention to end of life and long term care issues. One new thing I plan to do at freeforall is to write about North Carolina as a crucial battleground state in the upcoming election, which it was in 2008 for the first time in several decades. I have lived 40 of my 44  years in N.C. and have always paid great attention to politics in my state, which could well decide the Presidential election this year.

    A year ago tomorrow I joined TIE, and did so as Austin, Aaron and I were seeking to obtain resources to make blogging a more “official” part of our jobs/lives. We managed to do that, but the initial arrangement has ended. Getting paid to blog definitely goes down in the ‘be careful what you pray for you might get it’ category for me, because the pace of blogging since Labor Day has been exhausting, and in some ways took the fun out of it. Many have already noticed that we have down-shifted a bit and each of us has been re-evaluating blogging on the back side of our past funding arrangement. Given these changes, it made sense on a variety of levels for me to go back to blogging alone. Though my work will likely appear in a few other places, this RSS feed should have all of my blogging.

    Blogging at TIE was a great experience for me and I learned a great deal from, and greatly admire my co-bloggers.

    • Austin has a keen eye for detail and has shown a singular focus that has enabled TIE to be known for focusing on the evidence. TIE has a special place in the blogosphere amidst all the noise and Austin is ultimately responsible for this success
    • Aaron brings great energy, passion and advocacy to blogging, but is capable of seeing evidence that proves him to be wrong, publicly saying so, and changing his mind. This is rare
    • Kevin may be the best  health policy law blogger in the U.S. on a word for word basis and can sort through the chaff for the wheat in health law like no other
    • Harold brings a generosity of spirit and granting people the benefit of the doubt without giving up his principles or shying from the debate. I wish all of us did this so well

    Thanks guys, and thanks to readers for comments, interaction and exchange.

    DT

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  • On The Record (with daily recap)

    • Don Taylor and Jim Capretta debate “What is the best way to provide high quality, affordable care to all Americans?” (video, ~ 90 minutes)

    Today in TIE: Austin on who gets proton beam therapy, Aaron writes about docs struggling to make ends meet, and Kevin on how the First Amendment and Green Tea are related.

    DT

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  • On The Record (with daily recap)

    CBO: Updated estimates of insurance coverage provisions in the ACA

    Today in TIE: Austin on docs inducing demand.

    DT

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  • On The Record (with daily recap)

    Today in TIE: Austin parses supplier induced v. supplier-sensitive care, Don will debate Jim Capretta on health reform tomorrow night, and Aaron on Philly Cheese steaks and a follow up, and Austin and Aaron have a cool new gig with JAMA.

    DT

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  • Debate with Jim Capretta

    I will be debating Jim Capretta on the question ““What’s the Best Way to Provide Americans Affordable, High-Quality Health Care?”

    Wednesday, March 14, at 7:30pm in the Fleishman Commons in the Sanford School of Public Policy at Duke University. The event is part of the Sanford School’s series “Gridlock: Can Our System Address America’s Big Challenges?”, and it co-sponsored by the Thomas Center International. Jim is a 1987 graduate of the Duke Sanford School (Masters of Public Policy). The event will be moderated by Christopher Wolfe, co-Director of the Thomas Center, who asked me if I would debate Jim.

    The event is free and open to the public, and it will be broadcast live on Duke University’s Ustream channel, where it will later be archived. In addition, Cara Rousseau (@cararousseau), Social Media Manager at Duke University, and others will live tweet the event under the hashtag update: hashtags are: #dukelive and #hcr. Karen Kemp and Mary Lindsley of the Sanford School have done lots of work on the event.

    Jim has published a book “Why Obamacare is wrong for America“, and I have laid out my views on the Affordable Care Act being a good first step in the ongoing efforts to reform health care as outlined in my book “Balancing the Budget is a Progressive Priority” which is available as an e book now, and which will be out in fuller form published by Springer in April, 2012. There are a few blog posts on the topic as well.

    DT

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  • On The Record (with daily recap)

    Today in TIE: Kevin on primary care capacity in the ACA, Aaron on ‘more like Krugman his two cents‘ which followed Austin and Harold’s weekend thoughts about advocacy, Aaron laments the ‘Medicaid is bad for you meme (again)’, Don on the long term care counterfactual, while Austin links to a study on the effect of Massachusetts insurance expansions on health, and shares Chapin White’s take on Avik Roy’s take on Chapin’s paper. And it is only M0nday….

    Bracket advice. Go with the chalk in a weak year; upset special The Bonnies over Florida State who may still be celebrating….

    DT

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  • The long term care counterfactual

    I wrote last week about the shrinking private long term care insurance (LTCI) options.

    From the comments to that post,wintercow20 asks:

    …Wouldn’t it just be simpler to institute a forced savings system in general rather than trying to figure out who may be using LTC or not?…

    And I answered that yes, it would definitely be simpler, and noted that the risk profile of LTC use of persons attaining age 65 is best addressed via some sort of social insurance-based approach. At a minimum, it seems clear that private LTCI is unlikely to work well for a variety of reasons (more context on public v. private provision of LTCI: here, hereherehere).

    Also in the comments Theodore Whitfield provides a reasonable back of the envelope calculation of what a Medicare or Social Security-based LTCI program might cost and notes:

    …Admittedly this is just a quick, approximate analysis, so I would put much faith into the specific estimates. But it does suggest that funding LTC through SSI or Medicare might be very expensive…

    Lets take away the uncertainty–LTC funding via Social Security or Medicare would be very expensive. However, providing LTC is very expensive now. Most of it is provided by family members on an informal (unpaid basis) and there are a variety costs (lost wages for caregivers, negative impacts on caregiver health, etc.) that are not so easy to estimate. The AARP estimated the costs of informal care provided to adults with limitations in Activities of Daily Living to be $450 Billion in 2009. And Medicaid is the payer of last resort for nursing homes and finances around 4 in 10 dollars spent on NHs (~$150 Billion annually), the most expensive LTC setting that exists.

    All of that happens now and will continue to do so by default. Much of the debate about the CLASS act, or about any discussion of expanding social insurance to cover LTC implies that the admittedly big cost of doing anything new is correctly compared to zero.* That is incorrect. The correct counter factual for any LTCI proposal is the piecemeal system that we currently have and its costs, including the already large public expenditures.

    The most important thing in public policy is counter factual thinking, and many seem to struggle with understanding the correct LTC counterfactual.

    DT

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  • On The Record (with daily recap)

    Today in TIE: Austin on screening, Don on shrinking private LTC insurance options, Aaron notes that every dollar of ‘savings’ reduces someone’s income.

    On The Record fondly recalls going to his first ACC tourney 30 years ago today with his dad (the one where UNC held the ball, essentially from the opening tip of second half in the Final v. Virginia…bringing the shot clock to college hoops). The Tar Heels had a freshman, last name Jordan.

    DT

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  • Shrinking private LTC insurance options

    Prudential announced this week that they will stop taking applications for private Long Term Care insurance (LTCI) at the end of March according to a WSJ story by Leslie Scism. Several other insurers have also exited this market in recent years, which means that private insurance options are shrinking as the baby boomers move toward needing LTC.

    Medicaid exists as a de facto nursing home insurance plan with the deductible essentially being your wealth (Medicaid pays for ~40% of all NH costs in the U.S.). Before that, families provide a tremendous amount of informal long term care, which is both expected by many while also being very burdensome and costly, both in explicit financial terms as well as in other ways. That is the default system.

    Prudential notes two primary reasons for their exit:

    • claims being higher than predicted
    • interest rates being very low

    The first reason they put down to “increasing life expectancy”, but I am not sure I buy that. Life expectancy has been increasing for quite a while. The more likely culprit for higher claims is adverse selection, which just means the people signing up had higher risks than average, which you might expect to be particularly bad for a type of insurance that is so rare (less than 10% of those over 50 have any). Interest rates may seem unrelated to LTC, but effect the return on investment that insurance companies can easily obtain with the premiums for a type of insurance in which persons may pay in for many years with no claims before having large claims later. Prudential says they will honor existing contracts, but premium increases for all members are likely in spite of such policies typically being sold with flat premiums (State regulators have consistently approved such increases, believing default of insurers to be the only other option).

    In short, it doesn’t appear that purely private LTCI markets can work, even with tax credit purchasing incentives that we have had for years. In the aftermath of the CLASS program demise, some noted the biggest problem within CLASS was the inability to assign an actuarially fair premium, which is important in a purely private insurance market, and allowing for simple underwriting could improve CLASS. However, the Prudential story and the move out of this industry by other private insurers shows they haven’t been able to assign actuarially fair premiums either.

    Far more important than focusing on how premiums are set for a small pool is forced risk pooling of some sort, to get all those at risk of needing LTC into the pool. In one sense, if you are OK with families providing care and Medicaid picking up much of the nation’s NH bill then you could argue we have a system. If you don’t like this system, it is amply clear that a purely private insurance-based one won’t work, and some sort of forced risk pooling will be required. The question remains, how will we insure LTC?

    DT

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  • On The Record (with daily recap)

    Today in TIE: Austin on supply-sensitive care and crowd-sourcing provider-insurance integration.

    DT

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