By now we’ve all heard about major retailers opening earlier and earlier on Thanksgiving day, promising to turn Thanksgiving Day into one of the biggest shopping days of the year. (On a side note, several states including Massachusetts don’t allow stores to open on holidays, so the big box retailers will be promptly opening at 1am on Friday.)
The most surprising move was from Kmart, where executives decided to open stores at 6am on Thanksgiving Day. The announcement by Kmart was quickly followed by Walmart, Target, Kohls and it seemed like almost everyone else. This year, Americans may have to take their turkey on the go instead of enjoying the holiday at home.
I’m a little conflicted on opening stores on Thanksgiving. After all, the holiday is supposed to be about being thankful for the things we already have in our lives. And truly, only in America do we trample over one another and fight for consumer goods the very day after we are thankful for family, friends, and what we already have in our lives. To me, encroaching on Thanksgiving Day just seems… well wrong. As one author put it, it’s easy to forgo shopping on Thanksgiving if for no other reason than to not force some single mom to ring up worthless purchases instead of enjoying Thanksgiving with her children.
But what about that single mom or the man/woman working at Walmart? We all know that Walmart doesn’t pay their workers a liveable wage (a lot of Walmart’s employees are on SNAP or Medicaid). Working retail on a holiday usually means being paid time and a half, a not insignificant amount of money for those struggling to make ends meet.
So is “Black Thanksgiving” really all that bad? I’m still not a fan but the jury could be out. What do y’all think?
Let’s be honest, Americans don’t often “look to Kentucky” as an exemplar for a lot of things. But Kentucky is turning out to be a bright and shiny star for President Obama’s health care reform law. And here’s why…
Kentucky governor Steve Beshear is one of the only Southern governors to apply the Affordable Care Act as it was written – persuading the Legislature to expand Medicaid eligibility as well as create a state-based health insurance exchange. The effect? In a state where 15% of the population is uninsured (about 640k people), over 56k have already signed up for new health care coverage. The majority have signed up for Medicaid, but about eleven thousand people have signed up for private health plans.
Creating a state run exchange instead of relying on the federal website has proven to be a godsend for many states, not just Kentucky, as the federal website has continued to flounder. For those who are salivating at all of the chatter about cancelled insurance plans and skyrocketing premiums, this article from the Washington Post describes the Kentucky experience in Breathitt County. These are the very people the law was designed to help – those with low incomes that are too high for traditional Medicaid but too low for insurance. Those with part-time jobs that don’t offer insurance. Those who never knew they were eligible for health insurance and those who could never afford the care they needed.
To the generation that preceeded mine, the assassination of President John F. Kennedy is one of those seminal moments in history, a moment burned into the collective memory of our nation. Like those of us who witnessed the terror of September 11th, the generation that witnessed the death of President Kennedy will forever remember that moment 50 years ago, where they were and what they were doing when the President was killed. Fifty years ago today in Dallas, one of America’s most admired Presidents was assassinated.
“But wait… imagine if you’re the survivor of the heart attack death sex!”
“The moment you claim you know everything is the moment you’ve created a ceiling at the level of knowledge that you’re willing to learn.”
Unless you’ve been living under a rock, by now you’ve probably heard that a lot of people are having their health insurance plans cancelled next year by their insurance company. And yes, President Obama promised everyone that if they liked their plan, they could keep their plan.
The President apologized for that statement on Thursday – one he never should have made by the way; we all know that nothing in life is guaranteed except for death and taxes – and he offered a solution by stating that policyholders could keep their insurance plan for another year if they so choose.
Well… there’s just one problem. Actually three problems.
1. Obama’s decision has no actual regulatory bearing on insurance companies. In other words, if the company wants to terminate your policy even if you want to keep it, it can still do so. There’s absolutely no incentive for insurers to keep those policies around.
2. Insurance is regulated at the individual state level, meaning that state regulatory agencies will have to approve the extension of the cancelled plans. There’s no official word yet on which states are likely to do that and which are not.
3. Policyholders actually have to renew their plans. Depending on when the termination letter was received, some of these people may already have signed up for other plans, not thinking that the President would allow this “get out of jail free” card to appease angry citizens.
There’s also a few things to remember about the cancelled plans and the health exchange enrollment numbers.
1. The cancelled plans only affect about 5% of people with health insurance. And for most of those people, the policies they had were terrible insurance policies (I said most, not all). The policies were terminated because they didn’t comply with the basic requirements of the Affordable Care Act; many only offered “catastrophic” coverage but no routine coverage or coverage for preventative services. They’ll probably find better plans on the exchanges.
2. The enrollment numbers are low and quite frankly look bad. Some of the low numbers certainly have to do with the problems plaguing the healthcare.gov website, but if history serves as a good guide, we should expect the numbers to be low. The chart below depicts enrollment in Massachusetts after it required residents of the Commonwealth to obtain health insurance. Initial enrollment was paltry at best but ramped up quickly as the deadline to purchase insurance or pay a tax approached. We should probably expect the same for the Affordable Care Act as the March deadline approaches as well. One can only hope the website will be fixed by then.
3. Enrollment in Medicaid has been rather robust, partially contributing to the low enrollment on the exchanges. People who are newly eligible or were always eligible for Medicaid and never knew are enrolling like crazy.
4. And lastly, and I’ll admit this is a completely partisan comment, the GOP would like to repeal the Affordable Care Act and return to the business as usual plan. This last graph from CNN shows that the “business as usual” plan wasn’t working so well for a lot of people. Projected spending on health care by 2029 was almost 50% of family income prior to the passage of the Affordable Care Act
The law is certainly not perfect, and the website is definitely a disaster (although I tried it yesterday and it seemed to be working okay). But relax people; as with any new major piece of legislation, there are going to be kinks to work out.
In September, Victor Fuchs wrote an opinion article in JAMA titled “Current challenges to Academic Health Centers” discussing the perils facing academic health centers in the future. Fuchs offers some valid points as to why academic medicine is becoming increasingly threatened in the current health care environment.
Academic health centers (AHC) are at the top of the medical pyramid. They are the referral centers for tertiary care when community hospitals do not have the technology or expertise to take care of complex patients. AHCs are often the location of last resort for many patients without insurance or with specialized medical conditions. They are the centers of breakthrough research, the pioneers of new interventions, and by and large the centers of education for the nation’s future crop of physicians.
Their missions of pioneering health care, education, and breakthrough research come at a price, and that price is that care provided at AHCs is often expensive. In the current environment of cost control, Fuchs argues that without change AHCs “may lose their place at the apex of US health care.” He states that AHCs must change how they organize, price and deliver care, changes that ultimately will affect their education and research missions. But like all hospitals, AHCs also face the problem of changes in the US patient population and shifts in location of service. The inpatient hospital population is becoming older and more chronic illness, while the bulk of care is moving from the inpatient to the outpatient and ambulatory settings. AHCs may find it particularly difficult to quickly shift care from inpatient to outpatient as many AHCs are located in urban centers with aging infrastructure, where high property values and construction costs make it difficult to build new structures or convert existing structures.
But Fuchs also argues that the way we pay for medical care is by far the biggest threat. And while his general assumption is correct, I take issue with his argument. Fuchs states that payment has shifted from fee-for-service to bundled payments, which is true, but he argues that the shift has meant no longer ordering every test, drug, or procedure that offers some benefit but instead to the “socially optimal amount of care.” Fuchs states that by controlling costs, public and private payers are implicitly asking physicians to redefine optimum care away from what is medically defined to what is socially preferable. Fuchs goes on to say that eliminating “waste” is a surrogate for prescribing “socially optimal” care.
In doing so, Fuchs ignores the obvious – that not all care of marginal benefit may be worth the costs, especially to the patient who cannot pay. Physicians across the country are constantly confronted with trying to provide what is “medically optimal” yet not financially possible for the patient. Furthermore, physicians often blame patients for being “non-compliant” with the prescribed “medically optimal” therapy when in fact the patient would love to comply – if they only had more money.
Undoubtedly, Fuchs raises the controversial point of what amount of benefit justifies the cost of an intervention. What he ignores is that “benefit” is largely determined by the patient…
Humans will always make mistakes regardless of their training, experience, or determination. In other words, the universal constant is that human infallibility is impossible, and those who build a system that depends on the absence of serious human mistakes will fail utterly.
We must expect literally every medical order to contain a potentially lethal mistake.
~John J Nance, JD
What other enterprise in this nation with such high responsibility and potential liability would tolerate the level of individual practice variation that has become standard in medicine? Try this: Would you fly on an airline that lets their captains decide individually whether to use flaps or checklists, or turn on all the engines for take off? Would you want your neighborhood nuclear power plant to run in freeform, avant-garde style by a manager who thinks he’s smarter than the rules and is intent on experimenting with, say, the cooling valve positions and fuel rod extraction procedures?
~John J Nance, JD
Hawaii today became the 16th state to affirm marriage equality when the state’s Senate voted in favor of a marriage equality bill that passed through the House last week. The Senate had previously approved the bill which was amended in the House. Governor Abercrombie is expected to sign the bill into law.
In addition to become the 16th state to affirm marriage equality, Hawaii is the 7th state this year to pass same sex marriage legislation. To say the least, 2013 has been a big year for marriage equality.
When a true genius appears, you will know him by this sign: that all the dunces are in a confederacy against him.