How Will We Know If HealthCare.gov Is Fixed?

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Weekend Edition Saturday

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Health care specialist Stacy Chagolla helps William Bishop compare plans at an Affordable Care Act enrollment fair in Pasadena, Calif., this month.

David McNew/Getty Images

Health care specialist Stacy Chagolla helps William Bishop compare plans at an Affordable Care Act enrollment fair in Pasadena, Calif., this month.

David McNew/Getty Images

Saturday is the day the Obama administration set as its deadline for making HealthCare.gov a "smooth experience" for most users.

A tech-savvy team of engineers, database architects and contractors has been working through the holiday to ensure the White House makes good on that promise, but judging the success of their efforts may take some time.

How will we know whether the website is fixed? NPR's health policy correspondent Julie Rovner says that partly depends on how you define "fixed." She joins Weekend Edition Saturday host Scott Simon to explain what that means.

Interview Highlights

What "fixing" HealthCare.gov means

Remember the promise is to have it working for what they call the "vast majority of users," by which the administration means 80 percent of visitors to the site.

That means 1 of every 5 people will still need to use a call center, an in-person counselor, or a paper application due to a technical problem or because his or her individual situation is too complex to be handled online. So Amazon or Orbitz this is not.

But then again, this is not buying a TV or a plane ticket, either. Many people have pointed out that spending a couple of hours buying health insurance online is still a lot faster than the old way, when you might have had a 50-page paper application and a process that literally took weeks.

How the administration has been fixing the website

There was a little show and tell earlier this week, where the White House actually showed reporters some of the 300 or so people who have been working pretty much around the clock from various centers located in the Washington, D.C., suburbs.

They've got a separate hardware team doing upgrades to increase the website's capacity, for example � they're saying it should be able to handle 800,000 separate visits per day going forward.

Then another team is working on software. They're fixing bugs and trying to make the website more user-friendly for consumers.

Will anyone be able to tell if the site is really fixed?

That's the really frustrating part. I'm not sure we will, at least not at first. We do already know it's working better than it was in October � which, frankly, was a pretty low bar to get over. The administration has all kinds of fancy metrics to show how well the website is working, but we don't have our own independent access to them.

We do know a big test is likely to come on Monday, when people who have been talking to relatives over the long holiday weekend � or who wake up and suddenly realize it's December and they want coverage in January � all try to sign on at once.

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Key parts of the site that must wait

Insurance companies are getting increasingly worried. It seems that while so much effort has been going into what they call the "front end" of the site � where consumers go to compare insurance plans and sign up for coverage � some parts of the "back end" of the site � where insurance companies actually get paid � haven't even been built yet.

The administration says it will get that done before money has to begin to change hands sometime in January, but given that nothing up until this point has happened on schedule, that doesn't make insurance companies feel a whole lot better about things.

One piece of the site that will wait an entire year

Small businesses were supposed to be able to sign up online to enroll their employees through the federal website starting this month. That was already delayed from Oct. 1. Now that won't happen online until next November.

They can still compare plans online, but they'll have to use paper applications and go through an insurance broker or agent or an insurance company directly, unless they're in one of a handful of states that's got its small-business exchange up and running.

The administration has been pretty candid about this � they've said their top priority is to make the website work for consumers first, and pretty much everything else is taking a back seat.

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Inequality Is (Literally) Killing America

Only a few miles separate the Baltimore neighborhoods of Roland Park and Upton Druid Heights. But residents of the two areas can measure the distance between them in years�twenty years, to be exact. That�s the difference in life expectancy between Roland Park, where people live to be 83 on average, and Upton Druid Heights, where they can expect to die at 63.

Underlying these gaps in life expectancy are vast economic disparities. Roland Park is an affluent neighborhood with an unemployment rate of 3.4 percent, and a median household income above $90,000. More than 17 percent of people in Upton Druid Heights are unemployed, and the median household income is just $13,388.

It�s no secret that this sort of economic inequality is increasing nationwide; the disparity between America�s richest and poorest is the widest it�s been since the Roaring Twenties. Less discussed are the gaps in life expectancy that have widened over the past twenty-five years between America�s counties, cities and neighborhoods. While the country as a whole has gotten richer and healthier, the poor have gotten poorer, the middle class has shrunk and Americans without high school diplomas have seen their life expectancy slide back to what it was in the 1950s. Economic inequalities manifest not in numbers, but in sick and dying bodies.

On Wednesday, Senator Bernie Sanders convened a hearing before the Primary Health and Aging subcommittee to examine the connections between material and physiological well-being, and the policy implications. With Congress fixed on historic reforms to the healthcare delivery system, the doctors and public health professionals who testified this morning made it clear that policies outside of the healthcare domain are equally vital for keeping people healthy�namely, those that target poverty and inequality.

�The lower people�s income, the earlier they die and the sicker they live,� testified Dr. Steven Woolf, who directs the Center on Society and Health at Virginia Commonwealth University. In America, people in the top 5 percent of the income gradient live about nine years longer than those in the bottom 10 percent. It isn�t just access to care that poor Americans lack: first, they are more likely to get sick. Poor Americans are at greater risk for virtually every major cause of death, including cancer, heart disease and diabetes. As Woolf put it, �Economic policy is not just economic policy�it�s health policy.�

Tracing health disparities back to their socioeconomic roots adds context to growing calls for pro-worker policies like raising the minimum wage and providing paid sick leave. Lisa Berkman, director of Harvard�s Center for Population and Development Studies, presented a range of evidence indicating that policies supporting men and women in the labor force�particularly low-wage and female workers�lead to better health for themselves and their families.

Continue reading…

The Single-Payer Alternative

Rush Limbaugh�s take on the disastrous rollout of the Affordable Care Act could, ironically, warm the hearts of those at the other end of the political spectrum. He contends that President Obama knew all along that the Affordable Care Act would crash and burn, but pushed it through so that the conflagration would clear the way for single-payer health insurance.

The conspiracy charge sounds deranged, but problems with the new health insurance system may indeed revitalize demands for more substantive reforms, which many policy makers and voters set aside in the putative interests of political pragmatism. Whatever the advantages of a single-payer system such as that currently administered by Medicare, one view held, American voters were unlikely to get behind it.

Yet one of the greatest advantages of a single-payer system � its relatively low administrative costs � has been thrown into sharp relief by problems registering with the new health exchanges. Andwhile Republicans despise the Affordable Care Act despite its conformity with many of their earlier proposals, their proposed changes (other than simple rollback) look complicated, kludgy and costly to administer.

The malfunctioning website has magnified problems inherent in coordinating enrollment across many different companies in many different exchanges in cooperation with many different government agencies. The harmonization challenges are orders of magnitude greater than those faced by a single company or a single state, making streamlining difficult. Improved software can do only so much.

In theory, competition and choice should increase efficiency. In practice, health insurance companies are able to take advantage of the complexity and uncertainty surrounding health care choices to make comparison shopping very difficult.

Lack of clear information about the prices of medical procedures, combined with a proliferation of insurance options whose potential benefits will be strongly affected by unpredictable events (such as being involved in an automobile accident or developing cancer), put consumers in a weak position.

The process of negotiating relationships with new health care providers because old ones are �out of network� is physically and emotionally exhausting. Insurance companies benefit from promoting policies that are difficult to understand and make consumers fearful of any change in their coverage. That fear and aversion has spilled over into the transactions required for many people to benefit from the Affordable Care Act.

David Himmelstein and Steffie Woolhandler, co-founders of Physicians for a National Health Program, regularly assert that elimination of the huge paperwork and overhead imposed by private insurance companies could save enough to cover the estimated 31 million of Americans who will remain uninsured under the Affordable Care Act.

My fellow Economix blogger Uwe E. Reinhardt, expanding on this theme, notes that the Institute of Medicine of the National Academy of Sciences recently estimated excess administrative costs of $191 billion, again more than enough to attain truly universal health care coverage.

Most such estimates are limited to the monetary costs incurred by insurers, doctors and hospitals and don�t include the value of the time that health care consumers must devote to managing a torrent of inscrutable paperwork that can become truly frightening for the critically ill.

Even if its rollout becomes more expeditious, the Affordable Care Act does little to reduce the incentives that companies have to barricade themselves behind high information and transaction costs. In the financial sector, I previously noted, this perverse incentive is described as �strategic price complexity.�

A complicated new program applied to a complicated old industry makes it hard for everyone to figure out exactly what they will be getting relative to what they are paying. As a result, many ordinary people and small businesses fall prey to redistributional paranoia.

Accusations of ripoffs proliferate, along with assertions that the Affordable Care Act is unfair to young people or that it simply represents transfers from the affluent to the poor, or from whites to people of color.

The program clearly has redistributive impact, but much of it will be muted over the life cycle. People who pay more for their insurance will get more benefits in return. The biggest transfers will go from the healthy to the sick (who are sometimes poor precisely because they are sick) and from one part of the health care system (emergency room care) to another (insurance-covered routine care).

But the structure of the program seems unintentionally designed to intensify distributional conflict. Its highly means-tested subsidies create strong political resentments and contribute to very high implicit marginal tax rates on lower-income families.

A single-payer insurance system, whether based on an extension of Medicare or on the Canadian model, promises many profoundly important benefits. Right off the mark, it promises simplicity.

No wonder conservative pundits are afraid of it.

The Single-Payer Alternative

Rush Limbaugh�s take on the disastrous rollout of the Affordable Care Act could, ironically, warm the hearts of those at the other end of the political spectrum. He contends that President Obama knew all along that the Affordable Care Act would crash and burn, but pushed it through so that the conflagration would clear the way for single-payer health insurance.

The conspiracy charge sounds deranged, but problems with the new health insurance system may indeed revitalize demands for more substantive reforms, which many policy makers and voters set aside in the putative interests of political pragmatism. Whatever the advantages of a single-payer system such as that currently administered by Medicare, one view held, American voters were unlikely to get behind it.

Yet one of the greatest advantages of a single-payer system � its relatively low administrative costs � has been thrown into sharp relief by problems registering with the new health exchanges. Andwhile Republicans despise the Affordable Care Act despite its conformity with many of their earlier proposals, their proposed changes (other than simple rollback) look complicated, kludgy and costly to administer.

The malfunctioning website has magnified problems inherent in coordinating enrollment across many different companies in many different exchanges in cooperation with many different government agencies. The harmonization challenges are orders of magnitude greater than those faced by a single company or a single state, making streamlining difficult. Improved software can do only so much.

In theory, competition and choice should increase efficiency. In practice, health insurance companies are able to take advantage of the complexity and uncertainty surrounding health care choices to make comparison shopping very difficult.

Lack of clear information about the prices of medical procedures, combined with a proliferation of insurance options whose potential benefits will be strongly affected by unpredictable events (such as being involved in an automobile accident or developing cancer), put consumers in a weak position.

The process of negotiating relationships with new health care providers because old ones are �out of network� is physically and emotionally exhausting. Insurance companies benefit from promoting policies that are difficult to understand and make consumers fearful of any change in their coverage. That fear and aversion has spilled over into the transactions required for many people to benefit from the Affordable Care Act.

David Himmelstein and Steffie Woolhandler, co-founders of Physicians for a National Health Program, regularly assert that elimination of the huge paperwork and overhead imposed by private insurance companies could save enough to cover the estimated 31 million of Americans who will remain uninsured under the Affordable Care Act.

My fellow Economix blogger Uwe E. Reinhardt, expanding on this theme, notes that the Institute of Medicine of the National Academy of Sciences recently estimated excess administrative costs of $191 billion, again more than enough to attain truly universal health care coverage.

Most such estimates are limited to the monetary costs incurred by insurers, doctors and hospitals and don�t include the value of the time that health care consumers must devote to managing a torrent of inscrutable paperwork that can become truly frightening for the critically ill.

Even if its rollout becomes more expeditious, the Affordable Care Act does little to reduce the incentives that companies have to barricade themselves behind high information and transaction costs. In the financial sector, I previously noted, this perverse incentive is described as �strategic price complexity.�

A complicated new program applied to a complicated old industry makes it hard for everyone to figure out exactly what they will be getting relative to what they are paying. As a result, many ordinary people and small businesses fall prey to redistributional paranoia.

Accusations of ripoffs proliferate, along with assertions that the Affordable Care Act is unfair to young people or that it simply represents transfers from the affluent to the poor, or from whites to people of color.

The program clearly has redistributive impact, but much of it will be muted over the life cycle. People who pay more for their insurance will get more benefits in return. The biggest transfers will go from the healthy to the sick (who are sometimes poor precisely because they are sick) and from one part of the health care system (emergency room care) to another (insurance-covered routine care).

But the structure of the program seems unintentionally designed to intensify distributional conflict. Its highly means-tested subsidies create strong political resentments and contribute to very high implicit marginal tax rates on lower-income families.

A single-payer insurance system, whether based on an extension of Medicare or on the Canadian model, promises many profoundly important benefits. Right off the mark, it promises simplicity.

No wonder conservative pundits are afraid of it.

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Making Moves In Food Delivery, Chess And Health Care

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All Things Considered

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The online magazine Ozy covers people, places and trends on the horizon. Co-founder Carlos Watson joins All Things Considered regularly to tell us about the site's latest discoveries.

This week, Watson tells host Arun Rath about a delivery service that allows you to track your food in real time, a chess master who is making the board game sexy and his recent interview with President Bill Clinton.

The New And The Next Shaking Up The Food Delivery Model Enlarge image i Radius Images/Corbis Radius Images/Corbis

"A couple of young guys who were UC Berkeley grads � food obsessed � were finding that they couldn't get their favorite foods delivered. So, they starteda new service called Caviar, that for a flat fee is creating quite the Uber-like stir around San Francisco and now in Seattle and New York. ...

"They've got a lot of your basics, whether it's fish tacos or pulled pork sandwiches, but they also have some of the higher-end restaurants who in the past have been a little hesitant about delivery who have agreed to do it."

Read 'Caviar: Like Uber For Eaters' At Ozy.com

Sexy Moves In The World Of Chess Enlarge image i Courtesy of Ozy.com Courtesy of Ozy.com

"Chess is not always the sexiest sport. But the No. 1 chess player in the world is a young guy from Norway named Magnus Carlsen, who is becoming quite the sensation. He is not only a champion chess player but he is also a male model and that's a very different look from Bobby Fischer or Garry Kasparov, who were two other famous chess champions of the past. ... Guys like Kasparov and others are saying, 'I hope he does really well and puts chess back into the larger mainstream conversation.' "

Read 'Meet the New Ambassador of Chess' At Ozy.com

President Bill Clinton Talks Health Care With Ozy Youtube/YouTube

"He reminded us that when President George W. Bush rolled out the Medicare Part D plan that there also were a number of hiccups in the early days. So, that was his way of offering context to the current troubles with HealthCare.gov. And saying, be a little bit patient. While there may be a number of troubles in the first couple months with HealthCare.gov, they ultimately should be fixable and this won't have been the first time that we've had to smooth over some things in the early going."

Read 'Assessing the Healthcare Rollout' At Ozy.com

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When Caregivers Are Abusers: Calif. Complaints Go Unanswered

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Weekend Edition Saturday

6 min 2 sec Playlist Download Transcript   Enlarge image i

Jim Fossum holds a photograph of his aunt, Elsie Fossum, who died from injuries her caregiver said were the result of a fall.

Mina Kim/KQED

Jim Fossum holds a photograph of his aunt, Elsie Fossum, who died from injuries her caregiver said were the result of a fall.

Mina Kim/KQED

Nurse assistants and home health aides provide intimate care, bathing, feeding and dressing the elderly, disabled or ill. So what happens when an abusive caregiver hurts a patient?

Public health regulators in California have been letting many complaints sit for years � even when they involve severe injuries or deaths.

'Beaten To A Pulp'

Elsie Fossum's nieces and nephews say she was the aunt you wanted to have.

"She gave us our first car," Janet Flynn remembers. Her brother, Jim Fossum, chimes in: "A '59 Ford Galaxie 500, with massive fins on it."

Flynn says their aunt, a librarian and teacher who never married or had kids, always looked chic.

Enlarge image i

Elsie Fossum's niece, Janet Flynn, and nephews Jim Fossum, left, and John Fossum, say they never heard from California's Department of Public Health following their aunt's death.

Mina Kim/KQED

Elsie Fossum's niece, Janet Flynn, and nephews Jim Fossum, left, and John Fossum, say they never heard from California's Department of Public Health following their aunt's death.

Mina Kim/KQED

"She would come for the summer with this tiny Samsonite suitcase," Flynn says. "And she would be impeccably dressed, mixing and matching, and her hair was always done. Always looked wonderful."

But on the morning of July 3, 2006, Elsie Fossum lay in a pool of blood on the floor of her bedroom at Claremont Place, a Los Angeles-area assisted living facility. The 95-year-old Fossum had lived there for two years.

Her eyes were bruising black, her lip was badly cut, and her right arm was broken. But she was alive.

The lone caregiver on Fossum's floor that night said Fossum fell, but Beverlee McPherson, a registered nurse who supervised nurse assistants at Claremont Place, suspected abuse.

"She looked like she went four or five rounds with Muhammad Ali," McPherson says.

Unable to take much food or water through her swollen mouth, Fossum died of dehydration less than three weeks later. A Los Angeles County coroner could not rule out assault and called the manner of death undetermined.

McPherson is resolute.

"Oh, I'm 100-percent convinced she didn't fall out of bed, 100 percent," she says. "If you saw this woman's face, I mean, her entire face was beaten to a pulp."

'Staying On Top Of Complaints'

Emergency room nurses who treated Fossum at a nearby hospital also suspected abuse. The hospital quickly notified the California Department of Public Health, the agency responsible for decertifying nurse assistants who violate standards of care.

Cases Closed With No Action Taken

The number and rate of license revocations against nursing assistants and in-home health aides suspected of abuse have plunged, while cases closed without action have increased.

Enlarge image i Center For Investigative Reporting/KQED Center For Investigative Reporting/KQED

But internal documents obtained by the Center for Investigative Reporting show department investigators shelved Fossum's case for six and a half years.

CDPH Director Ron Chapman blames the delays in handling complaints on a backlog of more than 900 cases that piled up between 2004 and 2008.

"There were a number of reasons for that backlog, including poor management decisions during that time," Chapman says.

The department implemented a plan in 2009 to address the backlog, says Chapman, who was sworn in to his position in 2011.

"In the two years that I've been in the job, there's now new management from top to bottom, and we're staying on top of all the complaints as they come in," he says.

Yet the number of nurse assistants facing disciplinary action following complaints has dropped, from 27 percent a few years ago to 9 percent last year.

Chapman says he sees no evidence that addressing the backlog has undermined the quality of the department's current work, but Marc Parker, who headed the investigations section for nine years, says he was forced to cut corners.

"Hundreds of cases were closed, hundreds, with nothing but a phone call," he says.

'A Failure To Protect'

Parker says without visits to facilities, investigators are unable to see the layout of a room, conduct impromptu interviews, or assess a person's body language. Parker retired in December of 2011, earlier than planned.

"I could not protect the public any longer," he says. "There was just a failure to protect the most vulnerable people in our state from abuse and neglect."

A Sudden Drop

The California Department of Public Health is required to notify the attorney general's office when its investigators find evidence of crimes, especially violent acts, at health care facilities. After 2009, the department all but stopped sending patient abuse deaths to state prosecutors.

Enlarge image i Center For Investigative Reporting/KQED Center For Investigative Reporting/KQED

Public health regulators are required to report all suspected crimes to the state attorney general. In the seven years before addressing the backlog, the department referred an average of 37 deaths a year. Last year, they referred three. The year before that, two.

"We don't understand that decline in numbers," Chapman says. "It's very concerning to me and we are looking into it." He says his staff is drafting agreements with the attorney general's office to improve communication.

As for Elsie Fossum's suspicious death, department investigators closed her case this year, and decided no action was warranted against her caregiver.

Also this year, however, the Los Angeles County Sheriff's Department opened a homicide investigation into Elsie Fossum's death. Her caregiver is the sole person of interest. Chapman now says he's willing to review the case.

Elsie Fossum's nephews and niece say they never heard from the Department of Public Health. Flynn says their calls and emails to state agencies and local police have turned up little information.

"I would think that this would be very chilling to anyone who has loved ones in a facility, especially if you think safeguards are in place and you think that staff are qualified and that this is being regulated, and this I find chilling," Flynn says.

This story was co-reported by Ryan Gabrielson at the Center for Investigative Reporting.

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