Julie Boonstra is the Michigan leukemia patient who recorded a commercial for Americans for Prosperity (AFP) earlier this year, describing the disruption to her treatment when she lost her health insurance because of Obamacare. [Interesting update: as of this writing, at 2:30 PM PDT on 16 March, the AFP website is unavailable. Here is the error page that comes up when you try to access it.]
If Boonstra made a mistake, it was thinking that she could assert this, without revealing every detail of her insurance problems, and not come under vicious attack from the media, Harry Reid, and even from a Michigan congressman, Democrat Gary Peters. She wasn’t intensively detailed and explicit about the problems she has faced. And the media, along with Democratic politicians, have taken that as an opportunity to call her a liar, and create a false narrative that she is actually better off now than before, and is saving money on her health care.
Remember this episode, because it’s a guide to how Democrats and the media will react in the future to complaints about Obamacare. They won’t care to find out the particulars; they didn’t in Boonstra’s case. If they consider the possibility that there are other factors beyond the few basic facts they have looked up online, they won’t pursue them any further. They haven’t in Boonstra’s case. They will go only as far as they must, to identify “facts” that tell the story they prefer – and then they’ll call the aggrieved party a liar and declare victory for Obamacare.
That’s what they did last week, when Glenn Kessler of the Washington Post (keeper of the “Pinocchios”) verified online that the monthly premium for Julie Boonstra’s new insurance plan is likely to be (although not guaranteed to be) substantially lower than what she used to pay, and that, combined with the annual out-of-pocket cap of $5,100, it would theoretically give her a lower total bill for 2014 than she had in 2013.
“Denial!” “Debunked!” “Liar!” screamed the anti-Boonstra headlines across the leftosphere. Some variations had Boonstra being exploited by AFP and the villainous Koch brothers. Kessler upped the Pinocchios for Boonstra’s story from two to three. The wicked, evil right-wing conspiracy was now just making stuff up: unable to find actual Obamacare horror stories, the wing-nuts were manufacturing them from thin air.
No one seemed interested in checking on what seems obvious to responsible adults about Boonstra’s story. You don’t get the same for less in this life. That’s not how it works. If your premiums go down, especially if they go down by hundreds of dollars a month, you’re not getting what you used to get for higher premiums.
What is Boonstra not getting now, that she was getting for the $1,100 a month she used to pay? And is she in limbo right now, waiting for coverage to start? As a leukemia patient, she can’t go for very long in limbo. There are prescriptions and recurring procedures she’ll need. Her old insurance was cancelled at the end of 2013, and we’re two and a half months into the new year. What is her status right now, as opposed to what her theoretical status might be when the new insurance plan is in place?
Fortunately for all of us, Dan Calabrese at the Detroit News did take the trouble to find these things out, obtaining the information from AFP, which Boonstra authorized to convey it. It turns out, as anyone with common sense would expect, that she is in limbo on several points at the moment (like many people who have signed up for insurance through the Obamacare exchange); she has had to miss procedures because of the delay and uncertainty about what’s covered; there is a prescription she’s been using that her new plan doesn’t cover; and it can already be established that she has less coverage for types of care than she had under the old plan.
Moreover, her $5,100 annual cap applies only to in-network services. Calabrese points out that if you know anything about aggressive cancers, you know that there’s a greater likelihood you’ll have to go out of network for some services. If Boonstra has to go out of network, her annual cap doubles to $10,200.
But that’s not even the whole story (speaking here in my own voice). There’s no guarantee that the out-of-network services will even be covered. And Boonstra simply doesn’t know, because she hasn’t received a contract yet from Blue Cross Blue Shield Michigan (BCBSM). Any pretense on the part of third parties to know more than she does about what will be covered for her is just that: pretense.
Boonstra already does know she’s getting less for less money. What she doesn’t yet know is how much less. But she knows that she’s had to miss procedures because of the uncertainty, and that services she’s had to use over the last five years – at least one drug, and in-home care when she was bed-ridden during treatment – are not covered by her new plan.
She’s a legitimate victim of Obamacare – and her critics are a pack of baying jackals who don’t care about the truth.
Burying the bad news in the details
This false-narrative triumphalism will only get worse, as the problems with Obamacare become buried more and more under layers of bureaucratic procedure. In 2014, we have a transient moment in which millions of people are able to make direct comparisons with the known, experienced quality of pre-2014 insurance and medical care. But the teachability of the moment will fade with time, as people lose touch with what the alternatives used to be, and know only what happens, from now on, when they show up for medical care. In many ways, it will become harder to prove that Americans are getting less than we used to.
Consider Julie Boonstra’s Loratadine, for example, the prescription drug that’s not covered under her new, cheaper plan. Why isn’t it covered? That’s a question we know to ask in 2014. In five years, will we still know to ask it? And what impact will it have on hundreds of thousands of cancer patients, that it isn’t covered under at least some plans out there? – plans that customers are having to select largely in the blind on such issues?
I don’t know, and neither do you. But Obama and the Democrats have made health-care policy as if it doesn’t matter what happens to Julie Boonstra and the many others who’ve been on Loratadine, and who now find it’s not covered under a plan they were forced by law to switch to. Every one of the specific questions that will arise ought to be asked and answered, but the sheer volume of detail in each situation will make accountability impossible.
There is another way in which Boonstra will be particularly vulnerable, one I unearthed while doing my own research on BCBSM. BCBSM is doing pioneering work in moving to a “value-based pricing” or “purchasing” model for health services. The theory behind it is not necessarily pernicious, but it can easily become so when wielded by a central authority with no market accountability (e.g., the U.S. federal government). The theory is that procedures may be overprescribed or overused, and that assessing their effectiveness through outcomes is required to prevent waste in the system.
Instead of insurance companies merely accepting all the bills for procedures and paying them straightforwardly, an index, or “multiplier,” will be developed (scroll down to “Value-based Payment Modifier”), to grade hospitals and physicians on the outcomes they’re achieving with the combination of measures and procedures they use. Compensation will then be adjusted so that the practitioners with the more effective outcomes overall get the top dollars, while those who don’t achieve “value” most effectively are docked for their underperformance – i.e., paid less.
Obviously, defining “value” and “effective” will be key (and will be subject to moral hazards big enough to drive a semi-trailer through). This is the aperture through which the “death panel” argument has entered.
In theory, the value-based purchasing method will reveal which procedures and measures are the most effective, and which deliver less bang for the buck. Most of us can see the danger in this approach, however, as we can easily imagine being the unusual case that would respond well to the less-favored and statistically less-effective procedures. If a doctor is considering an MRI, or surgery, or an unusual treatment for us, do we want her thinking about the facts of our case and her best judgment, or about damaging the multiplier that will determine her practice’s or hospital’s compensation?
Patients like Julie Boonstra, about whose medical problems the statistics are often ambivalent, at best, will be the big losers under the value-based purchasing system. There will be an inherent bias against taking them on at all, and if they are taken on, the bias will shift to doing less for them, rather than more, given that doing more is likely to prolong their lives at increasing expense.
For Boonstra, the inevitability of such calculations was built into the high premium she used to pay. That premium reflected a whole philosophical approach: a mindset that said the medical system would put more into her, and not anticipate punishment for doing so.
A much lower premium has to be based on a different approach – and, in fact, it is. Value-based purchasing changes the premise. It says there will be punishment for prolonging life at increasing expense.
The Obamacare law requires Medicare to implement a value-based multiplier starting next year. But it will be coming soon to everyone’s medical care. BCBSM is getting out ahead of the power curve, already putting together a broad network of Michigan hospitals and clinics, some of which have been using value-based purchasing since late 2013. (See link above; see here for more on BCBSM’s additional future program for lower-cost health plans with a value-based purchasing model.) The University of Michigan hospital, where Boonstra has been getting her care, is in BCBSM’s value-based purchasing network.
It’s quite reasonable to be concerned, at this point, that the decline in the standard of care for Julie Boonstra under Obamacare has only just started. With value-based purchasing in the driver’s seat, however, it will become nearly impossible to compare the new standard of care with anything else, and imagine a different approach or the possibility of more favorable outcomes. The American health care system, with its much-superior statistics for people with the worst health problems (see here as well), will be gone.