Slashdot Mirror
Healthcare.gov and the Gulf Between Planning and Reality
An anonymous reader writes in with this excerpt from Shirky.com. "The idea that 'failure is not an option' is a fantasy version of how non-engineers should motivate engineers. That sentiment was invented by a screenwriter, riffing on an after-the-fact observation about Apollo 13; no one said it at the time. (If you ever say it, wash your mouth out with soap. If anyone ever says it to you, run.) Even NASA's vaunted moonshot, so often referred to as the best of government innovation, tested with dozens of unmanned missions first, several of which failed outright. Failure is always an option. Engineers work as hard as they do because they understand the risk of failure. And for anything it might have meant in its screenplay version, here that sentiment means the opposite; the unnamed executives were saying 'Addressing the possibility of failure is not an option.' ... Healthcare.gov was unable to complete even a thousand enrollments a day at launch, and for weeks afterwards. As we now know, programmers, stakeholders, and testers all expressed reservations about Healthcare.gov's ability to do what it was supposed to do. Yet no one who understood the problems was able to tell the President. Worse, every senior political figure—every one—who could have bridged the gap between knowledgeable employees and the President decided not to. And so it was that, even on launch day, the President was allowed to make things worse for himself and his signature program by bragging about the already-failing site and inviting people to log in and use something that mostly wouldn't work. Whatever happens to government procurement or hiring (and we should all hope those things get better) a culture that prefers deluding the boss over delivering bad news isn't well equipped to try new things.'"
>> a culture that prefers deluding the boss over delivering bad news
I'm pretty sure the guy at the top was in on the ruse too.
>> no one who understood the problems was able to tell the President
Isn't there a petition system for that? :)
When both parties work together toward a common goal, we can put a man on the moon.
When both parties work against each other, and try to stop each other every step of the way purely for their own political agenda, we can't even launch a damn website.
The Internet King? I wonder if he could provide faster nudity.
Just ask Pelosi: they had to launch the website so they could find out what would crash it.
In the end they will lay their freedom at our feet and say to us, Make us your slaves, but feed us. - Fyodor Dostoyevsky
While there is plenty of blame to go around, I am still left wondering where the investigative journalism was regarding the true progress of ACA implementation as the 3 years progressed up to this point.
So, while the press is justifiably having a field day with the sheer incompetence displayed here, where were they while all this was developing?
"If you want to improve, be content to be thought foolish and stupid." - Epictetus
Isn't it more like the gulf between focusing on a service versus focusing on the nepotism behind awarding contracts to provide that service?
So the *signature* piece of Obama's second term agenda -- the legislation he's harped on loudly and constantly -- launches with an epic fail. The contractors working the site were sounding alarms well in advance of the launch. And yet Obama is somehow utterly unaware that the launch could be anything but a total success? I call bullshit. Either Obama is the most disconnected president in recent history when it comes to the success of his *core legislative agenda* or he's just bullshitting about not knowing there were issues on launch day.
In the end they will lay their freedom at our feet and say to us, Make us your slaves, but feed us. - Fyodor Dostoyevsky
I think the most interesting thought in the article was about the author's observation of contempt between modern managers (in the example in the publishing business) and the engineers who actually create and manage systems. I'm also drawn to how articles written with sources inside the Administration refer to the technical people as 'Technicians' instead of what they probably were 'Senior Software Engineers' or appropriate equivalent title. I certainly don't think of myself as a technician, and I find the term somewhat demeaning somehow.
Subject pretty much says it, both the legistlation and implementing regulations were hope-based....
CGI was selected in part because they were one of only a handful of companies that got on the task order from DHHS that covered this and many other big CMS contracts. This system is designed to make it extremely difficult to just start a business and put out a bid. The justifications for it are very flimsy and center around things like making sure that some fly-by-night company doesn't get the contract/screening out junk bids. Poblem is, they don't actually work. In many cases, they just let the "primes" that win the slots act as funnels for the actual work done by subcontracts which just adds to the cost of the contract.
Another thing, if the reddit thread on this was correct, CMS needs to do what the DoD increasingly does with overtime which is to scrutinize or reject invoices with more than 80 hours per two weeks per employee unless the overtime was either authorized or can be explained in reasonable terms. Overworked government contractors don't get rich; their employers do at the expense of the employee and government. One thing often left unappreciated by the general public is that unpaid overtime is literally stealing employment from the employee because a salaried employee is only authorized to bill so many hours to a contract during a period of performance.
If only there was this much scrutiny and post-mortem analysis over other government failures such as, oh, I don't know, the multi-BILLION dollar failure joint strike force fighter that nobody wants (other than private contractors who are making billions).
Thank gawd, however, that we have this eagle eyed scrutiny over a website that's a few months over deadline and a few million over budget.
I think that the Members of the House who were newly elected in 2010 after the ACA, resulting in the GOP retaking the House, and re-elected in 2012 are rightfully following what the people in their districts want them to do: oppose the ACA. There are a handful of districts which voted for both Obama and a Republican Member of Congress, but there aren't many, and those few are pretty squishy about what to do. My own Congressman came back into Congress in 2010 (he had been unseated in 2008) and then defeated in 2012 by a Democrat; he wasn't following the will of the voters who showed up on election day 2012, other places, the story is different.
when non-engineers that dont understand technology but make engineering decisions, shit like this happens.
shocker.
Anons need not reply. Questions end with a question mark.
The task was simple. Make a friggin website that takes user input and spits out insurance options. If this happened where I work, they'd fire the whole lot without question. Probably enact some kind of legal investigation as to where all the money went too.
If Congress can't handle a simple friggin website project, it's time to clean house and Enact term limits. Restructure the entire congressional seating process, and give people more control over who's buying the laws for us. It's time to change that whole mess.
Join the Slashcott! Feb 10 thru Feb 17!
(If you ever say it, wash your mouth out with soap. If anyone ever says it to you, run.)
I reject that sentiment. The statement was a motivating tool. It may not have been said - it probably didn't need to be said during the real mission as these were people that worked with those astronauts for years before the launch occurred. They didn't need to be told that the future of the space program and the three astronauts hung on their actions. But it got the point across to the audience, who didn't have that relationship.
It could be argued that complacency within the Space Shuttle design team engendered a feeling of "failure is never an option." Why else be so confident in a design that allowed them to remove crew escape contingencies and quote a 100,000 in 1 failure rate?
My web domain.
Next time try being a little more subtle - not even Obama himself thinks this mess will be fixed in six months.
If you want to pretend to be a left wing loony, "keep the gov't out of my medicare/obamacare" is a little too stupid.
Try "keep the evil businesses out of my business".
the worst fears of the GOP will be realized - people will be getting better healthcare at lower cost.
The GOP by and large isnt bothered if your costs get lower (though, in reality, it is not actually possible for the majority's costs to get lower when we are now covering higher risk people); the concern is that we are going down a path of surrendering every area of life to government control. The idea that the government has the right to tell you to buy X product in order to live in this country is problematic; and its problematic that the government is OK with saying "it doesnt matter what bad choices you make in life, we (that is America at large) has your back".
Theres a term called "enablement" when dealing with someone who has an addiction / other problem; it refers to feeding their bad choices by taking away all consequences. What do you suppose happens when everyone is paying into insurance to cover the terrible choices others make? Or, I suppose, we could fix that by legislating exactly how people can live everyday life, but Im not seeing that as much better.
Seems to be a clasic case of the Themocline of Truth. http://brucefwebster.com/2008/04/15/the-wetware-crisis-the-themocline-of-truth/
I still don't get how the website could have failed so incredibly miserably.
The problems the site faces seem to be elementary, the type of mistakes that I made when I was first doing web development. I get that the scale of the site is massive, and that at that scale you have to do many things a little differently than smaller-scale web apps. But this was a president who had very tech-savvy people at hand on his campaign, and even in his first term (Look at "change.gov" for example; that site gets massive traffic and holds up pretty well, even if the responses from the WH are patronizing as hell at times). How come this site crashed and burned so pathetically?
The Affordable Care Act : AKA ObamaCare
Well, the website had 4 major functions:
1) Comparison shopping. In retrospect, it could have been handled by a private company that Travelocity like didn't sell insurance, but instead helped you shop.
2) Subsidy. According to the law, you only get a subsidy through a state-run exchange (the Administration has chosen to ignore the actual wording of the law to include the Federally run exchange two.)
3) Seeing if people should be shuttled off to the mediocre but cheap care of Medicaid.
4) As a showcase for the law. This was to be something concrete to show what great things progressive government is capable of.
Bureaucrats are comfortable generating reality. To a large extent this becomes their job; if you are in charge of an environmental clean up you will move the goalposts around to match what you can do, and if you can't even meet these mutable goals you figure out a way to measure it so that the result are met. Plus you take any reports that indicate failure and "massage" them until they look good; and if the underlings who create these horrible truths won't shut up you punish them or just get rid of them.
This works well when the facts are a bit fuzzy and you are able to control the flow of information to your superiors and ideally the public. The problem is that the skillset that enables these people to survive and thrive in a bureaucracy aren't the skills required to deliver a functioning and realistic test passing product. So you have a product such as healthcare.gov which is going to be wildly exposed to the public and the scrutiny of people you can't control (the press and political opposition) and oddly enough it blows up.
People look at the hard numbers and say this is a pile of crap that doesn't work. Yet I am willing to bet two key things are happening:
One is that there are reports flowing up to the top people (who don't understand technology) that are a combination of saying that it works far better than the "detractors" are claiming while simultaniously blaming some other party with lesser abilities to communicate with said superiors.
And two that the company that won this contract is awesome at participating in this reality distorting circlejerk. I bet that the reports and other paperwork was Washington gold; the product of top-of-the-class-MBAs. People for whom facts are not only to be ignored but to be looked at with suspicion and hostility.
So the question of which development style should have been used or which technology was best are nearly moot; in that every choice would have been made based upon the criteria of "It must look good in a report"
I suspect that the only lesson learned from this in Washington is that if you love your career that you should not get involved in a project that involves a measurable end product that is delivered to the public.
The various opposition groups will probably try to score various points based upon actual facts such as cronyism and poor testing but the reality is that 5 minutes into getting power they would hand a similar project over to their insider friends and primarily demand good paperwork over an actual product.
So to prevent this type of disaster you can't look at say agile practices in software but maybe agile type practices within government itself.
between a piece of legislation and a website? The Affordable Care Act is NOT a website. The failure of the website does not equate to a failure of the Act. Mainly, it's indicative of the fact that government contracts go to companies that are good at getting government contracts, NOT companies that are good at the work for which the contracts are granted.
If you want X to be understood as Y, then just say Y!
That's not rocket science...
bickerdyke
Way to take that line out of context. "Failure is not an option." wasn't about general day to day stuff, it was about saving the lives of 3 astronauts during an emergency situation. In fact, the mission (LANDING ON THE FREEKIN MOON) was indeed a failure.... They DIDN'T do it!
The whole "failure is not an option" thing is fine when you have lives in danger and the whole world is watching, but you don't get to use it about your website, no matter how many jobs are at stake. The message to take away here is "Even a million jobs are not worth 1 human life." If you understand and live by that, you will be a better person. Otherwise, you're just another scumbag millionaire who doesn't care about people.
I tried to use healthcare.gov soon after it first came online. It was very slow, and eventually the system got to a point where it wouldn't let me go forward with my application or do anything else. A few days later, I tried again. This time, it complained that it couldn't verify my ID, and it told me call an 800-number or submit my ID online. The 800-number was closed at that time, so I decided to upload one of the identification documents. A week or so later, I still couldn't use my account, and I had not received any email about it either. Next, I tried calling the 800-number, which seems to be contracted with Experian. Experian asked for a "reference number" that the web site was supposed to have provided, but it didn't. Without that number, Experian refused to help me. The main healthcare.gov phone number could not help me, either. Finally, I tried creating a new account, and at some point the site asked me a few multiple-choice questions about my previous addresses and so forth. This is apparently the ID "verification." I had never gotten to this page on my original account! Eventually, I was able to look at the insurance plans available. My guess is that my original account ended up with bad data in it, and there was no way to recover from it other than creating a new account.
As soon as we decided that hospitals were legally required to give you health care if you walked into the emergency room we decided that health care is a human right. That debate is over. So now what do we do about it? You can either have the blood suckers feed off a system they're not paying into, or you can require they pay into it like every responsible adult has been doing for generations. The government is not requiring me to do ANYTHING really. They've created a new income tax (you're exempt if you have no income) and a corresponding tax break if you happen to buy health insurance. While it may be slimey it's perfectly within the normal business of government to enact income taxes and tax breaks. IMHO single payer or Medicare-for-all would've been a preferable option, but it wasn't politically viable, so we got this. It's not great, it's basically a big handout to the insurance companies. Have you watched their stock prices? They've shot up over the last few years. But at least the bums who were living off me in the form of higher premiums I was having to pay each year will now be paying in. And if someone was really sick and was unable to get health insurance at any price before now gets health coverage.. isn't that GOOD? My ex-wife couldn't get private health insurance. I know, because we tried. She had a clotting disorder but was generally a healthy and able-bodied person. But nope, can't buy health insurance. So unless her provider got her on a group plan, she was completely SOL. If more people like her, and even people who are not able-bodied can get some insurance now then that's awesome.
Check out my lame java blog at www.javachopshop.com
In my group there is a person with that specific responsibility. They communicate the possibility of not meeting a deadline and make contingency plans to get the best result given the circumstances.
That person should be fired, and IIRC they have already resigned.
Now find senior advisors who weren't responsible for communicating the risks but knew about them anyways. Ask them why they didn't communicate the risks to the President and based on their answer either fire them or reprimand them.
Send the message that there will be accountability. Why is that important? Unfortunately, be it in Government or the private sector, there is a culture of "that wasn't my job". Everyone knows the project will fail, every single fucking person from the junior engineer to the senior project director know. But everyone winks at each other across the table at meetings and agrees that "failure is not an option, it will be done on time". And inside their heads and within their small groups everyone is saying "well it's not my job to sound the alarm". There is no incentive to take that political hit and say "Boss, we might have told you several times that everything is OK but honestly there are some severe risks to launching by the deadline and we need to start planning for a delay or reduction in features". Instead, when shit hits the fan it's like a mexican gunfight, everyone points a finger at someone else and says "well he knew too" or "that wasn't my job to bring up that this would never work."
Engineering is hard, failure happens. It really shouldn't be punished (except where people just failed to do their jobs), instead it should be learned from so that the same mistakes are not made again.
One day, when software engineering management is a real discipline, they will pound it into the heads of MBAs and PMPs that failure is not only an option, its the most common result so make sure the lines of communication are open, that people feel comfortable communicating risks and saying no, and that all the stakeholders know that the engineers cannot travel through time, so if you start a 1 year project 9 months before you want it to launch then you are SOL and have to pick what features are most important.
I hate "you have more than one number one priority" more than "failure is not an option" and I feel people who say one usually say the other.
Warning signs for that culture include:
"The chinese have the same word for risk as they do have for opportunity",
"With that attidude of seeing only problems we never would have gotten a man to the moon",
"I need visionarys, not objection raisers",
"If you are not with my vision, you are agains us",
and actually understanding Dilbert cartoons.
bickerdyke
provider->employer
Check out my lame java blog at www.javachopshop.com
In a former life I did a lot of gov contracting. For any project, you couldn't get your GPM (gov program manager) to sign off on anything. Why? Because they had to go to their boss to get approval. Who also had to go to their boss to get approval and so on.
Why? Because they didn't want to be the one to blame if something went wrong. If anything, they were very apt to go up the flag pole for anything, but the issue was you never got an answer for anything.
This seems to be the case for healthcare.gov, no one made actionable decisions.
The more you hear about how he supposedly didn't know this or that, the more you have to wonder if he isn't a simple community organizer.
When Fascism comes to America, it will call itself Anti-Fascism, and tell you to give up your guns.
Politicians don't get their rewards through revenue-generating web sites, they get their rewards through being able to convince the public to re-elect them. Although Obama clearly screwed up on this one, usually it's not a problem when government sites or projects are over budget or don't work: costs are shifted around, data is presented in more favorable ways, and taxes are used to pay for it. The result is that voters get fooled into thinking that they are getting value for their money, vendors get paid off and end up supporting the politicians that shoved money their way, and the politicians get reelected. And the system works so well because nobody ever wants to admit mistakes: politicians want to pretend everything is working, and if that fails find someone else to blame; companies and even competitors pretend everything is fine because they want to get more contracts; and voters don't want to admit they were fools voting for this.
....The idea that the government has the right to tell you to buy X product in order to live in this country is problematic...
There's more than one way of looking at it, and I'll try to explain it in a way that even the most neo-liberal, free-market capitalist would understand. Before Obama Care, back when Barack Obama was probably the name of somebody living in a cave in Afghanistan, the government was requiring those who sold a "product" (medical care) to give it away for free to those who could not or would not pay for it (the uninsured). Forcing "retailers" (hospitals) to give away their "product" (medical care) for free is not a sustainable business model, especially when in some "markets" (states), such as Texas, 20% of the population "cannot pay for the product" (is uninsured). But rather than go out of business, the "retailers" (hospitals) divided the cost of giving away their "product" (medical care) to "unpaying customers" (uninsured patients) and added it to the overhead payed by their paying customers (insured patients). The insurance companies turned around and increased the "price" (insurance premiums) they charged for "X product" (health insurance); thus making "product X" (health insurance) more expensive; thus resulting in more "unpaying customers" (uninsured patients) demanding "free products" (health care) from "retailers" (hospitals), thus further increasing the "price" (insurance premiums) charged for "X product" (health insurance) etc. etc. etc.
But comparing an inelastic market to a normal consumer product with elastic demand, is really as nonsensical as my post.
I think what Richard Feynman said at then end of the appendix to the report on the Space Shuttle Challenger failure may also apply in this situation.
For a successful technology, reality must take precedence over public relations, for Nature cannot be fooled. --Richard Feynman
Planning? What planning? Hoping. Commanding. Directing. Praying. Lying. Concealing. Misdirecting. Deceiving. But no "planning" of the type that experienced project managers would recognize.
People need to realize that law cannot set a strict date for software releases! Project like this should have been released gradually to small city, smaller state, then state by state. After every release check issues, then fix them. Even Brodway learned to tests their plays in smaller/controlled population.
>> If Congress can't handle a simple friggin website project, it's time to clean house
Replace "Congress" with "the current president" (you know, the one in charge of IMPLEMENTING the law - http://www.archives.gov/exhibits/charters/constitution_transcript.html) and I'll agree with you,
How about some other perspective: in 1941, the US entered into a total war, the last such war we have seen. Essentially the entire output and focus of the country was directed towards the task of winning the war. I'm not sure getting healthcare.gov up and running was really quite the same priority.
There is a common myth that the high cost of health care is due to uncompensated obligatory emergency room care. Like many myths, it provides comfort to the general public, who are always looking for easy explanations for the complex problems of the world. But like all myths, it has the downside of being false.
In particular, the percentage of a hospital's expenses spent on uncompensated care is about 6% (in 2011, 5.9%)
http://www.aha.org/content/13/1-2013-uncompensated-care-fs.pdf
The mandate to provide emergency care to all those that show up in the ER was part of the Emergency Medical Treatment and Active Labor Act of 1986.
http://en.wikipedia.org/wiki/Emergency_Medical_Treatment_and_Active_Labor_Act
Turning back to the first link: what was the percentage of uncompensated care in 1985, before the Act? 5.8% So as a result of the treatment mandate, the percentage of hospital's uncompensated care went up all of 0.1%. (From then to today; there was a spike up to 6.4% the year after the Act was passed).
Undoubtedly, uncompensated care is a problem. It's just a rather small problem. Far bigger is the lack of market forces that removes any incentives to inefficiency.
As a side matter; I'm very sorry to hear that about your wife -- there is definitely a significant need for improvement in the system for helping people with pre-existing conditions.
One of the most helpful things I ever realized is that Design and Management think in terms of yes / no and Engineers think in terms of shades of gray. It will work vs it will work to "x" sigma are very different things and you have to have some skill to translate.
There is a common myth that the high cost of health care is due to uncompensated obligatory emergency room care.
The high cost of health care - as seen for by those without insurance - is the inability of the common man to receive services at the negotiated rate of insurers. An X-ray for a major insurer is $27. Double it and add a zero if I walk into the emergency room without insurance. Pills for your condition? $4 co-pay at the in-network provider for the insured. $40 a pill if you're on your own. Don't pretend the insurer is paying $40 a pill, that's just the price the uninsured pay.
If I could pay the negotiated rates for day-to-day services, I'd have the highest deductible plan someone would sell me - saving my insurance for something actually worth insuring against - catastrophe. Unfortunately, that's not an option.
Well, it is true that gerrymandering leads to extremists, but gerrymandering really only is that bad in large states. I live in New Hampshire, I'd like to see you try and draw a district map in New Hampshire which was more than 55% Democratic, as we only have 2 districts and both are always competitive. On the other hand, Massachusetts has no Republicans in Congress; and even then Barney Frank quit in a huff when his Newton district was redrawn to be even a little bit competitive and he'd have to spend time debating some hopeless Republican; how humiliating for him.
I used to live in California, and the gerrymandering there was horrible and resulted in the legislature being filled with morons and parasites. It'd be nice if you could mandate a computer algorithm to draw the lines based solely on population, city boundaries and a minimum number of polygons.
Usually, it's a requirement (or, in the case of HeathCare.gov, several requirements).
Cheers,
Dave
They that can give up essential liberty to obtain a little temporary safety deserve neither safety nor liberty.
Ben
Super summarized.
Who concedes decision-making power of the most important item on one's list? It's more than a conundrum, it's a full-blown mystery.
It baffles me, but the President surrendered leadership on his signature legislation at the beginning. One of his first moves was to let partisan Nancy Pelosi take the lead and also take the process into the back rooms with lobbyists in tow. He surrendered his promises of an open and transparent legislative process with seats at the table for all.
Can we call this the Vasa effect? Named after the pride of the Swedish marine that sank minutes into its maiden voyage, killing dozens of the crew.
https://en.wikipedia.org/wiki/Vasa_(ship)
It is not a partisan statement to say that the world's only superpower shouldn't be run/led by some dumbass community organizer with no management experience.
That might be true in an authoritarian regime, where orders from the top are expected to be carried out by subordinates (cue 'In Soviet Russia' jokes). But managing a political process in a democracy differs from corporate central planning. Where, if you don't maintain a consensus, the electorate can rise up and undo your best laid plans.
Have gnu, will travel.
The one positive thing the Bin Laden raid, Obama was at the controls making the tough calls.
Even with only a 50/50 chance the person in the compound was Bin Laden, the American public would *never* have forgiven the President for not sending a team to the compound. The President made the *only* decision that politics allowed for.
If no raid had occurred then right before the election there would have been a leaked story about a compound that may have held Bin Laden and the President decided to do nothing about it. The President had no choice but to go if he wanted re-eelction.
Keep in mind that he barely won while getting credit for taking out Bin Laden. Yes, barely won, the margin of votes was small in key states that could have tipped the electoral college vote either way.
The government is not requiring me to do ANYTHING really
Its requiring us to pay for insurance that covers things that have NOTHING to do with hospital visits.
It would be one thing if the discussion were just for critical care-- and I bet conservatives would be more divided in that case (certainly I would). Thats NOT the discussion; we're at a point where existing insurance plans are being canceled because they dont provide enough coverage.
IMHO single payer or Medicare-for-all would've been a preferable option,
Dont be surprised when the government tells you that you are not allowed to eat cheetos because it costs other taxpayers dollars.
And if someone was really sick and was unable to get health insurance at any price before now gets health coverage.. isn't that GOOD?
Sure, if you ignore economic realities and forget all the reasons that we discarded communism and socialism, despite how great they sound in theory. You cant legislate away poverty, and you cant make communism or socialism work no matter how hard you wish.
I see the appeal to emotion, and I am sorry for your ex-wife, but the reality is that nothing is free in life. The only way to make it free will just bring all of the leeches out of the woodwork. Does this mean that some people get the short end of the stick? Yes, sadly, it does; but the alternative is to ensure that everyone gets the short end of the stick.
While it may be the Republican's view that government does not work and should be reduced, it's the Democrats who are proving out the validity of that view.
Since the Democrats do not seem to have that view, it seems then a totally valid view to have given those most opposed to it are providing the evidence.
"There is more worth loving than we have strength to love." - Brian Jay Stanley
You cant legislate efficiency; adding red-tape and bureaucracy has never made things work better / faster.
False. 26 Republican States refused to create their own website by the December 31st 2012 deadline, forcing the Federal government to create 26 websites in less than a year.
So you are arguing that some big social programs are best handled at the state level, that they should not be done at the federal level? That they can not be done right at the federal level?
If you are budgeted 40 hours a week for six months, you can only work 40 hours/week for six months as a government contractor, salaried or not. Those are literally the only hours you can legally bill to the customer. That means that if you do 80 hours a week with only 40 paid, the business has literally taken away your ability to make a salary for those remaining 3 months unless they have new coverage. It is worse than normal salaried over time.
I take it then that you don't think car insurance should be mandatory.
Uncompensated care is only part of the issue. The other part is that ER care is incredibly expensive, and yet it is being used as the primary care provider for millions. Also, because the mandate is only for ER care, people can't always get treatment until they can credibly claim that their malady has progressed to the point of being an actual emergency. So a condition that might have been treated inexpensively with a visit to a nurse practitioner now needs to be triaged and managed at a 24-hour emergency center where everyone is being paid overtime - and the condition may now require hospitalization.
Anyway, the post you replied to wasn't really making the point that the ER mandate caused the spike in healthcare costs - he was just claiming that the enacting of the mandate represents the real point at which our country instituted socialized health care... not when Obamacare passed. People calling Obama a "socialist" may or may not have a point, but their criticism also then applies to Reagan.
W..w..W - Willy Waterloo washes Warren Wiggins who is washing Waldo Woo.
Do you know what a community organizer does day-to-day? Typically, what they're doing is taking charge of groups of volunteers. That means the difference between a community organizer and a manager is that the community organizer has to contend with the fact that they can neither fire the idiots nor offer any financial incentive to do what the organizer says.
In my view Obama has been fair-to-middling as president. There have been some serious problems, some serious successes (e.g. Osama bin Laden), and a lot of kinda-working things (including healthcare.gov, which I was able to successfully use last Friday). The economy doesn't suck as much as when Obama took office, but is far worse than it should be. The response to Hurricane Sandy wasn't perfect, but was a lot better than what happened with Katrina.
The last 5 presidents with significant business management experience were: George W Bush, George H W Bush, Jimmy Carter, Herbert Hoover, and Warren Harding. Not exactly what I would call a litany of greatness.
I am officially gone from
I was at a multi billion dollar corporation. The CEO wandered by and chitchatted with the programmers about how their specific projects were doing.
He only did this once a year or so for each department. It took about an hour of his time per department.
He would also meet with the supervisors and then the managers.
She was like chocolate when she drank... semi-sweet at first and then increasingly bitter.
According to Wikipedia, "In left-right politics, right-wing describes an outlook or specific position that accepts or supports social hierarchy or social inequality."
Rand Paul is all about small government--which pretty much by definition means right-wing according to the definition above.
Rand Paul calls himself a "constitutional conservative" and a "libertarian conservative." He opposes federal government involvement in health care, thinks it should be entirely privatized. He thinks the 14th Amendment shouldn't apply to kids of illegal immigrants. He shares some of the views of the religious right--he is against abortion even in cases of rape or incest, and he is opposed to same sex marriage.
As soon as we decided that hospitals were legally required to give you health care if you walked into the emergency room we decided that health care is a human right.
That isn't how it works. Hospitals are only required to provide just enough emergency medical care to stabilize you. They aren't allowed to refuse that much, even if you don't have medical insurance or other proof of your ability to pay. That doesn't mean you get the care for free, however: you will still be billed for it, and (IIRC) medical bills are one of the harder items to discharge in bankruptcy. The hospital may never get back the full cost of that emergency care, but they are free to try.
The actual cost of the portion of required emergency care which isn't actually paid back is small enough to be considered irrelevant.
As I see it, there are two major problems with the no-insurance penalty. First, the ACA's proponents claimed that the penalty was a fine, not a tax, right up until the Supreme Court said that it was only constitutional in the form of a tax. Meaning that the ACA was passed under false pretenses. Second, coupling revenue with policy undermines equality under the law. What's the difference, really, between taxing everyone 100% of their income, with a 70% rebate for those who "voluntarily" limit their speech to approved topics, and simply fining you 70% of your income for speaking on unapproved topics, leaving you with nothing? Apparently the constitutionality of any action depends on whether the government pursues it through the courts, where the Constitution occasionally applies, or through the IRS, where there are no limits. That is simply unacceptable for any constitutional democracy.
An income tax should be just that: a tax on income. It shouldn't vary from one bit of income to another depending on how much total income you have or how much you conform to the wishes of those in power. $X in income should always equal $Y in taxes. If you want a so-called "progressive" tax, implement a rebate system—but not through the IRS. The IRS's job should be simple and straightforward, without a bunch of loopholes and exceptions and tax breaks and special rates depending on how much you happened to make that year.
My idea of a proper income (more accurately profit) tax form:
If you buy or sell a good at the market price, the additions to Line 1 and Line 2 cancel each other out. Line 3 is thus only affected by (a) selling services (which would include income from labor), and (b) buying or selling goods at a price other than the market price.
"Market price" is ill-defined, but if you insist on having any sort of income tax, I think it's more or less inevitable that you will need to somehow convert the value of non-cash goods into a common currency, even though the concept makes no sense economically. (Prices only exists for specific goods at the times they're sold; anything else is merely a subjective estimate.) Note that this makes no distinction between "business" and "personal" expenses, which was always a rather arbitrary dividing line anyway.
"The state is that great fiction by which everyone tries to live at the expense of everyone else." - Bastiat
At least $600 million was spent on a website! with another $1 billion going to state exchanges to setup portals. Manned by SEIU aand Acorn people. They managed to sign up a dog and several hundred people yet not 1 person is paying as there is no setup for taking payments! Valerie Jarrett's daughter and son-in-law work at the Canadian company. Michelle obama's school buddy also works there as a VP. She started 6 weeks after the passage of obamacare ( passed late at night on a holiday with lots of bribes) obama knows all about this as obamacare is not about providing healthcare to anyone but a way to massively increase taxes and deny healthcare as punishment for not obeying the state. Example is myself in California. +$5,600 tax with $5,000 deductible. More then $10 grand I have to pay out for 1 person! More people today have lost their healthcare under obama. The estimate range from 50 million in 2013 to everyone come 2014! plus the millions and millions of people who have either lost their jobs or have had their hours reduced to 29/hrs. But don't worry as obama made sure he and congress and aids do not have to participate and use obamacare as you will be paying their medical care.
You know when you're a liberal, when your plans don't coinside with reality, and you blame reality for the outcome; instead of the validity and viability of your plan.
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False. 26 Republican States refused to create their own website by the December 31st 2012 deadline, forcing the Federal government to create 26 websites in less than a year.
You are ill informed at multiple levels. (1) The federal government only needed a single website. There is only one federal exchange. (2) The federal government knew it needed this website as soon as the legislation was passed. They have had over three years to implement it.
I'm pretty sure we all know why the large providers negotiate the rates that they do -- bulk, and extortion. If Banner doesn't want my [large number] patients at $50 an X-ray, we'll see if Mayo does.
Self pay rates are certainly negotiable, and available -- unfortunately, negotiating self-pay somewhere between the baby's fever and his treatment isn't always practical, and Walgreens isn't even amused if you ask for your pills on the cheap -- so here I am, buying insurance again.
An easy and simplified example is dental. In the "bad" parts of town, where they advertise services in at least two languages, you can almost always get services for whatever baseline your local government subsidy care pays for the service. There's considerable competition for dental patients, and the $525 the state will pay for a root canal - as opposed to the $1,100 they want to ask you for - will almost always get accepted if you offer it. [YMMV in the dental office with the marble waterfall in the waiting room.]
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Aside, I was poor and young once, and eschewed insurance. Then, I got a job and a family, and opted for the best insurance I could afford, and never looked back. I lost my job a while back and moved to contract, and had a short gap this year while we waited for my wife's insurance to cover us all. It's an uneasy feeling, knowing that as someone with a job, the wrong car accident or trip down stairs, or strange lump in the wrong place could have ruined me (and my children) financially.
I just need to shut up and pay the small fortune in extortion, I guess.
Overall, I do like taxes. I drove some awesome roads this weekend, and everywhere I pissed along the way had sewage. It was pretty awesome.
Proving once again (as if proof were needed) that science and politics are the worst possible companions. Read the Feynman Report on the Challenger disaster ( http://www.ralentz.com/old/space/feynman-report.html [among many others]) where he lambasts NASA decision makers for using politics-inspired wishful thinking instead of science to decide to launch over strenuous objections by staff scientists and engineers. This meme is seen throughout history as the politics of wishful thinking crash onto the iceberg of reality time and again.
Organization? You must be joking..
It's the MBA mindset of setting a goal and striving for it, no matter what. Once we set our sights on something, we can't be stopped. Not by the realities of the marketplace, the laws of physics or the US Federal Code. There is no surrender, retreat or regrouping.
I think a lot of these people watched too many John Wayne marine corps movies. Where the squad charges the machine gun nest and keeps going until the hero lobs in the grenade. Except that the military doesn't really do things this way. But all the 4-F draft candidates and people who got shit college degrees for the deferral think that's the way things work.
Have gnu, will travel.
What a snappy soundbite! However, it seems contradicted by all available facts. *Government-run* healthcare services based on legislated bureaucracies are the ones that put the US "private enterprise" model to shame for return on costs. It turns out you *can* legislate efficiency, as demonstrated in numerous working examples, even if dogmatic right-wing beliefs say this is impossible.
Slippery slope arguments are always true, amirite?
Nowhere in my posts do I advocate for mandated healthcare at the federal level -- only that I think the current system is pretty FUBAR.
George W Bush knew that there were no WMDs in Iraq, but he had to go ahead too.
The system was doomed from the start.
By your comment, I'm pretty sure you've never worked a contract for government at a high level.
For a reality-based perspective, understand that silos are DEATH to most projects, and government structures are ALL SILOS. The fact that every single one of the "senior political figures" refused (make no mistake--it is always an active decision) is just par for the course.
So, how to change this? There are two key policies that must be implemented from the top:
1) The career of anyone who lies or fails to report bad news up the chain to those who need it is over, regardless of that person's position.
2) The reporting of bad news is to be treated as a problem to be solved, not an issue with the messenger (or the person who caused it).
Example: at a major metropolitan newspaper, a tech made a mistake and rm -rf * the website's home directory. He immediately reported it up the chain and the team dropped everything and worked on restoring the files. They then sat down and discussed how to mitigate the problem so that human error could not cause the same situation or how it could be restored quicker when it happened again. No retaliatory action was taken against the tech.
Yeah, right.
https://en.wikipedia.org/wiki/Soyuz_1
Prior to launch, Soyuz 1 engineers are said to have reported 203 design faults to party leaders, but their concerns "were overruled by political pressures for a series of space feats to mark the anniversary of Lenin's birthday."
Only stupid executives think this way. Smart executives -- Jeff Bezos comes quickly to mind -- listen to engineers. Especially ones who suggest your company commoditize all the web service components you need, and then rent them to the world.
"We receive as friendly that which agrees with, we resist with dislike that which opposes us" - Faraday
Sure, but there was no law against delivering incremental features early in order to gain experience and have a fallback in case of partial failure. As the article points out, they had (and are having) an incremental roll-out anyway, it's just a lousy incremental roll-out.
I thought that was the phrase...
It is always easy to spot the breitbart.com fans in the office:
1) They all subscribe to the "Nancy Pelosi as ultimate evil librul WITCH" theory - despite Pelosi being an ordinary centrist Democrat. Which is to say, a bit to the left of the DLC/Third Way, a bit more to the left of the neoliberals: just about at the median of US voters.
2) They have no understanding of how a legislature that intends to endure for many years and which uses parliamentary rules of procedure, actually works
3) They have no understanding of what the Speaker of the House's job actually is.
sPh
Pelosi is, to be sure, a very good political manager (and therefore a very effective Speaker of the House). Perhaps that is what makes her unforgivable compared to Boehner and - particularly - Cruz.
There is a also a myth that hospitals and hospital emergency rooms are required to provide care for medical conditions. They aren't - they are only required to stabilize and provide palliative care to any patient who arrives at their doors. Colon cancer and no insurance? The ER will give you a diagnosis and some painkillers, then on your way.
sPh
Just thought we should memorialize that as the deep, thoughtful, centrist political analysis of the Anonymous Coward at 45521181.
sPh
Your post might be on point if A) uninsured emergency care constituted a large portion of hospital expenses, and B) Obamacare was solely about rectifying that and requiring emergency-care insurance. Who knows, a lot of conservatives might have been behind that.
But thats not what Obamacare is, and theres about a million reasons to object to it. And regarding "A", a quick google turned up a Kaiser Foundation link indicating that,
Uncompensated care will make up just 2% of total health care spending in the U.S. in 2008
Examples please, of where additional regulation or legislation has reduced costs and driven up efficiency.
You dont have to have a car to breathe, or live in the US. It also isnt the same thing: theres no parallel with car insurance of the threat that the government will now have a say in how you live (ie, being healthier).
Also, Im pretty sure you dont need a license to even drive, as long as its on your own private property; the personal mandate doesnt take that route, it just says "if you live in the US you must buy insurance".
Pretty sure I didnt say any of that, but good strawman. There are a lot of people who make poor health choices, and telling them that they no longer need to worry about the consequences sure isnt going to get them to make better choices.
I've heard it argued that the only real way to find compromise is to do the deals in the back room. The problem is that you're not even allowed to talk about compromise in politics since things are so polarized, but the final law had a TON of compromise in it.
So, you hash things out in a back room, and then everybody stands up and talks about how wonderful the resulting product is in lockstep. You don't have to talk about the bazillion compromises that were proposed and never accepted, just the ones that made it into the final agreement.
The real problem is with voters who care more about sound bites than good policy. Our politicians pander to what gets them elected.
First off, let's not call human beings blood suckers, okay?
Second thing, having insurance--even if it's Medicaid--means you get preventive care and you get to see a regular doctor in a regular office for regular prices for ordinary things before they become emergencies. That's how it lowers the cost.
That's not new information. You're just being disingenuous.
Complete bullshit. Obama won the electoral vote 332 - 206. Suppose you give Romney all the close states, so anything less than a 55% win for Obama counts as a Romney state, okay? That gives Romney Florida (29), Ohio (18), and Virginia (13), changing the totals to Obama 272 - 266. You'd have to throw in Colorado (9), which Obama won by 5.37%, to make it a Romney win.
You do know people can look things up and check your facts, right?
Say what you want about the bin Ladin raid, about the ACA, about the website, whatever. But your point about the 2012 election being on the cusp is just completely wrong.
The President knew. He didn't want to know. But, he knew. At the beginning and end of each day, he is a Community Organizer, and that is all he is. He has no Executive experience of any kind. He has never been trained as an Executive, just as a Lawyer, that has focused on ways to get around the Constitution of the USA, period. He has trained himself on how to usurp the Constitution and the Bill of Rights. He has no financial training or experience. He has nothing going for him to even suggest he has Presidential capabilities. He only knows one formula for accomplishing anything. That is to divide and concur. Get two factions locked in combat with each other so he can do what he wants while they fight. When you start tallying up his accomplishments what do you come up with? He has spent more money than any President, ever. Is that a good accomplishment? He has single-handedly created more Government bureaucracies than any other 4 Presidents combined. Good or bad? He has dismantled our military leadership, and invited our Enemy's military onto our soil. Good idea or bad? He has lied to the country on so many occasions that the average citizen now has to assume he is lying to them whenever he speaks. He has wielded his Presidential power to attack, cripple, or just block all that do not share his ideology about anything. All of our bureaucracies that were originally empowered to enforce our Laws, Taxes, etc. have been converted into his personal attack-dogs, for his personal use. Good or Bad? He signed the "Unknown piece of Legislation" known as the Affordable Care Act into Law with absolutely no idea how to go about implementing it, or even understanding the huge amount of complexity of our National Healthcare system, or even how to go about fixing those areas he felt were lacking. Obama doesn't even have enough common sense to understand how to eat an elephant. He believes it must be consumed in one bite. Maybe someone with as big a mouth as he has doesn't consider that an impossibility, but the impossibility is still there. In his Signature Legislation, he has doomed many Americans to death due to lack of healthcare, when its expressed purpose was supposedly exactly the opposite!
The GOP by and large isnt bothered if your costs get lower (though, in reality, it is not actually possible for the majority's costs to get lower when we are now covering higher risk people); the concern is that we are going down a path of surrendering every area of life to government control. The idea that the government has the right to tell you to buy X product in order to live in this country is problematic; and its problematic that the government is OK with saying "it doesnt matter what bad choices you make in life, we (that is America at large) has your back".
Theres a term called "enablement" when dealing with someone who has an addiction / other problem; it refers to feeding their bad choices by taking away all consequences. What do you suppose happens when everyone is paying into insurance to cover the terrible choices others make? Or, I suppose, we could fix that by legislating exactly how people can live everyday life, but Im not seeing that as much better.
Because everyone knows that if someone gets sick, it's always caused by their own bad choices (like being born) and should be either denied care, or financially punished into bankruptcy.
And I agree totally. High risk people shouldn't be covered at all if they're not rich. Don't "enable" them - they're all just evil, godless liberals sponging off the hard-working REAL Americans. Fuck 'em.
I've heard it argued that the only real way to find compromise is to do the deals in the back room.
Perhaps if *both* sides go into the back room. However when only one side goes into the back room with their lobbyists and special interests in tow you do not get compromise. You get partisanship, and guess how the other party responds, with more partisanship.
... the final law had a TON of compromise in it.
Compromise between liberal democrats and conservative democrats. That doesn't really count.
Complete bullshit. Obama won the electoral vote 332 - 206. Suppose you give Romney all the close states, so anything less than a 55% win for Obama counts as a Romney state, okay? That gives Romney Florida (29) [at 50%], Ohio (18) [at 51%], and Virginia (13) [at 51%], changing the totals to Obama 272 - 266. You'd have to throw in Colorado (9) [at 51%], which Obama won by 5.37%, to make it a Romney win.
You are only including the states that had a 51.5% or less win for Obama, not 55% as claimed. You failed to consider Pennsylvania (20) at 52%, New Hampshire (4) at 52%, Iowa (19) at 52%, Nevada (6) at 52%, Minnesota (10) at 53%, Wisconsin (10) at 53%, New Mexico (5) at 53%, Michigan (16) at 54%, and Oregon (7) at 54%
Basically 64 electoral votes needed to flip. Florida, Ohio and Pennsylvania represent 67 and there Obama's vote represent less than 52%. But lets go with the math you actually used (margin) rather than the math you claimed to have used. Why not go from a 5.37% margin to 5.39% it only a different of 0.02%? Then we can include Pennsylvania (20)
So, a 5.4% swing could have made it a solid Romney electoral college victory. As the NY Times reported, the President received an 11% favorability boost from the successful raid. Suppose we generously expect only a swing of half that magnitude when the October surprise leak occurs **right before** the election informing the public of a decision **not** to conduct the raid. That's 5.5%. Now consider how much of that 11% faded by election day, lets generously assume three quarters of it evaporated, so that by election day the boost was only 2.75%. We are looking at a 8.25% shift from favorable to unfavorable by flipping the decision from go to "no go".
You do know people can look things up and check your facts, right?
Apparently not you, saying lets go with 55% states but only including 51.5% states.
Say what you want about the bin Ladin raid, about the ACA, about the website, whatever. But your point about the 2012 election being on the cusp is just completely wrong.
Whether we use your erroneously stated argument, or your unintentionally used argument, its pretty clear that flipping the Bin Laden raid story from go to "no go" could have easily changed the election. All it took was a 1% shift in Florida, a 3% shift in Ohio and a 5.4% shift in Pennsylvania.
It is always easy to spot the breitbart.com fans in the office:
Really? I don't think I've been to Breitbart's website.
1) They all subscribe to the "Nancy Pelosi as ultimate evil librul WITCH" theory - despite Pelosi being an ordinary centrist Democrat.
Really? I called her partisan, not "evil witch". I'll go further and suggest her agenda is different than the President's, which leads to the confusion over his surrendering leadership to her.
In any case, thanks for your amusing post. You truly identified the political hack whose mind exists in some strange bubble, yourself.
It seems to me that that wonky pricing is BECAUSE insurance exists, and any legislation that further entrenches the insurance system is backwards.
Ideally we would get out of this system where you literally cannot afford common procedures like childbirth without insurance, not make it mandatory for everyone.