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On the Third Hand: Stress list

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When you read health insurance articles here, or anywhere else, you probably end up wanting to throw the article against a wall about five times per article.

This is a particularly dangerous situation when you’re reading the articles on a phone, or a tablet, and you really could throw the article against a wall, and end up with glass in your eye. And maybe a strong suggestion from the folks around you that you ought to look into stress management.

Here’s a look at some of the ideas floating across my screen this week that are challenging my own stress management skills.

1. It’s not that big of a deal for the Patient Protection and Affordable Care Act (PPACA) public exchange system if UnitedHealth Group Inc. (NYSE:UNH) (and Assurant Inc. (NYSE:AIZ), and, partly, Humana Inc. (NYSE:HUM), and many, many CO-OPs, and, you know, a bunch of others) leave the exchange system, because there are still a lot of insurers selling plans through the exchange system.

The Bloomberg editors presented one spectacularly mindless version of this argument in an editorial we published, just to give readers an idea of the kinds of views that are out there.

The most irritating part of that particular editorial is the editors’ blithe assertion that executives at Aetna, Anthem and Humana are all happy with their companies’ PPACA exchange programs. But, note: Executives at all of those companies expressed concerns about the performance of their companies’ exchange programs during third-quarter earnings calls, and Humana has already announced plans to cut back on its 2016 exchange plan efforts. Humana also announced plans to jump into Aetna’s arms about the same time insurers were figuring out how the PPACA 3R’s risk management programs — the reinsurance, risk-adjustment and now-infamous risk corridors programs — would really work.

See also: 5 ways PPACA cushion programs could drive dealmaking

Elsewhere in that editorial, the Bloomberg editors say that all that has to happen for the exchanges to do better is for Congress to extend or expand the 3R’s programs.

OK. All that has to happen is for Congress to help strengthen PPACA programs.

And on what planet, exactly, is that going to happen? 

Of course, to be charitable: Congress could do something. Insurance companies and hospitals give money to Republicans, too. But the idea that Paul Ryan will let a PPACA helper bill sail through the House does not seem to be a sure thing.

2. Calm statements from the U.S. Department of Health and Human Services (HHS) about how vibrant and viable the exchange system is are helpful. One of the huge problems with everything to do with PPACA implementation is that we can never tell whether insurance company executives and state-based exchange program managers are really happy, whether they’re unhappy but being sincerely polite, or whether they’re furious but muzzled by HHS nondisclosure agreements. 

The people inside HHS and its Centers for Medicare & Medicaid Services (CMS) division are clearly having knockdown fights over all of this stuff. But we never get a milligram of the information needed to figure out who at HHS or its divisions has even a small clue as to what’s going on, or any evidence that any part of HHS is sincerely interested in working with insurers to make the exchange system work properly.

The statement HHS released Thursday about how well the exchange system is working actually conveys an idea that completely contradicts the apparent thesis of the statement. HHS officials seemed to want to convey the idea that the exchange system is doing fine, but, instead, the message is that they’re ignoring insurers’ complaints.

The statement also conveys the ideas that HHS officials probably wouldn’t understand insurers’ complaints even if they were listening; that they’re not making any effort to let insurers come up with their own exchange system rescue effort; and, really, that they’re mostly just going out on job interviews. Why would they waste their job board search time trying to figure out something as complicated as the exchange system?

3. It’s fine for the health insurers if the exchange program flops, because the insurers still have huge, profitable Medicaid and Medicare operations. Uh, right. Because we all know that Medicaid and Medicare are so completely independent from the governmental entities that created PPACA World, and we know that the Medicaid and Medicare systems are so wonderfully immune from government intervention. 

I mean, OK. Maybe, whatever the risks that are involved with turning health care finance over to the government, we should have a single-payer, government-run health insurance system, at least for some kinds of basic health care needs, for moral and practical reasons. I don’t really agree with that, exactly, but, in practice, I’m too soft to want us to let people with broken legs die on the sidewalk. That means, implicitly, I’m in favor of at least enough of a single-payer charity care system to pay hospitals for part of the cost of caring for people with broken legs who are lying on the sidewalk. 

But: Whatever the morality of government health care programs, and whatever benefits they might possibly have for the patients, or for society as a whole, they’re not necessarily great for private insurance companies. I think insurers that are joyous about the idea of trading a messy, dysfunctional, freeish commercial market for the glories of bidding for giant government plan contracts subject to election-year whims may end up wondering what they were smoking.

4. Returning to medical underwriting and risk pools for people with high blood pressure will be peachy keen. There are some general pockets of support out there for penalizing high-income people who go without health insurance, then suddenly want health insurance after they have heart attacks.

But I don’t think a single person outside of the health insurance community, and, possibly, the diehard Ayn Rand objectivist community, is enthusiastic about a return to the days when health insurers were rejecting applicants over common health problems, and scouring the applications of new enrollees who developed serious health problems for signs the enrollees had failed to report care for acne and hangnails.

Those wonderful days when people with diabetes or cancer who ended up in the risk pool in California had a $75,000 annual cap on benefits, and when people who had diabetes or cancer in Illinois had to wait years for a slot in an oversubscribed risk pool program.

So, on the one hand: argh.

On the other hand, I don’t have any great answers, either. Everyone is right. Health policy life is unfair.

On the third hand, if HHS would just stop issuing those idiotic statements about how great everything is working, and PPACA exchange defenders would stop boasting about how much the insurers still in the exchanges love the exchanges, that might at least make the fundamental unfairness of health policy a tiny bit less annoying.