Monday, January 13, 2014

Obamacare updates January 13 , 2014 -- Obamacare Enrollment Explained In Three Charts

Obamacare Enrollments Show Low Uptake by Uninsured, Hoisting Insurers on Their Own Petard

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One of the few saving graces is that the health insurers’ scheme to enrich themselves known as Obamacare may be going pear-shaped from the standpoint of their profits.
First we had the mess of the website, and recall that fixing the back end was lower priority than improving the much-higher-profile consumer experience. So insurers had to process a lot of completed applications manually, which imposed unexpected costs on them. Second, many of the initial enrollees (and presumably a not-trivial proportion of the later ones) were assumed to have pre-existing conditions, as in have costly ailments that had gotten them denied. While insurers did expect to have that population sign up, they didn’t plan on them being vastly more enthusiastic about Obamacare than other target populations, since it would create an significant adverse skew in the insured population, potentially leading to a death spiral (in general, if an insurance pool does not have enough good risks to compensate for the poor ones, the cost of insurance is so high that the good risks drop out because the insurance is clearly uneconomical for them, leading to further rate increases and more thinning of the better risks).
The Wall Street Journal tells us that Obamacare looks to be falling short of insurers’ fond hopes on a third front, that of the level of participation by the uninsured. Remember, even after Obamacare, many uninsured were expected to remain uninsured, due to the fact that some low and moderate income individuals eligible for subsidies would still find the cost to them too high. Brookings last September summarized the projections: of 60 million uninsured, 17 million would obtain insurance via Medicaid expansion. Of the remaining 43 million, 22 million, or roughly half, were expected to sign up, leaving 20 million, or roughly half, still without coverage.
Now remember, the picture so far is incomplete, since the data in the Wall Street Journal story is only as of the end of December, when consumers have until March 31 to sign up. And these snippets come either from small scale surveys or from a few of the insurers themselves. But they paint a broadly similar picture: the uninsured are participating at considerably lower rates than anticipated.
And it’s not simply the gross numbers, the 2.2 million that have enrolled, but the composition. Various sources indicate that the overwhelming majority of enrollees were previously insured. Either they had employers who used Obamacare as an excuse to drop coverage, or their plan was cancelled for not meeting Obamacare coverage standards, or they dropped their current individual policy and purchased an Obamacare plan instead. While the first two categories could produce more revenues to the insurers, the last type, people who switched from a plan they’d purchased in the individual market to an Obamacare plan, almost certainly isn’t, since they buyer would choose it only if he thought it was a better deal given his circumstances. For instance, non-Obamacare plans permit different pricing for men and women, while Obamacare plans require the same pricing for men and women who fall in the same bucket otherwise (same age, geographic location, smoker/non-smoker status). But younger women actually incur somewhere between 10% and 60% more in healthcare care costs than men, which means they typically pay higher premiums. This group would be likely to give Obamacare a hard look relative to their current plans.
In fairness, there’s a lot turnover in the individual insurance market (as in they might obtain a job with a large employer who provides insurance and thus drop coverage, or have a change in personal circumstances that leads them to upgrade or downgrade their coverage). That means you’d expect a fair number to switch over to Obamacare. But even allowing for this behavior, the proportion of uninsured enrolling is much lower than anticipated. A McKinsey survey found that only 11% of Obamacare enrollees had been uninsured. An agency, Health Markets, said that 35% the coverage it arranged was for the uninsured. A survey by Priority Health found only 25% had not had coverage before.
This gives an idea of how severely enrollment of the uninsured so far is undershooting expectations:
Michigan insurers collectively expected 400,000 of the state’s 1.2 million uninsured people to join private plans this year, Ms. Budden said, citing an internal analysis of insurers’ rate filings. As of the end of December, only 76,000 enrollees had arrived, many of whom were previously covered.
The McKinsey survey also didn’t give great cause to be hopeful. Of the people who’d looked at plans but decided not to buy, 52% found them to be unaffordable. Another 30% had “technical challenges”. It’s possible that many in that cohort will figure out how to surmount those problems and will sign up by the end of March.
Some experts saw that the uninsured might reject Obamacare. A January 13 post on Bob Laszewski’s blog (hat tip Lambert) observed:
But what if most of the uninsured literally don’t buy Obamacare?….
As I have reported on this blog before, many working class and middle class subsidy eligible people will find health insurance premiums on the exchanges, after federal subsidies, at about 10% of their after-tax income. The average standard Silver plan deductible is almost $2,600 and the average Bronze deductible is $4,300 according to Avalere Health.
More than two-thirds of Silver plans sharply reduce the number of hospitals in their provider networks over typical employer plans according to a McKinsey study. That means most of the second lowest cost Silver plans––the plan the subsidy is tied to––will be a narrow network plan.
It therefore becomes a difficult decision deciding whether to buy or not buy a health insurance policy.
The Journal oddly placed the best summary in the middle of the story:
“I don’t know we’re growing the number of people with insurance here, so much as we’re just adding complexity,” said Geoff Bartsh, vice president for policy at Medica Health Plans in Minneapolis.
And since complexity generally means more cost, the insurers may not come out of their little scheme to get the government to drive new customers to them anywhere near as well as they’d hoped.


HHS official: We have no idea how many people have paid their first month’s ObamaCare premium


Of course they don’t, silly. How would they? They haven’t built that part of the site yet.
As of a week ago, Bob Laszewski’s best guess based on his chats with friends in the industry was 50 percent. The feds probably have some inkling of the actual number, not from but from trying to reconcile their data on O-Care enrollees with the data various insurers have. The whole point of building the website was to avert the need for that; someone would sign up on, they’d make payment through the site, the info and money would be automatically forwarded to the insurer, and the conveyor belt would keep moving. As it is, with glitchy files still being transmitted on the back end, both sides have to compare notes periodically via a laborious reconciliation process to make sure they have the same information. Checking payments is just one facet of that, but a long and important one — as noted in the clip, until the feds know that you’ve ponied up for your premiums, they can’t get things moving for you on subsidies.

Which reminds me: If you read only one story today about enrollees struggling with premiums, skip the stuff about the website and check out what a young Obama fan told TPMabout having to pay 300 bucks a month for his new coverage. I’m not sure what the takeaway is — that coverage under the Affordable Care Act ain’t so affordable, that young adults need to make better life choices so that they can afford the essentials, or that New York City is basically unlivable for the middle class. Other TPM readers aren’t sure either. I’m going to go with all three.

Security expert: Hackers could upload code to to take control of users’ computers


If you believe the various security professionals who spoke to Reuters, and why wouldn’t you, HHS has done next to nothing to plug the 20+ security holes they’ve been warned about since October. Including one, allegedly, that would let hackers remotely access people’s computers by uploading some sort of worm to the server.
I honestly don’t know what to believe. There’s no reason to doubt the security pros and every reason in the world to doubt that HHS equipped the site with sturdy security before rolling it out. We don’t even have to draw an inference from the overall half-assed execution of as of October 1st; remember, HHS’s own security people were waving red flags before launch day. And yet, despite endless stories about the site’s vulnerabilities and high-profile testimony by security experts before Congress in November about just how bad things are, there have been no major breaches to date.

That we know of.
Hackers could steal personal information, modify data or attack the personal computers of the website’s users, he said. They could also damage the infrastructure of the site, according to Kennedy, who is scheduled to describe his security concerns in testimony on Thursday before the House Science, Space and Technology Committee…
Kennedy said he last week presented technical details describing the vulnerabilities in the site to seven independent cyber security experts, who reviewed videos of potential attack methods as well as logs and other documentation…
“The site is fundamentally flawed in ways that make it dangerous to people who use it,” said Kevin Johnson, one of the experts who reviewed Kennedy’s findings.

Johnson said that one of the most troubling issues was that a hacker could upload malicious code to the site, then attack other users.
“You can take control of their computers,” said Johnson, chief executive of a firm known as Secure Ideas and a teacher at the non-profit SANS Institute, the world’s biggest organization that trains and certifies cyber security professionals…
“We don’t know how bad it is because they don’t have to tell us,” Strand said.
A contractor who’s worked with HHS counters that you can’t know how vulnerable the site is unless you’ve hacked into it, which Kennedy et al. haven’t done. Kennedy did, however, write a short bit of code to see if he could harvest any personal information about users from the site. He collected 70,000 names and e-mail addresses in … four minutes. (He didn’t hack, he claims; the information was accessible on the Internet somehow and his code accessed it.) So how do we reconcile all of this? Three possibilities. One: The security pros are simply wrong. Why they would all be wrong, though, I have no idea. Clearly the site appears to the trained eye to be susceptible to major hacking, even though there’s no hard proof. I suppose that, in the mad rush in November to patch its problems, HHS closed the security holes without cleaning up all of the code, leaving it looking somehow like the site is vulnerable when it really isn’t. Anyone buy that? Me neither.

Two: The security pros are right but hackers, for whatever reason, have laid off Maybe it’s because they don’t want to mess with the feds on a matter so visible, knowing that a highly public hack of the government’s new health-care showpiece would bring down the wrath of the DOJ upon them. Or maybe they’re just too kind-hearted to mess with a site that’s all about helping people get medical coverage. Hackers take legal risks all the time, though. And if anything, the public prominence of just makes it a juicier (and conveniently low-hanging) fruit to pick, I’d imagine. Even if most hackers are inclined to lay off, the basic dynamics of bad apples and bunches suggest that there’s at least one person out there who couldn’t resist screwing with it.
Three: The site’s been hacked and we just don’t know about it. The feds are keeping that info verrrry close to the vest, knowing that the last thing the big O-Care rollout needs after the big “it’s fixed!” publicity for in December is news of a massive security breach. They need people to keep enrolling to get anywhere close to their target by March 31st. A scare story about vulnerabilities being exploited to steal people’s data would bring things to a screeching halt, maybe even to the point of congressional Democrats peeling off lest they take any more political uppercuts from O-Care. But if that’s what happened here, where’s the evidence? There couldn’t be a huge hack of a site like this without someone, either on the inside or outside, finding out about it and leaking it, right? The hacker himself might brag about it somewhere online, unable to resist showing off his trophy. And yet, as far as I know, nothing like that has happened. No one’s offered any evidence of a wide-scale malicious security breach.
Just as I’m writing this, I see the AP has a story on the wires about one of the CMS officials who waved a red flag before launch now pronouncing the site safe. Apparently, it passed a security test just recently — and yet here’s Kennedy and crew telling Reuters it’s a disaster. What’s going on here?

‘Nothing to see here’: DC’s Obamacare exchange website still glitch-plagued

Points of order about the ‘huge surge’ in Obamacare enrollment numbers

By Doug Powers  •  January 14, 2014 11:47 AM
**Written by Doug Powers
The Obama administration continues to stuff rolled-up socks down the front of the ACA enrollment trousers for artificial enhancement of the numbers, and much of the mainstream press can always be counted on to help them sell the claimswithout question:
What the administration isn’t passing along (or the media in many cases fails to demand from them) is how many of those “enrollments” have actually paid and are covered:
Heidi Moore, U.S. finance and eonomics editor at The Guardian, tells us in the accompanying video that Obamacare has a two-step sign up process — applicants sign up through the government-run exchanges, but then have to connect with the insurance companies separately to pay.
“A lot of people aren’t taking that second step,” explains Moore. “They’re not going to the insurer because they’re not fully informed. Insurers are finding they’re ending up with a lot more applications than payments. [At the end of last week and into this week] if those insurers don’t receive their payments, the people who spent all that time signing up won’t be covered at all.”
Naturally the people who haven’t paid are being lumped into the “covered” number. What’s the real number of people who are actually covered? We won’t find out before this year’s election, that’s for sure.
Also, the Affordable Care Act is so “affordable” that 79 percent of those who have purchased a plan are receiving financial assistance. So, if you opposed Obamacare from the start, the new promise is “if you don’t like somebody else’s plan, you get to pay for somebody else’s plan.” And that promise will not be broken.
Yesterday, Kathleen Sebelius had this piece of disingenuous information:
I’m happy to report that today’s enrollment show great progress nationwide—more than 6 million are covered: 

Obamacare Enrollment Explained In Three Charts

Tyler Durden's picture

By now the distinction that "enrollment" in Obamacare does not actually mean coverage should be painfully clear: one still has to pay, and according to a recent analysis up to 50% of "enrollees" in any given state have not paid, which means the White House's number of 2.1 million sign ups through December 28 is vastly overstating the reality (especially if one ignores the 5+ million of torn up, lost insurance policies as a result of Obamacare). But even if one clearly delineates what is meant by "enrollment" in the most epic failure of a ponzi scheme to ever emerge from a developed nation (with a recently disclosed penchant for Big Brother-yness), what conclusions can one draw about the current participants in obligatory, socialized insurance as most recently disclosed by the administration? Here is the summary:only 24% of all new insured are in the targeted 28-34 age group; only 21% of participants will get no subsidy (which means 79% will be subsidized), and finally more women (54%) than men have signed up.
The above in charts, with commentary from Bloomberg:
About 30 percent of new enrollees are under 35. White House officials say that’s an acceptable mix, and they expect more young people to come on board closer to the March 31 deadline. “We think that more and more young people are going to sign up as time goes by, based on the experience in Massachusetts,” Gary Cohen, deputy administrator at the Centers for Medicare and Medicaid, said on a conference call with reporters. “We’re actually very pleased with the percentage that we have right now, and we expect that percentage to increase.”
Most of the people who bought coverage on the exchanges this fall got subsidies to help them afford the premiums. That’s in contrast to the first month of the program, when less than one-third of buyers were subsidized. People earning up to four times the poverty rate—as much as $96,000 a year for a family of four—can get help buying coverage.
The numbers released today don’t count people who bought health plans off the exchanges. Given the website’s technical problems, people buying insurance who earn too much for subsidies may have bypassed entirely and purchased plans from brokers or directly from insurance companies. The government doesn’t yet have data on how many people got coverage directly.
Under Obamacare, insurers can’t charge men and women different rates—or, as Health Secretary Kathleen Sebelius put it, “Starting in 2014, being a woman is no longer a preexisting condition.” That generally resulted in lower prices for women compared with insurance markets where underwriting by gender is allowed, so it’s not surprising women signed up in greater numbers.

Uh oh: Just 24% of ObamaCare sign-ups so far are young adults


HHS was aiming for … 39 percent, notes Philip Klein. As you know, the fewer “young healthies” there are on the exchanges to subsidize expensive treatments for sick people with their premium dollars, the less sustainable those exchanges become. HHS has two and a half months left to hit its target, but as Klein notes, if you assume five million total enrollments by March 31st, fully half at this point would need to come from young adults to hit the 39 percent threshold.
Which is to say, your premiums are probably going up next year. But you knew that.
People signing up for health insurance through the Affordable Care Act’s federal and state marketplaces tend to be older and potentially less healthy, officials said Monday, a demographic mix that could cause premiums to rise in the future if the pattern persists…
“We’re pleased to see such a strong response and heavy demand,” said Kathleen Sebelius, the secretary of health and human services. “Among young adults, the momentum was particularly strong.”
Officials for the first time released basic demographic information about the people signing up for insurance. Of those who signed up in the first three months, 55 percent are age 45 to 64, officials said. Only 24 percent of those choosing a health insurance plan are 18 to 34, a group that is usually healthier and needs fewer costly medical services. People 55 to 64 – just below the age at which people qualify for Medicare — represented the largest group, at 33 percent.
No surprise, really. Humana, an insurance giant, warned last week that it “expects the risk mix of members enrolling through the health insurance exchanges to be more adverse than previously expected.” If their numbers are tilting old and sick, everyone else’s must be too. Two obvious caveats, though. One: There’s every reason to expect a crush of enrollments from young adults before the March 31st deadline. Most sick people will have already signed up by then and there’ll be renewed media coverage about the mandate penalty in the weeks approaching deadline. As word trickles out through the mostly ignorant target population, some chunk of young adults will respond by signing up at the last minute. The demographic mix will get better. So much better as to hit 39 percent, though? Two: According to experts, missing HHS’s target of 39 percent enrollment by “young healthiest” wouldn’t be a total disaster. According to Kaiser, a 25 percent enrollment rate would drive costs up for insurers by 2.5 percent but would still give them a narrow profit margin. (Another expert thinks costs would increase 3.5 percent under that scenario, which means insurers really need something closer to 30 percent enrollment by young adults.) That’s bad news for you and me, since we know who’ll be on the hook for those costs, but nothing so dangerous to the industry that it would jeopardize its stability.
Bob Laszewski, meanwhile, takes a long-term approach to this problem. The important number isn’t enrollment as of March 31st, he says, it’s enrollment as of, say, 2016. That’s when the “risk corridor” (i.e. bailout) provisions of O-Care sunset and that’s when we’ll really know if the law’s sustainable without federal largesse.
I think we’re going to ultimately need about 20 million people for a sustainable pool. It doesn’t need to be this year. That’s what the transitional risk corridors are all about. But it needs to happen in the first few years. So when I hear people talk about the goal being seven million, I think, “time out.” This needs to be 20 million people within three years.
The problem with the enrollments today is that they’re so small, it’s less than 10 percent of the uninsured coming in, it really can’t be anything but sick people. So if it’s going to be sustainable you need loads of people coming in the door. So when I judge where Obamacare is on December 31st or March 31st, I want to have confidence that this thing is ramping up to 20 million. I want to see momentum.
They’ve signed up a little more than 500,000 young adults so far. If Laszewski’s right about a pool of 20 million uninsured to make this thing float, that means the feds need more than seven million more “young healthies” over the next three years. He thinks the individual mandate has been so weakened that it’s destined for waiver or repeal, but I don’t know: The more desperate the White House gets for young adults to sign up, the more it’s going to want that mandate bludgeon to keep the pressure on them to sign up. (The mandate penalty becomes considerably more expensive starting next year, remember.) There’s no political class in America that can be taken for granted as easily as young voters. Why do them a favor by lifting the mandate?
Another good question:
HHS still hasn't released # for those who paid. Is it possible those who haven't paid yet are younger, meaning 24% is inflated?

As of Thursday, Laszewski was hearing from industry sources that only 50 percent of new enrollees have paid so far. It’s true that some insurers have pushed their payment deadlines back to the end of the month to give people more time, but not all have — and if we’re still at 50 percent a third of the way through, how many can we reasonably expect will make good on their first month’s premium by the end of the month, realistically? Maybe 85 percent? 90? If the latter, we’re talking about more than 200,000 people nationally who’ll have missed the payment deadline, which means insurers will then have to decide whether to extend the payment deadline into February(!) or start canceling coverage for new customers they’d much rather keep. And all of that is on top of sorting through glitchy applicant data from, which Laszewski estimates still represents roughly five percent of total online applications. January’s going to be a long month.

HHS IG reports Medicare paying far too much for … penis pumps


Say, isn’t this the kind of nonsense the IPAB is supposed to prevent? Unless Medicare is saying that penis pumps are totally effective, of course:
Taxpayers paid nearly $175 million for vacuum erection systems (VES), commonly known as “penis pumps,” from 2006 to 2011, according to an inspector general report released on Monday.
And if it’s not bad enough that taxpayers paid for these systems, they also overpaid for them as well:
The federal government paid more than double the retail price for VES, the Department of Health and Human Services IG found. Medicare prices for the systems, the report said, “remain grossly excessive compared with the amounts that non-Medicare payers pay.”
Medicare paid 473,620 VES claims during calendar years 2006 through 2011, according to the IG report.
Frankly, I’m surprised that I’m the first one at Hot Air to grab this story from Lachlan Markay at the Washington Free Beacon. It’s got great potential for a series of double-entendres. Not to inflate anyone’s expectations, of course, but if this post lasts longer than four hours, please consult our website administrator. Lachlan himself notes that “Medicare payments for VES [vacuum erection systems] have swelled in recent years.” Groan.
On a more mature level, this calls into question the entire assumption that government can control costs through central command. The IPAB, authorized within the ObamaCare law, would have the authority to deny payments for services and devices, which Congress would have to override with supermajorities. In this case, though, Congress explicitly granted HHS the authority in 2000 to reduce the reimbursements for VES in an attempt to reduce taxpayer bills for the systems. HHS then authorized CMS to take action … which it never did.  Call thatregulatus interruptus.
Are these devices effective treatment for erectile dysfunction? Perhaps, but only for a limited range. Then again, Viagra and Cialis are effective as well, but few if any insurance plans cover those. Unlike birth control medication (in its primary use), VESs and Viagra treat actual physical ailments but mostly remain elective and outside of insurance coverage. Why Medicare pays the bills for these devices is a question some taxpayers might want to ask, but even apart from that, this story says a lot more about regulatory dysfunction than it does about erectile dysfunction. Anyone who believes for more than four hours that the massively complex ObamaCare regimen will decrease that dysfunction and produce more rational outcomes should consult a head doctor immediately.
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WaPo: Get ready for the second wave of ObamaCare market disruptions


Over the weekend, it seems as though the national media finally figured out what most ObamaCare critics have predicted all along.  On Friday night, the New York Times covered the mess made by the law’s incompetent implementation with providers and insurers, leaving consumers holding the bag.  By Saturday night, the Washington Post had deduced that this was just the entrée. A much bigger wave of disruption will hit when the employer mandates go into effect for 2015 (via Instapundit):
When millions of health-insurance plans were canceled last fall, the Obama administration tried to be reassuring, saying the terminations affected only the small minority of Americans who bought individual policies.
But according to industry analysts, insurers and state regulators, the disruption will be far greater, potentially affecting millions of people who receive insurance through small employers by the end of 2014.
While some cancellation notices already have gone out, insurers say the bulk of the letters will be sent in October, shortly before the next open-enrollment period begins. The timing — right before the midterm elections — could be difficult for Democrats who are already fending off Republican attacks about the Affordable Care Act and its troubled rollout.
Golly, who could have predicted that? Well … we did. Politico even reported on it a month ago. Didn’t the Post try connecting the dots when HHS delayed the employer mandate to mid-November of this year rather than the first of October in a futile effort to delay the effect until after the midterms?
Oh, and by the way — we found out three months ago that HHS predicted this effect in 2010, shortly after the ObamaCare bill passed in Congress.  Somewhere between 40% and 67% of people who have existing group insurance plans will lose them, which may mean as many as 93 million Americans will get thrown out of their existing insurance this fall, Avik Roy reported at the time for Forbes:

“The Departments’ mid-range estimate is that 66 percent of small employer plans and 45 percent of large employer plans will relinquish their grandfather status by the end of 2013,” wrote the administration on page 34552. All in all, more than half of employer-sponsored plans will lose their “grandfather status” and get canceled. According to the Congressional Budget Office, 156 million Americans—more than half the population—was covered by employer-sponsored insurance in 2013.
Another 25 million people, according to the CBO, have “nongroup and other” forms of insurance; that is to say, they participate in the market for individually-purchased insurance. In this market, the administration projected that “40 to 67 percent” of individually-purchased plans would lose their Obamacare-sanctioned “grandfather status” and get canceled, solely due to the fact that there is a high turnover of participants and insurance arrangements in this market. (Plans purchased after March 23, 2010 do not benefit from the “grandfather” clause.) The real turnover rate would be higher, because plans can lose their grandfather status for a number of other reasons.
How many people are exposed to these problems? 60 percent of Americans have private-sector health insurance—precisely the number that Jay Carney dismissed. As to the number of people facing cancellations, 51 percent of the employer-based market plus 53.5 percent of the non-group market (the middle of the administration’s range) amounts to 93 million Americans.

Even now, the Post is hedging its bets a bit:

The transformation of the small-group market is just one of the many ripple effects of the Affordable Care Act that will reshape the insurance industry in coming years. With millions of previously uninsured people getting coverage, the insurance industry’s business model is being upended, and that’s leading to changes involving all sorts of products, not just those sold through the online marketplaces to individuals.
The impact of cancellations in the small-group market is expected to be less dramatic than in the individual market, partly because a higher percentage of small-business policies provide more generous benefits. Still, the changes being made by the insurance industry are leaving some small-business owners confused and disillusioned about the law — whether it is directly to blame for the changes or not. …
Now that insurers aren’t able to charge more to people with preexisting conditions, companies with sicker workers may see lower premiums, while those with a healthier workforce may see higher premiums. Many small businesses are also discovering that the new plans have more restrictions on access to specific doctors, hospitals and prescription drugs.
The reason, said Robert Zirkelbach, a spokesman for America’s Health Insurance Plans, the industry’s main trade group, is that the law requires small businesses to purchase coverage that is more comprehensive than what some buy today, and that drives up costs.

In other words, the law is to blame for those cost hikes, thanks to the coverage mandates and price-fixing on riskier consumers. That will mean a lot of businesses opting to dump coverage — and a lot more Americans having to navigate the much more expensive individual exchanges for coverage, and probably a lot more of those opting to pay the fine and forget it. If you think this month is “disruption,” you ain’t seen nothing yet.