Friday, July 21, 2017
Today’s Health Insurance Issues With Dave is a short quiz. Grading is Pass/Fail.
You find that you are going the wrong way on Gates Mills Boulevard. Do you
A. Turn around in the first available driveway
B. Turn at the first intersection or median cut-through
C. Push the Detonate button and blow-up your car
D. A or B whichever comes first
If you chose A, B, or D, please forward your copy of this quiz to your Congressional representative. The subject line should be Healthcare. If you chose C, you may already work in Washington.
Monday, July 10, 2017
Need a surgeon? Would you consult Dr, Jack the Ripper? Would you hire Godzilla for your next construction project? And yet, we have entrusted our healthcare system to Paul Ryan, Mitch McConnell, and Donald Trump. What could go wrong?
The U.S. Senate is about to return from their latest vacation. The push is on. Senate Majority Leader Mitch McConnell is determined to get his legislation, the Better Care Reconciliation Act of 2017 (BCRA), passed before their next vacation, the August recess. Faster legislation, but not necessarily good legislation.
Health insurance is regulated on both the federal and state level. Our elected officials in Washington and Columbus have been very busy. Some of their focus has been on tax cuts, election nullification, and sabotage. And every once in a while, when they have nothing better to do, they put some effort towards solving problems.
A key element of the Patient Protection and Affordable Care Act (Obamacare) is the Individual Mandate, the requirement to purchase insurance. This blog and numerous other published articles have noted that the Individual Mandate traces its roots to the conservative Heritage Foundation over twenty-five years ago. The logic is simple – If we are going to offer health insurance to all Americans and cover preexisting conditions, we must have everyone participate.
You can’t fund a healthcare system if only the sick and the responsible are participating.President Trump and Congress are actively sabotaging the system. As previously discussed, Mr. Trump’s first Executive Order directed federal agencies to “waive, defer, grant exemptions from or delay the implementation of the Act…” And with that the IRS stopped holding tax returns that didn’t include proof of insurance coverage. Enforcement became optional. But that isn’t enough for Congress.
The New York Times recently reported that a bill is moving through Congress that would prevent the IRS from enforcing the Individual Mandate. Why leave anything to chance? With the replacement bill floundering and Obamacare, by default, looking better every day, it is important to the Republicans to harm PPACA any way they can. Every healthy person that chooses to not purchase coverage is a future rate increase for everyone else.
* * * * *I’ve left the message on our system. Every comment on this blog is appreciated. He had given his response a lot of time and thought, so much that he wasn’t able to call my office until 10:30 on a Saturday night. He was careful to mask his number to evade the caller ID but, oddly enough, forgot to leave his name. My reader wanted me to know how much he respected President Trump and that my opinion wasn’t appreciated, though he didn’t use those exact words.
Monday, July 3, 2017
At some point we have to ask, “Where the Hell are we going?” Seriously, we have a couple hundred Congressmen and 50-60 Senators gambling with 20% of our economy and people’s lives in an effort to negate the 2008 and 2012 elections. And leading the charge is a guy so obsessed with his predecessor that he would sign a bill mandating daily doses of arsenic if he was told that it would reverse an Obama achievement.
The Patient Protection and Affordable Care Act (Obamacare) was passed in 2010 after months of Congressional hearings, public meetings, and debate. The final law borrowed heavily from Republican plans pushed by The Heritage Foundation, Newt Gingrich, and Mitt Romney. It was not the traditional Democratic plan focused on either a Single Payer or Public Option. Like all compromises, there was plenty to love and lots to hate in the PPACA. But the legislation’s intention was to give every American access to affordable healthcare.
Obamacare fell short of its goal.
What is the goal of the American Health Care Act (AHCA)? What is the goal of the Better Care Reconciliation Act (BCRA)?
Both the House and the Senate bills are focused on tax cuts, Medicaid reduction, and defunding Planned Parenthood. Neither has a single provision to lower the cost of healthcare. Neither provides access for a single American. Both bill would eliminate health insurance coverage for over 20 million Americans over the next ten years.
The AHCA and the BCRA are both championed and denigrated by President Trump. It just depends on the hour. The reason is simply. He doesn’t care. He just wants a win.
On Friday Senator Ben Sasse (R-NE) revisited a different Republican option, Repeal Now – Replace Later. His website features his newly found relevance since President Trump has reversed himself and is now embracing this idea. This simplistic concept features a triumphant Republican controlled Congress repealing OBAMAcare and then, now with a clean slate, the Republicans invite the Democrats to join them to create a similar system. Yes, this is exactly like an arsonist burning down his own home and then demanding that you help him rebuild it.
There are, of course, other options. Steven Brill, author of America’s Bitter Pill, published an article last week in the Washington Post. Nine ways to really fix Obamacare is a short list of common sense solutions that advance the goals of access and affordability. There are Republican and Democratic ideas incorporated into these nine changes. It is a short article. Click here to read it.
I don’t know that there is a road to an insurance nirvana. But if there is, it certainly isn’t paved with bad intentions.
Monday, June 26, 2017
Passover is my favorite holiday. And my favorite part of the Passover Seder is the singing of Dayenu. As we list each miracle and wonder that was done for us, such as freeing us from slavery or saving us at the Red Sea, we say Dayenu. Dayenu is loosely translated to “That would have been enough for us”.
The Patient Protection and Affordable Care Act (Obamacare) was a poorly written bill. It was compromise legislation that didn’t fully satisfy anyone on the left or the right. But when asked over the last seven years what Obamacare did well, I have always cited the expansion of Medicaid. If the Patient Protection and Affordable Care Act had done nothing but expand Medicaid – Dayenu!
Destigmatizing Medicaid was the first positive step we could take as a society to help the poor and working poor. And Medicaid helps more than just the poor. It also helps the disabled and the elderly. Medicaid is our insurer of last resort, which means that an awful lot of our friends and neighbors rely on this government provided insurance.
In Greater Cleveland Medicaid coverage allows those in need access to our world-class medical facilities, highly trained doctors, and needed prescriptions. Medicaid even covers office visits which are much cheaper and more convenient than the inefficient emergency room.
The Kaiser Family Foundation has done extensive research on Medicaid. Their Medicaid utilization graph has appeared on numerous TV shows as well as in newspapers such as the New York Times and the Plain Dealer. On a national level Medicaid covers:
- 49% of all births
- 76% of all poor children
- 60% of all children with disabilities
- 64% of all nursing home residents
- 30% of all adults with disabilities
There has been excellent reporting on Mitch McConnell’s Senate “working draft”, the Better Care Reconciliation Act of 2017 (Trumpcare). Steven Koff of the Plain Dealer has delivered some of his best work. The New York Times has again proven why it is the paper of record. The “working draft” is only 142 pages. It is a quick read. Follow this link. We’re talking about the way we, all Americans, access and pay for healthcare. We are talking about nearly 20% of our economy. It is your responsibility to at least read McConnell’s plan. You have the time.
We can discuss the merits of a huge tax cut for the wealthy. We can wonder how eliminating the individual and employer mandates while retaining guaranteed issue won’t destroy the insurance market. We can go page by page through the BCRA and ask “Why?” But for today, I just want you to read the bill. And if you do that, it will be enough for me.
Friday, June 23, 2017
President Lyndon Johnson declared the War on Poverty in 1964. It was a sincere effort, but poverty persists to this very day. Senate Majority Leader Mitch McConnell, President Trump, and Speaker of the House Paul Ryan have decided that a War on the Poor is a better idea. They are weaponizing healthcare. The opening salvo was the American Health Care Act (AHCA). And yesterday, June 22, 2017, we got the working draft of the Better Care Reconciliation Act of 2017 (BCRA). The names might imply that these efforts are designed to enhance our access and payment of healthcare. A more honest name might have been Bang Bang You’re Dead.
The Senate released a “working draft”. This could be the actual bill. It could be a Trojan Horse. Since McConnell is trying to ram this through under the Senate’s rules for reconciliation, we may not know until the last possible moment.
I apologize for focusing so much on process, but that is where we must start. Leader McConnell is an incredibly cynical politician. He is a master of the game. We need to at least know some of the rules.
Under reconciliation, McConnell only needs 50 votes for a tie. Vice-president Pence would then cast the deciding vote. This “working draft” could be introduced as legislation. Debate will be limited to TEN HOURS. The Democrats would be able to introduce amendments, but debate is limited to TWO MINUTES per amendment. The Republican majority could quickly defeat all of Dem’s motions. Then, at the nine hour fifty minute mark, McConnell could introduce the actual legislation as a replacement amendment. The real bill is then passed before anyone can read or debate it.
Farfetched? Really? Have you been paying attention?
This blog will analyze the “working draft” over the next few days, but we must first focus on the process. Certain key Republican Senators and lobbyists have had advance copies of the BCRA. The first to complain weren’t Senators Portman or Collins. The first to the TV cameras to voice their disapproval were Senators Cruz, Lee, Paul, and Johnson who represent the extreme right wing of their party. They voiced opposition to the concessions made to the moderates. It feels like the fix is in.
I may see a Trojan Horse. The poor and working poor are staring at a tank.
Monday, June 19, 2017
I felt the first large drops of rain before I had managed to get in four miles. I had planned to golf, but there had been an 80% chance of thunderstorms. So I was walking. I was now in the Mayfield Village Wetlands, a mile long circle of bridges and gravel. I tried to stay on dirt and gravel paths to keep my focus on where I stepped as opposed to how far I was walking or the hot, sticky air. This particular trail was designed to be walked clockwise. I, of course, was going counterclockwise. I laughed at the thought. NO ONE WAS IMPACTED BY MY CHOICE. One path was as good as another.
Senate Majority Leader Mitch McConnell (R-KY) is engaged in a different type of exercise. He and his new best friends aren’t trying to lose a couple of pounds. President Trump, Speaker of the House Paul Ryan, and McConnell are trying to eliminate a legacy. They are not alone. There appears to be plenty of Republicans who would like to return to 2005, a time when they controlled the House, the Senate, and Bush was the president. A time before their failures. A time before Obama.
Many of their actions are petty and/or irrelevant. Then there is healthcare. For seven years McConnell and Ryan cynically fanned the flames of hatred and resentment of Obamacare, the Patient Protection and Affordable Care Act. Now it is Trumpcare and they own it.
Some paths lead nowhere. Some are dead ends.
Somewhere in Washington, behind locked doors, thirteen Republican Senators are creating the Senate version of Trumpcare. No hearings. No amendments. No debate. We are discussing how Americans access and pay for healthcare. We are talking about nearly 20% of the economy. We are talking, but they aren’t talking to us.
One of the senators is Rob Portman (R-OH). I have contacted his office about the secrecy. I have asked about specifics. What I’ve received, to date, was a form letter about his commitment to the treatment of opioid addiction. He is clear that he doesn’t support the House bill (The American Health Care Act) that doesn’t do enough to protect Ohioans dependent on the Medicaid expansion. Our governor and my local congressman, David Joyce (R-OH) have also voiced concerns.
OK, now what?
This secret bill is being cobbled together to garner 50 Republican votes in the Senate. That is all McConnell needs. Fifty, and then Vice-president Pence casts the tiebreaker. And the fate of millions of Ohioans depends on Rob Portman having more influence in the Senate than Senators Ted Cruz, Rand Paul, and Mike Lee. This dangerous path leads us to a cliff. Who are we willing to lose?
Wednesday, June 7, 2017
The coroner was ready to address the press. She stood behind the podium with its bank of microphones, looked directly into the cameras, and delivered her judgement. “The cause of death was thin skin.” Several reporters nodded in agreement. They had been predicting this would be the answer. But one journalist refused to close his notebook and felt compelled to get a clarification. “Pardon me, Madame Coroner, but you are saying that the deceased perished from thin skin?” “Yes”, she replied without even a hint of emotion. “So the 27 stab wounds had nothing to do with his death?” “Well”, the coroner replied, “if he had had stronger skin he’d still be with us today, wouldn’t he?”
There was a rumor in 1897 that Mark Twain had died. A newspaper printed an obituary. Twain’s response was “The reports of my death are greatly exaggerated”. I was thinking of this earlier today as President Trump was again telling the American public that Obamacare is imploding. It is true that our current health insurance system seems to be having difficulty breathing, but the first step might be to convince Trump to stop choking it.
Yesterday’s big news was Anthem Blue Cross and Blue Shield’s announcement to abandon the exchange market in Ohio for 2018. This was not a shock to those of us following the shenanigans in Washington. This business decision by Anthem will be spun more than a dreidel during Hanukkah, but their simple words tell the real story:
Anthem has a long history of serving individuals in our communities. Customers have grown to expect great value and access to health care coverage from us. And our desire to meet those needs has not changed. But the current regulatory climate and the uncertainty it has produced in our industry do not give us the clarity and confidence we need to commit to offering broad-based, affordable health plans for 2018. So, while we wait for new regulations to be released, we’ve made the difficult decision to reduce the number of Individual health plans we’ll offer next year.Please note that Anthem isn’t crying poverty. There are no claims of insurmountable losses. Washington seems determined to play politics with Anthem’s clients and gamble with Anthem’s money. Anthem walked. My clients have been calling all day, mostly elderly, Medicare beneficiaries who aren’t impacted, to ask what they need to do. The answer today is – NOTHING. We may need to take action in November, but there is absolutely nothing to do today.
There have been members of Congress and various Republican state officeholders who have been attempting to kill the Patient Protection and Affordable Care Act (Obamacare) since its inception. There were the 60+ votes in the House that we’ve discussed ad nauseum. There have been various law suits from red states. Some of the suits have been more effective than others. We don’t have Medicaid expansion in all 50 states, thus blocking millions of Americans from access to healthcare. Other cases involve subsidies, who gets them and how much.
CWRU Professor J. B. Silvers, the former CEO of QualChoice, published an article on January 4th of this year on MarketWatch year about the dangers of repealing Obamacare without a comprehensive plan. He returns again and again to market uncertainty. The insurers have to trust the government to not change the rules in the middle of the game. AND THEY CAN’T.
One example he (and others) cited was an initial risk reduction program built into Obamacare to defray the high cost of claims anticipated during the first three years of the program. The claims were significantly higher than anticipated, “But when the time came to pay for the risk reduction in the Obamacare exchanges, Congress reneged and paid only 12% of what was owed to the insurers.” This shortfall chased some insurers out of the market and forced those remaining to raise rates significantly last year.
And now we are in the middle of another bait and switch.
One of the lawsuits the Obama administration had been fighting was designed to eliminate a special subsidy for those Americans earning between 138% and 250% of the federal poverty level. This additional benefit not only helped to make the premium affordable, it also reduced the deductibles and out of pocket limits for these insureds. The Obama administration had won a stay while the fight went on in the courts. Trump could simply drop the fight. He has been threatening to do this for months. The insurers would be left holding the bag. This is a link to an April Forbes article on the issue. Katherine Hempstead of the Robert Wood Johnson Foundation is quoted in the article. “It probably was inevitable that the threat of cost-sharing reduction non-payment would be dangled for leverage.”
What we learn, time and again, isn’t that Obamacare is imploding. It is being sabotaged. It is under attack. And if the way we deliver and pay for healthcare, nearly 20% of our economy, suffers an untimely demise it won’t be from thin skin. I think we have to see who is holding the knife.