Monday, March 27, 2017

Let Me Help You To Hurt Me

You never write about medical issues. Why don’t you ever talk about heart conditions or even cancer other than yours? How about the latest prescriptions? You never cover any of them in your blog.

This is Health INSURANCE Issues With Dave. This blog covers health insurance, an organized method of compensating medical providers. It is not about health. In fact, our system has never been about your health.

Blue Cross was created in 1929 as a way to prepay days in the hospital. Blue Shield soon followed to prepay for the services of doctors. Health insurance, pooled risk and shared responsibility, was also created in the 1930’s to cover medical expenses. Congress gave us Medicare in 1965 to help pay for the medical bills of the elderly. And even Medicare Part D (Rx) was designed, in part, to cover the high cost of prescriptions for senior citizens. The focus has never been on health, just the COST of health care.

The Patient Protection and Affordable Care Act (PPACA) was passed in 2010 to provide health insurance for every American. That was the goal. The combination of expanding Medicaid, tax credit subsidies, and the elimination of medical underwriting was supposed to remove every obstacle from our country achieving universal coverage. That didn’t happen. We have fewer people uninsured, but there have been significant problems with the PPACA.

Last week the Republicans attempted to pass the American Health Care Act (AHCA). This was a first. For ninety years we have tried to find better ways to pay for health care. This law wasn’t about that. Trumpcare’s only goal was the repeal of Obamacare. The vote was scheduled on the seventh anniversary of the passage of the PPACA to emphasize the point.

This blog reviewed the original AHCA when it was first released a couple of weeks ago. This half-baked compilation of grudges and campaign rhetoric found few friends outside of the party leadership. Governors and members of Congress of states that had expanded Medicaid worried about the citizens who would lose coverage. The absolutists on the far right, the Freedom Caucus, derided the bill as Obamacare-light. Last week President Trump, Speaker Ryan, and various Congressmen negotiated the dismantling of consumer protections and coverage guarantees. But it wasn’t enough. With nowhere near enough votes for passage, both Trump and Paul Ryan now each claim responsibility for pulling the bill. Neither could have afforded another embarrassing defeat.

And who did Trump blame for his failure to repeal Obamacare? The Democrats!

The Republicans have been beating the Democrats over the head with a baseball bat for the last seven years. The bat broke on November 8, 2016. President Trump is mad that the Dems didn’t buy him a new bat.


Tuesday, March 14, 2017

It Should Be My Choice

I want more choices.

Damn Right!

The government limits what I am allowed to buy. It isn’t up to Washington to tell me what I need.


All those extras just add to the cost.

Yes, make it cheaper.

I’m tired of the nanny state. Too many politicians are butting in. They are taking money out of my wallet. Let me make my own decisions. I want more choices.

I’m with you.

Yep. I’m going to call my Congressman and demand change.

Me, too.

I’m tired of Washington adding thousands of dollars to the price of a car. I don’t want to pay extra for air bags. Seat belts are a waste of my money. I never wear them. Man, there’s a bunch of stuff like this. Anti-lock brakes? Really? I want to get rid of all this unnecessary crap and get a better price on my next car.

Cars? I thought you were talking about health insurance.


When Tom Price, Secretary of Health and Human Services (HHS) says that he wants Americans to have more choices what he is really saying is that the current policies are too expensive because they are too comprehensive. Americans no longer have the opportunity to purchase inadequate health insurance policies. All policies are now required to cover the ten Essential Health Benefits (EHB). Which of the following would you like to leave off your next policy? Are you sure?
  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Pregnancy, maternity, and newborn care
  5. Mental health and substance use disorder services
  6. Prescription Drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services
  10. Pediatric services
How could you know that you’ll never have cancer or a chronic back problem? Which benefits can you eliminate? The easy one is maternity. How much does a 60 year old pay for maternity? About the same amount as a 22 year old pays for prostate cancer. The truth is that you can’t make an informed decision. You can’t guarantee that you will never suffer from depression or get hooked on opioids after major dental work. And none of that really matters because it assumes that you would be making these choices with your eyes wide-open and know exactly what types of coverage you would be eliminating. You won’t.

This whole push to get policies sold across state lines is about removing care. Ohio, for example, recently passed legislation guaranteeing coverage for the treatment of autism. That is a Republican governor, a Republican controlled senate, and a Republican controlled house voted to grant this benefit for all of Ohio’s children. Tom Price wants you to have the opportunity to purchase a cut-rate policy from Tulsa based Shaky Ground Mutual. Minnesota may be leading the way towards the new, useless policies. More importantly, it won’t be until you go to the doctor that you will find out that your child’s autism or your cancer isn’t covered.

It may be difficult to read today’s heavily regulated health insurance policies, but these have much less fine print and legalese than what we used to provide. Remove the regulations and we immediately return to the gobbledygook of the past. If locked doors keep honest people honest, than regulations are the locked doors that protect the consumer from our insurance providers.

Please don’t confuse this post as a full-throated endorsement of the Patient Protection and Affordable Care Act. It is not. The PPACA is a badly written law that needs significant changes if it ever has a chance to succeed. Most of our representatives in Washington know this. That’s not repeal. That’s repair.

Will the Republicans overcome their obsession with our last president and choose to do what’s in the country’s best interest? I don’t know. It is the one choice they didn’t want.




Wednesday, March 8, 2017

Our New Law Is Better Than A Poke In The Eye With A Sharp Stick

Our friend Paul inherited a car. It only had a few miles and still had that new car smell, but it wasn’t brand new, it wasn’t the exact car Paul wanted, and he hated the color. Paul despised the car. The Check Engine light came on as Paul took the car out for his first drive. He cursed the car and threatened to drop it off at the junk yard. He didn’t fix the problem. He never even looked to see why the idiot light was on. Paul continued to drive the car without bothering with routine service after other warnings lit up his dashboard. The Check Oil light had only elicited more curses and more threats of the compactor at the junk yard. But no matter how badly Paul abused the car, the damned vehicle started every day and managed to get him wherever he needed to go. Now, a couple of years into Paul’s ownership, the car is starting to stall and it has difficulty going up hills. Paul is telling everyone that this car, this worthless piece of garbage, needs to be replaced. And that is our friend Paul Ryan’s relationship with Obamacare.

The Chairman of the House Ways and Means Committee, Kevin Brady (R-TX), introduced the Republican alternative to the Patient Protection and Affordable Care Act (Obamacare) yesterday on TV. His main thrust was that Obamacare is failing, a disaster, and that the Republicans have to do something. Anything would be better! And to test that theory we have the American Health Care Act.

Seven years in the making! And, as White House Press Secretary Sean Spicer was quick to point out yesterday, the American Health Care Act is only 123 pages as opposed to the PPACA that is a whopping 974. That alone makes it a better law.

There will be any number of analyses published over the next week. My peers and I have received countless calls and emails about this first stab at (in) replacing Obamacare. Before we spend too much time on this, we need to acknowledge that there are serious divisions within the Republican Party and that much of this will be changed. Senators from states that expanded Medicaid have no interest in explaining to the folks back home why they lost their health care. Congressmen on the conservative fringes have had the luxury of passing bills that could never become law. They have no interest in supporting anything that might even appear to be pragmatic. So no, don’t get too worked up about the American Health Care Act. Senators like Bill Cassidy (R-LA) have already declared it DOA.

A more relevant question may be whether this is a serious piece of legislation or simply one more opportunity to pander to the Republican base. Both Congressman Brady and Congressman Ryan suggested that the public should read the law. Part of this is bluff. They are hoping that the average American’s eyes glaze over while reading the highlights on the lead page. News organizations, researchers, and the author of this blog accepted their challenge.

Let’s explore priorities. Health care is almost 20% of the U S economy. Any replacement of the PPACA would have to provide for the seamless transfer of one payment system for health care to another. Billions of dollars (and millions of lives) are at stake. So the Republican bill would have to address all of these issues thoughtfully, carefully. How did they do?

The first issue, the most important task of this legislation, appears on Page 2. Yes, before we can tackle the individual mandate, preexisting conditions, or even Medicaid expansion, the first thing we have to do is defund Planned Parenthood. The AHCA goes to great pains to describe Planned Parenthood without mentioning it by name. It isn’t till the bottom of Page 4 that we move on to Medicaid.

Much has been made of the possible changes to Medicaid. The simple explanation is that the states that expanded Medicaid would have to do more with a lot less. The real pressure points are 2020 and after which at first seems far away, but is actually less than 3 years till implementation.

Our next section dealt with the payments that hospitals receive for uncompensated care (DSH). The idea is to improve access for the uninsured and Medicaid patients. These payments were reduced due to the anticipated success of Obamacare. The goal was to have everyone insured. The AHCA reinstates the payments.

On Page 10 we arrive upon the other issue that appears to have been keeping Speaker Ryan up at night. The next 7 pages deal with preventing lottery winners from accessing Medicaid. Seven! This change should guarantee that our budgets will now be balanced.

The next few pages guarantee that states aren’t forced to pay for aliens (international or intergalactic) and how home equity loans impact Medicaid qualifications. By Page 25 we get to Medicaid funding which kills another 20 pages. On Page 45 we finally get to Subtitle D – Patient Relief and Health Insurance Market Stability, a nine year $100 billion funding mechanism to the states to expand coverage options. Finally, some meat.

The rest of the document details which taxes are to be repealed, which repurposed, and which just simply delayed till someone else is in office. The individual mandate is eliminated in favor of a different penalty for opting out of coverage. Older adults are charged higher premiums with the hope that young, healthy individuals will sign up in droves and make the system work. And, of course, there are a number of favors included to make some donors happy such as the repeal of the tanning tax and the reinstatement of the deduction for insurance executive compensation.

The media, both right and left, will hit the high points. And more importantly, most of those points will be the ones debated and changed in the weeks/months to come. I wanted to focus on the issues that the Ways and Means Committee thought were most important, the issues that they hit first. There is one other issue that I thought was unusual. Section 6, about 80 pages or so into this bill, repeals the employer mandate, the rule that forced employers with more than 50 employees to provide health insurance as of December 31, 2015. Not the end of last year. Not the end of this year. Obviously, one of the Congressmen has a very important constituent who didn’t bother to cover employees in 2016. Perhaps Chairman Brady? Gosh it is always great to know a Congressman. Heck, it is better than a poke in the eye with a sharp stick.