Sunday, May 21, 2017

Hey Nancy, Queen Me!

Paul Ryan triumphantly moved his pawn to the last square. “Hey Nancy, queen me!” His gallery went wild. He jumped out of his chair and high-fived his backers. “You da man”, his new friend, Donald Trump, shouted from the front row. It wasn’t until he returned to his seat that he noticed that his opponent had remained silent, oddly silent, throughout the celebration. But that didn’t matter to Paul. He leaned back in his chair and didn’t even bother to hide his smirk. Nancy Pelosi reached for her rook, pushed it three blocks to the right, and said “Checkmate”.

While the TV has been Trump 24/7, there are other news sources helping to bring important info to the American public. Excellent reporting from Bloomberg Politics on May 18th revealed that “the American Health Care Act, H.R. 1628, hasn’t been transmitted from the House to the Senate, according to Senate Bill Clerk Sara Schwartzman”. Confirmed by CNN, House Bill 1628, the American Health Care Act is sitting in Paul Ryan’s desk while he sweats out a Congressional Budget Office report.

The danger of creating a piece of legislation that is designed more to punch your opponents in the nose than to solve a particular policy problem is that the House can pass just about anything by a simple majority but that the Senate’s rules are a lot more complicated. The Senate’s filibuster and reconciliation rules shaped the final structure of the Patient Protection and Affordable Care Act (Obamacare). And Trumpcare will only become law if the legislation meets these same arcane regulations. And we won’t know until Wednesday, when the Congressional Budget Office releases their scoring, if the AHCA complies.

The minimal requirements are that the American Health Care Act must reduce the deficit by at least Two Billion Dollars. That removes the possibility of a Democratic lead filibuster and allows the Senate to pass legislation by simple majority. The bill must also provide the proper optics. If the CBO report comes back with too many people losing their coverage, that too could bury the legislation. The original House version had only 24 million Americans losing their coverage, not nearly enough to slow Speaker Ryan. The uninsured issue could cause real concern in the Senate, but doesn’t force the House to act. But if the deficit reduction goals weren’t met, the House will be forced to retool the AHCA and then VOTE AGAIN. President Trump and Speaker Ryan twisted an awful lot of arms to get those 217 votes a few weeks ago. Could he get them again?

The biggest problem with the AHCA isn’t that it fails to answer how all Americans can access and pay for healthcare. The biggest issue is that its starting point is the repeal and replacement of Obamacare. The goal is to eliminate President Obama’s legacy, not affordable healthcare and certainly not patient protection. There can’t be any real progress or any true bipartisan effort until our elected representatives choose to fix the existing law. There are responsible Democrats and Republicans who will privately acknowledge that there are ways to improve the PPACA that both sides could accept once the focus changes from the name to the content.

Mark Bertolini, the chairman and CEO of Aetna, was recently quoted as saying “Single-payer, I think we should have that debate as a nation”. In the attached article Bertolini describes the public/private partnership that already exists in both Medicare and Medicaid. He also notes that the insurers already run many of these programs and process the paperwork. Some are viewing this as expanding Medicare Part C, the Advantage Plans, to all Americans both under and over 65. I look at this as a direct extension of my blog post of April 2010 where I claimed that the insurers would eventually push for a single-payer type of system.

Democrats like Pelosi wanted a single-payer program in 2010. Republicans have long promoted market-based solutions such as the Advantage Plans. It is difficult to predict how soon the adults in Congress gain control of the news cycle, much less the legislative agenda. But no one wants to campaign on the value of taking access to healthcare away from Americans. Paul Ryan had a minor victory two weeks ago. Nancy Pelosi appears to still be winning the chess match.


Monday, May 15, 2017

Screaming Meemies

I visited the Senate day care center on Friday. The room was filled with Screaming Meemies. One little girl had the word Protocol on her t-shirt. She was standing in the middle of the room, hitting herself in the head with a wooden spoon. It was a big room. On the south side there were several old men in rockers with sobbing babies sitting on their laps. The old men were crying about a past that might not have ever happened. The babies were crying about a future that never will. And in one corner a child kept wailing “nobody likes me” as tears flowed down his face. “Who’s that” I asked Mitch, the facility director. “Oh, him? That’s the health care bill. We found him in a basket on our doorstep a week or so ago. Nobody likes him!”

There are days were it feels like we are all stuck in the Senate day care center. The unexpected firings and resignations, alone, could fill the daily news cycle. Add the Russians, the specter of war, and all of the questions about the economy, taxation, and regulation and we are on overload. Wouldn’t a nap sound good right now? Perhaps a vacation? But we are adults and we don’t have the luxury of allowing ourselves to be distracted. And since this is Health Insurance Issues With Dave, we are going to spend some time with that lonely unloved health care bill.

That also means that we are stuck spending more time with Mitch.

The Senate Majority Leader opened the door and brought into his chamber the bill he never wanted. He could have turned to Senators Susan Collins (R-Maine) and Bill Cassidy (R-Louisiana) who have been working for months on legislation. Both have years of experience on this issue. Or, the Majority Leader could have attempted to create a bipartisan group to draft meaningful legislation like the gang of six in 2009 that worked on the original bill. Instead, McConnell assembled 13 other Republicans, all male, who represented the full diversity of Republican thinking from Conservative to VERY Conservative.

The current fight in the Senate, in those rare moments when they can focus on something other than the President’s antics, has not been about healthcare or preexisting conditions. This being Republican legislation, the first big issue is Medicaid.

Senator Rob Portman (R-Ohio) is being portrayed as a moderate since he has expressed real concern about slashing Medicaid. The Wall Street Journal is reporting that Senator Mike Lee (R-Utah) and others are “weighing faster and steeper cuts in Medicaid”. The question is never about who is served by Medicaid and how much is really needed to provide for their care. That doesn’t appear to be relevant. The issue is strictly how soon can Medicaid funding be cut and by how much.

We might want to remember that Medicaid serves a number of communities. The schools depend on Medicaid funding to help defray the cost of educating children with disabilities. The AP quoted Kriner Cash, superintendent of the Buffalo, New York public schools. 80% of his students are low income and 22% have disabilities. The district currently receives approximately $2.5 million annually from Medicaid.

…individual student care comes with highly variable costs, especially in the case of students with disabilities.
Those costs would not be considered in a system where money is allocated on a per person basis regardless of need. And need does not appear to be relevant to our senators.

At some point our senators may resolve the Medicaid issue to their satisfaction and then move on to preexisting conditions, maternity care, and the Essential Health Benefits. Or not. The Senate may just cobble together something as unsatisfactory as the American Health Care Act, but set it up where their bill wouldn’t go through reconciliation so that the Democrats can kill it with a filibuster. That is a scenario only someone as cynical as Mitch McConnell could orchestrate.

The reporters are trying to get details about the latest Trump debacle and Senator Collins just plaintively asked if we could have just one day without chaos. There is a lot of unhappiness in the Senate day care center, but it is time for our friends in Washington to finally work across the aisle to fix the way we deliver and pay for healthcare in this country. Soon, before we all become a bunch of Screaming Meemies.






Wednesday, May 3, 2017

They Don't Need To Do A Thing

They didn’t look 74. He was reading, sitting mostly in the shade, his skin dark and leathery. And, he still had a full head of hair, though it appeared very white against his well-tanned face. His wife was still working on her tan. She wasn’t that far behind. She was filling out a yellow bikini and, like Sally, frequently moving her beach chair to catch the best rays. We talked for a few minutes before he asked my occupation. Once I said health insurance he began to ask questions.

We just got back from a week in Mexico. (Feel free to insert your wall joke here!) We talked with Europeans, Canadians, Mexicans, and lots and lots of US Citizens. World affairs dominated our conversations with the Europeans. Canadians wanted to know “What the Hell is going on?” The Mexicans seemed to politely concentrate on their culture. Americans immediately asked healthcare questions as soon as they learned that I was an agent. Thank G-d for the NFL Draft. It was my major break from shop talk.

I talked with business owners overwhelmed by changes in the group health insurance market. There were hospital workers worried about facility consolidations and closings. Republicans sought reassurance. “It is going to get better, right?” Dems seemed worried about everything. Cost? Coverage? Preexisting Conditions? Americans, now accustomed to simple answers to complex questions, wanted to know what was going to change and when it was going to happen.

There are no simple answers.

I left for vacation as the Republicans struggled with their amended American Health Care Act (Trumpcare). In a rush to accomplish something/anything within the first 100 days of this term, a stab was made at both healthcare and at the budget. Neither got done. Nothing changed while I was gone. There was a lot of grandstanding in Washington and Harrisburg. Lots of angst everywhere else.

There are Congressmen on TV declaring that the new, new, new plan still doesn’t protect their constituents with preexisting conditions. Other Congressmen are pooh-poohing the issue. And the President is unclear, at best. Worse, all of these elected officials are Republicans. Somehow the Democrats have extricated themselves from this circular firing squad. Would that the American people were so lucky.

Today is Wednesday, May 3rd. The President and Vice-President are busy twisting arms and begging for votes. They hope to have a vote tomorrow afternoon. Why? Surely it isn’t because they have a solution. Trump needs a victory. The Republican controlled Congress needs to prove that it can pass a bill.

The current sticking point appears to be preexisting conditions. The MacArthur Amendment appears to open the door to shuttling the sick to an insurance Siberia of underfunded high risk pools. According to FamiliesUSA, there was a fund of $13 billion per year for ten years to help protect high risk individuals from higher premiums. An additional $8 billion dollars was dumped in yesterday to help make the final push for approval. That isn’t $8 billion per year. No, that is $800,000 per year, essentially no change at all.

We have already seen what happens when you underfund high risk pools. Over 30 states tried one version or another prior to the Patient Protection and Affordable Care Act (Obamacare). Even the PPACA had a high risk pool to help during the transition. The $5 billion dollar fund quickly evaporated.

Conservatives James Capretta and Tom Miller tackled this issue in the Spring 2010 edition of National Affairs. They lay out a compelling argument for high risk pools and a well-regulated insurance market. They also call for reasonable funding - $15 - $20 billion per year. That was in 2010. The current bill calls for less money, not more. It also calls for less regulation. It is a recipe for disaster.

The elderly couple on the beach asked if they should finally purchase a Medicare Supplement. I took a few minutes to explain the basics of Medicare Part A and Part B, the drug benefits of Medicare Part D (Rx), and even Medicare Advantage Part C. That’s when their faces lit up and they remembered that they had advantage plans through UnitedHealth Care. I confirmed that their coverage was working for them and congratulated them on the choice. They are lucky. They don’t need to do a thing.

If you are under age 65, you aren’t that lucky.



Picture by David L. Cunix