Just Politics?

Otto von Bismarck is credited with “Politics is the art of the possible, the attainable — the art of the next best”.  The goal is not to posture and make noise.  The goal is to govern and get things done.  As in any art, there are greats, near greats, and others.  The US government is a huge stage.  The greats shine.  The near greats and others are exposed.

I spent a good part of today slogging through the 393 pages of H.R. 6800, the HEROES Act.  The US House of Representatives passed this bill on May 15, 2020.  There is a talent to drafting legislation, to knowing your goals and working through the various previously passed laws to get to your desired results.  The bill, like all Congressional bills, has any number of items which any of us could disagree.  Legislation produced by either the House or Senate are starting points.  The final legislation is produced in the conference committees that work out the final details.  The House got their work done on May 15^th, over two and a half months ago.  The Senate couldn’t generate its bill by its own deadline of last Thursday.  There is way too much disagreement within the Republican ranks and President Trump and his team seem to have different goals.  A Republican compromise was released this week.  It was DOA.   Senator Lindsey Graham (R-S.C.) is prepared to immediately jettison one the White House’s priorities, a billion dollar plus new FBI building and has guessed that over 50% of the Republican Senators would vote against their own opening gambit.  There is no Senate bill.  The basis of all future negotiations will be the HEROES ACT.  So let’s take a look.

H.R. 6800 impacts almost all Americans.  Since this in Health Insurance Issues With Dave, we should take a look at a few of the provisions specifically relevant to health insurance.

• Provide significant funds to the Center of Medicare and Medicaid Services for Program Management dealing with coronavirus on the state level
• Create a Special Enrollment Period for individuals over and under age 65
• Allow the government to pay for COBRA for those impacted by COVID 19
• Modify and expand the Paycheck Protection Program
• Increase the flexibility and carry-over provision of the Flexible Spending Accounts (FSA)
• Relax the employer filing requirements of certain employer/insurance forms
• Eliminate cost-sharing for COVID 19 treatment
• Provide funding and establish requirements for COVID-19 testing and contact tracing
• Require employers to develop and implement infectious disease exposure control plans

Details?  It is probably best to look at this as just part of a starting point.  Negotiations will begin in earnest in the next day or so.  Millions of Americans are dependent on state based unemployment insurance and the extra money provided by the federal government.  That is currently $600 and set to end this week.  The Heroes ACT extends the $600.  The current Senate offer is $200.  Again, this extra money ends in a few days.  That may be the main focus of this week’s talks.  The rest, such as FSA flexibility and COBRA funding, will fall into place.  This blog will report the results as available.

But if you are unemployed, if you are trying to determine how to pay for your COBRA health insurance, this isn’t politics and the art of the possible.  This is money and the key to survival.

DAVE

www.cunixinsurance.com

Picture – Grand Masters – David L Cunix

Picking Your Battles

Senator Claire McCaskill (D-MO) knew that she was going to have a tough reelection race.  It was 2012 and Missouri had taken a turn to the right.  Mitt Romney was going to beat President Obama.  The key would be to choose her opponent.  Knowing his weaknesses, Senator McCaskill chose Representative Todd Akin and helped his campaign.  It has been eight years and many of you still recognize his name and his statements about “legitimate rape”.   McCaskill picked her battles and won the war.

This blog has detailed the Obama administration’s decision to include birth control pills, IUD’s, and the Morning After Pill as part of the Preventive Care Benefit of the Patient Protection and Affordable Care Act (Obamacare).  The first of close to a dozen posts about this issue was More Free Stuff which was posted on July 24, 2011, almost nine years ago.  To be clear, I was not then nor am I now personally opposed to these forms of birth control.  This is not about my personally held beliefs.  Nor do the inclusion of or opposition to these birth control methods have much to do with medicine, insurance, or health care.   This is a battle over control and religion.  Kathleen Sebelius, then the Secretary of Health and Human Services (HHS), picked this battle.  And she won the war, until this week when the war was lost.

The Supreme Court decided in a 7 – 2 vote this week that businesses could limit or exclude coverage for birth control under religious or moral grounds.  The case, Little Sisters of the Poor Saints of Peter and Paul vs. Pennsylvania, was nine years in the making.  Chief Justice Roberts has expressed his frustration in having the birth control issue making its way to his court again.  He couldn’t understand why the two sides couldn’t find a way to accommodate each other’s beliefs and needs.  I am personally shocked that the Chief Justice would actually expect either side to want to accommodate the other, much less make an honest effort at accommodation.

The Obama administration proposed a compromise in February 2012.  The impacted employers wouldn’t have to pay for birth control.  The employers could opt out and the insurance companies would front the cost.  As noted in my post of February 13, 2012:

Senator Roy Blount (R-MO) quickly released a statement via email.  It stated, in part:
“It’s clear that President Obama does not understand that it isn’t about cost – it’s about who controls the religious views of faith-based institutions.  President Obama believes that he should have that control.  Our Constitution states otherwise.
Just because you can come up with an accounting gimmick and pretend like religious institutions do not have to pay for the mandate, does not mean that you’ve satisfied the fundamental constitutional freedoms all Americans are guaranteed.”

A year later in the post The Great Imposition, February 11, 2013, we learned that there were people who weren’t just offended that their businesses might be providing birth control to their employees.  We then discovered that the inclusion of birth control in individual policies meant that other people will be able to make their own decisions.  There appeared to be a large number of Americans who felt compelled to impose their religion/morality/choices on others.  You may not have realized that you were accepting someone’s definition of religion when you were accepting a job in their machine shop or dental office.  Now they were upset that they couldn’t extend their reach to complete strangers.

According to the Jesuit Review, in a survey of American Catholics including many who go to Church regularly, “just 8 percent said contraception is morally wrong, with 89 percent saying it was either morally acceptable or not a moral issue at all.”  This, again, is a reminder that this entire issue is about control and religion.

As we have previously discussed, our health insurance policies covered birth control pills even when they didn’t.  Under the old rules, teenage girls would complain about difficult menstrual issues and the family doctor would prescribe birth control pills to help regulate their cycles.  Two problems solved!  The pills weren’t free, but the parents who could afford the cost didn’t mind.  Those who could not afford the cost of the monthly prescription were sent to Planned Parenthood (yes, that Planned Parenthood) for a reduced cost or even free.  This was a workaround, neither efficient nor 100% honest.  The PPACA ended all of that.  Birth control was now available to everyone, not just to those who could afford it.  Universal access was not universally appreciated.

We learned in 2010 that corporations are people.  People may not be people.  Certainly people aren’t always treated as people.  But corporations are not only people, but it turns out, as I noted in a post from July 3, 2014, these entities can even have sincere convictions.  The Supreme Court (Burwell vs. Hobby Lobby), days earlier in a 5-4 decision, continued the trend of dehumanizing individuals while we anthropomorphize corporations.

This week’s Supreme Court decision was in response to a Trump administration action taken in October 2017.  At the time this action seemed as much about Trump scoring A Small Victory as it did about birth control.   The key was that it opened up the possibility of eliminating the benefit under either religious or moral grounds.  In my opinion the most important issue was that since the Obama administration had the power to define these forms of birth control as part of Preventive Care, the Trump administration could just as easily change the definition.  Two of the more liberal justices, Elena Kagan and Stephen Breyer, agreed that that each administration had the right to create exemptions.

So what does it mean? When it comes to the Supreme Court, I always turn to Amy Howe a reporter at ScotusBlog.  Here is her summation:

“As both Alito’s and Kagan’s opinions suggest, the battle over the exemptions from the birth-control mandate may not be over yet. Instead, the dispute will go back to the lower courts for them to weigh in on whether the expansion of the exemptions was the product of reasoned decision-making, virtually guaranteeing that the litigation surrounding the exemptions will continue until well after the 2020 election. And depending on the results of the election in November, a change in administration could lead to efforts to narrow or eliminate the exemptions. But at the very least, today’s decision cleared the way for employers to claim the exemptions going forward.”

We can’t always pick the battles we wish to fight, nor is there ever a guarantee of victory.  Former Senator McCaskill easily won in 2012, but she lost by 6% in 2018.  The battle over the access and payment of birth control will continue.  Each side will celebrate some victories and each side will suffer some defeats.  It is a battle both sides want.

DAVE

www.cunixinsurance.com

Picture – Armed With A Pen, Hardly Dangerous – David L Cunix

Construction vs. Destruction

Ronald Reagan famously said that the most terrifying words in the English language are, “I’m from the government and I’m here to help”.  The line garnered laughs and applause whenever he delivered it.  We’ll never know who wrote the quip or whether he really believed it.  But he had been an actor and he delivered the line with style and it was well received.  People in the southeast, an area ravaged almost annually by hurricanes from the Atlantic or the Gulf of Mexico, failed to see the irony.  The people living in the tornado alley states of Oklahoma, Kansas, Iowa, and others also cheered the line.  And so it became apparent that federal help (money) is good help as long as it is for you and wasted if it is for someone else. 

Some of us are looking for a bigger picture, a way to describe the value of federal help, money, and regulation that can potentially help large segments of the American public.   The expansion of Medicaid, a federal-state partnership to provide health insurance to the poor and working poor, is one of those programs.  The Medicaid expansion was a key component of the Patient Protection and Affordable Care Act (Obamacare).

I had the great pleasure of hearing freshman Congresswoman Lauren Underwood (D-IL) speak while I was in Washington a few months ago.  Prior to her election she had been a nurse.  She drafted H.R. 4996, Helping Medicaid Offer Maternity Services (MOMS) Act of 2019.  Her legislation was designed to expand Medicaid services a full year postpartum.  The logic was clear.  “The majority of pregnancy-related deaths happen after the day of delivery, and nearly one quarter of deaths happen more than six weeks postpartum.”  It took a nurse to bring this to Congress’s attention.  I was so impressed with her presentation that I went to her office and got more information from her legislative aide.  Who benefits from this expansion of Medicaid?  Obviously the families of the women who have just given birth.  These are families in urban, suburban, and, importantly, in rural areas.  This also helps to make sure that medical providers, doctors and hospitals, are compensated in these settings.  Rural hospitals suffer from uncompensated care.  This is a solution.

H.R. 1425 – The Patient Protection and Affordable Care Enhancement Act includes Congresswoman Underwood’s Medicaid expansion.

The House of Representatives passed H.R. 1425 earlier this week.  The goal is to make the PPACA more effective.  Like the bill it is tweaking, this enhancement is neither perfect nor likely to garner a lot of support from the Republicans in the Senate.  The point is to put forth constructive, useful rules to make it easier for Americans to access and pay for health care.

My blog post from eight years ago today scoffed at the intellectual dishonesty of repeal and replace and asked instead for revise.  H.R. 1425 is a good starting point for an honest debate about revising the PPACA.  Sadly, you can only have a serious policy debate if you have participants from both political parties and the attention of the president. 

H.R. 1425 has its detractors.  Some are just the usual suspects who appear to believe that they were elected to Congress simply to disagree with whatever the other side does.  We won’t waste time on them.  Nor will we mention some of our Congressional delegation more intent to have their pictures taken than to ever do anything.  There is a good chance that these Congressmen have not bothered to read the bill.  They have legislative aides for that.

The American Action Forum “is a center-right policy institute providing actionable research and analysis to solve America’s most pressing challenges.”  Christopher Holt, the Director of Health Care Policy, published an executive summary of H.R. 1425 on June 25, 2020.  This is the link.  It is only 7 pages and worth the read.  Spoiler Alert – he is not a fan. 

Mr. Holt’s analysis is instructive.  You may like what he dislikes.  Or, your thoughts find a home in his words.  What is clear is his honesty about how his perspective impacts his view of the law. 

Here are some of the key goals and provisions of the Enhancement:

·       Reduce premiums by bringing healthy people into the insurance pool.  This is done by limiting and/or eliminating short term policies

·       Expand the Tax Credit Subsidy to make insurance more affordable

·       Fix the “Family Glitch”, the problem when the employee has coverage from work, but the coverage for dependents is too expensive.  This was determined to be a huge issue since 2014.

·       Provide funding for reinsurance on the state level.  The states that have done this have shown real savings on insurance premiums.  We keep hoping Ohio would do this.  The funding would help.

·       Incentivize the states that haven’t expanded Medicaid to finally do this.  This might be what it takes to get states like Kansas and Missouri across the finish line.

·       Money for outreach and advertising for the annual open enrollment

·       The Medicaid postpartum expansion

·       The government would be allowed to negotiate with the pharmaceutical companies over pricing.  This was H.R. 3 passed earlier in the term.

Those are some of the highlights.  Mr. Holt has his thoughts.  For a different perspective, you might also want to look at Katie Keith’s article in Health Affairs.  She is a touch more positive.  But whether you are in one camp or the other, an honest reading of H.R. 1425 is to see the beginning of a conversation, a path forward.  It is construction not destruction.  After 10 wasted years where little has been accomplished, wouldn’t it be great if the people we elected to help make our lives better focused on that job?  Health insurance, the way most Americans access and pay for care, is an issue for all of us.  I’d love to hear our Congressmen tell us that they are from the government and that they are here to help and mean it.

DAVE

www.cunixinsurance.com

Picture – Clearing A Path – David L Cunix