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Wednesday, March 19, 2014

Health Care Reform Articles - March 19, 2014

The Irony of ObamaCare:
Making Inequality Worse
The Irony of ObamaCare: Making Inequality Worse
The promise of Obamacare was the right one and the hope for extending healthcare coverage to the un-and under-insured a step in the right direction. Yet the unintended consequences will hit the average, hard-working American where it hurts: in the wallet. Currently a national dialogue is emerging by all political parties on the issue of income inequality. That is a debate worth having. The White House and Congressional Democrats are “resetting” the domestic agenda following the negative fallout from the rollout of the ACA. They plan to shift focus from health care to bread and butter issues of income inequality that have eroded the American paycheck for decades.
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Obama Presses Case for Health Law and Wage Increase
—New York Times, December 4, 2013
Ironically, the Administration’s own signature healthcare victory poses one of the most immediate challenges to redressing inequality. Yes, the Affordable Care Act will help many more Americans gain some health insurance coverage, a significant step forward for equality. At the same time, without smart fixes, the ACA threatens the middle class with higher premiums, loss of hours, and a shift to part-time work and less comprehensive coverage.
  • Transferring A Trillion Dollars in Wealth: Most of the ACA’s $965 billion in subsidies will go directly to commercial insurance companies, one of the largest transfers of public wealth to private hands ever. Since the ACA passed, the average stock price of the big for-profit health insurers doubled, their top executives were paid more than a half billion dollars in cash and stock options, and in the past 2 years, the top 10 insurers have spent $25 billion on mergers and acquisitions.
  • Strangling Fair Competition: Before reform, different types of health plans were regulated under different bodies of law. The Obama Administration has blocked many non-profit health funds from competing for the law’s proposed trillion dollars in subsidies by refusing to set fair regulations for different types of plans. The unbalanced playing field will give employers of people covered by these plans powerful incentives to drop coverage.
  • Moving to Part Time Work: The Administration’s experts say employers won’t follow the incentives and drop coverage. But they also told the nation that employers would not cut workers’ hours to get below the 30-hour per week threshold for “full time” work, even as 388 employers announced hours cuts since early 2012.
  • Cutting People’s Pay: If employers follow the incentives in the law, they will push families onto the exchanges to buy coverage. This will force low-wage service industry employees to spend $2.00, $3.00 or even $5.00 an hour of their pay to buy similar coverage.
    http://www.unitehere.org/files/unitehere-obamacare-report.pdf

Silly Republican Insurance Reform Ideas––Selling Insurance Across State Lines and Association Health Plans

There are news reports indicating Republicans will be proposing such longstanding health insurance reform ideas as selling insurance across state lines and association health plans.

These ideas have been around for some time and have served Republicans as convenient talking points out on the campaign trail positioned as common sense alternatives to Obamacare.

When I discuss these ideas with people in the insurance industry––people who know how their market really works––these ideas generally command plenty of snickers.

Selling Insurance Across State Lines
Presumably, Republicans are targeting the many state benefit mandates that drive health insurance policy prices up. The idea is to allow the sale of policies from states with the fewest benefit mandates to be able to be sold in a high mandate state––thereby encouraging the state with more mandates to curtail them.

There are a number of problems with this idea:
  1. IF it did attract new carriers to a market, it would be a great way to blow up an existing health insurance market––for example, the high market share legacy Blue Cross plan whose business is in compliance with all of the existing state benefit mandates. A new carrier could conceivably come into the market with much lower rates––because it is offering fewer benefits––attracting the healthy people out of the old more regulated pool leaving the legacy carrier with a sicker pool. Stripping down a health plan is a great time tested way for a predatory insurance company to attract the healthiest consumers at the expense of the legacy carrier who is left with the sickest.
  2. It's a 1990s idea that fails to recognize the business a health plan is in in 2014. Health plans don't just cross a state line and set up their business like they did decades ago when the insurance license and an ability to play claims was a all a carrier needed to do business. This idea was first suggested by the last of the insurance industry cherry pickers back in the 1990s and it has long outlasted its relevance. Building a new health plan in a market can easily cost hundreds of millions of dollars over a plan's first few years of operation. The most important thing a health plan now offers is not an insurance contract but rather a comprehensively managed provider network. Just look at the capital costs for the new co-ops under Obamacare that are often receiving something approaching $100 million each to set up a new plan. Georgia, for example, passed such a law in 2011 and not a single new carrier entered the state because going into business in Georgia would be about a lot more than simply having a licensed contract to offer and there just aren't a lot of cherry pickers left to want to exploit this opportunity.
  3. It doesn't solve the problem it identifies. The problem this solution targets is that there are arguably too many benefit mandates unnecessarily driving costs up. So, solve that problem. Why do we even need to enact this convoluted and market obsolete idea? Why even encourage the return of predatory health insurance cherry pickers? Why create a two-tiered market? Why not fix the real problem and create a level playing field for everyone at the same time? I suggest the supporters of this idea first ask the leaders of the insurance industry if they would even do this under the best of circumstances.
Association Health Plans
Small group health insurance costs a lot more than big group health insurance. This idea is based upon the commonsense notion that if you pool lots of small buyers together you can get them lower costs.

Commonsense unless you know how the insurance markets work.
http://healthpolicyandmarket.blogspot.com/2014/03/silly-republican-insurance-reform.html?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+HealthCarePolicyAndMarketplaceBlog+%28Health+Care+Policy+and+Marketplace+Blog%29

Nine Questions About My New Medical Home


March 17th, 2014 
by Matthew Anderson

Sometime in the past five years — it’s hard for me to say exactly when — I suddenly found myself living in a new home.  I must admit I am still a bit disoriented by how this happened. But it did. People keep telling me that everything will be ok but I am not entirely sure.
For example, in my old home we had occasional family meetings; things are different now. We now have weekly (and monthly) meetings. The many new administrators ask us to complete personality surveys. Once we had to figure out what items we should take from a sinking yacht in the South Pacific (hint: the $100 bill will be useful). Another time we had to decide if we were a “Wow” or a “Thinker.” We are asked to figure out how we can do a better job for them. I guess, like all forms of therapy you don’t get better unless you change.
Despite all these meetings there are a series of things I still don’t understand. I am afraid to raise my hand at the meetings and give the impression I’m a bad sport so I have written my questions down.  Please, please don’t think I am a Luddite who wants to go back to the old home.  In fact, what I dislike most about the new home is precisely the way — even in its differences — it resembles the old home.
1. Is this a home or is it a hostel?
One of the things that drew me to family medicine was the desire to build long-term relationships with families.  I went to weddings and graduations; I was asked to be a godfather. I was there when babies were born and came into bedrooms to declare deaths. I could meet my patients on the street. I had families where I cared for five generations.  At the time insurance companies didn’t generally dictate to people whom they could or could not chose as their doctors. Patients who liked me stayed and those who didn’t went to other doctors. All of this felt something like a home.
All that has changed now.  Pretty much everyone will be on a managed care plan that will limit their choice of providers.  If the system runs as intended, decisions about which doctors patients can see will be made every two years by the rational economic decisions of their employers.  There will be nothing special anymore about the relationship between the doctor and the patient.  As this has been explained to me, it is not really a problem “because you are a member of a team.”
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http://healthaffairs.org/blog/2014/03/17/nine-questions-about-my-new-medical-home/

Morning Plum: What the Obamacare enrollment numbers mean

  • BY PAUL WALDMAN
    The Obama administration announced late yesterday that 800,000 people have signed up for new health insurance so far in March. That brings the total under the Affordable Care Act to over 5 million and makes it likely that 6 million will have enrolled by March 31, the last day to sign up before getting a fine. That 6 million number would meet a projection made by the Congressional Budget Office. So what are we to make of those numbers?
    To a degree, targets like these are arbitrary when we’re judging the law’s success. It isn’t as though we’ll say that if 5,999,999 people signed up by the end of the month then the law has failed, while if 6,000,001 sign up then it has succeeded. Nor does that number include the millions of people who have been enrolled in Medicaid, many of whom are getting health coverage for the first time. And the number of people signed up will continue to rise, particularly since the fines are quite small in the first year but get larger over time. But it’s worth remembering that for all the time we spend gaming out the political winners and losers of Obamacare, there are real people’s lives at stake.
    If you were just watching political ads, you’d think that there were precisely zero Americans who had actually been helped by the ACA, since for some rather strange reason, the law’s advocates seem reluctant to actually tell the individual stories of those who have gotten covered for the first time, or can now get coverage despite a pre-existing condition. Meanwhile, the law’s opponents have spent millions of dollars blanketing the airwaves in states with upcoming elections, telling horror stories of people whose lives have allegedly been devastated by the ACA. And yes, nearly every one of those stories turns out to be utterly bogus when it is examined. But how many voters know that?
    Another reality works against the administration: It’s now easy to blame everything that goes wrong in anything having to do with health care on the ACA. Sure, premiums have gone up every year for as long as anyone can remember. But this year’s increase? Obamacare! Your boss decided to cut back your benefits to pad his bottom line? Obamacare! And did you know that under Obamacare, people will continue to fall ill and even die?
    And Republicans work like dogs to undermine the law and make sure it helps as few people as possible, then hold up their success at denying the law’s benefits to their own citizens as evidence that the law was misconceived in the first place. Nowhere is this more evident than on the issue of the expansion of Medicaid, where most Republican-controlled states have said no to the federal government’s offer of billions of dollars in what is essentially free money to get coverage for poor Americans.
    Most cruelly, many of the states that have refused to accept the Medicaid expansionare those where Medicaid benefits are most stingy to begin with. Each state sets its own eligibility levels, and not too surprisingly, states run by Republicans tend to set them extremely low. So for instance, if you’re a single parent in Alabama with two kids and you earn a princely $3,221 a year, the state considers you too wealthy to get Medicaid. In Texas, which has more people living without health insurance than any other state, that figure is $3,737. Millions of the working poor could have gotten coverage from Medicaid through the expansion, but their state legislators and governors quite literally believe that it’s better for a poor person to have no health coverage at all than to get coverage from the government.
    By one analysis, 5.2 million Americans who could have gotten Medicaid if their states had accepted the expansion will remain uninsured. And if you asked those people in a poll whether Obamacare had helped them, they’d quite reasonably say no.
    So Republicans in those states can laugh all the way to election night. They got to screw the poor, which, let’s be honest, they were inclined to do anyway, and in doing so they also did political damage to the Obama administration. Quite a trick.

    Our View: Debate distracts from real MaineCare issue

    If this bill fails to pass, tens of thousands of Mainers won’t get the care they need.

    The Maine House will take up the MaineCare expansion bill this week and members should be clear about what’s at stake.
    The bill would accept federal funds for three years to cover as many as 70,000 uninsured people with the state’s version of Medicaid. After two years of debate, you’d think that much would be clear, but it’s not.
    The LePage administration and its allies called it a budget-busting expansion of welfare, even after the nonpartisan Office of Fiscal and Program Review determined that it would be a financial plus for the state. The opponents have said it would run up unpaid bills to Maine’s hospitals, but the Maine Hospital Association says just the opposite, saying that not expanding MaineCare would put their members at a fiscal disadvantage.
    And the governor has called the bill “sinful” because some elderly and disabled MaineCare recipients remain on waiting lists for additional services, even though defeating the bill would not shorten those lists and passing it would. The compromise bill sponsored by Republican Sen. Roger Katz would direct funding toward reducing and eliminating the waiting lists over time.
    subsidized coverage no bargain for many
    Now the opponents argue that the expansion is unnecessary because most of the people who would receive MaineCare coverage are already eligible for subsidized health insurance under the Affordable Care Act. But this is also not a reason to defeat MaineCare expansion.
    While it’s true that some of the people could buy subsidized insurance on the exchange, tens of thousands would not.

    Maine House advances Medicaid expansion bill, but Republican support still lacking

    The House passes 97-49 but still shy votes of two-thirds margin that will be needed to override Gov. LePage veto.

    By Steve Mistler smistler@pressherald.com
    Staff Writer
    AUGUSTA -- A bill to expand Medicaid to more than 60,000 uninsured Mainers was dealt another blow Tuesday following a pitched debate and vote in the House.
    The House voted 97-49 to approve the bill, the second vote since the Senate did the same last week. However, neither vote was the two-thirds margin that will eventually be needed to get by a certain veto by Gov. Paul LePage.
    Additional votes are needed before the bill is sent to the governor. However, there’s been a shift in rhetoric since the Senate gave first approval to the proposal last week, from an attempt to win votes, to the battle of public opinion.
    Democrats, who have made Medicaid expansion a policy priority, have emphasized the human impact of not extending the public health insurance program -- known in here as MaineCare -- to 60,000 and 70,000 people who earn as much as 138 percent of the federal poverty level, just over $15,856 a year for an individual. Republicans continued to emphasize the future costs of growing a $2.5 billion program while predicting that expansion will doom spending on programs in the state’s budget.
    While a majority of lawmakers support expansion, its defeat appears increasingly likely. Republicans and Gov. Paul LePage, who has made defeating the bill a priority as he heads into his reelection campaign.
    Nonetheless, the rhetoric has increased. Last week Democrats said not expanding Medicaid will increase the likelihood that over 150 low income Mainers with chronic illness will die. Republicans have accused Democrats of calling them murders.
    Rep. Deborah Sanderson, R-Chelsea, said Tuesday that it “boggles the mind” that anyone would consider expansion given the program’s effect on state budgets.
    “If we expand Medicaid we will experience a fiscal tsunami,” she said.
    Democrats who spoke during the floor debate cited the number of people who would gain health care coverage and the fiscal impact in their respective counties.

    By Jackie Farwell, BDN Staff
    Posted March 18, 2014, at 2:22 p.m.
    AUGUSTA, Maine — The test results are in for 25 Mainers who recently volunteered to test their bodies for a battery of chemicals commonly found in consumer products.
    Every participant, from current and former lawmakers to mothers and an electrician, tested positive for phthalates, a group of chemicals used to soften plastics that studies have linked to serious health problems, such as reproductive birth defects among boys and higher rates of asthma and allergies, according to the Alliance for a Clean and Healthy Maine, a coalition of environmental and health organizations that announced the findings Tuesday afternoon at a State House event. Levels in some participants far exceeded national averages.
    Paige Holmes, 34, who lives in Lisbon with her two young sons, tries to avoid phthalates by using glass and stainless steel containers instead of plastic and switching out her vinyl shower curtain for a cloth one. Since becoming pregnant with her first boy seven years ago, she has taken steps — from buying organic and local foods to making her own household cleaners to reading product labels — to limit her family’s exposure to chemicals.
    So she was astounded to discover she had the highest overall level of phthalates in the study group. Two types of phthalates commonly found in personal care products were detected in her body at levels higher than those of more than 90 percent of all Americans.
    “I’ve done so much, I had thought, to protect my family, and then to see that I had the highest levels despite everything I had done to be proactive about this was just really shocking,” Holmes said.
    She wants to see policymakers take action and manufacturers begin to disclose the use of phthalates in their products.
    “The reality is you can’t really shop your way out of the problem, because this information is not available,” Holmes said.
    Phthalates are found in hundreds of consumer products, including vinyl flooring, garden hoses, shower curtains, inflatable toys, adhesives, detergents and raincoats. The chemicals are also a common ingredient in fragrance used in personal care products such as soaps, shampoos, and nail polishes.
    Phthalates can escape from products into dust and the air, entering the body through breathing, eating and skin contact. Some studies have found phthalates can disrupt male hormones early in life, while others have tied them to slowing brain development and immune system problems.
    While the U.S. Centers for Disease Control and Prevention has found widespread phthalate exposure among Americans, it cautions that the health effects remain unknown. Finding detectable amounts of phthalates in the body doesn’t mean that exposure will harm a person’s health, according to the CDC.
    Pregnant women and children are more vulnerable to phthalates and also face higher exposures, according to the Maine report. By reducing testosterone and thyroid hormones, phthalates particularly threaten early childhood development, but also pose risks to teens and adults, the report states, adding that there’s “likely no safe level of exposure to hormone disrupting chemicals.”
    Phthalates are already banned in toys and products marketed to children under three, and all seven types tested in the Maine study have been targeted by various state, federal and European agencies, according to the report.

    What the U.S. really needs is a single-payer health system

    By Samuel Metz, M.D.
    The Oregonian, March 17, 2014
    Imagine all your medical information imprinted on one wallet-sized card. Then you lose it. Is this an inconvenience, or a catastrophe?
    In France, Taiwan and other countries providing universal health care at lower cost, it’s an inconvenience. Get a replacement, and all is well. No harm, no foul.
    But not here. In Oregon, and anywhere in the U.S., your medical records determine the kind of care you get, and maybe if you get any care at all.
    It’s a life or death issue.
    We are the only country in the world that uses our medical records, along with residence, age, military status, number of co-workers, our employer’s choice of insurance companies, part-time status, income and size of family to determine how much care we will receive and which providers we can see. We then repeat this every time we change residence, age, military status, etc.
    No wonder it takes a massively expensive computer system to figure all this out. No wonder it cost Oregon millions of dollars to design this Cover Oregon computer system, repair it, maintain it and change it. And given that thousands of Oregon families need this computer system to work before they can get health care, it’s no wonder we are incensed when this computer system doesn’t work.
    None of these millions spent on computer design, repair, maintenance or change goes toward medical care.
    All other industrialized countries provide better care to more people for less money than we do. How do they do it? Everyone, sick or healthy, is in one risk pool – human beings. Everyone, rich or poor, receives one set of benefits – treatable conditions are treated. Americans are unhappily unique in insisting health care be dependent upon our age, employer, medical records and all these other factors, but not upon our need.
    It is unrealistic to expect our Cover Oregon website to function perfectly for each of the millions of Oregonians simultaneously and desperately attempting to use it. Yet, here we are. We created a website-based health care system in which software separates patients from health care, and now we live with the consequences.
    It doesn’t have to be this way. If we want to provide better care to more people for less money, we should learn from countries already achieving it.
    Scrap the website and software. Treat every Oregonian the same – you get the care you need when you need it, no matter who you are. Divert the money we pay in premiums and out-of-pocket expenses into a common fund that pays for us all.
    This is not a fantasy. Every country in the world that uses such a single payer system provides better care for less money than any of our computer-driven websites could possibly achieve.
    Imagine an Oregon in which everyone gets cost-effective care, regardless of medical condition. In this better world, we still risk accidental release of our medical records. But in this better world, the lapse is an embarrassment, not a death sentence.



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