Biggest Hurdle Standing in the Way of Obamacare Reform

During the two recent Congressional Recesses, we’ve seen countless pictures of angry town hall meetings where people with so-called “pre-existing” health “conditions” have expressed their fear that the Republican Congress is working to take away health coverage they gained under Obamacare.

Some of the shouting and finger-pointing are manufactured by the Democrats’ “Resistance Movement” but some of it is genuine fear from people who suffer from debilitating diseases with no possible “cure” but – potentially — years of expensive control.

These are exactly the people Congress wanted to help when they created Obamacare.

The people who are coming to town halls have a point. Their justifiable anxiety (some of it sparked by politicians and the news media) stands in the way of a down-payment on reforming Obamacare in short run and reforming our health care delivery system in the medium to long term.

Their small numbers are magnified because it is an axiom of American democracy that we have a collective responsibility to care for those who cannot care for themselves

Obamacare Redefined “Pre-existing Condition”

These vocal town hall participants are part of the 1 percent of the USA population that incur 23 percent of the cost of health care in the United States.

Numerous studies have demonstrated that 5 percent of the population incurs 50% of the cost of health care in the United States.

Prior to Obamacare many states set up “high risk insurance pools” to help these people who were considered “uninsurable” in the private, non-(employer) group health insurance market because they had a serious and significant “pre-existing condition”.

The pools were narrow in coverage, exorbitantly expensive, limited to a pre-determined number of people regardless of the number who needed this assistance and capped maximum payments.

Other patients with – for example “seasonal allergies” were not considered to be “high risk” but were “rated” by private insurers.

“Rating” meant that the insurance company charged an additional premium for every “rated” condition that specific insured person might ever had symptoms of – even without a diagnosis – or sought treatment for.

The result was that the many of the most seriously ill Americans could not afford health insurance or, as a result, adequate health care.

How “Community Rating” Increases Risk to All

Obamacare changed this by imposed “community rating” regulations which limit insurance companies to considering only age and continuous coverage before application (no gap in insurance greater than 63 days) when determining the premium for that patient or family.

Now, any person between the age of 26 and 64 is charged the same premium – regardless of their individual health or claims experience.

Employer-based health insurance uses “community rating”. Every employee pays the same insurance premium per individual or family covered regardless of age or health. “Pre-existing conditions” can be excluded only if the insured has a 60 day “gap” in coverage.

Medicare uses a similar eligibility formula but their “community rating” is dependent on insured’s income during the previous calendar year – everyone with the same income in that calendar year pays the same Medicare premium.

Generally, employer-based insurance and Medicare “forgive” such a “pre-existing condition” after 12 months of continuous insurance coverage.

Theoretically, if the “community rated” pool is large enough and diverse enough the insurance company can absorb the cost of any single large claim because there are relatively few large claims as a percentage of the total claims paid.

Why Obamacare Insurance Mandate?

This theory is behind the “insurance mandate” in Obamacare. Everyone in the United States must obtain health insurance or pay a fine to enlarge the size of the insurance pool.

But this theory has not played out in practice.

Average estimates are that 5.2 million Americans with incomes over 138% of the Federal Poverty Line (included those turning 26 and no longer covered under their parents) bought Obamacare approved private health insurance policies in 2016.

That is fewer than the 8 million who decided it is cheaper to pay the IRS fine than buy insurance under Obamacare.

Those Americans are “betting” they won’t need health care.

The result is a smaller pool of people who know they are going to file health care claims; older people, people with more health issues – i.e. people with “pre-existing conditions” or “chronic” diseases (for example Type II Diabetes).

Smaller pools and proportionately higher utilization of increasing costly care left insurance companies with little choice but to increase “community rated” premiums for everyone or to exit the Obamacare market entirely.

The result is a pool of beneficiaries in a state of uncertainty exasperated by the uncertainties created by a Republican Congressional effort to “replace” Obamacare with something more “affordable” for more Americans in the private and employer insurance market places.

To Lower Insurance Premiums, Share the Risk

Instead of creating hysteria and fear among those who most need help to pay their health care bills and, in-so-doing, delay relief for 95% of Americans, let’s take a cue from Medicare and create a program tailored to these special cases.

Presently, the poorest older Americans are assured of care through a joint Medicare/Medicaid program.

Why can’t Congress similarly “guarantee” coverage to people under 65 with “pre-existing conditions”?

Instead of paying the Obamacare subsidies to private insurance companies, Congress should create a special category under Medicaid to manage care for at least the 1 percent – if not the 5 percent – of “high risk” patients.

Enrollees in the special group would contribute to the cost of their care according to their ability to pay, just as they do under current Obamacare, in exchange for a guarantee of access to quality care. The government would pay their claims (at Medicare rates) through the Centers for Medicare and Medicaid services.

The risk of a disproportionate number of catastrophic claims would be dramatically reduced for private insurers.

The reduction in risk should lower the cost of insurance premiums by as 25% for the average American.

The less expensive the cost of “peace of mind” health insurance brings the more premiums the insurance companies could sell further sharing the risk.

Equally important, politically, this approach – which addresses the heart of the problem Obamacare set out to “fix” — should be able to attract at least some moderate Democratic support in the United States Senate.

Bi-partisan support for any Obamacare repeal or repair is a pre-requisite to attacking the real problem — the unsustainable cost of health care in America.

Emperor’s New Clothes —

 

As promised on Saturday’s AM860 Radio Show — for those not familiar with the fairy tale/ now allegoric

https://en.wikipedia.org/wiki/The_Emperor%27s_New_Clothes

Photo Courtesy of Wikipedia

 

Importing Cheap Labor Eliminates American IT Jobs

Immigration policy played an important part in the debate before and after the 2016 election.

The debate was focused on whether or not to protect undocumented aliens in the United States because they do “jobs Americans won’t do” – for example agriculture, food processing, and unskilled construction.

But no attention has been paid to protecting jobs Americans are doing from documented alien labor.

Despite the loss of +/- 200,000 US technology jobs, the United States Citizenship and Immigration Services (USCIS) proceeded to awarded 85,000 “temporary high skilled knowledge worker” non-immigrant visas (H1-B) to foreign contract worker firms and American technology firms — 85,000 direct competitors for the limited number of IT jobs available in 2016 and 2017.

Why are we not Employing American Workers?

The phenomenon is not new. Computer World estimates that at least 776,000 tech workers have entered the United States to directly compete with American workers between 2007 and 2017.

For the last few years, the majority of these visas (65,000 annually) went to India-based contract labor (outsourcing) firms. The firms, in turn, hire BA graduates from Indian colleges and universities to fill the visas.

The advanced degree quota for H1-B visas (20,000 annually) go to high technology companies — Facebook, Apple, Google, Microsoft and Intel, to name just a few.

In addition, H1-B visas are issued to American college and universities above the annual quota stipulated by Congress.

While, at the same time, the National Institutes of Health spends $11 million a year to help US citizen Ph.D. graduates in STEM to find alternative careers. There are not enough jobs for all the Ph.D. graduates USA universities produce.

Solution: Hire a Made-in-America Worker

The H1-B visa program poses a direct threat to US technology workers – both present and future – as the numbers of these workers have continued to grow despite a general weakening of demand for IT workers in the United States.

In recent years more and more high profile American companies have fired entire departments of American workers and hired H1-B replacements.

  • Southern California Edison
  • Northeast Utilities
  • Toys R Us
  • Disney Company http://www.mercurynews.com/2016/09/06/emmons-when-walt-disney-co-replaces-americans-with-h1b-workers-its-a-small-world-for-sure/
  • University of California San Francisco Medical Center
  • Too many more to name

In all of these situations, the American workers were required to train their replacements as a condition of receiving their severance pay!

Many of the displaced workers had 10, 15 or 20 years of service to the firms that dismissed them in the name of profits. http://fortune.com/2015/12/24/disney-bob-iger-compensation/

Turn-off the Spigot

Despite extensive investigation and numerous hearings before Congressional Committees no action has been taken to correct the abuses of the H1-B program.

Currently there are three bills pending. One in the Senate and two in the House, including one authored by Silicon Valley representative Zoe Lofgren which would require H1-B employers to pay 150 to 200 percent of the current prevailing wage for that job classification – a move that would bring the program back to its original intent. Once, again, the H1-B visa would be reserved for the rare, unusual and uniquely skilled job creator.

In addition, the Trump Administration has issued an Executive Order to “study” the problem but did so without turning off the spigot.

Exactly the opposite should be done.

There is a practice from an earlier time in information technology that applies to the current H1-B situation.

Before every executive had a laptop with a company performance dashboard in the middle of his/her desk, IT departments used to produce volumes of paper reports. Periodically, the queue of reports had to be “cleared” to reduce wasted paper and reduce labor costs.

The IT Department would simply stop printing all the reports one Friday evening and wait to hear on Monday who called and asked for their report. If no one asked for a specific report by the following Friday, it was discontinued.

Instead of waiting for Congress – which has shown no appetite to touch anything related to immigration this year – let’s just turn-off the spigot by Executive Order.

Don’t hold a lottery to award the 85,000 2017 H1-B visas and see if any labor shortage occurs – if any company mounts a court challenge in the name of shareholder profits.

It is more likely that the result would more be more jobs and better wages for American technology workers.

Public Option is Part of Fix for America’s Broken Health Care System

In the aftermath of the latest Republican House of Representatives’ attempt to “repeal and replace Obamacare” two things are certain.

  1. Health care is an entitlement due to all American citizens and a smaller group of legal non-citizens.
  2. Health care costs too much for too many people.

Quinnipiaq polling found only 17 percent of people approved of the Republican health care bill after hearing Congressional Budget Office projections that 14 to 24 million Americans might lose their health care coverage if the American Health Care Act became law.

Only eight percent of respondents supported just repealing Obamacare without replacing it.

But more than 50 percent want significant changes to the program.  Changes that will reduce cost – the cost of insurance and the underlying cost of health care.

Americans Reject Government-Run Health Insurance

It is an axiom of American politics that Americans reject a public health care option.

I don’t know whether to be worried or amused that members of Congress do not recognize the USA has a defacto public option?

Rhetoric to the contrary: 49.6 percent of the American people get their health care paid for by a government-run insurance program. The dictionary definition of a public option!

Consider the facts.

There are 47.2 million Americans on Medicare.

More than 70 million Americans are covered by Medicaid through a variety of programs that have been added over the last half century.

  • Medicaid covers about 40% of all children in the United States
  • Medicaid pays for about 50% of maternity expenses in the United States
  • Medicaid pays for 2/3 of nursing home expenses in the United States

The Veterans Administration claims 8.9 million health care plan participants.

The Bureau of Indian Affairs provides health care for approximately 2.2 million American Indians and Eskimos who live on traditional native lands.

The United States military insures +/- 14 million uniformed active duty and retired service members and their families.

The Obamacare private health insurance exchanges subsidizes premiums for 11 million Americans without employer based health insurance who are not eligible for either Medicare or Medicaid.

Approximately 4.8 million federal employees including civil service, executive and legislative branches and the courts participate in the federal government (employer) health insurance program

Add it all up — 154.8 million Americans get their health insurance from the federal government at a cost of +/- $2 trillion (about 64% of all health spending in the United States).

Embrace Reality with Public Option

What if Congress seized on the opportunity instead of railing against “government intrusion into health care”? They could turn the USA public option into a benefit instead of a financial sink hole with a bad reputation – an excuse for the escalating cost of care in America.

Let’s start with a new piece of legislation that all Americans without a law degree can understand:

A public option health insurance program open to everyone from age 0 to 64 years not covered by private employer health insurance. The plan would cover all currently mandated Essential Health Care Benefits.

To succeed Congress must remove the “Medicaid stigma”— the broad public perception that Medicaid is health care for only the poorest people delivered by less skilled personnel in substandard facilities. The insured cannot be embarrassed to “show their card”!

The new product must appeal to the 11 million who are currently insured under Obamacare exchanges and to some portion of the remaining 23 million Americans in the private insurance market. People must be willing to pay out-of-their-pocket to belong to the program.

This alternative begins with assuring prompt access to current-in-industry standard treatment in first class facilities – for example, Kaiser, Humana, Cleveland Clinics, and Sutter Hospitals – probably operating only as health maintenance organizations.

Congress should “guarantee” the plan offers best-in-class care options by enrolling themselves, their families and their staffs in the new public option.

The public option must be a good enough product to compete as one of the choices for Federal employees and their families.

Access to a public option health insurance card could bring the nation’s 8.9 million veterans improved care in their home communities.

How to Create a Realistic Funding Source: Follow the Money

A new and realistic funding source must be a cornerstone of the new legislation — fair to all, affordable and paid for now and into the future (not adding to the national debt).

There’d be some savings to be recouped into the public option funding pool from existing government activities:

  • Collapsing the five or six government insurance bureaucracies into a single department.
  • Eliminating the Obamacare guaranteed profits to private insurers.
  • Claims processing through Centers for Medicare and Medicaid Services (CMS) at .84 cents a claim

There would be new funds earned from premiums paid by insured – based on income.

But these savings and premium payments would not come close to paying for the subsidized care of close to one-third of Americans = +/- $1 trillion/year

Every American has to know where the $1 trillion is coming from, how it will be collected, and how it will be spent.

Since the 1980s there has been a shift in our economy from production (30%) to consumption (70%).

Fewer good paying manufacturing and other semi-skilled jobs have swelled the rolls of Medicaid and reduced the role of employer-paid insurance.

Logically, then, the new source of revenue to pay for public option health care (even to continue to pay for Obamacare and Medicaid) must come from the consumption side of the ledger – taxes paid by the ultimate consumer.

Take a Small Step First

Congressional Republicans should acknowledge reality — pass legislation authorizing the development of a public option health insurance program effective January 1,2019.

Force Democrats – who have long argued for a public option — to “come to the table” leading to lasting, bi-partisan legislation.

Establish a budget line item and allow tax reform legislation to move forward.

Provide certainty to the current health insurance market and warn against unjustified 2018 insurance premium increases.

Encourage the health care industry, fearing further regulation, to come to the table with alternatives to ever escalating health care costs.

Isn’t that the bottom-line for all Americans?

Health Insurance Drives Sky-Rocketing Health Care Costs

Health Insurance Drives Sky-Rocketing Health Care Costs

My girlfriend, Sandy, and I had our first springtime “spa-day” last week.

Being “girls” we talked about our travels, our families, and fashion while enjoying a pedicure.

Sandy worked in the health care industry before her recent retirement, and I have consulted extensively to large health care organizations over the years.

Not surprisingly the conversation quickly turned to health care – the Republican proposal to repeal and replace “Obamacare” and the just published Congressional Budget Office analysis of that proposal.

Beyond our professional experience, we are consumers. We are experiencing the increasing cost of health care insurance, co-payments, drugs and other expenses.

Spending Other People’s Money

Over our sun-drenched lunch, Sandy and I talked about the growing role of government into our health care system and about some of the unintended consequences.

During his very wonky Power Point press conference, Paul Ryan accurately pointed to the spending of “other people’s money” as a powerful driver in the alarming rise in the cost of health care. http://www.cnn.com/videos/politics/2017/03/09/paul-ryan-full-health-care-bill-powerpoint-presenation.cnn

Let’s break this down.

  1. Obamacare requires that every American citizen must be covered by health insurance. Americans are required by force of law buy to insurance from a private insurer if they are not covered by an employer plan and have an income above the Federal Poverty Line.   That insurance must include benefits you or I might or might not want.
  2. Your individual premium is calculated on age, number of insured in the family, and the average cost of all the mandated benefits – whether you may use them or not – because someone else insured by the same company may – indeed – use those benefits. That is called sharing all the risks.
  3. If you do not buy insurance, the Internal Revenue Service will impose a penalty (i.e. a tax on you) that is used – in theory – to help pay for health insurance or Medicaid for your neighbor whose income and family size qualify them for help paying their legally required insurance premiums.
  4. All insurance payment premium payments for health insurance are paid into the insurance companies’ premium account(s). Premium accounts  are a pool of money in which your individual contributions can no longer be identified or separated out for your specific use.

Once our dollars are pooled with every other tax payers’, we have no control over how they are invested or spent.  They become someone else’s to spend on any person or any benefit – at any price the insurer agrees to.

The more services the government mandates insurers to cover from first dollar or after a minimum co-payment, the less sensitive the consumer is to how much that service costs.

For example, last Tuesday my allergy doctor suggested a vapor treatment for my pollen-driven chest. I said okay. It never occurred to me to ask how much does the treatment cost because I won’t get a bill. The charge will merely be an object of curiosity when the insurance company sends me an explanation of benefits they paid.

If I had to pay the bill for that treatment, I would have asked more questions about the cost and efficacy.

Are government bureaucrats creating an almost irresistible temptation for the health care providers? In a word, YES!

If the insurer is required to pay – no questions asked – for tests and treatments, the profit-making health care eco-system is going to prescribe more tests and charge more for them.

The Affordable Care Act (Obamacare) mandates for first dollar coverage of preventive and diagnostic testing exaggerate these consequences.

The more services are mandated without adequate cost controls, the more the insurers must charge in premiums and co-pays.

Faced with exploding insurance costs for all of us, is it time to change the assumptions about personal responsibility for your own health care and government’s power to mandate that responsibility be underwritten by the taxpayer?

The Purpose of Health Insurance

“Sandy, I think I remember paying bills from the pediatrician when Craig was a kid – like his well-baby care? What do you remember from your children?”

“Yes”, she replied “I remember paying the pediatrician”. Sandy was living in the mid-west at that time and remembers she took her children to community childhood immunization clinics that were “much less expensive” than the pediatrician.

When Craig was born, insurance paid for hospital costs for both of us – but I paid a contracted amount – directly – for my obstetrical care – spread over the pregnancy.

I was in graduate school and working for the University of California’s Statewide Office of Administration at the time. That meant I had really good (state employee good) health insurance.

What I experienced was normal practice in the 1970s.

I don’t remember when the practice changed and I stopped paying doctors’ bills and started paying only a co-payment – and it doesn’t matter. The point is health insurance started out as hospitalization or serious illness insurance – not the primary vehicle for obtaining routine care.

Health care coverage, today, is not only protection against major illness, major accident or hospitalization. It is, also, really pre-payment of anticipated routine services – an indeterminate number of services each at an indeterminate cost. Indeterminate is driving rising premiums and deductibles.

Necessity is Driving Innovation

While Congress is debating how to insulate more people from a price and service model no longer affordable for either the American tax payer or the individual middle class consumer, a few health care practitioners are developing real solutions in real time for real people.

Here are two examples I found – without even trying – that are working in local practices today.

As of January of this year, my dentist is offering patients an annual contract for care. For a monthly fee paid automatically via credit card, the dentist will provide all preventive care and fillings. Other services are paid by the patient at a discounted price – determined before service.

The monthly expense is two-thirds of what my previous dental insurance company charged for a smaller benefit. If I were to need a crown, I would still pay less, out of pocket, than the previous premium plus co-pays.

Not only is this a good deal for the patient, it is a good deal for the dentist. If a majority of his patients subscribe to his plan, it smoothes out the cash flow peaks and valleys of a traditional small business and it allows him to schedule his employees – hygienists, dental assistants and office staff –efficiently.

This efficiency removes time consuming disputes with insurance companies.

Taken as a whole, the dentist can grow his practice while, at the same time, controlling his payroll costs. In other words, he can make a larger profit on same or lower revenue.

While we were talking, Sandy remembered a friend whose family practitioner has a similar program for healthy patients not yet eligible for Medicare. That doctor charges a flat fee of $2000 a year for all routine and sub-acute office visits plus annual preventive care – including blood draws and other routine laboratory testing.

That patient must still purchase major medical (i.e. hospitalization and catastrophic illness) coverage. But, according to my quick Google search, those policies start at about $600 a year. https://healthplans.com

This approach is definitely a money saver. It’s less than the cost of Medicare plus a Medicare Supplemental Plan for someone who meets the health criteria implied in the contract.

Here, too, the regular payments help to smooth the doctor’s cash flow and simplify insurance claims processing – benefitting the bottom-line.

Both of these patient/provider contracts are treated equally with employer-based health care premiums for tax purposes through the use of Health Savings Accounts – an objective of the GOP sponsored plan. http://www.hsacenter.com

Could these be early signs of return to a health care model more typical in the 1970s? A model middle class Americans and their health providers can afford.

When routine health care was something consumers paid out-of-pocket, we paid attention to how much it cost. We shopped around for the best deal.

Old fashioned competition is the elixir of innovation – a tonic the American health care system urgently needs.

Graphic — screen shot by author.  With all thanks to MSNBC and my Samsung Smart TV

House Intelligence Committee — the Schiff “Indictment”

For listeners of my March 25 AM 860 Radio Program here is the link the House Intelligence Hearing from March 20.

Ranking Member Schiff’s “indictment” is in the first 20 minutes of the total 5 hour recording

https://www.c-span.org/video/?425087-1/fbi-director-says-hes-investigating-links-trump-campaign-russia

 

This information is offered for your private use with all rights and copyright belonging to CSPAN.Org

With my thanks to CPAN!

CBO Waves Yellow Flag at GOP Healthcare Bill

CBO Waves Yellow Flag at GOP Healthcare Bill

By the time I had printed out a copy of the just released Congressional Budget Office (CBO) cost estimate of the GOP proposal to “repeal and replace Obamacare” my inbox had filled up with draconian headlines and alerts:

A complete reading of the 27 page report paints a more complicated picture but does urge caution as the House of Representatives moves to debate, amend and attempt to pass the American Health Care Act (AHCA).

Assumptions

To reach the cost estimate, the CBO had to begin by making a set of assumptions.

1. Health care is an entitlement – just like Social Security and Medicare.

2. The nation’s health care eco-system is a permanent fixture that cannot be evolved and made more cost-effective.

3.  Health insurance is and should be the future primary source of payment for an individual’s health care.

4.  The non-group insurance market place will see a smaller portion of premiums returned as benefits to insured individuals – resulting in higher out-of-pocket expenses for the insured.

5.  Higher out-of-pocket expenses are, by definition, bad for the insured individual.

      6.  Absent a government mandate and associated tax penalty, about 14 million Americans will choose to go without health insurance.

7.  Absent a government mandate, many employers will stop offering health insurance to their employees.

Everyone in business knows step one in making a go/no go decision on any proposed project or product rollout is to validate the underlying assumptions. If even one of the assumptions is proven to be invalid, then the rest of the analysis is immediately called into question.

The project cannot be green lighted until all of the assumptions are deemed valid – either by addressing the flaw in the proposed project that invalidated an assumption or by proving the assumption, itself assumed the wrong input or outcome.

Below I’ve made a quick pass at whether the American Health Care Act should be “green or yellow lighted” – based on CBO assumptions.

Health Care Is an Entitlement

Let’s give the Democrats their due. Regardless of its flaws, the Affordable Care Act of 2009 firmly established health care as an entitlement due every American.

Other entitlement programs – i.e. veterans’ benefits, government pensions, Social Security and Medicare all require some prior contribution by the individual beneficiary. The beneficiary is said to have “paid into the system”– before receiving a specific and defined benefit.

For example, in Social Security there is a legally defined, published maximum benefit paid monthly regardless of how many additional dollars the recipient may have (or is) paying in Social Security taxes.

Payroll taxes (Medicare, Social Security etc.) deducted from your wages are deposited into a trust fund to be used to pay your benefits in retirement. Congress considers these benefits to be “earned”.

Contrast the new health care entitlement. It is paid for entirely by current income tax payers, in addition to taxes paid for their own future Social Security and Medicare benefit (or taxes on these benefits), and by future tax payers (borrowing). Borrowing that is moving the nation ever closer to the “fiscal cliff”.

There is no dedicated new funding source to pay for this new entitlement.

The taxes – now suggested for repeal by the GOP bill – are a mirage. They “move the chairs around on the deck of the Titanic”. The tax paid in column A is credited back in column B or passed on in higher health insurance premiums. There’s no new money except borrowed money!

Show Us the Entitlement Money

Republicans in the House of Representatives need to affirm healthcare is an entitlement and then develop a new funding source to pay for it. They are, after all, the “party of fiscal responsibility. Or, they’d like to have us believe they are?

The GOP (Study Group) should recognize that voters’ theoretical – i.e. gut reaction – to the idea of “government controlled health care” (2010) and their opposite reaction to getting a new health care “benefit”(2012) are both rational.

Voters are afraid of government mandates but will punish anyone who tries to take away a benefit bestow by those mandates once they’ve experienced it.

In 2016 voters supported “repealing” the higher cost of Obamacare era insurance premiums, co-pays and deductibles. They did not vote to give back the additional benefits received from Obamacare!

Accepting that a new entitlement exists does not mean the entitlement cannot be changed. The fact is that there are too many mandates, rules, and required benefits under the current law.

But any change made must demonstrate that is a fairer, better deal for a majority of Americans. Most Americans must be able to see and feel – experience – that the change is a better deal and be willing to pay for it, directly, or it is not going to work in practice.

Health Care Eco-System is Static

The CBO analysis completely misses the most compelling problem. Their analysis assumes the current structure is here to stay and that all reforms will be made through and not to the existing health care delivery model.

That assumption is incorrect.

The cost of health care services, drugs, appliances and anything else associated with the delivery of health care in America today must be changed – lest it bankrupt the nation.

The government is consumed by the question: How to pay for insurance premiums covering the unaffordable existing health care model?

At the same time, the American private sector (the consumer) is already experimenting with new models – more efficient and less costly.

Twenty of the nation’s biggest employers are banding together to create the Health Transformation Alliance aimed at using modern technology to control the rising cost of employee health care benefits. These employers, including American Express, Verizon and IBM (Watson) all understand the power of information to spearhead innovation.

These major employers are making an investment in reform because they remain committed to maintaining health insurance as a necessary employee benefit – calling into question, as well, the CBO’s 7th assumption.

These two CBO assumptions are incorrect. That means the 10 year projected cost estimate is reduced to pure conjecture.

14 Million More Uninsured in 2020

Not even the CBO “believes” this assumption.

Instead, they argue that an expanded range of choices in insurance products available to younger Americans – after the expiration of government mandates – will actually attract more young and healthy Americans to the non-group insurance market after 2020. This will positively impact the ratio of younger/to older Americans involved in the market place.

CBO projects a 10 percent reduction in overall insurance premiums as a result.

But – and here I agree with the CBO – the American Health Care Act – needs to be improved for older Americans still too young to qualify for Medicare.

These are people whose income exceeds the ridiculously low federal poverty guidelines – making them ineligible for Medicaid – who cannot afford health insurance premiums of $12,000/yr or more – that are only slightly reduced through $4000 “tax credits”.

Some of these people are, also, sicker and more expensive to care for.

A Roadmap for Dialogue

To their credit, the CBO has done an extraordinary job of laying out the challenges not just to the current House AHCA proposal but to the underlying problem of health care delivery costs, as well.

How much better off would the nation be if Congress – both Republicans and Democrats – were to embrace the cost estimate as a starting point?

“What-if” the ACHA were viewed as a bi-partisan starting point from which our health care eco-system is encouraged to evolve?

  • “What-if” Medicaid could be reformed and modernized into an attractive, affordable option for some middle-aged, middle income Americans as well as those too poor to pay health care?
  • “What-if” members of Congress were to work with all the stakeholders (from the President to the smallest tomato grower) to examine, question and rethink each CBO assumption?
  • “What-if” Congress started a discussion that engages provider, payer and patient in a singular effort to achieve better quality and lower cost health care for all – i.e. those who must rely on the health care entitlement and those who must pay for it?

But, as the CBO report cautions, it’s not possible to put such far-reaching improvements into place by 2020 as the AHCA requires.

Congress must learn from its past mistakes. Reforming the healthcare entitlement must be both bi-partisan and implemented over a 10 year time horizon that allows for intermittent adjustments as circumstances require.

Photo at US Capitol by Author — March 2,2017

Here’s What GOP American Care Act is not -- Affordable

Here’s What GOP American Care Act is not — Affordable

“If you want your legislation to last, it has to be bi-partisan,” — Ron Johnson, Republican Senator from Wisconsin, told the No Labels Problem Solvers Conference in Arlington, Virginia, on March 1.

He illustrated his observation, echoed the next day by my own Congress member, Anna Eshoo (Democrat – California), by pointing to Obamacare and Dodd-Frank. Both were rammed through Congress without a single Republican vote and are now targets of a Republican majority in Congress. Sadly, it appears the House Republicans have not learned the lesson.

Every comment made by House GOP leadership, the White House, and Republican members of the Senate point to a decision to ram the Budget Reconciliation Legislative Recommendations Relating to Repeal and Replace of the Patient Protection and Affordable Care Act through Congress on a party-line vote.

Once again, the victory will be pyloric and short-lived.

Healthcare is 20 percent of the United States economy. It impacts each and every American. It’s a huge problem and it can only be solved through a bi-partisan debate in full view of the American people.

Obamacare Impacts 330 Million Americans

Right after the conference, I shared a lunch table in the Longworth Congressional Office Building cafeteria with a couple from Mississippi.

Just as it does in almost every conversation in the Capitol, healthcare costs came up as we were just sharing our experiences from meeting with our representatives.

Owners of a small business, the Smiths described the difficulty they have in providing health insurance to their employees. The individual monthly premium is $400 a month – split 50/50 between the employee and the employer. “It’s the most we can do to pay half the cost.”

The median income in Mississippi is about $37,000/year – meaning a family of four participating in employer-based health insurance is paying 17 percent of their pre-tax income for health insurance. The policy has very high deductibles. In a word it’s “unaffordable”!

An average family of four in Mississippi is only a few dollars above the federal poverty line. But if their employer offers health insurance, they are not eligible to enroll in Obamacare – where the same monthly premium would be heavily subsidized.

Friday, standing, jet-lagged at my regular grocery store I was chatting with the man standing behind me in line. I said I’d been in Washington and the conversation, inevitably, turned to healthcare. He said he pays $1000 a month to cover his healthy family of four on an employer-based plan.

Before the Obamacare mandated changes in his coverage, he complained, he always had an annual preventive physical. Now, he has to pay $40 for the initial visit, $40 dollars for each of the routine tests and $40 for the follow-up visit. He concluded his prevent care is too expensive when prioritize against co-pays for his children. He figures he will go to the doctor when he gets “really” sick.

Nothing in the newly released GOP plan addresses either of the problems which these accidental meetings illustrate.

  • It does nothing to reduce the cost of health insurance because it does nothing to change the underlying healthcare cost crisis.
  • It does nothing to reduce the employer-based premium increases triggered by Centers of Medicare and Medicaid (CMS) Obamacare mandates.

Healthcare is an Entitlement

The Republicans’ most conservative members are still resisting reality. They claim that they must repeal Obamacare because the country cannot “afford another entitlement”.

Get over it.

  • Supreme Court ruled there is a universal right to care for all people at the emergency room door.
  • Once the government provides a benefit to some portion of the people – it cannot be taken away – only expanded in the name of equity.

But the conservative wing of the Republican caucus is partially right: The USA cannot afford another entitlement that is not paid for before and after it is granted.

Rather than repeating the mistake the Democrats made when they enacted Obamacare on a party-line vote the Republicans should take the time necessary to craft a bill that clearly addresses the coverage issues and is paid for.

A Down Payment on Reform

Paul Ryan must have been joking when he said “every American should read the bill”. Take a look here.

I read it but I didn’t understand all of it – just like most members of Congress!

Speaker Ryan surely recognizes the importance of slowing down the process of moving the proposed legislation to give his team a chance to garner at least some bi-partisan support for the plan.

That begins with the Congressional Budget Office (CBO) “scoring the bill”. How many people will get coverage under the American Health Care Act (AHCA) at what cost to the tax payer, and what’s the indirect impact be on employer-based insurance health insurance premiums?

CBO scores are notoriously inaccurate – over-estimating the benefits of legislation and under-estimating the costs. But they offer a starting point for a negotiation.

The current 120 page bill is nothing more than a “strawman” that will be modified by the long process of moving legislation into law.

In business the “strawman” plan is assumed to be a “starting point” — something that every member of the team can “take shots at” (debate and amend) in an effort to improve the proposal and, through participation, to encourage skeptics to “buy-in”.

For example, what-if Republicans (based on CBO estimates) offered to improve out-year Medicaid funding in exchange for Democrats supporting equal tax treatment for Americans with employer-based and private purchased health insurance?

No Democrats may come around to voting for the plan but, at least, the American people will see Ryan and his team willing to compromise to improve the bill.

Because of the limitations of the Congressional Budget Reconciliation process, the AHCA cannot address the underlying problem: the cost of health care. The reality is that no health insurance plan Congress generates can be affordable and effective without addressing the underlying problem.

To insure that Congress takes on the larger problem with urgency, the current bill must be amended to include concrete triggers guaranteeing healthcare cost containment legislation is written, investigated, debated and passed prior to the effective dates of AHCA.

For example Democrats get stronger drug pricing controls and the Republicans get malpractice reform.

Only by incorporating these guarantees in this first bill can we, the people, be assured the subsequent legislation will ever be introduced – let alone passed.

The battle ahead will be fierce — fiery.

Reimagineamerica will continue to observe, educate, clarify (if possible) and prepare each of you to be an active advocate in the battles to come.

Photo Credit: the author’s iPhone with thanks to MSNBC live broadcast

What Americans Don’t Want to Hear About Healthcare

What Americans Don’t Want to Hear About Healthcare

I decided against going to a Healthcare Town Hall Meeting with a local Congressman because I knew the outcome before the gavel went down.

There will be a lot of speculative hysteria surrounding potential changes to Obamacare benefits or changes to Medicare.

Let’s relax. Entitlements once granted never go away – they take on a life of their own.

What attendees won’t be told is that Obamacare is collapsing under its own weight – insurers are fleeing in droves unable to sustain the coverage losses they’ve experienced over the last few years.

Nor will they hear the Congressional Budget Office prediction; Medicare Hospital Trust Fund will be bankrupt in 2020 and the larger Medicare Provider Trust Fund will be exhausted in 2028.

But Obamacare and Medicare are not the problem – they are just a symptom.

Medical Bills Are Killing Us

In a seminal piece written for Time Magazine in the summer of 2013 Steven Brill laid out the problem in detail.

Medicine in 21st century America is big business. It’s very profitable for employees and stockholders.

The United States of America spends more on healthcare than the next 10 biggest spenders combined! Based on exhaustive comparative studies of Adult Welling Being the additional $650 billion a year does not result in better outcomes for Americans.

McKinsey Consulting studies have shown that the average private healthcare employer has a net operating margin (profit) of 16.2 percent compared to ExxonMobil’s 8.2 percent.

Spending for healthcare services, drugs, devices and facilities equals 20 percent of total USA Gross Domestic Product (GDP) or about $4 TRILLION a year – every year.

By comparison, the American Association of Civil Engineers estimates the total national backlog of needed infrastructure (airports, trains, highways, energy grids, etc.) will equal only $3 trillion by 2020.

Healthcare Spending is Out of Control

We see the headlines – EPIPEN price increases from $57 to $600 per prescription in a decade.

New York is the financial capital of the world – right? Wrong, of the 18 largest employers in New York four are banks and eight are hospitals.

We have heard for years that employer based (and private) insurer payments to doctors, laboratories and hospitals needed to be increased to cover the losses health care providers experience in serving Medicare patients, Medicaid patients and the uninsured.

If Medicare is “unprofitable” why does every major for-profit healthcare system aggressively pursue those patients? It’s simple. The Medicare payment formula includes a guaranteed percentage of profit!

It stands to reason, then, that if there are 23 million more insured patients the providers’ need to recover “uncompensated care” costs has decreased but medical spending continues to increase dramatically.

While healthcare is something we all need; we’ve come to expect someone else to pay for. On average, the patient pays only about 12 percent of the total bill.

That’s made us insensitive to prices and providers greedier. The escalating greed is reflected in the skyrocketing price of health insurance.

Medicare Cost Data for All

If we want good healthcare coverage with reasonable insurance premiums, Americans must become active consumers. We must advocate for a system without hidden costs.

If we want the impending debate in Congress to conclude with a better outcome than just “Obamacare2.0”, we, the people, are going to have to hold our representatives’ feet to the fire!

We must insist they begin with a comprehensive investigation of the underlying costs of healthcare.

Rather than focusing on perpetuating yet another “entitlement”, Congress’s objective must be to reduce the cost of care for all Americans – not just those who receive government subsidized care.

Brill argues that Medicare can compute the real (true) cost of delivering each health care benefit they cover. They reimburse providers based on cost of service delivery in the provider’s region in the country – i.e. cost of a day in hospital costs more in California than in Idaho.

Then Medicare applies a percentage of profit authorized by Congress to the provider. Cost plus profit is the contracted price Medicare pays to providers – no negotiation.

But Medicare is prohibited by Congress from sharing that cost data.

As consumers we have to start to shop for the best deal even if someone else is going to pay the bill!

As voters we must insist Congress allow Medicare to share their cost data — putting other insurers in a stronger negotiating posture with healthcare providers. The result would be a better deal for both patient and insurance carriers.

Manage Costs or Ration Care

As a nation, we cannot continue to fund a healthcare system that has no self-discipline. To do so would pass an immoral debt onto several generations of Americans not yet born.

If we are going to make the promise universal health care (not single payer health care) an affordable reality for all we must be willing to make changes in the ways we consume and pay for healthcare – that includes Medicare patients.

  • A redefinition of what health insurance is and what it pays for.
  • A reorganization of how we deliver healthcare to increase efficiency and reduce costs.
  • Rapid adoption of technology to both better determine diagnosis and treatment and to manage chronic disease
  • Greater transparency so that patients can make smarter decisions about where and how they will receive necessary care.
  • Greater transparency around the relationship of drug development costs and drug prices
  • Medical malpractice tort reform.
  • Identification of realistic funding sources for health insurance subsidies, Medicaid, Medicare and veterans’ health care.

The good news is there is a great marketplace of ideas about how to tackle all of these issues.

The bad news is that all of the good ideas are being drowned out by the political rancor on both sides of the aisles of Congress and the army of special interest lobbyists who feed that rancor.

Over the next few weeks, I’ll explore each of these opportunities with you – so that we can help our fellow citizens understand both their possibilities and possible perils.

It is up to us to engage our elected representatives in “fixing healthcare for all”, not fighting to score political points for the 2018 mid-terms.

Will Trump Administration End before February Does?

Will Trump Administration End before February Does?

Melania Trump’s decision to remain in New York until late spring may turn out to be prescient. Donald Trump may be joining her in New York sooner than any of us thought possible.

Every new administration makes a certain number of “rookie” mistakes in the first few weeks in the White House, but the Trump Administration’s errors in judgment and substance have no historic precedent.

This administration has become a Saturday Night Live skit – rendering the television show’s weekly realistic rather than comedic recaps – all-the-more frightening.

Many were alarmed by the chaos of the first two weeks that included unnecessarily inflaming our relationships with Mexico, Canada, China and NATO. http://www.reimagineamerica.org/good-grief-president-trump/

Twitter and other attacks on the judiciary were rebuked by the Administration’s own Supreme Court nominee.

On the Sunday news shows, junior adviser Steven Miller — made a maniacal claim that President Trump’s national security powers “will not be questioned” instead of apologizing for the botched rollout the President’s refugee pause. His performance was chilling rather than reassuring.

National Security Adviser – General Michael Flynn — deliberately lied to the sitting Vice President of the United States but was only forced to submit his resignation three weeks later after government officials “leaked” the facts to the Washington Post.

White House Chaos

It is axiomatic in our history that military leaders do not speak in public about their civilian leadership.

But only days after a meeting with President Trump, General Tony Thomas, the head of Special Operations Command, put his job on the line saying at a military conference “our government continues to be in unbelievable turmoil” while the nation is at war.

The general speaks for many in government and out.

It is apparent to anyone who has any management experience in either business or government that this White House lacks all the requisites for success – a strategy that the nation “buys into”, an experienced, competent, honest — and in this case unquestionably patriotic — leadership team and a disciplined management process.

Reorganize or Resign By February 28

Speaker Ryan has invited President Trump to address a joint session of Congress on the evening of February 28,2017.

If the President cannot turn White House disorder and disarray into order and calm plus resolve the lingering questions about both his and his aides competence and loyalty to the Constitution – his speech to Congress should be cancelled.

Instead he should resign.

In order to avoid a constitutional crisis the President needs to take a deep breath and start over again. He has to have the humility to ask for advice and help.

He has to have the good sense to follow the advice – especially when it comes from multiple sources within his inner circle, his administration, his political party, and from his constituents.

If I were Chief of Staff today, I’d give the President six pieces of advice:

  1. Lose the Twitter Account! Public policy cannot be conducted by stream-of-conscience.
  2. Develop a “thicker skin”. Whatever the issue, it’s really not about you, it’s about the American people
  3. Build on your strengths and minimize your weaknesses. Be a CEO — delegate operational management to (COO)Mike Pence retaining responsibility for setting the strategy, making “big deals, and messaging.
  4. Engage the “Presidents’ Club”. Ask each of the five living ex-Presidents for their candid advice and their help in finding the experienced people needed to “shore-up” the administration.
  5. Develop positive working relationships with leadership of both parties in Congress.
  6. ABOVE ALL, come completely clean today about any relationships with Russia or Russian interests that you, your family, your campaign team or anyone remotely associated with your government has now or has ever had.

Breach of Trust

If you are to govern the United States and to have the respect of world leaders – friend and foe, alike – you must have the absolute trust of the national security and intelligence communities and the American people.

Leaks over the past few days from various intelligence sources to respected news media outlets are nothing short of alarming. The leakers claim they are withholding information for fear that sensitive intelligence could be compromised. https://www.wsj.com/articles/spies-keep-intelligence-from-donald-trump-1487209351?mod=djemalertPolitics

Congress and the FBI must have immediate access to whatever people and documents are required to conduct public hearings that will allay the concerns of all Americans about any possible connections to Russian intelligence organizations and personnel by any member of your campaign team, the Trump Corporation, the Trump Administration or Trump family members.

This includes release of all Trump tax returns!

With all due respect, Mr. President, if you are not willing to cooperate completely to resolve all possible conflicts that could compromise the Trump Administration in dealing with the Russian government – at noon on February 28,2017, you should board the Trump Inc. plane and return to your private life in New York.

We’ll be just fine without you!