Archive for the ‘Cross State Lines’ Category

Is Healthcare Reform dead? Maybe, but the President promises to sign Exec Orders allowing for health plans to be offered through Associations. It could be that now is a good time to discuss selling cross state lines.

October 12, 2017

It sounds as though President Trump may sign executive order(s) this week or next that would permit the forming of association health plans (AHPs) that would provide plans for employers and/or individuals. Years ago we called them Multiple Employer Trust (MET) or Multiple Employer Welfare Arrangement (MEWA) and so forth. They provided affordable competitive alternatives that could be easily sold across state lines.

If AHPs, METs and MEWAs are well managed then why not give employers more alternatives to lower cost and improve benefits? We’ll discuss AHPs in more detail next week after President Trump signs and releases the details of his Executive Orders allowing for AHPs.

The President states that his Order will allow for selling cross state lines which is the topic of today’s post.

When discussing the prospect of selling health insurance cross state lines, during the heat of HCR earlier this year, there were objections to this idea, some reasonable. Now, given the status of HCR in Washington DC and the probability of no significant reform, maybe we should kick this around a bit, and debate the reasonable objections.

One objection, to selling cross state lines, was a fear that sub-standard benefit plans might be offered which if sold to unsuspecting employers could lack benefits, ;eave people hanging with large medical bills and cause problems. Clearly, some folks have gotten comfortable with the pre-set benefit designs of ACA even with their increase cost and inflexible nature of only having 4 “flavors” from which to choose.

The opponents of selling cross-state lines were/are afraid that carriers would build plans in one state with stripped-out benefits and lower cost then sell those plans in another state. The purchaser might think they are buying a “gold or silver” plan but under closer scrutiny would be getting something less.

The goal of lowering cost and providing alternatives to the rigid expensive metallic plans is appealing but one must admit than when more alternatives are available the potential for confusion is there.

The opponents other reasonable objection is that if lower cost plans are offered cross-state lines that it might imperil the financial stability of in-state plans. Examples of in-state plans could be plans associated with the Blue Shield and Blue Cross organizations but one could add many HMOs which tend to be landlocked so to speak. These in-state plans often have large market share and wield political clout within their state’s legislature.

If plans with large market share, such as the Blues or HMO, experience group migration to lower cost plans, offered by AHPs or plans from other states, then their revenues could be reduced. But, would their profitability be impaired? The fact is that well designed, properly presented and purchased lower cost plans could pull groups away from large in-state plans. In business that’s called competition, isn’t it?

Another obstacle, maybe the biggest, cited by opponents is that you have 50 independent state insurance commissioners most of which don’t want to relinquish any control over the plans in their state. It’s a turf thing. Some of these Insurance Commissioners, especially ones from large liberal states, do not want to see any plans compete with their state’s ACA Exchange. They will resist AHPs and selling cross state lines.

Shouldn’t we consider the idea of selling across stateliness as a chance to increase competition and lower cost? Clearly, it would allow smaller insurers, that are excellent companies but not household names, compete with the huge carrier names we all recognize.

One step that would be easy and helpful is to expand the ERISA Preemption which would allow small employers to get access to great self-funding plans.

Self-funded plans are regulated by ERISA and managed by the Department of Labor. Insurance commissioners only get to rule over the “fully insured” insurers in their states so ERISA plans will be largely free from the heavy burdens many states put on fully insured plans.

However, many states have recently enacted bills to “kill” self-funded plans and prevent smaller employers, with 100 or fewer employees, from getting access to these plans. These state by state “option killing” rules would need to be addressed.

For example, California established arbitrary rules, under Senate bill 161, that mandate how self-funded plans can be priced. Proponents of SB161 admitted that the purpose of this stifling legislation was to prevent smaller employers access to stop-loss plans by making the prices too high thus forcing smaller employers to buy the Exchange.
It was a double blow to employers however because employers did not go to the Exchange because it is not competitive yet were/are blocked from competitively priced self-funded plans.

ERISA and its State Preemption capabilities could be expanded to make it easier for fully insured plans to market across state lines. It could reduce the burdensome processes and long approval times by insurance commissioners and allow more flexibility.

We have all heard the statistics that 1/3 of the counties in the United States have only one insurer offering plans. Expanding ERISA could give the folks living and working in those counties some well deserved relief.

How could insurers offer lower cost fully insured plans yet still offer benefits comparable or richer than the benefit mandates of Platinum, Gold, Silver, etc.?
It’s easy and affordable. It should have been done already and could be accomplished tomorrow with the right vision.

Next week we’ll discuss the details of the President’s Executive Order concerning AHPs and just how to make these affordable (lower cost) alternatives compliant!

Let me know your ideas for selling cross state lines OR your reservations about doing so. I’d love to get your input.

We might as well air this option out a bit because we’re all in this together.
Until next week.

Mark Reynolds
559-250-2000
mark@reynolds.wtf

 

The calendar once again makes its call. For me – Platrix Chapter 2, “Queen of the Cow Counties” No one can resist the call.

October 5, 2017

Two times each year your humble author retreats from his solemn duties to Trek to
E Clampus Vitus, Platrix Chapter #2, that most ancient and honorable group. This is one of those times, kid. Would you like to read just a bit about The History of ECV.

E CLAMPUS VITUS is said by its adherents to be the most ancient of all fraternal orders. It’s founding, as the tale is told, was coeval with the origin of the human race.

It is related that in 1852 Steamboat Jake. a merchant from Yreka, thinking to improve his business by fraternal affiliations, made arrangements through certain Clampers for initiation into the Masons, the Odd Fellows and E CLAMPUS VITUS at one bargain priceof $98.50. When the various brethern were assembled at the Hall of Comparative Ovation and Jake, bound and blindfolded was brought to be initiated, the question arose as to which Order should first apply the branding iron. It was agreed that the oldest should have priority.

 The Odd Fellows presented their claim for that honor, stating that their order was created by a charter issued in the form of a golden tablet by the Emperor Titus to his Jewish Legion in the first century A.D.

 The Masons disputed the claim, relating the scholarly history of Reverend Dr. Anderson to prove that the Grand Master Moses often marshalled the Isrealites onto a regular and general lodge whilst in the wilderness, and that King Solomon was “Grand Master of the Lodge at Jerusalem”.

 The Noble Grand Humbug of E Clampus Vitus then rose and confounded the rival oraganizations with proof abducted from the unimpeachable unwritten works of St. Vitus, the final authority in all such matters, that E CLAMPUS VITUS was founded by our Clampatriarch Adam himself in the Garden of Eden, and that the original Staff of Relief, which figures so greatly in the Clamper ritual, was a branch that Adam broke from the Tree of Knowledge and smuggled out with him, hidden beneath his apron, when he was driven from Eden. All present in the Hall agreed that such antiquity was beyond compare.

The senority of the Clampers was recognized, and Steamboat Jake accordingly was given into the hands for initiation. It is then told that by the time they were through with him he had lost all desire for further fraternal connections.

 The unsurpassable antiquity of E CLAMPUS VITUS has been recognized and proven on many occasions. There are those who claim they can trace it through the times of the Old Testament and the beginnings of the Christian Era when its rites were conducted in the catacombs of Rome and referred to as the “Enigmatical Book of Vitus” and the “Curious Book of the Clampers”. These tales tell how it was spread through Europe by the Frolicking Friars, and carried to the Orient by the indomitable Vituscan Fathers.

According to the Clampers, the introduction of the order into the United States has long been shrouded in mystery and legend. Only recently has the true history been traced by the Royal Platrix Chapter and the Archivist of the West Virginia Lodge. The result of this research supposedly proves by documentary evidence that the secrets and symbols of E CLAMPUS VITUS were imparted by the Emperor of China, Tao-Kwang, Great Hotchot of the Chinese Grand Lodge to Caleb Cushing when the latter visited China in 1844 to negotiate the first treaty between the United States and the Celestial Kingdom. Cushing was specially charged by the Emperor to deliver the secrets and signs of authority to Ephrairn Bee, innkeeper of Bush Creek, Boone County, Virginia, to be disseminated by him at his descretion among the fellow citizens so that the Chinese and American People might henceforth be united by the Bonds of Fraternal Brotherhood as well as by the more formal ties of diplomatic relations. By virtue of his authority, Ephraim Bee traveled about his native state organizing lodges of E CLAMPUS VITUS in villages and county seats. 

It is also said that among others, a number of drummers were taken into the order, with or without authority from Bee. These travelers took the gullible villagers and townsmen along their routes into the Brotherhood, until by 1849, the East and Middle West were dotted with Clamper Lodges. From these Lodges many lusty Clampers went West in the Gold Rush and founded the historic lodges in the mining camps that constitiuted themselves as guardians of the morals of these communities.Their duty as they saw it was to prevent the preachers and pious wives who followed the 49′ers, from imposing any excess of morality that might hamper the full enjoyment of life. How well the Clampers performed this function is commonly known, despite the lack of written records. This lack of written records is attributed to the circumstance that during the meetings there was never anyone capable of keeping the minutes and that afterwards no one remembered what had taken place.

As E CLAMPUS VITUS mushroomed along with the rapid growth of the gold towns, it declined as rapidly as they did, and, therefore, lived only in the memory of a few ancient dwellers in the mountains and in the annals of the county histories until, in 1930, when a new prophet, a second Ephraim Bee , appeared in the person of Carl Wheat to reorganize the historic organization. 

Members of the Ancient and Honorable Order of E CLAMPUS VITUS have always been adventurers and many have been leaders in conquest of their respective countries. The most noteworthy of that band of stalwarts was Juan Rodriquez Cabrillo, a doughty explorer in the service of the Spanish Empire, who on October 19, 1542, raised the Spanish Flag at a point near the beach city of Hueneme in Ventura County and took possession of the land in the name of the King. Cabrillo is buried on San Miguel island and some Clampers make an annual pilgrimage to his grave. 

Sir Francis Drake was a Clamper but not in good standing because of his piratical exploits until June 15, 1579, when this bold bucaneer reached California in the famous ship, the “Golden Hind”, and anchored in Drakes Bay where he raised the English Flag and took possession for Queen Elizabeth and called the land New Albion.

Then Spain decided to occupy California to protect her colonial possessions, so two courageous Clampers were selected for the expedition: one was Don Gaspar de Portola, and the other was Father Junipero Serra. These men raised the Emperors flag at San Diego on May 17, 1769.

After Mexico revolted from Spain, an admirable Clamper, General Antonio de Santa Ana, ordered the flag of the Mexican Republic raised at Monterey on January 7,1769. 

John Charles Fremont was a peritatetic Clamper and he raised his ensign as Captain of the United States Topographical Engineers above every camp that he made in California during his expeditions between 1844 and 1846. That flag is now in the custody of the Southwest Museum in Los Angeles. 

On June 14, 1846, a Sonoma group of justly indignant Clampers rebelled against the aggression of Mexican officials. They captured the garrison at Sonoma, issued a clampotent proclamation declaring California to be an independent republic and raiseda crudely designed but historic Bear Flag.

 Clampers played an important part in the history of California in the nineteenth century because the American membersof this Order worked in unison. Commodore John D. Sloat in command of the Pacific Squadron of the U.S. Navy captured Monterey and on July 7, 1846 he instructed a fellow Clamper William Mervine to raise the flag of the United States above the customhouse. When Fremont learned of Brother Sloat’s coup he ordered the Bear Flag struck at Sonoma and replaced by a 28-star flag of the United States.

It is manifest that Clampers have been leaders throughout the history of California and the flag-raising members of the Order of E CLAMPUS VITUS have contributed glamor and deeds of courage and gallantry to our heritage. It must be noted however that this history has never been proven.

 CREDO QUIA ABSURDUM – BECAUSE ITS ABSURD I BELIEVE
QUOTED FROM E CLAMPUS VITUS, THEN AND NOW, 1852-1979

As for me, I’ve been a “clamper” since 1992 at the Tehachapi Loop.
How many of you are Brothers of the Order?

Next week, we’re back to common sense ideas for healthcare reform. Promise!
Until then remember, we’re all in this together.

Mark Reynolds, RHU
559-250-2000
mark@reynolds.wtf

 

Graham-Cassidy Healthcare reform bill: sure, it’s dead but was it just AHCA 3.0? Let’s look closer.

September 28, 2017

Not living nor making my living with in the political pressure constant in Wash DC it’s hard to look at this new GOP effort, the Graham-Cassidy bill, without a healthy bit of skepticism.

Why is that? Have you ever witnessed some one make a decision based upon desperation or a willingness to “settle”? We all have. It’s common in personal relationships, it’s frequent in business decisions, and it’s compulsory in politics.

The Graham-Cassidy bill GCB) looks and feels a lot like a political effort to avoid “doing nothing” and facing constitutes after having made the promise to “repeal & replace” the ACA. If you were a GOP legislator up for re-election in 2018, especially in the House, do you want to go home  at the end of the year to face those who trusted you when you said “Obama-care must be repealed”? Of course you wouldn’t, no sane person would. But, we’re talking about politicians not sanity.

Here are a couple of points from GCB for reference:

  • Says it repeals the Individual mandate but truthfully only reduces penalty to zero. If you don’t want to buy, don’t worry, no penalty.
  • Says it repeals the Employer mandate but truthfully only reduces penalty to zero. If you don’t want to provide coverage, don’t worry, no penalty.
  • Maintains guarantee issue with no pre-ex while reducing penalty to zero for no coverage. Like the other GOP attempts this adds the burden to premium calculations and to premium payers.
  • Eliminates only the medical device tax while leaving all the others such as the Cadillac tax. Why not eliminate all the taxes.
  • Maintains Medicaid expansion and its subsidies but does so in a block grant manner.
  • Converts Federal subsidies given to states into Block grants so states can use as they please. Giving states flexibility sounds great but this may create chaos between states.
  • Gives states freedom to determine Essential Health Benefits and how block grant funds are to be spent. This sounds good except for the poor souls in liberal states like NY and Ca. who will see those funds spent on more freebies and no accountability.

There are countless other provisions that are a mirror of the two previous failed GOP attempts but I won’t burden you with this.

So, the language you will hear from supporters will be:

  • This is our last chance to get rid of the evil Obama-care.
  • If we don’t do something now then we won’t have another chance.
  • Doing something is better than doing nothing
  • Choice is clear, you’re either for Socialism or federalism.

If this effort fails the GOP folks can return to their districts and tell their supporters that “I tried but we just did not have enough votes” “Re-elect me again and we will continue our fight to repeal the evil liberal OB-care”.

Then, what are we suppose to do, vote for a Democrat or not vote. This is political baloney at its worst or best depending on your perspective.

If the GCB passes its initial vote in the Senate it will still face an incredible battle in the House. Plus remember that the House GOP is in a worse pickle that the Senate so they will try to flavor the baloney to their best interest.
I actually give it a 60/40 probability of passing the initial Senate vote.

OK, enough huh? Let’s watch this debate (debacle) unfold. It does not need to be this way but the swamp has not yet been drained, as they say.

Until next week, we’re all in this together.

Mark Reynolds, RHU
559-250-2000
mark@reynolds.wtf

Two things that unite us as Americans: One is the start of the Football Season. The Other is Catastrophic events like 911 and hurricanes.

September 14, 2017

This week’s Post about PCORI, established in 2010 by the ACA, was printed, polished and ready to go until about 6am this Monday morning. That’s when I started watching the news that was showing the various memorial services to 911 on the East coast. It reminded me again of how united and how resilient the people of the United States are when times are tough.

Recently, we have all been saddened and heartened with the stories from Hurricanes Harvey and Irma. The pictures and interviews display how Americans of every race and origin willingly help out other Americans of every race and origin when the time comes.

The 911 memorials today may become a bit smaller in years to come but if and when the next event occurs we know that Americans will not hesitate to jump into the fight to help others when needed.
To quote the famous philosopher and great fiddle player Mr. Charles Daniels: “you just go ahead and lay your hands on a Pittsburgh Steelers’ fan and I think you’ll finally understand”.  Which means, that Packers fans and Cowboy fans or Dolphin fans alike will step up to help a fellow American when outsiders bring trouble to the United States.

As I watched a few of the speeches this morning it made me start to think about how, as Americans, we are resilient and we are resolved to the actions needed to protect ourselves and others from future harm. Americans will do what needs to be done if given good leadership and good planning.

However, over the past 16 years, plus the 10 years prior to 911, it seems that politicians often forget this aspect of our citizens and instead start thinking about their next election. Political correctness, identity politics, and a complacent culpable media add to the danger we face.

But this week instead of PCORI, the ACA, the media or politicians I want to focus on the core strengths we have as Americans. Those strengths that led our ancestors to leave their original homes to traverse across great oceans and  mountain ranges to build the greatest country the world has ever known.

The past 4 weeks have shown us how we come together when times are tough. The memorial ceremonies for 911 show us how we come together as a nation when attacked. Now, we just need to maintain that steadfast resolution on a day-to-day basis. Help your neighbor when they need it, forgive that careless driver that cut you off this morning, and continue to pray, praise and donate to our fellow Americans who need our help.

Let me finish with a thought about the idea that the football season being a factor of unity. Some may disagree (probably soccer fans) but for six months each year three hundred of million American come together to root for their favorite team or teams. Whether its high school, college, the NFL or even Pee-wee or arena one must admit that we are avid fans. Heck, look how many people watch the Super Bowl each year (without any rioting in the stands).
So, back your favorite team which I know for all of us is Team USA.

Next week, we’re back to common sense solutions for healthcare, OK?
And remember, we’re all in this together.
Until next week,

Mark Reynolds, RHU
559-250-2000
mark@reynolds.wtf

Promoting “polls” that suggest a change in “favorable vs. unfavorable” opinions is the new technic to support the ACA. Can we trust these polls?

September 7, 2017

You’ve probably seen them, too. Polls that show the “favorable” opinions about the ACA increasing dramatically. Since the introduction of the failed House and Senate bills to replace the ACA more articles are stating that opinion polls are showing the “favorable” attitude about the ACA increasing.

Who in the world did these polls approach. And I do mean “in the world”, because if anyone likes the ACA better now than before January 2017, they must have been people from other world counties. Another likely scenario would be that the polled population was previously uninsured who are now covered by either Medicare expansion or a state exchange with full or nearly-full subsidy.

Who could find the ACA more favorable after 7 years of:

  • Double digit premium increase (100%+ in many areas)
  • 50% fewer providers in the PPOs
  • Crappy benefits with higher out of pockets
  • Limited number of insurers

The answer is that no one would find the ACA more favorable unless:

  • You paid premium before but now it’s paid for you.
  • You were uninsurable before and had no coverage.
  • Had no coverage before but what the heck – its free now.
  • You are Harry R or Nancy P or Z Emanuel or J Gruber.
  • Or one of their relatives (even that’s unlikely, though).

The key to the outcomes in these kind of polls is often the format in which questions were formulated to meet the desired outcome of the pollster. In a sensitive issue such one’s health care it is easy to ask a yes-no question in a manner that leads the subject to the answer desired.
For instance: if I asked you “Do you think it’s fair for insurers to decline an applicant for coverage?” you could easily say NO. But, would your answer change if you knew that the applicant had several opportunities to enroll before but chose not to until just recently after a negative diagnosis was received?

Our citizens are smarter than politician think, or want for that matter, so they know what should be done. However, if they are polled with questions impossible to answer then it skews the outcome. As Ms. Vido, in My Cousin Vinny, said “It’s a bullshit question”. By that, as she goes on to explain – “It’s a trick question. No one could answer that question.” So how are we to believe these polls?

Or let’s say you were asked – “Sir, do you still beat your kids?”. Of course you don’t because you never have but you must answer yes or no. The point is that professional pollsters conducting polls for entities with certain agendas can make the American public seem like it supports or does not support an issue based on the specific outcome desired.

So, don’t you find it difficult to believe that any American would answer that he/she is more favorably inclined toward the ACA today than they were 1 or 2 years ago? Unless, it was because they were among the citizens outlined above.

I know I can be a skeptic or even a cynic, as I’ve mentioned before, but some things are beyond giving the benefit of the doubt.

Now, if you were to ask people the following questions you could be sure of people’s true opinions:

  • Do you think premiums increasing 100% per year is reasonable?
  • Do you think insurers should be subsidized by the government.
  • Do you think PPOs with half the Doctors carved out provide good service?
  • Do you think the premium you pay should be tax-deductible?
  • Do you think people who choose not to enroll should be GI with no Pre-ex later?
  • Do you want your plan to cover pediatric dental if you are a single 50 yr. old male?
  • Do you think healthy working-age people should get their coverage for free?
  • Do you think the Congress should have been better prepared to offer a replacement plan for the ACA?
  • Do you think calling the House or Senate’s bill a “repeal” was an assault on your intelligence?

I guess I got on to another rant there for a moment but you get my meaning. It is very difficult to believe that tens-of-millions of our hard-working premium-paying citizens would find the ACA more favorable today than they did a year or two ago.
But, what do you think?

Until next week, just remember that we’re all in this together.

Please keep praying for the folks in south Texas and Louisiana. They have a long haul ahead.

Mark Reynolds, RHU
559-250-2000
mark@reynolds.wtf

Have you ever felt the need for a good rant? I mean a real kick-in-the-a__ good old fashion rant.

August 17, 2017

If one thinks about our politicians and how they should fix our healthcare finance and delivery system it can lead a person to a good rant. I’m sure you agree.
But first, let’s make sure we’re all on the same page here. So, just for clarity’s sake, let’s define what I mean when I say “rant”.

Definition: Rant

VERB
  1. speak or shout at length in a wild, impassioned way:
    “she was still ranting on about the unfairness of it all”
NOUN
  1. a spell of ranting; a tirade:
    “his rants against organized labor”
There, now we can read on without fear of missing the point of my tirade, diatribe and fulmination. Besides, sometimes don’t you just need to say “WTF”?
I’ve promised before that we could resolve the whole healthcare reform issue in 45 minutes if you just put me in a room with 4 other people I know and let us map out the steps to increase access, improve benefits and lower the cost of healthcare without leaving any citizen behind. OK, Maybe 90 minutes.
I realize that sounds brash and vain but in the absence of political pressures I believe that statement is 100% true.  Give us a policy wonk to write it all up in proper form and it would be done.
We know that won’t happen, of course? So, let’s take a few moments to identify some of the dopiest, self-serving, and even cruel aspects of what we have witnessed from our politician’s approach to helping America improve its healthcare financing and delivery system.
7&1/2 Years – Just by stating 7 & 1/2 years you know exactly what I mean. If you had over 7 years to plan something would you have a better action plan than the GOP did on Repeal & Replace? Of course you would because you aren’t a politician with no accountability.
Think of what one can achieve given 7&1/2 years:
* Graduate from High School and finish 4 years of college.
* Meet, court, and marry the mate of your dreams.
* Plus get divorced if you follow the national averages for marriage.
* Give birth to 4 kids-one at a time. Crazy but achievable.
* Join the military and do 3 tours in some hell hole location.
* Find your dream job, tire of it, quit and move to another state.
* Vote for your Congress-person 3 times
* Note for your Senators once
Overall outcome – Our country is getting screwed by the vary people we elect to make our lives better and safer!
Individual mandate – to appease the insurance industry for forcing it to accept anyone regardless of health without any wait for covering pre-existing conditions this mandate was promised to get every citizen covered. But, instead of making it workable the penalty was set so low that no one worried about it. The result, as expected, was that only the very sick and people who would have bought insurance anyway actually bought insurance. Then to make it worse add a rule so that people who did not buy could buy later after the Doctor delivered a costly diagnosis.
Overall outcome – premiums for individual plans increased over 100% since 2013.
3:1 Premium ratio – The promise was that changing this ratio from the traditional 5:1 ratio that insurers would lower the cost of premium for older folks in their 50s and 60s. The problem was, of course, that with GI and no pre-ex the insurers naturally increased the rates they thought they needed to cover the folks in their 50s & 60s. Then the simple affect of 3:1 math  kicked in increasing the premiums on the least costly, least likely to use their plans and on those most likely to go without coverage. That being young healthy people in the 20s and early 30s.
Since the penalty for no coverage was less than a month’s worth of Starbucks for some people and the youngsters knew that they could buy insurance later, if they needed to, anyone could have projected the result.
Overall outcome – premiums increase for younger folks as well as older folks.
Insurer Subsidies – Since insurers were being forced to accept everyone, regardless or health or previous coverage, and pay for almost everything, and I mean everything, this provision was included to “insure” the insurers that they could make money in the new world of ACA. Of course, insurers rely on actuaries and actuaries need to CYA which meant that they would price and build plans with the premiums they thought they would need. In addition they developed the idea to slash 50% of the doctors fro their PPOs to further reduce the potential for members to incur claims.
Overall outcome – Premiums increase as though there were no subsidies promised. Plus, now insurers are unsure if President Trump is going to release the subsidy payments so rates are being increased even more.
* Footnote: many health insurers are showing huge profits and the price of their stock has increase 30-50%. Check out the rise in stock price over the past 2 years for UHC, Anthem, Aetna, and Centene. Insurers have increased premiums and changed their plans/networks so much that it can be argued that they don’t actually need the subsidies.
We should call this a “corporate entitlement program”.
Subsidies in State Exchanges – the concept of a market place where individuals could shop for the best coverage for their families sounds like a noble idea. But, when you pair that with premium subsidy for enrollees who have incomes higher than Medicaid enrollees the idea loses its merit. It is reported that 90% of citizens covered in State Exchanges have their premium paid by the ACA. This causes several problems. The insurers can theoretically charge whatever they desire because they know the ACA is paying for it. But at the same time insurers must overcome the GI and no Pre-ex provisions. Add to that, limited choices, few insurers participating, narrow networks, and poor marketing to really damage a good idea.
Overall outcome – Covered members are “hooked” on their subsidy yet get very little choice in their coverage. Many states have no insurers while states with functioning Exchanges offer very limited choices. On top of that the premiums for these plans continue to increase by double digit.
SB 161 – this is a California law but other states have similar legislation. SB 161 effectively eliminates Self-funding with Stop Loss re-insurance as an option for employers with fewer than 100 EEs. Self-funding could be effective at maintaining rich benefits and  lowering cost for both employer and employee but SB 161 eliminates that potential. California implemented SB 161 specifically to eliminate competition to its ACA Exchange for group plans, called Covered California. Very few employers have purchased their group plans through Covered California so the effect was detrimental to small employers.
Overall outcome – Employers with fewer than 100EEs lost because they no longer have self-funding as a reasonable alternative for the increasing cost of fully insured plans. The insurers no longer worry about the competition to their plans from employers self-funding with stop loss. Big loss for small employers!!Expanding Medicaid – since we’ve written about this so recently I won’t bore you with too much. Medicaid expansion was promised to be the means for poorer citizens to get coverage because they could not afford to pay premium regardless of the price of the premium. It was designed as an entitlement program. Clearly this has affected the Repeal and Replace efforts of a spineless Congress as well as Governors unwilling to give up the 90% Medicaid reimbursement..
Overall outcome – it has made it politically risky and therefore impossible for the GOP to keep the promises it made over the past 7+ years. It means that middle-class Americans are screwed for the foreseeable future, doomed to see their benefits erode as their premiums and out of pocket costs increase.

I could go on for a while, maybe for hours, but you can see by the subject matter that things are mucked up. I always get some good feedback to our Posts so if you can add anything to my list I will appreciate it.
Alright, that’s my rant. I can’t say I feel any better but I know I’m not alone in my opinions or emotions.
I know we’re all in this together so I hope it helped you a little.
Until next week.
Mark Reynolds, RHU
559-250-2000
mark@reynolds.wtf

Surprise-surprise, the Senate failed to pass anything for Repeal and Replace. Now, What? Here’s an idea for the White House to consider.

August 3, 2017

You have read it here before that I think creating a real solution for reforming healthcare is simple and straight forward.  I know that sounds naïve given the complexity of healthcare financing and delivery as well as the influence of political correctness and our politician’s drive for self-preservation.

But for the Trump Administration, now would be a perfect time to submit to Congress a complete package of reform to replace the ACA with a reform package created from real world workable solutions.

I’ll outline the ideas below but to set the table we suggest that the title and first line of the bill should be, in legislative speak, “The following repeals entirely the Patient Protection and Affordable Care Act including all of its subsequent regulations, etc, etc, etc. & so forth”.

That title does not mean that we will not implement or retain certain portions or aspects of the ACA such as kids to 26, guarantee acceptance, and so on. But, we will abandon all of the taxes, the mandates, the public exchanges, restrictive rating rules such as 3:1 premium ratio and the Minimum Loss Ratio.
But, we begin with a framework that will meet the intent of all good Americans.

After you read the Basic 12 we’ll talk about the folks included under the Medicaid Expansion.
Here are 12 basic ideas that frame a bill to replace the ACA:

  1. Make health insurance premium 100% tax-deductible for anyone who pays it.
  2. Make all fully insured plans for individuals and families guaranteed issue but with a reasonable Pre-existing period for no coverage for prior 63 days.
    * Pre-ex period: 6/12 months, which means no coverage for that specific condition    for 12 months if treated within previous 6 months.
  3. Group plans of 2+ employees remain guaranteed issue with No Loss-No Gain Take over. This would follow the Pre-ex explained in #2.
  4. Allow carriers a reasonable corridor for Risk Adjustment Factors (+or- 15%). Also let insurers determine their area rating factors based on their data and statistics.
  5. Tort reform: Loser Pays and/or Fixed Attorneys at 15%.
  6. Eliminate mandated benefits such as the Metallic Plans
  7. Allow carriers and plans to sell across state lines. (Expand ERISA preemption)
  8. Re-insurance Pools designed to help insurers price their plans without the detriment of people “gaming” the system or to others in the system.
  9. Make HRAs and MERPs permissible and available to implement on all plans.
  10. All insurers must publish and release statistics and experience data.
  11. Health plan commission set at level 7%, does not increase as premium does and use universal enrollment forms for all group plans and all individual/family plans.
  12. Providers must post their rates per service. Hospitals must post their outcome statistics as well as infections, error rates, and other outcome data.

You see that I did not include the Medicaid Expansion coverage above.
I would leave the current Medicaid Expansion with Federal subsidy in place for two years following enactment. Then, starting January 2020 for example, reduce the Federal match for the Expanded coverage by 15% per year until it equals the Federal match standard for each state’s traditional Medicaid population: the disabled, the poor, and pregnant woman.

Each state then has a few years to determine for its own citizens if or how it chooses to provide subsidies for the able bodied working age folks that sought coverage on Medicaid under the ACA. States may even decide to let their folks use the state’s subsidy to pay for the plan the citizen chooses instead of forced enrollment on a crappy Medicaid plan. Folks on Medicaid would appreciate that freedom.

We also need to allow employers to build incentives to support wellness plans. If we want to bend the cost curve downward we must address behavior and expectations through real wellness and benefit structure.

So, that can be the Trump Administration’s starting point.  It would eliminate mandated benefits and dopey pricing rules that automatically increase premiums. It would eliminate mandates, taxes, and guidelines that choke off competition.

It would retain the perks implemented the first 3 years of the ACA such as kids staying on parent’s plans, guarantee issue and no penalties for pre-existing conditions. Plus, it would encourage competition by giving insurers an incentive to participate and compete which will bring down premiums and keep the benefits we all know we want.

So that you don’t think I’ve gone completely crazy I should say that I don’t think any of the above will happen. To be sure, there will be lots of hand-wringing and belly-aching about the failure of the ACA but no real action will be taken.
Remember, I’ve previously confessed that  I’m an optimist trapped in a cynic’s body.

And sorry for that opening in the title “Surprise-surprise”. I was not trying to imitate Gomer Pyle. (Maybe that’s too dated for you younger readers). It was my attempt at sarcasm for having any hope that Congress could get anything meaningful accomplished.

Well, that’s it. Let me know what you think and what you would add to make it work.
After all, we are all in this together!

Next week we’ll have a suggestion for Congress in lieu of repeal and replace.
Until next week,

Mark Reynolds, RHU
559-250-2000
mark@reynolds.wtf

What would the consequences be if the GOP passes NO legislation to Repeal & Replace? Let’s look at the impact on insurance coverage.

July 27, 2017

As I write this post, the Senate has voted to open hearings and take amendments for the Senate’s R&R bill. Basically this is the Senate’s last effort do accomplish anything  for now on Repeal & Replace. Without being pessimistic, I would wager that the smart money will be bet on nothing coming of this.

Regardless of one’s political leaning everyone must agree that action is needed to either replace the ACA (with something better) or make repairs to the ACA (that will keep it alive). I realize that is a big summation but if we are honest then we must conclude that the ACA is failing so one way or another action is needed. Either for the benefit of the millions of Medicare Expansion subsidized enrollees or for the tens-of-millions of premium paying citizens and employers, the ACA needs either fixed or replaced.

So, what would the consequences be if our House & Senate don’t do anything. That is, if they don’t provide or modify the subsidies for the insurers and all of the other ACA issues that need changed to survive or don’t replace the whole darn thing, then we will see a number of absolutely predictable results.

Of course, the Politician’s thoughts will immediately turn to their own future and the 2018 elections (probably have been already) but I want to focus on the impact to all of us, the hard-working premium paying, mortgage paying, car payment making, tax paying citizens. It won’t be good but let’s look at it:

  1. Regardless of whether or not the subsidies of the ACA are paid to insurers we will see:
    a. Premiums for individual plans increase double-digit (20% or more) and be projected to continue for the next few years.
    b. The Counties without an insurer for the individual ACA plans will continue to increase. It’s projected that as many as 1/3 of all counties will have no individual ACA plan available. In the more rural states we could see the number of counties with no individual plans exceed 80% of the counties within those states.
    c. The number of insurers willing to even offer plans anywhere in the country will decline, including those insurers offering plans outside the ACA Exchanges for both group and individual plans.
  2. Medicaid enrollment will continue to rise. Even though Medicaid plans provide lower benefits and there are fewer providers, most people don’t realize those facts until it’s too late. Besides, the idea of “free insurance” will become more and more appealing as premiums continue to rise for the tens-of-millions of premium paying citizens that use very little or no healthcare each year. “Why should I pay premium when I never use my plan and those folks are getting it for free?”. Right?
  3. To summarize: fewer insurers offering fewer choices with few participating providers all at premiums increased each year.
  4. Of course, the result of # 1, 2, and 3 above will lead to another crisis because there won’t be enough money to pay for all of the Medicaid claims and insurer’s subsidies. Which will lead to:
    a. Increased taxes or create new taxes on benefits to generate more funds.
    b. Decrease the benefits at either the plan benefit level or utilization level. That means the IPAB “Independent Patient Advisory Board” or Death Panel will decide what gets authorized and covered and what does not.
    Your 90-year-old mom may need a new hip but will the IPAB authorize it?”

We could go on and on because it is clear that the entire healthcare finance and delivery system will feel the impact of our Congress doing nothing.

One additional concern is the “overly optimistic political corrected” desire to pass a “skinny bill” that would simply repeal the Play or Pay mandates. That could be catastrophic to insurers and to premiums that would need to be increased.

I don’t understand politics and have the scars to prove it but I do try to understand human nature. Human nature will drive most politicians to look out for themselves in their own individual voting district throughout the healthcare debate.
Sad thing is that the GOP seems to be immobilized from taking action on R&R  due to the criticisms from people who wouldn’t vote for them regardless of any action taken.

Makes you want to ask, “So, a small percentage of people in your district, who wouldn’t vote for you under any circumstances, are preventing you from doing what’s right for tens of millions of American?”
As I said, I don’t understand politics.

Sorry for the negative outlook concerning our Congress and especially its leadership. But, since neither the House nor Senate bills actually repeal the ACA there seems to be little to ignite optimism.

I think we can point to the children’s book “The Emperor’s New Suit” as the beginning of the GOP’s downfall.  You can’t tell people it’s an ACA repeal bill, while leaving the core foundation of the ACA including taxes, and expect the people to embrace it. Reducing the Play or Pay penalties to zero and calling it repeal  does not repeal the Play or Pay core fear of the ACA. It only increases premiums.

Well, we’ll see what happens this week and together we will address it.
Because, we’re all in this together, right?
Let me know what you think.

Until next time.

Mark Reynolds, RHU
559-250-2000
mark@reynolds.wtf

 

The Cruz Amendment, what would it do for Healthcare Reform? Maybe, just maybe, it would provide options.

July 20, 2017

As I write this Post today, the Senate’s two attempts at HCR are on hold for voting purposes. Initially, the public reason given for the delay is that they are waiting for Senator McCain to be released and back at work. Please join us in wishing the Senator a speedy and full recovery!

Now, we hear that Leader McConnell is pulling the bills back all together.

In the interim let’s discuss the possibilities of the passing the BCRA (Better Care Reconciliation Act), or any Reform or Replace legislature, with the Cruz Amendment (CA) included. The opposition argument against the CA is some what logical and makes for good debate even though the opposition is too scripted and predictable to be conclusive. Their argument is that the CA will cause premiums to increase dramatically on full service standardized or ACA type of benefit plans. What’s wrong with that argument? Plenty!

For one, it makes us accept (or forget) that premiums haven’t already increased dramatically (over 100%) and done so to the point of being unaffordable.

Two, the opponent’s argument conveniently forgets to acknowledge that the ACA Bronze Plans and even Silver Plans leave members with such high out-of-pocket costs that the plans provide no real benefit for basic primary care or for higher cost care such as diagnostic care for most Americans covered by those plans. Who can afford to pay a $6,500 deductible before their plan pays anything?

Three, their argument neglects the fact that insurers are so regulated and handicapped by the ACA that the insurers have skinnied down PPOs to the point that finding a doctor to accept your Bronze/Silver plan is nearly impossible. In addition, by eliminating 50% of the providers in your area the opportunity for you to even receive care is reduced.
You might have a Health Plan Id card in your pocket but you have no providers at which to use it.

The opponents of the Cruz Amendment want you to forget that the ACA has allowed or even forced insurers to offer high-priced, high out-of-pocket, skinny network plans that people would not want to purchase unless they were forced to do so. And could not afford the richer Gold and Platinum plans available.

And don’t forget the subsidies paid to insurers which further drive up the costs of the ACA plans because we all pay those subsidies don’t we. Those subsidies also skew the pricing assumptions that insurers usually make.

Remember that the Cruz Amendment would require insurers to offer standardized HCR metallic-like health plans before they are permitted to make other plans, with less benefits, available. It is not a license for insurers to offer only stripped out benefit plans. It’s a chance for insurers to offer more options from which individuals and small employers can choose.
So, what could the Cruz Amendment create?

The obvious goal is that it could create a menu, with more options, from which Americans could choose the benefits important to them.
For example.

Individuals:

  • Young healthy men or woman(or older) might select benefits with limited  or no maternity coverage.
  • Older men or woman might select plans with richer Rx benefits than younger folks.
  • Young people might be more willing to buy catastrophic coverage with a deductible of $10,000, for example.
  • Certainly, many people would not want to pay for built-in pediatric dental that is forced on current ACA plans.
  • There are dozens of examples of how plans could be built and priced for more choice.

Small Employers:

  • Could purchase low-cost catastrophic plans then implement an HRA to enrich their employee’s benefits. (Thousands of employers would do this.)
  • Provide multiple options so employees can choose from more than a couple options
  • The employer’s HRA plans would provide employees with better choices so that they might include their families. It’s be nice to be able to afford to include their kids on the parents plan.
  • Employers could lower the cost and improve benefits for their employees.

The argument against the Cruz Amendment uses the well-tested tactic of fear to gain support for the opposition. Yet the opponents must rely on our faulty memories to forget that premium have increased by over 100% while out-of-pocket costs have increased and provider access is scarce, since the ACA went into play March 23rd, 2010.

What the Cruz Amendment needs is a solid national promotion campaign with an articulate spokesman to lay out the facts. The GOP must tell America that having more options from which to choose does not guarantee poorer benefits or higher premiums.

I recognize that I am being pretty basic here and that there are a few more details to address such as subsidies for those that need them, Medicare expansion, logical pre-ex provisions and more. But all of that can be resolved when we let competition take hold.

Fortunately these types of health plans and the solutions they bring are part of a solution for which your author has some experience. I challenge anyone to debate this issue with us. That is, if the opponents use facts and real experience.

What do you think?
Remember, we’re all in this together!

Mark Reynolds, RHU
559-250-2000
mark@reynolds.wtf

Why are some Republican Senators suddenly so opposed to their own Senate Healthcare Reform bill? Follow the money!

July 13, 2017

Money, that’s it, that’s the reason why a handful, but growing number, of GOP Senators are opposing the Senate’s current R&R effort. (Please forgive me for referring to it as R&R since we know it’s not either.) But the point is, their opposition is not about their concern for the poor or any other human related issues. It’s about the money attached to Medicare Expansion.

The creators of the ACA understood human nature and politicians so they knew that if the ACA could get states hooked on and depentant upon the billions of Federal dollars committed for ACA enrollees created by the Medicare Expansion then those states, or more appropriately those politicians, would be reluctant to give up those dollars. Actually, the ACA proponents knew that Politicians would be unwilling, actually unable, to give up those Federal dollars; as if those dollars were an addiction.

You’ve read in previous Posts how the Medicare Expansion works. It promised states that the Feds would pay 100% of the costs for those enrollees initially then reduce to 90% after a few years. Meaning the states had to come up with no more than 10% to cover the millions of newly enrolled healthy working age citizens getting their health coverage from Medicaid.

You will remember that Medicaid was originally created for the young, the disabled or pregnant citizen and that the Feds matched the state’s spending on a graduated scale based on each state’s average “prosperity rating”. So richer states like California and New York received only a 50% match while poorer states such as Mississippi received up to 75% match. These figures and factors have applied for years and as you can see are much lower than the Federal match for enrollees under the ACA’s Medicare Expansion.

Bottom line is that  which means a “political” problemthe 31 states, that accepted the Medicare Expansion, are hooked on the higher reimbursements from the ACA.

Some GOP Senators from states that excepted (swallowed) the Medicare Expansion pill now are getting pressure from their home states to keep the funding for Medicare Expansion in place. The reason is that to reduce the matching funding would cause these states a budgeting problem.

The current GOP Senate bill retains the concept of Medicare Expansion but starts to reduce the matching % in 2021. Then, by 2024, (6 years from now) the matching % would level off and be the same % as the state’s Federal match for regular Medicaid enrollees. Seems fair doesn’t it but to Governors of those states hooked on the Federal ACA match it creates a budget issue and therefore they have a “political” problem.

For the past 7+ years the GOP used the “Repeal and Replace” mantra as its campaign slogan which worked and added thousands of Republicans to every level of government office from your local representatives in city, county and state positions to Congress and Senators including a bunch of Governor’s seats. So all of a sudden the success of the GOP to unseat Dems from all of these seats has put many Republicans in a position of responsibility over budgets and caused the GOP a political problem. Now it appears that many have forgotten their pledge to Repeal & Replace the ACA which helped get them elected. Funny how quickly some politicians forget their promises, isn’t it?

Make no mistake about the magnitude of this issue. We’re talking about hundreds of billions of dollars that the states will see reduced over the coming few years. Those state politicians will be faced with citizens (voters) that will fear that ( and be told by Dems) that their public subsidy (premium or benefits paid by Government) are being reduced or eliminated. The Governors and Senators of the Expansion states fear the back-lash from those healthy, often young, able-bodied and often working citizens who are currently covered by Medicaid who that their subsidy will be reduced or eliminated.

Do you think the Dems will exaggerate or try to capitalize on this in their campaigns?

So, that’s it! It’s not about a better healthcare reform package or helping the poor or the disabled. It’s about the money, the money to which these Expansion states are now addicted. Of course the cynic in your author assumes that the politicians in those Expansion states are more concerned about their own re-election than on what’s good for America. I pray that I am wrong about this.

As I write this Post we are hearing that the Senate will introduce a new R&R bill this week that will be “better” than the Senate’s current Better Care Reconciliation Act.
I wonder; Better for Whom?

Let me know what you think.
Also let me know what you think would happen if the GOP does nothing about R&R but simply props up the ACA for another year? Let me know.

You know I believe that we are all in this together and by being together we will overcome any obstacles facing us. However, when one sees politicians act or react for their own benefit it makes a person wonder.

Until next week.

Mark Reynolds, RHU
559-250-2000
mark@reynolds.wtf