Archive for the ‘healthcare reform’ Category

Insurers expected to increase ACA premiums sharply this Fall because they did not get their “bail out” funds. Guess who gets the blame?

April 12, 2018

 

Isn’t it interesting that when predictions come true about the failures of the ACA, the Left and the Media go looking for someone to blame? In this case the failure predicted is collapse of ACA State Exchanges with the projected “premium spikes” for the Fall of 2018 and the blame goes to Congress and the President.

But the blame game continues as Insurers, politicians at every level, and the Media lay the blame for the expected premium increase squarely on the Congress and the President. The “blamer’s” logic is that Congress failed to include any funding for bailing out Insurers in the Tax Reduction and Jobs Act in December 2017.

 The “blamers” also are saying that the GOP  had a chance to lower rates with an amendment that a couple Republicans had hoped to attach to the $1.3 billion  spending package passed on March 23, 2018.

Let’s clarify a couple things:

  • The ACA’s re-insurance “subsidy” program paid participating insurers huge taxpayer subsidies from 2014 until the program was scheduled to expire at the end of 2016.
  • The subsidies were designed help get the ACA Exchanges up and running but not remain intact beyond that point. The intent was to cover two issues:
    • One – the claims of high-cost patients for whom the law’s preexisting-conditions provisions provided guaranteed coverage.
    • The extra subsidies were supposed to keep premiums from skyrocketing. Obviously that failed as premium increased astronomically each year since 2010. By the end of 2016, premiums had doubled from pre-ACA levels.
  • The premium spikes you are hearing about will only affect the individual plans in state exchanges, the so-called Obamacare Plans. The premium increase will impact less than 10 million Americans and 90% of those receive subsidies so they pay almost nothing for their coverage and care. 
  • These points are important to remember because the Media will try to stir up activist who will then cry for single payer.

 You know this Post is no fan of the GOP’s efforts to R&R the ACA over the past 12 months, actually past 7 years. Additionally, we predicted delays and Democrat inspired litigation issues as the GOP continues its piecemeal approach to fixing our healthcare finance and delivery system.

We have already witnessed evidence of this by the lawsuits filed against the President’s efforts for Association Health Plans and allowing Short Term Medical plans to extend to 12 months.

Who does this lack of “bail out” impact the most? The Media would try to make you believe that the folks covered will be harmed but as we stated earlier that is untrue since 90% of the folks covered by these Omabacare plans pay nothing or almost nothing for their premium or services that they receive.

So, who else does this impact? The answer is the states that so enthusiastically embraced the ACA and rushed to create their Exchanges back in 2010 through 2014. They knew that their citizens would get the subsidies offered so they anticipated great enrollment numbers and enrollees would be “hooked” on Obamacare and unable to leave. It’s the so-called “blue” states feeling the biggest impact.

Reports indicate that some states are seeking their own solutions. Ironically, this funding issue may actually cause states to adopt realistic changes and better solutions than the ACA could ever provide. Let’s face it, government bailouts, especially bailouts for government initiated programs, seldom resolve issues and generally lead to more and more funding. Lot’s of examples of that over the pass 50 years.

Some reports indicate that a few states (mostly blue) are looking for how a they could restore the individual mandate (IM). Actually, there are many experts,”real experts”, who believe the elimination of the IM will lead to more reliance on Employer sponsored coverage thus reliving that burden on the states where the citizen lives.
Two things come to mind about that.

  • One – Employer sponsored plans tend to be less costly to members and provide richer benefits than the ACA individual plans.
  • But we wonder- Do “blue” states really want their citizens to leave the state-run and controlled plan for an Employer’s plan? The state would lose control/dominance over that member so you decide the state’s motivation.
  • States are in the news about their plight and their possible steps to fund the Insurers themselves. But will any of them really step up? Or is it just talk?
  • It is realistic to see states take steps to utilize the opportunities President Trump set forward with AHPs and 12 month Short term Med Plans. We’ve already seen efforts by Utah, Iowa, and Wisconsin to initiate steps in that direction.
    Of course, the Dems have threatened litigation.

In an election year it’s easy to predict that these issues will get much press, mostly uninformed or lopsided, but that noting will be resolved. As we’ve witnesses in the discussion concerning the Daca folks and immigration, issues are more important than solutions for certain politicians.
This premium spike issue will work for candidates because most or our citizens will not realize that it affects only the Exchange Individual plans (less than 10 Million people) which is less than 3% of our total population.

The states that ramped up their subsidized Exchange Plans as well  as expanded Medicaid eligibility are in a financial bind. As stated by Mila Kofman, executive director of the D.C. health exchange, “States don’t print money, and individual markets, to become stable, need an infusion of federal dollars,”. Doesn’t the verbalization that “states don’t print money” sound a bit creepy coming from a bureaucrat’s mouth?

In 2010 to 2014, many of us predicted that the ACA subsidy program would become an issue, when it became clear to us that the Federal funding for these programs would cease in 2016. Come on…, we all know that States receiving Federal subsidies is like an addiction! Did anyone expect States to wean themselves off the addiction?

You can see now that while the Media gives time for politicians (including a few in the GOP) to complain and lay blame the crisis was predictable and the solutions are available. But, it’s an off-year election year so getting elected and re-elected is more important than real solutions.

What do you think? In this case we truly are all in this together because the assistance the politicians seek for less than 10 million will adversely impact 330 million of us.
Again, that’s 330 million people impacted so, we really are in this together!

Until next week,

Mark Reynolds, RHU
559-250-2000
mark@reynolds, wtf
It stands for “Walk the Faith”.

 

 

Healthcare utilization drops but healthcare costs increase. What’s up with that? That’s right, Americans used less healthcare but costs increased?

February 15, 2018

As you can imagine (or at least hope) there are groups that closely study the results of American’s consumption of healthcare and the cost of delivering that care. The Health Care Cost Institute (HCCI) is one of those groups. The following is a short summary of HCCI’s recent study as well as facts about healthcare. It’s very interesting and supports the ideas and actions supported by your humble author in earlier Posts.

HCCI’s annual Health Care Cost and Utilization Report analyzes health care spending and utilization from 2012 to 2016 for people up to age 65 with employer-sponsored health insurance. That means HCCI analyzed actual utilization data from employer group plans.

One of the many interesting facts identified by HCCI’s analysis is, Americans consumed (used) the same amount or less health care in 2016 than they did in 2015. However, rising prices caused overall spending in 2016 to grow faster than any time in the last five years. 

Niall Brennan, president of HCCI, states;
“It is time to have a national conversation on the role of price increases in the growth of health care spending,” said Niall Brennan, MPP, president of HCCI. “Despite the progress made in recent years on value-based care, the reality is that working Americans are using less care but paying more for it every year. Rising prices, especially for prescription drugs, surgery, and emergency department visits, have been primary drivers of faster growth in recent years.” (HCCI Press release)

Here are some of HCCI’s facts & conclusions:

  • While the number of emergency room visits rose just slightly, the average price for an emergency room visit grew steadily over the five-year study for a 31.5 percent cumulative increase, driving the increase in outpatient spending.
  • The average price of surgery went up as well, pushing up spending for both inpatient and outpatient care.
  • The average price for surgical admissions increased by nearly $10,000 or 30 percent over the five-year study period, despite a -16 percent cumulative decline in utilization.
  • The price for outpatient surgery rose more than 19 percent.
  • Over the five-year study period, prescription drug spending had cumulative growth of 27 percent, despite a flat or decreasing trend in generic drug prices and despite a decline in utilization of brand prescription drugs.
    *The increased spending was driven by double-digit price increases from 2012 to 2016 for brand prescription drugs.
  • Total spending on primary care office visits fell by almost 6 percent over five years due to a decline in the number of visits.
    *This was offset by a 31 percent spending increase on office visits to specialists and a 23 percent increase in visits for preventive care, changes that could be partly attributable to changes in billing practices or in the way people seek care.

“While consumers, especially those with employer-sponsored insurance, may not feel the direct impact of these charges via out of pocket payments, they ultimately pay through increased premiums and decreased benefits,” added Mr. Brennan.

Are these conclusions realistic – Yes!

  • Since 2011, HCCI has tracked, independently analyzed, and reported health care spending, utilization, and prices each year in its Health Care Cost and Utilization Report using de-identified claims data of people up to age 65 with employer-sponsored health insurance.
  • For this report, HCCI analyzed data from roughly 4 billion claims of nearly 40 million individuals. Claims data came from four of the largest health insurance providers in the U.S. representing about 26 percent of the employer-sponsored insured population. 

Isn’t it interesting that as utilization of healthcare services goes down the overall cost of health care goes up for both employees and employers?

Makes one ask: Why is it that when the Government gets involved costs go up and its the average tax-paying premium-paying citizen who bares the brunt of that cost increase.

  • It happened with Medicare and Medicaid.
  • It happens with military costs.
  • It happens with roads, bridges and all other infra-structure costs.

Why would we be surprised that the Government mandated Affordable Care Act would increase the costs on that which it sought and still alleges it controls?

It almost makes me want to re-print a couple dozen of our previous posts that describe how to lower cost while increasing coverage and access to healthcare. But, I won’t.

We want to thank the Health Care Cost Institute for its reporting and for the effort it makes to gather the information it reports. Americans would be doomed were it not for organizations that watch over our nation to report back to us.
Lord knows we can’t depend on the Press  any more, to do that! Sorry, that’s the cynic in me!

In the weeks to come, as we look at various efforts to create alternatives to the ACA, we will include additional statistics concerning healthcare utilization and spending. The statistics and utilization figures we have captured for years could help build solutions that lower costs to employers, employees and members while increasing benefits and access.

It isn’t that hard!

Let me know if the stats above shock you or infuriate you. I look forward to seeing what comes out of the many States that are trying to overcome the ACA. We’re in this together so let’s shout out when we see something that makes sense.

Until next week.

Mark Reynolds, RHU
559250-2000
mark@reynolds.wtf

Some States are taking steps to “develop” lower cost health plans that will help lower costs and improve access. But, they face opposition!

February 8, 2018

In previous Post, we discussed President Trump’s Exec Order allowing health plans to be created that would lower cost with benefits people really want but not be compliant with the ACA. A few states are moving in that direction. The plan development from these states is just getting started, for sure, but already there are promises from pro-ACA advocates to sue any State or Insurer that implements such plans.

We’ve seen litigious threats and real lawsuits, in other efforts to bring common sense ideas back to life. Limiting “immigration” or “visa” permits from certain countries, increasing border security, and even lowering taxes have all come under siege and litigation by the left. The Left continually tries to thwart  President Trump’s  efforts to improve the economy, increase jobs available, improve security, and well, Make America Great Again.

So, why should we be surprised that the pro-ACA advocates would threaten lawsuits against states when the State’s leadership is trying to increase health plan alternatives, lower cost and improve access to providers.

The good news should be reported that the various state leaders out in front in these attempts to improve healthcare delivery and finance are doing so with the right ideas and ideals in mind.

These state leaders are seeking plans and ideas that:

  • Include complete transparency. Transparency where the consumer could see the actual cost of treatment. Patients and their Doctors should be able consider the effectiveness as well as the cost to benefit of any treatment.
  • Change the treatment practice of ordering multiple tests to avoid potential liability. Treatment should focus on healing the patient not avoiding lawsuits.
  • Create a free market environment that allows providers and pharma to make a profit but avoid the outrageous pricing scenarios we see today.
  • Allow small employers to “partner” with insurers. This means allow employers to purchase coverage for catastrophic events and self insure the healthcare under a certain value, for example $10,000. This can be done using currently available HRAs.
  • Allow for employers to “incentivize” their employees to make better choices. Today employers fear being sued if they encourage their folks to stop smoking or lose 20 lbs. with a health plan that gets richer as the employee gets healthier.
  • We must stop federal government interference in the local marketplace. The rules and restrictions of the ACA are driving up the costs and the one-size-fits-all policies just don’t work.
    * For employers in some states, such as California, we might need some Federal assistance in the form of ERISA.
  •  Most agree that it is important to develop ways to help insurers provide coverage to the individuals who are driving the majority of the costs.
    * Let’s face it, the statistics prove that less than 5% of any group will incur more than $5000 (or even $10,000) in medical charges each year.
    * But, in that 5% of the population, the medical charges can be huge, catastrophic as they say, and there is little the citizen-patient can do about the cost of his/her treatment. So, insurers honestly need assistance to finance these charges.

The point is that we are watching state regulators look at realistic ways to improve access and lower cost without penalizing our citizens for their healthcare usage.

Remember this fact, the enrollment in ACA individual plans at the close of this year’s open enrollment is only about 8 million enrollees. The plans we’re discussing above could be considered as alternatives by 50 to 100 million employees currently in small group plans around the country.

But, these new ideas will be criticized and litigated simply because they conflict with and/or weaken the ACA. If 50 million of our fellow citizens could get access to enroll in these lower cost plans, would that not be a good deal. We might make America’s healthcare great again. Sorry for that.

Anyway, we should be glad that there are creative people developing ideas and even real plans that will increase access to more providers, provide the benefits people really want, and lower cost in both premium and out of pocket. As we said in previous Posts, you won’t see or hear much about it in the Media so we’ll have to watch for it ourselves.

But then, we’re all in this together, so let’s keep watching together.
Let me know what you think.

Until next week.

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

Enrollment period for ACA Individual plans is over. All the effort and stress for 8 million citizens.

January 4, 2018

We talked a bit about the craziness surrounding the open enrollment period for individual plans on previous occasions. Now the open enrollment period is over and the media will quiet down.

But, the other 300+ million Americans adversely impacted by these individual plans should continue to raise hell! As we’ve discussed in previous posts the entire private sector healthcare system of finance and delivery is suffering because of ACA imposed rules, metallic plans, burdensome regulations, and liberal press bias.

We should not begrudge these 8 million Americans, in fact it’s just the opposite, I wish the number included every American not covered by an employer sponsored plan or Medicare/Medicaid. If the reports are correct there could be another 20 to 25 million Americans on individual plans but choose not to for one reason or another.

The fact remains that Democrats inflicted us all with the ACA in an effort to take over private healthcare so that the government would then control 100% of the health finance and delivery system in America. But, they failed.

Their failure is not due to efforts by the GOP which we’ve all seen to be dysfunctional, pitiful and weak. No, the ACA’s failure is due to the character and spirit of free markets and the American people.

But, once again, the efforts by Liberals cause the many to pay extra for the few. In this case, the many have seen their premiums increase 300%, their doctors disappear off PPOs, and the number as well as quality of the health plans offered reduced.

We see similar punitive results in the liberal assault on so-called climate change. Their efforts here are another example in which the people who can least afford it bear the brunt of the cost. We all want clean water, clean air and blue shies. But, the regulations demanded by liberals raise the cost for Americans struggling to get by while the governments in India, China, and other polluting countries just skip on by.

I start out 2018 with this rather negative post not because I think the future is bad or that we are doomed to the same crappy health plans forever. I begin 2018 with this message because I know we all need reminded and that while you and I are busy living our lives there are others who won’t give up the fight.

I think 2018 will bring continual reminders about the need to change or repeal the ACA. But since the Congress and Senate seem incapable of pulling it together the changes we need will likely come in piece meal bills and directives.

So, don’t begrudge the 8 million mentioned above because many of them could not qualify for or afford coverage before the ACA. The ACA would never have gotten a foothold and could have been avoided had the GOP implemented GI back in 2002-2003 when they implemented HSA and HRA plans. It could have been simple!

I think change is coming and is in the works as you read this. Let’s not forget the potential for Association Health Plans and the ability to sell across state lines were put into motion in 2017.

We have reason to be angry but we also have reason to have hope. Let’s watch for the incremental glacial movements in 2018 that will bring relief to the millions of premium paying citizens of America.And I’ll keep you updated along the way.
Happy New Year.

Let me know what you think because you know we’re all in this together!

Until next week.

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

Eliminating President Obama’s Cost Sharing Reduction (CSRs) payments. Is it legal, constitutional, and a good idea? Let’s discuss.

October 19, 2017

Our intent was to continue discussing President Trump’s EO providing for the formation of Association Health Plans. But, in the interest of fair discussion, maintaining topical subjects and allowing more details from HHS, Treasury and IRS to develop, let’s discuss the President’s Executive Order discontinuing the Obama era subsidy payments to insurers. Is President Trump’s action legal or even a good idea?

First of all, how else does anything get done in Washington to correct any issues let alone the problems caused by the ACA if steps aren’t taken to initiate action by Congress. It seems that our Congress can only take action when there is a crisis or deadline. It is certain that Congress, particularly the GOP, does not have the stones to take on the opposition to changing the ACA without some catalyst to make them do so.

Which brings us to the Cost Sharing Reduction payments, the subsidies paid to insurers for low-income citizens out-of-pocket cost, which President Obama initiated. The Courts have already ruled that these payments are unconstitutional. 

The money for the subsidies was never appropriated by Congress, but President Obama paid insurers anyway.  The payments were ruled illegal by a Federal Appeals Court last year, but the order was stayed pending congressional action.

It’s estimated that about 6 million enrollees in the exchanges qualify for the cost-sharing payments this year, costing the federal government about $7 billion in 2017.  Insurance companies are required to fund the payments to reduce deductibles and co-insurance even if they are not reimbursed by the federal government.

If this were not the case then any President could initiate payments out of the US Treasury for any project a President desired. For example, President G.W. Bush could have pulled funds to start and continue the war in Iraq.

President Trump would be free to start writing checks to pay for the new border wall between the US and Mexico without the approval or appropriations from Congress. I’m sure most Libs would love that. In a country where the citizen’s freedoms are set for in the Constitution do we want our leaders to be free to pick the laws he/she wants to ignore or follow? 

So, if President Trump can’t decide unilaterally to pay for the border wall then how could President Obama decide to make payments to insurers unilaterally?

Consider some perspective. These CSRs are intended to cover the out-of-pocket costs such as deductibles, copays, and co-insurance  for low-income citizens covered on individual plans through an ACA authorized state exchange.

Also for perspective it’s important to remember that only about 10 million Americans are actually covered by the individual exchanges. As stated above, experts calculate that the CSRs affect about 6 million citizens.

So, once again a big hub-bub is created in the media for 6 million folks in a country of 330 million about payments estimated to $7 Billion. It might also be interesting for Americans in 48 states to know that about 3 million of the 6 million people receiving the CSRs reside in California and New York.

The point isn’t that these people don’t need and deserve assistance. Nor is the point that citizens from two of the most liberal states in America require around half of all these payments. The point is that the actions taken by the Obama administration to make these payments was/is unconstitutional. Even though those 6 million good Americans may deserve this help, don’t we need to follow the law. Why didn’t the Obama administration do the right thing and shouldn’t we expect Congress to do the legal thing.

Maybe the states should make these payments to insurers out of their own state treasuries. The payments might then be accounted for and more closely monitored. But, certainly the citizens of these states would be acutely aware of the impact.

Sure, I realize the GOP did not vote for the ACA and now the issue flares up during the GOP’s leadership which seems unfair and certainly untimely. The Obama team was masterful in its timing of many aspects of the ACA which is worth an entire Post on its own. 
But, the GOP had 7+ years to develop a workable replacement and failed to do so.

Next step? We’ll discuss further but first, stick to the facts and the constitution. Second, write and present a realistic replacement plan that provides solutions for all Americans including low income citizens, employees, employers, patients, providers,  that provide more alternatives, better choices and lower costs as its focus.
Simple, right? We’ve already outlined it in previous Posts.

Let me know what you think.
I enjoy the feedback especially since we’re all in this together.

Until next week.

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

 

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

 

PCORI – is this a worthwhile expense on your health plan or another example of Government bureaucracy and waste?

September 21, 2017

Evaluating the benefit of PCORI, the Patient Centered Outcomes Research Institute, relative to the impact on healthcare costs and efficacy of current treatment protocols may be impossible. One’s opinion may well be determined by your baseline feelings about redundant government programs, government bureaucracy, or even political positions.

One could also add data security to the list of concerns. More about that below.

Honestly, it is hard to justify the added expense to health plan costs or the benefit to healthcare practitioners and their patients. If the goal is to study comparative outcomes for current practice protocols then how will the analysis be delivered. One problem is that the PCORI has no authority to implement any findings nor to direct healthcare practitioners to modify their practices. Another problem may be human nature, that being, Doctors wanting to practice in their own experienced manner.

We all want affordable high-quality healthcare with the latest and most effective technology. There’s no argument there. But, given the history of what happens in the private sector when government intercedes don’t we have the obligation to investigate and challenge the established bureaucracy?

There are already at least two notable government agencies that experts say could incorporate the PCORI objectives with in their current structure. One is the National Institutes of Health and another is the Agency for Healthcare Research and Quality,

The Agency for Healthcare Research and Quality has the stated mission of “making health care safer, higher quality, more accessible, equitable, and affordable”. It is considered small by federal government standards with a budget of about $440 million. Believe that, small at $440m? Anyway, the mission for the AHRQ sounds like something we want so why couldn’t it dish out the $3.5 Billion expected to be awarded by PCORI?

Plus, the GAO (Government Accountability Office) states that the PCORI won’t go through a review by any independent outside entity until 2020, after the program has run it’s course, awarded an expected $3.5 billion and PCORI is no longer operative.

So, one must ask, is PCORI a worthwhile venture or just another government program scheduled to end but destined for in perpetuity?

After reviewing many of the awards given to date it is easy to lean toward the obvious: that PCORI has both great waste and great potential, depending on one’s fiscol perspective.
Let’s look at a couple PCORI awards:

  • One project looks at how doctors can create a “Zone of Openness” with patients which was part of $61 million in awards. Were you wondering about your doctor’s “Zone of Openness” the  last time you were waiting to see the doctor, dressed in your paper robe, sitting on that awkward metal bench covered in butcher block paper?
  • $14 million for a study on the appropriate dose for aspirin being taken to prevent heart attacks. Too much and you could bleed to death. How long have doctors been practicing this treatment protocol and they don’t know the correct dose?
  • $500,000 went to AHIP (America’s Health Insurance Plans) to “build and maintain support from health plan leaders” and to “identify important gaps in availability of health insurance administrative data”.
    A spokesman for AHIP stated that sharing health plan data is “complex” and “requires a significant amount of review and expertise from the industry”.
  • $249,000 went to Society of General Internal Medicine for a 2 year program, as stated “to help us develop a better understanding of the attitudes and knowledge of our membership”.
  • I’m not kidding!

Will we see any demonstrative results from the $3.5 billion in research awards expected to be doled out? Good question! Supporters say that we will see the results in articles published in medical journals and through presentations , seminars and other public dissemination. Since the PCORI has no authority the information obtained will not be sent out as directives to be followed. That part may be good.

In fact, some legislators and professional groups are concerned that the government, particularly CMS, may try to use the PCORI results to limit or restrict healthcare services to citizens covered by Medicare and Medicaid. That means our senior folks covered by Medicare and Medi-cal. We were told about this potential issue in 2009, remember. 

Will doctors change due to PCORI?

  • Some who belong to large practice groups might if directed to by their group.
  • If payments for services rendered are reduced as a result of  procedures deemed ineffective by PCORI then doctors may change. 
  • Unless there are consequences, either financial or legal, doctors may not modify their current practices simply because of a result of a PCORI award.

My initial opinion was that PCORI was another example of over-reach by the government adding cost to premiums as well as costing taxpayer billions of wasted dollars and unneeded oversight. After doing my research and preparing for this Post, I have found no reason to modify my initial opinion.
Hey, maybe my opinion is just like the results of the billions spent on PCORI; nothing changes!

One other thought has lingered with me since 2010. The ACA also mandated that all health plans submit their data to the CMS and PCORI for the purpose of analysis. By data I mean every individual’s personal & private information including SS#s, employment & health status, and specific information on every healthcare service incurred.

So, how has that data been protected and by whom? The list of entities that have had data breaches is endless and includes cities, states, nations, government agencies, many insurance carriers, and thousands of other private businesses.
Here is a short list with the estimate of records stolen :

  • US Office of Personnel & Management -22 Million
  • Yahoo 1st time -500 Million
  • Yahoo 2nd time -1 Billion
  • Equifax – 143 Million (this is recent and huge!)
  • E-bay -145 Million
  • Anthem -80 Million
  • Target -40 Million
  • Home Depot -56 Million
  •  Sony – 77 Million
  • What are the odds that your personal info was not part of at least one of these?
  • Do you think the health records of our citizens stored at CMS are an attractive target to hackers?

As I said, it was a lingering thought!

Well, you can give it some thought and ask yourself some questions. Have you read or heard anything about PCORI in the past 2 years. Probably not because one of the operative guidelines of PCORI is to be invisible and not draw attention.

Geez, does that makes sense; a government bureaucracy created to analyze comparative treatment outcomes but do so without making any news?

That’s it for now. Let me know what you think or if you’ve seen any data that shines a positive light on PCORI. I want to be fair in our review.

Next week we’ll look at the Graham-Cassidy Healthcare reform bill now being urgently pushed by the GOP. The Senate has until Sept 30th to get it started with only 51 votes.

Until next week, let’s work together and stay positive.

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

The Expansion of Medicaid was one of the biggest obstacles to Repealing, Replacing or even Repairing the ACA. Let’s dig into it & understand why.

August 10, 2017

As usual, the national discussion to repair nearly any Federal program often obscures the important issues that could actually help make a difference. In addition, the media likes to lock-on to buzz words or sound bites to ignite hysteria.  Therefore, attention is on the wrong issues that are actually hyped up in an effort to gain viewers.

Plus, Politicians get side-tracked, either intentionally or not, but they focus on the wrong issue because they all fear the potential of giving their opposition ammunition for their next re-election. Cynical I realize, but am I wrong?

There were at least two such issues obscured by these efforts during the recent GOP efforts to R&R the ACA.
One issue was the promotion of the number of citizens covered under individual plans, either through Exchanges or direct to insurer. That promotion often misstated the variance in the number of citizens covered under individual plans prior to and after the ACA as well as the vast difference in benefits.

But the second issue, that the Press and the GOP either ignored or misjudged, was the impact of the Medicaid Expansion which is what we will discuss today. We’ve talked about Medicaid Expansion before but let’s “expand” that discussion to look at some real numbers. Then, we’ll see why the Dems were so clever with Medicaid Expansion and why so many Governors and GOP Senators are reluctant to give it up.

Nationally, Medicaid enrollment is 73,421,500. Of that total, 14,409,000 are due to the Medicaid Expansion. That’s a growth in Medicaid of over 20% nationally. The reason for the explosion was, of course, the Federal subsidy for ACA Medicaid is 90% so the financial impact is huge.

I’ll use California as an example because its numbers really expose the issues caused by a Governor’s acceptance of the Medicaid Expansion. First, two comments. First,  the California Governor responsible for accepting expansion was Republican Arnold Schwarzenegger (alleged Republican anyway). The second is that if I were from one of the 49 other states I would be PO’ed that Ca has so many people on Medi-cal (Ca calls it Medi-cal instead of Medicaid).

California has roughly 40 million residents. Based on stats from Jan-Mar 2016 Ca had 13,107,000 residents on Medi-cal. That’s 1 out of every 3 residents is covered by Medi-cal, a government entitlement program. Holy cow, does that amaze you? Disturb you?
But, the numbers get worse.

Of the 13,107,000 covered by Ca’s Medi-cal in the Spring of 2016, 3,541,700 are due to Ca’s Expansion of Medicaid. They are called “Newly Eligible”. Stated by percentage, Ca’s Medi-cal population increased 37% from 2014 to 2016. Does that amaze you?

A few weeks ago we discussed the Federal reimbursement share under the standard Medicaid program compared to the Federal share under the ACA. You will remember that the subsidy is structured based on the financial prosperity of each state. For example, under standard Medicaid subsidy, in existence for 50 years, Ca gets about 50% of its Medi-cal cost paid by the Federal government but Mississippi gets 75% paid. Theoretically, I guess Ca is a more prosperous state than Mississippi.

But, as you remember, the ACA subsidy for Medicaid expansion started at 100% then dropped to 90% where it will continue unless changed. There is your first clue.

California gets 50% reimbursement for its regular Medi-cal enrollees but it receives 90% reimbursement for its ACA Medicaid (Medi-cal) enrollees. If the ACA goes away or the subsidy is changed or lowered, then how does Ca cover those 3,541,700 residents that are currently covered by Medi-cal. Those folks get their coverage for free and the ACA is paying for it. Granted, Medicaid, even if it’s called Medi-cal, is not the best insurance but it is free.

Of the 31 states that expanded Medicaid, 14 of them have Republican Governors. Many of those states such as Alaska, Arizona, Kentucky, Maine have GOP Senators. The point is those 14 Governors must balance their budgets each year, unlike US Senators or Congress-folks, therefore, some of those Governors leaned on their Senators to oppose any reform that lowered or eliminated the state’s subsidy for Medicaid expansion.

Back to California, sorry. You can see by the numbers that if the Medicaid subsidy were lowered by any amount that the great State of Ca would have a huge budget issue. Now, Ca could eliminate the coverage provided by Expansion but then those covered residents, some of whom are actually legal and may vote, might stay home on election day.

Or, Ca could maintain the coverage for the “newly eligible” 3,541,700 Medi-cal folks and Ca could pay for the difference between the current 90% subsidy and the 50% paid under standard Medi-cal reimbursements. I don’t even need to do the math for you on that calculation(even if I could do the math) because it will be a staggering number for the Ca legislature to address.

So, when the GOP returns to Repeal &Replace “or Repair” it must do a better job of promoting its intent for this population of people. No question that these covered folks can’t have the proverbial “rug” pulled out from under them. It wouldn’t be fair even if the GOP was willing to accept the political fallout.

The House bill would have allowed for folks to use their subsidy to buy their own private insurance outside of an Exchange and directly from an insurer. Is that a good idea?

So, that’s one reason why so many US Senators and Congress-folks were reluctant to support either the House or Senate’s attempt at R&R. I think a few Senators and Congress-folks opposed these R&R attempts out of contempt for the President while others could not resist the support they receive from special interest group such as Planned Parenthood. Both bills were not good products so it made it easier for opponents to resist even if their reasoning was self-centered or vengeful.

For now, you know the importance of the Medicaid Expansion so that what ever comes out in the coming months you will be informed. At least I hope this helps.

Let me know what you think because we are all in this together.
Until next week.

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