Archive for the ‘pre-existing conditions’ Category

What if SCOTUS holds that the ACA is Unconstitutional? What can the GOP put in its place? You hold the solution, here!

January 10, 2019

Several years ago I jotted down a few ideas which, if implemented, would address at least the biggest issues in medical insurance and healthcare delivery: cost and access. With the recent Court decision deeming the ACA unconstitutional we need, that is the GOP, needs to offer betters solutions. The ideas below are a start toward that better solution.

You all know that I am an optimist trapped in a cynic’s body so my hopes of replacing the ACA with a workable solution are real but also guarded. But, what if you/we were asked for input to design a workable solution. Could you do it?

I have expanded the solutions, since jotting down my initial 12 points in prior posts, because I believe that there is an easier and less expensive means to address healthcare financing for the chronically poor, the uninsurable and the chronic uninsured. You may think that I have left a few issues untouched and if so let me know your thoughts.
However, I know that these ideas, if put in place, build the framework to address:

  • Those that want to buy insurance but are un-insurable.
  • Those who want to buy but who can’t afford the premiums charged for insurance.
  • Those who currently buy and pay for their coverage but are finding the increasing premium too much to pay. 
  • Those that don’t want to buy or will wait until they have a problem to buy insurance.
  • Guaranteed acceptance.
  • Pre-existing conditions.
  • How to push premiums lower
  • How to push unit cost of healthcare lower
  • Transparency (Total & Complete Transparency).

So, together we can develop the core outline of what Congress could build if it truly tried to bring about the best reforms for our system. Please give us your input to improve upon these points as well as address issues that we have not addressed or not addressed well.

It may be fun and interesting but who knows we might even make a difference.

Since Americans are used to the ACA mandates of kids to 26, unlimited lifetime, and wellness or preventive let’s leave those in. But,  let’s eliminate the Medical Loss Ratio (MLR) limits since no other industry in the world has its profit margin restricted like insurers are by the ACA. Other than that let’s assume we have a blank canvas upon which we can draw our ideas.

Here are the basic ideas to include in 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 prior coverage.
    Example – Pre-ex period: 12 months.
  3. Group plans of 2+ employees remain guaranteed issue with full take-over or “No Loss-No Gain” as it used to be called..
  4. Allow carriers a reasonable corridor for Risk Adjustment Factors (20%). Also, eliminate artificial pricing rules (such as 3:1 ratio) and let insurers determine pricing with their area rating factors based on their data and statistics.
  5. Tort reform: Loser Pays and/or Fixed Attorneys at 15%.
  6. Allow carriers and plans such as Association Health Plans to sell across state lines. (Possibly the most difficult of all.)
  7. Eliminate Essential Health Benefits and allow No new benefit mandates from states or Feds for five years. Allow insurers freedom to build plans as they determine.
  8. Mandate HRAs and MERPs permissible and available to implement on all plans.
  9. All insurers must publish and release statistics and experience data.
    It’s ok and can remain consistent with Hippa.
  10. Universal enrollment forms for all group plans and all individual/family plans.
  11. Health plan commission set at level 7% and does not increase as premium does.
  12. All Providers must post their rates per service. Hospitals must post their outcome statistics as well as infections, error rates, and other outcome data.
  13. State based or plan based re-insurance pools to assist Insurers in controlling premiums. If unlimited lifetime benefits are retained then Insurers and Plans need support to handle the increasing number of mega-claims. 
  14. Providing coverage for those who can’t afford to pay premium regardless of its cost:
  • Eliminate Exchanges. Allow people to be enrolled directly with the Insurer or Plan of Choice.
  • The IRS can maintain these enrollment records and disperse payments to Insurers and do so without adding fees to premiums.
  • That also eliminates the huge fees added to premiums by Exchanges to compensate the Exchanges.
  • Set the income levels for participation in subsidies (even use the current formula).
  • Eliminate the Medicare Expansion as it pushes people toward poverty.
  • Instead, keep these folks covered by the private market and allow them to obtain their coverage from private Insurers and Plans.

I also think we need to build incentives for employers to support wellness plans. If we want to bend the cost curve downward we must address behavior and expectations through affective wellness and benefit structure.

I do address coverage for the poor as I mentioned above. Setting a poverty level which assists folks in need but forces folks into Medi-Cal (Medicaid for outside Cal) is problematic as it may discourage folks from working their way out of their financial circumstances. Besides, those Medi-Cal plans “suck”. You would not want to be covered by one so why push these unfortunate folks into it.

So, this is our starting point. I encourage you to give this some thought and to give us your input. If we offer a worthwhile solution then who knows; we might make a difference. That’s what I mean when I say “We’re all in this together”.

Let me know what you think.
Until next week.

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

U.S. Court rules the Affordable Care Act is unconstitutional. What should Americans expect?

January 3, 2019

So far, it’s amazing how little attention this Court’s decision is getting. Maybe there’s too many other headlines on which the Media must focus. Border security, N Korea, aggressive moves by both China and Russia, the 2,500 point reduction in the Dow, or the booming economy and threats of Fed interest rate increases, partial Gov. shutdown, or maybe even Christmas (Nah, probably not) are all getting headlines but the ACA being deemed unconditional is not.

Maybe the Media and the ACA supporters don’t want to highlight the Court’s decision for some political reason. The GOP doesn’t want to focus on it because it wasting of the best opportunity to Repeal & Replace. No, the GOP really has nothing to gain in bragging about this Court’s ruling.

To be fair and honest, there is nothing anyone on either side of the issue can do right now because the Court’s ruling will not be effective for at least a year and the Left will appeal the Court’s decision. Many believe this decision will be decided by the Supreme Court.

The Supreme Court (SCOTUS) is allegedly a “conservative” based court with a 5/4 advantage to conservatives. But, we can’t forget that it was Chief Justice Roberts who allowed the ACA to live based on his opinion that the non-compliance penalty was a tax and not a fine as the Dems had argued. 

That still seems surreal to remember that the Dems argued, even before SCOTUS, that the individual penalty was a fine and not a tax. Even the first sentence in Judge Robert’s opinion made opponents believe the ACA would be struck down but then cam the Judge’s second sentence which stated that the fine was indeed a “tax”. I can still remember where I was when I heard that and how fast the Media jumped on the initial statement believing the Court was striking down the ACA.
Geez, that was a bad day for American premium-payers!

So, what should we expect for the next 12 months? Not much really. The Politicians will try to use the Court’s decision to their own advantage regardless of which side of the opinion they stand. But, the only Republicans who may speak up will be the conservative group referred to as the Freedom Caucus. This handful of GOP reps fought hard for R&R but were unsuccessful due to the jello-filled backbones of the GOP leadership.

Heck, even reducing the penalty to zero, instead of repealing it completely, was weak. As you’ve read here before, your humble author has stated many times that setting a fine to zero does not mean a potential penalty is no longer in effect.

As of this moment, the partial Gov shut down is consuming the Media and the Left. They think this is an issue on which they can take the biggest political advantage so they will keep the Court’s decision in their back pocket, for now.

But, Republican, if they are smart, will introduce a replacement for the ACA that includes the features everyone likes but without the features that increase premiums. It is possible and you will read about it in next week’s post.

For now, sit tight. If you have coverage now, which I know you do, then you have nothing to worry about. People concerned about Pre-ex conditions also have nothing to worry about. In fact, the 10 million Americans covered by Exchanges who receive premium support have nothing to worry about either.

The fight will not be pretty and the Media will paint a picture of people suffering in the streets, of children not being immunized, of woman not getting prenatal care (or birth control pills) because they could not get the medical attention they need and deserve.

But, we’re in this together so let’s let people know that there is a better solution and it would increase benefits and lower costs. More to come.

Until next week.

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

Another year in which we can all say “Merry Christmas” without fear of persecution. Thank you Mr. President!!

December 20, 2018

It’s five days before Christmas and while the Stockings are not yet hung, I bet most of us are thankful that the “war on Christmas” has been placed on-hold, for another year.

So this week instead of promoting or dissecting some aspect of healthcare reform let’s look for aspects of 2018 and our own lives in America that bring peace and good will to man. Sorry that isn’t PC, should have said “good will to us all”.

I say Thank You to:

  • First Responders who run toward the crisis or danger while we run away. These brave men and women are better civil servants to our Nation than anyone else, especially politicians, can ever brag to be.
  • Military that in spite of a decline in funding and respect over the past 10 years continue to keep us save by stopping the dangers over there from reaching over here. I did not join the military when I was of age, a decision I regret to this day.
  • Law Enforcement officers on a daily bases as they walk or drive into unknown danger without hesitation and without the support of too many in our nation.
    We should all stand each time the National Anthem plays!
  • Teachers who signed up to help educate our future generations and continue do so even when facing the toughest environments. Wouldn’t it be easier to teach if English was the required language, parents would help from home, and Unions cared about kids more than self-preservation?
  • Moms for doing what they do to love their children even when we are unlovable. Giving birth might be the easy part for Moms these days as they too often take on the role of both parents and both bread winners in American homes. Moms are the first responders for our families and they need our help and thanks.
  • Our Churches that stand for the true Word of God and don’t give in to the secular-worldly efforts by too many to cast shadows upon what we all know is right.
  • Co-workers that come to work each day to work as a team toward similar goals of creating good products, good service, and respect for team.

Thank God, above all else, for His gift of the Lord Jesus Christ, for us all. God so love the world that He gave His only Son for us that we might have eternal life. To those of you who are believers you know that a relationship with Jesus Christ does give us an eternal home but also gives us a relationship throughout the year like none other possibly could.

That’s just a few.
To whom or what are you thankful that makes your life safer and better?

Love to hear from you and especially at Christmas we should know that we’re all in this together. 

Merry Christmas to all!! And to all, until next week.

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

 

Add Electronic Data Collection to the burdens the ACA has added to each of us. Now we must monitor our personal data for hacking, miss-use and mistakes.

November 29, 2018

The idea of maintaining one’s historical data in an easy to access place where it will always be available is appealing. Whether it is one’s financial records, tax information or family photos, list of friends and contacts or even entertainment it’s becoming easier to maintain any or all of that information in an easily accessible place.

Add to that list the collection, maintenance and storage of all our personal medical records and you have a life full of history at your finger tips. doesn’t that sound appealing? Can you imagine being able to easily look up every medical checkup you’ve ever had, every lab result or every x-ray you’ve ever had and every procedure and every prescription you’ve ever had or taken. Wouldn’t that be convenient not only for your own use but for family members who may be responsible for you, someday.

The ACA included provisions which mandated all providers move to electronic record keeping. The stated goal of the idea (mandate) was to improve efficiency and outcomes of healthcare encounters by being able to better maintain, track and share data between providers. Makes sense doesn’t it?

The implementation of this ACA mandate was not easy nor has it been completed by every provider in the United States. Many small providers or rural providers lacked the resources and capacity to quickly comply. Large providers may have had more resources or better access to technology to help them comply but they also had much larger patient base with huge amounts of data to input.

Your humble author has written and spoken many times about the concern we all should have about this vast collection of “very personal” medical data being stored in a single data base and the ease in which it can be shared. Why was I and still am concerned?

Events, briefly reported in the news, have proven that security is the reason why we should all be concerned or at least not surprised when our own personal data is stolen by hackers or internal evil-doers. Let’s face it, hackers have already demonstrated their ability to get into and steal data from the US Government Personnel Records as well as banks, credit card issuers, credit reporting agencies, Sony, Facebook, Google, and dozens of insurance companies.

Why would we think that our personal medical history, stored by our personal doctor, local lab or local hospital, would be better protected than the biggest tech companies, Insurers and banks in the country not to mention the United States government, itself?

Well, let’s add one more concern to collection and storage of our personal health information. That would be incorrect data.

That’s right, just simple mistakes of data input that might influence a provider to make a draw an incorrect conclusion which could lead to an incorrect diagnosis and worse treatment for a patient. Sounds too simple to worry about, I know. But think about the impact of adding or omitting a single word from the input of data in a patients record.

Let’s say that a Doc is trying to type or dictate that “The patient has a history of high blood pressure.” but instead it gets entered in the records as “The patient has no history of high blood pressure.” You can probably think of many other examples which could be more serious or at least more embarrassing.

Such as, a woman, age 34, goes to her doctor presenting symptoms of nausea, fatigue, and bloating. The doctor runs a panel of tests and after review enters his thoughts into the record “Blood tests reveal no blah, blah, blah but that the patient, Mrs. Jones, tested positive to being pregnant’. The potential problem is that Mrs. Jones’s husband had a vasectomy 5 years earlier. You can imagine the discussion that followed.

But, the doctor had an exceptionally high number of patients to see that day, was rushing to get through and in addition was trying to get finished in time to go watch his 14 year-old son play baseball that afternoon. The record should have stated “Blood tests revealed no blah-blah including pregnancy”. I don’t need to explain further the complications this mistake could cause Mrs. Jones.

Truthfully, we should be more concerned with hackers and evil-doers than mistakes in input. The hackers will use our information for evil and the results could be far more harmful, except maybe for Mrs. Jones.

So, what do we do?  There is probably little that any of us can do. If your general provider has a website on which patients are allowed to access their own data then we should access it from time to time. For instance, my provider’s group provides me access to what they call “My Chart”. I go there from time to time, generally after getting an email from them prompting me to do so. These records available on your provider’s website provide a good means to at least try to verify that your data is accurate. If nothing else you can verify what is says about the Rx you take, your next appointment or just the accuracy of your date of birth. These sites generally allow you to print your information which can be handy if traveling out of country or for a provider not able to access the data.

The easy access to helpful personal health information is a benefit when protected properly. It’s just that no one can guarantee us that they can protect our information. There’s nothing you or I can do about the security of our data or that our data is collected in the first place.

Over the past 30 years I’ve stated many times that the concept of Managed Care is really designed to provide Insurers a means to manage their cost and it’s up to us to actually manage our care. Electronic records are one more aspect of our care which we must manage if we want it to be accurate and safe.

In this case we all are subject to the same risks so once again I say; we’re all in this together.

Until next week.

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

Post Election Review: What’d we gain and what’d we lose. By “we” I mean the average premium paying American citizen!

November 8, 2018

It’s only 12 hours post Election Day as I write this so everyone is still playing nice and watching for the “first dig of the spur” from the other side. When you read this, in 24 hours, I wager that the language used in the political discussions will already have turned back to negative, divisive or worse.

Will the House be nothing but subpoenas, investigations, impeachment, and obstruction?
Will the Senate, as well as other conservative voices reciprocate.
Will anything meaningful for America get done before the 2020 election?
Will we see nothing but gridlock and scapegoating?
I’ll let you fill in the answers to those questions!

Here are a couple random thoughts both Nationally as well as here in good ol’ California.

  • I doubt that the Employer Mandate will be eliminated which we have discussed in previous Posts. That is not a bad outcome because the GOP tinkering with the ACA was not helping.
  • Will the Individual Mandate be re-instated?
    Probably not, even though it should be.
  • Will anything positive be done to improve the ACA’s adverse rating methodology and burdensome fees and taxes added to it?
    Probably not!
  • Will “Single Payer” or “Medicare for All” advance anywhere in the Country or in  any State?
    Probably not, though it will get a lot of press coverage.
  • Will the truth about coverage for “Pre-ex conditions” come out showing that the Dems and the Media were fear-mongering the issue?
    Probably Yes, but people will need to listen closely to hear the truth!
  • Will premiums start to go down on ACA compatible plans?
    Definitely not!

 

What about the Golden State: California?

  • Will AHPs or STPs be allowed to exist and help the tens of millions who could benefit from them?
    Nope, not without a insurrection?
  • Will Insurers be allowed to restrict small employers access to HRAs with subtle threats to insurance brokers?
    We’ll see but I know one Insurer that for sure will not be restricting HRAs.
  • Will Californians see their premiums continue to increase at each renewal?
    Yep, but the Media will state that the increases are lower due to the good-work of the ACA. We’ve discussed that  effort in subterfuge before, too.
  • Should employers continue to sponsor group health plans for their employees
    Absolutely and do so with the Employer Driven method proven so effective.

Am I concerned about the future for healthcare financing and delivery in California?
I have been concerned about this issue since 1985 so I will continue to be concerned but I will not give up hope. Sooner or later (probably later) the status will become so unbearable that the solutions will be so amazingly clear that even the Dems in California can see it.

Let’s allow them to think that independent-competitive insurance plans operating in a less government regulated environment is their idea! Maybe that will do it.

Regardless, we’re all in this together, so keep the faith and keep watching for more “common sense solutions” as we venture forth together.

Until next week.

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

Headlines read, “Somebody Needs To Fix It” as we near the mid-terms. They mean healthcare, of course!

October 25, 2018

That’s right, as predicted here, healthcare and insurance coverage is taking center stage in many mid-term races across the Country. The Media is inserting itself with stories that suggest one GOP candidate after another is against covering pre-ex or  for repealing the ACA, or Short-term plans are good and so forth.

The biggest, most threatening and most mis-reported is the candidate’s stance on the coverage for Pre-existing conditions. I have not read or heard of even one candidate that proposes the elimination of guaranteed acceptance or coverage for pre-existing conditions. He or she would be a fool to do so but here’s how the Media spins it. 

Many in the GOP and other so-called Conservatives support the Trump Administration’s actions that:

  • Allow Short-term Medical Plans to extend coverage for up to a year.
  • Allow for  Association Health Plans that allow “affinity” or groups of similar nature to band together for the purpose of buying insurance.

Both of these ideas are opposed by the Democrats and other single-payer big government healthcare proponents who don’t support solutions that might actually work and therefore provide options other than a government-run plan.

That comment is not cynical, by the way, because any debate about these plans includes the usual sound bite rhetoric opposing STPs and AHPs.

But back to the point, the Dems and Media, during these mid-terms, are trying to paint the GOP with the label of “taking away coverage for Pre-ex” because pre-ex is not usually covered by STPs and AHPs and those plans will have some latitude in coverage.

Our citizens will always have access to ACA plans that are GI and cover Pre-ex so the argument should be an easy one to overcome. But it’s not.

The typical scare tactics are being employed:

  • To frighten citizens into believing that their coverage will be taken away.
  • To scare people into thinking that their premiums for their ACA plans will increased simply because of these “evil” STPs and AHPs. 

The good news that:

  • I think most Americans are smarter than the Media or Democrats give credit.
  • Plus, people with Pre-ex conditions most likely already have their coverage.
  • And 85% to 90% of individuals covered under the ACA Exchanges are subsidized therefore costing the member little or nothing to get coverage.

But, the Media needs to talk about something so as it does with so many issues it projects hypotheticals on to an issue that does not exist. Then that hypothetical gets reported by other outlets two or three times and “bingo” it’s a news story that gets legs.

It’s a fact and for certain that our health care system needs fixed. There are easy steps, which we have Posted before, that could lead to better coverage, better access and lower costs if only they would put you and me in charge.

Next week we’ll discuss the coming mid-term election with some specific ideas for people who really want a better-less costly healthcare solution. That’s why we call it the “The Solutions Based healthcare Blog” and because we’re all in this together!

Until next week.

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

Autumn is a Season for two things: Elections and partisan promotion of the ACA’s Health Plan Exchanges. Boy, do facts get skewed for both!

October 11, 2018

I know my title was remiss by not including football and the World Series both of which are far more fun than mid-term elections or the ACA open enrollment period. Remember, this is a healthcare blog so I will stay on message.

I don’t want to address the facts, stats, and promises politicians make at election time but I do want to point out a few corrections or misunderstandings (make that mis-information) that ACA supporters use to promote the Government run Health Exchanges at Open Enrollment (OE). You see Autumn or rather the Fall season signals the coming Open Enrollment period for Government run Exchanges so the proponents of the ACA, which includes most of the Media, many Think Tanks and Foundations and all Democrats work to sell the Government run program to our citizens.

How do they do that? They start with some statistics reported in a manner that supports their position even if it requires a skewing of the facts, which we’ve witnessed in the past. As your humble author has written before, the media has often delivered a biased lopsided view of the current status of the health plans that we all require. They write of Out of Pocket costs, of higher deductibles, of pre-existing conditions, of premium increases, of provider access and even lack of choices in a manner that suits their agenda.

Which is to scare the common sense out of people so that single-payer government-run healthcare sounds like a good idea.

Recent reports are cheering the modest increases in premiums this Fall. For example, Covered California is bragging that the premiums for SHOP, the exchange for small employers, are increasing only 8.3%. We’ve discussed this issue before and revealed the real facts concerning the status of premiums.

First, what other good or service in your life is increasing its cost by 8.3% this year. And, if it did, would you be satisfied with the benefit of that good or service?

Second, the 8.3% increase is multiplied times a rate that has already been increased by as much as 300% over the past 7 years. We’ve discussed the impact of compound interest before, haven’t we?

But, proponents (Democrats and media) have to try to sell their product and to do so requires a real “sales job”.

Another set of facts released deal with the increase in “plan deductible”. The data clearly shows that the deductibles we have on our plans has been steadily increasing. For Employer sponsored plans statistics reveal that:

  • 85% of members have a deductible on their plan
    (10 years ago it was 59%. In 2000 it was less that 25%)
  • the average plan deductible selected by applicants is $1573 up from $1505 a year ago. That’s a 5% increase in deductible in addition to increased premium.
  • 25% of Employer plans offer a deductible of $2,000 or higher.
    (These employers need to add an HRA for their EEs)
  • Plan deductible is just a portion of Out of Pocket costs which is an issue for many and we’ve discussed in many Posts.

What do all of these statistics have in common? They are driven by increasing premiums which is the predictable outcome of an overly regulated government-run healthcare system.

As we’ve discussed before 152 million Americans (close to 60%)  get their health plan from their Employer. So, we should ask a few questions in order to maintain a solid fact-based rational for this mess.

  • Q: Why do Employers spend any money to provide a health plan?
    A: To attract and maintain a competitive workforce.
  • Q: Do Employers want to offer a health plan with huge OOP?
    A: No, they want to provide the richest plan possible.
  • Q: What is the primary reason driving Employers to provide plans with higher deductibles and OOP?
    A: Premium costs! Employer premium costs have tripled in past 7 years!
  • Q: Would Employers offer richer plans if they were affordable?
    A: Absolutely, they want to retain the best workforce possible and rich benefit plans help assure that goal!

Remember, current data shows that there are more open jobs available than people seeking a job. That means competition for employees.

Sometimes, I wonder why an Employer would purchase its group benefit plan through a Government run Exchange. There are probably a couple of reasons.
The Employer:

  • May believe it is too small to get a private group plan.
  • May not be able to meet participation  guidelines of private plans.
  • May not have a good insurance broker to guide it.
  • May be uninformed or mis-led to believe an Exchange is the only option.

Almost anything can be packaged and promoted to sound appealing.
For example: let’s say that you are selling cars but only offer your cars in the color white. However, your competitors offer cars in many different colors including white. Would you need to promote your cars in a manner that made potential customers think that your cars in white were better than the competitors cars in various colors?
Of course you would or else you go out of business.
However, if you were being subsidized by the government then you could say almost anything to compete.

We’ve discussed in previous Posts that the media will be increasingly bold in its attacks on pre-ex, premium leveling off, OOP on plans as well as unexpected OOP, choice and many other areas to support candidates in the mid-terms coming in November. We need to continue to be aware and make others aware so that these scare tactics do not work!

That’s why we’re all in this together! To help one another.

Until next week.

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

Why do California’s state politicians dislike Californians so much? Gov. Brown just signed legislation that guarantees Ca’s citizens will see no relief from rising health plan premiums.

September 27, 2018

Some things are just too crazy to understand such as why California’s legislature and Governor continue to put forth healthcare related legislation that guarantees the good premium-paying citizens of CA will get no relief.

The legislation that the Governor just signed, SB 910 and SB 1375, put a “ban” of the health plans referred to as Short-term medical plans as well as on Association health Plans both of which came about as a result of the Trump Administration’s efforts to lower healthcare cost and increase alternatives. The proponents of the bills Gov. Brown just signed applaud that this moves CA one step closer to universal coverage which to them means “state run healthcare”.

As we’ve discussed in previous Posts, the efforts in healthcare related legislation by CA’s liberal politicians cause more pain, both physical and financial, to 90% of the population just to move toward their stated goal of government run healthcare. One piece of legislation after another, over the past 10 years, has reduced access to care, raised cost of insurance and increased out of pocket cost for patients. I could list numerous pieces of legislation that punish the majority but did nothing to benefit the people the Legislators claim to help.

SB 161 is a good example of these bad bills. In legislative hearings the proponents of SB 161 openly stated that their goal was to eliminate competition for the group plans of Covered California. So SB 161 was created to restrict small employers from gaining access to lower cost group health plans that utilize self-insurance and stop loss policies. The result – small employers lost access to competitive group health plans and of course we all know that Covered Ca’s group plans suck.

This time, the CA legislature’s goal is to block both Short-term medical plans (STPs) (what liberals refer to as junk insurance) as well as Association Health Plans (AHPs).  Democratic Senator Ed Hernandez, who authored the afore mentioned SB 161 has also authored SB 910 and SB 1375 which ban STPs and AHPs respectively. Remember that both of these health plan options are designed to offer more choice, that means potentially better alternatives than the ACA’s metallic plans provide.

The opponents of these innovative and competitive types of coverage claim that because these plans are exempt from some of the Affordable Care Act rules these plans will “cherry pick” healthy citizens. That these STPs and AHPs would leave the un-healthy citizens on the current plan offerings of the ACA, which we all know suck.

BTW, by suck I mean:

  • Too expensive
  • Too high out of pocket limits.
  • Too much risk for “unexpected” costs as we’ve discussed.
  • Too skinny provider networks
  • Too few options for individuals and families

The Liberals claim that the STPs and AHPs are bad because:

  • They can underwrite which means they can accept or reject applicants.
    (While not all are accepted this does bring premiums down)
  • That members with pre-existing conditions might see their claim denied.
    (Folks with Pre-ex could remain on the ACA compliant plan of their choice)
  • They don’t need to cover ‘essential health benefits which Liberals always highlight includes mental health and maternity care.
    (Not everyone needs maternity care, pediatric dental, or mental health benefits so AHPs and STPs can cover what folks really care about at lower premiums)

The real story is that California’s liberal legislature has convinced itself, and any new politician that joins them, that CA needs “universal coverage” run by the State of Ca. Can you imagine how horrific a state run plan would be for everyone including those citizens with pre-existing conditions. (Who the Libs say they care about)

Have you ever tried to fight the Government when it makes a mistake? It’s impossible to get help, a correction, satisfaction or relief.

But, if your private plan’s Insurer mucks something up you can get relief or at least an explanation. Plus, you have a regulatory body such as the Dept. of Insurance or Dept. of Manage care to step in, if needed. Insurers try to avoid intercession by regulators.

Who would you rather fight: the State Government Bureaucracy that does not give a hoot about us as individuals or an Insurer that lives in fear of the DOI?
You know the answer!

The sad fact is that we are all being penalized as the CA tries to implement its vision of state run health care. As stated many times, 90% of us are paying increasing premiums while getting decreasing benefit and the legislation the Governor just signed won’t make it better for the 90% of us.
Enough on that!

As a random thought, have you noticed the press and liberal candidates increasing the fear mongering about pre-existing conditions. As we predicted a month ago,  every article about health care includes a paragraph or two about the GOP’s desire to cut off your coverage for your pre-existing conditions. These statements would be laughable if it weren’t so darn serious.

As I’ve stated, no Conservative or Republican would dare take Guarantee Issue and Coverage for Pre-ex away from us. Remember, these people want re-elected more than anything. Why would they do something stupid like that? Plus, the Insurers have learned to be profitable in the new era, very profitable.

OK, next week you’ll read about E Clampus Vitus as I venture to my Fall Trek. I hope you will enjoy reading about the history of the Clampers.

Always remember, we’re all in this together.

Until next week.

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

We warned you about the Employer Mandate. The Congress is working quickly toward an outcome that makes little sense! let’s see why.

September 20, 2018

You read here on August 16th 2018 how the US House passed out of Ways and Means a bill  which would suspend the employer penalty payments for the period after December 31, 2014 up to January 1st, 2019. Again Yes, you read that correctly. For years, 2015 through 2018 the employers affected by “play or pay” would not be required to make the penalty payments. I’m sure it’s some clever GOP move to throw off logic.

The Bill was voted out of the House last week which means the Senate gets a whack at it. Will it make it into law before the mid-terms? I doubt it but let’s take a look at the brilliance of our House GOP as it stumbles over itself yet again in its efforts to repeal and replace the ACA.

Here are a few high points of what H.R. 3798 would provide:

  • Change the ACA employer coverage mandate threshold for “full-time employee” to 40 hours per week, from 30 hours per week. (May increase uninsured ranks)
  • Keep the ACA employer coverage mandate from applying to any month beginning after Dec. 31, 2014, and before Jan. 1, 2019. (Will employers that complied receive any restitution?)
  • Postpone the start date of the ACA excise tax on high-cost health benefits packages to Dec. 31, 2022, from the Dec. 31, 2021, start date now in effect. (No one likes this tax or even understands who will pay it. Why not just eliminate it?)
  • Repeal an ACA excise tax on indoor tanning services. (Duh, who cares!)
  • Require employers to provide Form 1095 coverage statements to individuals only when individuals ask for the statements, instead of having to send the statements to all employees, recently departed employees and certain dependents every year.
    (This is not a bad idea, but if there is no Individual Mandate and no Employer Mandate why is reporting necessary at all?)

Here are the challenges as stated by experts:

One challenge supporters of H.R. 3798 face is finding new federal revenue, or new federal spending cuts, to offset the effects of ACA employer mandate changes on the federal budget.

Analysts at the Congressional Budget Office estimated in a report posted Tuesday that H.R. 3798 could cut federal revenue by about $12 billion in 2019, and by about $52 billion over the period from 2019 through 2028.

The delay in the effective date of the employer mandate and the change in the definition of full-time worker could cost the government about $46 billion in revenue over the 10-year period starting in 2019, according to the CBO analysts.

Here’s what I said before and I’ll say it again:
Is it even close to being a good idea in the first place or just a political gimmick by politicians so that they have bragging points as they campaign for reelection? We know from the Individual Mandate that they won’t repeal it outright but rather they will  simply reduce the penalty to zero. Jeez, that’s a cowardly way to legislate.

As we asked previously, is the employer “play or pay” mandate a good idea or should it be eliminated? Plus, what effect will it have on the thousands of employers and hundreds of thousands of employees who complied already?

I am a free market, let the private sector resolve it and keep the Government the hell out of it, kind of guy. But, this issue is a complex one because as I mentioned tens of thousands of employers have already taken steps to comply.

Those employers stepped up to do what was required, those employers purchased the plans that complied with the law and spent money that the non-compliant employers did not. It would be unfair for non-compliant employers to avoid the penalty while other employers have already spent untold fortunes with no hope of getting that money back.
Can these employers, who feel they were forced to comply, receive any restitution equal to what they paid to comply?

Remember this example:
If Company A and Company B both bid on the same project they would both include all of their operating and legacy costs in those bids. Therefore, if Company B provides no health plan, because it was and is noncompliant, then its costs might be lower thus allowing it to submit a lower bid and possibly win a project over Company A which does provide benefits.

Personally, I think an employer who provides benefits is probably a better run company and certainly tries to take care of its staff. So, that employer should have an advantage but money is money which means the buyer may take the lower bid. That sucks but happens.

But, the other side of this is the employee’s. Hundreds of thousands of employees have been offered and enrolled on a health plan, possibly for their first time. What happens to them if their employer discontinues a plan because it’s no longer required legally? Many would go without coverage simply due to affordability.

Let’s face it, the ACA has caused premiums to increase astronomically over the past 7 years on individual plans (all plans really). These employees, pushed off an employer sponsored plans, would be required to go into that ACA Individual Plan jungle, and I do mean jungle as it is a “freaking” mess in that market. Would those employees want to pay those high premiums – could they afford those premiums? Probably not.

In addition, the health plan landscape, that is alternatives and access, varies greatly state by state. Many states, like California, are not allowing any of the Trump administration’s new ideas to come to California. California says No AHPs, No to skinny plans on top of what California had already implemented to harm small employers with its stop loss killing legislation known as SB 161.

Again, I would wager that many employers, who bit the bullet and complied, will maintain their plans thus continuing the expense they incur. The elimination of the penalty will make it so that non-compliant employers will be allowed to continue not providing benefits, not spending those funds and may think they have a financial advantage in the market against competitors.

So, against my human nature and all that helps one develop values I don’t think the “Play or pay” mandate should be eliminated for large employers. In fact it should be enforced. The IRS has had difficulty identifying which employers should or should not be Playing and less success in getting noncompliant employers to pay. Big deal – get it done so that the law is applied equally.

So, even though the House will be in recess as you read this, you will be informed. Together we need to stay focused on healthcare issues like this. Can you think of a single big government bureaucracy that has ever not fouled it’s intended objective? No, so when we identify issues that need attention or fixed or eliminated we should shout for it.

That way they’ll know that we’re all in this together.

Until next week.

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

Higher Out of Pocket cost for healthcare services seems to be a surprise to some. Question for you: Who hasn’t expected that? Let’s explore this.

September 13, 2018

Over the past few months we’ve seen a steady increase in articles and news headlines with stories about how people have experience higher Out of Pocket (OOP) than they ever expected. The stories, and there will be more before election day, actually highlight many of the fundamental flaws in the ACA that we have been discussing for years.

But, their tactics are clever, if not devious, as the authors carefully imply the cause of these flaws is a result of the GOP and the Trump Administration’s tinkering with the ACA. Of course the GOP changes have nothing to do with higher OOP and higher premium of the Obama administration’s signature healthcare bill, The Affordable Care Act. Stills sounds awkward calling it the affordable care act, doesn’t it?

First question that comes to mind is: “who could be surprised that higher premiums, higher deductibles, skinny networks, and record Insurer profits would lead to higher OOP for members?” I have no doubt the stories and the examples about which they write are 100% true. But, none of us should be surprised because it is election season.

Of course, the GOP has tinkered around the edges of the ACA which the authors can use as side notes to imply a cause. But, there is not one change by the GOP that would have led to more OOP than the ACA plans provided for prior to January 2017.

There has been no change to the metallic plan structure or minimum claim payout requirements legislated by the GOP. Unfortunately, we could have really used some legislative fixes to actually improve or eliminate the ACA but that’s an old story which we have discussed over the past 2 years.

So, what causes the surprise of the higher Out of Pocket.

  • Number one issue that always surprises folks is the high deductible plans with naturally higher OOP. When we shop for our health plans aren’t we all are surprised and dismayed by the cost and benefits?
  • We’re surprised that for the premium we pay the plans provide no benefit for RX or Office Visit copay until after the higher deductible is met. Many have stated that the Bronze plans actually encourage folks to defer of seeking healthcare.The metallic plans suck for sure but the OOP is foreseeable if not predictable.
  • The biggest shock comes from services provided outside the PPO network (OON) of the member’s plan. Members may try to use PPO Docs but sometimes it’s not possible because the PPO networks have been cut down so much. The shock comes from the OON provider’s invoice due when providers “balance bill” the patient for services outside of the PPO network. Those charges can be huge and generally not predictable. A patient may have an emergency situation or complex health treatment which will absolutely with 100% certainty result in unexpected charges due to OON providers.

A recent survey by the Kaiser Health Foundation compared the level of “worry” Americans have with their ability to pay various costs they incur.
The survey reveals the percentage of folks concerns about their ability to pay their bills.  The respondents who stated they were Somewhat Worried to Very Worried is staggering yet predictable:

  • 67% concerned about unexpected medical bills.
  • 53% concerned about health insurance deductibles.
  • 46% concerned about gasoline or transportation costs.
  • 45% concerned about RX costs. (Seems low doesn’t it)
  • 43% concerned about their utility and electric costs.
  • 42% concerned about their monthly health insurance premium.
  • 41% concerned about their rent or mortgage.
  • 37% concerned about affording food.

Of the 8 categories we see 4 of the largest concerns are healthcare related.
The bigger issue should be that those 4 categories do not occur independently. We pay premium to be covered and majority of IFP Plans (Individual or Family Plans) are Bronze or Silver so we have larger OOP for both Rx and most medical services. Then add the Out of Network balance billing concern and we have a potential and predictable catastrophic event. But, that’s no surprise is it?

Most Bronze plans have deductibles of $5,000 or higher with no first dollar Rx  benefit and OOP of $7,000 or higher. If a Bronze Plan is what a member can afford then OOP costs can be somewhat projected, in the absence of out of network care. I think most Americans would agree that the high premiums they pay for even a Bronze plan, with its high OOP, is not acceptable. Particularly healthy Americans who, as we have discussed in prior discussions,  pay a large “surcharge” to compensate for the UN-healthy.

We appreciate KHF’s efforts to report results and surveys concerning healthcare costs and delivery. They do a good job of compiling and reporting results and area specific trends. But what we see in many reports is the presenter adding commentary concerning unrelated but politically expedient issues.

Lately, the most added unrelated-issue is the impact members would experience if the GOP eliminates Guarantee Issue and coverage for Pre-existing conditions. It would be suicide for the GOP to eliminate GI and Pre-ex coverage but it wouldn’t be the first time the GOP shot themselves in the foot. Even if the court rules on the GOP case in favor of the 19 states suing the ACA , the GOP will continue to provide for GI and Pre-ex. If the GOP does not maintain GI and Pre-ex then the next two election cycles will be a disaster for them.

We discussed if previous posts that as we approach the mid-term elections we will see an increase in stories designed to cause fear for our citizens who may have ongoing healthcare conditions. Fear mongering politics is sad but it’s true.

So, what are we to do? Just as we’ve discussed before; we stay informed and prepared so we can correct people when they are citing information that you know is wrong. We must be prepared to help our fellow citizens be informed so that they do not succumb to the fear tactics that work so well on the uninformed.

We can do this because; we’re all in this together!

Until net week.

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