While We’re Ducking and Dodging

While we’re ducking, dodging, and otherwise attempting to avoid damage from the GOP, they’re still busy with legislation to make our lives just a bit more difficult.  Cases in point:

The House leadership has delayed, but hasn’t promised to discard, a bill, HR 367, to allow the general sale of silencers — which the proponents tell us will mitigate hearing loss for gun owners.  Pro Tip: A nice pair of headset style ear protectors will set you back about $30.00 (if the foamies will do you can buy’em for about 12 cents each in a bucket of 200) as opposed to spending $1300.00 on a suppressor for your AK/AR-some number or another.

The GOP tax cut legislation, which somehow is being titled “reform,” is a walloping giveaway to the top income earners in the U.S.  Not sure about this? See the Institute on Taxation and Economic Policy, that tells us those in the bottom 20% will see 1.3% of the tax benefits while the top 1% will enjoy 67.4%. Bringing this closer to home, the top 1% of income earners (which amounts to about 0.4% of our population) will get a 70.7% share of the tax cuts. For all that chatter about the Middle Class, the plan doesn’t really help middle class Nevadans:

“The middle fifth of households in Nevada, people who are literally the state’s “middle-class” would not fare as well. Despite being 20 percent of the population, this group would receive just 4.6 percent of the tax cuts that go to Nevada under the framework. In 2018 this group is projected to earn between $38,900 and $60,600. The framework would cut their taxes by an average of $380, which would increase their income by an average of 0.8 percent.”

Just to put this in context, a family in Nevada’s middle income range would see a tax cut of about $380…meanwhile back at the home mortgage, if that family is in Reno where the average home loan is about $187,000, the monthly payments are about $855 per month.  Congratulations Middle Class Nevadans, you may receive an annual prize of 44% of one month’s mortgage payment.  Color me unimpressed.

The GOP passed its version of the FY 2018 budget on a 219-206 vote.  Representative Mark Amodei (R-NV2) voted in favor of the bill; Representatives Kihuen, Titus, and Rosen were in Las Vegas attending to their constituents in the wake of the massacre at the music concert.   The AARP was quick to notice that the Republican plan calls for $473 BILLION to be cut from Medicare over the next 10 years.   Expect a cap on the Medicaid program funding; it wouldn’t be too far off to estimate cuts of about $1 TRILLION in that category.   Beware when Republicans speak of “entitlement reform,” that simply means cutting Social Security benefits and Medicare.  When they say “welfare reform,” they often mean cutting Food Stamps, Housing Assistance, and Medicaid.   Representative Amodei might want to explain why he supports cutting Medicare by $473 billion over the next decade?

Those in Nevada’s 2nd Congressional District can reach Representative Mark Amodei at 202-225-6155 (Washington DC) 775-686-5760 (Reno), or 775-777-7705 (Elko);  the office addresses are — 332 Cannon Building, Washington, DC 20515; 5310 Kietzke Lane #103, Reno, NV 89511; 905 Railroad Street, Ste 104D, Elko, NV 89801.

GOP assault on health care in rural Nevada

There’s a tendency to see social needs as an element of urban living in major cities like New York City, Los Angeles and Chicago, and rural poverty as something that happens in Appalachia.  This perspective obfuscates two features of life in Nevada.  For all intents and purposes Nevada is an urban state.  Not only is Nevada “urban” it is getting more so.  In 1970 about 80.9% of Nevada residents lived in urban areas, in 1990 the percentage was 88.3, and as of 2010 the percentage was 94.2% [ISU.edu]

By contrast, New York state as of 2010 was 87.9% urban, and Illinois 88.5% urban, while Nevada is closer to California’s 95% urban population. [ISU.edu]  However, to perceive rural Nevada as a wonderland of “freedom” and rugged individualism is to miss some crucial figures describing life in the “cow counties.”

For example, Pershing County has an 18.3% poverty rate; the US poverty rate is 12.7% [census] but the county does support a critical care hospital with a skilled nursing facility  with a maximum capacity of 25 residents.  The county’s population also includes 11.1% disabled people under the age of 65.   Given these figures, perhaps some politicians would like to explain why slashing Medicaid now and all but eliminating the national program by 2027 would be a good idea for Pershing County, Nevada.

Neighboring Humboldt County has a lower poverty rate, at 9.4% and a lower rate of disabled individuals under the age of 65 at 8.3%, but reducing the Medicaid program would have a deleterious effect on its 53 bed hospital, with an ICU, Obstetric services, and skilled nursing facility for 30 residents.  What effect of cutting Medicaid might be seen in the county’s ability to care for its aging population, including its hospital’s plans to incorporate a “memory care services unit” in its offerings?  [hgh] Recall that some 60% of all skilled nursing home residents get their health insurance coverage from Medicaid.

More populous Elko County has a poverty rate of 9.9% and an 8.4% rate of individuals with disabilities under the age of 65.  The county is home to a short term acute care hospital with 59 beds, and a resident center for 110 people needing skilled nursing care.   Again, if 60% of those SNF residents rely on Medicaid for their insurance coverage then cutting funds in 2027 then 66 families will be under increased pressure to find suitable and appropriate care for elderly family members.

Now, consider that Nevada is an urban state, and that should the Republicans get their wish for a capped Medicaid system of block grants then the state would be tasked with allocating increasingly spare resources to maintain nursing home and hospital facilities statewide.  Given the 2.115 million people in Clark County contrasted with the 52,168 population of Elko County, the 6,650 in Pershing County, and the 16,842 in Humboldt County — where are the monetary resources likely to go?

If Congressman Mark Amodei (R-NV2) and Senator Dean Heller are truly representing the needs of rural Nevada, then offering platitudes about “freedom,” “free enterprise,” and “individual initiative” are a poor substitute for enacting legislation to maintain and improve the health care facilities and the insurance availability to those facilities for northern Nevada rural citizens.

It’s not over until the fat lady sings adios to the current Congress

This is your Monday morning reminder that Republican attempts to kill the Affordable Care Act and Medicaid aren’t history.  The Graham-Cassidy Bill, which would mean a net loss of coverage for 243,000 Nevadans, still lives, and at long as it does so we have to keep those phone lines busy.

Please let Senator Heller know that his latest attempt to foist off a “Repeal and Replace” effort onto Nevadans is actually worse than his last performance on behalf of the Senate’s “skinny bill.”

“Graham-Cassidy’s impact on coverage in 2027 would be similar to that of the Obamacare Repeal Reconciliation Act (ORRA), the so-called “repeal and delay” bill that the Senate failed to pass in July. Under both the ORRA and Graham-Cassidy, these three major policies would be in effect a decade from now:

• Repeal of the mandates for individuals to obtain health insurance coverage and large employers to offer insurance

• Elimination of subsidies for nongroup health insurance

• Elimination federal funding for the ACA’s Medicaid expansion” [CAP]

No individual or employer mandates to stabilize the insurance market, no assistance for those trying to find insurance in the private market, and the loss of Medicaid assistance for working Americans.  And, why all of this effort?

The Republican plan to lower taxes for those in the top 1% of American income earners won’t “add up” without cutting help for average Americans under the ACA and without pulling the rug out from under those (including retirement center residents and children) who are insured by Medicaid.

Senator Heller can be contacted at:  202-224-6244; 702-388-6605; and 775-686-5770

You may also want to thank Senator Catherine Cortez Masto for her support of Nevada families who rely on the ACA and Medicaid for their health care insurance needs.  202-224-3542; 702-388-5020, and 775-686-5750.

GOP: Poor Excuses and Paucity of Empathy

By all accounts the Graham-Cassidy+Heller version of health care destruction would yield a net coverage reduction for 243,000 Nevadans. Overall it would mean a 31% cut in Medicaid for children — that’s right — children.  There’s another 15% cut for services for people with disabilities.  And what’s the rationale for this atrocity?

(1) Because we promised!  This is probably the silliest reason to do anything ever.  I may have promised to offer someone a ride to go shopping, but if there’s a blizzard on the way then it’s downright stupid to “keep the promise.”

(2) Because Obamacare is failing!  And why would that be? Because Republicans refused to make some simple fixes (risk corridors, risk sharing, and reinsurance) and the individual health insurance is unstable.  It’s a classic case of tossing the baby out with the bathwater.  Or, of finding some perfectly “fixable” problems with a law and using those to rationalize pitching the entire thing.  Head UP: They’ll try this same approach with the financial sector reforms in the Dodd Frank Act.

And then there’s the part the Republicans aren’t talking about.

(3) Because they’ve wanted to get rid of Medicaid, Medicare, and to privatize Social Security from time out of mind.

This comment sums up the situation:

“The two keys to the Republican attitude are money and ideology. If you view the modern G.O.P. as basically a mechanism to protect the wealthy, Medicaid is an obvious target for the Party. The program caters to low- and middle-income people, and its recent expansion was financed partly by an increase in taxes on the richest households in the country.”

The concept can’t be articulated more simply or directly.

Then there are the sputtered talking points, common among Republican politicians and supporters to hike around the obvious but unspoken issues they have with the Affordable Care Act.

If we don’t pass this we’ll have socialized medicine.  Please.  Even Single Payer (or Medicare for all) isn’t socialized medicine.  Medicare insurance is used to pay PRIVATE providers for medical treatment.  This obviously isn’t a nationalized medical service plan.  Only by artificially conflating medical insurance with medical services can anyone assert that this is “socialism.”

There are no guarantees in life.  So if a family in Minnesota who has a child with muscular dystrophy may be required to pay higher premiums that’s the way the markets work.  It doesn’t get more morally bankrupt than this — especially since the current system does guarantee coverage for families with chronically ill children.

This issue is long past being a public policy issue, it has devolved into pure politics in which ‘points’ are scored by a party desperately hoping to cut taxes for its most generous donors at the cost of Americans’ health care.

So, every few weeks we’ll have to call our Senators to beg them not to destroy the Affordable Care Act and Medicaid for ourselves, our families, our friends, our neighbors, and our fellow citizens.

Call Senator Heller at his Las Vegas Office 702-388-6605; his Reno Office 775-686-5770; or his DC Office 202-224-6244. 

You may also want to call Senator Cortez-Masto to thank her for her support of health care access for Nevadans. 202-224-3542; 702-388-5020; 775-686-5750.

It’s Official: GOP Hates Women — Scamcare Edition

In case there’s anyone left who thinks the Republican Party is representing the needs of women in this country, the contradiction is right in front of us in the form of the Graham-Cassidy+Heller (tagging along) bill.

Amy Friedrich-Karnik, senior federal policy adviser at the Center for Reproductive Rights, pointed to a statistic from progressive think tank the Century Foundation that estimates 13 million women will lose access to maternity care services if the ACA is repealed. Friedrich-Karnik explained that the bill also blocks Medicaid patients from using Planned Parenthood, which bars access to essential preventative care like birth control, cancer screenings, and STD testing and treatment. “It also slashes Medicaid overall and into the future, and so really impacting particularly low-income women and women of color who rely on Medicaid broadly for their health care,” she said. According to the Kaiser Health Network, Medicaid pays for nearly half of all births in America and covers family planning services for 13.5 million women. [Jez]

Not only is the bill a golf ball shot to the back of the head for Nevada women, it could cost the state some $250 million in funding:

Specifically, the proposal would eliminate the marketplace subsidies and federal dollars that states that chose to opt-in to Medicaid expansion under the ACA, like Nevada, currently receive, replacing them with block grants to be doled out to states, which would be left with the responsibility of deciding how to spend that money. It also converts almost the entire Medicaid program to a per capita cap, under which the federal government would set a limit on how much it reimburses states per enrollee, and allows states to waiver certain provisions from the ACA that require insurance companies to cover certain services and bars them from placing annual or lifetime caps on coverage. [NVInd]

Got that? Nevada gets a per capita cap, AND insurance corporations could refuse to cover pre-existing conditions, maternity care, family planning, women’s health care services, AND the corporations could revert to that wonderful old scam — the lifetime limit on coverage.  This isn’t as bad as the former “skinny” bill — it’s worse.

Senator Heller might have wanted to give this version some thought before he inked his name on the paperwork to co-sponsor the bill, but he didn’t.

It’s understandable that Nevadans are tiring of calling, writing, and sign making, but if Republicans are nothing else they are persistent.  They’re counting on public apathy, ignorance, and fatigue.  Not this time. Not on American health care. Not on our watch.

Senator Heller’s Washington DC office number is 202-224-6244.  Calls are tallied, and at some point the number of calls opposing this iteration of scam-care needs to impinge on the amount of money Republicans are counting on from the Koch Brothers and other right wing radicals.

Hellerisms on Parade: Health Care Edition

And then there was this:

“The individual mandate I thought was atrocious, was wrong and shouldn’t have been in Obamacare at all,” he said. “I don’t think your government should tell you to buy something that you can’t afford. And if you can’t afford it you pay a fine. Yet 90,000 Nevadans pay the fine.” — Senator Dean Heller

Let’s start with the assumption that Senator Dean Heller is a capitalist, a firm believer in the free market system.  He’s certainly reinforced this impression given any occasion to do so.  So, why was there an “individual mandate” in the Affordable Care Act?  — The answer is capitalism.

The more precise answer is the “adverse selection” problem in free markets.  The most concise explication I’ve found for this comes from the Economist’s View:

“To explain how the adverse selection problem arises in these markets, note that people purchasing health insurance generally have better information about their health status than the people selling the insurance. If insurance is offered in this market at somewhere near the average cost of care for the group, people will use the superior information they have about their own health status to determine if this is a good deal for them. All of the people expecting to pay less for health care than the price the companies are asking for the insurance will drop out of the market (the young and healthy for the most part; all that is actually needed is that some people are willing to take a chance and go without insurance). With the relatively healthy people dropping out of the insurance pool, the price of insurance must go up, and when it does, more people drop out, the price goes up again, and the result is just like in the used car example above: The market breaks down and nobody (or hardly anybody) can purchase insurance.”

Now, if a person is reasonably conversant with capitalism and the patterns intrinsic to the operation of free markets, then the problem of  ‘adverse selection’ should be part of that person’s lexicon.  Granted it’s not an easy thing to explain, but the Economist’s View post quoted above offers the “used car” analogical example which makes the concept more accessible.   Therefore, if Senator Heller is indeed a capitalist, and if he has better that average economic knowledge base, then his explanation of his opposition to the individual mandate makes absolutely no sense whatsoever.

There’s also the political side of the issue, recall that Obama’s original plan didn’t contain an individual mandate while Secretary Clinton’s proposal did, and the result:

“Once elected, Obama quickly recognized the inescapable truth: An individual mandate was essential to make the plan work. Without that larger pool of premium-payers, there is no feasible way to require insurance companies to cover all applicants and charge the same amount, regardless of their heath status.” [WaPo]

There’s just no way to get around the problem of Adverse Selection, and still have an insurance system based on free market capitalism. 

Those still unsure about their understanding of Adverse Selection and how it operates in a free market system may want to consult some of the following sources:  Investopedia is a good source for short, concise, definitions of economic terms such as Adverse Selection. The Economic Times also has a dictionary style definition.  Risk Management specialists have a more technical definition.  Those wishing to dive a bit deeper into the weeds might want to see the World Bank’s explication.   There’s also an explanation from the National Association of Insurance Commissioners which goes into greater depth. (pdf)

Granted the individual mandate isn’t popular — that part is easy — but anyone who professes to be a free market capitalist (as does Senator Heller) can’t ignore the principle of Adverse Selection and how that concept impacts the insurance markets.

The alternatives to a purely market based insurance system in which the most people possible can obtain health insurance at relatively affordable rates are problematic for the free-marketeers.  A public option (federally sponsored insurance program operating in the general market) is one possibility.  Another alternative simply removes the free from free market — the single payer, or Medicare for All proposal, in which public insurance pays for medical services delivered in the private market.  At the furthest end of the spectrum would be nationalized medical health services such as the British or French systems. The arguments for and against each of these are ideological and political, and not necessarily relevant to the discussion of free market based health care delivery.  However, they do mitigate, from divergent directions, the issue of Adverse Selection.

The problem for Senator Heller is that he can maintain his free market positions OR he can oppose the individual mandate, but in light of the persistent and perpetual issue of Adverse Selection he can’t do both.

Amodei: Several Days Late and More Dollars Short

So, Representative Mark Amodei (R-NV2) spent time with reporters to talk about (1) Race relations in America? — uh, that would be “no.” Or, (2) American strategy in the Middle East and South Asia? — no, not that either. Perhaps it was (3) Infrastructure investment and jobs programs?  — no, that didn’t form a major part of his remarks. Maybe it was (4) tax reform, or at least tax cuts?  — well, that wasn’t a focal point either.  He wanted to talk about health insurance, “repeal and replace,” as if the GOP hadn’t bungled its strategy and tactics to an extent that was truly remarkable in modern politics.

Never one to climb out on even the sturdiest branch and get ahead of the game, or even to keep up with the topics at hand, Representative Amodei continues to play the “repeal and replace” tune without acknowledging that his party had seven years to come up with a viable, specific, and practical PLAN to replace the Affordable Care Act.  Not to put too fine a point to it:  They Blew It.   However, this doesn’t prevent the Representative from belaboring the issue, rather like listening to someone who persists in telling us what he did on Labor Day during the New Year’s Eve party.

 

 

Heller’s Dipsy Doodle on Health Care: Centene Edition

Here we have Senator Dean Heller’s comments on access to health care insurance in Nevada — and some translation.

“I welcome Centene’s announcement that it will offer plans on the Nevada exchange, providing Nevadans with additional health care options so that no county in our state is bare. I was proud to work with Governor Sandoval to make sure that people living in all of Nevada’s 17 counties have the option to purchase coverage on the exchange next year,” said Senator Dean Heller. “Nevadans have been left with dwindling choices when it comes to their health care coverage, and it’s more evidence that Obamacare is failing. That’s why I continue to work for health care solutions – like the Graham-Cassidy-Heller plan – that return power to the states, protect Nevada’s most vulnerable, and repeal Obamacare’s onerous mandates that continue to squeeze hardworking Nevadans who can least afford it.”

Huh?  Working with Governor Sandoval to make sure people can purchase health insurance plans in the individual market certainly wasn’t in evidence when Senator Heller voted in favor of the last Senate version of the risible ‘repeal and replace with nothing’ bill.

And, no, the ‘dwindling choices” aren’t the product of failing ACA provisions — the choices are dwindling because insurance corporations are facing unpredictable (anathema to insurance) situations created by the President’s threat to cut the cost sharing provisions, which Senator Heller persists in inferring are “insurance company bailouts.”

And, there’s that Graham-Cassidy amendment to which Senator Heller amended himself, which turns Medicaid into a block grant program with an altered formula and which cuts lower income family’s access to affordable insurance plans in the individual market.  That, to put it mildly, isn’t a solution.

And so it goes…into the 2018 election.

Thanks Mr. Trump: Anthem Pulls Out of ACA market

This from Fortune magazine on Anthem’s decision to pull out of the Nevada health insurance exchange:

“In its announcement, Anthem said it had spoken with state leaders and regulators, but the deteriorating market, paired with uncertainty at the federal level, led the company to make a “difficult” decision. The Senate recently failed to make good on the GOP’s years-long campaign promise to repeal the law known as Obamacare, and insurers say Trump has added to instability in the markets with threats to stop paying so-called cost-sharing reduction subsidies.”  (emphasis added)

The administration has several ways to sabotage the Affordable Care Act and failure to support the cost sharing reduction subsidies is one of the prime one.

Thanks Mr. Trump.

Rest and Repair: Progressive Dreams and Conservative Nightmares

When last we spoke, the topic was moving from how to stabilize the individual health insurance plan market toward how best to deliver the services and do so without bankrupting American workers. Now we’re in the land of Progressive Dreams and Conservative Nightmares.

Republicans use the expression “patient centered medicine” as code for a system n which the individual (and individual policy holder) is responsible for how much, and what kind, of insurance coverage he or she may have.  This system works in theory, but has severe implications when it collides with reality.  As noted here, and in other analyses, the delivery of health care is not a “market” in the true sense of the term.  A market requires a voluntary transaction, and a diagnosis of a serious illness or the result of an accident aren’t voluntary in the sense of a face life or other form of elective medicine.  Not only is there not a market in the economic sense of the term, but health care is not necessarily an “individual” matter.

Philosophical Review and Reality Check

If I choose not to seek treatment for a communicable disease, perhaps because I don’t feel I can afford the treatment, I am placing my co-workers, neighbors, and heaven only knows who else, in peril.  If I choose not to seek rehabilitation after having an accident causing injury, then I place my own productivity in jeopardy, and reduce the value of my services to my employer and co-workers.  If, for financial reasons, I choose not to have something such basic as an annual physical exam, then I have chosen to ignore the ramifications of this decision on those around me.  My ‘freedom’ places the freedom of others to function in a safe and secure environment in jeopardy.

Arguing that “freedom” requires I accept responsibility for my own health — and health care — in turn requires that everyone else accept the same responsibility even though we have no control over the actions and decisions of others which may impact our own health.  This would be caveat emptor carried to irrational extremes.

If we’ll accept the notion that we are herd animals in our present form, and our socialization requires we not place others in jeopardy willfully or involuntarily, then what options are available within the current system to make sure we are healthy enough to be productive and not ‘infect’ the neighbors?

Dreams and Nightmares

At the risk of inserting more artificiality into this discussion, let’s assume that we maintain our system of paying for medical services with a combination of out of pocket and insurance resources.  What systemic changes can we make to expand the resources to more people in the individual (and employer) markets without changing the fundamental nature of our system?  The options range from tweaks to overhauls.

At the tweak end of the spectrum Senator Claire McCaskill (D-MO) offers a plan to allow residents in areas abandoned by health insurance corporations to purchase insurance offered by companies on the District of Columbia Insurance Exchange.  As discussed yesterday, a more middle of the spectrum suggestion is to revise or renew insurance company options for risk adjustment, risk corridors, and reinsurance to encourage the corporations to remain in rural markets.

The public option model moves us along the spectrum, and is available in legislative form in the text of HR 1307 in the 115th Congress.

“For years beginning with 2018, the Secretary of Health and Human Services (in this subtitle referred to as the ‘Secretary’) shall provide for the offering through Exchanges established under this title of a health benefits plan (in this Act referred to as the ‘public health insurance option’) that ensures choice, competition, and stability of affordable, high-quality coverage throughout the United States in accordance with this section. In designing the option, the Secretary’s primary responsibility is to create a low-cost plan without compromising quality or access to care.”

The public option provides insurance plans which could be restricted to abandoned areas or extended nationwide depending on the final structure of the legislation.

Republicans see a slippery slope in the public option proposal — today the public option tomorrow the single payer plan.  As noted previously, there’s nothing “socialized” about proposals establishing Medicare for all, because the Medicare insurance plan pays for privately delivered services.  However, again, Republicans see any extension of access, with public support, as a step towards nationalized health care.  This makes for intriguing intellectual disputation, but it doesn’t really further the process of making more Americans healthier, or easing the burden of health care insurance from American businesses.  The burden is illuminated by the often quoted:

“For large multinational corporations, footing healthcare costs presents an enormous expense. General Motors, for instance, covers more than 1.1 million employees and former employees, and the company says it spends roughly $5 billion on healthcare expenses annually. GM says healthcare costs add between $1,500 and $2,000 to the sticker price of every automobile it makes.” [CFR]

A pre-ACA Rand study supported the general conclusion that employer sponsored health care insurance combined with rising health care costs was a drag on economic growth:

“The analysts found no significant relationship between the percentage of workers with ESI in the U.S. industries in 1986 and the percentage change in employment in the corresponding Canadian industries over the 19-year study period. The lack of a relationship suggests that excess growth in health care costs does have adverse economic effects and that these effects are more pronounced in industries that have a higher percentage of workers with ESI.”

While the Republicans may envision nightmares of nationalization, some of the industries which provide employer sponsored insurance who support their agenda are simultaneously encumbered with expenses not shouldered by their foreign competitors whose employees are provided with public sponsored health insurance.

Perhaps we could advance our public discourse on health insurance if (1) we would stop discussing the topic as if it were an ethereal scholastic issue in which generalizations and speculations replace hard data and human experience; (2) we would look at a variety of proposals ranging from small technical changes to the Affordable Care Act to technical changes to stabilize the insurance market to full public support for privately delivered health care services.

*H/T to Mark Stufflebeam and @Karoli for suggestions and resources!