Category Archives: Medicare

Senator Heller’s Second Shot at Slashing Medicare and Medicaid

“This morning, the Senate Budget Committee will consider a resolution that instructs lawmakers to find ways to reduce Medicaid spending by $1 trillion (and Medicare spending by $473 billion) over the next decade, according to supporting documentation that Democrats are publicizing.” [WaPo]

Here’s the strategy: “A fast-track “reconciliation” process that would allow for tax cuts costing $1.5 trillion over ten years that require only a simple majority to pass.  The $1.5 trillion cost would not have to be offset by closing tax loopholes or ending unproductive tax breaks, and thus would add to the nation’s deficits, which are already growing as the baby boomers retire.  In addition, the resolution would allow the Senate Finance Committee to cut critical programs under its jurisdiction, including Medicaid, Medicare, and basic assistance for poor seniors and people with disabilities, and then use those savings to make the tax cuts even larger (so that the net cost of the tax cuts and the budget cuts combined equaled $1.5 trillion).  The reconciliation process is the same process that Congress tried to use to repeal the ACA and requires only a simple majority to enact law.”  [CBPP] (emphasis added)

And, there we have it: (1) If it’s a Republican budget, then adding to the federal deficit doesn’t matter; (2) in order to provide for tax cuts to the top 1% of income earners in the United States, the Committee can slash funding for Medicaid, Medicare, basic assistance for senior citizens, and people with disabilities.

The trick is that the Senate Republicans have to pass a “budget” slashing spending for those aforementioned Medicare and Medicaid beneficiaries, elderly people in poverty, and disabled people, in order to create ‘space’ for the “reforms” in their tax legislation.  The buck slashing needs to stop here.

Please contact Senator Dean Heller, and let him know that these are not Nevada priorities.




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Filed under Health Care, Heller, Medicaid, Medicare, Nevada politics, Politics

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.

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Filed under Amodei, Economy, Federal budget, Health Care, health insurance, housing, Medicaid, Medicare, Nevada, Nevada economy, nevada health, nevada taxation, Politics, Republicans, Taxation

Rest and Repair: ACA and market stabilization

Senator Dean Heller (R-NV) might have wished for a kinder, gentler, headline from the Reno Gazette Journal, but he got this one: “After weeks of waffling, Heller votes ‘yes’ on failed ‘skinny repeal’ of Obamacare.”  Rest assured, he’s promised to work on health insurance reform as part of his duties on the Senate Finance Committee.   This would be as good a time as any for him to demonstrate his knowledge of the insurance sector.

Heller Plays the Bail Out Card: Game One 

Let’s track back a couple of paces in time to review how Senator Heller presented his ‘moderate’ credentials on economic concerns.  While Nevada was in the throes of the Great Recession brought on by the Wall Street Casino machinations, Senator Heller was touting his opposition to the Dodd-Frank Act to insert some common sense regulation of the banking industy, casting it as follows: “Heller mentioned he was the only member of the Nevada delegation to vote against the bank bailout. He called the Dodd-Frank bank regulation bill “cover for those who voted for the bank bailout.”  In short,  that “cover” was the regulation of some of the practices that caused the collapse of the investment banks in the United States.  Senator Heller calculated that the use of the phrase “bailout” would be sufficiently negative to thoroughly obscure his support for the deregulation of the banking sector and the Wall Street Casino players therein.  There’s little reason to doubt he’ll try this play again in 2018.

McConnell Tees Up the Bail Out Card: Game Two

After the “skinny bill” failed, Senate Majority Leader Mitch McConnell provided the framework for the next time Senator Heller might want to play the Bail Out card:

“Now, I think it’s appropriate to ask, what are their ideas? It’ll be interesting to see what they suggest as the way forward. For myself I can say — and I bet I’m pretty safe in saying for most on this side of the aisle — that bailing out insurance companies with no thought of any kind of reform is not something I want to be part of. And I suspect there are not many folks over here that are interested in that. But it’ll be interesting to see what they have in mind.”  (emphasis added)

If Senator Heller didn’t mind obfuscating the purpose of the Dodd Frank Act (by calling it a bail out), he’ll certainly not mind playing the same game with the attempts to improve our health insurance system.  It would be very tempting for him to try this play one more time to cover his opposition to the very proposals that would stabilize the individual health care insurance markets in this country.  For the record, I’m assuming that if a proposal helps an insurance corporation, then Senator Heller will be sure to call it a “bail out.”   Or, in the immortal words of President George W. Bush, “There’s an old saying in Tennessee—I know it’s in Texas, probably in Tennessee—that says, ‘Fool me once, shame on…shame on you. Fool me — you can’t get fooled again.’

Making Mountains from Mole Hills

There are justifiable questions about the stability of the individual health insurance market, but before we launch major proposals in this direction it’s important to note that for all the palaver about the collapse, demise, descent or whatever of the Affordable Care Act, that individual market has been stabilizing on its own.  The Kaiser Family Foundation released its report on this market:

“Large premium increases, typically granted by state regulators, in 2017 contributed to the improved financial performance, as insurers adjusted for a sicker-than-expected risk pool, the analysis finds. However, data on hospitalizations suggest that the risk pool was not getting progressively sicker as of 2017, supporting the notion that the large increases were necessary as a one-time market correction.

Slow growth in claims for medical expenses also played a role in insurers’ financial improvements, according to the analysis.”

So far so good, but there are issues to be faced.

“Although the analysis finds the market is stabilizing, it notes that ongoing uncertainty over payment of cost-sharing subsidies to insurers and enforcement of the individual mandate could lead insurers to leave the market or charge higher premiums in 2018.”

We can now safely assert that when Senator McConnell (and perhaps Senator Heller) speak of “bailing out” insurance companies they may be referring to proposals to provide more certainty to the insurance corporations that the administration will, in fact, make good on those promises to come through with cost-sharing subsidies.  That’s truly stretching the definition of a bail out, but it may prove a highly convenient hook on which to hang Republican rhetoric.

The previous post mentioned the Three R’s — risk adjustment, risk corridors, and reinsurance.  Here’s one proposal for the last on the list:

“Senator Kaine and Senator Tom Carper of Delaware on Wednesday introduced legislation to create a reinsurance program to help insurers offset the cost of covering older, less healthy customers. That type of program—which provides payments to insurers that enroll high-cost individuals—was originally part of Obamacare until it expired last year, and Republican legislators in Minnesota and Alaska have embraced the idea as a way to stabilize insurance markets in those states. “That’s something that should have some bipartisan appeal,” Kaine said. [Atlantic]

Reinsurance was in place until 2016 in order to ease any problems with corporations insuring a high number of risky policy holders, such as those with pre-existing medical conditions.  Re-establishing it would serve the same stabilization purposes today.   The Kaiser Family Foundation provides an explanation of risk adjustment and risk corridors which don’t require an MBA to understand. Neither of these constitute any form of “bail out.”

Conflation Projection 

Conflation is too often a vehicle for obfuscation.  For example, one of the Republican objections to the ACA continues to be the incantation: Socialized Medicine!  There’s no hint of socialized medicine in the ACA, it’s a full bore market based system of encouraging  affordable health insurance policies sold by PRIVATE companies to PRIVATE CONSUMERS for use to pay PRIVATE HEALTH CARE PROVIDERS.  However, this doesn’t prevent Republicans from speculating on the ulterior motives of Democratic advocates of expanding access to affordable health insurance policies.

“Soon, they’ll want a public option!” And, then they’ll want Single Payer…and there you have it Socialized Medicine.

Let’s stop here before the fog gets too thick, and explore other options for improving health care access in another post.

*Thanks to @Karoli and Mark Stufflebeam for suggestions and references. 

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Filed under Health Care, health insurance, Heller, McConnell, Medicare, nevada health, Politics

The Moderate Heller Myth: Health Insurance Edition

Senator Dean Heller (R-NV) has cultivated his “moderate” image to the point that this adjective is attached to him with remarkable consistency — when if a person does even a perfunctory piece of research on his actual voting record what emerges is the model of a hard line conservative.  There is a pattern.  The Senator expresses “concerns” with a bill; then announces with ranging degrees of fanfare his opposition to a bill “in its current form,” then when the rubber grinds on the road surface the Senator votes along with the Republican leadership.

Why would anyone seriously believe he would support fixing the Affordable Care Act’s problems and not ultimately support what is now being called the “skinny repeal” version in the Senate based on the following voting record:

In 2007 then Representative Heller voted against the Medicare Prescription Drug Price Negotiation Act (HR 4).  Then on August 1, 2007 he voted against HR 3162, the State Children’s Health Insurance Program reauthorization.  The next day he voted against HR 734, the Prescription Drug Imports bill.  On March 5, 2008 he voted against HR 1424, the Mental Health Coverage bill.  Further into 2008 he voted “no” on HR 5501, the bill to fund programs fighting AIDS, Malaria, and Tuberculosis, and “no” again on the concurrence version of the bill in July.   If he had a ‘flash’ of moderation during this period it happened in the summer of 2008 when he voted in favor of HR 5613 (Medicaid extensions and changes), HR 6631 (Medicare), the latter including a vote to override the President’s veto.  By November 2009 he was back in full Conservative mode.

He voted against HR 3962 (Health Care and Insurance Law amendments) on November 8, 2009, and HR 3961 (Revising Medicare Physician Fee Schedules and re-establishing PAYGO) on November 19, 2009.

In March 2010 Heller voted against HR 4872 (Health Care Reconciliation Act), and HR 3590 (Patient Protection and Affordable Care Act).  He also voted against the concurrence bills.

January 19, 2011 he voted in favor of the Repealing the Health Care bill (HR 2).  He also signaled his stance on Planned Parenthood when he voted in favor of H.Amdt. 95 (Prohibiting the use of Federal funds for Planned Parenthood) on February 18, 2011.    He was in favor of repealing the individual mandate (HR 4), of repealing the Prevention and Public Health Fund (HR 1217).  May 4, 2011 he voted to repeal funding of the construction of school based health centers (HR 1214).

There was another “soft” period in some of his initial Senate votes in 2011, especially concerning the importation of medication from Canada (interesting since many prescription drugs are manufactured in other overseas sites).  See S. Amdt 769, S. Amdt 2111, and S. Amdt 2107 in May 2012.  On March 31, 2014 he voted in favor of HR 4302 (Protecting Access to Medicare).

He was back riding the Republican rails in September 2015, supporting an amendment to defund Planned Parenthood, (S. Amdt 2669) which failed a cloture vote.   Then on December 3, 2015 he voted in favor of another ACA repeal bill (HR 3762).    If we’re looking for patterns in this record they aren’t too difficult to discern. (1) Senator Heller can be relied upon to vote in favor of any legislation which deprives Planned Parenthood of funding for health care services, (2) Senator Heller can be relied upon to vote in favor of repealing the Affordable Care Act, and (3) Senator Heller’s voting record, if it illustrates any ‘moderation’ at all, comes in the form of dealing with prescription drug prices, but even that is a mixed bag of votes.

Thus, when he makes comments like the following:

“Obamacare isn’t the answer, but doing nothing to try to solve the problems it has created isn’t the answer either,” the statement read. “That is why I will vote to move forward and give us a chance to address the unworkable aspects of the law that have left many Nevadans — particularly those living in rural areas — with dwindling or no choices.

“Whether it’s my ideas to protect Nevadans who depend on Medicaid or the Graham-Cassidy proposal that empowers states and repeals the individual and employer mandates, there are commonsense solutions that could improve our health care system and today’s vote gives us the opportunity to fight for them. If the final product isn’t improved for the state of Nevada, then I will not vote for it; if it is improved, I will support it.”

We should examine them with some caution.   If he is referring to rural Nevada voters as ‘victims’ of the Affordable Care Act he might want to note that before the ACA there was one insurer in the northern Nevada rural market and if there is only one now that’s really not much of a change, much less a “nightmare.”  Nor is he mentioning that the proposed cuts to Medicaid will have a profoundly negative effect on rural Nevada hospitals. [DB previous]

That Graham-Cassidy proposal isn’t exactly a winner either:

“The new plan released Thursday morning and written by Republican Sens. Lindsey Graham (S.C.) and Bill Cassidy (La.) would block grant about $500 billion of federal spending to the states over 10 years to either repeal, repair or keep their ObamaCare programs.”

We have no idea if the number is an accurate estimate of what would keep the health care systems of all 50 states afloat — no one seems to want to ‘score’ anything these days.  Additionally, Americans should be aware by now that when Republicans chant “Block Grant” they mean “dump it on the states, wash our hands, and walk away” while the states struggle to keep up with demands to meet needs and provide services, operating on budgets which cannot function on deficits.

Then, there’s that perfectly typical Hellerian comment: “If it is improved, I will support it,” leaving the issue entirely up to Senator Heller’s subjective assessment if “it” has improved his re-election chances enough to go along with it while not upsetting his very conservative base.  Meanwhile, the media persists in repeating the “Moderate Heller” mythology, and we haven’t even begun to speak of his actions to thwart and later repeal any common sense regulations on the financial sector.


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Filed under conservatism, Health Care, health insurance, Heller, Medicaid, Medicare, Nevada Test Site, Politics, public health, Republicans, Rural Nevada, SCHIP

It Ain’t Over Until The Fat Golfer Sings

Senator McConnell’s Secret Health Insurance Shop is still working, with the Lobbyists/Elves seeking a way to offer goodies acceptable to the wavering and the wanton.  Keep calling!  and if you’d like more information to substantiate your comments there are some excellent sources.

Kaiser Family Foundation:   Your one stop center for research and analysis on health insurance issues.  Definitely a “bookmark this” recommendation.  Today, KFF notes that before the implementation of the ACA individual insurance plans for health care did not cover delivery and maternity care  in 75% of the policies; 45% of the policies didn’t cover substance abuse treatment; and 38% failed to cover any mental health care services.

If terms like “risk adjustment,” “re-insurance,” and “risk corridors” seem like something written in Minoan Linear A, the KFF has an excellent summation of these technical terms in easily understood American English.

There are also some analytical pieces on the impact of Republican suggestions for health care insurance “reform” as they relate to rural health care in the following:

Human Rights Watch — Senate Health Care Bill A Swipe At Rural United States.

MSNBC/Scarborough – Rural Health Care Would Be Savaged By This Bill.

There’s a narrative going around that Democrats haven’t brought anything to the table, which depends on whether we’re taking the long or short term view.  In the short term this would be true — because the McConnell Secret Health Insurance Shop didn’t invite any Democratic participation,  for that matter there seems to have been some Republican Senators who were left in darkness.  The longer view would note some of the following:

Senator Franken’s “Rural Health Care Quality Improvement Act of 2016” (pdf) S. 3191 (114th Congress) was introduced in July 2016 and “died” in the Senate Finance Committee.  The bill would have amended two titles of the Social Security Act to improve health care in rural areas of the United States.

There is Representative Jan Shakowsky’s CHOICE Act, H.R. 635, which would establish a public option under the ACA.  See also S. 194, Senator Sheldon Whitehouse’s CHOICE Act.  There’s Rep. Gene Green’s HR 2628 to stabilize Medicaid and the Children’s Insurance program.  Rep. John Conyers introduced his form of “single payer” in his Medicare for All bill, HR 676.  On the topic of making pharmaceuticals more affordable:  Senator Sanders – Affordable and Safe Prescription Drug Importation Act S. 469.  Senator Klobuchar has a bill “… to allow for expedited approval of generic prescription drugs and temporary importation of prescription drugs in the case of noncompetitive drug markets and drug shortages.” S. 183. Rep. Kurt Schrader introduced H.R. 749 to increase competition in the pharmaceutical industry.  Senator Ron Wyden introduced S. 1347, RxCap Act of 2017.

Senator Klobuchar has also introduce a bill supporting Alzheimer’s caregivers in S.311.  Rep. Derek Kilmer’s bill, H.R. 1253, seeks to improve access to treatment for mental health and substance abuse issues.   This is by NO means an exhaustive list of what can be gleaned from Gov.Track, but it does illustrate that the Democrats are not without suggestions — negotiating drug prices for Medicare, stabilizing the current system, public options, single payer — it’s just that these bills won’t get out of Republican controlled committees and they didn’t make it into Senator McConnell’s Secret Shop.

Indulge in no victory dance, we’ve seen this movie before … don’t believe that some minor blandishment won’t be enough to lure Senator Heller from his current position …don’t think that the products of McConnell’s Secret Shop have stopped coming off their assembly line.

Senator Heller can be reached at 202-224-6224;  702-388-6605;  775-686-5770

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Filed under Health Care, health insurance, Medicaid, Medicare, nevada health, Pharmaceuticals, Politics, public health

All Quiet on the Humboldt

When last we heard from Rep. Mark Amodei (R-NV2) it was in early May at which time he smoothly flipped his vote on the disastrous ACA replacement bill, with a convoluted explanation that “it” wouldn’t hurt Nevada…and then came the CBO scoring.  The District 2 Congressional representative has kept his head down like a ground squirrel in his burrow by the side of the highway.  This prevents him from dashing into the roadway, or as constituents might call it — holding an in person town hall meeting.

Tossing statistics about like so much confetti doesn’t remove the cold fact that the bill for which Amodei voted cuts $839 Billion with a B from the Medicaid expansion.  Cue the GOP lament that there are “able bodied” people who benefit from the Medicaid program, a program initially meant to serve the desperately poor.  The expansion aided people who may not be homeless without a tent but who were certainly desperate in terms of their ability to afford health insurance for themselves and their families.  These are the people who waited until the medical situation was so dire expensive emergency room treatment was required; who used the emergency rooms as a form of walk in clinic for the lack of any more available alternative; who went without any medical attention whatsoever — 48,000 who died according to the Harvard study because health insurance was unaffordable.

Representative Amodei may not have believed the ACA replacement bill would have profound impacts on Rural health services, but other politicians from other states have pointed this out with remarkable clarity.

Missouri, for example, refused the Medicaid expansion, and the results aren’t positive, as described by Missouri Senator Claire McCaskill:

“Well, we have, first, more than 2 million Missourians live in rural areas of our state. And 41 percent of our state’s hospitals are in rural areas. We know that they are under particular stress right now, particularly in states like Missouri that have refused the money that has been offered them for their Medicaid program under the Affordable Care Act. We know that there’ve been 78 rural hospitals closed, including three in Missouri. We know that 74 percent of those hospitals were actually in states that refused to accept the Medicaid money that was offered by the federal government back to the federal taxpayers in those states.”

Arkansas which accepted the Medicaid expansion also has some issues related to its rural hospitals:

“The ACA’s crafters essentially made a deal with hospitals: The ACA cut Medicare reimbursements, but the reduction in uncompensated care through the Medicaid expansion helped offset some of those cuts. Without that offsetting boost, some of the state’s smaller rural hospitals might not be able to survive. A hospital like Baxter — the fifth most Medicare-reliant hospital in the nation, according to Moody’s, thanks to the community’s significant proportion of retirees — would be forced to make dramatic cuts in services without the Medicaid offset. “The expansion of Medicaid through Arkansas Works is one of the key components that’s been able to help us through the change in the ACA,” Peterson said. “Not just Baxter, but it helps all of rural Arkansas.”

What is true of Missouri and Arkansas is true for rural health care in general:

Of the more than 11 million people who have gained Medicaid coverage through the ACA expansion, nearly 1.7 million live in rural America, according to new CBPP estimates (see Appendix Table 1).  The expansion population is more rural than the population as a whole: rural residents make up 12.1 percent of the population of expansion states but 14.1 percent of expansion enrollees in these states.  In at least eight expansion states, more than one-third of expansion enrollees live in rural areas: Alaska, Arkansas, Iowa, Kentucky, Montana, New Hampshire, New Mexico, and West Virginia.

The Medicaid expansion has been a lifeline for rural areas in other ways.  The ACA coverage expansions, especially the Medicaid expansion, have substantially reduced hospital uncompensated care costs: uncompensated care costs as a share of hospital operating budgets fell by about half between 2013 and 2015 in expansion states.[8] Reductions in uncompensated care and increases in the share of patients covered by Medicaid have been especially important for rural hospitals.

Nevada hasn’t been immune from the problems associated with a lack of access to affordable health insurance and uncompensated care:

“Rural residents are themselves a public health challenge, as they are generally older, more isolated and less likely to be covered by insurance than their urban counterparts. They’re also more likely to smoke, suffer from obesity and hypertension and die from complications of diabetes.

But preventive care that could head off medical emergencies is hard to come by in many areas. Nevada’s rural and “frontier” counties – a term used for the state’s most-remote and sparsely populated regions – and reservations face severe shortages not just of doctors and primary care services, but also nurses, EMTs, dentists and substance abuse and mental health professionals. And in some areas, the numbers are dwindling, despite efforts to reverse the trend.”


And so, there are rural hospitals in Representative Amodei’s district — Elko, Lovelock, Battle Mountain, Yerington, Winnemucca, Ely, Fallon and others — wondering what effects will be felt if the GOP adopts the framework in the House bill for which Amodei voted.   Residents in Tonopah watched as their hospital closed in August 2015, an unfortunate testament to the perils of privatization.  The question which might, and should be raised, to Representative Amodei in some town hall (should he ever emerge) is how does the Republican version of health care insurance “reform” protect rural hospitals from financial pressures endangering rural hospital administration.

Ah, but all this is “old news” now that the Representatives voted on an unscored bill in their haste to get something, anything, done and have tossed the blazing ball into the lap of the Senate — in which we might expect Senator Dean Heller to lament the inadequacies of the measure to the Heavens, and then vote along with Senate leadership for the final (probably dismal) result.

Let’s guess that Senator Heller will announce his ‘profound misgivings and questions’ and then after consultations with some officials, reverse his position and do what he has always done — vote against any augmentation of health insurance affordability for his constituents (see his votes on SCHIP on multiple occasions.)

And so it remains — all quiet on the Humboldt — as Representative Amodei and Senator remain quiet (unless we count Heller’s scripted telephone town hall) on an issue of profound significance to District 2’s health care service providers.

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Filed under Amodei, health insurance, Heller, Medicaid, Medicare, nevada health, Nevada politics, Politics, public health, Rural Nevada

Medicare Fraud and the Public Images

Loretta Lynch

You go! Attorney General Loretta Lynch’s announcement about Medicare fraud prosecutions isn’t getting the play accorded to more “hot topic” issues, but it’s an important step in doing two things – actually getting fraud out of the Medicare system; and, two dispelling the GOP inference that fraud in social and health care systems is something done by imaginary welfare queens and ne’er do wells.

Who’s getting prosecuted?

U.S. law enforcement officials have charged 301 suspects with trying to defraud Medicare and other federal insurance programs in 2016, marking the “largest takedown” involving health care fraud allegations, the Justice Department said on Wednesday.

The national sweep resulted in charges against doctors, nurses, pharmacists and physical therapists accused of fraud that cost the government $900 million, the department said. The cases involved an array of charges, including conspiracy to commit health care fraud, money laundering and violations of an anti-kickback law. [NatMemo] (emphasis added)

That gives us a general idea that no, the fraudsters weren’t those so often maligned by conservatives as the “undeserving” poor who take advantage of “sacred tax dollars.”  These are professionals, presumably unwilling to settle for professional earnings, income derived professionally.  We can get a bit more specific.

“One group of defendants controlled a network of clinics in Brooklyn that they filled with patients through bribes and kickbacks.  These patients then received medically unnecessary treatment, for which the clinic received over $38 million from Medicare and Medicaid – money that the conspirators subsequently laundered through more than 15 shell companies.” [Lynch DoJ]

How many “undeserving poor” launder money through 15+ shell corporations?

Detroit clinic billed Medicare for more than $36 million, even though it was actually a front for a narcotics diversion scheme.” [Lynch DoJ]

“…another defendant took advantage of his position in a state agency in Georgia by accepting bribes and recommending the approval of unqualified health providers.” [Lynch DoJ]

Lovely.  Another Department of Justice public statement offers a few more details.

“According to court documents, the defendants participated in alleged schemes to submit claims to Medicare and Medicaid for treatments that were medically unnecessary and often never provided.  In many cases, patient recruiters, Medicare beneficiaries and other co-conspirators allegedly were paid cash kickbacks in return for supplying beneficiary information to providers, so that the providers could then submit fraudulent bills to Medicare for services that were medically unnecessary or never performed.  Collectively, the doctors, nurses, licensed medical professionals, health care company owners and others charged are accused of conspiring to submit a total of approximately $712 million in fraudulent billing.”  [HCFU DoJ]

What’s been the nature of the Congressional interest in the Health Care Fraud Unit’s efforts?  In 2013 it was to cut funding for Medicare and Medicaid fraud prosecution efforts. [CNBC] [WaPo] We might also want to remember that any additional mandatory funding beyond 2013 levels did not start  until 2015. [HHS]

The notion that “waste, fraud, and abuse” are associated with government employees and the undeserving – is directly challenged by the efforts of the Departments of Health and Human Services and the Department of Justice, and their findings that the fraudsters are among the professional civilian population – ready and willing to line their own pockets with tax dollars.

But don’t necessarily trust me, listen to the Inspector General:

“Health care fraud drives up health care costs, wastes taxpayer money, undermines the Medicare and Medicaid programs, and endangers program beneficiaries,” said Inspector General Levinson.  “Today’s takedown includes perpetrators of prescription drug fraud, home health care fraud, and personal care services fraud, three particularly harmful types of fraud plaguing our health care system.  This record-setting takedown sends a message to would-be perpetrators that health care fraud is a risky way to line your pockets.  Our agents and our law enforcement partners stand ready to protect these vital programs and ensure that those who would steal from federal health care programs ultimately pay for their crimes.” [DoJ]

Health care fraud investigators and prosecutors should be among the nation’s heroes, not castigated as ‘gum’int bureaucrats,’ and should have budget and resource support commensurate with the importance of what they are trying to accomplish.


Filed under Medicaid, Medicare

Medicaring and the Great Entitlement Fight

Medicare LogoThe great entitlement fight continues, on ground carefully prepared.  Therefore, some basic information should be inserted before launching yet another discussion.

Reviewing the Obvious

The term “entitlements,” which formerly inferred that the benefits were mandated because the individuals had paid for them (Social Security, Medicare), has been folded back into an argument in which Social Security, Medicare, and public assistance programs are lumped together under the umbrella phrase “welfare.”   In one of the latest iterations conservatives have defended the privatization of the Medicare program as a way to “strengthen welfare for those who need it.” [Ryan, TPM]

This oversimplification comes with some ideological baggage.  Representative Ryan continued: “If I could sum up that disagreement in a couple of sentences, I would say this: Our plan is to give seniors the power to deny business to inefficient providers. Their plan is to give government the power to deny care to seniors,” he said, according to prepared remarks.”  [Ryan, TPM]  While this may sound logical when expressed in highly generalized terms, the practical realities are obviously more complex.

The first practical reality is that Medicare is a single payer health insurance program, the participants in which are all 65 years of age are older.  This translates to health care access for approximately 44.6 million Americans. [HHS] While the Department of Health and Human Services administers the programs, the actual implementation of the insurance services are performed by private firms, the most recent contracts for which were announced in 2009.  [HCF] This insurance program works like all others — the bigger the pool, the more manageable the risk, the more manageable the risk, the more sustainable the policies.

The second practical reality is that it takes two to make a market.  It’s all well and good for Representative Ryan to call for the elderly to “deny their business to inefficient providers,” IF there are providers.  Prior to 1965 approximately 50% of Americans over the age of 65 had either NO medical insurance coverage or had coverage woefully inadequate to meet their needs.  [NCM] T’is an actuarial fact that older people require more medical services, thus the more people in the pool the more sustainable the program.   The hard truth is that the elderly and disabled have no leverage to promote efficient providers or deny custom to inefficient providers IF there are no providers, or very few willing providers,  in the first place.

Broadening the Definition of Welfare

One of the more popular recent arguments for the privatization of the Medicare program is that because the elderly are likely to “take out” of the program more than they paid into it some “subsidy” is involved, and if there is a subsidy the program is, by definition, a welfare program.

In the Samuelson version of Medicare as Welfare argument the elderly are getting more affluent, and healthier, therefore there should be means testing for Medicare insurance.  Omitted from Mr. Samuelson’s argument is that one of the prime reasons the elderly have more disposable income in general than they did in 1965 is that they no longer face unaffordable health insurance premium costs.

Samuelson goes on to contend that means testing is “fair” because the elderly survived the Recession in better financial shape than younger people, and that half the nation’s wealth is owned by those 55 and older.   Again, he conveniently omits the fact that this wealth is increasingly accumulated by a smaller percentage of the total population.

The last Profile of Older Americans issued in 2011 (pdf) by HHS reports:

“The median income of older persons in 2010 was $25,704 for males and $15,072 for females. Median money income (after adjusting for inflation) of all households headed by older people fell 1.5% (not statistically significant) from 2009 to 2010. Households containing families headed by persons 65+ reported a median income in 2010 of $45,763.”

A person’s wealth may increase as property values improve, and total wealth nearly always assumes the inclusion of all assets, but the income available for the purchase of health insurance is another matter.  Yes, there may be some people 55 and older who are increasingly affluent — but the majority of the elderly in this country who are a portion of the 99% are not part of Samuelson’s subset of the affluent elderly.

It’s hard to find much sympathy for arguments which assert that because wealthy Americans are called upon to pay into an insurance program for services which support fellow, less affluent, Americans this is necessarily worthy of the pejorative label  “socialism.”   Likewise, to contend that the entire Medicare program should be means tested because a few affluent people have the wherewithal to avoid using it is to impose the interests of the few upon the needs of the many.   Besides, premiums for Medicare Part B are already pegged to income levels.

Destroying the Village to Save It

The prophets of doom and gloom argue that the very solvency of the Medicare program is problematic and therefore only privatization or means testing are the best alternatives to salvage that program.

The means testing argument is perilously close to advocating the creation of a two-tiered health insurance  system for elderly Americans.  One proposal from the Right suggests that the affluent should be “means tested” and thereby receive fewer benefits while the less wealthy should be enrolled in Medicaid-like welfare programs.  [Cowen WaPo] Translation: The wealthy elderly will get the medical care they can pay for while the remainder (perhaps 99%?) will get what the Congress is willing to fund.

The critique of this thinking can be summarized as follows:

“Financing health care through revenues paid into a single, universal risk pool establishes equity by using progressive tax policies, while providing broad political support for a program from which we would all benefit equally. Providing benefit levels inversely related to life-time income might create the appearance of equity, but, in fact, it destroys equity by forcing many of us into a welfare program, impairing access to the health care that we need.”  [PNHP]

The perfect storm for the elderly in America would be a Medicare program in which (1) senior citizens would be driven back to the private markets with little or no guaranteed competition incentivizing health insurance corporations to reduce premium rates or provide more coverage, and (2) a means tested system in which the universal risk pool is divided into segments by income, and (3) the designation of less affluent, or poor, American elderly as “welfare recipients” in a Medicaid program, in which (4) the financial support would be in block grant form to the states and subject to budget cuts any time the Congress was moved to practice Austerity Economics.

The Trouble With Statistics

There are two ways to reduce spending on Medicare (a) increase the eligibility age and  (b) decrease the benefits.  But LOOK! People are living longer, therefore some economies must be made for the health of the system.  This was argued in a recent Reno newspaper LTE:

“That Americans are living longer is a gift, yet programs that serve these older Americans do not reflect critical changes in life expectancy. When Medicare was established in 1965, men had a life expectancy of 67 and women 73. Today, on average, a man reaching age 65 can be expected to live until 83, women until 85.”

Not. So. Fast.  Some care should be taken with those longevity figures.  Not only do we have an income gap widening in the United States, we also have a widening longevity gap.

“In 1980-82, Dr. Singh said, people in the most affluent group could expect to live 2.8 years longer than people in the most deprived group (75.8 versus 73 years). By 1998-2000, the difference in life expectancy had increased to 4.5 years (79.2 versus 74.7 years), and it continues to grow, he said.

After 20 years, the lowest socioeconomic group lagged further behind the most affluent, Dr. Singh said, noting that “life expectancy was higher for the most affluent in 1980 than for the most deprived group in 2000.”  [NYT 2008] see also: [IJE abstract] [NYT 3/2008]

There’s a racial component to these statistics as well, with whites generally having longer life expectancies than African Americans.  [AJPH] If a person is arguing that “life expectancy” is now 78.9 years of age — that’s true — for White Americans nationally.  For African Americans the number is 74. 6.  If a person is a Native American in South Dakota the life expectancy is 68.2. [KFF]

Longevity 1

As we can see from the chart, some caution should be applied to the tendency to over-generalize about the longevity of Americans.  While increasing the eligibility age for White Americans might seem to make sense, it doesn’t hold quite so well for African Americans, and comes nowhere close to securing the argument if one is considering the longevity of Native Americans.  Further, as the income gap continues to grow, and as it is demonstrable that the income disparity informs the longevity tables, could it not be argued that increasing the eligibility age serves only those already reasonably well served?

The Selection of Oxen To Be Gored

The one proposal which has not attracted the attention of the Beltway is the notion that there is another way to improve the solvency of the Medicare program.  It just happens to be the most painful for the 1%’ers.

“Elite anxiety over entitlement-driven budget deficits and accumulating national debt has created a powerful class in the nation’s capital. The agenda of this class is in many respects on a collision course with mounting demands for action by those lower down the ladder to address the threat to government social insurance programs.” [NYT]

This “elite anxiety” puts the blinkers on the obvious solution to many of the financial issues facing both Social Security and Medicare. Raise  or eliminate the income cap.  Failing to eliminate the cap subject to social insurance taxation, at least increasing the current $113,700 to, say, $250,000 would go a long way toward improving the fiscal outlook of Medicare.  What percentage of the U.S. population would be asked to contribute more if the cap were placed at $250,000?

Earning Over Cap 1

It’s remarkable that 1.2% of the total U.S. population has been so successful at promoting reductions in social insurance, and especially Medicare, programs keeping the focus of the media — and thereby the public — on the Cut Side of the ledger and with barely a mention of the revenue increasing alternatives.

And there are alternatives, what would eliminating the cap do?

“According to the Social Security Administration, fully eliminating the cap on taxable earnings would be sufficient to fully close the projected shortfall. If newly-taxed earnings above the taxable maximum were credited toward benefits, eliminating the cap would close most, but not all, of the gap.” [EPI]

If eliminating the cap altogether isn’t acceptable, then perhaps raising and indexing the earnings cap to include 90% of earnings might be considered.  The EPI suggests that this would cut the shortfall by half.

The EPI offered a third alternative:

“A third option would be to split the difference: eliminate the cap on earnings for employer contributions, and raise the cap to cover 90 percent of earnings for employee contributions. With earnings up to the employee cap credited for benefit purposes, this change would reduce the long-term shortfall by about three-fourths.” [EPI]

The objections to the elimination of the cap center on two major points (1) the more Social Security collects the more benefits it will owe, and (2) the elimination or modification of the earnings cap “isn’t fair.”  The first need not apply to Medicare, and the second serves primarily to confirm the unfortunate perception that the wealthiest among us are being “picked on” for the benefit of that amorphous 47%, although it is asserted that those suffering the most would be those immediately above the income cap level.    The problem with the last argument is that this will be the case in any endeavor in which any standard is established.

Meanwhile, the assault on our social insurance programs continues, and 13.1% of the Nevada population which is over 65 may well wonder what happens next.

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What Do I Care If You Click The Link? The Nevada Health Link

Nevada Health LinkOkay, I’m an old fogey.  So, what do I care if you click the link to find out more about  the Affordable Care Act health care insurance plans available to you whippersnappers?

Because this is good news for all of us, and Dean Baker of the Center for Economic and Policy Research, helps explains why this is in my own best interests:

“This is good news. It means that tens of millions of people who are uninsured now will likely be insured in the next year or two as a result of the Affordable Care Act (ACA). However this is actually the less important aspect of the program. The more important part is that those of us who now have insurance will have real health care insurance for the first time.”

That’s right, those  who are already on employer paid plans or like me, are signed up for Medicare — we’ll get BETTER health care.  How does that work?

First, as a person in the Medicare program I get more preventative services at less cost to me.  Medicare now covers mammograms and colonoscopies — not that I particular enjoy those activities — but it is nice to know that they are covered by the Medicare program. That alone makes the sessions less uncomfortable — as if anything could really make a mammogram a “lovely outing.”

Second, I don’t have to worry about the household accounting associated with falling into that miserable prescription drug do-nut hole.  It won’t be there anymore after 2020.

Third, after seeing what happened to an even more elderly relative who was getting prescriptions from a family doctor, and two or three specialists, and then having prolonged sessions at the pharmacy discussing what could be taken when and with what…. whatever… the ACA provisions for coordinated care seem very appealing.  I was confused, I can only imagine the bafflement on her part.

Fourth, I like the part wherein the Medicare program is pretty well guaranteed to last until 2029, actuarially longer than I’ll probably last, it’s nice to know the insurance will be there.

Okay, enough about me, how about you?  How does it help me if you can purchase a health care plan in an exchange/market?

No offense please, but every time someone uses the emergency room for medical issues that could have, should have, been taken care of in a doctor’s office, we’re all out MONEY.  ER’s are expensive, and the more that’s squandered getting health care in the wrong place the more my taxes for the local hospital district have to increase to pay for the services.   I don’t mind that you take the kid to the hospital with the latest fracture or most recent abrasion — I do care when the kid is taken in for a good old fashioned serious cold that could be treated less expensively in your doctor’s office.

Then there’s the fact that for all intents and purposes Medicare is an insurance program.   The entire idea of insurance is that the more people in the pool  the less expensive the premiums will be for everyone.  This is why I was one of those “single payer” people.  However, the single payer idea didn’t fly, and there wasn’t even enough appetite for a “public option” to create more competition in the insurance market.  So, we have the next best thing, one stop shopping for uninsured people, with subsidies to the insurance companies if necessary to recoup the costs of the coverage.

Why do I care if you get insured?  Simple, the easiest answer capitalism has to offer — competition.  Remember, there were some parts of the country, and northern Nevada was one of those parts, in which there wasn’t much competition for individually purchased health insurance policies.  Not much competition means not much incentive to bring down the costs. “No incentive to keep costs down” isn’t part of classic economic theory in regard to pricing, and it isn’t an economically healthy thing.  We will have a better “market” for health insurance when there is more competition.  That’s what those exchanges provide — good old fashioned competition for your business.  If health care costs can be on a less steep trajectory, the longer the Medicare program stays solvent.

I also care because I am truly old enough to have seen people working past their “sell by” date because their health insurance depended on being on someone’s payroll.  Again, older, sicker, people please take no offense, but wouldn’t it be better for the youngsters to get employed in your place, IF you have insurance options that don’t depend on employer contribution insurance?  If a person is hanging on to a job solely for the purpose of maintaining health insurance, that isn’t’ a good thing for this economy.

Finally, the introduction more options for individually purchased health care policies would help people I know — the young family whose first child was born with a heart defect, easily repaired by prompt surgery, but should that family be denied future health care coverage because the little one had a “pre-existing condition?  I think not.

So, go ahead if you don’t already have health insurance — click the link, and see what’s available in the marketplace for you.

Nevada Health Link

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Filed under Health Care, health insurance, Medicare

There’s Much More Than Just Obamacare in the House Hostage Note

Ransom Note

What do the following two statements have in common? Hint: Both press releases from the Nevada Republican representatives in Congress would give a person the distinct impression that the House GOP wants to hold the debt ceiling hostage in order to get a one year delay in the implementation of the Affordable Care Act.

Flashback: 9/20/13 “The coming 10 days will give the American people a clear view on who stands with the middle class, small business owners, and seniors, among others, in opposition to the implementation of the ACA and ongoing fiscal practices that undermine the economy.” [Rep. Mark Amodei]

Flashback: 9/20/13: “During the August work period, I heard from constituents throughout the district who made their wishes clear: keep the government open and alleviate the burdens placed on them, their families, and their businesses by the flawed health care law. The CR passed today by the House reflects those priorities – it keeps the government open, controls spending, and defunds an unworkable law. The House has heard the voice of the American public and it is now time for the Senate to act.”  [Rep. Joe Heck]

However, according to the House Appropriations Committee that’s not the only hostage being held at knife point:

“In return for a one-year suspension of the debt ceiling, House Republicans are demanding a yearlong delay of Obamacare, Rep. Paul Ryan’s tax reform plan, the Keystone XL pipeline, more offshore oil drilling, more drilling on federally protected lands, rewriting of ash coal regulations, a suspension of the Environmental Protection Agency’s efforts to regulate carbon emissions, more power over the regulatory process in general, reform of the federal employee retirement program, an overhaul of the Dodd-Frank financial regulations, more power over the Consumer Financial Protection Bureau’s budget, repeal of the Social Services Block Grant, more means-testing in Medicare, repeal of the Public Health trust fund, and more.”  [WaPo/NtlRev] [NtlRev] (emphasis added)

In short, what the House Republicans are demanding isn’t JUST a delay in the implementation of the Affordable Care Act, but the adoption of their entire Tea Party Agenda — without delay — and all this for a one year extension of the debt ceiling.

All of this makes the statement of Representative Dina Titus (D-NV1) much more sensible:

“With just days remaining before the end of the fiscal year, Republicans continue to put politics ahead of the economy by risking a government shutdown for the sake of their flawed ideological principles. This continuing resolution is not a real plan to fund the government; it is a destructive attempt to deny health care to those who need it the most. It’s time for Republicans to get serious, stop playing political games, and finally start working for the American people.”

Right, this hostage taking is anything but a ‘real plan.’  The House GOP is essentially saying that unless they get everything on their agenda they will gleefully try to blame the Senate and the Administration for their own obstructionism.  Further, this isn’t an exercise in Checks and Balance government — this situation IS a prime example of a willful minority throwing a tantrum unless they get everything they want when they want it.

There’s more considered opinion  from Rep. Stephen Horsford:

“Not only does this irresponsible continuing resolution lock in deep and irresponsible sequester cuts, it also will raise Nevadans’ health costs and deny them the health coverage they need.

“It’s time for all parties to come together to find a way to stop sequester cuts and find a responsible compromise that funds our vital social programs. Nevadans cannot afford to be caught in the political games of the Tea Party. We cannot afford to continue lurching from fiscal crisis to fiscal crisis. We should work to reduce our deficits and debt in a fair and responsible way.”

Rep. Horsford adds the sequestration cuts to the mix and correctly observes that this is, in almost every categorization possible, part of “the political games of the Tea Party.”

The Tea Party Faithless are perfectly happy to make health care insurance less readily available to millions of Americans, content to brush aside the potential calamity of a  national default on our credit obligations on international markets, and all merely to advance an agenda devoid of proposals for realistic solutions to both immediate and long term problems.

We do, if fact, now understand that the GOP has become the party of the selfish, the self-centered, the polluters, the exploiters, and the Big Banks and hedge funds … it’s all in the Hostage Note.

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Filed under financial regulation, Medicare, Nevada politics, Republicans