Tag Archives: Affordable Care Act

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.

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Filed under Health Care, health insurance, Heller, Medicaid, Politics

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.

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Filed under Economy, Health Care, health insurance, Heller, nevada health, Nevada politics, Politics

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.

 

 

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Filed under Amodei, Health Care, health insurance, Nevada politics, Politics

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!

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Filed under Health Care, health insurance, Politics

Caveats and The Unspoken Big Lie

So, we have two sources telling us that approximately 24 to 26 million people will lose their health care insurance if the Republicans are successful in jamming through their tax shift proposal masquerading as a ‘replacement’ for the Affordable Care Act.  Therefore, it’s now time for a new ‘talking point’ from the GOP, especially since some Republicans like Rep. Mark Amodei are on record saying:

When asked what his plan for a change to Obamacare would be, Heller said, “If you like your health care, you can keep it,” a statement that echoes a promise from Obama that later ended up being false.  Amodei said he would not vote for any plan that resulted in reduced coverage for anyone.  “No, I don’t think you can say forget it, we’re going to let them be uninsured because as a practical solution, that’s not an answer and somebody ends up paying in the end anyhow,” Amodei said. [RGJ 2/22/17]

Well, now we know with some certainty that the GOP replacement bill will result in reduced coverage, and some people and families will be uninsured.  How to escape this trap? A new talking point!

“No one will lose their coverage.” 

The HHS Secretary Tom Price, whose replacement would have cost some 18 million their insurance, opined:

“Success, it’s important to look at that,” he said. “It means more people covered than are covered right now at an average cost that is less. I believe that we can firmly do that with the plan that we’ve laid out there.”  Not exactly.

Then, there was Pete Sessions, a Republican from Dallas, telling his listeners:

“Nobody is going to lose their coverage,” Sessions, chairman of the House Rules Committee, told CNN. “You’ll be able to keep your same doctor, you’ll be able to keep your same plan.”

A spokeswoman for the congressman later explained that Sessions meant Americans will have the choice whether to obtain or maintain coverage — not that the GOP bill would take coverage away. The American Health Care Act would nix the ACA mandates requiring Americans to have health insurance.” [DMN]

And, there it is, the Big Caveat, which makes taking health insurance away from working American all AOK.  You can “choose” to keep your health insurance! IF and ONLY IF you can afford it. ?

However, even IF you can afford it, the policy you can purchase may not be truly comprehensive. A young person may have to get additional insurance if he or she marries and there is a pregnancy in the plans. More cost. A plan may not cover preventative care? Or mandatory coverage for cancer screenings?  More cost.  It doesn’t take too long to add up the extras until what has been basic coverage becomes optional coverage. Then the risk pool is reduced and the premiums go up. That is how insurance works. The larger the risk pool the lower the premium costs.

Thus, “you can keep your health insurance” IF:

  • You can afford it in the first place, not likely if you are among the low wage workers in this country.
  • You can afford it and are willing to accept lower levels of coverage, and you don’t mind having to pay for additional services for additional  premiums.
  • You are willing to shop for insurance coverage every time the circumstances of your life changes; as in pregnancies, pre-natal care, caring for a special needs child, a family member needs rehabilitation or mental health care.
  • You are willing to see your local, and especially rural, hospitals see higher levels of uncompensated care.
  • You are willing to accept that your doctors and other health care professionals will see less reimbursement for services rendered.
  • You are willing to forego coverage for preventative screening and treatment for medical conditions.

Access to health insurance isn’t the same as having health care insurance.  As the now commonplace tweet has it: “I have access to a Mercedes Benz dealership — that doesn’t mean I can afford to buy something of their lot.”

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Filed under Amodei, Health Care, health insurance, nevada health, Nevada politics, Politics

Myths and Legends: The Medicaid Issue in Nevada

There was a Republican politician on my television screen this morning telling me, or trying to tell me, that Medicaid was “meant for mothers, children, and those who couldn’t work…” This is outdated. Then, he tried to convince me that Medicaid was being “abused” by those who work and ‘game the system,’ while spouting platitudes about the Free Market and the Joys of Competition.  Let’s start at the very beginning.

This is the explanation of Medicaid as reported by Nevada’s Division of Health Care Financing and Policy (pdf)

“Medicaid is the nation’s main public health insurance program for people with low incomes and the single largest source of health coverage in the U.S.”

The program is meant to help people with low incomes.

“The PPACA extended coverage to many of the non-elderly uninsured people nationwide. The June 2012 Supreme Court Ruling made Medicaid expansion optional for states, and Nevada elected to join the expansion and maximize federal dollars. Effective January 1, 2014, this move broadened Medicaid eligibility to nearly all adults under age 65 with income at or below 138% of the Federal Poverty Level (FPL). At the end of SFY 2014 that meant that there were an additional 125,989 new enrollees in Nevada Medicaid, and increased expenditures of $154,816,777.00. These new expenditures are 100% federally funded.” [NV med pdf]

Medicaid expansion added those working Americans who were earning 138% of the poverty line and below, (pdf) and more specifically: (1) Those between the ages of 19 and 64 who are earning less than 138% of the FPL. (2) Pregnant women in homes earning less than 165% of the FPL. (3) Children from birth to 19 years of age in homes wherein the earnings are at or below 205% of the FPL, with a small premium required in some cases. Translated into real people with real levels of low income earned, this means a family of four would be eligible for Medicaid in Nevada if the family earnings are less than $2795 per month; for pregnant women if the earnings are at or less than $3341 per month; and families are eligible for the kids’ Check Up program if family earnings are less than $4151 per month.

If we calculate annual earnings, then monthly earnings of $2795 mean an annual income  of $33,540. At $3341 annual earnings of $40,092, and at $4151 annual income of $41,630. Nevada’s median income is $52,431 (2015). To put these numbers in perspective, the average weekly wages of a person working in a private restaurant in this state are $382, or $1528 per month ($18,336 yearly). [DETR] The average rent for a 2 bedroom apartment in Las Vegas, the obvious site for most private restaurants, is $932 per month. [RJ] In short, not only are wages not all that generous in Nevada, the benefits available for Nevada families aren’t all that generous either.

Republicans, however, strenuously oppose benefits for adults capable of working. This would make infinitely more sense IF and ONLY IF they were willing to support a living wage for all employees. One really doesn’t get to have it both ways.  Either you want a reduction in benefits that most working people can afford to purchase on their own because they have the financial resources to do so, or you want lower wages which mean that individuals and families cannot afford those things, like health insurance, and the public benefits are required to make up the difference.  However, at this point we slam into another GOP myth.

Free market competition will make health insurance affordable for everyone, even those who are working in low wage jobs.  Good luck with that. Personally, I have yet to hear anyone explain with any specificity why health insurance corporations will be flocking to Clark, Washoe, or even Esmeralda counties because there is more “free market” applied to the situation. If the insurance companies weren’t wildly excited about selling individual and family health insurance before the enaction of the ACA, why would they do so now? Unless, of course…

They could sell policies that didn’t cover all that much? That cost more for those between the ages of 50 and 64?  That didn’t cover maternity expenses? That didn’t cover preventative care? That didn’t cover drug rehabilitation and mental health services in parity with physical treatments? That only covered the items required in those states with the least consumer protections? And, even then all we have to look to is the situation in Nevada when insurance corporations were free to offer what they were pleased to call comprehensive policies.  Again, if they weren’t interested in selling a plethora of individual and family policies then why believe they would be now?

And that Free Marketeering? It doesn’t work in the health care industry:

“In a free market, goods and services are allocated through transactions based on mutual consent. No one is forced to buy from a particular supplier. No one is forced to engage in any transaction at all. In a free market, no transactions occur if a price cannot be agreed.

The medical industry exists almost entirely to serve people who have been rendered incapable of representing their own interests in an adversarial transaction. When I need health services I often need them in a way that is quite different from my desire for a good quality television or a fine automobile. As I lie unconscious under a bus, I am in no position to shop for the best provider of ambulance services at the most reasonable price. All personal volition is lost. Whatever happens next, it will not be a market transaction.” [Forbes]

The only thing I can say with any certainty is that the Republicans have little idea exactly what constitutes a Free Market, and instead are waving it like a banner crovering their underlying desire to be free from the moral requirements compelling us to be our brother’s keepers.  The range of misanthropic explications are appalling, from “we need not do anything because the poor will always be with us anyway,” to “when Jesus told us to provide for one another he only meant fellow Christians.”

The Repeal and Replace campaign is as void of humanity as it is of understanding of the reality of most family economics, and of the comprehension of what the term ‘free market’ actually means.

 

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Filed under Economy, Health Care, health insurance, Politics

Questions for District 2’s Representative should we ever see a town hall session

Representative Mark Amodei (R-NV2) was pleased to spend his 2016 campaign season supporting the candidacy of one Donald J. Trump.  Now that the campaign is over — there are some pertinent questions the District 2 Representative might address should he ever have one of those ‘town hall’ things.Carter Page

#1. Do the constituents in your district deserve a full and complete explication of the ties between the present administration and the Russian government, its agents, and its affiliated operatives? How likely is it that there will be a full explanation without an independent commission investigation?

We have some hints at the extent of Russian meddling with our elections and administration in chart form here,  Mr. Trump’s connections in Russia here, and the implications here. And, Politifact’s explication here.   There’s the Carter Page  connection. The Roger Stone connection.  More about Wilbur Ross, the administration’s Secretary of Commerce here. A bit of the Russian reactions recently in this article. What of the activities of Paul Manafort?  The names, in the post Flynn flood, keep coming up and out. It seems necessary to have a full, independent, and comprehensive investigation to determine the extent and implications of the Trump ties to the Russians.

#2. How do you explain support for a health care  act which replaces the Affordable Care Act with legislation that doesn’t offer a route to affordable health insurance plans for working Americans? And, which looks for all the world like a whopper tax cut for millionaires, billionaires, and insurance corporations? 

This topic has been explored in the Washington Post, in the Fortune Magazine, and in Slate.

Will the replacement bill require insurance plans to cover mental health services on par with physical health coverage?

Will the replacement bill require insurance plans to cover pre-natal, maternity, and post-natal expenses for American families?

Will the replacement bill require that consumer protections provided by state insurance commissions be retained?

How will be the replacement make health care policies more ‘affordable’ without going back to the days when insurance companies could sell low coverage/high deductible policies which left families with massive medical debt?

How will the replacement bill maintain the fiscal health of rural hospitals and clinics?

Now, all we have to do is wait for Representative Mark Amodei to hold a meeting with constituents to address these, and other issues.  I’d not like to hang by my hair for as long as this might take.

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Filed under Health Care, health insurance, Nevada politics, Politics, Republicans