Tag Archives: AHCA

Rural Nevada Health Care and the Great Bamboozle AHCA

The state of Nevada consists of 110,567 square miles of miles and miles and miles.  271,985 people live in those miles and miles and miles out of a total population of  2,940,058.  A quick poke at the calculator shows a state in which 93% of the population is urban, while most of the real estate is rural.   This situation poses some easily apparent problems for health care services and the delivery thereof.

Rural health services must literally cover wide spans of territory in which there is a small population.   There is one hospital in Battle Mountain (Lander County, NV) to serve a total population of 5,702.  There is one hospital in Winnemucca (Humboldt County, NV) serving a total population of 16,528.  There is one hospital in Lovelock (Pershing County, NV) with a total population of 6,753.  There is one hospital in Elko (Elko County, NV) serving a population of 48,818.  Two conclusions can be reasonably drawn from this quick view of the northern tier of rural counties: (1) In none of these areas can a hospital draw upon “economies of scale” in terms of hospital services.  The obvious example may be that an expectant mother will usually require the same obstetric services in Battle Mountain, as in Winnemucca, as in Las Vegas or Reno.  (2) These rural hospitals serve populations which are generally not as affluent as in urban areas;  the rural per capita income lagging slightly behind urban areas. [RH] This places the northern tier of counties in a predicament similar to other western states:

“In the rural West, many farmers, ranchers and other agricultural workers are self-employed, so they can’t get coverage through an employer. Hence, a higher percentage of agricultural employees are covered by Medicaid (11 percent) than in non-agricultural industries (8 percent). Before the ACA was enacted in 2010, workers in the agricultural sector had fewer options, so many remained uninsured. But under the Obama-era plan, many states expanded Medicaid, increasing the percentage of those covered. Under the AHCA, that expansion would be significantly scaled back, according to the Joint Economic Committee report.”

Thus, the National Rural Health Association issued this warning:

“Though most rural residents are in non-expansion states, a higher proportion of rural residents are covered by Medicaid (21% vs. 16%). Congress and the states have long recognized that rural is different and thus requires different programs to succeed. Rural payment programs for hospitals and providers are not ‘bonus’ payments, but rather alternative, cost effective and targeted payment formulas that maintain access to care for millions of rural patients and financial stability for thousands of rural providers across the country. Any federal health care reform must protect a state’s ability to protect its rural safety net providers. The federal government must not abdicate its moral, legal, and financial responsibilities to rural, Medicaid eligible populations by ensuring access to care.”

In short,  cuts to the Medicaid program will disproportionately affect rural health care providers serving rural populations.

But, but, but, sputter the advocates of the Republican offering — We’re Giving People A Choice — you can buy what you want!  Not. So. Fast.

“Though some provisions in the modified AHCA bill improve the base bill, NRHA is concerned that the bill still falls woefully short in making health care affordable and accessible to rural Americans. For example, the modified bill contains a decrease in the Medical Expense Deduction threshold from 10% to 5.8% in an attempt to assist Americans between the ages of 50 and 64 who would see their premiums skyrocket under the current plan. However, this deduction is not a credit and therefore would be of little use to low income seniors that are in very low tax brackets or do not pay income tax at all. Additionally, the new amendments to freeze Medicaid expansion enrollment as of Jan. 1, 2018, and reduce the Medicaid per-capita growth rate will disproportionately harm rural Americans.”

Well, that didn’t go well.  What about that “get what you want argument?”  The first question might well be — What can you afford?  The annual earnings of a farm or ranch owner (manager) in Nevada is reported at an annual mean of $91,970.  However, the range runs from 10th percentile $39,850 to 90th percentile $150,410.  The annual mean wage for a farm or ranch worker is $34,520. [BLS]  Nevada’s reported average annual mean for farm and ranch workers is slightly higher at $36,480. [DETR download] Now we have a problem — 138% of the federal poverty level is $16,374 for a single person or $33,534 for a family of four.   Our hypothetical average annual mean earnings for a farm or ranch worker isn’t eligible for Medicaid expansion enrollment, but has an income well below the Nevada average household income average of $52,431, or 63.96% of the annual average household income level.

How to market an insurance policy this hypothetical average family could afford?  Either offer a comprehensive insurance plan and provide premium assistance to make up the difference between what the premium costs and what the family can reasonably afford — or there’s always the Junk Insurance option.   Consumer Reports offered some excellent advice concerning what constitutes Junk Insurance — aka “affordable plans” —  watch out for fixed benefit indemnity plans, and medical discount cards.  Another Consumer Reports bulletin specified the elements of Junk Insurance, your insurance plan could be very hazardous to your physical and financial health if it contains: Limited benefits; Low overall coverage limits; unrealistic “affordable” premiums; No coverage for important health care services; Ceilings on categories of care; No limits on out of pocket costs; Random catches — like covering hospital care after the second day, when it’s known that the first day is usually the most expensive.

The problem at this juncture for rural Nevadans is that those in the agriculture sector may or may not have earnings allowing them to enroll in Medicaid.  If “yes” then a reduction in Medicaid — whether it happens now or just after the 2020 elections — will have a negative impact on many citizens in the northern tier of “cow counties;” similarly, a return to the Bad Old Days pre-ACA makes those who are certainly less than affluent vulnerable to the offerings of Junk Insurance, which is fine as long as they don’t mind paying for a product which will not cover their medical expenses at the time they actually need it.  Exacerbating this issue is the fact that jobs in agriculture (farming and ranching) are listed by Forbes as the 4th most dangerous occupations in the country.

There’s no way to bestow a bright face to the Republican tax cut disguised as a health insurance ‘reform’ bill in terms of what happens to rural Nevadans and their health care providers.  Those it doesn’t cut out completely it leaves vulnerable to incomplete and almost useless “catastrophic coverage” plans — which for too many policy holders leaves them facing health care costs well beyond their ability to pay for out of pocket.  If there were a recipe for increasing the “uncompensated care” costs for local hospitals and clinics this is definitely IT.  Rural hospitals and clinics, already stretched to meet costs, would be especially at greater risk — and we haven’t even touched on the topics of long term care for the aging or home health care services which prevent individuals from having to reside in more expensive residential care facilities in rural areas.

NOW is the time to contact, and continue to contact, our Senators (Heller and Cortez-Masto) and urge their opposition to this assault on medical care for northern Nevada citizens and their health care providers.

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

Amodei’s Bubbles: Republican Dreams for the AHCA

Nevada Representative Mark Amodei (R-NV2) is eager to let his constituents know that the District will not be negatively impacted by the GOP health insurance/tax cut bill currently being drafted in secret on Capitol Hill.  Not. So. Fast.

First, there will be losses.  Total coverage losses are projected to be felt by 37,500 under the AHCA, and 5,700 of those will be children, another 700 are disabled individuals in District 2.   Representative Amodei is optimistic about what will happen to these constituents —

Any Nevadan who has enrolled in the expanded Medicaid program from its inception in 2014 through the end of 2019 is free to remain in the program so long as their income does not exceed 138% of the national poverty level; …

In short, according to Rep. Amodei, his constituents are to be carefree and happy about their health insurance coverage until the end of 2019.  It’s now 2017.  Thus the recipients are to be reassured for another two years because:

  • Nevada will continue to receive the enhanced federal Medicaid funding for enrollees that it is currently receiving for as long as that enrollee stays in the program;

  • Present expanded enrollees lose eligibility only if they exceed income of 138% of the national poverty level, or if they elect to take employer provided or private health insurance;

Lovely, until we peek into the House version (the basis for the Senate version) and find:

“Medicaid provides coverage for over 70 million individuals and relies on both federal and state funding to continue growing. Under current law, the federal government covers, on average, 57 percent of each state’s total Medicaid costs, no matter the amount. The states pay for the remainder.

In contrast, under the AHCA’s per capita cap Medicaid program, starting in 2020, the federal government would provide states with a flat, capped dollar amount of funding for each person they enroll. The dollar amount is based on states’ 2016-level per-enrollee spending.”

One way to interpret this is that the District’s enrollees will be fine for the moment, but should be aware that the sword labeled ‘the Medicaid Per Capita Lid’ is swinging over head.  This has the potential to burst the first of Amodei’s bubbles.

Secondly, there’s this part of Representative Amodei’s eternal optimism:

“While we understand that Medicaid Expansion will eventually be phased out, we expect the recovery of our economy to continue, giving us reason to believe we will not need as robust of a safety net as we once needed at the height of the recession.  Additionally, with Nevada leading the nation in job growth in 2016, we also can expect employer-based coverage to become available to more people.”

A bit of confusion reigns here — don’t worry about Medicaid expansion cuts because Nevadans will be covered — but notice that the Medicaid expansion will “eventually be phased out.” One really doesn’t get to have it both ways.  But, there’s more.

Yes, the Gallup 2016 Job Creation Index gives Nevada top marks for job creation, but remember that this polling is based on asking workers if the employer is increasing hiring.   It is also statewide.  If we drill down we find positive news, but an incomplete picture.

“Employment increased in Nevada’s two large counties from September 2015 to September 2016, the U.S. Bureau of Labor Statistics reported today. (Large counties are defined as those with 2015 annual average employment of 75,000 or more.) Washoe County’s employment rose 5.0 percent and Clark County’s employment rose 3.7 percent.” [BLS]

What we are required to believe  is that employment increases in District 2 will be sufficient to cover some 37,500 people who will need to find employer paid insurance coverage by 2020.  Exactly how this is supposed to happen isn’t all that clear.

There are too many “ifs” in the proposition to adopt it with any enthusiasm.  IF there is continued employment increases — in the face of the financial deregulation legislation in the House and Senate which threaten to recreate the Wall Street Casino environment that wrecked Nevada’s economy in 2007-2008.  IF the employment increases in the rural portions of District 2 are sufficient to put Medicaid expansion enrollees into employer plans.

And then, there are the problems intrinsic in the AHCA in the employer sponsored insurance plans.  Those believing that the AHCA will deliver the same level of health insurance coverage in employer sponsored plans as the ACA may be in for a rude shock.

“The amendment (to the AHCA) would allow states to apply for waivers to rescind two major regulations of Obamacare, if the state can prove that healthcare costs would decrease as a result. That has led to concerns about its potential effects on the individual insurance market, but it could also change insurance for people that get coverage through their employers.

One of those Affordable Care Act-implemented protections — called essential health benefits (EHB) — requires insurers to cover a baseline of 10 health procedures and items including emergency-room visits, prenatal care, mental-health care, and some prescriptions.

Under Obamacare, employer plans could not place a lifetime limit on the amount that the plans pay out on EHBs, and required plans to limit the amount of out-of-pocket costs an employee had to pay annually, according to The Journal. That made plans more costly for employers but also provided better coverage for employees.”

Thus, there are three problems — junk plans might be back in the market; essential benefits can be reduced; and lifetime and annual benefit limits could be reintroduced.  We can safely assume that Representative Amodei’s analysis contains the usual measure of Trickle Down Happy Talk (if only the tax cuts are big enough all employers will hire enough people to make the magic happen! — See Kansas) and assumptions which sound superficially rationale but don’t hold up to much scrutiny.

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Filed under Amodei, health insurance, Medicaid, nevada health, Nevada politics, Politics

It’s Going to be Fabulous!

If the question is: “What’s going to be fabulous?” The answer is probably nothing.  Thus far the administration hasn’t delivered on much.  Sights! Sounds! Drama! notwithstanding, it’s Shakespearean “Sound and fury, signifying nothing.”

The Muslim Travel Ban met yet another defeat on its way to the Supreme Court.  Supposedly it needed to be enacted Immediately to prevent the Threat of foreign terrorists, but time has passed (along with the time the Muslim travel ban was supposed to be in effect, during a study period) and behold a plethora, a horde, of heretical fanatics didn’t launch an assault.  Nothing there.

The wall seems like a distant memory,  as much fantasy as the idea the Mexican government was going to pay for it — IT, the wall, fence, river boundary, natural obstacles, or whatever.  Nothing there

The President’s first executive order called for the repeal of the Affordable Care Act, and authorized agencies to grant waivers, but pointedly did NOT offer to infringe on “authority granted by law to an executive department or agency, or the head thereof.” Other Executive Orders follow the same pattern. Call for the study of some topic, require a report, and then infer that the report would be fodder for legislation. Perhaps the closest analogy to these orders might be a Christmas List — “Dear Santa, please bring us justification for the following rule changes or legislative priorities.” Lots of smoke and mirrors, without much there there.

An important point to note in terms of the Republican version of health insurance “reform” is that it is far more about tax cuts for those earning over $200,000 than it is about making health insurance affordable for average Americans.  See also: Vox and Atlantic, Forbes.  The median household income in Nevada is $52,431.

And speaking of Nevada — what can we expect?

“371,000 Nevadans stand to lose their health coverage.1

Nevada stands to lose $16 billion in federal assistance to help provide health coverage to its residents.2

Approximately 71,000 Nevadans who currently get financial assistance to help pay for their health coverage will lose this help and will no longer have affordable coverage options. In 2016, Nevadans receiving financial assistance saw their monthly premiums reduced on average $268 thanks to this help.3

The now-historically low rate of uninsured people will spike, with the number of uninsured in Nevada increasing 95 percent by 2019.4 This will reverse the immense progress that has been made to expand coverage. Between 2013 and 2015″

And there’s more:

“187,000 people stand to lose health coverage, most of whom are working.6 The Medicaid expansion has extended health coverage to lower-income Nevadans who hold down jobs that are the backbone of the state’s economy—from fast food workers to home care attendants to construction workers to cashiers. Repeal will leave these hard working Nevadans out in the cold.

Nevada will lose billions in federal Medicaid funding. Over the course of a year and a half alone, Medicaid expansion brought $1 billion in federal dollars into the state economy.7 The impact of that lost federal Medicaid funding will have a ripple effect throughout the state economy, affecting hospitals, other health care providers, and businesses.”

And More!

“The Medicare donut hole will re-open. This will leave Nevada’s seniors and people with disabilities with a gap in prescription drug coverage and forced to pay thousands of dollars more in drug costs.

  • Seniors and people with disabilities in Nevada have saved approximately $123 million on drug costs thanks to the ACA’s closing the Medicare donut hole.14

  • In 2015 alone, approximately 34,000 seniors and people with disabilities in Nevada saved on average $967 on drug costs.15″

Nothing in this truncated list of horror makes it sound like Republican health insurance legislation will be Fabulous.  Unless, of course, we mean “fabulous” in the sense of some gory fable designed to send small children to the floor while checking for monsters under the bed.

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Filed under Health Care, health insurance, Medicaid, nevada health, Politics, Taxation

Here’s What Senator Heller Is About To Support

The GOP controlled Senate is trying to fast-track a backroom health insurance bill which contains some exceedingly unpopular provisions, including the following:

Age Tax:  A provision gives insurance corporations the power to charge up to 5 times more for people aged 50 to 65.  It is estimated that premiums could rise as much as $8400 for a person 64 years old.

Ending ACA Protections:  The bill ends ACA protections, and allows insurance corporations to sell policies with lifetime and annual limits, policies Consumer Reports and other consumer protection organizations have categorized as Junk Insurance.

Cuts critical coverage: The bill in its current form allows insurance corporations to refuse to cover maternity care, substance abuse, and opioid addiction treatment. If a person has a pre-existing condition the insurance corporation could refuse to provide coverage for the prescription medication or services needed.

Benefits insurance corporations at the expense of the policy holders.  Insurers could use more of a person’s premium payments for profits if the states opt out of the medical loss ratio rules; current rules have reduced costs and recovered nearly $3 billion for millions of families.

Ends Medicaid Expansion: Ends Medicaid expansion and guts Medicaid help for senior citizens, children, and people with disabilities.

Caps Medicaid: Places caps on Medicaid which endangers 1 out of every 5 Americans.

Cuts care:  The bill in its current form cuts care for nursing home patients, Veterans’ care, care for people with disabilities, and care for those with opioid addiction.

Tax Cuts for the Wealthy: The bill in its current form provides large tax cuts for wealthy Americans and for corporations.

 “A study by the Tax Policy Center, a nonpartisan research group, found that when the bill would take full effect in 2022, 40 percent of the benefits from the tax cuts would go to the richest one percent of the country. Those households would receive an average tax cut of $37,000, or 2.1 percent of their incomes. People in the lowest income bracket would get an average tax cut of $150, an amount that is just 0.9 percent of their earnings.” [NYT March 15, 2017]

It’s hard to imagine a collection of provisions such as this could even be remotely classified as “moderate.” It’s simply window dressing on the egregious House version of the bill.  Expect some tip of the hat to “protecting those with pre-existing conditions,” with a major loophole to allow the insurance corporations to charge higher premiums for those who have pre-existing conditions.  Also in the window dressing category — we’re going to cut Medicaid assistance to the states, but we’re not going to do it for X number of years (the current X = 7).  A cut is a cut no matter when it happens.

Let Senator Dean Heller know how you feel about his support for this bill. Soon, before the Senate has the chance to ram this through without public hearings, and with a limited amount of time for representatives and citizens to review the provisions.

H/T to Andy Slavit for his succinct summation of the bill, from which this post is taken.  Follow him on Twitter for more information!

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Filed under Health Care, health insurance, Heller, Politics