Tag Archives: Obamacare

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

GOP: Poor Excuses and Paucity of Empathy

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

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

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

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

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

This comment sums up the situation:

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

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

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

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

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

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

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

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

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

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

Thanks Mr. Trump: Anthem Pulls Out of ACA market

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

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

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

Thanks Mr. Trump.

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Filed under Health Care, health insurance, nevada health, 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

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