Near universal health coverage achieved in six states and DC

An article by Michael Rainey of The Fiscal Times (see link below), called “How six states achieved near universal coverage” noted the success of covering at least 95% of their people. These six states are Hawaii, Iowa, Massachusetts, Minnesota, Rhode Island and Vermont. The District of Columbia also fits the bill. Per the article:

“A half-dozen states and the District of Columbia have health care insurance rates of over 95%, achieving near-universal coverage. Three researchers at the University of Pennsylvania — including Ezekiel Emanuel, a key architect of Obamacare — said Monday that the Affordable Care Act has everything to do with those results.

Here’s how the states achieved such high insurance rates, according to the authors:

Expanding Medicaid: States that expanded their Medicaid programs as allowed under the ACA had about half the uninsured rate (6.6%) in 2018 as states that did not do so (12.4%). ‘Nearly 5 million people would gain health insurance if the remaining 14 states expanded Medicaid,’ they write.

Extending enrollment periods: High-coverage states countered the Trump administration’s efforts to shorten enrollment periods and reduce informational assistance.

Lowering premiums: States enacted additional subsidies and reinsurance programs to keep premiums low, a crucial factor in maintaining insurance coverage from year to year.

Simplifying options: Some states limited the number of options available to counteract “choice overload,” which can reduce signups through consumer paralysis.

Maintaining individual mandates: Five low uninsured states maintain some kind of individual and employer mandates, which may help persuade healthy people to sign up.

The lesson, the authors say, is that near-universal health coverage can be achieved without national legislation. ‘While it is easy to dismiss the ACA and focus on the promise of Medicare for All, there is a more straightforward path to universal coverage,’ they write, ‘adopting a handful of relatively simple policies and programs at the state level can ensure health insurance coverage for nearly all Americans.’”

This article echoes what can be achievable if Medicaid is expanded and the other above steps are taken. The three states who drag the results down for the country – Texas, Florida and Georgia – did not expand Medicaid nor run their own Healthcare exchanges. Of the six states over 95%, it should be noted Iowa and Hawaii use the federal Healthcare Exchange, while the other four run their own exchanges.

I have long said Medicare for All is something to be explored, but it requires detailed analyses (and time) of its costs and impact. In the interim, I have strongly advocated improving the Affordable Care Act. The goal is access to care, in my view. The employment paradigm has been changing for some time, where fewer full-time workers are being used than before. We are seeing several industries move to a largely part-time workforce, such as in the retail, restaurant, and hospitality industries. We have seen contractual employment continue as well as the growth of gig economies. Health care access needs to come from somewhere.

What I do not care for is the hyper-politicization of this topic. Republicans (including the president) have actively sabotaged the Affordable Care Act, cutting funding to insurers, not mentioning the negative talk about it. It has still survived. Some Democrats choose to throw progress out and go full bore with Medicare for All. Again, that is a detailed undertaking and no candidate can accomplish this without buy-in from both parties.

So, let’s improve what we have. States who have not expanded Medicaid have been economically short-sighted and harmed their citizens. I have argued for repaying insurers who were harmed by the reneging on funding commitments, inviting them back into markets. Where choice is not available, introduce a Medicare option. I would also lower the eligibility for Medicare to age 60 or 62.

These are practical options that may move the needle upward like in those six states. Let’s talk about that.

https://finance.yahoo.com/news/6-states-achieved-near-universal-224827646.html

Two rising sea stories from today

In my newspaper today, two articles caught my eye about the impact of rising seas. The first is an editorial entitled “Rising seas eroding coastal property values,” written by Orrin Pilkey, the co-author of a study of this subject.

The other is an article called “Highest tide in 50 years swamps Venice,” by Elisabetta Povoledo of The New York Times. Beginning with the sensational, per Povoledo, “The Mayor of Venice, who said that the city ‘was on its knees’ has called for a state of emergency and the closing of all schools after the Italian city was submerged under…an exceptionally high tode – the highest in 50 years.”

At six-feet, the rising sea level in Venice waa the most since 1966. Yet, per the article, “Last year, as severe weather in Italy killed 11 people, ferocious winds drove the high tide in Venice to more than five feet above average sea level.”

In Pilkey’s editorial, the study was reported in his book with Keith Pilkey called “Sea level rise: a slow Tsunami on America’s shores.” “The First Foundation, a non-profit research group with flood risk, analyzed 13.3 million real estate transactions, and compared the results to 25.6 million properties along the east coast and Gulf coast of the US. They concluded that there was a $15.8 billion loss in home value appreciation between Maine and Texas from 2015 to 2017.”

Pilkey made reference to increasing “sunny day flooding.” They note the sunny day flooding will increase even more until it becomes more permanent. In essence the sea water comes up through the storm drains in the street leaving standing water. A key quote toward the end of the article is a warning. “I know that if my family were living in or near a sunny day flooding area, I would urge them to sell and leave.”

Low lying coastal cities are at great risk. Global climate scientists have long said the City of Miami is the most at risk city in the world. Miami Beach is already seeing many more days of sunny day flooding. The state that had the most property loss in value is Florida. I would hope the leaders of that state would be banging the drum the loudest. As for Venice, they rely so much on tourism. Yet, that future looks to be at grave risk given its low sea level status.

Note: Below are two links to these articles:

https://www.newsobserver.com/opinion/article237245139.html

Note further: A famous climate change “denier” in words does not match his rhetoric with his actions. Per a Politico article in May, 2016 entitled “Trump acknowledges climate change — at his golf course:”

“The New York billionaire is applying for permission to erect a coastal protection works to prevent erosion at his seaside golf resort, Trump International Golf Links and Hotel Ireland, in County Clare. A permit application for the wall, filed by Trump International Golf Links Ireland and reviewed by POLITICO, explicitly cites global warming and its consequences — increased erosion due to rising sea levels and extreme weather this century — as a chief justification for building the structure.” These actions support the concerns of the Pilkey study of property values being at risk due to sea level rise.

The most realistic path to ‘Medicare for All’ says a former Insurance CEO

I said back in 2010 to a healthcare consulting colleague, we will eventually need to consider national health insurance, but it won’t happen. When he asked why, I responded the “Healthcare industrial complex is too powerful.” People forget the reason we have the Affordable Care Act is CFOs were tired of rising healthcare costs to their bottom line.

Healthcare is a complex topic and the ACA added to that complexity. It has since gotten better, but we need to shore it up to stabilize it more, rather continue to allow it to be diminished as its opponents have down for several years.

But, national health care under the banner of “Medicare for All” is worthy of consideration with data and analysis. This retired actuary, benefits consultant and benefits manager supports data driven analysis to improve what we have and consider more substantive changes. JB Silvers, a former health insurance CEO and professor of health care finance at Case Western University, penned an article called “The most realistic path to ‘Medicare for All'” in The New York Times earlier this month. Here are excerpts from the article:

“Much to the dismay of single-payer advocates, our current health insurance system is likely to end with a whimper, not a bang. The average person simply prefers what we know versus the bureaucracy we fear.

But for entirely practical reasons, we might yet end up with a form of Medicare for All. Private health insurance is failing in slow motion, and all signs are that it will continue. It was for similar reasons that we got Medicare in 1965. Private insurance, under the crushing weight of chronic conditions and technologic breakthroughs (especially genetics), will increasingly be a losing proposition.

As a former health insurance company C.E.O., I know how insurance is supposed to work: It has to be reasonably priced, spread risks across a pool of policyholders and pay claims when needed. When companies can’t do those fundamental tasks and make a decent profit is when we will get single payer.

It’s already a tough business to be in. Right now the payment system for health care is just a mess. For every dollar of premium, administrative costs absorb up to 20 percent. That’s just too high, and it’s not the only reason for dissatisfaction.

Patients hate paying for cost-sharing in the form of deductibles and copays. Furthermore, narrow networks with a limited number of doctors and hospitals are good for insurers, because it gives them bargaining power, but patients are often left frustrated and hit with surprise bills.

As bad as these problems are, most people are afraid of losing coverage through their employers in favor of a government-run plan. Thus inertia wins — for now.

But there’s a reason Medicare for All is even a possibility: Most people like Medicare. It works reasonably well. And what could drive changes to our current arrangement is a disruption — like the collapse of private insurance.

There are two things insurers hate to do — take risks and pay claims. Before Affordable Care Act regulations, insurance companies cherry-picked for lower-risk customers and charged excessive rates for some enrollees…”

There is only one solution: pooling and financing many of the risks related to chronic and acute health care issues. A study by my former company noted generally 15% of participants drive 80% of the claims costs in any given year. It may not be the same 15%, but with major chronic issues, some could continue to be in the mix. The principle of insurance is to pool those risks, so that good risks can moderate the higher risks.

The ACA uses the private insurance system, exchanges and expanded Medicaid. Unfortunately, there are about 15 states who still have not expanded Medicaid. Medicare for All would consolidate the risk into one place, eliminating the profit load and reducing the relative administration cost of insurance companies. I have suggested for several years to do a pilot and expanded Medicare eligibility from age 65 to age 62, or even lower. This would let us measure the impact of such a change.

Yet, what we don’t need is this to become political. What people do not realize is the ACA has been sabotaged on several occasions by my former party which drove some insurers out of the market and increased premiums for everyone else more so than they otherwise would have been.

So, let’s cut to the chase and study options. And, politicians should let people who know what they are doing do the analysis. The ACA was made too complex and the exchange roll out was botched. On the flip side, what the GOP did in 2017 was sloppy and poorly staffed, so what was voted on woulf have been harmful to many.

Our children deserve better

Two time Pulitzer Prize winner Nicholas Kristof wrote an editorial earlier this week in The New York Times called “Our children deserve better.” It is a clarion call to our nation showing the plight of kids in America.

Here are a few quotes to frame the issue:

“UNICEF says America ranks No. 37 among countries in well-being of children, and Save the Children puts the United States at No. 36. European countries dominate the top places.

American infants at last count were 76 percent more likely to die in their first year than children in other advanced countries, according to an article last year in the journal Health Affairs. We would save the lives of 20,000 American children each year if we could just achieve the same child mortality rates as the rest of the rich world.”

“Half a million American kids also suffer lead poisoning each year, and the youth suicide rate is at its highest level on record….The Census Bureau reported this week that the number of uninsured children increased by 425,000 last year.”

These are different views and sources of the threats to US children that note we have a problem. Another source I read a couple of years ago noted America has a much higher maternal mortality rate at child birth than other civilized countries, which further endangers children as well as the mothers.

Yet, these issues are not being discussed in the halls of government. We have a poverty problem in our country with too many living in or just above poverty levels. We have not expanded Medicaid in fifteen states whose numbers are worse than these national numbers per capita. We have not addressed our national water crisis which has a Flint, MI like exposure to lead in too many cities and a volume of available fresh water issue in other places. We have not invested as we should to diminish crime and provide more opportunities for jobs in disenfranchised areas. There are several pockets of success that can be emulated in more cities.

We also need to address better gun governance, especially with the number one gun death cause by far being suicide and a non-inconsequential accidental gun death rate. And, we have not dealt with the continuing and rising exposure to technology and artificial intelligence which have taken and will take even more jobs in the future. Finally, there is that climate change thing we need to deal with.

These are real problems. And, they will get worse. Data driven analysis of causes and solutions are needed. They are both multi-faceted. Investing more now, will save huge amounts later. This is not just an urban issue, it is rural one as well. The opioid crisis is rampant in these impoverished rural areas, for example.

None of the solutions will fit on a bumper sticker. And, political attempts to oversimplify issues should be questioned. Here is an easy contradiction to spot – if people believe gun deaths are a mental health issue, then why the effort to eliminate or not expand mental health benefits?

Please make your legislators aware of these issues and ask pointed questions. These questions deserve answers, not bumper sticker slogans. These concerns deserve to be talked about, studied and acted upon.

We should pay attention when people sound alarms at their own peril

It fascinates me when an old post starts getting some attention. Right now, one called “Who is Paul O’Neill and why should his opinions matter?” is getting a few looks (a link is below). In essence, O’Neill was fired as Secretary of the Treasury for voicing an opinion the President did not like.

What did he say, you ask? He said he was concerned about the debt and felt the Bush Tax Cuts were unneeded. This is after Bill Clinton handed a surplus budget to the younger Bush. It should be noted the debt is now 5 times larger.

Recently, the well respected Director of National Intelligence Dan Coats resigned under pressure as he told the inconvenient truth about Russian influence and its continuation. Like O’Neill, this clarion call should be heeded. Like with General James Mattis’ resignation last December, Coats departure is giving GOP Senators pause, yet they refuse to act.

Back in late 2007, a Texas financial analyst noticed that people who could “fog a mirror,” were getting huge mortgage loans on properties that seemed to be over-inflated in value. He did his homework and was able to get a meeting with the CFO of Bear Stearns. He told the CFO he thought Bear Stearns was over-extended with risk and was going to to go under.The CFO thanked him and the guy uttered these parting words – well, I am going to bet against you. Within the year, Bear Stearns was bought for a very discounted price before it went under.

Colin Kaepernick is a good NFL quarterback, but he has been blackballed from the league after calling attention to the unequal rights and treatment of Blacks in America. His civil protest was hyper-politicized by a hyper-political president, so he was blackballed, a term which seems apt. Yet, we have a difference in how Blacks are treated. Even further, our society is more economically unequal than it has ever been, with haves owning much greater shares. A society cannot withstand such differentiation for too long. Kaepernick’s protest should be heeded not condemned. His protest is far more emblematic of American values than a flag or anthem ever could be.

Those who are giving clarion calls should be given due consideration. There are financial analysts who have cautioned against Brexit from the outset. Those concerns have fallen on too many deaf ears. Their corollary message is even more dire – do not leave the EU without a deal. That is beyond poor stewardship. It matters not what the current PM says. Yet, if it does happen, it is only fitting that Mr. Johnson is the one trying to deal with the fallout.

Before I close, let me go back to someone who is similar to the Texas man who tried to forewarn Bear Stearns. The movie “The Big Short” highlighted one person of several who saw the housing recession coming. When his concerns fell on deaf ears, he had them create a product to pay off if he was right.  The industry laughed at him until a couple of years later they realized he was right. His clients made a fortune. The movie ends by telling us what this man is now investing in – water. While it does not get much play here, we have a global water crisis which rivals climate change as a concern. He saw it coming.

https://musingsofanoldfart.wordpress.com/2013/03/20/who-is-paul-oneill-and-why-should-his-opinions-matter/

Blue Cross Blue Shield of North Carolina ACA premium rate cut request

Earlier this week, Blue Cross Blue Shield of North Carolina (BCBSNC) has announced a request of a premium rate cut for the second year in a row under the Affordable Care Act. They announced a request of a 5.2% rate reduction for their 435,000 members and one of 3.3% for small businesses in the state. It would have been three years in a row, but as I mentioned in earlier blogs, the Trump decision to renege on paying insurers for absorbing co-pays and deductibles for people making less than 2 1/2 x poverty limit caused premiums to increase for all.

This shows the ACA is stabilizing for insurance carriers who have been at it a few years. It would be nice to get more carriers back in for members to have choices. Many left when the Senate, led by the GOP defunded the risk corrider payments to the tune of 89% of the adverse selection cost. These carriers left the markets with the US government owing them money.

These two efforts to dampen the ACA have gone largely unreported. But, there is one more which is critical that impacts premiums and threatens the entire ACA. The tax bill passed by the GOP led Congress eliminating an unpopular feature of the ACA, which required individual coverage. It was called the individual mandate. By obligating people to have coverage, it lessened the risk on the insurers which will keep premiums lower than they would be otherwise.

Here is what BCBSNC said in their announcement as reported by The Charlotte Observer.

“The rate of decrease requested for 2019 would have been larger, the company told the Observer in 201, if the GOP tax reform legislation signed by President Donald Trump hadn’t repealed the ACA’s individual health insurance mandate.”

Further, several GOP led-states are suing the federal government to rule the ACA unconstitutional due to the elimination of the mandate. The tax laws are complex, but it is going to end up at the Supreme Court. It is thought by experts this case is weak, but the Trump Justice Department has decided to not defend the law which helps so many. Ironically, this is happening as it stabilizes even more, the GOP lost seats because of their ham-handed efforts to repeal it and when some Democrats want Medicare-for-all.

Credit risk appraiser Moody’s buys a firm that assesses climate change risk

Even for those not very familiar with Moody’s, this headline speaks volumes about the impact of the risk of climate change on our country and planet. In a July 24, 2019 article in The New York Times by Christopher Flavelle called “Moody’s Buys Climate Data Firm, Signaling New Scrutiny of Climate Risks,” the company that measures credit risks for bond investors in companies, cities, counties, states and countries, has added to its expertise. Per Flavelle’s article

“Moody’s Corporation has purchased a controlling stake in a firm that measures the physical risks of climate change, the latest indication that global warming can threaten the creditworthiness of governments and companies around the world.

The rating agency bought a majority share in Four Twenty Seven, a California-based company that measures a range of hazards, including extreme rainfall, hurricanes, heat stress and sea level rise, and tracks their impact on 2,000 companies and 196 countries. In the US, the data covers 761 cities and more than 3,000 counties.

‘We are taking these risks very seriously,’ said Myriam Durand, global head of assessments at Moody’s Investor Service, who said the purchase would allow its credit analysts to be more precise in their review of climate-related risks. ‘You can’t mitigate what you don’t understand.’

Sudden shocks such as floods, wildfires, or storms can hurt businesses and send residents fleeing, taking away the tax revenue that government s use to pay debts. And, longer term threats – such as rising seas or higher temperatures – can make those places less desirable to live in, hurting property values and, in turn, the amount raised by taxes.”

To illustrate this risk, the same day I read a reprint of this article in The Charlotte Observer, the local paper ran a story on the town of Fair Bluff, NC which has been flooded twice in that past four years due to Hurricanes Matthew and Florence which lingered over their area. Sitting near the Lumber River, the citizens of Fair Bluff saw the river rise well beyond flood range. The previous flood of this magnitude occurred 90 years before. Sadly, the population and business is declining due to rebuilding costs. As a result, so is the tax revenue to provide services.

There is a huge financial impact of climate change on the lives and business of people and communities. Rebuilding a town that may continue to be in harms way adds to the risk and some people are choosing to relocate. And, It is not just small towns. Houston has had two major floods over the past five years, as well. Houston has felt on a larger scale what Fair Bluff has felt. Not only do the rains of the Hurricane sit over them, the rivers upstate overfill and flow toward the sea. This causes extra flooding.

So, Moody’s is improving their ability to assess repayment risk to bondholders. A city that has rebuilt or prepared poorly is at greater risk of flight of people, businesses and tax dollars. What should also be alarming to American citizens is while Moody’s is taking forward thinking action, the US government is stripping climate change reports from their websites and demoting, transferring or running off Ph.Ds who are expert in measuring and addressing climate change. In short, we are throwing away a technical advantage that could help the US and the world.

Repeating what Ms. Durand said above, “You can’t mitigate what you don’t understand.”  So, please ask all politicians what they plan to do about climate change including the US president. And, a question for those who still buy the hoax stuff, why is Moody’s spending all of that money on a hoax?