That healthcare thing

In more than a few surveys, the majority of Americans have noted that healthcare is a key dinner table issue. In several surveys, shoring up and stabilizing the Affordable Care Act (ACA) is preferred by a smaller, but still majority of Americans, than its repeal.

With a background of being a former benefits actuary, consultant and manager of benefits, here are a few facts and observations that I encourage you to research and verify.

– The ACA borrows from a Republican idea implemented by Governor Mitt Romney in Massachusetts which was advocated by de facto Tea Party leader Senator Jim DeMint for the whole country. Some elements can be found in a healthcare idea of Senator Bob Dole when he ran for President in 1996. These are reasons Republicans had a hard time with other ideas to repeal and replace it.

– The ACA is designed to require employer and public plans to offer certain minimum level benefits. The non-employer benefits are delivered through healthcare exchanges of policies and the expansion of Medicaid for people near or in poverty (32 states and the District of Columbia elected to do this).

– The biggest benefits of the ACA are guaranteed issue and renewability of coverage and the premium subsidy for people with incomes up to 4 x poverty limit. If you or a child has a preexisting condition, guaranteed issue and renewability are huge benefits.

– The botched roll out of the online exchanges sits at the feet of President Obama. For this to be such an important issue, it deserved better planning. The online exchanges are doing much better now, but you don’t get a second chance for a first impression. And, this poor roll out was used as fodder to nay-say the program, even though the problems were fixed.

– The ACA has experienced higher premiums due to adverse selection (pent-up demand and more high risk than better risk customers), but it is frustrating that the Republican Senators and President have masked their role in making premiums even higher. Senator Marco Rubio led an effort to strip 89% of the funding to insurers for initial adverse selection a couple of years ago and President Trump stripped out funding for co-pays and deductibles for lower paid people last year. Both of these changes cause premiums to increase even more than they otherwise would have.

– The lack of expansion of Medicaid in 18 states means the ACA is still not fully implemented. Per The Commonwealth Fund, this implementation would help people, rural hospitals and state economies. GOP Presidential candidate John Kasich called Medicaid expansion a no-brainer when he did it in Ohio as Governor.

The ACA is not perfect, but it is working OK. It could work even better if it were stabilized and improved. Taking away the mandate will be harmful and cause premiums to go up even more. What troubles me in our zero-sum game of politics is we are foregoing improving an imperfect law, which we have done countless times before on major changes. The way I see it, Congress and the President own this law now. If it fails, people should look to them asking why did they let it happen. This impacts people.

I have mentioned before several changes to consider. National healthcare is not going to happen in our country as it is too political and the healthcare industrial complex is strong. Yet, I advocate expanding Medicare in a targeted way down to age 62 (or maybe 55). Unlike the more complex Medicaid, Medicare actually works pretty well and strips out the profit load embedded in insurance premiums. This will reduce exchange premiums and Medicare premiums, as it makes both audiences younger on average.

I think we need to reconstitute the adverse selection and co-pay subsidies to insurers. The federal government needs to repay insurers they stiffed and invite insurers who left back into the exchanges. I would also recommend the remaining states expand Medicaid and I would add back the mandate for coverage, even though this feature is unpopular. If there are areas where competition is not significant, select use of Medicare (or Medicaid) could be deployed in those counties.

There are other changes that should be considered, but we need to shore this thing up. Congress and Mr. President, the ball is in your court as well as the legislatures for those eighteen states.

 

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My former party does not know much about healthcare

The Graham-Cassidy Bill seems to be on its last legs, but these bills are like Jason – just when you think you kill the serial killer, he remains alive. This latest effort may be the worst bill by my former party, which I left in 2006. It is apparent to me that Republican leaders don’t know much about healthcare and don’t care to know or take the time to know. That includes the man in the White House who just wants to sign something that negates something Obama did. “Who knew healthcare could be so complicated?” he asked earlier in the year. The answer “Everyone, but you.”

Every bill either put forth by the Senate this year or passed by the House has been scored poorly by the Congressional Budget Office (CBO), has been not appreciated in polls and has been denigrated by medical and hospital associations. Not involving women, Democrats, experts and due process in the planning revealed a haphazard approach to legislation.The Graham-Cassidy Bill is the worst of the bunch as it places the burden, and eventually all of the financing, on the states. In a nutshell, the bill says we cannot figure this out, so we are punting it to you.

In addition to the tens of millions of Americans negatively affected by these bills, if passed, the authors make a concerted effort to kick people in poverty and near-poverty in the teeth. Since we have a poverty problem in America, these bills are especially cold-hearted. And, Graham-Cassidy gives states the right to do away with pre-existing conditions, which was incorrectly refuted by Cassidy after being called on the carpet by Jimmy Kimmel. Seeing protestors in wheel chairs at the Senate was telling.

Further, I have shared with Senators, Congressional Representatives and the White House, these bills would be dilutive to the economy. Standard & Poor said yesterday in their global report the Graham-Cassidy would harm the American economy by $240 Billion through 2027 and cause 580,000 job losses. In a nutshell, when people in need no longer have insurance, the trade-off becomes between food/ rent and medicine. So, less is spent in the market place which dilutes the economy.

Yet, let me emphasize one thing that has been raised by more than a few state Medicaid Directors and Governors. Building a new healthcare delivery system will take longer than the time given. In my view, it will take longer than even these folks are thinking about. In business and government, leaders tend to vastly underestimate the complexity to set-up administration of things. As President Obama found out, setting up healthcare exchanges was hard and initially failed to deliver.

This is an important observation about the Affordable Care Act. It is in place. It is not in a death spiral and it is not broken. From the lens of fewer uninsured, it has been successful. Yet, it needs improvements, but first it needs to be stabilized. Part of the reason for the latter is the GOP’s efforts to hamstring its success by defunding subsidies for adverse selection to insurers. Coupled with slow funding of other subsidies, nineteen states who did not expand Medicaid and general naysaying, the law has not been given full opportunity to be successful.

So, this retired benefits actuary, consultant and manager recommends the ACA be stabilized under some version of the bipartisan Alexander/ Murray Bill. Then all members of Congress can spend more detailed and thoughtful time in deciding how healthcare can be delivered going forward. My recommendation is they improve the ACA.

Lyin’ Eyes

The Eagles sang about infidelity in their popular song “You can’t hide your lyin’ eyes. And, your smile is a thin disguise.” I mention these lyrics because of the lack of fidelity to the truth exhibited by various politicians.

The comedian Jimmy Kimmel is being vilified by conservative news sources regarding his calling on the carpet Senator Tom Cassidy about his misrepresentation of what is included in the Graham-Cassidy Obamacare replacement bill. Based on fact checkers, Kimmel knows what is in Cassidy’s bill more than Cassidy does.

This would not be the first time politicians have lied about Obamacare. Obama oversold it saying you could keep your plan, which was at odds with most insurance changes. Yet, the lion share of the lying has been by Republicans. This law is imperfect and needs improvements, but it is not in a death spiral or is broken as portrayed by the GOP. The GOP has also not been forthcoming about their multiple attempts to hamstring the law at the expense of Americans increasing their premiums even more.

But, no US politician can lay a hand on the  greatest liar on record. This man has been measured by Politifacts as telling the complete truth only 5% of the time. When partial truthtelling or more is included, the rate increases to 31%. Saying it differently, this man lies 69% of the time, which is consistent with his rate of lying on the campaign trail. This man, of course, is the White House incumbent.

What I have noticed over the years, when politicians lie, the people who are most harmed are US citizens. The reasons and broadcast success rates for the Vietnam War were packed with lies. The sad truth is the percentages of those who died or were injured were much higher for African-Americans and poorer Americans. They bore the brunt of the lies.

Scrolling forward, when Trump and other politicians lie, people tend to die at higher rates. If the ACA is replaced as planned in GOP bills, more folks will be uninsured and  be at risk. By pretending climate change is not a threat or that governing environmental issues are less important than business leaders’ companies, people will die.

I recognize politicians have always lied, but never before at this rate or with such impunity. Our leaders dishonor the flag when they lie so much. And, they hurt our standing in the world. Right now, other world leaders do not trust Trump. They have good reason.

 

 

 

 

A few obvious statements

There are lot of important things we should be talking about, but let me make a few obvious statements about what is.

– While it remains to be proven whether the President of the United States colluded with Russia to get elected it is painfully clear he has lied about no involvement from any of his campaign team with Russians.
– While Junior says nothing was gleaned from the meeting with the Russian attorney, there are two truths using his own words in emails. He expected and relished in getting Russian government dirt on Hillary Clinton. And, he lied about the meeting, the purpose of the meeting, that Kushner and Manafort did not know and then released emails after being advised the NY Times was going to. Now, he says his father did not know, but frankly, why should we believe him now?
– if the GOP led Senate passes a bill to repeal and replace Obamacare using only GOP votes and the bill gets reconciled with the House bill and signed into law, it will harm two groups – a great many Americans and the Republican Party.
– The US has begun its official demise as the global leader. With the pulling out of the Paris Climate Change Accord and poor performance on the world stage at the G20 meeting, coupled with the retrenchment on trade and proclivity for untrustworthy behavior, this President has done huge damage to our reputation. If you have not seen it, check out the scathing review of Trump by an Australian political reporter who is saddened by this.

These stories are critical. We need Americans to pay attention to legitimate news sources. You could start with everyone being condemned by the President as fake news. Based on his lying and denials that are eventually disproven, people should not take this man at his word. He has not earned that right.