Medicaid expansion – letter to the editor

When the Affordable Care Act was passed in 2010, a key element was for people who made less than 133% of the poverty limit based on their family size. This group would pay no premiums through a state-by-state expansion of Medicaid. The federal government said it would reimburse each state for 90% of that cost.

At this point in 2022, there are twelve holdout states that have not expanded Medicaid. That leaves 2 million Americans with access to no healthcare coverage. The holdout states include my home state of North Carolina and big states like Texas, Florida and Georgia (see link below to a NPR article).

North Carolina was close to passing Medicaid expansion, but the effort stalled once again. Here is a letter I sent to my newspaper that they graciously printed this morning.

NC and Medicaid

As a retired benefits consultant and former benefits manager for a Fortune 500 company, I was hopeful that the N.C. General Assembly would at long last pass an expansion of Medicaid to fully comply with the Affordable Care Act. Failing to do this has harmed N.C. residents. Our economy has been impacted and some rural hospitals have either closed or are in financial trouble, according to the Commonwealth Fund, a nonpartisan healthcare advisor.

As former GOP presidential candidate and Ohio governor John Kasich noted when Ohio expanded Medicaid years ago, it was a no-brainer with the federal funding the state has realized for years now. Please move forward on Medicaid expansion.

We have heard of food deserts in largely rural states which impact people in need more than others. But, we also have healthcare deserts as well. Taking only one data point, it is not a surprise to learn that maternal mortality rates in these states are worse than in other states and first-world countries. Note, this is mother’s dying in childbirth. That is a sad state of affairs, especially for a country who claims exceptionalism.

https://www.npr.org/sections/health-shots/2021/07/01/1011502538/12-holdout-states-havent-expanded-medicaid-leaving-2-million-people-in-limbo

Rural Health Care is suffering (and COVID-19 has made it worse)

In an article called “The South’s health care system is crumbling under Covid-19. Enter Tennessee” by Daniel Payne of Politico, the demise of heath care in more rural areas has been exacerbated by COVID-19.

A key reason is the closing of rural and small town hospitals that has severely impacted immediate health care. A key paragraph from this article is telling:

“Of the 50 counties with the highest Covid deaths per capita, 24 are within 40 miles of a hospital that has closed, according to a POLITICO analysis in late January. Nearly all 50 counties were in rural areas. Rural hospital closures have been accelerating, with 181 since 2005 — and over half of those happening since 2015, according to data from the University of North Carolina. But that may be just the beginning. Over 450 rural hospitals are at risk of closure, according to an analysis by the Chartis Group, one of the nation’s largest independent health care advisory firms.”

These hospital closings are not new nor did they just happen. The financial difficulties predate the passage of the Affordable Care Act. In essence, a significant portion of the cost of running these hospitals went toward indigent care, meaning people without insurance. In some cases, it was over 50% and even as high as two-thirds of the hospital budget. This meant some of the revenue may be reimbursed by the local county, but if the county was in financial trouble or this was a private hospital, the hospital was out of luck.

The ACA brought with it the expansion of Medicaid, should a state opt in to cover people. The federal government would reimburse the state those costs for three years and then drop to 90% thereafter. All but fourteen states have so expanded. Per the non-partisan Commonweath Fund, Medicaid expansion helps the state economy, rural health care and the people in those locations. Former Republican presidential candidate John Kasich called Medicaid expansion a “no brainer” when he was governor of Ohio.

And, these hospitals are usually a major employer in these towns. So, when one closes, a lot of revenue leaves the town budget and economy. Belhaven, NC Mayor Adam O’Neil, a Republican, pleaded with the state leaders to expand Medicaid, but to no avail. So, he walked to Washington, DC to plead his case there. It should be noted that North Carolina remains as one of the fourteen states who have not expanded Medicaid.

As a retired benefits consultant, manager and actuary, I know the ACA is not perfect and could use some shoring up. But, a key reason for the ACA is patients need access to care and hospitals need to get paid for services rendered. If a patient has health care insurance, he or she will seek more preventative measures to stave off problems. Plus, he or she will seek care if needed, rather than avoiding it.

All of the above greased the skids for a problematic response to COVID-19. Without hospitals close by, people would forego care until it was too late. Plus, coordination of care with doctors to do triage and offer vaccines is hindered.

The ACA is not perfect, but it has improved access care for many people. I have written before about some suggestions to improve it. Yet, in fourteen states, the ACA still has not been fully implemented and in many of those states, they lag other states on health care results per the Commonwealth Fund. Expansion of Medicaid could be a major step.

https://news.yahoo.com/public-health-disaster-shuttered-hospitals-110000044.html

Our children deserve better – a repeated pre-pandemic clarion call

The following post was written a couple of years ago. Although the pandemic has rightfully gotten our attention, this story bears repeating.

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.

*Note: The number of states who have not expanded Medicaid is now twelve. Here is a link to a tracking of the states who have and have not. What puzzles me is this change would help people in rural areas, which tend to vote more conservatively. So, not expanding Medicaid hurts health access, but also rural hospitals and economies, with the federal government funding 90% of the cost. As former Republican governor of Ohio and presidential candidate John Kasich said, Medicaid expansion is a “no brainer.”

Shore up the ACA – letter to the editor

My local newspaper ran my following letter to the editor Sunday. I have been preaching the message of improving the Affordable Care Act for seven years offering suggestions. I will link to one of those posts below. What I have never cared for is the naysaying, sabotaging and attempts to repeal it that have been a substitute for debate in the Republican party.

The legislation Republicans almost rammed through in 2017 was ill-conceived, poorly developed and punitive to multiple millions of Americans. These were the key reasons Senator John McCain saved the GOP from itself and voted it down before he died.

“Three times now the U.S. Supreme Court has upheld the Affordable Care Act in the face of Republican attempts to rule it unconstitutional.

Per this retired actuary, benefits consultant and benefits manager, the ACA is not perfect and could use some improvements. But it is helping Americans, including provisions required in employer sponsored plans, which people tend to forget.

What has puzzled me for 10 years is that the law is somewhat based on Republican ideas, the latest being Romneycare in Massachusetts, which at least one Tea Party leader, S.C.. Sen. Jim DeMint, once supported.   

My strong advice to my former party, stop trying to screw Americans by killing the ACA and let’s find ways to shore up its deficiencies.”

Please stabilize the Affordable Care Act NOW to help Americans | musingsofanoldfart (wordpress.com)

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.

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.

Musings at the start of summer

The longest day in the Northern Hemisphere is upon us. Maybe with this extra daylight we can have more illumination on issues. It seems we have a bad habit in our country of governing off rhetoric rather real information.

Saying it more basically, we believe our own BS. It is puzzling why we would make decisions off stuff we made up. Yet, that gets to the heart of the matter. The authors of change don’t necessarily want to solve the problems. They just want to win the election game of optics.

A good example is the secretive Senate effort to develop a repeal and replacement bill for the ACA. The effort has several of the remaining Republican and all of the Democrat Senators up in arms. What is missing is open and honest debate. What is missing is open acknowledgement of Republican efforts to strangle the imperfect law by withholding money from insurance companies promised them to take on adverse selection (higher risk).

Another good example is withdrawing from the Paris Climate Change Accord where America abdicated a global leadership role. While the President and EPA Director tell us there is not consensus on man’s influence on climate change, they fail to tell us that there is an overwhelming consensus from the scientific community. They also fail to heed the recommendations of countless companies, cities and states to remain, including ExxonMobil and Royal Dutch Shell. The sad part is the job growth and investment in renewable energy is growing rapidly and large companies like Amazon. Google, IKEA, Walmart et al are leading the way.

Let’s hope our myopic leaders will use today’s extra sunshine to see the light.

The exact opposite of what is needed

Since tribal fervor gets in the way of good information sharing and debate, we end up with laws, bills and executive orders/ comments which are the exact opposite of what is needed. This troubles me greatly, as if you took the time to look at data and explained what the change would do, people would not be supportive of the change.

Here are a few working examples:

– Treating Muslim Americans poorly, blocking travel from Muslim countries, and criticizing the London Mayor who is an exemplar of successful Muslims in the western world make us less safer. Ostracizing Muslims feeds into the recruiting messaging for Islamic extremist groups; welcoming Muslims and involving them in conversations and diligence is making us safer.

– Defunding Planned Parenthood will increase the abortion rates, health care cost and poverty. Poverty is highly correlated with larger family size. Family planning reduces the number of unwanted pregnancies. Plus, women’s health for low income families improve which saves money.

– Cutting back on renewable energy investment and tax breaks will be dilutive to job increases and rural economies. Many of the solar and wind energy jobs are occurring in rural settings where they are needed. The market for solar and wind energy continues to rapidly grow as the prices fall. Investment in these areas is accretive to growth.

– Regulation is not the enemy. Inefficient and ineffective regulation are. Dodd Frank needs improvement, but we need to be mindful of the changes. The ACA needs improvement, not repeal. Very few industry leaders advocate for regulation – it does not mean they don’t need them, especially when greed exists. We need to govern our regulation either paring, repealing or improving where needed. Here is an example – when Erskine Bowles was asked to head the Small Business Administration he reduced the application for assistance from 42 pages to two.

– Pulling back from global leadership will make the world less safer. America helps provide guardrails to global crises. The more we abdicate responsibility, the less safe it becomes for America and the rest of the world. We must be engaged and collaborative.

I have many other examples. What do you think? What are your examples?

 

Celebration for passing a bill may have been premature

With a White House eager to claim legislative victory, there was a celebratory bash after the Republican led House passed the AHCA by a squeaker of margins 217 to 213. The bill has been vilified by several advocacy groups like the AMA, American Cancer Society and AARP and it has still not been scored by the Congressional Budget Office. The bill is also dead in the water in the Senate “once it gets sent there.”

Wait a minute, the last sentence said “once it gets sent there.” To the surprise of some Republican House members, the AHCA bill has not yet been sent to the Senate. Why, you might ask? Since the House did not wait for the CBO to score the cost and impact of the bill on the numbers of uninsured, it cannot be included in the budgeting process, and would thus require 60 votes, not 51 to pass in the Senate. The whole idea was to sneak the bill through this process, so it did not need the super-majority of 60 votes, which it cannot achieve.

Unless the CBO scores this where it saves a threshold amount of the budget, it may not qualify. So, the House leadership has not yet sent the AHCA to the Senate. If they did and the CBO results were not favorable, the House would have to start over. Again, I should reiterate that this bill cannot get even the 51 votes needed due to the impact on Medicaid. As we speak, about two dozen state governors are beseeching the Senate about not harming Medicaid. Unlike the House, the Senate is actually listening.

So, the victory lap on mile 250 of the Indy 500, may have been premature. Voting on something without knowing its impact is not the wisest course of action and is unbecoming of a legislator we trust to do our homework.

 

ACA truths Republicans don’t want you to know

The Affordable Care Act is an imperfect and complex law, but it is actually working pretty good. It does need improvements, but a few of its imperfections have been heightened by our Republican friends in Congress and in state legislatures. Yet, they do not want you to know about these actions, some of which are quite devious and harmful to Americans. To be frank, this subterfuge frustrates me as people are harmed as the GOP tried to waylay the law.

What has not been reported very much in main stream news is Senator Marco Rubio’s successful efforts to stiff insurance companies. These companies were promised additional funding for taking on excessive bad risk, called adverse selection. This was done successfully when the Medicare Part D plans were rolled out. By stiffing the carriers, the insurance companies had to raise premiums even more than they otherwise would have. Some even left the exchanges as this action hurt their bottom line. Let me say this plainly. Senate Republicans screwed Americans with higher premiums to try and strangle the ACA. Rubio even bragged about this on the campaign, so please Google “Senator Marco Rubio and risk corridors” to read about what he did.

On the state level, 19 Republican led states chose not to expand Medicaid, a key component of the ACA. 31 states who did so are seeing fewer personal bankruptcies and better hospital accounts receivables. Republican John Kasich, who expanded Medicaid as Governor in Ohio and ran for President, said “Medicaid expansion is a no brainier.” I would have likely voted for Kasich had he won the GOP nomination.

Then there is the naysaying that has been facilitated by the 50 plus repeal votes. Far too many folks never gave the ACA the benefit of the doubt. It is imperfect and the exchanges were rolled out horribly, for which I blame former President Obama. Yet, this law has made a huge difference in the lives of many Americans.

Finally, what is ironic is the ACA is built off a Republican idea. This is a key reason Republicans don’t have a good replacement. In fact, former Senator Jim DeMint, the initial Tea Party leader, strongly advocated Romneycare, on which the ACA is loosely based, for the whole country. He even wrote a letter to President Bush advocating for it. Yet, when Romney ran for President in 2012, DeMint said both Romneycare and the ACA were unconstitutional. This hypocritical change of heart can be easily found by Googling “Senator DeMint and Romneycare.”

People need to know the truth. This is not false news as our President likes to claim. Please research these facts and read as much as you like. Then, ask your representatives to start governing with real information and look to help Americans. I strongly recommend we do not repeal the ACA and improve the law. To do otherwise, is poor form for those who hindered it at the expense of Americans.