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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Truth does matter

“We pay more taxes than anybody else in the world,” said President Trump on August 10, 2017 having said similar statements on more than a few occasions.

“You know this Russia thing with Trump and Russia is a made-up story,” said the President to Lester Holt on May 11, 2017 which he has said on multiple occasions.

The cut in the subsidies will only affect the “gift” to the insurance companies, said the President to his cabinet in October, 2017 when he defunded some ACA subsidies to the companies to repay them for subsidizing co-pays and deductibles for people making less than 2 1/2 times the poverty limit. He used variations of this theme on several occasions to defend his cuts to financial help to those in need.

The two common threads of these statements are they are all lies and were uttered consistently by Donald Trump. Yet, this should not be a shock to anyone as the man has a hard time telling the truth.

Per Politifacts, on 483 measured statements by the President, 69% of the time they were either mostly false, false or pants-on-fire false. In other words, more than 2 out of 3 statements he makes or tweets should not be considered as true.

In a fairly recent interview with The New York Times, the reporters measured the President averaged lying every 75 seconds. The Washington Post counted 1,950 false or misstated claims in his first 347 days. This is consistent with statements made by his five biographers who note Trump has a hard time with the truth.

But this is not news to most Americans per a Quinnipiac Survey. The survey said 62% of Americans do not think Trump is honest. And, in a University of Missouri Journalism survey, the President was listed in the bottom ten of trustworthy news sources, meaning the ten least trusted sources.

The truth matters. The Russia thing is real, whether it links directly to Trump or not, as intelligence officials say he is at minimum an unwitting participant in the meddling. In fact, General Barry McCaffrey, the most decorated retired four star general said this weekend that the President is a “serious threat to national security,” based on his adoring view of Putin.

On the taxes comment, we just reduced taxes with this lie laying groundwork. We are increasing our debt by $1.5 trillion to try to make a pretty good economy even better. On the health care subsidies, this lie covered for a change that will increase our debt by $10 billion meaning it impacts taxpayers as well as non-subsidized premium payers, not insurers.

Our problems are complex and they are hard enough to solve when we deal with the truth. When our leader lies and others support his lies, solving problems become even harder. The truth matters. And, with respect to his many alleged affairs and sexual misconduct, I would bet on the women’s stories as being more true than his defense.

A few straightforward suggestions to fight poverty

“If incarceration had come to define the lives of men from impoverished black neighborhoods, eviction was shaping the lives of women. Poor black men were locked up. Poor black women were locked out.”

The above quote comes from the Pulitzer Prize winning book “Evicted” by Matthew Desmond. Its subtitle is also telling – “Poverty and Profit in the American City.” The dilemma is we have a poverty problem that stretches from urban to rural America. Yet, it manifests itself daily in the eviction courts of American cities and towns, whether it is from apartments, houses or mobile homes.

The book speaks of how fragile the rental community is regardless of race, yet the black community tends to have a higher rate of exposure to evictions in urban areas. Unexpected expenses, transportation problems, and tragedies can push people paying a very high portion of their rent over the edge and out the door. Ideally, 30% of family income should be toward housing and utilities. Too many of these folks are paying well above that percentage.

It should be noted that there are other drivers of fragility. Some have opioid and other dependencies. Some are fragile due to too many children that stretch the budgets of even the best planners. Some are in downward spirals with unsupportive landlords. And, many of those unexpected expenses that arise are healthcare related.

What are some suggestions to remedy these issues? Based on my experience as a volunteer Board member helping working homeless families and my reading, I would like to throw out some ideas for consideration.

First, we need to talk more about it. America has a huge disparity in distribution of wealth which is not talked about enough by leaders. Where and to whom one is born are greater predictors of success as the American Dream  has waned for too many.

Second, we need to fund more family planning efforts not less. There is a high correlation between poverty and large families. When family planning is funded and birth control access and education are increased, poverty declines, system health care costs decline and abortions decline.

Third, more mechanisms to reduce evictions need to be in place and funded. Crisis assistance funds show success in helping keeping the electricity on and, when funded, reducing the number of evictions. Stopping homelessness (or fragility) before it starts can make a huge difference and will have a positive echo effect.

Fourth, we must invest in impoverished  areas making them more suitable for families both with opportunity and resources. In their absence, crime and other poor influences fill the void.

Fifth, while I have concerns about the new Tax law with its impact on debt and heavy emphasis on the wealthy and corporations, a huge opportunity was missed when we could have added an increase in the minimum wage tying it to automatic increases due to wage inflation. I worry that less money than expected by the law’s drafters will end up in the hands of workers.

Sixth, we must address our opioid crisis in America. To be frank, cutting access to healthcare and mental care insurance benefits are not the answer. We must stabilize access and cost of healthcare, yet opposite measures have been taken in the past few years under the guise of political gain.

There are many more ideas, but these will help. On the investing front, many locations have seen success with using historical tax credits leveraging private money. There is a concept called ABCD (Asser Based Community Development) which shores up or repurposes an deteriorated asset creating jobs.

But, first we need to talk about this real and pervasive problem.

 

 

 

The President almost did something good, then…

People need to know that our President is not big into details, nor does he care to be. He is not very conversant on healthcare or the Affordable Care Act, for example. Yet, he almost slipped up and accomplished something good. Alas, he changed his position within 24 hours.

Just last week, he signed two executive orders to help healthcare in the US. Neither order would be very helpful and both will cause premiums to go up under the ACA. In fact, he said if we eliminate the subsidies for deductibles, co-pays and co-insurance on people making less than 2 1/2 the poverty level it would just hurt the insurer’s profits. That simply is not true, as our deficit would go up by $20 Billion per annum and people without subsidies would see premium increases.

But, while this was going on, Senator Chuck Schumer kept telling him about the bipartisan effort of Senators Lamar Alexander and Patty Murray that would stabilize and improve the ACA. Their efforts would restore the subsidies that Trump wanted to do away with. Insurers were pricing 2018 premiums higher sans these subsidies,

Trump encouraged Alexander while Schumer did the same with Murray. The President actually did the right thing, as Alexander and Murray were going about their business in the right way with hearings and committe meetings. This is how legislation should be done, which has been lost on our two Congress chamber leaders.

When Alexander/ Murray announced they reached agreement, the President was supportive. Alexander actually thanked the President for his role in making it happen. Yet, just after Alexander called to thank him, Trump changed his mind and now does not support it. Less than 24 hours had elapsed.

Of course, his support may change and Alexander/ Murray are not done yet, but Trump had a chance to take credit for helping Americans. This could have been a helpful major piece of legislation, which is missing from his tenure. Alas, he realized he would be helping the ACA and he had to destroy it. That is what he promised to his base. While imperfect, the ACA is not broken, but it does need improvements. If it eventually fails, it is on this President and Congress’ shoulders.

Are you going to believe me or your own eyes?

The man residing in the White House has basically told his followers that everyone else is lying, only believe me. By itself, that is a pretty audacious claim, yet when the man’s history is reviewed, truthful is not the word his biographers or business relationships would use to define the man. Yet, his fans still follow his lead.

It is very difficult to manage the response to three major hurricanes. Yet, don’t lie to people and tell them everything is going well in Puerto Rico, when it is obviously not. As the Mayor of San Juan said bluntly, “we need to get our shit together.” The better answer would have been for the man in the White House to say we have been slow to get help to people, but here is what we are going to do about it. This same Mayor was ticked off today when a DHS person said Puerto Rico is a “good news story.”

The same man is trying to ram a tax cut through that may offer some relief for middle class families, but who is he kidding? The percentage reductions for the top of the house are substantively more than for the middle class. Abolishing things like the estate tax (which already does not exist on the first $5 million of inherited assets) and the Alternative Minimum Tax (which is what most of these high earners pay) is a windfall. And, let us not look past the comment that a tax cut that will impact the debt by $2 Trillion will create sufficient economic growth to pay for that increase. If we can grow our way out of the problem, let’s cut the taxes to 0%.

The same man has echoed the party line that the ACA has failed, but there are a couple of things he is not letting on. It is not failing, but needs improvement. And, it could be doing even better if it were not for the sabotaging done by the man and his party. Premiums are even higher and carriers are fewer in part due to the efforts of the Republican Party leadership, including the man in the White House. The sad part is most Americans have no clue about this sabotoging role, but it is entirely true.

Finally, just a thought to consider. Why did the man in the White House refer to African-American protestors who civilly made a statement taking a knee during the national anthem as “sons of bitches,” yet made no such references to torch bearing White Supremacists chanting “blood and soil” and carrying Nazi slogans? Then, he said his words had nothing to do with race, yet that is why these men risked their careers by protesting.

On this latter point, my wife shared with me the comments of a third generation soldier. He said he, his father and his grandfather fought people who were not permitted to civilly protest their leadership in WWII, Korea and Vietnam. To him, to see the man in the White House criticize Americans for exercising their rights of civil protest, citing the reason to condemn them so as not to offend the flag or the military, is what this soldier fought against.

 

The President and Congress own Obamacare

I have written often about the imperfect Affordable Care Act and ways to improve it. I have written often about the Republicans role in sabatoging the ACA making premiums even higher by not funding promised payments to insurers for adverse selection as well as naysaying the law and not expanding Medicaid in 19 states.

This sabatoge continues under this President who says the ACA is in a death spiral. It is hurting in many areas, but stabilizing in others. He said he wants to let it implode and then fix it.

Mr. President, that is not good enough. You are threatening to cease further promised payments to insurance companies which will harm people. You see, what you and Congress fail to realize is you own Obamacare. If it fails, it is on your watch. And, to be frank the significant majority of Americans and the press do not recognize the role you played in hamstringing the imperfect law.

My strong advice is to do what is necessary thinking of its patients and users. Those Americans out there deserve your best efforts to help them. Watching the ACA fail after you greased the skids is extremely poor form and uncaring. It is that simple. Fix the ACA. That is what is done to laws that need it to help people.

Sunday sermon-ettes, the sequel

Good Sunday morning all and enjoy the day. A few tidbits have been bouncing around in my head, so I will commit them to writing for your review and critique. The tidbits are light on religious tone.

Guns and butter: For some reason, in the US we spend more time discussing protecting the right to own a 34th assault weapon than feeding 34 people. We have far too many food deserts in our country where the closest food is a convenience store. Far too many in our country are undernourished. Yet, pick up any local paper on any day of the week, and you will find multiple gun killing stories. Better gun governance is essential, but it is a nonstarter with the NRA who is more interested in gun sales. I think our priorities are off.

Kicking poor people in the teeth: Along those same lines, our President is pushing the Republicans in the Senate to vote on whether to kick 22 million Americans in the teeth or 34 million, many of whom are in poverty or near poverty. It should be noted the President said he would not touch Medicaid. I guess that detail escapes him in his desire to have a photo op of him signing something.

Brexit is a hard pill to swallow: The word Brexit sounds like one of those new fangled drugs to cure something you did not know you should worry about. I think voters were not told the whole story and many are wishing they had a do over. As foretold, the financial companies who based their EU regional business in London, are making definitive plans to move. Bank of America just announced a move to Dublin, Citigroup is moving folks to Frankfurt and other places, and Japanese banks are doing likewise. While I  understand the desire to fully govern your future, the UK is harming its future growth. That is not just my opinion, but that of financial experts.

Shrinking to greatness is not a good strategy: Speaking of financial growth, limiting relationships with other countries is not conducive to growth. And, a venture capitalist noted that what creates jobs is customers. Plus, when we discuss global trade, we need to reflect the whole picture and that is the foreign owned companies who make things here with American workers. Why? Selling big durable products is more cost effective and less risky if they are not shipped from abroad. Just ask BMW, Toyota, Husqvarna, Michelin, Mercedes, Volvo, Mitsibishi, etc. about their plants here in the US.

The bible says many things: There is a minister who upsets a few applecarts by preaching that the bible should not be cherry-picked to support points of view. His obvious example is in Genesis where God tells Adam and Eve to go forth and multiply and then gets mad at them when they like being naked with each other. The question is how did they know how to go forth and multiply? The minister’s premise is we should take away the overarching messages that are taught therein and remember the context of when the bible was written.

So, on that note, go enjoy your day, whether you choose to practice your multiplication tables or not.