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

KISS – Keep it Simple Stupid

We should remember this acronym, KISS. It stands for Keep it Simple Stupid. Donald Trump certainly does. There is a reason why he speaks in a bumper sticker fashion. He does not know or care to know details. He just needs a prop, a message or a hook. Then, he repeats it over and over, sometimes a half-a-dozen times in one a short speech.

Whether people think Mike Bloomberg or Tom Steyer are the best candidates for the Democrat nomination, note how simple they are keeping their messages in TV commercials. They focus on how weary we all are of the current president. But, the ideas are straightforward:

– we must act on climate change (both)
– we must improve health care access (Bloomberg)
– we must help more people prosper under the economy (both)
– we must have better gun governance (Bloomberg)
– we must have term limits (Steyer)

Steyer has added another key element which I like, people are treating each other better than the folks in Washington treat each other. That has resonated with me and someone I know who voted for Trump because he disliked Hillary Clinton.

I am not saying these are the best candidates. But, I am saying they are worthy of people’s consideration. I encourage all Democrat candidates to boil their messages into simpler themes. And, stop the circular firing squad. A good idea should not matter from whence it came.

Those imperfect candidates

The search for nirvana, whether it is the perfect partner, job, setting, workout, dinner, vacation, etc. is an endless search. There is no such thing. The same goes for presidential candidates, regardless of party, country, state, locality, etc. And sadly, the better candidates get tainted once they have been elected as they make compromises and decisions which you may not like. Or, maybe when looked back on with a different context, those decisions look foolish.

I have been watching the circular firing squad of the Democratic party candidates for several months. I see more fanatical followers of candidates use a scorched earth mindset to destroy the candidates that are not their favorite. I witnessed this in 2016, when some Bernie Sanders were so adamantly against an imperfect Hillary Clinton, they could not bring themselves to vote for her. The current US president used this ammunition to create even more distaste and get those voters to stay home, vote for Gary Johnson or Jill Stein or even vote for him as a change agent. It worked as he needed less than 100,000 voters spread among three states to win.

Every Democratic candidate has good selling points. And, every Democrat candidate has faults. I will not belabor either one of these lists, as my purpose is not to analyze the veracity of one or the other here. I will save that for a future post, when the slate gets more manageable. I will add every Democrat candidate has a better moral and ethical compass than that of the incumbent president. Conservative writer David Brooks noted that Trump does not seem to be able to show empathy. Almost every situation is exploited to elevate himself. Yet, in so doing, he reveals a very shallow and egomaniacal person. At times he reveals his corrupt nature.

Yes, I want the next president to focus on climate change, healthcare, career training for new and emerging jobs, better gun governance, etc. Yes, I would like them to deal with the debt and deficit. Yes, I would like them to restore America’s reputation as a trusted, fair and reasonable global partner. But, I would like my president to represent our better angels, not our worst demons. The current one does not. Issues are used to divide, not galvanize. I want a president to shine a spotlight on poor behavior, not condone it or discount it.

So, as people look for perfect candidates, remember this biblical example. We had only one perfect person walk the earth – and we killed him. Let’s not kill the Democrat candidate in search for nirvana.

A few climate change tidbits

There was good news, bad news and ludicrous news that occurred this week. Here is a Friday rundown.

On the good news front, The Charlotte Observer did an excellent editorial called “Federal disaster relief: Tossing cash in the ocean in NC.” The gist is the US Army Corps of Engineers is spending “$237 million to rebuild dunes and widen the beach on 10 miles of Topsail Island shoreline.” The sad part is the rebuild is occurring only a year after an earlier rebuild. Per Orrin Pilkey a Duke emeritus professor of geology and an expert on coastal erosion, “‘These projects can only be characterized as madness. The sea-level rise is clearly accelerating, increasing intense storms are expected as has happened in the last four years, and the amounts of money spent on these beaches will need to be expended again and again for years into the future.'” Per the Observer, “piling cash into the sand won’t stop that for long.” Ten years ago, the largest global pension trustees did a study that noted the cost of addressing climate change was in the multiple tens of trillions of US dollars.

On the ludicrous front, US Secretary of the Treasury Steve Mnuchin decided to follow his boss’ lead and pick on Greta Thunberg. In essence, Mnuchin said she needs to go back and get an economic degree and then explain why we should fight climate change. OK, Mr. Mnuchin, please tell me how spending cash to rebuild sand dunes over and over again makes financial sense? Help explain why the present value cost of renewable energy such as wind and solar, which includes the cost of acquisition, transportation, environmental degradation, production, maintenance of byproduct, and litigation is far cheaper than the present value cost of coal energy? And, while your at it, why did a Mayor, with an accounting background, in a Texas town choose a 100% renewable energy proposal over a fossil fuel one due to cost and guaranteed pricing for twenty-five years? What this shows to me is grown people are trying to denigrate a young girl as if they do, then climate change is not an issue.

On the bad news front, the courts threw out the climate change inaction case against the US by twenty-one children and now young adults. The case had merit and moved up to a district courts where it was dismissed by a 2 to 1 vote. The courts did agree with the plea to do more about climate change, but did not feel the case warranted further action. It has spawned other cases in other cities and helped fuel an advocacy to do something about climate change. What the plaintiffs will do next is uncertain at this point. It should be noted the suit against Exxon Mobil by three states is still pending. Using Exxon’s own data, the lead state New York Attorney General, is arguing that Exxon Mobil misled its shareholders and possible investors on the impact of climate change on its financials. That is securities fraud under the guise of the SEC.

The takeaways from the above are clear in my mind. Dealing with climate change is a “pay me now or pay me later” proposition. A key is we cannot put the climate back together again if we wait too long to act more aggressively. I have quoted Pilkey before, but one message bears repeating. People would be foolish to buy property on the shore and should think about selling what they have now. That cuts to the chase.

The other takeaway is the young people get it. The older people in positions of power either don’t get it or cannot say that they do, as they take so much funding from the fossil fuel industry. Coal is in the demise and more coal plants have been closed under this president than under his predecessors. That would be a good question for Messers. Mnuchin and Trump that Ms. Thunberg might want to ask. She might also want to ask why the Trump Organization petitioned, in writing, the Irish government to build a sea wall at a Trump golf course to hold back the rising ocean due to climate change. It does not take an economist to call BS on that one.

Bad habits

Aristotle said we are creatures of habit. Implicit therein is the habits can be good or bad. Charles Duhigg wrote an excellent book called “The Power of Habit,” where he noted the way to stop a bad habit, is to identify the trigger and replace the bad habit with a better one.

Old habits. The bad ones can be as simple as too many fried foods or sweets to smoking regular or e-cigarettes to drinking more than one should. Or worse. The good ones could be regular meditation, prayer, yoga or exercise, reading or selective and portion controlling eating habits.

Or, the habits could be less concrete. Kindness, civility, and decency are enviable habits, just as rudeness, bullying, lying etc. are habits to avoid emulating.

I have shared before that I am an alcoholic. Yet, to avoid a future train wreck, I stopped drinking more than twelve years ago. The key was a day-by-day mantra I learned from another struggling alcoholic – “I am not going to drink today.” Another key is the substitution of other habits – fruits and fruit juices, selective sweets, hot tea, etc. – instead of a drink.

Another habit I had to lick was to get my weight in order. The stopping drinking helped, but I was carrying too much. Over about a five year period, I have been able to drop 45 pounds. The keys have been fewer white foods – those wonderful carb loaded potatoes, pasta, rice and bread. The other key is portion control whether it is a meal or snack. On snacks, serve a small bowl and leave the bag in the pantry. On meals, serve smaller portions and avoid the temptation to go back.

Plus, I added a daily exercise routine of about fifteen minutes after I shower. This is supplemented with walks and hikes a couple of times a week.

Good habits. Make sure they are sustainable. That had been a dieting and exercise challenge before and my weight yo-yoed. Best wishes on finding better habits should you need to go down that path.

Dark Waters is a must see

On Friday, I went to see the movie “Dark Waters” about a long uphill battle some West Virginia families had against Dupont. Mark Ruffalo stars and co-produces the film, playing the attorney, Rob Bilott, who fought so long and hard as a favor to his grandmother. The movie also stars Anne Hathaway as his wife, Tim Robbins as his managing partner and Bill Pullman and is directed by Todd Haynes. Some of the families impacted by Dupont and involved in the court cases show up in cameos throughout the movie.

The movie is a must see. Your emotions will flow with Bilott’s throughout the movie. You will be inspired by his courage and tenacity and that of the first client a farmer named Wilbur Tennant, ably played by Bill Camp. You will also be saddened by how a company could cover-up for decades they were harming their employees, community and the buying public. Yes, we too, are also impacted by this story. Not to spoil the plot any further, but the word “Teflon” plays a key role.

Like “Erin Brockovich” before it, these movies should not have to be made. Companies need to do the right thing. Yet, when government agencies ask the companies and industry to police themselves, short cuts are made and information is hidden. Think Boeing for a recent example. Dupont is not very happy this movie was made. They should not be as it paints them many times over in a very poor light. They had many opportunities to do the right thing, but did not until their hand was forced. Even then, it had to be reinforced.

I will stop short here. Please go see it. Make sure the kids see it, as well. This is why our voices matter.

Former Arkansas surgeon general brags on Medicaid expansion

I have written often about the Affordable Care Act not being fully implemented since 15 states have not expanded Medicaid. Rather than repeat my arguments, let me reference the attached editorial written by Dr. Joe Thompson, the former Surgeon General of Arkansas, which I read in Friday’s The Charlotte Observer. The reason for their interest is North Carolina has a Democrat governor working with a Republican majority General Assembly and the issue of Medicaid expansion is of importance. The editorial is entitled “Medicaid expansion works in deep red Arkansas. It would work in North Carolina too.”

“My home state of Arkansas is unusual among Southern states in having adopted Medicaid expansion early and in our own fashion.

I was Arkansas’ surgeon general in 2013 when the state first faced the question of whether to expand Medicaid. Like North Carolina now, Arkansas then had a Democratic governor and a Republican-controlled legislature. Fortunately, we avoided an impasse; lawmakers on both sides of the aisle came together to approve an innovative alternative to traditional Medicaid expansion that provides private health insurance coverage to about 250,000 people earning up to 138% of the federal poverty level.

The effect on Arkansas’ uninsured rate was swift and dramatic. A 2015 Gallup report showed that since Arkansas’ Medicaid expansion program took effect in January 2014, the state’s uninsured rate had been cut roughly in half, dropping from 22.5% to 11.4% ― the biggest reduction in the nation.

According to the U.S. Census Bureau, Arkansas’ uninsured rate was 8.2% in 2018. North Carolina’s was 10.7%, the ninth-highest rate in the nation. Arkansas’ reduced uninsured rate led to a 55% reduction in uncompensated-care losses at hospitals. This has been especially important for rural hospitals, which treat many low-income patients.

Since January 2010, only one rural Arkansas hospital has closed for financial reasons. In the five neighboring states that have not expanded Medicaid, more than 50 rural hospitals have closed, according to the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill.

Expanding Medicaid also has helped stabilize Arkansas’ health insurance market, improve competition and control premiums. Since 2014, at least three insurers have offered plans through the Health Insurance Marketplace in each county in the state. The competition encourages low rates: In 2014, 38 states had marketplace premiums lower than Arkansas’; today, only six states have lower premiums.Medicaid expansion has brought billions of new federal dollars into Arkansas’ economy: $1.7 billion between January 2014 and June 2015 alone, according to the Kaiser Family Foundation. Arkansas also is saving money because some individuals previously covered under traditional Medicaid, which in Arkansas is 30% state and 70% federally funded, are now covered under Medicaid expansion.

The federal government currently is paying 93% of Medicaid expansion costs and will pay 90% in 2020 and thereafter. A consultant told a legislative task force in 2016 that Medicaid expansion would save Arkansas $757 million between 2017 and 2021.Thirty-six states have now decided to accept Medicaid expansion.

Arkansas has become a firmly red state, but it has reauthorized its Medicaid expansion program with a supermajority vote every year because of the demonstrated benefits to the working poor, the economy and the health care infrastructure. Last year, Arkansas added a work and community engagement requirement that currently is blocked by a federal judge’s order, but however that issue ultimately is resolved, it is clear that Medicaid expansion has had tangible, positive results. There’s a reason the number of states rejecting it continues to shrink each year.

Joe Thompson, MD, MPH, is president and CEO of the Arkansas Center for Health Improvement. He was Arkansas’ surgeon general under Republican Gov. Mike Huckabee and Democratic Gov. Mike Beebe.”

In spite of efforts to naysay it, hobble it and kill it, the Affordable Care Act is stabilizing some. It needs more stability and Medicaid expansion would help in the remaining 15 states. I have also advocated the US government paying back the money they withheld from insurers causing some to leave the market, inviting those companies back to the market. I have also advocated the reduction of the Medicare eligibility age from 65 to age 62 or even 60. And, where options don’t exist, Medicare could be offered as an option for younger adults.

What frustrates this retired benefits manager, consultant and actuary is the fact people getting harmed by decisions to harm the ACA is not a major factor. There is too much focus on winning an argument that people getting screwed does not seem to matter. Please help make it matter. Even as we speak, the eating away at the edges of the ACA could lead the Supreme Court to rule it unconstitutional. If this occurs it would be a damn shame.