Category Archives: Congress

Rural Hospitals to Fail If Medicaid Expansion Ends

In April of 2015, I wrote the following post, Hospital Closures Due to Failure to Expand Medicaid.

This morning, Health Affairs posted a brief, Ending Medicaid Expansion Would Cause Rural Hospitals to Go Under.

As the current regime in Washington, and its allies in Congress slowly dismantle the ACA, rolling back Medicaid expansion will lead to rural hospitals closing, and rural patients being forced to travel long distances to get to a hospital, or to forgo medical at all.

What impact this will have on the entire health care sector is too early to tell, and what this may mean for workers’ comp, is also speculative, but it can’t be good if hospitals in the heartland go out of business.

Some way to make America great again. On the backs of, and on the health of, rural Americans who voted for this clown.

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GOP Tax Reform: Say Goodbye to the Middle Class

As a student of American Social history, I am acutely aware that for much of the 241 years of the Republic, the majority of the American people were not what we today would call “Middle Class.”

In fact, they were cash poor, dirt farmers, tradesmen, owning very little except what they could carry on a horse, mule, or in a wagon as they migrated west in search of better opportunities.

Until the New Deal, the Middle Class as we know it did not exist in such great numbers. True, there was a middle class in the cities and towns of the East Coast and Midwest, but most of them were descendants of immigrants from the 17th and 18th centuries, and rose steadily into the middle class as the nation’s economy shifted from a mercantile to an industrial economy in the first half of the 19th century.

Consider the following quotes from three US presidents regarding the power of money and corporations. You will notice that none of them are wild-eyed radicals in the least.

“I hope we shall crush in its birth the aristocracy of our monied corporations which dare already to challenge our government to a trial by strength, and bid defiance to the laws of our country.”

Thomas Jefferson

“Mischief springs from the power which the moneyed interest derives from a paper currency which they are able to control, from the multitude of corporations with exclusive privileges… which are employed altogether for their benefit.”

Andrew Jackson

“I see in the near future a crisis approaching that unnerves me and causes me to tremble for the safety of my country. Corporations have been enthroned, an era of corruption in high places will follow, and the money-power of the country will endeavor to prolong it’s reign by working upon the prejudices of the people until the wealth is aggregated in a few hands and the Republic is destroyed.”

Abraham Lincoln

So it is no surprise that the Republican Party is ramming down the throats of the American middle class, a tax reform bill that will effectively wipe out the remaining members of the middle class, and redistribute the wealth to those making over $75,000 and those at the very top, the oft-mentioned 1%.

My fellow blogger, and unsuccessful Democratic candidate for County Legislator in upstate New York, Joe Paduda, wrote a very potent analysis of the GOP tax scam legislation. Yes, I did call it a scam, but that is not my word. Others have used it in the past few days in an effort to derail and stop it from passing.

Besides destroying the middle class, it will as Joe points out, bankrupt the health care system. Then we will have to go all the way to a single-payer system just to get the whole thing working again.

Here is Joe’s piece in its entirety:

The tax bill’s impact on healthcare or; If you like your cancer care, you can’t keep it.

        

The GOP “tax reform” bill will directly and significantly affect healthcare. Here’s how.

It removes the individual mandate, but still requires insurers to cover anyone who applies for insurance. So, millions will drop coverage knowing they can sign up if they get sick.

How does that make any sense?

Here’s the high-level impact of the “tax bill that is really a healthcare bill”:

The net – healthcare providers are going to get hammered, and they’re going to look to insured patients to cover their costs.

The real net – The folks most hurt by this are those in deep-red areas where there is little choice in healthcare plans, lots of struggling rural hospitals, and no other safety net.  Alaskans, Nebraskans, Iowans, Wyoming residents are among those who are going to lose access to healthcare – and lose health care providers.

Here are the details.

According to the Commonwealth Fund, “repeal would save the federal government $338 billion between 2018 and 2027, resulting from lower federal costs for premium tax credits and Medicaid. By 2027, 13 million fewer people will have health insurance, either because they decide against buying coverage or can no longer afford it.”

Most of those who drop coverage will be healthier than average, forcing insurers in the individual market to raise prices to cover care for a sicker population. This is how “death spirals” start, an event we’ve seen dozens of times in state markets, and one that is inevitable without a mandate and subsidies.

For example, older Americans would see higher increases than younger folks. Here’s how much your premiums would increase if you are in the individual marketplace.

So, what’s the impact on you?

Those 13 million who drop insurance, which include older, poorer, sicker people, will need coverage – and they’ll get it from at most expensive and least effective place – your local ER. Which you will pay for in part due to cost-shifting.

ACA provided a huge increase in funding for emergency care services – folks who didn’t have coverage before were able to get insurance from Medicaid or private insurers, insurance that paid for their emergency care.

From The Hill:

[after ACA passage] there were 41 percent fewer uninsured drug overdoses, 25 percent fewer uninsured heart attacks, and over 32 percent fewer uninsured appendectomies in 2015 compared to 2013. The total percent reduction in inpatient uninsured hospitalizations across all conditions was 28 percent lower in 2015 than in 2013. Between 2013 and 2015, Arizona saw a 25 percent reduction in state uninsured hospitalizations, Nevada a 75 percent reduction, Tennessee a 17 percent drop, and West Virginia an 86 percent decline.

If the GOP “tax bill” passes, hospital and health system charges to insureds (yes, you work comp payer) are going to increase – and/or those hospitals and health systems will go bankrupt.

What does this mean?

It means we of the middle class had a very good run, but the ruling class has spoken, and they want us to disappear, or at least shrink to the point that we become unimportant to their pursuit of greater wealth. Why else would the donor class of the Republican Party, the Koch Brothers, the Mercer family, Sheldon Adelson, and the rest of their donors threaten members of Congress with no more funds for their re-election if they fail to pass this bill?

There is a word for that, it’s called Extortion. And we are the sacrificial lambs.

No Paradox

Sometimes, the solution to a problem is staring you right in the face, but you refuse to see it because you are blinded by your perceptions, your beliefs, or the distortions others have placed in your mind by lies and falsehoods spread about the real benefits of the solution, or the downsides.

Case in point, the question of single-payer health care in the US. The health insurance industry and their lobbyists and defenders in Congress have done a great job poisoning the minds of many Americans against the idea of single-payer, whether on ideological or economic grounds.

Yet, many of these same Americans are getting some form of government-sponsored health care, either Medicare, Medicaid, Tricare, or health care through the Veterans Administration. So, it was striking that before the enactment of the ACA, many Tea Party protesters shouted or carried signs that read, “Keep your hands off of MY Medicare!”

What they did not know or realize, was that it wasn’t THEIR Medicare, but the government’s Medicare. They were ones receiving the benefits.

So, it struck me this morning when I read an article by Tom Lynch of the Lynch Ryan blog, Workers’ Comp Insider.com.

The article, The American Health Care Paradox: A Lot Of Money For Poor Results, compares the US health care system with the health care systems of the OECD nations (Organization for Economic Cooperation and Development).

The OECD has 35 members, of which the US is one, and was formed in Paris in 1961. They promote policies that will improve the economic and social well-being of people around the world. It also performs annual comparative analyses of issues affecting its members.

Health care is one such issue, as is life expectancy, infant mortality, obesity, and death rates from cancer, among other health care-related topics.

But regarding health care, as Tom reports, on a per capita basis, we spend 41% more on health care than our wealthy nation peers in the OECD, and 81% more than the entire OECD average.

The following graph indicates amount of public versus private funding of health care among the OECD nations, as well as the OECD average. The light blue bars indicate private funding; the dark blue bars indicate public funding.

OECD Health Care Funding — 2015

According to Tom, while our public funding (Medicare, Medicaid, etc.) is comparable to many of the other countries in the OECD, private funding in the US is more than 100% greater tham Switzerland, and 300% greater than the OECD average.

Life expectancy:            US: 78.8 years (76.3 men, 81.2 women)
UK: 81 years (79.2 men; 82.8 women)
Japan: 83.9 years (80.8 men; 87.1 women)

Infant mortality:          US: 6.1% (per 1000 live births) 45% higher than UK at 4.2%, and 265%                                                higher than Japan’s at 2.3%.

Obesity and overweight rate is exceeded only by New Zealand. Finally, the rate of death from cancer per 100,000 people is 188, Mexico’s is 115, Japan’s is 177. But we lead the world in smoking cessation (whoopee!). So, I guess we can all breathe easier now than the rest of the world, especially the third world where so many start smoking at a very young age.

Into this discussion, Tom throws the current Republican tax plan, which he rightly says will throw 13 million people off of health care, and see $25 billion cut from Medicare.

Tom says that fixing health care will take time and a lot more money, and he is skeptical that the GOP tax scam will do that.

Duh! Of course it won’t. That’s the whole point of the tax scam and the umpteenth attempts to scuttle the ACA. They don’t believe in health care as a right for all Americans. It is in their DNA as Libertarian Conservatives. They are not Republicans, at least not like the two Republican presidents who tried to get health care passed, Theodore Roosevelt and Richard Nixon.

No, they want the money for their fat cat donors. They even said so publicly and bragged about it. And if all those votes to repeal and replace ACA didn’t convince you that they are fundamentally opposed to any government-sponsored health care, except their own, then you are blind.

The solution is staring you in the face on the above chart, Every other OECD member nation spends more publicly for health care than we do privately, and we are getting bad outcomes. Why is that? It is because health care is not like other consumer goods, and therefore should not be funded or marketed by private companies.

It is long past the time we should follow suit and do what every other OECD country has done, create a single-payer, improved Medicare for All system and stop fooling ourselves that the private market works. It does not, and the proof is in the metrics on cost, life expectancy, infant mortality, obesity and cancer deaths, etc.

Executive (Dis)order

The signing this morning of an executive order by the Orangutan will have, in the opinion of some of the bloggers and politicians, spell disaster for the nation’s health care system.

It will, if carried into action, likely siphon healthy people from the Affordable Care Act-compliant market, continuing a pattern of regulatory actions under the Trump administration that have undermined the ACA.

The rationale for such a move that has been given is that since Congress has not been able to repeal and replace the ACA, an executive order will, piece by piece.

Coupled with the recent budget move to eliminate the CHIP program for children’s health (New York State faces dire consequences if Congress does not act on CHIP), and cut backs to Medicare and Medicaid, the intent here is to privatize health care for some, and eliminate it for others, and to get government out of health care providing altogether.

There are provisions in this order for greater competition, short-term coverage, and lower premiums with less coverage. Why this is better is beyond me, unless the Orangutan is seeking to destroy health care so that single-payer will be the only option.

Cutting healthy people out of the ACA means leaving sick people to struggle with a health care law that many say needs to be fixed, not repealed and replaced. But because the Tea Party ranted and raved before it was enacted, and the Orangutan and the GOP campaigned on getting rid of it, they had no choice but to sabotage it if they could not do so through legislation.

I predict that we will soon see the total collapse of our health care system thanks to this stupid, overreaching, and ill-advised Executive Order. I even read today that the Vice President had to remind the Orangutan to sign the darn thing, something that almost slipped what is left of his so-called mind.

Welcome to Crackerbox Palace.

The End of the World Is Near (The Health Care World, That Is)

Fellow blogger, Joe Paduda, brilliantly summed up the current GOP attempt to blow up the nation’s health care system in today’s post.

Rather, than repeat and comment on what he wrote, I am letting you read the post here.

Then there is a great graphic on what the Cassidy-Graham bill will mean for states, and from a brief look at it, I can say that they are playing favorites with some, but not all of the states of the former Confederacy, and sticking it to those states in the North (and West like California) who they have disdain for.

Because of it’s dire impact on the health care system, it should actually be called the Butch Cassidy and the Sundance Kid bill, because like those two 19th century bandits, they are going to rob us blind. How do you say “We are taking back your health care” in Spanish?

But, in actuality, it is just another way of giving a tax break to the wealthy at the expense of everyone else.

If this bill passes, and the Orangutan signs it, the end of the world in health care would soon follow. The only option then would be single-payer, and it would be ironic and even cruel if that was the GOP’s game plan all along. Wreck the health care system so that single-payer is the only option left, and if that fails, they drop the whole thing and move on.

We shall see next week, as there are two Senators who may hold the future of health care in their hands, Collins of Maine and Murkowski of Alaska.

The “Curse” of For-Profit Health Care

Recently, Vermont Senator Bernie Sanders introduced a Medicare for All bill into the U.S. Senate, and many Democratic Senators signed on as co-sponsors of the bill.

Earlier yesterday morning, on his way to a photo-op in Naples, Florida to see the damage from Hurricane Irma (why didn’t he go to the Keys), the Orangeman tweeted that Senator Sanders’ bill would visit a curse on the U.S.

This from a man who said that he preferred the Canadian system, and told the Australian Prime Minister to his face, and the cameras, that they had a better health care system than the US.

What are we to make of someone who likes other countries health care systems as long as it is not our system? What do we do when the elected leaders of this country are dead set against providing the best health care system to their constituents, and in fact, are determined to take away what little health care they already have?

I find it rather odd, and callous that the Orangutan calls Sen. Sanders’ plan a curse, when millions of Americans are cursed everyday with not having any health care, or minimal care at best.

No, what is a curse are families going broke paying for medical care, individuals forgoing needed care because it costs too much, doctors and nurses burned out because they are overworked, underpaid (in some cases), and trying to work in a broken, bureaucratic, sclerotic, and byzantine system.

The American “health care” system is the curse. The cure, or rather the silver bullet for this vampiric monster, is single-payer. Maybe Sen. Sanders’ bill won’t pass this time, with this Congress and this President, but it or something like it should in the future.

Our curse as a nation is in our slavish devotion to making everything conform to the will and whim of the free market. We have seen that the free market is great for the production and selling of goods and services, but health care is not a consumer good. It is a right of every man, woman, and child.

The Canadians, the Australians, the British, and many other nations are not so slavishly devoted to the free market as we are when it comes to providing health care to all their citizens, and they cannot be called “Socialist” or “Communist” in any way, shape, or form.

Only because of the greed of a few insurance companies, Wall Street players and their investor clients, as well as very wealthy Libertarian brothers from the energy sector do we continue to be cursed with the worse system for providing health care.

Finally, the ultimate curse this nation has is the individual who said single-payer would be a curse. And like Dracula, only the light of day will stop him.

Follow-up to Insurers Jacking Up Premiums Ahead of End of CSR’s

Health Affairs blog posted the following stating that if the Administration terminates cost-sharing reduction payments (CSR’s), the states can use 1332 waivers to fund their own.

Here is the article in full by Steven Chen:

One of the main causes of instability in the Affordable Care Act (ACA) health exchanges, aside from the constant stream of repeal-and-replace efforts, is the uncertainty over the future of the cost-sharing reduction (CSR) payments. CSR and the advanced premium tax credits (APTC) are subsidies created by the ACA to enhance the affordability of the qualified health plans sold on the health exchanges. Whereas the APTC reduces the cost of premiums to beneficiaries with incomes between 100 and 400 percent of the federal poverty level, CSR lowers the out-of-pocket expenses of beneficiaries with incomes between 100 and 250 percent of the federal poverty level.

Unlike the APTC, whose legal status is not in question, the U.S. House of Representatives had challenged the appropriation status of the CSR payments by filing a lawsuit against the Obama administration, thereby creating doubts about CSR’s future. In addition to the said litigation, the current administration has compounded the uncertainty by often withholding the CSR payments until the 11th hour and threatening to terminate the payments completely.

This uncertainty comes at a cost. Some insurers have cited the uncertainty as one of the reasons for their exodus from the health exchanges while others have referenced the uncertainty as a source for their 2018 premium hikes. While the extent of the premium increase is yet to be determined, a study by the Kaiser Family Foundation estimated that without CSR payments, the insurers would need to raise silver plan premiums by about 19 percent.

Can States Step In?

What can States do if the administration follows through on its threat to terminate the CSR payments? A simple solution is for the States to provide the CSR payments themselves. In addition to making health insurance affordable, CSR payments are cost effective: The provision of CSR payments by the Federal government lowers the silver plan premiums offered on the health exchanges because the insurers are compensated for the reduced cost-sharing they are required to provide. Without the CSR payments, insurers will raise silver plan premiums—including the premiums for the benchmark silver plans—to offset their losses, which leads to higher APTC for all eligible beneficiaries, ultimately resulting in greater overall Federal expenditure. The aforementioned Kaiser Family Foundation study quantified this effect by demonstrating that if CSR payments were terminated in 2018, although the Federal government would save $10 billion from not making the CSR payments, it would have to pay an additional $12.3 billion in APTC, thus increasing overall Federal expenditure by $2.3 billion.

Creating a State-administered CSR mechanism will undoubtedly require expenditure from the State. While some will argue that the limited resources available in State budgets would render the idea all but theoretical, it would be beneficial to examine how States can use Section 1332 of the ACA to fund—and potentially profit from—providing CSR.

The California Example

The intricacies of a Section 1332 State Innovation Waiver (1332 Waiver) have been explained in depth elsewhere, but on a fundamental level, Section 1332 of the ACA permits a State to apply for a waiver to modify or waive certain provisions of the ACA, such as the individual mandate and the establishment of health exchanges, among others. The waiver application must satisfy four statutory constraints—comprehensiveness, affordability, scope of coverage, and will not increase the Federal deficit—but should an application meet all the criteria, the State is eligible to receive any APTC or CSR that the State would have otherwise received without the 1332 Waiver. In layman terms, if a State can create a system that meets the Federal standard at a cost that is the same or less than the existing Federal model, the State gets to keep the money the Federal government would have otherwise spent.

Using California as an example, Covered California showed that the termination of CSR payments by the Federal government would cause insurance premiums for silver plans in the individual market to increase by 16.6 percent in 2018. The study also showed an inverse relationship between CSR and APTC: The Federal government paid $750 million in CSR payments in 2016, but if it were to defund CSR payments, not only would it not receive any savings, it would incur an additional $976 million in APTC spending. Using these figures as illustration, if the Federal government had terminated CSR payments in 2016 and if California had provided CSR payments through a 1332 Waiver, under this scenario California would have to pay $750 million in CSR payments, but it would receive $976 million from the Federal government in lost APTC payments—payments California would have otherwise received without waiver—ending up with a total net profit of $226 million! California could use the profit to create a reinsurance program to bolster its health exchange, to increase payments to providers, or it could spend the excess on non-health related projects like fixing potholes and infrastructure because there is no restriction on the usage of the excess pass-through funding.

Even without a lengthy legal analysis, it is obvious this waiver satisfies all the statutory constraints: (1) since the waiver does not modify the Essential Health Benefits or any coverage requirements, it meets the comprehensiveness test; (2) since the waiver would lower premiums and out-of-pocket costs, it would actually improve affordability; (3) since the waiver would improve affordability, it is expected to increase scope of coverage; and finally (4) the numbers show that the waiver will not increase the Federal deficit. In fact, it should be intuitive why this proposal would meet the requirements of the ACA — it was built to be part of the ACA to begin with.

While the Administration isn’t obligated to approve any waiver applications, a 1332 Waiver application that creates a State-operated CSR payment mechanism—and uses the excess pass-through funding to finance a State reinsurance program—is conceptually consistent with the Administration’s emphasis on enhanced State flexibility and empowerment. The first executive order by the Administration, for example, promised to provide greater flexibility to the States under the ACA. Moreover, the Secretary of Health and Human Services recently sent a letter to State governors encouraging the application of 1332 Waivers and even provided a checklist to help expedite the process.

Given the cost-saving advantages of CSR payments, it is puzzling that the Federal government would consider terminating this effective subsidy. In addition to the money the Federal government would save, forcing States to spend the time and expense to develop and administer separate CSR operations also argue against ending Federal CSR payments. Indeed, even Republican members of Congress have begun to warm to the idea of continuing CSR payments. However, should the Federal government decide against it, States have a viable, and potentially profitable, means of administering CSR payments to stabilize their insurance markets.