Year: 2017

Mar
9

ACA Deathwatch: Republicans should hope AHCA doesn’t pass

Posted by Joe Paduda on Thursday, March 9th, 2017 | Comments

I’ll stipulate to this – ACA needs major fixing. See below, and multiple past posts, for my take on what’s needed.  Unfortunately that doesn’t look likely.  The internecine warfare among Republicans over the American Health Care Act was inevitable, and will not be easily resolved.

That’s because there’s no consensus among Congressional Republicans on what healthcare reform should look like, who should pay for it, or what the priorities should be – access, coverage, cost control, less government intrusion, lower taxes, budget deficits are all in play, and many conflict. There’s also palpable and well-justified fear of the conservative infrastructure, a force including media outlets, think tanks, consultants, donors, and fringe groups that is extremely vocal, very powerful, and critical to the political future of individual Republicans.

Outside the reliably Republican world there is even more danger lurking.

What’s not being reported is this – If AHCA passes, the Republicans are in deep trouble.  10 – 15 million Americans will lose coverage (and loss aversion is powerful indeed).  Insurers will drop out of many markets overnight.  Hospitals, especially in rural America, will get crushed due to lower reimbursement and higher bad debt. Trump voters who believed him when he said he’s lower costs and improve insurance are going to be disappointed indeed. Deficits will go up.

Thus Republicans are in a can’t win situation; they have to deliver on impossible campaign promises, and if they do, voters will blame them for loss of coverage, higher prices, and anything and everything related to healthcare.

While Republicans battle amongst themselves, the medical provider community – AMA, AHA, American Nurses Association – just about every national interest group has come out firmly against AHCA. Insurance companies are warily walking the fence, not willing to provoke a tweetstorm but concerned indeed that AHCA will pass and their risk pools will crater. Seniors are up in arms, outraged that they’d have to pay more (!) for insurance if younger people don’t subsidize their needs.

There is a possible compromise bill, Cassidy Collins does offer some hope as it would likely garner support from both sides of the aisle if it gets any attention – and a lot of modification along the way.  But that is a very big “if”.

While all have different and specific issues, the net is this: AHCA will not lower the cost of care, and will increase the number of Americans without health insurance by at least 10 to 15 million people at the outset.

If AHCA passes, that number will inevitably increase as insurers’ risk pools experience worsens when fewer young people enroll, driving up costs for older folks. The death spiral in the individual markets will accelerate until…something happens.

There’s no question ACA needs fixing.

  • An excellent start would be to re-fund the risk corridor program killed by Sen Rubio in 2015 when he was able to force thru defunding of risk adjustment in the budget agreement.
  • Adding a public option to markets with limited choice would provide an insurance backstop, much like residual markets in workers’ comp.
  • Increasing the penalties for failing to carry insurance is another wise step.
  • Replacing deductibles with co-insurance requirements would help ensure people could afford the care they need while making sure the high-utilizers think long and hard about their medical care.
  • Requiring all to take greater responsibility for personal behaviors that increase health risks should be front and center. Obesity, substance abuse, medication adherence and failure to utilize preventive medicine should all be addressed

The intractable problem is cost. AHCA focuses on insurance markets, subsidies, eligibility, and credits.  It does nothing to address what drives cost – the massive waste due to unnecessary care and inflated prices for drugs, services, devices.

What does this mean for you?

AHCA won’t pass, a fate Republicans should be forever grateful for.

 

Mar
8

WCRI – What’s happening with medical?

Posted by Joe Paduda on Wednesday, March 8th, 2017 | Comments

Hospitals are losing work comp share. You would think that’s good news as non-hospital care is much cheaper.  But that may well be wrong. 

The hospital info was the headline from Carol Telles’ kickoff presentation Friday morning at WCRI’s Annual Conference. Workers’ comp patients are using less inpatient hospital care AND care is moving from hospital facilities to ambulatory surgery centers.

This isn’t specific to work comp.  Care has been moving from inpatient to outpatient to non-hospital facilities for decades.  Way back in the eighties – when I started my career in what was then known as “cost containment” – the big effort was to reduce hospital length of stay and admission rates. Over the last thirty (gulp!) years we’ve seen massive shifts in the location of care, as procedures that once HAD to be done on an inpatient basis – think back surgery – moved to outpatient facilities.

The result – outpatient/ambulatory facility use for all payers grew dramatically over the last 30 years, while inpatient admissions actually decreased over that period. This despite the aging and fattening of America.

For work comp patients, this trend persisted across all states – but this did NOT result in lower cost. In fact while the decrease in inpatient admissions was in the low single digits, costs per admit increased on average 24%. This makes sense. As providers and payers have moved patients to outpatient locations, only the sickest and most risky patients have required inpatient treatment. Unlike ambulatory surgery centers, hospitals have a broad array of emergency and life support resources needed.

Not surprisingly, hospitals are pretty unhappy about this. They are losing healthy, easy, well-insured patients to doctor-owned facilities, but get to keep treating the risky, low-health-status Medicaid and uninsured patients. Over the years, hospitals’ patient population has gotten more expensive to care for and less likely to have good outcomes.

What this means for workers’ comp

To fight back, hospitals are getting much better at revenue maximization.

In English, that means they get as much revenue from vulnerable payers as possible to offset lower reimbursement for unprofitable patients. And you, work comp payer, are about as vulnerable as it gets.

While fee schedules in some states (Maryland for example) generally protect work comp payers, most states’ fee schedules ensure work comp is very lucrative indeed for hospitals.

And no, your PPO isn’t helping.

Work comp PPO discounts may look ok, but the actual cost of treatment has been ballooning in many states. Payers THINK they are doing fine when they see the “savings” below fee schedule, but many aren’t focused on the real problem – how much they are paying.

What can you do about this?

Direct care to providers that deliver the best value, defined as cost divided by quality.

 

 

Mar
7

ACA Deathwatch – (some) Republicans reveal their bill

Posted by Joe Paduda on Tuesday, March 7th, 2017 | Comments

Good morning all – it’s going to be a busy day in health reform land – so here’s the latest.

Republicans have released their long-secret healthcare plans; don’t get all excited as it’s going nowhere, mostly because Congressional Republicans aren’t all behind it.

This legislation will have to pass the House and Senate.  It will not pass the Senate as is, because four Republican Senators have publicly stated they will not vote for the bill due to concerns over Medicaid coverage.  Three other Republican Senators have expressed concern with the cost of the bill, and appear reluctant to vote in favor.

For the bill to pass, at least 7 Democrats would have to get behind it- which is highly unlikely.

Republicans will not ask CBO to score the bill – thus we don’t know what the impact on federal deficits would be.  There’s also no estimate of how many would gain or lose insurance.

And, Freedom Caucus members in the House are denigrating the bill as “Obamacare Lite”, demanding a “clean repeal” instead of a replacement.

So, this is mostly an academic exercise, but does provide a starting point for the GOP.  Here are the key points from the bills, with my quick take appended:

  • Eliminates subsidies, replacing them with age-based tax credits ranging from $2000 to $4000
    MCM – this does little to help lower-income Americans; the current subsidies haven’t been enough to drive participation, so these lower amounts won’t do much.  Also, these aren’t income-based, so it amounts to a giveaway to wealthier Americans who don’t need the subsidy. UPDATE – late change to the bill adds income levels that would change credits.
  • Eliminates premium-support and deductible/copay funding 
    MCM – these subsidies help poorer Americans pay for deductibles; eliminating them is a major concern of insurers, and several insurers have said they will immediately move to end coverage without the subsidies
  • Roll back Medicaid expansion, capping payments to states
    MCM – Anathema to many GOP Governors and several Senators from expansion states.
  • Delays the Cadillac Tax
    MCM – this would reduce tax receipts, leading to higher deficits
  • Ends most of tax provisions of ACA, reducing taxes to wealthiest Americans
    MCM – this will result in higher federal deficits, a key issue with at least three R Senators
  • Eliminates the individual mandate requirement and tax penalties for failure to maintain coverage
    MCM – this would likely reduce the number of young members who subsidize older and sicker people, leading to higher costs for older members.
  • Requires people to maintain coverage or be subject to a 30 percent penalty.
    MCM – Many would likely face this penalty as 24%+ of people 26-64 have a pre-existing condition, and those who lose employer-based coverage would have a tough time paying the entire premium themselves without a job
  • Ends all federal funds to Planned Parenthood
    This troubles some Republicans as PP provides a lot of healthcare to lower-income women.

The legislation is exposing splits among and between Republicans on ACA and health reform.  Republicans opposed ACA, but for diverse reasons; costs too high, mandate, tax provisions, Planned Parenthood.

But there is no unity around a solution.  It’s easy to rally opposition to a complex issue; many Democrats have been pointing out problems with ACA for years. It’s far harder to come up with a new solution because everyone has different priorities and ideologies.

What does this mean for you?

The ACA Deathwatch clock moved forward a bit – but not much…

Mar
6

Opioid use in work comp has dropped – and cannabis does reduce chronic pain

Posted by Joe Paduda on Monday, March 6th, 2017 | Comments

Several states have seen precipitous decreases in the amount of opioids dispensed per claim.  KY, NY, MD, and MI all saw reductions in excess of 35%.

In every one of the states WCRI studed, at least 30% of patients with opioid scripts also had a script for a central nervous system depressant.  That’s just remarkable; the risk of adverse consequences goes up dramatically when patients take both drugs.  The good news is the percentage of workers who were prescribed this combination declined in most states – but the average decrease was a few percent.  While there can and may well be good reasons for docs to prescribe these drugs for individual patients, the research indicates there are significant risks.

Some have said medical marijuana should be considered an alternative to opioids.  If that’s a valid claim, that’s wonderful news indeed – and not just for growers, marketers, and pizza purveyors.

Dean Hashimoto MD reviewed the National Academies of Science’ report on all literature and evidence concerning the medical use of marijuana. Summary is here.

There’s conclusive support for cannabis’ ability to reduce chronic pain in adults, BUT at great risk of motor vehicle accidents and the development of schizophrenia and other psychoses.  This is a big deal, as most patients using medical marijuana cite chronic pain as the reason for consumption. There’s a lot of evidence that medical marijuana is effective – evidence derived from well-controlled clinical trials.  But little is known about efficacy, dosage, frequency, administration routes, or side effects.

There was moderate support for better sleep outcomes but at the price of impairment of learning and memory and increased dependence on other substances eg tobacco and alcohol.

Interestingly, there isn’t enough data or research to associate non-medical cannabis use with occ injuries or accidents.

There’s more good news.

Two solid studies documented significant decreases in opioid overdose mortality rates and opioid addiction in states that allowed medical marijuana.

What does this mean for comp?

Well, 22 million Americans used cannabis in the last month. So it’s real, and it’s common. There’s no legal way to use the banking system to pay for medical marijuana, and there’s no guidance on dosage or other prescribing standards.

And there’s conflict between state regulations, case law, and federal law.

We live in interesting times indeed.

 

Mar
4

Calling out Coburn at WCRI

Posted by Joe Paduda on Saturday, March 4th, 2017 | Comments

Some WCRI attendees thought my public criticism of former Republican Sen. Tom Coburn (OK) was inappropriate (many did not).

Here’s why I called him out.

First, in talking about disability, Coburn asserted that SSDI – Social Security Disability Income – participation has exploded due to Democratic policies and politics. He said 25 million Americans are now covered by SSDI.  That is flat-out wrong.

I questioned him publicly about his figure, asking where he got it.  He immediately backtracked, saying it may be 22 or 25 million.  I responded that, according to a quick google search, the actual number was less than 15 million.

Coburn had blamed the opposition party for a huge growth in SSDI that NEVER HAPPENED.  He either made up the number of SSDI beneficiaries, was misled, or lied.

The real number, according to expert Yonatan Benshalom of Mathematica, is 9.8 million. Yonatan’s source is here. [Thanks Yonatan]

Why this matters

If Coburn’s false claim was allowed to stand, many in the audience may have left WCRI believing it.  As policymakers, regulators, and thought leaders in workers comp, they would then have perpetuated the myth.  That would lead to wrong decisions, lousy policy, and “solutions” for problems that don’t exist. For example, lawmakers may have sought legislation requiring an MSA-type allocation to indemnify SSDI for occupational disability from work comp insurers.

A more complex issue involves Coburn’s false assertion that the ACA was rammed thru “without any Republican input.” I noted that:

  • The ACA’s core design came from the conservative Heritage Foundation
  • The Gang of Six – half Dems, half Reps, met multiple times while ACA was being written – the Republicans were Enzi, Snowe, and Grassley, all of whom dropped out of the Gang under pressure from Republican Minority Leader McConnell.
  • As a results of those meetings and other dialogue, multiple components of ACA were added or changed in an effort to garner Republican support including:
    • removal of any public option
    • addition of the Cadillac Tax
    • reduction of the penalty for uninsurance
    • removal of funding requirement for abortion services
    • allowance for “religious” health insurance

Responding to my statements, Coburn said since he “was there”, he knew more about this than I did.  He said was part of the Gang of Six – which he wasn’t.  He WAS involved in a previous version of the “Gang” that dealt with tax reform –– but he was not involved in the Gang’s healthcare discussions. [I was peripherally involved via discussions with Congressional staffers and a meeting with Sen Ron Wyden (D OR) about reform]

There are many sources that refute Coburn’s false statements; here’s one.

For those interested in the real story, an excerpt:

[Senate Finance Committee] Chairman Max Baucus (D MT), in the spring of 2009, signaled his desire to find a bipartisan compromise, working especially closely with Grassley, his dear friend and Republican counterpart, who had been deeply involved in crafting the Republican alternative to Clintoncare. Baucus and Grassley convened an informal group of three Democrats and three Republicans on the committee, which became known as the “Gang of Six.” They covered the parties’ ideological bases; the other GOPers were conservative Mike Enzi of Wyoming and moderate Olympia Snowe of Maine, and the Democrats were liberal Jeff Bingaman of New Mexico and moderate Kent Conrad of North Dakota.

Baucus very deliberately started the talks with a template that was the core of the 1993-4 Republican [health reform] plan, built around an individual mandate and exchanges with private insurers—much to the chagrin of many Democrats and liberals who wanted, if not a single-payer system, at least one with a public insurance option. Through the summer, the Gang of Six engaged in detailed discussions and negotiations to turn a template into a plan. But as the summer wore along, it became clear that something had changed; both Grassley and Enzi began to signal that participation in the talks—and their demands for changes in the evolving plan—would not translate into a bipartisan agreement.What became clear before September, when the talks fell apart, is that Senate Republican Leader Mitch McConnell had warned both Grassley and Enzi that their futures in the Senate would be much dimmer if they moved toward a deal with the Democrats that would produce legislation to be signed by Barack Obama. They both listened to their leader. An early embrace by both of the framework turned to shrill anti-reform rhetoric by Grassley—talking, for example, about death panels that would kill grandma—and statements by Enzi that he was not going to sign on to a deal.

The false narrative that Democrats rammed thru ACA without any Republican involvement has become accepted fact by many who haven’t read anything but headlines. Coburn’s false statements perpetuated that nonsense, and he deserved to be called out publicly for them.

There’s a bigger problem here – ideological blinders worn by some make it seemingly impossible for those individuals to accept facts. Fact-free discussions, or, even worse, decisions based on beliefs that are the opposite of reality lead to bad public policy.

What does this mean for you?

The people who attend WCRI are enormously influential in our little industry.   They will determine the future of workers’ comp, how employees are treated and who will pay for that treatment.

They deserve to hear the truth.

PS – to the several anonymous commenters – as I’ve stated here numerous times, I don’t publish anonymous comments from cowards afraid to identify themselves.

Mar
3

WCRI – Does the “Grand Bargain” exist? Should it continue to?

Posted by Joe Paduda on Friday, March 3rd, 2017 | Comments

WCRI CEO John Ruser PhD led the final panel discussing the status and future of workers’ comp as the Grand Bargain between employees and employers.

Bruce Wood and Emily Spieler PhD sparred over who pays for workers’ comp and tort issues in workers’ comp, specifically negligence and the burden of proof.  Spieler suggested we need to consider costs, how those costs are distributed, and who pays those costs.

David Deitz MD PhD jumped into causation, noting this was a “particularly thorny issue in the 21st century.”  Home-based employment, diseases of life, and other factors make it very difficult indeed to establish who is “responsible” for 50% of the cause of an injury.  The issue – people need care, and we should be talking about how to get them the best care and not argue about who pays.

Editorial note – That, dear reader, is a critically underappreciated point.  We are fighting over who pays, and we should be focusing on optimal care.

David Michaels PhD discussed the challenges of occupational disease – attribution/causation, long-term loss of wages and compensation therefore, cost shifting to SSDI, and harm caused to undocumented workers. Bruce Wood asserted that the undocumented worker issue was not work comp related, but rather a failure to enforce immigration laws.

Spieler asserted that she doesn’t think WC was ever set up to pay for long-term wage loss, or permanent and total (PTD) disability.  She noted research indicated 20% – 40% of workers who suffered amputations didn’t file work comp claims – even if it was clear it the injury was work related.

Ruser asked Deitz about the level and quality of medical care given to work com patients. Uniformly, it isn’t as good as that delivered under group health. But, he argued that work comp is diverging away from where group health is headed, towards value-based care.  That divergence is highly problematic.  FFS – the ONLY reimbursement system existing in workers comp – rewards doing more to get paid more regardless of quality. That’s inherently in conflict with a drive towards quality which is happening in the real world outside work comp.

Deitz would roll work comp medical into group health if he was convinced anyone injured in the workplace could access care.  As not all employees have coverage, that world does not yet exist.

Michaels argued that we’ve really dropped the ball on injury prevention, especially when compared to Germany where there remains a strong focus on prevention.  I hear that, but given the steady decrease in claim frequency over the past three decades, I’m not sure there’s an economic argument to be made around that level of prevention. Tied to Michaels’ argument is an OSHA prevention program that links safety to profits and financial results.

In contrast Wood opined that most employers invest in safety and loss prevention, leading to a to-and-fro between Wood and Michaels on involving public health officials to intervene with employers who don’t adequately address loss prevention.

My takeaway – a bit too much in the weeds, and not enough discussion of where work comp is going given the dramatic changes occurring in our workforce today and tomorrow. I’d have liked to see a bit more on historical perspective; work comp laws and systems were set up 100 years ago when most work was heavy manual labor leading to trauma.  Today, it’s diseases of life, of aging, of comorbidities and cumulative trauma, which are inadequately addressed at best.

Thanks to IAIABC’s Jennifer Wolf-Horejsh for asking about the 50+ million workers who are in non-traditional employment arrangements (my words not her’s).  Spieler asked if we need a national non-employment linked disability program to help address this issue going forward.

Kudos to Spieler for noting that wage replacement adequacy is a major problem; Indiana just raised their very-low indemnity payment basis and few in the audience supported that increase in a show of hands.

Jim Hudak of Paradigm addressed this in a very good question summarizing how employment has changed drastically from days of pensions, good health benefits, and life-long careers with the same employer.  Work comp has NOT adapted, as the social safety net has deteriorated. and employment-based benefit system has all but disappeared

Mar
3

WCRI – will value based care come to workers’ comp?

Posted by Joe Paduda on Friday, March 3rd, 2017 | Comments

Value-based care is growing rapidly in the real world outside workers’ comp.  An excellent session asked if VBC will come to work comp.

Work comp care management today is really fee and utilization management using discounted networks and external vendors.

VBC involves bundled payments and is focused on the patient’s experience and results. Simply put, Value = Quality divided by Cost. That requires evidence based medicine, clinical practice guidelines, measuring outcomes, and monitoring and ensuring use of all these tools.

While VBC is complicated to implement in the real world outside work comp, the additional complexities inherent in work comp make it even more complex.  Dr Page noted there are few active VBC initiatives in workers’ comp.  While several states appear to support pilots, they are few, far between, and there doesn’t seem to be any results available just yet.

Dr Page sees objective measurement of outcomes – from the patient’s perspective – as key to the adoption of VBC in work comp.  She identified a sustained return to work as the desired end point.  While that’s true, as we learned yesterday – and undoubtedly you were well aware of this – there are any number of factors driving RTW that have nothing to do with medical care.  Employee-employer relations, psycho-social issues, the availability of employment are just three.  That being the case, I’m a little skeptical about the utility of RTW as the outcome point.

Other barriers to implementing VBC are

  • the need for accurate, consistent, and comprehensive data;
  • comfort and trust between the parties (alert!),
  • and the inherent complexity of designing payment formulae that consider outliers, risk adjustment, comorbidities, and specific state laws favoring or limiting opportunities to direct patients to use and stay with specific providers.

So, while VBC has a lot of promise, my sense is we aren’t going to see any widespread use for a very long time.

Dr David Deitz noted that one challenge is the lack of ability for or interest among orthopedic surgeons in sharing risk around RTW may be a significant obstacle to surgical bundles.

What does this mean for you?

VBC is an idea whose time has come in the real world, and likely won’t ever come in workers’ comp.

Mar
3

WCRI – Attorney involvement; data says…

Posted by Joe Paduda on Friday, March 3rd, 2017 | Comments

A really interesting (nerd alert!) presentation from the ever-informative Dr Rebecca Yang dug into factors associated with attorney involvement in work comp claims.

Dr Yang contrasted states with very low vs very high attorney involvement.

NJ and IL both had attorneys involved in almost half of LT claims with defense attorney payments over $500. However costs were relatively low considering the high involvement rate…

Multiple factors are involved in determining a permanent partial award in IL, and before 2011 there were no published standards for determining awards. That lack of standardization and potential for additional payments for PPD vs TTD benefits in IL may well have motivated patients to seek attorney assistance.

NJ also had higher attorney involvement.  To get a permanency rating, patients have to attend two hearings, and there are often dueling medical experts disputing each others’ findings. For experienced attorneys, these hearings can go quickly as benefits are resolved by negotiation and agreement.  Thus, there is more attorney involvement, but lower per-claim costs for attorneys.

In contrast, Texas and Wisconsin had the lowest incidence of attorney involvement, at 14% and 13% respectively.

In TX, maximum attorney fees were set by regulation and just increased in January of this year.  WI’s standards, fee structures, and processes are efficient an relatively easy to navigate for the layperson.

 

Mar
2

WCRI – worker outcomes – it’s blindingly obvious

Posted by Joe Paduda on Thursday, March 2nd, 2017 | Comments

Now on to the real stuff – deep research into issues of interest only to we real work comp geeks.

Dr Bogdan Savych started off this brief and information-stuffed session.

Across 15 states, 14 percent of workers with lost time injuries didn’t have a substantial and persistent return to work (this is PRELIMINARY and subject to change) – why?  what drives this?

Among the biggest drivers – workers who strongly agreed that they were afraid of being fired or laid off had “worse outcomes.”  As over a quarter of workers fell into that category, that’s a big issue. There are both literal interpretations of this – perhaps the worker was justified in fearing a layoff and broad interpretations of this – perhaps the work environment was low trust.  These workers were also more likely to hire an attorney.

Takeaway – the employee’s work environment, and interpretation of that environment, is a major driver of “permanent disability.”  So, think less about medical issues, and much more about these “other” drivers.

Glenn Pransky of Liberty Mutual was next up.  Dr Pransky is one of the industry’s leading researchers on disability issues (kudos to Liberty for continuing to support the Center for Disability Research and similar efforts.

Glenn noted that one driver was the patient’s communications with the payer.  Workers were sometimes thrown off by negative language used by the claims adjuster in the initial encounter or call.  If they feel their needs aren’t being taken into account or they are being treated unfairly they are more likely

The top return to work coordination skill – communications. That’s the result of research conducted in Canada about a decade ago, research that is very likely true today. In fact, Glenn and others conducted a study a few years back that evaluated the impact of improving the initial contact with the case manager, focusing the patient on problem solving and not using words like “claimant, investigation, liability, etc.

What’s interesting here is this is – in large part – old news, yet we still need to hear this.

More importantly, to paraphrase the previous White House, we need to STOP doing stupid stuff.

Clearly we KNOW this language, the style of communication, the employee’s workplace satisfaction are critically important to disability. Yet far too often we still talk to patients not as people but as “claimants”, and treat patients as legal claims, not as people.

Takeaway – treat patients as you would want to be treated.

Mar
2

WCRI – Congressional perspectives

Posted by Joe Paduda on Thursday, March 2nd, 2017 | Comments

Boston’s always beautiful in March – some days are even more beautiful than others. No better place for the annual gathering of the work comp geeks – myself included aka the WCRI Annual Issues & Research Conference.

The kickoff session featured two former denizens of Capitol Hill opining on the impact of the election on healthcare, labor, and work comp. Former Rep Henry Waxman (D CA) and former Sen Tom Coburn (R OK) took to the podium for a moderated discussion and audience Q&A.

WCRI CEO John Ruser started off asking about the Executive Orders issued by President Trump, specifically the drop 2 regulations for every one adopted. Waxman spoke briefly about the complexities, but focused on the lack of consensus among Republicans on healthcare reform and noted that, due to this lack of consensus, they are looking to the President for leadership.  But the President is not providing leadership on healthcare, so we’ve got a hot potato situation.

Coburn attributed problems to a lazy Congress passing large numbers of bills written by departmental Secretaries; elected officials aren’t developing the legislation but rather using language handed to them. He also believes Congress has abdicated and/or lost much of its rightful place as an equal player among the three branches of government.

ACA

Ruser led off with a hypothetical question about what parts of ACA should be kept if the law is repealed and replaced.  This was the wrong question, as it deals with a – in my view – highly unlikely hypothetical. Instead, the question should have been “what’s going to happen with ACA? Will it be repealed? What will pass if anything?”

Waxman doesn’t believe ACA will be repealed.  In contrast, Coburn thinks that all we have to do is publish prices for health services and outcomes and people will go to those providers with the best prices and outcomes.  I don’t know what planet he lives on, but parents with sick kids, individuals with mental health issues, or children of ailing and incompetent parents are never going to be able to make appropriate “Market based” decisions.  Oh, and insurers are never going to insure people with pre-existing conditions – and they’ll look to cancel policies for those who have the temerity to get sick.

This isn’t an economic decision folks, it’s your daughter or son.

Coburn promoted a bill that is under consideration – Burr Hatch Upton.  He believes this bill will be similar to what comes out of Congress.  Details on this here.

He also said there was no attempt by Democrats to involve the GOP in ACA – a statement that is patently false.

Cost shifting

Waxman responded to Ruser’s question about the potential for healthcare changes on case or cost shifting to work comp.  He talked about Medicaid changes that may well reduce enrollment in Medicaid – didn’t speak to workers comp.  Not surprising as he isn’t a work comp guy.

Coburn is a practicing physician, he discussed unfunded liabilities, asserting $105 trillion in future unfunded liability for medicare medicaid etc, noting that we are hurting Millennials as they will have to pay for this.  This is somewhat interesting as he voted against requiring the feds to negotiate pricing for drugs for Medicare.

Unfortunately these two gentlemen weren’t really equipped to address the question – no fault of their own as this is an esoteric topic.

Federal oversight of work comp

Waxman doesn’t see the new Administration moving to increase federal oversight of workers comp, as there’s been no indication from the nominee or administration about this.  that and there are too many other issues re far more important.  Coburn agreed with Waxman and cited lack of Constitutional support for federal involvement in workers comp.

Coburn discussed the expansion of the definition of disability under SSDI, and the subsequent increase in beneficiaries.  He sees SSDI as a social safety net.  All the data supports his case that SSDI enrollment has increased and there are now 25 million Americans are on ssdi – a number that isn’t right.  The actual figure is 4.8% of the population – or 15 million people.

An audience member asked if the Grand Bargain is being dismantled.  Coburn noted that there’s no requirement that SSDI factor in the cause of the disability; SSDI is responsible for disability regardless of the cause.  He said the real question is should work comp cover the entire cost of the disability?  

That’s an excellent question – I believe the answer has been, and still is, yes.