Apr
8

“Sharing ministries” are NOT health insurance

To those who took my April 1 post on the Administration’s decision to use “sharing ministries” as the basis for their new health reform plan for fact – I’m kinda sorry. 

The April Fool’s post has been a tradition here; this year’s effort caught more folks than most of the previous ones. But after I stopped high-fiving myself, I realized that what was most disturbing was it’s kind of believable.

As in, the knuckleheads in the current Administration might actually think “sharing ministries” are the answer to our healthcare crisis.

Ha! you say; no one is that naive.  To that I say, well, hundreds (ok, maybe scores) of readers thought the post was real, mostly because we’ve been numbed by the endless stream of lies, twisted facts, made-up statistics, and idiotic policy proposals coming out of Washington.

So, yeah, ditching insurance for “sharing ministries” is about the worst “solution” one could come up with. I say this despite the 18 commenters who responded to the post, many happy with their decision to dump insurance and pay into some form of “sharing ministry”.

While I appreciate that people of faith may trust others who appear to share their same views, I’d strongly encourage anyone – especially the million of so Americans who already are enrolled in one of these plans – to reconsider their decision. Like, NOW.

 

Because while legal under the ACA, these plans are NOT insurance, can dry up and blow away at any time, are NOT regulated, are NOT legally required or obligated to pay any claim, and are NOT required to keep enough money on hand to actually pay claims. (graphics from Commonwealth Fund)

What does this mean for you?

The net is this – when you NEED health insurance, you REALLY need it. And there are NO guarantees these sharing ministries will be there.

 


Mar
29

Another reason Single Payer is inevitable

Earlier this week President Trump called for the GOP to become “the Party of Great Healthcare.”

He wants three Senators to come up with a “terrific, beautiful” healthcare plan.

What Trump is actually doing is accelerating the day when Single Payer becomes reality.

In one tweet, here’s why:

Stick with me here. The President doesn’t know the difference between tax policy (deductibility) and healthcare benefit design (deductibles). Unless, of course, he was referring to the deductibility of health insurance premiums, which many think is “ridiculously high”. Except, of course, Trump wasn’t.

Many may say, “yeah, that’s just a typo”, or “doesn’t matter, we know what he meant”.

And those many are dead wrong.

Trump  – and his gang of three who are supposed to come up with a new Great Healthcare Plan – don’t know anything about the healthcare problem in this country, what’s driving it, how financing works, how people are affected, what the tradeoffs are, or anything else.

Healthcare is enormously complicated, accounts for 1 of every 6 dollars in our economy, employs 16 million Americans, and is deeply personal. The GOP has never come up with any plan that remotely addresses the problem with healthcare, namely prices are too high, many can’t afford insurance and quality is spotty at best.

Their go-to solution – the free market – is no solution at all.

In the “free market”, no insurer is ever going to insure your pre-existing condition, nor will it ever  cover your kids to 26, nor will it pay for all your care no matter how sick you are or how expensive it gets. 

About 5 minutes after Trump’s gang of three starts working on their Great Healthcare Plan their heads will explode. They have no idea what they are doing and a real solution requires them to abandon long-held fictions about healthcare and the economy.

Which is why Trump’s Great Healthcare Plan will make Single Payer reality.

To quote Winston Churchill;

You can always count on Americans to do the right thing – after they’ve tried everything else.

(here’s a very funny infographic on TrumpCare)


Oct
12

Friday catch-up

Another crazy busy week is coming to a close, and its time to catch up on what I missed, didn’t get to, or just figured out.

I know what you’re doing this weekend…you’re going to be poring over NASI’s annual report on workers’ compensation which just hit the virtual newsstand – and you need to get a (free) copy. For those unfamiliar with the report, it is the only comprehensive, national report that provides detailed, state-by-state financials on medical and indemnity spend by type of payer. Along with a treasure trove of other great info.

The big news – total work comp medical paid in 2016 dropped (!) 0.3% from the previous year. Work comp spent just over $31 billion on medical in 2016.

What’s driving the decrease? I say a big contributor is reduced spending on pharmacy, which I’ve been tracking for 15 years.

Notable – WorkCompCentral’s William Rabb teased out one major issue – the worker-unfriendly government in Michigan’s efforts to cut benefits for workers resulted in a 15% drop in benefit payments. Ouch.

Kudos to Accident Fund’s United Heartland for talking about the good work they do helping patients recover. I’ve had the honor of working with folks at AF and United Heartland in the past – they are good people focused on doing the right thing.

Work comp bill review and case management company Genex’ acquisition of Priority Care Services will cause a bit of disruption in the specialty services sector. Sources indicate PCS will be the “home” of specialty services in the Genex/Mitchell operation, with everything but IME and Pharmacy consolidated under PCS.  More on this later, as there are repercussions…

Healthcare costs are almost $20,000 per family. While premiums in the ACA marketplaces have stabilized, the reality is premiums would be significantly lower if the Administration hadn’t stopped making cost sharing payments and Sen. Marco Rubio R FL hadn’t cut off the funds needed to help start-up insurers compete with the big boys. Rubio’s action singlehandedly killed off several new insurers founded to offer competitive insurance…so much for the “free market”!

Last, this drives me NUTS – managers, execs, supervisors who use the “I” word all the time. There is no “I” dammit. There is only “we”.  This is not about you, your feelings, your work, your anything.  It is about everyone working towards the same goal, and when you say “I did this” or “My results were X” you denigrate the contributions of others, make them less likely to work to achieve future goals, and send a signal that you have a fragile ego that needs stoking.


Oct
8

Are claims that “Medicare for All” will hurt Medicare accurate?

CMS Administrator Seema Verma said last week that “Medicare for All would become Medicare for None.”

Verna said – and I quote:

A) “By choosing a socialized system, you are giving the government complete control over the decisions pertaining to your care, or whether you receive care at all.”

Uh, Medicare’s recipients are pretty damn happy with Medicare’s “government run healthcare” today – much happier than those of us insured thru employers

Verna fails to explain how MFA is fundamentally different from Medicare as it exists today – and therefore would somehow become this “government-controlled healthcare” monster.

Her claim appears to be based on unfounded assumptions, namely MFA would be fundamentally and in some ways diametrically different from Medicare. Yet she provides no credible rationale for this assertion, instead using code words such as “socialized medicine” to grossly mis-characterize the proposals for MFA (note I’m not advocating for MFA, as I’ve said before, however I do believe something like it is in our future because the current system is unsustainable)

In fact, the MFA proposals consistently support keeping the core of Medicare the same, just expanding it to include the rest of us.

B) “Rather than straining Medicare, we are working to strengthen Medicare.”

I call Bullshit.

Recall that her boss, President Trump, and the Republicans in Congress proposed a budget that would cut $537 BILLION from Medicare over the next decade. I’m hard-pressed to figure out how cutting over a half-trillion dollars from Medicare will “strengthen” it.

Finally, she says C) “Let’s learn from the mistakes made in Medicaid when the Affordable Act pushed millions of able-bodied Americans into a program designed for pregnant women, children, aged and those with disabilities, only to then incentivize states to serve the able-bodied before protecting Americas most in need.

The ACA did not “push” millions of able-bodied Americans” anywhere. The reality is those “able-bodied Americans” could not afford or get health insurance – it was too expensive, wouldn’t cover their pre-existing conditions, or just wasn’t offered, period. The “free market” failed them – and Verna et al have yet to offer any plans that would help millions of working-classAmericans get affordable health insurance

It also didn’t favor those new Medicaid members over current ones – that’s just not true and is a blatant mis-characterization of the law.

What does this mean for you?

I’ve been waiting for the current Administration’s national strategy/plan to fix healthcare. If this is symbolic of their thinking, we’re going to get MFA sooner than I thought.


Sep
18

Why a Texas court case is hugely important to you.

You or your spouse may well have a pre-existing health condition, one that, back in the bad-old pre-ACA days would have made it hard if not impossible to get insurance coverage in the individual and small group insurance markets.

Those days may be coming back.

A Texas court case is scaring the bejesus out of many; the Trump Administration and several state attorneys general are suing to overturn provisions of the ACA that require health insurers to cover pre-existing conditions.

If this scares you, you’re not alone. More than half of people polled are afraid their insurance costs will go way up, and 4 out of ten think they may lose insurance coverage if insurers no longer have to cover pre-existing conditions.

An old athletic injury, skin cancer, stomach trouble, anxiety, a heart murmur, migraines, allergies – all those and many more are pre-existing conditions that, if the lawsuit succeeds, would likely prevent you from getting individual insurance coverage for those conditions – if you could get insured at all.

Before the ACA,

  • you couldn’t leave their job to try something new or retire early – a condition known as “job lock”
  • small employers’ costs went up dramatically if workers got sick or had specific conditions because their insurer wanted to dump them.

Under the ACA, insurers must cover pre-existing conditions, and can’t charge individuals, families, or small businesses more based on those pre-ex conditions.

This strikes me as eminently fair; I had cataract surgery and started getting migraines years go, and until the ACA I had no coverage for ANYTHING related to my eyes or brain. That was pretty scary; any medical care related to those rather important organs was money out of our family budget.

Here are some of the conditions that you are insured for under the ACA, conditions that would not be covered if the lawsuit succeeds.

I’m all for freedom and choice and all that stuff.

What I’m vehemently against is stupid public policy that results in you going bankrupt because an insurer won’t cover your pre-existing condition.

For those who claim the “free market” will fix this – you are smoking crack. No insurance company will cover your pre-ex condition – or your spouse’s, or kids’ – unless they are forced to.

What does this mean for you?

If Trump et al win this suit, your freedom to change jobs just disappeared.

 

 

 


Sep
5

Making “Medicaid for All” work

The US healthcare “system” is headed towards a cliff, and when it hits the edge, Medicaid may well be the replacement.

Briefly:

  • Managed Medicaid plans would be offered in every state
  • people would sign up for the plan they want, with the option of enrolling in regular fee for service Medicaid
  • funding would be from payroll taxes, individual service-based fees, and federal funds
  • provider reimbursement would be pegged to Medicare for ALL payers, eliminating payer-shopping by providers and increasing Medicaid FFS reimbursement

The details…

There are two ways this would work – Medicaid for All (MFA) becomes the way all of us get coverage, or Medicare remains in place for elderly folks and Medicaid covers everyone else.

It’s entirely possible employers continue providing basic healthcare coverage, but really, do they want to? It’s expensive and a pain in the neck. Instead, employers will be able to offer supplemental insurance (similar to what happens in Canada, the UK, and other countries) as an employment benefit.

Today, Medicaid comes in two general flavors – “classic” and Managed Medicaid.

Classic is fee-for-service Medicaid, where members can go to any provider that accepts Medicaid. Providers are paid on a fee for service basis, at rates that vary greatly between states (states set reimbursement).

Managed Medicaid is an option in almost every state. The states contract with healthplans to provide integrated Medicare and Medicaid in what are called “dual eligible” programs (members are eligible for both Medicare and Medicaid).

The Managed Medicaid (MM) plans are paid on a capitated basis – that is, a flat fee per member. That fee is based on the health status and health risks of the members; the sicker the member is, the higher the capitation amount.

This arrangement incentivizes MM plans to figure out the optimal ways to keep members healthy and keep costs down – keep them out of the ER, avoid inpatient hospital stays, and encourage healthy behaviors. If costs come in under budget, the plans make money (usually a couple percent at most). If not, the plan loses money – not the taxpayer. (MFA will be based on Managed Medicaid)

(a detailed explanation is here.)

Today, states with these plans in place enroll members in different ways. Some randomly assign members to plans, others allow more assertive competition among the plans for members. I’d expect this to continue under Medicaid for All; existing enrollment processes would be expanded, systems upgraded, and communications refined to address the broader market. Every fall, MM plans would compete for members, enrolling them before the end of the calendar year.

Individual contributions to premiums would be income-based (as under ACA today); there could be low copays for certain services but paperwork for members would be almost non-existent. (All Medicaid members today have ID cards that enable electronic record sharing, billing, and claims submission.)

Funding would be a combination of service-based fees (copays and co-insurance), payroll taxes, federal funds, and perhaps general state funds.

Remember, as employers would no longer have to deliver health insurance, those dollars could be spent on higher wages, to offset payroll taxes, or for other purposes. Similarly, individual payments for premiums, high deductibles and the like would be eliminated, altho some of those “savings” would go to higher payroll taxes to cover Medicaid for All.

Provider reimbursement would be up to the MM plans negotiating with providers – who would remain independent (unless they are employed in a health system that is also a MM plan provider). However, FFS Medicaid reimbursement would be increased to mirror Medicare’s rates.

Why this is the future

US healthcare is not sustainable. Period.

Family health insurance premiums are nearing $20,000, the number one cause for bankruptcy is medical debt, Medicare and Medicaid are the largest chunks of the federal budget, and industrial competitiveness is hampered by healthcare costs which are double the average costs in other countries.

And, 74% of Americans are worried about losing their insurance.

So, we can either keep driving off the cliff, or take an alternate route. One that will be very rocky, cause a lot of headaches and heartache, disrupt businesses and families and providers, but one that sooner or later, we’ll have to choose.

What does this mean for you?

It’s not a matter of if, but when.

Note – happy to engage in fact-based, citation-supported conversation. “I heard this” and “everyone knows” arguments are not helpful.

 


Sep
4

The case for Medicaid for All

When Single Payer becomes the law of the land, Medicaid will be the foundation.

We’ve looked at the current push for Medicare for All, the factors that I believe will drive us to some form of single payer, and posted a primer on Medicaid.

Here’s why it’s going to be Medicaid for All.

  1. Medicaid for All will spread the cost of universal coverage across states, reducing federal financing requirements.
    Medicaid is a state AND federal program; States provide a lot of the funding for Medicaid; on average the Feds contribute 63% and states 37%. This is critical, as Congress will want to spread the cost of a Single Payer solution and there’s no better way to do this than require states to pony up big dollars [State contributions vary based on a state’s average personal income relative to the national average; states with lower average personal incomes get more federal dollars.]
  2. Medicaid is already built to cover everyone.
    Medicare covers people of all ages, Medicare is very much elder-care focused.
    Adapting Medicare to handle everyone from newborns to elderly, maternity care to pediatrics will be difficult, time-consuming, and expensive. Medicaid does all this and more – today.
  3. Generally, Medicaid is less expensive than other “systems”.
    This is due to much lower provider payment and significantly lower administrative costs. Yes, this means providers are going to be paid less.
  4. Medicaid member satisfaction is pretty good; access to care is not much of an issue.
  5. Medicaid-based Exchange programs are much more successful in the Exchanges than commercially-based plans.
    The Centenes et al [Medicaid-based plans] understand the demographics of the uninsured, have lower medical costs, and already have provider networks, customer relations operations, workflows and processes set up and operational. At the end of the day, lower cost wins – and their costs are lower.
  6. Medicaid is a simple, fully-integrated healthplan.
    Medicare’s alphabet-soup of Parts A B C and D is confusing and convoluted, with different payers often covering the same individual. This increases administrative costs, member hassles, and decreases quality of care (co-ordinating pharmacy and medical care between different payers is problematic at best.
  7. Managed Medicaid plans are working.
    These plans currently exist in most states, and many have been able to deliver excellent care at lower costs through innovation and very tight focus on outcomes. One example is using paramedics to deliver care. [disclosure – I sit on the board of Commonwealth Care Alliance, a Massachusetts healthplan that serves dual-eligible members]

Tomorrow I speculate on how Medicaid for All will integrate with Medicare and employer-based coverage.

What does this mean for you?

Better care, lower costs, while a big impact on pharma, device companies, healthcare systems, and healthcare providers.


Aug
30

Medicare for All – explaining what it means and what it would cost

Yesterday we gave a brief overview of Medicare – the various parts and pieces.

Today – what exactly is the plan, who would pay for it, and how much would it cost?

Sen. Bernie Sanders, (I VT) is the original MFA (Medicare for All) advocate, and most other candidates echo his plan – which is pretty simple:

  • Everyone is enrolled in MFA
  • No one pays copays or deductibles
  • You can choose any healthcare provider
  • It isn’t really “Medicare” for all, but rather a simple “everything is covered” plan
  • Funding would come from:
    • higher taxes on high-income earners
    • re-instatement of the estate tax
    • payroll tax of 6.2% for employers
    • 2.2% income based premium for individuals and families
    • taxing capital gains as ordinary income
    • repealing tax exemption for premiums etc.

There’s been a lot of press about this, with claims and counterclaims muddying the waters  – but the net is this:

Sanders’ plan would enroll pretty much everyone.

The plan would save costs by:

  • reducing total provider compensation by 11% – 13% (physicians make a lot more money here than they do in most other countries)
  • it would do this by setting flat reimbursement rates – today employer plans pay about 40% more than Medicare, and much more than Medicaid (generally speaking).
  • However, reimbursement would be higher than today’s Medicaid rates.
  • MFA advocates note that administrative costs would be a LOT lower, as doctors and hospitals wouldn’t need the big IT operations and personnel required to track down payers and get reimbursed

MFA would be phased in over four years.

What would it cost?

That’s a tough one – the CBO won’t score it.

One Koch-funded research center came out with a report that said it would A) cost $32 trillion over ten years, and B) reduce total US healthcare costs by some $2 trillion while covering 30 million more folks. (yes, this was Mercatus’ higher estimate, but they fudged other numbers to make costs look higher, so I’m going with that figure)

Bernie and other advocates, claim savings would be higher – so the total cost would be lower.

However you slice it, you have to remember that employers and individuals would no longer be paying over a trillion dollars for healthcare every year via payroll taxes and premiums and deductibles and copays.

And yes, you’d save a lot of money by reducing provider reimbursement to Medicare rates.

Who and what gets disrupted?

Insurance companies. It isn’t clear who would administer this program, perhaps the current companies that handle much of Medicare. However, many or most commercial health plans, Medicare Advantage plans, Managed Medicaid plans (disclosure I am on the Board of one – Commonwealth Care Alliance) would shrink or disappear entirely.

Revenue Cycle Management – this huge industry would become obsolete overnight.

Millions of workers – no longer needed to handle the morass of regulations and insurer requirements

Pharma – Bernie would negotiate with pharma and medical device companies – as every other country does – to get the lowest possible prices.

Brokers and consultants. Ouch.

Remember – the US healthcare system is enormously inefficient, overall delivers mediocre-at-best results, and is not sustainable.

What does this mean for you?

Opponents of MFA would be well served to come up with a better answer than MFA, because that MFA is getting traction.

 


Mar
12

Why isn’t anyone talking about health insurance costs?

A couple years ago, we heard endless stories about how “Obamacare” premiums were shooting up, individual health insurance was unaffordable, and families were going bare because the morons that came up with the ACA screwed it up.

Now, with average premiums up 30 percent, we hear…crickets.

The reason premiums have gone up by about a third is simple; President Trump stopped the payments that subsidized low-income folks and insurers are scared he’ll stop enforcing the individual mandate. Unsurprisingly, many people dropped coverage, and insurers had to raise premiums because their risk pools worsened.  

Chart credit Charles Gaba, ACASignups.net

If CSR payments were still in place, and insurers assured the mandate would be enforced, premium increases would be less than half they are today.

What’s scary about this is how easily the media’s focus is influenced by outside efforts. Instead of informing us of this very real, and very important issue, the media is all wrapped up in arming teachers, death penalties for drug dealers, and Stormy Daniels.

What does this mean for you?

A reminder that all of us have to stay focused on the important stuff, not the shiny objects.

 

 


Dec
4

Why the GOP tax bill increases health insurance premiums

I received several emails from readers challenging my statement Friday that the GOP tax bill will result in higher health insurance premiums.  Here’s how.

Briefly, the Bill lets you buy health insurance after you get sick – without a penalty. It’s as if this guy was signing up for auto insurance post-crash…

Both the House and Senate versions of the bills end the penalty for those who don’t have health insurance. This penalty does 2 things; it financially penalizes those who go without coverage, and it generates funds that help pay for healthcare for others.

What the tax bills DON’T do is change the requirement that insurance companies cover anyone who applies.

Imagine if you were able to buy auto insurance after you crashed. Why would you bother to sign up and pay those premiums if you didn’t have to?

BTW, there’s a ton of research and history that shows what a bad idea this is, how much damage it does to insurance markets, and what we can expect.

Folks, this is just ONE example of the dumb ideas in this bill, from people who claim to understand how the free market works.

What does this mean for you?

Insurance rates are going to go up.