Happy Memorial Day Weekend!

Hope yours is filled with family and friends…and time to reflect on those who gave their lives for us.

Thanks to them, we have much to be thankful for.

Starting with…despite what many think we’re NOT in a recession…

From the Guardian’s survey…

The vast majority of respondents, 72%, indicated they think inflation is increasing. In reality, the rate of inflation has fallen sharply from its post-Covid peak of 9.1% and has been fluctuating between 3% and 4% a year.

In April, the inflation rate went down from 3.5% to 3.4% – far from inflation’s 40-year peak of 9.1% in June 2022 – triggering a stock market rally that pushed the Dow Jones index to a record high.

And job creation has been pretty darn great.

Government works!

Remember the botched start-up of the ACA aka “ObamaCare” way back in 2014?

Well, like many new and really big change, its gotten a whole lot better. Almost 2/3rds of Americans view the ACA favorably.

For some, “Obamacare saved my life”…

Support for recovering addicts…

This is really good news…The Feds and California are partnering on a program that pays addicts continuing to remain sober.  The program – “contingency management” –

is the gold standard for stimulant use disorder because you can win things for good behavior. But not a lot of places are providing it yet,” said PK Fonsworth, a psychiatric emergency room doctor and addiction psychiatrist in Los Angeles. (cite WaPo)

Research shows promise for contingency management. For instance, study participants achieve significant periods of sobriety, agree to long-term addiction treatment and even reduce risky sexual behavior.

The Biden administration is pushing more states to consider the approach, calling it a “proven treatment” that “remains underutilized.”

Kudos to CMS (Medicare and Medicaid) and the Golden State for the collaboration.


For those I caught with my April Fool’s post…I hope you took it in the spirit in which it was intended…

Okay, back to reality (oh no….)

Hospital closures and cutbacks

Another hospital in a non-Medicaid expansion state is closing its ER and shuttering its inpatient care facility. The facility was acquired by a competitor a mile away a few years back…if this goes like most acquisitions folks around Anniston Alabama will likely have poorer outcomes and pay higher prices…

Ignore the corporate happy speak from the owners…this is the same stuff every exec that buys a rival hospital says.

Oh, and here’s research showing the link between Medicaid expansion and hospital closures.

Consolidators are doing just fine…the CEO of CHS just “earned” $8.3 million in pay and perks.

Obamacare…aka the ACA.

Remember way back when folks got all worked up about the ACA, how it was going to kill off old folks, destroy the “best healthcare system in the world”, cost millions of jobs and bankrupt thousands of small employers…and lots of people hated it?

News flash – Americans like it.  A lot.

That’s because:

  • Pre-existing conditions are covered.
  • Kids can be covered under the parent(s)’ insurance till they are 26.
  • 45 million Americans get insurance thru Obamacare and/or benefit from its provisions.
  • Provisions ensure adequate benefits for mental health, emergency care, maternity and child care and seven other key healthcare needs.
  • People who actually had Obamacare plans realized it saved lives.

Oh, and since people with health insurance are healthier than those without, if they’re hurt on the job, they recover faster and employers don’t have to pay to treat co-morbidities. 

We’re going to dive deep into the ACA in a coming week…stay tuned for more facts.

Change Healthcare cyber attack

It isn’t over. Owner United Healthcare recently stated patient data had been stolen by hackers.

This is a much bigger story – with much wider implications – than many think.

What does this mean for you?

More stuff affects you and your business than you may think. 


Healthcare regains the political stage

Healthcare has not been on the political landscape since the last attempt to overturn the Affordable Care Act aka ObamaCare failed…and then-candidate Trump talked up his very-hard-and-actually-impossible-to-locate HealthPlan.

Just-released polling indicates several healthcare issues are top-of-mind for voters across the political spectrum.

  • 4 out of 5 voters say it is “very important” for candidates to talk about healthcare affordability...making healthcare the second most important topic among respondents.
  • The ACA is back in voters’ minds with almost half of poll respondents stating the ACA’s future is “very important issue”.
  • Medicare and Medicaid are also top of mind for voters as is access to mental healthcare with 75% and 70% of respondents respectively stating these issues
  • Related, about a quarter of voters (24%) say they would only vote for a candidate who shares their views on abortion.

What does this mean for you?

As America ages and healthcare becomes increasingly unaffordable, more voters are more about healthcare. 



Updates on the ACA

With the GOP attorneys general’s case to overturn the ACA pending before the Supreme Court, you may want a refresher on what the ACA is, where it is working and when it isn’t, what the problems are.

And more importantly how we can fix it.

One of the nation’s leading experts on the ACA- Charles Gaba – will cover all that stuff tomorrow in a webinar.

The Milbank Quarterly will also be publishing experts’ views on the ACA.

As I mentioned last week, Biden will likely be limited to administrative orders, as the GOP-run Senate (pending the Georgia runoff) is not likely to help him implement structural improvements.

What does this mean for you?

A lot of boring wonktalk about the ACA which is nonetheless really important.



Enough obsessing…here’s what the election means for healthcare.

Like many, I’ve been spending far too much time obsessing over election results.

It’s a waste of time and energy…and completely useless; rather than dive into Maricopa County absentee ballot trends, time is far better spent figuring out the election’s implications.

I’ll stipulate that come January there will be a Democrat in the White House, a Democratic majority in the House of Representatives, and probably a very narrow Republican majority in the Senate (although that depends on Georgia’s Ossoff – Purdue results and the Warnock – Loeffler runoff).

Here’s what this means for healthcare.

The ACA is here to stay – whether it gets fixed is up to the Senate.

The Affordable Care Act needs work, but gridlock may keep it stumbling along.

Biden’s wish list includes:

  • lowering the eligibility age for Medicare to 60,
  • allowing the federal government to negotiate with pharmaceutical companies over prescription drug prices,
  • spending $775 billion on caregiving to address the need for home health,
  • expanding financial assistance for health insurance,
  • creating a “public option” government health plan, and
  • changing the individual mandate to ensure folks are incentivized to get health insurance.

Without a Democratic Senate, much of the list (lowering Medicare age, public option, $ for caregiving) is unlikely to happen...but Biden can use Executive Orders to address some key problems.

Expect a slew of Orders on issues including:

  • expanding family planning services;
  • expanding value-based care to – perhaps – include pharma (a backdoor way to partially address drug costs);
  • free and expanded testing for COVID,
  • transparency on medical billing, and
  • a mechanism to address surprise bills.

A Biden Administration will double down on the opioid crisis, taking much more aggressive action to make profiteers such as Purdue pay huge penalties. Criminal charges may well be levied against those profiteers along with efforts to reclaim dollars parked overseas by the Sackler family (owners of Purdue).

Of course, this depends on the Georgia runoff, scheduled for January 5 with early voting starting December 20.

What does this mean for you?

Its a lot more productive to focus on the implications and how they may affect you, your family, your community and your business than to worry about stuff we can’t control.


If the Supreme Court kills “Obamacare”

With President Trump’s nominee for the Supreme Court all but confirmed, there are huge implications for healthcare. If the Court rules the ACA/Obamacare is unconstitutional, “a host of provisions may be eliminated” including:

  • protections for people with pre-existing conditions,
  • subsidies to make individual health insurance more affordable,
  • expanded eligibility for Medicaid,
  • coverage of young adults up to age 26 under their parents’ insurance policies,
  • coverage of preventive care with no patient cost-sharing, and
  • lower drug costs for seniors using Medicare’s drug benefit.

Today, a brief summary of the court case and analysis of two major implications.

A week after the election the Court will hear the Trump Administration and Republican State Attorneys General argue that the entire ACA/Obamacare must be struck down. Health policy nerds (guilty!) will recall that lower courts ruled that Congress’ elimination of the individual mandate killed the entire ACA; this is the Trump/Republican AGs’ argument.

Democratic Attorneys General have argued that the mandate can and should be separated from the rest of the ACA.

We don’t know how the Court will rule. We do know that after Barrett’s confirmation, the Supreme Court will have a 6-3 supermajority of conservative justices. According to HealthAffairs, writing about the lower court’s ruling, Judge Barrett “does not clearly state her own view but signals support for the dissent’s view (full invalidation of the ACA).” [emphasis added]

Seniors and Hospitals will be dramatically impacted if the Supreme Court overturns the ACA/Obamacare (we’ll address other implications tomorrow).


Ending the Medicaid expansion will eliminate benefits for seniors and others in Medicaid expansion states with incomes just above the poverty line.

The ACA closed the “doughnut hole” in the Medicare drug plan, saving a million seniors about $3,200 each. If it is overturned, seniors with high drug costs to treat chronic diseases such as MS, hepatitis C, some cancers, and some autoimmune diseases will see much higher costs.


Many hospitals are already in financial distress, especially in rural areas and states that did not expand Medicaid.

Tennessee and Texas lead the nation in hospital closures, with one-fifth of the Lone Star State’s rural hospitals already closed or close to it. Just north, a grassroots movement in Oklahoma driven by closure of a half-dozen rural hospitals, is gaining traction.

While Becker’s reports all but one of the hospitals going belly up are in states that didn’t expand Medicaid. 

If the Court overturns the ACA/Obamacare, many more rural and smaller hospitals will shut down, leaving healthcare deserts behind.

(Work comp is also affected – albeit indirectly)

What does this mean for you?

If you are a senior concerned about the cost of drugs, and/or live in a rural area, the Court’s decision will have real consequences.



The most ridiculous thing I ever heard.

You Bet Your Life was a 1940’s radio quiz show featuring comedian Groucho Marx; contestants vied for prizes and cash.

If you or your family members have pre-existing medical conditions, the election is a reprise of the show – Republicans want to end coverage for pre-ex, and Democrats will keep that coverage in place.

If the Trump Administration’s Texas lawsuit backed by Republican Attorneys General succeeds, you can lose coverage for pre-existing conditions if you change healthplans, switch jobs, move, marry, divorce, or have a child. If Trump and Republicans win the case in Texas;

Briefly, Republican Attorneys General have sued to overturn the ACA, and the Trump Administration is aggressively supporting the suit.  The Trump Administration and AGs’ claim the entire law must be thrown out because the individual mandate — a penalty imposed on people who chose to remain uninsured – was killed by the Republican Congress in 2017.

In so doing, it would end protections for those with pre-existing conditions.

Make no mistake, if Trump et al win the suit and you have to change health insurance plans, you are at real risk of losing coverage  – or having to pay so much you can’t afford it.

Despite President Trump’s assertions, there is No Republican plan to assure those with hypertension, diabetes, a history of heart disease, cancer, anxiety disorder, or any other health condition will be able to afford health insurance.

If you just won lotto, you’re all set. If not, you’re screwed.

Ignore Trump’s claims that there is a replacement plan in the works because:

What they do have is bait-and-switch.

As Groucho would say about the Republican claim they’ll cover your pre-ex;

What does this mean for you?

If you or a family member have a pre-existing condition, this election is about you.

If you aren’t sure, here’s a list.

And if you think you can hide your condition, you can’t. 


The Trump Healthcare plan explained – briefly

Yesterday we discussed Presidential candidate Joe Biden’s healthcare plan.

Today we’ll do the same for President Trump’s healthcare plan, which was promised to be ready before the upcoming election…

Five times this year President Trump has promised he will unveil a replacement for “Obamacare”. As of this writing, I have not been able to locate any such replacement plan documentation, web pages, policy statements or plan descriptions other than a couple described below. If you have any details, please share in the comments section below.

It’s not just me – Forbes wasn’t able to locate the President’s plan.

So, if you are looking for a brief explanation – you can stop reading here.

For those who want more detail, here it is.

Unfortunately it appears the White House’s healthcare page has not been updated since 2017 so we will have to rely on public pronouncements and speeches.

Trump’s campaign site does have a list of objectives, but no actual plan, policy description, or details on how these will be met:

This has made it rather difficult to analyze Trump’s plan, so we will have to use the President’s pronouncements to assume what his plan will be. Please note that wherever possible I have cited official White House or Trump Administration sources below.

Pre-existing conditions

The President has repeatedly stated that his plan will require “health insurance companies to cover all preexisting conditions for all customers,” including during a press briefing in early August. In that briefing, Trump stated:

Over the next two weeks, [emphasis added] I’ll be pursuing a major executive order requiring health insurance companies to cover all pre-existing conditions for all customers. That’s a big thing. I’ve always been very strongly in favor — we have to cover pre-existing conditions. So we will be pursuing a major executive order, requiring health insurance companies to cover all pre-existing conditions for all of its customers.

This has never been done before, but it’s time the people of our country are properly represented and properly taken care of.

[note – requiring health insurers to cover pre-ex conditions is imbedded in the ACA (sometimes referred to as Obamacare) and is the law of the land today as that provision of the ACA remains in effect.] source cited is US Dept of Health and Human Services, part of the Trump Administration

Takeaway – taking the President at his word, any new healthcare plan will provide coverage for pre-existing conditions. We do not know if the Trump Healthcare Plan will allow insurers to charge extra for that coverage, or limit coverage to some dollar amount. (that is not allowed under the ACA)

Medicaid changes

Trump has sought to end Medicaid expansion, change funding, and institute work requirements. While these all sound good in sound bites, like many complex issues things sound a lot less good when you peel back the curtain.

Ending the expansion of Medicaid would crush hospital financials, especially in rural, western, midwestern and southern states.  In many areas Medicaid is a critical funding source for facilities; those states that have expanded Medicaid (including deep red Oklahoma) would be in dire straits if the rug was pulled out from under them.

The President has pushed hard to change the way Medicaid is funded to a “block grant” method.  Essentially a block grant is a fixed amount of funding; this would replace part or all of the current funding which is based on a percentage of expenses.

Simple in concept, this is much harder to implement, and completely unsuited to our current situation where Medicaid enrollment is rapidly growing due to the fallout from COVID. We haven’t heard much about block grants of late from the President, so not sure if they are still under consideration.

The same is true for work requirements. Many low income folks don’t have internet access, which is required to submit the detailed documentation required under state Medicaid work requirements. Then they need reliable transportation to get to work – which many don’t have. And there are few jobs available these days in many states due to COVID.

Takeaway – Trump wants to end Medicaid expansion, change its funding mechanism, and require some recipients to work. It is highly doubtful any of this will happen.

Drug prices

The President has authored several executive orders around drug prices, but didn’t follow through on actually implementing those orders.

Trump’s move appeared to be intended to force pharma manufacturers to the bargaining table, but that hasn’t happened. Despite Trump’s statement that he would take unilateral action if pharma didn’t cooperate with him by August 25, he didn’t follow thru on that threat.

More troubling, pharma execs don’t know anything about any meeting or discussion.

Takeaway – no significant action to control drug prices is likely.

What does this mean for you?

It’s really hard to say. 



The Biden Healthcare plan explained – briefly

Healthcare will be the most significant near-term impact of this election.

If Joe Biden wins and the Dems take the Senate, here’s what we can expect.

Biden’s healthcare plan addresses the biggest problems with the ACA (known to some as Obamacare).

  1. Individual health insurance plans are way too expensive.
  2. About a third of all states didn’t expand Medicaid
  3. The big insurers have little competition.
  4. Medicare – and Medicare recipients – are paying far too much for drugs

Briefly, the Biden Plan would:

  • Cap individual health insurance premiums at 8.5% of income
  • Set up a public option like Medicare anyone could buy into
  • Allow 60-65 year olds to buy into Medicare
  • Have Medicare negotiate drug prices with manufacturers
  • Solve the Medicaid expansion problem by covering low-income folks in non-expansion states through a Federal program
  • Ban surprise medical billing for insureds that require out of network hospital care
  • Ensure pre-existing conditions are covered

The additional costs would be paid for in part by savings (e.g. drug costs) and abolishing the capital gains tax break for those making more than a million dollars a year. (More detail on this plan, along with pros and cons – is here.)

Does this solve the ACA’s problems?

It’s not a cure-all, but Biden’s plan does go a long way to fixing the ACA’s two biggest problems – healthcare is still unaffordable and prices are still too high.

For most families covered under the plan, healthcare costs would likely decrease significantly. The 8.5% cap on insurance costs is a major change as insurance premiums in many areas are north of $12,000 a year.

Healthcare providers would:

  • Scream if folks now covered by private insurers switched to a Medicare-type program as reimbursement would drop;
  • Cheer if a lot more patients had health insurance; hospitals’ indigent care costs are escalating rapidly

The real problem with healthcare costs in the US is our prices for services are way too high. Covering a lot more Americans thru a government plan would force facilities and providers to get a lot more efficient.

Over the last six years I’ve done many a deep dive into the ACA’s shortcomings and why they exist; posts are here.

Bob Laszewski penned a very good piece on the plan here. Well worth a read.


The most important thing you aren’t paying attention to

Is the ACA case in Texas.

Briefly, Republican Attorneys General have sued to overturn the ACA.  The AGs’ claim the entire law must be thrown out because the individual mandate — a penalty imposed on people who chose to remain uninsured – was killed by Congress in 2017.

You may recall that, in addition to the mandate, the ACA:

  • expanded Medicaid to more low-income families and individuals
  • reduced seniors’ drug costs by closing the “Donut Hole” in Part D plans
  • reduced insurance costs for older Americans
  • increased funding to fight healthcare fraud
  • increased funding for rural healthcare
  • increased tax credits for small businesses providing health insurance
  • provided insurance subsidies for families making less than $88,000
  • required insurers to offer complete insurance coverage to all without discriminating by medical condition, age, or sex

If the Republican Attorneys General prevail, the ACA will be overturned, and health insurers will be allowed to:

  • stop covering pre-existing conditions; 
  • stop covering your adult kids;
  • limit your maximum dollar benefit;
  • exclude different types of medical care
  • medically underwrite small groups; and 
  • subsidies for folks buying health insurance go away.

Meanwhile, there is NO alternative plan if the judge rules in favor of the AGs. While HHS Secretary Seema Verna says there will be a replacement plan, there are no details about this “plan“, and no information whatsoever from the President or Congress.

photo credit Leslie Boorhem-Stephenson for the Texas Tribute,

I don’t understand how the entire law can be overturned because one part of it is no longer in effect – but I’m no attorney and will leave that to those readers who are.

From a political perspective, this doesn’t seem too smart on the part of Republicans.  People hate losing things they already have – much more than they don’t like not getting things they wish they had. And if the ACA is overturned, millions of voters – including millions of seniors – will be really mad.

What does this mean for you?

If you’re a Medicare recipient, parent, make less than $88,000 a year, are a small business owner, have pre-existing condition, and/or need comprehensive insurance coverage…

nothing good.