CBO Again Says No-Go on Senate Healthcare Bill, Deductibles Soar!

New Orleans   The nonprofit Congressional Budget Office had a more leisurely schedule in costing out the latest, zombie Republican Senate effort to replace Obamacare with something, almost anything more draconian. The numbers were the usual at one level: 22 million would lose coverage by 2026, 15 million of them immediately. Medicaid would be hammered with a 26% cut over the next decade. Like I said, the usual.

There were a couple of new twists though that caught my eye.

The CBO number also took a look at the impact of going all-Trump on a repeal now and punt down the field until some later date. 32 million Americans would lose coverage on that less than brilliant, but certainly spiteful, bitter pill strategy. That’s 10 million more than under the original Senate slice. Majority Leader Mitch McConnell is pressing for a vote on something, in fact just about anything, next week so that he can count the bodies and move on or move home. That’s going to be a hard bill to force feed.

The other factoid that caught my eye went to my long term grievance: no cap on deductibles.

Just to reprise my constant complaint. In bargaining union contracts for lower waged service employees, all of the companies had compliant plans under the Affordable Care Act, but they also included deductibles that ranged from $4000 to $6000 on top of the 9% monthly payments for coverage. The result for lower waged workers making less than $20,000 per year is that there was almost zero participation, but they were also excluded from any of the subsidies or cost-sharing of Obamacare, even though they could participate in the marketplace and pay full price, because they technically had coverage under their employers miserable plans. We found ourselves having to advocate nonparticipation and paying the fine.

The CBO noted that under Obamacare the average deductible for single person coverage was in fact $5000. Under the Republican Senate bill they estimated that the average deductible would soar to $13,000 per person on individual coverage. Remember that’s a deductible, meaning the individual would shell out $13,000 before getting any benefits from the so-called health insurance and after paying a monthly premium. Who is going to buy that pig in a poke? Eliminating the mandatory requirement means that’s an easy guess with the answer being: nobody!

Face the facts. At this level of deductible, this is nothing more than catastrophic care. Why would anyone sign up if they felt kind of healthy, and kind of lucky, unless they were suddenly feeling a little woozy, or a fortune teller told them to look out.

Meanwhile what we have, warts and all, is becoming more popular, up to 60% support, and the Trump Administration is debating outright sabotage, as distinguished from Congressional sabotage, I guess.


Humpty Dumpty Health Care

Paris   Nothing like a couple of weeks on the road, three countries, a half-dozen or so cities, and the siren song of home, heat, and humidity all sounds better and better. Of course there’s no escaping the headlines or the occasional questions from random people from all walks of life about what thoughts we might have on Trump. As excited as people around the world were about Obama as president, they are mystified by Trump. They are not alone.

The Republican Senate’s efforts to not just repeal-and-replace Obamacare, but to cap entitlements for Medicaid and pretty much kick the teeth out of the poor, elderly, disabled, and others seems to have alienated a couple of senators, while others wanted a chance to run up and kick harder and go for the kill. The New York Times reported that Senator Portman from Ohio has been a huge problem behind-the-scenes for the Republican majority leader and his efforts to pull together the votes. Seems he was concerned about what might happen to 700,000 people in Ohio that had gained coverage under the Affordable Care Act. Wow! That’s a good question for a lot of politicians from a lot of states it would seem. Turns out that when you push Humpty Dumpty off the wall, it really is hard to put the pieces back again.

And, in fact as the votes collapsed on the latest Senate version, there was an even greater implosion on the latest Trump twitter tantrum urging just repeal and deal a couple of years down the road. Seems immediately three Republican women in the Senate from West Virginia, Maine, and Alaska said the equivalent of “what are you pulling my leg,” saying that it would be reckless and irresponsible to simply repeal and blow the Act up.

Many of the Republican governors with shorter terms and quicker elections who are forced to be closer to their constituents also got their back up on these draconian cuts and caps in Nevada, Ohio, and elsewhere. They have earned some thanks as well.

I wish there were a lesson learned on the order of “don’t mess with entitlements,” but we know better. Like a bad dream, they’ll be back with more mischief and other attempts, and one way or another, they will have to do something now, we might hope, to fix some of the pieces of Obamacare that are broken.

Will they reach out to Democrats? Do they really have a choice?

Maybe this will be a twist on the old story, that if you break it, you own it. In this case, the message to the Senate might be, if you can’t break it, then do your job, and fix it.


The Wide Applications of “Kill it to Save it”

New Orleans   Reading the desperate comments from President Trump and some of the hard-far-right-conservative Republican Senators on the eve of their “holiday” making the case that because they couldn’t agree on a new bill to replace the Affordable Care Act, then they should just repeal it all, give the existing situation a year to go, and try to come up with something down the road, brought one statement clearly to mind: “kill it to save it.” For me the resuscitation of this old Vietnam War justification for similar atrocities was easy because earlier on Wade’s World. I had interviewed Corey Dolgon, a professor at Stonehill College in Massachusetts about his new book, appropriately entitled, Kill It to Save It: An Autopsy of Capitalism’s Triumph Over Democracy.

In his book, Professor Dolgon argued that energy for change from the social movements of the 60’s dissipated from near misses and fatigue with the wind down of the Vietnam War under President Richard Nixon, but rather than the scorched earth war conceit of “kill it to save it” vanishing, instead it became a crushing weight, dominating institutions and policy in the United States. Dolgon revives attention to President Jimmy Carter’s “crisis of confidence” speech, but then watches Carter’s accurate analysis drift into the politics of destruction. You get the basic message Dolgon has to offer. He cites more modern examples from Katrina to the dismantling of higher and lower education regimes to extend his case and stretch forward his analysis. No doubt if I had been talking to Dolgon after the latest nihilist shots at the Affordable Care Act, he would have had a field day.

Peggy Noonan, the moderate conservative Republican and recent Pulitizer-prize winning columnist for the Wall Street Journal spits into the wind with an argument that Majority Leader Mitch McConnell’s threat to Republicans that he was going to have to start talking to Democrats since they couldn’t agree on how to repeal-and-replace Obamacare, should be recast as a promise. She makes a good point that something so “intimate,” in her words, as someone’s healthcare should in fact be a bipartisan project in the vein of Roosevelt’s efforts for Social Security and Johnson’s work to win Medicare, regardless of the Obama “going alone” model which passed the Affordable Care Act, but also devastated Democratic majorities in the House and Senate over time and, like or not, has left us in the situation we have now.

The cornerstone of her argument and that of anyone willing to be honest about it all is that Obamacare had flaws, huge ones, though we may all disagree on what and what. I’ve been harping on the failure to cap deductibles at a reasonable level, following the Massachusetts model, for years now, because it has blocked the participation of lower waged workers with technically qualifying plans, which are ridiculously unaffordable and offer minimal benefits. In fact they put lower waged workers in the same untenable situation described for rising seniors beneath the Medicare qualifying age under the mean-spirited Republican offer.

We could go on and on and even make good sense, but all of that would depend on reducing the polarity of politics, and for reasons good and bad, a terrible healthcare bill is a safer bet than one where all parties would agree.


Welcome to the No-Insurance Emergency Rooms as Long as They Last

New Orleans  The Congressional Budget Office has released its score on the cost and impact of the Senate Republicans version of healthcare coverage. The bottom lines have gotten wide publicity. 22 million will lose insurance by 2026, 15 million almost immediately. 15 million lower income people will lose Medicaid coverage. It wasn’t big news that this will be an income transfer from the poor to the rich, because we had already known that was coming in all the Republican bills.

Elderly people hoping to live long enough to qualify for Medicare will have to run the gauntlet, unless they are wealthy. The New York Times gave two examples from the CBO report that were appalling.

for a typical 64-year-old with an annual income of $26500, the net premium in 2026 for a midlevel silver plan – after subsidies – would average $6500, compared with $1,700 under the Affordable Care Act. And the insurance would cover less of the consumer’s medical costs. Likewise, the report said, for a 64-year-old with an annual income of $56,800, the premium in 2026 would average $20,500 a year, or three times the amount expected under the Affordable Care Act.

Yes, you understand the math. In the first example that’s a quarter of the person’s income and in the second it’s more than one-third, 36% to be exact.

The Senate added an amendment at the request of the insurance industry recently that anyone not on insurance more than 60 days would have to wait 6-months to get coverage and pay 30% more on their premiums. The industry recognized that as bad as this bill is, no one is going to get coverage until they are sick, so they wanted to try and put some boulders in the road.

And, of course they are right. With no mandate and no penalties for not having insurance most people will not get insurance for the plain and simple reason that they won’t individually be able to afford it unless their employer is providing it for them. Young people on insurance will be rare. For the rest of the population, health insurance will be the American version of Russian roulette. How long can you wait before getting insurance? People will be arbitraging their family fiances against their lives.

What if you are diagnosed with cancer or something and have to wait 6-months for treatment? In the short term survival for you and tens of millions of others will mean throwing yourself on the mercy of the hospital emergency room, as long as the law doesn’t allow them to refuse service, and until so many of these hospitals go bankrupt from providing care without government support or private insurance payments.

There’s a reason why hospitals, doctors, nurses, and everyone connected to providing health care services have opposed these bills. It’s not because many will lose their jobs as healthcare facilities go under, which they certainly will. They aren’t politicians. They’ll see the people dying at their door, too late to save, and too poor for the insurance, yet too rich for any assistance. Who wants to live through that?


When National Healthcare is Not Mean, but Vindictive, Not Policy, but Politics

New Orleans  Healthcare is a huge part of the overall US economy and, arguably, of critical importance to every American. Regardless of the cliché, it is in fact a question of life and death. Yet we are watching a horror show spectacle of a White House that is clueless about anything but whether or not it can claim a “win,” and a Congress that is cunning and calculating without any field of vision that can see past 2018 and the midterm elections.

Meanwhile the public is treated to media coverage that, rather than focusing on the complexity of the bill and its evisceration of any semblance of public policy, treats the whole affair as if this were an extra innings baseball game and the only real issue was whether or not Majority Leader Mitch McConnell can get enough votes to pass the Senate version before the totally arbitrary deadline of July 4th. Well, perhaps not totally arbitrary, since McConnell is worried that when his caucus goes home for the recess their constituents will kick their asses so badly his whole secret legislative architecture will collapse.

Remember Kellyanne Conway, so discredited as a Trump aide that we’ve been spared her doublespeak recently. Well, she was back on this bill with the outrageous claim that no one can support, that, oh, no, there are no cuts to Medicaid in the Senate bill, which everyone knows is wrong. Good try, Kellyanne, now go hide out again, because this time there weren’t even any headlines following such an outrageous claim.

How about we look at how the Senate went from mean to downright vindictive? Their bill restored funding for what is known as “disproportionate share” money to hospitals. Pay attention in class now, friends, this is important. In places like Louisiana where I live we know a bit about “disproportionate share” payments because in their heyday they figured so prominently in statewide political scandals. Ever popular, former multi-term Governor Edwin Edwards did court and prison time on the issue of having unduly helped some friends get such money to build hospitals in poorly served and lower income areas of the state. Indeed, disproportionate share payments were designed to subsidize health care costs in lower income and ill-served areas originally in order to assure communities that these institutions could survive, because a “disproportionate share” of their patient base was poor. Obama’s Affordable Care Act flipped the script here. By assuring that everyone would have to get insurance and providing subsidies for lower income families and Medicaid expansion, disproportionate share payments would be phased out to pay for Obamacare. In fact now is the time when $43 billion would be reduced between 2018 and 2025.

What did the Senate do in their bill? They buckled to the lobbyists and restored these disproportionate share payments, but, now get this, only to states that had not expanded Medicaid coverage. This allows them to punish those states and their people by cutting the subsidies to Medicaid in their bill and rewarding the scofflaws by restoring the disproportionate share payments.

Now it’s politics that inflicts real pain and terrible consequences. Need a vote in Alaska or Maine, then sweeten the pot on opioid money even though states throughout the country are reeling under such a crisis. Take away support for mental health coverage, but throw some dollars out here and there to get a vote. Cutback money for the elderly poor on Medicaid, but kick the can down the road past 2018 so that you can keep the votes with a wink and a nod until the oldsters figure out the con.

None of this is good policy, and, frankly, I’ll be darned if I even understand how it is good politics, when all of these repeal bills are wildly unpopular in every poll of the American people. The public wants to live, not die, at the hands of government. Why isn’t that news everyone understands?


PriceCheck Tools Can Save Big Money on Health Costs

New Orleans   Recently I read a disturbing and powerful indictment of the cost and provision of health care, An American Sickness: How Health Became Big Business and How You Can Take it Back by former New York Times reporter Elisabeth Rosenthal. In devastating detail, she documented the wide variety of prices for basic and specialized medical procedures and drugs between hospitals in different cities, different countries, and within the same communities. Finishing the book, I couldn’t help but think about whether her work was citizen empowering or would simply be too complex and confusing for regular folks to sort out for themselves, especially when sick and fearful in the face of medical issues.

I am finding some comfort in reading that some local newspapers, including one of my own in New Orleans, The Times-Picayune, have gotten their arms around this problem in a very helpful way, that needs to be replicated everywhere. Working with Clear Health Costs, a new journalism enterprise based in New York City, they developed a tool they call PriceCheck. In a partnership, which also included the local Fox station, they launched with 700 prices from area outfits obtained in an initial survey. Subsequently, readers have crowd sourced another 700 prices from their own inquires and experience. All of that triggered, or perhaps shamed, providers into submitting another 2000 prices for common procedures

Obviously the news sources are heavily promoting their project, as rightly they should, and from the stories they report, it is having an impact.

Powerfully, they are collecting great first-person stories from people who have resisted predatory pricing from their own provider, gone to the online PriceCheck tool at www.NOLA.com/health or www.Fox8live.com/health and done their own comparison shopping to great advantage. One woman faced with an estimate for an MRI that was over $4000 used the tool to cancel that appointment and visit a local clinic for the same examination and only paid $672, saving thousands obviously. She was in good company as others were trying to also hold their providers accountable.

I found it interesting, and disturbing, that almost all of the reporters found almost all of the patients unwilling to reveal their names. Between the line that speaks to a fear of retaliation from medical facilities and professionals or of being black-balled for needed health care. Whatever happened to the dictate of the Hippocratic Oath for doctors to “do no harm?”

Not surprisingly, many institutions were resisting transparency and refusing to share pricing information with either their patients or the public. The privately operated Tulane Medical Center, an HCA facility, which at least used to stand for Hospital Corporation of America, in partnership with Tulane University, was militantly opposed and resisting. The Times-Picayunealso noted that the insurer Blue Cross/ Blue Shield was also resisting.

This is going to be a door-to-door dogfight, and as long as its each family facing off by itself against these huge institutions, the immediate odds are against them, no matter how many stories are in the news. Nonetheless these kinds of tools put bullets in a consumer’s gun, so let’s hope a thousand similar flowers bloom, so that consumers can vote with their feet and force prices to leave the stratosphere and come back to eye level.