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?


Healthcare Plan is a Killer

Little Rock   How many of us have heard from our mothers that “if we can’t say something good, then don’t say anything at all.” I wish that were the case with the Ryan and some Republicans’ healthcare bill. So far, I’m failing to find any silver lining, other than it’s not a total repeal where we have nothing, but that’s too thin a reed to grab.

There are still no Congressional Budget Office tabulations on the cost of this proposal or the number of people likely to lose healthcare. Some Republicans are even wary and unhappy about being forced to vote on this thing without even that meager level of information. Reporting by the New York Times finds Standard & Poor’s in a report has estimated that 2 to 4 million people would drop out of the individual insurance market, largely people in their 50s and 60s who are too young to qualify for Medicare because of higher costs. Why? One feature of the new proposal is that it would allow insurance companies to increase the gap for older Americans from three times the young to five times the young causing premiums to soar to unaffordable levels.

Several researchers listed the predictable outcomes of transferring these decisions to the states by citing not theories, but the facts on the ground based on what states had done where they have had discretion in the past and get caught with budget shortfalls similar to the ones faced in the 2008 Great Recession. They talked about the blood on Arizona governor Brewer’s hands when that state stopped paying for transplants and allowed people to die. They talked about how states had dealt with billions of dollars from the smoking settlements with tobacco companies and the meager percentage of the funds that had gone to cessation programs as opposed to budget shortfalls, capital expenditures, and a bit of whatever.

Unbelievably there are some Republican Senators who still bridle at any plan at all. More troubling have been some arguments that some are starting to make that we might be better with nothing at all, though that strains credibility as well.

You know it’s bad when we aren’t even getting into the weeds on things like the impact on women. The ban on Planned Parenthood funding just seems like a bizarre, mean spirited outlier which must just drip with questionable legality. Past the first mention, the fact that people would be barred from buying insurance with governmental support that paid for abortions also seems like a flashpoint that hasn’t gotten much attention. Props though to Planned Parenthood for having pushed away the offers for not only continued funding at half-a-billion bucks but an increase, if they were just willing to make a deal and stop doing abortions anywhere, regardless of the fact that no federal money funds any part of their abortion service anyway. Comforting to know that a least one major national nonprofit is unwilling to abandon its mission for money. That must have been something of a shock to the Trumpsters, though the so-called offer was likely something of a wink-and-nod, and never serious anyway.

Or how about mental health services? Will they continue to be supported? Believe me our partners in Alaska with the Mental Health Consumers Action Network (MCAN) are having emergency meetings and deep discussions about this.

The list is endless. The pain tremendous. The death count will be astronomical.

Here’s my point in a nutshell: all of this is bad, and we still don’t know the half of it.


Affordable Care is Simply Not Affordable

HealthCareGovSiteNew Orleans    The more studies that are done, the more time that passes, the more it seems impossible to get around the core issue embedded in the compromises of the Affordable Care Act: it’s just not affordable for lower income families.

The government’s projections for the current signup period are frankly modest at about nine million signups, rather than the twenty million projected several years ago for this period. Given the number of states that continue to boycott the expansion of Medicaid, which is where a lot of the gap for the uninsured continues, the budget offices are finding the predicted costs of Obamacare are about 20% lower than originally expected.

Furthermore, the mandate is not pushing enough people into insurance who don’t have it, particularly among lower waged workers. Studies are finding that at about $40,000 the maximum participation is achieved. Lower income families are simply paying the penalty, because it’s cheaper than the insurance bite.

Reports from employers are very depressing, though not surprising. Having represented big health care employers with sorry health plans for decades and seen the abysmal participation figures, we were hardly shocked, but still reading figures for huge food service companies with tens of thousands of employees and their reports of only 500 workers out of 25,000 actually signing up for employer insurance is ridiculous. The workers are blocked from access to ACA marketplace subsidies and cost sharing because they have opted out of corporate insurance, but they have opted out because the costs are too high and the benefits are too crummy with essentially catastrophic coverage and deductibles as high as $6000. Who can afford any of that on $10 or $15 per hour?

Increasingly, it seems clear we have a little bit of something for health insurance, but it’s only a bit better than nothing, and under the private company and corporate-centered regime, it’s too pricey and too paltry. We need real national health insurance, but that means a more significant governmental investment, and that is a bridge way past the level of political consensus.

It is also way past the level of public support, which fuels the continued opposition to Obamacare. When even the primary beneficiaries of the program among low-and-moderate income families are still priced out of the market, who is left to show the program the love it needs and deserves?

Half-stepping clearly has only gotten us halfway to where we need to be. We shouldn’t be surprised, but that doesn’t make it any easier to live with the disappointment or the continued perilous state of national health protection in the United States for low-and-moderate income families.


Affordable Care Act Renewal Time and the Puzzles for Workers

healthcareNew Orleans      The window has now opened for new signups under the Affordable Care Act.  This time around there won’t be any do-overs or make-ups, I’ll bet.  The Administration is already soft selling the numbers and predicting less than 10 million enrollees by the end of 2015, dampening expectations, either tactically or determinedly.

            This is also the renewal time for last year’s enrollees.  The earlier guidance from DC had been to just let your plan automatically renew, and you would be OK.  Now the new message is that everyone needs to start shopping on the marketplace website to try and find the best deal.  Generally the average of national insurance increases is relatively modest, but some renewals are as high as 20%.  Furthermore there are some new companies entering in different states and reducing prices to catch up with some market share, so there may be bargains if you take the time and go on.

            Cross your fingers and hope it all works this year!  There will be fewer navigators, so in many places you will be on your own.  Less money for the program this year, and what programs that were funded are beating the bush in the nooks and crannies of the country for new enrollees.

            Interviewing Kim Bobo, the executive director of the Chicago-based Interfaith Worker Center on Wade’s World on KABF/FM 88.3, she was recalling the old tradition in some large cities in the USA where churches and synagogue basements once housed worker centers that were designed to give people advice on these kinds of programs.  There’s not much of that now.  Kim’s network of 200 worker centers are focusing, appropriately on wage theft and basic rights, but this Obamacare is complicated and not easy to add to the menu.  Local 100 United Labor Unions is using our experience as navigators during the first year to establish Citizen Wealth Centers in Houston, Dallas, Baton Rouge, New Orleans, and Little Rock to support our members and their communities, but there’s no question the demand is going to outstrip capacity everywhere.

            And, confusion reigns.  There are some questions where no amount of research or direct calls to CMS and other experts have yet given us confident answers, so this is a call for a bit of crowdsourcing help.  The employers over 50 workers are coming under the mandate this year, and these high deductible plans are spreading, as are so-called “skinny” plans and other offerings that may not even meet the basic requirements, yet are likely to dominate lower waged work and the service sector.  There’s a penalty for employers of $2000 per worker if they offer nothing or an unqualified plan.  That much is clear.  There’s a higher penalty of $3000 per worker though if that worker goes to the marketplace, buys insurance there and gets a subsidy.  At the same time corporate consultants are telling bosses to audit their workforce to establish that they covered 70% of the workers and offered plans to everyone.  Makes it seem like they have to hit 70% or over, doesn’t it?  We need to know for certain.

Here is where we’ve suddenly gotten bogged down as we look at some crummy plans and whether or not there is an organizing campaign that might be possible by having workers desert the company’s bad plan for the marketplace where they might get both a better plan and a better deal.  We really need to know, yay or nay, whether or not workers might have some leverage in pushing for a better plan if they deserted the company’s pretend plan and triggered penalties individually?  And, if workers were able to organize more than 30% out of the plans, does the whole crummy corporate plan fall like the house of cards it is?

Like I said, it’s muy complicado, but vitally important and important now.  If anyone out there is confident they know the answer, let us know ASAP!



Small Employers and Nonprofits Caught in Healthcare Bind

why-small-businesses-arent-using-the-health-insurance-tax-creditNew Orleans    Talking to small employers about the health care exchange has been a slog, and it doesn’t look like it will get that much easier soon.

The numbers are also somewhat daunting in the aggregate. Businesses with fewer than 50 workers don’t have to provide coverage under the mandate. They employee 34 million people though which is not insignificant. According to the Kaiser Family Foundation, many of them in fact are dropping coverage with only 44% of companies with 3 to 9 workers offering anything for health care compared to 52% a decade ago. Wellpoint, one of the big-boy insurers said they handled 300,000 fewer folks in small-group plans in 2014. Aetna claimed it wasn’t hemorrhaging clients, but is doing a deal with Walmart’s Sam’s Club to offer a private exchange option outside of the marketplace, which seems to indicate otherwise.

Many smaller employers add up the costs and what they can afford to offer and realize with the subsidies their workers can get through the marketplace, keeping a small-group plan actually gives their workers worse coverage at higher costs than they can afford to provide. According to the New York Times there are even insurers trying to exploit potential loopholes that seem against the rules, like Health Care Services Corporation, which is trying to offer a private-exchange where a boss can have a group plan paid with pre-tax dollars and somehow still allow some of the lower paid workers to go to the marketplace for a better deal. This is the kind of stuff that gives all of us migraines.

Furthermore the only real “carrot” here is a tax credit for the small businesses. The tax credit is a come-on for a couple of years and might or might not be continued, which poses a problem. Plus there are lot of workers that are employed by nonprofits. I know and in the old expression, “cuz I are one.” Tax credits are worthless for nonprofits because they can’t be used.

But, it all gets you thinking. I had an organizer the other day with our local union who has worked as part of our team for more than 16 years. He wrote me indicating he was getting to an age where he thought he might be able to get a better deal than our employer-paid, good benefits, Humana plan for both him and for us. In a number of our nonprofits we’re pinched by the gap, where we’re paying almost $1000 per month for older workers and only a couple of hundred for younger workers in their 20s and 30s. It’s also fair to say that we don’t pay extravagantly to say the least. Would they all be better off if they went to the marketplace, and we raised their wages a bit and provided some kind of separate health care benefit? As nonprofits we don’t have the before and after tax problem except when it comes to paying social security and similar requirements. As a matter of principle we have always had health care coverage for our workforce, but we’re now caught in the grips of “mission-and-means” conflicts when suddenly and shockingly our own workers might be more able to get better health care than we can afford and provide by going through the marketplace, and we might have more money to get where we’re going.

Did I mention already that talking to small employers about SHOP and the Affordable Health Care is confusing and a slog already? Yes, I guess I did, and the more conversations we have with some of them, it becomes hard to tell if the marketplace is embracing them as employers or moving them to let their workers do their best with Affordable Care.

Mid-November when the marketplace opens again is going to provide some real headaches and gnashing of teeth for lots of people and employers making decisions about what’s best, even those that want to do right.


Are New Obamacare Rules Another Step Backward for Low Wage Workers?

lowwageNew Orleans    It isn’t hard to understand the thinking behind the new IRS regulations to clarify the rules for employers who might be trying to hustle the margins on the Affordable Care Act and “dump” workers onto the system to save a couple of bucks.  The problem is that the rules completely ignore the reality of lower wage workers and the inadequacy of the ACA to provide them with basic health care in a flawed system dependent on shoring up private insurance companies.  Here’s why.

The new rules say that employers cannot fulfill their obligations by transferring money to workers to assist them in enrolling by paying their premiums and cost-sharing.  The IRS has effectively determined that so-called “employer payment plans” make employer contributions taxable and do not qualify to prevent penalties for not providing employee health insurance.  Part of this is based on an assumption that may hold true for large scale, legacy employers, but is non-existent in the service industry where so many lower wage workers are employed.   As Robert Pear writes in the Times:

When employers provide coverage, their contributions, averaging more than $5,000 a year per employee, are not counted as taxable income to workers. But the Internal Revenue Service said employers could not meet their obligations under the health care law by simply reimbursing employees for some or all of their premium costs.

As Local 100 of the United Labor Unions bargains with large regional and national healthcare companies on units with hundreds and thousands of workers, we grapple with this problem continuously.  These employers offer health insurance but historically the premiums have been so high for workers making less than $12.00 hour that participation was minimal, certainly less than 10% of the workforce and usually less than 3% of the workers, most of whom were confronting health issues so were willing to sacrifice paychecks for health coverage.  Now companies have giant loopholes which allow them to qualify their plans by reducing the premiums to less than 9.5% of income but putting no limits on the level of the deductibles, which are often ranging over $5000, effectively meaning that the workers in normal circumstances will be paying for so-called health insurance that will give them virtually no benefits.  All of these workers would be better served by accessing the marketplace and they would save money doing so because they would access subsidies and cost sharing support.  Because the Act in its current form is largely an insurance company support mechanism rather than a comprehensive health care alternative, we have been desperate to convince employers to work with us to find a solution that would not cost them anymore than they have to pay, but give the workers real coverage.  In state after state where the reimbursements for nursing homes, mental health and mental retardation, and other health support services have been frozen or cut, the companies aren’t sitting on extra money, so they’ve been listening, but now the mountain has become even higher to climb.

Oh, the new rules threw a scrap on the table for organizations like Local 100 and our partners who have been determined to help people enroll in Obamacare.

In a separate rule, the administration prohibits states from imposing onerous restrictions on insurance counselors, who educate consumers and help them enroll in health plans. Under the rule, states cannot establish standards that impair the counselors’ ability to help consumers or to perform other tasks required by federal law.

So, states will not be able to block the work of navigators, though unfortunately navigators will be forced to tell lower waged workers that their options are in many cases somewhere between bad and non-existent in service sector jobs.  The IRS regulations are meant to prop up private health insurance companies with more robust employer participation, but are presuming a workforce from the 1950’s, not the dominant lower waged, service sector employment of the 21st century.

This isn’t going to end well for lower wage workers and their families.