Republicans Red-Circle and Two-Tiered Medicaid Provision Won’t Work on Obamacare 2.0

Kaiser Family Foundation

New Orleans   The Republicans in the House of Representatives introduced their whatchamacallit healthcare bill which some other Republicans are calling Obamacare 2.0, and you can bet that’s not a compliment. The rest of us might take some small measure of comfort in that, but this is more of a “hold your breath and hope for the best” moment than a relief. Before anyone jumps off a cliff or heads for Canada, it’s important to understand that this hodgepodge of a bill is kind of a rough draft. The House Committees in fact are planning to try and move this bill forward without a firm estimate on the number of people it will cover or, more importantly practically and politically, the number it will not cover. Even more surprisingly, this thing breaks a cardinal rule of all card carrying Republicans: it lacks a price tag!

So, let’s take some deep breaths and a couple of pain pills and look at some of the hidden explosives in their attempt to put their finger in the wind and see what kind of gale force comes back at them. I’m going to avoid some of the easy shots, like the fact that governmental leverage on private insurers and costs seems to be going out the window or that a 30% penalty on any break in coverage is many magnitudes worse than the Obamacare 1.0 penalties or that much of the coverage is going to be catastrophic. We’ll have plenty of time to watch all that unravel as this bill is pulled in on one gurney after another into legislative emergency rooms. We’ll pass on by the deliberate and discriminatory attack on Planned Parenthood or the fact their bill seems to allow no insurance that will cover any voluntary abortion, because we’ll have to address those issues separately and soon.

I’m just going to focus on one of the more egregious and blatantly political and deliciously chicken chirping pieces of this bill. They realize that the major advance in healthcare coverage has been to lower income people through expanded Medicaid, and they recognize that politically they can’t handle the blood on their hands of just throwing people off of insurance without any alternatives. So, their proposal is that they will continue to pay the full federal freight as promised to the states through 2019, so for almost three years. Beginning in 2020 though they would red-circle those enrollees and continue to pay full sticker price for them, but for all new enrollees after 2020 they would two-tier them to a lower level of federal financing. Those of us with experience with labor contracts are very familiar with these kinds of tactics. The goal is see the red circled group gradually diminish or in this case, die, and pay less, often much less for the newcomers. As most companies could share with the Republican legislators, this is a prescription for pretty much universal unhappiness and a political gift to organizers and progressives since it creates a huge, semi-permanent second-class constituency ready to constantly demand first-class status which is the American way.

The Republicans will then be forced to defend something that is their worst nightmare: an entitlement. No matter what lipstick they try to put on this pig, funded high or funded low, it will still be an entitlement, but to their horror it will be an entitlement where the recipients aren’t grateful, but mad as wet hens.

Furthermore, just to see the whole scenario rollout here, what will keep all of the schoolhouse door governors who have been unwilling to expand Medicaid because they weren’t sure what would happen after the first couple of years to the federal-state costs from now jumping into Obamacare 2.0 while the window is open until 2020 so that their state’s citizens aren’t the last ones left behind the door when the health insurance was being given out.

The good news for poor people in the United States is that millions more would be covered, and entitled. The sweet irony would be that the cost of Obamacare 2.0 going into the 2020 election for President would be even higher, the Republicans would have to defend it, candidates would claim they were going to get rid of the two-tiered proposal if elected, and some form of publicly funded healthcare in the United States would be set in stone.


Where are the Citizen and Patient Protests to Protect Affordable Care?

New Orleans   In the activist moment with cries for resistance, I wonder why the healthcare issue is being left behind by many, as well as the current Obamacare beneficiaries, and why we are not all massing in protest at the threats and head fake proposals to replace care?

Don’t misunderstand me, I’m aware of the moving stories at some of the Congressional town hall meetings where some of the sick and infirm along with others have asked their electeds the hard, life-or-death questions, involved in eliminating healthcare insurance. I know the risks to the Affordable Care Act and the fear it has stirred has increased support for the Act past 50% in the polls. I know the Koch Brothers are trying to rekindle their grasstips base to demand repeal or else. I know the Freedom Caucus, concerned Republicans, and others are pointing out the costs and naked emperor-has-no-clothes aspects of Speaker Paul Ryan’s so-called secret plan demonstrating their divisions. I know the President has discovered that health care is complex. I know various sides, pro and con, are on the airwaves with video and sound bites.

What I don’t know is why we aren’t seeing people in motion in serious numbers?

With more than 20 million people on Obamacare and many of them on the highly threatened expanded Medicaid coverage the ACA triggered, that would seem a big and bad base ready for action. If our neighbors and friends in this group are just scared and confused, how about the many millions in schoolhouse door states that stubbornly refused to expand care, take Texas for example? Or, Florida, Georgia, North Carolina, and Wisconsin? Don’t tell me there aren’t millions in that number caught in the gap between low income qualification and not enough income to afford insurance. And, how about all of the service workers in nursing homes, home care, food service and elsewhere with company provided play pretend policies with $5000 and more deductibles who want reform so that they can finally have coverage?

Don’t tell me there are not millions mad and desperate for care?

Where is the campaign that moves people state to state in this fight, like the effort that helped win the fight in the first place? Where are the community organizations that are listening to their members and making this the issue they are moving on right now?

Is the issue too complex as Trump claims? The tactics are numerous, so are the targets the problem? Sure the distance is huge between us and DC, both physically and philosophically, but how about state legislators and governors, those are closer, and every report seems to say, governors are on their knees begging the White House not to cut and run on Obamacare, dumping the problem to them without enough money to fix it. How about hospitals? If we start hitting them hard on charity care that they are supposed to be providing, but aren’t and their tax exemptions, maybe they would get in gear. A couple of thousands of them according to IRS reports are making more than a million a year, so they might move to the feet and voices of patients’ protests and demands?

The problem with resistance is that it’s reactive. We need offense, not just defense. We need it now before our weaknesses devour our strengths.


Loopholes on Employer Mandates of Obamacare Killing Low Wage Workers

ACA-Employer-Mandate1Shreveport    The devil is in the details, and lower waged employers, like large nursing home chains, have figured out a way to be the devil with the details when it comes to making a mockery out of the employer mandate to provide healthcare coverage. Bargaining a renewal contract for Local 100 United Labor Unions at a nursing home in Shreveport that we had represented for almost thirty years was a case study in the travesty of the law and the tragedy for the workers.

In fulfilling the information request and providing details on the health insurance offering for the workers, this company, the second largest nursing home chain in Louisiana, gave us a mishmash of materials forcing the bargaining committee to ask a number of questions hoping for a glimmer of hope that didn’t seem obvious from the materials, but no such luck.

We saw two plans. One that covered some our bargaining unit, including the activities director and maintenance staff. The other for all of the certified nursing assistants.

The first plan was no Cadillac plan, believe me. The deductible was $2500 for an individual in or out of the network. The examples of coverage were cautionary. If you had a baby costing $7540 from the hospital, the plan would pay for $3530 and you would be out $4010. The second plan was from land of Simon Legree. The deductible was a whopping $6350 per person, the highest we have seen or heard of anywhere, no matter the low wage employer! Worse, it covered almost nothing. Having a baby with the same cost would have the plan paying less than a grand and in fact only $940 while the patient paid $6600 with the deductible now stated to be $6400 and something called “exceptions” adding another $200. Managing diabetes was another example where if the cost were $5400 on the first plan, the worker would pay $3280 and the plan $2120. On the second plan we devolve into farce, where on the cost of $5400, the plan would pay a measly $20 bucks and the worker would pay $5380. Yes, $20.

This is more than enough to describe the horrors here, but adding insult to injury, remember that the worker would also be paying for this sorry story. The rate of payment was not fixed which was a first for in our experience, but was calculated to the wage of each individual worker so that the company could squeeze the last penny of the 9.5% allowable for an Affordable Care Act plan from the worker. The cap was $175 per month at the highest worker’s wage and the minimum was around $111 per month figured at the individual worker’s hourly wage times 130 hours for a regular employee times 9.5%. No math shaming here but if you are a certified nursing assistant to elect this plan the employer begrudgingly was providing under the employer mandate of Obamacare, you would be paying anywhere from about $1300 to $2100 for the ability to claim health insurance on your job where you would then have to pay more than $6000 before you got the first dollar worth of health insurance benefit. The math is daunting. These are workers making less than $20,000 per year and closer to $18000 annually who would be paying up to $8000 out of their income to access any benefit from the policy! Incredible!

The employer insisted that the plan qualified, despite our objections, and, frankly, it may. The employer had no answer to the question of why all workers were not put in the first plan which was hardly a gift. The employer pretended not to have available the number of workers who had elected to pay for this travesty of insurance, even as the union asked if it was more than one and less than ten workers.

Meanwhile the workers are blocked from the subsidies and cost sharing payments provided under the Affordable Care Act, because their employer supposedly provides health insurance if that is what you call what is described here. And, to pile on since none or next to none are foolish enough to join this so-called plan that means beginning in 2016 the workers will pay a 2.5% penalty on their gross income or $450 to $500 for not having insurance, so their boss can take more money to the bank.

Needless to say there’s no Medicaid expansion yet in Louisiana – and many other states. This is not a health care solution for lower waged workers who desperately need health care protection!


Legislators Leveraging Hospitals to Pressure Governors to Expand Medicaid

Mid City ERNew Orleans       In Florida, there is a well-publicized breech between the Republican Governor and the Republican-controlled legislature over their budget shortfalls and the need to bridge the gaps by expanding Medicaid.  The governor, Rick Scott, has gone to wild extremes of suing the federal government to try to force a change in the already settled matters of disproportionate share funding and blaming the federal government rather than adding Florida to the list of Affordable Care Act states.   Scott believes the hospitals, desperate for more funding and some in danger of closing, are lined up against him.

Interestingly in Louisiana much the same Republican-on-Republican division has also quietly broken out over disagreements over budget gaps and health care needs.  The legislative session is almost over, but rifts are huge.  Governor Bobby Jindal is so dedicated to his ambition to fail as a Republican presidential candidate in hopes some other Republican will win and give him a job, that he has chained himself to the hospital door to prevent the expansion on Medicaid for the 400,000 uninsured in the state.  Interestingly, the Jindal “no-tax” pledge of the state’s health to Grover Norquist has created devastating economic consequences in Louisiana especially with the cataclysmic dip in oil prices.

Public education is more popular in Louisiana than poor people or their health care, and the evisceration of the higher education funding under Jindal has also reached crisis proportions.  In a slick political move in the funding chess game, House leaders, who are obviously disproportionately Republican decided to fund higher education – against the Governor’s budget recommendations – in the next year leaving the state’s health care system at least $200 million short.   And, this starves a health care system that is invariably ranked near the worst in the country, and also threatens dubious agreements that Governor Jindal concocted with private companies to take over Louisiana’s public facilities.  Another $33 million in state is also needed to leverage federal funds to finish building the new hospital facility in downtown New Orleans that was designed to replace the Charity Hospital, shuttered after Katrina.

Tellingly the Advocate reported that “…Capitol insiders said they believe House leaders left health care alone on a limb to create pressure for the Legislature to expand Medicaid…a proposal that Jindal and the Republican controlled Legislature have rejected so far.”  The same report, referencing again unnamed “Capital insiders” added that they “…also suggested that House leaders left health care unfunded to cause hospital and other health care lobbyists to rev up their considerable sway to pressure anti-tax lawmakers to approve more tax measures.”

Regardless of what the Supreme Court decides about subsidies under Obamacare and any number of other issues, it seems the only thing stopping expansion of Medicaid, even among hardcore “hospital door” politicians trying to block health care for the poor, is political stalling and logrolling as Republicans try to position their “never Obamacare” positions with the desperate needs of their own health care systems and their longtime supporters and friends in their state hospital facilities with their deep community support and large payrolls.  Last minute, Hail Mary, lawsuits and meaningless pledges to DC power players are not going to be enough to protect the ideologues from their own citizens and their needs.  It seems the clock is ticking in our favor, if people can live long enough to make it.


This song goes out to a faithful reader who made the suggestion of posting this great video on the next blog about health care.  Thanks Mike.

Pokey LaFarge’s  Close the Door – Live 


Affordable Care Act Gap Hits Black and Hispanic Adults the Hardest

100423483-health-care-cost-insurance-gettyp.530x298New Orleans    I’m not going to say that we’re not making progress because enrollment under the Affordable Care Act continues to increase despite opposition.  On the other hand there is no way not to be disappointed and outraged about the millions of uninsured adults that are caught in the gap between politicians and good public health policy
because of the failure to expand coverage to all states in the country.

The Kaiser Foundation released a report on what the people look like that are caught in the gap, and, unsurprisingly, they are disproportionately non-white, black, and brown.

Overall, more than four in ten (41%) uninsured adults of color would be eligible for Medicaid (based on income, immigration status, and age) if all states adopted the Medicaid expansion, comparable to the share of White uninsured adults who would be eligible.  If all states expanded Medicaid, nearly six in ten (57%) uninsured Black adults would be eligible, but only about a third (34%) of uninsured Hispanic adults,
reflecting the fact that a greater share would not qualify based on  their immigration status

This isn’t pretty at all and of course it’s life and death.

The southern states is where most of the damage is done, and given their size the worst of it is obviously in Texas, Florida, and North Carolina.

Overall, more than half (53%) of poor adults in the coverage gap reside in just three states, including Texas (26%), Florida (18%), and North Carolina (10%).  However, the distribution of people in the gap across states varies by racial and ethnic group. For example, four in ten (42%) of the 1.6 million uninsured poor White adults in the coverage gap reside in Florida (20%), North Carolina (11%), and Texas (10%), while nearly half (47%) of the 1.0 million uninsured poor Black adults in the coverage gap reside in Texas (18%), Florida (14%) and Georgia (14%).  Among Hispanics, more than eight in ten (81%) of the 0.9 million uninsured poor adults in the coverage gap reside in just two states, with six in ten (61%) in Texas and one in five (20%) in Florida.

It makes me wonder how Republican candidates for President can pretend that they might want to increase their share of Hispanic votes in the case of Bush and Rubio in Florida and Cruz in Texas, when they have not advocated expansion of care.  What says Rand Paul from Kentucky, where care has been expanded, and he is trying to position himself to get more black votes? Is he going to step up for expansion?

We could go down the list of the Republican hopefuls.Scott Walker of Wisconsin and Bobby Jindal of Louisiana are clear in their call to “let  my people die!”  But how about Huckabee, the former governor of Arkansas who had his own healthcare plan once upon a time?

Expansion for all should be a litmus test for voters in 2016, just as firmly as it has been a litmus test for the opposition in Congress for the last half-dozen years.


Please enjoy The Mountain Goats “The Legend of Chavo Guerrero” and Mumford & Sons “The Wolf”  Thanks to Kabf. 


Remember Bush’s Medicaid Expansion? Same Problems with Obamacare!

52524b892476c.preview-300Ocean Springs    News analysts are already noticing some shifts in the dogmatically ideological opposition of the Republicans to Obamacare as they come to grip with the fact that despite a plethora of problems, two million people are likely to start the new year, 2014, enrolled under the Affordable Care Act or Obamacare with millions more to come.   These numbers are certainly beneath expectations and predictions but still start to represent a growing constituency that is not going to be happy and will be quick to defend against losing these new entitlements.  The Republicans are going to have to learn the lessons taught about new social programs since Roosevelt that once on, there’s no going backwards.

Similarly, I found it interesting to read Richard Thaler and Cass Sunstein’s book, Nudge:  Improving Decisions about Health, Wealth, and Happiness, especially the chapter which looked at the government’s problems during the George W. Bush Administration in expanding drug coverage for Americans under Medicaid Part D.  Wow, talk about some same-same in the mess and mayhem that we’ve now so quickly forgotten.

One of the things Thaler and Sunstein found that is definitely true of Obamacare is the fact that “the more choices you give people, the more help you need to provide.”  Amen!  With four levels of benefits and over 30 company plans on offer in Texas for example, even with websites humming, these are just plain hard choices for families, especially those who have been previously uninsured and are therefore unsophisticated about the various options.  Furthermore, as they reminded about Medicaid Part D, “…many people are still not enrolled in the program…four million uncovered Americans is a large number.”

Part of what the authors argue is that when people don’t know what choices to make or are confused by default they make no choices whatsoever.  With this experience then and now with Obamacare, it seems even clearer that they are correct that it would have been better to enroll eligible people by default and let them elect to move to other plans or decide to continue to be uninsured than scale the complex maze to coverage.

Thaler and Sunstein were also very critical of random assignments, similar to what some states like Arkansas have adopted for their Medicaid expansion programs in the absence of choices, because random assignment didn’t work for Plan D because it mismatched people’s drug needs insurance policies that were unable to handle it.  Random assignment, they argue correctly, is more about protecting each company’s market share than fitting the consumer’s needs.  Better for people to have what they refer to as a “choice architecture” with a clear path of decisions for the consumer so that a better informed choice can be made.  As they state flatly, “Random default plan assignment is a terrible idea.  If a poor person is assigned to a bad plan and does not switch, her drug bills may rise, or she may decide to stop taking an expensive drug, as some already have.”  They give an example of a Massachusetts company, Experion Systems, that developed a better on-line “drug plan assistant” tool to “guide better decision making” and was much more user friendly that the government’s website.

Sound like deja vu all over again?  And, these are self-styled “libertarian” economists not some more ivy-covered red-heads, so to speak!

We could have learned from the Bush Administration, but unfortunately even the Republicans that were part of that play seem so committed to fighting their losing Pyrrhic fight against Obamacare that they didn’t help us keep from stumbling once again and making the same mistakes this time around.

We gotta learn!