Obamacare is Delivering Some of the Goods in Poor States

Screen Shot 2016-08-14 at 10.37.59 AMNew Orleans   There are now some thirty states that have expanded eligibility for Medicaid under the Affordable Care Act. There are twenty states – and a lot of the Republican Congress — that are still dragging their wagons through the dirt, and, if researchers are right, putting their people under the ground as well.

Researchers connected with Harvard’s Public Health School conducted an important experiment. They surveyed people in Kentucky and Arkansas before Medicaid expansion in 2013, again after the first full year in 2014, and finally at the end of 2015 with another year under peoples’ belts. They used Texas as the so-called control state for comparison, since Texas refused to budge on the Obamacare Medicaid expansion for lower-income, working families. Bottom line: 5% more people in Arkansas and Kentucky, too very different states with different approaches on the expansion, felt that they were in “excellent” health compared to do-nothing-much Texas.

Reading about the researchers work on the Harvard Public Health website and its lead author, Dr. Benjamin Sommers, an assistant professor there, offered a good summary that goes deeper than 5%:

Sommers and colleagues surveyed approximately 9,000 low-income adults in Arkansas, Kentucky, and Texas from late 2013 to the end of 2015. The results showed that, between 2013 and 2015, the uninsured rate dropped from 42% to 14% in Arkansas and from 40% to 9% in Kentucky, compared with a much smaller change in Texas (39% to 32%). Expansion also was associated with significantly increased access to primary care, improved affordability of medications, reduced out-of-pocket spending, reduced likelihood of emergency department visits, and increased outpatient visits. Screening for diabetes, glucose testing among people with diabetes, and regular care for chronic conditions all increased significantly after expansion. Quality of care ratings improved significantly, as did the number of adults reporting excellent health.

Debate over? Of course not. Many will wonder, and wait, until larger studies, including the government’s own, provide more data on whether or not people really are healthier or just feel healthier.

Regardless, how people feel may not answer the medical questions fully, but could start to provide answers for the political questions. As we find every day, particularly in the Age of Trump, people vote on how they feel, not based on the facts of the matter. If everything were equal, politicians would see that the trend line of how people feel about their own health and Medicaid expansion is now improving annually. If it continues along these lines, politicians will start playing “duck and cover” which might mean more expansion in the twenty holdout states.

There’s a big “if” though. These same politicians would actually have to care about the poor families that are the beneficiaries of Medicaid expansion, and believe, regardless of the evidence, that they vote, and that some of these poor are their voters.

It might be easier to deliver better healthcare than to convince elected officials of the value of the poor and their votes.


Penalties Under the Affordable Care Will Hit Lower Income Workers Hard

tax-penalties-carousel-rappler-20140416New Orleans    The good news in the narrative of Obamacare is that everyone gets covered, there are basic guarantees, and in 60% of the states more people, particularly lower income children, are covered by expanded Medicaid. Those are just the highlights, and they are lifesaving. The controversy continues for conservatives and businesses around the mandates, the fact that all businesses of a certain size are required to provide coverage. In truth, this is largely a fiction. The quieter, more painful, side of the mandates is the fact that everyone is required with some exceptions to embrace the coverage offered and available, and if not are also required to pay a penalty. The penalties were relatively trivial, but are becoming more expensive.

The fictional burden for companies has proven to be Swiss cheese, a drum I’ve admittedly been beating for several years now. Payments for monthly premiums could not be higher than a certain percentage of a worker’s gross payroll, but unlike the Massachusetts model, there were no limits on deductibles and little to none on co-pays. Nursing home chains, janitorial contractors, mental health and home care providers and untold other employers demanded and eagerly received from the insurers bare bones, narrow network plans with deductibles ranging from $4000 to $6500 along with significant increases in co-pays and of course required payment of monthly premiums.

The real cost to employers? Almost nothing in practice, because lower waged workers, making less than $15 or $20 per hour are priced out of such policies both by dollars and common sense. If a nursing home worker is making $10 per hour – and many aren’t! — and works an industry standard 35-hour week while being paid for annual labor about $18,000 in gross wages, and might be facing a $5000 deductible and to be conservative another $1000, she would be losing one-third of her income before she was able to access any benefits from the plan other than the statutory minimums. Why would she enroll in the employer’s plan if she were looking after her own economic self-interest? No reason, and in fact as Local 100  looks at the participation numbers from workers we represent, almost no one is signing except those who anticipate critical or catastrophic care situations like imminent surgery.

The math for the worker in this situation when required to pay penalties, as they are in Arkansas for example, at the 2.5% assessment would be $450. Cheaper to pay the piper than the policy. In Louisiana, Texas, and the other 18 states that did not expand Medicaid, if these workers would have been eligible, and with this income and likely family size, most of them would have been, they are exempted from paying the fine. There are other exemptions, but most are catastrophic in nature as well: homelessness, medical debt, unemployment, and worse.

Everyone is talking about inequality. Politicians, economists, and columnists on all sides of the spectrum make the point about jobs increasing but wages remaining stagnant, so the paradoxical impact of this healthcare conundrum is that the pain will worsen for lower income workers with largely frozen wages. In a ton of states not only will these workers not get raises, but they will pay in this example a fee out of their tax returns collected by the IRS.

For the nursing home worker we have used as an example, a $450 penalty under the Affordable Care Act is equal to twenty-five cents per hour in lost wages. In states throughout the South with strapped budgets and reduced reimbursements for such workers, they would need to win a 2.5% wage increase just to stay even, and without a union that’s not going to happen, and in all likelihood even with a union that’s going to be rare. Such a worker, and there will be millions of them, will wake up in 2016, 2017, and find themselves in a situation where they are in a double bind with a smaller paycheck and still no healthcare coverage thanks to the miserly offering of their employer and the loopholes that allow farcical coverage to mask as real insurance.

This is a huge problem, and it is not going to end well.



Texas Goes to War Against Obamacare Navigators

15099269_s-200x238New Orleans   The news on enrollment under the Affordable Care Act puts the numbers through December 28, 2013 at more than 2.1 million people with 24% under 34, 37% between 34 and 55, and 33% between 55 and 65.  Officials for the Kaiser Foundation which has been following all of this carefully, said these figures are highly acceptable including the young enrollments, arguing that even if they stay the same through March 31st, when more younger, healthy registrants are sought, it would only lead to a 2 or 3% price increase for 2105.

            All of which is a battle cry for the right to double down, and they did so with a vengeance in Texas, which is the biggest prize for enrollment in Obamacare, by trying to deliver a body blow on all of the federally funded navigators assisting enrollment.  New rules being promulgated by the Insurance Commission are expected to go into effect on March 1st in the critical last full month for enrollment for this year ending on March 31st. 

            The Houston Chronicle couldn’t have been clearer in laying out the facts, which make it impossible not to see this as a full frontal, political assault to try to discourage and thwart enrollment before the deadline, as Governor Rick Perry has advocated loudly.

The proposed rules being developed by Texas Department of Insurance Commissioner Julia Rathgeber would require health care navigators receive an additional 40 hours of training on top of the 20 to 30 hours required by federal law. The rules would require navigators hired by local organizations through a federal grant to take an additional 40 hours of training on Medicaid rules, ethics and privacy.  ACA navigators also would pay training fees of up to $800, an additional $120 for six hours of continued education, plus a $50 registration fee. They also would have to undergo a criminal background check and a fingerprinting process that could cost up to $62, prove their U.S. citizenship, and provide documentation of their educational credentials.

By comparison, Texas Department of Insurance-certified counselors under the Health Insurance Advocacy and Counseling Program -which provides enrollment assistance on Medicare benefits – are required to complete 25 hours of training.   Navigators who help citizens enroll in Medicaid, the Children’s Health Insurance Program, the Supplemental Nutrition Assistance Program and Temporary Assistance for Needy Families are required to take only four hours of training. Those navigators operate under the Texas Health and Human Services Commission’s Community Partner program.   Counselors working in those programs do not have to pay fees for training or continuing education. They also do not have to submit to fingerprinting or criminal background checks.

            With organizational fees of $1800 and per navigator costs of $1000 a head, the first hope in Texas is to price navigators out of business.  The second hope is to stall them past the deadline.  One source argued that changing the budget for navigators would take weeks for them to get the money to pay these fees, which for big programs add up to tens of thousands of dollars, and then going through the actually training and waiting for the criminal checks could add more weeks or even months.   In Arkansas, the backlog of criminal checks delayed certification there for 10 weeks for many navigators.  The tests and training is not ready.  God only knows what so-called “educational requirements” are now involved for navigators or where this mess will end?

            The first question on the lips of many navigators involved in the critical enrollment process in Texas and elsewhere was whether the Justice Department would move to enjoin these obviously discriminatory barriers.  The second question was whether it was time for navigators to just do their jobs, since it was “life or death” for many people to acquire the insurance, and let the chips fall where they may.


Obama: He’s Got This!

New Orleans  After Romney’s 47% comments went viral, I thought the campaign was done, and you could put a stick in it.  I still think he may have lost the race there by showing both his disregard for huge parts of the electorate and coupling that with his choice of Paul Ryan, pushing seniors and others with a stake in entitlement programs like Social Security and Medicaid the final distance towards Obama.

It’s a mystery to me how Obama allowed Romney to get back into the race with the first debate.  I thought talking was Obama’s forte?  The debate once again exposed his tentativeness around conflict, which has been a consistent vulnerability throughout his first term, exploited continually by the hardcore, ideological Republican opposition.  Obama does dial down the enthusiasm everywhere when he says, “I’ll fight for you,” and it becomes so obvious that he just plain doesn’t like to fight.

Anything can happen in an election, but having come back in-country, caught up on a lot of the papers and studied the polls, I think Obama’s got this one locked down for this Tuesday, all except the shouting.

No small reason for me finally feeling confident about the race lies in what looks like insurmountable leads in the key battlegrounds of Ohio and Florida that are now trending more than 5 points ahead for the President, comfortably past the margin of error.  Additionally, it appears that based on known Democratic registrations, Obama is leading comfortably ahead of Romney on what has become the critical early voting numbers, which are key tests of organization and have people finally “voting with their feet.”  The hard facts that 23,000,000 voters have already cast ballots and Obama is likely significantly ahead, I take is important.

Governing is a whole different problem.  Looking at a map in my local paper showing where Obama is leading or leaning versus Romney, it is startling how similar the overlay of a map of the residual labor union strength would be.  Not that Obama is going to do much for unions even though they are critical to any Democratic victory now or in the future.

On the other side I read the column by the former solid sports reporter in my hometown paper, who now writes op-eds for them from a hard right, whack perspective and I tried to puzzle out his absurd argument that we should vote against Obama because he was a “collectivist.”  Huh?  “By the people, of the people, for the people” is now a bad thing, so anarchy hooray, I guess.  Obama and the Democrats got lucky that the conservative wing is so whack now that they are pushing away as many votes as they are holding.  Eventually the conservatives in the Republican Party are going to hose them down or force them out so that they have a chance again at the White House.

Until then, we’ll win with Obama on Tuesday, and it won’t necessarily decide much of anything other than how bad the alternatives might have been.


Paul Ryan: OMG, Where is Sarah Palin When We Need Her?!?

Missoula  Coming off the river after a great 10 days of fishing and fun, topped off by a pig roast and hootenanny with good friends, old and new, we headed into our Missoula home away from home, the Break Café and Bakery, our favorite local coffeehouse, though we wish the coffee were better….Plug in all of the electronics since they are screaming for juice, and as the emails start pouring in it becomes clear that the Tea Party and Little Government intellectual and ideologically dogmatic Congressman from Wisconsin, Paul Ryan, is destined to be Governor Romney’s vice presidential pick – OMG what a kick in the guts:  it just takes your breath away!   Now we have toadying to the rich and Wall Street at the top of the ticket and wet kisses to the most reactionary of the Republican regressive reprobates at the bottom of the ticket with Ryan.   Sarah Palin, where are you when we need you, we have now gone from the ridiculous to the obscene.

On the upside, we can’t say there’s not a clear choice now, if anyone had thought that.  Romney has suddenly made a statement to the hard right that is a big sloppy kiss, and to the rest of us has been clear that there is no longer a “moderate” George anywhere around.  It’s ass kicking time, and it’s our butts that have a bull’s-eye for his foot.

Social security, Medicaid, social services, and safety nets, Ryan is clear with his no compromising, “cut first, look later” style that there’s no hope for any of these constituencies from the sick to the seniors if this team emerges victorious.  They would be S.O.L!  Uh, that means, we would all be S.O.L.

If there had been any warm fuzzy headed doubters before, that’s all over, Grover.  It’s the battle of the knifes now, and it’s ON!


Enforcing Adequate Medicaid Cover for the Poor

Nmedicaid+comicew Orleans Reading the report was one of those Sports Center “come on, man!” moments.  This couldn’t be true.  The top Democratic were filing an amicus curia (friend of the court)  brief with the Supreme Court to try to overturn the Obama Administration’s efforts to allow cutting the standards of health protection under Medicaid for the poor by various states.  Furthermore, this was no rouge group but heavy hitters like Nancy Pelosi, Henry Waxman, Harry Reid, and Max Baucus.  They were joined in similar amicus briefs by former health officials, civil rights groups, the AARP, and others.  What the heck?!?
Here’s the problem.  The feds sent a truckload of money to the states and in California where this case arose the number is $20 billion.  The states have to pick up between 25 and 50% of the costs with the feds on the long end of the stick for 75 to 50% depending.  In the crushing domino fall of the USA economic meltdown not surprisingly the poor would be first in line for a beating.  States in dire straits whack down on their Medicaid spending to save money by cutting the standards of care giving themselves a break and finding a friend on the other side of the deal in the federal government which therefore also saves on its share, leading Obama, the health care coverage so-called advocate, to pop the poor hard.  Reimbursement rates get cut when this happens, so doctors feel the system and the poor not only have diluted coverage but no providers either.
Robert Pear of the New York Times is on this beat and cites the other problem which is the requirements of the law:

“Federal law says Medicaid rates must be ‘sufficient to enlist enough providers’ so that Medicaid beneficiaries have access to care to the same extent as the general population in the area.”

In other words the law is clear that you cannot discriminate in health care coverage, the decisions of life and death, against the poor.
The Obama Administration, seeking the cowards’ cave, argues that enforcement of that unambiguous standard should be the “exclusive responsibility” of federal health officials.  The Congressional caucus and anyone else caring two cents about the 55,000,000 who are covered under Medicaid, know that the feds simply do not have the resources or bureaucracy to police all of the standards in 50 states down to the nap, so they want poor people to be able to sue California and others when they are chumped and cheaped out.  In past presidential administrations such lawsuits were not greeted with universal cheer, but they were recognized as having a vital role in securing the standards of health care and protecting the poor.
What is the political equation which makes it acceptable for the Obama Administration to aid and abet discrimination against the poor and encourage by passivity killing them with neglect?