Real Health Care Reform Requires A Price Reduction Conversation

After weeks of silence, followed by news of Obamacare sabotage, health care reform policy returns to center stage. Last week, Bernie Sanders revealed his Medicare for all plan, and Republican Senators renewed efforts to repeal and replace Obamacare with a plan (Graham-Cassidy-Heller-Johnson (GCHJ) plan) that will leave tens of millions without health insurance. If it seems like American health care reform continues on the road to nowhere, it's because it does.

The Sanders plan is long on moralizing (yes, health care should be a right) and short on concrete ideas to address health care costs. The plan includes all of the usual policy proposals to lower health care costs: administrative simplicity, enhanced negotiating power with prescription drug makers, federal subsidies for health care worker training, incentives for doctors to provide better care, and making rich people and employers pay more of the costs for national health care. The only thing new about the Sanders Medicare for all plan is that now it is official.

The Graham-Cassidy et al plan put out by Republican Senators Bill Cassidy (a doctor), and Lindsey Graham is a lot like other Republican health care reform proposals of late in that it looks to reduce federal funding of health care by replacing current subsidies with smaller block grants. The bill would also reduce the amount of money the federal government gives to states to fund their Medicaid programs. But mostly the bill, if passed, will unabashedly, take health care away from millions who currently have it with no pretense of offering them anything in return. There's more awfulness to read in Cassidy-Graham, but the overarching message is that Americans do not have a right to federally funded health care.

So here we are, again, with two opposing policies on American health care reform. Meanwhile, big pharmaceutical companies continue to introduce drugs approaching or surpassing the half a million-dollar cost mark. Employers persist in maintaining health plans whose costs they cannot manage. Workers' keep on watching health care premiums eat up their small wage increases. Politicians continue to move money around from one powerful health care interest group to another. And Americans continue to fall for the you-can't-put-a-value-on-your-health and the importance of American innovation cons to justify uniquely high-priced American health care.

No Shame In the Health Care Price Game

No one disputes that
America has the highest medical care prices in the world. But in typical American fashion, some of us like being at the top of even this list. Defenders of high-cost American health care claim the costs are high because we as a country can afford it, and that that's the price tag for medical and drug innovation. But neither of these claims is necessarily true or right. Tens of millions of Americans cannot afford to pay for health care, and the high price of medical innovation shouldn't go unchallenged.

Last week there was a report about a new cancer drug with a $475,000 price tag. And it seems like just last year we in awe about a new Hepatitis C drugs that cost about $80,000 per patient. Also, just two weeks ago,
Texas Medical Center was bragging about its $50 million worth of floodgates protecting it from Hurricane Harvey. Yes, America obviously has a lot of money to invest in medical care, but is it investing it wisely, is the greatest number of people helped by these investments and who gets to make these decisions. Continue Reading...


Affordable Health Care Is No Where In Sight

Don't be fooled. After finally agreeing to pay the August Affordable Care Act (aka Obamacare) cost sharing reduction (CSR) payments to insurers, Trump and corrupt Secretary of Health & Human Services, Tom Price, remain committed to destroying Obamacare. Their goals are to pay less in subsidies that help people purchase individual health insurance plans and pay for medical care, and to scare health insurers away from the exchanges by injecting uncertainty about future subsidy payments.

Unfortunately, and despite the latest CSR payment, Trump and Price's sinister plot to undermine Obamacare is having the intended effect. Because health insurers cannot be certain that this Administration will not stall or stop future subsidy payments, they will increase rates by a higher percentage than they otherwise would have. And when health insurers feel uncertain and are afraid they won't meet their financial objectives, they take it out on everyone. That means health insurance premiums may be higher for everyone next year, even employer-sponsored group health plans.

But that is not all on Trump and Price. Their childish, mean-spirited antics only highlight a fundamental problem with a for-profit, private sector led health insurance industry. You see, American health insurers have always insisted that their profits be assured. Taking a loss in one line of business (selling to individuals) and making it up in another line (employer-sponsored and other group insurance), but still making an overall profit, is viewed as a loss for them. They want all of their lines of business to be profitable all of the time.

Even if Trump and Price admit that the Republican health care reform efforts have failed, that they will now honestly administer the Obamacare law as intended, and promise to make all future CSR payments on time, insurers will still raise rates higher than are needed until they feel comfortable that their profits will continue. How long will they wait until they are comfortable that their profits are not in imminent danger? They will wait as long as they want to, which is forever, and there is nothing we can do about it.

Health Insurers Will Always Inflate Premiums

It is so disingenuous for Obamacare critics to imply that the health insurance market was ok or even better before Obamacare. How they ignore or explain away that purchasing individual health insurance pre-Obamacare was hit or miss or that finding comprehensive and affordable coverage was impossible is beyond my comprehension.

Purchasing individual health insurance pre-Obamacare was a long and difficult experience. First, you had to find a reputable insurer that sold individual plans, and then you had to work with an insurance broker to apply and purchase the policy because you couldn't work directly with the insurer. And that describes the not too bad parts of that old way of purchasing insurance. The fact that tens of millions could not purchase individual health insurance, some because they didn't want to, but many because they were denied or couldn't afford it, tells you everything you need to know about why Obamacare or something like it was bound to happen.
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Medicaid For All Will Make Health Care Just Another Commodity. So What!

I finally agree with what health care policy writers have been saying for months—An American Medicaid or Medicare For All program may be imminent. I reach this conclusion not because of the recent failure by the Republican-majority Senate to repeal and replace the Affordable Care Act (aka Obamacare), but due to the comments of many doctors following this failure. Medical providers sense the change in attitudes away from a for-profit, insurance company driven health care system, and they want to make sure that their role is safe from public backlash and government changes.

And to make it clear on where they stand on this impending new health care world, they are reviving their
objections to the “provider” label. Although decades old, doctors hate the provider label now more than ever. They find the use of the term condescending because it links them with other medical care professionals like nurses and physician assistants—people not at their level of expertise. But the primary reason many doctors dislike being called “providers” is that they see it as a “commoditization of the doctor-patient relationship” and now you’re messing with their money.

Commoditization refers to the process by which goods become so similar that their only distinguishing characteristic becomes price. The development of tablets and smartphones are an example of commoditization. They all have the same or similar features like touch screen and syncing with other devices, etc. And even though I prefer Apple products and give the company credit for pioneering much of the technology now available on other devices, I know that I could accomplish pretty much the same tasks with a non-Apple tablet, phone or computer and at a much lower cost.

Apple is not afraid of commoditization; it expects and thrives in this type of environment. It sees the competition as good for customers because it pushes the company to innovate more. Doctors, on the other hand, hate the idea of commoditized health care. They don’t want to compete on service or price. In fact, the real reason doctors and hospitals don’t want electronic medical records or to publish their prices has nothing to do with costs but because they are afraid a competitor will “steal” their patients if they had access to this data. And, of course, doctors think that their product (health care services) is unique

To date, we have protected doctors and hospitals from real competition and allowed them to charge whatever they want for their services. A Medicaid or Medicare For All single payer health care system that includes electronic medical records and price transparency will force doctors and hospitals to compete on price. This type of system is good for the public because it’s one of the few ways, other than forced price reductions, to make health care affordable. Doctors and hospitals won’t like this more transparent health care system, but who cares; it’s coming, and they know it.
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The Health Care Reform Fight Is Just Beginning For Some Of Us

While the health care reform debate stalls in the Republican-majority Senate, individuals health insurance purchasers like me are left wondering what's next. Will Health and Human Services Secretary (HHS), Tom Price, miraculously develop a base level of professionalism and sense of duty to administer the Affordable Care Act (aka, Obamacare), the law of the land, for now, the way it was intended? Will Republicans restore the funds for the risk corridors so that insurers are certain that the government will cover losses they may incur? Will HHS role out a robust national open enrollment program for the exchanges and will they staff the effort appropriately? Or will the Senate, like the House, find a way to pass their awful health care bill, the Better Care Reconciliation Act (BCRA) before the 2018 Open Enrollment on the Exchanges?

We, I, need answers to these questions soon because the fall health plan open enrollment season is just a few months away. My current health insurer has already sent me a good luck because we won't be here for you next year letter. And health insurance companies need answers to these questions now to make decisions about what, if any, plans they will offer to individual health plan purchasers.

Reason To Be Afraid For The Future Of Individual Health Plans

It's so disheartening to witness long-term Republican lawmakers and the White House react so vindictively to their current legislative debacle. After seven years of ranting about the awfulness of Obamacare and promising a better replacement, they delivered bupkis. But don't expect these guys to hang their heads in shame, that's a completely unfamiliar emotion to them. In fact, they can't even call their failure a failure. This is
a line from the official statement put out by the Majority Leader's office on the Obamacare repeal vote.

" Regretfully, it is now apparent that the effort to repeal and replace the failure of Obamacare will not be successful."

In other words, Obamacare, which provided health insurance and health care to millions of people, is a failure but the seven-year long Republican effort that created the unpassable Trumpcare is not. The fact that McConnell refuses to acknowledge that Republicans do not have a better alternative to Obamacare that they are all willing to vote for makes me queasy.

And what's even scarier about the future of the individual health insurance market is that where McConnell leaves off in his hypocrisy and projection, Trump picks up with his mean, hateful, nastiness. Since being elected, (gag)
Trump has boasted about letting 'Obamacare explode,’ ‘die on its own,’ or ‘fail,’ as he and his fellow Republican liars and obstructionists do everything they can to undermine the law. He threatened explosion when the House wavered in passing their crappy health care reform bill, the American Health Care Act (AHCA); and now he's threatening the same thing now that the Senate's bill is down and out (for now). I think Trump is dumb enough to try this strategy, and with his devil's helper, HHS Secretary Tom Price, things could spiral out of control quickly for people like me. Continue Reading...


Now Is The Time To Start Talking About Health Care Rationing

We are right to mock the hypocrisy of elected Republican officials that criticize the Affordable Care Act (aka Obamacare) for leaving millions of individuals uninsured and doing little to address the high cost of health insurance. Instead of creating policies to address these two Obamacare shortcomings, Republicans decided to exacerbate them by withholding funding to insurance companies that all but ensure that premiums will rise even higher and fewer individuals will have health insurance. We are also right to sneer when conservative intellectuals and Libertarians extol the virtues of a so-called free-market health care system where people are free to buy or not to buy any level of health insurance, and from any location they want. When the reality is that health insurers aren't in the habit of offering a la carte health plans. There's also the issue of opaque pricing with “free market health care.” Another issue with conservative and Libertarian views on health care is that half of the purchasers can buy insurance at a significant discount because of the workplace health insurance premium tax exclusion and the other half have no such benefit.

But at some point, and I think the time is now, Obamacare supporters and proponents of single payer or universal health care will have to realistically and publicly address how their proposed policies will deal with the problems of health care costs and affordability. Unlimited health care at any cost paid for by the government is not a realistic option, and no such system exists anywhere in the world. There are and should be limits on the amount of medical care an individual receives if they are not paying for it or if doctors and hospitals determine additional care would have no meaningful impact.

Our current U.S. health care system already places limits on the amount and form of medical care individuals receive. Sometimes these decisions are based on ability to pay the cost of care, and at other times they are based on medical science. However, this approach of rationing medical care won't be sufficient in a Medicare For All style system. Rationing of medical care will have to be front, and center of any government paid health care system. But that is not to say that people will not have access to care the government won't pay for; they are free to purchase health insurance or health care individually.

Some people may believe that a government codified system of medical care rationing harms the poor and favors the rich. Not necessarily. First, the poor won't likely pay anything for their medical care, and they will have access to preventative and continuous care that should improve their health status. Second, the poor won't have to pay for costly medical innovations, one of the real drivers of outrageous U.S. health care costs, but they will benefit from them. And third, the stigma applied to government-provided health care is diminished and so is the incentive for doctors and hospitals to treat the poor differently.

Okay, But Not Now

Right now proponents of government-paid health care for all our engaged in a battle to keep the poor from losing access to medical care. They may feel that they have to accomplish this goal first before they can start the conversation about their ideal health care system. Meanwhile, opposers of government-based health care use the socialists, communists, and hippie-dippy, out-of-control spending argument to make universal coverage look less attractive than the status quo. And I fear they are winning this argument because of a weak counter-argument of a greedy, evil opposition.
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The Republican You Either Don't Need Or Want Health Insurance Reform Bill

We will never know what the private health insurance market would look like today regarding cost and affordability if the Affordable Care Act (aka Obamacare) never became law. However, there is every reason to believe that premiums would be as high if not higher than they are today and that coverage for many people with pre-existing medical conditions that purchase individual plans would be unaffordable or unavailable. But as we contemplate what would have been we should also dread what will be.

Very soon, Republican elected officials will likely pass a health care bill, or tax bill if you prefer, that will return us to the health insurance status quo, but with a twist. The Affordable Health Care Act (AHCA) passed by the House and the Better Care Reconciliation Act (BCRA) proposed by the Senate make the pre-Obamacare health care status quo look not so bad. The BCRA effectively makes individual health insurance plans worthless.

The Better Care Reconciliation Act allows health insurance companies to get away with paying barely half the cost of medical care while charging individual purchasers more than they currently pay in premiums, copays, deductibles, and coinsurance. These provisions in the bill are not just a case of more money for less coverage; they are an attempt to eliminate the individual market for all but the wealthy. Furthermore, these features of the bill are a way for the government to pay less in premium subsidies because people who can't afford these skimpy plans will drop out of the individual market altogether.

This Law (BCRA) Stinks

Bill Clinton called Obamacare, "the craziest thing in the world," he was referring to the fact that the law offered no financial help to purchase health insurance for millions of individuals. These are people like me that didn't qualify for Obamacare subsidies, Medicaid, Medicare or the employer health insurance tax exclusion. We have to pay 100% of the cost of our health insurance even though most of us are not wealthy. Meanwhile, Obamacare supporters, especially the ones responsible for administering the ACA, downplayed the size of this group or claimed that they would get around to helping us eventually.

After winning the majority of seats in the House and Senate and electing a Republican president, Republican officials seized on Bill Clinton's statement claiming their health care reform bill would eliminate the craziness.
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The Splintered Health Care Policy Goals of Conservatives Are All Bad For The Poor

Before the passage of the Affordable Care Act (aka Obamacare), America had not had a conversation about health care policy in decades. So it's understandable that many elected officials lacked knowledge about America's health care system and assumed it was performing as intended. From what they understood the health care status quo met the needs of the wealthy, professional and middle classes. And the poor, elderly and veterans had government-provided insurance.

But looks can be deceiving; individuals without any group-provided insurance were left to the mercy of the health insurance market. A market that left over 40 million of them uninsured. Obamacare came along and upset the peace of health care policy reform at the best and worst possible time.

It was the best time for an Obamacare-type law because
about 40 million Americans did not have health insurance and Obamacare provided coverage to almost 40% of them. And it was the worst time for an Obamacare-type law because the country was and is so divided on most major public policy issues. Major health care reform was introduced in a politically polarized era that became even more polarized when Trump won the presidential election, and the Republicans won a majority of Senate and House seats.

More Than A House Divided

The Republican/conservative health care policy stance is much more splintered than it is among Democrats/liberals. Democrats want Medicare or Medicaid for All, universal health care or single payer. Or maybe they just want more federal funding for the Obamacare exchanges. It depends on which group of Democrats you ask, but at least they all want a health care reform policy that expands coverage to all Americans, Republicans disagree with Democrats on the very definition of universal access to health care. Remember when the Republican Party stupidly referred to health insurance/care access as "freedom?"

But idiotic catchwords aside, Republicans and conservatives also disagree with each other on the policy goals of health care reform. First, there is Senate Majority Leader, Mitch McConnell's (a real life villain) view that replacing Obamacare is the ultimate policy goal. He couldn't care less about the contents of any health bill and its impact on the public. His only health care reform policy objective is to convince enough Republican senators to pass an Obamacare repeal bill quickly.
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Americans Never Really Wanted A Fairer Health Care System, And They're Not Going To Get One Anytime Soon

A recent New York Times article laments the "halfhearted opposition" to the pending passage of the American Health Care Act (AHCA, aka Trumpcare) by powerful groups such as doctors, nurses, hospitals and patient advocates. Health policy experts condemn the "fast-tracking" of the ACHA in the Senate. And the Jeff Sessions' hearings and other Russia collusion noise, crowd out national reporting on the AHCA as the Senate is weeks away from passing their health care reform bill.

The AHCA passed by Congress and currently undergoing revisions in the Senate, rewards the healthy and wealthy and punishes the sick and poor. Some people are appalled and baffled by the impending passage of legislation that brings more inequality into an already unequal system. Isn't it more sensible to provide the most financial assistance to people that need the most health care? Well this is America, where a near majority believes it's okay that the rich can afford better health care than the poor.

The Poor Cost Too Much

Many people think the sick are responsible for their illness(es) due to their engagement in "voluntary health risks" or "changeable behaviors." Never heard these terms before? Me neither. I guess using the term
unhealthy lifestyle didn't sufficiently make the point that sickness is a choice, and an expensive one at that.

By some estimates an unhealthy lifestyle cost hundreds of billions of dollars each year in medical care. A recent
study contracted by General Electric estimated the cost of cancer care due to an unhealthy lifestyle at around $34 billion per year. Other studies put the annual costs of treating alcohol abuse at an estimated $176 billion, smoking at $137 billion and obesity at $147 billion (2008 number for obesity). These issues—cancer, alcohol abuse, smoking and obesity—costs nearly a half trillion dollars in health care each year.

But cost concerns are not what allow the Republican Congress and Senate to easily take away health insurance from the sick and poor. The truth is that despite the passionate town halls, we don't want the poor to live as long as the wealthy. We would save money if they did not. According to the Congressional Budget Office (CBO) score of the AHCA,
that savings is about $3 billion, to start (represents reduction in Social Security payments due to early deaths). Continue Reading...


Health Care Reform Sausage-Making Grinds On

Overpricing and overcharging minorities and the poor in hospital ERs; health care specialists are driving up the cost of care; Mylan is waiting out the outrage over its high-cost Epipen and continuing its price gouging, and major health insurance companies settling multi-million dollar Medicare and Medicaid fraud cases with the government. The American health care system is a disaster and a disgrace. Greed and self-interest are its fuel. It's opaque. It's irredeemable.

And, the Affordable Care Act (aka Obamacare) trying to work with and maintain the American health care system, only highlighted all its ills. But at least the Democrats engaged in a comprehensive and intensive effort to improve one of America's biggest problems. Unfortunately, you can't say the same about the Republicans. From the start, and I'll give them credit for not lying about how vile the process would be, Republicans engaged in health care reform sausage making. Their health care reform plan consists of a three-step sausage making process—gut as much of Obamacare (cut taxes) via reconciliation, eliminate health care reform regulations, pass general health care regulation through the normal legislative process.

And like most sausage making, the Republican health care reform work is occurring out of sight. There are no experts to advise on the combination and impact of different policy options. In fact, Republicans in the Senate decided not to send their reform proposals through committees and instead assigned 13 Senators to review the House bill for further tweaking. This not-at-all discriminating approach to health policy reform all but guarantees an unappetizing product for millions. There should be no expectation of a Senate health care reform bill that is much better than the bill signed by the House. In fact, the Senate bill may be even worse than the House bill.

Initially, House Republicans were transparent about their health care reform bill. They made it clear that the Obamacare repeal law, the American Health Care Act (AHCA) was step one of a 3-step process to replace Obamacare. They collaborated with the Health & Human Services Secretary, Tom Price, to sell the proposed law to the public. And, lastly, they waited for the CBO score before deciding not to vote on the legislation. In the end, transparency was political poison for the House, and they resorted to secret meetings and hiding drafts of the revised proposal. The result was a reform bill that was just as bad as the first one but easier to pass politically. Republican senators have no desire to repeat the mistakes of their House colleagues. There will be no false starts on voting and no or little sharing of policy details before the vote, and there will be a vote and the bill will pass.

A Senate version of the AHCA will look a lot like the House version, but with
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Universal Health Care Opposition Research, Is It Worth Reading?

After spending years studying the Affordable Care Act (aka Obamacare) and related health care reform proposals, I am on a journey to explore the other side. While I've made a point over the years to read the health care reform opinions of Obamacare opponents, I never took seriously their prescriptions. But with the dreaded feeling that the country is on the path to indefinitely postpone the next level of health care reform, I decided to read and reread the writings of those who think our most recent health care reform efforts were a big mistake.

So this past weekend I read a lot of Michael Cannon
articles and blogs. Cannon is the Director of Health Policy Studies at the libertarian Cato Institute and an avowed Obamacare hater. Cannon is famous for his many attempts to sabotage the Obamacare law in its early stages by mounting a legal challenge of the subsidies provided to federal exchange enrollees. He also encouraged states not to create their own exchanges (this approach went hand-in-hand with his legal challenge as to whether the federal government could provide subsidies to non-state exchange enrollees). Of course Cannon does not view his fight against Obamacare as sabotage, and although I think it clearly was, I am setting this aside for now.

Today, I'm more interested in understanding the health care reform viewpoint of single payer and universal health care opponents. But not just any opponent, more specifically, I am interested in comprehending the beliefs of the policy wonks, the die hard free market crusaders that oppose government playing any role in providing or paying for health insurance and health care. Consequently, I am reading the works of Michael Cannon and Ron Paul. Free market conservatives draw many negative conclusions about universal health care, including:
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As GOP Looks To Drag Health Care Backwards, Health Insurers Look Forward

Recently, Congressman Steve Chabot of Cincinnati, Ohio wrote on his blog, "I haven’t seen so much misinformation and hysterics about a piece of legislation in a long, long time—maybe ever" about the passage by the House of the American Health Care Act (AHCA). I guess he was asleep during the passage of the Affordable Care Act (aka Obamacare). But all kidding aside, I strongly suspect that the Senate will continue the House's work to make American health care look more like it did pre-Obamacare. They never thought health care reform was necessary in the first place.

Republicans have the numbers to pass the health care bill they want; still, I can't help but think that a return to the status quo is not in the country's future, at least not long-term. You see, Republicans may think that they are about to accomplish something that's never happened before, taking away a huge federal entitlement program, but not even health insurers are prepared to return to the bad old days. Insurers know they passed the big-changes-are-coming-moment and are in the redefining-and-refining-our-purpose-moment, and if the GOP had consulted them during the health care reform debate, they would know this also.

What Health Insurers See As Their Future

Optimizing value by providing doctors with data analysis services.
Last week Humana's CEO, Roy Beveridge, described the country's third largest health insurer as
an IT company focused on data analytics to improve health care value. According to Beveridge, the future of health care may be using data to understand risk better and sharing this data with doctors to improve patient outcomes. Doctors can use this data to determine which patient populations need what care and how often to engage with them.

Focusing in on getting a bigger piece of the (new) pie.
Also, last week, health insurer Aetna, Inc.,
announced it would pull out of the Obamacare exchanges for next year. In addition, Aetna CEO, Mark Bertolini, reportedly said, the country needs to have a conversation about single-payer health care. However, instead of health insurers competing with the government to offer health insurance, Bertolini envisions health insurers managing the single-payer program for the government, as it does with Medicare and Medicaid.

Enhancing patient access to health care services.
The Blue Cross Blue Shield Association is looking to help the very population the AHCA would possibly harm, the poor and isolated. Recognizing that not everyone has access to reliable transportation to get to non-emergency medical appoints BCBSA is
piloting a program to partner with Lyft to provide free rides to its members. Continue Reading...


Obamacare Supporters May Accomplish More By Focusing On Multiple Policy Issues To Reduce Health Care Costs

You chose the wrong job. You're the wrong gender. Your lifestyle choices suck. You should pay for your risks. You're a celebrity and should stay out of the health care debate; also that's not how preexisting condition provisions work. The anti-universal health care set has a rational, in their eyes, retort for every appeal for government-paid health care for all.

Mocking the emotions of Medicare For All supporters is so easy it's been pushed down to the level of millennial reporters. And the formula for attacking their opponents is always the same—a charge of too much emotion and not enough facts. The fact that they know little about how health insurance and risk management works, the history of health insurance plan design and access, and the conflict associated with insurers determining risk while seeking profit is unimportant to them.

There's a wall between supporters of government-sponsored health care and those that oppose it that won't come down with appeals to decency and empathy. Still, a change in public policy is the only solution to addressing health care access and affordability. And while it may appear that policy just tilted for anti-government assisted health care reform with the Republican-majority Congress's vote to make health care less affordable for millions, that may not be a bad thing for two reasons.

One, overall the Affordable Care Act (aka Obamacare) is popular among the majority of Americans despite a vicious sounding minority that demonizes people who need assistance paying for health insurance and health care. If Obamacare "supporters" see the nation returning to pre-Obamacare days when coverage could be denied outright or so expensive as to represent a denial, they may demand to return to the protections offered by Obamacare or even greater protections.

Two, Obamacare supporters should take this as a sign to expand their support for health care reform by supporting policies that may potentially reduce health care costs. Policies that focus on alleviating hunger, especially among children and the elderly, should be at the top of the list. Also, addressing homelessness and mental illness is essential to reducing health care costs. These are issues policy advocates, and elected Democrats should include in any federal budget and hold firm on their passage. Of course, there will be opposition, possibly as strong as is currently for Obamacare, but with proper messaging, voters may come start to realize who want to address their needs and concerns.

Not everyone engages with the health care sector every day or even every year, but hunger, homelessness, mental illness and drug addiction are issues most people encounter regularly. Obamacare proponents have nothing to lose by dissecting and addressing the individual drivers of health care costs; it may even be easier than focusing solely on health insurance, which is too complex for most people to understand. Continue Reading...


America's Culture Wars Stand In The Way Of Real Health Care Reform

America has always been a nation divided. The country fought over its divisions in a gruesome war, one side lost, and the nation stitched itself together again. But the stitches never healed and America never adopted a unified identity. This lack of identity led to smaller wars, culture wars, including conservative values versus liberal values, and the role of government versus the responsibility of the individual.

And with the election of Donald Trump, America's culture wars has reached fever pitch. So much so that some people believe America is headed for a second Civil War; but if not war, towards defining a new national identity. But don't underestimate America's ability to make minor adjustments and put off making tough decisions. A second American civil war is unlikely, but so is adopting a national identity acceptable to all. More than likely, America will move in the direction of greater universality in some areas because political and social forces at the time pushed us there.

We are currently experiencing a grudging push by some toward universal health care because, despite Trump supporters' hatred of their cultural opposites, many of them need assistance paying for health care. Even conservative columnist, George Will, thinks single payer health care in America is inevitable. This is good news for single payer advocates like me because single payer would improve access to health care. On the other hand, single payer health care will not reduce the cost of health care because America is not ready or willing to address the issues that make American health care so expensive, especially the issue of poverty. Continue Reading...


Tom Price Asked Doctors To Tell Him How They Want To Get Paid. That's Ridiculous.

The big health care story last week was Trump threatening, again, to let the Affordable Care Act (aka Obamacare) implode if Democrats did not work with him to pass his health care reform bill. It's a story worth reporting because it clearly shows that Trump just wants to tick health care reform off his to-do list. Something he can brazenly claim is better than Obamacare, even though it won't be, and that he accomplished quickly and through force.

Meanwhile, while Trump was undermining Obamacare with threats, Health & Human Services (HHS) Secretary, the greedy and corrupt, Tom Price, was actively weakening the law. After the Republican health care reform law debacle, Price wasted no time tweaking Obamacare administrative provisions that will most definitely result in fewer people enrolling on the federal exchange. He did this by greatly reducing the annual open enrollment period and placing restrictions on special enrollment periods and requiring documentation for life events such as marriage, birth, and losing workplace health insurance, etc. The new rules also force you to pay the full year's premiums unless you have a life event like new job-based coverage, eligibility for Medicare or Tricare, etc. With this new rule, you cannot stop paying premiums the last few months of the year, as you could under the old Obamacare rules, to save a few bucks. Price and HHS also gave insurers the green light to offer slightly skimpier health plans. Bonus!

But Price's week wasn't done. The former doctor who wants to get rid of Medicare and Medicaid because he believes the reimbursement rates are too low
asked doctors for ideas on how they should get paid. Specifically, Price was referring to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which replaced the old system of paying doctors for Medicare services. MACRA is an attempt to move away from paying physicians based on the number of patients they see (fee-for-service model) and towards a system based on value and quality of services. Therefore, MACRA also requires reports on quality and pays physicians extra for meeting quality standards.

Price portrays MACRAs quality standards as so burdensome to doctors that they could lead to burnout and more doctors leaving the profession. He doesn't support bundled payments and likely doesn’t support value-based health care at all. He uses his credentials as a former orthopedic surgeon to claim he knows better than anyone that value is hard to define and therefore, unfair to pay doctors according to value-based standards.
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Medicare For All Requires New Health Care Industry Players

It seems everyone working in the health insurance and health care industries feels entitled to large profits. And they will do or not do just about anything to get their share of the multi-trillion dollar a year health care "market." Doctors thumb their noses at "low" Medicare and Medicaid payments, limiting the number of patients in these programs that they will treat. Health insurers balk at insuring the very sick without government subsidies to reduce their financial risk. Pharmaceutical companies threaten to curb drug innovation unless they are allowed to impose astronomical markups on existing products and enjoy long patent periods. And hospitals do whatever the heck they want to make a buck--different prices for the same care with no transparency or explanation. And these are only four of the big players in the health care market; there are many others elbowing for their share.

Under these conditions, American health care reform that tries to lower costs is dead on arrival. The powerful groups benefitting from our overpriced health care system aren't going to accept a pay cut. Some may suggest incentives to get doctors to accept lower reimbursements, like subsidizing their student debt or even reducing the requirements and the number of years it takes to become a doctor. Others may suggest performance bonuses, like the ACA tried.

There are a lot of good sounding suggestions for lowering health care costs, including drug re-importation, universal use of electronic health records, value-based health care pricing, hospital consolidation, competitive bidding for supplies, focus on tertiary care, etc. You name a health care cost cutting idea, and great minds have already penned it.

One health care cost cutting idea receiving more attention is allowing future American doctors to enroll directly into medical school instead of first getting a 4-year undergraduate degree. Medical students and the country would save a lot of money, and their student loan excuse to demand high salaries falls away. Many countries with similar or better health care outcomes require 5-6 years of schooling to become a doctor versus 8 in the U.S. But American doctors won't easily give up the prestige of being a doctor and, therefore, will continue to demand higher salaries.
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Step One Of The Cruel Republican Health Care Bill Could Actually Pass

How bad the American Health Care Act (AHCA), the Republican replacement for the Affordable Care Act (aka, Obamacare), will be for the mentally ill, women, poor people, children, older people, and people needing drug treatment is still unknown. However, everyone expects these groups to receive less financial support in purchasing health insurance and in accessing health care. Meanwhile, the young, healthy and the wealthy have something to smile about if the AHCA becomes law.

But According to Donald Trump, weakening Medicaid and providing skimpier subsidies than Obamacare is just the first step in the rollout of the Republicans' great health care reform plan. For step one of the bill making process, Republicans had to navigate a complicated legislative process called reconciliation, as Paul Ryan likes to remind everyone, including critic, Senator Tom Cotton. So Ryan took this opportunity to do something thoroughly Republican and eliminate the Obamacare-related taxes for the rich and warn the poor that their health care free ride was over.

Don’t Underestimate The Republicans Capacity For Cruelty

After rolling out step one of the American Health Care Act, Republicans in Congress proceeded to make some of the dumbest and most hypocritical remarks in political history. I'm being dramatic but I'm not the only one that attacked Congressman Jason Chaffetz's on Twitter for his dumb iPhone remark, or who was disgusted by Senator Tim Scott's dissing of the Congressional Budget Office (CBO) because he suspects it will reveal the bill as a huge takeaway for the millions who got insurance under Obamacare. And let's just try and forget Paul Ryan's misleading, inaccurate and amateurish PowerPoint presentation where he revealed that he doesn't know the definition of insurance, and his performance on Fox News where he coldly stated that he didn't care about the windfall his bill gives to the rich.
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Let's Hope The Republican Health Care Plan Stays In The Basement

Everyone wants to see the Paul Ryan/Tom Price Affordable Care Act (aka Obamacare) replacement bill, even most Republican lawmakers. But Ryan and Price would rather look like a putz than reveal who will be the primary losers under their new plan. They are also afraid that their fellow Republicans will join the media in ripping their plan apart. They have no desire to be once again the objects of a mocking press, Democrats and Obamacare supporters for their inability to present a Republican, majority-supported Obamacare alternative plan.

After embarrassing leaks describing their reform paralysis at the Republican retreat in Philadelphia earlier this year, and the leaked draft that revealed a proposal to base tax credits on age instead of income, Ryan and Price literally went underground (House basement) to reveal their latest proposal to a select group of lawmakers. There's plenty to mock about this childish approach to drafting legislation. But like all things related to Republican health care reform efforts, this latest hide and seek stunt is about politics and not providing affordable health care. Ryan can't keep putting out bad proposals that the rest of the GOP won't support. At least not publicly. He failed in his promise from years ago to lead the effort to draft an Obamacare replacement bill and is now just a mere figurehead of the process. Health care reform is now a Senate and White House effort with Ryan serving as secretary and spokesperson.

And with Senator Mitch McConnell and Secretary Tom Price leading the effort, we can expect more drastic cuts to federal subsidies and fewer people with insurance coverage than if Ryan had pushed through all of his lackluster reform ideas. McConnell has always wanted to push health care reform back to the states via high-risk pools and other disproved policies. But states have made it clear that they need federal government funds and they like the money Obamacare provided. Therefore, I expect the new Republican health care reform bill to grandfather Medicaid expansion for the states that adopted it. And based on past Ryan/Price proposals and the Trump Joint Congressional speech this week, we can easily assume that the crux of the law includes health savings accounts and tax credits that will mostly benefit the well-off, healthy and young Continue Reading...


The Battle Between The "I Was Helped/Hurt By Obamacare" Snowflakes

Since the presidential election, Trump supporters and non-supporters have accused one another of being Snowflakes, or overly sensitive. However, recently the term Snowflake is used increasingly to describe Trump supporters. Countless articles in liberal and conservative media publications warn about the dangers of referring to all Trump supporters as racists, misogynists or uninformed. They claim that these negative characterizations are starting to backfire and result in Trump supporters clinging to him even more.

And many Trump voters admit that they are completely turned off by liberal attacks and hurtful characterizations. Not surprisingly, Trump non-supporters refuse to alter their depiction of Trump voters. They find their characterization of Trump voters accurate and their feelings not worth protecting given the potential harm a Trump Administration can cause. Add to this war of words the contentious issue of affordable health insurance and health care, and you get a mini battle between people that claim Obamacare helped them versus people who claim it hurt them. Both camps have its share of Snowflakes with the "Help" combatants referring to the "Hurt" combatants as selfish and heartless, and the "Hurt" section referring to the "Help" warriors as smug.

The "Hurt" group desperately wants to explain its objections to government-mandated health insurance. They don't like being forced to pay higher premiums than they otherwise would to subsidize health insurance for people who can't afford it. Some in this group don't want to subsidize anyone's insurance but most object to subsidizing people they characterize as able-bodied adults who made bad life decisions. A typical social media thread between the two groups has traces of the culture war happening between Republicans and Democrats.

(This is a real, abbreviated thread from a health care Facebook group. I purposefully exclude the name of the group and the contributors):
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Obamacare Supporters Divide Into Groups To Protect Their Interests, But Not Everyone Is Represented

There's a lot of speculation about which group of Americans will be hurt the most by impending Republican health care reform legislation. People with preexisting conditions may see these exclusions return in some form. People with life-threatening medical conditions requiring expensive medical care may see the return of annual/lifetime limits. Group health plans may see their tax-favored plans altered and made less attractive. And freelancers and entrepreneurs may be forced to return to traditional employment, if available.

Everyone that is not wealthy enough to pay for health insurance or fortunate enough to have someone else pay for it has a reason to be concerned about Republican changes to the Affordable Care Act (aka Obamacare). And that's because health care reform is just an unwanted political exercise to Republicans. Made necessary by a law, that despite its shortcomings had a larger goal of providing affordable, comprehensive health insurance to all Americans.

Things Are Different Now

Oddly, not repealing Obamacare is more popular than the law itself. A lot has changed since the law's inception in 2010. While Republican lawmakers waited and tried to hasten the law's collapse by ending funding for the risk corridor program, something else happened—lives were saved. Cancer diagnoses that would never have occurred did. People with life altering mental illnesses started receiving treatment that allowed them to be more productive. Various artists obtained insurance for the first time in decades. The Obamacare death spiral that House Speaker Paul Ryan was so hoping for and wrongly claims is upon us didn't happen soon enough.

There are just too many Obamacare success stories getting in the way of the GOP narrative that every single component of the law has been a total failure. Not that Republican lawmakers are not trying to continue to push the narrative of Obamacare as the dumbest law ever passed by the government. They've even gone so far as to claim paid protesters are behind the current, vocal swell of support for the law, and are giving shout-outs to their well-funded and well-organized protesters to counter this support. This Retweet from the Heritage Foundation says it all:

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Can Price And Ryan Con America Into Accepting Less Health Insurance Protection?

It is official, the corrupt and greedy former orthopedic surgeon, Tom Price is the new head of the Department of Health and Human Services (HHS). What changes he will make to the Affordable Care Act (aka Obamacare) weighs heavily on a lot of minds. Will it be a slow dismantling of the law or full replacement? Will he work with House Speaker, Paul Ryan who promises to have a House plan ready in 2017, possibly by the end of the first quarter of the year? At the moment, who knows what he'll do, but expect a lot of noise over the next month from the GOP about their Obamacare replacement plan.

In fact, the show of the Republican's impending replacement plan has already started, with Paul Ryan as its star. First, he hosted a televised town hall in January, trying to convince America that Obamacare was in a death spiral. His criticism of Obamacare continued on the Charlie Rose show, and every other time he is in front of a television camera or reporters microphone. And just this week the American Action Network (AAN), using footage of Paul Ryan and hinting at his BetterWay plan, ran a television ad claiming Republicans have a plan.

After leaks of a clueless GOP grappling with health care reform at the Republican retreat in Philadelphia last month, Paul Ryan is eager to change the narrative. He is building up his party's Obamacare replacement reveal the only way he knows how, by using his star power and telling a bucket full of lies.

Ryan is not as smart as he wants people to think but unfortunately, he has a reputation for being the smart guy that's not afraid of getting into the weeds of policy. He's hoping that his undeserved reputation as technical but empathetic, will allow Republicans to replace Obamacare with less health care coverage. He doesn't frame his proposal as less than Obamacare. Instead, it is referred to as patient-centered and freedom (from costly mandates for coverage you don't need). Continue Reading...


Republicans Need Help "Fixing" Obamacare, We Should Offer Some

Last week's Republican House and Senate retreat in Philadelphia revealed what we already knew; they don't have a plan to replace the Affordable Care Act (aka Obamacare). This week there were reports that some Republicans have given up on repeal and replace and want to “fix” Obamacare instead. Also, this week, shady Congressman Tom Price came one step closer to becoming Secretary of Health & Human Services when the Senate Finance Committee approved his nomination without Democratic support.

It's been a frustrating week for Obamacare supporters concerned about the future of health insurance and health care in America. Every statement about health care reform, even if it is a repeat of what's been said before is scrutinized for new meaning. But for now, we are in limbo, and that is not a bad thing. Things could be worse. We should use this time to put forth some ideas on health care reforml.

Obamacare Could Be Better

Everyone agrees that Obamacare plans could be better—more affordable and there should be more of them. Also, there's majority agreement that some provisions of Obamacare are keepers, like no prohibitions on coverage for preexisting conditions, keeping dependent children on employer-provided plans up to age 26, and receiving subsidies to pay for coverage. But these goodies cost money and require trade-offs. So knowing that Republicans would prefer the government get out of the health insurance business, what suggestions would you give them if they were forced to stay in it. Keeping in mind that you can't get everything you want.

Protests are fine, but how can we improve Obamacare when we know universal coverage is out of the cards in this new Republican reality?

First, agree not to turn Medicaid over to the states via block grant or any other program. States may know their constituents better than the federal government, but equality often comes in a distant second to state budget priorities. We can't trust states to cover everyone who needs Medicaid. We also can't trust them to regulate the quality of care Medicaid recipients receive. Medicaid patients wait longer to see a doctor and get a lower quality of care than patients with private insurance.

Instead of Medicaid block grants or any other state-based Medicaid program, the federal government should run the Medicaid program just like it does with Medicare. Everyone gets the same benefits, and medical providers must meet predetermined quality standards in exchange for higher reimbursement levels.

There is no way for the government, federal or state, to get around paying for health care for the poor. States can assist in this effort by addressing the poverty in their communities, but they should stay out of the health care business for the poor.
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Republican Health Care Reform Plans Are Getting Less Comprehensive And Less Acceptable

To borrow a line from Hamilton, the musical, [Republicans are having their] "governing is harder moment" with health care reform. Just this week they added two more health care reform proposals (outlines) to the seven they conjured up since 2009. The latest health care proposals are near opposites of each other and include an Affordable Care Act (aka Obamacare) light plan and a worse than before Obamacare plan with no subsidies, or possibly, insurance for the sick and poor.

The Road To Still No Health Care Reform Bill

Whenever Obamacare opponents provide an Obamacare alternative plan, its contents are 90% Obamacare is an abject failure, and 10% (usually a bulleted list), here's my plan. Because the focus is not on reforming America's complex and pricey health care and health insurance sectors, their plans come up short in money, benefits covered and access, when compared to Obamacare. This opposition-focused exercise that Republicans are engaged in has produced nine proposals so far.

  • The Obamacare Replacement Act
  • Patient Freedom Act
  • The American Health Care Reform Act
  • The Patient Choice, Affordability, Responsibility, and Empowerment (CARE) Act
  • Health Care Choices Act
  • A Better Way, To Fix Health Care (Reform Plan)
  • The Patients' Choice Act
  • Health Care Freedom Act
  • Empowering Patients First Act
So, from 2009 to 2017, Republicans have been unable to agree on a unified health care reform plan. But this week they are meeting in my hometown of Philadelphia to map out their policy agenda. According to leaked photocopies of the retreat agenda, there was a Thursday morning session labeled Keeping Our Promise On Health Care. And unless some waiter recorded this session, we probably won't know for some time what Republicans plan to do with American health care. Will they agree on a unified reform proposal—there's no shortage of them, including the two announced just this week? Will they, as Trump mused, wait to see if Obamacare explodes and then "rush" to fix it in 2018, after the mid-term elections? Or will they propose a series of health care reforms stretched out over several years? And will these reforms be more health care or health insurance-centric?

More Words Don't Equal More Coverage

Republicans' Obamacare replacement plans are all over the map. Some focus on health care and health insurance reform together, others one or the other. At first glance, they seem to be growing further apart. But look closer at the latest alternative from Senator Rand Paul, the Obamacare Replacement Act, and you may find several similarities to the plan Congressman Tom Price, proposed in 2009. The Secretary of Health & Human Services nominee, Price, is credited with proposing one of the most comprehensive Obamacare alternative plans, the Empowering Patients First Act. Paul's plan is short on details, but he and Price have the same or similar philosophy about American health care policy. The Acts similarities are notable. For one, both authors are physicians, but the similarities don't stop there.
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Without Universal Health Care, Adopting Electronic Health Records Becomes Harder

In his January 6, 2017, interview with, President Obama said that one of the great disappointments for him regarding the Affordable Care Act (aka, Obmacare) was the difficulty in getting doctors and hospitals to go paperless. His interviewers, Ezra Klein and Sarah Kliff, expressed surprise that the President chose this as one of the great disappointments of such a controversial law. But I get it.

The U.S. is a world technology leader. Home to the world's largest and richest tech companies like Apple, Microsoft, Intel, Google and Facebook. But whether we are the best in tech is a matter of debate. Some believe Israel is tops in tech, claiming it has the brightest software engineers in the world, responsible for creating the best firewall software and other tech innovations. Still, others give a shout-out to Denmark, Finland, Sweden and Estonia, well known for extending tech to all of its citizens who use it in the everyday lives, even more than Americans.

But despite the great things that other countries are doing with tech, I think it is fair to say that that America has the resources and capability to lead the world in health information IT; if we wanted to. And maybe that is the primary reason that electronic health records (EHRs) are still a hope of Obama's.

What Are EHRs And What Are The Benefits and Challenges Of Using Them

Electronic health records are digital records created on a computing device by doctors and other medical care providers and staff about a patient's treatments and care. They have many potential benefits for patients and doctors, including:

  • Less paperwork—won't have to provide the same basic information to every new doctor
  • Fewer medical errors—doctors can receive warnings and alerts about allergies and prescribed drugs
  • Easier remote access that may also expand the use of telemedicine—patients can communicate with providers online and make appointments
  • Better diagnosis—doctors have a more complete and up-to-date picture of a patient's medical status
  • Less diagnostic testing—doctors can see previously ordered tests and won't duplicate unless necessary
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The Republican Alternative To Obamacare Always Has And Always Will Be, Personal Responsibility

Trump voters don't like the Obamacare subsidies or the Medicaid expansion because they help the undeserving. Consequently, they are okay with repealing and replacing Obamacare with something better, and they believe Trump can provide it because he is a businessman. Yeah, they believe that. And while I play around with the idea that Trump will surprise Republicans by proposing single payer health care so that he can brag about accomplishing something President Obama could not, the realist in me expects a plan similar to the alternative "plans" already offered up by Republicans. And the overarching theme of all of these plans is, personal responsibility and nothing says personal responsibility like putting aside your money to pay for your out-of-pocket health care expenses. You don't need subsidies. You just need a good tax deal to help you better use the money you should have. And that's why Republicans love health savings accounts (HSAs) so much.

Health savings accounts (HSAs) allow individuals to set aside money in tax-favored accounts to pay for medical care and prescription drug expenses. So, in addition to paying health insurance premiums, deductibles, coinsurance and copays, you can put some "extra" money in a tax-free HSA account. Think of HSAs as the health insurance version of the 401(k) retirement savings plan. Before 401(k) plans, employers provided pension plans to workers and their retirement benefits were pretty much guaranteed. Employers typically financed these plans but some plans required small employee contributions—it was an employer responsibility or a shared responsibility between the employer and employee. Then came the 401(k) plan with its risk of losing money, high finance fees, and employee-only or employee-mostly contributions. Responsibility shifted.

And how has the retirement income responsibility shift worked out? Well, just the other day, the Wall Street Journal reported that many supporters and early adopters of 401(k) plans acknowledge that they were mistaken in its benefits. Continue Reading...


Thinking Of Health Insurance/Care As A Reward For Working Is An American Problem

As the year 2016 comes to an end, many Americans are worried about the future of the Affordable Care Act (aka, Obamacare). Those who want to see the Act survive the likely oncoming assault by Congress and the new Administration are mobilizing to make their repeal objections heard. They are creating or joining social media groups, attending rallies, organizing events and writing campaigns, supporting related non-profits and calling and writing their elected representatives to voice their opposition to repealing the law.

Even some non-supporters of Obamacare have concerns about a full repeal. Many have insurance because of Obamacare, and they like some of the Act's provisions such as prohibiting the denial of insurance or treatment due to a preexisting medical condition. But then there is the hardcore minority who want full repeal of the law even if it means losing their insurance coverage. And one of the main reasons for their discontent with the law is that it provides free or subsidized coverage to the non-working poor. A
recent article in The Atlantic captured these sentiments when it quoted two central Pennsylvania, Trump voters:

“but everybody's gotta get out there and get a job to help pay for it.”

“I’m worried about people being willing to work hard and stopping being dependent on the government,”
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Rx Drug Price Reform Is Not A Question Of Price Vs. Innovation, But One Of Public Vs. Private Innovation


Last week, Sarah Kliff wrote an interesting piece about why prescription drug prices in America are so high compared to other industrialized countries. The international comparisons aren't new, but the conclusion that Americans have to choose between high drug prices and innovation is interesting. In a nutshell, Sarah reports that America subsidizes the world's prescription drug costs to incentivize investment in drug innovation by pharmaceutical companies and financial investors.

Sarah's article was a timely piece because also last week, the U.S. Congress passed the
21st Century Cures Act. This Act's been in the making for about two years and is the largest health care reform Act since Obamacare. It is nearly 1,000 pages, with a price tag of over $6 billion. And guess what, it includes lots of stuff about health care innovation as well as reducing approval standards for Big Pharma to bring their drugs to market. And just yesterday, the Senate, with a vote of 85-13, ended debate on the bill.

You can read the entire act
here (it's at least worth a quick review).

Most of the Act's provisions, which President Obama will sign in the next few days, are uncontroversial and good. The Act provides more money for drug therapy and cancer research, mental health research and care, state opioid abuse programs and more. But not everyone's happy with the Act, including prominent Democratic Senators, Elizabeth Warren and Bernie Sanders. Both see this bill as a handout to pharmaceutical companies because of the provisions that may allow them to bring products to the market quicker than they can currently and with less attention to drug safety and efficacy.

But even Senators like
Al Franken who approved the bill, lament that it does nothing to address high prescription drug prices. And the total elimination of anything to address prescription drug prices in such a relevant and related piece of legislation is more disheartening than Sarah Kliff's high cost or innovation conclusion.

The 21
st Century Cures Act could easily have been, The Pharmaceutical Innovation And Price Reduction Act. Continue Reading...


Trump's Family And Friends May Decide The Fate Of Obamacare

Donald Trump is the U.S. President-elect, and everyone who writes and cares about health insurance and health care policy in America is eager to learn what he and his Republican colleagues in the House and Senate will do with the Affordable Care Act (aka, Obamacare). Will they repeal it? Replace it? Both? Neither? We can reasonably expect that over the next four years, Trump will sign off on some policy changes to Obamacare and millions may lose their health insurance.

Still, the larger Obamacare repeal and replace questions remain, will Speaker of the House, Paul Ryan, get to institute his
Better Way (to Fix Health Care) outline? Or will professional President Obama hater and Senate Majority Leader, Mitch McConnell, get to declare Obamacare a total failure with no need to replace? It's looking increasingly likely that they may both get what they want although not because of any powers of persuasion they have, but because repealing and replacing Obamacare will help some Trump family members and friends.

Before he won the election, Trump said he would repeal and replace Obamacare with "something much better for everybody." He also called Obamacare, "A complete disaster." But after he won the election, he said that there are parts of Obamacare that he likes and wants to keep: allowing children to stay on their parents' health plan up to age 26 and the one about people with preconditions (he meant pre-existing conditions, but he's careless and uninformed). Then last week it was reported that Trump has
family and friendship ties to a health insurance start-up, Oscar Insurance, that isn't doing so well. Continue Reading...


So Much For Anti-Elitism, The Health Insurance Status Quo Survives


The upper middle class benefits a lot from the current system of access to health insurance.  They are more likely to have jobs that provide health insurance that they can easily afford, and they benefit favorably from the tax treatment of these workplace benefits.  So, it is fair to assume that the majority of these individuals do not support changes to the health insurance and health care status quo.  But the question on many people's minds is whether the unveiled contempt for the professional elite will impact their health care status.

The election of Donald Trump as President of the United States and a majority Republican House and Senate all but ensures changes to health insurance and health care policy in America.  What those changes will be is anyone's guess. Does it mean a cap on pre-tax health insurance premiums that most benefit the upper middle class?  It could since there is bipartisan support for such a change.

But I'm betting it won't be for several reasons. One, Trump supporters have yet to articulate what health care reform should look like. Two, most Trump supporters don't understand health insurance or the health care industry well enough to suggest any meaningful changes to them. And, three, many middle class people rely as much on workplace health insurance and its favorable tax treatment as the elites they hate.

But what is the point of beating the elites in a national election, if you can't also make them suffer?

Will Hate Trump Logic? Continue Reading...


A Fragmented Health Insurance System Needs The Same Cure As a Fragmented Health Care System—Integration

There is a lot written about the downsides of fragmented health care. Most stories start out with an example of an extremely ill person, whose condition gets worse as they go from one medical specialist to another and one facility to another, taking one drug after another. The result is usually that the person suffers for a very long time until someone mercifully steps in to help coordinate care or the patient dies. No one is to blame for the person's suffering or death because they did what they were supposed to do. It's only after the fact that we find out that things should have gone better.

The good news is that there are solutions to address the horrible consequences of fragmented health care. Before the production of these solutions, a very sick person had to rely on the kindness and fortitude of family and friends to navigate a system where no one person could or would answer all of their questions. Harvard Business Review has an article
here on how to improve fragmented health care. The Affordable Care Act (aka, Obamacare) also works to try and improve the delivery of health care through Accountable Care Organizations (ACOs).

What Is An Obamacare ACO?

According to Jenny Gold, writing in Kaiser Health News online, a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation, "An ACO is a network of doctors and hospitals that share financial and medical responsibility for providing coordinated care to patients in hopes of limiting unnecessary spending." Currently, Obamacare ACOs are Medicare-based only.

Addressing the physical and mental suffering and costs of fragmented health care is one of the best components of Obamacare, even if it only addresses a small percentage of the insured. But wouldn't it be great if Obamacare addressed the fragmentation of health insurance programs instead of maintaining or add to them?

A Fragmented Health Insurance System Is A Bad Thing.

I'm not claiming that America's fragmented health insurance programs are as bad as fragmented health care. It's not. Still, fragmented health insurance is a big problem in that it separates us into groups with different levels of coverage, at varying rates and ends up costing us all more than if we were in one group. Instead, we are left with at least six groups—Disabled, Old, Poor, Veterans, Traditionally Employed and Individually Employed—each expected to carry its own financial weight. A difficult and unnecessary standard to meet and maintain...
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Obamacare Critics Or Explainers Don't Care About People Without Subsidies

Open enrollment on the healthcare exchanges doesn't start until November 1 but news of projected premium increases of 22% to 25% hit the streets last week. Write ups about the rate increases can be divided into two camps—the beginning of the end of Obamacare and it’s not as bad as you think because... That “because” refers to the fact that the increase, although huge, does not apply to the vast majority of health insurance purchasers. It does not apply to the more the 50% of Americans who get health insurance from their employers or seniors, veterans, the disabled and poor. It also does not apply to about 85% of people who purchase individual policies on the exchanges. It does apply to the millions of people, like me, who do not receive a health insurance premium subsidy.

So one camp want to amplify the harshness of the Obamacare increases, with the
Wall Street Journal (WSJ) going as far as to express its condolences to people, like me, who are stuck paying the full premium increase. But with their condolences comes a healthy dose of we told that arrogant President Obama that Obamacare was destined for failure. They don’t really care about the individuals paying high health insurance premiums, just like they never cared about the people paying even more or being denied coverage for preexisting conditions pre-Obamacare.

And then there is the, it’s
not as bad as it looks camp. They want to stress how few people have to pay the full increase in premiums without subsidy support and how subsidies will increase in step with premiums for those eligible for them. Some go into the mathematical weeds to prove their point of just how nearly insignificant this non-subsidy group is, with estimates ranging from 1.5 million people to as high as 9 million people. And then there is a very small subset of this camp that unfortunately includes some in the Administration, that claim millions of non-subsidy people are probably eligible for subsidies but just don’t know it. Continue Reading...


Workplace Health Insurance Is An Exclusive Club That Has Outlived Its Usefulness

The Obamacare marketplace has a big problem—too many sick people and not enough healthy people. The problem is so bad that health insurance companies claim they lost billions of dollars and some are leaving the exchanges. Unless the federal marketplace can enroll more young and healthy people these insurers may never return. Another proposition outlined in a New York Times article by Margaret Sanger-Katz, is for the remaining states to expand Medicaid, which will bring down health insurance premiums for everyone.

In her article, Sanger-Katz refers to a study by the Dept. of Health and Human Services that concluded that marketplace premiums were lower (in the high single digits) in states that expanded Medicaid compared to those that did not. That is great news but it’s not enough to offset premium rate increases in the high double digits. For that we need exactly what the health insurance companies claim they want—a healthier risk pool. Moving employer-sponsored health insurance to the exchanges give us a healthier risk pool that will lower premiums, but there is strong opposition to this.

Employers want to hold onto their health insurance programs because they want to control how much they contribute to them. Health insurers want to maintain these plans because they can better predict their risk and set their rates to ensure they always make a profit. Employees want to keep their employer-sponsored coverage because they don’t want to assume the responsibility of choosing and paying for their own coverage. They also want to keep their employer and government subsidies.

Anyone who thinks that these strong powerful advocates for employer group health insurance are going to suddenly decide it is in the public interest to have one health insurance risk pool is mistaken.
Individuals covered by employer health plans make up about half of the insured population. They are over 150 million individuals strong and it will take the other 150 million plus individuals to force change in our health insurance and health care system. And the first thing we other 150 million plus have to do is stop acting like workplace health insurance is more virtuous than other types of health insurance. Continue Reading...


Aetna Was Dumping Unprofitable Policyholders and Mismanaging Risks Long Before Obamacare

If the presidential candidacy of Donald Trump has taught us anything it is that the federal government is a good punching bag and scapegoat. Yesterday, Aetna Chief Executive Officer, Mark Bertolini, took some time on the bag. Bertolini announced that the company “decided to reduce our individual public exchange presence in 2017.” Aetna will pull out of 11 states on the public exchanges but continue to sell individual policies off of the exchanges. The reasons provided for the pull out, in insurance-speak, were an unbalanced risk pool and “inadequate risk adjustment mechanism.”

What Aetna means by “an unbalanced risk pool.” Put plainly, Aetna did not sell enough policies to healthy people with low to no health care expenses to cover the cost of care for the unhealthy people it sold policies to.

What Aetna means by “inadequate risk adjustment mechanism.” The Affordable Care Act risk adjustment programs are technical. There is a state-based risk adjustment and reinsurance program and a federal risk corridor program. Basically, these programs give money to, take it away from or share it among insurance companies to balance out their losses and gains.

Is It Really The Governments Fault…?

Aetna stated that, it might return to the exchanges in the future, “should there be meaningful exchange-related policy improvements.” This shameless blaming of a federal program to increase access to health insurance is a disguise to hide Aetna’s incompetence at predicting and managing risks.
Aetna has a history of not anticipating changes in the health care market and of dropping unprofitable policyholders. Continue Reading...


It's Ridiculous How We Let Health Insurance Companies Bully Us

Health insurance companies have a reputation for being bullies. Policyholders feel bullied when their medical claims are denied or processed incorrectly. Hospitals and doctors feel bullied when the bills they submit are refused or amended, or when procedures are not covered. Employers feel bullied when their rates go up automatically. In fact, no one is exempt from the bullying tactics of the big bad health insurance company. Their latest victim(s)—all of us!

My Way Or The Highway

Four large health insurers (Aetna and Humana and Anthem and Cigna) are trying to merge into two and the federal government has filed lawsuits to prevent that from happening. Now, the two companies that will surface if the mergers go through (Aetna and Anthem) are threatening to withdraw their plans from the public health care exchanges. It’s hard to know if Aetna and Anthem are threatening to leave the health care exchanges because they are losing money or because of the government lawsuits. But does it really matter.

Aetna and Anthem are both making moves to increase their profits and shareholder wealth. Any savings they receive by increasing their size and bargaining power with hospitals and doctors will stay with them. There will be no premium savings for policyholders, just more money for shareholders. But if these mergers do not happen, their next target is likely to be the exchanges. Because if they can’t realize increased profits by extracting bigger discounts from health care providers and hospitals, they will do it by minimizing losses on the exchanges.

Profits Without Risks

Through the individual mandate we require healthier people who need little or no health care to purchase insurance to offset the costs of care needed by the sick. Healthier people lose money by subsidizing the sick. However, health insurance companies are not willing to subsidize losses they incur on the exchanges with profits they earn from their other lines of business, like Medicare Advantage and Medicaid.
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Obamacare Can Feel Like A Prison Sentence

I don't have a problem with the Affordable Care Act's (aka Obamacare) individual mandate. I am willing to pool my limited resources with others so that we all have health insurance coverage. But I have to admit that I am starting to feel the squeeze of my non-subsidized, high premium, high deductible health plan. So much so that I think I want out of Obamacare. Honestly, I'm not quite there yet but it may not take much more to get me there.

I already pay nearly $4,000 per year in premiums for a plan with a $6,500 deductible and 60% coinsurance and no out-of-network, non-emergency coverage. And yes, it is a Bronze level plan. I did the research and I used the latest decision support tools and based on my age and excellent health status, which includes never taking a prescription drug, this is the best plan for me. But the plan sucks in both terms of coverage and costs. My only other option—pay a penalty and pay any medical expenses I incur out-of-pocket—is an even worse option. I deserve better choices than this.

And to make my situation even more difficult, there is speculation that insurers will drop many of their Bronze-level plans in 2017, forcing me into a higher premium tier. But who cares about me? A $4,000/$6,500 Bronze plan is equivalent to a $5,500/$5,000 Silver plan, right? No. I don't have an additional $1,500 to pay in premiums that I will never get back. My spirit for the greater good has monetary limits and it ends at the Bronze level.
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Despite Resistance, We Are Getting Closer to a Public Option Health Plan

Politicians at all levels are too afraid to upend a health care system that does not work for all because of the impact that change will have on some. The fact that that "some" consists of about 16 million health care related jobs and 18% of the U.S. economy is reason to think before we act. But with nearly a century to think about and work out a better health care policy, it’s clear that there’s never been a real strategy for revolutionary change. Instead, politicians focus on incremental health care policy changes, like the President’s latest proposal for a limited public health plan option.

On Monday, July 11, 2016, President Obama became the first sitting U.S. President to write an article for publication in a scholarly or academic journal. Published by the Journal of the American Medical Association (JAMA),
the article titled, "United States Health Care Reform: Progress to Date and Next Steps," recounts the process of health care reform from 2008 to the present. The article outlines the many legislative actions the President and his administration took to:

  • expand health insurance coverage
  • provide financial support to health insurance buyers
  • improve health care technology and research and
  • reform health care payment models
The President makes a case for the need for more incremental health care reform, including a public option in geographical areas that have little or not health insurer competition. But some Democratic politicians fear even this modest proposal. According to an article in, Democratic Senator Heidi Heitkamp said this in response to a limited public option: “I think it's critically important that we stop trying to complicate healthcare and we start taking a look at what needs to be fixed in ObamaCare.” Besides being one of the dumbest statements ever made about the already impossible to understand U.S. health care system, it shows a real fear of the inevitable.

If health insurers merge as planned or drop out of the exchanges leaving little or no health plan options to choose from, something has to fill the gap. The only thing that can is a public option. Those who think that reducing the number of health plan options on the exchanges is a way to undo Obamacare are being naïve. People still want and need health insurance, not to mention that they are required to have it. I don’t see any other option but to offer a public health plan where few or no health plan options exist.
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Paul Ryan's Elitist Health Care Plan May Have Some Appeal

Paul Ryan and the Republicans in the House have taken a beating in the media for their impotent Affordable Care Act (aka Obamacare) alternative plan. The criticism is warranted. After so many years of promising to produce an alternative to Obamacare, the best the Republicans can provide is an outline of a policy. Yet there is learn a lot we can learn from Ryan’s proposal. We can learn about Ryan’s personal views on life and health.

Paul Ryan’s Obamacare alternative was written from the perspective of a healthy and fit person who expects to stay that way.

  • If you are really sick and traditional health insurance companies don’t want to insure you, Ryan’s sympathy is with the health insurer.
  • If you have a serious health condition requiring lots of medical care, healthy people should not have to subsidize your health care expenses. You should be forced to maintain continuous coverage, at a higher rate, pooled with other seriously ill people.
  • If you are currently active and healthy, you should have a policy tailored to your individual health. If you want a skimpy health plan, you can have it.
  • If you are currently healthy, you should receive tax credits (or portable payments) that you can save until you need it or use it to pay for dental or vision care.
  • If you can afford to set aside thousands of dollars to pay your medical expenses, you should be able to do so with tax-free dollars in a Health Savings Account.
There’s no denying that Paul Ryan is a health and wellness elitist. He has no empathy for people who are ill through no fault of their own. He thinks health status is a lifestyle choice, just as he thinks poverty is a lifestyle choice. Health status is a lifestyle choice for some, but certainly not everyone. Ryan can’t see beyond his face in the mirror to draft a national health care policy that addresses the diversity and complexity of the American health care system.

Buuuut… If you are healthy like Paul Ryan, it’s not hard to find his Obamacare alternative plan appealing. Continue Reading...

Poor Management of Health Plans Will Be Employer Legacy

Some employers readily provide free health insurance to their employees. Some engage in “tough” negotiations or use innovative financing techniques to gain temporary health insurance savings. However, most employers simply accept annual health insurance cost increases that they then shift to workers. Workers have no control over how their employers manage health insurance costs. Or do they…?

What Could Happen

When the Affordable Care Act (aka Obamacare) became law, its supporters and opponents anticipated the end of workplace health insurance. So far both are wrong... Now there is a new theory cropping up about the impending demise of workplace health insurance. The theory is that employers are doing such a poor job of managing health insurance costs that they are neglecting their fiduciary duty and opening themselves up to potential lawsuits.

This is an intriguing theory and it is not surprising that it is now getting attention. Employees have filed numerous lawsuits over 401(k) retirement plan fees, so suits over high deductible health plans must be the logical next step. Right? Also, the Department of Labor’s new retirement account fiduciary standards requiring brokers to make recommendations that are in the best interest of their clients could easily be extended to health insurance brokers. Right?

It’s not like employees haven’t sued insurers and employers before over health care related issues. Employers have been sued for:

  • denying coverage for specific medical care procedures or inadequate health care (e.g., Wal-Mart)
  • firing older workers for potentially having higher health insurance costs
  • firing workers with high medical expenses
Not to be left out, employers filed their own lawsuits against insurers and plan administrators over high health care costs. Such was the case with Hi-Lex Controls and Blue Cross Blue Shield of Michigan (BCBSM). The Hi-Lex case involved a dispute over hidden fees BCBSM tacked on to claims it processed for self-funded groups like Hi-Lex. This is how it worked. Continue Reading...

I Really Do Get Why Obamacare Opponents Don't Like This Law

Like many Americans this week I viewed a lot of online video clips of interviews of the late Supreme Court Justice, Antonin Scalia. Scalia had a lot to say about Obamacare and none of it was supportive of the law. He accused the majority of his fellow justices of abusing their position to uphold a law they wanted instead of following the Constitution. Meanwhile his views on Obamacare were not personal, but legally based.

And then there are the other opponents of Obamacare that I am starting to understand more now. These opponents fall into two camps, but really just one. The first camp hates the idea of government-run health care for all Americans. They think a private, market-based system would do a better job. For them, government-run anything means high-costs and poor service. Don’t ask this group to explain how this is any different from the market-based system currently in place. They just know that if the entire system were government-run, things would be worse than they already are. No evidence needed.

The second Obamacare opponent camp is similar to the first in that they also champion a private, market-based system. They are not anti-government like the first camp; they are just pro-market when it comes to any good or service with profit potential. Taking a hugely profitable, shareholder-loving sector like health care out of the market would hurt the economy. These are the folks who spend a lot of time claiming health care is not a right. They also claim that greater competition in the health care market is the answer to controlling health care costs and increasing accessibility. But above all else, health care is a service that must be paid for by the individual.

I don’t agree with Scalia or the anti-government, pro-market Obamacare haters; however, I do acknowledge that they have very strong beliefs.

Scalia was known for his love of the written word and languages. Everyone who’s read the Affordable Care Act agrees that it is no friend of the well-written word. I think Scalia took great offense to what he viewed as a third rate law. And I also believe that he thought President Obama got something he did not deserve—a great law, not in substance but in historical significance. He was an intellectual elitist that hated the idea of an unworthy law credited to an unworthy person. In this sense, his objection to the Affordable Care Act was personal. Continue Reading...


Unions Should Support The Health Insurance and Retirement Savings Needs Of All Workers

Organized labor deserves a lot of credit for its early efforts at getting health insurance and retirement benefits for workers. But labor also has a history of being slow to adapt to economic, social and political changes that challenge its mission. This has led to a slow erosion of labor union membership in the private sector. It has also resulted in attacks on the health and retirement benefits labor fought so hard for.

I applaud labor's support for the Affordable Care Act (aka Obamacare), and its wider support for universal health care. However, ironically, some of labor's biggest concerns these days involve provisions of Obamacare it sees as unfavorable to its members--the perceived threat to
multiemployer health care plans and the "Cadillac tax" (an excise tax on high value health plans). Granted, these provisions are not favorable to unions as they currently operate. But that's the public policy point. Union friendly policy makers are less concerned with the role of unions and more concerned about health and retirement plan access and affordability for everyone. I'm concerned that labor's historical reality of focusing on its narrow interests and its members may cause it to miss out on an opportunity to help achieve the universal health and retirement benefits it claims it wants.

There are several health insurance and retirement plan issues unions can support, and that are growing in economic, social and political importance.

Health care price transparency. Doctors, hospitals and insurance companies have given little substantive attention to the need for providing prices for medical care to consumers. Even as consumers are forced to assume a greater share of the cost of care by way of large deductibles, the medical care establishment consistently pushes back on real price transparency.

  • Labor unions should advocate for a change to the Employee Retirement Income Security Act (ERISA) to mandate real medical price transparency by insurers and health care providers. ERISA is a federal law that sets standards for private health and retirement plans. Currently, many insurers provide limited tools that give questionable estimates of cost for some care. Providers offer even less assistance and routinely prescribe care without any consideration of its price and if a cheaper alternative is available.
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Depressing Health Care And Retirement Affordability News And Taxes


I’m feeling quite negative at the moment. It’s a strange and unsettling feeling for me. One thing I am feeling especially negative about is the unaffordability of health insurance, health care and retirement, and the government’s Band-Aid approach to addressing these issues. So far this week I’ve read a series of articles that provide examples of how bad things are and how unlikely they are of getting better. These articles spotlight how the private health insurance, health care and retirement saving systems continue to shut the door on any hope of reform.

To its credit, the federal and state governments continue to put forth proposals and pass legislation to abate the affordability crisis. These programs include:

  • Accountable Care Organizations (ACOs)
  • Obamacare
  • Automatic IRA
  • myRA
  • Retirement Savings Contributions Credit (SAVER’s Credit)
  • State IRA programs
But these efforts are still Band-Aids, at a time when we need a massive overhaul of the current systems. And we can start by comprehensively addressing government subsidies that make private sector plans more attractive than public sector solutions.

Rethinking Employment-Based Health And Retirement Plan Tax Incentives

Most workers don't understand the link between the workplace benefits they participate in and the federal tax code. Their employee benefit plan information is littered with terms like pretax, tax-free, tax-deferred and tax-favored, but they would be hard pressed to explain what these terms mean. However, if the link between health and retirement benefits and the tax code was severed, they would immediately figure out that something terrible happened. Their paychecks would be smaller. And they would insist on getting their government tax subsidies back.

Of course workers don't view tax-favored employee benefits as federal government subsidies. They think they are entitled to keep as much of their hard earned money as possible and who cares that only employer-sponsored health and retirement plans receive the subsidy. It's not their fault that not everyone gets it. The tax code is full of provisions that benefit some and not others.
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The Next Big Health Care IT Startup Should Focus On Health Care Fraud

There are a lot of new and exciting health care information technology (IT) companies sprouting up. Most are taking advantage of the many opportunities made possible by the Affordable Care Act, aka Obamacare. These startups are using large amounts of anonymous data from Medicare, Medicaid and private insurance databases and their own sophisticated algorithms to make health insurance and health care easier to purchase and use.

This is all great stuff but health care has an even bigger problem that these data mining and analyzing geniuses can and should address. The problem is health care fraud—a multi-billion dollar a year problem. Technology firms should create algorithms to scan health care claims and financial data to identify and prevent fraud. This type of sophisticated response is needed because health care fraud perpetrators are usually insiders that are very good at crafting and hiding their schemes.

Unfortunately, creating health care fraud detection algorithms may be the easy part for the tech industry. The challenge for these firms is working with the health care industry usual suspects including medical providers, insurers, associations and government regulators.

The health care industry is a special kind of place with several factions fighting hard to protect their members’ interests. There is also the issue of navigating a highly regulated industry and interacting with multiple government agencies. It’s kind of like old school meets new school with old school having more money, a huge head start in regards to understanding the industry and its regulations and established relationships with government policymakers. But if the nation is serious about reducing health care fraud, it is going to need the help of big data analyzing IT firms.

Health Care Fraud Is A Huge Problem Continue Reading...


Universal Health Care Will Result In Necessary Job Cuts


Whenever there is a debate about universal health care, opponents of such a system often cite medical provider shortages as a concern. They claim increasing access to health care for everyone somehow disadvantages the previously insured. Boohoo.

Once everyone has access to health care forget trying to get a same day or even same week appointment when you contact your doctor, they claim. What was a reality before health care reform, longer wait times than other industrialized nations, is made out to be a “new” safety issue. Opponents of universal health care conveniently ignore the fact that there has always been a waiting list for medical care for everyone but especially those who cannot afford it.

The medical care provider shortage scare tactic is a bogus excuse designed to maintain the status quo and to hide an even bigger concern of health care reform opponents. What health care reform opponents fear more than a medical provider shortage is health care industry workforce changes. When millions were losing their jobs during the Great Recession, the health care industry was adding them at a record pace. And this
record growth is projected to continue for years to come. Ironically, a lot of this growth is due to more insured individuals because of the Affordable Care Act.

However, there is increasing concern in the health care industry that what Obamacare giveth, the next step in health care reform, universal health care or single payer, will take away. This type of fear is not unique to the health care industry. Many industries actively oppose changes for the common good in an effort to hold onto “unneeded” jobs. Just ask
Senator Mitch McConnell how he feels about the Obama Administration’s recently announced climate change regulations (Clean Power Plan) and their perceived impact on coal jobs that were already declining. Continue Reading...


The Wrong Type of Collaboration: Unions, Employers, Insurers, Et Al., and the Alliance to Fight the Forty


Last week I wrote a LinkedIn post urging employers to collaborate with insurers and other businesses and use their collective clout to hold the line on over the top hospital and other medical care costs. Little did I know at the time that employers were actually collaborating with insurers and others on a health insurance plan issue. Unfortunately, the issue that they see as most worth collaborating on involves maintaining the status quo. Specifically, employers are working with unions, big pharma, large health insurance companies, benefit association groups and others to repeal the Affordable Care Act’s (aka Obamacare) “Cadillac tax.”

Earlier this month 17 organizations including Cigna Corporation, Pfizer Inc., Laborers International Union of N.A., BCBS Association, American Benefits Council, and Independent Insurance Agents and Brokers of America
registered as the lobbying group, Alliance to Fight the Forty. The “forty” these groups are fighting is the 40% excise tax, included in the Affordable Care Act, on benefit plans worth more than $10,200 for individuals and $27,500 for families. The tax is effective starting January 1, 2018, and indexed to inflation thereafter.

The tax affects an extremely small percentage of health plans and individuals (in the future, not in 2018). Benefits up to the threshold amount are not subject to the tax, so participants in these plans only pay the tax for amounts above the $10,200 and $27,500 limits. In addition to generating revenue to increase access to health insurance to individuals without coverage, a goal of the tax is to discourage offering extremely generous health benefits with low employee premiums and cost sharing.

Wrong Side Of History

It is easy to understand why unions, brokers, insurers and large employers want to repeal the Cadillac tax. The tax is a potential major disruption to the generous benefits their constituents currently receive. Unions in particular have a long
history of thwarting meaningful national health care reform because of their focus on their members to the exclusion of everyone else. Continue Reading...


It’s On. Financial Services Firms Won’t Give Up Their Control Over Retirement Plans Without A Fight.

It is fair to say that before federal and state lawmakers started focusing on individual access to health insurance and retirement plans, the private sector was okay with maintaining the status quo. A system where if you worked for a large employer and were continuously employed, you could receive subsidized health insurance and have access to a convenient workplace retirement plan. And, the higher your income the more you benefitted from the tax-favored design of these plans.

Then along came the Affordable Care Act (aka Obamacare), bringing the lack of access to affordable health insurance for tens of millions to the top of the public policy agenda. Sensing an inevitable shift in the status quo, private sector health insurance companies and big pharmaceutical companies mobilized to protect their interest. Change to the status quo was fine with them as long as the status quo did not change. Additions to the status quo that left the existing system intact are okay. They lobbied hard to get everything they wanted and little or none of what they did not, and they succeeded.

Soon after, the federal and many state and local governments turned their focus to individual access to retirement savings plans. They found similar problems as with access to health insurance. The lower an individual’s income, the less hours they worked, and the smaller the company they worked for, the less likely they were to have access to a workplace retirement plan. To address the issue, lawmakers proposed their own plans. Some wanted to allow workers without workplace retirement plan access to federal or state retirement plans. But most elected to design new plans that had some but not all of the features of 401(k) style defined contribution plans. Now who would have a problem with this approach? The current system showed little or no interest in these workers. Surely, the financial services sector would not object to everyone having access to a workplace retirement plan. Well, some of them kinda do object.

We Don’t Need No New Plans

Large financial institutions were not completely supportive of the idea of adding “new” retirement plans. They felt like they already had products to meet everyone’s needs even if they did not market these products to the individuals policymakers were trying to help. When President Obama announced the creation of the MyRA (My Retirement Account), many financial service providers scoffed. They called and small potatoes and redundant.

Some suggested that the
states might be able to do a better job at addressing the retirement plan access problem. Continue Reading...

Employment-Based Health Insurance Supporters Should Get Out Of The Way Of Health Care Reform

By all accounts, and there are many, employers are committed to providing workplace health insurance for the foreseeable future. For them, offering coverage is purely an issue of competitiveness. The primary purpose of providing coverage is to attract and retain workers. Period. End of Story... Having a happy and healthy workforce was never a stated goal. However, it appears their selfishness is catching up with them and they know it. Even their traditional allies are questioning the benefits of continuing the health insurance access status quo.

Republicans Challenge Tax Status of Employment-based Health Insurance

Republicans in Congress and the Senate are rethinking the favorable tax treatment workplace health insurance plans currently enjoy. With the urging and free counsel of several conservative intellectuals, Republicans are adding language to their many Obamacare alternatives that would reduce, cap or eliminate these tax advantages. A
proposal, Empowering Patients First Act, from U.S. Representative Tom Price would provide tax credits to everyone purchasing individual coverage and cap the tax benefit of employer-provided coverage. An earlier republican proposal, the Patient C.A.R.E. Act, also calls for “reform” of the tax treatment of employer sponsored health insurance coverage to pay for tax credits provided to individuals who purchase coverage. And the latest proposal from the Republican Study Committee, American Health Care Reform Act, would eliminate the tax-favored status of employer-based health plans. The plan would instead provide a tax deduction to individuals and families to pay for health insurance.

If it looks like Republicans are looking to shake up the world of employer-sponsored health insurance, it is because they are. But let’s not give them too much credit because Obamacare already has a provision to limit or cap the tax benefits of workplace health insurance—the Cadillac tax. Ironically, many republicans want to repeal this tax. Even Representative Tom Price has called for repeal of the Cadillac tax before he put forth his proposal to offer something similar. Go figure.

Groups Defend Health Insurance Access Status Quo

Still, don’t expect businesses and the lobbying groups to take this sitting down. Trade groups, professional associations, insurers, brokers, human resources and benefit professionals will more than likely resist any changes to the workplace health insurance status quo. They will boldly claim the current system works and it is what workers prefer. Oh, yeah, they already claimed that. They will also claim that they support efforts to increase access to affordable health insurance to the unlucky millions who do not have workplace health insurance, and they’ll leave it at that.
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Birth Of A Health Care Reform Movement

There are powerful social and economic movements going on in America today. Some of the more known movements include Black Lives Matter, Occupy Wall Street and The Tea Party.

  • Black Lives Matter is a protest and advocacy movement founded in 2012 to address the dehumanization of black people.
  • Occupy Wall Street is a protest and advocacy movement started in 2011 to address social and economic inequality.
  • The Tea Party is a political movement established in 2004 promoting a fiscally responsible and limited government.
These are three very different movements with different objectives, but what they all have in common is their mission to bring national and even international awareness and change to issues impacting the nation. One has had more success than the others because of its continuous mainstream media coverage and impact on political elections. But the other two are finding that the issues they champion are resulting in proposed legislative and corporate changes. For example, cities, states, federal contractors and private companies are creating laws and policies to increase the minimum wage for workers. Also, the criminal justice system is receiving greater scrutiny in light of its many failures in black communities.

The individuals these movements represent want to change the status quo. And what they are finding out is that it is not easy. The Occupy Wall Street protestors know well how harsh the opposition can be. Politicians and many in the mainstream media often treat them with disdain. The Black Lives Matter protestors have to constantly defend their existence to critics and supporters. Even the Tea Party, the most organized and well funded of the three modern social movements has its haters among the elite.

As these movements struggle to develop their platform, their powerful critics, including many in the media and elected politicians, label them subversives and their leaders, hustlers. They say they are unorganized, naive and unable to articulate their purpose. As was the case for all new social, economic and political movements in the U.S., the odds are against them. Much as it has been for those looking to reform the American health care system.
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Can The Apple Watch Replace Traditional Wellness Programs?

Jeb Bush's remarks about how the Apple Watch can transform the American healthcare system didn't go over really well with people who already dislike him and his family. Granted he is not the most articulate guy and we know he's a poor listener, but I'm not sure he meant to say what a lot of people are accusing him of saying. People accused him of saying that the Apple Watch could replace Obamacare or basic medical care.

And while I will never be caught defending a Bush (I have yet to resolve the trauma I experienced when Dubya first became President), I think Jebya was just looking for an opportunity to let everyone know how much he loves his Watch and how it's changing his health habits. And I get it. I got my Apple Watch (Sport) on April 29th and the fitness tracking apps have changed my life. I love getting the reminders to stand and the awards for meeting my fitness goals. Even when I don't receive a reminder, I check to make sure I am on track to meet my daily exercise, calorie and standing goals. If it is getting a little late in the day and I haven't met my goals, I'll clean my bathroom. I leave items I need on the top floor of my house so that I can get them one at a time. I make my dog walk a little longer than she probably wants. I won't go to bed until I meet all of my fitness goals for the day and I refuse to change my goals to make them easier to reach.

As a result, I feel lighter and stronger and motivated to keep using the Activity and Workout apps on my Apple Watch. I look forward to even more apps of this type. I love my Apple Watch!

But if you know anything about my background as an employee benefits professional who helped enroll hundreds of people in health insurance plans, you know I would never suggest that anyone stop paying their health insurance premiums and use the money to buy an Apple Watch. The Apple Watch and other fitness trackers are a great supplement to health insurance, not a replacement of it. But Jebya's jumbled remarks did make me think of something the Apple Watch could replace, and that's a traditional workplace wellness program

Apple Watch Vs. Traditional Workplace Wellness Programs Continue Reading...

Workplace Health Insurance—It’s Not Dead Yet


A lot of people are betting on a future without employer-sponsored health insurance. Entrepreneurs are creating businesses based on this model. Health insurance brokers are courting individuals and enjoying record-breaking business growth. And politicians from all parties are proposing limits to the favorable tax treatment of workplace health insurance. Meanwhile, employers are acting like business as usual in administering their health insurance plans.

They continue to rely on lame tactics like wellness programs and private exchanges to control health insurance costs. When just a few years ago employers were mocking the return on investment (ROI) claims of workplace wellness programs. Today they vainly commit to these programs despite all the evidence their initial skepticism was right. They embrace the private exchanges created by big insurers and big consulting firms. The same groups they’ve been partnering with for decades and whose only talent is to create more ways to shift costs to employees. So in a sense it really is business as usual for employment based health insurance. Without optimism or enthusiasm employers continue to employ the same follow-the-leader strategies they’ve been using since, well, forever.

Regulation and Revolution Continue Reading...

Will Obamacare Challenge Employer’s Total Compensation Models?


It is difficult to know how American business owners really feel about the Affordable Care Act (aka Obamacare). It’s difficult because most of what you hear on the issue comes from politicians, public policy researchers, academics and professional associations. They all have opinions and predictions about what Obamacare means for businesses.

For some, Obamacare is viewed favorably because it gives businesses health insurance options that never existed before. Small businesses especially know how complicated and expensive individual and group health insurance was to obtain pre-Obamacare. But for others, Obamacare is viewed as a huge regulatory burden. Somehow worse than the before model… Meanwhile nearly all of these proponents and opponents neglect to discuss probably the biggest challenge businesses face because of Obamacare. That challenge is how to maintain traditional compensation structures that favor businesses.

Employee Benefits As A Form Of Compensation

For more than half a century employers were able to include “benefits” as a form of compensation they provided to workers. And as employer-provided health insurance became increasingly expensive, employers started to share just how much they were paying for these benefits with workers. They wanted to make sure that workers understood that compensation didn’t just come in the form of a paycheck. So, large employers in particular started distributing annual total compensation statements.

These total compensation statements include pie charts dividing up all of the compensation employees receive. And while cash compensation remains the biggest chunk of the compensation pie, the health insurance, and to a lesser extent, retirement plan funding slices are significant. But Obamacare has the potential to change how employees view their total compensation and how they want to carve it up.
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What Does Being "Lazy" Have To Do With Health Insurance? Nothing.


Yesterday one of the kindest individuals I know made some horrible comments implying Obamacare favors the "lazy" at the expense of the motivated. He does not think it fair that the rest of us should pay for health insurance for these "lazy" individuals. As if not being able to afford the high cost of health insurance means you are lazy.

Unfortunately, this is the typical argument of the uninformed or those with a vested interest in maintaining the status quo. He was a member of the former group (but currently informed and reformed). But it is the latter group who was clearly shaping his opinions about who is "entitled" to healthcare in America. Even though these individuals have been wrong about nearly everything they said would happen under Obamacare, they continue to repeat their distortions. Obamacare has not:
  • Caused employers to lay-off millions of workers
  • Increased the costs of health insurance above previous trend levels
  • Created death panels, etc.
Facts mean nothing to these angry opponents of Obamacare. Instead of railing against over priced medical care or wealthy doctors and health insurers, they direct their anger at the poor. But maybe I'm giving these folks too much of my time. Only a change of heart can change their opinion about Obamacare, because factual information sure isn't working. So let's just leave these curmudgeons to their indifferent beliefs. They have little to no power to change the direction of Obamacare.

I’ll save my disdain for the uncaring and self-interested politicians and their ilk that do have the power to make changes to Obamacare—like the newly announced candidate for President of the United States, Ted Cruz. It wasn’t until yesterday when I read “the comments” and learned of Cruz’s announcement that I started to think about what American health care would look like under a Cruz White House. Until then the only thing I knew about Cruz’s stance on health care is that no one in the world wants to repeal “every word” of Obamacare more than this guy. (Well, maybe a few conservative intellectuals who would rather set themselves on fire than live in a world where a law enacted by President Obama defines the nation for years to come… But I digress.)
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What’s The Future of Pre-Tax Health Insurance Deductions?

Every year workers save thousands of dollars by participating in workplace pre-tax employee benefit plans. Most of these workers know they are saving money by participating in these plans because someone told them so. However, many do not know why or how much they are saving. But if these benefits vanished, the effect would be immediate and painful.

If this all sounds confusing, that’s because it is confusing. For decades, workers who participate in employer-sponsored cafeteria plans enjoy tax savings that non-participants do not. But that may be changing. The passage of Obamacare, along with several White House tax-reform proposals, and tax recommendations by politicians and thinkers from all political parties is threatening to change this confusing and unequal system.

Employer-Based Cafeteria Plans

Cafeteria Plans are difficult to explain and even more to understand. They are also known as Section 125 plans because they are part of and subject to provisions of Section 125 of the Internal Revenue Code. As part of the tax code, they have specific features that allow employees who purchase benefits under the plan to reduce their gross income and, therefore, the amount of taxes they pay.

Cafeteria plans may include a suite of underlying employee benefits such as medical, dental, vision and group term life insurance, and flexible spending accounts.

A cafeteria plan arrangement is a complicated way of incenting employers to offer workplace health and welfare benefits and for employees to participate in them. However, now that Americans have different options for purchasing insurance and given the fact that millions do not have access to these workplace-only benefits, proponents of employee benefit tax reform are looking to change the system.

Times Are Changing

Obamacare did not address the unequal tax treatment of health insurance in the workplace versus the individual market, however, several Obamacare “alternatives” drafted by conservatives do.
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The Better Mind and Body Obamacare Alternatives


I am committed to discovering and learning from every Obamacare alternative available. So far I uncovered two conservative proposals—The 2017 Project Proposal and the Save Our Healthcare Proposal. But after reading two proposals from conservative elites, one (2017) a lot more detailed than the other (SOH), I am already feeling distracted. So I went searching for something else, something different, and something unique. And I found it—two very different “alternatives” to Obamacare… The first alternative comes from Whole Foods (supermarkets) co-founder and libertarian, John Mackey. The other alternative is health care sharing ministries.

Whole Foods

Everyone who visits a Whole Foods market knows it is an experience. The staff is nice, friendly and helpful. The food is super fresh and a lot of it is organic. They offer products you cannot find elsewhere. And you can easily spend $100 and not have enough food for one meal, but still walk away smiling. Now Whole Foods is not the only high-price supermarket, but it’s owner is the only corporate big shot that has his own health care reform plan.

John Mackey, Whole Foods co-founder, got in a lot of trouble for his comment that Obamacare is fascism. He later apologized for his poor choice of words, but he no doubt still believes them to be true. In true libertarian fashion
his health care reform plan calls for more personal responsibility and less (really, no) government intervention, unless it is pro-market intervention.

The Mackey (8-point) Health Care Reform Plan
  1. More high deductible health plans and health savings accounts (HSAs)
  2. Same tax treatment for individually purchased and employer-provided health insurance
  3. Right to purchase health insurance from any state
  4. Abolish all health insurance plan mandates (these are benefits that a state or the federal government requires a health plan to offer. For example, alcohol and drug treatment, hearing aids, mental health benefits, etc.)
  5. Implement medical tort reform to limit the amount of damages patients can collect
  6. Health care costs transparency
  7. Reform Medicare (that’s all it says…)
  8. Allow tax deductible charitable donations to help others who do not have private or publicly provided health insurance
Mackey’s plan has some of the same elements as the 2017 Project health care reform, proposal, including equalizing tax treatment for employer and individual health insurance, using HSAs and purchasing coverage across state lines. It also has a few things in common with Dr. Ben Carson’s Save Our Health Care proposal, including tort reform, HSAs, and charitable contributions. Continue Reading...

Dr. Ben Carson’s Alternative to Obamacare Suffers From Status Quoitis


It was my mother who introduced me to Dr. Ben Carson's personal life story. Because of her, I read his autobiography, Gifted Hands: The Ben Carson Story. And several years later I watched some of the made for TV movie based on the book (I lack the patience to watch an entire movie). The book is the tale of how he overcame poverty and anger and became a renowned pediatric neurosurgeon.

Before his retirement as a physician I would hear his name or see him on the news as one of the doctors performing groundbreaking surgery to save someone's life. And I would think to myself, oh that's the guy who... I have to admit I was proud of him and his accomplishments. So I was eager to read his alternative plan to Obamacare.

Where to begin?
  • First, the name of the project is Save Our Healthcare
  • Second, it is a “partnership” between Newt Gingrich’s American Legacy Political Action Committee (PAC) and Dr. Carson, who serves as the project’s Chairman
  • Third, there are five parts to Dr. Carson’s health care reform project
Dr. Carson’s Five Health Care Reforms

Dr. Carson outlines his health care reform proposal in a
five-part video series on the Save Our Healthcare website. Here is a summary of his reforms:

Part 1 – Creation of personal, tax-free health savings accounts (HSAs) established at birth. Account funding can come from you, the accountholder; a family member, employer, charity, and even Medicaid Continue Reading...

The 2017 Project's Health Care Reform Proposal - Obamacare Alternative?


America’s health care system is among the most muddled, expensive and unfair health care systems in the world. There is medical care rationing based on ability to pay. Medical care prices are set indiscriminately and are rarely available in advance of service. And some groups pay much less for much better health insurance than others.

Fixing such a complicated and costly system does not come easy or quick. So when I hear the criticisms about how the Affordable Care Act (aka Obamacare) got so much wrong, I question their motives. Does any sensible person honestly believe that any law could address all the issues that plague our health care system on the first try? No. People who hate Obamacare are either looking out for their own self-interest, hate government intervention even when warranted, or have an intense resentment for a certain person or persons.

Still, I never dismiss criticism of Obamacare outright. It needs improvement and even the most hateful opponents may have some ideas worth incorporating into the law. Or they may have ideas that make us grateful that Obamacare came first.

The 2017 Project - Health Care Reform Proposal

The 2017 Project’s health care reform proposal is the conservative alternative to Obamacare. The entire
proposal is on the 2017 Project website. The proposal has a three-legged strategy. The three (3) legs are: Continue Reading...

Who Really Wants To Repeal Obamacare


It’s 2015 and the Republicans have a majority in both the U.S. House of Representatives and the Senate. And I, like a lot of people, want to know what they plan to do to the Affordable Care Act (aka Obamacare). Will they try to repeal it? Will they chip away at it by revoking components they especially do not like? Will they sit back and wait for the Supreme Court to gut the law by eliminating most of the subsidies? Will they pass their own version of Obamacare? Or, and it’s a big or, will they just leave it alone.

Well, we don’t have to wait and see what the new majority will do, they are already doing it. Senate Majority Leader Mitch McConnell and House Speaker John Boehner are going the chip away route. The House recently passed legislation to change the law’s 30-hour workweek threshold to 40-hours. A few other provisions of the bill the Republican leadership plan to change include elimination of the employer and individual mandates. They also want to ditch the medical device tax and the Independent Payment Advisory Board (IPAB).

But how will the newly elected majority’s constituents react to this approach of eliminating only parts of Obamacare. Will that be enough to satisfy their multi-year thirst for absolute repeal of the law? Probably. Survey after survey has shown that while self-identified Republicans and conservatives claim to want to repeal Obamacare they do like some of its provisions. Components of the law they like include covering adult dependents on their parents’ health plan up to age 26 and preventing insurers from denying coverage due to a preexisting condition.
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If One of Obamacare’s Biggest Critics Wants to Use It To Save His Business, Can It Really Be That Bad?

I read a ton of employee benefit articles everyday. And when you read as much as I do you start to think you can predict where the field is going. Of course not everyone agrees with my opinions. But that doesn't stop me from sharing them...

For example, it's my opinion that some of the biggest Obamacare critics will eat their words. I'm not just talking about these critics being proven wrong because that happens daily. I mean they will embrace the very law they claimed was the worst thing to ever happen to America. Don't agree? Well, how about this as an example...

In 2012 Donald Trump
said this about Obamacare,

I know so many people who have companies where they are going to close them up as soon as it [Obamacare] really starts kicking in, which is in '14."

Irony of ironies, Trump Entertainment plans to stop paying for health care for thousands of union workers as it tries to avoid going out of business. And here is the kicker,
Trump Entertainment wants to provide these workers with a $2,000 stipend to purchase coverage on the federal exchange. Yes, instead of ruining companies, one of Obamacare's greatest foes is trying to use it to save one of his. Continue Reading...