Tag Archives: single-payer

Lost in the Marketplace: Thoughts on the ACA Exchange


Like many of you, I have been unable to apply for an insurance policy on the Marketplace that opened October 1.  That was also the start of “open enrollment” at my work, and I was hoping to see if there was a cheaper option for my family available with similar coverage, even though I would not qualify for a subsidy.  I also wanted to be able to give you more detail about the process and possible pitfalls by trying it myself, since I didn’t have time to train as a navigator.  My window of choice closed for a year, and I gave up trying to log in to stay out of the way of those still trying. 

 

Twice, I got a user name and password and was sent an email to complete the registration process.  Although I clicked the email link as quickly as my fingers would go, within 10 seconds of receiving it and 30 seconds of completing the password entry, the healthcare.gov site said I was too slow—sorry, go back to the beginning and try again.  Perhaps I would have had to grow up with video games to get the required hand-eye coordination speed? Maybe it was a subtle way to get younger, healthy and well-coordinated sign-ups first?

 

It is possible to look at the available plans for a given county without registering—in my county, for an individual/ family policy, I would have a choice of BCBS or Humana.  There is no link within the site to provide nitty-gritty details though.  To get those on your own, you have to apply.

 

I’m going to recommend you work with a navigator unless you are very well versed in health insurance policies.  Be very careful of fraud and check the credentials of whoever you are working with.  Here are some factors to consider.  Remember that the 60% cost coverage on bronze policies and 70% for silver does NOT mean it will work out that way for you personally.  All that means is that for a “typical” subscriber, the insurance will pay 60 or 70% of the total covered services after the premium.  From what I am hearing, the costs to subscribers will be front loaded in the form of significant deductibles that must be paid before the insurance kicks in.  I would advise not selecting a deductible of an amount you don’t have already in savings.

 

If you don’t have insurance now, you may be getting some services from a free clinic, discounted/sliding scale service from a physician or clinic, and/or free medications from a Patient Assistance Program.  I know none of these safety net services is ideal and that people with insurance generally have more options than you have right now.  However, you need to know that once you have insurance, these options will no longer be a plan B for you.  You can’t go to the free clinic on a day when you don’t have your co-pay or co-insurance money unless you are going to lie, because the ones I know of only accept uninsured patients. Your doctor or clinic may not be able waive a part of your co-pay or deductible—that is considered criminal fraud in some cases, against their contracts with the insurer.  Every policy I’ve ever had says, in fine print within the manual, that my policy can be cancelled for breaking the contract if I don’t pay my share through co-pays and deductibles.  So you want to check and see if that is in a policy you are considering.

 

Medication co-pays can add up quickly.  If you are getting 4-5 medications through free Patient Assistance Programs, even if they aren’t the most effective ones for your condition—will you have the funds to buy them? Depending on the co-pay tier, you could be shelling out $150 or more a month. If it is possible to view the formularies for the plans you are considering, and find out the co-pays for your medications, I would recommend it.  You need to know that insurers can change their formularies without your permission and without warning.  If you aren’t in an open enrollment period when that happens, you’ll be stuck with it for awhile.

 

If possible, it would be good to look at the provider networks for each plan, for both primary care and specialists you need, and see if they are taking new patients.  Be careful to note if there are restrictions on laboratories and radiology facilities you can use—I have learned there are a couple of new plans that will restrict lab services to only one company, Quest.  You don’t want to go to a non-contract lab for blood work and find out later the bill is fully on you.  If you see mental health providers, check to see if there is a carve-out policy that delegates management to a sub-insurer.  I’ve been told by a navigator this is not an issue with the plans in our county.  These can be a significant barrier to care, in my experience.  Even without a carve-out, check the mental health provider network and ask if your primary care provider can be included—a critical feature to allow initiation of treatment while you are waiting for a mental health referral.

 

If you are uninsured and have significant chronic conditions already being managed through charity services, you may find out that you can’t afford to switch to insurance even with the subsidy and even considering the tax penalty.  Being uninsured is frightening, because the gaps in charity coverage are tremendous and you never know if you will acquire a new condition and be left without help.  At the same time, you do not want to be left unable to purchase ongoing treatment you already know you need.  You don’t want an insurance card you can’t afford to use.  I have seen this happen many times, in person, to families who had insurance and too much income for their children to get Medicaid or AllKids but not enough to pay for services or prescriptions.  It is a difficult decision—don’t make it lightly.

 

If you have no chronic conditions, you may decide it is worth the risk to sign up for insurance.  That’s the function of insurance, as you know—it is a risk pool, where we enter not knowing who will need to use the funds we add to the pot.  We don’t expect to each get back the amount of services we have paid for with our premiums—we don’t even want to, because that would require illness or injury.  The more healthy people who sign up and contribute, the lower the cost for everyone in the pool, and the more total profit for the insurers.  You could be helping other people in your state more than yourself, or they could wind up helping you. 

 

One thing is for sure—we are all, through the forced wealth transfer in the ACA, helping to line the pockets of private insurers and strengthen their position at the lobbying table.  We are taking a large step away from single payer, a public option and even community level grassroots safety nets by doing so.  Ought we to use much time and energy to prop up a plan with such fatal flaws at the core? 

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Filed under Exchanges, Healthcare reform

The Light of the World is in You: It has not been Overcome


When I was 4 years old, I announced to my family that I was going to “be a doctor when I grow up.”  Why?  Because my preschool friend’s father was one, and I thought he was cool.  At age 49, 18 years into practicing pediatrics, my reasons have of course entirely changed.  I may or may not have grown up.

 

The same thing has happened with my advocacy for single payer.  When I started this, I was (in hindsight) incredibly naïve about the political world and the forces of power at play.  I did not have an inkling of how easy we are to dupe and manipulate—how our emotions can be hijacked by a researched phrase or just a word, and how we can imagine the resulting confabulations are our own.  I had spent decades in school and then working out the intricacies of how to take care of patients in the exam room.  I thought I was keeping up with politics the whole time, but I had only a very superficial grasp.

 

So when I heard about Medicare for All the first time, having been in practice long enough to be distressed by the strange abuses of economic power in medicine, I felt as if I had “come home”—that this was a beautiful solution to our problems and that all I had to do was make sure everyone understood it well enough to insist we have it.  It felt like a religious conversion must feel.  Everybody in, nobody out!  What could be better?

 

Don’t panic.  I’m not giving up.  It’s just that my reasons now are entirely different.

 

The first time I spoke publicly on healthcare reform, I was terrified before standing at the microphone.  I had never been a natural public speaker and used to have a tendency to be shy.  What happened, right as I opened my mouth, seems to have been lasting, because I’ve never been afraid of speaking since.  As I looked out at the audience, I could see who was there supporting the cause, who was uncertain, who was ready to give me what-for—and all of the sudden, I realized I loved them.  Instead of wanting approval or love from them, I felt an deep sense of compassion and affection in my heart, for them.  I thought, “Look how hard we are trying to get this right.”  I wanted to do my best job to pitch my lot in, not with only some of them but with everyone there.

 

In the years afterwards, I have slowly learned more about politics, power, and human nature.  I’ve given up the Democratic party, many subtle forms of utopianism, the myth of progressive evolution of our species, and the hope that single payer would work here the way it has in other countries.  I’ve given up my school-girl belief that our government is in any way composed of “we the people” and realized that both self-described conservatives and liberals are pawns in a game we will probably never fully understand, both seeing some true problems in each other but neither seeing our own.  At the same time, I know that because I’m human too, I am most certainly under the influence of wrong ideas I also cannot see.

 

The extent of entwinement of Capital in our governance is now so tight and the wealth and power disparities among us so gaping that I no longer think any of the traditional routes of change, using civilized and orderly processes, will do anything to influence our course.  Even social issues like marriage equality are probably not shifting for the reasons we think.  As we enter into more and farther reaching global trade agreements, it will become progressively less important for Capital to worry about keeping us pacified, and the disconnection of our votes from policy will become more apparent.

 

In this setting, I have to agree with my conservative friends that handing over health insurance financing to the government sounds suicidal.  We will get single payer, friends—when Capital has worked out how they can do it and still profit.  So it won’t be the same egalitarian and high-functioning system we’ve seen elsewhere.  On the other hand, our health financing is already under the thumb of Capital and Unelected Governance.  And we already all pay for the whole thing.  We are, right now, in it together.  We just can’t see it, and those running the show don’t want us to.

 

Some of my friends think the order of change needs to be campaign finance reform, a third party, an amendment to remove the personhood of corporations—then Medicare for All.  I toyed with those ideas, but I think now it is impossible. If we got those things, it would be in name only.  Real change of that sort would be too unacceptable to Capital. 

 

Throughout history, when great wealth and power disparities have become intolerable to the masses, the result has always been revolt.   Disparities are destabilizing.  Utopians for the underdog arise (often highly anti-intellectual), power is overthrown, and the whole cycle starts again.  The problem is that now the tools of battle have changed.  I do not believe the planet can survive the process of another American Revolution or Civil War.   And even if it did, unless we have learned to see each other differently—the way my perspective shifted when I looked out at that first audience—there would be no point in revolution anyway.  It would be palliative care, hospice for humanity.  Eventually we’d wind up right back here.

 

If there is no escape from malign power, what then?  I support single payer, because I think there is a ghost of a chance that seeing ourselves with a common purpose—a decent healthcare system—might help us also have different eyes for each other.  It is a tremendous long shot.  I don’t expect or want Utopia to result—just a little moderation of the divide between us.  I don’t see that we can pursue entire withdrawal of energies into small communities and let government pretend to drown itself in a bathtub.  That’s just a word game, and we are the losers.  The power won’t release us—it will just change its name.

 

What else?  Insurance reform, even single payer, can’t possibly be a whole response to the brutality of our healthcare system.  Not knowing how on earth to make a difference in this mess, I keep coming back to the one thing I can do, immediately and every day—practice love.  Love is the ultimate subversion to power and Capital.  Power has no idea what the hell to do with Love—it has no weapons or means of control against it.  If you want to love, no one on earth can stop you.  It isn’t real love, though, if it only applies to those who accept your particular ideology.  Love means, in whatever circumstance you find yourself, whether that’s on Facebook or facing a room of the “enemy”, that you refuse to play by the rules of labels and stereotypes.  For us, right now, we can say “everybody in, nobody out.”

 

Some of my friends in religions believe in a Utopia where the powers of good triumph over evil, finally and definitively.  I don’t.  Neither do I believe in the converse.  I’m not a supernaturalist, and if I use the word God I am speaking metaphorically.  The most resonant words in the Bible for me are “The light shines in the darkness, and the darkness has not overcome it.”  Not the light burning up the darkness.  Just shining on in spite of it. At the end of the world, even if we annihilate ourselves, in our last breath and heartbeat, we can keep that light of love, our stubborn kingdom of heaven, on fire. Amen.

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Filed under citizen responsibility, Healthcare reform

Truth Hearing: Your Help Needed!


Now that I’ve finally done worrying with and studying for my every 10 year board recertification, it’s time to get busy for a more important project: Truth Hearing.  On July 31, the day after Medicare’s birthday, I have reserved the big room in the Huntsville Main Library from 6 to 8 pm.  I will invite local and state leaders to sit on a panel of listeners, while members of our community testify about their personal experiences and difficulties accessing healthcare.

 

Healthcare Now came up with this idea several years ago.  I only learned about it recently and thought it sounded just right as a project for North Alabama Healthcare for All (NAHA, our chapter of Physicians for a National Health Program).  In this Truth Hearing, leaders will be asked only to listen—not to question us or respond with canned speeches.  Of course, I expect many of them will want to hang around afterwards for conversation, and that’s fine.  But I don’t want any of them using this as a chance to push their own agendas.  There will be no PowerPoint presentations or speeches.

 

Just us, telling our stories and listening to each other.

 

There is an onslaught of propaganda from every direction, and not only from Fox and MSNBC or other media avenues.  We have let ideologies, stereotypes and sound bites invade us on our Facebook pages and in everyday conversation.  Reminds me of wearing designer clothing labels and paying to advertise someone else’s product on our rear ends.  It’s high time to unplug our ears, rip off the labels, and find out what is really happening, in the homes of those we share our weather with.  Not only that—we need to do it repeatedly, at least once a year, to learn what the corporate press and the politicians are not going to tell us.  As the ACA rolls out, we should be sure to learn the real effects of turning our health over to the unelected governance of private insurers.

 

I know it won’t be a random sample.  Sometimes it seems ridiculous that we respond so intensely to stories, statistics be damned.  But maybe we can put our story-loving selves to good purpose.  A story of injustice, with a face and a voice, can be a tipping point—if not for social change, it can change us on the heart level, and that’s where real healthcare reform needs to begin.

 

To do this right, I need some help.  Our core membership for NAHA is very small, and I am not a great organizer.  I hope some of you can pitch in for this event.  I want to fill up those 200 seats.

 

This week I am going to send out invitations to listening leaders.  I’d like your feedback on the composition of the panel, which I think should be no more than 10 to 15 people.  Each invitee will be allowed to send a suitable proxy if unable to attend—failure to appoint a proxy will result in an empty chair with a name card.  Here’s my working list:  2 members of the Madison County Legislative Delegation (one from each party); 1 member of City Council; 1 member of the Madison County Commission; the Mayor; Mo Brooks; our two Senators; our Governor; our regional Health and Human Services director Pamela Roshell (because our Exchange will be run by the fed).

 

I need two people to help with coordinating audio services with the library.  I have paid the fee out of my pocket to reserve the room and will also pay to rent the microphones/ speakers, but I do not have a free day between now and July 31 to get trained in using the library equipment.  I think two people willing to commit to that would be safer than one.

 

I need helpers to sit up front, to be ready to stand with those who want to testify but are anxious about standing alone.  Needs to be folks who are comfortable holding hands with strangers if asked.  I need greeters at the door to welcome attendees.

 

I need help with getting the word out.  I will have a flyer ready by the beginning of July (although if any of you are good with catchy artwork, your help is very much welcome), and I need people who will commit to sending it out by email, posting it around town, and pestering their friends to come.  I need help making contact with press, so we can get coverage.  I know a fellow who has recently started working with Story Corps at NPR and will ask him if he might want to attend, in case he would like a follow-up interview with a family. When I have the flyer ready, I will also put an event page on FB and ask you to share invitations with friends.

 

I need 2 camera people (with equipment) to video the event, so we can put coverage on YouTube afterwards.  Those testifying will be asked to sign a release, although we will have an option for those who desire not to be recorded to have either only their voices heard or to be omitted from the video completely.

 

I need people willing to tell their healthcare access stories—not their political solutions or problems but the stories of what actually happened to them because of difficulty getting healthcare.  It would be ideal to have at least 12 committed in advance, since each person will have 3 to 5 minutes to speak. I know talking about personal health and financial matters in public can be difficult. Heck, public speaking on anything at all can be scary!  We are ready to stand with you.  We need a few brave souls to tell the truth—the whole point of a Truth Hearing.  You are certainly welcome to omit the specific details of your medical diagnosis and focus only on how your life has been affected.

 

I know I’m asking a lot, and all of you have other work to do.  If I don’t get sufficient help, I will play Little Red Hen and do what I can—but if you want a meaningful, effective event, please step up! Email me at pabston@aol.com and tell me what you can contribute.

 

I have been listening to healthcare stories for my whole career.  Families in my office who have suffered the ill effects of being uncared for and rejected by our profit-driven medical system tell me on a daily basis what it is like.  More than anything else, their stories have made me determined to stick with advocacy for Improved, Expanded Medicare for All—everybody in, nobody out.  I have the numbers and knowledge of experience in other countries to back the concept up, but at the end of the day, it is always real people that keep me in the fight.  Will others in our audience and on our panel be similarly moved?  Let’s listen to each other and see what happens.

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Filed under citizen responsibility, Healthcare reform

Alabama Medicaid: a Sandcastle by the Pink Pony Pub


In a little over 6 months, adults in most states who qualify for Medicaid under the ACA Expansion will suddenly have Medicaid cards.  We’ve made no moves towards that in Alabama.  We’ve said to our minimum wage workers, “What’s in your wallet?  Oops, nothing! Hate it for you.”  If you’ve listened to Governor Bentley closely, he has been mighty careful with his phrasing—instead of saying an absolute no, he says he will not agree to expand Medicaid as it is currently structured

 

The legislation to do that was passed and signed, but it will not be fully in effect until October 1, 2016.   However, with the Expansion fully funded by federal money for the first 3 years, the timeline for restructuring would allow Alabama to have the new program in place before we have to foot any of the bill for newly covered persons.  That means we should jump right in at the earliest possible time for the Expansion.  Don’t let Governor Bentley off the hook—he is getting what he asked for.

 

I agree our current structure is a sandcastle by the Pink Pony on the Redneck Riviera, waiting for a hurricane.  It is oddly dependent on overuse of ER and hospital services to draw down extra federal matching money.  Instead of just a 2:1 federal match, we were getting an effective 9:1 match once the money had been recycled in various legal but bewildering ways—and an effort to decrease excess hospital use would have removed funding needed for outpatient services.  So, yes, it had to be revamped.

 

There are some good things in the new design, mainly the flexibility to use funding for nonmedical items that would improve health and keep patients out of the hospitals, like the air conditioner example.   There are also enormous potholes—no, make those sinkholes—in the new proposed design.  I’m not even going to count the number of times the word incentive is used or try to fix that right now.  The only incentive is a perverse incentive, unless it relates to satisfaction in doing good work. But pay for performance is the zeitgeist. 

 

Here’s the big rub: the legislature intends to “transfer risk” to providers and away from the state.  The Medicaid budget is a hot potato they want to throw somewhere else, anywhere else.  So instead of dealing with this risk by increasing revenue, what did they do?  Decide that providers would have to worry about making ends meet, not the state.

 

The law sets up RCOs—Regional Care Organizations—to manage patients within regions.  Each RCO would be given a set amount of money per covered patient – capitation—and then required to cover any needed care.  If medical expenses in that region unexpectedly are higher than the budgeted amount, the RCO has to cover the costs.  The RCO must have a reserve of $ 2.5 million of provider front money in order to be given the contract, so we are not talking about a group of pediatricians and family doctors.  From what I am hearing, mainly hospitals will be the “at-risk” providers.

 

The law says these RCOs are not to be considered insurance companies.  Come on, folks, give us a break.  That is exactly what they are—they will be insuring Alabama’s Medicaid program.

 

Why is this a problem?  Let me count the ways.  First, we have a history of providing insufficient per person funding for Medicaid, because we won’t stop our corporate handouts. We have one of the worst funded programs in the country, 3rd from the bottom in per person spending for Medicaid but 10th from the bottom in overall healthcare spending per person.  Don’t believe it if you hear we are spending too much money on our current program.  Dividing those inadequate funds into RCOs will not help.  If you don’t have enough money in the bank to pay rent, writing 5 smaller checks to the landlord is an interesting thought—but sweetie, I’m sorry to tell you, at least one of those checks will bounce.  The state plans to pass the blame on to the providers for not performing magic tricks. Providers won’t put up with that for long.  They will exit the program and leave patients in the hands of a third party payer, in a system with few remaining physicians.

 

Second, once we turn hospitals into insurers, can we talk conflict of interest?  Faced with a risk sinkhole, our hospital-insurers will be forced to limit services.  I have already heard talk that in one region, children may not be allowed to go to the Children’s Hospital in Birmingham but could be sent to Vanderbilt, because the costs to the RCO will be lower.  I don’t have any problem at all with Vanderbilt and send patients there regularly, but the choice of Children’s Hospitals should not be made on the basis of cost.  It should be based on the skills of the particular specialists.

 

Let’s say that against all odds, we do fund the program fully.  If our hospital-insurers come in under budget, they get to keep the surplus.  Anyone can be corrupted with a carrot like that.  I would far rather have my local hospital put in that position than one of the out of state third party payers like Centene.  But we are all human, and every one of us is vulnerable to perverse incentives.

 

I knew, while this bill was in progress, that there was no way to interfere with the intention to transfer risk.  The legislature was hell bent to do it.  I think now is the correct time for some effort at damage control, because the state has to get a waiver approved before the restructuring can happen.

 

I admire and respect the people running the Medicaid program in Alabama, especially Don Williamson, who has always been a friend to children.  He has taken a bad piece of legislation and is trying to make the best of it.  I think we should help by asking the feds to fix what our legislators would not.  No matter how much they try to wiggle out of the risk, the truth is that all of us who live here share the risk.  A failed Medicaid program will come down on our heads, in failed hospital systems and loss of shared medical services.  So let’s make this work! We need a restructured Medicaid to do the Expansion.

 

 Here is the link to the concept paper submitted to CMS (Centers for Medicare and Medicaid Services).  When the final application is submitted, we will have a 30 day comment period with CMS on their public site.  I don’t know that date yet but expect it soon.  I thought I’d let you know now, so you can study this a little and be working on your comments.

 

Here are mine, so far.  If you have suggestions, please comment.  There may be a better way to design the capitation floor in my first element.  I’m setting the bar at what might sound low to you, the 25th % tile, but it would be higher than our current rate.

 

Dear CMS,

 

As a pediatrician in Alabama who helps care for the poorest children on Medicaid, I am concerned about Alabama’s 1115 Medicaid Waiver application for RCOs.  It is very important for the plan to be approved expeditiously, because the possibility of our state accepting the Medicaid Expansion hinges upon restructure.  However, the plan as it stands will put our hospitals in the position of insuring the state against high medical costs in an environment of historically inadequate funding.  In addition, if adequate funding is provided, the plan creates a perverse incentive for RCO providers (whom we anticipate will be primarily hospital systems) to cut needed patient services in order to retain surplus funds.  I believe these problems can be mitigated by the following:

 

1) Require the state to maintain a capitation payment rate that is never lower than the 25th percentile of per patient cost in the southeast region, to guard against insufficient funding of the program.  A floor on capitation payments is critical to prevent collapse of Alabama Medicaid.

 

2) Require that any surplus funding an RCO does not spend be used for patient-related improvements to services in the regions (not for construction) OR be returned to the state general fund.  This avoids the risk of perverse incentives for hospitals to cut patient services in order to increase their income and allows the state to receive the benefit of any cost-saving.

 

Sincerely,

 

Pippa Abston, MD, PhD, FAAP

Huntsville, AL

 

As always, I want to remind you that we can more effectively cope with the Medicaid funding woes by changing to a much larger risk pool—all of us.  We all share the real risk, so let’s design our system to reflect that.  Improved, Expanded Medicare for All, not Medicaid, is what we need.

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Filed under Medicaid, SCOTUS Ruling on ACA

Cruelty or Care? The Choice is Yours


Well.  From the beginning, I have been telling you all that the so called “Patient Protection and Affordable Care Act” is neither protective nor affordable to patients.  We can keep the same PPACA abbreviation and call it what it is:  The Profiteering Protection and Affordable Cruelty Act.  Although I read the whole darn thing, I lack a background in law or politics.  As the specific corporate protections emerge from this convoluted mess, I have to say I didn’t foresee some of them.  I knew it would be bad, just not all the details of said badness.

 

The latest in our story of woe?  Insurers and some employers have discovered an irresistible loophole that allows skimpy policies covering only a few outpatient services.  The key phrase is “minimal essential coverage”, previously defined in federal law under the IRS Act of 1986.  I noticed some folks had conflated that term with “essential health benefits”, but EHB are mandated items on state Exchange policies starting in 2014.  No plan will be allowed to put lifetime or annual dollar limits on coverage, but outside of the Exchanges, other details of minimal essential coverage are minimally described.

 

I think I was fooled by the ACA’s opening paragraphs allowing insurers to temporarily restrict annual limits on essential health benefits until 2014.  I missed the absence of any requirement to offer those benefits at all, at any date, except on the Exchanges.  Insurer can’t restrict annual dollar amounts of those benefits if they are offered.  In a stunning twist on catastrophic coverage, it is possible for insurers to cover only the required preventive services and omit the catastrophes.  You can get your colonoscopy “free” if you have a non-grandfathered plan, but any follow-up surgery is entirely on you.     

 

The most minor effect is that employers who offer bare-bones policies and employees who get them are exempt from the ACA penalties.  I see some reference to this loophole only applying to large employers, but I don’t know how that was determined.  I don’t see it in the IRS code that I found, which includes as minimal essential coverage “B) any other plan or coverage offered in the small or large group market within a State.”—it may be elsewhere.  It seems to me it would apply to any size group policy offered outside of the Exchanges. If one of you can find me the relevant law making this only applicable to large employers, I’d be grateful.

 

The worst effect is that employees who have minimal essential coverage are not eligible for premium subsidies on the Exchanges, as far as I can tell.  This also seems to be the IRS’s interpretation: “A month is not a coverage month for an individual, and thus no premium tax credit is allowable for the individual’s coverage, if the individual is eligible for minimum essential coverage other than coverage offered in the individual market for that month.” If you can show me in the law itself or in administrative policy how it can be read otherwise, please post a link.  Maybe the IRS can do some creative adjusting.  Generally their creativity seems to apply only to corporations.

 

How many employers will use these plans to avoid penalties and thus apply this affordable cruelty to their employees in the process?  You know it will start with those who already pay poor wages.  As healthcare costs rise, don’t be surprised if you get this offer you can’t refuse in your own benefits package.   

 

Do I have grounds to put the word “cruelty” in place of “care” in the ACA?  The law is no longer new.  It is now part of our healthcare system.  I don’t know what else to call a system that not only allows but entrenches the abuses I see in my office.  Children who desperately need skilled child psychiatrists but whose insurance does not have a single child psychiatrist, skilled or unskilled, on the panel.  Children who don’t get the care they need because their parents delay over co-pays and deductibles.  Parents who work long, hard hours at low pay, producing goods and services we use without gratitude or notice, whose “non-emergency” pain goes untreated because of money.   Who try to smile at me in front of their kids, as if it doesn’t hurt, but cry when I take them in another room.  I refuse to make excuses for this awfulness or play around with euphemisms.  Cruelty, brutality, callousness—many words apply, and none of them is “care.”

 

I can hear the defensive talk already, from people who won’t be able to believe their beloved party would intentionally expose us to this treatment.  It was an oversight, right?  The law is complicated.  We missed this problem, and they did too.  We have a bumbling, well-meaning but hapless government, like a dog that’s so ugly it’s almost cute.  Don’t buy it.  Somebody had better ask what the President and insurers knew and when they knew it.  Remember the industry was mighty cozy with our Executive Branch during construction of the law.  Is it just now that this minimalist option has been discovered?  Or is this a convenient time for discovery, well into the second term?  Will we allow the President to wash his hands of the disaster and pretend he never imagined anyone would behave so?

 

What will it be, folks?  Do you want to keep trying to pass legislation to close loopholes, even though the insurers are always one step ahead?  How long will you continue to support and vote for people who cater to them?  When will you finally say “don’t let the door hit your butt on the way out”—and insist on real insurance and real representation?

 

Improved, expanded Medicare for All is a simple, achievable, affordable, practical next step.  It doesn’t require revolution, utopia or socialism.  Even conservatives can embrace it.  We have the structure in place.  We are only waiting for you.  Will you speak up?

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Filed under citizen responsibility, Exchanges, Healthcare reform

Redefining Affordable: The Future of Health Insurance Premiums under the ACA


In a move that goes beyond redefining the word “is”, the IRS has released its final rule on what will be considered “affordable” premiums for families.  Although you will not be on the hook for a tax penalty if the premiums for your entire family exceed 8 % of your income, an increasingly common problem, you will not be eligible to purchase a subsidized plan on the coming Exchanges as long as your individual premium for your employer plan is 9.5% or less of your household income.

 

Do you see where this is going?  Let’s say your employer really doesn’t want to pay the wrist-slap penalty for failing to provide you with an “affordable” insurance option.  So she finds a policy that costs exactly 9.5% of your total household income, which includes your spouse’s two part-time jobs.  You have two children, and your spouse’s jobs don’t include benefits because they are part-time.  Could a policy covering all four of you cost 38% of your income?  I used to have an option for individual or family coverage through my employer, but now there are premiums based on number of persons in my family.  Even those of us with decent incomes are going to be hard-pressed to come up with that money, and remember—this is only the premium.  It does not include the “cost-sharing” of co-pays, deductibles, and non-covered services.

 

For low-paying jobs, where it would be hard to find a policy that meets the criteria of essential health benefits for 9.5% of salary, look to insurers and the feds to get really creative finding loopholes.  Less of your body might be essential than you now imagine.  There are already waivers for so-called “mini-med” insurances until 2014.  Do you really believe the waivers will disappear on schedule?  I’m not holding my breath.  Some sort of redefinition is probably already in the works.

 

If a state refuses to participate in the Medicaid Expansion, your children might still be covered if you are under the poverty line.  Children in families up to 300% of poverty are generally eligible for the SCHIP programs (ALLKids in Alabama).  But what about you and your spouse?  Oh, well, the IRS says.  You don’t have to buy insurance—we won’t penalize you.  You can “keep the coverage you have”, even if it is no coverage.

 

Can you hear me now? As long as private insurers are part of our healthcare system, our health is at risk.  The insurers need to keep our care costs high, so they can rake in their allowed percentages, so there will be little effort to make serious improvements to healthcare that would keep us healthy at less cost—steps like eliminating subsidies for producers of toxic and obesity-promoting foods, getting corporate food out of the school lunch program, repairing the broken FDA, reducing our exposure to environmental poisons, or financing our public health system effectively.

 

Let’s get serious about healthcare reform—we need Medicare for All, now more than ever.  Look at the estimates for taxpayer funding under this system, a pre-paid plan with no co-pays or deductibles.  It’s affordable for ALL of us, no creative re-defining needed.  Medicare for All—everybody in, nobody out.  Look for a chapter of PNHP (Physicians for a National Health Plan), Healthcare Now, or other single payer groups in your area, and find out what you can do to make it happen!  If you are in North Alabama, we’ll be expecting you.

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Filed under HHS rules on ACA

Going Home Another Way– Why We Need to Thank Jan Brewer


Surprise announcement on the healthcare reform front this week—Governor Brewer of Arizona has announced she wants her state to participate in the Medicaid Expansion.  I’m posting a link to the Huffpo article, even though I realize it is not the most unbiased source, because of the comment section.  Scan through it if you have a few minutes because of late work openings from icy roads today! (Hey, give us a break, Yankees—we want to sleep in now and then, and if we have to declare black ice that is almost as imaginary as a Te’o girlfriend, cut us some slack).

 

Notice a common theme?  Apparently she is doing the “right thing for the wrong reasons.”

 

I understand what they are saying.  They think she should have a change of heart and do it because she cares about the uninsured poor, not because she wants Arizona’s cut of the money.  But that kind of thinking isn’t helpful.  We have to stop insisting everyone gives us good reasons for actions, as long as there ARE actually good reasons and evidence.  Let her use whatever reasons she needs to use, as long as she does the right thing.

 

I’m not a believer in using any means to a good end—the path to a goal needs to be as ethical as the goal itself, or something screwy will happen.  The end result will be tainted by what it took to get there.  I’ve seen it happen in person too many times to believe otherwise.  But reasons are not the same as means, even if they make us roll our eyes.

 

Neurology research points more and more to reason being evolved as an overlay—something may we generate AFTER we decide what we are really going to do.  We crave reasons and can’t avoid making them, but we have to take them with a grain of salt, because we don’t always know where they really came from.  As Pascal said, “the heart has its reasons of which reason knows nothing.”  It might have been a word we didn’t even know we noticed.  We use reasons to persuade each other, so being a skillful reason maker does matter.  What we DO with our reasons matters more.

 

Why do we need to be more generous in our tolerance for reasons?  Because that’s how we are going to get the good things we need.  People who oppose a good plan and change their minds need to save face—they need to be able to get there another way.  If we have single payer healthcare one day, it will not likely be because all the Tea Party people suddenly become tree huggers—it will be because they have another reason that makes sense to them.  Let it go!  Even better, thank them.  Maybe they’ll return the favor, when our reasons sound flat-out looney to them.

 

I’m very interested if Governor Bentley will be able to catch this wave.  Our Alabama Medicaid Advisory Committee just announced they are recommending we restructure Medicaid by using Community Care Networks instead of the third party vultures.  I’m not entirely pleased with parts of the plan, but I suspect almost anything would be better than having 15% of our Medicaid budget eaten up by the bad guys.  Although Bentley said he planned to turn down the Expansion, he left himself an out—he said he wouldn’t expand Medicaid in its current form.  Very important words!

 

Here’s your chance, Governor.  Medicaid will not be in its current form.  Jan Brewer has provided a Red State argument for doing the Expansion.  We could copy them on something good for once!  And fellow Progressives, let’s just clap our hands and get busy with nonpartisan rationales for single payer.  Everybody in, Nobody out—a winner for all reasons.

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Filed under Medicaid, Politics