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31 Million Uninsured Under the PPACA . . .

Over at “Economists View,” Anne and Muses are having a discussion over why some 30-something million will be uninsured under the PPACA Paul Krugman: The Obamacare Shock. The conversation goes back and forth citing references without giving any real explanation of what the 31 million is composed of and why they will not be covered. For some reason today, I can not log-in and add to the conversation with an explanation of the 31 million.

Perhaps it is a little known fact; but states today can, if they so choose to do so, qualify Medicaid coverage for everyone. States can also cover beyond 100% of FPL which some states do. The majority of states do not cover certain single adults as determined by each state’s rules for Medicaid coverage.

“Currently, few states cover non-disabled, non-pregnant parents up to 138 percent of FPL in Medicaid, and even fewer states cover such adults without dependent children. At present, only 18 states provide comprehensive Medicaid coverage to parents at or above 100 percent of FPL ($18,530 for a family of three in 2011), and the median state covers working and non-working parents up to only 63 and 37 percent of FPL, respectively. The majority of states do not cover non-disabled, non-pregnant adults without dependent children at any income level, and many low-income women only qualify for Medicaid coverage when they are pregnant. As has been noted, ‘it’s a very common misconception that Medicaid covers all poor people, but that’s far from the truth.'”

“Nationally, just over half (53 percent) of the uninsured who would be newly eligible for Medicaid are male. This is not surprising, since, as indicated above, Medicaid has historically had much broader eligibility for parents than for adults without dependent children, and a high proportion of these parents have been single mothers. ‘Overall, 47 percent of the uninsured who would be made newly eligible for Medicaid under the ACA are women.” Opting into the Medicaid Expansion under the ACA: Who Are the Uninsured Adults Who Could Gain Health Insurance Coverage?.

The expansion of Medicaid to 138% of FPL under the PPACA would have mandated state coverage for single adults not qualifying for the PPACA and its subsidies. The SCOTUS decision to allow states to back out of the expanded Medicaid coverage up to 138% FPL was previously mandatory under the PPACA with the threat of the removal of Medicaid subsidies. States not expanding Medicaid coverage will maintain the status quo and many who would have been covered under Medicaid may now go uninsured as they will not qualify for the PPACA. The state exclusions for which many blogs, politicians, and conservative think tanks such as Cato blame the PPACA as causing is the result of states not expanding Medicaid and accounts for 15.1 million uninsured of the potential 31 million. Another estimated 11.2 million are considered to be illegal residents of the US who will not be covered by the PPACA. Treatment of Non-Citizens under the PPACA and do not have healthcare insurance. The balance of the uninsured is made up of those exempt from being insured, those opting out and paying the penalty, those who may not understand how to apply for Medicaid, etc.

Without a doubt, Republicans hope the constituency will not understand the issues and blame the PPACA for the lack of coverage of single adults by using the 31 million as a political numeric. It is also doubtful whether there is a real concern by politicians for the coverage of illegal residents. I also believe it to be ironic when Republican-lead states are concerned a Republican-controlled House may pull the carpet out from under them by negating funding for the expansion of Medicaid in the future.

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Medicare Claim Costs Growth Under 1% in 2013??? Why?

All nine of S&P Healthcare Economic Indices showed slower annual growth rates for February 2013 compared to January 2013. As measured by the S&P Healthcare Economic Commercial Index, healthcare costs covered by commercial insurance plans rose by 4.62% in February, down from +5.41% reported for January. Annual growth rates in Medicare claim costs increased by 0.78%, according to the S&P Healthcare Economic Medicare Index, down from +1.40% recorded last month.” Annual Growth Rates Decelerate in February 2013;  https://www.spice-indices.com/idpfiles/spice-assets/resources/public/documents/11477_sphealthcare-press-release.pdf?force_download=true

heathcare

When economists such as Tyler Cowen and Congressional leaders such as Ryan and McConnell are calling for cuts in Medicare, and Medicaid;  one has to wonder what the basis is for doing so. Medicare and its associated programs have dropped below 1% cost claims growth in 2013. According to Glen LaFollette and Louise Sheiner, healthcare in the US is sustainable at 1% growth and will not crowd out the other necessities. “An Examination of Health-Spending Growth in the United States: Past Trends and Future Prospects”  http://www.bancaditalia.it/studiricerche/convegni/atti/fiscal_sustainability/session_3/Follette%20Sheiner.pdf

 

What gives?

For partisan and give-Barrack Obama-no-quarter-reasoning, politicians claim the PPACA will have no or little impact on healthcare costs. Hoping for pie-in-the sky universal health care today, some rather reasonable writers and blogs have also joined the bandwagon of claims against the PPACA (or Barrack Obama) and are advocating the same lack of impact. Train-wreck Baucus successfully scuttled single payer healthcare insurance (with the help of Lieberman) and kept prominent advocates away from the bargaining table having  protestors arrested. Baucus now advocates backing away from the PPACA. Then what has made government healthcare programs decrease in cost? Maybe the last couple of years of decreasing cost growth are the result of the healthcare industry and the healthcare insurance companies taking heed to the needs of the population and developing a heart??? Naaaawwwwwww, I don’t think so. It is still the same industry; but as a result of the PPACA, the industry is rapidly preparing for the implementation of the PPACA.  Some answers PPACA:

hard times or recession, accounted for only about 1/3 (37 percent) of slower growth in the nation’s health care bill.  My guess is that most of the effect was felt in the private sector.

“During 2009–11 per capita national health spending grew about 3 percent annually, compared to an average of 5.9 percent annually during the previous ten years. job loss and benefit changes that shifted more costs to insured people. We found that these enrollees’ out-of-pocket costs increased as the benefit design of their employer-provided coverage became less generous in this period. We conclude that such benefit design changes accounted for about one-fifth of the observed decrease in the rate of growth. However, we also observed a slowdown in spending growth even when we held benefit generosity constant, which suggests that other factors, such as a reduction in the rate of introduction of new technology, were also at work.” The Independent Payment Advisory Board and Medicare Spending: New Research Suggests a Change in Our Medical Culture; Maggie Mahar, Healthbeat Blog, http://www.healthbeatblog.com/2013/05/the-independent-payment-advisory-board-and-medicare-spending-new-research-suggests-a-change-in-our-medical-culture/

and the chief Actuary for Medicare?

“Paul Spitalnic, sees the recent past as prologue – at least to the near future. On April 30, he sent a letter to Marilyn Tavenner, acting Medicare administrator, saying that based on the most recent numbers, the projected 5-year average growth in Medicare per capita spending ia 1.15% , and the 5-year average growth target is 3.03 percent.” As a result, he advised Tavenner that we won’t need the IPAB until 2016—at the earliest.”  The Independent Payment Advisory Board and Medicare Spending: New Research Suggests a Change in Our Medical Culture

If Spitalnic’s and the S&P Healthcare Indice projections prove true over the next few years; Medicare will not be growing faster than GDP and healthcare costs would not be adding to the deficit or crowding out spending on education, infrastructure or the environment as predicted. There is no evidence the trend will not continue and Medicare cost growth is at the lowest level since its beginnings.

Health Beat Blog: “Michael Chernew, a Harvard health policy professor and co-author of the paper, told Modern Healthcare that slower growth was due to more than the weak economy or increases in out-of-pocket spending as employers shifted costs to employees. Instead, the results appear to point to a shift in culture and physicians who have who have grown more focused on greater efficiency in the last five years.” Economy Less of a Factor for Healthcare Spending, New Studies Say“; Melanie Evans; Modern Healthcare;  May 6, 2013

Or perhaps it is what many have said with the advent of the PPACA, a change has and is being brought about in how we are being treated. The overall cost model is moving from a services for fees treatment scenario to a better outcomes and efficiencies for fees scenario.

“The cost saving measures within the PPACA appear to be keeping medical expenses flat during the implementation of efficiencies. For example, in 2012, the average price paid for medical care, doctor visits, operations, glasses, etc. rose at about the same rate as other prices in the economy or less than 2%. Healthcare share of the economy in 2011 shrank from 17.12% to 17.04% due to other aspects of the economy growing faster. BEA Analysis; USA Today; Health Care Spending is Transferred Out of ICU

“‘Until now, the government has paid on volume. Now, it’s trying to pay more on quality,’ says Person, a doctor of internal medicine, as well as CEO of Essentia, which has 18 hospitals and 68 clinics.” For example: “Essentia now provides 300 of the sickest congestive heart failure patients with electronic home scales that relay information, such as weight and symptoms, to a nurse several times a week. The steady monitoring of small things has cut 30-day admissions to less than one-tenth of the national average and saved millions of dollars.”  Health Care Spending is Transferred Out of ICU; USA Today; March 4, 2013;  http://www.usatoday.com/story/news/health/2013/03/04/health-care-spending-growth-slows/1963165/

This is precisely what was provided to me by the Great Lakes Home care nurses. Each morning I would weigh in and take my blood pressure three weeks after my open-heart surgery. The nurse would come once per week to my home to which I was confined and check on me. These type of visits by nurses also gave me an early exit from the hospital initially even though the visits were 2-3 times per week and at a far lower cost than keeping me confined to the hospital (I was bouncing off the walls and wanted out).

“One big change is the government’s revived push toward managed care. The government wants to pay a lump sum for a patient or diagnosis, demand higher standards and expect the medical provider to get the job done for that cost. Rather than cutting reimbursement rates, the government is raising the bar for what it expects for every dollar it spends.” Health Care Spending is Transferred Out of ICU

says Person, the hospital chief: It is now the law, and it has teeth. We’re getting paid less,” he says. “We have to be more productive and efficient.” Health Care Spending is Transferred Out of ICU. USA Today; March 4, 2013

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What Is The Out of Pocket Maximum You Will Pay Under the PPACA?

There are quite a few blogs in the blogosphere who tend to get the PPACA wrong and conflate the issues of it well beyond what is reasonable and truthful. Maybe they just do not know what the facts are and miss the benefits of the PPACA to dwell on the negatives exclusively.  Many  tend to dwell  on the amount of money one has to pay out in insurance and deductibles,  what the PPACA does not do, and why we should go back to  . . . ahh nothing? For the record, the PPACA is not single payer nor is it even universal healthcare. It is a convenient compromise which has many positives which did not exist previously. Some thoughts for those who think differently .  .    .

Maggie Mahar at The Health Beat Blog: “Even if you do not qualify for a subsidy, your out of pocket spending is capped at about $5,500 for an individual; $12,000 for a couple. (That includes deductible and co-pays under a Bronze plan–or any other plan). 

A couple earning $65,000 joint might not have $12,000 lying around –especially if they were young. But they could work out a payment plan with the hospital or surgeon– paying, say $5,000 up front as a sign of good faith, and $7,000 over time. If they had to, they could borrow the $5,000 from relatives or friends or a credit card.(These days it’s pretty easy to get a credit card that charges 0% interests on cash withdrawals for 6 months to a year). 

Bottom line: they don’t lose their house, and they don’t go bankrupt. A $12,000 bill is the worst that can happen to them, even if they’re in a horrible accident and in the hospital for 3 months. 

There will also be no annual limit or lifetime limit on how much the policy will pay out. 

This is why the ACA is a boon—even for people who don’t qualify for subsidies. You can’t be ruined by medical bills, and they can stop paying even if you have a very expensive chronic disease.   

As for poor people –if they’re below 133% of poverty, they’ll be on Medicaid (once all of the states expand Medicaid which, eventually, they will).If they’re above 133% of poverty, the subsidies are rich enough to make insurance comprehensive  affordable.”  Maggie Mahar in an email.

Families USA Foundation:  Worry Less, Spend Less: Out-of-Pocket Spending Caps Protect America’s Families;  “The Affordable Care Act initially sets the level of these new caps by referencing an existing definition—the annual out-of-pocket spending limits for high-deductible health plans that are associated with Health Savings Accounts (HSAs). If these caps went into effect in 2011,they would be $5,950 for individuals and $11,900 for families.http://www.familiesusa2.org/assets/pdfs/health-reform/out-of-pocket-spending-caps/National-Report.pdf “Worry Less, Spend Less: Out-of-Pocket Spending Caps Protect America’s Families”

I am not a big fan of Barack Obama who wanders down the double yellow, weaving from one side to the other in attempts to secure his place in presidential history; but in the end, we are better off with the PPAC than what we had before “nothing.”

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