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Health Care Thoughts: Obamacare Meets Immigration Reform

by Tom aka Rusty Rustbelt

Health Care Thoughts: Obamacare Meets Immigration Reform

With the passage of the Senate version of immigration reform we have some details to ponder.

Illegals who become “provisional” for up to 13 years will not qualify for some Obamacare credits and subsidies.

Workers who receive “unaffordable” insurance coverage from employers will be available for Obamacare subsidies, and the employer penalized up to $3,000. Provisional aliens would not be qualified for the subsidies, which could give provisionals up to a $3,000 cost advantage over U. S. workers.

Whether this was intended or just thoughtless drafting remains to be seen.

And of course, the Senate bill is just a starting point in a long hot political debate, so this may become nothing at all.


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Health Care Thoughts: California Assembly Bill 880 (pending

by Tom aka Rusty Rustbelt

Health Care Thoughts: California Assembly Bill 880 (pending)

It was a no brainer to predict Obamacare would have a major impact on restaurant and retail employers, especially in the throes of a weak economy. The composition of the work forces and often slim margins guarantee problems.

Darden Corp. (Red Lobster and Olive Garden) is infamous for whining and threatening layoffs, and of course Wal-Mart is well know as the “evil empire” of employers (the ACA part-time employment provision is often referred to as the “Wal-Mart loophole).

A clear result of Obamacare was for employers to consider cutting as many employees as possible under 30 hours. In California this would make many employees of corporate giants eligible for Medi-Cal, and California politicians are not happy, thus the pending legislation.

Employers with more than 500 employees would pay a penalty (possibly $6,000 or more per year) to the state treasury for every employee on Medi-Cal. This appears to apply to seasonal workers, although the commentaries I have read are rather murky on the details. More research to follow. This could have a major impact on seasonal agricultural employment.

It occurs to me one solution would be to reduce the number of part-time employees and just make the full-time employees work harder. I’m not certain that is what the Assembly intends.

Stay tuned, this is a giant laboratory.

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Health Care Thoughts: Cap per Procedure

by Tom aka Rusty Rustbelt

Health Care Thoughts: Cap per Procedure

Some employer health plans are experimenting with a cap-per-procedure system, allowing $X for a certain procedure and forcing employees to pay any difference.

This is not as harsh for employees as it first sounds, as the plans are using this as leverage to cap fees from providers, in effect pre-negotiating the fees within the employee cap. This is directed mostly at hospitals, which have wildly differing charge-masters.

This could be favorable for lower cost providers, and we were using this strategy for ambulatory surgery centers a decade ago (ASCs generally have lower prices and better patient satisfaction).

Experimentation is good, but this is gonna be a wild ride for the next few years.

HT: NYT 6/24/13


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Health Care Thoughts: Tenet Buys Vanguard, Wave of the Future?

by Tom aka Rusty Rustbelt

Health Care Thoughts: Tenet Buys Vanguard, Wave of the Future?

The three most frequently used words in health care strategy today are:

Integration – more providers employed by hospitals, networks and corporate providers

Consolidation – networks and corporate providers getting larger
Alignment – trying to develop business models that make sense for front line providers in these behemoth organizations, now and in the future

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Obamacare – Fear – Mongers Poison Minds; Hatred Blinds

Maggie Mahar at Health Beat Blog Obamacare – Fear – Mongers Poison Minds; Hatred Blinds” writes about the confusion about, the anger at, and the mischaracterization of the PPACA by every day people, medical workers, and politicians. Having myself presented the facts to rebut assumptions and fallacies, I find her comments interesting and on the money. Most who nit-pick on the PPACA have no obtainable and immediate alternatives in hand to replace the PPACA leaving a return to what was in place previous to its passage. The healthcare industry and Congress has done nothing to improve the situation pre-PPACA. There is no evidence they would move forward with a better alternative to the PPACA if it was repealed.

Maggie’s words:

Judith Mayer Lynn, uninsured and battling breast cancer, should be a fan of the Affordable Care Act1. Instead, Bloomberg reports, she know little about it. When Bloomberg interviewed the 56-year-old she was unaware of subsidies in the law that will help people like her buy coverage in 2014,. “Lynn didn’t know the Affordable Care Act requires insurers to pay for prescription drugs, hospital stays and other services she has spent the last two years scrimping to afford. Nor did she realize she can no longer be denied a policy due to her illness”.

When told of the benefits, “Lynn remained unconvinced, skeptical of insurers and government alike. ‘It’s a joke,’ she said. ‘There’s going to be loopholes in all of these provisions.1’”

If you showed Lynn the list of “essential benefits” that insurers will have to include in the policies they sell to people like her, could you persuade her to read the list—and explain where she saw the holes? Probably not, as her mind is closed to a discussion. In an interview at an Access to Healthcare office in Las Vegas, Lynn said she was unaware of those benefits — and didn’t trust Obama to produce them anyway.

The Poison: Hatred

Perhaps, I should not be surprised. We live in a nation where in 2009, a U.S. Congressman felt free to shout out “You Lie” during a televised presidential speech to a joint session of Congress2. (President Obama had just said that the legislation would not mandate coverage for undocumented immigrants. This is, of course, correct. South Carolina Rep. Joe Wilson (R) later apologized.)

Yet that did not stop another Congressional Republican from calling out the President earlier this month. In a scathing speech on the floor of the House3, Rep. Jim Bridenstine (R-OK) derided President Obama as a “dishonest, incompetent, vengeful liar” who lacks a “moral compass.” Bridenstine cited HHS Secretary Kathleen Sebelius’ efforts to promote enrollment in the Affordable Care Act as one reason President Obama is “not fit to lead.” Bridenstine did not apologize. Instead the next day, he told a talk show host that he had “gotten great encouragement” for his remarks from fellow Republicans. I have followed U.S. politics for many years. Never have I seen a president so hated — not Nixon, not LBJ at the height of the War in Vietnam.

Politicians Are Not Alone in Teaching Americans Not to Trust Obamacare

Lynn recalls one of her surgeons telling her that he was leaving the business because the health-care law dictates what he can charge patients1. This the Bloomberg article notes is “something the legislation doesn’t do.“ Why would a surgeon claim that the Affordable Care Act will be setting his rates? Presumably, he reads newspapers. How could he be so uninformed?

“There is a lot of distrust,” Sherri Rice, chief executive officer at Access to Healthcare explains. When her nonprofit group began asking members about the ACA last month, about half knew little about its provisions and another quarter were “furious” about it, she told Bloomberg. Such anger makes it difficult to think clearly—or take in information. This may explain why Lynn’s surgeon thinks that under the ACA he will be told what he can charge patients. Perhaps he too is so “furious” that the facts don’t register. Hatred blinds.

Educating the Public

The Brookings Institute’s Henry J. Aaron is one of many who blames the Obama administration for not doing a better job of educating the public. “We haven’t seen a lot of energy from the administration on public education. They ceded the field to those who were largely hostile to the bill to frame it in the public’s mind1.”


Aaron is right that Obamacare’s opponents have “framed” the issue. They have outspent supporters by 5-to-1 on TV ads, according to advertising analyst Kantar Media1. But their idea of “framing” is to define an idea with a catchphrase. If some facts do not fit into the frame, they are ignored explains linguistics professor George Lakoff. The “frame” becomes a lens through which conservatives invite us to see policy issues. For example, Laskoff observes, the phrase “tax relief” creates a context, signaling that taxes are bad and this is why we need “relief.” “Obamacare” is, itself a frame, which suggests that the Affordable Care Act will create a “nanny-state,” with the president becoming a national nanny who will tell us what we must do.

When you are lying, repetition is important. (Goebbels used this technique to his advantage) Laskoff points to a speech by Rick Santorum where he repeatedly refers to the President “not listening to the voice of the American people” (14 times) “because he knows better than you” (5 times)4, and is using the Government to run your lives by taking away your “rights” (10 times), and “freedoms.”(12 times “Death panel” became one of the most successful frames. Conservatives favor sound bites that are short, snappy and click shut like a box. Like advertising slogans, they are designed to make people stop thinking.

More, progressive formulations encourage thought. Often, they raise questions5: is health care a “right”, a “privilege”, or a “moral responsibility”—something that, we as a civilized society, we owe to each other? “Individual responsibility” is a phrase that conservatives favor. Each of us is responsible for ourselves, period. By contrast, “shared responsibility” opens the mind to consider the possibility5 that employers, employees, government, and the health care industry itself should share in funding universal healthcare.

Television Ads

It is difficult to explain Obamacare in a one-minute TV ad because health care reform turns on the details–thousands of details. And often, these are interlocking details: you cannot understand one without understanding the next paragraph in the legislation. For example: If you are self-employed, unemployed or work for an employer who does not offer benefits you will be able to purchase your own coverage in the Exchanges — marketplaces where insures will be regulated and will not be able to charge you more if you suffer from a pre-existing condition. If you earn less than $46000, you will be eligible for a government subsidy in the form of a tax credit that will help you pay the premium.

That is just one fact—and it I took me a full paragraph to convey a fairly accurate basic description of who will be eligible for a tax credit.

The definition also raises questions. For example, a reader might well ask; If I have to wait until I get a tax credit (when I pay my 2014 taxes in April of 2015) how will I pay the premiums on my insurance at the beginning of 2014? The answer is that the IRS will forward the money to your insurer in 2014, estimating how large your subsidy should be based on your 2013 income. Then when you file your 2013 taxes in 2014, you and the government will settle. If your 2014 income turned out to be lower than expected, the government may have underestimated your subsidy, and will owe you money. If, on the other hand, you earned more than expected, the subsidy may have been larger than it should have been, and you will owe the government money. To me this sounds fair; but, it doesn’t fit into a sound bite. I spent two paragraphs explaining it.

If a reader were skimming a newspaper story he might not take in those two paragraphs — especially if he already had heard conservatives “frame” the idea that you might own the government money as a “tax credit trap.” The phrase suggests that the tax credit is a trick leaving many Americans with what calls “surprise tax bills5” in the spring of 2015.

Suddenly the tax credit does not sound like such a good deal – unless you took the time to read the full explanation.

In October, the Public Will Need a Crash Course in Obamacare

Let us return to the idea to the idea that the Obama administration has done a poor job of educating the public. “For the last couple of years, the Obama administration has done too little to explain what was in the law, and to mobilize support,1” says Henry Aaron. Bloomberg observes that in April of 2013 U.S. health secretary Kathleen Sebelius “offered a different take on timing: “’It didn’t make sense for the U.S. to contact the uninsured long before they can actually sign up for coverage1.’”

I think Sebelius may well be right. Americans are not interested in poring over the many details of Obamacare when it seems a distant possibility. (Polls show that Conservative diatribes have convinced many that the law already was repealed.) People will be much more interested in listening to the facts about the ACA in October, when it is becomes clear that the law is a reality, and that they are faced with a decision. Should I sign up for insurance? Right now Republicans are telling them that, under reform coverage will be unaffordable. Often they throw out numbers like “30% increases.” Here the fear-mongers are speculating about the cost of insurance premiums in the Exchanges where individuals buy their own insurance. But keep in mind, only a small minority of Americans will purchase coverage in these Exchanges

The majority of Americans work for large companies and are offered tax benefits at work. The Congressional Budget Office tells us that Obamacare will have a “negligible” effect on their premiums6.

As for premiums in the individual Exchanges, today Democrats cannot tell you exactly how much your coverage will cost if you buy your own insurance in 2014. This makes it difficult to rebut claims that costs will skyrocket. Everything will depend on your age, your sex, your income, where you live—and how insurers decide to price their products. They will be competing for market share, and will be trying to calculate how to price their product to attract young, healthy customers.

Premiums in the Exchanges: Much Will Depend On Where You Live

In states like New York, insurers now have to follow rules that are very similar to the regulations in the Affordable Care Act. As a result, it is unlikely that individuals buying their own insurance will have to pay more than they do today. In fact, they will probably pay less because in the Insurance Exchanges they will be part of a large group, and thus the insurer’s administrative costs will be lower. In addition, if an individual earns less than $46,000 he will be eligible for a government subsidy, which will slash his premiums.

On the other hand if the customer is a healthy 30-year-old male who lives in a state where insurers are allowed to charge women three times as much as they would charge a man for exactly the same policy and where they charge someone suffering from a pre-existing condition four times as much; the 30-year old man who is purchasing insurance in the Exchange may well be asked to shell out significantly more than he does today. This is because, under reform, he, his sister, and his mother (who suffers from diabetes) will find themselves on a level playing field: Insurers will not be able to gouge his sister or his mother.

(Put that way, reform doesn’t sound so bad does it? Even a progressive can use words such as “gouge” and “level playing field” to “frame” the issue.) Then again, consider how many words I needed to explain the variables that will determine whether your premiums will go up or down in the Exchanges.
It is much, much easier just to scream “sticker shock.”

In October, the Administration Will be Able to Offer Specifics

In the fall, progressives will have an easier task. They will be able to say: “Here in North Carolina an individual will be able to choose from a menu of five plans that range in price from $____to $____a year. Here are the details on the co-pays and deductibles. You will notice that in the plans where premiums are lower, co-pays are higher. In all of these plans your total out-of-pocket spending will be- capped at $6500 a year — no matter which plan you choose, or how much care you need.”

Armed with this information, reform’s supporters will be able to answer the false claims that you are hearing today. (This is why the fear mongers are now becoming louder and more hysterical—as we approach October they know their days are numbered.) “Enroll America” also will point out that: “different plans use different provider networks—you will find a list of their networks here. Some plans charge more because they think that you will pay more for their networks of hospitals and doctors. But they may be wrong: some customers will choose one of the less expensive plans.”

In October, progressives will put premiums in the contexct of subsidies, explaining that “If you are single and earn X, you will receive a government subsidy of $______ . If you are a 40-year-old couple with one child earning Z, you will receive a tax credit of $_____.” When Obamacare’s supporters have hard numbers, and can spell out what reform will mean for YOU and your family, uninsured, self-employed and unemployed Americans will be much more eager to learn about the details of healthcare reform. This is when they will be ready for a crash course in Obamacare.

Educating the Public: Reaching Out at the Right Time

As Joanne Peters, an HHS spokeswoman told Bloomberg: “Our outreach will kick into high gear this summer leading into the fall1, when we’ll be talking to Americans across the country to prepare them to enroll in coverage beginning October 1. Our deliberative tactics build on the lessons we’ve learned, including reaching people with the right message at the right time, when it’s time for them to act.”

“You want outreach and communications with real intensity in the six months when people can go online and sign up1,” adds Tara McGuinness a White House spokeswoman, referring to the open enrollment period that begins in October 2013 and runs through March 2014. In six months, “Enroll America” should be able to get the facts out there to most of the people who, at that point, will want to hear more about how “Obamacare” might help them. Granted, reformers still will have to contend with the conservative crusade to poison our minds by planting seeds of suspicion. This campaign has been going on since 2009. That’s four years of misinformation and outright lies.

Nevertheless in October of 2014, when “Enroll America” has the facts on pricing, I am hopeful that mainstream journalists will at last feel able and willing to call misinformation what it is: “a lie.”

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Welfare Reform Kills II

Earlier I noted the research of Peter Muennig, Zohn Rosen and Elizabeth Ty Wilde which proves (at all standard confidence intervals) that welfare reform killed people.  I was alarmed that almost nobody but the must read Bill Gardner noticed this research.  Now Dylan Matthews has a long excellent post on the research and other evidence that anti poverty programs save lives.

This should transform the political debate entirely.  I expect it to have almost no effect.  But the best of the blogosphere is doing its best.

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Health Care Thoughts: Conference Wrap-up

by Tom aka Rusty Rustbelt

Health Care Thoughts: Conference Wrap-up

So I do some conferences with a lot of people who are way smarter than me, people literally and figuratively on the cutting edge.

What thoughts are dominating health care these days, especially the provider community? Here is a list of frequent talking points, further in-depth discussion of some of them later.

The provider community is in chaos, seeking “what is the best strategic move to insure survival?”

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Guest post: The Affordable Care Act’s Prevention and Public Health Fund

Guest post by Michael Cahill

The Affordable Care Act’s Prevention and Public Health Fund: Why it needs to succeed for America’s Economic Future

What will it take for the Affordable Care, known more commonly as Obamacare, to succeed? Realistically speaking it will take a lot of things for the ACA to be a real success, but one vital area will be managing America’s chronic health problem. This is where Prevention and Public Health Fund comes it. Never heard of it before? Well let’s start with a little background.

The fund was established when the Care Act was signed into law back in 2010. It’s mission is to fund projects aimed at improving American public health. For example outreach programs about healthy food options, walking and biking infrastructure projects, or increasing access to blood pressure screenings at the dentist’s office.

Before the sequester the fund was supposed to invest $15 billion during its first 10 years. But Republican lawmakers have slashed its budget by 40 percent since last year. Now the fund is also being victimized by the Department of Health and Human Services who announced plans in April to withdraw $454 million from the fund.

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Health Care Thoughts: Rand Paul is a Loon, However…..

by Tom aka Rusty Rustbelt

Health Care Thoughts: Rand Paul is a Loon, However…..

Rand Paul told an Iowa crowd about “Obamacare codes” and listed some of the wackier codes.

Problem is, he is referring to the ICD-10 adaptation, which was first set in motion by the Bush 43 administration.
ICD-9 has about 17,000 diagnosis codes, ICD-10 has more than 150,000 codes.

Why are we adopting the ICD-10 system?
1) Europe did it
2) “Big IT” will make a huge fortune from the conversion
3) Data miners will have lots and lots to mine

What does it do for providers and patients? Absolutely nothing except cost and a messy transition.

So Paul could have made a valid point about government mandated waste, but that would not have been a good sound bite.


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Health Care Thoughts: On the Road Again

by Tom aka Rusty Rustbelt

Health Care Thoughts: On the Road Again

The rest of the week is taken up with a conference, at which I will spend time with health professionals from all 50 states, the professionals including physicians and nurses, executives and managers, lawyers and CPAs, financiers, government regulators, consultants and media.

Anyone have a burning question for which I should find an answer? My official role is to evaluate the quality of the conference, sort of a mystery shopper, and this allows me to talk to lots of people.

Next week, disaster relief in Oklahoma.

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