Presidential Debate Uno-What Did they really say about health care?

A few months ago I wrote an article entitled Why We Don’t Want to Get Rid of Medicare, Our Best Tool For Health Care Reform which alluded to Republican attempts to “block grant” both Medicare and Medicaid programs and Mitt Romney, Republican Presidential Candidate stated as much in his debate with Presidential Obama last night. To the one person who questioned the validity of my previous article, please feel free to eat crow now. This piece reviews the 2010 health care reforms that Mr. Romney would eradicate, based on his debate comments.

Medicaid

Romney indicated there is broad based support to have the federal government just give state governments money to administer their own Medicaid programs for low income residents, without government mandates. Sure, who wouldn’t want more money to meet a social need, without strings attached? The problem with this is the federal government is funded by all states and all residents and not merely a few, though as Mr. Romney has suggested 47% of us are just free loaders, enjoying life on the dole. To be fair, funding Medicaid benefits is a challenge for all states because the federal government does not pay anywhere near the cost of the program. Some states, like Oregon have used this challenge to come up with a creative health care plan which assigns values to health services and targets public dollars to those which do the most good for its Medicaid population. Actually the Oregon approach is also used in Scandinavia and Europe, where programs funded by the government must meet certain criteria for health effectiveness.  This is incidentally, what the Accountable Care Act and the Center for Medicare and Medicaid (CMS) programs seek to accomplish.

 Having completed many fifty-state analysis of Medicaid and other health programs, there is currently sufficient variety in state Medicaid programs. Some of the variables include; at which level of poverty must one bear in order to become eligible for state medical assistance, variations in plan benefits, and levels of cost sharing. As a tax payer we have to ask ourselves if it is prudent to merely give money to another agency without some performance expectations and program measurement criteria. States who wish to modify their Medicaid plans may currently do so under Section 1115 Waver Plans, which has been around for over a decade. Nearly half of the states already have 1115 Waivers.

Medicare

Mr. Romney indicated he wouldn’t change Medicare for those who are retired or near retirement, whatever that means (needs their votes), but his plan is to have eligible residents under age 55 subject to block granting for a health care budget. What this means is a fixed allowance would be given to each eligible person to purchase insurance and then get rid of the most popular social program today, Medicare. I wonder what would happen to the “hold harmless” clause that prevents health care providers from charging patients more than what they receive in reimbursement without Medicare setting the standard.  Block granting is a means to affix a budget for a health care spend, similar to what many employers do for their health care programs. This is a way to increase cost sharing among program recipients and to fix costs for the plan sponsor. The problem with this approach is two-fold; you are ultimately passing on a greater burden of health care expenses to those who are least able to pay for it. Let’s face it many seniors have to choose between dinner and their medications, especially since the U.S. government chooses not to bargain with the pharmaceutical companies. Secondly, eliminating the largest stakeholder would remove much of the systemic power for change in health care processes. The arc of Medicare is sufficiently large that as a nation we are able to conduct low-cost demonstration projects to find out which is the best way to align physician compensation with improved clinical results for patients. And changes made by Medicare or CMS do impact the entire health care delivery system in the United States. No other element of the health care system has this much influence.

In order for the country to effectively lower the cost of health care proportionally, we must create a better model of delivery and block granting Medicare by allowing private sector insurance companies to do this is not the answer. What you may ask is wrong with this, well for one thing, private sector insurance companies charge three times as much as Medicare for plan administration and this does not include the margin for profits. As an expert in the health insurance industry and someone who used to negotiate employer plans, I understand all too well the various loads and expense factors which the private sector includes in administration. So, the smart health care consumer will want to spend less for the administrative load, just as the smart investor does for mutual funds. But the Romney health care answer would simply foist the health care purchaser into the already more expensive private sector marketplace. Additionally, the private sector has long had the reputation for “cherry picking” risks and avoiding those folks who are more likely to need health care services. In fact, this is the main reason we have Medicare today, because the private sector insurance companies did not want to serve the elderly, much less the low-income elderly. In conclusion, if you want to have less of your insurance premium dollars paying for your actual health care, have difficulty finding an insurance company that will accept you, and be responsible for a much greater portion of your health care expenses, then by all means, the Romney Plan is for you.

Health Care Expenditure Oversight by A Panel of Experts-Yeah or Ney

Another one of the health care reforms Mr. Romney would obliterate is the Independent Payment Advisory Board which is an appointed commission of health care experts, which would have the authority to rein in Medicare spending. Romney used the scare tactic harking back to the anti-Clinton-health-plan era, which is that this panel would tell you what medical treatments you could have. This is not true, as the advisory panel would examine treatments for targeted diseases and view the most effective outcomes and recommend practices which would save the nation money in the Medicare program without harming the patient. By the way, this is also a process I was involved in while working as an internal consultant for a large hospital group.  The government wouldn’t be telling you what procedure you can have but rather what it is willing to pay for. This is exactly what we need a speed checking device on the gas pedal, as Medicare spending is a huge concern and our elected officials have conflicts of interest from drug company, medical supplier, and big hospital corporations who contribute to their election campaigns.  Do you want someone who is beholden to a private company with a financial interest in the outcome deciding what your health benefits will cost? Why wouldn’t you want an informed unbiased group of experts who use data driven consensus based process making this national policy decision?  Mr. Romney said that private sector always hasbetter solutions than government and solutions to health care spending should be left to the private sector. Well, if that is the case, then why is health care so expensive when we already have private sector individual and employer-based insurance? The answer is none of those stakeholders can change the health care delivery system on their own and we need to work together as a nation to accomplish this gargantuan task.

Hopefully this will clear the fog on the fifteen minutes of the debate which was devoted to health care.

This article was written by Roberta E. Winter, MHA, MPA, and may be reprinted with her permission or better yet, just share it on the paperless wings of the world.

Supreme Court Ruling and Medicaid Changes-Impact on the "47%"

Supreme Court Ruling on Health Care Reform-Impact on the 47%

Presidential Candidate,  Mitt Romney has identified the 47% of the country’s population which he doesn’t care about and this article addresses how the Supreme Court rulings on the Patient Protection and Affordable Care Act will impact “their” access to Medicaid and subsidized health care through the insurance exchanges in 2012. This article will also inform health care administrators in various government and nonprofit agencies who will be implementing the law. Additionally, business owners should have an understanding of the eligibility rules for the subsidized insurance plans, as, unbeknownst to Mr. Romney; people in the “47%” can actually have jobs and not have any health insurance. So, to all of you people out there who are working either part-time or full-time or unemployed, read on to learn what your options will be in 2014, assuming the health care reforms are not dismantled.

Supreme Court Ruling on Health Care Reform

Though the Supreme Court indicated the federal government could not use its bully pulpit and reduce federal government Medicaid payments to states which chose not to comply with the health care reforms for Medicaid, the government is allowed to implement the sweeping health care reforms. This means the requirement to purchase insurance stands, along with the scheduled subsidies for individuals to be able to purchase medical insurance and so does the government’s ability to tax individuals (and corporations) who opt not comply. So for those of you who think the health care changes are not going to happen, you better get busy on the implementation.

Affordable Care Act Impact on Medicaid Programs

Under the Patient Protection and Affordable Care Act, there are a number of changes to Medicaid, the jointly run federal and state program for the significant population of poor people living in the United States. Presently under the Medicaid program, low-income single people are not eligible for the program unless they are disabled. Under the rules change, low-income people, earning 133% of the federal poverty level, which is $11,170 for a single individual[1], could have an income of $14,856 and still qualify for Medicaid Insurance.  Also, people who are working full-time and only earning minimum wage, in states which do not have minimum-working-wages may only earn $11,000 a year, working at $5.50 an hour.

Impact on the Working Poor

Under the health care reforms, states can choose how far they want to go to participate in the revised Medicaid eligibility standards, in other words, to fully offer the program to all of their eligible poor residents (who must be citizens by the way). A quick way to gauge the impact of the Medicaid expansion for each state is to look at Department of Labor information for states lacking any minimum wage criteria and thus are likely to have a higher degree of individuals who are classified as the working poor.[2]  In this category are: Alabama, Louisiana, Mississippi, South Carolina, and Tennessee. To further underscore that point, these states actually have a minimum wage standard which is lower than the federal benchmark of $7.25 per hour are: Arkansas, Georgia, Minnesota, and Wyoming. A high five to all of the states who at least meet the federal wage standard and a special mention for the following states who have minimum wage guidelines higher than the federal mandate: Alaska, Arizona, California, Colorado, District of Columbia, Connecticut, Florida, Illinois, Maine, Massachusetts, Michigan, Ohio, Oregon, Nebraska, New Mexico, Rhode Island, Vermont, and Washington. The latter states perform their own economic analysis and arrive at a wage that theoretically is a “living wage” for a full-time employee.

Though there are federal inducements to cover the newly eligible Medicaid population, it remains to be seen which of these states will agree to implement the program, because after all they will have to contribute to the cost of it. For example, someone working full-time at the federal minimum wage and living in Texas would make $14,500 a year, which would qualify that individual for state Medicaid insurance based on the threshold of 133% of Federal Poverty Limits for 2012. I am betting there are quite a few individuals in that category in the Lone Star State.

Changes to the Qualifying Criteria for Medicaid

The income calculation to determine whether or not someone qualifies for state Medicaid will be vetted using electronic income verification via your social security number and also include a personal declaration for those who lack regular employment, such as those who perform any-odd- job they can find in this economy. To Mr. Romney these are your bottom 47% but to the rest of us working stiffs, these are the people who mow your lawns, take care of your children, serve you lunch, and answer the phones in a myriad of locations. You would be surprised who is working for minimum wage or barely more than that. There is such a stigma in this country for earning a low wage people are reluctant to speak up, but if you are extremely wealthy by accident of your birth you can bellow all you want.

Under the Modified Adjusted Gross Income (MAGI) Medicaid criteria there is no longer an asset limit to qualify for Medicaid, so for example, one could own a home and qualify. Increasingly in my fundraising work I speak with senior citizens who qualify for federal poverty status, because all of their investments have dried up and they get minimal interest on any cash reserves that have left. Though they may have a dwelling, this does not make them wealthy and typically they even convey that back to the ever handy bankers with a reverse mortgage. Additionally, the income criteria may be reviewed for re-certification annually.  And finally, the members of the household who are included in the income qualification standards are the same as those for federal income tax filings.[3]

Children within 200% of the federal poverty level are eligible for Medicaid, which is the same standard as the CHIP or Children’s Health Insurance Plan, which has been around for years and is highly successful.

Pregnant women are eligible for Medicaid if their income is within 185% of the federal poverty rate and this is also the standard most states already use.

There are some new eligibility inclusions for families who are taking care of parents and caretakers of other relatives as well.

Categorically Eligible Medicaid Patients Unaffected by the Reforms

If you are unfortunate enough to be blind or disabled the health care reforms for Medicaid do not change your status, because you are already eligible regardless of being single and lacking children. Foster children will experience no change in their Medicaid eligibility either. And finally, those covered on Social Security (dual eligible patients for both Medicare and Medicaid) are also unchanged by the Medicaid updates.

Unintended Consequences

Though it is a good idea to find a way to expand the social safety net through improving health care access by increasing some level of payment to hospitals and clinics, this legislation doesn’t address the unreasonably low reimbursement for physicians who are expected to treat all of these new patients. The Medical Home legislation and some of the Centers for Medicare and Medicaid demonstration projects are investigating methods to improve the primary care treatment dichotomy, but the results are not available yet. Conclusion, many states will be reluctant to increase their Medicaid budget, which must be funded by sales or income taxes from state residents.

As one of the part-time workers who is in the bottom 47% by virtue of the fact I have not earned more than $20,000 a year since the 2007 regulatory failure which resulted in the economic meltdown, I guess this makes me less important to Mr. Romney and his cronies, but I can tell you this, the only magic underwear I believe in are those you buy at the department store.

And this is the healthpolicymaven signing off.

This article may be reprinted with the permission of Roberta E. Winter, MHA, MPA or preferably, share it virally without her permission.

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[1] http://aspe.hhs.gov/poverty/12poverty.shtml#thresholds

[2] http://www.dol.gov/whd/minwage/america.htm

[3] http://www.hca.wa.gov/me/documents/ME2014_Changes_Comparison_Fact_Sheet.pdf

Akins Assault on Women's Health & Dignity

Assault on Women’s Health Revisited with Senator Akin, leaving the Republican Party Belly-aching

Though the memory of the 2011 Republican attempts to redefine the rape of an unconscious woman as a noncriminal activity and thus not rape, are still etched in my memory, the party continues to horrify the nation with its Neanderthal postulations. The latest assertion came from Senator Akin from Missouri, who stated that women are unlikely to get pregnant in a true rape situation, because the woman’s Zen warrior vagina is able to battle the offending sperm from penetrating her nubile eggs.  OK, Akin didn’t say that part, but I thought I would add some humor to the situation.  Once again we seem to have a Republican senatorial candidate who still wants to redefine rape, so this ugly issue has not been vanquished.   In the interest of refining the conversation by adding some facts, this article will address actual data on rape, biology, and national data on abortion services for women.

Once and For All Here Are the Definitions and Data on Rape

The New York Times reported that nearly 1 out of 5 women admitted to having been sexually assaulted in the United States. The National Intimate Partner and Sexual Violence Survey, which was funded by the Department of Defense reviewed the records of 16,507 adults and of those, 33% of the women indicated they had been raped, beaten, or stalked, or horrifically, in combination. Rape was defined as a completed forced penetration, forced penetration facilitated by drugs or alcohol, or attempted forced penetration. If you apply this relationship to the U.S. female population about  1.3 million American women are rape victims annually. In the same survey 1 out of 71 men also reported they had been raped. [1]

Biology

The ability of a sperm to penetrate an egg or ovum has little to do with the female vagina’s functioning, but rather with the sperms facileness and speed within the window of opportunity in terms of the female ovulation cycle. The vagina is the entry point for the sperm. Where the individual woman’s work really comes into play is in the ability to carry the fertilized egg through  the development cycle of the pregnancy term. The woman’s “welcoming vagina” does not clinically decide pregnancy, as-in- yea for the good guy and nea for the rapist.

Implications for Women’s Health Care

The assault on women’s health care has been ongoing for years, but the attempts to offer low income women the same health care options that wealthier women have for family planning has increased the temperature of this pot boiler. In my previous articles on statewide positions for reproductive autonomy I have revealed which states restrict oral birth control, even for private sector employees, those that restrict birth control options for any state worker, and of course, those seeking the personhood amendment for an unborn fetus. If these states are so concerned for the unborn child, let’s take a closer look at the welfare of children in Missouri, which spawned the odious Senator Akin.

Missouri  currently has a ban on abortion, which is not enforceable because of federal protection under Roe-V-Wade. Though Missouri has not criminalized abortion (yet), it is one of the more restrictive states for this medical procedure. For example, in the State of Missouri, all private insurance plans are restricted from providing abortion coverage in their health plans. This flies in the face of the national statistic which indicates that 46% of private employer plans offered abortion services in their group medical plans according to a 2003 Kaiser Foundation Survey.  So Missouri already makes it tough for women who are forcibly impregnated.  Missouri also denies access to abortion for Medicaid women.

According to the Kaiser Foundation 2010 National Insurance Survey, 82% of Missourian women had some type of insurance, with nearly 19% on Missouri Medicaid or other state subsidized plan for women living in poverty. Compared to the nation, Missouri is in the middle in terms of how much income a woman is allowed to have in order to qualify for its Medicaid program, at 185% of the federal poverty level.

Akin has created a lot of belly-aching though his views are shared by many in the Republican Party which has recently come out with its formal platform stating it is against abortion even in the event of rape or incest.  Though I pride myself on my objectivity and data-driven approach to policy making and of course my voting process, my ability to consider any Republican candidate as suitable material for elected office is waning when the party spends its time coming up with this type of proclamation during one of the worst economic depressions the United States has seen. To all women in this country, I remind you that we are at least 51% of the country’s population and I encourage you all to vote with your autonomous vaginas in-tact.

For more information on how your state ranks in terms of reproductive autonomy, contact the healthpolicymaven, who conducted a fifty-state survey in 2010 and recently updated it in 2012.

And this is the healthpolicymaven signing off still unpenetrated by the Republican attempts to control my privacy.

This article was written by Roberta E. Winter, MHA, MPA, and may be reprinted with her permission. I do encourage you all to share it virally for this issue deserves attention.

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[1]Naomi Wolf,  Vagina, A New Biography, Published by Harper Collins, September 2012,  Chapter, The Traumatized Vagina, p. 97

Employer Rules for PPACA Grandfathered Health Care Plans

Rules for Employers with Grandfather Exceptions for the Health Care Mandates

The Patient Protection and Affordable Care Act mandates that employers with health care programs meet certain requirements for employee participation, coverage limits, and treatment of pre-existing conditions upon enrollment. Having just spent the past few days studying the grandfather provisions for the health care reform implementation in 2014, this article is meant to provide a bit of illumination to any confused employers or their staff. Generally grandfathered group health care programs will have a calendar year or a fiscal year plan renewal date. Since this is the time when changes are introduced each year, if a plan has a June anniversary date, it would have had to apply for grandfather status by the June 2011 anniversary. Hence the first anniversary of a grandfathered plan is likely to have occurred by now and this is the time when a plan administrator may be required to show the plan meets the PPACA requirements.

What is NOT Affected by the Grandfather Provision

Provisions which are unaffected by the grandfather provision are lifetime benefit limits and the rescission rules. Rescission rules allow insurance companies to retroactively cancel insurance contracts due to fraud. Individual insurance contracts can have benefit limitations, which can be maintained in the contracts after January 1, 2014. Insurance companies must now meet certain standards in order to cancel a contract retroactively; specifically they must show the individual insured intentionally defrauded the insurance company at the time of the application.

Grandfathering Election-Opting Out of the Mandates

In order to opt out of the insurance mandates, employers can elect to have their current health care plan arrangement remain in force until January 1, 2014, when all plans must comply with the PPACA requirements.  However, the grandfather rules are murky and this article highlights some of the sticking points. The main reasons employers may choose to keep their current plans in force and wait out the health care reform implementation are to save money, avoid some of the mandates, and aversion to change.  Unfortunately once an employer elects to grandfather an existing health care program, there are strict rules which must be followed, subject to reporting, and audited by the government.  Let’s examine what these requirements are: disclosure and documentation, phase-in levels for lifetime benefit limits, measuring benefit parity, assessing increases in employee copayments, and calculating employee cost sharing increases.

Disclosure and Documentation

Presently under the ERISA rules, employers who have health & welfare plans are required to provide employees with a Summary Plan Description of plan benefits, identification of the plan administrator, and other pertinent contact information. The PPACA expands on these mandates by requiring documentation of the Patient Protection Provisions such as disclosure of patient rights for emergency room parity, parity between in-network and out-of-network cost sharing for certain services, and the ability to self designate a personal provider for pediatrics or OBGYN without a referral. The insurance company who has the contract will incorporate these mandates into the annual Summary Plan Description as it does for all other state and federal requirements.

Calculating Benefit Parity for Your Plan

To establish benefit parity there are three methods to assess appropriate levels of plan benefits for non-network services including; contract payment at in-network levels, payment at Medicare levels, and payment at out-of-network benefit levels.  The rule states that whichever method provides the highest benefit payment for the insured is the deciding factor for compliance. There are several ways an employer sponsored medical plan can meet this mandate, including having the same benefit level, such as 80% for all essential services. Grandfathered plans do not have to comply with this provision until 2014.

Phase-In of Lifetime Benefit Limits

Since September 23, 2010 all new insurance plans must offer an unlimited lifetime benefit for essential medical insurance services. Essential services include hospitalization and non-elective doctor’s services among other things. There is a phase-in provision for existing plans, which must comply with this schedule for contract limitations for essential benefits:

October 23, 2011-$750,000

October 23, 2012-$1,250,000

October 23, 2013-$2,000,000

Special Enrollee Provision

If you are one of the unfortunate thousands of people who have maxed out on their insurance contract benefits, you may now enroll on the group insurance plan via the Health Insurance Portability and Accountability (HIPAA) rules. Also the group insurance rules do apply to an individual plan if it was obtained when a group insurance plan was cancelled. The HIPAA rules stipulate that the individual must have 18 months of creditable coverage from the group plan in order to be eligible. HIPAA also stipulates the insurance company may only look-back six months to determine a pre-existing condition and the exclusion period cannot exceed 12 months for those conditions. And finally, in order to secure the provision, the individual must not have had a break-in-coverage longer than 63 days. The previous employer (if this is the case) must notify the newly eligible special enrollee with a 30 day window for re-enrollment on the group medical plan. Anyone who has maxed out of the prior contract benefits must be notified of this right to re-enroll.

Limits on Increasing the Deductible or Co-payments for Grandfathered Medical Insurance Plans

If your firm has elected to grandfather its health insurance plan, the ability to increase the plan deductible between 2010 and 2014 is limited to the CPI or Consumer Price Index plus 5% per year.  Co-payment increases are limited to a $5 increase per contract year.  And finally, a decrease in a benefit, such as the emergency room benefit of more than 5% may disqualify the plan. Anything larger than any of these thresholds is likely to trigger a disqualification of the grandfathered exception.

Pre-Existing Condition Waiver Rules

All plans must comply as of January 1, 2014 with removal of any pre-existing condition clause for enrollees. However, for children, this restriction was removed as of September 23, 2010.

Transitional Rules for Cost Sharing

The Accountable Care Act allows the employer to elect to change the non-fixed cost sharing arrangement in the medical plan without losing its grandfathering status. Changes made after March 23, 2010 and adopted by June 14, 2010 are OK until the next plan year. The formula for calculating the acceptable zone for a fixed-amount cost sharing scenario is as follows:

1.        Determine the CPI based index ($387.14 in 2010)

2.       Add the CPI factor to this base

3.       Convert to a percentage increase

4.       Determine the net allowable increase

5.       Generally a maximum of 15% is an allowable increase

The easiest way for an employer to avoid this hassle is simply to change its group insurance plan from a fixed amount cost sharing formula to a percentage cost sharing formula. In the years when I was in the benefits brokerage business, all of my clients had a percentage co-payment arrangement anyway. The government probably had to come up with this formula for certain industries, a necessary complication I suppose.

Rules to Avoid Disqualification of a Grandfathered Medical Insurance Program

The rules are fairly straight forward here including:

1.       Benefits may not be reduced below allowable levels

2.       Essential benefits may not be eliminated

3.       Increases in co-payments may not be increased beyond the stated level

4.       Employer contributions to the medical plan may not be reduced beyond the allowable level

5.       Annual benefit limits must comply with the phase-in schedule

6.       Documentation of plan benefits must comply with the new rules

7.       Evasion of compliance or overtly attempting to usurp the standards is not allowed

For What it’s Worth-Professional Education for Insurance Agents

I spent about three days studying a college level course on the Accountable Care Insurance Mandate Requirementsin order to become familiar enough with the rules to pass a Washington State approved continuing education course exam for renewal of my insurance license. Though I no longer sell insurance, I do keep my license current to competently critique the field. I was actually surprised by the rigor of the course material, but it should be noted that insurance agents can choose to sit in seminars where no testing is required to meet the continuing education edicts or they can opt for less challenging material.  Washington State requires 24 hours of continuing education to renew a life and health (disability) insurance license every two years. Not all states require this much rigor, but most states have some education requirement in order for the agent to renew his or her license. And the good news is, for all of those who hate federal edicts; these requirements are determined by each state, with an elected insurance commissioner. The only exception to this is for those representatives who sell Medicare supplement contracts, who must undergo even more rigorous education and marketing oversight, which are nationally mandated. The latter is also a good thing, as the elderly are vulnerable and the Medicare program is paid for with our tax dollars, so oversight is warranted.

This is the healthpolicymaven signing off, license in hand.

This article may be reprinted with the permission of Roberta E. Winter, MHA, MPA.