ACA Repeal: Update

I’ve been quiet about the recent AHCA legislation. Frankly, the House bill isn’t good for most Americans, but the assumption is that the Senate will heavily revise the bill before it has a chance for passage. So it’s hard to say what the final legislation will be at this point.

Then it goes to conference committee and the result will return to each chamber for a vote.  So this is a long way from being done.

There are a number of articles enumerating the problems in the House bill. The major issues are

• Loss of health insurance for millions of Americans
• Impact on the solvency of hospitals and clinics serving rural areas — where most of the poor live
• Reductions in Medicaid coverage, especially for children
• Allowing states to reduce coverage standards in insurance (depart from the ACA’s Minimum Essential standards) — reducing what the insurance buyer gets for their money
• Raising costs drastically for consumers between the ages of 50 and 64 (1)

With all of these issues, we are still expecting the repeal bill to result in sharply higher premiums for health insurance.

The only positives in this bill are tax reductions for the wealthy.

My major concern is with health screening and checkups. The ACA recognized that the main way to reduce health care expenditures is through early detection and treatment of disease. Removing access to doctors means later detection and much higher costs.

Example: breast cancer, cost of treatment by tumor stage

Stage

0                                         $71,909

I/II                                      $97,066

III                                      $159,442

IV                                      $182,655 (2)

Reduction is access to health care is a commitment to higher medical spending or to reduction of life expectancy.

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Sources:

1. Harris Meyer, “15 quick facts from CBO report on Obamacare repeal bill,” Modern Healthcare, 24 May 2017. http://www.modernhealthcare.com/article/20170524/NEWS/170529946?utm_source=modernhealthcare&utm_medium=email&utm_content=20170524-NEWS-170529946&utm_campaign=mh-alert
2. Helen Blumen, Kathryn Fitch, Vincent Polkus, “Comparison of Treatment Costs for Breast Cancer, by Tumor Stage and Type of Service,” Am Health Drug Benefits. 2016 Feb; 9(1): 23–32.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4822976/

Your Health: The Right to Life?

The US was founded on the promise of “the Right to Life, Liberty and the Pursuit of Happiness” in Jefferson’s Declaration of Independence.

From the start, the relationship between the country and this promise has been at best inconsistent and sometimes ironic. After all, the principal writer of the Declaration, Jefferson, was a slave-owner.  So for whom was this promise made? Everyone? Or the wealthy, the planters, the slave-owners and the merchants? (Remember, there were no factories — that was before the industrial revolution.)

The inconsistency continues to this day.

We have groups concerned with whether babies or born, but not with what happens to them after they are born. How long do they live? What’s their quality of life? As Ed Cara notes, in some areas of the US, children will now have shorter lives than their parents. (2)

A new study in the Journal of the American Medical Association talks about discrepancies in life expectancy. I’ve blogged about this before, but it’s nice to see authoritative sources recognizing the issue.

The new statistical analysis shows that there is a difference in life expectancy of up to 20 years based on the county in which you live. In this analysis, the issues affecting life expectancy are

• Income and poverty
  • The wealthy live longer
• Race/ethnicity
  • Both Native Americans and African Americans have a shorter life expectancy
• Regular exercise
  • Those who do live longer
• Obesity, Diabetes and Hypertension
  • Shorten life expectancy
• Education
  • Each level completed adds to life expectancy
• Quality of health care
  • Higher quality is associated with living longer
• Having health insurance
  • Having health insurance promotes longer life
• Access to physicians
  • Having more physicians in an area helps

These factors translate into differences in life expectancy in the US based on where one lives:

• Residents of central Colorado, coastal California and the New York Metro area live longer
• Residents of eastern Kentucky and much of the Old South, especially along the lower Mississippi River, have a shorter life expectancy
  • The Old South in this case includes Alabama, Arkansas, Georgia (outside of Atlanta), Louisiana, Mississippi, Oklahoma and Tennessee (outside of Nashville)
  • The two metro areas, Nashville and Atlanta, offer much better life expectancy than the rest of their states

The states with the lowest life expectancy are those with the lowest spending on public health and health education.

One limitation of this study is that the analysis is at a county level, and there is only selected data available at that level regarding health. In particular, suicide is now one of the top 10 causes of death in the US. Suicide isn’t reported accurately or consistently, and there is limited data available on the causes of suicide.

A second limitation is the inter-relationships between some of the factors measured. For example, wealth is associated with having health insurance, with less use of cigarettes, and with living in an area with better access to medical professionals. By breaking the analysis into this much detail, does the report understate the role of wealth in life expectancy?

By the way, I use the image of Ben Franklin on some of these posts for the following reasons:

• His brilliance
• His common sense
• His skill at negotiation
• And among the Founding Fathers of the US, he became a profound opponent to slavery

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Sources:

1. Laura Dywer-Lindgren, et. al., “Inequalities in Life Expectancy Among US Counties,1980 to 2014,” JAMA Intern Med. Published online May 8, 2017. doi:10.1001/jamainternmed.2017.0918. http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2626194
2. Ed Cara, “Kids Will Die Younger than Their Parents in Some Parts of the US,” Vocativ. 9 May 2017. https://www.aol.com/article/news/2017/05/09/kids-will-die-younger-than-their-parents-in-some-parts-of-us/22077174/

 

 

ACA Repeal — the Backdoor Method

Apparently, the bill to keep the government operating excludes payments to insurance companies that subsidize healthcare for those buying insurance through the Marketplace. The tactic is to force insurers out of the market, thus closing the door on the Affordable Care Act.

In theory, that would cost anyone with a subsidy their healthcare.

We’ll see what happens next.

Equality of Education; Inequality of Teacher Pay

In theory, the quality of teacher impacts the quality of education students receive. In the Brown v. Board of Education of Topeka decision in 1954, the USSC rejected the argument that students in unequal schools could receive equal education. However, if teachers are important, then how do we reconcile the Court’s decision with these findings:

• There’s a huge disparity in teacher pay between school systems. Affluent districts pay much higher salaries than others.
• Charter schools, which are supposed to be the road to improve education, pay much lower salaries than most public school districts.

New Jersey treats teachers as public employees, and their salaries are public information. Without going into detail on all 650 public school districts and charter schools in the state (available at reference 1 below), here’s the outlines of the situation:

• The median salary in 2016 for a school teacher in NJ was $66,117 per year.
• Northern Valley Regional district in affluent Bergen County paid the most, with a median salary of $105,650.
• Teachers in the Edison Township school district in Middlesex County had a median salary of $95,432.
• At the other end, Milford Township in Hunterdon County had a median salary of $48,007.

New Jersey just isn’t that large geographically. The cost of living is relatively uniform across the state.

Many/most of the charter schools are worse: for example the Jersey City Global and Red Bank charter schools both have median salaries of $42,000. Of course, the charter schools haven’t been around as long. We could expect salaries to increase with teacher seniority. However, the need to generate profits at many of these schools may restrict what goes into the classroom.

If you were a capable teacher, where would you want to teach? Where would you expect the best teachers to go? How does this reconcile with equality of educational opportunity?

By comparison, NJ is one of the best-paying states for teachers in the US. The only states that pay as much or more are Alaska, California, Connecticut, District of Columbia, Massachusetts and New York. Maryland pay is lower than NJ, but close. (2) Conversely, South Dakota and Mississippi are at the low end of teacher pay, paying less than 65% of what New Jersey pays.

Again, where would the best go?

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Sources:

1. Tom Davis, “NJ Median Teacher Salaries, Highest To Lowest: How Much Does Your District Pay?” NJ Patch, 24 April 2017. https://patch.com/new-jersey/princeton/s/g3o6z/n-j-median-teacher-salaries-highest-to-lowest-how-much-does-your-district-pay?utm_source=alert-breakingnews&utm_medium=email&utm_term=weather&utm_campaign=alert
2. National Center for Education Statistics, 2013. https://nces.ed.gov/programs/digest/d13/tables/dt13_211.60.asp

No room for historical revisionism

I’ve been a history buff for years. Growing up in Kentucky, I dealt with people intent on glossing over the evils of slavery. I was born less than 90 years after the Civil War ended, and there are people still intent on re-fighting that war today.

This bit from History.com leaves little room for gloss. Written about a skirmish in Arkansas in 1864,

The Rebels’ treatment of black troops was harsh. No black troops were captured, and those left wounded on the battlefield were brutally killed, scalped, and stripped. The Washington Telegraph, the major Confederate newspaper in Arkansas, justified the atrocity by declaring “We cannot treat Negroes taken in arms as prisoners of war without a destruction of social system for which we contend.”
http://www.history.com/this-day-in-history/confederates-inflict-pain-at-battle-of-poison-spring

The men ultimately responsible for this atrocity were Confederate General John Marmaduke, later governor of Missouri, and Confederate General Samuel Maxey, who later represented Texas in the US Senate.

I rather suspect that in the current era, both would have been imprisoned or shot for war crimes. However, in Missouri and Texas, they get elected.

I was in Charleston a few years ago when a tour guide tried to claim that the Civil War wasn’t about slavery. That’s a difficult case to make if you look at the newspaper and diary accounts from that time. We’re better off being honest with ourselves about our past and our future.

 

ACA Rule Changes

If you were waiting for changes that would actually help consumers, don’t hold your breath.

Absent the actual repeal the administration sought, it announced rule changes late yesterday affecting consumer access to healthcare and the percent of costs health insurance will cover under marketplace plans. The point of the changes is to incent insurers to continue offering health insurance on the ACA marketplaces. The technical term for this is “market stabilization.”

A cynic might wonder why these changes come out on the even of holidays when most people will be distracted and might not notice.

The rule changes focus on what the insurance industry calls “adverse selection.” Insurers are concerned about people buying coverage only when they expect they will use it, and then dropping it immediately — which forces the insurer to take a loss on the policy.  The rule changes are designed to prevent that.

Here’s the basics:

• Silver level plans will cover 66% of consumer medical costs, down from the original 70% requirement.
• The new rules increase also increase subsidies to consumers buying these plans — provided the administration actually commits to making these payments.

At issue are cost-sharing payments that low-income people enrolled under the healthcare law receive to help cover out-of-pocket expenses. Trump has threatened to withhold the payments as a means to force Democrats to negotiate on healthcare legislation.(2)

[Actually, these subsidies can help people making up to $60,000 per year, which is more than “low income.” Half of US households earn less than that.]

• As previously noted, the enrollment period is being shortened from three months to six weeks, starting November 1st.  Given the problem that CMS has had in handling the volume of people applying for coverage in the longer period in the past, it’s essential for consumers to apply as early as possible.
• The administration is making it harder for consumers to qualify for special enrollment periods (SEPs). More people will be required to submit supporting documentation than in the past, which will extend the time required for enrollment. If approval is delayed by three months, the consumer will be required to pay for coverage for two of those months.
• Consumers are being restricted in terms of their ability to change levels of coverage using a SEP.
• Insurers can refuse to cover people who have failed to pay premiums for this insurance in the past. If you’ve had coverage and dropped it, you may have to wait a year or more before being able to get coverage again.
• The determination of whether an insurer has an adequate network of doctors and hospitals in a state will be turned over to the state. Some states are much more rigorous than others.

The new rules don’t address some of the key issues challenging insurers:

• Will the government continue to pay subsidies to help people afford insurance?
• Will the government use financial penalties to force consumers to carry insurance?

Trump has said that he would eliminate the penalties and the subsidy, but his bill didn’t pass and no one knows about  his current thinking. A negative on the first question will drive insurers out of the market. A negative on the second will raise costs for everyone who needs insurance.

There’s speculation that the reduction in benefits for the silver policy might allow insurers to reduce the cost of these policies. However, any reduction will be subject to higher out-of-pocket costs for consumers who do incur expenses. The net impact isn’t clear.

Are these rule changes even needed? The Congressional Budget Office has stated that it expected the insurance markets to be stable in 2017 without these changes.  So, what is the point?

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Sources:

1. Virgil Dickson, “White House finalizes ACA rule to strengthen individual market,” Modern Healthcare, 13 April 2017. http://www.modernhealthcare.com/article/20170413/NEWS/170419936?utm_source=modernhealthcare&utm_medium=email&utm_content=20170413-NEWS-170419936&utm_campaign=am
2. Associated Press, “Democrats seek to resolve health payments on spending bill,” 14 April 2017.
3. Timothy Jost, “Examining The Final Market Stabilization Rule: What’s There, What’s Not, And How Might It Work?” Health Affairs Blog, 14 April 2017. http://healthaffairs.org/blog/2017/04/14/examining-the-final-market-stabilization-rule-whats-there-whats-not-and-how-might-it-work/

ACA Repeal: Here we go again

According to one report, VP Pence has offered three changes to the repeal bill to win Freedom Caucus support for the Trumpcare bill:

• Elimination of requirements for what insurers must cover
• Eliminating coverage for pre-existing medical conditions
• Eliminating limits on what insurers can charge people with medical conditions

Whether the bill can retain any support among moderates in the GOP with these changes is questionable. These provisions will cause problems for hospitals and healthcare providers, and result in more people having no health insurance coverage, and may allow a sharp increase in insurance prices for consumers, as the Congressional Budget Office has predicted.

This simply makes a terrible bill worse.

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Sources:

1. Marlene Satter, “Freedom Caucus would support health care bill that kills 3 ACA provisions,” BenefitsPro, 10 April, 2017. http://www.benefitspro.com/2017/04/10/freedom-caucus-would-support-health-care-bill-that?kw=Freedom%20Caucus%20would%20support%20health%20care%20bill%20that%20kills%203%20ACA%20provisions&et=editorial&bu=BenefitsPRO&cn=20170413&src=EMC-Email_editorial&pt=Consumer%20Driven%20PRO