States AGs revolt as House and Senate Bills expand Medicaid

Expect more states to join the 13 AGs who threatened to sue if either health bill is enacted by Congress claiming certain Senators and Representatives were given sweetheart deals to get them passed.

Forty-three states are facing financial deficits given the down turn in the economy. According to a CNN report December 10, "As states attempt to get their budgets in line for the new fiscal year, ...budget constraints are causing 25 states to reduce services to their residences. So far 17 states have already made cuts or are considering cuts to programs that affect low-income children's and family's access to health insurance and health care services." In the last House vote of 2009, it passed the "Jobs for Main Street Act" by a 217-212 vote along party lines, which provided states with some funding mostly for current operations, including $53 Billion for extending benefits/health insurance subsidies for the unemployed and $23 Billion for Medicaid.

Given that Medicaid is a program jointly funded by federal and state governments and administered by the states, it is easy to see why states are financially unable to expand benefits programs. It seems Congress is out of touch with the reality of the severity of the economic crisis and continuing politics as usual, in these are anything but usual times. Unlike the federal government states cannot just print money. Despite claims to the contrary by our politicians, neither bill seriously does anything to bend the proverbial cost curve downward. However, as mentioned before in this blog, both do an extensive amount of cost-shifting.

No one wants to see anyone without healthcare, but it's time we take the politics and politicians out of it. The reason why became clear in talking with a friend who is an Indiana State Representative. He said, "So much of what we do with regard to legistlation is in response to some horrific hardship case we hear about. We feel compelled to right a wrong, and so we pass legistlation. But we don't take the time to look circumspectly at the issue to understand the potential unintended
consequences of what we pass."

It seems Congress is using the same rationale my friend described. Poorly, reasoned laws are worse than none at all. Let's be financially responsible and fair to all our citizens. Perhaps the States can succeed in getting Congress to appreciate we need to be writing good bills rather than paying people off to pass any bill.

Social Safety Nets with Growing Holes

After much hoopla, Congress finally began its Christmas vacation last week.

House or Senate plan, public or private, it really doesn't matter - what the politicians seem to have forgotten is that any plan must be underwritten correctly and with the appropriate safeguards or it won't be solvent. For some reason, beneficiaries tend to get upset there is no money to pay claims.

The CBO takes a snapshot in time approach to financial analysis. This static accounting approach does not account for the way human beings react in the real world, a fact they readily admit with multiple disclaimer footnotes in all their reports. Rather, what is needed is an underwriting analysis of the proposals. Underwriters try to predict the future given past behavior, human nature, changing market conditions and nature of the risk pool. The fact that accountants rather than underwriters are determining the feasibility of our social welfare programs may explain why Medicare, Medicaid and Social Security are projected to have a combined deficit of well over $100 Trillion into the future.

Underwriting isn't sexy enough for the politicians, which is no doubt why they ignore it entirely. Underwriting is risk assessment, and sometimes risk management; the very words convey dullness and boredom. No, it's much more exciting for Democrats to accuse Republicans of wanting you to die, and die quickly, and for Republicans to say that Democrats want to kill Granny. But where does this leave the American people? Don't we deserve better?

HR3962: Duty or Charity - Covering Congenital or Developmental Deformities

HR 3962 assures that children with congenital or developmental deformities be covered under group health plans. But children born to a "covered" parent already have these benefits. The question is - who will benefit from this rule change?

It is quite popular for those who would like to adopt children to go abroad to do so. Many choose to adopt a child with special needs, such as a cleft palate, who would be less likely to be adopted by a local couple. These children may require one or several surgeries as they grow. No doubt, this is a noble and charitable deed. This is not an unknown risk, the parents had full disclosure of the condition when they adopted the child. Often employer health plans willingly choose to extend coverage for such conditions under their plan in these circumstances. Understanding that such generous coverage necessitates higher premiums to pay for it, the question is should an employer-provided health plan be forced to participate in the employee's charity? Health plans do not typically cover adoption as part of their reproductive health options coverage. Parents pay tens of thousands of dollars of their own savings to adopt. Is it unreasonable for them to bear the full
expense of their decisions, rather than mandate it be cost-shifted to their employers, particularly in these difficult economic times?

This does not need to preclude parents from adopting a child with congenital or developmental deformities. Today, many developing countries have first-world internationally accredited hospitals where these children can have the necessary procedures at a tiny fraction of what it would cost for the same care here. It may be easier for the child and parents, given the staff speak the child's native language, as well as English.

HR 3962: Domestic Violence - No Longer PreExisting: Is This Enabling?

Clearly, a first case of domestic violence should be covered under any health plan. The question is how many times should a person let someone beat the daylights out of them and a third party be forced to pay for their care? Given that mental health coverage is unlimited under this bill, shouldn't there be some personal responsibility on the part of the patient to get the help they need to assure this doesn't happen again? Would it not seem reasonable that if this person is seeking treatment and another episode occurs, it should be covered,
but any subsequent costs incurred as a result of abuse should be the patient's responsibility? To force insurers and employers to continue covering the costs of domestic violence makes them in essence a facilitator of abuse. Does this really help the patient come to terms with the situation?

HR 3962: Why is Government Insuring the Already Well-Insured?

HR 3962 provides current retirees with protection against reductions in retiree health benefits now offered by companies or employee organizations. Historically, this has been a popular benefit with unionized companies, particularly in manufacturing. This bill does not mean that such plans must continue the same benefits for current employees. Most retiree health plans will not be able to as they tend to be underfunded given usage patterns and health status. With the Cadillac health plans provided, these employees are accustomed to going to the doctor for every sniffle. These retirees also tend to have metabolic syndrome - obesity, diabetes and hypertension, as well as, cardiovascular disease and tend to need joint replacements to a greater degree than the general population.

However, retirees need not worry because under this bill the US government becomes the reinsurer of retiree health benefits. This means the US taxpayer will underwrite future benefits for these folks. Here's how it works: If the retiree has a large claim, the plan will pay the first $15 thousand in medical expenses. The government will pay 80% of the next $75 thousand in claims up to $90 thousand in claims. If there is a $90 thousand claiming a given year, the US Government will reimburse the plan $60 thousand or in this example 2/3 of the costs. Benefits will be paid from the Retiree Reserve Trust Fund, with $10 billion from the US Treasury. It would seem these people are better off than most retirees. What reason would our politicians in Washington have for being so generous with our tax dollars for people who already have retiree health benefits?

According to this legislation, the DHHS Secretary can stop taking applications for participation in the program or reduce payouts at any time to ensure the government reinsurance program does not exceed the appropriated  funds. This gives the government considerable leverage over private retiree health plans. It also gives the government considerable leeway in how to administer the trust fund, who may receive reimbursement and at what levels should the fund run out of funds. Given this $10 billion is a one time appropriation according to the CBO budget analysis  (Page 11), what happens when the money does run out? This would seem to place the current politicians in Congress in a powerful position for future elections with one of the most active and well-mobilized voting blocks.

HR 3962: Mental Health Parity is the End of Disability Insurance

Until HR 3962, mental health conditions were subject to a plan’s limits. While this change will no doubt have the effect of dramatically increasing healthcare expenditures, it will have catastrophic effects on the disability insurance industry. In fact, it will virtually eliminate it entirely within about 2 years.

Disability insurance is income insurance if you are sick or otherwise unable to work. Typically, there is a two-year limit on mental nervous illnesses. The thought is - if there is a problem, this should give the person adequate time to get the help they need to recover. Presumably, if a person was capable of working before, that person should be able to be treated.

There are a few things that one must understand about this product: Disability claims routinely go up when the economy goes down. They also rise when a given employer is having financial difficulties and the fear of layoffs is real. Not too surprisingly mental-nervous conditions top the claims list, with depression or anxiety leading the pack. In fact, if employees know it is likely that they will be laid off or given a pink slip, it is not uncommon for them to take preemptive action to assure their income by claiming disability. Since all it takes is a healthcare provider’s note to get the process started, some employees will have their provider write a note the very day they are laid off. Keep in mind, full benefits are good till the end of the day.

As the former Chief Medical Officer for a global disability and workers’ compensation carrier who has reviewed thousands of disability claims, this is what you will commonly see: Providers often refuse to release psychiatric notes claiming patient privacy, despite signed releases for exactly such records. They will often re-write office notes or summarize notes so that insurers do not know what treatment has been given. In fact, there is great variability and little coordination of the treatment that is given. Anyone from a licensed social worker, psychologist, masters level psychologist, masters level degree in counseling, doctoral psychologist, neuropsychologist, psychiatrist, family practioner, physician’s assistant or nurse practitioner may be “treating” the person.

Many times the mental-nervous issues are situational, in which work often helps, but little or no tools are given to the patient as to how to better cope, other than to write them off work. It seems patients often spend their sessions rehashing their problems. There is no documentation of actual counsel given or progress made. In medicine, if it isn’t written in the medical records, it wasn’t done. Often little or no objective testing has been done to determine exactly what the diagnosis is, or if it is even real, versus secondary gain – such as a disability check. Many real physical conditions never receive a full medical work-up. As with other conditions in medicine, medical personnel often add to the prescriptive regimen without checking to see if the medical regimen is causing the problem. Another important issue is the number of people diagnosed with personality disorders in the workplace. There is a prevailing notion that these diagnoses preclude people from working, when in fact many are capable of functioning at a very high level; the issue is how they relate to others, not whether they have the actual knowledge base to do the job.[See the article Personality Disorders in the Workplace.] Granted some disorders are more amenable to treatment than others, however, quite a number of those in the mental health field seem to think these diagnoses are a lifetime pass.

Due to the delays from providers and frequent lack of objective evidence or testing, it takes thousands of dollars and months of time to prove the whether or not the disability is legitimate. The two-year limit at least puts a tail on it for employers and insurers. This bill will mean a guaranteed income to age 65 for the insured who finds a cooperative provider or switches providers often enough to keep the insurer a couple of steps behind. Given the outlook for the economy and this legislation, no good company will be able to afford to continue to provide this valuable benefit to their employees. No disability insurer will be able to continue to stay in business if HR 3962 passes the Senate. Instead, expect disability carriers to stop renewing policies and begin liquidating operations in the coming year.

HR 3962: Pre-existing condition or war injury?

Unless you have been out of the country or trapped under the cone of silence, you have no doubt heard that the House of Representatives narrowly passed HR 3962 – the Affordable Healthcare for America Act – Saturday night, 220 to 215. There are many issues in this bill that it seems both healthcare organizations and the media either haven’t read or didn’t understand. We will address them point by point over the next week or so.


Let us begin today by looking at those pesky pre-existing conditions...


SEC. 211. PROHIBITING PREEXISTING CONDITION EXCLUSIONS.

A qualified health benefits plan may not impose any preexisting condition exclusion (as defined in section 2701(b)(1)(A) of the Public Health Service Act) or otherwise impose any limit or condition on the coverage under the plan with respect to an individual or dependent based on any of the following: health status, medical condition, claims experience, receipt of health care, medical history, genetic information, evidence of insurability, disability, or source of injury (including conditions arising out of acts of domestic violence) or any similar factors.


As written, the burden of caring for our injured war veterans is lifted off the shoulders of the Veterans Administration and places it squarely on the backs of private insurers as our veterans transition back into society. Due to the rapid emergency medical response of our military, we have not had the number of deaths in Iraq & Afghanistan that we have in other wars; but we have had more injuries that previously would have killed our troops. Consequently, many have needed prosthetics and extensive rehabilitation. Good prosthetics cost tens of thousands of dollars and robotic prosthetics (hands that work like hands, such as the DEKA arm, rather than a hook) are near six figures.

This bill also provides for mental health parity. This means private insurers cannot limit mental health benefits. Given that in combination with the pre-ex elimination, the VA can also shift its mental health counseling to the private sector. With many of our troops having had multiple tours of duty, it should not be surprising that they will need some assistance readjusting back to civilian life. When vets get care at the VA, it is easier to gather data for researching what care works best and implement current standard of care treatment. In the private sector, this is much more difficult as it means educating all possible providers who may have varied or no experience treating vets.

In March, Uncle Sam floated the idea of having private insurers reimburse the Veterans Administration for care for service-related injuries. [Washington Post] After protests from veterans groups, the executive branch appeared to back off. Under this bill, House has managed to get the government off the hook again for its obligations to our wounded heroes. This is morally reprehensible.

HR 3961, HR 3962, the Medicare SGR & the Debt

We are still awaiting the CBO's scoring of the bill which came out of the Senate majority leader's closed door discussions. Similar to the "bill" sent to the CBO by the Senate Finance Committee, it is still in the conceptual stage and has yet to be officially written.

On the other hand, the bills in the House were merged to form H.R. 3962, the Affordable Health Care for America Act, which was released October 29th. As mentioned in the analysis of the Baucus Bill, H.R. 3962 does not include fixing the physician reimbursement rate (Medicare SGR). While it claims to save the federal government $104 billion, it leaves in place the 21% SGR cut scheduled for 2010, and makes no further provisions to fix the formula. This is clearly unsustainable, as providers will have no choice but to opt out of the program, leaving seniors without care.

Interestingly a separate bill, H.R.3961, the Medicare Physician Payment Reform Act of 2009, was introduced the same day. It restructures the SGR formula, increasing physician payments for Medicare, Medicare Advantage and TRICARE. One quarter of that increase would come from premium increases paid by Medicare Part B enrollees. Ultimately, this bill is estimated to increase the direct spending of the Federal government by $210 billion over the 2010-2019 period.

According to the numbering system, it seems the Medicare Physician Payment Reform Bill was introduced first. It seems someone in the House was aware of the SGR problem. Since this wasn't an afterthought, wouldn't it have been logical to have “fixed” the problem in the comprehensive bill before introducing it? After all, for months politicians have been insisting that we must have ONE bill to reform healthcare. But without the "fix," House politicians could and did proceed to hold press conferences, claiming victory and “savings” for the American people all the while putting us $100+ billion further in debt. This behavior is disrespectful of the hardworking Americans who voted them into office and it does nothing to increase sustainability or affordability.