Hopeful Breast Cancer news

While breast cancer is generally pretty treatable (given early detection and regular exams), some forms of the disease are especially pernicious. Now, the Feds have "approved a new "smart bomb" drug ... that can help women with one of the most hard-to-cure types of breast cancer."

Called Kadcyla, it attacks HER2-positive form of breast cancer; it's not necessarily a cure, but it does appear to add several months to victims' lives. It's actually a hybrid, combining an older drug (Herceptin) with the powerful chemo med DM1.

Does it work as advertised?

You be the judge:

"In a trial of 991 women with advanced HER2 breast cancer, those who got Kadcyla lived on average 5.8 months longer than those getting more standard chemotherapy ... meant about 2 ½ years of life after diagnosis, compared to two years for those on standard therapy."

Pretty convincing.

There's some bad news, though:

"A nearly 10-month course of therapy costs $94,000"

And who knows if it'll be covered under The ObamaTax. Not to mention the new taxes on medical device and other research companies.

Kadcyla, we barely knew ya.

With this ring...Ooops

Way back in Aught Eight, Bob posted on an interesting, and growing, phenomenon:

"[A] poll conducted by the Kaiser Family Foundation, a leading health policy research group, found that in the past year 7 percent of U.S. adults married so one or the other could get on a partner's health insurance plan."

He remarked at the time that this was quite extraordinary, and wondered if we'd be seeing more of this.

Well, we may never know, because thanks to The ObamaTax, that avenue is being quickly cut off:

"By denying coverage to spouses, employers not only save the annual premiums, but also the new fees ... This year, companies have to pay $1 or $2 “per life” covered on their plans, a sum that jumps to $65 in 2014"

That extra fee is to help offset the cost of adding so many folks to the rolls of the insured, thereby making insurance even more expensive (very Orwellian, really: "we'll cut your premiums by 3000% by increasing your premiums"). New ObamaTax regs will require employers to offer coverage to dependent children (if by "children" you mean "26 year old adults"). Curiously, though, there's no such provision (yet) requiring such coverage for spouses. This has been going on for a while now: many employers require working spouses - whose employers offer health insurance - to take that coverage instead. This latest just codifies the practice.

Of course, that presents a new challenge: what if the spouse's employer doesn't offer coverage, or the spouse doesn't work outside the home? The Exchanges seem tailor-made for this, if they work as advertised.

Any bets on that?

Finally the problem is not insurance it is the cost of Healthcare

It is Time, hardly a mainstream or respected publication anymore, but that makes it all the more shocking they finally came around to the cost problem, not evil greedy insurance companies.

http://healthland.time.com/2013/02/20/bitter-pill-why-medical-bills-are-killing-us/

"Stephanie was then told by a billing clerk that the estimated cost of Sean’s visit — just to be examined for six days so a treatment plan could be devised — would be $48,900, due in advance. Stephanie got her mother to write her a check"

"About a week later, Stephanie had to ask her mother for $35,000 more so Sean could begin the treatment the doctors had decided was urgent."

"Sean was held for about 90 minutes in a reception area, she says, because the hospital could not confirm that the check had cleared. Sean was allowed to see the doctor only after he advanced MD Anderson $7,500 from his credit card."

"The total cost, in advance, for Sean to get his treatment plan and initial doses of chemotherapy was $83,900."

The whole article is great for how infuriating it is.  So much was wrong with this entire situtation.

1. We already have small group reform which guarantees them coverage and subsidized rates. How can they borrow $83,900 to pay for treatment but couldn't borrow $500 to $1,000 a month for a real insurance policy?
2. Max rates $5K HSA with Anthem wouldn't have cost that much more than their worthless $469 a month policy. 
3. $5,628 a year in premium for a $2,000 daily hospital benefit is absurd. 
4. Finally the most important part, they could have gone to UH Ajiuha new cancer center and had an entire course of treatment for $83,900. Hospitals charge these ridiculous amounts because people pay them. CTCA is just as bad. 

 I would argue the system worked perfectly this time.  Someone made a bad decision by not buying the proper insurance. They then followed it up and made another bad decision by insisting on going to an overpriced hospital. They paid for it themselves, that is exactly how it should work.

It's when they bring to light the hospitals charges we see the problem;

 "Dozens of midpriced items were embedded with similarly aggressive markups, like $283.00 for a “CHEST, PA AND LAT 71020.” That’s a simple chest X-ray, for which MD Anderson is routinely paid $20.44 when it treats a patient on Medicare, the government health care program for the elderly.

Every time a nurse drew blood, a “ROUTINE VENIPUNCTURE” charge of $36.00 appeared, accompanied by charges of $23 to $78 for each of a dozen or more lab analyses performed on the blood sample. In all, the charges for blood and other lab tests done on Recchi amounted to more than $15,000. Had Recchi been old enough for Medicare, MD Anderson would have been paid a few hundred dollars for all those tests. By law, Medicare’s payments approximate a hospital’s cost of providing a service, including overhead, equipment and salaries."

The more stories like this printed maybe the politicians will stop beating up on the payors and do something about the providers and abusive charges.

In Memorium: Raymond E Mincer, CLU

In Judaism, when one learns of a death, one praises God, saying: "Baruch atah Adonai, Dayan HaEmet," "Praised are you, O God, the Righteous Judge."

Ray Mincer, who passed away this morning at the ripe young age of 78, certainly deserves the Good Lord's attention. I was privileged to know, and be close friends with, Ray for the past 23 or so years. He was a true mensch.

We met when he dropped by the office one day to help out our agency's founder on a case, and for the next couple of years, Ray helped me with some of my more .. um.. interesting cases. Then, in 1993, Ohio adopted a Continuing Education requirement for agents. That fall, we both attended a - how to put it nicely? - "less-than-compelling" (but very expensive) all-day CE seminar. At one of the breaks, we got to talking, and decided that we could do this, too (well, not the boring part, of course). And thus was born Miami Valley Insurance Educators.

Although a practicing and proud Lutheran, Ray had an uncanny Yiddish accent (much to my own chagrin - I have none). More often than I care to think, he would slay me with a classic Jewish joke, delivered dead-pan, in a flawless Yiddish dialect.

Over the past half dozen or so years, Ray fought - successfully - a series of various cancers. This last one, though, proved too much: after the latest, unsuccessful, round of chemo, and with several "appliances" attached to his failing body, he finally declared "enough."

Two weeks ago, my better half and I traveled to Cleveland (where Ray and Joyce had moved a few years ago, to be near their terrific son and his family). I am so glad we did: it was a special time to reconnect, and to see him laugh, and grimace, joke and reminisce.

Cancer may have taken my friend, but nothing can take the years of joy we shared, and the memory of his wry smile from me.

Godspeed, Ray, Godspeed.

Unclear on the concept: Teacher Fail

The crybabies  "educators" in the Mason, Ohio (northern Cincinnati suburb) Education Association seem to have missed the news that The ObamaTax would, in fact, affect them:

"The union representing 640 teachers and their families has filed a grievance over TrueCost ... several teachers who were pregnant were forced to deliver their babies at another hospital, or face the alternative of thousands of dollars in medical bills"

Boo. Hoo.

As regular IB readers know, managing networks has become a favored new tool for reining in health care costs:

"What if you could unbundle your provider network, and steer your insureds to cheaper/more efficient docs and hospitals? Might not that improve the bottom line?"

It doesn't help, though, when the district itself keeps waffling on how they're going to resolve the standoff. In the end, it looks like they'll stick to their original plan and keep TrueCost in place.

The teachers themselves seem not to have learned much the past few years. According to noted rocket surgeon and local teachers' union president Karrie Strickland, "It is not our responsibility to alter the way health insurance costs, claims and bills are paid in the health care industry in Cincinnati."

Sorry, Karrie, but you get an F (for Fair Share).

[Hat Tip: FoIB Holly R]

Dangerous Musings [Updated & Bumped]

[Originally posted February 19, 2013 - scroll down for update]

The National Association of Alternative Benefit Consultants is the organization which sponsors my CBC designation. It's made up of, and run by, good folks, and does a good job of hunting up interesting ways for agents to expand their business. Sometimes, though, I just shake my head in bemusement at what they send out.

Case in point, a recent email with the provocative title "HSAs, HRAs - Alive & Well Under PPACA‏"

I'm going to elide over the HRA (Health Reimbursement Arrangement) for now - although that model has some interesting challenges under The ObamaTax, as well - and focus on Health Savings Accounts.

As we've written, HSA's are essentially outlawed under the 'Tax, because despite their built-in cost efficiency (or perhaps because of it), they fail to meet the minimum essential coverage requirements under the train wreck law. NAABC's email avers that "many employers will switch to CDHPs, either in the Exchanges or through ERISA plans to escape the regulations of the PPACA.  Even a one-deductible, 100% coinsurance plan will qualify under the "Bronze" level in the exchanges."

Their position relies on this statement from the IRS:

"Section ... directs that the limit on deductibles described ... for a health plan offered in the small group market be applied so as to not affect the actuarial value of any health plan. We interpret and implement this provision through our proposal ... by authorizing a health insurance issuer to make adjustments to its deductible to maintain the specified actuarial value for the applicable level of coverage required ... we propose that a plan may exceed the annual deductible limit if it cannot reasonably reach a given level of coverage (metal tier) without doing so.”

Which should clear up any confusion on that issue.

But of course it doesn't, any more than relying on the IRS hotlines during tax season. The agency goes on to "clarify" its position:

"We propose to use a ‘‘reasonableness’’ standard and request comment on what evidence or factors should be required from an issuer and considered in determining whether this standard is met with respect to health insurance coverage ... While it may be possible to develop plan designs to meet all of these constraints, we believe it could be difficult to develop plans with reasonable coinsurance or equivalent cost sharing rate" [emphasis added]

Talk about weasel words. Does any sane person really think it's a good idea to rely on the generosity and open-mindedness of the IRS? The NAABC seems to think so, because they end their email with this citation from the IRS regs themselves:

"A health plan’s annual deductible may exceed the annual deductible limit if that plan may not reasonably reach the actuarial value of a given level of coverage a ... without exceeding the annual deductible limit"

Uh-hunh.

So it seems that the IRS has left us a loophole through which we can drive our HSAs.

Or does it?

Cavalcade of Risk #177: Health Insurance Update edition

Anisha Sekar makes her CavRisk hosting debut this week with a tribute to the ACA. Do stop by.

DNRs & Libertarian Choices

Was helping a friend deal with some family medical issues that unfortunately are not looking good. Due to inadequate insurance they are not getting the care they need. The problem is actually very solvable, they are just choosing not to solve it.

This made me think of Do Not Resuscitate(DNR) orders, perfectly legal requests that medical care not be provided. The individual above has self imposed a DNR on themselves by not taking the steps to get the insurance that will allow them to get the care they require to stay alive. All perfectly legal.

Why can't someone choose to forgo insurance and make the same decision? Instead of spending $5000 per year in health insurance, they'd rather spend the money someplace else, which should be a perfectly legal decision. We as society will honor that decision and not provide them care if something does happen.

This thought process is considered uncivilized, cruel, and all sorts of other not-so-nice adjectives. We are told Society has to provide care to those that need it. OK, then why don't we need to provide the same care to those that sign DNRs?  What about those that refuse to seek treatment they need, like non-compliant diabetics? Shouldn't care also be forced on them?

Tuesday ObamaTax LinkFest

In no particular order:

■ Sales ObamaTaxes - Did you know that there's a sales tax on the policies we'll have to buy? Yep, ObamaTaxed if you do, ObamaTaxed if you don't.

Sweet.

■ As Nate's indicated, small business is a lot more interested in self-funded plan designs these days. Even The Gray Lady seems to have noticed. Of course, according to the solons at that august publication, it's a "loophole."

If you say so.

■ Upward, ever upward: The Congressional Budget Office has issued newly revised estimates of what those ostensible ObamaTax "subsidies" (aka redistribution) are going to cost.

Surprised?

■ Finally, the preference cascade of businesses ditching their health insurance plans continues apace. Grocery behemoth Kroger's CEO acknowledges this reality, as does Dunkin' Donuts (mmmm, donuts). As we've noted before, Wendy's is certainly considering it, as is Taco Bell. The Financial Times has a pretty exhaustive round-up of employers looking to get off the health insurance roller coaster.

Not as smart as I thought I was

My plans for an early retirement seem to have hit a road bump. I have been discussing with a select few brokers methods we came up with to avoid paying any penalties and offer coverage possibly cheaper then $2,000.

Today one of them sent me a link with the basic concept outlined for all to see in LifeHealthPro.

It is possible my phone was tapped, or one of the brokers got loose lips; more likely the flaws in PPACA are just that glaringly obvious:

"PPACA will require self-insured plans to cover a package of basic preventive services without imposing deductibles, co-payments or other out-of-pocket "cost-sharing" requirements on the plan enrollees. But PPACA exempts self-insured plans from most other new coverage requirements."

"But, to avoid paying the new PPACA uninsured penalty tax, an individual worker simply needs some kind of minimum essential coverage from the employer, not necessarily coverage through the plan that meets the PPACA minimum actuarial value standards ...An employer could offer one plan that would meet the PPACA minimum actuarial value requirements for one rate, and then offer a skinny, possibly cheaper minimum essential coverage plan alongside the minimum actuarial value plan"

There really is no excuse for any employers to get stuck paying penalties, because there are numerous solutions to avoid or greatly minimize them. 

Wish I could charge those fees....

Some interesting numbers in the AP article about Pre-Existing Condition Insurance Plan (PCIP) quietly being shut down:


"PCIP has served more than 135,000 people ..."the administration said the program has spent about $2.4 billion in taxpayer money on medical claims and nearly $180 million on administrative costs"

The numbers that really jumped out to me were the 135,000 people and $180 million on administrative fees, as I make my living on administrative fees.  So I did some quick looking around, and found that PCIP programs  started rolling out in August through October of 2010. Only 103,160 were covered as of 12/31/12 so 135,000 was the total; not everyone was covered the entire time.

Assuming everyone started in August, that is 29 months, so the numbers don't look as bad. Let's even assume that for all 29 months they covered 135,000 individuals. Their administrative cost averaged $45.98 Per Member Per Month. On small groups I am a happy camper at $25 Per Employee Per Month (which includes dependents). On a PMPM basis I would be elated with $20.

From what I have heard and seen of the program, they didn't even expect you to manage claims, just shuffle the paper. Which explains the $17,777 in average claims. I need to keep a closer eye out for the next RFP they put out: wouldn't take many contracts like this to retire very early. 

Ow! Ow! (This Sceptered Isle Part CCLXXI)

Here is a disturbing story from the London Daily Mail.

It's even more disturbing when you consider that - on average - citizens in the U.K. have but one ovary and one testicle to begin with.  But perhaps the most disturbing of all is this statement:

“The NHS normally pays out around £20,000 if the wrong testicle has been removed.”

Uhhh . . . normally?  Normally??

Oh well, surely no price is too large to pay for the security of a national single-payer medical insurance plan.  

Your (Examination) Table is Ready...

We've been writing about the coming wave of "concierge" medicine for over six years, so this is nothing new to our readers:

"New data from a national survey of nearly 14,000 physicians ... found that 9.6 percent of “practice owners” were planning to convert to concierge practices in the next one to three years."

That's nearly 1 in 10 practitioners, which is pretty significant. The usual suspects are cited: low Medicare and private reimbursement rates, which are only getting worse under the ObamaTax. And the so-called "Doc Fix" continues to hang as an albatross around the future's neck.

What's even more frightening, though, is that the phenomenon seems to be specialty-independent; that is, it's not just primary care, but surgeons and oncologists and, well, the list goes on. Which makes sense: health care is (pretty much) health care, and someone has to pay for it.

Which brings us to the uptick in concierge-style medicine. Some 20 percent of docs already restrict "the number of Medicare patients in their practice and one in three primary care doctors – the providers on the front lines of keeping the cost of seniors’ care low – are restricting Medicare patients." So if you can't get into your primary care doc, good luck getting a referral to that cardio guy you need to see.

Concierge-style medicine seeks to get around that problem by having patients contract directly with the provider. Of course, this will work better for some practice areas than others, primary care being the most obvious. How - or even if - this would work with, say, surgeons or radiologists seems unclear at this point. On the other hand, it was essentially the premise (and "promise") of HMO's. On the other hand, we've seen how those have worked out over the past decades.

The biggest problem right now is the threat that HHS Secretary Shecantbeserious will pull another mandate out of her...um... pocket and render the whole point moot.

ObamaCare...pushing & pulling and going nowhere

There has been a movement to repeal the Health Insurance Tax (HIT) on fully-insured premiums, and now comes a new bi-partisan effort in Congress. An effort last year failed.

The part that confuses me is why you would tax premiums in the first place. Besides the current tax write off, in 2014 most premiums would be subsidized. So the government wrote a bill to subsidize premiums and then will tax those same premiums on the back end. Why not just do nothing; or if that doesn't generate enough subsidy, just reduce the subsidy by the amount of the HIT tax?

Besides creating more work for CPAs and greater opportunity for fraud, the subsidy/tax combination accomplishes nothing. Giving someone a dollar then taxing them a dollar is just wasting time.

PPACA Identity Theft to cost $? Billion per year

I don't think many of us will be surprised to find out the drafters of PPACA either didn't see this coming or weren't smart enough to do something about it.

Start with the fraud we know is happening;

"Using stolen names and Social Security numbers, criminals are filing phony electronic tax forms to claim refunds, exploiting a slow-moving federal bureaucracy to collect the money before victims, or the Internal Revenue Service, discover the fraud. 

Parton was a victim of what officials say has ballooned into a massive, and dangerous, illegal industry that could cost the nation $21 billion over the next five years, according to the U.S. Treasury Department."

I have seen higher estimates from CNN

"Last year, the IRS reported 938,664 fraudulent returns related to identity theft, totaling $6.5 billion, Treasury Inspector General for Tax Administration J. Russell George told a House subcommittee this month."

This fraud is so easy and so rampant because it is done online with no face to face contact or verification.

Now lets look forward to PPACA subsidy and verification. 474 pages of rules can be found here.

The exchanges are suppose to mainly be websites where someone can go online and purchase insurance. Again no face to face contact or method to verify identity.

Employers will be notified if one of their employees received a subsidy after the fact.  They can appeal, which would mean hours dealing with the IRS or some similar agency trying to convince them you don't owe a penalty. Anyone that has had tax issues can attest as to how efficient and cost effective this is. In most cases it would probably be cheaper to just pay the $2,000 penalty.

Individual applicants will certify what they are eligible for, with minor verification. Read any of the annual Medicaid reports to see how rampant with fraud and errors that already is. It is key to remember that no one has a vested interest in keeping people off Medicaid, it is never their money. They get paid to process paper. not protect the financial interest of the plan. The same problems exist here, it is much easier to just approve a subsidy and let someone else appeal than to question it. I deal with this all the time with unemployment; every employee I fire was let go - according to them - for lack of hours. I spend a few hours dealing with paperwork showing it was for cause, and the majority of the time they don't collect. The rest of the time Ohio Jobs and Family tells me I didn't properly fire someone and awards them unemployment anyway. Never for lack of hours but no one is EVER held accountable for lying on their unemployment insurance claim form.

Illegals, on a daily basis and with ease, already steal SSNs to work, how much harder is it going to be to apply for insurance with a Subsidy?

How do you recover stolen HealthCare?

It is problem enough when the government, through lax enforcement, watches $6 billion a year in refunds walk out the door. As an employer, I will someday pay a share off that. Of immediate concern is a system that allows systemic fraud for which I am immediately liable; $2,000 to $3,000 a year for a couple employees plus hours and hours of my time trying to fix it is something I can't afford.

All of this raises one final question: is this a bug in the system or intended?

No means...."No"

Since North Carolina has officially put the kibosh on both a state-run ObamaExchange and Medicaid expansion, some folks are wondering "why?"

Something that gets short-shrift in the media is that, in addition to forfeiting tax-payer subsidies, states with Federally-run Exchanges also get to avoid the employer mandates.

But it gets better:

"Justice John Roberts deemed the taxes levied for noncompliance to be too low to constitute a real mandate. They are simply taxes – and in many cases they apply only when employees are eligible for federal tax credits"

But Henry, we already know this; so what?

Here's what:

"If tax credits are disallowed under federal exchanges, such taxes are no longer applicable. Oklahoma and other states are currently suing the federal government to enforce these terms of the Affordable Care Act."

North Carolina Gov McCrory seems to be playing a game of poker here: if Oklahoma's lawsuit is successful, his state can piggyback onto that. If not, well, there's little downside for his state's employers, and economy. And, of course, he can always revisit the idea of setting up a state-run Exchange.

Win-win-win.

[Hat Tip: FoIB Jeff M]

From the P&C Files: Malpractice makes Malperfect?

My favorite EconBlogger, Jason Shafrin, has an interesting post up on the cost of medical malpractice (aka medmal) coverage for various specialties.

Can you guess which one has the highest rates?

Click on over to Jason's place for the answer.

Buyer's Remorse?

Heh:

"According to backers of [The ObamaTax], enrollment faces big obstacles as polls and focus groups suggest a majority of uninsured people aren’t aware of the new coverage options or the availability of subsidies toward the cost of health insurance premium ..."

One wonders if folks are beginning to wake up to the cold, hard facts.

Ah:

"It might seem odd that the law’s supporters should need to convince Americans to purchase a plan, given that those who don’t will be taxed. But the tax will be less expensive than the cost of coverage."

Asked and answered.

We've been saying this for quite a while (although, to be fair, so has everyone else with an IQ above double digits). There are so many ways to game the system - and of course, folks in states with Federally-run Exchanges get no subsidies, making compliance even more expensive - that it's hard to see why any of the PrObamaTax hordes will bother to participate.

Which won't stop them whining, of course, about the unfairness of it all. Oh, bother.

Cavalcade of Risk #177: Call for submissions

Anisha Sekar hosts next week's Cav. Entries are due by Monday (the 18th).

To submit your risk-related post, just click here to email it.

You'll need to provide:

■ Your post's url and title
■ Your blog's url and name
■ Your name and email
■ A (brief) summary of the post

PLEASE remember: ONLY posts that relate to risk (not personal finance tips and the like). And please only submit if you are willing to link back to the carnival if your submission is accepted.

Runs on the ObamaExchange

Tomorrow's the deadline for states which have yet to make their pitch to Secretary Shecantbeserious regarding how they want to handle those Exchanges.

Here's a quick run-down as of this afternoon:

■ Mississippi is sticking with its game of chicken: they've officially turned down Mme Secretary's offer of a Fed-State partnership. Assuming they don't reach some other arrangement, The Magnolia State will default to a Federally-run model.

■ FoIB Patrick P reports that Illinois has been conditionally-approved to set up its State-Fed Partnership type Exchange. Patrick asks, with 16 carriers offering over 260 plans, "think Navigators will be able to handle explaining this?"

Exit question: It's clear that states choosing a Federally-run Exchange forfeit tax-payer subsidies. What's not so clear is what happens if it's a Partnership operation?

■ And FoIB Jeff M, checking in from The Tar Heel State, sends along the news that North Carolina will not be setting up its own Exchange, putting further pressure on Ms Shecatbeserious and her all-star band of technowizards to design and implement yet another Federally-run version.

■ And, finally, via email from UHC, we learn that, nationally, "the deadline for employers to notify employees of the availability of Health Benefit Exchanges has been delayed from March 1, 2013 to late summer or fall of 2013." Oh goody. Because nothing says "success" like pushing back crucial deadlines as the clock ticks down....

And this just in: "The U.S. Department of Health and Human Services (HHS) hopes to take bids from insurers that want to participate in the federal health insurance exchange programs from March 28 to April 30." Yes, one whole month to submit your bids - you hear that Anthem, UHC and the rest?

It'll be interesting to see which carriers take the bait.

Gorillas in the Mist?

On the one hand, medical technology continues its amazing advance. On the other, the "human interface" continues to be an obstacle to that progress.

Case in point:

"A new psychological study from Brigham and Women's Hospital has demonstrated how 83 percent of radiologists fail to spot the [foreign object] that is in the image below - despite running their eyes over it four times on average."

Do you see it?

If so, then you may have a future as a top-notch radiologist. Sleep tight!

Principles vs Politics in regards to Medicaid Expansion

I read in today's USA Today, only paper at the hotel, that Governors in Wisconsin and Indiana have passed on expanding Medicaid in their State. A rare display of standing on Principle. How are we to end the welfare state and entitlement problem if we continue to expand these programs that reduce and eliminate the need and incentive to work?

The easy math is free money from the Federal Government can't be passed up.

The correct math is there is no such thing as free money. A few thousand dollars in Federal crack to cover someone's Medicaid expenses doesn't begin to cover the cost of someone spending a lifetime working part time or entry level jobs and living off the taxpayor. Compounding the problem is the fact that it doesn't stop when that worker retires: kids raised under that lack of a work ethic are more likely to grow up and also live off the tax payor. Medicaid expansion is just one more step to creating a permanent welfare class. Everyone works 29 hours a week and gets by on Food Stamps, Medicaid, and Section 8 housing.  And then they and the media decry the income gap between these part timers and people working 70 hours a week to support them.

Also of interest is Indiana's request for an exemption; they had a very effective HSA Medicaid model that was being cancelled for not being ideologically consistent with ObamaCare. We'll see what HHS deems more important: a successful and proven program to deliver better benefits at a lower cost, or expansion of the Government Welfare model.

Health Wonk Review: Cupid edition

Peggy Salvatore presents this week's very sweet collection of wonky blogposts. It's really well done - there's no question that she read each entry, and adds helpful context to each one.

Kudos!

Mississippi Burning (The ObamaTax)

In a post yesterday, we reported on the travails of The Magnolia State's ObamaTax Exchange efforts. HHS Secretary Shecantbeserious had denied their request to install a state-run program, citing lack of inter-agency coordination, and had countered with an offer to set up a joint Fed-State operation.

As Mike pointed out, this seemed odd: "And yet, the federales tell Missippi that there's every possibility of coordinating with the same state agencies, under the same governor,  in a fed-state partnership Exchange."

I posed this dilemna to Elizabeth Festa of the National Underwriter (she wrote the original story which prompted my post). After a few emails back and forth, she came back with the Feds' final "answer" to this apparent contradiction: "Don't worry your pretty little heads about it."

Okay, that's a paraphrase; their actual reply was "a  partnership marketplace can still be set up without help from the governor's office because HHS has such a heavy role."

I'm pretty sure that my version would have gone over better.

The problem, of course, is that this is a non-answer. As I pointed out to Ms Festa (who seems like a very well-meaning and industrious person), "the HHS folks are being deliberately obtuse. Cohen (HHS) says "With ... no formal commitment to coordinate with other State agencies, we do not see a feasible pathway"

[As I explained to Ms Festa, I omitted the issue of the Governor's apparent recalcitrance because it's largely a distraction from the key issue]

I continued:

"But if MS agrees to a (Fed-State) Partnership, there's still not going to be any coordination. And if the HHS answer to that is "a  partnership marketplace can still be set up without help from the governor's office because HHS has such a heavy role," then Chaney's right when he says that "[t]he feds call the shots and we do all the work." And in that case, the lack of agency coordination becomes even more intensified."

One supposes that this could still end amicably, but at this point, it seems less likely. Ms Shecantbeserious has a pretty critical timing problem here: if they can't reach an agreement, then it automatically defaults to a Federally-run Exchange.

So what's the problem with that, Henry?

Well, there's (at least) two:

First, that countdown clock keeps on tickin', and HHS will have one more Exchange to set up (and how swimmingly is that effort going, Madame Secretary?). And second, it means that Magnolia State residents will forfeit any potential premium subsidies.

Nice.

Another Hidden ObamaTax

Hadn't thought of this before (my bad), but there's another little gem implicit in The ObamaTax:

Currently many (most?) working folks get their health insurance through employer-sponsored plans. And many of these folks pay their portion of the premium pre-tax, via Section 125 (or "cafeteria") plans.

Since many (most?) group plans will be going away over the next few years, employees dumped onto the Exchanges will lose that feature, and will have no alternative but to pay all their premiums with after-tax dollars. Adding insult to injury, a lot of these folks will be making too much money to qualify for any subsidies. And, of course, those in states with Federally-run Exchanges will get none.

But remember,The ObamaTax will lower your health insurance costs by 3000%.

[Hat Tip: Ace of Spades]

Tuesday Health Notes

■ First up, some great Food Pyramid news:

"Researchers ... in Spain have found that beer can help the body rehydrate better after a workout than water or Gatorade."

Apparently, the carbonation is a key factor, and the carbs help out, too.

■ Next, some good news for stroke survivors:

"A single injection, then a five-minute wait ... Now they're walking more steadily, reading more easily, concentrating better, speaking more clearly and regaining use of once-rigid limbs"

The secret? A 25mg shot of etanercept (an anti-inflammatory med). And the results?

"Of the total studied, more than 80 percent saw improvements in their ability to walk; more than 80 percent had less spasticity; and more than 85 percent exhibited improved motor function."

So if you (or someone you love) had a stroke, this may be just what the doctor orders.

■ Finally, the feel-good story of the week (or more), an early (and amazing) Valentine's Day gift. Forget flowers, candy and PJ's, here's a gift that truly keeps on giving:

"Three days before Valentine’s Day, a Florida woman gave her husband the most special gift of all ... Melissa DeGeso-Jones had her kidney transplanted at Florida Hospital in Orlando to her husband, James Jones, who has been suffering from renal failure."

His next major challenge? How does he top that?

Warning signs...

Earlier this week, we noted that the problems which the Much Vaunted National Health System© is experiencing at Stafford and other facilities is nothing new or even particularly obscure. What we didn't know at the time, though, is that they were warned about these problems by none other than  Sir Donald of Berwick (well-known to regular readers of InsureBlog):

"Its 84-page report ... warned ministers that the [MVNHS©] did not pay enough attention to quality of care because it was too focused on targets. It concluded that hospitals were “hitting the target and missing the point”.

Ouch!

Pretty sad when one of the architects of The ObamaTax finds your system critically flawed.

Missing Mississippi

Y'know, for an agency facing a quickly-approaching deadline, the folks at HHS seem to have an attitude problem:

"[Secretary Shecantbeserious] rejected approval of the Mississippi insurance commissioner’s state-based exchange application ... To be successfully approved and to even work as a marketplace, a state-based exchange would need working relationships with other state agencies ... there was no possibility of coordinating strategy with other agencies under his authority"

Which is all well and good, but fails to address the Magnolia State's main problem with the premise, to wit:

"[T]he health insurance exchanges mandated by [The ObamaTax] are not free-market exchanges. Instead, they are a portal to a massive and unaffordable new federal entitlement program. They trigger new taxes on businesses and will ultimately drive more people onto Medicaid rolls"

Please, Gov Bryant, tell us what you really think.

Underscoring the divide is the inherent conflict between what Madame Secretary wants and that pesky 10th Amendment. It seems reasonable to predict that this issue will also head to SCOTUS in the near future. How that plays out will be interesting to watch.

ADDENDUM: In the comments, Mike points out the fallacy of Ms Kathy's contention that that there's "no possibility of coordinating strategy with other agencies under his authority." In his link, a local paper reports that (as Mike puts it) "the federales tell Mississippi that there's every possibility of coordinating with the same state agencies, under the same governor,  in a fed-state partnership Exchange."

So which is it, Madame Secretary?

Draft Dodging

As Bob noted last week, some of the 58 states have begun to take a serious look at how their Exchanges (if any) will be run. A key issue is the role of agents/advisors, and how they're to be qualified and compensated.

Now comes word that HHS Secretary Shecantbeserious is planning to "start registering agents and brokers around July 1."

Okay, when you're through laughing, we can continue.

Have you noticed the little countdown timer in our sidebar? That's the countdown to the day the Exchanges are to go "live." The date? October 1st. Now, keeping this in mind, wrap your head around this:

"The federal exchange managers want to promote the agents by publishing lists of individual exchange producers starting in August and lists of the producers registered to sell Small Business Health Options Program (SHOP) exchange coverage starting in September." [emphasis added]

Now, given the institutional efficiency for which the HHS is so widely admired, what are the odds of this actually working out?

Yeah, that's what I think, too.

Anther question we might be asking ourselves is whether or not any sane insurance agent wants to participate. After all, under a state-regulated system, worst case scenario is generally a fine and/or loss of license. But these are (presumably) going to be subject to Federal laws, so the down-side must surely be more serious, no?

Which is not to say that it won't happen (I'm still on the fence, for example), but it does give one pause. And since that clock is clicking down at a pretty good clip, this may end up being a rather high-stakes game of chicken with Ms Kathy.

The Social Problem of Medicaid Expansion

Avik Roy has done a good job explaining some of the financial misconceptions our Governor has used in proposing Medicaid Expansion in Ohio.


Not discussed are the common sense social problems with expanding it. Simply: why bother working? When I was younger and wanted money, I got a job. When that wasn't enough, or I wanted a new car or paid myself to go to school, I got a second job. There have been a couple times in my life I held had three jobs. 70 to 80 hour work weeks were not uncommon; even now, with one job, 70 hours is not uncommon.

Our present-day welfare state, on the other hand, discourages work. Work just a little, be sure to show less than $15,000 in income on paper, and you can qualify for all sorts of benefits:

·Free Health Insurance under Medicaid Expansion
·Free food and spending cash with your EBT card
·Housing assistance
·Utility Assistance
·Education Assistance

Why get a second job or work more hours and lose all the free benefits? I see McDonald's and other fast food companies that are looking for workers. How can we have this level of unemployment and demand for assistance but unfilled entry level jobs?  That is a sure sign government assistance has supplanted the need to work.

We might have a Republican Governor in Ohio but we need a Conservative to replace him.

TPAs to pay for Birth Control

Apparently I am going to be spending a fortune on birth control, sadly I don't expect I will have time to use any of it.

"The preamble to the proposed rule suggests several ways in which this could be done, but the basic idea is that the TPA would take responsibility for providing coverage, and in turn contract with an insurer in the individual market to provide the coverage.  The insurer would in turn pass the cost of the coverage (which now will be a real cost since the insurer has no responsibility for covering maternity or any other health care costs) on to a federally facilitated exchange (FFE), which would offset the cost through a reduction in user fees — in other words, the insurer would receive a reduction in the user fee it otherwise owes to the FFE to cover both its costs and any administrative costs incurred by the TPA."

That's just the summary. Where to begin....

I have never seen a contraception-only policy before; are they even legal to sell?

I need to find a carrier, send them eligibility on a regular basis, and not get paid for any of it?

I am going to be really pissed if some carrier has a data breach and exposes PHI or Red Flag Data and I have to deal with the cost for services I didn't get paid for; I haven't seen any mention of immunity.

Will MLR apply to these policies? I foresee a lot of work to provide a small dollar benefit. In fact, I could see the administrative cost being higher then the cost of the drugs.

And who gets the rebates?

"Insurers providing contraceptive coverage would be responsible for notifying plan participants and beneficiaries of the availability of the coverage using language found in the proposed regulation.  The notice would be provided separately from any other plan information, generally on an annual basis."

There starts the excessive administrative fee.  Apparently single males would also need to be offered this policy and notice?

Fraud potential in this is huge: I don't see where anyone is asking the TPA to verify who these policies are being purchased for.

Old Dominion vs The ObamaTax

Well, well, well. So it's not just universities and businesses cutting employees' hours to avoid some of the more pernicious elements of The ObamaTax. Now, states are getting in on the act, too:

"Virginia ... is about to limit part-time employees to 29 hours per week in order to avoid triggering Obamacare’s requirement that employers provide health insurance to those working 30 hours per week or more."

That's because the state can ill-afford the estimated $100 million+ cost of implementing the train-wreck. Look for at least a few more of the other 57 states to follow suit.

Feature or Bug?

The other day, we reported on the latest scandal plaguing (heh) the Much Vaunted National Health System©.  And despite the fact that, as Mike pointed out, we covered this very same facility (among others) over three years  ago (!), little has changed, and nothing has improved.

Now comes British Health Secretary Jeremy Hunt (the MVNHS© version of HHS Secretary Shecantbeserious), openly calling for a police investigation into the affair, opining publicly that it's "absolutely disgraceful” that no doctors, nurses or managers have been held to account for the substandard care which led to the deaths of up to 1,200 patients."

Which begs the question:

If, after (at least) three years of ongoing and documented “abuse on such a wide scale,” isn't it fair to ask whether this might actually be by design, and not happenstance? After all, none of this is "news;" indeed, it's been common knowledge for some time. And yet, it's only after a British newspaper reported the abuse in detail that a high government official thinks it's time to ditch the famous stiff upper lip, and get cracking. 

But wait, it gets worse:

"[Secretary Hunt] admits he is not sure which hospitals are doing a good job ... I think it’s absolutely outrageous that potentially more than a thousand people lost their lives because of poor care and not a single person has been brought to book."

A suggestion, Mr Hunt? Try a mirror.

War is peace. Freedom is slavery. Ignorance is strength.

California seems to be getting jittery that when Obamacare takes hold next January, there won't be enough doctors in the state to treat the expected number of new insured patients.

“Some lawmakers want to fill the gap by redefining who can provide healthcare.  They are working on proposals that would allow physician assistants to treat more patients and nurse practitioners to set up independent practices. Pharmacists and optometrists could act as primary care providers, diagnosing and managing some chronic illnesses, such as diabetes and high blood pressure.”

[via Instapundit]

In this case, California may be awakening to the false promises of Obamacare.  Because in the real world, it has become increasingly apparent that Obamacare can’t be installed as written; that Fed regulations are impediments to its effective management; that the result will more likely be increased, rather than reduced, cost of medical delivery; and that therefore Obamacare is more likely to raise rather than lower everyone’s medical and insurance costs.

What to do?  It now occurs to California that maybe it could REDEFINE “medical care”.

So the California legislature will consider whether you really need a doctor if you are a diabetic. Or whether you can get perfectly fine medical attention from a nurse practitioner’s independent practice.  In California, anyway.

The public needs to know much more about this  - and I’m sure we will.  But right now, the legislature is sorta asking Californians to believe that this here Smartcar is actually a fine modern automobile.