Top of the Week Roundup

#1: Golden State heads' up:

Californians Without Health Insurance Will Pay A Penalty — Or Not 🤔https://t.co/iqNtoEsHGy

"Californians must have health insurance starting next year or face a HEFTY tax penalty. But..."#California #Healthcare #Obamacare pic.twitter.com/MNMlW1Gd44

— Steve Downey (@DowneyInsSvc) December 16, 2019

We previously covered this at the beginning of this year, when California "enacted legislation that permanently establishes different enrollment dates within the state, both on and off-exchange."

Hunh.

#2: Across the Pond, the Much Vaunted National Health Service© continues swirling:

"Nearly half of [NHS] cancer patients in Wolverhampton are being kept waiting to start treatment for longer than the recommended two months." https://t.co/2gt5NuzbXC

— AssocAmerPhys&Surg (@AAPSonline) December 15, 2019

As we've long noted, this is a feature, not a bug.

#Medicaid4All

#3: Finally, as we wait for final numbers from Open Enrollment v7.0, this interesting observation from FoIB (and actuary) Greg Fann:

Only 1 of the 3 ACA individual market population groups has had an enrollment increase from 2017-2020, and it did so in the two years that outreach funding declined. We need to concern ourselves with other aspects that drive enrollment results. https://t.co/Vi1plXTIxU

— Greg Fann (@greg_fann) December 3, 2019

Sharing is Caring - Or maybe not

Over the years, we've written pretty extensively about Health Care Sharing Ministries (HCSMs), both their advantages and their flaws.

On the one hand, they are ACA-compliant, which means that they technically check the Mandate/Tax/Penalty-avoidance box. And, they are typically far less expensive than comparable ObamaPlans.

On the other hand, they are underwritten, and they are not insurance, which means that there are few (if any) consumer protections available for folks who enroll (notice that we can't call them "insureds"). They often have religious restrictions, as well, which could be problematic for some.

Back in August, we noted that Washington State insurance regulators were taking a hard line against Aliera's HCSM arrangement:

"The top insurance regulator in Washington state is accusing a high-profile health care cost sharing ministry, and its program manager partner, of trying to avoid state insurance regulation by wrapping ordinary health insurance in a health care sharing ministry wrapper."

Fast forward to now, and co-blogger Bob tips us to this item from the Peach State:

"... health shares marketed by Georgia-based Aliera, the company through which Greer bought his plan, exemplify those risks, with the company under investigation or ordered to stop selling plans by regulators in at least four states."

I can sympathize with Alierra's clients: as anyone who's recently shopped at the 404Care.gov site can attest, plans are increasingly expensive, both in premium and potential out-of-pocket, even with subsidies (tax credits). So it's easy to understand the allure of alternatives like health sharing, while overlooking the very real pitfalls.

I must say, I'm not sure how insurance regulators think they have the authority to ban an explicitly non-insurance product, but maybe that's just me.

#CaveatEmptor

MVNHS© & Medicaid4All: A Study In Health "Care"

As we've long noted, when health care is a "right" bad things happen:

"Quebec’s health minister said Thursday he would sign a ministerial decree to block dentists from withdrawing from the public health system amid a bitter standoff over contract negotiations."

Here, of course, we have the 13th Amendment.

For now.

As we've also long noted, Britain's Much Vaunted National Health System© (which is based on that premise) continues to prove my conclusion true:

One of the worst nights in A&E

It’s not safe

It’s not fair

Not fair on patients

And it’s not fair on staff

Im so angry because this hasn’t ‘just happened’

Result of decisions by politicians, who ignored warnings

They need to take responsibility
Start taking this seriously pic.twitter.com/XCnclzNE9t

— Dr Sonia Adesara (@SoniaAdesara) December 7, 2019

And that, dear readers, is what awaits us with #Medicaid4All.

Google vs Privacy

"I'm the Google whistleblower. The medical data of millions of Americans is at risk - Anonymous"

Hunh?

Well:

"I didn’t decide to blow the whistle on Google’s deal, known internally as the Nightingale Project, glibly. The decision came to me slowly, creeping on me through my day-to-day work as one of about 250 people in Google and Ascension working on the project."

The challenge, of course, is how we define privacy these days. As co-blogger Kelley recently pointed out about this very story:

"In America only one State (New Hampshire) stipulates in its laws that the patient owns information in the medical record. In all other States it either stipulates that the Provider (Hospital and/or Physician) owns the medical record or there is not such stipulation."

And when we use devices, we've given explicit permission about what the folks on the other end may do with it.

From 4 years ago:

"[I]f a person receives a wearable device through their hospital or doctor, the healthcare data that device collects is covered by HIPAA. At least, the data HIPAA defines as protected healthcare information (PHI) is safeguarded."

And we've seen how well that's worked out.

[Hat Tip: FoIB Shari G]

Weird 404Care.gov Tricks

Working with a new (to me) client on an Exchange plan, husband and wife, $28,000 annual income (2020). Very vanilla, no real issues. Plug in their demographics, hit the button, and see that they qualify for a fairly substantial subsidy tax credit. The only 'off' thing is that the income is 100% from hubby (this comes into play in a moment).

So continue on to the quote screen, see that they can buy a $5,250 deductible HSA-compliant plan for about $50/month (total for the two of them, after applying $1,250 subsidy). Nice.

Yesterday, Suzy stopped in to pull the trigger, and we went to sign them up. We carefully went through each screen, and confirmed that we'd entered all the relevant personal info for both of them. But when we got to the "checkout lane," the premium had gone from $50 to almost $80, and - weirder still - it seemed to only list Suzy.

Hmmm.

So, we call the 404Care.gov hotline, and sure enough, they were only showing her as on the plan; keep in mind, we both saw me click the buttons to include hubby. Okay, no big deal, nice guy at the other end got us all hooked up, hubby added and, lo and behold, a miracle:

Instead of $80 for Suzy alone, it was $40 for the two of them.

And yeah, I'm thinking this, too.

Apparently the gummint also works in mysterious ways. How else to explain why it's half the cost to insure both of them?

404Care.gov Enrollment: Week 5 Results

As we head into the home stretch:

[click to embiggen]

Total plan selections are down from last week, which makes sense: at this point it's primarily fence-sitters finally taking the plunge. Ditto on new consumers, down by about 25%.

Will be interesting to see how this week, the final one of Open Season Enrollment '19, shapes up.

Is this the "Next Big Thing?"

Probably not, but still very promising:



Regular readers will be familiar with Dr Rob, one of the pioneers of the Direct Primary Care (DPC) practice model. As the video explains, he's expanded the practice to include family medicine and even an obesity focused doc. As always, we wish Dr Rob the greatest success, and are delighted that he's taken this to the next level.

Oh, you wondered why I said it's probably not "the next big thing?" Well, for starters, lacking availability of true catastrophic health insurance plans (which are illegal under ObamaCare), folks still need to have some kind of insurance coverage for big ticket items, which means double coverage.

For another, DPC proponents decry the lack of choice offered by narrow networks (now the norm), but this seems to me to be the epitome of such.

I do like that they're looking beyond the scope of individual subscriptions ("retail") and seeking to partner with employers. The issue there, of course, is capacity and scalability. Will be fascinating to see this develop.

Sure, sure, but hey: Free! A #Medicaid4All Story

Shot:

Rationing—in the form of waiting lists—has left hundreds or even thousands of Canadians to die without surgeries, the Vancouver Sun reports. #canada #healthcare https://t.co/p5gHucPziZ

— Texas Public Policy Foundation (@TPPF) December 5, 2019

Chaser:

“In the U.S., we already have a single-payer health care system, called the Veterans Administration Hospital system. A 2015 internal audit of the VA reported, ‘307,000 veterans may have died waiting for care.’” @DavidBalatHC @RightOnHC https://t.co/iZ80TcyO16

— Texas Public Policy Foundation (@TPPF) December 5, 2019

Interesting ACA case: Tax Credit Conundrum edition

Sometimes Open Enrollment can be interesting. Case in point: Pastor Jerry.

Pastor Jerry is the newly hired clergyman for a local church, with a nice compensation package made up of three parts: a salary, a housing allowance, and a reimbursement arrangement for medical insurance. The salary and housing allowance are fixed, known costs, while the health insurance budget is "up to $2,000 a month." And therein lies the rub:

Based on his salary/housing allowance, his family qualifies for about $800 in tax credits (aka "subsidy"). Nice, but not the end of the story. The problem is that if his employer reimburses him for the premium and/or out-of-pocket expenses that increases his annual income and screws up the subsidy calculation. It's kind of chasing its own tail. I spent quite a bit of time in separate phone calls with the nice folks at 404Care.gov; the best advice (well, the easiest advice) was to just forgo the subsidy and avoid the whole mess.

There's a lot to be said for this: indeed, the KISS Principle holds much sway. But I really hate to leave (government) money "on the table," and wracked my brain trying to come up with a better way.

Lying in bed the other evening, it hit me: when choosing how much of one's subsidy to use, folks almost always pull the trigger for the full amount (which makes sense: results in lowest premium). But one can, in fact, choose to use $0 upfront, and just claim it the following April. This was a true epiphany: it means there's no real downside, nor is there any possibility of "clawback." Indeed, the worst case scenario is that he gets very little money back, but it's still better than having to cough it up in the following year's taxes.

Pretty nifty.

Oh, we also discussed precisely how to handle that out-of-pocket reimbursement, and decided on an HSA over an HRA. They'll be working with our friends at FlexBank on this.

Exit question:  given the facts above, what potential issue do you see regarding the employer's reimbursement versus the delayed tax credit?

The Importance of Life Insurance: Real Life

Co-blogger Bob V tipped us to this important, all too common story:

"My husband is my caregiver, and spending $45 a month on his life insurance means I won't be alone if he dies."

Rebecca Chamaa was diagnosed with paranoid schizophrenia, and relies on her husband as her primary caregiver and advocate. If he were to die, she would need to be able to afford a full-time nurse (or equivalent), which can get pretty spendy. Hence, the importance of life insurance:

"Like many people, my husband had a small life insurance policy at work, but that policy wouldn't cover our mortgage or provide enough cash for me to stay in our home, pay for funeral expenses, and arrange for someone to help me with household tasks, or at a minimum some caregiving activities."

Very moving, very timely.

Waiting on the MVNHS©

And we do mean waiting:

[click to embiggen]

Thanks to our friends at the Association of American Physicians and Hospitals, we learn that north of four-and-a-half million Brits are on waiting lists. For those keeping score, that totals out to almost "7 percent of the entire British population."

Talk about a 7 percent solution...

And it's not just in hospitals:

Girl, 12, dies after waiting for an hour for an ambulance@JoeSilverman7 https://t.co/FfH2fUTkGx @MailOnline

— Christopher Gaska (@ChristopherTodd) November 23, 2019

#Medicaid4All

404Care.gov Enrollment: Week 4 Results

According to email from the Feds, "in week four of the 2020 Open Enrollment period, 703,556 people selected plans using the HealthCare.gov platform."

Of course, this just means that folks have added plans to their carts, the real numbers will be when (if?) they actually pull the trigger and send in a check.

In any case, here's last week's snapshot:

[click to embiggen]

Total plan selections are down about 7% from Week 2 (we missed last week dues to Thanksgiving travel). New consumers are down, as well, as are renewals.

This makes sense, however: we're already a month into the process, and (presumably) most of the folks who are going to make a choice have already done so. I do expect a slight uptick the final week as procrastinators make their choice.

November is LTC Awareness Month

While we're primarily focused right now on Open Enrollment v7.0, November is also a time to be thinking about Long Term Care, both its cost and how to fund it.

One issue is a common misconception that getting older automagically means a decrease in one's quality of life:

"Most older adults and caregivers mistakenly believe that sharp declines in quality of life are inevitable with age ... The majority of seniors think that depression, dementia and lack of mobility can’t be helped."

But are they correct?

Not necessarily:

"Nearly 40% of respondents are not aware that certain prescription medications can impact cognition, and only half know that certain medicines should be avoided as a person gets older."

And that's just the tip of that iceberg. Click on through for more.

Oh! And click here for the survey results themselves.

[Hat Tip: FoIB Randy G]

What started out as a dream cruise became a nightmare hospital stay for one Atlanta-area couple:

"The two sailed out of Galveston, Texas, on Nov. 11 .... Days later, [Stephen Johnson] went into diabetic shock."

And as if that wasn't bad enough, the ship's doctor recommended that he be airlifted to a hospital in Progreso, Mexico. What happened next should come as no surprise to regular readers:

"When it came time to check out of the hospital, however, the two were not allowed to leave without paying their $14,000 hospital bill in full."

To be fair, the hospital is claiming that it's not the money, but the fact that, in their opinion,  Mr J is still too ill to travel. The good news is that actor/director Tyler Perry has stepped up to cover their bill.

There are actually a number of issues here, pretty much all of them falling on Mr J. For starters:

"Austin said her fiance does not have private insurance."

Why not?

After all, it's the law, right?

According to sources, Mr Johnson is 31 years old. We'll assume that he doesn't smoke, and that since he's wealthy enough to self-insure and pay for a cruise, doesn't qualify for a tax credit (aka "subsidy). A quick trip to 404Care.gov yields this (for example):

An Anthem Bronze plan with a $5,500 deductible is about  $11 per day. Seems pretty affordable to me.

Of course, we already know that most American health insurance ends at the border, which is why we always recommend an inexpensive travel medical plan. The good news is that that's also pretty affordable, as well. We'll assume a 10-day cruise:

Our friends at Global Underwriters offer a "Diplomat International" plan with $1,000,000 of coverage and a $2,500 deductible for $15.

Looks like Mr J chose poorly. 

Oh, and by the way: It took me less than five minutes to track down his age (already know he was from Sandy Springs) and run 404care.gov and travel medical quotes. All these so-called "journalists" had to do was call their own freaking agents. But here we are, doing the job "journalists" can't be bothered to do.

It’s All About the Optics

Recently it came to light that Google and Ascension Health have entered into an agreement wherein Google has been given access to medical health data held by Ascension. It now appears that Congressional Leaders have requested information from Google on “Project Nightingale”. Google has until December 6 to respond to the four Democratic Leaders of Congress.

According to the Wall Street Journal report, at least 150 Google Employees have access to the data on tens of millions of patients. On the surface it looks bad, but let’s drill down on what is happening.

“Although the project is HIPAA-compliant, not all policymakers are sold on the deal.

"Despite the sensitivity of the information collected through Project Nightingale, reports indicate that employees across Google, including at its parent company, have access to, and the ability to download, the personal health information of Ascension's patients," the letter reads, according to CNBC.”

First, let’s look at who has control of the patient’s records. In America only one State (New Hampshire) stipulates in its laws that the patient owns information in the medical record. In all other States it either stipulates that the Provider (Hospital and/or Physician) owns the medical record or there is not such stipulation. In states where there is no stipulation in law, it is recognized that the Provider owns the information in the Medical Record. While the Medical Record is about a patient, it is created by the Provider and his/her staff.

Second, what a Provider can or cannot do with those medical records. If the Provider wants to let a third party, not the patient or insurance company, have access to the records, then the Provider and the Vendor sign a Business Associate Agreement (BAA). A BAA is designated as a HIPAA compliant way to ensure that Private Health Information (PHI) is protected by the Vendor.

“Once a covered entity has identified their applicable business associates, it is necessary to ensure that these third-parties will only use any provided PHI in a secure and established manner.

“Covered entities may disclose protected health information to an entity in its role as a business associate only to help the covered entity carry out its health care functions – not for the business associate’s independent use or purposes, except as needed for the proper management and administration of the business associate,” HHS maintained on its website.”

Providers utilize Vendors for various tasks that revolve around the use of PHI. There are storage facilities for actual paper charts. There are vendors that create electronic communication that the Provider can send out to Patients reminding them of appointments or letting them know about a new service offered by that Provider. There are billing companies hired by Providers to handle their patient revenue. And, finally, there are companies like Google that do analysis on Patient Data for Quality Improvement.

Finally, since a BAA is a tool from HIPAA, all the guidelines of HIPAA apply to the vendor and to the vendor’s employees, so the information is secure.

'Tis a poser

So, FoIB Holly R sent this along:

"Every NICU bed at this hospital is equipped with a webcam so parents can always check on their babies."

Hunh.

I replied:

"I like that!

Although: I guess there could be privacy issues?"

Parents can stream the live feed to their phone or other device. The story doesn't say whether or not the feeds are monitored at the hospital, but one presumes this would be the case.

My concern is that with the spate of hospitals and medical equipment hacking, is there a legitimate concern about this from the parents' perspective?

Whaddaya think?

From the P&C Files: Collison Report

Heh:

A Good Cause

From a friend's daughter:

"Hi, I'm Vanessa Leahr and I live with multiple chronic health conditions including a connective tissue disorder called Ehlers-Danlos Syndrome, Postural Orthostatic Tachycardia Syndrome, Complex Regional Pain Syndrome, Gastroparesis, and more.

 I recently  started an online shop called DAZZLING THEM: DESIGNS BY VANESSA L. as a creative way to make money to help pay for my medical expenses and raise awareness for my conditions. 

Please check out my shop, and share this link with friends and family to help me grow my business."

On Vanessa's behalf, thank you for taking the time to read this message, and I hope it piques your interest.

And speaking of #Medicaid4All

Britain's Much Vaunted National Health Service© continues to cover itself in .... glory (for certain values of "glory"):

Or left in hallways to die. https://t.co/LJvZpXKyIg

— Beau Geste (@BeauGeste11) November 21, 2019

But hey: Free!

Self awareness and Health "Care"

Heh:

#Medicaid4ALL