Category: Health Alerts

Have House Republicans Cast Their First Vote for Obamacare?

A similar version of this Health Alert appeared at Forbes.

Former Speaker of the U.S. Representatives Newt Gingrich said something last week that many feared, but few have been willing to admit: Republicans in Congress have no intention of repealing and replacing Obamacare with patient-centered health reform.

Faced with an interviewer who seemed to believe opposition to Obamacare is actually opposition to Barack Obama, and who suggested that after this president leaves office, opposition will soften, Mr. Gingrich accused his former colleagues of misrepresenting their commitment.

Now that we are in the twilight of the Obama presidency, and Republicans have majorities in both chambers of Congress, they should be able to put such charges to rest. Unfortunately, last week’s overwhelming bipartisan support in the House of Representatives for a deal to lock in Obamacare’s way of paying doctors sends a terrible signal.

Budget Gimmicks Hide the $213 Billion Cost of Medicare Doc Fix

The headline of the Congressional Budget Office’s (CBO) damning assessment of the fiscal damage done by H.R. 2 — the so-called Medicare doc fix negotiated secretly by House Speaker John Boehner and Minority Leader Nancy Pelosi — is that the deal will add $141 billion to the deficit over the next ten years.

Even this appalling outcome is sugarcoated. After unpacking the gimmicks underlying the estimate, the actual result is much worse.

First, the worst gimmick: The bill increases spending on the Children’s Health Insurance Program (CHIP) by almost $40 billion. Yet, the CBO only includes less than $6 billion in its estimate of the bill’s costs. How did over $34 billion of CHIP spending simply vanish into thin air? Easily! Much of it was already in the baseline.

Welcome to the weird world of federal budgeting, where the so-called baseline is the source of much mischief. Recall the entire reason Congress had to patch Medicare payments to doctors at least once a year for over a decade is because the budget baseline was determined by an unrealistic formula called the Sustainable Growth Rate (SGR).

Because that formula would have led to pay cuts that would have made it uneconomical for physicians to see Medicare patients, Congress had to increase physicians’ fees beyond the baseline. Most importantly, until now, those pay increases have been paid for by spending offsets.

Physicians never had their Medicare pay cut to the level dictated by the baseline. There was simply no crisis that had to be averted by last week’s budget busting Medicare doc fix.

Kick the Medicare Doc Fix Down The Road

Confident Doctors

A similar version of this Health Alert appeared at Forbes.

Congressional leaders from both parties have agreed on a long-term, so-called “doc fix” that claims to solve the problem of how the federal government pays doctors who treat Medicare patients.

Currently, Congress has a certain amount of money every year to pay doctors. This amount of money increases according to a formula called the Sustainable Growth Rate (SGR), which was established in 1997. The SGR is comprised of four factors that (by the standards of federal health policy) are fairly easy to understand. Most importantly, the SGR depends on the change in real Gross Domestic Product (GDP) per capita.

The Medicare Part B program, which pays for physicians, is an explicit “pay as you go” system. Seniors pay one quarter of the costs through premiums, and taxpayers (and their children and grandchildren) pay the rest through the U.S. Treasury. Therefore, it is appropriate taxpayers’ ability to pay (as measured by real GDP per capita) be an input into the amount.

The problem is the amount is not enough. If growth in Medicare’s payments to doctors were limited by the SGR, the payments would drop by about one-fifth, and they would stop seeing Medicare patients. So, at least once a year, Congress increases the payments for a few months. The latest patch (H.R. 4302) was passed in March 2014 and runs through March 31, 2015. It costs $15.8 billion.

This has happened 17 times since 1997. Congress has never allowed Medicare’s physician fees to drop. So, why not pass a long-term fix? This would finally free politicians from having to grub around every year finding money to pay doctors, and they could turn their attention to loftier matters.

Actually, there are plenty of reasons to be skeptical of any “doc fix”, and certainly this one.

Congressional Budget Resolutions Shoot for the Sky; Miss Low-Hanging Fruit

The House Budget Committee and the Senate Budget Committee have passed budget resolutions that shoot for the sky with respect to health reform. Their proposals recommit the Republican majorities to patient-centered health reform and show a path forward for the next president. However, they do not harvest some low-hanging fruit offered by President Obama. Failure to do so might doom patient-centered health reform to the forever future.

Paying for the Medicare “Doc Fix”

doctor-xray-2The Medicare Sustainable Growth Rate (SGR) formula was passed as part of the Balanced Budget Act of 1997 to reduce the growth in Medicare spending. The so-called SGR was designed to collectively penalize physicians for exceeding the benchmark expenditures established by Congress. The SGR automatically reduces physician payments under Medicare by a proportion that will lower spending back to the designated growth rate. However, the SGR has not reduced spending primarily because Congress has continually postponed the cuts year after year rather than reform Medicare in sustainable ways. Since 2003 Congress has postponed the cuts 17 times. Beginning in April, physician fees will be cut by 21.2 percent if Congress does not kick this can down the road an 18th time. Congress has not repealed the SGR mostly because it would cost $140 billion over 10 years and require offsets.

The SGR clearly isn’t working; the reason Congress won’t allow the cuts to take place is because too many seniors would lose access to physicians willing to treat them. What is needed is fundamental reform. But a good first step down that road would be to repeal the SGR and pay for it with several costly offsets. Two good ideas that President Obama has supported in the past include: 1) reducing the percentage of Medicaid provider taxes that states are allowed to use to qualify for a federal match; and 2) eliminating some of the Medigap Supplemental Plans that everyone agrees leads wasteful spending.

Obamacare’s Second Open Season: Average Premium Up 23 Percent – After Subsidies

With enrollment data through February 22, the administration finally declared Obamacare’s second enrollment season closed and released its report on the results. (Although, people who have to pay Obamacare’s mandate/penalty/fine/tax as a result of information disclosed in their 2014 tax returns will have a special open enrollment in April).

Obamacare’s supporters cheered that enrollment hit 11.7 million people, exceeding the low-ball estimate of 9.1 million the administration made last November. Lost in the enthusiasm for Obamacare’s new high-water mark are a few uncomfortable facts.

First, the average premium — net of subsidies — has jumped 23 percent from 2014. In both years, insurers covering almost nine in ten Obamacare subscribers received subsidies to reduce premiums. The average monthly premium, before insurers receive subsidies, across all “metal” plans, is $364 in 2015. The average subsidy is $263, resulting in a net premium of $101 (Table 6). In 2014, the administration reported an average premium of $346, less an average tax credit of $264, for a net premium of $82 (Table 2). Therefore, the gross premium increased 5 percent but the subsidy declined by a scratch. Due to the power of leverage, this resulted in subscribers seeing an average premium jump of 23 percent.

Let Medicare Patients Decide Which Accountable Care Organization to Join

Woman Using Exercise MachineA similar version of this Health Alert appeared at Forbes.

One of the reasons people rebelled against Obamacare was that it financed the growth of government-run health care through drastic cuts to Medicare. According to the Congressional Budget Office (CBO), Medicare spending will see a $455 billion cut over the next decade, which would finance almost half of Obamacare spending.

Most of the Medicare cuts were simply reducing the fees Medicare pays doctors and hospitals. These payment mechanisms would make a Soviet bureaucrat blush. William Hsiao, the economist who designed the Medicare Prospective Payment System, determined Medicare’s fees as follows:

“He put together a large team that interviewed and surveyed thousands of physicians from almost two dozen specialties. They analyzed what was involved in everything from 45 minutes of psychotherapy for a patient with panic attacks to a hysterectomy for a woman with cervical cancer. They determined that the hysterectomy takes about twice as much time as the session of psychotherapy, 3.8 times as much mental effort, 4.47 times as much technical skill and physical effort, and 4.24 times as much risk. The total calculation: 4.99 times as much work. Eventually, Hsiao and his team arrived at a relative value for every single thing doctors do.” (Rick Mayes and Robert A. Berenson, Medicare Prospective Payment and the Shaping of U.S. Health Care, Baltimore: Johns Hopkins University Press, 2006, p. 86.)

Instead of Fee-For-Service (FFS), Medicare planners and their academic supporters endorse various bureaucratic methods of paying for “value” – as perceived by the government. Indeed, Sylvia Burwell, U.S. Secretary of Health & Human Services, recently expressed the – ahem – aspirational goal of tying 85 percent of Medicare’s payments to value by 2016, and 90 percent by 2018.

Government Bailouts Business Strategy for Obamacare Health Insurance Co-ops

The insolvent Iowa-based health insurance cooperative, CoOportunity Health, had to be taken over in December by Iowa insurance regulators.  Iowa and Nebraska’s Guarantee Associations — and state and federal taxpayers — are now on the hook for millions in claims the insurer could not pay.

CoOportunity Health wasn’t a traditional health insurer.  Rather, it was a taxpayer-funded, non-profit health insurance cooperative (co-op) established under the Affordable Care Act (ACA). The co-op program is plagued by numerous flaws. When co-ops were established, they had no customers and no historical actuarial data to assist in setting plan premiums.  Startup funds and cash reserves were mostly borrowed from taxpayers. According to industry data only one of the 23 co-ops was profitable last year (a 24th co-op located in Vermont failed before it even got off the ground). While some of the remaining co-ops are losing money because of small size, others appear to have the strategy of losing money to gain market-share at taxpayers’ expense.

Prior to its first open enrollment, chief operating officer (COO) Cliff Gold told the Lincoln, Nebraska Journal Star that ‘CoOportunity would be a market disruptor,’ and ‘we’re nonprofit, we have absolutely no profit motive.’ Apparently Gold’s comments were meant to be taken literally; CoOportunity lost around $163 million in 2014 — its first year selling health insurance.  An attorney hired to help liquidate the firm says doctors/hospitals are still owed some $100 million.  Unfortunately for Gold, even nonprofit health insurers need to earn a profit to avoid bankruptcy. The Iowa Insurance regulators shuttered the failing insurer once it became clear CoOportunity would not receive another government emergency solvency loan and its anticipated $126 million risk corridor (bad-risk) bailout would be reduced by about half.

Sicker-than-average Iowa and Nebraska residents flocked to the CoOportunity’s generous benefits. It offered large provider networks and rich benefit packagesall for a low premium. This sounds great if you’re an Iowa or Nebraska resident with chronic conditions.  But it’s not so good for taxpayers who have to bailout the losses. CoOportunity didn’t just suffer adverse selection — a situation where it attracted costlier-than-average members. It played a game of chicken with other insurers, when it purposely designed plans and set premiums it knew would disrupt the market.  Indeed, The Wall Street Journal referred to it as Fannie Med, in reference to Fannie Mae, the infamous government-supported mortgage insurer whose risky investment strategy contributed to the financial crisis that tanked the U.S. economy.

Obamacare versus the Affordable Care Act

A similar version of this Health Alert appeared at Forbes.

In March 2010, Congress passed, and President Obama signed, the Patient Protection and Affordable Care Act (ACA). The ACA was never implemented as written. The ACA authorizes subsidies to health insurers operating in state-established exchanges, but not the federal exchange. Some 37 states opted not to establish their own exchanges. Nevertheless, the Administration has been paying subsidies to insurers in those 37 states.

On March 4, the Supreme Court heard oral arguments in King vs. Burwell. At stake is the Administration’s payment of subsidies to health insurers operating in states which use the federal exchange. The Supreme Court is expected to announce its decision by July. A decision to uphold the ACA, as written, will surely cause millions of people to stop paying premiums that will double, triple, or more after the Supreme Court strikes down the illegal subsidies.

Many assert that this will cause an immediate crisis that Congress and the President will have to resolve immediately. This is an overly dramatic reading of events.

First, those who will drop Obamacare plans are not enthusiastic consumers of Obamacare. Last year, about one in five Obamacare enrollees stopped paying premiums. Rather, employer-based health benefits have been shrinking as Obamacare has increased the regulatory burden of offering benefits on employers, and incentivized them to reduce working hours. According to the Congressional Budget Office, there will be 2.5 million fewer full time jobs in 2017 than if Obamacare had not been enacted.

Guess Where Fair and Transparent Hospital Prices Exist?

Britain has long had an active cash market for medical care provided by private hospitals, which helps people get around the long waits in the National Health Service, and also serve people from abroad.

Nuffield Hospitals advertises firm, fixed, all-inclusive prices good for 60 days after an initial consultation. For more complex procedures, one pays for the initial consultation and the hospital develops the price from that. The Nuffield price generally includes post-operative care, rehab, and required readmissions.

Like Walmart, Nuffield will match competitor prices under reasonable conditions — “If you find an alternative private hospital in your local area offering a better price for the same surgical intervention, sold with the same service conditions, we’ll lower our price to equal it.” The conditions require the other private hospital be within 15 miles of the Nuffield hospital, exclude NHS private patient prices and require a written quote.

Bupa offers private insurance, elder care, and private hospitalization. Beneficiaries of its Health Cash Plan pay providers, send Bupa the bill and receive the Bupa contract amount in cash. Bupa advertises no pre-authorizations to see specialists and 24/7 phone consultation with nurses and GPs.