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Gender: Female
Hometown: Washington state
Home country: USA
Current location: Directly above the center of the earth
Member since: Sat Aug 16, 2003, 02:52 AM
Number of posts: 51,907

About Me

Major policy wonk interests: health care, Social Security/Medicare/Medicaid, election integrity

Journal Archives

The nation's large self-insured employers are beginning to abandon their health benefit programs


Two big employers are planning a radical change in the way they provide health benefits to their workers, giving employees a fixed sum of money and allowing them to choose their medical coverage and insurer from an online marketplace.

Sears Holdings Corp. and Darden Restaurants Inc. say the change isn't designed to make workers pay a higher share of health-coverage costs. Instead they say it is supposed to put more control over health benefits in the hands of employees.

The approach will be closely watched by firms around the U.S. If it eventually takes hold widely, it might parallel the transition from company-provided pensions to 401(k) retirement-savings plans controlled by workers and funded partly by employer contributions. For employees, the concern will be that they could end up more directly exposed to the upward march of health costs.

"It's a fundamental change?the employer is saying, 'Here's a pot of money, go shop,' " said Paul Fronstin, director of health research at the Employee Benefit Research Institute, a nonprofit. The worry for employees is that "the money may not be sufficient and it may not keep up with premium inflation."

Comment by Don McCanne of PNHP: Many larger employers have said that they do not want to be the first to initiate major structural reforms in their employee health benefit programs - reforms that would bring the employers relief but at a cost to their employees - but that they would quickly follow others out the door. It looks like the door has opened.

This is a very fundamental change in employee health benefit coverage. The Affordable Care Act relies heavily on self-insured large employers maintaining their coverage of a large percentage on America's workforce, so that the Act can concentrate on lower-income and uninsured individuals. Under the radical change described in this WSJ article, employers will discontinue their self-insured programs and switch to a defined contribution - a specific dollar amount that employees will use to shop for health plans in these employer insurance exchanges.

There has been considerable discussion recently over converting Medicare to a defined contribution - premium support or voucher program - in which the costs to the government would be fixed to some index of inflation, whereas the greater increases in health care costs would be borne by the Medicare beneficiary. Thus health care would become less and less affordable, especially for those with greater health care needs.

With this move by employers, they are putting in place the same perverse defined contribution approach which we have determined would be so destructive to our Medicare program. And, oh yes, the benefits consultants and health insurers are jumping in to draw off even more health care funds in administrative costs - already one of the greatest burdens in our health care system. The executive vice president of WellPoint says, "Within the next two or three years, it's going to be mainstream."

Further, as was reported in yesterday's Quote of the Day, over 90 percent of individuals do not select the Medicare Part D drug plan that would be best in their individual circumstances. It shows that health insurance shoppers really do not know how to shop for health insurance. Obviously comprehensive health plans are much more complex, and it would be virtually impossible for individuals to select the best plan, even with the language of simplified plan descriptions called for in the Affordable Care Act.

In fact, several studies have shown that most individuals select plans based primarily on the lowest net premium, with very little attention paid to plan benefits and cost sharing. The most common strategy for insurers to keep premiums low is to use large deductibles and coinsurance, though they also manipulate benefits and provider networks to reduce costs. Besides the increasing deductibles, coinsurance is particularly a problem since it is a percentage of the charges rather than a dollar copayment which is usually much smaller. Low premium plans tend to set coinsurance rates at very high percentages. As this article states, the savings will be dependent upon "workers' voluntary choice of skinnier coverage." It's all the workers'fault!

It is likely that the initial defined contributions will be fairly close to the amounts that employers are currently paying for the health benefit programs, so the immediate impact will not be transparent. Only after many employees face bankrupting medical debt - a phenomenon that will increase as the employer contribution buys ever less insurance - will the implications be clear. It is tragic that so many will have to experience financial hardship before we are ready to get serious about fixing our system by enacting an improved Medicare for everyone.

Haven't we had enough policy discussions to understand what is happening? Why aren't we doing anything?


Rep. Jesse Jackson, Jr. Forced To Sell Luxury Townhouse To Pay Medical Bills


In a statement released by Rep. Jesse Jackson, Jr.'s chief of staff, Rick Bryant, Rep. Jackson and his wife have made the decision to sell their townhouse in Washington D.C. to defray medical expenses Jackson has acquired for his depression and bipolar disorders. "Like millions of Americans, Congressman Jackson and Mrs. Jackson are grappling with soaring health care costs and are selling their residence to help defray costs of their obligations," the statement read. "The congressman would like to personally thank everyone who has offered prayers on behalf of his family." Jackson aides could not say how much, if any, of the expenses are covered under his health insurance plan.

Comment by Don McCanne of PNHP: Those who say repeatedly that everyone should have the same health care coverage as members of Congress should check with Rep. Jesse Jackson, Jr. He is losing his Washington, D.C. townhouse because of medical bills.

Other than the statement released by his chief of staff, we don't know any of the details, and we shouldn't since common decency dictates that we respect his privacy.

We could speculate on the great many potential factors that might be involved as to why a member of Congress faces a financial hardship due to medical bills, but we won't, even though many come to mind. We'll merely state that we need a health care financing system that removes financial barriers to care - for everyone. A properly designed single payer national health program would do that.

Anthem Blue Cross eliminates doctors affiliated with UCLA and Cedars Sinai


Two of the most prestigious names in Southern California healthcare--Cedars-Sinai and UCLA--are getting shut out of a major insurance plan for being too expensive.

In a bold cost-cutting move, Anthem Blue Cross has eliminated doctors affiliated with the hospitals from a health plan offered to about 60,000 employees and dependents at the cash-strapped city of Los Angeles.

The city opted for Anthem's plan because it will save $7.6 million in annual premiums next year by excluding physicians from the two institutions known for tending to the Southland's rich and famous

Comment by Don McCanne of PNHP: The explosion in limited-network private insurance plans is taking choice away from more and more patients. The business tools that private insurers use to control costs are very different from the patient-service tools of a single payer national health program. Not only do the private insurers' tools restrict patients' care, but they are also quite ineffective in controlling overall spending, as is demonstrated by the fact that our health care costs are about twice the average of other nations.

Under a single payer system, all legitimate costs are paid by the government and are not linked to specific health plans assigned to different individuals - a very inefficient and fragmented method of financing health care. Using the example of UCLA, there would be no tiers of private coverage and no problem with an underfunded Medicaid program. The hospital costs would be globally budgeted, just as are police and fire departments. Separate, extraordinary costs of research functions would be funded through our National Institutes of Health. Education grants can be provided through the global budgeting process since house staff members are, from a financing perspective, really just low-paid hospital employees.

We need to get WellPoint/Anthem Blue Cross and their ilk out of our health care and out of our lives. Let's improve our own Medicare program and then provide it for everyone.

Insurance companies trying to get even LOWER actuarial values for ACA exchanges approved


Recognizing that these ACA provisions will have a major impact on the cost of coverage, we believe that the important goals of the EHB package can be met if HHS and the states place a high priority on offering affordable coverage options to consumers. In addition, consideration should be given to lowering the minimum actuarial value for coverage sold in the exchanges to ensure the availability of affordable coverage options and to allow smoother transitions to the new benefits packages.

Comment by Don McCanne of PNHP: As the Affordable Care Act was being drafted, many of us in the policy community were very disappointed with the decision to include in the state insurance exchanges low actuarial value plans, as low as 60 percent (the plan pays 60 percent of covered costs and the patient pays the other 40 percent plus 100 percent of all services and products not covered). Even with the subsidies, the financial barriers to care will be too great for many patients. Now AHIP - the all-powerful health insurance lobby organization - is asking Congress to lower even further the minimum required benefits and the actuarial values of the plans.

The reason is obvious. They explicitly state that "affordability should be the cornerstone of consideration," but they are not referring to affordability of health care, rather they are referring to the affordability of their own private health insurance plans. They want their premiums to be low enough for middle-income Americans to be able to purchase their plans. They remain silent on the fact that reducing minimum benefits and reducing actuarial values of the plans will shift large portions of the costs to those who need care. (Again, the cost sharing subsidies are not adequate for covered benefits, and the patient is responsible for 100 percent of the costs of excluded benefits which would increase with this proposal.)

The private insurance industry got virtually everything that they asked for when the bill was written. Now they are coming along with a pitch that appeals to members of both sides of the aisle - we should make insurance affordable by allowing individuals to "buy only the insurance you need." For people who are healthy on December 31, 2013, can they really feel secure with a low actuarial value, minimal benefit plan that begins on January 1, 2014, when they have absolutely no idea what health problems they may face throughout 2014 and into the future? Of course not, though the high premiums of plans with adequate coverage may serve as enough of a deterrent that they would want to or may even have to take the risk that they will remain healthy throughout the year - a safe bet for the insurers but a big gamble for the patient. With time, it becomes even more treacherous for individuals to bet that they will remain healthy forever.

It is particularly appalling when they say that the principle reason for the Affordable Care act was to enable people to purchase health insurance. Some of us thought that the principle reason should have been to remove financial barriers to essential health care for everyone.

Really, haven't we had enough of Congress and the Obama administration supporting the private insurance industry? How about demanding support for America's patients instead? Throw out the insurers and enact an improved Medicare for all. We just might have to throw out the politicians to get there.

My comment: And here I thought that 60% actuarial value was pretty shitty. No wonder medical bankruptcies in MA have not dropped very much. How in fucking hell is anyone supposed to know what "only the insurance you need" will be?

Why there are conspiracy theories at all

I certainly don't think that the 9-11 truth movement has a lock on the actual truth. I also don't agree with the official "conspiracy nut" stance, which is to deride anyone who suspects that our government hasn’t told us the truth about what they know. To criticize “conspiracy theorists” is to blame the victim instead of taking on the perpetrators. There is a reason why people come up with conspiracy theories—they happen to be a normal and healthy response to the experience of being forbidden access to relevant information and being constantly lied to by the people who do.

The radical therapist Claude Steiner once said that paranoia is actually a heightened state of awareness, in which the paranoid put together narratives that make sense of the only information they have available. He gave an example of a woman he treated who believed that her husband was engaged in several elaborate plots on her life. What Steiner did was to interview the husband, who was disturbed by his wife's narrative. The husband was in fact thinking of having her permanently committed to the funny farm, but he always responded to his wife's questions about what was wrong between them by saying “Nothing, honey.”

That was the crux of the problem. The wife was in a heightened state of awareness and knew only that “Nothing, honey” was a pile of steaming bullshit. Not having access to real information about what was going on in her husband's head, she invented it out of whole cloth. Steiner's ultimately successful therapy was simply to convince the husband to stop lying and withholding information. In this case, the husband did not exactly lead the examined life, and was unaware of the harm that social “white lies” can sometimes cause. Being genuinely concerned about his wife, he agreed to try to be more introspective and commit to being honest about his feelings. The wife agreed to acknowledge this effort, and to be more persistent about asking for information instead of automatically assuming the worst. Of course our superiors who run our imperial government have no such commitment to making it all better for the rest of us—see the classic Ingrid Berman/Charles Boyer movie Gaslight for a psychological take on their game.

The bottom line here is that it is a basic requirement of sanity to be able to make sense of one's information environment, to be able to put it into a coherent and meaningful picture, and if those people who know what is going on behind closed doors constantly lie to the public and withhold information, the inevitable result is that some people will naturally want to fill in the blanks by any means possible. This process is analogous to the effects of sensory deprivation—float in one of those tanks long enough to deprive your brain of all sensory input, and it will quickly start inventing some.

Current official explanations of 9-11 are like a picture puzzle with half the pieces missing. Many people have been taking magic markers and extrapolating from what is visible to fill in the missing spaces in an attempt to put together the entire picture. They are constantly ridiculed for this, and opinion makers who wish to be taken seriously always bog the discussion down in disputes about whether or not the colored-in parts really look like the original pieces. Some will be closer approximations than others, of course; many may well be wildly off. But the really important issue (which remains for the most part unaddressed) is “What in bleeding hell gives our government the right to hide the pieces in the first place?”

Attacking people who are trying to make sense of their information environments with limited data is highly unethical, no matter how nutty their theories may sometimes sound. It's exactly like putting a rape victim on trial for her previous sexual history instead of going after the rapist. Theories may fall anywhere on a continuum from plausible to seriously off-base, just as women's prior sexual histories may vary from none to very experienced. By any objective analysis, some unofficial theories of what happened on 9/11 are prim virgins in high-collared white lace blouses, and some are prancing around in tight red spandex streetwalker outfits. But either way, it just plain should not matter—critics should focus on calling the rapists, liars and secret-keepers to account rather than slandering their victims.

“Conspiracy theorists” are commonly dismissed as irrational or unscientific. It's true that scientific training helps people to cope with not having certain and final answers, and that only a minority of the population has such training. However, one important part of scientific training is learning to avoid speculating beyond the data, but this requirement of the scientific process depends critically on the assumption (which is almost always valid) that scientists will present all relevant data and methodology to their research community as accurately and as completely as they can. Since this condition is not currently met by our government (and most certainly not by the 9/11 Commission), it is outrageous to attack as “unscientific” people who express concern about a government that insists on keeping secrets from them, especially when those secrets threaten the foundation of our democracy. The attacks should be directed instead toward those who are keeping what should be publicly available information from them.

How long will the official arbiters of “reality” continue to defend the rapists, the liars, the secret-keepers who conceal information that in a real democracy ought to be made available to the public? If we could spend $40 million investigating a blow job, surely we could spend more than $15 million on finding out what really happened on the day of the worst attack on our soil. I hope that more people will join with those who are demanding honesty and transparency in the public sphere. The urge to be accepted as a real member of the elite class of reality creators, those who claim the right to lie and withhold information on the grounds that they alone are entitled to decide what the public should know, can be very tempting. Any person who gives in to this temptation badly fails our democratic republic. What is tyranny but a system in which rulers assert the right to know everything about their subjects while keeping their own operations strictly undercover?

Dr. Bob Bowman, an actual rocket scientist, once said that the real truth about 9/11 is that we don’t know the truth about 9/11. When he speculates, he always labels his speculations as such—something that some of our more imaginative theoreticians should also consider doing.

Medical debt in MA remains unchanged after reform

The reason most MA residents approve of reform is that 85% have never been expensively sick. The mandatory underinsurance is a disaster for the 5% who incur 50% of all health care costs, and for the 15% who incur 85% of costs.


Architects of the pioneering 2006 Massachusetts health law, which required most residents to have insurance, expected it would reduce families’ medical debt. But the most recent data suggest the scope of medical debt has remained largely unchanged.

Temporary lapses in insurance coverage and increasingly common plans with high deductibles and copayments have contributed to medical debt, leaving some people struggling to pay bills for hospitals, doctors, and ambulance companies. Rising health costs and the recession also probably played a role.

AG ruling ends program of Canadian drugs in Maine, leading to higher medicine costs for many

And those motherfucking whores for the 1% say they believe in "free markets."


Attorney General William Schneider’s determination that CanaRx, a Canadian firm that distributes prescription medications by mail, cannot be licensed in Maine imperils more than $3 million in annual savings budgeted for the state employees’ health plan.

The decision affects approximately 1,200 Maine households, according to CanaRx senior program adviser Chris Collins. It also poses financial repercussions for the city of Portland and Guilford-based Hardwood Products Co., both of which have contracted with CanaRx for years.

Five questions to ask candidates about Medicare


Some proposals currently under consideration would save the government money by increasing out-of-pocket health care expenses for older adults and people with disabilities. For example, the aforementioned Ryan plan would convert Medicare into a premium support, or voucher, system, under which beneficiaries would receive a defined contribution from the government to buy health coverage. This voucher would likely not keep pace with rising health care costs. As a result, over time, the voucher would be insufficient to purchase coverage that provides the same health security Medicare offers today.

“Five Medicare Questions for Candidates” also focuses on how candidates plan to improve the program, for example by reducing the cost of coverage for beneficiaries. People with Medicare already spend 15 percent of their household incomes on health care, five times as much as non-Medicare households. Moreover, half of all people with Medicare have annual incomes of less than $22,000. They cannot afford to pay more for their health care. Estimates suggest that under the Ryan plan people with Medicare would spend thousands more per year in health care costs.

“We encourage everyone to ask tough questions of those who hold the future of Medicare—and therefore of our health and retirement security—in their hands,” says Joe Baker, president of Medicare Rights. “It is important to know how prospective lawmakers intend to change programs that millions of people depend on.”

Bureaucratic nightmare for health insurance for part time employees

Health Affairs Blog
August 31, 2012
Implementing Health Reform: A Summer Lull

Employment Status And Waiting Periods

On August 31, 2012, the IRS released Notice 2012-58 addressing the question of how full-time employment status is to be determined for deciding whether an employer owes a tax penalty for under section 4980H for failing to provide health insurance (or adequate or affordable health insurance) to full-time employees who consequently receive premium tax credits. On the same day, the IRS, Department of Labor, and Department of Health and Human Services jointly released notice 2012-59 addressing the question of how the ninety-day waiting period limit for employment-based health insurance enacted by the Affordable Care Act as section 2708 of the Public Health Services Act would be applied.

Alternatively, if the employee worked on average less than 30 hours a week, the employer can treat the employee as a part-time employee for a subsequent stability period and not offer insurance. The employer can take up to 90 days for an "administrative period" before the stability period begins during which the employer can determine eligibility and add the employee to its health insurance program. In no event, however, can the combined measurement period and administrative period extend beyond the last day of the first calendar month beginning on or after the one-year anniversary of the employee's start date.

Ongoing employees with variable hours can also be made subject to measurement periods and stability periods, with the measurement periods lasting 3 to 12 months and the stability periods lasting for the same period of time but in no event less than 6 months. If an ongoing employee is determined to be part-time during any measurement period, the employer can deny coverage to that employee without risking a penalty for the next stability period. If the employee is determined to be full-time during the measurement period, the employer must insure the employee for the following stability period or risk paying a tax penalty.

In sum, variable-hour employees may be insured one year, not insured the next, depending on their hours of work during the prior "measurement period." An employer can take up to 90 days following the measurement period for an administrative period before coverage begins, but if an employee is already covered under a stability period, the employer must make the continuing eligibility determination before the stability period ends to avoid gaps in coverage.

Comment by Don McCanne of PNHP: The administrative nightmare created by the Affordable Care Act not only adds to the expensive public and private bureaucratic waste that characterizes our health care system, it also fails to adequately address fundamental issues such as equity and universality. This brief summary of the rules establishing whether or not an employer must provide coverage for employees based on a variable number of hours worked and on seasonal variations in employment, and how soon the coverage must be offered, demonstrates not only the complexity of just this one issue, but also demonstrates how easy it is for an individual to fall through the cracks.

Under a single payer system, everyone is covered. There would be no need to be concerned about part time and seasonal work in determinations of eligibility. And there would be no need for all of the rest of the administrative complexity that this law creates - complexity that shoves patients in and out of different programs and will leave 30 million with no coverage at all. Insane.

My comment: This does not discuss at all the problems with going on and off of Medicaid for people who lose jobs and may possibly get rehired in 6 months or so.

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