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Posts Tagged ‘Affordable Care Act’

Originally published at caesarrodney.org

The cost of healthcare in Delaware is again rising rapidly.  It is looming as a major budgetary issue for the State of Delaware current employees and pensioners. Delaware’s Medicaid budget is increasingly strained. There is a steady flow of articles in the News Journal about the rising cost of health insurance, the rising cost of pharmaceuticals, and the rapid rise in both co-pays and deductibles for patients. There are, however, a few elements in play that have been overlooked, and may have significant effects in the short-term on the overall costs of both insurance and actual healthcare delivery.
While it is abundantly obvious to everyone that utilizes healthcare services that both co-pays and deductibles have risen in an effort supposedly to keep the cost of the overall premium down, the complaint has been made that this discourages the use of health insurance for routine care because of the high out of pocket cost. This is only a part of the problem.
While it is true that discouraging the use of healthcare services saves money for the insurance carrier, there is another side to this disincentive. I am referring to a phenomenon that we see frequently in medicine. Patients, who are usually quite economically aware of the deductible are also very aware that once the deductible has been met, all further healthcare is essentially free for the rest of the year until their deductible resets.
As a consequence, those who have had some healthcare incident recently often then seek out other elective healthcare treatments, medications, and surgery they might otherwise postpone. “I might as well get it done now under this year’s deductible.” Whenever there is an uptick in elective medical services, there is also an uptick in the sheer number of expensive adverse outcomes, although the percentage still may be very small.
Thus costs to the insurer go up. We are seeing this more frequently in our office this year and it is very common toward the end of the year that our services for elective surgeries become highly demanded. In common terms, the patients want to get the elective surgery done before the end of the year when their deductible resets. This is a strong economic motivation.
Quite obviously this will cause a substantial increase in overall costs to Medicare, Medicaid, and the health insurance industry.  All three of these entities have responded to the increasing costs of expanded coverage of the population by increasing the scrutiny over authorized services and increasing the frequency of denials of authorization, in short, rationing services.
The former of these two phenomena, elective utilization of health services after meeting the deductible, tends to raise overall spending on healthcare. The latter, rationing, of course, does the opposite and tends to lower overall expenditure. The question of which will be the dominant effect will be answered by the insurance actuaries when the next year rates are published. Most anticipate substantial rate increases.
There is, however, another phenomenon that we are seeing increasingly. This is the absolute lack of access to physicians. Increasingly, fairly young physicians are retiring from practice for a host of reasons. Dr. Ezekial Emanuel, one of Obamacare’s chief architects, famously said last year on television when asked about this phenomenon that “They will have to work. We will make them”. It turns out not to be true. What turns out to be reality is that doctors will not work under those circumstances and it further turns out that many doctors, especially those who are older and more experienced, easily have the wherewithal to retire.
In addition to this there is the phenomenon of “Community Care Plans”. These are Medicaid plans offered through the Obamacare exchange. In our office we have been getting dozens of phone calls from people asking whether we participate in these plans and if we know anybody who does participate in these plans. The truth is there is a very thin panel of doctors. By my count, looking at the Delaware panel of doctors for United Healthcare “Community Care”, fully one third of the listed entities were either not doctors, were duplicate listings, or were the names of facilities. Most of the family practices on the list are closed to new patients.
In my specialty, Orthopaedics, there are six surgeons listed who are all based at Crozier Chester Hospital in Pennsylvania. In short, there is very limited access to contracted physicians and surgeons. The net result is that the patient’s have a heavily subsidized health insurance card which is not capable of giving them access to healthcare except under convoluted circumstances, usually the Emergency Room. This is of course a very effective mechanism for United Healthcare to control its costs and continue to receive subsidies from both the federal government and the State of Delaware who offers these plans. The State can then say it has expanded the pool of people with health insurance even though that insurance is unusable.
The actual number of previously uninsured people now receiving preventative care is surprisingly small. As the Oregon experiment demonstrated with over a decade of data, the addition of Medicaid insurance to the uninsured population does not change their pattern of choice of the emergency room for their care. In fact, the net result was quite the opposite, emergency room utilization increased. It is not yet clear if that is happening or will happen in Delaware but similar efforts in both Massachusetts and Vermont have had identical outcomes to Oregon.
The news is not bad for everyone. Large hospital systems are suddenly thriving because their previously uninsured patients are now covered by Medicaid. The insurance industry is consolidating and the large carriers are reaping windfall profits from subsidies. For the moment, Delaware continues to have its state Medicaid insurance program subsidized by the federal government.
Soon enough though, federal Medicaid subsidies to Delaware will cease and the full burden of cost will return to the Delaware budget. The insurance industries will be squeezed by the “Death Spiral” as healthy patients decline to purchase the ever more expensive policies and only the expensive chronically ill remain in the insurance pool. In 2018 penalties, fees, and taxes are set to essentially end the health insurance industry as we know it.  Medicare has not yet been reformed and its insolvency has been accelerated by almost a decade. Small hospital systems will consolidate into large systems but will become de facto accountable care organizations, responsible for all community health, but presumably with highly restricted budgets based upon an insolvent single payor. Hospital care is costly and limited access to care is inevitable.
The “Affordable Care Act”, clearly misnamed, appears to be yet another example of “The Uncannily Predictable Law of Unintended Consequences”. Acronym TUPLUC.
C.D. Casscells, MD
Director, Center for Healthcare Policy
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The Washington State Supreme Court voted 6-3 to strike down charter schools, saying they “aren’t governed by elected boards and therefore not accountable to voters.” Read the decision here

Some background: In November 2012, voters approved a referendum to establish as many as 40 charter schools in the state. Charter school opponents became “Alarmed over the lack of local accountability and fiscal impacts of the Act” and filed a lawsuit against the network. The Washington State constitution says funding must be given to “common schools”, which were essentially defined as traditional public schools. The main complain is, charters and other school choice options are “selective” and force traditional schools to take “problem students.” The schools must also be “uniform”, or the same. If charters have lotteries and restrictions public schools do not have, then the schools are no longer uniform and charters cannot be provided public funding.

Delaware has a similar constitutional law which requires the government to fund a public education system, though it does not say the schools have to be run by the government, only provided. But the point is the same: these rules were set up not to ensure everyone an education, but to make sure as very few kids would be able to have an option besides the traditional public school. The way public schools are funded requires as many kids as possible to get into the buildings so the schools receive money.
Anti-charter proponents celebrated; at long last, they have succeeded in their quest to prevent students from going to a charter school. Most of these children will either end up home-schooled, sent to a private school which can take them, or, most likely, sent back to traditional public school where their attendance will ensure the schools get more taxpayer dollars and make any sort of education reform even more unlikely. Sadly, some adults are so opposed to school choice, the idea that a child might leave public school, that they openly cheer for the demise of alternative schools and education freedom just to make sure public schools (and those whose livelihood derives from public schools) keep getting money AND the status quo is maintained.
If you don’t think there is a problem yet, keep in mind SAT and ACT scores are flat, or even in decline. Here’s an article from left-leaning Slate acknowledging this.
The excuses abound: more students are taking the test (which is 1. dumb policy and 2. aren’t we supposed to improve everyone’s education? Isn’t that the whole point of No Child Left Behind?), Common Core State Standards are so stringent they are raising the bar too fast, the SAT and ACT are not fully aligned with student goals. The problem with this argument is, scores have declined for decades now in reading, and since 2006 writing scores declined across all ethnic and gender groups, and is now being eliminated from the SAT. Therefore, blaming Common Core for raising the bar and making the test now too difficult is a convenient overlook of the long-term problems we’ve had in this country.
What is not acknowledged is the stark reality: Most students just are not ready for college. Some ought not to go, but even then too many students are graduating high school lacking the basic skills needed to obtain a decent-paying job and career advancement opportunities. Of course, every entity except our current education system is to blame.
The same people who go after charters almost always include homeschooling and private schooling as a problem as well. Their attacks on charters and choice are little more than a thinly veiled effort to push all students to attend public schools, no matter how good or bad the school is run, no matter how ridiculous the government mandates are, or even irregardless of whether public education is right for every child.
Take the battle over HB 50, the Opt-Out bill. Supporters see this as a way for parents to have a say in their child’s education and keep their children from having to submit to a standardized test many feel is a problem. We agree- parents should be allowed to have a say in their child’s education, and absolutely students, especially in public schools, are over-tested. But what HB 50 supporters do not seem to understand is how futile their efforts are the long run, the “big picture” if you will. HB50 supporters seem to believe if you just get rid of Smarter Balanced Assessment Consortium (SBAC), somehow everything will be alright in the end. But they continue to believe in the system which gave them SBAC, they will find the bureaucracy will just provide a new program and standardized tests with similar, if only slightly different, objectives.  As long as they continue to keep the current system of education in place, there will be no real change.
Supporters of HB50 and anti-testing advocates also need to find a common alternative to Common Core/SBAC which will give principals the data they need to measure student progress and teacher competence. There are, in fact, teachers who are incompetent; admitting this is not “anti-teacher”, but a reality that no organization has complete competence from every single member. Not every student is motivated to learn on their own. Not every school is run well, or run poorly. As long as a method of measuring student progress is offered, education progress can be made.

Education Savings Accounts by themselves will not improve our education system, but they will move us forward when parents realize they do have the power to improve their children’s education if they want to. It’s parents, not school boards, not school districts, not teacher’s unions, not elected officials, not employees of the state Department of Education, not employees of the U.S. Department of Education, not private sector companies, who ought to have the final say in how their child is education. With a more competitive education system in place, one which empowers teachers and principals to do what is right, one which allows parents to have choices beyond what is in their zip code, education will improve.

And for those who say it won’t, look at our university system. We have arguably the best system on the planet, and there are plenty of public and private schools to go to. Oh, and public schools receive plenty of funding and are in no danger of going under, even though the government provides student loans to students who might go to a private school.

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The official posture of the De. State Government is that Delaware has a state-sponsored health insurance exchange, Chooseheathde.com. The Supreme Court and the federal Department of Health and Human Services (DHHS) say otherwise, that Delaware has a federal exchange. Why does this matter?

It matters to the 90% of the people who purchased their health insurance through the DE exchange and received a tax subsidy. It also matters to the other 5 million people in the US who did the same. If the Supreme Court decides FOR the plain language of the Affordable Care Act in the King v. Burwell case, which will be heard in March, and upholds the ACA, which is likely, then those aforementioned people lose their subsidy, and likely their insurance, and may have to refund the IRS in their next tax filing for 2014 and 2015. They would be retroactively declared in default of their policy and therefore responsible for their health care costs directly.

The case is very likely to be ruled in favor of the legislation as written, that on January 28th the House Committee on Energy and Commerce requested the contingency plan in writing for the expected ruling from the Supreme Court. The same question put to the office of the Insurance Commissioner and the state Department of Health and Social Services referred me to the Federal DHHS and Sylvia Burwell for answers. Whereas the federal government has a contingency plan should the Supreme Court rule in favor of the plaintiffs in King v. Burwell, Delaware does not have one.

The only possible interpretation of this is that Delaware does not have a state-sponsored exchange and therefore is financially vulnerable to the outcome of the Supreme Court case. The state government should be aggressively making contingency plans for this outcome which will affect not only the thousands of Delawareans who are relying on tax subsidies to cover the cost of insurance plans purchased through the state exchange, but also for our state’s budget, should the cost of health insurance be dumped onto Dover from Washington D.C.

Chris Casscells, M.D.

Director, Center for Healthcare Policy

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Happy Thanksgiving! We hope you have a happy and safe holiday.

For this week’s post we are going to respond to the post of blogger Lyman Stone, a grad student at George Washington University’s Elliott School. In his November 21 blogpost titled “North Dakota, Illinois, and Delaware: A Boom State, a Struggler, and a Winner”, he wrote about Delaware’s migration and why the state has had an overall increase in people from 2000-2010 (source: U.S. Census). His top four points and our response:

1. “Many of the people Delaware loses, as I’ve already shown, are richer people. That is to say, Delaware is exporting its richer people (many of them retirees) to states like Arizona, Florida, Virginia, and Texas. Meanwhile, it is inundated with floods of lower-income, somewhat less-educated individuals. Delaware’s in-migration includes very high rates of retiree migration and migration of the young.”

Delaware lost roughly $480 million in net wealth from 2000-2010, predominately from New Castle County (source irs.gov). Some of that wealth went across the border to Chester/Media, PA; many of the top 1% retired to Florida or Arizona, but many people did stay in Delaware and moved to Kent or Sussex Counties where property is even cheaper and cost of living is lower than New Castle County. Delaware’s low property taxes attract retirees mainly from DC, MD, NJ, and NY. Young people move to New Castle County for the corporate jobs. But Lyman is missing this point: Families with school-age children tend not to stay in Delaware. (see here and here). Unless the parents can afford a private school or get to a good charter school, the parents more often than not leave for PA. A graph within the presentations in the links shows a huge drop-off with parents with at least one child aged 5 or older leaving for places like Valley Forge or Media while parents with children 0-4 stay in Delaware. So it’s like “come when you’re young, leave when you have a family, return when you’re ready to retire”.

2. “Once again, like Illinois, Delaware has lots of high-traffic borders and nearby border metro areas, thus we can fruitfully look to policy variables as one part of the explanation. Delaware has income taxes at a similar rate to most of its regional peers (though much higher than Virginia’s) and is in the minority of states in that it still has an estate tax. In that regard, it is peculiar that so many retirees would choose it.

That is, until we recall Delaware’s three most salient tax features: it has no sales tax (thus reducing cost of living), among the lowest property taxes in the nation (reducing cost of living), and funds its infrastructure through tolls and user fees more than any other state (reducing burdens on people who drive less: young and old). Its taxes overwhelmingly fall on businesses, but it attracts businesses by offering highly favorable legal and regulatory conditions.”

Delaware has a gross-receipts tax, a tax on business revenue BEFORE profit and loss is considered. Only Virginia has both a gross receipts and income tax, both of those rates are lower there than Delaware. The result has been that Delaware has had more businesses closing than opening and we are 51st in the country in jobs created by existing firms (Source: deconfirst.com). This means no state or DC is worse than Delaware at getting businesses already here to hire more people. The state is very good at helping start-ups but not good at helping established businesses, especially medium-sized businesses.

Delaware’s Court of Chancery is known for its fairness, and incorporation laws are lax. This is favorable to larger businesses to want to headquarter here, which is why the Wilmington area has so many corporate offices with high-paying administrative jobs. This is a good thing for the state but again, this benefits larger businesses and not small- or medium- sized businesses.

3. The net result of Delaware’s policy choices is that “New Economy Index” produced by the liberal-leaning Progressive Policy Institute ranks the 2nd best in the nation, the conservative-leaning American Legislative Exchange scores 27th in their “Rich States, Poor States” publication, the business-backed Tax Foundation (disclosure: my former employer) ranks 14th-best, and even the libertarian Mercatus Center identifies as 17th “most free” in their Freedom in the 50 States report. A report by 24/7 Wall Street found Delaware to be the 13th best-run state in the nation, and academic measures of state corruption rank Delaware no worse than middle-of-the-pack. In fact, it is a real challenge to find any organization that scores Delaware poorly on any major policy metric or index.

Corruption in Delaware is not as bad as it is in places like Illinois, Rhode Island, California, or Louisiana. But saying it’s “good” is more on an indicator of how corrupt those states are. Delaware’s small size means “everyone knows everyone” attitude impacts the government but the state is not very forthcoming with state pension data or with how education dollars are being spent. That said, we are better than every other Mid-Atlantic state besides Virginia. We posted on the Tax Foundation’s analysis.

4. Likewise, Delaware has one of the lowest average price levels of any state in the region (except Virginia), and that price level is lowest in southern Delaware, where in-migration is highest.

I’ve repeatedly cast Delaware as a state that’s providing opportunities: for the young, for the less educated, and also for regional retirees who may not have the money for a bigger relocation to Texas or Florida (or who may not want to pay property and sales taxes in those states). That’s because Delaware’s migration record is simply the strongest across the most different categorizations of almost any state, especially among states without major oil and gas reserves. I’d love to hear more from people familiar with Delaware on how the state attracts people: beaches with rising popularity? corporate headquarters? retirement communities? strong university recruitment? sprawl from Philadelphia?

To Lyman’s final point, Delaware IS a very attractive place between Philly and Baltimore/DC. We are a train ride or short drive from all three cities and only three hours from New York City. The Beaches draw in tourists and retirees, and there is some Philly sprawl in the Claymont area. But Delaware is beginning to lose our status is a “tax haven”, now that Nevada and North Dakota are competing with us for our corporate business. The state spends way too much money and like most states will suffer from having to choose between Medicaid and public education once the federal government cuts back on its Obamacare obligations by 2019. Our three casinos are losing money and, barring a change in visitor habits ore legislative policy, will go out of business; 6% of our state’s revenue comes from casino taxes. We have a state carbon tax and cap-and-trade system (Regional Greenhouse Gas Initiative) which is costing so much money CRI’s Energy Policy Director Dave Stevenson and our board member John Moore are suing DNREC to prevent a new carbon tax fee from being imposed on residents and businesses.

Delaware’s population is aging at a faster rate than the nation as a whole; right now half the state receives Medicare or Medicaid. By 2030 that number will be closer to 67% at current migration rates. Sussex County is already 25% senior citizens and that number grows ever year. As much as we at CRI love our seniors, someone has to help pay for Medicare/Social Security/ public housing assistance/public transportation, and other quality-of-life benefits seniors need to enjoy their retirement since we know the Feds won’t meet their future obligations.
Because of its strong migration record in a highly competitive area, other states could benefit from studying Delaware’s experience and determining which policies they can adopt for their own states.

Please don’t pass a gross receipts tax or block natural gas pipeline from reaching your states. We have high electricity prices and a mediocre public education system. Don’t be so aggressive and seizing abandoned property, even down to the Amazon gift cards which went unused. End the prevailing wage and establish a Right-to-Work law if your state doesn’t have one yet.

What do you think about Lyman’s blog post or our response?

Please consider eliminating your state’s sales tax and lowering property taxes, and have a court system which is seen as quick, efficient, and fair.

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The open period was supposed to start in October and go to Dec 31. That would allow the ins companies to get set for the 2015 year. The previous March deadline was set because they knew few people would sign up right away.
The rates for this year are going to be very high and a lot of employers will drop out. I am expecting a 25-50% rate hike and many people are going to lose their subsidies as the data gets cross checked with the IRS.
Overall the destruction of the health insurance industry is working quite well and there should soon be no other choice but what is offered by the government as in Medicare. Already the exodus of good doctors has started and health related businesses, like the Scooter Store, are going bankrupt and closing. This is going to be a big downturn of 16% of the economy.
Coventry is essentially already out, Aetna remains in a diminished capacity. Blue Cross Blue Shield of Delaware is gone, absorbed by Highmark. The Delaware Health Commission released its plan this week and it disingenuously presumes a constant insurance market which the State can control. The truth is everyone wants a single payer system, everyone also wants to BE that single payer.
And yes, doctors are quickly moving to drop Medicare and Medicaid and some insurance altogether. Many are simply retiring. Some of my close colleagues are retiring by this year’s end and all are younger than me, mostly family practice. Everyone assumes that when control is established  that doctors will just work for less, but to the contrary, they just won’t work. This is the consummate flaw in Ezekiel Emanuel’s thinking. He says that they will have to work as told, but the truth is doctors will not be forced to practice bad medicine and, by and large, they can afford to quit, so they are and will in droves.
On a national and local level, Walmart, Home Depot, Walgreens, and Target have all cut back health insurance for those working less than 30 hours/week. On a local level,  Highmark just had its premium increases cut dramatically by Insurance Commissioner Karen Weldin Stewart, which means that they will not offer some products. They cannot calculate the rates now because the sign up period has been delayed onset until after the election cycle. On good background I believe that Highmark will withdraw risky insurance products in the Delaware market.
On a very anecdotal level, one of my patients who employs 47 people has directed his human resource person to fire 5 people so as to be well beneath the 50 person threshold for ACA. This is just as a precaution, in case they 50 employee mark is hit inadvertently.
The White House Administration has declared a moratorium on data release from CMS and the Federal Exchange Website.  I do not find any reason to be optimistic about the landscape.

Dr. Casscells, Director

Center for Healthcare Policy

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CRI predicted years ago charity care would soon become a thing of the past. That’s because the Affordable Care Act, which just about everyone calls Obamacare, is set up to remove charity care from the equation.

Charity care is free healthcare many doctors provide as a service to the community. There is (or was) no financial incentive; a doctor did it because he or she believes in helping their fellow human beings. This was a way for very poor people and/or those who don’t have health insurance to receive healthcare they could not otherwise afford. Well, no more (in Delaware at least):

State to cut ‘charity care’ for near-poor

Delawareans pinching pennies near the federal poverty level – making from $16,100 for an individual to a maximum of $47,700 for a family of four – will lose health coverage through the state’s Community Healthcare Access Program (CHAP) starting Feb. 1, state officials said late Monday afternoon.

CHAP is a state-run program that offers discounted medical services for those not eligible for Delaware’s Medicaid program. The state earmarked $478,000 in tobacco settlement funds for the program this fiscal year.

CHAP recipients are ineligible for Medicaid either because they are undocumented immigrants or make more than 138 percent of the federal poverty level, Delaware’s cutoff for Medicaid assistance. The federal poverty level is $11,670 a year for an individual.

State officials said they will offer an alternative to CHAP on a case-by-case basis, only for those who can prove they are ineligible for other plans or are exempt from the federal insurance mandate.”

Now some of those who were on this program were individuals not legally authorized to be in the country. However, some were and will no longer receive help, and even for those here illegally, most medical professionals will tell you their desire is to help everyone who needs it, no matter what, because it is their calling.

“This is charity care and charity care more or less will be going away based on the mandate that everyone must have health insurance,” said Rita Langraf, secretary of Delaware’s Department of Health and Social Services, referencing the 2010 Affordable Care Act’s requirement that everyone should have health insurance.

The department is taking that mantra seriously. Landgraf said the state will continue to offer coverage for the undocumented population past Feb. 1, but CHAP recipients who make up to 200 percent of the federal poverty level will need to find new coverage.”

This is another problem. DHSS Secretary Landgraf is saying the state will ensure those not authorized to be here will receive benefits not extended to American citizens. Why? Because ACA mandates that all citizens must have health insurance- note the bolded words.

The main reason charity care is disappearing is because the government will begin reimbursing doctors for care previously provided as charity. This means taxpayer dollars will flow into doctor’s pockets for services they were going to perform anyway. If you were going to do something you always did, say brush your teeth, and the government offered to pay you to do that, would you turn that offer down? Most people would not and thus the government is ensuring a larger budget deficit for a service they don’t need to pay for. The other thing this will do remove the “good samaritan” role of medicine, eliminating volunteerism in favor of “rent-seeking” from the government (seeking public money for private bank accounts).

The health insurance exchanges open on Saturday and we were now only hours away from knowing what the 2015 insurance rates will be. If you haven’t yet received a letter notifying you of your insurance status for 2015, you will get it very soon. On Thursday CRI will publish another article on healthcare breaking down the new rates, discussing what you can expect going forward, and discussing how you can Impact Delaware!

photo:myptsolutions.com

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