Author Archive | John Barrett

Sen. Tom Coburn: Why the New Health Law Could Decrease Competition & Increase Costs | Health Reform Report

Supporters of the Patient Protection and Affordable Care Act argued before the passage of the new law that health care in America needed more “choice and competition.” So they may be surprised to learn the massive overhaul actually could decrease choice and competition.  In fact, an accumulating body of data shows the new law is on track to actually reduce competition between health care providers, which will increase health costs for patients. There are good reasons for concern.

An implicit pledge of the health overhaul is that delivery will be improved through “Accountable Care Organizations.” ACOs are generally envisioned as teams of doctors and nurses share savings in their coordinated effort to deliver higher quality, lower cost health care.  Coordinated care is a great goal, but there are good reasons to be concerned that ACOs will not accomplish. 

First, there is the question of whether or not there will be shared savings. During the past decade, the Medicare program conducted a pilot project in which teams of health care providers could share savings from coordinated care, but only half of the teams in the demo experienced any savings. 

Second, there is the issue of who will share any savings. The health overhaul left in place existing federal restrictions on physician referrals and further barred physicians from having ownership of hospital endeavors. So, unless the rules for ACOs are changed dramatically, ACOs could accelerate the trend of physicians leaving private practice to work in a centralized hospital setting. 

Physicians are already exiting private practice in droves. A recent national survey of more than 2,000 physicians found that more than seven in 10 physicians said they would leave their medical practices for hospital or work-part-time, stop taking new patients, or simply retire altogether.  As a former Medicare official recently noted, “in 2005, more than two-thirds of medical practices were doctor-owned, a share that was largely constant for many years [but] by next year, the share of practices owned by physicians will probably drop below 40 percent, according to data from the Medical Group Management Association.”

At the same time, over the next three years, three in four hospitals or health systems reported they plan on hiring more physicians, and more than half said they will buy entire medical practices  Last year alone, half of new doctors were hired by hospitals.

Respected Harvard health care economist Regina Herzlinger has noted that ACOs hold promise or lead to peril in direct relationship to how they are designed and implemented.  Her conclusions, based on a careful examination of the consolidated health care system in Massachusetts, underline the importance of provider groups of all sizes being enabled to share with patients in any savings.  And, just as important, rather than adopting a one-size-fits-all rules, regulators must adopt a flexible ACO structure that is predictable, yet adaptable.

Many health care providers and policy analysts have offered their prognostications, but Herzlinger’s focus on properly aligning underlying incentives is key.  ACOs could further diminish the quality of patient care if they fail to preserve, and build on, the primacy of the patient-physician relationship.  Unfortunately, the current outlook is not encouraging.

A widely-read recent New York Times article noted “consumer advocates fear that the health care law could worse some of the very problems it was meant to solve -by reducing competition, driving up costs, and creating incentives for doctors and hospitals to stint on care.”  A White House official also recently acknowledged that “the economic forces put in motion by the [health legislation] are likely to lead to vertical organization of providers and accelerate physician employment by hospitals and aggregation into larger physician groups.”

A former Medicare policy advisor said the law assumes “doctors will fold their private offices to become salaried hospital employees, making it easier for the federal government to regulate them and centrally manage the costly medical services they prescribe.”  Certainly, many of the new law’s changes will centralize decisions in Washington, DC, removing power from physicians while dramatically increasing the control of federal bureaucrats and politicians. 

 Economic theory suggests that consolidation of providers under a hospital will increase a hospital system’s market share and negotiating power over remaining providers. As massive hospital systems grow even larger, choice and competition will be reduced in the health care marketplace and costs to consumers will increase even further.

 Such a conclusion is grounded not only in economic theory, but experience. The consolidation of providers is one important reason that health care costs in Massachusetts already are the most expensive in the nation. As the Massachusetts Attorney General concluded in a report earlier this year examining the underlying drivers of health costs, “price variations are correlated to market leverage…of the hospital or provider group compared with other[s] within a geographic region.”

California appears to suffer from a similar problem. The Center for Studying Health System Change studied California’s experience in attempted health reforms and also concluded “proposals to promote integrated care through models such as accountable care organizations could lead to higher rates for private payers.”

And, if these trends were not concerning enough, there is a final wrinkle worth noting. Because the new law cuts nearly $530 billion from Medicare to spend on new programs, some providers are finding their current business model financially unsustainable. 

 Faced with the prospect of shutting its doors or merging with competitors, many health care providers are being consolidated with other types of providers.  The Wall Street Journal recently noted that Moody’s Investors Services informed analysts to “expect consolidation in health industries, as providers acquire different health-care entities to diversify.”  A Deloitte study echoed Moody’s findings, saying “there is considerable [mergers and acquisitions] activity, particularly among those organizations experiencing threats to their reimbursement levels.”  While corporate motives driving these mergers may be benign, the impact on consumers’ wallets will nonetheless be real and potentially significant.

None of these changes are good for consumers, patients, or health care providers. Even supporters of the health care overhaul will be forced to admit the failings of their massive overhaul as costs increase, providers consolidate, and choices for consumers are reduced.  But the likely problems with ACOs are really just a symptom of the larger problem: a massive 2,700 page government-centered approach to health care that fails to fix many of the basic problems and makes some problems even worse.   That is why the best way forward is to repeal the law and replace it with sensible, proven reforms that will reduce costs, increase competition, empower patients, realign incentives, and put federal health spending on a truly sustainable path.   

Tom Coburn, MD is a United States Senator from Oklahoma.


Workers Get Health Care Allowances

New Laws Give Employees Money to Buy Individual Health Insurance

Park City, UT December 1, 2010

For information contact John Barrett at (626 797-4618

Zane Benefits, Inc. helps employers take advantage of new IRS laws (Section 125 and Section 105) that allow employers and employees to contribute tax free dollars to individual health insurance costs.    Zane Benefits’ solution involves a switch to employer-funded individual health insurance in which each employee receives a tax-free monthly allowance to purchase their own individual policy.

Individual health insurance used to be expensive and hard to get. However, due to health insurance reforms, individual policies are now more affordable and accessible. For example, insurance companies must now accept children regardless of preexisting conditions, and guaranteed acceptance is being extended to all citizens over the next few years. Additionally, a new federal risk pool is now available for anyone who cannot find health insurance on the individual market.

Many employees are able to buy individual policies for less than the monthly amount funded by the company. The allowance can also be used for eyeglasses, dental care and other medical expenses. Today, there are various ways for all employees to get some kind of health coverage through state and federal programs.

Zane Benefits offers two options (“ZaneHRA” and “ZanePOP”) to employers that want to make the switch to employer-funded individual health insurance.

ZaneHRA, which is a defined contribution health plan, works best for companies that want to offer health benefits, but cannot offer group health insurance due to high cost or participation requirements. With ZaneHRA, employers offer a defined contribution health plan in which they make available monthly contributions (“allowances”) that employees choose how to spend. Employees can use their monthly “ZaneHRA Allowance” to reimburse their individual health insurance costs and eligible medical expenses 100% tax free.

ZanePOP, which is a premium-only-plan for individual health insurance, works best for companies that do not offer health insurance or have employees who are not eligible for a group health insurance plan. With ZanePOP, employers allow employees to reimburse themselves for individual health insurance costs using pre-tax salary. Employees typically save 20-40% on their insurance premiums. Employers save an additional 7.65% in FICA taxes on all reimbursements.

According to Rick Lindquist, who manages Zane Benefits’ affiliate distribution, “an employer can setup a ZaneHRA or ZanePOP plan in 10 minutes online. Once the plan is setup, it takes less than 5 minutes per month to administer because we integrate with the company’s existing payroll service.”

Zane Benefits has built a web-based training program to help insurance agents and CPAs learn the new rules. “Our products are distributed in all 50 states by independent licensed insurance brokers. However, many agents do not realize individual health insurance can be reimbursed tax free. We are working hard to educate brokers on these new products so that they can help their clients.”


Union Drops Health Coverage for Workers’ Children

By Yuliya Chernova

Associated Press

One of the largest union-administered health-insurance funds in New York is dropping coverage for the children of more than 30,000 low-wage home attendants, union officials said. The union blamed financial problems it said were caused by the state’s health department and new national health-insurance requirements.

The fund is administered by 1199SEIU United Healthcare Workers East, an affiliate of the Service Employees International Union. Union officials said the state compelled the fund to start buying coverage from a third party, which increased premiums by 60%. State health officials denied forcing the union fund to make the switch, saying the fund had been struggling financially even before the switch to third-party coverage.

The fund informed its members late last month that their dependents will no longer be covered as of Jan. 1, 2011. Currently about 6,000 children are covered by the benefit fund, some until age 23.

The union fund faced a “dramatic shortfall” between what employers contributed to the fund and the premiums charged by its insurance provider, Fidelis Care, according to Mitra Behroozi, executive director of benefit and pension funds for 1199SEIU. The union fund pools contributions from several home-care agencies and then buys insurance from Fidelis.

“In addition, new federal health-care reform legislation requires plans with dependent coverage to expand that coverage up to age 26,” Behroozi wrote in a letter to members Oct. 22. “Our limited resources are already stretched as far as possible, and meeting this new requirement would be financially impossible.”

Behroozi estimated that the fund faced a $15 million shortfall in 2011 and more in the following years for the coverage of workers’ children.

The union said in a statement that the state required the fund to participate in a new program — the Family Health Plus Buy-In Program — beginning in 2008. The union said it expected that by joining the program, many of its members would qualify for state assistance for health-insurance coverage. “Instead they raised insurance rate increases without any increase in funding, and then cut Medicaid funding to the same workers nine times in the last three years,” the union said in a statement.

But the state denies requiring the union to join the program. “The state is not forcing 1199 to do anything regarding its employee health insurance,” said Jeffrey W. Hammond, spokesman for the New York Department of Health.

Home-care agencies that contribute to the union fund collect their revenue from the state’s Medicaid program. Over the past two years the state cut about $370 million in Medicaid reimbursements to home and community-based care programs, according to New York State Association of Health Care Providers Inc., a trade association that represents agencies that employ home attendants.

“In home care in general, whether in a union or a non-unionized workplace, they are dealing with the crisis of trying to do more and more with less and less, and cut on top of cut,” said Christine Johnston, president of the association.

For the 1199 fund, premiums rose because Fidelis realized that the home health-care attendants are sicker than average, according to Mark Lane, president and chief executive of Fidelis Care. “These people are hard working people. There’s physical labor, which manifests itself in terms of more chronic and acute care type of illnesses,” said Lane.

As premiums went up and employer contributions remained constant, the benefit fund started cutting the rolls of eligible members. In the past three years the 1199 fund reduced its total enrollment in half, to less than 40,000 currently.

“We hope the state of New York will do the right thing and provide the funding necessary for this most vulnerable population of direct caregivers,” the union said in a statement.



Business Wire –

Nov. 22: New York – 2010 is Year Zero for health reform the year against which the effects of the new Patient Protection and Affordable Care Act (PPACA) will be measured.

Growth in the average total health benefit cost per employee, which had slowed last year to 5.5%, picked up steam, rising 6.9% to $9,562, the biggest increase since 2004, according to the latest National Survey of Employer-Sponsored Health Plans, conducted annually by Mercer.

Employers expect high cost increases again in 2011. They predicted that cost would rise by about 10% if they made no health program changes, with roughly two percentage points of this increase coming solely from changes mandated by PPACA for 2011. However, employers expect to hold their actual cost increase to 6.4% by making changes to plan design or changing plan vendors.

Mercer’s survey includes public and private organizations with 10 or more employees; 2,836 employers responded in 2010. “Employers did a little bit of everything to hold down cost increases in 2010,” said Beth Umland, Mercer’s director of health and benefits research. “The average individual PPO deductible rose by about $100.

Employers dropped HMOs, which were more costly than PPOs this year. Large employers added low-cost consumer-directed health plans and found ways to encourage more employees to enroll in them. And more employers provided employees with financial incentives to take better care of their health.”

Large employers experienced a sharper cost increase than smaller employers in 2010. Cost rose by 8.5% among employers with 500 or more employees, but by just 4.4% among those with 10–499 employees.

“Large employers may have been taken by surprise by the uptick in the cost increase this year,” said Susan Connolly, a Partner in Mercer’s Boston office. “Higher prices for health care services seem to be part of the equation, but if the recession caused a slowdown in utilization last year, we may also be seeing the effect of employees getting care they’ve been putting off.”

Enrollment in CDHPs offered by the nation’s largest employers jumps sharply in 2010

Overall enrollment in high-deductible, account-based consumer-directed health plans (CDHPs) grew from 9% of all covered employees in 2009 to 11% in 2010.

CDHP enrollment has risen by two percentage points each year since 2006.

With the cost of HSA-based CDHP coverage averaging just $6,759 per employee among all employers in 2010 – almost 25% lower than the cost of PPO coverage the appeal of these plans is clear.

“As both employers and employees become more comfortable with high-deductible plans, we’re seeing more organizations willing to commit to the consumerism concept,” said Ms. Connolly. “Over the past few years employers have worked on finding a balance between giving employees more responsibility for their health care spending and providing the support to help them succeed.”

Already committed to employee health management, employers add financial incentives to build participation

Employers will soon be more limited in how they can shift cost to employees.

Starting in 2014, PPACA sets minimum standards for “plan value” (the percentage of health care expenses paid by the plan) and “affordability” (the employee’s share of the premium relative to household income). These changes are bringing greater focus on improving workforce health as a way to control health benefit cost.

Over the past decade employers have added a wide range of programs under the employee health management or “wellness” umbrella, from health risk assessments (offered by 69% of large employers in 2010) to disease management programs (73%) to behavior modification programs (50%).

In 2010 more employers added incentives or penalties to encourage more employees to participate: 27% of large employers with health management programs provided incentives, up from 21% last year. In addition, the incentives are becoming more substantial. Three years ago, a token gift like a hat or water bottle was the most common incentive for completing a health risk assessment; now it is cash (typically, $75) or a lower premium contribution (typically, a reduction of $180).

Results are encouraging: For a second year in a row, medical plan cost increases in 2010 were about two percentage points lower, on average, among employers with extensive health management programs than among those employers offering limited or no health management programs.

Very large employers are also increasingly willing to reward employees who demonstrate responsibility for their own health. More than a fourth of those with 20,000 or more employees require lower premium contributions from nonsmokers – 28%, up from 23% last year. An additional 6% provide other incentives to nonsmokers.

Employers drop retiree medical plans in favor of subsidizing individual coverage

The prevalence of retiree medical plans slid to its lowest point ever in 2010, with just 25% of large employers offering an ongoing plan to retirees under age 65 (down from 28% in 2009) and just 19% offering a plan to Medicare-eligible employees (down from 21%). An additional 10% of employers have closed their retiree plans to new hires but continue to offer coverage to employees retiring or hired after a specific date.

A diminished tax break for employers who provide retiree drug plans and the anticipated availability of better Medicare coverage as the government shrinks the so-called “doughnut hole” gap in prescription drug coverage are among the factors that have employers reexamining their retiree health programs.

As some employers take the step of terminating group coverage for retirees, they are softening the blow with a subsidy to help pay for individual coverage. Nearly one in ten of the largest employers (those with 20,000 or more employees) now provide such a subsidy in lieu of a group plan.


What You Need To Know About The One‐Year Tax Deduction On Health Costs For The Self‐Employed

On September 27, 2010, the Small Business Jobs and Credit Act of 2010 (H.R.5297) was signed into law. The legislation provides an important tax break for the over 23 million self‐employed Americans that represent 78 percent of all small businesses in the U.S.

The self‐employed have not received the same tax benefit related to health insurance expenses that all other businesses entities have enjoyed. Various business entities are able to fully deduct the cost of health coverage as a business expense, saving them a significant amount in payroll taxes.

With the passage of the Small Business Jobs and Credit Act, the self‐employed will be allowed to take a one‐year tax deduction for health costs in determining payroll tax (self‐employment tax.) Here is some guidance to determine whether you can benefit from this new deduction:

1)  Who can qualify for this one‐year self‐employment tax deduction on health costs?

Self‐employed business owners that meet all of the following requirements can take advantage of this new tax deduction:

•    Files an IRS Form 1040 Schedule C tax form or Schedule E with earned income ‐ this includes sole proprietors, single member LLCs, and sole owner S‐Corporations.
•    Pays self‐employment taxes via IRS Form 1040 Schedule SE.
•    Pays for individual or family health coverage in 2010.

2)  When can I take this deduction?

This deduction is available for health costs paid by self‐employed business owners in 2010. Self‐ employed business owners should look to take advantage of this deduction when preparing their taxes next year in time for the April 15, 2011 tax filing deadline.

3)  How much will I save with this one‐year tax deduction on health costs?

The self‐employed must pay the employer and employee contribution to payroll taxes, totaling up to 15.3 percent on business income. For the self‐employed, payroll taxes are called self‐ employment taxes.

To calculate your savings from this new tax deduction, simply add up your total 2010 health insurance costs and multiply that by 15.3 percent. The resulting amount will represent how much you will save on your self‐employment taxes when filing your 2010 taxes next year.

According to a report on individual health insurance released by America’s Health Insurance Plans (AHIP), annual premiums averaged $2,985 for single coverage and $6,328 for family plans nationwide in mid‐2009. A majority of the self‐employed with health coverage currently purchase it via the individual insurance market.

Based on these average premium costs, the new one‐year tax deduction on health costs for payroll tax purposes would save self‐employed business owners approximately $456.71 to $968.14 in taxes.

•    NOTE: If you qualify for this deduction and your annual income is above the maximum wage limit subject to payroll (FICA) taxes, currently $106,800, then you will receive a lower tax benefit. Please contact your tax professional to assist you with calculating your exact tax savings.

4)  What if I purchased health coverage mid‐year or am planning to purchase health coverage this year, will I still get the benefit from the tax deduction?

If you meet the above qualification requirements in Question 1, you can still benefit from this one‐year tax deduction.

Since the benefit of the deduction is larger for those with higher health costs, those who purchased coverage mid‐year or will be purchasing health insurance in 2010 will simply have a smaller tax benefit when they file their taxes in 2011.

5)  What are the next steps a self‐employed business owner should take to ensure they qualify and benefit from this one‐year self‐employment tax deduction on health costs?

Self‐employed business owners should inform their tax professional about this new one‐year tax deduction. Prior to filing your taxes next year, your tax professional can determine whether you qualify and can take this tax benefit.

6)  Why is this tax deduction benefiting the self‐employed only available for one‐year?

Lawmakers only extended this tax benefit to the self‐employed for one‐year to provide some temporary bottom‐line cost savings to America’s smallest businesses in this difficult economic time and also, to minimize the cost to the federal government.

It is important to reiterate that the self‐employed are the only business entities which do not receive a business deduction for their health care costs. All other businesses are able to fully deduct their health costs lowering their payroll tax liability. We feel that self‐employed should have the same tax treatment of health costs as all other businesses.



Business Wire –

Nov. 8: Orange, CA. – As states around the country begin to assemble their own health insurance exchanges as mandated by healthcare reform, the nation’s leading expert on such programs believes some fundamental essentials must be followed in order for these exchanges to be stable and sustainable.

“State exchanges need to be as welcoming to those currently insured as they are to the uninsured,” said Ron Goldstein, president of CHOICE Administrators, the nation’s leader in developing and administering employee-choice health benefit programs. “Exchanges will need to appeal every bit as much to individuals and small groups who do not qualify for subsidies or tax credits as they do to those who qualify for these incentives. Only by being inclusive to all individuals can a state exchange attract the type of balanced enrollment that will allow it to be a stable and sustainable force in the market.”

As the architect and president of CHOICE Administrators, Goldstein oversees the nation’s oldest and most successful private health insurance exchange for small and mid-size groups – CaliforniaChoice. Launched in 1996 CaliforniaChoice currently works with more than 10,000 employers and covers 150,000 members. In August it became the first health insurance exchange in the nation to reach the 20 million member-month historical plateau.

Leveraging this experience, Goldstein believes that in order for state exchanges to be balanced and sustainable, they must focus on a three-pronged formula for success. “First, state exchanges must harness existing sales and enrollment channels such as brokers and general agents who already have established relationships in the market and who know how to get the job done,” he says. “It is vitally important that we don’t unnecessarily disrupt the market or force purchasers away from something that is already working.

“Second, state exchanges will need to make sure they are operationally and administratively excellent with a strong consumer focus,” Goldstein continues. “And third, they need to acknowledge that there will remain a market outside the exchange providing businesses and consumers choices in their healthcare decision making.”

Health insurance exchanges are a key feature in the Patient Protection and Affordable Care Act, which mandates that every state establish a health insurance exchange by January 1, 2014, or default to a federal “fallback” exchange.

Exchanges are designed to promote choice and make health insurance purchasing more value based by allowing an individual or small business to compare the costs and benefits of various health plans and benefit options. With such information in hand, purchasers will be able to do a better job selecting a health plan that best fits their needs and budget.

“Exchanges may end up the yardstick by which health reform is judged for generations to come,” said Goldstein. “Making health insurance more accessible and affordable for all Americans is an awesome task and noble goal. If we all pull together, we can make it work.”


New Governors to Target Health Law

By JANET ADAMY  Associated Press

Scott Walker, Wisconsin’s Republican governor-elect, says he plans to join a lawsuit over the health law.

Newly elected Republican governors are planning to blunt key parts of the federal health overhaul and join lawsuits against it, suggesting states could trump Congress as the hottest front in the fight over the law. There’s also a major lawsuit against xarelto, click here to see the side effects of Xarelto. And see if you or a loved one could have a case against xarelto.

Republicans recaptured at least 11 governors’ seats from Democrats in Tuesday’s election, winning in Pennsylvania, Ohio, Michigan, Wisconsin, Kansas, Oklahoma, Wyoming, Tennessee, New Mexico, Iowa and Maine. Democrats reclaimed at least two seats from Republicans, in California and Hawaii.

House Republicans have pledged to repeal the law, which is designed to expand insurance to 32 million additional Americans, or at least choke off funding to implement it. Democrats in the Senate can block any repeal, and the defunding strategy faces roadblocks.

While governors can’t avoid much of the law, they can throw sand in its gears and keep states out of involvement in a central part of it—new exchanges for selling insurance policies.

Wisconsin’s Republican governor-elect, Scott Walker, met with lawmakers Wednesday to discuss how to minimize the state’s participation in the law’s expansion of Medicaid, the federal-state insurance program for the poor. He also wants to lean on private entities to run the insurance exchanges, where lower earners who qualify for tax credits and small businesses will shop for insurance starting in 2014.

Under Gov. Jim Doyle, a Democrat, Wisconsin ambitiously courted early health-law money, including funding for free birth control.

Mr. Walker is worried that the Medicaid expansion, initially paid for by the federal government, will be too costly once states must begin paying for a portion of it in 2017.

“Free money is not free,” he said in an interview. “If we can’t afford it, it doesn’t matter how much of it is free.”

Mr. Walker, along with new GOP governors in Wyoming and Oklahoma, said they planned to join in the legal fights against the law’s requirement that most Americans carry insurance or pay a fine.

Plaintiffs in the largest suit, a 20-state effort led by Florida’s Republican attorney general, plan to reach out to as many as six states with newly elected Republicans to join the effort, according to a person familiar with the case, though it may be too late to join.

Health-care companies say GOP gains at the state level offer new opportunities to influence how the law is implemented.

“We have more Republican governors who may have interest in different models,” Aetna Inc.’s Chief Executive Ronald Williams told analysts in a conference call Wednesday. So the discussion “may very well tip it more toward market-based solutions as opposed to others.”

In a recent NBC News/Wall Street Journal survey, 51% of respondents said it would be acceptable to repeal the law. President Barack Obama said Wednesday he wanted to know which parts of the law Republicans don’t like.

“When it comes to pre-existing conditions, is this something you’re for or you’re against?” he said at a news conference, referring to the mandate on insurers to cover those who already have ailments.

“Helping seniors get their prescription drugs—does that make sense or not?” he said.

Mary Fallin, a Republican elected Oklahoma governor, said she was emboldened by a largely symbolic 65%-35% vote in her state for a measure opposing the individual insurance requirement.

“I think the people of Oklahoma have spoken that they’re concerned and they do not support the program of taking over the health-care system,” Ms. Fallin said.

She said she was looking at whether Oklahoma can lean on an existing public-private program that provides insurance to the poor as an alternative to the law’s Medicaid expansion.

“We certainly will try to minimize the impact the new federal law will have on the state of Oklahoma and certainly on our budget with unfunded mandates,” Ms. Fallin said.

Should states opt out of the law’s Medicaid expansion, they would have to remove themselves entirely from the Medicaid program—an unlikely outcome.

But Ray Scheppach, executive director of the National Governors Association, said states were likely to press the federal government to delay the expansion beyond 2014 given states’ bleak budget picture.

Matt Mead, Wyoming’s Republican governor-elect, can appoint his own attorney general and insurance commissioner-two positions with ample influence over the law’s enactment.Mr. Mead said in an interview that the current governor, a Democrat, has already begun preparing the state to operate the insurance exchanges, but he hasn’t decided whether he will go forward with running them. The federal health law provides for state-based exchanges but allows states to leave operation to the federal government.

“It’s just a question of what is right for Wyoming,” he said


States, not Congress, can thwart healthcare law

Los Angeles Times – Reporting from Washington and Chicago —

House Republicans swept to power Tuesday with promises to roll back the new healthcare law and subject its creators to a merciless round of congressional investigations.

But the fate of President Obama‘s sweeping overhaul will probably be determined not in Washington but in state capitals across the country, where the GOP also scored dramatic victories.

Republican governors and legislatures, who are charged with carrying out crucial parts of the law, will be in a position to put pressure on the White House to scale back some plans, including the extension of government-subsidized health benefits to millions of uninsured Americans.

State Republicans could also temper insurance regulations and compel a relaxation of new mandates set to take effect over the next few years.

And by joining a multistate legal challenge, Republican governors may further embolden conservative judges to invalidate a new requirement that Americans get health insurance beginning in 2014, a key pillar of the healthcare law.

The governors-elect of Kansas, Oklahoma, Wisconsin and Wyoming have already indicated they want to join the 21 states suing over the law.

“While there are some important decisions still to be made in Washington, the real action is out in the states,” said Alan Weil, executive director of the National Academy for State Heath Policy.

With Democrats in control of the Senate and President Obama sure to veto any healthcare repeal, House Republicans have little power to force many changes from Washington.

But Republicans gained at least 11 governor’s offices last week, while losing three, flipping states such as Wisconsin and Pennsylvania where Democratic governors had been moving aggressively to implement the new law.

The GOP will also control state legislatures in at least 25 states next year, up from 14. Among actions expected of the states under the law are creating state-based insurance exchanges in which people who don’t get benefits at work would be able to shop for health plans starting in 2014.

Many of the newly elected officials, such as Florida Gov.-elect Rick Scott, ran blistering campaigns against the healthcare law. Scott, a former hospital executive who personally bankrolled one of the first ad campaigns against the healthcare bill in 2009, has called the law the “single largest government power grab in history.”

However, Weil and other healthcare experts who are working with states say it is unlikely that even the most critical Republican politicians will simply refuse to implement the law.

GOP officials in many states that are fighting the law in court — including Virginia, Florida, Louisiana, Minnesota and Nevada — have already convened healthcare task forces to work on the overhaul.

“If I had been a member of Congress, I would have voted against the law,” said Louisiana Insurance Commissioner James Donelon, a Republican. “But it’s the law, and we will comply with it until and unless the courts or Congress change it.”

Republican governors have another incentive. The new healthcare law authorizes federal officials to operate an insurance exchange in any state that chooses not to do so.

“Having the federal government march in” is not appealing to many state leaders, said Timothy Jost, a law professor and consumer representative to the National Assn. of Insurance Commissioners.

But resistance to the new law has already emerged in several statehouses. Legislatures in Minnesota and Rhode Island in the last year have rejected bills to create insurance exchanges.

In California, legislation creating an exchange passed without a single Republican vote in the Senate.

Now, several governors are also looking at ways to slow down a major expansion of the Medicaid program, the federal-state insurance program originally designed for poor children.

Beginning in 2014, the law directs states to open Medicaid to all low-income residents, a move that is estimated to cover an additional 16 million people by 2019.

While the federal government is to provide most of the new funding, some state analysts predict it will be difficult for financially strapped states to shoulder even a small increase.

“This recession was so big and broad and wide that it will have repercussions for a decade or more,” said Ray Scheppach, executive director of the National Governors Assn.

State lawmakers may also resist efforts by the Obama administration to expand state oversight of insurance premiums, a key goal of the new healthcare law. Bills to strengthen state regulation were recently quashed in California and Pennsylvania.

Some state insurance commissioners are also looking to petition the Obama administration to delay other new regulations that require insurance companies to spend more on their customers’ medical care.

Maine was the first state to make such a request, citing concerns that the requirement set to take effect in January would force insurers to flee the state, leaving consumers with fewer choices.

Other states are expected to seek waivers from the so-called medical loss ratio provision in coming months.


Employers Looking at Health Insurance Options

The new health care law wasn’t supposed to undercut employer plans that have provided most peopleT in the U.S. with coverage for generations.

But last week a leading manufacturer told workers their costs will jump partly because of the law. Also, a Democratic governor laid out a scheme for employers to get out of health care by shifting workers into taxpayer-subsidized insurance markets that open in 2014.

While it’s too early to proclaim the demise of job-based coverage, corporate number crunchers are looking at options that could lead to major changes. Gov. Phil Bredesen, D-Tenn., said the economics of dropping coverage are “about to become very attractive to many employers, both public and private.”

That’s just not going to happen, White House officials say.

“The absolute certainty about the Affordable Care Act is that for many, many employers who cover millions of people, it increases the incentives for them to offer coverage,” said Jason Furman, an economic adviser to President Barack Obama.

Yet at least one major employer has shifted a greater share of plan costs to workers, and others are weighing the pros and cons of eventually forcing employees to strike out on their own.

“I don’t think you are going to hear anybody publicly say ‘We’ve made a decision to drop insurance,’ ” said Paul Keckley, executive director of the Deloitte Center for Health Solutions. “What we are hearing in our meetings is, ‘We don’t want to be the first one to drop benefits, but we would be the fast second.’ We are hearing that a lot.” Deloitte is a major accounting and consulting firm.

“My conclusion on all of this is that it is a huge roll of the dice,” said James Klein, president of the American Benefits Council, which represents big company benefits administrators. “It could work out well and build on the employer-based system, or it could begin to dismantle the employer-based system.”

Employer health benefits have been a middle-class mainstay since World War II, when companies were encouraged to offer health insurance instead of pay raises. About 150 million workers and family members are now covered.

When lawmakers debated the legislation, the nonpartisan Congressional Budget Office projected it would only have minimal impact on employer plans. About 3 million fewer people would be covered through the job, but they’d be able to get insurance elsewhere.

Two provisions in the new law are leading companies to look at their plans in a different light.

One is a hefty tax on high-cost health insurance aimed at the most generous coverage. Although the “Cadillac tax” doesn’t hit until 2018, companies may have to disclose their exposure to investors well before that. Karen Forte, a Boeing spokeswoman, said concerns about the tax were partly behind a 50 percent increase in insurance deductibles the company just announced.

The tax is 40 percent of the value of a plan above $10,200 for individual coverage and $27,500 for a family plan. Family coverage now averages about $13,800.

White House adviser Furman said blaming a cost increase next year on a tax that won’t take effect for eight years “stretches credibility very far past the breaking point.”

Bigger questions loom over the new insurance markets that will be set up under the law.

They’re called exchanges, and every state will have one in a few years. Consumers will be able to shop for coverage among a range of plans in the exchange, with a guarantee they can’t be turned down because of an existing medical problem. To help make premiums affordable, the law provides tax credits for households making up to four times the federal poverty level, about $88,000 for a family of four.

Bredesen said last week that employers could save big money by dropping their health plans and sending workers to buy coverage in the exchange. They’d face a fine of $2,000 per worker, but that’s still way less than the cost of providing health insurance. Employers could even afford to give workers a raise and still come out ahead, Bredesen wrote in a Wall Street Journal opinion piece.

Employers are actively looking at that. “I don’t know if the intent was to find an exit strategy for providing benefits, but the bill as written provides the mechanism,” said Deloitte’s Keckley, the consultant.

Erin Shields, a spokeswoman for the senators who wrote that part of the law, says she’s confident that when companies do the math, they’ll decide to keep offering coverage.

That’s because employers get to deduct the cost of workers’ health care from the company’s taxes. Take away the health plan and two things happen: Employers lose the deduction and they’ll probably have to pay workers more to get them to accept the benefit cut. Not only will the company’s income taxes go up, but the employer will also face a bigger bill for Social Security and Medicare payroll taxes. So it’s not as simple as paying $2,000 and walking away.

“It is clearly cheaper for employers to continue providing coverage,” Shields said.

Another wrinkle: the health insurance tax credits available through the law are keyed to relatively Spartan insurance plans, not as generous as most big employers provide. Send your workers into the insurance exchange, and valuable employees might jump to a competitor that still offers health care.

MIT economist Jon Gruber says it’s impossible to create new government benefits without some unintended consequences, but he doesn’t see a big drop in employer coverage. “This is a brave new world with uncertainties,” said Gruber. But “the best available evidence suggests a small erosion. It’s not going go down wildly.”


Health Reform’s $550B Hidden Costs to Taxpayers


Pop Quiz: if McDonald’s offered a 30 percent discount on hamburgers, would consumption increase, decrease or remain unchanged?

If you said “increase,” you understand a basic principle of economics that most Americans with common sense realize even without completing Econ 101. The idea that “if you tax something, you get less of it” is the same principle in reverse. Yet Congress completely ignored this truism in passing the health bill last March.

Notwithstanding President Obama’s firm pledge to the contrary, “Obamacare” included a plethora of new taxes that will impact Americans at all income levels. Indeed, less than half the revenue raised by Obamacare comes from taxes explicitly limited to high income households ($200,000 for individuals/$250,000 for families).

The remaining new taxes affect all consumers and include levies on prescription drugs, medical devices, health insurance providers and even tanning parlors. These and related revenue increases amount over 10 years to more about $225 billion (over $700 per U.S. resident), an enormous burden on the economy.

It is bad enough that the President would violate so flagrantly his own repeatedly-stated tax pledge. Even worse, Congress completely ignored hundreds of billions of dollars in hidden costs related to these taxes. Recall that virtually any increase in taxes results in lost production. So if we tax prescription drugs and medical devices, fewer people will buy them. The net dollar value of this lost production is called “deadweight losses” by economists, but it’s simpler to call it a social welfare loss.

This may seem trivial. However, economists have figured out that for every additional dollar imposed in new federal taxes, social welfare losses amount to 42 cents per dollar of new tax revenue collected.

Thus, every dollar of tax-financed spending really costs society $1.42 — one dollar in visible transfers from taxpayers to the government and another 42 cents in hidden losses related to unseen goods and services that would have been produced but for these added taxes.
You would think that Congress would take into account such massive hidden losses when debating proposals as expensive as health reform. Yet it does not. By ignoring these costs, the true costs of health reform — even if accepting the unrealistic way in which the bill was scored –were probably $157 billion higher than advertised.

But the bill also included Medicare and Medicaid savings that even the Medicare actuary has said “may be unrealistic,” along with an assumed 21 percent reduction in physician payments that no one expects to happen. Including the added taxes needed to cover $550 billion in savings never realized or to pay the roughly $300 billion needed over 10 years for a “doc fix” to avert deep cuts in physician pay, the overall hidden social welfare costs of taxes needed for health reform would rise to $550 billion.

Imagine you were a member of Congress who reluctantly cast a vote for health reform because Presidential arm-twisting persuaded you that the benefits exceeded costs. Had you been aware that the true cost of the bill was at least half a trillion dollars more expensive, might that have changed your vote?

It is distressing to think that such a massive cost would have made no difference in how some members of Congress evaluated this plan. Health reform barely passed the House. Yet a mere four more “no” House votes would have defeated it.

It is plausible to believe the outcome would have been different had Congress been made aware of the enormous, hidden costs embedded in this bill. Like the consumer who jumped at McDonald’s 30 percent off sale, Congress passed a plan that appeared to be about 30 percent cheaper than it actually will be after purchase. And now, we all are beginning to pay the price for this hasty and ill-informed decision.

Conover is a research scholar at the Center for Health Policy and Inequalities Research at Duke University.