Survey on the Affordable Care Act

Following the botched rollout of the affordable care act, people are dazed (perhaps a better term would be "shock and awed' by the limp and incompetent rush to open the exchange on time rather than do  it right the first time.  Having to do it  over must have cost big time !

The good news for those of us who see the ACA as a mis-step toward uniform health care (note I did not call it Universal Health Care.   An inadequate and poorly constructed Universal Payer Plan is not necessarily uniform.

The very public event has opened the door for much discussion and now the time is ripe for changing the plan to something much better, less expensive and equitable, not designed to redistribute wealth. That is not what health care is about.  Obama's plan is deceitful in most ways..  The only redistribution of wealth would be to insurers, big  pharma, and the U.S. government at taxpayer expense.

Freedom Works has just released a survey that you should look at and participate.  This is your chance to participate with new ideas.

Freedom Works is an organization now intent upon  health reform and maintaining the underlying freedoms we as all Americans cherish.

How will Freedom Works support our goals for health reform? Freedom Works not only is interested in health care, it also  works across a wide variety of niches with a consistent underlying standard based on our most fundamental beliefs of freedom and constitutional law.

An email arrived in my inbox from Freedom Works that i would share with all my readers, providers, patients, employees of our health system and leaders in Congress.

This is your chance to weigh in on improving the Accountable Care Act.  Take the Survey constructed by Freedom Works.

Looking Back at 2013

This report is somewhat late due to last minute projects at the end of 2013 and the confusion about the individual mandate, the botched launching of health benefit exchanges and some other unexpected tasks

We reviewed the 'best"  Health Train Express posts of 2013 as measured by the number of comments and our analytics.

IRS VIOLATES HIPAA FACES LAWSUIT BY A "J Holiday Message for Health and Wellness WHY AREN'T DOCTORS INVOLVED IN HEALT Does Obama really want the Affordable Care Act Covered California What They Said Before the Train Wreck: The To Sebelius will be a no-show at Obamacare hearing The Beginning or The End to the Affordable Care Act There were many more 'favorites".  The highest number of page views was in the category of the Affordable Care Act. This was to be expected, given the high ranking of the ACA for search engines. Visit the sites on Health Train Express for many more interesting topics. Health Train Express has archived our posts dating back to 2005.  The focus of posts has changed over the  years, and reveals the dynamism of health care and reform.

Happy New Year .... NOT for Health Reform

Should we be content that we made it through 2013, it seems we always do, no matter what happpens.  Now is the time to become accountable and assertive to determine our future health care.

Many aspects come together to produce 'the perfect storm'.  This storm is not necessarily a destructive one. It has set off an early warning signal for our country that we must be cautious of how we reform our health system.

Nevertheless our health system is in shambles, further delays in revising it, or continuing on with the ACA will lead to a train wreck.

Obamacare is focused on health insurance, with caveats, rewards, and penalties.. Neither patients or providers were the center of the reform.  The  item that did serve patients was solving the pre-existing conditions as a reason  for denying coverage,and eliminating the cap on coverage.

Health Reform will not take place in isolation or in one swoop,  and despite the ACA we will not yet have a functioning plan, nor will we if we continue with the present legislation.

Health Train Express receives a daily stream of analysis and recommendations for future modification to our system.  Neither hype, grandiosity, political motives nor slick marketing by 'celebrities' is going to 'fix' our system.

The good news is that we do have the finest scientific and technical resources already at our beck and call. All of this is available, it's a question of distribution, and we can compare it to supply line  management. We do not need a "Manhattan Project" to invent a new technology.  We already possess it. Perhaps this is an oversimplification, however many have compared our system to other industries, such as the airline business, the banking business and shipping businesses. No one model correctly addresses health financing.

There are aspects, accessibility, funding, prevention, and correcting the huge cost disparites and how to correct the burden for deficits & reimbursements.

Although  the ACA passed in 2010, we are more than three years down the road,  and most of the ACA has not occurred.  Further delays will occur now due to the inability to implement the first stages and mandates.  What has happened is the insurance companies have been sent into disarray, and have been asked already to double back.

The extent of increases in implementation cost will accelerate further and even cancel whatever cost reductions are predicted by the ACA.   Some studies have already demonstrated this fact.

Fortunately, the disagreements and controversy have focused attention on our health system for many who have been  passive and willing to accept the system for what it is. Each  year we witness a steady increase in premiums, increasing deductibles, increasing co-payments and decreasing reimbursements. We have mistakenly used tax law to minimize or maximize gains from insurance coverage with MSPs, HSAs, and now face a myriad of new, unproven schemes such as Accountable Care Organizations (ACO) predicted to decrease cost and improve quality.

It is a highly complex equation, involving some market economics, and a system of reimbursement that defies logic.  For some time the financing has been approached as a point of service transaction(POS) with creative financing such as capitation, some tax credits, and deductions. A portion of the state's public social service system is deemed 'free care' although it is not.

There are many 'misnomers' , such as 'usual and customary charges', pre-paid rates, adjustments, and cash deductions, Insurance companies have based their rates and policies upon algorithms and actuarial analysis, and a 'fudge factor' for unpredictability.

Many have sad, health care is a right, based upon aspects of the constitution in regard to the pursuit of happiness and freedom.  Although the word health does not appear in the  constitution, health can be construed to be a part of pursuing........life and happiness.

Others state that health care is not a right and not everyone should have health coverage, with a bit of 'they don't deserve it.  Neither truly can be legitimized by such a callous attitude.

What we need is a steady hand on the system that will deal equitably and with imperturbability the illnesses of human life and the equal ability to cope with it.

Freedom Works is an organization now intent upon  health reform and maintaining the underlying freedoms we as all Americans cherish.

How will Freedom Works support our goals for health reform? Freedom Works not only is interested in health care, it also  works across a wide variety of niches with a consistent underlying standard based on our most fundamental beliefs of freedom and constitutional law.

An email arrived in my inbox from Freedom Works that i would share with all my readers, providers, patients, employees of our health system and leaders in Congress.

This is your chance to weigh in on improving the Accountable Care Act.  Take the Survey constructed by Freedom Works.

ObamaCare: We Did Not Know What was In It Until It Passed

It did pass, and we still don't know what  is in it.  Each day we learn of waivers, modifications, amendments to 'fix' fatal flaws in the law.  This is the simple part.....getting people to sign on for health coverage....the doorway to health and wellness.

Dates have been set, mandates have been put on hold, insurance policies were cancelled, no wait..Obama says "Kings X", I take that back. Sebelius smiles and goes before congress, non-plussed.  She must be close to retirement so no problem and undoubtedly she will be through with her public service.  I wonder if she has health coverage?

Many of us have tried to take the high road and plan health reform logically analyzing each step as we proceed.  This is almost a futile endeavour, because the landscape is constantly changing.




Secretary of Health and Human Services Kathleen Sebelius testifies at a Congressional panel last week. The White House has outlined a new exemption under the Affordable Care Act

n a last-minute policy change, the Obama administration waived the so-called individual mandate under the Affordable Care Act for people whose individual health insurance policy is being canceled.

The act requires most Americans to have qualified health insurance starting in 2014 or pay a tax penalty, unless they meet one of myriad exemptions. One is if qualifying coverage would cost more than 8 percent of household income (the affordability exemption). Another is they can prove a hardship such as homelessness, bankruptcy, domestic violence, large medical debts, utility shutoff notice or death in the family.

Under new guidance issued late Thursday, the Centers for Medicare and Medicaid Services (CMS) said that having an individual insurance policy canceled now qualifies for the hardship exemption.

The process is not really that simple:

People who qualify for the cancellation hardship exemption have two options:

-- Don't buy coverage and don't pay a fine.

-- Buy a bare-bones catastrophic policy on an exchange. These catastrophic policies do not meet the requirements of the Affordable Care Act, but people who buy them won't owe a fine. Before Thursday's rule change, to buy this policy a person had to be younger than 30 or meet the affordability exemption.

To qualify for the new policy-cancellation exemption, consumers must complete a hardship application, which will let them purchase a catastrophic plan or receive a penalty waiver, according to Centers for Medicare and Medicaid Services. (For the application, see http://1.usa.gov/19YrBnK.)

To purchase the catastrophic policy, they must submit the form, and evidence of a canceled policy, to a company selling such policies in their area.

The announcement came just days before the Monday deadline for enrolling in coverage to start Jan. 1, and insurance companies are not happy.

When Obama announced another policy reversal in November - saying insurance companies could temporarily renew certain policies that were to be canceled because they did not comply with the act - he gave states the option of allowing that or not.

Covered California did not. As a result, most individual health policies in California that are not grandfathered will be canceled Dec. 31.

Some customers of Anthem Blue Cross and Blue Shield of California will be able to keep their non compliant policies until the end of February or March, respectively, under a settlement with the state insurance commissioner.

People with individual plans that are grandfathered, meaning they had them before the act was signed in March 2010, may keep them until the insurance company decides to cancel them.

It appears that nothing is guaranteed as to the roll out. Insurers, providers, hospitals are all nervously watching and waiting. 

The United States of Affordable Care (Act)

Health Care Financing would seem to be a long way off from the patient waiting to see their physician.

In today's world the quantitiy and qualitiy of care depends very much upon the type of health insurance the patient has to use.   The care may be far different according to region, or state.

The term 'public health ' is a misnomer. The public health system is not accessible to all people for a number of reasons.  Many perceive public health as inferior to the 'private system of health care", and only would access a center if there were no other option. Many current users of public health and/or Federally Qualified Health Centers would not even know how to access ' private care'. Learn more about them here and here and  here.  I particularly like the last one. No one home --

The resource cannot be found.

If you are successful, the rules are as long as the Affordable Care Act.

A new term which may be unfamiliar to most providers and/or patients is the "Federally Qualified Health  Centers".  These centers are found more commonly in areas of low economic assets and amongst many people who fall in the range of the Federal Poverly Level (FPL).  And here are the numbers which are both unrealistic at the lower end and even more unbelievable at the top end.

• $11,490 to $45,960 for individuals
• $15,510 to $62,040 for a family of 2
• $19,530 to $78,120 for a family of 3
• $23,550 to $94,200 for a family of 4
• $27,570 to $110,280 for a family of 5
• $31,590 to $126,360 for a family of 6
• $35,610 to $142,440 for a family of 7
• $39,630 to $158,520 for a family of 8

We seem to be an impoverished nation in the world of developed countries.

Many of these centers predominantly serve 'medicaid' beneficiaries. They also serve ( unintentionally) to isolate medicaid and those who are receivng public assistance from the main stream of health care.  Hospitals and providers also treat these patients differently, not so much in terms of the quality of care they receive....rather the accessibility.  Many budgetary decisions by states often effect Medicaid patients first, because large portions of state budgets are allocated to Medicaid.

There is a non-admitted  'caste' system when it comes to medical care.  It largely is secondary to income and location, and in cities there is often a sharp divide between those living in upper middle class neighborhoods and lower class neighborhoods.

The situation is also becoming worse, and there is no sign the Affordable  Care Act will diminish the divide.
Although the ACA specifies preventive medical care  (for free)  Despite being "free", there will be a cost. There are 14 general categories,   22 special categories for women, and 25 categories for children.

A disturbing distinction between public health and private health financing is also more evident with the introduction of health information technology. In order to qualify for Grants for Information systems and operational financing a non-profit status is a requirement, which immediately rules out most entrepenurial systems (ie, private fee for service office and/or clinics, as well as some hospitals.

Health Reform: A Play in Multiple Acts

It is a very exciting and troubling time  for health care in the United States.  The stage is set for multiple acts occurring simultaneously.

For those who have boots on the ground with financial commitments and assets the changing landscape means unknown profits (if any) or losses.  Health institutions and providers charged with improved outcomes and 'less cost' are facing the conundrum of supplying more care with less money.

Leonard Zwelling M.D., a Houston physician who was a congressional staffer during the writing of the affordable care act puts it this way, as he discusses a statement made by

Norman Ornstein, a scholar at the American Enterprise Institute, one of the leading experts on the workings of Congress, summed it up in one sentence during a briefing for the press and politicos in November 2008. He said:

"Every one's idea of health care reform is the same: I pay less."

Where I was trying to get my head around a solution to the three tenets of my idea of health care reform, everyone around me was trying to preserve or increase his piece of the health care payoff pie. I was looking for a legislative solution to assist the country in arriving at the place where the rest of the civilized world was - the provision of some form of universal health care as a right of citizenship. Everyone else was looking to cut a deal that preserved his place at the trough of health care profiteering. Guess who won?

With the full cooperation of the Congress and the White House, health care was not even remotely reformed. The Affordable Care Act is not about health care reform. It is about money, particularly preserving the insurance industry's hold over how health care dollars are spent.

Hospitals and providers had little to do with the Affordable Care Act.

"The Affordable Care Act continued to allow hospitals to jack up prices with no relation to actual costs. Only the doctors gave up something because, unlike the insurance industry and the pharmaceutical industry, medicine did not speak with one voice when lobbying on Capitol Hill and thus could largely be ignored. This is health care reform? I don't think so.

The reason the Affordable Care Act did what it did is because that's what it aimed to do - increase access to insurance for the uninsured, get everyone else to pay for it, and make sure no one currently in the health care business loses a dollar from the amounts they are already extracting from patients and doctors alike.

Complicating Ornstein's comments are the multiple scenes ongoing in the 'reform' efforts

Technological advancements such as

Health information technology which includes electronic health records, health information exchanges, the proposed upgrading of the ICD - 9 to ICD -10, the advances in mobile health, telemedicine and more.......

The increased regulatory arm with meaningful use in 3 steps.  MU is linked with financial  incentives from CMS to offset the expense of providers and hospital acquisition of electronic medical records.

The challenging role of an unproven health benefit exchange system, with an incomplete back end disconnecting the actual payment to insurers.





The details of connecting the dots are only now coming into focus for bureaucrats and congress who badly underestimated the complexity of health care delivery.  The turmoil is clearly more evident among providers, hospitals and the patients who are the "guinea pigs"

During the next 12 to 24 months the 'symphony" will unfold.  Will it be harmonious or an unfinished symphony?

Freedom of Information Act Request filed by Health Train Express

Doctors Complain They Will Be Paid Less by Exchange Plans.  Many will opt out of private plans. News reports indicate that 70% of California MDs will not participate in the Health Exchange and the Private plans Some have complained to medical associations, including those in New York, California, Connecticut, Texas and Georgia, saying the discounted rates could lead to a two-tiered system in which fewer doctors participate, potentially making it harder for consumers to get the care they need.

Insurance officials acknowledge they have reduced rates in some plans, saying they are under enormous pressure to keep premiums affordable. They say physicians will make up for the lower pay by seeing more patients, since the plans tend to have smaller networks of doctors.

If you’re a physician and you’ve negotiated a rate from insurance, shouldn’t it be the same on or off the exchange?” said Matthew Katz, executive vice president of the Connecticut State Medical Society. “You’re providing the same service.”

The benchmark for physician fees is the rate the federal government sets for services provided to older Americans through Medicare. In many markets, commercial plans may pay slightly above the Medicare rates, while doctors say that many of the new exchange plans are offering rates below that.

Physicians are uncomfortable discussing their rates because of antitrust laws, and insurers say the information is proprietary. But information cobbled together from interviews suggests that if the Medicare pays $90 for an office visit of a complex nature, and a commercial plan pays $100 or more, some exchange plans are offering $60 to $70. Doctors say the insurers have not always clearly spelled out the proposed rate reductions.

Health Train Express has filed a FOIA request from CMS (Freedom of Information Act which will require full disclosure to the providers and public  (ie, transparency that Obama claims to encourage)  Watch for the published link in about one month

Affordable Care Act "It ain't over until it's Over"

If you are reading this blog and waiting for me to tell you what is going to happen in health reform, you have come to the right place.  I know as much about this as Kathleen Sebelius or Barak Obama.

I am certain that makes you all feel better.

I know that is reassuring to my readers, because Obama and Sebelius had access to and heard many learned opinions on developing the affordable care act. However they were not listening and the elephant in the room was political intrigue, and 'what's in it for me ?"

Today my spouse received the magic letter from Covered  California stating that she has qualified, and now all she has to do is go to the website  log-in and pick her (Silver plan) That is no small task.

Among many other things, the subsidies make no logical sense to me (or others)  I need all of my funds to support myself and my disabled wife who has been unable to work for over ten years.  $250 USD would help pay for the pain medication she takes as a result of a bad wrist injury in 2002. After that she was uninsurable, so I am grateful that the ACA now affords her the ability to become insured until she reaches age 65 and  will be eligible for Medicare.

 It seems that my user id and/or password is incorrect, and I do not remember any of the questions, or answers for the security questions. Small wonder....their selection of Q&As is quite a mystery to me. I am so old I don't remember who my best friend in high school was, no the color of my first car, nor my favorite food (I like them all). Whatever happened to my mother's maiden name?

I called the telephone numbers listed on Covered California for lost user ids/passwords, and was either greeted with a busy signal or a 'we are busy right now, go to our web site, coveredca.com. Now would anyone call them if they had not already tried to use the web site.  The live on line chat room brings up a blank white screen.

The ACA has created stress for all of us, not knowing the eventual outcome...success or failure or some point in between  For those whose former policies  have been cancelled I say let's let them get to the front of the line.

It makes a lot of sense......they are already paying customers and the system needs their premium dollars now.

Everyone else should wait several weeks. Another month won't make much difference to those who have not been insured for the past decade or so.

Although I have never liked insurance companies, I do feel empathy for the mess the affordable care act has produced on top of the measly 15% margin they must operate upon now, and all those pre-existing condition patients waiting in the wings.

As Yogi Berra (byname of Lawrence Peter Berra) once told me, "It ain't over, until it's all over"  (Yes, he did tell me that personally when I was a sprite living in Connecticut.)  My Dad took me to at least a hundred Yankee games in the Bronx. I also have a signed Mickey Mantle original photo of the "Bronx Bomber"

So what does that have to do with the ACA? Let's listen and take seriously what Yogi had to say. I trust him, after all he was a Yankee on a team that broke all records winning  7 world series' back to back.

Would you rather trust President Obama, our Congress, or Secretary Sebelius?  After all Yogi batted left handed and threw right handed. (source Wikipedia)/