Health Reform and Spudnutz

I stood in line at 6:45 Sunday morning to purchase donuts at a very popular local donut shop—Spudnutz—at Lake Okoboji. The line of donut seekers stretched far out the door. I did not receive donuts until 7:50 am. I waited more than an hour for donuts (Yes, very good donuts). Nine people were working in that donut shop that once housed an auto mechanic shop.

If either the Senate bill or the House bill that was intended to repeal and replace the Affordable Care Act (ACA) became law, I fear none of those nine hard-working people would have health care coverage in the future. For many of my patients and for, I believe, the employees of Spudnutz, I give thanks for the defeat of the Senate “skinny” repeal legislation.

The fallout from the middle of night vote in the US Senate defeating the “skinny” repeal of the ACA includes statements from as the Republicans saying that the states need to be given the flexibility to decide health care for the residents of their states or the Republicans saying able-bodied individuals ought to work with the expectation that they could then have employer based health insurance. Both statements reveal neither Republicans do not know nor do they care about the health coverage for poor and middle-income Americans.

The ACA gave the states the ability to decide whether to run a state based exchange, gave the states via a Supreme Court ruling, the ability to expand Medicaid or not, continue to give the states the power to determine insurers in the Individual Market, and finally gave the states the ability to administer the Medicaid program even though the federal government is paying 90 percent of the cost of the expansion.

In Iowa, these state determinant elements of the ACA allowed Governor Terry Branstad’s administration and the Republican run Legislature to quash establishing an Iowa-specific Exchange, to trash talk the ACA at every available opportunity, and to withhold assistance to what was our new start-up cooperative insurance entity, CoOportunity Health, when it failed. The Republicans are now gladly propping up Medica, the only remaining health insurer in the Iowa Individual Marketplace. All the while President Trump continues to threaten to end insurance subsidies which would further destabilize the individual market not only in Iowa but across the country.

Iowa chose to expand Medicaid for which I applauded them. Governor Branstad and the Iowa Legislature then chose to turn the entire state Medicaid operation over to three for-profit manage care companies. I argued strongly against for profit corporations taking this role (see previous blog posts). These companies suffered a cumulative loss in the first year of $224 million for which the state of Iowa was billed only an additional $10 million. I do not know how much the federal government was billed. In addition, both patients and providers have complained about how the managed care companies have administered Medicaid in Iowa.

Nineteen states chose not to expand Medicaid thereby withholding health care coverage for more than four million US citizens.

In Iowa, a well run State Exchange with the full backing of the state government and state assistance for Co-Oportunity Health in the manner and amount that Medica is now receiving state assistance would have led to a much more stable individual insurance market. Additionally, I believe a state administered Medicaid program, the type of program we had prior to the managed care corporations taking over, would have been a much better use of taxpayer dollars and provided a better system for both patients and providers.

I believe there is every justification in calling the Iowa experience with the ACA “TerryCare,” with   its state imposed limitations.

Given Iowa’s experience and the 19 states that chose not to expand Medicaid; a belief that states did not have the power nor use the power to affect the ACA is simply wrong. It also calls into question whether states should be given more flexibility regarding health care coverage decisions.

I do believe able body individuals should work; I also believe that under a Republican plan for health care for those on the lower rungs of the income ladder, that their usual jobs would not have health insurance as a benefit or that the options for health insurance would be limited and cost far too much. The current system of Medicaid for individuals working at the very lowest paying jobs and government subsidies for individuals at the next higher level of paying jobs are not only desirable but are necessary.

As we move forward in this fight for health reform, I think our goal should be to keep affordable, accessible health care for employees such as those working at Spudnutz. The “skinny” repeal would not have allowed for such coverage.

Hopefully, a bipartisan approach will bring stable and ongoing health care to Americans. There are currently many thoughts, plans, and ideas floating around in Washington. Please see the blog entry entitled, “Health Reform and Nick Bath”, March 2017, for some solid ideas.




Health Reform and Blood Money

In 2003, Iowa used part of its portion of the 1998 Tobacco Settlement monies to help build a new Supreme Court Building. During those years and later, Iowa Republican legislators sought to reduce the funding and scope of the Iowa Tobacco Commission, which was created to use the settlement monies to help Iowans to either quit smoking or not start. I said at that time, that using the tobacco settlement monies for any use other than health care was wrong. As a former Chair of the Tobacco Commission, I viewed this money as blood money because it was being paid out to partially compensate for the death and disease that cigarettes had caused Iowans for many decades.

Similarly, I use the same term, blood money, today regarding the U.S. Republican House and Senate efforts to repeal and replace the Affordable Health Care Act with a plan that will reduce wealthy individuals’ taxes by over $600 billion over ten years by taking a similar amount of money from the Medicaid program and from subsidies used to supplement poor and low-income individuals’ effort to pay for premiums in the health individual insurance market. If this effort is successful, people (the Congressional Budget Office (CBO) estimates 23 million Americans under the House Bill and 22 million under the Senate Bill) will lose health care coverage. Additionally, regarding the individual insurance market the CBO said, “Under this legislation, starting in 2020, the premium for a silver plan would typically be a relatively high percentage of income for low-income people. The deductible for a plan . . . will be a significantly higher percentage of income, also making such a plan unattractive . . . as a result, despite being eligible for premium tax credits, few low-income people would purchase any plans.”

Some of those people will die and many will suffer without health care coverage. Both the House bill and the proposed Senate bill will transfer money to the wealthy at the expense of the lives of others. This is the new explanation of “blood money”.

As Paul Krugman said in today’s New York Times, “More than 40 percent of the Senate bill’s tax cuts would go to people with annual incomes over $1 million . . . while . . . according to best estimates, around 200,000 preventable deaths” would occur with the loss of health care coverage for 22 to 23 million Americans.

How do you have a credible public relation campaign with this stark contrast between greed and suffering? Rod Whitlock, a lobbyist for hospitals and individual with disabilities, who I knew when he worked with Iowa’s U. S. Senator Chuck Grassley, said on National Public Radio last Saturday that both House and Senate Republicans explain and sell this idea by separating the tax cuts immediately and forestalling the Medicaid cuts for a few years.

The separation of tax cuts and Medicaid cuts by a period of time is designed to distract the public from the connection.  The other way to hide this transfer of wealth from low and moderate income Americans to the wealthy is by couching the effort as a way to eliminate the individual mandate, which works, and which the CBO supports, and which Medicaid patients and low-income Americans buying into the individual health insurance market are not affected by because they are exempt from paying the income tax penalty fee.” Warren Buffet, one of the wealthiest men in the US, described it best saying the Senate bill was the “Relief for the Rich Act”.

As I have said before regarding the ill- fated Co-Oportunity Health—the Iowa and Nebraska health care cooperative which sold policies on the Exchange in the individual market—after three months of operation, this health insurance company had requests for 24 solid organ transplants (hearts, lungs, kidney, liver, etc.). People with these conditions will again be without health care coverage and subsequently without health care if either the House or Senate Bill passes.

President Trump called the House Bill “mean.” If the Senate Bill forces 22 million people off of health care coverage instead of 23 million Americans can that be considered less “mean”?   Polls regarding the Senate bill seem to agree with the “mean” assessment. I prefer Paul Krugman’s “cruel and immoral” assessment.

Wikipedia says, “After the crucifixion of Christ, Judas returned the payment to the chief priest, who took the silver pieces and said, “It is not lawful for to put them into the treasury because it is the price of blood.”  This quote is drawn from Matthew 27:6

For me, using Tobacco Settlement money for an Iowa Supreme Court Building while trying to cut funding to help Iowans quit smoking defined the price of blood in 2003 by our state government.  Similarly, exchanging tax cuts for the rich with the loss of health care coverage and subsequent morbidity and mortality for the poor and low income is the 2017 definition of “price of blood,” this time by the Federal Government

Two addendums: One) If the Republicans actually wanted to lower the cost of health care and improve health care coverage for Americans, their bill would address the travesty of the ever increasing cost of medicines. The recent obscene jump in the price of long-acting insulin is only one of hundreds of examples.

Two) As I have said before, health care coverage helps create a society where mental health needs are met; where individuals with addictions to various legal and illegal substances such as alcohol, tobacco, opioids, and methamphetamines are addressed; where cancer is prevented or caught early; and where the effects of chronic illnesses are lessened.The overall effect is a safer, less violent, happier, healthier society, from the youngest to the most elder among us.

To the wealthy, I say the taxes you pay to support health care coverage under the Affordable Care Act (ACA) is a great investment.  It is time to let our conscious and morality guide us to do what is right.