Health Reform and Why Words should matter

Ah, words! Especially to writers, they are more precious than jewels, as essential as air, and powerful enough to create entire worlds. We chase them, massage or mince them, we roll them around in our mouths, savoring every delicious subtlety. Mostly, we love them.

~Tammy Letherer

Ms. Letherer wrote these words on a blog entry entitled “Why Words Matter (In and Out of the Locker Room), on October 16, 2016.  In that post, she discussed her unhappiness with Donald Trump’s language regarding women.

In Iowa, former US Representative Bruce Braley lost his Senate race with Joni Ernst in large part to an audio tape of his words to political contributors in Texas disparaging our senior Senator, Chuck Grassley, describing him as “a farmer from Iowa who never went to law school.”

This year’s health care debate centered on the Republicans’ efforts to repeal the Affordable Care Act (ACA) has led to many statements by Republican leaders in Iowa which should come back to haunt them this Halloween season and for seasons to come, as Bruce Braley’s words haunted him.

US Representative David Young gave verbal support of a previous bill that passed the House but was rejected earlier this summer by the Senate. This was a bill that President Trump described as “mean”. Those words of support by Representative Young for a ‘mean’ health care bill should be remembered.

On September 26, the Senate bill that was pulled from consideration by Majority Leader Mitch McConnell because of a lack of support. However, Senator Chuck Grassley gave strong verbal support for the bill saying, “You know, I could maybe give you 10 reasons why this bill shouldn’t be considered, but Republicans campaigned on this so often that you have a responsibility to carry out what you said in the campaign. That’s pretty much as much of a reason as the substance of the bill.”

Senator Grassley’s verbal support for a bill that he believed had multiple reasons not to be considered should also be remembered by Iowans.

Iowa Governor Kim Reynolds also gave verbal support for this most recent bill even though it would take money from Iowa for health coverage when our for-profit Medicaid program is losing money and our individual insurance market is on life support.

She said, “People were sold a bill of goods with Obamacare.” Is taking money away from Iowa going to make Iowa healthcare better? Senator Grassley is saying, in so many words, that the Senate bill was also a ‘bill of goods.’ Iowans should also remember Kim Reynolds’ words.

Bruce Braley learned the hard way that words matter; will Representative Young, Senator Grassley, and Governor Reynolds also discover that their words matter? My underlying message, especially for Senator Grassley, is that campaign promises are not nearly as important as improving health care coverage for Iowans.

Finally, on the final day of September, my wife and I walked the Ledges State Park in Boone County. Due to a washed out road, access to the beautiful sandstone canyon was limited to pedestrian traffic. After walking past the washed out site, the road through the canyon was passable and we saw several empty parking spots. The symbolism of the empty parking spaces struck me as an analogy for health care in Iowa: if Medicaid is cut back and if the individual market implodes, I fear empty hospital beds, empty clinic exam rooms, and empty hospitals. The ‘road closed’ sign will be up for Iowa patients without health care coverage.

Iowans deserve health care and words should matter.



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.

Health Reform and the Orphan called Individual Health Insurance Market

Last week, the buzz in Washington, DC where I heard numerous lectures and personally talked to two U. S. Representatives and two U. S. Senators was about impending health care legislation in the Senate and particularly focused on the imminent crisis in Iowa where there probably will be no insurers for the individual insurance market in 94 of its 99 counties in 2018.

Seventy thousand Iowans may not have health insurance next year in a state that prides itself as an insurance state. Iowa is the poster child for the deficiencies in the individual insurance market. Across the nation, only a few counties in Tennessee have that known potential for 2018, though several potential fixes are being discussed at the federal and state levels.

I discussed my idea to stabilize the individual insurance market by allowing individuals ages 55 to 65 years old to buy into Medicare (see my blog entry titled, “Health Reform and Nick Bath”).

My point today is that the individual insurance Market was a mess before the Affordable Care Act (ACA). The individual insurance market is a mess now, under the ACA.  And, it will continue to be a mess if the House’s  American Health Care Act should become law as it currently exists without significant changes by the Senate. One of the imperatives of the ACA was that because of pre-existing condition exclusions, the individual market worked for the healthy but left many people with chronic diseases uninsured or placed those policyholders in unsatisfactory High-Risk Pools (I have had patients in that Iowa High-Risk Pool).

Now, with the continuation of the ACA and after the filure of Co-Opportunity Health—a federally established cooperative health insurance company—the existing companies could not survive the cost of the individuals with chronic illnesses and the lack of a majority of healthy policy holders.

I contend that the lack of the federally promised protections for Co-Opportunity Health, the lack of support from the State of Iowa to establish a state-based Exchange and having an inadequate public out-reach effort for insurance enrollment helped create the current crisis.

Furthermore, I believe the House’s proposal to allow states to re-establish exclusions for pre-existing conditions, change the essential benefits requirements, force older policyholders to pay higher premiums, and re-establish High-Risk Pools will simply place us in a time warp with the same inadequacies that we had in the pre-ACA world.

I fear we have two false premises driving the Republican efforts for health reform. One is the belief that unfettered capitalism with unrestricted free markets will succeed in the health insurance market. Unfortunately, such capitalism has winners and losers. This time the losers will be individuals with chronic illnesses and older Americans. The second false premise is that if we only had a health care system like we had in the 1950s, we would be happy.  Unfortunately, health care advancements that save lives, extend lives, and significantly improve the quality of life costs money. In the 1950s, people died of cancer, heart disease, and strokes. Today, people with those and similar conditions live well but at significant expense.

I recently traveled to France and I was struck by how many famous and gifted men and women in history died or suffered because of health problems that are now easily treated. My best example is my favorite painter, the impressionist Claude Monet, whose later work in the early 1900s was undoubtedly lessened by severe cataracts.

I hope the moderate Senate Republicans understand these thoughts regarding the inherently unstable individual insurance market. It has no parents and no one to care for it. It is orphaned. I hope the moderate Senate Republicans believe government exists to protect those who will lose in an otherwise unfettered free market system. I hope that moderate Senate Republicans realize that we are not living in the 1950s anymore. I hope that moderate Senate Republicans realize we live in the wealthiest nation in the world. I hope that moderate Senate Republicans realizes that no one should be without healthcare.

Health Reform and High Risk Pools

United States House of Representatives Speaker Paul Ryan is right.  High Risk Pools could be the solution that solves some of the current problems with our health care system.
Even though High Risk Pools have not worked in the past (most immediate for me is the example of my home state Iowa), even though I believe that states have neither the expertise,  the competency, nor the will to run High Risk Pools. Even though I have railed time and again against High Risk Pools as being anti-universal coverage, I now propose a new concept for High Risk Pools.

A quick primer: High Risk Pools are used to offload a particular group of individuals with chronic diseases such as diabetes, heart diseases, and chronic obstructive pulmonary disease,  from the general insurance market because they have pre-existing conditions, which will cost insurance companies too much to care for them.  Separating these individuals from the healthier general insurance pool allows for lower rates for the larger majority of people buying health insurance. Several years ago, we did this separation of individuals when we set up a program to pay for renal dialysis patients.

Why do I propose High Risks Pools might work now in the current political climate of repealing and replacing the ACA? My proposal is that we consider people 55 years old and older as a High Risk Pool and allow them to buy into the federal High Risk Pool that currently exists using income adjusted subsidies. That High Risk Pool is called Medicare.

This  Medicare idea is a version of an idea I admit “stealing” from Dr. Michael Kitchell, a neurologist and a leading medical thinker in Iowa.

For all the same reasons that I listed in my April blog post regarding Medicare expansion, I think this proposal works. I am merely renaming it. As Victor Hugo said, “No army can withstand the strength of an idea whose time has come.”


Health Reform and Nick Bath

Nick Bath is the senior health policy aide to Senator Pat Murray (D) of Washington. I met Nick several times when he was a health policy aide to now retired Senator Tom Harkin (D) of Iowa.

Nick is a Harvard law graduate, a classical pianist (according to his bio), and reminds me in both looks and mannerism of British actor Hugh Grant when Grant was a younger man.

Senator Murray is one of the primary health care advocates and strategists in the Senate. Because of my previous association with Nick and Senator Murray’s important health care advocacy, I compose the following letter to Nick regarding the current health care crisis and unknown future of health care which evolved from the recently failed partisan attempt to repeal and replace the Affordable Care Act (ACA).

Dear Nick,

In light of the recent failed attempt to repeal and replace the ACA with a convoluted replacement law, which was in actuality a tax cut bill and an indirect way to change major public policy—Medicaid—that would have left 24 million Americans without health coverage within 10 years, I humbly present a potential bipartisan proposal to Senator Murray for her consideration.

My proposal would allow uninsured Americans 55 years and older to buy into the Medicare program using federal subsidies or tax credits for those with low incomes. I would restrict these individuals to certain Medicare options; those being Accountable Care Organizations (ACOs) for health care delivery.

This proposal works in four ways to deal with some of the inadequacies of the current ACA.

First and foremost, Medicare for people 55 years old and older would stabilize the individual health insurance market by removing the highest cost segment of the market from the insurance pool.

Second, this Medicare expansion would remove from Medicaid and thus, from the responsibility of the states, a large group of individuals with a high cost of care. For states that have expanded Medicaid, they would see an immediate reduction in their Medicaid populations and Medicaid expenditures. For those states that have not expanded Medicaid, they would see this population covered and the potential for Medicaid expansion for those states becomes less costly.

Third, this limited Medicare expansion allows these individuals to discover and deal with chronic health conditions, as well as preventable and treatable conditions such as colon, breast, cervical, prostate, and lung cancer. Thus, improving the lives of these Americans as well as creating a healthier cohort when they become 65 and enter into traditional Medicare.

Finally, this proposal places these Americans into a value-based health care delivery system. Which, I believe, has the best chance of providing high quality and efficient health care to them.

If we take President Trump at his word that he wants to change the current system in a way that provides affordable health care to previously and currently uninsured Americans, this plan stabilizes the cost of health insurance for all Americans.  I think this proposal would help accomplish his goal.

If we take President Trump at his word that he want to work with Democrats to create a bipartisan fix to the ACA, then I believe this proposal would appeal to moderate Republicans as a reasonable tweak to the current health care system. I have already proposed this idea U. S. Representative David Young (R), a moderate Republican who did not support the failed repeal and replace bill.

If this Medicare expansion plan could be presented and agreed upon, I think Democrats could consider some compromises in other areas, which in the overall calculation, would still make this bipartisan approach worthwhile.

Thank you for your serious consideration of this proposal and for all the good memories I have of our previous conversations when you worked with Senator Harkin.

Best regards,

Dave Carlyle MD