How Obamacare is Affecting Our Family

Millions of Americans have lost their health insurance as a result of the Affordable Care Act (ACA), also known as Obamacare.  Since October 1, 2013, over four (4) million have lost coverage.  This does not include employers that are part of the large group insurance pools or self-insured employers.  Most of these have yet to decide how they will handle the ACA’s ever-widening stranglehold on the insurance industry.

 

Like many Americans, our family is insured through an employer, particularly my wife Lisa’s company.  This week, we received a letter (email) from Lisa’s corporate headquarters informing us that they will continue to provide insurance to employees through the year 2014.  They explicitly state that they have made no decision regarding future employee health insurance coverage beyond the next year or two. 

 

In fact, Lisa’s employer clearly states:  “[I]t is your obligation to purchase health insurance. . . .  Contrary to popular belief, employers are not required to provide healthcare insurance. . . .  Further, no employer is required to provide insurance to spouses or pay for coverage for dependents.”  The letter goes on to explain that Americans have three paths to obtaining health insurance:  Employer-Sponsored plans, Healthcare Insurance Market Exchanges (ACA controlled), and Government-Sponsored plans like Medicare or Medicaid.  In this discussion, the email further emphasizes that “employers may offer new ways to enroll in healthcare coverage, for example, through the private Healthcare Insurance Marketplace Exchange.  Also, more and more employers are holding employees more accountable for their lifestyle choices.” 

 

The not-so-subtle threats do not stop there.  “Although the Company has made a concerted effort to control our medical benefits costs, we continue to face rising costs and need to address them.”  They note that changes in the healthcare market, costs have risen significantly in 2013 alone.  The company’s projected estimates for 2013 healthcare expenses fell short by $8 million, a 13% shortfall.  In addition, 2014 healthcare costs will add another $8 million to the costs.  This means that for Lisa’s company alone, healthcare costs will have increased over $20 million since the beginning of 2012.  That’s a 36%+ increase in just two years.  From what I can gather, employers across the country are facing the same problem.

 

But how does the ACA affect my family directly?  The letter from Lisa’s company gives us some clues.  First, our insurance premiums are going up nearly $400.  The only reason it is not going up further is because Lisa’s company has chosen to help offset some of the increased premium costs by covering a portion of the increase.  Part of the $400 is the $63 “re-insurance fee” imposed on all insurers by Obamacare.  The rest is due to the effect the ACA is having upon the insurance market. 

 

In order to keep our monthly insurance premiums from going up too drastically, Lisa’s employer has elected to increase our “Out of Pocket” (OP) maximum by $3,000.  Because of Lisa’s cancer, we reach our Out of Pocket maximum every year. Even with the increased OP maximum, next year we will meet the new OP maximum as well.  That means, for us, our healthcare costs will increase next year by nearly $4,000. 

 

These figures do not include the myriad of new taxes that we will pay next year due to the Affordable Care Act.  Fortunately, we do not plan to sell our home in 2014.  That would increase our taxes by over $15,000.  So, think about it.  We are just one family.  Obamacare will cost us thousands of dollars next year alone.  There are millions of Americans who, like us, will be paying thousands more next year because of the ACA.  Millions are losing their healthcare coverage already, forcing many of them into more expensive, government controlled plans.  I expect that millions more in the next few years will also be dumped by their employers and private insurers.  And as a result, they will likewise be forced into insurance plans controlled by the federal government.  If we had to move today from Lisa’s company sponsored plan into a comparable insurance policy through the federal government’s ACA-controlled “Healthcare Insurance Market Exchange,” our premiums would increase 400%.   The ACA may help many poor, uninsured and underinsured Americans, but it is also financially crippling many other Americans.  Is it right to harm millions of Americans, even if it means other Americans benefit?  We could have accomplished the same goal without this devastating, poorly conceived law.  It certainly isn’t fair to us.            

 

Affordable Care Act: Compliance Standards

The Affordable Care Act of 2010 (ACA), also known as Obamacare, created a new oversight structure to allegedly manage the “quality and efficiency” of healthcare delivery in the United States.  Prior to this time, federal oversight of healthcare quality was primarily limited to the regulations related to Medicare and Medicaid laws.  Most governance with regard to healthcare quality was done by each individual state.  Under Obamacare, federal oversight has been expanded to cover all healthcare, whether the provider is a doctor, a hospital, a nursing home, etc.  Add to this, previously only quality of healthcare was monitored; now quality and efficiency will not only be monitored but federally regulated for all healthcare delivery as well.

 

Under the authority provided by the ACA, new compliance rules have been established by the Department of Health and Human Services (HHS) in Washington, D.C.  These rules are technically voluntary, but no healthcare provider may receive any federal funds if they do not comply.  Therefore, effectively, this forces virtually all healthcare providers to comply with the new rules and regulations authorized by the Affordable Care Act. 

 

So, hospitals and doctors across the nation are now diverting millions of dollars in resources to comply with the new rules and regulations set down by the HHS.  In College Station, Texas this means that hospitals in our area have had to hire new staff simply to meet these new ACA compliance standards, or shift these responsibilities to already overworked hospital staff.  Compliance officers now keep up with these voluminous and highly complex regulations, as well as oversee the implementation of these compliance rules throughout their hospital departments.

 

As a result, nurses and/or other specified staff are required to call every patient after they leave the local hospital and ask a specific set of questions, many of which do not apply to a particular patient’s situation.  The hospital is measured against an ideal goal established by the HHS in Washington.  Even though a question may not apply to a particular person’s situation, the hospital is negatively affected by an answer HHS deems unsatisfactory. 

 

For instance, one question local hospitals are required to ask each patient is “Have you been contacted by Home Health regarding your follow-up care?”  Most patients do not require follow-up care, much less Home Health care.  As a result, if hospital representatives are not savvy enough to recognize this, they will ask the question without any adjustment, and thus produce results that will hurt the hospital’s compliance rating.  This in turn will affect hospital reimbursement in the future, for the ACA provides HHS the authority to penalize hospitals that fail to meet “quality and efficiency” standards.

 

Over time, hospitals in our area will find ways to address the problem, either by training their staff responsible for follow-up calls differently, or they will secure home health follow-up for every patient, thereby increasing the overall cost of healthcare delivery.   In any case, the “one size fits all” approach from Washington, D.C. seems absurd to locals who deliver healthcare services every day. 

 

In addition to a limited number of questions asked by a hospital representative in a follow-up phone call, there are other surveys that are performed by an outside HHS approved agency overseeing a hospital’s compliance.  A series of detailed questions are asked and the hospital’s “quality and efficiency” is measured by the results of these questions.  One of the measures is whether or not the hospital’s compliance representatives reach at least 60% of the patients in follow-up phone calls.  That means if a hospital does not contact at least 60% of all discharged patients every month -- and keep in mind that this contact is valid only if the patient answers all questions of the survey required by HHS -- then the hospital is penalized for not providing quality care.

 

Another such question is: “During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it?”  The HHS compliance requirement for local hospitals is an average positive response of at least 72.5%.  That means nearly three-fourths of all respondents must answer that they received satisfactory responses most of the time in order for the hospital to receive a satisfactory compliance grade by HHS.  This might seem like a reasonable guideline for measuring how a hospital or hospital service is doing relative to patient expectations, but this particular measurement becomes part of the “quality and efficiency” markers for a hospital’s overall rating and reimbursement rate by the federal government.  This rating even affects reimbursement from insurance companies in the federal health insurance exchanges. 

 

Does this subjective assessment actually determine whether or not quality healthcare was delivered?  No.  Certainly, it is a useful indicator to the hospital.  But should it be a determining factor in how much money a hospital receives in reimbursement?  Obviously, the HHS thinks it should.

 

Below are a series of questions from the compliance surveys which measure local hospitals’ quality and efficiency compliance.  The percentage listed next to the question is the minimal HHS standard to receive a “green” (satisfactory) quality and efficiency score. 

 

1.      During this hospital stay, how often did nurses treat you with courtesy and respect? (91.0%+)

2.      During this hospital stay, how often did nurses listen carefully to you? (87.6%+)

3.      During this hospital stay, how often did nurses explain things in a way you could understand? (85.5%+)

4.      During this hospital stay, after you pressed the call button, how often did you get help as soon as you wanted it? (72.5%+)

5.      How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted? (74.5%+)

6.      During this hospital stay, how often was the area around your room quiet at night? (76.2%+)

7.      During this hospital stay, how often did the hospital staff do everything they could to help you with your pain? (89.1%+)

8.      During this hospital stay, did doctors, nurses, or other hospital staff talk with you about whether you would have the help you needed when you left the hospital? (86.9%+)

9.      Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? (83.7%+)

10.  During this hospital stay, how often did doctors treat you with courtesy and respect? (96.5%+)

 

These are representative questions from the HHS-directed “compliance protocol” for local hospitals in our area.  In addition to the specific questions, patients were asked to provide overall ratings of the hospital, as well as their willingness to recommend the hospital to others.  These and the results of several other similar questions are then tabulated and an overall rating score for the hospital is derived.  This score is compared to a previously established quality and efficiency compliance standard by HHS. 

 

Do these questions actually tell anyone about the quality or efficiency of the healthcare provided by a local hospital?  It certainly measures a certain sense of patient satisfaction. And this information could be useful to a hospital.  But does it really tell us anything about the medical care provided by the hospital or other healthcare provider?  Does this not merely create an illusion of healthcare quality?  Because won’t hospitals begin to adjust their practices to produce the kinds of results the HHS is trying to elicit?  So, on paper patients will appear satisfied with the kinds of things HHS deems important, but does this really qualify as “quality and efficiency compliance”? 

 

Clearly, HHS uses other standards to measure quality and efficiency.  Hospital readmission rates are reported, as well other information, but the mere reporting of these statistics should be deemed compliance.  However, under the ACA, if results do not match the HHS-established “compliance standards,” hospitals are no longer deemed in compliance with quality and efficiency standards.  As such, in the case of the information provided above, compliance includes the percentage of patients contacted after a hospital stay, and the number of surveys completed by patients, as well as satisfactory results of these surveys.  A hospital is not in compliance if they do not produce satisfactory survey results.  This seems insane.

 

Moreover, each department within a hospital is similarly measured.  A “compliance percentage” for each service is produced by the questions asked.  The score is based on the subjective answers provided by the patients, not by the actual actions of the hospital service in question.  For instance, if a patient answered “yes” to the question, “Do you have any discharge questions,” that is viewed as a negative mark toward the overall compliance score.  Or if a patient answered “no” to the question, “have you set up your follow-up appointment with your physician,” then the compliance score for that department is affected.  This is true even if the department has no responsibility for the patient’s follow-up appointment with their doctor.  Nonetheless, each department is given a compliance score and they are graded by the HHS on whether or not they produce satisfactory compliance scores. 

 

It seems to me that this method for evaluating healthcare delivery is not only inefficient, it ultimately does not measure quality of care, nor does it truly measure efficiency.  It seems to be a bureaucratic political tool to reinforce the illusion that the ACA will improve healthcare in the U.S.  Imagine that hospitals and other healthcare providers begin adjusting their practices to produce high scores according to HHS expectation.  The HHS can then report that the quality and efficiency of healthcare in the U.S. has dramatically improved under the ACA.  However, these statistics actually only demonstrate that healthcare providers have managed to manipulate their practices to produce the image of improvement. 

 

Let me provide a comparison.  In the past, when I took my automobile into my car dealer’s service department for maintenance, I might or might not receive a satisfaction survey.  In the last few years, as I’m leaving the dealer, my service representative now reminds me not only that I will soon be receiving the survey and would I please complete the survey, but that if they do not receive an excellent rating on every question, their commission will be affected.  In fact, they might not even receive a commission if I am not completely satisfied in every single detail of my experience.  As a result, I now answer my surveys as “completely satisfied” on every question.  Why?  Because my service representative is outstanding, and even though other aspects of my experience might be mediocre, I won’t risk him being affected by my answers.  So, the tactic used by the service representatives – i.e. to inform me how the system actually works – affects my responses.  And thus the system only produces the illusion of customer satisfaction.  This is likely to happen with regard to healthcare quality and efficiency compliance as well.

 

If this is the case, then why do it?  Because the people who implement these techniques are not interested in the truth about the issue; they are only interested in the political effect the illusion produces!  Don’t be duped by the way the HHS is utilizing their authority under the ACA.  The mission is political; it is not even remotely connected to improving healthcare delivery.  

 

Egypt's Turmoil 2013: What Happened to Hope?

Not long ago, optimism and hope reigned among many around the globe. An "Arab Spring" seemed to be emerging, with tyrants and dictators overthrown along with their repressive regimes. Back then, one of IDEO's contributors shared a sense of optimism with regard to Egypt's revolution and the toppling of the Mubarak regime. At the same time, they cautioned that Egypt's aspirations for democracy would not be so easily achieved. Their caution was prophetic, for Egypt is once again in turmoil. For the elections in the wake of Mubarak's fall, produced an overwhelming victory for members of the Muslim Brotherhood, an organization not known for its democratic ideals. In Egypt's "first" revolution, muslims, Christians and secularists, liberal leftists and wary conservatives, all stood side by side as they called for Mubarak's ouster and for a new and free democratic Egypt. When their protests grew large enough to topple the Mubarak regime, it seemed Egypt had an opportunity to establish a new and free democratic society. Even when members of the Muslim Brotherhood won the presidency and the majority of seats in the new Egyptian parliament, people still held out hope for democracy. But President Morsi and his parliament chose to impose their own religious, political and economic ideology upon the Egyptian people. They produced a new constitution that failed to protect the liberties and rights of the Egyptian people, especially the religious minorities and secularists in the country. They moved the nation toward an islamist state, dividing the nation even more than it had been. [By islamist, I mean the belief that islam should be the basis for law and society, thereby ignoring -- even repressing -- the rights of those who do not agree with the tenets and beliefs of Islam, and in some cases preventing non-muslims from having any significant role in governing or making of laws.] While Morsi's dream for Egypt did not seem as extreme as the mullah controlled regime of a nation like Iran, it, nonetheless, oppressed and repressed the sizable minorities in the country who wanted their own rights and freedoms to be protected, not dictated, by the government. Of course, there were economic realities that contributed to the current "second" revolution, but these seem to be secondary. One need only look at the rhetoric espoused by Morsi supporters and critics alike. Morsi supporters claim that the revolution is anti-Islam and that protestors are upset that Morsi and the Egyptian parliament passed a constitution along with several laws that would bring Egypt in line with islamic law or principles. Anti-Morsi protestors cry out for freedom and complain that Morsi and his supporters were trying to make Egypt more islamist and less democratic. Both sides seemed to be in agreement; however, one views Morsi's political moves as good and morally right, while the other considers these moves anti-democratic and morally unjust. As our earlier IDEO contributor suggested, without political inclusion of minorities in the crafting of Egypt's new laws and constitution, the result would be a failure to achieve democracy. As A. Hussein suggested, democracy is difficult to achieve. But one thing is certain: whenever any group, religious or otherwise, imposes its view of "the good" upon others in a society, democracy is not present. And in the case of "democratic" political structures where majorities control via the electoral process, this is all the more evident. In 1780 John Adams put it this way: even when majorities when elections, a "tyranny of the majority" is still possible. We have seen this in America on many occasions, and we are now witnessing the consequences of this in Egypt. A. Hussein's and John Adams' caution is still relevant: majority rule is not equivalent to democracy or its relative, the republican/representative form of governance. Let us not give up on true democracy, for at its root, its goal is the freedom to govern ourselves and chart our own destiny as free individuals.