Introduction by Paul Craig Roberts
The article below is the most comprehensive analysis available of
“Obamacare” – the Patient Protection and Affordable Care Act. The
author, a knowledgeable person who wishes to remain anonymous, explains
how Obamacare works for the insurance companies but not for you.
Obamacare was formulated on the concept of health care as a
commercial commodity and was cloaked in ideological slogans such as
“shared responsibility,” “no free riders” and “ownership society.” These
slogans dress the insurance industry’s raid on public resources in the
cloak of a “free market” health care system.
You will learn how to purchase a subsidized plan at the Exchange,
what will happen when income and family circumstances change during the
year or from one year to the next, and other perils brought to you by
Obamacare. It is one of the most important articles that will be posted
on my website this year.
Americans will be shocked to learn the extent
to which they have been deceived. The legislation neither protects the
patient nor are the plans affordable.
The author shows that for those Americans whose income places them
between 138% and 400% of the Federal Poverty Level, the out-of-pocket
cost for one of the least expensive (lower coverage) subsidized policies
ranges from 2% to 9.5% of Modified Adjusted Gross Income (MAGI), a tax
base larger than the Adjusted Gross Income used for calculating federal
income tax.
What this means is that those Americans with the least or no
disposable income are faced in effect with a substantial pay cut. The
author provides an example of a 35 year-old with a MAGI of $27,925. The
out-of- pocket cost to this person of a Silver level plan (second least
expensive) is $187.33 per month. This cost is based on pre-tax income,
that is, before income is reduced by payroll and income taxes. There
goes the car payment or utility bill. The lives of millions of Americans
will change drastically as they struggle with a new, large expense –
particularly in an era of no jobs, low-paying jobs and rising cost of
living.
The author also points out that the cost of using the mandated
policies will be prohibitive because of the large deductibles and
co-pays. Many Americans will find themselves not only with a policy they
can’t afford, but also with one they cannot afford to use. Those who
cannot afford the insurance, even with a subsidy, will be faced with a
costly penalty, and in many cases, this, too, will be difficult, if not
impossible, to pay. As each year’s subsidy is based on last year’s
income, there will be a substantial year-end tax liability for those who
must repay the subsidy in whole or part because their income increased
during the year. The stress alone from such a regressive scheme is,
without a doubt, not conducive to good health and well-being.
Diets will worsen for millions of Americans as they struggle with a
new large expense. Thus, the effect of Obamacare will be to worsen the
health of millions. Indeed, a “glitch” in the legislation allows
millions to be priced out of coverage.
http://www.huffingtonpost.com/2013/01/30/obamacare-glitch-priced-out-of-health-care_n_2585695.html?view=print&comm_ref=false
Alternatively, Americans might be able to acquire health insurance coverage but have no doctors willing to treat them.
http://www.californiahealthline.org/road-to-reform/2013/access-denied-implications-of-medi-cal-pay-cut.aspx#
The demand that Obamacare places on household budgets in which there
is no slack makes me wonder where the president’s economists were while
the insurance lobby crafted the product that serves the profits of
insurance companies. Two well-known economic facts are that real family
income has been stagnant or declining for a number of years and
Americans are over their heads in debt.
How does Obama preside over a recovery when consumer purchasing power is redirected to insurance company profits?
Obamacare not only rations health care by what a person or family can
afford, but also has implications for Medicare patients. Hundreds of
billions of dollars are siphoned from Medicare to help pay the cost of
Obamacare. The health care provided to Medicare patients will decline
with the reduced payments to care providers. Health care seems destined
to be rationed according to the age and illnesses of Medicare patients.
Those judged too old and too ill could be denied expensive treatments or
procedures that would prolong their lives.
Obama will rue the day that his name was put on this special interest
legislation, and most Americans, once they realize what has been done
to them, will be angry that special interests again prevailed over the
health of the nation.
OBAMACARE: DEVILS IN THE DETAILS
The Patient Protection and Affordable Care Act of 2010, commonly
referred to as the ACA or Obamacare, will go into full effect in 2014.
This decree mandates that all Americans must purchase and maintain
government-approved health insurance or pay a penalty to the IRS. Touted
as a plan to provide all Americans with access to medical care, in
reality, this compulsory shakedown commands everyone to purchase
insurance that for many will be too expensive, even with government
subsidies – or unaffordable to use – or both.
The ACA was not selflessly designed with the intent of providing
affordable and equitable medical services to those in need, but rather
to acquire taxpayer money for the private insurance companies under the
seemingly helpful guise of health care and the ideological excuse of
personal responsibility. It takes money from ordinary people and gives
it to a medical insurance industry that profits handsomely from this
legally-enforced corporate welfare – all while keeping Americans locked
in the same broken system that puts profit before patients. The law was
essentially written by business executives from the industry so that
special interests would not be upset and profits assured.
There’s a lot to digest about how the ACA works and much is buried in
a complex, convoluted maze of regulations and procedures. A few
websites contain explanations, but very important details have either
been left out or glossed over. These details are well worth
understanding so you will know what’s at stake for you and your family.
This lesson is not meant to convey a political opinion. This is how the
ACA works and under this law, there are no sacred cows.
In today’s lesson, you will learn why 2013 is an important year for
many of you with regard to your income and the ACA. We will discuss 1)
use of Modified Adjusted Gross Income, 2) tax credits (help paying for
insurance), 3) your share of the premium, 4) paying back the tax credits
to the IRS, 5) expansion of Medicaid and estate recovery which could
affect you if you are put into that plan, 6) inadequate coverage in most
subsidized plans, 7) penalties, 8) exemptions and 9) a few tidbits.
We’ll also take a look at the agenda of Enroll America and the Health
Insurance Exchanges, and what you can expect to hear in the very near
future.
Here we go. Fasten your seat belts.
1. HEALTH INSURANCE EXCHANGE BASICS
In 2014, each state will have an Affordable Insurance Exchange where
qualified individuals and families with incomes between 138 and 400
percent of the Federal Poverty Level (FPL) can shop for commercial
insurance policies. Most individuals and families with incomes at or
below 138 percent FPL will be put into Medicaid. You may be eligible for
help paying for your insurance in the form of a tax credit. In most
states, the Children’s Health Insurance Program (CHIP) will continue to
cover children in families with incomes up to at least 200 percent FPL.
Some states may offer a Basic Health Plan for those who earn up to 200
percent FPL and are not eligible for Medicaid. Under limited
circumstances, you may also be eligible for a cost-sharing credit.
Eligibility to receive a tax credit, the amount of your tax credit
and your out-of-pocket share for the insurance will be determined by
your income and where you fall in the Federal Poverty Level Guidelines
(FPL). This is easy to understand.
Your annual gross income determines which FPL you’re in. For example,
based on 2012 FPL Guidelines, an individual with an annual income of
$33,510 is at 300 percent FPL; a family of 4 with an annual income of
$69,150 is at 300 percent FPL. To see where you’re at, try the handy
calculator at this link. FPL Guidelines are revised every January, so
the 2013 edition should be up soon.
http://www.safetyweb.org/fpl.php
The ACA requires use of MODIFIED ADJUSTED GROSS INCOME (MAGI) instead
of Adjusted Gross Income for all determinations made by an Exchange
including eligibility for Medicaid except in certain cases. So, in this
lesson, we’ll refer to annual income as MAGI.
Modified Adjusted Gross Income (MAGI) is defined as Adjusted Gross Income PLUS
a) all tax exempt interest accrued or received in the taxable year;
b) the non-taxable portion of Social
Security benefits provided under Title II of the Social Security Act
which includes old-age benefits, disability benefits, spousal benefits,
child benefits, survivor benefits and parental benefits;
c) tier 1 Railroad Retirement benefits that are not includible in gross income; and
d) the exclusion from gross income for citizens or residents living abroad.
The adoption of MAGI, created by the ACA, is defined in a new section of the IRS code.
2. DETERMINING ELIGIBILITY FOR A TAX CREDIT
The tax credit is to help you pay for insurance. The ACA says it must
be based on annual income for the tax year it’s received, but since you
will need help paying for your plan during that year, the ACA allows
for advance payment of the tax credit.
Here’s an example of what that means: Let’s say you apply for
insurance at an Exchange in 2014. Therefore, 2014 is the tax year you
will receive your tax credit, and per the ACA, the amount you receive
must be based on that year’s MAGI. But, that year’s MAGI won’t be
available until 2015 when you file your 2014 tax return and you need
help paying for your insurance plan when you buy it in 2014. So, the
amount of your tax credit has to be determined on information that is
available such as your prior-year (2013) tax return. Thus, the tax
credit morphs into an ‘advance payment of the tax credit’ (also referred
to as an advance premium assistance credit). Now you see why 2013 is an
important year for many of you.
The ACA allows for limited disclosure of tax return info in order for
an Exchange employee to verify your citizenship status and MAGI, and,
not only to let you know how much your advance tax credit will be, but
also to see if you are eligible to receive this in the first place. An
Exchange can also consider using your real-time income by looking at
your state’s most current quarterly wage database, or it may agree to
accept paper verification (pay stubs, etc.) as a last resort or an
attestation of your income with no verification. Creation of a federal
‘data services hub’ is in the works so your income information will be
more readily accessible. But, no matter how this plays out, you’ll still
receive an advance payment of the tax credit because your actual MAGI
for 2014 will not be known by you nor can it be verified by an Exchange
until you file your 2014 tax return in 2015.
Ultimately, no matter which method is used – prior year or partial
current year – this advance payment of the tax credit carries with it
some heavy-duty consequences which are discussed in topic 4 of this
lesson.
3. TAX CREDITS AND YOUR SHARE OF THE PREMIUM
The amount of your tax credit will be based on the second lowest-cost
Silver plan in the area where you live and your MAGI. Here’s how this
works – it’s quite simple:
a) First, the amount you will pay
out of your pocket for that Silver plan – copays and deductibles not
included – will be a specific percentage of your MAGI, and you will pay
this to the insurer on a monthly basis. The way this percentage will be
calculated is described a few lines down.
b) Next, your share will be
deducted from the cost of that Silver plan and the difference will be
your tax credit which the government will pay directly to the insurer on
a monthly basis when you purchase a plan.
The specific percentage you will have to pay for the second
lowest-cost Silver plan will be based on your FPL using a well-greased
sliding scale. As your FPL increases little by little, the percentage
you will pay increases. The same percentage applies to an individual or a
family. Here’s how much of your MAGI you will pay for that Silver plan:
— up to 138 % FPL: 2% for people legally present less than 5 full years and residents of states that do not expand Medicaid
— 138-150% FPL: 3 to 4%
— 150-200% FPL: 4 to 6.3%
— 200-250% FPL: 6.3 to 8.05%
— 250-300% FPL: 8.05 to 9.5%
— 300-400% FPL: 9.5% – there’s no range, but the dollar amount of your
share will change because 9.5% of a lower MAGI is less than 9.5% of a
higher MAGI.
Here are two examples in dollars using 2012 FPL Guidelines and an
estimate for a second lowest-cost Silver plan which will vary depending
where you live – actual costs are not yet available:
a) You are 35 years old and the
price of the second lowest-cost Silver plan for an individual in the
area where you live is $4,750 with no tax credit. If your MAGI is
$33,510 ($2,792.50 per month) putting you at 300 percent FPL, your share
for that Silver plan, per the chart above, would be 9.5 percent of your
MAGI which comes to $3,183 ($265.25 per month). Your tax credit would
be $1,567 which is the difference between the unsubsidized cost of that
Silver plan and your share.
b) You are 35 years old and your
MAGI is $27,925 ($2,327 per month) putting you at 250 percent FPL, so,
your share of that Silver plan would be 8.05 percent of your MAGI which
comes to $2,247.96 ($187.33 per month) and your tax credit would be
$2,502.
If the second lowest-cost Silver plan is too expensive, you can apply
your tax credit to a Bronze plan which will be cheaper but less
comprehensive. If you want a better plan than the Silver, you will have
to pay the full difference in the premium.
Don’t forget that your share of the monthly premium will be figured
on your MAGI which is pre-tax income. So, after you deduct your income
taxes and your share of an insurance plan, will you be able to cover
your monthly basic living costs including paying off debt you may owe
and still have some cash left to pay for medical care if you have to use
your insurance? Check out topic 6 in this lesson for a rundown of plans
and coverage you can expect to find at an Exchange. Hope you don’t
faint.
Once you purchase a plan, your share and your tax credit won’t
change until the next enrollment period unless, before that time, your
income goes up or down enough to bump you into a different FPL or you
get a job with insurance. You can let your Exchange know by phone or via
your online account, or, your Exchange might notice while cruising the
data services hub you learned about in topic 2 and notify you that you
must ‘up’ your coverage or that you’ve been tossed into Medicaid if your
MAGI has decreased enough to make you eligible for that plan. Exchanges
will be encouraged to use as many different avenues as possible
including private databases to keep tabs on your income.
Thus, you could end up bouncing from Medicaid to a subsidized plan or
vice versa. By the same token, you could take some extra work to help
pay the bills or to save for a vacation, and, oops, you went over 400
percent FPL and are no longer eligible for a tax credit. The Exchange
may not find out about this unless you spill the beans, but, no matter
how it all plays out, income changes will catch up with you when you
file your tax return.
To be eligible for a tax credit you must file your tax return no
later than April 15. Married taxpayers must file a joint return.
Individuals who are listed as dependents on a return are ineligible for a
tax credit.
If you are eligible for Medicaid, you will not be allowed to receive a
tax credit or a cost-sharing credit although some states impose premium
and cost-sharing charges on certain Medicaid enrollees per the Deficit
Reduction Act of 2005 (DRA) and clarified in the Tax Relief and Health
Care Act of 2006.
On January 22, 2013, the Centers for Medicare & Medicaid Services
(CMS) proposed allowing states to further increase Medicaid premiums
and out-of-pocket costs by 5 percent. The most egregious part of this
proposed rule says that states may allow providers to deny services for
failure to pay the required cost-sharing in certain circumstances. The
Obama administration is behind this proposed rule hoping to persuade
states to expand Medicaid since many have refused and others are still
undecided – the expansion of Medicaid is an integral part of the ACA.
Allowing states to further increase premiums and cost-sharing for the
poorest segment of the population underscores the existing political
bias toward low-income Americans despite rhetoric which claims
otherwise.
https://www.federalregister.gov/articles/2013/01/22/2013-00659/medicaid-childrens-health-insurance-programs-and-exchanges-essen-
tial-health-benefits-in-alternative#h-186
http://www.nytimes.com/2013/01/23/health/medicaid-patients-could-face-higher-fees-under-a-proposed-federal-policy.html
Affordability rates (the percentage of your MAGI the government has
decided you can afford to pay for insurance) are based on boardroom
formulas which don’t take particular individual needs into account such
as housing costs, property taxes, debt, education, transportation,
retirement savings, etc. Also, FPL Guidelines are standard across the
country and do not take into consideration those who reside in a more
expensive region or vice versa. They are one-size-fits-all with the
exception of Alaska and Hawaii. See topic 8 in this lesson to learn
about exemptions.
Check out what self-proclaimed health care expert Jonathan Gruber
says about affordability and get a load of all the “formulas.” According
to Mr. Gruber, you may be having too much fun in life and need to get
serious, buy health insurance and live under a rock in order to pay for
it. He was involved with Romneycare in Massachusetts and was also Mr.
Obama’s go to man under a no-bid contract. Per a bar graph on page 6 of a
report prepared by Stan Dom for the Urban Institute, subsidized plans
under the ACA are estimated to cost 2 to 3 times more (give or take)
than the subsidized plans under Romneycare. Per several surveys during
the years that Romneycare has been in effect, many low and modest income
MA residents have had difficulty paying for those plans and the
out-of-pocket costs to use the insurance, particularly chronically-ill
residents.
http://ebookbrowse.com/1493-gruber-will-affordable-care-act-make-hlt-ins-affordable-reform-brief-v2-pdf-d124754327
http://www.statecoverage.org/files/TheBasicHealthProgramOptionUnderHealthReform.pdf
4. PAYBACK OF TAX CREDITS TO THE IRS
Perhaps you recall hearing politicians including Mr. Obama say if you
can’t afford to pay for health insurance, the government will help you.
That was one of the key talking points repeated non stop. We just went
over the help part – the tax credits. Now we’ll look at what Mr. Obama
et al didn’t tell you which is important to understand because it could
cause you some serious financial distress.
Remember the “advance payment of the tax credit” in topic 2 of this
lesson? Well, essentially, that was a loan from the government which was
paid in advance to the insurer on your behalf when you purchased your
plan, and, as you know, loans have to be paid back. So, when you file
your tax return for the year you received your “advance tax credit”
(your loan), if your income has changed, you have to settle this with
the IRS. Here’s the deal:
a) If your MAGI is higher and the
increase puts you into a higher FPL, you may have to pay back a portion
or all of the tax credit because it was based on a lower MAGI. In other
words, you could have an additional tax liability on top of the income
taxes you already paid (or still owe) because you received a higher tax
credit than you were entitled to.

b) If your MAGI is lower and the
decrease puts you into a lower FPL, a refund could be coming to you
because you were eligible for a larger tax credit than the government
paid to the insurer. In other words, you overpaid for your portion of
the insurance premium.
c) If you earned a bit more or less, but your extra earnings or loss didn’t bump you into another FPL, you’re home free.
To figure out your payback, you will have to enter the relevant
figures on the reconciliation page of the tax return. Changes in filing
status such as the number of people in your household will also have an
impact. For those of you who marry or divorce, the rules for the payback
amount as well as the amount of the tax credit you are eligible to
receive will make your head spin – the computation includes pre- and
post-marriage FPL and uses the highest FPL of the two people involved.
Ditto for divorce.
Here is one of the reconciliation explanations in IRS-speak: Your
liability for an excess tax credit you received must be reflected on
your current year income tax return subject to a limitation on the
amount of such liability.
Oh! Limitation on the amount of such liability. That sounds good.
Let’s take a peek at the payback limitations on record at the time of
this writing. “At the time of this writing” are the operative words
because the cap has been increased twice since the ACA was signed into
law. The original payback was capped at $400 for families under 400
percent FPL and $200 for individuals. We’ll skip over the first
increase. The story behind the second one is that a particular revenue
stream was removed from the original law, so something had to be done to
compensate for this lost money. Thus, an amendment was passed that
increased the cap using a sliding scale, thereby putting a huge
financial burden on the backs of the very people the ACA claims to help.
In other words, tag, you’re it. You are the cash cow.
Here are the current sliding-scale caps:
If the household income (expressed as a percent of poverty line) is:
less than 200 percent, the applicable dollar amount is $600
at least 200 percent but less than 300 percent, the applicable dollar amount is $1,500
at least 300 percent but less than 400 percent, the applicable dollar amount is $2,500
Effective date: the amendment made by this topic shall apply to
taxable years ending after December 31, 2013. Very truly yours, House
Ways and Means Committee
The name of this bloodsucker is The Comprehensive 1099 Taxpayer
Protection and Repayment of Exchange Subsidy Overpayments Act of 2011.
http://www.gpo.gov/fdsys/pkg/PLAW-112publ9/html/PLAW-112publ9.htm
But wait, there’s more!
a) Update: Today (Feb. 17) (2011)
the House Ways and Means Committee approved the 1099 repeal bill which
requires consumers earning more than 400 percent of the poverty line to
pay back the [entire] subsidy.
http://thehill.com/blogs/healthwatch/health-reform-implementation/144847-1099-repeal-gets-trickier-with-house-bill
b) Also, per IRS final regulations:
for taxable years beginning after December 31, 2014, the payback caps
may be adjusted to reflect changes in the consumer price index.
Payback amounts are reduced to one-half for unmarried individuals who
are not surviving spouses or filing as heads of households. There is no
help if you get hit with a payback and many of you will have difficulty
paying this liability.
Chances that you may have received an incorrect tax credit are not
exactly slim because this poorly thought-out scheme does not take into
account the unpredictable and complex financial situations that confront
the low and modest income population.
Keep in mind that by ending up in a higher FPL, you may also have to
pay more out of your pocket for an insurance premium. You learned how
that works in topic 3. If you can’t afford a higher premium and drop
your insurance, you may still owe a payback plus a penalty for being
uninsured which is also MAGI-based. Penalties are discussed in topic 7.
If your MAGI puts you over 400 percent FPL, you just knocked yourself
into left field and are on your own paying for an insurance plan on the
open market. And, you may also be required to payback the entire tax
credit.
If you get a job during the current year that offers health insurance
which is not more than 9.5 percent of your total salary and the
coverage is not less than 60 percent, you must take that insurance or
pay a penalty for being uninsured. But, you may owe a payback for the
months you received a tax credit before you landed the job. How large
that payback is will depend on your MAGI for the entire tax year, not
just on your income during the months you received the tax credit. Or,
you may lose a job during the year and have a significantly reduced
income even though the amount reported on your tax return is high
because you had a job for part of the year. In this case as well, your
payback will be based on your MAGI for the entire tax year.
More interest income from taxable and tax-exempt savings or a
year-end bonus could also contribute to an increased MAGI and the
possibility of a payback as well as taking extra work to help pay the
monthly bills, house and car repairs, educational aspirations or a
vacation. So, whether or not you end up in payback land will depend on
how close you are teetering on the edge of an FPL. Ditto for your share
of the premium and the amount of your tax credit.
The payback may stop many of you from purchasing insurance at the
Exchange because you know in advance you will not have the money to pay
it. If this is the case, you may be allowed to negotiate a lesser tax
credit by paying more out of your pocket for your monthly insurance
premium in order to avoid or decrease the payback. It’s a crap shoot.
Considering what you’ve learned so far in today’s lesson, many of you
will find yourselves between a rock and a hard place under the ACA, and
you will be forced to make untenable choices. Given the skyrocketing
costs of food, heat and other basics, how will you even tread water
under this set-up, nevermind get ahead?
Being told you will receive help from the government if you can’t
afford to purchase insurance and finding out at tax time this was really
a loan and you owe the IRS a substantial debt on top of your income
taxes is outright shameful. But most politicians have no shame – which
brings us to the next topic.
5. MEDICAID EXPANSION AND ESTATE RECOVERY
In order to expand Medicaid, several Medicaid regulations were changed:
a) the income limit for
eligibility was increased to 133 percent FPL, but since states must
apply a 5 percent disregard, this effectively raises the eligibility to
138 percent FPL
b) Modified Adjusted Gross Income will be used in most cases to determine eligibility (also applies to certain CHIP applicants)
c) the age limit was increased to 64, childless adults will be eligible; and
d) the asset test was dropped except for certain groups such as the elderly and people on Social Security Disability – BINGO!
The fact that the asset test was dropped is very important, but
before we look at why, you must first understand that if an Exchange
determines you are eligible for Medicaid, you have no other choice. Code
for Exchanges specifies, “an applicant is not eligible for advance
payment of the premium tax credit (a subsidized plan) or cost-sharing
reductions to the extent that he or she is eligible for other minimum
essential coverage, including coverage under Medicaid and CHIP.”
Therefore, you will be tossed into Medicaid unless there are specific
rules as to why you would not be eligible. If you are enrolled in a
private plan through an Exchange and have been receiving a tax credit,
and your income decreases making you eligible for Medicaid, in you go.
If you are allowed to opt out because you don’t want Medicaid, you will
have to pay a penalty for being uninsured unless you can afford to
purchase insurance in the open market.
Just so you’re clear on this: the ACA stipulates that the system will
ensure that if any individual applying to an Exchange is found to be
eligible for Medicaid or a state children’s health insurance program
(CHIP), the individual will be enrolled in such a plan.
Furthermore, to increase enrollment in health coverage without
requiring people to complete an application on their own, states are
advised to automate enrollment whenever possible by using existing
databases for social services programs such as SNAP (food stamps) to
enroll people who appear eligible for Medicaid but are not currently
enrolled. Therefore, you could find yourself auto-enrolled in Medicaid
against your will if your state acts on this advice.
Many times over Mr. Obama et al told you that all Americans would
have choice. Choice was another big talking point. Are poor and
low-income Americans undeserving of choice? Is the ACA a class-based
system? Maybe they meant that for this segment of the population, the
choice would be between Medicaid or a penalty for remaining uninsured.
This is blatant discrimination.
Here’s why dropping the asset test got the BINGO – Estate Recovery!
You won’t find the following info in the ACA. It’s in the Omnibus
Reconciliation Act of 1993 (OBRA 1993) – a federal statute which applies
to Medicaid, and, if you are enrolled in Medicaid, it will apply to you
depending on your age.
a) OBRA 1993 requires all states
that receive Medicaid funding to seek recovery from the estates of
deceased individuals who used Medicaid benefits at age 55 or older. It
allows recovery for any items or services under the state Medicaid plan
going beyond nursing homes and other long-term care institutions. In
fact, The Centers for Medicare & Medicaid Services (CMS) site says
that states have the option of recovering payments for all Medicaid
services provided. The Department of Health and Human Services (HHS)
site says at state option, recovery can be pursued for any items covered
by the Medicaid state plan.
b) The HHS site has an overview
of the Medicaid estate recovery mandate which also says that at a
minimum, states must pursue recoveries from the “probate estate,” which
includes property that passes to the heirs under state probate law, but
states can expand the definition of estate to allow recovery from
property that bypasses probate. This means states can use procedures for
direct recovery from bank accounts and other funds.
c) Some states use recovery for
RX and hospital only as required by OBRA 1993; some recover for a few
additional benefits and some recover for all benefits under the state
plan. Recovery provides revenue for cash-strapped states and it’s a big
business.
Your estate is what you own when you die – your home and what’s in
it, other real estate you may own, your bank account, annuities and so
on. And even if you have a will, your heirs are chopped liver.
Low-income people often have only one major asset – the home in which
they live and, in some cases, this has been the family home through
several generations.
So what this boils down to is: if you are put into Medicaid –
congratulations – you just got a mandated collateral loan if you use
Medicaid benefits at age 55 or older! States keep a running tally.
Estate recovery can be exempted or deferred in certain situations
after your death, but the regulations for this are limited and
complicated with multitudes of conditions. You may not have an attorney
on speed dial, but with regard to this hundred pound gorilla, it sure
would be handy.
Should you decide to ask your congresscritter about estate recovery, be prepared for responses such as:
— “Estate recovery doesn’t apply
to you.” (Great news. Please overnight a copy of the amendment to OBRA
1993 that stipulates estate recovery is no longer required and no longer
allowed. Here’s my address.)
— “Oh, estate recovery is state, I’m
federal.” (Wrong – estate recovery is federally mandated although the
estate recovery program itself is administered by each state.)
— “I don’t know anything about
this.” (Highly unlikely because the expansion of Medicaid is an integral
part of the ACA and estate recovery is not a secret.)
— “The ACA wasn’t about revamping Medicaid.” (As explained above, Medicaid regs were revised in order to expand Medicaid.)
— “I’ll look into that and get back to you.” (Don’t hold your breath – they don’t want to go there.)
If you ask about estate recovery when you contact an Exchange or
speak with an outreach agency, you’ll probably run into a brick wall or
be told it doesn’t apply to you – whatever. But, it doesn’t matter
because what you are told is not legally binding. What is legally
binding is your signature on the Medicaid application which indicates
that you agree to the terms of the contract – which brings us to another
item in OBRA 1993. Read on.
OBRA 1993 also contains procedural rules intended to ensure that
individuals are informed about Medicaid program requirements including
disclosure of estate recovery before they complete the application
process and also during the annual re-determination process.
Notification of estate recovery should be on the signature page of your
state’s Medicaid application and is usually a one-liner: I understand
that if I am aged 55 or older, (name of your state’s Medicaid plan) may
be able to get back money from my estate after I die. (Use of the word
‘may’ doesn’t mean if the state feels like it – it means recovery will
take place unless there are specific circumstances for exemption or
deferment as mentioned above.) There are also strict recovery/repayment
clauses for injury-related settlements disclosed on the signature page
and a few other ditties that apply to you or a family member who is
enrolled in Medicaid. All of these items must also be disclosed in your
state’s Medicaid handbook.
Under the ACA and proposed federal rules for implementation, states
will be required to provide a single, simple application to apply for
and enroll in Exchange plans, Medicaid and CHIP, and consumers must be
able to apply by phone, in person or online. The Secretary (HHS) is
charged with this task and it’s in the works. This begs an answer to the
following questions:
— Will Medicaid applicants be
diligently informed about estate recovery and other rules that apply to
Medicaid enrollees on this single application? Failure to do so would be
in non compliance with OBRA 1993 and would also be deceptive.
— Will applicants be provided with a
signature page that contains appropriate disclosure of these rules so
they can be reviewed before signing on the dotted line?
— How will appropriate disclosure
and obtaining a signature work for those who are bumped into Medicaid
due to a decrease in income or who might be auto-enrolled because they
were presumed eligible through a database.
If an applicant or someone who has been bumped or auto-enrolled in
Medicaid is not satisfied with the terms of the Medicaid contract, lack
of another health insurance option that is in the best interest of
low-income earners represents undue and unconscionable advantage being
taken of this segment of the population under a law that mandates health
insurance or a penalty.
Do the health insurance policies enjoyed by lawmakers on Capitol Hill
and paid for by taxpayers include an estate recovery program?
Medicaid is poor, underfunded, overstretched and constantly bombarded
by state budget cuts – even before an ACA expansion. It offers a low
quality of care in many states, and, in general, represents inequities
in care. Office-based doctors typically refuse to accept Medicaid
patients, thus, millions thrust into this plan will have difficulty
finding a primary-care doctor or a specialist.
A perfect example is the December 2012 federal appeals court decision
that allowed California to cut reimbursements by 10 percent to doctors,
pharmacies and others who serve low-income residents under the state’s
Medi-Cal plan (a version of Medicaid) due to state budget issues.
California was already at the bottom of the rate-reimbursement heap
which made finding doctors difficult for residents in Medi-Cal. This
decision will further reduce the number of health care providers willing
to take new Medi-Cal patients, thus jeopardizing their access to
primary and specialized care. Under the ACA’s expansion of Medicaid,
state budget crises across the nation will exacerbate the ongoing
problems regarding access to care for Medicaid patients, particularly in
states that have a high low-income population.
http://www.sfgate.com/health/article/Medi-Cal-cuts-upheld-by-appellate-court-4116971.php
6. INSURANCE PLANS AT THE EXCHANGES
Below are the 4 plan levels that will be offered at Exchanges for
people between 138 and 400 percent FPL. Each one has government-
approved benefits including prescription coverage. You will be entitled
to one free preventive visit each year. Per the most recent study
commissioned by the Kaiser Family Foundation, several cost-sharing
options were estimated for non-group (individual and family) Bronze and
Silver plans. Cost-sharing is the amount you must pay to use your
insurance. Your share of the premium is not part of cost-sharing.
http://www.kff.org/healthreform/upload/8303.pdf
The way this works is you will pay for all your medical care until
you reach the annual deductible. Then you’ll pay the applicable
percentage of coinsurance until you reach the annual out-of-pocket
spending cap which will be set on a sliding scale. Annual means these
amounts start again the following year, and if they change, you will
find out when you re-apply for insurance. There will also be copays – an
amount you will pay to the doctor for an office visit.
Here are the current estimates:
Bronze: cheapest and dry as dust with 60/40 coverage – a win-win for insurers
a) annual deductible of $4,375 for an individual (double for a family) with 20 percent coinsurance,
b) annual deductible of $3,475 for an individual (double for a family) with 40 percent coinsurance
Silver: next cheapest – offers an illusion of coverage at 70/30
a) annual deductible of $2,050 for an individual (double for a family) with 20 percent coinsurance,
b) annual deductible of $650 for an individual (double for a family) with 40 percent coinsurance
Gold: expensive – 80/20 – better coverage
Platinum: most expensive – 90/10 – most comprehensive coverage
A fifth plan will be available for the under-30 crowd and people who
have been granted a hardship exemption. See topic 8 in this lesson.
Coverage in this plan will be less comprehensive than the Bronze – it is
primarily for major-medical expenses except that it has a free
preventive visit. Cost-sharing for people at 138 to 200 percent FPL is
estimated to be a bit less than the Bronze and Silver estimates
mentioned above.

The high deductibles in all but the two most expensive plans could
saddle you with mounting bills for routine care and may stop you from
seeking necessary treatment for illness or injuries. Many of you will
find that the promise of access to affordable health care really means
access to inadequate coverage at a price the government has decided you
can afford to pay.
The number of drugs in each plan at an Exchange will vary from state
to state. In some states, plans will offer up to 99 percent of available
drugs and others only 45 percent which means you may not have access to
the specific drugs you need. Perhaps Big Pharma will change its stance
on this before 2014.
The cost of plans at an Exchange will vary from state to state based
on where you live and your age. The ACA allows insurers to charge older
customers up to three times more for a plan, even if they are in good
health, as long as the state in which an Exchange is located doesn’t
have a law that caps age-rating. Some Exchanges will tuck an
administrative fee of 2 to 4 percent into premiums to help cover
operating expenses.
Cost-sharing tax credits will be available if you are below 250
percent FPL to protect you from high deductibles and copays – but only
if you purchase a Silver plan. If you buy the cheaper Bronze plan, you
won’t be eligible for these credits, which are, by the way, direct
federal payouts to private health insurance companies.
Obamacare has no cost controls. There is nothing stopping the
insurance companies from increasing their rates, and Washington has
already estimated higher premium costs at the Exchange for 2016 which
doesn’t mean that 2015 won’t have an increase. Sounds like 2014 prices
will be an Introductory Offer. Get ‘em while their hot!
7. PENALTY FOR BEING UNINSURED
The ACA requires that people who have been deemed able to purchase
health insurance but decide not to buy it starting in 2014 will owe a
penalty (a tax) to the IRS. Here’s what this looks like:
a) In 2014, the annual penalty
will be $95 per adult and $47.50 per child, up to a family maximum of
$285 or 1 percent of family income, whichever is greater.
b) In 2015, the penalty will be $325
per adult and $162.50 per child, up to a family maximum of $975 or 2
percent of family income, whichever is greater.
c) In 2016, the penalty will be $695
per adult and $347.50 per child, up to a family maximum of $2,085 or
2.5 percent of family income, whichever is greater.
The IRS collects the penalty, but the ACA stipulates that taxpayers
shall not be subject to any criminal prosecution or penalty, tax liens,
seizure of bank accounts or garnishment of wages for failure to pay it
and no accumulation of interest on the unpaid balance. So, it appears
that all the IRS can do is deduct the penalty from a refund it owes you,
and if you’re not due a refund, then you’ll have an outstanding tax
obligation.
Keep in mind that the penalty is described in annual amounts but is
really monthly. So, if you are uninsured for only part of the year, you
will accrue only 1/12 of the total for each month you are uninsured
unless you qualify for an exemption.
8. EXEMPTIONS FROM THE PENALTY
You may be eligible for official permission that excuses you from
having to pay the penalty for being uninsured. The requirements are:
a) If the cheapest health care
plan available costs more than 8 percent of your MAGI after subtracting
the tax credit or employer contribution, whichever is applicable.
b) Your income is so low that you aren’t required to file federal income taxes.
c) You are between jobs and without insurance for up to three months.
d) You have a sincerely-held religious belief that prevents you from seeking and obtaining medical care.
e) You are in jail.
f) You are an undocumented immigrant.
g) You are a member of an Indian tribe or a religious group currently exempt from paying Social Security tax.
If item d) is the case, you must file a sworn statement as part of
your tax return, and should you obtain care during the tax year, the
exemption will no longer apply and you will have to pay a penalty for
being uninsured. Per H.R. 6597, medical care is defined as acute care at
a hospital emergency room, walk-in clinic or similar facilities.
Medical care excludes treatment not administered or supervised by a
medical doctor such as chiropractic, dental, midwifery, personal care
assistance, optometry, physical exams or treatment where required by law
or third parties such as an employer, and vaccinations.

If you think you can’t afford the amount the government has decided you
can afford to pay for your insurance plan, and you don’t fit into any of
the categories described above, you can apply for a Hardship Waiver.
Details have not yet been provided regarding hardship eligibility
requirements under the ACA, but, for an idea of what they might look
like, let’s check out what the deal is in Massachusetts which already
has a mandated health insurance law – Romneycare! In fact, Romneycare
was the model for Obamacare. That’s why some people call Obamacare,
Obamneycare.
To qualify for a Certificate of Exemption under Romneycare, a
Massachusetts resident must demonstrate that health insurance is not
affordable due to one of the following:
1) homelessness;
2) eviction or foreclosure notice;
3) domestic violence-related medical trauma;
4) major long-term illness of a child;
5) death of your spouse;
6) your house burned down; or
7)
“you can establish that the expense of purchasing health insurance
would cause you to experience serious deprivation of food, shelter,
clothing or other necessities.”
Ya gotta luv number 7. And in Massachusetts, exemptions come with an
expiration date, so you have to clean up your act in short order. Under
the ACA, the Secretary of Health and Human Services will determine if,
indeed, you have suffered a hardship that keeps you from being able to
pay for coverage.
9. OTHER TIDBITS
There is much more in the ACA including all kinds of rules and
penalties for employers, employees and the self employed as well as the
Accountable Care Organization (ACO) model which will be mandated
starting in 2014. The latter works as follows: under the simplest option
available, a small group of doctors and hospitals – an ACO – will
manage your care and be graded and paid based on the outcome of all
patients who seek treatment with that ACO. The ACO will also be rewarded
with a share of the savings in health costs it achieves by following
best treatment practices and reaching specific benchmarks set by CMS.
The second option, “shared savings plus risk,” is for larger ACOs.
Providers will receive a lump-sum payment to treat their patients and
assume a portion of the risk for above target spending but are eligible
to keep a greater portion of the savings.
Either of these options reduce patient care to numbers and paperwork
because doctors are essentially controlled and incentivized by an
administrator in some far-flung office. The ACO model is the insurance
industry’s version of “budgeting” the cost of health care which
ultimately benefits insurers at the expense of doctors and their
patients.
Doctors say that basing their pay on treatment outcomes creates an
incentive for them to avoid tough cases whose outcomes could “kill my
numbers.”
“Paradoxically,” writes Dr. G. Keith Smith, “doctors who are
doing sham surgery will be the ones with the best outcomes, as their
patients, many of whom don’t need surgery in the first place, will
exhibit great, basically perfect outcomes.
Physicians who don’t do
unnecessary surgery will be pushed to do so to improve their ‘scores.’
‘Pay for performance’ trends in medicine are not a good idea in my
opinion. Paying based on patient outcomes will have perverse effects,
not the least of which will be the complete denial of care to the very
sick.”
http://www.medibid.com/blog/2012/10/your-disease-can-kill-you-in-more-than-one-way/?utm_source=Registered+Physicians&utm_campaign=8f9028ddaf-October_Physician_Newsletter11_17_2012&utm_medium=email
The ACA also requires Health Insurance Exchanges to establish a
navigator program to inform the uninsured about the availability of
government-approved subsidized plans at an Exchange and to facilitate
enrollment in these plans, but it leaves the design of the program up to
each Exchange.
Depending how an Exchange sets up its program, some Navigators will
sell plans offered by an Exchange while others will be responsible for
maintaining the existing market but may also be allowed to sell Exchange
plans. All seller Navigators will be compensated either by Exchanges or
insurance carriers for the plans they sell. Many options are being
considered by Exchanges including using insurance agents. Hopefully,
Navigators and insurance agents will not be knocking on your door or
contacting you by phone. That would be over the top. Here’s a link to
read what the California Exchange is pondering with regard to its
Navigation program.
http://www.healthexchange.ca.gov/StakeHolders/Documents/CHBE,DHCS,MRMIB_StatewideAssistersProgramDesignOptionsRecommendationsandWorkPlan_6-26-12.pdf
10. ENROLL AMERICA, HERNDON ALLIANCE & THE EXCHANGES – MASTERS OF SPIN
Since many Americans don’t know about the ACA, somehow the word has
to get out and people must be encouraged to purchase health insurance
either in the open market or at an Exchange. And who better to do this?
Enter “Enroll America” – a nonprofit 501(c)3, financially backed by
Aetna, Blue Cross Blue Shield, UnitedHealth, America’s Health Insurance
Plans, hospitals, associations that represent drug manufacturers and
nonprofits with vested interests. For insurers and pharma, the ACA is
manna from heaven – scratch that – manna from Capitol Hill – and the
dollar signs in their eyes are on fire! These profit seekers and
connected nonprofits will be using every avenue possible to maximize
their bottom lines.
The mission of Enroll America per its website is to “ensure that all
Americans are enrolled in and retain health coverage.” It’s Board of
Directors and Avisory Council reads like a Who’s Who in the Medical
Industry Cartel – CEOs, presidents, vice presidents and directors of
such entities as the American Hospital Association, Express Scripts,
Medicaid Health Plans of America, Kaiser Permanente and many others –
the list is long. If you would like to donate to these mega-profit
vultures, you can do so on the Enroll America home- page. The goal is
$100 million by 2014.
http://www.enrollamerica.org
In its publication, “Ten Ways to Make Health Coverage Enrollment and
Renewal Easy,” Enroll America has recommended availability of web-based
applications to increase the places where people can enroll in coverage:
at home, at grocery stores, community health centers, state fairs,
sporting events, places of worship, and more. Gee, you can apply for
insurance while you pray. How thoughtful.
http://www.enrollamerica.org/best-practices-institute

The strategy for insurers and state Exchanges to persuade you to
purchase insurance and warn you about the penalties includes using ads,
social media, blogs, YouTube, Flickr, Twitter, hospitals, health
centers, McDonald’s, in-store radio announcements, ballparks, county
fairs, libraries, laundromats, community events, libraries, county fairs
and drugstores – you name it. Blue Cross Blue Shield has partnered with
H & R Block. Health insurers are already setting up shop inside
some supermarkets so they can answer your questions and sign you up for
coverage while you do your grocery shopping. They will likely be showing
up in shopping malls – maybe even in parking lots, on street corners
and at church fairs. And, their aim is to recreate themselves from the
bloodsucking leeches that they are to your new, cool-dude friends.
We’ll be living in Occupied Territory.
Let’s connect some dots. The executive director of Enroll America is
Ron Pollack, also president of Families USA – a nonprofit and friend of
the industry. On its website, Families USA bills itself as “a national
non-partisan organization dedicated to the achievement of high quality,
affordable health care for all Americans.” Philippe Villers and Robert
Crittenden, M.D. are on Families USA Board of Directors. Mr. Villers is
also on the BOD of Herndon Alliance, Bob Crittenden is a Herndon staff
member and Ron Pollack is a Herndon founder.
http://www.familiesusa.org
Herndon Alliance is an influential health care spinmeister creating
messaging to change public opinion and tweaking each message to reach
particular groups.
Herndon has close ties to Capitol Hill and helped market the ACA
providing words politicians and supporters should use to promote the
bill. For example, during the national health care debacle a few years
ago, you heard Mr. Obama et al continually talk about ‘choice,’ ‘we need
a uniquely American solution,’ ‘fair rules,’ ‘investing in America’s
future’ and ‘high-quality, affordable healthcare.’ That last one is used
in Families USA mission statement. The Council for Affordable Health
Insurance, a frontgroup for the industry, gets right to the point – its
name. Ron Pollack worked with the Obama administration to help reshape
public opinion of Mr. Obama’s unpopular health care bill. Leading up to
2014 when the Exchanges are scheduled to open, there will most likely be
a blitz of TV ads in which you will hear many of these same nebulous,
feel-good words. And, you’ll undoubtedly read or hear plenty of Herndon
spin from your Exchange and throughout your state in the immediate
future.
In the interest of coming up with messaging, Enroll America held a
few focus groups and commissioned a nationwide survey in fall 2012.
Research was provided by Celinda Lake from Lake Research Partners, a
national public opinion and political strategy research firm. One
takeaway was when a monthly premium cost was given, the majority of
people polled thought that it was too expensive and the ACA would not
provide affordable and comprehensive coverage even with the government
tax credits (subsidies). So, Lake Research Partners advised Enroll
America not to mention specific costs but to use the phrase ‘free or
low-cost plans.’
http://www.nytimes.com/2012/12/20/us/officials-confront-skepticism-over-health-law.html?ref=us&_r=0&pagewanted=all
Herndon has been working on messaging various parts of the ACA that
will be used by outreach partners, insurers and state Exchanges. Its
messaging is not based on truth or evidence – Herndon actually stays
away from any mention of facts as you read above regarding the cost of
plans. Instead, its messaging is designed to mislead an uninformed
public.
A few of Herndon’s target populations include voters, people of
color, red states, skeptical audiences, and you’ll love this one –
Elevator Language with a list of succinct scripts to use based on the
person you’re speaking to during the ride. You must check out Herndon’s
website and read the many instructions of what to say and what not to
say. You’ll either get very annoyed or laugh yourself silly.
http://herndonalliance.org/resources/research/communications-tips-exchange-talking-with-voters.html
http://herndonalliance.org/resources/implementation-basics/communications-tips-to-use-with-skeptical-audiences.html
Here are some examples of Herndon spin regarding the ACA:
— Use “family values” when talking to the public about the expansion of Medicaid. Is estate recovery a family value?
http://herndonalliance.org/resources/what-s-new/talking-about-medicaid-connecting-with-the-public.html
— When talking about the ACA’s
required Accountable Care Organization (ACO) model that will pay doctors
according to patient outcomes and reward them for savings they achieve,
Herndon says to call this “Coordinated Patient Care” and “do not
connect pricing with rewards or incentives for doctors” or “with
lump-sum payments for medical care” and do not mention “payment based on
positive patient outcomes.” Why not? The three do-nots are how ACOs
work. (ACOs are described in topic 9.)
http://herndonalliance.org/resources/system-change/payment-reform-quality-care-pricing.html http://herndonalliance.org/resources/system-change/coordinated-patient-care.html
— Here’s an award winner:
“Members of Congress will purchase their insurance at the Exchange. If
members of Congress are part of the marketplace then it’s got to offer
quality plans and protections.”
http://herndonalliance.org/resources/research/communications-tips-exchange-talking-with-voters.html

— Stressing that under the ACA
insurers won’t be able to deny coverage for pre-existing diseases is a
Herndon biggie. In fact, you heard this many times over from Mr. Obama
and other politicians. But a loophole in the law allows insurers to
rescind (cancel) your policy if you intentionally put false or
incomplete information on your application. The ACA says you must be
given at least 30 days’ notice before your coverage can be rescinded,
giving you time to appeal the decision or find new coverage. So, if your
care becomes costly for the insurer and you didn’t mention you had a
rash on your arm when you were 15, that’ll work. How can you prove if
leaving this out was intentional or not? It’s them against you.
Enroll America’s Best Practices Institute is publishing a series of
briefs on the best way to write and design websites and marketing
materials, no doubt, using Herndon messaging. PR and marketing firms are
helping various state Exchanges come up with appealing branding such as
using a name everyone will like and spiffy logos with cool type styles
in colors that will appeal to all audiences. Branding lessons include
advising Exchanges which words to ‘embrace’ such as emphasizing choice,
control, transparency and competition. Other messaging includes, “the
Exchange should be viewed as an educator, not an enforcer” and using the
word ‘marketplace’ instead of Exchange is a must. Tennessee Health Care
Campaign will be telling potential customers “. . . the exchange offers
us more choices, greater control over our health care, and more
competition to control costs.” It’s all Herndon’s handywork in one form
or another.
http://dhmh.maryland.gov/exchange/pdf/Brand_Recommd_may182012_final.pdf http://www.thcc2.org/PDFs/rtm_exchange_talking_point.pdf
More choice means choice of insurance companies, not choice of
doctors and hospitals. In rural areas, there may be only one insurer
offering plans which means one network and doctors may not be taking new
patients. This happened in MA under Romneycare, and on top of that,
many doctors would not accept people in the subsidized plans because of
time-consuming red tape and low reimbursement rates. Under the ACA,
insurers are planning to limit networks in the cheaper plans at the
Exchanges. Having too few doctors in a network is a means of suppressing
the use of health care which increases an insurer’s profits. Further on
in this lesson, you’ll learn that the Maryland Exchange has been
advised to ignore negative problems such as not enough doctors to serve
the newly insured.
http://www.kaiserhealthnews.org/Stories/2013/January/23/HMO-limited-networks-comeback-in-exchanges.aspx
Choice is definitely a non starter for people found eligible for
Medicaid – the ACA allows no other choice for this segment of the
population and many doctors do not accept Medicaid. As for giving you
greater control, considering all the rules about income and FPL, not to
mention the data-mining to monitor your income during the year and those
nasty tax credit paybacks, it’s you who is being controlled. And
competition? Read this stunning op-ed by Nomi Prins: “Real Danger of
“Obamacare” Insurance Company Takeover of Health Care.”
http://www.nationofchange.org/real-danger-obamacare-insurance-company-takeover-health-care-1352648027
In Enroll America’s January 15, 2013 press release, Executive
Director Rachel Klein says the ACA offers the promise of “access to
comprehensive, affordable health coverage.” That is a false promise. As
you learned in this lesson, coverage in the plans that will be offered
at the Exchanges, with the exception of the two most expensive, is
anything but comprehensive – the cheaper plans are unaffordable to use.
Furthermore, how can she claim that the cost of the plans are
affordable? Ms. Klein should be well aware of the nationwide survey
Enroll America commissioned in which the majority of people polled said
that the plans are too expensive.
http://files.www.enrollamerica.org/news-room/press-releases/Enroll_America_Plans_Major_Affordable_Care_Act_Enrollment_Campaign_1-15-13.pdf
http://www.nytimes.com/2012/12/20/us/officials-confront-skepticism-over-health-law.html?ref=us&_r=0&pagewanted=all
Currently PR firms are working with some state Exchanges to develop
effective communications plans and advertising campaigns. Names include
Mintz & Hoke, Hill & Company Communications and Weber Shandwick
just to name a few. Ask the Massachusetts Health Insurance Connector –
the prototype of an Exchange in the land of Romneycare – how much it
spent on PR contracts over the years. In 2007, board members signed off
on a two-year contract with Weber Shandwick for $1.85 million the first
year with nearly $3 million for advertising – commission on media buys
not included. And, by the way, the MA Connector upper management boasts
six-figure salaries. Former MA Connector Executive Director Jon
Kingsdale’s salary in 2007 was $225,000 and increased in 2008 to
$231,750. In 2007, Deputy Director Rosemary Day alternated between a
four-day and five-day work week to the tune of $175,000. These are only
two examples of the many high-flying salaries at the MA Connector, an
operation run by politicians and unelected political appointees and
influenced by executives from the private insurance industry,
http://www.wickedlocal.com/cambridge/news/x497793387/Connector-re-ups-contract-with-Cambridge-based-Weber-Shandwick http://www.boston.com/yourlife/health/other/articles/2007/01/27/6_figure_pay_for_care_plan_overseers/?page=full http://www.highbeam.com/doc/1G1-166773095.html
Add up pay scales like that for every Exchange in the country, throw
in some bennies, a PR contract for each Exchange, campaign costs and
compensation paid by Exchanges to Navigators for plans they sell – a
grand and costly effort to push more people into America’s for-profit
health care system. Your tax dollars at work and mega bucks that could
be used for actual hands-on medical care.
The Maryland Exchange has three campaign funding levels – Basic, Plus
and Full-Scale – with a total for year one, two and three. Basic
funding for year one is $2,450,000, Plus is $4,000,000 and Full-Scale is
$6,300,000. See p.137 at this link for years two and three.
http://www.dhmh.maryland.gov/exchange/pdf/FinalAdvertisingReportWeber.pdf

The following, from the maryland link above, gives you an idea of some
of the strategies that will be in play, most likely in all states. The
Maryland Exchange has been advised by Weber Shandwick to “establish a
system to monitor newspaper, radio, TV and online conversations about
the Exchange and the program and to establish procedures and priorities
for responding to negative media stories, op-eds, blogs and reports.”
You can find this in the Risk Management and Responses section of
Maryland’s strategic marketing plan.
In the Earned Media/Public Relations section, advice includes “ . . .
putting out stories on the first effective enrollees, enrollment number
milestones, and enrollee testimonials. Each of these becomes the focus
for positive, brand-reinforcing stories. There will also be the risk of
negative stories, including potential topics such as enrollment snafus,
delays in issuing insurance cards, the cost of Qualified Health Plans
[government-approved plans], claims of ‘shoddy’ Bronze coverage,
incidents of physicians refusing to accept enough new patients to serve
the uninsured and other negative topics.” “While coverage is bound to
include some level of criticism it can be success- fully countered by
putting a human face on heatlh reform.”
The Social and Digital Media section advises an invasion of the
Internet including social media to market health insurance by
“delivering the right messages to the right audience at the right time,”
(probably using Herndon spin) to “help drive enrollment in the
Exchange,” and also flooding newspapers with op-eds to contradict
reported adverse effects of the ACA.
More details can be found at the Maryland pdf link below. It’s worth
looking at this presentation to grasp the big business approach of
Exchanges which is clearly profit-driven. The Maryland Exchange strategy
is just one example. The goal of Exchanges is sell, sell, sell.
http://www.dhmh.maryland.gov/exchange/pdf/FinalAdvertisingReportWeber.pdf
Exchanges certainly have a lofty goal – promote success stories only
and be ready to contradict and cover up the bad stuff as quickly as
possible. Massachusetts residents have been there. The Connector and
state politicians including the governor made sure that anyone being
harmed by Romneycare would not be heard in spite of statewide survey
reports put together by outreach agencies advising state legislators and
powerplayers that low-income people were not faring well under this
law. Various issues were spelled out and testimonials were included, but
residents’ concerns about the adverse effects of Romneycare were
ignored. MA national legislators also went along with this agenda as did
the mainstream media.
When $130 million was needed in 2009 to balance the Massachusetts
state budget, the Connector – with the blessing of MA Gov. Deval Patrick
and the MA legislature – removed about 28,000 legal immigrants –
working people paying taxes – from their insurance plans. Another 8,000
or so were barred from enrolling in insurance plans because the MA
legislature voted to cap enrollment in the subsidized plans. This took
place at the same time Mr. Obama was trying to sell the ACA to the
nation, so, under pressure from Washington, the MA legislature restored
some of the money, and the Connector dumped these people, without their
consent, into an out-of-state plan with higher copays, less
comprehensive coverage and next to no doctors or safety net hospitals in
its network.
http://www.huffingtonpost.com/iyah-romm/lessons-from-massachusett_b_380718.html
This has huge implications for the ACA. If legal immigrants can be
removed from their plans and others denied enrollment when a state
budget is squeezed, which vulnerable segment of the population is next
in line? The good news is these legal immigrants in MA sued the
Connector and its then-Executive Director, Jon Kingsdale, and the
Massachusetts Supreme Judicial Court ruled unanimously that the state
could not violate their right to equal protection under the state and
federal constitutions and fiscal considerations alone can not justify a
state’s invidious discrimination against them. As a result of this
decision, the state had to come up with some bucks, and the Connector
was forced to put the plaintiffs back into their original plans.
http://www.healthlawadvocates.org/priority-areas?id=0015
Getting back to Enroll America, Herndon Alliance and some of the
less-than-honorable Exchange strategies – it’s one thing to inform
Americans about the ACA and Exchanges that offer the possibility of
either purchasing high-deductible or catastrophic coverage with a loan
from the government to help pay for it or being tossed into expanded
Medicaid – but, mounting a costly, massive campaign to purposely deceive
and manipulate the public with the unstated goal of more profit for the
already extremely lucrative health insurance industry is disgraceful.
———————————————-
Is the ACA a fair law if it helps only one small segment of the
population but hurts and exploits a larger number to do so? The way this
law works is fundamentally unfair and will not bring medical care to
the many, but, instead will progress to greater personal debt for
individuals and families who can’t afford the “affordable” insurance as
well as those who must keep an eye on their income to avoid the many
traps and false ends this law creates. At their expense, the forced
purchase of health insurance will bring increased revenue to the
industry, not to mention more kickbacks to Congress, and in the very
near future, the health insurance industry will be “too big to fail.”
The ACA is most definitely a “uniquely American solution” which has
little to do with reforming this country’s barbaric health care system.
It merely controls peoples’ finances and choices while leaving insurance
companies in charge and does virtually nothing to end their abuses. It
will leave many millions of Americans uninsured and millions more
underinsured at a staggering cost to taxpayers.

Politicians, health care policy wonks and vested interests will brush
aside the ACA’s adverse effects. You’ll hear that some have fallen
through the cracks of health care reform but the problems can be easily
tweaked. You will also witness the usual dog-and-pony show on Capitol
Hill in which the two parties play the blame game. The
bought-and-paid-for mainstream media will regurgitate whatever
Washington feeds it, and TV talking heads will chime in, inviting their
“experts” to analyze the situation while real people in the real world
struggle to get by under this law or fall by the wayside.
Good luck everyone and watch out for the folding chairs.
addendum:
Obamacare architect leaves White House for pharmaceutical industry job
http://www.guardian.co.uk/commentisfree/2012/dec/05/obamacare-fowler-lobbyist-industry1
Physician payments based on outcomes
http://www.medibid.com/blog/2012/10/your-disease-can-kill-you-in-more-than-one-way/?utm_source=Registered+Physicians&utm_campaign=8f9028ddaf-October_Physician_Newsletter11_17_2012&utm_medium=email
