Unaffordable Healthcare

Trump’s latest Executive Order is another swipe at Obamacare, but it does not repeal or replace it.
In general, the executive order has no force of law itself. What it does do is influence how regulations are put together. It is those regulations that represent how a law is implemented and how it is enforced.  Trump’s executive order asks three federal agencies to consider possible new regulations that could help achieve certain goals, like providing more policy options for the young, allowing small business associations to provide health insurance plans that cross state lines and expanding access to short-term insurance policies, those that offer coverage for 90 days or less. It is not clear what those rules will say.

Previously Trump issued an executive order that let a broader range of employers stop offering free contraception through their healthcare plans.  It said that regulations should interpret the Supreme Court Hobby Lobby decision to enable employers who have a sincerely held moral and/or religious convictions to opt out of the free contraceptive benefit currently in their policies.  Loosely interpreted, an employer could be morally opposed to paying more for healthcare. 


Anytime a benefit is excluded from a policy, the plan costs less. If you find paying more for health insurance morally offensive, you can now opt out of providing free contraception. It is that simple.

The other thing Trump can do is use Executive Orders to curtail the activities of the executive branch of government.  This allowed Trump to use executive orders to shut down the Affordable Care Act website for 12 hours every Sunday during open enrollment, cut the budget by 40% that funds groups that help people enroll, and cut the advertising budget for the ACA from $100 million to $10 million.  Such actions make it less likely people will enroll.     In addition, his decision to limit enforcement of the ACA has wide consequences.  Knowing that the individual mandate is unlikely to be enforced and the companies will unlikely be penalized for not offering insurance makes it less likely those people will purchase expensive exchange policies.

Trump is seeking to end subsidies paid directly to health insurance companies that help low-income people.  He wants that money paid directly to the states instead.   Trump is also seeking to eliminate the exclusivity requirement that all plans be conforming to the ACA and offer the essential health benefits, such as well-care like physicals and/or preventative care like mammographies, as defined in the Affordable Care Act.

The real impact of these executive orders will be felt by the self-employed, the working poor, and the middle class.  What this means is that those who are not covered by group benefit plans, plans provided by their employer, are going to be unable to purchase health insurance.  Not because it won’t be available, that is a false premise.  They won’t be able to buy it because what will be available will be unaffordable.  This year, in California, a policy covering two adults in their 50’s and their grown child will likely cost more than $20,000, with a $10,000 deductible and copays of $70 for specialist visits.   Because of the exodus of young people into lower costs products that will likely result from the implementation of the executive order, the increase in the cost of this same policy could be up to 40% or more.  What family can afford $42,000 in payments before the insurance company contributes their first dollar?

It should be noted that the states, not the federal government, set policy prices.  Policy prices for 2018 have been set.  At this point, states are not authorizing new policy types or increases in costs to offset the uncertainty.   What happens in 2019, at this point, is unknown.  In California, is an insurance company pulls out of the state, they have to wait 3 years to come back in.  Insurance commissioners can stop the exodus of insurance companies by either making them be all in or all out.  We will have to wait and see if more carriers pull out and if state insurance commissioners hold the line on cost.

Remember, State Insurance Commissioners are politicians and subject to influence.  If you are angry, this is the place where your voice can be heard.  

Minda Wilson

Author of Urgent Care

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Republicans vs. Democrats – Someone should spank them both

In the recent weeks,
Republicans and Democrats have again put their hat into the ring that is healthcare reform. Republicans still want to honor their promise to repeal and replace.  Democrats want to protect their legacy.  Since neither plan considers affordability, either way, the people will suffer.

Republicans have revised their plan in hope that they can get something passed before the end of the month.  If this happens, they will avoid having to start all over and create a new bill.  Their plan replaces tax subsidies; instead of the government paying money directly to insurance companies they will make payments to the states in the form of block grants. People would be able to increase their contribution levels to Health Savings Accounts and other pre-tax benefits. The states would use the money to subsidize their own health plans.  The penalties for uninsured individuals who are uninsured as well as corporations who do not offer insurance would be eliminated.  Limits would be placed on Medicaid spending.  And, hard to believe, the repeal of the medical device tax, which has been on the agenda since day one, is also on the table.

With no federal programs in place, the states will have to create their own.  Since health insurance is still controlled at the state level, this would not make significant changes in the markets.  The financial and other safeguards that were put in place, i.e. no preexisting conditions, no higher premiums for older adults, would be determined at the state levels.  With subsidies gone, and if the federal government continues to limit payments to the states for Medicaid and other programs, it is likely the level of care available will be affected. Each state would decide who would be protected and how.  Just like it was before Obamacare.

All these changes do nothing to control the cost of insurance.  Insurance companies can still charge whatever they want. It is still up to each state’s Department of Insurance to set prices; and, so far, these institutions have done nothing to control runaway insurance premium costs.  The Democratic answer seems to be Bernie Sanders’ latest proposal “Medicare for All!”.  The first problem is that the government actually pays for very limited coverage, Parts A and Part B only.  The rest is covered only if seniors purchase supplemental insurance.

Senator Sanders’ own state adopted such a single-payer plan.  It lasted less than a year.  When Vermonters found out that to keep the program going without filing bankruptcy they would have to raise their state income tax payments from 14% of income to 24% of income, they chose to abandon the program.

Paying out an additional ten percent of one’s income proved too much a disincentive for Vermont’s citizens. That is in a state with relatively few illegals, a relatively healthy population, and low healthcare costs.  You can imagine the financial impact such a plan would have on a national scale.  A 10 percent increase would be nothing when you start adding in the cost of illegals, the underinsured, etc.

The solution to all of this is rather simple.  If health insurance is treated like a utility, we can regulate the money that comes in and make sure that money is used to pay for medical expenses instead of health insurance oversight, review and administration.  Maybe if the legislation focused on that, we might get somewhere.

Minda Wilson

Author of Urgent Care

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Republicans quickly reject their own revised bill

Yesterday, Senators voted for debate, not passage.  Once they agreed to debate the first thing the Republicans did was quickly reject their own revised bill,  the Better Care Reconciliation Act, once their leading proposal for repealing and replacing Obamacare.

The Senate rejected the bill, 43 to 57, despite having added a provision from  Sen. Ted Cruz (R-Texas) favored by conservatives and another from Sen. Rob Portman (R-Ohio) to court centrists worried about Medicaid cuts.

The Cruz provision allowed insurers to offer several plan types including cheaper plans that cover smaller ranges of benefits as long as that state offers one plan that has the broad coverage required by Obamacare. 


The Portman provision, the Medicaid wraparound, provides $200 billion dollars of support to states whose Senators were concerned about cuts to their Medicaid programs.  The incentive of $200 billion for their states was not enough. Of the 57 votes against, 9 were Republicans.

Minda Wilson

Author of Urgent Care

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its bad and know it will negatively impact Americans.

 "It's a sad day when..."

It's a sad day when your Senator votes yes for a healthcare bill even though they know its bad and know it will negatively impact Americans.  The Senators feel they have to vote yes in order to meet their promise to advance the ball on repeal and replace.

"Even Senator McCain, a man who is dying of metastatic brain cancer, who has nothing to lose, voted yes for debate, even though he is not behind the bill as it stands.  Remember, the Senators  voted yes for debate, not passage."

They did it because voting no would mean that they are 
"telling America that they are fine with Obamacare".

Minda Wilson

Author of Urgent Care

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Longer wait times to see a doctor, dramatic increases in the cost of insurance

"The Party’s Over"

With the death of the current incarnation of the Republican plan, we have to take a minute to consider what will continue to happen if nothing is done to repeal and replace or revise Obamacare.

The good news is that the expansion of Medicaid will continue and the federal government will continue to subsidize the states that cover those eligible for the expansion who apply.

This has had significant benefits by making working poor eligible for healthcare benefits.  In states like West Virginia, workers that are now covered have seen their wages increase, their children’s attendance at school increase and their use of the emergency rooms for medical treatments has significantly declined.  

That is where the good news ends.

In a large number of countries and in some states, there will be no carriers writing policies for coverage in the individual market.  That means that people who live in those counties/states will not be able to purchase health insurance of any type; and, the, in addition, they will be penalized for not buying insurance that is absolutely unavailable to them in any form.

For those that can purchase health insurance, including businesses, rates are expected to increase at least 20% for coverage next year.   Many companies are struggling to pay current premiums.  In certain states, including Texas, Connecticut, Maryland and Virginia, carriers have asked for premium increases in excess of than 50%.  A business that is struggling will be forced to drop their healthcare coverage.   If your business bought coverage and can no longer afford it, your employees may or may not be able to get coverage of their own, depending on where you live.

Co-pays will no longer be considered part of your co-insurance payments and, as such, may not count toward your deductible.  With individual deductibles on the increase from $2500 to as much as $5000, you might be surprised to learn that your co-payment will no longer count against your deductible.  This means that only co-insurance payments will apply.  Co-pays range from $45 to $115 per visit, depending upon the doctor.  Most plans now require a co-payment for all doctor visits and, in addition, you will be responsible for a co-insurance payment.  If you are on a 70-30 plan,  in addition to your co-payment you will be responsible for paying 30% of the amount billed to your insurance company.  This means that after you pay your co-pay, and the doctor bills the insurance company for the visit if the bill is $100 you will owe another $30 on top of your co-pay.  You now have to pay $75 for your visit, but only $30 counts towards your deductible.

The exchanges will continue to be funded by the government.  The exchanges duplicate 100% of the functionality provided by insurance company web sites. Since the taxpayers already paid for the cost of developing these insurance company sites, every year we support the exchanges we are paying again for something we already paid for.

The 5 million, plus, illegals that currently get healthcare paid for by the government will continue to receive this healthcare.  A number of subsidies paid will continue to be above and beyond what is really called for.  The Obama administration did not implement the electronic verification of citizenship nor did they implement the electronic verification of income.  Income and citizenship are input on the honors system.  We simply take your word.   Because all verifications are essentially done manually, if you claimed you were a citizen and you aren’t or you claimed an income below what you actually earned, you get the benefits you asked for.  Too bad for the tax payer!

Networks are going to get narrower.  It will get harder and harder to see a doctor.  Almost one-quarter of doctors are over 64, retirement or frustration will end their medical careers.  Since 2013, the year Obamacare went into effect, in addition to the loss of doctors due to changing careers or retiring, approximately 10% of doctors each year opt out and accept only cash.  This is especially true in the large cities and applies more specifically to professionals with excellent reputations who are tops in their fields.   These guys are so good, they can command any price, and people are willing to pay it. Why should they accept insurance when the reimbursement rates offered don’t cover the cost of doing business.

New doctors are not going into private practice; they are becoming part of large hospital systems and thus only take on patients that their hospital system will treat.  If your provider doesn’t have a contract with a big research facility and you have something that requires the sophisticated treatment such facilities can offer, you are out of luck unless you can pay for it.

The bottom line is this, the trends that started with the Affordable Care Act, less access to care, longer wait times to see a doctor, dramatic increases in the cost of insurance and even more dramatic increases in the out of pocket cost of care, will continue unless something is done.

Minda Wilson

Author of Urgent Care

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The Problem Isn’t Obamacare…It’s The Insurance Companies

Primary Care Doctor Explains:

“The Problem Isn’t Obamacare…It’s The Insurance Companies”

With premiums increasing for those with coverage through the ACA marketplace, a lot of people are criticizing Obamacare. But many doctors and healthcare professionals are saying that isn’t really the problem.

Cathleen London is a primary care physician in Milbridge, a rural town in Maine. She claims the problem isn’t Obamacare itself, but rather, the entire health insurance system and insurance companies are to blame.

Writing for the Portland Press Herald, London explains she is a a primary care physician who is on the front lines every single day, as  her town is very remote, which means it takes 30 to 40 minutes to get to the emergency room, which is why her office operates as an urgent care facility as well as a family medical practice.

It’s takes an ambulance about 20 minutes to get to her clinic and specialist care about 2 hours away, so Dr. London is trained to handle about 90 percent of medical problems.


DR. LONDON EXPLAINS THE FOLLOWING, WHICH WILL SHOW YOU EXACTLY WHAT’S WRING WITH HEALTH CARE:
One evening I was almost home after a full day’s work. Around 7:30, I got a call on the emergency line regarding an 82-year-old man who had fallen and split his head open. His wife wanted to know if I could see him, even though he was not a patient of mine.

Instead of sending them to the ER, I went back to the office. I spent 90 minutes evaluating him, suturing his wound and making sure that nothing more sinister had occurred than a loss of footing by a man who has mild dementia. When I was sure that the man would be safe, I let them go.

I billed a total of $789 for the visit, repair, after-hours and emergency care costs. Stating that the after-hours and emergency services had been billed incorrectly, Martin’s Point Health Care threw out the claims and reimbursed me $105, which does not even cover the suture and other materials I used.

I called them about their decision, said that it was not right and let them know they’d lose me if they reimbursed this as a routine patient visit. They replied, “Go ahead and send your termination letter” – which I did.

The same day, Anthem Blue Cross kept me on the phone for 45 minutes regarding a breast MRI recommended by radiologists on a woman whose mother and sister had died of breast cancer. She’d had five months of breast discharge that wasn’t traceable to anything benign (and it turns out the MRI is highly suspicious for cancer).

Anthem did not want to approve the MRI unless it was to localize a lesion for biopsy, even though the mammogram had been inconclusive! This should have been a slam-dunk fast track to approval; instead, dealing with Anthem wasted a good part of my day.

Then Aetna told me there is no way to negotiate fees in Maine. I was somewhat flabbergasted. I do more here than I did in either Brookline, Massachusetts, or New York. The rates should be higher given the level of care I am providing. I have chosen not to participate with them. This only hurts patients; however, I cannot keep losing money on visits.

I do lose money on MaineCare – their reimbursement is below what it costs me to see a patient. For now, that is a decision that I am living with.

I had thought those losses would be offset by private insurance companies, but their cost shifting to patients is obscene. I pay half of my employees’ health insurance, though I’m not required to by law – I just think it is the right thing to do.

My personal policy costs close to $900 a month for me and my sons (all healthy), and each of us has a $6,000 deductible. This means I am paying rack rate for a policy that provides only bare-bones coverage.

Something is wrong with the system. In one day, I encountered everything wrong with insurance. I am not trying to scam the system. I am literally trying to survive. I am trying to give care in an underserved area.

This is not the fault of Obamacare, which stopped the most egregious problems with insurance companies.

Remember lifetime caps? 

Remember denials for pre-existing conditions? 

Remember the retroactive cancellation of insurance policies? 

Returning to that is not an option.

Indeed it is not an option, Dr. London.  If Republicans get their way eventually by repealing Obamacare, it may be where we end up again. If Republicans really get their way, it’ll be even worse than it was before.

Minda Wilson

Author of Urgent Care

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Jordyn 21 Year Old Boy Killed by His Insurance Company

This is a true story.

Due to the fact that their son's death is so recent and raw, I have changed some of the details so protect the family.

"The story you are about to read is true, the names were changed to protect the innocent."

On the morning of Sunday, March 5th, at 4 am, Jordyn Smith died.  Jordyn was 21 years old.  While he didn't know exactly what he wanted to do with his life, he was working on it. He was handsome, over 6 feet tall, strapping, and athletic. He had a close group of friends that he had known since kindergarten.  Each one spoke at his funeral and told a story about how special he was to them and how much they meant to each other.

Jordyn liked to go to parties and, admittedly, had a drink or two with his friends before he turned 21.  The thing is, he never smoked.  He was passionate about music, loved rap.  He loved his sports teams and rooted passionately for the Rams.  You could never say a bad thing about them. He was a typical boy from a relatively small suburb growing up and finding his way.

Eighteen months ago, he was diagnosed with lung cancer.  For over a year, he was in and out of the hospital. First chemotherapy, then surgery.  They removed a good section of his lung.  This made him so sad because he was worried about whether he would have the wind to keep up with his friends when he was well.  Everyone told him that, once he got done with his treatments, and started exercising, his lungs would expand and he would be able to play soccer and basketball, two things he loved.

After the surgery, he had a lot of pain, which never really got better.  Worse, more treatments followed.  He had more radiation, more chemo.  His skin hurt from the radiation.  Through it all he was stoic and silent; complaining little and keeping up a strong front for his family.

After New Year, it looked like we were out of the woods.  Several months had passed since his last treatment.  There was talk of another round of chemo, but his tests were clear and he was recovering.  He felt so good that there was a big celebration party at his house and he started going to football games to see his beloved team.  And then it happened . . . .

Jordyn got a cold; a cold!  Because of the vulnerability of his lungs, it turned into pneumonia.  He couldn't breathe.  Within a week of getting sick, he was back in the hospital, hooked up to a breathing machine.  It took several weeks to get him off the machine and to stabilize him.  This last Friday, it looked liked he was finally going to be transferred out of the hospital to a rehabilitation facility.  The hospital required to test for infection prior to transfer.  When the blood tests came back, he had tested positive for infection.  Thirty-six hours later he was dead.

How could Jordyn have gone from able to be discharged to full blown pneumonia, 

without it being detected?  

Jordyn was another victim of the Affordable Care Act, and the power it imbued our insurance companies.  Insurance companies, not doctors, now dictate how often blood can be "routinely" tested or chest x-rays taken for a patient like Jordyn in order for a hospital to be reimbursed.

If more frequent testing is recommended by the doctor, to get paid approval is required.  If no approval is forthcoming, who gets stuck with the bill?  The delay, deny, die mantra of insurance companies let you know right away how long it will take to get and answer and the law gives them up to 90 days to respond.  For Jordyn, it led to his death.

Minda Wilson

Author of Urgent Care

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Minda WIlsons Response to Republican Proposals

President Trump said that healthcare is complicated. It is complicated;

but fixing healthcare is not.

The solution is simple and comes in 3 parts:

1)            True health insurance coverage, by a licensed entity, ie insurance company, gifting program, MEWA, or other legally approved entity, will provide catastrophic coverage, only.  This means that preventative care will not be covered.  Those costs should be paid individually by money set aside in your Health Savings Account, see below.

2)            In the aggregate, the price an insurance company charges for its policies should be no more than 1.4 times the money paid out by that insurance company for medical related services.

3)            All Americans should be able to set up Health Savings Accounts for themselves and their family members.  Contributions can be made by both employers, employees, and individuals.  Caps for these accounts should be set no lower than the cost of a family deductible, today about $10,000.

This proposal ties policy prices to money actually paid out for care.  If they spend more on care for your fellow policy holders your policy price will go up.  If they spend less, your policy price will go down.  The money they get for administration will be directly tied to the cost of care.  They less they spend on care the less they receive for administration.  It is just that simple.  You will be responsible for your individual healthcare needs.  If you don't take care of yourself, you will pay more.

Fixing healthcare only becomes complicated when you stop thinking about what a viable solution would look like and start thinking about how you can satisfy the insurance companies needs to continue using funds that are supposed to be used to pay for customer's healthcare needs, but instead are used to pay for health insurance company expenses.

The legislative proposals call for more health "insurance".  Allowing insurance companies accesses to more insureds and relying on them to agree to reduce costs makes no sense.  As a business person, if someone said, "I'll send more customers your way and let you decide whether or not your think the extra business is enough to make you consider lowering your prices!" , the odds of me lowering those prices is slim and none.

Affordability seems to be off the table.  Policy costs will continue to be negotiated at the state level.  Since all insurance companies typically have to do to raise rates is show more losses than anticipated or more expenses than anticipated, the odds of rates going down any time soon are non-existent.  Interstate insurance will allow companies incorporated in the most advantageous states to out compete those who are incorporated in states with higher levels of consumer protections.  While tax subsidies and/or tax credits are being considered, lower income families, and families that do not file itemized returns will receive little or no benefits.

Americans seem to have confused health insurance with health care.  Health insurance is supposed to spread the risk so that everyone who participates pays a little so that no one person has to pay a lot if they get sick.  Health insurance companies have become an investment vehicle to enrich senior executives.  As long as we continue to allow them to spend only 10% of what comes in to pay for the actual care part of their policy holders , there won't be much care there.

"The answer to our problem is to hold our insurers accountable; not promise them more business with no consideration for how much we will be charged"

Minda Wilson

Author of Urgent Care

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Debate Night - Future of Obamacare, Cruz vs. Sanders

Future of Obamacare, Cruz vs. Sanders

CNN Healthcare Debate with Jake Tapper & Dana Bash 

Minda Wilson , Author of Urgent Care response on the CNN debate


"If the debate taught us one thing, we learned that both participants come from very different philosophical points of view, are very passionate about what they believe and don't let the facts get in the way of their positions.

In the hair splitting department, Bernie Sanders believes that healthcare is a right, while Ted Cruz believes healthcare access is the right of all Americans.

Because healthcare is a right, Sanders expects the government to absorb the cost of providing it,  no matter how great the financial burden would be.  While Sanders expects the top 1% of the country to pay for it, he sees himself as a part of that group.  If His income as a Congressman puts him in the top 1% of earners. If he doesn't have the money, who does?  According to Senator Cruz, if we confiscated all the wealth from the "wealthy" we would not have enough revenue to carry for one year the additional costs of a single payer system which would provide healthcare to all Americans.

According to Ted Cruz, "What we should care about is access to healthcare, not insurance per se. "  This means that all people should have access to healthcare, but they still should pay for it themselves. With insurance costing at least $10,000 for a family and deductibles in excess of $5,000, how is the average family going to pay for their care?  Cruz thinks that allowing insurance companies to compete across state lines and reducing regulations the insurance companies because they would be making more money, would, out of the goodness of their hearts, pass this increased revenue onto consumers by reducing their prices.  This would result in a reduced costs for the family.

Both parties acknowledged our obligation to assist those who need help.  Agreement at last.  They also agreed that it is insurance companies and drug companies that are the bad actors in the story of escalating healthcare costs.  Both acknowledged that drug companies are not required to negotiate prices.  It was Ted Cruz who reminded us that, since the passage of Obamacare, health insurance profits have doubled and their margins have dramatically increased.  This means that the margins on each policy sold were greater than before Obamacare was passed.  However, when it came to tackling the problem of rising costs, both looked to the uncontrolled insurance companies to provide us with a solution.  Neither proposed any controls on costs.

Gruber, in his post-debate interview said, the problem with Obamacare was that insurance companies were not given the protections they wanted in order to participate in that market.  Both Senators Cruz and Sanders would think this is ridiculous.  Bernie thought insurance company executives were making enough money and didn't need more.  It was Cruz and his Republicans that voted against releasing an addition $7plus billion dollars to insurance companies to cover losses on Obamacare policies when those same companies were experiencing record profits.

What they didn't talk about was how the position each was advocating for had already failed.  In Congressman Sanders own state of Vermont, a single payor system was tried.  The system worked so badly and ended up costing so much that less than a year after it was enacted, Vermont pulled the plug.  They said that based on their one year of experience, state income taxes would have to be raised 10% across the board, for all taxpayers, in order to cover the costs of their single payor plan.  A 10% increase in taxes didn't seem to make sense, especially since that would only cover the costs for subsequent years if there were no increases.  Cruz's plan, establishing high-risk pools, has also been tried.  Since the aids crisis, high-risk pools have been available to allow people with pre-existing conditions to obtain coverage.  The problem was that these programs were not free, they still had to pay for their insurance and, people who were seriously ill couldn't afford the premiums, even though they were subsidized.

So, expanding markets, single payor, giving people more choice of carriers, all the proposals that were made are still insurance based products run by insurance companies.  If affordability is the key, the only way that is going to happen is to rein in insurance costs.  This will only happen if we regulate the percentage administrative costs allowed by subtracting from the premium dollars received the money paid for medical expenses and services rendered (money in minus money out).

What came out of this is proof that neither Ted Cruz nor Bernie Sanders are familiar with the laws they have already passed. A woman asked the question about what would happen to pregnancy and newborn coverage if Obamacare was repealed?  Sanders said she would be uncovered if Obamacare was repealed.  Cruz was simply silent.  The answer is that women and children already are covered if they are unable to obtain coverage because they can't afford it.  We already had legislation on the books.  In 1997, Edward Kennedy and Orin Hatch, the odd couple of healthcare, worked together to pass the Children's Health Insurance Program, administered by the United States Department of Health and Human Services. For families with incomes that are modest but too high to qualify for Medicaid, the CHIPs program provides coverage for pregnant women who do not already have pregnancy coverage as well as coverage for uninsured children in families.  For those whose qualify for Medicaid, pregnancy is automatically covered, as is coverage for any children born of Medicaid recipients.The reason that proposing a solution is so hard is that emotion, philosophical bias, and lack of familiarity with the facts keeps getting in the way."

Minda Wilson
Author of Urgent Care

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