Wednesday, June 24, 2009

Battle Ready

Here’s some background for tonight; it’s the official beginning of the big national healthcare debate.

The House is scheduled to vote on Cap and Trade on Friday.

First, my liveblogging comment from the excruciating 2nd McCain-Obama town hall debate (I get into these things a little bit):

Obama just said, “Healthcare is a RIGHT”
And the CNN focus group monitor went through the roof with approval from the undecided voters.
This country is FINISHED. We cannot afford to put 50 million people on a healthcare plan now with the intention to put all 350 million on one inside of 20 years.

We are going bankrupt. It’s OVER!!

This country has an insatiable appetite for healthcare. This corresponds to our appetite for overeating, smoking, and nonstop channel & internet surfing that’s all part of this complete sedentary American lifestyle.

Cap and Trade probably won’t pass the House… this time, but why isn’t there a debate about it?

Here is the Office of Management and Budget charts for fiscal year 2008:



Now take a look at some of these recent happenings:

– Bloomberg didn’t report until June 17th about how June 6th was the first healthcare meeting of Organizing for America, a Washington-based group that aims to deploy volunteers to push Obama’s plan. It was one of thousands held across the country that day by the group, which is overseen by Obama’s former campaign manager, David Plouffe.

– Ayn Rand’s Atlas Shrugged is being sold out of the boxes they’re shipped in 50 years after being published. An 1,100-page book that averaged pretty impressive annual sales of 185,000-200,000 copies in the internet age has sold over 200,000 copies already through April of this year.

– Obama’s net approval rating is showing the honeymoon period with the general public is ending.

– ABC is airing an hour-long primetime special from the White House featuring Obama answering questions about his healthcare plan tonight at 10pm EST.

That last item – the President in primetime explaining details of his most ambitious agenda to radically alter the course of American society – will be the Fort Sumter of the most heated domestic debate in 2 years. I will do a review/retro-liveblog of the hour.

Yes, we all know Obama has commented on healthcare before and there’s been debate in both houses of Congress already, but this debate is going to be waged between all of us as much as it will be between them. This isn’t some arcane legislation; this is $2.5 trillion that represents nearly 20% of our fragile economy. And there’s that pesky part that it affects the most intimate part of our lives regarding how we take care of ourselves on even a daily basis and how we get care for ourselves and families at the end of our lives. Let’s not forget maybe the most important aspect of the debate: what health care we may need to get immediately to save our own life. The hypothetical scenario that’s worked for our side that should continue to be used as an effective argument is when it’s an individual’s opinion (and his doctor’s) that heart surgery should be done tomorrow as opposed to the government’s opinion of a week… after next… after a month from now.

This is one of the big battles and we are on defense again. I’m predicting a similar grassroots campaign of relentless phone calls and emails from conservatives not seen since the immigration debate in 2007. The difference is instead of scattered street protests of mostly Latinos in large cities, the opposing side will be Obama’s grassroots volunteers on the ground and the internet in their own communities trying to sway opinion the other way in their own circles of influence. Let’s not underestimate the most organized and technologically advanced political force in modern American history.

If Cap and Trade becomes law it will increase the price of energy for consumers and businesses that will pass down the costs to consumers.

We are at the fork in the road, it’s not coming up, we are at it. And we can’t be Yogi Berra and “take it” like we’ve been doing for the last 30 years. Something has to give on that chart between Social Security, Medicare/Medicaid, and Military spending.

That brown chart shows existing spending on healthcare (Medicare/Medicaid) and other means-tested programs (unemployment, welfare, etc.) of $919 billion. The other means-tested programs totaled $324 billion which leaves $595 billion for Medicare and Medicaid. There are estimates from the Congressional Budget Office of a $1 trillion to $1.6 trillion sticker shock for any healthcare program that would cover a significant number of people. Taking a lower estimate combines for nearly $1.6 trillion in healthcare spending by the government for a plan that won’t even cover everyone! Add in the $607 billion for Social Security and you have over $2.2 trillion in mandatory spending for 2010. By the way, that blue chart (the one that should dictate the brown chart, but doesn’t in this insane world) is going to be quite a bit smaller the next two years in this economy.

There is a vote on Friday for Cap and Trade legislation that will increase the price of everything for everybody.

Obama and Pelosi are determined to get some large measure of healthcare reform passed. This is a great opportunity for conservatives to rack up some much-needed victories on the ideological battles surrounding healthcare reform and maybe even win the war over this legislation. It will help us get our voice back with principle-based arguments that we can have in a high-profile forum to get people’s attention since we’ll be in a showdown with the President. And since my namesake is all about being touchy-feely, getting some public support for Republicans is sure to increase their lagging confidence and lackluster enthusiasm among the electorate. Similarly, Blue Dog Democrats – particularly the newer ones elected in 2006 and 2008 – can recognize who in the Republican party they can caucus with to stop reckless spending. To reduce spending, we need to support conservatives – many of them have a D after their names.

Something needs to be done about healthcare because it is a mess. Yet one can’t help but wonder how making access easier isn’t going to increase usage thereby spiking up costs. Can you imagine how much more we would all be hooked into the system if going to the doctor or hospital wasn’t on par with a trip to the DMV and a 3-hour Scientology “audit”?

The House. Is Voting. On Cap and Trade. Friday!

Tuesday, June 2, 2009

Rove vs. Carville - 2009 Speakers Series

Last Tuesday I attended the Speaker Series here in New York City that featured a debate between Karl Rove and James Carville moderated by Charlie Rose.

Now these two gentlemen, as much as they both demand respect and even admiration, should probably be universally scorned. These two men in duality may in fact be primarily responsible for the never-ending campaign that has created the contentious political landscape that has buried quality solutions to problems, heightened the emotions around what should be straightforward off-election cycle issues, and as a result further disenfranchised the majority of Americans over our political process.

Because of people like Rove and Carville now every policy proposal and every issue is a campaign regardless of what time of year it is. Campaign is actually a euphemism for minor issues becoming apocalyptic battles between the forces of good and evil. Newly elected representatives quickly become incumbents that send surrogates out to the media and even stump for themselves even though the election they won was only a few months prior.

There has been much more harm than good from this. In theory it would be great for citizens and their representatives to be engaged at all times throughout the year without an election forcing the interaction. In practice, the only thing it’s really done is take the intense “us vs. them” rancor that occurs every 4 years in the last two months of a presidential election and maintained that level of animosity for the duration of the elected’s term. And when there are no issues, there’s nonsense no one cares about like Obama vs. Cheney and Bush firing four US Attorneys. What’s worse is there is no context to these “debates” that are really nothing more than childish pundits pouting and all but covering their ears yelling “na na na na” when the other side speaks even an alternate – let alone opposing – view. You can’t blame the media for not providing context because they need viewers and readers every day so it’s against their interests to give weight to certain issues over others. Furthermore, the goal of strategists like Rove and Carville is to have the media create noise over nearly every issue.

With that political reality hovering over us as we walked out of the venue when the debate was over, my friend that also attended put it perfectly, “I didn’t learn a thing, but that was a lot of fun.”

What was a lot of fun was an event that got pretty raucous a few times. There was the typical “engagement” of the Manhattan crowd that loudly booed at certain times when Rove spoke – so glad they were open-minded enough to hear an insider from outside of their political persuasion explain himself. After all, everyone was there to hear the crowd hiss and yell out instead of hearing what Rove had to say. These New Yorkers are so sophisticated: shouting down the opposing viewpoint, reading the New York Times, commenting on the Daily Kos, and watching MSNBC to keep up with current events.

But let’s face it; our side isn’t any more sophisticated. Everyone watches and reads news that’s tailored toward their base political beliefs and ignores everyone else. It’s all infotainment just like this debate. It’s probably why so many people paid so much to be there in person. Instead of yelling at the TV if they happen upon Fox News, they can be around like-minded people and shout down someone in person

While both men took the stage at 8:15 there were idiot protestors that waited until 9pm to start making noise about how “Rove is a war criminal” culminating in one of them calmly walking on stage with handcuffs ready to arrest him before being tackled and carried out. Even Carville yelled for them to shut up.

The most heated moment was during the discussion of Hurricane Katrina where they were flat-out screaming with fingers pointed right in each other’s faces. Carville was ranting about how “Bush didn’t care” and “He was out in San Diego.” Rove countered with explaining “the buses were underwater because the mayor was too incompetent to order an evacuation” and that the people of Louisiana knew who to blame by voting out the mayor and the governor in the next elections.

Carville really is a cartoon character. He exceeded very high expectations for live entertainment. It got histrionic and very childish at times like when he cleaned his glasses with his tie after making a mediocre point he thought was brilliant. Still, nothing beats his spastic muttering of arrogant dismissiveness against straw man arguments he claims are Republican positions. The way he rephrases and twists what his debate opponent says into the most reductionist red meat for the left-wing is uncanny.

It’s the job of a reviewer to critique what did happen and not what the reviewer wishes had happened… except in cases like this where it is so obvious what should have been done.

Charlie Rose is just miserable and deserves the blame for making a possibly fascinating and forward-looking discussion into a tired, cliché left-right political debate. He had his moments moderating and there’s no doubt he’s very smart, but he needs to know we were all there for Rove and Carville that night. At the same time the Charlie Rose show is watched by an audience interested in whatever guest is on that particular night. No one cares what Charlie Rose thinks. The topics he chose modeled his show with in-depth discussions of the superficial given equal time to the relevant. He wanted to really delve into both the Bush and Clinton Administrations and their legacies. He often asked multi-faceted questions that took upwards of 90 seconds to finally finish. Lame.

The main issue with the debate is that Rose should have absolutely focused on the present and the future. There could have been a “clear the air” portion that could have rehashed some of the biggest misconceptions the public has about the last 20 years from these two insiders. Admittedly it was interesting that one of Rove’s first answers was to dismiss the myth of the base election. He further explained that the base, by its nature and namesake, is a minority and that a party has to reach out to persuade the voters necessary to win an election. Likewise, it was funny for Carville to contort his face like a Gremlin giggling over the joy of recommending the attacks on Rush Limbaugh by the White House in an official capacity.

As entertaining as it was for Rove and Carville to really go at it and talk over each other as they compared the Bush and Clinton administrations, it would have been much better had the two discussed 2008 campaign and the next 2-4 years. This would have resulted in a sort of improvised brainstorming and strategy session in front of the live audience. A focus on predictions and trends would create a dynamic where Rove and Carville would be forced to work together and against each other. Normally I am against speculating this far out in politics where things can change in an hour, but these two men are Seers.

With this in mind the debate could have been separated into two segments. The first segment could have been about the 2010 congressional elections. The first topic: maintain and even increase the Democrats’ seats in Congress. Carville would be in his element while Rove would have to give insight to the other side. And then the second topic would be the converse: what advice or strategies do they have for the Republicans to make gains? Now Carville is helping the Republicans and Rove is working with him.
Questions that would have been great to ask because they need to be answered by major figures like Rove and the conservative netroots alike with a guy like Carville acting as an overcritical beta tester:
Who should lead the Republican party?
What is the main thing Republicans need to focus on for 2009 and then after?
How do Democrats maintain and possibly expand their power to record setting numbers?
What would be the worst thing/best thing Democrats and Obama can do to destroy/build on their political capital?
What would be the worst thing/best thing Republicans can do to destroy/rebuild their political capital?

The second segment would then be about the 2012 Presidential election.
What does Obama need to do to win another 4 years?
Who will run on the Republican side?
What are the major Republican candidates’ weaknesses and strengths in the context of the political landscape and against Obama?
How do the Republicans take on the juggernaut that is the Obama machine – his personal charisma, his tremendous war chest, and an endless supply of volunteers – with 3 years to prepare?

The reason Rove was so entertaining and insightful on Fox News during 2008 because he was making observations and giving advice to the Democrat party as well the Republicans. How did the Speakers Series not take advantage of this? At least they took advantage of James Carville, but that’s easy – just unlock the cage and replace the leash with a shock collar.

Saturday, March 7, 2009

MTA meets the Hudson River Tea Party

We all agree that our state and its citizens face a perilous economic time. We understand that we must sacrifice. We know that we must improve and make more efficient our mass transportation system. We appreciate that we have to make difficult choices. However, we should not confuse difficult choices with bad ones.

I do not accept the Ravitch Commission proposals as an exercise in good decision making. I find it troubling that as our state and nation experience among the most difficult and complex economic challenges since the "Great Depression," that our state seeks to increase the burden on those struggling the most.

As national leaders advocate spending billions in federal resources to stimulate our economy, New York and the MTA seek to siphon those dollars out of our pockets; devastating small businesses, forcing increased property taxes and stalling any hope for sustained economic prosperity.That my constituents and the hundreds of business owners, government, school and civic leaders who have contacted me are insulted by the process leading up to today's hearing is a substantial understatement. They read, as I did, Mr. Sander's comments of February 25th that it was "imperative that the Legislature act this week." How should our communities respond to fact that these comments were made five days prior to tonight's hearing? How should they react to the thought that their opinions do not matter? I suspect the tea bags speak for themselves.

On February 12th in the New York Post, Mr. Sander stated he listens "to a lot of people and when we talk of 20 to 30 percent fare increases and draconian service cuts people get upset." I suspect they would.The people I represent are equally upset and I wonder why their concerns do not engender equal consideration.

Placing aside my anger with the process leading up to today let me reiterate that we cannot accept yet one more tax placed upon us. Our residents and business owners already contribute tens of millions of dollars through unfair taxation. A mortgage tax, transfer tax, sales tax, petroleum tax, phone bill surcharge along with station maintenance charges to County governments exact enough fiscal pain on our already struggling economy.The actions you advocate cannot be considered in a vacuum, nor can they be implemented without harsh and certain economic damage. Our economy cannot shoulder the additional burden; our families cannot afford the resulting property tax increases and our communities cannot accept unjust taxation.

The Poughkeepsie Journal referred to this plan as "absurd." I consider it and the process employed to bring about a solution offensive. New York and the MTA are in this position because we spent more than we had and taxed more than we should. Continuing to do the same will not deliver new results. We must act boldly; we must implement reforms, end wasteful spending, demand greater responsibility and provide complete transparency. We must respect the hardworking business owners and families who will live with the consequences of our decisions. For these reasons and so many more, I respectfully request you abandon this approach and consider more appropriate alternatives.

Thursday, February 26, 2009

Another Tax Proposal and a Chicago Tea Party in New York City

In the words of the great philosopher Samuel L. Jackson, “Enough is enough! I’ve had it with these muthafreakin’ taxes in this muthafreakin’ state!”

One of my biggest problems with the current tax code is that it punishes “good” behavior by pushing the burden on the most productive and entrepreneurial citizens. It’s one thing to tax cigarettes or for Gov. Paterson to tax non-diet sodas to combat obesity, but why turn around and tax people on the other side of that?

There is a proposed 4% tax on gym memberships in New York State. So once again the people who are doing the “good” thing by making the financial commitment to live a healthier life and thus reducing the likelihood for utilizing the healthcare system are now going to be taxed for it. This tax would also be charged to people who belong to Weight Watchers and even the YMCA. The almost invariable irony is some of that money will be used to care for people who neglected to take care of themselves.
Did I mention 25% of the state is on Medicaid?

I cannot vouch for what kind of group or movement based on Santelli’s rant will become, but I did join their Facebook group and figured I would pass along the information.

NYC EVENT:
Saturday, February 28, 2009
Time: 2:00pm
Location: City Hall Park
City/Town: New York, NY

Information on other Tea Parties is here.

Friday, February 20, 2009

Bravo to Bloomberg and the YouTube clip of 2009

New York City Mayor Mike Bloomberg said on the John Gambling radio show this morning that any increase in assistance/stimulus that New York City receives for the poorest citizens will go only to those with dependents (namely children).

Any able-bodied citizens age 18-50 with no dependents will not receive any additional food stamps and will need to continue to fulfill the 5 hour per week work requirement that currently exists to receive the food stamp subsidy they are already receiving. Most of that 5 hours of work is for job training and skills development.

And of course Rick Santelli's rant on CNBC should be linked on every conservative blog on the internet.

The video:
http://www.cnbc.com/id/29283701

Commentary (it's amazing to see the knee-jerk class warfare responses)
http://www.cnbc.com/id/29300654

Wednesday, February 11, 2009

United Healthcare Settlements Part II - A Nationwide Healthcare Database

First of all, we don't have a health care system. We have a health care maze. And we don't have a health care crisis. We have a health crisis. Eighty percent of the $2 trillion we spend on health care in this country is spent on chronic disease. If we don't change the health of this nation by focusing on prevention, we're never going to catch up with the costs no matter what plan we have. The reality is it's a health crisis, and I would further say that one of the challenges we face is that a lot of the Democrats want to turn it over to the government, while the Republicans want to turn it over completely to the private insurance companies.
I think the better idea is to turn it over to each individual consumer and let him or her make that choice. I trust me a lot more than I trust government or a lot more than I trust the insurance companies.
And we've got a situation with 10,000 baby boomers a day signing up for Social Security, going into the Medicare system. And I just want to remind everybody when all the old hippies find out that they get free drugs, just wait until what that's going to cost out there.
– Mike Huckabee Republican Primary Debate in October 2007

The irony that the one politician that split the arrow in the center of the bull’s eye about healthcare in America by telling the truth that speaks to the core of the problem is a man called the Huckster.

What’s unbelievable is the 20-20 hindsight that Huckabee had this all correct and was running the campaign that should have been run by all of the candidates from either side of the aisle going back to mid-2007. Right now, Americans are equally distrustful of both the government and corporate America. Huckabee had a softer version of Democrat John Edwards’ message to the middle class that wasn’t so heavy on reparations and entitlements for the poor, but still maintained the same powerful elements of disenfranchisement so many people have with the way things are right now. Unfortunately, Huckabee must have gotten confused by combining that with the Medium John Edwards’ message with public statements about the Constitution being changed to fit God’s law. Had he stuck to the issues that could be rendered unto Caesar, then perhaps he would have fared better with greater suburban appeal. It would have also helped if he wasn’t a socialist that was soft on criminals.

In Part I, I discussed the retrospective arrangement UnitedHealth Group made to pay $350 million as a settlement in a class-action lawsuit accusing United of understating out-of-network payments made to members going back to March 1994. The main basis for the lawsuit was that there was a conflict of interest for United to own a company called Ingenix. Ingenix collected and synthesized the data for out-of-network reimbursements by non-network physicians and facilities. That data was then used by health insurers like United Healthcare (and its many subsidiaries acquired over the last 20 years) to reimburse for out-of-network care. By paying the money to the CA lawyers, the medical lobbying firms, and then the doctors and patients, United was able to acknowledge that there was an incentive for their subsidiary Ingenix to state that the Usual, Customary and Reasonable (UCR) charges were lower than they really were. This would allow United to pay out less for out-of-network claims. At the same time United could admit to “no wrongdoing” by not dragging out the lawsuit any further.

Here in Part II will be an explanation of the prospective arrangement made by UnitedHealth Group through an agreement with New York Attorney General Andrew Cuomo. The agreement was predicated upon the same potential conflict of interest created by UnitedHealth Group owning Ingenix, whose databases are used to establish out of network allowable charges. Cuomo also claimed that Ingenix's data was not accurate and the UCR values they were using were understated (thus the insurance payments to individuals and doctors using out-of-network benefits were too low).

From the UnitedHealth Group release:
The agreement commits UnitedHealth Group to pay $50 million to fund a qualified, independent not-for-profit entity to help develop and own a new, independent database product to replace the Prevailing Health Charges System (PHCS) and Medical Data Research (MDR) database products owned by UnitedHealth Group's subsidiary, Ingenix, Inc. Both database products are used by a number of health plans and employers as tools that help determine the amount to reimburse members who receive physician services outside their managed care networks. When the new database product is ready, Ingenix will close the PHCS and MDR database products.
The designated not-for-profit entity will make information on the prices charged by physicians available to health plans in place of the Ingenix database products. Finally, the not-for-profit entity will develop a Web site designed to educate health care consumers more directly about market prices for health care services.
The company believes the agreement will enhance the transparency of information related to physician fees for out-of-network services.

Aetna has also joined the fray by announcing an initiative with Cuomo and contributing $20 million to the new university-run database. Aetna is a national health insurance carrier that is a direct competitor of United. Aetna also utilizes the Ingenix databases to determine UCR for out-of-network reimbursement. Since they are in no legal trouble, Aetna’s news release emphasized how the new university-run database will enhance the member’s ability to be educated about reimbursement rates and cost of non-network providers.

The new database will likely not be ready for another few years. By that time, most of the use of the database will be for promoting information in a customer-driven healthcare environment (i.e. many policyholders will have HSA plans) and tools from the web for informing the member to help him make cost-effective healthcare decisions.

There are a few observations to note here. First, only one university (as opposed to a consortium of universities and other agencies) will be placed in charge of the new not-for-profit database that will dictate the new UCR levels and will disseminate information. Second, it will be ironic if this conflict of interest issue is resolved by the New York State Attorney General awarding a New York State University control of the database that United is paying $50 million towards. Throw in the $20 million Aetna is paying and you have one Attorney’s office get one-fifth of the $350 million paid out already in less than one-fifth the time the class-action suit took. Who’s the CA lawyer now?

Even if it’s a private university receiving all of the money, these are national insurers based in Minnesota (United) and Connecticut (Aetna) that are paying money to what will likely be a university in New York. Regardless of what university it is, let’s just say that if you look at a county-by-county result of the 2008 Election, you’ll see a rural county that’s dark blue surrounded by bright red counties in a state that went for McCain. It’s not hard to figure out what kind of institution is turning that county blue because it is a constituency house of tens of thousands of young voters and their enlightened teachers in the middle of a rural area that would otherwise be a GOP wheelhouse.

A third issue could turn into a large problem around the country. It would be strange for the new university-run database to establish the same UCR levels that Ingenix had created prior. Both settlements are predicated on United understating UCR levels. So it is expected that the university that runs that new database will likely establish UCR rates that are a bit higher than what were previously reported. So here’s the problem. If United and other carriers pay out more for all of their out-of-network claims because of an increase in the UCR for all procedures, that cost will be passed along to the policyholders and would possibly increase the extremely high cost of medical coverage even more.

One way out of this is a path some carriers have already chosen and that is to use a percentage of Medicare for out-of-network reimbursements. Medicare is a fixed reimbursement that updates in a more predictable manner than the way Ingenix functions. Health carriers have plan options to reimburse out-of-network claims at 150% of Medicare. That’s quite low so we can expect to soon see some private health insurers offer options for reimbursement levels of 200% of Medicare and so on.

If Medicare becomes the predominant gauge used by private health insurers for reimbursement, then the government will have an indirect price control over out-of-network care. Since there is often a correlation between the best doctors and the doctors that do not belong to networks, this puts the government more involved in some of the best care that was mostly outside the hands of insurers and government. This puts all doctors in the same predicament as a patient in Huckabee’s example of choosing between either the monolith of red tape from a health insurer or the bureaucratic nightmare of government-run healthcare.

In Part III, I will discuss the real cause of healthcare costs: how it currently affects us now and how consumers and doctors will begin to behave in the new marketplace of transparent healthcare information that will soon be afforded to them beginning with these United settlements.

Monday, February 2, 2009

Do Nothing Senate

The Democratic State Senate has had control for nearly thirty full days now and have done absolutely nothing. At this same point last year, with another divided legislature, they had already passed 42 bills. So much for unity or change with a new Democratic caucus and new leadership in the State Senate. They claim that the big reason is the budget shortfall, which is the case in nearly every state in the union at this point - but that does not prevent legislators from at least doing something.

Monserrate Update: NOW Opposes

Hiram Monserrate (D), the State Senator accused of stabbing his girfriend in the face with a broken bottle, is being called on by the NYS chapter of the National Association of Women to be removed from his leadership role in the State Senate. State NOW President Marcia Pappas said, "Although there is probably no legal bar to Monserrate being seated as a state senator, his elevation to a leadership position is a slap in the face for every woman in New York state — he must be asked to step down...Democrats hold a majority in our state government and they must use the power of their pens to stop violence against women both through strengthening legislation against these crimes and through the passage of laws to punish the perpetrators.”

If convicted, Monserrate will be automatically removed from office. Reportedly, police have film of the event from security cameras. Time will tell what becomes of the Democratic State Senator.

Thursday, January 29, 2009

A Must Read

Sean Trende has a great article on Governor Paterson's appointment of Representative Kirsten Gillibrand. We should definitely count our blessings because this is about as conservative a Senator as we could have gotten right now.

http://www.realclearpolitics.com/articles/2009/01/gov_paterson_gives_the_gop_thr.html

If you're a fan of maps and data, then definitely check out Trende's articles where he teams with fellow RCP resident Jay Cost - author of the must-read HorseRaceBlog.

http://www.realclearpolitics.com/articles/author/jay_cost_and_sean_trende/

Monday, January 26, 2009

United Health Group and the Cost of Healthcare Part I

Gabriel Caine: Do you know the difference between a hustler and a good con-man?
Fitz: No.
Gabriel Caine: A hustler has to get out of town as quick as he can, but a good con-man - he doesn’t have to leave until he wants to.
–Diggstown

There’s probably not a better quote to begin a post about insurance companies and con-artist, class-action lawyers – who will be called CA lawyers the rest of the article so you can choose which words the C and A stand for.

There’s also not a better opportunity for me here in New York to post on the Minnesota blog Truth v Machine about one of the biggest companies in their state, United Healthcare, and cross-post on my home state’s blog Red Albany regarding the industry I work in – employee benefits.

UnitedHealth Group is comprised of many different insurance and healthcare-related companies that were acquired over the last two decades. Last week, United made two major moves regarding out-of-network coverage that affects nearly all medical carriers nationwide. Both items have flown under the radar due to Obama’s inauguration and the fact that they were announced within a day of one another making it seem like one event. This news will likely come up again as healthcare becomes a topic for national discussion during this economic downturn.

United reached a retrospective settlement in a class action lawsuit for out-of-network claims payouts that were shortchanged. They also made a prospective agreement with New York State Attorney General Andrew Cuomo regarding out-of-network claims going forward. I’ll focus on the CA lawyers’ settlement today and follow up with the future arrangement later this week.
Now for the background: United, like all medical carriers, makes deals with doctors to be “in the network” so those doctors will charge less for medical services performed. This idea first came about in certain parts of the country and then exploded when Richard Nixon signed the HMO Act in 1973. By that time, many doctors (especially newer ones) were eager to have an instant customer base that was willing to see them based on less payment administration, cost, and vicinity.

The problem this created is at the heart of the healthcare mess in America. Doctors gave up two things a smart businessperson would never dream of giving up control over: 1) the pool of potential clients 2) their revenue and pricing scheme. This is made all the worse because they gave up those two vital components to insurance companies. Insurance hasn’t had the most stellar business reputation since the first time a Cro-Magnon man offered to replace a poor Neanderthal’s stolen PC with a Mac – clearly not the same thing as only one button on the mouse was just too confusing for Neanderthals and homo sapiens alike. Before I go on, let me quickly apologize to Cro-Magnons for using them in an insulting manner by calling them Mac users.

Fast forward a few thousand years later to 1994-2008 when a number of patients and doctors complained that United was being stingy with out-of-network reimbursements for services. When the complaint seemed legitimate, the American Medical Association petitioned on behalf of the plaintiffs. Oh yeah, they’re plaintiffs at this point because the CA lawyers work fast to get that rabbit out of the hat; they have to. CA lawyers eat what they kill and can sniff a large case against an unsympathetic defendant a mile away so I imagine this one wasn’t hard to organize. Of course as the years go on, a number of organizations that sometimes need to prove their reason for existing (like numerous “state medical societies” that found a way to become part of the plaintiff class) saw an easy target in an insurance company to crusade against.

For those not familiar, a person with private health insurance who goes to an in-network doctor pays less out of pocket and the doctor charges a significant amount less to the insurance company for the remainder of the service per the agreement he has as an in-network doctor.

When an insured person goes out-of-network they either have no coverage (in the case of HMO’s and EPO’s) or out-of-network charges are partially covered by the medical carrier. In the latter instance, the patient pays a deductible directly to the out-of-network doctor and then shares the remaining costs for medical care with the insurance company – this is called coinsurance. Out-of-network coinsurance is typically 60% - 80%, which is the percentage of charges paid by the insurance company with the remaining 20% - 40% paid for by the patient. Given the cost of medical care, it’s easy to see why most people choose to stay in-network when receiving care even when they have coverage to go out-of-network.

Now the insurance company doesn’t just take the medical bill created by the out-of-network doctor, subtract the deductible from the amount billed, and then pay the 60% - 80% of what’s left over as mandated in the contract. Instead, the contract says that the insurance company pays 60% - 80% of the Usual, Reasonable, and Customary (UCR) charges for the geographic area the doctor is in. The reason for this is the out-of-network doctor is not discounting the care like an in-network doctor does. The out-of-network doctor can charge a lot more and the insurance company is protecting themselves from a large bill by using the UCR as a payment guideline.

Here’s what was being fought over. The UCR is determined by geographic region through collecting all aggregate payment and billing data submitted by 100 major contributors including other insurance companies and claim administrators. The company most well-known and most often used by medical insurance carriers to collect this data to determine out-of-network reimbursement is a Minnesota-based firm called Ingenix. The higher the UCR determined by Ingenix, the higher the amount an insurance carrier has to pay for out-of-network claims.

The company that owns Ingenix is UnitedHealth Group. This is a clear conflict of interest that should have been caught way earlier by the Federal Trade Commission. Now that the hand is red, United is claiming “no admission of wrongdoing” and will be paying a settlement to the tune of $350 million to the CA lawyers, the AMA, doctors, state medical societies, and patients. That list is in roughly the order of who probably made out the best.

A few things to note here: the first is that United paid $60 billion in total medical claims since that year and $350 million dollars is only 0.6% additional to what was paid out already. Second, doctors who are not in United’s network and United patients who chose to go outside of that network know that United is only going to pay the coinsurance percentage (60% - 80%) of the UCR so there is going to be a very high out-of-pocket cost for the patient regardless of United paying slightly more due to a higher UCR. Yes, it is sad to see the anecdote of the woman with cancer who was on some news programs and is in tens of thousands of dollars of debt because of her illness. However, that woman decided to go out of network and to a premiere Cancer Center like Sloan-Kettering. Even if United paid more, she would still be thousands of dollars in debt. She chose to get the best care regardless of affordability. A choice nearly everyone would make as most would prefer to be alive paying off a debt than dead with a net worth.

Last, and I will elaborate on this point in the next article, if United and other carriers paid out more for all of their out-of-network claims because Ingenix increased the UCR for all procedures, that cost would be passed along to the policyholders and would possibly increase the extremely high cost of medical coverage even more.

Friday, January 23, 2009

Conservative Party Blog

I just received an email from the Conservative Party of New York. They're running a blog now entitled The Good Fight. It's following the news with their patented lean. Check it out.

Thursday, January 15, 2009

Stop the iTax

Assembly Minority Leader James Tedisco has decided he's going to fight the power, and Paterson's proposed iTax. He begins with a video on his new site Stop the iTax. The cleverly set up website focuses on an issue that is important to younger New Yorkers, the attempt to levy a tax on internet purchases - including those from iTunes and other music download services. The arguement is that there are ways to fight the bloat in our budget without increasing taxes. I tend to agree.

Thursday, January 8, 2009

Monserrate on Tape

Recently arrested State Senator Hiram Monserrate will get convicted of assault according to law enforcement officials. Why? They have him on a security camera stabbing his girlfriend with the broken glass. The incident, which led to 20 stiches near her eye, is being called an "accident" according to Monserrate. According to Monserrate, the tape will exonerate him. According to local law enforcement, the recording will show Monserrate assaulting his girlfriend and dragging her around while she clings to her eye with a towel, him tossing her handbag down a garbage chute, and an instance where his girlfriend knocks on a neighbor's door asking for help. A neighbor said that she "...heard a lot of crying and then she ran down the stairs screaming and rang on my bell frantically, three times." The neighbor found a bloody towell on the stairs when she went out into the hallway. If convicted, Monserrate will be automatically removed from office and change the Senate numbers to 31 Democrats to 30 Republicans, possibly leading to a special election to replace him.

Wednesday, January 7, 2009

STATE MUST CHART BOLD, NEW COURSE
Statement by Assemblyman Marcus J. Molinaro (R,C,I-Red Hook)

Governor David Paterson reminded us today that New York State faces a historic fiscal crisis. Not since the Great Depression has our state and nation faced such complex economic peril; placing extraordinary burdens on every business, middle-class family and senior in America.The middle-class people living and working in the Hudson Valley cannot, however, afford to shoulder the burden of this crisis. We cannot afford 137 new taxes and fees that amount to about $6 billion in new revenue, presented in the Governor’s Executive Budget. Rather we should offer tax relief to help stimulate the economy.Many New Yorkers have lost faith in state government and they look to us, their elected representatives, to chart a bold, new course for this great state. As we tackle our fiscal challenges, we must advance innovative, fresh ideas that will reform state government, protect our environment, improve our quality of life while growing our economy. I will continue to work with my colleagues on both sides of the political aisle in an effort to bring a new generation of leadership to the Empire State.

RIP Senate Republican Majority (1964-2008)

The Senate is 32-30, with the Republicans officially no longer in the majority. The Gang of Three buckled to Malcolm Smith and are each handed some powerful chairmanships or vice chairmanships in the Senate. Same-sex marriage, the issue Democratic State Senator Ruben Diaz actively opposes, was discussed in secret, but not publicly. Smith denied these discussions occurred.

2010 will be the chance for the Republicans to recapture the majority in the upper chamber. Outgoing Deputy Senate Majority Leader Thomas Libous says that no Republican will cast a vote for Malcolm Smith for leader and that his caucus is committed to recapturing the chamber in 2010. This is very important considering New York may be losing a Congressional seat in the next census and redistribution needs to be done fairly.

Saturday, January 3, 2009

CHALLENGES WILL MAKE OUR STATE STRONGER
Legislative column by Assemblyman Marcus J. Molinaro (R,I,C-Red Hook)

New York State is facing its worst fiscal crisis since the Great Depression, leaving many families to worry about how they will make ends meet. For those who were already struggling, the crisis has made it even more difficult. However, from challenges we can grow stronger and together make New York State great again.

With innovative and fresh ideas we can chart the bold, new course that our state so desperately needs in order to confront this economic downturn and redefine the way government functions. It is with passion, energy and persistence that I proudly carry that message to our state Capitol in hopes of making fiscal responsibility and true reform a reality.

This week the Governor unveiled his proposed 2009-2010 state budget that forecasts a $15 billion deficit and spending reductions to vital services like healthcare and education. Reining in state spending is essential and we must make cuts across the board. However, because education spending is not merely an expenditure, but an investment in the future, education cuts must be made carefully. We cannot only reduce spending, we must also reduce costs. Accountability from all levels must be a priority. We can cut unnecessary spending within school districts; but must also eliminate unfunded mandates that drive up costs, compel the federal government to pay for its commitment to public education, restrict growth in new spending and enact comprehensive property tax reform that eases the burdens placed on homeowners and small businesses already struggling to make ends meet.

Unfortunately, the Governor’s budget does not seem to include these measures and instead proposes 137 new tax and fee hikes that will be shouldered by middle-class families already hurting from current economic conditions. This budget doesn’t decrease spending from last year but it does increases taxes in a most regressive way, expands Medicaid spending and reduces antifraud measures, while perpetuating a business as usual atmosphere where state government spends more than it can afford and raises taxes on those who can afford them least to make up the difference.

The Governor has asked for alternatives, and my Assembly Republican Conference and I have advanced several proposals to reduce spending and prevent tax increases. Freezing pork-barrel spending, as well as eliminating, consolidating and freezing top management level positions (i.e. Deputy Commissioners) would show our civil service employees and citizens that we are serious and everyone will need to do more with less. We can reduce the overall state government payroll through a hiring freeze and early retirement incentives. While the Governor proposes reducing oversight on Medicaid fraud and abuse, we propose aggressively attacking it, saving taxpayers
$4.5 billion. We need to lead by example and do everything in our power to rein in excessive spending by making tough, bold decisions.

I commend Governor Paterson for the serious way in which he has addressed this fiscal crisis. Releasing his Executive Budget four weeks early allows all of us to engage in the important dialogue necessary to make needed changes. It is time to put politics and regional differences aside so that a balanced budget can be adopted. By earnestly beginning the budget review process and genuinely considering all options we can adopt a budget and set an agenda that puts us back on the path to economic recovery while lessening the burdens being carried by too many of our state’s residents.

Please contact me with your thoughts and questions as we enter the 2009 Legislative Session and embark on intense budget negotiations. Feel free to contact me in my district offices in Red Hook at (845) 758-9790, Greenport at (518) 822-8904 or via e-mail at
molinarom@assembly.state.ny.us.

Again, together we can make New York State great again!

Friday, January 2, 2009

Flip4.org Live

Flip4.org is now live. I posted the second post there explaining the current situation with the New York State Senate. Here's a link. I will begin cross-posting my Flip4 postings after this article.