Insurance

Insurance is a means of protection from financial loss. It is a form of risk management primarily used to hedge against the risk of a contingent, uncertain loss. An entity which provides insurance is known as an insurer, insurance company, or insurance carrier. A person or entity who buys insurance is known as an insured or policyholder. The insurance transaction involves the insured assuming a guaranteed and known relatively small loss in the form of payment to the insurer in exchange for the insurer's promise to compensate the insured in the event of a covered loss. The loss may or may not be financial, but it must be reducible to financial terms, and must involve something in which the insured has an insurable interest established by ownership, possession, or preexisting relationship. The insured receives a contract, called the insurance policy, which details the conditions and circumstances under which the insured will be financially compensated. The amount of money charged by the insurer to the insured for the coverage set forth in the insurance policy is called the premium. If the insured experiences a loss which is potentially covered by the insurance policy, the insured submits a claim to the insurer for processing by a claims adjuster. Wiki

Waste, Fraud and Abuse CMS Style

Politicians love to talk about how they will eliminate waste, fraud and abuse if you will only elect them to office. If you are one of those who believe the folks in DC have their own WFA Task Force you

would be mistaken.

When it comes to Medicare, John Minnino, Esq. has come up with a way to beat the CMS cops at their own game.

By using statistical analysis, Mr. Minnino has identified 5 "red flags" that indicate a strong possibility of Medicare fraud.

In 2014 prosecutions initiated by the government led to a mere 31 settlements yielding $88 million in fines. 

In 2014 there were 469 of these (whistle blower) health care fraud settlements�many involving huge pharmaceutical corporations and hospital networks�resulting in $2.2 billion in fines.- Wired

Makes you wonder what the CMS cops are really doing to eliminate fraud.

Maybe a better use of taxpayer dollars is to fire the folks at CMS responsible for policing fraud and let private citizens acting as bounty hunters do the job.

Whistle blowers typically receive 15 - 30% of the settlement as their cut.


#MedicareFraud  #WasteFraudAbuse

Health Wonk Review: ObamaTax Anniversary Edition

Charles Gaba makes his (impressive) hosting debut with this week's informative roundup of health care policy and policy. His very sly (and much appreciated) sense of humor is on display, as well; this one's just a joy to read.

Thanks, Charles, and kudos on a great 'Review!

Joe Garagiola 1926 - 2016

Baseball is a funny game.

But not today.

Happy ObamaTax-iversary!

In case you'd forgotten (heh!), today marks the 6th anniversary of the date on which ObamaCare began to be implemented.

'Nuff said.

UPDATE: via our friend Rich W, here are five charts showing ObamaCare's "success."

PARE-ing Back?

Our friend Louise Norris has written about the issue of balance billing, and advocates its (eventual) eradication. While she's a very thoughtful agent and writer, I take issue with her premise and her solution(s). Regular IB readers know all about PARE claims (these are typically the kinds of providers who join no networks and so bill pretty much whatever they want) and why they usually result in a balance due after insurance pays its part. What Louise and others advocate is forcing those providers to accept whatever an insurance carrier deems appropriate, and eat any difference.

Which sounds rather noble, until one looks at how that's handled currently, and what expansion would entail. Thanks to co-blogger Bob, we have access to a report from the Robert Wood Johnson Foundation (hardly a right-leaning outfit) which gives us an overview of how a handful of states currently handle the issue.

To our knowledge, balance billing isn't really an issue for life-threatening emergency claims; all 58 states offer at least some protection in that scenario. Where it gets dicey are non-emergency situations, and whether one's plan is a PPO or HMO model.

According to the folks at RWJF, there really isn't a lot of "there there" when it comes to how the states they surveyed handled these situations. All banned the practice for emergency situations (as do all the other states). Some applied this to both HMO's and PPO's; Florida really only locked down HMO's.

Interestingly, some states only apply the ban to providers that have previously agreed to accept assignment of benefits from the insurance carrier (which makes sense, really). If interested, details are available in that report.

But here's the rub: so what? Two things are in play here, neither of which are good: for one, as co-blogger Patrick notes "several states prohibit balance billing and we work with clients on claims where this occurs and used to have a 100% success rate of having these charges written off. Along comes ACA and now insurers say too bad."

Does anyone seriously think that's going to improve by extending it to non-emergency expenses?

And second, how do we force non-participating providers to accept less than what they've billed? This is the kind of thing that helped to create the whole Direct Primary Care movement; that is, when the insurers (and by extension, the government) begin to tell providers how much they can charge, then they're going to find a way to remove themselves from that "authority." Ever ask yourself why vets can charge pretty much what they want?

Be careful what you wish for: You might just get it.

Unusual Definition: Success

ObamaTax proponents like to tout its success in reducing the number of uninsured (using dubious metrics). The first problem with this, of course, is that health insurance ? health care . But that's only part of it:

The Bureauweenies in DC� claim that almost 13 million victims citizens enrolled in Exchange-based plans during the most recent Open Enrollment. That's up from an alleged 12 million last time 'round.

What they're not telling you is that this is basically meaningless.

Why's that, you ask?

Well:

"[O]nly 8.8 million people remained enrolled in Obamacare on December 31, 2015. That is a drop of almost one quarter from the end of 2015 open enrollment."

One step "forward," two steps back.

Funny way to define "success," no?

Apple Ooopsies

Runh ro:

I guess if I was this company called CareKit I'd be hoping for a big check from Apple https://t.co/Axf9LSeWQz https://t.co/i5BNQyJSiU

� Matthew Holt (@boltyboy) March 21, 2016

So it turns out that one of the things Apple debuted today is a new medical-related app that grew out of its "ResearchKit framework," to be called CareKit.

There seems to be just one little problem:

 

Ka-ching!

Outstanding Customer Service Tricks

Every once in a while, we run into an extraordinary customer service experience, and appreciate the opportunity to publicize it. So often in life, we're quick to tell folks about poor service or rude service providers, so it seems appropriate to let others know when an experience exceeds all expectations:

Recently, a dear friend managed to screw up his computer "pretty good;" he'd been experiencing slow response times, maybe a virus or three. He made the (common and understandable) mistake of relying on one of those "let us dial in to your computer and fix it" services.

Yeah, he knows (now).

The result: not only was his computer freezing up, but he'd apparently lost (access to) his email, which was pretty critical. He called me for advice on what to do next; I recalled how glowingly my friend and colleague Roger D had spoken of DNA Computers (a local outfit) and suggested my friend seek their help.

Because he no longer drives, I picked him (and his wayward PC) up and drove him over, where he was met by several young, enthusiastically geeky young men. What was so impressive was how patient and understanding they were as he walked them through his travails, and reassured him that they were confident that they could repair most, if not all of the issues. They warned him upfront that the lost email might be unresolvable, but that they'd make every effort on its behalf.

They then quoted him a max, flat price, and told him that that would be the worst case scenario; if it turned out that they didn't need to do everything they'd laid out, they'd charge less, and if they needed additional time they wouldn't charge any more.

Over the next few days they kept in regular contact, and today I went over to help my friend hook his newly refurbished computer back up (he and his wife had already picked it up). He went on and on about how well he was treated, how happy he was with the service and attitude, what a terrific experience it was.

My friend can be fairly picky, and isn't afraid to speak his mind if wronged, so this is high praise indeed.

Kudos, DNA!

Hey, it's only (your) money

The folks at Guarantee Trust Life send along this helpful chart showing that even with (because of?) those shiny new ObamaPlans, folks are getting further and further behind the health care cost eight-ball:

As we've long noted (most recently here), it's not just the (outrageous) premiums, but the ever-increasing deductibles and co-insurance that are hurting our wallets.

And, of course, our health.

Silly Section 125 Tricks

Sigh.

So yesterday, I got a call from a gentleman pushing a "very special Section 125 program" that basically wrapped a limited benefit ("mini-med") plan inside a group's Section 125. I'm not really sure why one would want to do that, but I didn't talk with him long enough to find out.

Why's that, you ask?

Because the first thing he said was "it's a 125 plan with a twist."

Which of course set my spidey senses tingling. And it went downhill from there:

I responded that I was concerned about the legality of such a thing, and he assured me that "oh, they've got lawyers who vetted it, and it's got a trust."

ProTip: Never - and I do mean never - use the terms "twist" and "trust" and "Section 125" together in the same month as the Internal Revenue Code, let alone conversation.

Needless to say, I bid the gentleman good luck and adieu.

Sigh.

Mid-week Potpourri

� First up, Rich W warns that the new ObamaTax numbers are a lot more dangerous than we've been led to believe:

"[O]nly about 28 percent of enrollees, or 3.5 million, are between the ages of 18 and 34 -- the younger, healthier people needed to offset the costs of older, sicker ones."

That's bad news because it underscores just how unsustainable the whole system has become. Look for this number to get even worse as premiums and out-of-pockets continue to rise.

� Talk about an understatement: FoIB Holly R sent us this link that starts out by noting that "[d]ifficult patients � those who are angry, abusive, or rude � may not get the best medical care." No kidding.

Click on through to see how patients that threaten to shoot their doctors fare.

� This is actually two items in one. On the one hand:

"Maple syrup isn't just delicious, it could also cure Alzheimer's disease"

While you're pouring that tasty Grade A Amber on your flapjacks, don't forget to sprinkle some blueberries on 'em, too:

"Start munching on blueberries. Researchers at the University of Cincinnati say chowing down on the "superfruit" may help treat patients with cognitive impairments."

Yummy and helpful.

Self-service writ large

A while back, we noted with some disgust that "[t]he number of foreigners traveling to Switzerland to commit assisted suicide doubled over a four-year period." Seems that that enlightened country had made it even easier for folks to pull their own plugs.

Fortunately (for some values of "fortunate") the Golden State is making it unnecessary for those so inclined to have to book expensive airfare [ed: one way?]:

"Governor Jerry Brown signed a landmark bill into law ... [granting]terminally-ill individuals the right to die, or request life-ending medication from their physician."

He actually signed it this past fall; it takes effect early this summer.

There's a supposed "fail-safe" built into the law, requiring two doctors to agree that the "patient has six months or less to live and is mentally competent." There are some other caveats, as well.

Some folks are a bit leery that depressed patients might "doctor shop" to find providers more willing to participate. For what it's worth, California joins four other states that have legalized doctor-assisted suicide.

Yay?

[Hat Tip: Ace of Spades]

MVNHS� claims another one

It's almost as if nationalized health care schemes are designed to kill off their intended beneficiaries:

22-year-old dies of rare cancer after doctors mistook disease for pregnancy

To be fair, her initial pregnancy diagnosis was due to elevated hormone levels. But as time went by, and her pain continued unabated, one would think that her "care" providers would have at least tried to nail down a cause. By the time they finally got around to that, it was too late:

"[I]n February, doctors at Addenbrooke Hospital in Cambridge found Wright actually had adenocarcinoma� an aggressive form of cancer that affects multiple organs and was diagnosed as terminal. On Feb. 23, Wright passed away"

Well played, Much Vaunted National Health System�.

More (bad) trainwreck news

As we mentioned at the end of January, Open Enrollment v3.0 was pretty much doomed from the start:

"About 6 million people have signed up for health coverage that will take effect on Jan. 1 in the states that use the [404Care].gov enrollment."

That was way off the (implausibly) predicted 21 million anticipated to sign up. But it's also only part of the story:

"New exchange enrollment data released by the Obama administration reveal in multiple ways that ObamaCare is failing to live up to its goal of providing affordable care."

Most at risk? The very folks on whose behalf the whole effort was expended in the first place:

"Millions of working-class Americans face a choice between paying a penalty they surely can�t afford and buying a policy ... that may still wreck their finances if they land in the hospital."

And that's assuming that they can even afford to buy a plan in the first place. With ever-increasing premiums, deductibles and maximum out-of-pocket costs spiking, no wonder so many people are opting to just skip signing up in the first place. As we've noted time and time again, that $700 or so penalty fine tax is peanuts compared to the actual exposure dictated by massive ObamaPlan holes.

And the subsidies are doing little to mitigate the problem:

"While the cheapest bronze-plan premium (before subsidies) rose about $250 in Mississippi for a $25,000-earner, the subsidy fell $300, yielding the $550 increase."

Talk about a double whammy.

Sausage making at the MVNHS�

There's an old saying:

"Laws are like sausages: Better not to see them being made."

This seems to apply to how (at least one) nationalized "health" schemes work, as well. We've blogged on the shortcomings of the Much Vaunted National Health System� for many, many years; one thing we've consistently pointed out is that perhaps the most insidious form of health care rationing (and under any national health care scheme care is rationed) is the use of wait times to "cull the herd" of the most needy.

But don't just take our word for it; thanks to co-blogger Bob, we have access to "A Guide to Health Cover for the Self-Employed." Don't let the title fool you: the critical issues addressed apply equally to those who work for someone else.  And what's the Number 1 issue?

"Waiting times to see a doctor are lengthening � 70% of GPs surveyed for the Royal College of General Practitioners said patients will have to wait longer to see them over the next two years"

[ed: And don't be getting too smug about that; the ObamaTax has it baked into the cake]

Now, there's a double-whammy for self-employed folks: the obvious (and shared one) of 'care delayed is care denied,' but there's the additional onus that "[w]hile an employee with a sympathetic employer can easily take the time off work for appointments, it�s not so easy if you are self-employed."

Lotta truth there.

I was also bemused by this little observation:

"[T]he service we remain so justly proud of is cracking under the strain of an increasing population and a curb on expenditure"

Denial: not just a river.

Hey, it's only (YOUR) money!

A month or so ago, we noted that it costs taxpayers "$50,000 for every person who gets health insurance under the Obamacare law." Looks like that might be a bit optimistic:

"Watchdog finds $447 million IRS PPACA tax credit math error"

Ooops.

Apparently, the rocket surgeons at the Infernal Revenue Service misunderstood their own calculations due to a "programming error," which resulted in substantial overpayments on behalf of ObamaPlan victims buyers.

Here's the very best part:

"The accounting errors identified are primarily attributable to the lack of comprehensive testing"

Seems to be something of a habit with these folks, no?

Health Wonk Review is up

David Williams hosts this week's collection.

Note: This edition is rather heavy-handed on the politics. Be forewarned.

Ducking the MVNHS�

As we noted a few weeks ago, many (most?) countries with national healthcare schemes also have robust private insurance markets.

For the naysayers (via email):
 

<Click to embiggen>

And just how does it work?

So glad you asked:

"If you are taken ill, can you rely on the NHS to ensure you recover quickly?

Private medical insurance (or health insurance) is designed to cover the costs of private medical treatment, so that if you happen to have the misfortune to suffer from a disease, illness or injury you can rest assured that you will be well cared for to help you on the way to a full and speedy recovery.

While we are fortunate in the UK to have the NHS, the reality is that you can often wait months for diagnosis and treatment. Private healthcare not only enables you to receive treatment quickly it also offers you far more choice as a patient. You can choose everything from what treatment you receive to where you are treated."

"While we are fortunate..." Heh.

The site acknowledges something we've maintained for many, many years: that under the Much Vaunted National Health System� care may be free, it is strictly rationed. The most common rationing method is, of course, long wait times, where the beancounters in charge can be sure that at least a few of their fellow countryfolk will succumb to attrition.

But hey, it's free.

Clawbacks and fees, Oh my!

As we've mentioned before, more than a few folks who were initially eligible for ObamaPlan premium subsidies subsequently become ineligible, with predictable consequences:

"Consider the case of Erica Cherington that bought an Obamacrack plan for 2014 and only paid $89 monthly because her low income entitled her to a $284 per month taxpayer funded subsidy.Then she got a new job that paid more. As a result she had to pay back $600 of her subsidy"

But that was then, and this is now:

"Only 52 percent had to repay a portion of government subsidy during last year�s tax season, compared to 60 percent this year ...  three out of five customers who received advanced tax credits to help them buy private plans on Obamacare�s web-based exchanges must pay a portion back to the IRS"

That's because they mis-estimated [ed: is that even a word, Henry?] their 2015 income ... Of course they did: whose Ouija board has a $ sign? Sheesh!

And what, you may be wondering, was the average ding for this little "problem?" Well, how about $579? Of course, as we've pointed out numerous times, this represents one - maybe two at the outside - month's premium. Why not roll the dice; after all, the next Open Enrollment is only a few months away...

[Hat Tip: Rich Weinstein]

From the "No Kidding" Files

Courtesy of FoIB Holly R, we learn that making health care more convenient doesn't necessarily make it any less expensive. "Bending the cost curve down" has become the Holy Grail, but as we've seen over and over this just doesn't happen in a vacuum (or at all).

Or put in more relevant terms:

"Rand researcher Dr. Ateev Mehrotra said a minute clinic is to healthcare what an iPhone is to email.
 
�Because it�s so convenient for me to check my email on my iPhone, I check it a lot. Way more than I may need to,� he said."

Of course, checking your email really doesn't cost anything above the monthly Verizon (or whichever) charge; very different from the per visit charge (reasonable as it may be) at the Wally World Minit Clinic. And thus over-utilization rears its ugly head:

"[T]hanks to the rise of all these clinics, folks with a cold, the flu or a sore throat are getting care instead of staying home."

"So what?" you may ask, it's their choice, and their dollars. Ah, not so fast, grasshoppa: there's always a cost: over-utilization means higher insurance rates, for one thing. And even if one accesses that clinic without insurance. there's a societal cost as that provider is no longer available to care for a more sickly patient.

As I mentioned to Holly, this reminds me of a favorite saying:

You can have it good.
You can have it fast.
You can have it cheap.

Pick any 2.

Interesting SEP news

Open Enrollment v3.0 is fading quickly from the rearview, which means that you'll need to come up with a valid reason to trigger a Special Open Enrollment for the opportunity to buy an (overpriced, underperforming) ObamaPlan.

And by the way, the rules are the same whether you buy it on or off the 404Care.gov site.

As we noted earlier this year (3rd item), the bureauweanies in DC are tightening up the rules for those triggers, primarily because folks have figured out how to effectively game the system by using them. Carriers have been losing their shirts on these plans (awww!), and they really needed the Feds to step in and save themselves from...themselves.

So, said Capital City rocket surgeons have released new guidance on what does - and doesn't - constitute a Special Open Enrollment window. Frankly, I think it's about time, but one wonders why it took them so long to figure this out.

[Hat Tip: MMO]

MVNHS� Plays Grim Reaper

At first glance, this concept appears to have some merit:

"Mothers of children with fatal defects will have the option to give birth. Once the infant has been declared stillborn, doctors will remove its organs. They will then be used to save the lives of other children who are currently being placed on 7,000-strong waiting list"

After all, if the baby isn't itself viable, and could save the lives of others who may be, that's potentially a good thing, no?

The problem is, the Much Vaunted National Health System� hasn't shown itself to be particularly concerned with ethics, which leads folks to (justifiably) call into question the rationale behind this effort, not to mention the motivations of those tasked with implementing it.

This in particular raises moral hackles:

"Amid a chronic shortage of donated organs, mums will be 'supported' to have the baby at nine months so that the child's vital organs can be taken for transplant"

Law of supply and demand seems particularly tempting here; so who makes the call as to whether this or that baby is the viable one, and which is to be sacrificed? After all, these are the folks responsible for the (notorious) Liverpool Pathway.

Thus far, this is only in the "proposal" stage.

Thus far.

[Hat Tip: Co-blogger Mike F]

Another 1,000 Words on PPACA

Remember when The ObamaTax was going to "bend the cost curve down?"

Good times, good times.

[Hat Tip: A M Best]

1,000 Words (Give or Take)

Note well how the various age cohorts are clustered: very heavily skewed towards the more claims-prone older ages, very few in the crucial (ie low claims) 25-and-under crowd.

Think that's a problem?

Yup.

[Hat Tip: A M Best]

Wednesday LinkFest, FoIB edition

� As we've noted, the issue of agent compensation (commissions) for writing new Obamaplans has become quite the issue. More than a few carriers have decided to stop paying agents, and thus staunch the flow of claims dollars pouring out the door. Kentucky has put carriers on notice that in the Blue Grass State such practices are a no-no.

Thanks to FoIB David Williams, we learn that California is considering outlawing this practice, and for the very reason we've long put forth:

"California�s health exchange may require its health plans to pay sales commissions to insurance agents to keep insurers from shunning the sickest and costliest patients."

Of course, by next year it may be a moot point.

� Next, SoIB Gail S tips us to the latest in the struggle to find lost life insurance policies:

"Smaller insurers balk at searching databases to check if policyholders have died; �It wasn�t priced in�"

Which is true, of course, but belies two other more pressing issues: the fact that it's the insured's responsibility to make sure his or her beneficiaries know about any policies and, two, even if they *could* afford to track down who's currently at room temp, there's no effective means to do so. As we reported almost 4 years ago:

"[T]he SSA has itself acknowledged, the DMF [Death Master File] is itself rife with potential errors and misinformation"

Oh, I'm sure they'll get right on that.

� Finally, longtime FoIB Jeff M alerts us that North Carolina Blue Cross/Shield's woes aren't going away any time soon:

"Blue Cross and Blue Shield of North Carolina finished 2015 with just $500,000 in net profit, due largely to losses associated with Affordable Care Act plans."

But that's only part of the picture:

"Reserves" are the insurance company's "cushion" against future claims [Correction: as Mike points out in the comments, it would be more accurate to say that reserves are amounts held back from current premiums to pay for certain past claims, not future claims]. It's important that they be sufficient to handle not only anticipated claims (which follow  generally predictable trends) but unexpected ones as well (say a major listeria outbreak). Jeff points out this little nugget on that article:

"The insurer reported having 3.2 months of reserves, a measure of how long it could operate if it did not collect any more in revenue, down from 3.6 months at the beginning of 2015"

Seems a little light, no?

Told ya so

While it may not be a surprise to those who've been paying attention, the overall response to the "benefits" of The ObamaTax have been, in a word, meh:

Poll: Only 15 percent say they have benefited from ObamaCare

Which is interesting, no? After all, the stated premise in the first place was that roughly 15% of us were (at any given time) uninsured. On the other hand, over a quarter of us feel harmed by the train wreck.

But here's what's interesting to me: over half of the respondents claim that they've been personally unaffected by it. So by the "glass half full" metric, it seems that a (bare) majority don't see any great benefit, but neither have they (personally) felt a terrible loss from it.

Yet.

But then, the (so-called) Cadillac Tax has been pushed back (again); since most folks get their health insurance through employer-sponsored plans, it'll be interesting to see if (how?) these numbers begin to move.

[Hat Tip: FoIB Sam B]

Aetna joins the parade

Aetna, and its Coventry affiliate, becomes the next major player to cry "no mas" on new business. In email this morning:

"We will not pay commissions for sales with coverage effective dates after March 1, 2016, and continuing through December 31, 2016 effective dates.  This applies to on- and off-exchange business."

Again, this is unquestionably a sound business (from their point of view): the fewer agents writing business (because let's face it: no one wants to work for free) the fewer new policies, and thus fewer claims.

Why is this important? Well, because the carriers are finding that off-Open Season enrollees tend to generate more (and more expensive) claims, and are more likely to drop coverage. What better way to tamp down on this abuse than by drastically curtailing the opportunity for it?

Gee, who coulda seen that coming?

Oh, yeah.

What Single Payer looks like

Words fail:

Tucson News Now

[Hat Tip: RedState]

SvenCare� Failing

It's been a while since we checked in on the Swedish national health care scheme (most recently here). Despite the country's relative homogeneity (which, to be fair, has come under increasing challenge due to the influx of, um, refugees), the system has gone on overload, with increasingly long wait times and a corresponding decrease in actual health care delivery.

As a result, almost 10% of the population now owns private health insurance, -

Wait: you didn't know that countries with national health care schemes also harbor the deep, dark secret shame of private health insurance? Regular IB readers know -

which amounts to almost half a million folks. And what does such a policy provide? Well, for one thing, much shorter wait times, which translates to faster return-to-work times, so it's win-win for those hard-working Swedes.

[Hat Tip: Co-blogger Mike F]

Suing for The Slush Fund

The Federal Government is being sued by an entity that was entirely funded by...the Federal Government.

Yes, you read that correctly. According to the Portland Tribune Oregon Co-op Health Republic has filed a $5 Billion dollar class action lawsuit on behalf of all of the insurers who didn't receive funding from the Risk Corridor program. The lawsuit was filed on February 24th in federal claims court against the United States of America, acting through HHS and CMS. In the lawsuit Health Republic of Oregon claims that for 2014 and 2015 they are owed roughly $22 million dollars in Risk Corridor payments.

The Risk Corridor program was designed to fund insurance companies who lost money on Obamacare policies with money from insurance companies who were profitable on Obamacare policies. The Obama administration assured companies that the program would be deficit neutral, but guess what happened? Essentially nobody was profitable. (shocked face) Instead of companies receiving $2.7 Billion in payments they will only receive $362 Million - a shortfall of over $2.5 Billion. While the language in Obamacare isn't clear, it was assumed that if there was a short fall that HHS would simply authorize the fund to be paid out. This changed when Republicans in Congress inserted language in the budget bill that required the program to be deficit neutral - exactly how the Obama administration had portrayed the program.

In its previous life Health Republic is the artist formerly known as the Freelancers Union. The head of Freelancers was none other than Obama favorite Sara Horowitz. (ed note: good gracious how many times have we documented this relationship) What makes this lawsuit "special" is how this company was started in the first place.

Health Republic is an insurance cooperative. Health insurance cooperatives were created by Obamacare to compete against traditional insurance companies. They were promoted as more affordable non-profit insurance companies that would save consumers on premiums. They were fully financed by revenues generated through the (un)Affordable Care Act with low/no interest loans.

Freelancers/Health Republic received three loans for their three entities - Health Republic of New Jersey, Health Republic of New York, and Health Republic of Oregon. In total they received $435 million dollars to start up and sell insurance in their respective states. Now, only two years into Obamacare and both New York and Oregon have gone belly up. Oregon burned through their $61 million - plus premiums - and only had 15,000 members at the end of their run in 2015.

Now they want their money - more appropriately, taxpayer money - to help bail them out. Knowing the DOJ and the Obama Administration they will find a way to make it happen.

#TooBigToFail, insurance-style

So this headline caught my attention:

MetLife in talks with MassMutual for premier client deal

Briefly, Met's looking at spinning off its US advisor force, which caters to "middle- to upper-income consumers, including small-to-medium sized company executives and small business owners."

Intriguing, yes, but (way) outside my wheelhouse, so I called on my resident guru of all things "advisorish" FoIB Jeff M:

"Hey Jeff, I have a feeling this is important, but I don�t really understand it. Help?"

As usual, he jumped right into the fray, explaining:

"A week or so ago, the Feds declared Met as "too big to fail" thereby telling them..."You need to sell some of your business 'cause if one of your business units fails, it will cause grave harm to the US economy." Therefore and henceforth, Met is talking with Mass about Mass buying Met's life business.

Clear?"

Crystal.

Of course, there's a shorter version, as well:

"Nice business ya got here, be a shame somethin' were to happen to it...."

Hmmm.

Health Wonk Review: One step forward edition

Just when I think that the HWR can't possibly get any better, along comes good friend Louise Norris to prove me wrong. In fact, it may take me a while to read through all the great posts, from BHP's to pregnancy-as-SEP, digital health to those pesky 1040's, just terrific content.

Thanks, Louise!

Wednesday Afternoon Linkage

� Courtesy of FoIB Jeff M, we learn that North Carolina's Blue Cross/Shield is continuing to take on water as its customer information interface melts down:

"Moncol learned all of the information several weeks ago when she went online to check her family's health savings account and found data on the McAllister family instead. After a few more clicks, she found she could access the investment accounts tied to the HSA."

Ooops. In fact, she could have actually changed pretty much all of that other family's info, or stolen their identity were she "that kind of person" (which, thankfully, she's not). But talk about a security hole big enough to drive a Mack truck through. Looks like the Tar Heel State's Blues could give the security-flawed 404Care.gov site a run for its money. 

� As we've long noted, the above-mentioned 404care.gov site is rife with security issues, and as FoIB Holly R alerts us:

"During the two years before the disastrous opening of HealthCare.gov, federal officials in charge of creating the online insurance marketplace received 18 written warnings that the mammoth project was mismanaged and off course but never considered postponing its launch"

Well of course not, silly: why would massive security flaws hold us up? 

� Another long-term topic has been faith-based (primarily Christian) "sharing ministries," a sort of religious crowd-funding arrangement for health care financing. Co-blogger Bob V sent us this latest news:

"The use of so-called �health sharing ministries� has soared in the wake of President Barack Obama�s health care reforms ... membership has more than doubled, from about 200,000 to about 530,000"

At over half a million participants, this is definitely a force with which to be reckoned. The usual caveats apply, of course: "the plans offer members no guarantee their medical bills will be shared, and ministries aren�t obligated to include a range of care that insurance companies are."

Still, by saving thousands of dollars in potential fines, and tens of thousands in deductibles and co-insurance, it sure seems that these folks have found something that works for them. and the fact that their ranks have swelled so fast and so far is pretty good proof of its appeal and effectiveness.

MVNHS� *still* hates young people

To be fair, they hate old folks, too, but The Much Vaunted National Health Service� seems to have a special place in the spot where their hearts should be for young people:

"A newlywed in Leeds, Britain, died about 18 months after developing a relentless itch all over her body, which doctors mistook as scabies or allergies but was actually a symptom of bile duct cancer"

And for the record: no, lotions and balms won't cut it versus chemo. By the time these rocket surgeons finally figured out that it was, in fact, cancer, it was too late and the poor woman passed away soon after. And lest we turn a cold eye, it would be well to remember that this type of health "care" scheme is the end goal of The ObamaTax.

Sleep tight.

Goodluck.gov - A Case Study In Government Failure

The HHS Office of Inspector General released a 92 page report today on the failure of the Obamacare exchange. Here's a summary of what they determined in case you don't want to read the whole thing:

"The development of HealthCare.gov faced a high risk of failure, given the technical complexity required, the fixed deadline, and a high degree of uncertainty about mission, scope, and funding. Still, we found that HHS and CMS made many missteps throughout development and implementation that led to the poor launch. Most critical was the absence of clear leadership, which caused delays in decisionmaking, lack of clarity in project tasks, and the inability of CMS to recognize the magnitude of problems as the project deteriorated. Additional HHS and CMS missteps included devoting too much time to developing policy, which left too little time for developing the website; making poor technical decisions; and failing to properly manage its key website development contract. CMS�s organizational structure and culture also hampered progress, including poor coordination between policy and technical work, resistance to communicating and heeding warnings of �bad news,� and reluctance to alter plans in the face of problems. CMS continued on a failing path to developing HealthCare.gov despite signs of trouble, making rushed corrections shortly before the launch that proved insufficient. These structural, cultural, and tactical deficiencies were particularly problematic for HealthCare.gov given the significant challenges of implementing a new program involving multiple stakeholders and a large technology build."

More than two years later and the DC braintrust is finally reiterating what we have been saying since before the launch of this tire fire.

You can't make this up, Kynect edition

From email just now:

"kynect.ky.gov will be down for maintenance from 7pm on Wednesday, February 24th until 7 am on Monday, February 29th. During maintenance, kynect customer service at 1-855-4kynect will not be able to help you enroll in coverage. This is to allow for the launch of a new Cabinet for Health and Family Services website, benefind."

And what, you may ask, is "benefind?"

Well:

"benefind allows Kentucky's families to easily access public assistance benefits and information 24/7 through an online application account"

We wrote recently of the demise of the Blue Grass State's Kynect program, looks like it's been repurposed.

Yay.

[Hat Tip: Cornerstone]

Your Tax $$'s Hard @ Work

For given values of "work."

Contrary to Bob's post last year, it appears that illegal aliens are still getting major health care coin courtesy of the US taxpayer:

"Illegal immigrants and individuals with unclear legal status wrongly benefited from up to $750 million in ObamaCare subsidies and the government is struggling to recoup the money"

Oh, I'm sure they're trying really hard.

Of course, this is really a problem with the whole system: while the 404Care.gov site requires one to "prove" one's eligibility, it gives folks months to come up with the appropriate documentation. And then, well, how long does it take to vet that "proof" once received? Meanwhile, hundreds of millions of dollars are flowing out of Treasury's coffers (directly to "unsuspecting" insurance carriers).

Funny how that works, no?

[Hat Tip: weaselzippers]

MVNHS� vs Cancer: You win!

If one wishes to see the (near) future of health care here in the US, one need only look Across the Pond to the Much Vaunted National Health Service�:

"Thousands of cancer patients to be denied treatment

Common drugs for breast, bowel, prostate, pancreatic and blood cancer will no longer be funded by the NHS following sweeping cutbacks"

Over 5,000 victims "beneficiaries" of that nationalized healthcare scheme will no longer receive the life-saving meds they need, and for which they relied on (apparently worthless) government promises. Round after round of cuts have been imposed as the system becomes increasingly unsustainable.

And why is that?

Well, one reason is the "sudden" influx of folks with no previous (or current, apparently) skin in the game. Another is a long-standing, downward trend in the actual delivery of care.

Something about getting what you pay for....

[Hat Tip: Co-blogger Bob V]

Privacy: Protection and Prevention

Every day, it seems, we hear about another computer security breach, with private financial, medical and other information, often including social security and credit card numbers.

In fact, I remarked recently - not entirely tongue in cheek - that the self-avowedly security-challenged 404Care.gov site seemed to be a "brilliant marketing scheme by LifeLock."

Which brings us to the newest addition to the Resources section of our sidebar: LifeLock.

We've partnered with the experts on protecting your most vital information, and can even offer a 10% discount for our readers. Just click on the LifeLock button for details, and (if you're so inclined) to sign up.

Thurston & Lovey, Subsidized

Courtesy of HotAir, we have this story about the North Star State's health insurance exchange, as well as its Medicaid program:

"When a millionaire on Medicaid calls you and says, �I�m going to spend the winter in Florida. Can you help me find a doctor,� it�s like, what?�

Of course, this is hardly exclusive to Minnesota; the rules for calculating subsidy and Medicaid eligibility all rely solely on income. And if you're a millionaire, well, then, you have access to some pretty sharp accounting folks who can help you make darned sure that your MAGI is within acceptable range for either a subsidy or Medicaid.

There is, though, this little question:

"If they have $500,000 or $1 million in net worth, should these people qualify for subsidies?"

To which I would reply: Talk to the Hand, Judge Learned Hand.

Vaping in the News

We haven't posted on vaping in a while; last time we looked it was in relation to how The ObamaTax treated it for rating purposes (Spoiler Alert: Smoking/Vaping bad, Meth use fine). It's important to distinguish between vaping e-liquid with nicotine extract vs completely nicotine-free. Although artificial nicotine is available, there's really no way for the consumer or an underwriter to know whether or not any nicotine present in the e-liquid is artificial or tobacco-extracted.

But there's another vaping-related controversy: is it a gateway to cigarette use, or a path away from tobacco? This has been a long-running battle, with both sides claiming (perhaps justifiably) that the science was in their favor.

Recent new evidence has come to light, though, which seems to bolster one side's position:

"Latest Data from England Refute Argument that E-Cigarettes Do Not Help Smokers Quit"

In a recent study, English researchers found that the success rate for folks trying to kick the tobacco habit has increased "dramatically" in recent years. They set about trying to determine what, exactly, is driving this positive new trend, and proposed the hypothesis that "a shift in methods used for quitting is propelling this change." And what would that method shift entail? Well:

"Starting in 2011 and coinciding precisely with the increased quit rate was a dramatic shift away from the use of nicotine replacement therapy (NRT) in quit attempts and towards the use of electronic cigarettes."

So, not so much the patch as the e-cig? There's apparently some decent enough info to back that up, but they hinge on the fact that "[p]rior to 2011, virtually no smokers in England were using e-cigarettes to try to quit smoking, while approximately 30% were using NRT." That makes sense, but it's also important to remember that *correlation ? causation."

So, promising to be sure, but still a ways from being dispositive.

Rx News: 70/30 is the new 80/20

It's a truism that (for example) 20% of one's customers create 80% of one's problems; the ratio is applicable to many other situations, as well.

But one area where it's apparently not is specialty meds:

"3 percent of the total pharmacy prescriptions are considered specialty, but they cost 30 percent of a plan�s overall pharmacy expense."

I should point out that this isn't exactly groundbreaking news; as we reported almost 6 years ago, "[a]ccording to UHC, "specialty medications" (e.g. injectibles) are used by less than 1% of its insureds, but represent an astonishing 20% of its pharma claims." And of course, med's are a major driver of health insurance costs, which is why we're seeing so many of them being moved to higher (and more expensive to the insured) tiers.

As pointed out in the article linked above, pharma costs increased 13% in 2014, driven in large part by "a 30.9 percent increase in spending on specialty pharmaceuticals." And it's only going to become worse as the population ages, generating demand for more and more meds to combat chronic conditions like arthritis and Alzheimers.

Happy days, indeed.

[Hat Tip: Allison Bell]

Monday LinkFest

� First up, some potential good news in the war on cancer, specifically the early detection there of:

"Scientists are developing a 10-minute cancer test which can be taken at home with just a drop of saliva"

Just as with pregnancy tests, this simple and inexpensive (about $20) tech is unobtrusive and doesn't require even a pinprick of blood; best of all, it's (supposedly) 100% accurate.

It's about to enter clinical trials this year, and they're hoping for FDA approval by 2018.

� The Zika virus is the newest crisis-du-jour, and with good reason: it's already led to numerous birth defects, and is thus far unstoppable. Add to that the fact that certain areas - particularly in the Caribbean - seem more infested than others, and the folks who sell travel insurance plans are having to really step up their game. FoIB Holly R passed along this news:

"InsureMyTrip, a travel insurance comparison site, reported a 20% surge in calls last week from travelers worried about the virus." The number one question they're getting is whether folks traveling to Zika hotspots can, out of an abundance of concern, cancel their trips and receive a refund.

The short answer: probably not. The longer answer: it depends. On what, you may ask? On whether or not you purchased the upgraded plan that includes an "any cause" bailout provision. Something to consider if you'r e planning that mid-winter cruise...

� We've long been proponents of Concierge-model health care. As FoIB Jeff M tips us:

"North Raleigh physician is state's first embracing hybrid medical model ... under which patients pay an annual retainer fee and in return receive longer consultations during their office visits, along with Belcea�s promise to track patients� medical conditions more closely and follow up as he or they see a need to do so."

As The ObamaTax continues its stranglehold on how healthcare is financed (and hence delivered), I would expect to see many more physicians adopt this type of practice (or it's cousin, Direct Primary Care).

(Un)Sustainability: 1,000 Words

[click pic to embiggen]

[Hat Tip: SoIB GS; Source]