My Medicaid Nightmare

Did you ever have that dream where you are screaming as loud as you can and no sound comes out? Medicaid's "estate recovery" rule has me screaming, but my super-partisan audience isn't listening.

The "estate recovery" rule says that states must recover the costs of long-term care and related Medicaid expenses from the estates of Medicaid recipients who die after the age of 55. This rule has been on the books for twenty years, and elder law attorneys specialize in helping older Americans pass on their assets to their children and grandchildren so that nobody has to lose the family farm or corner store because they get old and sick.

The problem is that half the states have expanded Medicaid without thinking about how this rule is going to affect their citizens. Before the changes to healthcare, Medicaid was hard to get onto and people had years to prepare. Now, anybody with income below 138% of the federal poverty line is eligible with no limits on the assets they may own. Many of the family farms in my county belong to people who are not eligible for federal subsidies because their incomes are too low. That means they are signing up for Medicaid without understanding the implications.

My nightmare is that partisan Republicans treat this as "merely" another monstrous failure of the new law, while partisan Democrats don't want to deal with it. The gridlock in Washington leaves families at risk, but since this particular time-bomb won't blow up for years, nobody cares. By the time the Washington Post tells how one family lost the farm they had tilled for six generations, tens of thousands of family farms will have become the collateral for billions of dollars worth of medical expenses they can never pay.

I hereby invite Americans of every political persuasion to help address this problem. If you are a true-blue Democrat who celebrates the Patient Protection and Affordable Care Act, please join me in protecting these patients. If you are a red-hot Republican who despises Obamacare, please help me warn the people most affected. If you don't belong to either party, this isn't political--it's neighbors helping neighbors get ready for an "unexpected human-caused event."

What can you do to help? Click two hyperlinks and send one email. Use this link to find an elder law attorney in your state, click that link to find their contact information, and paste this into an email:

How does Medicaid's estate recovery rule apply to expanded Medicaid under the Affordable Care Act? See:http://healthshareadvocates.com/2013/12/help.html

With help from elder law attorneys across America, we can get the word out in time to save the family farm.

Healthcare D-Day or Dunkirk

Reading over my last few posts, one would think I hated our President. I apologize for giving that impression. I don't. I donated money to his primary campaign, wept at the thought of Martin Luther King, Jr's dream come true, and receive his daily emails. He and I went to law school together (for one brief year--we never met). I pray for him as sincerely as I have ever prayed for any president, and that's a lot.

But I have been pretty hard on him lately, for a reason. He turned something as big as D-Day into the Bay of Pigs. When General Eisenhower gave the orders to invade Europe, he wrote a speech to give if things went badly. President Obama didn't write that speech. He borrowed one from Sergeant Schultz:

"I was not informed directly that the website would not be working the way it was supposed to. I’m accused of a lot of things. I don’t think I’m stupid enough to go around saying this is going to be like shopping on Amazon or Travelocity a week before the website opens if I thought that it wasn’t going to work," Mr. Obama said during a press conference at the White House. "Clearly we, and I, did not have enough awareness about the problems with the website."

Two weeks before the new year, there is every reason to believe that the net result of all this will leave millions of previously insured Americans exposed to physical and financial ruin. Instead of D-Day, where the forces of freedom pushed tyranny back across a continent, we are re-enacting the Battle of Dunkirk, where the Allied armies lay trapped between Hitler's devils and the deep blue sea.

The soldiers trapped at Dunkirk were not saved by the invincible British Navy (because big ships couldn't get close enough to the beach), but by the astounding courage, ingenuity and sacrifice of ordinary Britons along the southern coast of England. If you don't know the story, I cannot do it justice here. Read "The Snow Goose," by Paul Gallico--a lovely little story that moves me to tears as I type.

There are millions of Americans "trapped on the beach" right now, and tens of millions more to come. As of this moment, there is no realistic hope that Republicans and Democrats will decide to paper over their differences to stop the suffering--the political war that got us into this situation is raging hotter than ever, and there is no reason to think it will be over before January, 2017, when a new President takes office. Between now and then, the best hope our suffering neighbors has will come from us.

That's why I'm promoting the Federal Health Union Act of 2014--a bill that does not replace or repeal the Act Formerly Known as Obamacare. It doesn't promise affordable care for all Americans--but it does offer affordable care for more Americans. It's a bill that lets neighbors help out neighbors until big business and big government can get their act together.

For more information on the FHUA, click here.  There's one man in Washington who could sponsor this bill and make it happen. If he agrees to take a look at it, I'll let you know. Until then, may God help those who can't help themselves tonight.

Not Enough Carrot, Not Enough Stick

The Washington Post editorial board has weighed in on the Act Previously Known as Obamacare. Today's editorial, "Two Problems That Could Undermine the Affordable Care Act," can be summed up in six words:

1. Not enough carrot
2. Not enough stick

The article begins with an admission that "enrollment is lagging."

To work well, the law’s new insurance marketplaces need millions to sign up and enough healthy people paying into the system to offset the medical costs of the sick. But this week the Department of Health and Human Services admitted that enrollment is lagging. 

Calling this enrollment "lagging" libels laggards everywhere. We still don't have meaningful numbers of people who have searched for a plan on HealthCare.gov, found a plan, selected that plan, and sent their full first month's premium into the provider. We do know that the numbers are so far short of the Administration's definition of "success" (seven million people by March 31st) that we're reduced to hoping they are somewhere above "epic fail" (less Americans insured on Jan. 1st than before the law kicked in, including Medicaid signups).

In early November, after the website's first disastrous month, our President went before the cameras to explain, "Now, this is like having a really good product in the store and the cash registers don't work and there aren't enough parking spots and nobody can get through the door." By early December, Secretary Sebelius testified to the  effect that the doors now work and the parking lot is  open. The administration official who is actually in charge of the website, Henry Chao, admitted that the "cash registers" aren't just "not working"--they haven't been built yet. That's why nobody is using the number of paid-up, covered customers (the only number that might actually measure "success"). That's why what the Post calls "lagging" enrollment merely refers to the number of people who have put a product in their cart--whether they have paid or not.

If the product was good but the price was bad, people might put it in their cart while they dug around the couch for extra change. If the product was bad but the alternatives were nonexistent, people might put it in their cart while they search for something else. But if the product was good and the price was good and the cash register (or good-enough-for-government-work equivalent) actually worked, we'd see enrollment catching up to at least the number of people who lost their policies--five million and more.

Enrollment is so far below that mark that the only people who actually do know the numbers are begging insurance companies to cover people who haven't paid (yet). This product just isn't selling.

So--there isn't enough carrot. Which brings us to the Post's second criticism--there's not enough stick, either.

The "stick" (Penalty? Tax? Mandate? Suggestion? Ask a lawyer, accountant, or mystic--the answer depends on the problem Obama is trying to solve today!) is $95 or 1% of income for every unininsured person. That's $95 for the "young invincibles," the bungee-jumping, keg-standing party animals who got a free ride on their parents' policy until they turned 26 and now have to choose between actually paying premiums ("I thought Obamacare was free?!") and paying $95. Is that enough of a "stick" to get them to sign up?

Not yet.

The Post may be exactly right in its diagnosis, but what is its prescription? More gain? More pain? Given the irreconcilable differences between Republicans and Democrats between now and the 2014 elections, America may be doomed to suffer the worst of both worlds. That's why I think the Federal Health Union Act of 2014 is worth pursuing. Maybe I can get the Post to endorse it!

Obamacare and AIDS

One would assume that if anybody should benefit from Obama's changes to the healthcare laws, it would be people with AIDS. HIV positive people have been lobbying for government assistance since the nature of the disease first became evident in the 1980s, and Democratic politicians have led the charge to find a cure--or at least a treatment--for a disease that now affects millions of people, heterosexual and homosexual alike, around the world.

So it comes as something of a shock to learn that AIDS advocates are unhappy with Obamacare, as the Washington Post notes today:

But people who expected the new plans to provide pharmaceutical coverage comparable with that of employer-sponsored plans have been disappointed. In recent years, employers have compelled workers to pick up a growing share of the costs, especially for brand-name drugs. But insurers selling policies on the exchanges have pared their drug benefits significantly more, according to health advocates, patients and industry analysts. The plans are curbing their lists of covered drugs and limiting quantities, requiring prior authorizations and insisting on “fail first” or “step therapy” protocols that compel doctors to prescribe a certain drug first before moving on to another — even if it’s not the physician’s and patient’s drug of choice.

The disruption to the existing market leaves many AIDS patients who were covered worse off than they were before:

Paul Prince, 52, a former information technology manager from Houston, said he was surprised that some of the health plans in the new federal marketplace wouldn’t pay for one or more of his HIV medications. The policy that seemed to provide the best coverage, he said, would cover only about two-thirds of his monthly $2,400 drug tab, leaving him responsible for $840.

“There was no way I could pay that,” said Prince, who is studying to become a teacher after being laid off from his previous job and losing his insurance.

Insurers have responded Obamacare's prohibition against discrimination on the basis of pre-existing conditions by cutting costly benefits--like expensive drugs.  The Post cites a study by Avalere Health:

A new analysis of health plans sold in the federal exchange — which covers 36 states — and 14 state exchanges found that the benefits tend to be skimpier than in most other private insurance in the United States, with drug benefits a particular weak spot.

Right now, this only affects the 5% of Americans who get their insurance on the individual market, but the Post reports that many employers are already thinking about cutting costs the same way.

Dan Mendelson, Avalere’s chief executive, predicted that employers may soon adapt some of the benefit designs in the exchanges’ health plans. “We are already seeing interest,” he said, because they are less expensive for companies, shifting more of the expense to patients.

The Washington Post article makes it clear that (a) this problem affects a larger group of illnesses, including cancer, multiple sclerosis, rheumatoid arthritis and autoimmune disease and (b) AIDS activists are working hard to change the rules to solve the problem--for people with HIV.

If you care about someone with AIDS, read the Washington Post article and pass it on.

If you care about someone with cancer, multiple sclerosis, rheumatoid arthritis, autoimmune disease, or another disease that involves expensive medications, you may want to subscribe to this blog.

Healthcare and Kidney Failure

America is the most generous nation on earth. Of course, we are also the richest nation on earth, so we ought to be.  How about giving until hurts? How about giving something money can't buy--like a kidney?

Over 600,000 Americans suffered from end stage kidney disease in 2008, and the number is rising. Kidneys are the body's toxic waste disposal units--a mission so critical that God gave us two of them. If one fails, the other is there for back-up. If both kidneys fail, the only option is to pipe the blood out of the body through a dialysis machine that does the filtering for them or get a kidney transplant.  More than 50,000 living people have given a kidney to save a life. I am proud to claim one of them in my own extended family.  My niece's brother-in-law has one less kidney and one more brother than he would have had without modern medicine. Thanks to that heroism, my nephew hopes to live as long as any other American.

With only 6,000 living donors each year and 10,000 kidneys from other sources, most end-stage kidney disease patients depend on dialysis. According to official figures reported in the New York Times, in 2008 over 380,000 Americans were receiving dialysis, at a cost of just under $40 billion.

Kidney failure is the only chronic disease that automatically qualifies an individual for Medicare, regardless of age. According to the American Kidney Fund, other Medicare patients can choose to continue their own private insurance as long as they are willing to pay for it, but dialysis patients are limited to 30 months of coverage under an employer-provided plan even if that plan offers better care than Medicare.

It gets worse for transplant patients. The American Kidney Fund reports:

Patients who receive a kidney transplant must take anti-rejection or immunosuppressive drugs for the life of their kidney transplant. However, Medicare will only pay for these drugs--which average $17,000 per year--for the first 36 months after a patient receives their transplant. Patients who are unable to pay for the medications are often forced to discontinue their use, resulting in kidney rejection and a return to Medicare-covered dialysis treatments at an annual cost of nearly $71,000 per patient.

That's rough on my nephew, but now there's Obamacare--or is there? Millions of Americans who were expecting more security and better care have been unsettled by the spectacular failure of HealthCare.gov.  How does the new system work for kidney patients?

It isn't clear.

I visited HealthCare.gov to see whether kidney patients who are currently on Medicare can sign up for private insurance through the new exchanges. The online search tools told me all about Medicare and assured me that the new law would not take away my Medicare but had nothing to say about people who want off Medicare and on to private insurance that can no longer discriminate against people with pre-existing conditions.

So I called the 800 number and got the automated menu as I expected. One push of the "0" button broke me out of my robocall and I quickly got a very pleasant person who looked up the same articles I had been reading as she tried to figure out the answer with me. "Amanda" (not her real name) was able to tell me that it is illegal to sell insurance to somebody who is on Medicare (except for supplemental policies like Medicare Advantage). She figured out that a person who is eligible for Medicare (such as a kidney patient) is not eligible for any of the Obamacare subsidies. She couldn't say whether the system would allow a person who is currently on Medicare to pay their own way for a private plan.

Medicare.gov assures me that Obamacare won't take away my Medicare and offers me free colonoscopies. Their website indirectly alludes to $700 billion in cuts in Medicare through this optimistic paragraph:

The ACA ensures the protection of Medicare for years to come. The life of the Medicare Trust fund will be extended to at least 2029—a 12-year extension due to reductions in waste, fraud and abuse, and Medicare costs, which will provide you with future savings on your premiums and coinsurance.

Medicare's 800 number employs more robots than HealthCare.gov and insists that I type in my Medicare number. I could cheat and use my Mom's number, but that would be wrong. "If you do not have your Medicare number, you may wish to hang up." I hang up.

Searching for "Can Medicare patients choose Obamacare" gives me tons of hits--and they all promise me that I won't lose my Medicare. As far as I can tell, somebody at the very top made it clear that if you like your Medicare, you can keep your Medicare. (With so many people making the same promise, it sounds like this could turn into a post of its own, but that's for another day.)

How about Medicare supplemental insurance? That's usually the right answer for a person who wants more than Medicare. Now things get more troubling. According to "Beth" (not her real name), there are no options for "end of life treatment" for kidney failure in Minnesota. I'm hoping that doesn't mean what I think it means. Perhaps Beth got confused--it's a confusing situation. Fortunately, Beth's doctor in Saint Paul (who is as shocked as I am) is trying to find the answers. 

I hope there's a better answer for kidney patients than I've found yet. If you think I've stumbled onto the famous "death panels" here, you're wrong. Somebody is going to have to reduce the costs of all this care some time, and "death panels" may be the most accurate description of the body that tackles that terrible task, but this is just bureaucracy as usual. There should be a right answer to this question--we just haven't found it yet.

I appeal to readers from all points on the political spectrum to help out Beth. How does a patient with end-stage kidney disease take advantage of the new law? If Obamacare doesn't help them, are there private alternatives that do? Let's put our brains together, people, and make this world a better place!

Obamacare and Multiple Sclerosis

Obamacare was always expected to result in some "winners" and some "losers." The argument for the new law was that some people (especially the young and healthy) should pay a little more so that other people (the old and sick) could get the help they need. It's troubling to discover that some of the people who may get hurt the worst are those who are the sickest.

Approximately five percent of multiple sclerosis sufferers (those who were covered by individual insurance policies) have begun to discover how Obamacare affects them personally. Whitney Johnson had a policy that covered her medical bills even though they added up to $350,000 per year. Her existing insurance was cancelled and she was invited to pick a new policy from HealthCare.gov. She had not been able to get what she needed through the Exchange, so she went directly to her insurer--only to discover that all her new options were unaffordable.  She writes:

I know I have five more IVIG treatments coming up over the next six months that cost $40,000 each. My insurance coverage ends in December, and I have to have these treatments. As a mother with a brand new baby, it’s a little unnerving to know that I may not be able to receive the care I need. It’s a little unnerving to know my health insurance that was working just fine for me was taken from me. The doctors I have used for years that have kept me this healthy will be taken from me.

Whitney is one of "small percentage" who have had their policies cancelled, but many more Americans with MS will be affected next November, when employer-provided policies must comply with the new law.  The Multiple Scerosis Association of America highlights the particular questions MS patients need to consider. These include:

• Are my needed medications covered, and what are my costs?
• Can I keep my doctor and are there restrictions on which doctors I can choose?
• What plans can I afford and am eligible for?
• Can I afford my deductible?
• What are my expected out-of-pocket costs for equipment I may need?
• Do I have to try lower-cost medications before I will be approved for the drugs I use now?

Forbes Magazine worked through the cost of MS medications in today's article, "No, You Can't Keep Your Drugs Either Under Obamacare."

Take, for example, the drug Copaxone for multiple sclerosis.

Someone on a bronze plan would be responsible for paying about 40% of the drug’s costs out of pocket, on average. That comes out to about $1,980 a month.

If you buy the highest cost platinum plan, the out of pocket costs drop to $792 a month.

But you’re probably better off with the cheaper bronze plan anyway. Since you’re going to hit your out of pocket cap regardless of your plan, you might as well save money on the premium (which doesn’t count against your deductible or out of pocket limits) and race to the $12,700 spending cap as quickly as your family can.

After all, the provider networks used by low cost bronze and high cost platinum plans are often the same. The only thing that varies between different “metal” plans is often the co-pay structure. The benefits are similar. So why pay higher premiums just to lower your co-pays when you know you’ll hit the out of pocket limits anyway.

By purchasing a costlier, gold or platinum plan, you typically can’t buy up the benefit much, if at all. What you’re doing is just prepaying the cost sharing.

That's assuming the drug you use is on the government's "formulary list, the list of drugs that are included in Obamacare. Even if it is on the government list, it may not be on your plan's list. Betaseron, for example, will not be available through ExpressScripts starting January 1. Forbes notes the out-of-pocket effects:

If the drug isn’t on this formulary list, then the patient could be responsible for its full cost (with little or no co-insurance to help offset that cost). Moreover, the money they spend won’t count against their deductibles or out of pocket limits ($12,700 for a family, $6,350 for an individual).

If you are an MS patient who has adequate employer-provided insurance today, don't wait until next November to find out how this works for you. Talk to your human resources department soon! If your employer is even thinking about changing your plan, call Washington! (All you need is your zipcode to find your Congressman, and you can find your Senators here.)

Not one single elected official wants you to lose coverage--but it's up to people with MS and the people who love them to help busy politicians understand the implications of this law. Whether you're Republican, Democrat, or terminally-turned-off by all things political, please speak out and spread the word!

Contempt for Catholics

Cardinal Timothy Dolan, the archbishop of New York, says the Catholic church finds itself opposed to ObamaCare. This isn't how Roman Catholic bishops wanted this to go. According to Fox News, Cardinal Dolan directed his remarks to President Obama, saying:

We want to be with you. We want to be strong, and if you keep doing this, we’re not going to be able to be one of your cheerleaders.

Catholic leaders want health care for every person in America, from the baby in the womb to the stranger in our midst. Obamacare doesn't cover unborn babies or illegal immigrants. Instead, it mandates oral contraceptives, which do nothing to prevent conception, but instead flush each fertilized embryo from the womb.

Our government has begun negotiating with Iran's ayatollahs. Wouldn't it be worth their time to spend a little more effort on the bishops?

Navigator Training

One way to get paid for helping people choose healthshare is to sign up as a Navigator. The training is easy, free, and takes about 20-30 hours for most people. Navigators are paid $20/hour to help people understand their options and choose a plan that complies with Obamacare. Since Christian healthcare sharing ministries ("healthshares") comply with Obamacare, this could be the solution.

I have downloaded my Navigator training materials and will report

Is Self-Pay Better Than Medicaid?

If a person near the poverty line can afford to pay a doctor out of pocket, they may be better off not showing their Medicaid card. According to the New York Times, Medicaid Growth Could Aggravate Doctor Shortage. That is because existing doctors are expected to treat a growing number patients for a shrinking amount of money per visit.

In California, with the nation’s largest Medicaid population, many doctors say they are already overwhelmed and are unable to take on more low-income patients. Dr. Hector Flores, a primary care doctor in East Los Angeles whose practice has 26,000 patients, more than a third of whom are on Medicaid, said he could accommodate an additional 1,000 Medicaid patients at most...

Payment rates for Medicaid, known in California as Medi-Cal, are also low here compared with most states, and are being cut by an additional 10 percent in some cases just as the expansion begins.

Americans who qualify for Medicaid under the newly-expanded rules aren't eligible for subsidies on the new Obamacare exchanges, making it easier for many working-class Americans to get health insurance at the same time that it makes it harder for them to get health care.

A growing number of citizens are learning creative ways to pay their own bills, as Sean Parnell explains at TheSelfPayPatient.com. I'll be eager to learn what Sean says about hiding your Medicaid card from your doctor!