My name, it is Mulvaney, and I’m known quite famously

There’s now way this would pass the Senate, so, yeah, I wish a motherfucker would vote for VoucherCare in the House:

Office of Management and Budget Director Mick Mulvaney—previously a House GOPer known for being a budget hawk—kept the door open for President Donald Trump approving of some kind of overhaul of Medicare or Social Security.

Referencing the proposal oft-floated by House Speaker Paul Ryan (R-WI) to privatize Medicare by transforming it into what’s known as “premium support,” Mulvaney told CNBC’s John Harwood that his “guess is the House will do either that or something similar to that.”

Harwood brought up Trump’s campaign pledge not to touch Medicare and asked whether he would veto it.

“That’s not a really conducive way to sort of maintain a relationship between the executive and the administrative branch,” Mulvaney said. “Let them pass that and let’s talk about it.”

I realize they’ve passed stuff like through the House before without getting hammered, but if they think they can do it now, with a Republican president who might sign the thing, they’re in for a big fucking surprise.

What does Chuck Schumer look like?

Say Medicare privatization again, I dare you, I double dare you motherfucker:

“The Republicans’ ideological and visceral hatred of government could deny millions of senior citizens across the country the care they need and deserve,” Schumer said in the statement. “To our Republican colleagues considering this path, Democrats say: make our day. Your effort will fail, and this attack on our seniors will not stand.”

I don’t care how many fucking Russian twitter bots they send out there to talk up the glories of vouchercare, this aggression will not stand.

Round one

The first big battle of the Trump administration is going to be over Ryan’s plan to replace Medicare with vouchers. We’ve got to win this battle. Remember, Bush losing the battle to privatize Social Security was the beginning of the end for him. I’m calling my Congress people about this later today. Josh Marshall says Dems don’t have a plan yet:

Over recent days, as I’ve spoken to people in the world who might lead the fight against Paul Ryan’s plan to phaseout Medicare and replace it with private insurance vouchers and one message is quite clear: No one is paying attention. No one is ready. No one has a plan. Half the people are still too shell-shocked to think about anything. The other half are telling themselves something so crazy can’t happen. But wait, at least one person on TV is starting to talk about this.

More on Kentucky

Via Tbogg:


The 1115 waiver is how Montana, Alaska, Iowa, Arkansas and half a dozen other states have expanded Medicaid.  If straight up Medicaid expansion is replaced with a 1115 waiver Medicaid expansion in Kentucky, then most of the 420,000 people who are on expanded Medicaid in Kentucky will still have coverage although it has been worse coverage.

The 1115 waivers that have been approved have set some strict limits:

  • No more than 2% of income can be spent on premiums and only if people make more than 100% of the Federal Poverty Line
  • Cost sharing can be maxed out at 5% of income
  • Redetermination of eligibility can happen annually instead of every six months
  • Health Savings Accounts are approved with state seed money
  • Medicaid is not tied to job or educational efforts.

I don’t think Kentucky would go Arkansas model of paying for private insurance.  Arkansas is seeing that this route is extremely expensive.  So far it has not mattered for Arkansas as the Federal government has been paying 100% of the cost to expand Medicaid without calling it Medicaid Expansion or Obamacare.  That changes on 1/1/17 as the states will have to start kicking money in.  The Arkansas model will cost the state an incremental $15 to $20 million dollars per year over straight up Medicaid expansion.

If we assume the Center for Medicare and Medicaid Services follows their precedent, a probable Kentucky 1115 waiver will impose some premiums or mandatory HSA contributions, some non-ambulatory transportation services will be cut and cost sharing for emergency room visits will increase.  The premiums will push some people out of the program.  Everyone else will have another hoop to jump through but they’ll still have coverage.

I thought this was a 10% probability last night, but with new information I’m bumping this up to a 60% probable outcome.

Enough to Choke an Everglades Python…

I suspect our healthcare reform correspondent, Richard Mayhew, will cover this in more detail at some point, so I’ll keep it short:

Florida’s sleazy, serpent-like governor, Rick Scott, slithered up to DC this week to try to locate a fat wad of cash he could ingest to reimburse Florida hospitals for providing indigent care. 

He had to do it while still eschewing Medicaid expansion (Obamacare!), thus enabling Scott to get money from the Feds while saving face with the teaturds back home.

Mind you, Scott’s strategy is not the fiscally responsible move — the Obama admin peeps rightly pointed out that it’s more cost efficient (not to mention more HUMANE) to give people coverage and nip developing health problems in the bud rather than pay for a medical crisis in the ER. 

But bootstraps, welfare queens in Cadillacs and strapping young bucks buying t-bones, etc. So no.

Anyway, HHS Secretary Sylvia Burwell told Scott to fuck off. Basically, she said, “Swallow Obamacare, or depart, foul serpent! “

Well done, Madam Secretary!

Did I say I’d “keep it short?” Ha! Another lie! But that’s a perfect illustration of why morons and liars win healthcare reform debates. It takes too many words to explain. I’m out of them. Words, that is. The end.

Problems with high deductible health plans

From a loyal reader, I was pointed to this story down in Georgia concerning state employees getting a slightly better health insurance plan mid-year.  I want to highlight the problem with the original health plan.

This year has brought on an onslaught of changes, which included one form of insurance from Blue Cross Blue Shield of Georgia – a high-deductible HRA (Health Reimbursement Arrangement) – and no additional selections to choose from. It is no secret that an HRA is not a one-size-fits-all medical plan for every family, particularly individuals with long-term illnesses….In late December, our family was notified that our daughter’s occupational therapy would increase from a $25 co-pay to $127 per one hour session. We are facing $1,000 per month in medical bills between insurance premiums and four hours of therapy….

Health reimbursement arrangements/health savings accounts/high deductible health plans are designed to do one basic thing.  That thing is to shift costs onto the individual for anything that could vaguely look like a “day-to-day” expense.  The theory of change is that the individual will be much more price sensitive and thus a much better price shopper as well as being much more not consume any medical service in a marginal situation.  From here, costs will stabilize and eventually decline.  That is the theory of change.

It is a theory of change that is built on the Rand Insurance Experiment.  The Rand Insurance Experiment showed that making people pay out of pocket reduced health care consumption and expenditure.  However the Rand Insurance Experiment also showed that people are not perfectly rational, infinitely discounting, amazingly discerning health care shoppers; people are human with the limitations of bounded rationality that is shaped by information processing costs and competing priorities.  People being people instead of perfectly rationalizing agents means high deductible cost sharing plan designs don’t guarantee that people get the care that they actually need which leads to worse health outcomes including death in some cases.

High deductible plans are appropriate choices for some people.  They are not appropriate for everyone if we value appropriate as a means of providing effective, efficient care that meets the medical needs of an individual without bankrupting them or their family. 

If I was the health insurance dictator in this country, I would allow high deductible plans to be sold.  They would only be sold to individuals and families who are reasonably young (age is a pre-exisiting condition) without any signifcant claims history.  The policies would not be automatically renewed until the most recent claims and medical history was reviewed.  Furthermore, the potential buyer pool would be limited to people who have the ability to absorb a one-time shock of several thousand dollars without it being a crisis.  This sub-population is fairly small, and can absorb the risk shifting that is inherent in a high deductible plan design.  Anyone with chronic conditions or recurring health maitenance problems should not be a plan designed like this if the goal is to effectively manage health.

Same old Song and Dance

The House Republican Study Committee is offering a “repeal and replace” plan for Obamacare. If we assume that this is purely a marketing document aimed to fulfill the check box that there is a “plan” to “replace” Obamacare that can get 218 votes in the House, then this document aces that evaluation. However, my therapist asked me to try not to be a cynical bastard before my first cup of coffee every morning, so lets evaluate this plan on the following criteria:

  • Provides coverage for people with pre-exisiting conditions
  • Provides coverage for people who aren’t part of the Republican donor class
  • Attempts to bend the cost curve down
  • Covers neccessary medical processes

Before we evaluate, let’s go over the major policy planks.

  1. Repeal all of Obamacare including Medicaid expansion and the three legged stool of subsidies, community rating/guaranteed issue, and mandate.
  2. Give people a tax deduction of $7,500 for an individual and $20,000 for families
  3. Significant expansion of HSA tax advantages.
  4. $25 billion for state run high risk pools with premium support for any premiums that are over twice the state average for insurance.
  5. Coverage guarantee for pre-exisiting conditions only applies to people who maintain continuous coverage
  6. Allow insurance companies to sell a single product through a single state regulatory filing
  7. Allow small groups to pool together for better risk pool pricing.
  8. Improve pricing transparency
  9. Stop comparative effectiveness research
  10. Tort reform to cap damage limits
  11. Random anti-abortion plank

 The short version is MASSIVE FAIL

The long version is below the fold:

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