The Volunteer State opts out

Tennessee state legislators have passed a bill allowing their citizens to take a pass on ObamaCare�. What's interesting about this effort is that, according to its sponsor, it "doesn't argue for or against the federal law but simply "gives Tennesseans a choice."

Imagine that: Americans get a choice.

Oh, wait, don't even think about it.

The MVNHS� Cuts Deep (For Some)

Let's play a bit of Jeopardy.

The answer is: "(P)atient care would inevitably suffer"

The question is: What is the likely result of "53,150 posts ... lost across 155 hospital trusts, 126 primary care trusts, 23 ambulance trusts and 54 mental health trusts in England, as well as 15 Scottish trusts, nine Welsh trusts and six trusts in Northern Ireland."

Ooops.

Proponents of national health care schemes - like ObamaCare� - often tout economic and efficiency and more successful outcomes. One wonders how they can look at these results from the MVNHS� and keep saying that with a straight face.

Meanwhile, those in charge of putting tens of thousands of health care *workers* out on the street are livin' large:

"NHS bosses in charge of hospitals being forced to sack thousands of staff have seen their pay soar by up to 50 per cent in the past five years ... The chief executives at trusts facing the worst cutbacks are now on lucrative salaries far higher than the Prime Minister�s, with some earning more than �200,000."

One can almost hear the "cha-ching!" ringing in the ears of HHS Secretary Shecatbeserious and her minions.

The truth is that these kinds of systems are unsustainable, and lead to forced rationing of health care courtesy of the government, against which there is little (if any) recourse. One supposes that the Brits will continue to find medical tourism a more viable alternative.

YOUR tax dollars at "work"

Early last month, we reported that the folks behind ObamaCare� were using public funds to purchase webvertising on Google. Turns out, that's only part of the story:

"If you type �Obamacare� into a search engine � whether Google, Bing, or Ask � you�ll find that the first site that appears at the top of the page is healthcare.gov ... it comes up first, before anything else, because your tax dollars are paying for it to come up first"

That's known in weblingo as "Search Engine Optimization" (SEO), and it's very big business. Why HHS Secretary Shecantbeserious thinks it's a good idea to spend your money on it is, of course, the $64,000 question.

What's on your mind? ObamaCare� will tax it

Here's a little mind-game:

If you think about buying a car, but end up keeping your current ride, is that "economic activity?"

How about if you think about trying out the new Chinese place down the street, but opt to eat in instead?

The answer to both questions, according to Clinton-appointed Federal Judge Gladys Kessler, is a resounding "yes:"

"It is pure semantics to argue that an individual who makes a choice to forgo health insurance is not �acting,� especially given the serious economic and health-related consequences to every individual of that choice. Making a choice is an affirmative action, whether one decides to do something or not do something."

This would also seem to reinforce Mike's contention that we (formerly free) citizens will be required to consumer health care:

"Making health care compulsory would address actual need. Public funds would not be wasted on �insurance� but would be spent directly for health care. Everyone would then be healthy, happy, and handsome, and all our children would be smarter than average. Overnight, our life expectancy would be the highest in the world and infant mortality would drop to zero."

Now witness the firepower of this fully armed and operational Commerce Clause.

[Hat Tip: Ace of Spades]

Cavalcade of Risk #125 now online

FreeMoneyFinance blog makes its CavRisk hosting debut with a great selection of risk-related posts. Please stop by.

So, What's Your Exchange Policy? [Part 2]

In Part 1, we were introduced to Utah�s unique Health Insurance Exchange program. Today, we conclude our exclusive interview with the Exchange�s Director and Project Manager, and offer some thoughts and observations of our own:

InsureBlog: How do you get around the problem that the biz owner can't fully participate in the 125/HRA?

Patty/Sue: First, your readers need to understand that the whole program is based on the concept of �defined contribution.� So the employer agrees to set up (for example) a health reimbursement arrangement (HRA) or other similar plan, and to fund it at a previously agreed upon level. Once each employee has chosen a plan, premiums are forwarded to the appropriate carrier.

It�s true that the business owner doesn�t really get the same tax benefits of the HRA (or 125, etc) as the employee, but so far no one seems to mind [ed: or at least no one�s piped up about it]. Our take is that the employers are willing to trade a tax break for certainty and simplicity in the budgeting process.

IB: Are groups in the Exchange still subject to other rules, such as portability, COBRA, etc?

P/S: Yes, all the relevant rules and regs apply. We don�t provide the COBRA admin; our operating principle is to basically just stay out of the way.

IB: I have to ask this: what happens to the Exchange if ObamaCare� is, in fact, fully implemented? In other words, what about 2014?

P/S: Utah will continue the approach it�s taken since 2005, which is to provide a cost effective solution for small businesses. We are prepared to do whatever is necessary to meet whatever guidelines that ultimately go into effect.

And by the way, we�re not selfish: we�d be delighted to share our experience and expertise with other states that want to �facilitate, not mandate.�

IB: Our last question is about the large group pilot program. I understand that it�s new, so there�s not a lot to talk about, but I have to question the value of the Exchange to, say, a 500 person group. After all, an ERISA plan lets you do pretty much the same thing, you don�t really need Utah (for example).

P/S: That�s true, and we don�t really anticipate �jumbo� groups. The industry defines small group as 2-50 lives; we're also looking at programs for mid-size groups (51-99 lives).

IB: Okay, that�s all the questions I had prepared for you. Is there anything you�d like to add in conclusion?

P/S: Yes: our goal has always been to create a free market approach, cooperating with our stakeholders all through the process. We welcome broker feedback, for example, because they are stakeholders, as well. In fact, they�re our best marketers � as we noted before, they bring in the bulk of our business. And agent compensation through the exchange is the same as the traditional pipeline, so there�s no financial downside to the agent.

Thanks Patty and Sue!

Well, now you�ve seen under the hood of the Beehive State�s Exchange program. Is it perfect? Of course not, but it�s much more business-friendly (and ultimately consumer-helpful) than the Massachusetts or ObamaCare� versions. Bob and I do have some reservations, though:

First, it's still employer-based, so the plans aren't "portable;" that is, if an employee leaves the group, he can't just take the plan with him (aside from COBRA continuation, which is a short-term solution). That's not necessarily a fatal flaw, but it is something to consider.

Second, the website needs some tweaking:

The �Individual� portion is simply a conglomeration of eHealthInsurance-type links and product placement opportunities. Thankfully, it�s not a part of the Small Group program. Still, it�s kind of embarrassing.

And the site does �Small Group� a disservice with confusing and inaccurate descriptions of how that program really works.

Finally, since it�s such a new effort, with a very small population of covered lives, we really don�t know how rate renewals will go. I did ask about them, but decided not to include that in the post; as Bob pointed out to me, this metric is relatively meaningless because, by definition, we're only talking about a maximum of 550 covered employees (11 groups times 50 lives).

We certainly appreciate all the time and cooperation we received from Patty and Sue. They came across as professional, competent and very eager to make this program self-sustaining. It probably helps that they both come from the corporate world, so there�s actual real-world experience involved.

Making Health Insurance (Un)Affordable

The Montgomery Reporter states that 61 Alabama residents have taken advantage of the PCIP insurance plan for those who cannot meet underwriting requirements of traditional major medical coverage.

Nationwide enrollment totals around 12,000 participants, far less than the 200,000 that were expected to enroll.

The insurance was made available under the new federal health care law. It's designed to bridge the gap until 2014, when private insurance companies will no longer be allowed to deny coverage for people who have had certain major illnesses.

A spokesman for the Alabama Department of Insurance said cost may be a factor in Alabama's low enrollment. Premiums for people over 55 are $583 per month for the standard plan and $785 for the extended plan, plus deductibles and co-payments.

This begs the question, if some consider PCIP to be unaffordable, how will anyone pay for health insurance once health insurance companies are required to take anyone and everyone?

HHS Admits CLASS is Unsustainable

In a remarkable about face, HHS Secretary Sebelius admitted that CLASS, the taxpayer funded long term care program, is a Ponzi scheme. According to her testimony, CLASS, as it currently exists, is unsustainable.

The CLASS long term care insurance program is being canned before it ever got off the ground.

While it is good that the Obama administration recognizes and admits the plan is not sustainable, you have to ask yourself how much due diligence was done before the plan was actually written and enacted in to law? If they can be so far off in their financial calculations on a relatively small program, how much did they miss the mark on the wholesale takeover of health care for everyone under Obamacrap?

Grand Rounds: "Read This Quickly" Edition

In his characteristically caustic-yet-ironic style, DrRich (and no, that's not a typo) presents this week's collection of outstanding medblog posts. While you're there, you might also congratulate him on winning the 2010 Medical Weblog Award in the category of Health Policy and Ethics.

1.4 Trillion Reasons to Repeal The Bill

My better half believes that "there are no coincidences," which is helpful in considering these two news items:

Under ObamaCare�, "The Department of Health and Human Services will become the nation's first-ever $1-trillion-per-year Cabinet department in 2014."

One shudders at the thought of the damage that HHS Secretary Shecantbeserious can wrought with that much of our money.

On the other hand:

"The Congressional Budget Office (CBO) and the staff of the Joint Committee on Taxation (JCT) have estimated the direct pending and revenue effects of H.R. 2, the Repealing the Job-Killing Health Care Law Act, as passed by the House of Representatives on January 19, 2011 ... In total, CBO and JCT estimate that H.R. 2 would reduce outlays by about $604 billion and reduce revenues by about $813 billion over the 2012-2021 period."

Although I was assured that there would be no math, it appears that aborting ObamaCare� will save us over $1.4 trillion.

Yowza!

So, What's Your Exchange Policy? [Part 1]

Bob and I recently participated in a conference call, brainstorming about the potential for "defined contribution" health insurance plans. So, what's a "defined contribution" (DC) plan? It's pretty simple, really: instead of your employer choosing your health insurance plan, he gives you a "voucher" to buy whatever policy suits your particular needs.

I know, makes way too much sense; why is this "new?"

Some companies offer "cafeteria" plans which are, in essence, DC plans: the employer says "here are 6 plans from which to choose, I'll kick in $100, you pay the rest." The problem is that not every employer can afford to offer such plans (there are admin and other costs associated with them, in addition to the premiums), and some carriers don't offer multiple plan designs within a given group, or allow employers to offer plans from multiple companies.

So along come "Exchanges;" most notably, that which is part of RomneyCare and, of course, those planned for '14 under ObamaCare�. We've seen how "well" they work in the former, but one wonders if there isn't a better model.

The Beehive State thinks there is.

After the aforementioned conference call, I contacted the folks at the Utah Health Insurance Exchange; Patty Conner (the Director) and Sue Watson (the Project Manager) both graciously agreed to an interview to help explain the program to our readers. We'll focus here primarily on the small group (2-50 lives) market:

InsureBlog: How many businesses have registered, and then how many of those actually signed up for a quote? (And of those who did, how many indicated they had a broker?)

Patty/Sue: For the plan year beginning 2010, we had 11 groups in the program. For 2011, about 220 or so businesses �tested the waters.� All 11 of the class of �10 re-upped, and 31 additional groups came on board, bringing the total participating to 42 groups as of January, 2011.

But: last year businesses could only sign up for January; this year it�s �rolling,� and we�ll have 69 groups �live� as of March 1rst.

We�re seeing continuously growing interest as more employers become aware of the existence and benefits of the program.

Almost all of these groups, by the way, have and use brokers/agents throughout the process.

IB: How do you get around the adverse risk of carriers saying "hey, we may lose some money with sloppy underwriting, but we'll just nick Humana and UHC for the diff?" Also, can an employer offer more than one carrier? If so, what about participation issues?

P/S: �Uncommon Knowledge:� Utah first started working on this in 2005, looking to add economic value for small businesses in the state. We collaborated with business, insurers and agents in developing the program.

Unfortunately, the information on the website really doesn�t accurately reflect how the program works [ed: more on this in a bit]. The process isn�t complicated, but it does take some time.

There are (currently) four participating carriers. When an employer chooses to �try out� the program, he submits standard group information (name, address, EIN, number of employees, number of eligible employees, etc). Assuming the group meets participation requirements (e.g. a group with 20 employees but only 5 covered employees wouldn�t fly � just as in the �open market�) then the case is randomly assigned to two of the carriers.

At that point, employees go online and complete industry-standard enrollment forms (names, socials, medical history, etc) and these are forwarded to the two assigned carriers. The carriers pore over the information, and assign a rating class (aka rate factor) to the group. The two carriers� rate factors are then averaged (there�s a dispute resolution system in place if there are problems at this point). The averaged factors are then sent to all four participating carriers, which apply them to their standard (�street�) rates.

This is an �all-in� deal: a participating carrier can�t take a �pass� on a given group. So all four submit their rates for the plans they�ll offer and this is sent to the employer. It�s possible that in a given group of, say, 10 people you could have 10 different products chosen, and 3 or even all 4 carriers in that group. And remember, this is �all-in� so they have to live with that.

The key is that the carriers know this going in � remember, they helped design the program. It�s the free market at work. We like to say that our role is to �facilitate, not mandate.� [ed: I am so stealing that!]

In Part 2, we discuss how these plans work and play with Health Reimbursement Arrangements and similar �alternative benefits.� There�s also be a quick peek at large group plans and (of course) ObamaCare�. And to wrap things up, we offer our conclusions and some food for further thought.

Alzheimer's Update: Don't Forget that Martini

It's been a while since we've written about Alzheimer's disease, which is not necessarily an indication of our own state of mind (or lack thereof). The good news is that there's some heartening news on the Alzheimer's prevention front:

"Our vulnerability to dementia is influenced by our genes ... Experts now believe it may be possible to curtail the expression of such genes...

A daily cocktail or glass of wine may help delay dementia. Research has found that alcohol is an anti-inflammatory (inflammation promotes Alzheimer's) and raises good HDL cholesterol, which helps ward off dementia."

The bad news is that "binge-drinking makes it more likely" that one will contract the dreaded condition.

Exit question: since Aricept and Lipitor are reimbursable under a Health Savings Account (as well as Health Reimbusement Arrangements and Flexible Spending Accounts), can I run my fifth of Stoli through it, as well?

Die, Baby Joseph, Die: THIS is Government-run Health Care [UPDATED]

It doesn't get any more simple than this:

"The father and relatives of one-year-old Joseph Maraachli wept outside a London courthouse after an emotional Justice Helen Rady upheld the earlier decision of an independent provincial tribunal forcing the baby's parents to comply with doctors' orders.

With all of their legal avenues exhausted, the family will have to say goodbye to Joseph Monday morning � on Family Day � when his breathing tube will be removed."

Asking for some nod to compassion, Baby Joseph's father asked the court to allow the infant to have a tracheotomy, so that he could die without the horrific struggle that will mark his end when the breathing tube is removed.

Of course, this is the Government, and in typical Government logic...wait for it...the Government:

"refused to [allow doctors to] perform the procedure, citing serious risks of infection, pneumonia and other possible complications."

You know those condemned prisoners, the ones who murdered their helpless victims? I've often wondered why, in all the movies that depict "the needle," the executioner swabs the site. Why is that, I ponder? After all, he's being put to death.

I guess that's how the Canadian Government views Baby Joseph, too.

Oh, but don't get too worked up. After all, that's Canada - it'll never happen here.

Right?

Right?

[Hat Tip: RWN]

UPDATE (2/21/11): Thanks to reader "visceralrebellion" in the comments, we learn that Baby Joseph is to be spared the agony wished upon him by the Canadian "health care" system:

"Joseph Maraachli of Windsor, Ontario, who was to have his life support removed Monday at 10 am. against his parents� wishes, will now not die on the day that Ontario residents celebrate as Family Day. A hustle by pro-life and anti-euthanasia groups resulted in a change in legal counsel, which has led to at least a temporary stay of removal of the child�s ventilator."

This in no way vitiates the evil decision made in the first place, and there is little hope that Baby Joseph will live a long and healthy life, but it seems to vindicate those of us who raised our voices in protest at the inhumane treatment inflicted upon Baby Joseph and his family.

Preview of Banks' Q1 2011 Earnings

Scotia Capital, 18 February 2011Banks Begin Reporting February 24� Banks begin reporting first quarter earnings with Canadian Imperial Bank of Commerce (CM) and National Bank (NA) on February 24, followed by Bank of Montreal (BMO) on March 1, Canadian Western (CWB) (after market close) on March 2, Royal Bank (RY) and Toronto-Dominion (TD) on March 3, Bank of Nova Scotia (BNS) on March 8, and

Obamacare is Good News for High Wage Earners

If you earn a better than average wage, Obamacrap might be your key to job security. But if you earn less than the average bear you might want to retrain for a better job.

One of the hidden traps in Obamacrap and the mandate to buy health insurance is a built in incentive for employers to not only keep total employment below 50 lives, but to jettison low wage earners.

Others will pay the $2,000 fine rather than continue to provide health insurance benefits. Doing so will save them a bunch of bucks.

Experts expect the cost of family insurance provided under a group health insurance plan to be in the $20,000 range by 2014. If that happens, and some plans are already in range already, the employee contribution cap built in to Obamacrap is bad news for low wage earners.

The folks at Employee Benefit News found this nugget.

assume that an employee, Bob, is married with a family and is the sole wage earner. If Bob makes $125,000 per year, his employer, Acme Enterprises, may charge him 8% of $125,000, or $10,000, for his share of the premium. This means that Acme and Bob will each pay half. And Acme will pay a manageable (and historically reasonable) 8% of Bob's salary toward his insurance.

Conversely, Bob's co-worker Clara is also married with a family and is the sole wage earner, but only makes $25,000 a year. Acme may only ask for a $2,000 contribution toward her $20,000 premium and would be compelled to pay the $18,000 balance.

So Acme will pay nearly twice as much for Clara's coverage as it will for Bob's. And instead of health insurance costing Acme 8% of Bob's pay, it would be 72% of Clara's pay.

Good news for Bob.

Bad news for Clara.

In attempting to mandate how much an employee can pay for health coverage and tying the test of affordability to a person's household income, PPACA creates a new, insidious discriminatory intent against lower paid individuals.

Furthermore, raising the question of annual household income unnecessarily invades an individual's privacy by compelling employers to make someone's annual tax return part of their benefits administration.

Change you can believe in.

Cavalcade of Risk #125: Call for submissions

Free Money Finance makes its Cav hosting debut next week. Submissions are due by Monday (the 7th), and must include:

� Your blog's url
� Your post's url
� The post's trackback URL (if available)
� A (brief) summary of the post

And PLEASE remember: ONLY posts that relate to risk (not personal finance tips and the like).

You can submit your post via Blog Carnival or email.

ObamaCare� No Go? You Betcha!

FoIB Elena Marie tips us to this rather,um, provocative response to Judge Vinson's recent ruling:

"Alaska Gov. Sean Parnell said Thursday that he will not implement the federal health care overhaul passed by Congress last year after a judge in Florida struck down the law as unconstitutional."

Which really begs the question: why isn't every governor doing this? A Federal District Court has ruled ObamaCrap unconstitutional. In the real world, this means "No. Can. Do." But in the "political" world, it seems to mean "And your point is...?"

Sheesh!

Not so fast, David...

My good blog friend David Williams, proprietor of the usually well-informed and always interesting Health Business blog, takes a rare misstep in his post "Bye, bye brokers?" David's thesis is that, due to new Medical Loss Ratio rules, agents will be forced from the market and further, that that's no great loss.

As one might imagine, I disagree on both counts.

Let's start with his first point, that agents "often receive 10 or 15 or even 30 percent of the premium as commission."

I wish.

I can recall a time years ago when individual medical paid up to 20%, and group perhaps 15%. Those days are long gone. Today, individual business is in the 7-10% range (or less), and most small group plans are compensated on a flat fee (per member per month) which is much, much less than even the individual market pays [ed: let me guess, you make up for it on the volume]. If one does a good job, then one builds a "book" of such business, which then helps pay the bills. Remember though, that we can't raise your rates to pay for our expenses, which include office overhead, errors and omissions insurance, professional and license fees and the like.

David then points out that "When the going gets tough ... plans decide they�d rather use those precious dollars to pay their employees, cover overhead costs and make profits rather than seeing cash flow out the door to brokers." The problem, of course, is that insurance doesn't sell itself, so they're going to pay someone to market their products. Of course, those folks work for the carrier, not the client (employer), so don't look for any help on sticky claims problems. And, of course, the carriers want to make a profit, so good luck talking to a real person; remember, Customer Service is an expense, not a profit-center.

Which brings us to the next issue: "brokers claim to add a lot of value ... most have mainly just driven costs up. For example, it�s in most companies� interests to stay with one health plan over a long period of time. It keeps transition costs low and makes longer-term interventions such as disease management pay off." There are a number of problems with this vision: for one, brokers are the best interface an employer has with a carrier. They know whom to call, what questions to ask (and which ones to avoid asking), and understand carrier processes. In other words, for most small businesses, the agent is the HR department, at a fraction of the cost of a dedicated employee (or several employees).

And it is most definitely not in an employer's best interest to stay with a carrier for long periods of time: to understand why, simply Google "death spiral." It's a fitting rebuttal to a seriously deficient claim.

David then casts aspersions on our intentions by stating that "[s]witching plans frequently lets brokers earn more money: they can shop around for the plan that pays them the highest commission." This is so wrong, on so many levels, that it could well be its own post. In the interest of brevity, though, I'll let David in on a little secret: every carrier pays pretty much the same, level commission on small group business, and it's actually counter-productive for an agent to "churn." It's in the employer's best interests, however, for the agent to shop the group every few years (cf: "death spiral").

This one's particularly specious: "Switching plans also makes it look like they�re working hard, rather than being lazy by just recommending a renewal." As previously noted, it's in our best interest to leave the group as-is, although selling renewals in this market is a chore unto itself. The simple truth is that, if we don't actively review rates from other carriers, another agent's coming in the door behind us asking the employer why his agent isn't doing his job.

Finally, David believes that "health insurance exchanges and greater ability for small businesses and individuals to compare plans head to head will make it harder and harder for brokers to stay in business." There are (at least) two problems with this: first, that's exactly what a good agent does now, at no additional cost to the employer. And there's one such exchange which not only acknowledges the role of the broker, but actively seeks it.

But that's another post.

Nice try, my friend, but no cigar for you.

Health Wonk Review: VD (Valentine's Day) Edition

FoIB Louise Norris, blogress at Long Term Care Colorado, hosts this week's round-up of health care wonkery. As usual, she does an outstanding job of presenting each post with helpful and interesting context.

Obamacare - More Waivers

Obamacare (the law) applies to everyone. There are no opt out provisions in the law, yet HHS is handing out waivers and exemptions without rhyme or reason.

Latest count had us at 700+ groups covering over 2 million individuals that are granted spectator status for Obamacrap.

Now word comes that 4 states also don't have to pay or play.

the waivers have been granted to states that have programs allowing or requiring the kind of limited medical coverage plans that would otherwise be prohibited by ObamaCare. He said the waivers are good for one year and would not neccesarily apply to all plans in the states outside the state-based programs.

The four states (so far) are FL, NJ, TN and OH.

Now isn't that special?

Bank Index Poised to Hit New All Time High

Scotia Capital, 16 February 2011� The Canadian Bank index is poised to hit a new all time high surpassing the previous high reached in May 2007. The bank index hit another 52-week high yesterday and is only 3% below the all time high.� TD, BNS, NA, and LB recently reached new all-time highs. Individual bank share price performance versus their highs seems to be correlated with earnings

Pardon me Doc: Chart, Please?

Folks following along at home may recall the infamous "Doc Fix" that was touted as a way to control rising health care costs. Briefly: for the past dozen or so years, Medicare has been slated to cut physician reimbursements by 21%. And every time it comes up, it gets delayed...so far.

But that hasn't stopped the proponents of ObamaCare� from (disingenuously) pointing to these "savings" as a means of paying for that train-wreck. How do we know that the numbers are fudged? Well, Cato's Michael Cannon knows that a picture (or, in this case, a chart) is worth tens of millions:

As Michael explains: "the administration proposes to delay these cuts until 2014 at a cost of $54 billion. As shown by the black line, the administration proposes to pay for this additional spending by reducing the rate of spending growth in other areas of Medicare by $62 billion over the next 10 years. Note that only 6 percent of these Medicare "cuts" will occur in 2012 and 2013. The other 94 percent of the "cuts" will come after the administration has spent the $54 billion it wants to spend. Note also that the vast majority of the "cuts" would take effect after Barack Obama is no longer president." [emphasis added]

Perfidy, thy name is PresBo.

Information Bleg: Utah

If you're a Utah health insurance agent, or a small employer in the Beehive State, we'd like to pick your brains regarding the Health Insurance Exchange. Please drop us a line.

Your confidentiality will be respected.

Ye Olde MVNHS�

Here's what happens when you let the state determine your health care:

"Mrs J ... had Alzheimer�s and lived in a nursing home. She was rushed to Ealing Hospital one evening when her husband found she was having breathing difficulties ... He spent three hours in a waiting room without staff realising he was there, and so missed the chance to be with his wife as she died."

So compassionate and caring.

And this:

"A man who was diagnosed with stomach cancer ... was discharged ... on an August Bank Holiday weekend in a process described by his daughter as a �shambles�. He was left sitting in a chair, behind drawn curtains, for several hours in pain."

And finally:

"Mrs H ... was taken to Birmingham Heartlands Hospital ... While there she suffered serious falls but her only relative was not told, poor nursing records were kept and she lost 11lb ... she was found to have numerous injuries, was �soaked� with urine."

But certainly these are isolated incidents, not systemic failures, right?

Wrong. As FoIB Elena Marie points out, the Much Vaunted National Health Service� has been "condemned over its inhumane treatment of elderly patients in an official report that finds hospitals are failing to meet �even the most basic standards of care� for the over-65s."

That's not a few cherry-picked examples, that's evidence of wide-spread abuse and a breach of the social contract that these seniors entered into long ago. And it's what young Britons have to look forward to as they move into older demographics, as well.

But certainly it's just a matter of throwing more shillings as the problem, right?

In a word, no:

"The damning report warns that extra money will not help the NHS meet required standards of care and that more problems are likely as the population ages."

Ooops.

The problem, as explained by health ombudsman Ann Abraham, is that it's all about the attitude of those who are charged with providing the care in the first place. And Michelle Mitchell, who runs a British charity, concludes:

�The inhumane treatment of older people described in this report is sickening and should send shock waves through the NHS and Government."

And yet, this is the system most admired by Sir Donald.

Grand Rounds: "Just the facts, ma'am" Edition

Grunt Doc presents this week's no-nonsense version of Grand Rounds. It's brief, clean and gets right to the point. Do stop by.

Carriers Blink [UPDATED]

Last month, we reported that at least one carrier was seeking substantial rate hikes in The Golden State:

"California health insurer has stunned individual policyholders ... Blue Shield of California seeking cumulative hikes of as much as 59%."

Ouch!

Well, never fear, left-coasters:

"Three California insurers agreed to delay any rate increases for two months at the request of Insurance Commissioner Dave Jones."

Blue Cross is not to be confused with Blue Shield in this instance: the "Shield" has not agreed to the moratorium. On the other hand, Aetna and PacifiCare have both joined Blue Cross in agreeing to stave off their planned increases for two additional months. What's interesting is the basis for their action (or, rather, inaction):

"The pause will allow the department time to adequately review recent rate filings."

My question is: "Why?" We learned in the original post that the "insurance commissioner [lacks] legal authority to regulate insurance rates the same way he does automobile coverage." Recently, the law was amended to require "the insurance commissioner to review the reasonableness of health insurance rate increases but the commissioner is not authorized to reject unreasonable rate increases." So they gave him a knife, but purposely dulled the blade.

In other words, there's precious little that Mr Jones can do regardless of whether or not the insurers cooperate. So I ask again, why are they?

UPDATE: Thanks to Jessica in the comments, we learn that "Blue Shield of California has agreed to a request by California's insurance commissioner to delay a March 1 rate increase for 60 days."

Not to be a dullard, but I'd still like to know why.

It's not too late!

To present your beloved with what he or she really wants on Valentine's Day:

Nothing Says �I Love You� Like Life Insurance

Valentine�s Day is one of the more traditional holidays to express how you care for someone. However, according to a recent study published by LIMRA, fewer of us today have insured the financial future of our loved ones. In 2010, it was found that only 44 percent of U.S. households have individual life insurance, and 30 percent of U.S. households have no coverage.

Thanks to Taryn Grows at Intelliquote for the timely reminder.

We do not have these things

In Judge Roger Vinson�s January 31 judgement that Obamacare is unconstitutional, he quoted the following comment from a previous Supreme Court:

��Generally speaking, when confronting a constitutional flaw in a statute, [courts] try to limit the solution to the problem,�� [page 64]

Imagine that: Try to limit the solution to the problem.

If only we had a Congress that tried to limit its solutions to the actual, you know, problems. If only Congress, having observed 15% of Americans have no insurance, had tried to limit their solution to that problem - instead of using the crisis to attempt a takeover of 100% of American insurance.

For that matter - if only we had Federal, State, and local governments that limit their solutions to the problems.

Sadly we do not have these things.

The Berwick Chronicles

As we've long noted, current CMS Honcho Donald Berwick is not exactly averse to health care rationing. In fact, as Bob noted last summer, Sir Donald's "a self-professed supporter of rationing health care."

Of course, when he's trotted out in public, he sings a different tune. And he tries to dance around the simple fact that we can't keep the coverage we currently have and prefer. Or tries to, as he faces off with Georgia Congressman Tom Price:



[Hat Tip: RedState]

Dr Price is no stranger to IB; last summer, he schooled Nancy, Harry and Barry on the dangers of ObamaCare�.

Manulife Q4 2010 Earnings

Scotia Capital, 11 February 2011Event� The incremental cost of hedging more equity market and interest rate risk of C$0.08 per share garnered a disproportionate amount of attention compared to decent underlying trends in the business and the substantial reduction in risk exposure.Implications� We estimate base line run-rate earnings on a normalized basis of C$1.50 per share, including incremental

Obamacare is a Bust

Not even a year old, and already Obamacrap is a bust. Since the legislation became law, most carriers have ceased to issue policies with maternity benefits, some have stopped writing any business, most have stopped writing child only health insurance (except where bullied into it by local mandates), premiums have risen more drastically than they would have, over half the country wants Obamacrap repealed and depending on your perspective, the elections didn't go so well.

But other than that it seems to be working fine.

One provision in Obamacrap that still flies under the radar was one of the raison d'etre for Obamacrap in the first place.

Specifically, the mean health insurance companies were denying coverage to those with pre-existing conditions.

Enter Obamaman to the rescue. With a swish of his cape and super powers He almost singlehandedly made it possible for those with a pre-existing condition to obtain coverage through a national health insurance risk pool.

Well, it is available provided you have been denied coverage and have been uninsured for at least 6 months.

Sounds like a used car salesman doesn't it?

"Yes, you can own this beauty, even if others have turned you down due to bad credit. No, you can't have it today, but come back in 6 months and it will be waiting for you."

So how well has the Obamapool worked?

According to the Washington Post, in the last few months the number of people covered by Obamapool have increased by 50%.

And the crowd cheered.

In November there were 8,000 in the 6 month old pool. That number jumped to 12,500 by the first of February.

What's wrong with that you might ask?

Last spring, the Medicaid program's chief actuary forecast that 375,000 Americans would have joined new high-risk pools by the end of 2010.

Gosh, can the DC bean counter for Medicaid possibly have miscalculated?

Why would those who were denied coverage by a mean insurance company not accept free health insurance from the taxpayer?

Possibly because it isn't free.

It is very reasonably priced, but it isn't free.

The program is temporary, because, starting in 2014, the law will forbid insurers to reject customers based on whether they are healthy or sick.

Well if those who qualify can't afford a highly subsidized plan now, what will happen in 2014 when premiums are considerably higher due to the "guaranteed issue" mandate?

Late last year, administration officials said the plans' relative lack of popularity reflected early growing pains; they predicted that enrollment would grow swiftly as more people found out that they exist.

So the imperial federal government creates this great plan but is hiding their light under a basket.

They did a better job with Cars for Clunkers. In fact, the program did so well they ran out of money in a few weeks and had to find more Chinese federal dollars to fund the program. When the dust settled, over 700,000 Americans (possibly some not even citizens) took advantage of this wonderful program.

Let's recap.

The government sold 12,500 health insurance policies in 8 months and 700,000 cars in 6 weeks.

Doesn't seem like they are very good at selling insurance. Makes you wonder why they want so desperately to get in that business.

Perhaps they should stick to selling cars.

Great-West Lifeco Q4 2010 Earnings

Scotia Capital, 11 February 2011Event� GWO's Q4/10 reported EPS of C0.54 per share included non-operating items which, in total, added C$0.09 per share, resulting in adjusted EPS of C$0.45, below our estimate of C$0.48, and consensus of C$0.51. Results varied from strong (U.S.) to mixed (Canada) to weak (Europe).Implications� While we were not surprised by the asset impairment provision in Europe

Stupid Politician Tricks

Continuing the "stupid trick" theme, it seems the folks in DC don't have a monopoly on stupidity. Apparently this affliction is contagious as there are signs it is spreading outward from Washington and infiltrating the 57 states.

First up, from the land of fruits and nuts, California Senator Noreen Evans has decided it should be illegal for a health insurance company to deny coverage to someone who is currently incurring a claim.

It seems the senator had recently learned that a woman who is already pregnant cannot purchase health insurance for the express purpose of paying for her claim that is already in progress. Just because Medicaid will cover a pregnant woman, Sen. Evans thinks health insurance companies should share in the joy.

Without coverage through work or on a partner's plan, expectant moms face paying exorbitant prices for necessary prenatal care and delivery procedures. The American Pregnancy Association (APA) estimates that the cost of delivery alone is $6,000-$8,000, and that's for a normal pregnancy. High-risk pregnancies and hospital stays can tack on thousands.

The $6000+ figure is certainly in line with what I have seen, but then at the other end of the spectrum a complicated birth can easily run in excess of $100,000 for delivery and post-natal care.

I had a client a few years ago that wisely purchased health insurance BEFORE she got pregnant and ran in to trouble in her third trimester. Her pregnancy triggered a life threatening blood disorder requiring multiple transfusions at $10,000 each. Total bill for her care, some of which was in ICU, was close to $160,000.

Her plan paid all but the deductible.

So how much does Sen. Evans think the premium should be if carriers were required to literally "buy" a claim of this magnitude?

The APA estimates that approximately 13 percent of women who become pregnant each year are not insured, often resulting in inadequate prenatal care, which can lead to complications for the mother and child.

Why should health insurance companies shoulder the burden for a lack of planning and responsibility on the part of the woman? What if all insurance worked this way?

You would then be able to buy insurance on your car AFTER it was stolen or your home AFTER it catches fire.

Heck, you could even buy life insurance AFTER you are dead.

Apparently Sen. Evans isn't the only nut in the Golden State, Assembly-person Fiona Ma thinks it is unconscionable that Medicare and health insurance companies should require patients to pay a percentage of the cost of their medication instead of a nominal copay.

Melanie Rowen, an MS (multiple sclerosis) patient uses a drug that costs $700 per month to help control her illness. According to the report, Ass. Ma thinks that is outrageous.

Her insurance classified it as a specialty tier drug, also known Tier 4. That means she pays 30 percent of the cost of the drug rather than a simple co-pay.

Oh if only everything in life could be a "simple copay".

Need 4 new tires?

Just a simple copay.

Need a new roof?

Just a simple copay.

So, how much additional premium should the insurance company be allowed to charge to cover drugs that can run a few hundred to several thousand per month? I have a very good friend with two daughters that have Gaucher's disease.

Their medication, when they can get it, is $2,000 per dose.

Some cancer medications run $5,000 per dose and more.

Specialty tier pricing started under Medicare Part D. Michelle Vogel is executive director of the Alliance for Plasma Therapies and has been tracking the impact.

"Whatever happens with Medicare typically follows in private insurance, so when I was looking at the private plans, and especially in California, you're seeing the majority of plans, have put in Tier 4 plans," said Vogel.

So Medicare is to blame for this, not the bad insurance companies. It's about time someone else took the heat.

Ma is proposing legislation in California to prevent health insurers from moving vital medications to Tier 4 status.

"What we're trying to do is make ensure that patients are able to afford the medication they need.

And in doing so is making sure health insurance premiums go even higher.

Where is the logic in that?

Copays are one of the main driving force in rising health insurance premiums. For the most part, the public has no idea how much health care really costs, nor do they care.

As long as they can see a doctor or fill a prescription for less than $50 what do they care?

And that is the problem that leads to increased utilization and higher total spending on health care.

If everything in life were a copay where would we be?

McDonald's and Burger King would go out of business while Ruth's Chris would flourish. Why would anyone eat at a burger joint when any meal was only a $15 copay?

Copay's make the consumer stupid. They have no idea how much things really cost and there is no incentive for them to learn or try to save money.

Right now, New York is the only state with a law preventing specialty tiers. Ma plans to announce the specifics of her legislation on Thursday. However, state legislation does not impact self-funded health plans which cover about half of all employees with health insurance. Federal legislation is needed to change that.

The author of this piece, and possibly the other players in this article, need to brief themselves on the provisions of a federal law called ERISA.

ERISA, a law that has been on the books for over 35 years, allows self funded health insurance plans to bypass state mandates on most provisions which in turn leads to lower premiums.

Just another stupid politician trick.

WaiverMania: Piling On

Earlier this week, Bob made a compelling case that the Employer Mandate was, like the Individual one, unconstitutional. As long as we're on the subject, then, let's open this can o'worms even further:

"The Department of Health and Human Services has granted 733 waivers from one of the statute�s key requirements ... Congress can pass statutes that apply to some businesses and not others, but once a law has passed ... how can the executive branch relieve some Americans of their obligation to obey it?"

In other words:

"Are Health-Care Waivers Unconstitutional?"

It's almost as if the folks that passed this train-wreck hadn't read it.

Not yet . . .

The recent Florida ruling found Obamacare is unconstitutional because the individual mandate seeks to regulate economic inactivity which is the very opposite of economic activity. And because activity is required under the Commerce Clause, Judge Vinson concludes that the individual mandate exceeds Congress� commerce power. (page 56 of the Summary Judgement)

Now notice the Judge�s footnote on pages 55-56; Judge Vinson writes:

�The government acknowledged during oral argument in Virginia v. Sebelius that although people are required to buy health insurance under the act, they are not yet required to use it.�

�Not yet�, huh?

Why add "yet"? Why would the government say "not yet"?

It would make sense if the government thinks the time is coming (just �not yet�) when Congress will require people to actually, you know, use their insurance. Does that kind of government thinking worry you? It worries me.

Judge Vinson elaborates in the same footnote:

�But what happens if the newly insured (as a class) do not seek preventive medical care? . . . it would seem only logical under the defendants� rationale [the government is the defendant in this action] that Congress may also regulate �economic decisions� not to go to the doctor for regular check-ups and screenings to improve health . . .�

Which of course could eventually lead to this:

I say it�s time for Congress to face up to Americans� needs, and make health care compulsory.

Making health care compulsory would address actual need. Public funds would not be wasted on �insurance� but would be spent directly for health care. Everyone would then be healthy, happy, and handsome, and all our children would be smarter than average. Overnight, our life expectancy would be the highest in the world and infant mortality would drop to zero.

These comments were offered as irony. Sadly, it appears the government may actually intend to legislate compulsory health care � just . . . �not yet�.

Pots, Pans and EMR

Although the Brits' MVNHS� is frequently in our crosshairs, it's certainly not the only troubled nationalized health care scheme. Proponents often point to Sweden as a model of how well such systems can work. Leaving aside the fact that the Swedish population is much more homogenous than our own (or Britain's, for that matter), it's helpful to note that even that country's health care system is far from perfect:

"An overcrowded hospital in Gothenburg has resorted to giving patients in a children's ward saucepans and spoons to summon assistance in emergency situations."

But surely that's a one-off, right?

You be the judge:

"At another department, the staff shopped at hardware chain Clas Ohlsson to buy bells for their patients ... The Swedish National Board of Health and Welfare (Socialstyrelsen) found that hospital overcrowding is common at all nine of western Sweden's hospitals with emergency departments."

In addition to all the other (literal) bells and whistles, there's an acute shortage of hospital beds; this increases risks to patients' safety, let alone health. And it's not a new problem, either:

"We have for years nagged about the problem of overcrowding, but nothing happens," a caregiver reports.

On the other hand, the Swedes have been successful in reining in health care costs, right?

Um, not so much:

"The cost of paying for harm done to patients in the Swedish healthcare system has nearly doubled in the last decade."

Ooops.

It's easy to cut costs by supplying inferior health care, of course, but short cuts work only in the short run. Eventually, patients suffer, and they bring in the lawyers, costing the system tens of millions of dollars, and exacerbating the already critical problems facing the "Swedish Patient Insurance Scheme" [ed: really? They freely admit it's a "scheme?" Yup]. And just what kinds of problems are those?

Well:

"Mixed up test results, injuries suffered during childbirth, infections following surgery, and incorrect drug dosages are just a few of the medical errors that reveal it can be harmful to a patient�s health to end up at a Swedish hospital."

One wonders if they also practice meatball surgery.

The aforementioned MVNHS� continues its downward spiral, as well. If you're a Brit who expected a bit of personal privacy, then you may want to practice that stiff-upper-lip move:

"A new NHS computer system that will share the medical history of millions of patients with drug companies without proper consent is under attack from privacy experts, who say it is misleading, risky and potentially illegal."

Possibly also fattening.

The new system puts online a lot more information, which is supposed to be "anonymized." The problem is, there's so much info that, according to Dr Ian Brown of the Oxford Internet Institute, "participants in research can be "trivially" re-identified."

Add to that the fact that they've not been asked to consent to this new intrusion on their privacy, and one wonders why we're so bent on adopting our own version of national health care.

How Health Insurance Companies Rip You Off

Health insurance companies are robbing you blind. Used car sales tactics like bait and switch are rampant. They trick you when you buy. They trick you when you renew, and you won't know it until it is too late.

Every health insurance company has these plans. They look nice. They are relatively inexpensive. They appear to cover everything, so what's not to love?

These sneaky plans do not cover prescription drugs.

So what (you may say)? I don't use medication.

True, but health insurance is not designed for medical conditions you currently have but those that develop after the coverage is in force. If you currently have a treatable health condition, the premium or policy is designed to make you self insure that condition and they take care of the new stuff only.

Bet you didn't know that, did you?

All health insurance companies including Blue Cross, Humana, United Healthcare and others have plans that do not cover prescription drugs . . . EVER.

If you purchased health insurance direct from a carrier, or through an online direct marketing agency you may have bought one of these financial death trap plans and did not realize it. There are also some misinformed agents, as well as some just out to make a quick buck, that will push these plans on you if you are not careful.

One thing health insurance companies do at renewal is offer you a way to save money by making a change in your plan. One of the options they will put forth is a plan that does not cover prescription drugs. Often you can save 7 - 11% in premiums by opting for one of these plans.

But what happens when your health changes and you need a drug?

You pay for it.

Every time you fill the prescription, you pay and pay and pay. The carrier never opens their wallet and pays a dime toward the cost of your medication.

Never.

And drugs can be quite expensive. I have clients with drug costs in excess of $5,000 per month but they only pay a fraction of that. Many pay nothing for their drugs beyond the first couple of months of the year.

Before you buy or renew any major medical plan with any health insurance company, make sure you have not bought a financial snake that will come back and bite you.

Cavalcade of Risk #124 now online

Dr Jaan Sidorov hosts this week's roundup of great risk-related posts from around the blogosphere. Jaan's thoughtfully (and helpfully) broken the Cav into two general categories, making it even more useful.

Speaking of ObamaTaxes�...

So, you're a Californian who added your non-dependent 24 year old to your group health plan. Before you send that Thank You note to Barry, Harry and Nancy, you might want to read David Fluker's little-known factoid:

"California'stax law requires the state to levy taxes on any amount of premium paid by the employer for non-dependent children of employees."

What's that mean to you? Follow the link for the "rest of the story."

[Hat Tip: Bob V]

Schoolin' the Pool

Six years later, the Ohio legislature is again looking at reimplementing health insurance pooling for school districts:

"Mandatory health-insurance pooling for schools, a concept that last saw heavy Statehouse debate in 2005, could be poised for a comeback."

It's thought (hoped) that by joining together, they can leverage greater numbers into greater savings.

How much savings?

Well, it depends on whom you ask, but it's estimated that such a scheme could save school districts, and the state, upwards of $190 million a year (granted, that's at the high end).

The downside?

Well first, there's all those pesky collective bargaining agreements. Then, there's the logistics of implementing a rather large overhaul of education funding. And, once the dust clear, there's no guarantee that there will be any substantive savings.

Oh, and kudos to the Dispatch, which clearly and repeatedly referred to health insurance (avoiding the ubiquitous, yet annoying, conflation with health care).

[Hat Tip: FoIB Holly R]

Grand Rounds: Life's a Beach edition

Dr Ramona Bates hosts this week's round-up of great medblog posts, liberally sprinkled with warm and inviting beach scenes - a welcome respite indeed.

ObamaRipples�

Twice in the past week, I've had to break the news to anxious parents: no, you can't insure your perfectly health minor child.

Hunh?!

Late last week, a gentleman called in looking for coverage for his 9 year old son. The family had been covered by CareSource, the local Medicaid insurer. Due to changing circumstances, the child was no longer eligible, and the parents needed to find alternate coverage for him.

No luck.

This morning, a worried grandmother called. Her 16 year old granddaughter is in the same boat: she will be taking custody of the young lady (we presume) in a month or so, which will render the teen ineligible to continue her current coverage.

Again, thanks to the (unintended?) consequences of ObamaCare�, they're out of luck.

In the first instance, I suggested to the young man who called that we write a policy for both him and his daughter; in the second case, this is not an option. Grandma's on Medicare, and you can't add a child to a Medicare supplement plan.

I did suggest to both of them that they contact the state SCHIP plan (called Healthy Start here in Ohio). This program, available at no cost to children up to age 19, families and some others, uses means testing to determine eligibility. It's possible that either (perhaps both) of these children will qualify.

The downside, of course, is that their coverage will be paid for by thee and me, not the parents or grandparents, as would be the case with a *real* health insurance plan. You're welcome.

Is the EMPLOYER Mandate in Obamacrap Constitutional?

First, watch this:



In a recent post, I noted:

"I am not a Constitutional lawyer, and apparently neither is Obama or members of Congress, but it would appear to me that if the INDIVIDUAL mandate (requiring individuals to buy health insurance or pay a tax) is unconstitutional, then the same should apply to the EMPLOYER mandate."

That seems like a pretty obvious conclusion to me, especially watching that video, but Hank and I came to realize that it's not obvious to everyone. He asked two well-known health policy experts, Avik Roy (who also tipped us to the great video above) and Michael Cannon about their thoughts on the constitutionality of the Employer Mandate.

Michael felt that "the employer mandate is more likely to withstand challenge because the employers are already engaged in a form of economic activity."

Avik offered the same analysis, although with a bit more detail: "There is a big difference between the individual mandate and the employer mandate, unfortunately ... In all previous rulings related to the Commerce Clause, you had to be doing some activity in order to be regulated ... Employers, by contrast, can "opt out of" the employer mandate by closing down their businesses ... Think of all the other mandates employers face (OSHA, EPA, etc etc)."

With all due respect to these very bright guys: I don't think so.

For one thing, if we're going to use their definition of "commerce," then everybody engages in it: we buy gasoline that's trucked over interstate highways from state to state, Hank buys Georgia peaches in Ohio, the list goes on. So merely invoking the seemingly magical phrase "interstate commerce" becomes useless in this instance.

And there's a big difference between OSHA requirements, which require employers to provide safe working conditions but doesn't tell them which brand (or color!) of safety goggles to buy their employees. This is a far cry from requiring not only that an employer provide access to health insurance, but even what kinds of plans can - and can't - be offered.

Unless, of course, HHS grants a waiver.

The point is that the Employer Mandate is simply the other side of the Individual Mandate coin: Congress and the courts have used the Commerce Clause to PROHIBIT certain business actions, I don't see a reference to laws or decisions that REQUIRE businesses to do something they are not already doing.

Prior use of the commerce clause has not (as far as I know) required the employer to purchase items or services that would adversely affect their bottom line. In the case of the discrimination suit, NOT serving blacks DID have an adverse effect on the bottom line and ADDING blacks to the mix (so to speak) actually IMPROVED their bottom line.

Further, there are no known instances where the government used the commerce clause to require an employer to purchase a specific good or service that was substantially different from what they already were buying. And failing that, there were no tax penalties associated for non-compliance.

If a restaurant chooses to use beef graded as Choice, there are no requirements that they must only offer Prime or else be taxed for non-compliance.

Any abuse of the commerce clause requiring an employer to purchase something that has a negative impact on profits has not been evident under cases brought before the Supreme Court according to my research. It seems pretty obvious, then, that the Employer Mandate is no more valid than the Individual version.

HHS Sebelius Throws the Poor Under the Bus

In order to "help" states save money when Obamacrap expands the Medicaid roles by 16 million people, HHS Sebelius gave states the right to cut benefits as a cost saving measure.

The folks at New York Times give us this tidbit.

While state Medicaid programs must cover hospital and doctors� services, Ms. Sebelius said, many other services are classified as optional. The optional services, she said, include prescription drugs, physical therapy, respiratory care, optometry services and eyeglasses, dental services and dentures.

I am all about saving money, and while one may argue that any medical service is a necessity, I would submit that dental and speech are nice benefits but not totally necessary. There are plenty of people with full time jobs that don't have dental or vision insurance.

As for eliminating coverage for prescription drugs, one has to wonder why seniors on Medicare were given a drug benefit in 2006 after going for years without one, and now Medicaid says poor people will have to buy their own meds.

Given the way Medicare Part D (prescription drug coverage) operates, I fail to see that as a real benefit for most but I also realize some will disagree.

But I have to question the logic behind improving benefits to seniors for Medicare Part D while cutting benefits for the same coverage when it comes to the poor. Is Washington now deciding who is more deserving of prescription drug coverage?

�Just 1 percent of all Medicaid beneficiaries account for 25 percent of all expenditures,� Ms. Sebelius said, and 5 percent of the recipients account for more than half of Medicaid spending.

Well there you go.

Find those 1 and 5 percenters and kick them off the plan.

Seriously, those numbers are not just indigenous to Medicaid. You will find similar inequities in any health insurance program for individuals under the age of 65.

In addition, Ms. Sebelius said, states could save large sums by reducing premature births and medically unnecessary Caesarean sections, by reducing hospital admissions and by using proven techniques to improve the care of children with asthma.

I can't speak for other states, but over half of all births in Georgia are paid for by taxpayer dollars through the Medicaid program. Many of those are unmarried females under the age of 20.

Many who deliver here under Medicaid are not US citizens and they pay little if any taxes.

As difficult as these decisions may be, the few that actually do pay taxes in this country cannot continue providing unlimited medical care for anyone in this country legally or otherwise.