More Health Care Reform Catch-up

Yesterday I began the process of catching up with various odds-and-ends related to health care reform. Here’s some more items worth noting.

1. One of the items in the previous post considered whether the phrase “Medical Loss Ratio” is appropriate. Paying claims is, after all, the purpose of health insurance. So maybe such spending should be renamed “Wellness Investments.” But whether you call it Medical Loss Ratio or Wellness Investment (as the Venture, the fact is the MLR requirement contained in the new health care reform law is going to impact the way carriers and brokers do business. The Wall Street Journal notes that “the first to feel the effects of the nation’s health care system overhaul are insurance salespeople.” (A subscription is required to read the entire article). The gist of their point is that with only 20% of premium dollars to spend on all administrative costs, profits and commissions, today’s commission schedules in the individual and small group markets simply aren’t sustainable. My take is that a lot will depend on what state one works in. The differences in commission schedules from state-to-state are quite striking. In California it’s not uncommon for brokers to receive 20% of the first year commission on an individual sale. In states such as Texas and Georgia I’ve heard first year commissions top out at 10%. The transition to post-health care reform commissions in Texas and Georgia will be a lot less painful than in California. Whatever carriers are going to do about commissions they’ll have to announce sooner than later. The Medical Loss Ratio provisions of the new health care reform law take effect in 2011. So commission changes will need to be announced sometime in the Fall.
2. As I’ve written before, I don’t think commissions are going away. And in the small group market, where commission levels are lower than for individual sales, the need for major change to compensation schedules is relatively less critical. What will change, in both the individual and small group markets, is tying broker compensation to medical cost trends, which is what happens when renewals are linked to the then current premium paid by the group). Instead, carriers are likely to experiment broker compensation based on a flat fee per subscriber and/or dependent or tie the commission to the premium in-force at the time of the original sale (either of these formulas should be, and probably will be, subject to cost-of-living adjustments). Neither approach will be comfortable for brokers. During a webinar I participated in for Norvax, a poll of the 400+ brokers was taken: two-thirds supported keeping commission structures as is. Understandable, but not likely.
3. Brokers aren’t the only ones having to deal with new financial realities. The Motley Fool financial site shows the hit pharmaceutical companies will take as a result of the reforms. The amounts are large (for most drug companies $200-$400 million in 2010) although as a percentage of their 2009 revenue they seem slightly less severe (from 1.6%-to-5.6%). Not that this is an insignificant hit to a company’s bottom line, but it’s hard to feel too bad for these enterprises given the high prices Americans pay for the same pills sold for far less elsewhere.
4. A few weeks ago I ran a poll asking readers to predict whether health care reform would move consumers from small group to individual medical coverage, move them from individual to small group health plans or have no effect on either market. Over 100 readers took the time to respond and there’s a definite consensus: 69% predict health care reform will move consumers who currently are covered by their employers into the individual market. Only 17% expect the new law to have no effect, and 14% see the legislation to spark a migration from individual to small group coverage.
5. Reader Malcom Cutler posted an interesting question the other day about how the small business tax credit the Patient Protection and Affordable Care Act (“PPACA”) impacts the deductibility of premiums paid by small businesses. My thanks to reader Michael B who found the answer. Michael noted that in the IRS guidelines concerning the health insurance premium tax credit, it states that ” In determining the employer’s deduction for health insurance premiums, the amount of premiums that can be deducted is reduced by the amount of the credit.”  The IRS recently mailed out over four million postcards to small businesses about the health insurance tax credits. Brokers — and others — will want to stay up-to-date with the resources available to answer the inevitable questions coming their way. (For those interested, here’s a copy of the postcard).
6. Of course, the tax credit goes away if the health care reform package were to be repealed. The chances of that are slim. It will take a two-thirds vote of both chambers of  Congress to repeal health care reform while President Barack Obama occupies the White House. And even if a Republican were to take his place in 2013, 60 votes would be needed in the Senate to overcome a filibuster. In other words, repeal is unlikely. But it is, apparently, popular. According to a recent poll by Rasmussen Reports, 56 percent of respondents favored repealing the new health care reform law, while 39 percent opposed repeal. This percentage has been fairly consistent since passage of the bill. Of course, when people agree with the polls, they argue Congress should listen to the will of the people; when they don’t like the survey results they tend to praise those who stand on principle instead of basing their positions on, well, polls. So what one thinks Congress should do about this poll results depends a great deal on where you stand on the reform package. The reality, as noted above, however, is that the law is unlikely to be repealed. The reform legislation will evolve, even as it is implemented, but change is coming. The key is to prepare for it.
7. Preparing for reform is what the California Medical Association is doing. You may remember an earlier post on this blog about the CMA’s efforts to elect the former chair of its legislative committee to the California legislature. The theory is sound: there’s no better place to have a lobbyist than sitting inside the majority caucus. Especially with so many health care reform issues required to be made at the state level.  How much does it cost to buy an assembly seat?  The CMA and its allies have poured more than $200,000 into the race — including an independent expenditure committee set up by the CMA with an initial investment of $106,000 and not counting at least three “off-the-campaign book mailings. This investment is necessary because the CMA’s candidate, Richard Pan has been singularly unsuccessful in raising much in the way of campaign dollars from within the district. Obviously the CMA doesn’t care about the interests of the residents of the Fifth Assembly District. The job of the CMA is to look out for the financial interests of their members. And they’re certainly doing that. For all their dollars, however, the CMA is having trouble with their acquisition plans. They spent plenty trying to buy the official Democratic Party endorsement, but were blocked by supporters of a community-based candidate for the seat, Larry Miles. Their spending did, however, garner support from most of the Capitol establishment. But Mr. Miles is running a strong, grass-roots campaign and, from all accounts I’ve heard, the race remains extremely close. (By the way, I’ve known Larry since we were roommates in college — many, many years ago. Not surprisingly, then, I’ve contributed to his campaign. If you want to help Larry stand up to the CMA, or are simply interested in helping elect a qualified, thoughtful leader to the California legislature, I encourage you to  do the same).

 Well, that’s enough catching up for now. Please leave a comment with your observations of some of the more interesting health care reform related developments of the past few weeks. Thanks.

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The CMA, California’s 5th Assembly District and the Future of Health Care Reform

[Full Disclosure: This post is about the 5th Assembly District. The leading Democrat in the race, Larry Miles, is a Trustee on the San Juan School Board, an attorney, mediator and my close friend for over 35 years. I’m actively supporting his campaign.]

Regardless of whether health care reform passes the House of Representatives this weekend, a great deal of how health care reform takes shape going forward will be determined by the states. If national reform fails, state legislators, who for the most part have been holding back to see what emerges from Washington, will attack the problems inherent in the status quo with a vengeance. If Congress enacts President Barack Obama’s health care reform package, the terms of the new law creates substantial responsibilities on the states to implement many of its provisions.

In short, the health care reform debate won’t be over any time soon. It’s center of gravity will, however, shift somewhat toward the states. Special interests have recognized this coming reality and some are doing something about it.

Take physician groups, specifically, the California Medical Association. Even the most ardent supporters of the health care reform bill before Congress will concede it deals more with health insurance reform rather than medical cost containment. True, the legislation being considered by Congress has some cost reducing provisions and lays the groundwork for still more, but it also contains many elements likely to increase the cost of medical insurance. Having addressed the easy part of reform (changing how carriers do business) lawmakers will eventually have to tackle the hard, complex and politically charged work of constraining medical costs.

For now, however, President Obama’s health care reform package asks little sacrifice of doctors. And that’s just the way the American Medical Association and its affiliates like it. The Medical Associations exist, after all, to look after the financial interests of doctors as their focus on medical liability reform, medical physician payment reform, balance billing issues and the like makes clear. They are a political organization looking out for the best and specific interests of its membership. Nothing wrong with that. In fact, that’s what special interests groups are supposed to do.

What’s happening in the 5th Assembly District here in California illustrates just how serious the California Medical Association takes this role. There the CMA has recruited a candidate and is now seeking to buy the seat on his behalf. Thus the candidacy of Dr. Richard Pan in the 5th AD. (The 5th AD stretches from east Sacramento to Folsom).

Dr. Pan is by all accounts an outstanding pediatrician and a fine, decent person. Whether he had any political ambitions before the CMA came calling is unknown. He certainly cannot claim to be a community-generated candidate nor boast of much grass roots support in the district. In the financing period that ended December 31, 2009 (the last reporting period available) over 95 percent of Dr. Pan’s campaign contributions came from outside the 5th Assembly District. Even more revealing: over 95 percent of those campaign dollars came from the California Medical Association, other medical PACs, doctors, dentists and other members of the medical industrial complex. Calling Dr. Pan’s support from within the district “thin” would be an understatement.

But the CMA doesn’t care. They are not concerned with the interests of the residents of the 5th Assembly District. They want one of their own in the state legislature – one of their own who can look out for the interests of the California Medical Association.

In addition to pouring money into the campaign, the CMA has provided Dr. Pan with a campaign manager enamored with the Karl Rove school of politics, Josh Pulliam. Mr. Pulliam is well known for hardball tactics of the devious kind. He’s a brawler both in the political arena and beyond (Mr. Pulliam, is the alleged instigator of a melee at a Cubs-Dodgers baseball game involving players and fans when he reached into the Dodger bullpen and grabbed catcher Chad Kreuter’s cap). In fact, Dr. Pan has already had to apologize for Mr. Pulliam’s Liz Cheney-esque campaign attack on Larry Miles, the front runner in the Democratic primary. (Mr. Pulliam, like Ms. Cheney, fails to understand the role lawyers play in America’s system of justice).

The CMA’s concerns are not limited to the 5th Assembly District of course. In 2009 the California Medical Association Small Contributor Committee contributed over $925,000 to lawmakers and candidates. And this is just from one of their PACs. Nor does this total include contributions from their allies in the medical-industrial complex including contributions made by individual doctors, county medical associations and the like at the CMA’s request.

Nor is the substantial political spending by the CMA anything new. A recent report published by California’s Fair Political Practice Commission shows that, between January 1, 2000 and December 31, 2009, the CMA has spent over $9 million to influence elections (including ballot measures and giving money to political parties) and spent another nearly $14 million on lobbying activity to help shape legislation.

There’s nothing immoral with the CMA and like-minded attempting to foist Dr. Pan on the residents of the 5th Assembly District. They’re playing by the rules of the game. Nor is there anything wrong with the CMA spending large amounts on campaigns. It’s their money and again, they’re playing by the rules. While obnoxious, there’s nothing illegal with Mr. Pulliam’s hardball election tactics either. Politics is, after all, a contact sport. That the CMA and Mr. Pulliam are running Dr. Pan against a good friend of mine is just one of those things. May the best candidate win.

Nor is the CMA alone among interest groups concerned about how health care reform plays out. Others are spending tremendous amounts of money to influence elections and legislation, too.

What’s significant about the CMA’s efforts (and the efforts of other special interest groups) is what it says about the important role state legislatures will play in determining how national health care reform (assuming there is national reform) is implemented and how future health care reform efforts play out. Washington will still matter. Regulations will be developed there. Follow-on legislation will be voted upon there. But the role played by state lawmakers and regulators will be increasing The California Medical Association and their allies recognizes this. That’s why they want Dr. Pan in the State Assembly. They know one vote, one voice in the legislature, can make a difference.

Whether the CMA-led medical-industrial complex can purchase the 5th Assembly District for Dr. Pan is far from certain. The frontrunner for the Democratic nomination, Larry Mile, has built his campaign with a strong and broad foundation of local support. Significantly, Mr. Miles has won two elections in a school district that covers some 75 percent of the Assembly District. Then there’s the general election. Democrats only recently have come to outnumber Republicans in the District (and roughly 20 percent of registered voters are in neither party). But what’s significant is not whether the CMA wins. What’s significant is the money, resources and political capital they are spending to try.

[Note: As I mentioned at the beginning of this post, Larry is a long-time friend. I’ve contributed to his campaign (as has the California Association of Health Underwriters PAC).  Those readers of this blog wishing to join me in supporting Larry can do so at his web site or through ActBlue.]