Author: GOP needs strategy beyond anti-Obamacare

I know a lot of Republicans want to repeal the Affordable Care Act,  but I've had a hard time figuring out what,  if anything,  they want to take its place.  That's unfortunate,  given the power they hold in North Carolina and in Congress.

Philip Klein,  commentary editor for the conservative Washington Examiner,  agrees.  "If opponents of the law want to win the war over the future of the nation's medical system,  they will have to unite around an alternative approach,"  he writes in  "Overcoming Obamacare:  Three Approaches to Reversing the Government Takeover of Health Care."

Klein argues that there's not really a dearth of GOP alternatives.  Instead,  he says,  there are too many  --  and all of them tend to get drowned out in general discourse by the  "repeal"  rhetoric.

Health reform has never been a favorite GOP issue,  except for opposing expansion of government's role,  Klein writes.  You can fire up a conservative crowd by talking about tax cuts,  gun rights,  immigration or the war on terror,  he says,  but don't expect to get cheers for talking about tax treatment of health insurance.

"When Republicans utter phrases such as  'repeal and replace,'  what conservatives often hear is  'Obamacare Lite.'  As a result,  the prevailing question on the right often becomes,  'Why can't we just repeal the law and be done with the health care issue?'  The answer is that even if simple repeal were politically obtainable,  Americans would still be left with a broken health care system."

Klein groups the alternatives into three camps:  Reform,  replace and restart.  I'll loop back to these options.  For now, I'll settle for noting that Klein,  like many of other political perspectives,  believes more and better information about the cost of health care is essential.  "Give consumers the motivation they need to save money and the information they need to do so,  and suppliers of goods and services will respond by providing better value,"  he writes.  "For the most part,  neither feature exists in the American health care system."

Cool or creepy, iPhone tracks my every step

I was psyched to see that my new iPhone 6 came with the Health app.  But I was shocked when I opened it and saw that it was already tracking my steps,  my daily walking distance and the flights of stairs I had climbed.

What?  I didn't ask my phone to do that.  Not only did I not opt in,  I couldn't find a way to opt out.

My first reaction was  "How dare Apple tag me like a game warden tracking a bear?"  I wondered where all this data was going.  The Apple folks say it's stored only on my phone,  but after the disclosure that shared personal details after promising not to,  I had to wonder.  I learned that short of ditching my new phone I can't block the monitoring,  though I can tell my phone not to put the information on my dashboard.

I haven't done that.  In fact,  my next thought was "How do I get credit for all the steps I take when my phone is sitting in my purse?  Should I buy more pants with pockets?"

I'm sure I'm not the only one who views the explosion of physical data tracking with a mix of trepidation and fascination.  I grew up reading  "1984"  when it was actually set in the future.  I recently watched the excellent "Black Mirror" Netflix series,  which is enough to give anyone the shivers about where our technology is taking us.  Part of me wants to tell my phone to mind its own business.

But I'm as fascinated by numbers and competition as the next American.   I remember reading David Sedaris' New Yorker essay on  "Living the Fitbit life"  and suspecting that if I ever succumbed,  I'd be like him: "To people like Dawn and me,  people who are obsessive to begin with, the Fitbit is a digital trainer,  perpetually egging us on.  During the first few weeks that I had it,  I’d return to my hotel at the end of the day,  and when I discovered that I’d taken a total of,  say,  twelve thousand steps,  I’d go out for another three thousand."

I resisted when my brother bought a Garmin Vivofit and lost more than 30 pounds.  I poked fun at colleague Andrew Dunn when he got a device for Christmas and put out a query for Fitbit friends to share data with.

But now that this stuff is on my phone,  I've found myself testing whether the technology can tell whether I'm striding up the Observer's escalators or riding passively  (it can).  When I walked to the WFAE studio to talk about health care costs on Wednesday,  I was secretly pleased that my phone was logging those blocks.

So now I'm at 5,770 steps for the day,  with 11 flights of stairs.

It's a personal best in my short career as an iPhone 6 owner.  But it's well below my brother's rate,  not to mention David Sedaris'.

Dang it.

Healthy, wealthy and worried

Even people with health insurance who call themselves financially secure worry that they can't cover their out-of-pocket costs if a medical emergency strikes, a new survey from eHealth shows.

Two-thirds of 1,000 insured adults polled by Wakefield Research described themselves as financially secure,  yet half of that group said they would struggle to meet their deductible in case of an expensive crisis. The trend was even more pronounced among adults ages 25 to 39,  who described themselves as wealthier,  healthier and more optimistic about their finances than older counterparts. But 69 percent of the young adults doubted they could afford their deductibles.  Confidence about out-of-pocket costs was highest among those 55 and older.

Out-of-pocket costs are rising as employers and people who buy their own insurance try to rein in premiums.  eHealth's price index shows what many others have reported:  People are trending toward plans with higher deductibles this year.

eHealth, an online insurance exchange,  launched its Coverage Satisfaction Index to track consumer opinions about coverage,  health and finances  (read an overview of the December poll here).  The sampling was designed to be representative of the nation,  though the South accounted for 37 percent of those polled  (compared with 20 to 22 percent for the other three zones).  About 35 percent reported income of  at least $75,000,  with the rest evenly divided between those in the $35,000 to $74,999 bracket and those earning less.

Some of the results:

*Eighty-six percent described themselves as at least somewhat satisfied with the value of their current health plan,  with 40 percent saying they are very satisfied.  The poll found no difference among those who bought their own coverage and those who got it from an employer,  but those with such government-funded plans as Medicare,  Medicaid and military insurance topped 90 percent satisfaction.

*One-third of men and 38 percent of women said they've skipped medical procedures,  such as exams and immunizations,  to save money.

*Opinions are split on the impact of the Affordable Care Act on their health benefits,  with 32 percent saying it's positive,  28 percent negative and 40 percent saying there's no effect.  Those under age 40 were most supportive of the ACA,  with 45 percent citing a positive impact.

*When asked to name their top three financial fears,  "an expensive medical emergency"  topped the list  --  though that may be no surprise,  coming after a long list of questions about the costs of care.  Asked whether they spent more time thinking about the cost of their health insurance or their cable package,  63 percent said insurance and 37 percent said cable.

Coverage push tailored to LGBT community

A national coalition working to get lesbian,  gay,  bisexual and transgendered people health coverage under the Affordable Care Act has been working with North Carolina advocates to spread the word.

Out2Enroll,  a national initiative pushing enrollment in the LGBT community,  spent last week working with North Carolinians who are doing ACA sign-ups to make sure the message is spread in ways that include people who have often been shut out,  said Katie Keith, an Out2Enroll leader who did training in Charlotte,  Raleigh,  Greensboro and Asheville.

Many may be wary because they've faced insurance discrimination in the past,  said Keith,  whose Trimpa Group progressive consulting firm has long been active in sexual orientation issues.  The ACA,  often dubbed Obamacare,  explicitly bans discrimination based on sexual orientation or gender identity.  It also specifies that people changing gender can't be denied coverage by defining it as a pre-existing condition,  she said, though people still need to carefully check individual policies to see how such transgender issues as hormone therapy and counseling are covered.

"Folks don't think of health care as an equality issue,  but in many ways it is,"  Keith said.

Out2Enroll was created by Trimpa,  the Center for American Progress and the Sellers Dorsey Foundation.  Its web site offers consumer guidance on such issues as whether same-sex couples can apply for family coverage on the ACA exchange  (yes if they're legally married,  no if they're in a different type of partnership).  There's also a look-up to help LGBT people find enrollment help from groups that have gone through cultural competency training.  So far none of the Charlotte groups has the rainbow logo that indicates that endorsement,  but Keith says that's changing.  She met with local enrollment workers and spoke to some LGBT-welcoming churches during the North Carolina tour.

Research by the Center for American Progress,  a Washington-based progressive advocacy group,  shows the first year of the ACA has reduced the percentage of low- and moderate-income LGBT people who are uninsured.  In 2013 the group found that just over one-third of people with incomes at or below 400 percent of the federal poverty level  (the cutoff for getting federal subsidies)  were uninsured.  In 2014 that had dropped to 26 percent.

Real changes in Obamacare coming, analyst says

Last year's GOP efforts to repeal the Affordable Care Act were mostly political theater,  but expect to see this year's Republican-dominated Congress make significant changes,  College of Charleston Professor Jordan Ragusa writes in the Christian Science Monitor's DC Decoder.

"Don’t be surprised to see Republicans succeed in the 114th Congress modifying or even repealing some elements of the Affordable Care Act this session. In fact, I think it’s an inevitability,"  Ragusa writes.

I see a lot of forecasts about repeal and/or modification,  many of which are based on the writers' beliefs about the act dubbed Obamacare.  Ragusa seems to be a genuine Congressional process wonk who teaches courses about Congress and writes a blog called Rule 22,  a title based on a Senate rule regarding filibuster.

Regardless of the political passions swirling around the ACA,  full repeal of any complex legislation is rare,  he writes.  Thus,  last year's repeal votes were mostly about staking out a position,  rather than changing the law.

But this year's session started with House bills to modify specific parts of the act,  by exempting veterans from the employer mandate tally and increasing the number of hours workers can put in without being eligible for mandatory coverage from employers. That approach has a much bigger chance of success,  Ragusa says.

"What’s important here is that, even if Republicans are successful in their repeals efforts, it’s likely that major elements of Obamacare will remain in place. Indeed, some aspects of the law are incredibly popular," he adds.

So there's good news and bad for both parties. Ragusa also notes that an analysis of repeal trends in all types of landmark legislation since the 1950s indicates that the peak risk comes 10 years after passage.  That would be four years from now.  Next week, he says,  he'll post more about specific factors affecting the chances of repeal.

Blue Cross clarifies NC cost tool

When Blue Cross and Blue Shield of North Carolina unveiled a new online cost tool last week, the immediate concern raised by national experts and Charlotte health executives was that it wasn't clear what the numbers mean.

Blue Cross spokeswoman Michelle Douglas said Monday the company has added an explanation:  Cost estimates are averages based on historical BCBSNC claims data. Amounts listed typically include physician fees, facility fees and costs for things like anesthesia, drugs, medical supplies – as well as customer responsibility (deductible, co-pay and co-insurance). Your actual costs may be different based on variations in these factors as well as your health plan design, deductibles/co-insurance and out-of-pocket limits.

"The fact that hospitals say the numbers are Greek to them is indicative of why the tool was necessary,"  Douglas said in an email.  "Before, customers had no place to go and ask how much the total cost (physician fee, hospital fee, labs, anesthesia, etc.) of a health care procedure might be."

Meanwhile,  John Murawski with the News & Observer forwarded a message noting that UnitedHealthcare offers cost estimates to the public on its Health4Me mobile app  (it's free on for Apple or Android devices,  or see an online demonstration).

The UnitedHealthcare guest function lists estimates  "based on local market average costs,"  rather than breakdowns by provider,  as the Blue Cross tool does.  (UnitedHealthcare, Blue Cross and many other insurance companies offer more detailed members-only data,  including what patients can expect to payout of pocket based on their plan.)   I looked up knee replacement,  which the Blue Cross tool listed as ranging from $20,154 to $40,148 in the Charlotte area.  On Health4Me I got a Charlotte average of $60,185  ($59,125 for the procedure itself,  with the rest for pre- and post-surgical office visits and physical therapy).

So we're all starting to get a peek behind the curtain of health care costs.  But making sense of it is going to take a lot more work.

Moral Movement targets Medicaid expansion

The Rev. William Barber,  president of North Carolina's NAACP branch, is turning to the Bible in his call for state lawmakers to expand Medicaid coverage to impoverished adults.

"Gov. Pat McCrory and his allies in the North Carolina Senate and House are returning to Raleigh to continue their unrelenting War on the Poor,"  Barber says in a statement released Friday.  "The Governor and legislators of North Carolina need to be reminded of the requirements of the Constitutions they swore to uphold, drawn from Judeo-Christian values expressed in the Bible they hold when they are sworn into office. One particular scripture makes it clear that although they profess to believe in God and His sacred scriptures, their hearts and actions are far from Him: 'Doom to you who legislate evil, Who make laws that make victims; Laws that make misery for the poor, That rob my destitute people of dignity'  (Isaiah 10, 1-4)."

Barber (center)
Barber sent the statement in response to news of this week's meeting between McCrory and President Obama to discuss options that would let the state craft its own version of coverage for thousands of low-income people who fall into the Medicaid gap.  McCrory,  unlike some legislative leaders,  wants to find a way to take the money and expand Medicaid,  but with conditions,  such as tying eligibility to having a job or being in job training.  It's unclear whether the federal government would accept such a plan,  even if he could get the General Assembly to sign on.

Barber says McCrory's plan  "deviates in substantial ways"  from the intent of the program.  He also cited a recent Families USA study showing that many of the people who are now shut out of affordable coverage are working people in jobs such as construction,  food service and transportation, working for low wages without workplace insurance.  If their income falls below the federal poverty level  ($23,850 for a family of four),  they can't get subsidies to buy insurance on the Affordable Care Act marketplace,  either.

The statement was issued on behalf of the NAACP and the Forward Together Moral Movement,  which grew out of Moral Monday protests when the state legislature was in session in 2013 and 2014.  They'll convene for 2015 on Wednesday,  and it's a safe bet that protesters won't be far behind.

Who's taking biggest hit on workplace coverage?

I'm hearing a growing sense of frustration from people who pay a lot for workplace health insurance,  and a new study from The Commonwealth Fund confirms there's good reason.

The state-by-state analysis of employer coverage shows that residents of the Carolinas pay a steadily-growing portion of their income for premiums and deductibles. And in the South,  where median wages are lower,  those rising costs take a bigger bite,  the study concludes.  (Read the report here and check interactive state maps here.)

Especially hard hit are North Carolina employees with family coverage.  While costs for employee-only coverage here are in line with national averages,  family coverage costs more in North Carolina.  And premiums for family coverage are growing at just over 10 percent a year during the past three years,  compared with 5.9 percent nationwide and 7.2 percent in South Carolina.

Folks I talk to often blame Obamacare.  They're paying taxes to subsidize premiums and deductibles for people who don't have workplace coverage.  But employees who are eligible for coverage that meets the standards of the Affordable Care Act can't tap into those subsidies themselves,  even though they may be paying sums that seem far from affordable.

Researchers from The Commonwealth Fund conclude that the relationship between rising worker costs and the ACA is complex  (the fund is a private foundation that "underwrote a considerable part of the research" underlying the act).  Some aspects of the act,  such as allowing young adults to stay on parents' plans until age 26 and requiring full coverage of preventive care,  could drive up costs,  the report says.  But overall premiums were growing much faster in the years before the ACA kicked in than in years since,  the report notes,  indicating that such costs  "have been easily absorbed in insurance markets."

In fact,  the study indicates that North Carolina employers have seen a more dramatic slowdown in premium growth than counterparts across the country.  For instance,  N.C. premiums for workplace plans were growing at 5.6 percent a year from 2003 to 2010,  compared with 5.1 percent nationally.  But from 2010 to 2013,  N.C. premiums have risen by only 1.6 percent a year,  compared with 4.1 percent nationally.

So why doesn't this ring true to workers?  Because,  as I and many others have noted before,  employers are passing along a bigger share of the costs,  forcing their staff to cover a bigger share of premiums and/or higher out-of-pocket costs.  For instance, that 1.6 percent annual growth in the overall cost of a single-person workplace policy in North Carolina translated to a 4.7 percent annual increase in the employee's share.  And while the overall cost of a family policy in North Carolina has grown only 3.3 percent a year since 2010, the employee's share has risen by 10.3 percent a year.

"The key question is how to slow health care cost growth in a way that benefits middle class and lower-wage working families  --  that is,  keeping premium growth in check without eroding benefits,"  the Commonwealth study concludes.  "This will likely require concerted efforts that span the private and public sectors.  The challenge to policy leaders will be to pursue reforms that improve the quality of health care,  rein in cost growth,  and ensure that savings are shared with patients and families across the income spectrum."

12 hours of health and taxes

Those bracing for this year's tax season,  which features new complexities because of the Affordable Care Act,  can get free help at all H&R Block outlets from 9 a.m. to 9 p.m. Thursday.

To state the obvious:  This is a business hoping to sell you on its services.  Other tax preparers can help,  too,  and you may be able to get free tax help from community groups.

Image: H&R Block
But this is one of the first chances to dig into what the ACA means for you.  The company has prepared some catchy examples of how the tax penalty for being uninsured and changes in income for people who got subsidies could affect a 2014 tax filing.  And if you walk into an H&R Block office during Thursday's 12-hour marathon,  you can get an ACA tax impact analysis that will help you prepare as your tax forms roll in.

Kathy Pickering,  executive director of Block's Tax Institute,  says one of the biggest shocks may come for people who assume they'll only pay a $95 fine if they skipped insurance.   "The reality is that the penalty varies depending on each person’s situation, and consumers may find themselves paying a higher penalty that is up to one percent of their annual household income and would come straight out of their tax refund.  That could be a difference of hundreds of dollars,” she said.

For information on the penalty from other sources,  check,  Kaiser Health News and Consumer Reports.

Obamacare tax form debuts

The IRS has introduced the new form for people who got subsidized health insurance through the Affordable Care Act exchange in 2014.  As you may recall,  subsidies are actually tax credits paid in advance  (to the insurance company),  and this year's filing is when recipients find out whether they got too much or too little.

You should get this form from the government by the end of this month,  and as USA Today's Susan Tompor reports,  you don't want to lose it:  "Top of the list of papers not to toss: any form 1099, any W-2, and new forms related to the Affordable Care Act."  

I was perplexed by the time estimate included in the instructions for the new form 1095-A: 0.3 minutes to "complete and prepare this form."  I can't imagine reading any tax form,  let alone completing it,  in 18 seconds. But a volunteer tax preparer with the AARP called to note that the taxpayer doesn't actually have to do anything to prepare this form,  other than open it and make sure it's part of the 2014 filing.  So that 18 seconds may just be the time it takes government computers to spit out your form.

But don't expect things to be quick and easy if you're reporting Obamacare benefits  --  or trying to figure out whether you owe the new penalty for being uninsured.

"It will be very complicated this year,"  the tax volunteer said,  echoing a refrain heard across the board.  "It's going to be confusing.  People who are already confused with their taxes,  it's going to get worse."

If you're filing taxes in the Charlotte area,  let me know your experience.

And if you've got suggestions about the form itself,  let the IRS know:  "If you have comments concerning the accuracy of these time estimates or suggestions for making this form simpler, we would be happy to hear from you. You can write to the Internal Revenue Service; Tax Forms and Publications Division; SE:W:CAR:MP:T, 1111 Constitution Ave. NW, IR-6526, Washington, DC 20224."

I'm thinking it would take me more than 18 seconds just to write that address on an envelope.
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