On the Brink of a Government Shutdown over Obamacare

It is hard to imagine a political strategy less likely to achieve its intended outcome while simultaneously harming the economy than shutting down the government to prevent the implementation of Obamacare.

But that probably won’t stop Senator Ted Cruz from trying.  And unless cooler Congressional heads prevail this week, while he will do no real harm to Obamacare, he may well do harm to the economy.

Obamacare is the law, shutdown or not.  And no matter what, on Tuesday you will still be able to go to any hospital in the country and get treated, your doctor’s office will still be open, and your insurance company will still expect you to pay your premium.

But when the government is shut down, the stock market suffers. 

And a few points on the downside in our stock market that are attributable to a single event may be more significant than you think.

Let’s go back to 1995.  The Newt Gingrich-led House shut down the government twice – on November 14, 1995 for a week and on December 16, 1995 for three weeks.

Until then, 1995 had been a boom year for the U.S. economy.  The S&P Index rose 34 percent for the year.  But on the day of the first shutdown, the S&P was down 3 points, or one-half of one percent.  And on the next trading day after the second shutdown, it crashed 9 points, or 1.5 percent.

What is a one-half of one percent drop in the markets worth today?   

We can do the math for Senator Cruz.

At the end of 2012, the total market value of every company listed on our U.S. stock markets was $18.6 trillion.  The markets are even higher now, so we can estimate that today all those companies combined are worth around $20 trillion.

So one half of one percent – or about 9 points on today’s S&P – would subtract around $100 billion from the value of those companies.  That is roughly equivalent to the annual cost of Obamacare!

So isn’t it ironic?  A shutdown won’t shut down Obamacare, but it could hit businesses harder in one day than Obamacare would in an entire year.  And that’s on the conservative side.

People like Senator Cruz don’t want to think about this, so they might look at it another way.

They will tell you that we spend around $3 trillion annually on health and healthcare in the United States.  That is about 15 percent of the market value of all of the companies that are publicly traded on our stock exchanges.  They will argue that this is way too high.

I agree. We can probably do it much less expensively if we put more resources into prevention and public health, like other countries do.

Of those $3 trillion, federal state, and local governments directly or indirectly pay about 71 percent of the bill.  We pay another 12 percent out of pocket.  The remainder is paid by privately funded private health insurance.

So can Senator Cruz assume that if we repeal Obamacare, we won’t have to pay that 71 percent?  The answer is no, because these are pre-Obamacare percentages.

And what effect will this government takeover of healthcare formerly known as Obamacare have on these percentages?

Thegovernment’s share might go up 2 or 3 percent, private insurers might pay 1 percent less, and our out-of-pocket share will go down a couple of percentage points.

It is hardly seems worth working up a Congressional lather over this.

But consider something to which all members of Congress ought to be paying attention. 

If our stock market were to go down just 1.5 percent because of a shutdown, as it did after the last shutdown, then $300 billion will be lost to publicly-traded American companies.  That is equal to the total market value of every publicly traded company in Belgium, Turkey, or Chile.  It is twice the market value of every publicly-traded company combined in Israel, and three times the market value of all the publicly-traded companies in Ireland, Austria, or Kuwait.

Remember the years-long effect that the collapse of the Greek economy has had on the European and world economy?  $300 billion is approximately four times the total value of every publicly-traded company in Greece before the meltdown.

That’s something to think about on the brink of a shutdown.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

Hypocrisy In Motion

The latest Obamacare navigator “compromise” may calm one small battle in Florida.  But it won’t end the war on Obamacare being waged by hypocritical public officials around the country.

A couple of weeks ago, I wrote about the Congressional effort to undermine the Obamacare navigation program in its entirety.  A House Committee has ordered nonprofits winning navigation grants to produce reams of material, and promises to punish those that have failed to comply. 

Source: US Census Bureau

Navigators will assist people in applying for public or private insurance to pay for their health care.  

Navigators are not a new concept, created by Obamacare.  They are as old as Marco Rubio, and Obamacare is not the first federal initiative ever to fund them.  In fact, I implemented the policy of the Nixon Administration as a VISTA paralegal 35 years ago, navigating underinsured elders to the Medicaid program.

So we know that navigators can be trusted to do their jobs.

But that hasn’t stopped some public officials from sudden “worries” that navigators hired by nonprofit agencies will disclose private information that clients voluntarily give to them.

Three weeks ago, Governor Rick Scott of Florida – apparently trying to re-establish his credentials as the nation’s leading gubernatorial opponent of Obamacare after openly flirting with it during the 2013 legislative session – joined this chorus, wondering “how the federal government will prevent personal information from being stolen” by these nonprofits.

This was quite a contrast to enrollment efforts already well underway in states like Connecticut that actually want to help people get insured.

Then Governor Scott raised the stakes last week.  He ordered that no navigators be allowed in any state health department offices.  The reason this mattered is because in Florida, county health departments are actually arms of the state government, and their employees are state, not county, employees. 

So in banning the navigators from state offices, he was in effect banning outside navigators from enrolling people in county safety net clinics, federally-qualified community health centers, and a host of other facilities staffed by state employees.

He came under immediate fire from shocked public health officials, one of whom called the edict “cruel and irresponsible,” and said that it would compromise access to healthcare for “a multitude of needy Floridians.” Florida has the second highest percentage of uninsured people in the nation – two and a half times the rate of Connecticut.

A day later, state officials backed away after having an Emily Litella moment.  They realized that the counties actually own and control the properties in which the health department clinics operate.  The state employees, like the navigators, are just outside guests in these county buildings.   

A compromise of sorts was struck.  The state acknowledged that it had no authority to keep navigators out of the county buildings so long as the counties had them work outside of the actual clinic space.

Now most thoughtful people with any knowledge of history would probably use a colorful term here to characterize the state’s position.  I’ll just call it hogwash.

Public officials like Rick Scott are not the least bit worried about navigators being able to protect the privacy of individuals. How do we know this? 

Because Rick Scott was CEO of Columbia/HCA until 1997.  Like every hospital chain in the country, HCA hospitals have worked with navigators for years to capture Medicare, Medicaid, and insurance reimbursements for uninsured patients.  The navigators are often employees of outside entities working under contract.  Many even take a percentage of the billings for every person they enroll.

I know this because I competed with these companies when I was overseeing navigation programs for community nonprofits in Texas and Florida in the 2000s.  And these outside companies had access to all the private information about which Governor Scott professes to be worried today.

But there is more. 

In Florida, my nonprofit placed navigators in state health department clinics almost a decade ago and helped capture reimbursements for the state, relieving taxpayers of the bill.  No one accused us of breaching confidentiality.  But Jeb Bush – who had some common sense – was Governor then, and George Bush was President.

Hypocrisy is always in motion, and tough to pin down.  But in this instance, certain public officials made it too easy for us to see the real reason they want to prevent uninsured people from getting help paying the bills that clinics and hospitals must, by law, present to them.

They know for a fact that this part of Obamacare will work, and they desperately don’t want that to happen.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

Suicide and Obamacare

In 2009, there were 36,891 suicides in the United States, according to the CDC.  This translates to a rate of 11.9 for every 100,000 people.

And rates among certain groups were even higher.  For example, the suicide rate among veterans, according to the Veterans Administration, was three times higher – or 35.9 per 100,000 veterans.

Suicide is a problem that ought to command our attention.

And it does.  For many years we have used suicide data as surrogates for documenting the consequences of serious mental illness.  We all know that the “danger to self” standard we use for determining when people with mental illness qualify for emergency care is, in effect, a “suicide may be imminent” standard.

As a result, for many years community mental health organizations have also been asked to track suicides as a measure of the effectiveness of their programming. 

But there are reasons why focusing on suicide rates too closely leads to inadequate public policy.

Suicides are just the tip of the iceberg.

Many more people consider or attempt suicide than die from it.  If you really want to be staggered by a national statistic, CDC reported that in 2011 7.8 percent of the teenage population had attempted suicide.  That is one thousand times as many as had died from it.

Also, the overwhelming majority of people with serious mental illness who die early do so not because of suicide, but because they are undertreated for other chronic conditions (such nicotine addiction, diabetes, and cardiovascular problems).  Some of these are linked to treatments they receive for their mental illnesses.

Finally, at the community level the number of suicides is usually so small that it is nearly impossible for any single organization to affect the rate more than anecdotally.  The agency may be able to point to individual cases where its intervention made a difference, but it will probably never be able to move the rate on its own.

And when the suicide rates don’t move, policy makers use this to justify decisions to reduce or eliminate program funding. 

So what does Obamacare have to do with suicide?

Many other provisions of the law have been lost in the din surrounding the most visible parts of the Affordable Care Act.

One of these was a mandate that the Department of Health and Human Services focus on the quality of our health care.  Since 2012, it has been doing this, along with a number of agencies in the Department, including the Substance Abuse and Mental Health Services Administration (SAMHSA). 

SAMHSA has just invested over two years in developing a National Behavioral Health Quality Framework (NBHQF). 

When the NBHQF is finalized, it will open the door to the use of new standard outcome indicators in determining the effectiveness of health and behavioral healthcare in our communities. 

We will be able to add these indicators to suicide rates, giving state and local officials much more powerful tools in judging the effectiveness of community mental health programs.

For example, suicide risk assessments (NQF #0104) will become a standard diagnostic tool in provider settings.  Providers will also be expected to use depression screening tools such as the PHQ-9 at six and twelve month intervals to monitor patients consistently over time (NQF #0710-0712).  And risky behavior assessment and counseling for children under the age of 13 will become a standard of practice (NQF #1406), as will diagnostic evaluation of children with major depressive disorder (NQF #1364-1365).

These all focus our attention on the 999 in every 1000 who consider and attempt suicide in addition to the one who tragically commits it.

We can also expect the integration of health and behavioral healthcare to become more systematic. 

Cardiovascular and diabetes monitoring of people who are prescribed antipsychotics (NQF #1933-1934) will become a standard of practice, as will management of ADHD in children in primary care settings (NQF #0107-0108). 

These indicators focus our attention on some of the other reasons people with mental illness die so young.

We all have an opportunity to say how we feel about these indicators. 

SAMHSA has released the NBHQFin draft form, and is accepting public comments on it until September 17, 2013.  Comments can be submitted using an online form, and don’t have to be formal or comprehensive.

The NBHQF will be finalized after the public comment period.  Then it will begin to guide the funding and delivery of mental health services. 

But for the next week, we all can say how we think the government should measure the quality of our behavioral healthcare services.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/

Members of Congress Scrutinize Navigators More Than a Run-up to Possible War

In the nervous run-up to a possible military strike in Syria, fifteen members of Congress last week took time from their busy vacations to sign a letter demanding more information from governmental contractors. 

But the targets of their attention were not the defense contractors who received $161 billion for their services.  They were universities, legal aid organizations, and small nonprofits who will share $67 million to help citizens apply for health insurance beginning in October.

The Congressional Gang of 15 included Fred Upton from Michigan, Pete Olson, Joe Barton and Michael Burgess from Texas, Tim Murphy and Joseph Pitts from Pennsylvania, Marsha Blackburn from Tennessee, Phil Gingrey from Georgia, Steve Scalise from Louisiana, Gregg Harper from Mississippi, Corey Gardner from Colorado, Morgan Griffith from Virginia, Bill Johnson from Ohio, Billy Long from Missouri, and Renee Ellmers from North Carolina.

They sprang into action after the grants were awarded in mid-August, demanding a response in writing within two weeks.

Here are some of their demands (thank you to Kaiser Health News for linking to the letter):

• “a written description of the work that will be performed,” including “a description of the number of employees, volunteers, or representatives that will be utilized and the pay and duties for each.”  
• A detailed budget for the program.
• “a written description of the training or education employees, volunteers, or representatives must complete,” plus educational requirements of the organization “beyond that required by any federal or state entity.”
• Supervisory processes and procedures.
• A description of how the organization will use the information obtained, including in follow-up communications with anyone with whom the organization speaks who might want to register to vote.
• Any communications with any health provider or any health insurance carrier to whom any individual might be referred for health care or coverage.
• All materials related to the grant application and award process.

Imagine being a 20 year old navigator in Florida just trying to help someone get insurance.  Do you really want some Congressman from Michigan “ACORNing” you if the person also asks you how to register to vote? 

Florida’s governor and do-nothing insurance commissioner aren’t going to help you.  They’ve already signaled their mistrust of navigators. 

You might think that any member of Congress who devotes so much vacation time to finding out whether sick people are getting help in finding a doctor would pay even more attention to matters that could soon drag our nation into another war.

And you might think that any member of the Congress taking time demanding this level of scrutiny about a program to help people get insured would apply a similar standard to other federal contractors. 

But you would be wrong.

When there’s more at stake, they sit back and wait.

Fred Upton, who has been on the job for twenty-five years and wrote the letter to the community agencies, hasn’t said a word in public about Syria.  He did, however, help a Vietnam veteran get his long-deserved service medals this month.  Pete Olson has no public position on military action, but said Congress should approve any.  Tim Murphy and Steve Scalise are among 140 members who want Congress “consulted” before the U.S. goes to war. And Billy Long went out on a limb when he asked the President to “tell his side of the story.”

If only they were as deferential about demanding the details about a paralegal contacting an insurer on behalf of a man with mental illness or a woman with cancer.

And take a look at the chart.  The value of the navigator contracts is so small compared to defense services contracts that you can’t even see it with the naked eye. 

As for the scrutiny they give to these other contracts that are worth 2499 times the value of the navigator contracts:

• They don’t demand educational credentials.  In the Snowden case, a 29 year old high school dropout was given access to “some of the most highly classified information in our government,” according to Sen. Susan Collins.
• They don’t t-cross and i-dot in advance. “According to the US Government Accountability Office in December 2012, there was a backlog of approximately 25,000 audits of DOD contractors as of the end of FY2011. “This backlog represents hundreds of billions of dollars,” GAO reported, and “has quadrupled over ten years.”
• And they don’t demand details about the numbers of employees, volunteers, or representatives, including their pay and duties.   Over 6500 contractors are working on $2 billion NSA expansion projects, according to a recent article.  As to who those contractors are, that information is simply described as “hush-hush.”

There is reason for outrage here.  You can decide over what.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/