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Friday, May 1, 2020

Destabilization of the US Healthcare System Under the Covid Crisis

How secure is your employer health plan-this article reviews self-insured medical plans, which are largely unregulated and are estimated to impact 89 million employees and their families in the US. This table shows the greatest prevalence for self-insuring health plans are corporations with 500 or more employees, representing 90% of all employees on these plans. However, 13% of small employers with fewer than 100 employees are currently using this form of financing to pay for employee health benefits. This trend is increasing, which means more smaller volatile firms are assuming claims payment risk without insurance company guarantees. What happens to the employee healthcare for the 5.5 million employees and their families working for smaller firms when these businesses are forced to close because of Covid-19 or some other catastrophic loss? Will all of their medical claims be paid if the company goes bankrupt? Currently the only enforcement for these minimally regulated plans is through the Department of Labor, which requires annual reporting for plans which fall under the ERISA umbrella.

This table shows the number of self-insured corporate medical plans for 2019
Criteria # of Private Employers Proportion of US workforce Total Employees 2019 % covered by self-insured plans Total on self insured plans
#Ers >1000 Ees                    23,139 0.362        84,243,192 0.91        69,079,417
# Ers w 500-999 Ees                    18,645 0.125        13,714,500 0.82        11,245,890
# Ers 101-499 Ees                  126,647 0.125        13,714,500 0.25          3,428,625
#Ers 50-100 Ees                  169,239 0.289        31,707,924 0.13          4,122,030
All other                  337,670 0.100          6,753,400  >.01           1,124,037
Totals            32,500,000 1.00     150,133,516        89,000,000
Notes on sources
Metrics for % covered on self-insured corporate plans from Health and Human Services, US Gov
Job metrics drawn from Bureau of Labor Statistics, US Gov
The total number of jobs in the US in 2018 was 156 million, the estimate above is for 2019
US added 1,716,000 jobs in 2019, using an average growth of 143,000 jobs per month
All other category uses an average 20 employees/firm  to estimate total employees
Total employees covered on any type of employer medical plan in 2018 was 156,500,000
Metrics for employees covered on employer plans drawn from Kaiser Family

The genesis of self-insured health and welfare plans grew from the 1974 Employee Retirement Income Security Act (ERISA) enacted to create accountability for pension plans, but there was a provision for self-insured benefit programs. A 1978 amendment to ERISA created Section 125 plans which meant insurance premium payments were not taxed in these employer plans (yet another way the US government currently subsidizes private sector healthcare). The exorbitant cost of US healthcare has been the paramount reason for the surge in self-insured healthcare plans. These are plans brokered by insurance agents and consultants, as method to control corporate expenses and cash-flows. Self-funded plans are somewhat like private pensions, as there is a promise or expectation that medical expenses will be paid, but no guarantee. This lack of protection for the employees and their families is by design. ERISA created a provision for self-insured healthcare plans to be exempt from state insurance commissioner regulations BECAUSE THEY ARE NOT CONSIDERED INSURANCE. Additionally, since 80% of the funding comes from the cash flow of the employers who choose these types of plans instead of traditional insurance, which has guarantees of payment, there is an element of risk which is not transparent to employees. Plan participants receive minimal information in a dull Department of Labor document called a Summary Plan Description when benefits change.
Crib Notes on Self-Insured Plans
Self-insurance consists of four basic components, payment of claims, reserves for claims incurred but paid after contract year-end or termination, administrative fees, and re-insurance for claims which exceed an agreed threshold. Under self-insured plans, only losses beyond the targeted stop-loss provision, say $100,000 for an individual claim are paid by a third party, known as a re-insurance company. So, the employer, even firms with as few as 50 employees, must pay medical claims for all of their employees from their cash flow and the contributions the employees make to the program. To many employees these self-insured arrangements look like insurance plans, because they include participation in a preferred provider network of clinicians, probably a managed RX plan, and issue identification cards. For additional information on how these insurance plans work read Chapter 16-Insurance 101 in my guidebook to the US healthcare system (link found at the end of this article)
Employers are not legally required to set aside separate funds for unpaid liabilities for health plan or employee benefit plan liabilities, although in generally accepted accounting principles this is recorded on the balance sheet as current liabilities. This is of concern because your company’s self-insured healthcare plan is paying your medical services out of its cash flow. And in most cases, employees have no idea what this is or if their health plan is solvent. Lehman Brothers and Enron are two large companies, who were very profitable that went bankrupt, both for fiscal malfeasance, and their employees lost a lot of money.
My Employer’s Healthcare Claims Are Backed by a Reinsurance Company-Do I Need to Worry?
Re-insurance companies sell contracts to employers to cover claims beyond a contractual ceiling and are not exempt from failure. Though 2008 is in the rearview mirror, 2020 promises to make that fiscal crisis look like a cakewalk. American International Group (AIG), one of the largest most lucrative insurance companies at that time would have gone bankrupt if the US government hadn’t taken over the company. AIG’s chief executive, Maurice Greenberg was prosecuted by the Attorney General for the State of New York for fraud and made a huge settlement for financial malfeasance, thanks to his promotion of junk mortgage bonds as part of their investment portfolio. Bad investment decisions are made all of the time by insurance companies, just like banks, and other financial service firms, mostly out of greed. This is why the Dodd-Frank Act sought to correct the financial risk the US financial system was exposed to by avaricious financiers.
Here is a partial list of re-insurance companies that have gone bankrupt
Lumberman’s Mutual Casualty Company-2013-health insurance company
Reliance Insurance Company-2013-reinsurance
Freemont Indemnity Insurance Company-July 2002-health & workers compensation company
Legion Insurance Company-2003-reinsurance risk through Mutual Risk Management subsidiary
Top re-insurance companies today
Lloyd’s of London-UK
Hannover Ruck SE-GE
Berkshire Hathaway-US
Everest Re LTD-US
Swiss Reinsurance-US and EU
 How Do I know If My Company Medical Plan is Self-insured?
All ERISA plans are required by law to provide a Summary Plan Description (SPD), which must be available to plan participants, so if you are enrolled in a corporate benefit program, you are entitled to review the document. In addition, any ERISA plan must file an annual 5500 report and employees may have access to it.  The annual report will list generic information, like total claims paid and total plan contributions in a reporting year and won’t be terribly insightful for you, but it’s a start. The information that you really want to know includes:

  1.  Name of the re-insurance company- as this will allow you to look up the financial rating of this third party that is liable for payment of large medical claims above the stop-loss level your employer has chosen. You can review Standard and Poor’s or Moody’s to assess the financial status of this company.
  2.   Find out what the stop-loss level is for your employer’s plan, in other words, when does the re-insurance company start to pay the claims rather than your employer-if it is a lower limit, that means your employer is conservative and not assuming much risk. If the ceiling is high, then it means your employer is assuming more risk for claims payment directly. In today’s terms stop loss levels at or below $100,000 per individual claim are considered conservative, but for small firms this may not be conservative enough.
  3.  Once you see the total claims paid for enrollees on the Summary Plan Description (SPD) you can then gauge the “risk level” your employer has taken with the claims it is responsible for versus the third-party insurance company. Conservative companies have lower risk-levels, because they are paying a higher premium up front to transfer some of the risk for claims payment.
  4.  If you have had a surgery or major medical expense recently you will have current information on the cost of healthcare and you can gauge how much your specific claims impact the total shown for the company for the plan year.
  5.  If your employer has a benefits committee and you want to influence benefit plan decisions, try to get on the committee.
Covid-19 Pandemic Impact on Your Health Plan
With unemployment expected to reach 30% for much of 2020, the nation should be concerned about unfunded and minimally enforceable liabilities under health and welfare plans that are supposed to provide healthcare for 85 million employees. Yet, for an employee to even get access to information on her medical plan, she has to jump through all kinds of hoops, only to be offered scant information. Americans should demand more from their vaunted private sector healthcare plans including actual transparency, and proof of financial solvency for something as important as healthcare. As if that isn’t worrisome enough, the recent report from the Petersen Health System Tracker finds that there has been an 8% decrease in the number of employees who have access to company medical plans. (Matthew Rae, 2020) So, though roughly the same number of workers are covered on employer medical plans, the distribution is not equal for all workers. The same report found that only 24% of low-wage workers have access to employer medical plans.  If you are a low-wage worker, providing today’s “essential services” you are much less likely to have company provided healthcare. Yet the Trump Administration continues to attack the Affordable Health Care Act and Medicaid expansion, which is how many of these workers access health care. Your access to health care shouldn’t be based on your wage.  All of these reasons demand that healthcare become a national right, not a privilege for the lucky.

And this is the healthpolicymaven (a trademark in continuous use since 2007) signing off encouraging you not to sign blanket releases before you submit to medical procedures, do stipulate that for which you consent and for which you decline. This article was written by Roberta E. Winter, MHA, MPA, a freelance journalist, and is not subject to influence from medical device, pharmaceutical, hospital, or insurance industry sectors of the US healthcare system. For more information on the US healthcare system read;

Works Cited

Facts, Kaiser Family Foundation State Health. (2019). Health Insurance Coverage of Nonelderly 0-64. Retrieved May 1, 2020
Gaetano, C. (2017, April 7). More Americans Work at Big Firms Than Small Ones. The Trusted Professional-NYSSCPAs. (T. N. CPA's, Ed.) Retrieved May 1, 2020, from
Matthew Rae, D. M. (2020, April 3). Long Term Trends In Employer Based Coverage. Peterson-Kaiser Family Foundation Health System Tracker. Retrieved May 1, 2020, from

Monday, April 6, 2020

The Next Wave of the Pandemic Apocalypse

The Trump Administration have undermined the social safety net for most Americans with precision and a breathtaking ruthlessness over the past three years. Now you lose your job, then your healthcare and shortly thereafter, your credit rating which impacts your ability to get a job, obtain housing, or medical treatment. This negatively reinforcing loop doesn’t have to be that way and it isn’t in other industrialized countries.  Most Americans can’t make it more than a few months or even a few weeks on their disposable incomes. And our children, many of whom watched their parents grind it out through the mortgage meltdown of 2008 will be witnessing an even greater debacle. What does it mean for the survival of our nation if our young people feel hopeless?
This table lists components of the social safety network in a pre-Covid-19 pandemic state comparing the three-plus years under the Trump Administration to the state of the nation he inherited from in 2016.
Trump Actions Since 2017
Impact on Individuals
Access to healthcare requires a nondiscriminatory environment, a national effort, and funding-All of which were provided under the Affordable Care Act known as Obamacare AND are also part of Medicare
Funding for the Affordable Care Act has been cut by reducing non-participation penalties and eliminating the 3% medical device tax; A Supreme Court case is pending regarding the legality of the act because the penalty for not having insurance was nullified in 2017. Republicans have stated their goal is to gut Obamacare

Affordable Care Act provides subsidized medical insurance to 8.6 million households, down from 9.6 in 2016; due to Trump’s cuts in promotion of the program and funding; Despite Trump actions more states have opted to expand Medicaid access to the ACA standard, which is 133% of federal poverty rate
Uninsured population
In 2016 the US Census found 27.3 million had no insurance; no action has been taken to provide affordable healthcare in the Trump Administration
In 2019, 30 million people were without insurance; health insurance gains are reversing
Employment security
Unemployment rate in 2016 was 4.7%
Unemployment was 4.4% in January and as of the end of March 2020 was 13.1%
People in Poverty
40.6 million in poverty in 2016; Trump cut funding for school lunches and made it harder for families to qualify; In 2016, 22.1 million children received subsidized school lunches
38.1 million in poverty in 2019; 29.7 million children and youth receive school lunch subsidies in 2020; school closures mean they don’t eat
Affordable housing
549,928 people were homeless in 2016
US Census for 2020 finds 3.5 million people are homeless
Looking at the trends from the corona virus Covid-19 pandemic this table shows the impact on social safety systems in the current state, which is the Trump Administration under the Covid-19 siege.
Current state Trump Admin
Pandemic forecast
Access to healthcare
56% get health insurance through their employer; roughly 159 million people
For those who can’t afford to pay their COBRA or private healthcare premiums after job loss, this could result in another 47 million uninsured people
Uninsured population
30 million
Estimated to rise to 40 million
Unemployment rate
 15% as of April
Expected to reach 30%, the question is for how long and how many businesses will go under
People living in poverty
38.1 million
This number will explode when unemployment benefits expire and there are no jobs
People who are homeless
3.5 million
This number will skyrocket once the evictions start

Colossal Job Loss
Large businesses (airlines,Boeing) are currently being offered federal subsidies to try and stave off job loss, thanks to the Democrats who argued for these provisions in the federal lifeline. Initially Treasury Secretary Mnunchin wanted to offer funds without strings or public transparency. Small businesses are only being offered loans which they must pay back and their ability to do so is vague at best. Small businesses can’t go for months without normal operations, let alone take on a new debt. Small businesses employ more people than large corporations, so this could have a devasting impact on employment throughout the country. Also, small businesses lack access to affordable capital and typically invest their life savings to start their enterprises. Small businesses finance themselves at much less attractive rates than large corporations, who get a point-over-prime versus the small ones who use their credit lines at 10% or worse yet, take on credit card debt at 25% APR. Whereas, large companies rely on equity markets, meaning other people invest in their organization, they do not risk their own capital. Corporate executives don’t lose their homes, they may lose a bonus.
Impact on the Self-Employed
There are at least thirty million self-employed people in the US, which is a result of the decades long corporate gutting of jobs, to be replaced by workers who have no protections, no unemployment compensation, and no healthcare. (Microsoft started this trend and ended up settling a Department of Labor action because of it). Contract workers do increase profitability for companies, but at their own peril. Democrats argued for inclusion of self-employed workers in the pandemic unemployment compensation, which will help hourly wage earners, like Uber drivers, but won’t help small business owners who draw 1099 self-employment compensation. If you are a small business, like a C or LLC Corporation, nonpaying customers doesn’t mean you, as owner are unemployed. I suppose if a business lost all of its customers then the owner would be considered unemployed.
Irreparable Financial Devastation for Many
Only 10% of the iceberg is visible above the water line and there are pillars of the US financial system which depend on stability and these are the pension funds and a huge swath of private employer healthcare plans, which are self-insured.
Potential Failure of State and City Pension Plans
Pensions require financial solvency to pay their future obligations to retired workers and if entire industries fail, this ability could be destroyed. The Pension Benefit Guaranty Corporation, which is a US mandated watchdog for pension solvency, has a limited amount of funds to cover bankrupt pensions and it would not be able to withstand massive industry failure. In other words, pensioners may receive reduced benefits or stop receiving them.
Solvency of Self-Insured Medical Plans
For self-insured health plans, which have been purchased by firms with as few as fifty employees, the ability of those businesses to pay escalating medical claims when they are experiencing severe business downturns is questionable. Self-insured health and welfare plans are exempt from state regulation because of a 1976 federal law called ERISA, which means employees have no state protection agency to help them with late paid or unpaid medical bills.
Down Stream Impact
Any significant impact on the healthcare safety net impairs services for a community and Covid-19 is vividly illustrating the communities which were prepared and those that were not. Since the US healthcare system is based on a pay-for-service unrationed reimbursement methodology, all healthcare decisions are determined based on who pays. In the early weeks of the Covid crisis President Trump expressed concern about who pays for the testing, which delayed testing for weeks, dramatically increasing the spread of the airborne disease. In Korea, Australia, and Germany the question wasn’t who pays, because they have national healthcare systems. Those nations coordinated national efforts to arrest the disease quickly and as a result are not experiencing the job losses of the US. Further, in other advanced industrialized nations it is unthinkable for companies to be able to fire their workers to improve profitability. These nations require private companies to pay into job retraining funds, severance, and other social benefits to provide employment stability. The US has chosen to have an unstable workplace because it benefits Wallstreet, not the workers. If you look at real increases in household income, the increases are fractionally higher than they were forty years ago. Inflation adjusted gains in household income have decreased under the Trump Administration from a high of 5.2% of 2015 to 1.7% in 2017. Meanwhile the top 5% have experienced explosive income growth. The CIA Factbook ranks the US 40th in income inequality worldwide and at the bottom for industrialized nations.

It is easy to see why Elizabeth Warren and Bernie Sanders have such a strong following among reform minded voters, because nothing illustrates the inequities of the US financial system and the tattered social safety net than the Covid-19 pandemic, which has been mismanaged by the Trump Administration from the start. As King Louie said, “heads will roll,’’ hopefully with the 2020 election.

This article was written by Roberta Winter, a healthcare analyst and freelance journalist and author of Unraveling US Healthcare-A Personal Guide.

Wednesday, February 26, 2020

Covid-19-Your Risk Under the Trump Administration

Covid-19 is an acute respiratory virus that emerged in China, due to transmission from wild animals. Current thought is the new corona virus emerged from bats to civet cats to a market in Wuhan. More than 3,000 people have died from it this year and it has now spread to all continents except Antarctica. There is no vaccine and this corona virus is not like the flue, it is more severe, similar to the SARS virus. Most deaths have occurred in elderly men, but physicians who were in their prime have also died. It is a serious pandemic and the delays in acknowledging and trying to control it have worsened its impact.
 Delays in processing the tests for the virus, which must be approved by the CDC, have resulted in increased risk to communities. Currently, a UC-Davis patient from Solano County, which is where Travis Air Force Base is located, and is a quarantine site, is on a ventilator because the CDC dallied in approving testing for the disease.
Currently the death rate from Covid-19 is exceeding 1%, which is much higher than influenza and the rate of infection spread is 5 people for everyone who is in contact with the contagion.  By comparison small pox has a similar infection disbursement rate.We don't know how long the virus can remain active on surfaces, so it is not possible to have 100% certainty on controlling the spread.
The number of confirmed Covid-19 cases in the US is now 60 and yesterday, the CDC confirmed its first case through community spread, which means someone has contracted the potentially deadly virus without coming in contact with a person who had it. In other words, it spread through the air and it is highly likely there are many others who will also contract the disease in this manner. Meanwhile Trump has appointed Vice President Pence, who has no healthcare background to triage the Covid-19 national pandemic. Perhaps he will pray it away, but that is not a confidence builder for me.
The Trump Administration has cut funding to both the CDC, the disease prevention and the NIH, the research arms of the federal government. In order to pay for tax cuts for billionaires and huge corporations Trump cut frontline health services to protect us. Trump cut the Centers for Disease Control budget by 16% and Health and Human Services by 10%. And this doesn't include the chipping away at access to primary healthcare through the Affordable Care Act law suits. Further, Trump's only concern has been about the pandemic's impact on the economy during his election year, not the health of us all.

This is the first time I have republished one of my posts, but the article I wrote in 2017 shows how the damage the Trump Administration has inflicted on emergency preparedness and your health is now real.Please read this and understand how destroying public resources in healthcare and administration are NOT in your best interest.

This is the healthpolicymaven signing off encouraging you not to sign blanket releases at inpatient facilities-do specify that for which you consent and those services you decline.

The healthpolicymaven is a trademark for Robert E. Winter an independent  healthcare analyst and journalist who has published this column since 2007. She is the author of Unraveling US Healthcare-A Personal Guide, which reviewed healthcare quality throughout the US, including trauma centers.

Saturday, January 18, 2020

Accountability for the Trump Administration-Note to Future Grandchildren

Note to my future grandchildren,
Realizing you will inherit a vastly reduced natural world from the one I was bequeathed; I am compelled to document what I did to prevent the rapid slide toward unsustainability for us all. We were taught in pre-school and Sunday school to be humble and to share what we have with others, but these practices have been abandoned en masse by the Trump Administration and his industrial cronies. Though these people will not be alive to witness the destruction of your environmental health or your reduced life, they are making decisions today which will impact everyone on Earth for generations. Plenty of people have gone along blindly supporting these disrespectful public officials and corporate figures without a care for your future. America should not elect people to hold public office if they are unable to think multi-generationally, which means keeping your interests in mind. Here are the highlights of their plundering of your future:

Gutting the Environmental Protection Agency
The Trump Administration was co-opted with the oil and gas industry upon sweeping into office as the 45th presidency of the United States (in case the nation no longer exists later) and one of his first actions was to roll-back the clean water standards enhanced under President Obama. The clean water standards analyzed the impacts of upstream water sources, which run through public and private lands and their pollution impacts for major bodies of water, like the Salish Sea. Chemical fertilizers and petrol chemical runoff damage water quality which impact viability for Chinook salmon, the primary food source for Southern Orcas of our region. This means the likelihood of you ever seeing the Orcas freely travel in the sea are nil and the southern residents are headed toward extinction with only 72 remaining. Trump, has chosen to let the profits of a few farmers, ranchers, and extraction industry profiteers ruin water quality, which is essential for all life.

Secondly, Trump and his retinue of Environmental Protection Agency administrators have adopted less stringent air quality standards, which mean more children will die from asthma and adults from chronic obstructive pulmonary disease. In other words, these people can’t breathe and are being choked to death by Trump officials, who want to reduce fuel efficiency standards to pre-Ronald Reagan metrics of the 1970’s. This action means the United States will fall further behind the world in the adoption of new technologies which will produce more efficient vehicles, buildings, and energy systems. The creative jobs to bring innovative improvements to your life will go to other countries who are forging ahead with a vision for the future. Trump known as #45, has also killed the tax investment credits for alternative energies, which were so effective in decreasing dependence on fossil fuels and achieving true energy independence. Green energy conflicts with the profit making of the oil and gas industries so they have done everything they can to enhance their short terms profits without a care for your well-being.  This includes burning natural gas, which produces harmful methane gas because it is cheaper than processing it as a biproduct of the production of oil. Methane gas is more harmful to global warming than CO2.  Of course, air pollution causes cancer as well and the 45th presidential administration has actively worked to suppress scientific research proving harmful affects of environmental pollution.

Thirdly, the Trump bullies have forced out any public officials or civil servants who have objected to the lack of enforcement of EPA rules and stewardship of public lands, including the Bureau of Land Management which oversees protection of public lands which are not part of America’s national park system. Anyone who objects to the pilfering and abdication of  the public duty to protect our public lands has been silenced, as Stalin did in Russia. Even the Endangered Species Act has been pierced allowing short term economic considerations to be used to evaluate the value of saving species. This is no less than the selling out of your future, your right to enjoy nature on public lands which belong to all of the people, not just the people who live next to them.

Finally, there is ample scientific evidence which irrefutably shows the earth is warming, the oceans are rising, and catastrophic events are occurring more regularly, such as massive floods, wildfires, and crop failures. These events also impact the ocean’s food supply. Trump supporters have just chosen to ignore all of this proof and to exacerbate the problems by refusing to cooperate with global initiatives to reduce carbon pollution which causes global warming, and to actively promote less efficient water, electric, and other structural programs. These actions mean the USA is an energy pig and is spewing increased pollution into the earth’s air and waterways, especially from the coal industry.  It doesn’t have to be this way, but these adults, elected to represent your ancestors didn’t think about you when they made their profits.  They didn’t think about the jobs needed for the future, health impacts from pollution, or even basic health services for children, as the Republicans have actively worked to eliminate their health care. And children from low-income families, which represent 25% of American households, are treated even worse, because their school lunch money is now being reduced. These actions are nothing less than those of a bully, one who gave tax breaks to huge corporations and the rich while stealing lunch money from children.

Individual Actions That Can Make A Difference

Getting Out of The Car-Please know that I have spent all of my adult life fighting for environmental protections and have actually witnessed the improvement of air quality in the City of Seattle due to state EPA mandates and more efficient vehicles. All but one of the cars I owned was a compact, and one, the Volkswagen Rabbit was a subcompact. However, in 2003, I decided to experiment going carless and did not use my car for a year, which was eye opening because it increased my physical and mental well-being. Your father (who was still a preschooler) and I biked or took the bus everywhere. I made the leap to sell our car within fifteen months of this experiment. In that era, people were not always considerate of bicyclists and would scream at us. At the time, to be without a personal vehicle was considered odd on the west coast and I experienced a number of discriminatory practices because of it, including being rejected as a volunteer for the American Cancer Society because they didn’t think using public transportation was acceptable. Of course, I couldn’t do certain types of work either, but I kept my footprint local. Fortunately, the millennial generation came up with creative ways to get people out of their autos, including car and bicycle sharing programs. City planners also developed bike lanes and pathways for pedestrians to move efficiently in the urban environment. More people opted to live in cities, closer to their work, spending less time commuting. In Paris and New York, over 50% of their residents are carless households.  In Seattle it is very common for people to rely only on public transit, bike, or walk to work.

Reducing Waste-Growing up on a farm we didn’t waste much because there was no garbage pickup, so the more trash you had the greater your disposal problem. We burned some trash but mostly re-used containers, which were mainly glass. Pretty much everything we wore we made, except for shoes and blue jeans. So, as a young bride with a Save-the-whales bumper sticker on my subcompact car I practiced recycling 40 years ago. I set up a sorting station in my garage and would haul cans and glass to a recycling center. When I attended a group event, I would walk around getting aluminum cans for recycling rather than trash. Composting was a natural farm practice, but not so common in the city and I have practiced a casual composting practice for the past thirteen years.

Being Mindful About Consumption-We really are what we consume and it is better for all of us if we eat foods that are grown locally, which support local farmers and reduce transportation pollution. I eat very little meat and no beef. I made the decision to quit eating beef about a decade ago. My reasoning had to do with the industrial food supply system of the United States and also the harmful environmental impacts from beef operations. Feed lots in the US are places where the cow’s entire lives are spent in pens grown for food, with calves separated from their mothers early on. Much of the deforestation of the Amazon is due to ranchers gobbling up more land to grow beef. Beef is a very inefficient protein when you consider how much it extracts to produce a few grams of protein. Industrial runoff from beef and hog feed lots also pollute waterways. Other ways I have reduced my consumption is to make what I need rather than buy it from a store. Or I repair things before tossing them out. Vintage stores are all the rage now, which is basically a way to recirculate used items to those who are interested.

Voting-I want you to know that I have never missed a presidential election and only missed one local election in my life. Voting, just like writing to your elected representatives, and campaigning for someone are essential acts to maintain a democracy. The Trump Administration makes fun of democrats, their opposition party, the ones stopping the complete capitulation of the country to him. He also makes fun of educated people, women, persons with disabilities, and those from other nations. I have done everything in my power to demonstrate against, advocate for change, and help those trying to make changes against his venal administration.
So, my darling, even though I am no longer here, I want you to know I cared and I thought of you the whole time, and tried to make a difference.

This article was written by Roberta E. Winter, nonfiction author and freelance journalist since 2007.
Published January 18, 2020

Friday, November 29, 2019

Trump Scorecard-An Assessment of His First Three Years

Trump Scorecard-His First Three Years

No US president has inspired more vitriol than the current occupant, #45 Donald Trump. His supporters are quick to mention that he has done more than any other president, so this article reviews his policy changes and budget impacts in a handy table for your scrutiny.

Fact #1
Fiscal Spending & budget

Fiscal prudence matters, the only president to reduce the national deficit in modern times was Clinton
Trump has blown up the federal deficit, which has increased 39% (Davidson, 2019) in 2019 alone, and directly reflects tax cuts he gave to the top 2% and big corporations. The national debt is now $1,000,000,000,000 (a trillion). The entire GDP of the US is 20 trillion (about 25% of global GDP). That’s a lot of debt to service and less money for other programs.
To understand what this means think of the world as a community pot of money where foreign investors, largely China buy US debt as an investment. Should they ever cease to do this, the nation would have a historically massive depression, ruining the livelihoods of your children and grandchildren.
Fact #2
Increased the risk for global terrorism by facilitating the release of Isis members held in Syria after pulling US troops out
Trump pulled US troops out of Syria, where our allies, the Kurdish army (where women are fighters) were slaughtered without warning and forced to side with Russian ally, Assad.
The complete and total betrayal of long-standing US ally, the Kurdish Army, has resulted in the growing power of Putin, who controls Assad.
Fact #3
Reduced the competitiveness and efficiency of US motor vehicles and accelerated the growth in greenhouse gases by rejecting Environmental Protection Agency scientific recommendations
Trump has rolled auto fuel efficiency standards back to 37 MPG versus 54 under the Obama Administration. He is also attempting to force all states to accept his reduced standards for fuel efficiency and greenhouse gas causing exhaust. For decades 17 states have chosen to comply with California standards, including Washington.
Like Reagan he longs for the 1950’s, but the rest of the world has moved on with higher performing vehicles and more efficient infrastructure for the future. Retarding innovation in the US will not help with jobs or economic security, let alone offsetting damaging global pollution-we’ll all be choking on US exhaust soon enough.
Fact #4
Ripping up long standing agreements with US allies, including NATO, the North Atlantic Treaty Organization
Trump’s current budget includes significant reductions in funding NATO, which is a bulwark against Russia aggression to our European allies.
The world is a small place and shredding agreements with our allies will not make the US stronger, but plays directly into Putin’s hands and could potentially help China.
Fact #5
Interfering with Military Tribunal Findings for War Criminals
Trump threw out the prison sentences for three Navy Seal members convicted of war crimes, overruling the highest command when removal of the Navy Seal Trident for these miscreants was imminent.
All branches of the military require a kind of blind service based on honor. Humiliating seven peers who testified against Gallagher does not enhance this valor or the safety of our troops.
Fact #6
Has used public money to finance religious based sham family planning clinics which do not provide basic birth control education or services
It is unconstitutional to use public funds to promote any religious perspective in education or healthcare or anything in the public domain.
Our founding fathers specifically created a secular constitution to avoid conflicts among sectarian groups. Freedom of religion doesn’t mean your ability to impose your will on others, but their freedom from religious tyranny.
Fact #7
Undermined the Affordable Care Act by making it more difficult for people to enroll and eliminated some funding sources
The ACA or Obamacare was a revenue neutral bipartisan act that created a marketplace for millions of Americans to get medical care by subsidizing the purchase of medical insurance. The ACA also removed the pre-existing conditions exclusion and other onerous insurance industry restrictions.
Making it more difficult for working class people to get healthcare undermines the economy and especially family survival. The US birth rate is at an all-time low because of family concerns over the high cost of healthcare, childcare, and education that have gone unanswered under Trump.

If the United States is to survive, we must find a way to stop the rhetoric about “sides” as anyone with a decent education knows there are lots of gray areas in life and the tricky part is accommodating them in policy making. To date I have yet to see anything tricky or masterful in the Trump Administration policy making. As the fervor of the religious right builds as they approach their eschatological climax, those of us who are more sentient are reluctant to embrace the greenhouse gas which envelopes our globe slowly simmering us all.

And this is the healthpolicymaven signing off encouraging you not to sign blanket medical releases before inpatient procedures and do specify that for which you agree and those treatments you decline. Do not allow someone’s else’s religion to determine your health care.


Davidson, K. (2019, June 12). US Deficit Grew 39% in First Eight Months of Fiscal Year. Wall Street Journal. Retrieved November 29, 2019, from

Sunday, October 27, 2019

Medicare-for-all Assessing Value And Cost At The Individual Level

This is the final article in this series comparing U.S. healthcare reforms and focuses on basic value at the consumer household level. Discussion will include how much people are paying for their health care and their health insurance in relation to actual value. Value is determined based on affordability and access to appropriate care for all residents. This article, like the others review healthcare from an individual consumer perspective not an insurance company or medical institution one.
Cost of Health Insurance
According to the 2019 Kaiser Employer Health Survey, the average cost sharing for a single employee is 18% of the cost of their group insurance, so using the $6,896 national cost per employee, this necessitates a $1,241 contribution. (Kaiser Family, 2019) Even though you have no family members you would still have to pay $100 per month just for the medical insurance plan. The cost sharing for employees with family members is MUCH steeper at 30% of family premiums for group medical insurance, which could be as much as $20,000 so their share is $6,000 on average. As a former insurance broker, I can tell you many employers don’t provide any premium payment assistance for family coverage, which means those workers could be on the hook for the full 20 K. This is $1,667 per month, which is the equivalent of a mortgage, except lots of people would not be able to afford a house payment after coughing up money for their medical insurance. In a generous spirit, the US government does allow employees to pay for these eye-popping costs with pre-tax dollars, which mean that wage earners with higher incomes are actually getting more of a subsidy for their medical insurance cost.

In 2018, 11.8 million people were enrolled in the insurance exchanges through the Accountability and Affordable Care Act (ACA-aka Obamacare). (CMS’ final report shows 11.8 million consumers enroll in 2018 Exchange coverage nationwide, 2018)These programs are for people who don’t have access to employer provided medical insurance or whose employer plans do not meet the minimum standards for cost and coverage under the ACA. The average out of pocket cost for an enrolled individual with family members was $1,415 after tax credits subsidies. The ACA was designed to provide affordable medical insurance for low-income and middle-class residents by paying them to obtain insurance, using federal tax credits. Essentially, this is deeply discounted insurance, because insurance companies which participate agree to accept the tax credit as a premium contribution. The main difference here is the cost sharing for family coverage is not as great under the ACA exchanges as under private sector insurance plans. However, there is a wide variety of prices in the insurance exchanges, based on the state, age of the enrollee, family status, and coverage selected. This figure was used to identify the most affordable ACA offering, which was the bronze plan. If a family wants the silver plan, the cost would increase by approximately 20%. Silver plans have lower cost sharing for services than bronze plans for participants.

Out of Pocket Costs Hitting US Consumers
Premiums or upfront contributions for the cost of medical insurance are only one aspect of healthcare costs born at the household level. Upfront expenses include co-payments for treatments, which can be quite steep, costing thousands of dollars for a single surgery.

Finally, the number one costly item for US healthcare consumers are prescription drugs, which many residents must pay completely out of pocket, while others have co-payments for generic drugs and name brand drugs. US consumers are currently spending $10,045 per capita for prescription medications, again an amount almost equal to a mortgage. According to AARP, the average retail cost for prescription medications for seniors was $30,519 in 2017.  And this picture gets bleaker, 500,000 people in the US spend over $50,000 a year on their medications, which is the average annual income of an employee! Adjusted for inflation, drug costs are nine times higher than they were in 1960.

Medicare for All Analysis
Medicare for all is on the lips of half the population today, but it is important to note that Medicare is in fact not a free healthcare program.  The Medicare program requires a substantial payment from the government to stay solvent, which is paid for by payroll taxes, of which 1.45% comes from employer’s payroll taxes and employees pay. This isn’t enough money to pay for all program expenses, so the federal government also allocates other funds as required. Medicare is the second largest expenditure for the US government at 14% of total budget. Personally, I don’t have a problem with the government spending the bulk of its funds on programs benefiting the people, but we do have an obligation to make sure these programs are reasonably sustainable. Only Social Security expenditures exceed Medicare consuming a whopping 38% of the federal budget. Medicare costs are increasing and the taxes to pay for them will also. It is difficult to see how it can remain solvent without a payroll tax increase in the near future.

Secondly, Medicare participants do contribute to the cost of their care, through monthly premiums and co-payments for services. For the fortunate enrollees who can afford good supplemental insurance plans, those co-payments are paid by private insurance companies. However, 19% of Medicare enrollees pay all of their co-payments out of pocket and another 33% of enrollees are enrolled on Medicare Advantage HMO type plans. Low income Medicare recipients are called dual eligible, meaning they are covered by Medicaid and Medicare and these represent 22% of all enrollees. That leaves only 26% of Medicare enrollees who have purchased private supplemental insurance.

This tables shows the healthcare cost factors for US households, both private sector and Medicare, and public and government spending.
Medicare for All Assessment Criteria
US healthcare expenses per person
Private insurance/non-Medicare sector
Cost for Medicare enrollees
Net Impact on non-Medicare household
Insurance premiums

Co-payments for services

Household totals
Government cost
Estimated additional gov cost for non-Medicare enrollees

2,966 per capita
All figures are annual calculations, as true to per capita as possible.
The US government spend for private sector healthcare includes tax subsidies and comes from the GOA.
Medicare premiums are for Parts B and D as Part A is offered at no charge. Medicare supplements are not included because the price range was too great and only about half of Medicare enrollees have them. Instead the cost sharing figure for all Medicare enrollees was used.
The co-payment number is based on the private sector mean.

In conclusion it is important that we all have realistic data and expectations regarding the adoption of any national healthcare program. Based on my calculations, a 3% payroll tax, which would be born by employees and their employers would be enough to pay for the program. The US could for example adopt a national healthcare model like Australia where only hospital coverage and basic care is provided. Access to specialty care in Australia is subject to supplemental payments. However, there are many different ways to pay for national healthcare programs and examples include a VAT tax like Canada uses or a combination of income taxes and fees, like France uses. France has a tax on pharmaceutical companies to help pay for its national healthcare program, which could work in the US.

It is also vital to consider unintended consequences of pouring a lot more government money into a health system that is rife with abuses. A national healthcare program would have to curb abuses such as overcharging, eliminating incentives for unnecessary procedures, and focusing on primary health, not just geared toward making money. Reimbursements for services must be adequate, but it is to be expected that certain sectors, like insurance, pharmaceutical, medical suppliers, and some providers would be earning less.  Of concern is the fact Congress seems unable to control its spending, so this could really blow things up fiscally.  I suggest we appoint citizen representatives with knowledge of the healthcare industry for 4-year terms, with blinded voting, to avoid excessive pressures from the lobbying terrorists. Oh, and let’s overturn Citizens United and get back to the original voice of democracy in the USA.

And this is the healthpolicymaven signing off encouraging you NOT to sign blank medical release forms when you agree to procedures, to specify that for which you consent and that for which you decline.

This article was written by independent healthcare analyst and journalist, Roberta E. Winter and is not subject to any corporate approval. She is the author of a guidebook to the US healthcare system which focused on assessing quality. (Winter, 2013)

Works Cited

CMS’ final report shows 11.8 million consumers enroll in 2018 Exchange coverage nationwide. (2018, April 3). Retrieved October 27, 2019, from Centers for Medicare and Medicaid:
Kaiser Family (2019, September 25). Employer Health Benefits Survey. Retrieved October 27, 2019, from Kaiser Family Foundation State Health Facts:
Winter, R. E. (2013, July). Unraveling US Healthcare-A Personal Guide. In R. E. Winter, Unraveling US Healthcare-A Personal Guide (p. 216). Rowman & Littlefield. Retrieved October 27, 2019, from