Winners and Losers Under Trumpcare

March 15, 2017

 

It was interesting to read such a wonky OpEd by Doug Badger in the 3/14/17 edition of Twin Cities Pioneer Press, http://www.twincities.com/2017/03/14/doug-badger-have-20-million-people-gained-coverage-under-the-aca/, later reprinted in The Record http://www.recordnet.com/opinion/20170314/guest-view-that-20-million-figure-impact-of-obamacare-often-overstated.  He raises interesting questions about the accuracy of the mostly politically sourced data about the Affordable Care Act, or ACA, and the new Trump-Ryan-Bannon-Price Withdrawel of Care program humorously called the American Health Care Act or AHCA. He challenges the numbers tossed around about estimates of who gained coverage under the ACA. Doug’s assessment that the number of individuals who benefited from the ACA may be overstated is one piece of the puzzle that warrants further discussion. While an understanding of the number of people that gained coverage under the ACA, and how many more will lose it under any Republican idea proposed so far, including the AHCA, is essential to planning and to the metrics of success or failure, Doug kind of misses the forest for the trees.

Health care is complicated, and not something that lends itself to simplified political positions and silly slogans. It needs thoughtful analysis from many angles. There are so many moving parts including building, operating, and maintaining health care facilities, the location of such facilities, duplication of really expensive equipment for the sake of “being competitive,” the complicated business and clinical systems that deliver care, the training and licensing of the people who are “providers” of care, the health, mental and physical condition of the clients, their method of payment, and so much more. All of this so far has been paid for under the system of “Fee for Service” through the channels of private payments and insurance benefit remuneration. While Fee for Service is not a perfect system, and leads to a great deal of inefficiency, unnecessary duplication of equipment and facilities, and potentially massive overtreatment and profiteering, it secures a predictable flow of cash for providers and health care systems.

Deconstructing the “health care system” by looking at any one factor really doesn’t paint an accurate picture unless one understands the system as a whole. “Insurance coverage” is one such factor, and though very important, it has little to say directly about the “effects” of coverage. Whether the number of people who gained some level of coverage increased by 20 million, or something less, is really not the issue. The real issue is what happened in the last seven years when those folks gained coverage. A transfer of wealth in the form of taxes from the top 1% provided insurance subsidies and directly funded Medicaid eligibility for millions of the poorest Americans. To determine what effects that investment had on the system overall requires the analysis of huge amounts of data about each of the moving parts mentioned above, and many more. That analysis is important because it speaks directly to what will collapse when those now receiving coverage lose it, and the taxes flow back into the wallets of the extremely wealthy, which is really all Trump-Ryan Care promises.

Let’s look at just two effects, and the benefits derived on a system-wide level from these effects. Many of those who received new coverage under the ACA were unemployed poor or working class poor with marginal employment. Many qualified for either good quality employer based plans under the employer mandates, or an affordable individual plan, maybe with subsidies, from an exchange, or became eligible or aware of eligibility for Medicaid under the exchanges. Suddenly, the whole picture of health care delivery shifted dramatically in participating states. There was new and predictable remuneration infusing into a system that previously was required to provide services for “free.” One effect was emergency departments suddenly had far fewer patients needing to be treated for free, and those formerly lost fees no longer had to be subsidized by private paying patients and insurance covered patients. So hospital and community clinics could actually plan, based upon expected (and discounted) fee revenue, and shift operations by creating more appropriate facilities and systems. Some of them expanded or bifurcated their emergency departments to create spaces designed more like outpatient clinics. Others added new drop-in outpatient services.

A second effect was fewer really sick people. Suddenly, people who had never before seen a physician, began seeking care instead of remaining undiagnosed. Some specialty clinics that formerly treated mainly uninsured people in publically owned, university, or not-for-profit facilities, such as cancer treatment centers, are now seeing patients who have a new source of payment for services. This predictability of payment has allowed the expansion of cancer centers and other surgical facilities in participating centers. While the “Fee for Service” model is not necessarily the most efficient or appropriate, it is at least predictable when you can identify the source of payment for every patient and every procedure.

The other side of this coin is the sudden loss of coverage looming under all of the Republican proposals so far. Trump/Ryan Care-AHCA is not about delivering more health care at all. It is first a repeal of the ACA, and secondly, a “replacement” piece that is not replacement at all. It appears to be a tragic loss of coverage for some of the most vulnerable people in the land. The loss of funding for coverage is a transfer of wealth from insurance benefits, back to the most privileged Americans, the top 1% of wage earners and asset holders. Whether 5 million or twenty-four million lose their coverage isn’t the issue. The issue is the possible wholesale collapse of the health care systems that expanded under the ACA.

 


Dentists are Targets of ADA Lawsuits

April 25, 2011

Dentists are targets of plaintiffs (actually in Sacramento, ONE PARTICULAR PLAINTIFF by the name of Scott Johnson…) who use the ADA to create an opportunity for a form of legal extortion. Not the American Dental Association ADA, but the Americans with Disabilities Act ADA, which dentists like to refer to as the “AwDA” as if that is clear. OK, I’m sorry for the reverse psychology of the attention grabbing title for this post, but driving to and from my clients’ offices recently, I saw the potential for many of them having this kind of nuisance suit.

The ADA specifies architectural standards that are mandatory. In 2008, the rule for changed for  “handicapped” parking, now referred to as “Accessible” or “Van Accessible” or “disabled” parking. Today, if you have parking in your complex, you need at least one accessible parking space. If you have only one accessible space, it must be Van Accessible. For greater numbers of spaces, your can look at a striping chart available here from the Department of Justice.

The disabled plaintiff does not even have to call your office for an appointment, but can do this as a “drive by” infringement on his/her rights. Here’s how it’s done. John Doe, the disabled plaintiff, sees your parking lot has no spaces adequately striped and designated with the proper blue signs, diagonal striping, 12″ “NO PARKING” lettering on the pavement, and 96″ of passenger side clearance. Here is a picture of a legally sized space in Lodi.

 The van parking has the correct width and the corridor is correctly sized as well. Note the  “VAN ACCESSIBLE” blue sign on the left. Across the street is another facility in close but not perfect complete compliance. The signage is also correct, but most advisors recommend a blue stripe to identify the no parking zone. I do  not think this one is so far afield that it would draw a lawsuit.

Here is my client’s parking:

Since there is no other van accessible parking in the complex, and only these two spaces, this is a potential lawsuit. The plaintiff drives by and discovers that he cannot access the building at all because there is no van accessible space. He sends a letter saying you are in violation of the ADA, and requires you to send a list of your violations and a correction or mitigation plan. Most owners ignore the letter. It is followed by another letter that insists on a sum of money, $5000 to $10,000 to prevent a lawsuit. If you send it, he stops action. If you don’t, he files the lawsuit.

A February 2010 issue of the Sacramento District Dental Society News featured several articles about Mr. Johnson’s escapades and has some additional advice from qualified inspectors called Certified Access Specialists or CASp. More information is also available from the CalChamber.

Mr. Johnson is a quadriplegic attorney. He apparently has a successful career making a bad name for my second profession, and is making his living suing and threatening to sue business owners. But he is not always successful. Recently a business owner filed a countersuit and won. Johnnie Walker manages a business property at 6500 Watt Avenue in Sacramento. Mr. Johnson had the last word, insisting on a formal inspection after the improvements are complete, but the judge ordered him to pay Mr. Walker’s $5100.00 court costs.

Bottom line: Have your property inspected. Contact a CASp and let the inspector start in the parking lot and continue through the entire office. Plan to be in compliance with the ADA and have a certification of your inspection and improvements. A list of Certified Access Specialists is available from Governor Brown here.


Welcome to Jay Hislop’s Blog!

January 5, 2011

Welcome! Please check back frequently for updates to the blog.