Have a Good Week My Fellow Americans!

Pelosi predicts passage of ObamaCare within the next 60 days – urges Dems. to pass bill irregardless of public opinion polls – “We know what is better for Americans than Americans do” is her compelling theme. 

Editor’s Note:   The socialists in Washington are not listening. They dont care about you or what you think.

Dear Newsmax Reader:Please find below a special message from our sponsoring advertiser, Ameripac. They have some important information to share with you. Thank you.Newsmax.com
ObamaCare Summit Fails The Smell Test

ALERT: If it looks like crap and smells like crap well then it’s just a big pile of crap. Democrats continued to pile it on refusing to discuss real healthcare issues.

Obama’s NEW Government Takeover Scheme Creates Socialized Health Care
Select Here to STOP Socialized ObamaCare:


Obama cut off discussion continually and said “move on” to stop the GOP from discussing anything that would make a real difference in healthcare reform.

Obama ignored the American public and Republicans as Reid threatened to implement ObamaCare using budget “reconciliation” with no final House or Senate Vote saying we have done this before and we can do it again.

Thousands joined us for ObamaCare Summit Online Tea Party at ObamaCareSummitLiveTeaParty.com. The “SUMMIT” was not carried by most stations and even CPAN snubbed it putting it on CPAN-3. Who watches CPAN-3 anyway?

Americans watching overwhelmingly said they were disappointed in the arrogance of Obama and his lack of respect for differing proposals pushing for costly comprehensive reform instead of discussing incremental steps to curb costs. Most of the comments on our twitter link at #AmeripacHCR said that the bill should be scraped and Congress should start over.

Ameripac broadcast the entire proceeding online and participants saw that Obama offered nothing new in a scheme that defrauds America. A snide Obama dominated and lectured, defending his plan that repackages the same approach already taken by the U.S. Senate. Americans have already rejected the scheme he did not want to discuss at all in the Latest Rasmussen Poll – as 56% Oppose ObamaCare!!!!

Obama’s NEW Government Takeover Scheme Creates Socialized Health Care
Select Here to STOP Socialized ObamaCare:


What will we get from this Summit?

Obama likes to do summits spending hours talking with cameras rolling. In January, Obama hosted 50 CEOS to talk about streamlining government operations and improve efficiency. We got a bigger government, with more employees and a record deficit.

In December, an Obama Forum on Jobs and Economic Growth, with business, labor and nonprofit leader and “thinkers” to talk about ways to get people back to work resulted in record unemployment and a shrink economy.

Obama has lied again. The nonpartisan Congressional Budget Office (CBO) cannot even score the latest ObamaCare scheme because it lacks enough detail to do so. The White House claim that the scheme will save $100 billion over 10 years and $1 Trillion over 20 years is refuted by the Wall Street Journal that estimates the bill will cost $950 billion over 10 years. We will get a tax increase to balance out Obama’s scheme as more than $1,000,000,000 is needed in the next 10 years.

Democrats will shove ObamaCare down every Americans throat like it or not, it will happen and Obama is pushing it through and it must be stopped.

White House Communications Director Dan Pfeiffer said. “We took our best shot at bridging the differences.” He then indicated that the White House is open to the Democrats using a parliamentary tool called “reconciliation” to pass the bill without 60 votes in the Senate, saying that the president’s proposal is designed for “maximum flexibility” so that it could be attached to a budget bill as a way of averting a Republican filibuster.

Every person will be hurt with increased costs of an out of control Government Run Health Care bureaucracy taking over private insurance with Federal regulations. The scheme completely ignores and does not include sensible Republican proposals for a series of modest changes to bring down costs and improve coverage, including measures like tort reform and new freedoms for insurance companies to compete and sell policies across state lines.

A record number of Americans are out of work and ObamaCare funding is more than $1 Trillion short and cannot be paid for without new taxes.

This is outrageous and exactly what Americans do not want. FAX NOW AND OFTEN AND MAKE CALLS TO CONGRESS. We need your continued help more than ever as Socialized Health Care MUST STILL Be Stopped.

Obama’s NEW Government Takeover Scheme Creates Socialized Health Care
Select Here to STOP Socialized ObamaCare:


Keep calling your Senators and Representatives today, toll free numbers include 1-877-851-6437 and 1-866-220-0044, or call toll 1-202-225-3121 AND REGISTER YOUR OUTRAGE at Arrogant ObamaCare TAX Increase!

CALL PRESIDENT OBAMA 202-456-1111 and 202-456-1414 expressing your outrage at incompetence in crippling and obstructing the “bipartisan healthcare reform summit”.


NOTE: We need TENS OF THOUSANDS of faxes and PHONE CALLS and EMAILS delivered to ALL Congressmen right away!

This is a fight for the very heart of America. We can WIN this fight! With Senate Republicans now forcing Democrats to “ping-pong” the Obamacare bill back and forth between the two Houses, we can capitalize on the divisions within the Democrat Party itself! If we can STOP Reid and Pelosi from getting enough votes in either House — that means THE BILL WOULD DIE!

We CAN still win, by keeping the Democrats from getting the votes they need to pass Obamacare… but we can’t do it without YOUR help!

Obama’s NEW Government Takeover Scheme Creates Socialized Health Care
Select Here to STOP Socialized ObamaCare:


TAKE ACTION: We don’t have much time before the liberal Democrat leaders in the House and Senate begin their backroom deal-making to work all of their deals and compromises, in hopes of getting enough votes to pass ObamaCare. We have to start NOW in letting ALL of these people who are supposed to be representing US in Washington, that we are NOT going to put up with this — and that they MUST LISTEN TO US and KILL THE BILL!

We CANNOT let the radical liberals in Congress — and the White House — force this plan for socialized health care on the American people! That’s why we’ve set up our website to enable you to send a strong message to every single member of the U.S. Senate and House of Representatives, OPPOSING this outrageous plan.

For about what it would cost you in time and telephone charges, you can send Blast Faxes to Democrats, Republicans, Independents — EVERYONE in BOTH houses of Congress, DEMANDING that they REJECT this socialized health care plan NOW!

This fight CAN BE WON! Please, take action right away to STOP this bill in the U.S. Congress!


Alan M. Gottlieb
Chairman, AmeriPAC

Obama’s NEW Government Takeover Scheme Creates Socialized Health Care
Select Here to STOP Socialized ObamaCare:


Please make checks payable to AmeriPAC:
American Political Action Committee (AmeriPAC)
PO Box 1682
Dept Code 3742
Bellevue, WA 98009-1682

Paid for by AmeriPAC, a federally-authorized and qualified multicandidate political action committee. Contributions to AmeriPAC will be used in connection with federal elections. Maximum contribution per individual per calendar year is $5,000. Contributions from foreign nationals and corporations are prohibited. Contributions are not deductible for federal income tax purposes.


Avizent Introduces New Captive Program

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MyHealthGuide Newsletter
News for the Self-Funded Community

Published weekly by MyHealthGuide, LLC (www.MyHealthGuide.com). This Newsletter is for personal, non-commercial use only.  This weekly newsletter is FREE OF CHARGE to subscribers.  Subscribe free. Send news, press releases and announcements to mailto:Info@MyHealthGuide.com.


General & Company News

Avizent Introduces New Captive Program Covering Excess Risk for Employee Health Benefits

Nurtur Acquires ActivHealth and Wellness by Choice; Gains Exclusive Partnership with Duke University Center for Living

TriZetto Launches Electronic Record for Health Plans Covering a Third of Americans

Click4Care Offers Payors First Worry-Free ICD-10 Conversion for Care Management

One Call Medical Addresses the Industry’s Top Three Work Comp Concerns — Medical Costs, Accountability, and Education — with “Smart” Diagnostic Management

National Business Group on Health Expands EMPAQ® Partnership with the University of Michigan Health Management Research Center

Bravo Wellness’ First Year Results for Simonton Windows Exceed Expectations

SIIA TPA-MGU Forum Has Strong Advance Reservations

People News

Delta Dental Names Alicia Weber SVP & Controller and John Yamamoto, DDS, MPH, VP of Professional Services

Market Trends, Studies, Books & Opinions

Health Reform Summit Outcome: Insights & Talking Points

Towers Watson Survey: Employer Health Cost Rate Increases to Slow to 6.5% This Year

Legal, Legislative & Regulatory News

SIIA Sends Letter to Congressional Leaders Responding to the Health Summit and Presenting Case for Self-Funding

TPA is a Fiduciary Despite Disclaimer

Medical News

Exercise Reduces Anxiety by 29% Among Chronic Patients


Standard Stop-Loss Employer Disclosure Form Endorsed

Upcoming Conferences

Editorial Notes, Disclaimers & Disclosures

General & Company News

Avizent Introduces New Captive Program Covering Excess Risk for Employee Health Benefits

MyHealthGuide Source: Avizent, 2/23/2010, www.avizentrisk.com

COLUMBUS, OH — National claims and risk management service provider Avizent announced the creation of an innovative health benefits captive program for self-funded employers.

The program, called Avizent Benefit Re, is designed to cover excess insurance costs, and is available to employers with 50+ employees and a minimum of $25,000 retention in their health plan. It offers employers the potential for more freedom and flexibility in their benefits, and significant cost savings on premiums for excess insurance.

Captives and self funding arrangements are options usually limited to Fortune 500 companies and large employers. Avizent, which has offered group and risk sharing services for more than 13 years, has developed this new health benefits captive program to help a wider range of employers maximize their savings and encourage those who are not self-funded to consider the option.

“We listened to our clients and to the market, and we understand that there is a real need for programs that help defray the cost of health benefits,” noted Rick Stasi, Chief Operating Officer for Avizent Alternative Risk. “Many employers like the flexibility and cost savings of self-funded programs, but have been concerned about the financial risk. Our program provides the coverage and protection employers of all sizes need to enter the self-funded market.”

Excess insurance provides coverage for additional costs that may occur within an employer’s health benefits. Avizent’s program covers a range of expected and unexpected losses. In the event of an unexpected loss, such as a high cost transplant or high risk pregnancy, the excess captive would cover the amount over the selected self-insured retention amount, which can range from a minimum of $25,000 to $150,000. Also, the captive program provides aggregate excess protection for all claims over 125% of the expected losses.

Offering ways to help employees improve their health and manage costs are key factors in the success of a self-funded program. Employers who provide wellness programs and reduce losses could not only save on their self funding premiums, but can also receive back up to 70% of their excess premium dollars paid to the captive by way of program dividends.

Avizent’s Alternative Risk team has more than 30 years of experience designing successful captive programs for employers in a variety of industries. For the new health benefit captive, they will work with leading national excess carriers, which will provide actuarial services and pricing, and carry the risk. The program allows clients the flexibility to work with third party benefits administrators and networks of their choice.

About Avizent

Avizent, based in Columbus, Ohio, is one of the fastest growing national risk management service providers. They offer claims management, medical managed care, alternative risk options and RMIS technology. The company has offices in 40 locations across the United States. Call 888-646-9675 and visit www.avizentrisk.com.


Editor’s Note: Readers should take advantage of Ernie Clevenger’s weekly newsletter – its free and highly informative.

Student Athletic Plans – Who Wins?

Texas public school districts purchase limited student accident athletic insurance plans usually through a bid process. Every year districts  will receive, on average, four or five bids from interested carriers. The reason there are only four or five bids is because there are usually only four or five carriers in the market in any given year. And, these players change frequently, with some getting out and others, seeking profits, getting  in.

Student accident plans are underwritten on an excess basis, i.e, the plans provide secondary cover always. But, in Texas, with one of the nation’s highest uninsured populations, student accident plans, for all practical purposes, are primary policies. Little Johnny breaks his leg at football practice – since his parents have no health insurance at all, the limited student accident plan pays up to it’s benefit maximums and has no other insurance policy to coordinate against.

Marketing expenses for most of these plans are high. Out of every premium dollar, an accounting is established to segregate and book expenses. Administration costs run from 15-22%, agent commissions run up to 15% (split between the writing agent and the Managing General Agent and Master General Agent), and reserves account for about 22%. The balance remaining is available to pay claims.

Policies offered are two fold; a basic plan with limits of up to $25,000 per year, and umbrella cover that takes over at $25,000 and covers expenses up to a limit such as $5,000,000. This seems sufficient but a careful review of plan policy limitations may bring a better understanding of the risk to be assumed by the insured that is not covered by the policy. For example, a football player in South Texas became permanently paralyzed  two years ago – his medical care expenses exceeded $500,000 but his student accident plan paid only about $40,000 despite the fact that the policy limit was $5,000,000. His family is now suing the school district’s agent and insurance company.

Several carriers have developed their own proprietary network of physicians whom they tout provide lower than usual health care costs. This is a good marketing ploy, but in reality there are no significant savings to be realized.

Marketing of student athletic insurance is usually through selected brokers who are assigned a territory. These agents/brokers are exclusive marketers. Since there are only a few carriers in this market, these agents and brokers in essence are in a monopolistic position and their success is predisposed to a large degree.

A district’s decision to purchase student athletic insurance is always impacted by athletic directors and their coaches. Their input is important and agents and brokers know this. Thus, strong marketing efforts are directed towards these centers of influence, with hunting trips, seminars, etc., as a proven marketing ploy. There is nothing at all wrong with this, as this is a usual business practice in any business. But, for one to enter this line of business it helps to have a background in school district employment (retired football coach, ex-athletic director, etc.) and access to a nice hunting lease as well.

Texas school districts purchase fully-insured student athletic insurance cover. We know of not one district that self-funds their athletic programs. We find this curious since almost 100% of all Texas public school districts self-fund their group health plans with success (including the TRS ActivCare Plan which is self-funded).

Why don’t districts self-fund their athletic insurance as well?

There are advantages to self-funding. Premium taxes of almost 3% of premium is eliminated. Marketing fees are reduced. Reserves are held and invested by the district, earning investment income. Ability to directly contract with area physicians at lower rates provide additional savings.

There must be a reason districts do not self-fund their athletic insurance plans but do self-fund their million dollar group health plans.

Agents and brokers, who are exclusive marketers, have the most to lose if districts self fund their plans. Lucrative commissions are lost – up to 15% or more of annual premium is paid up-front to the agent every year. Why would agents and brokers want to jeopardize this income? Why would these agents advise their clients of this potential plan saving strategy? They dont.

A district should consider a self-funded approach. Specific stop loss cover can be purchased with a $25,000 retention for about $4 per participant. A third party administrator can be retain to pay claims, on a per claim basis of $10 (maybe even less than $10 per claim). Local doctors can be contracted with at Medicaid rates, a substantial claim savings to the district.

So, who wins in the current athletic insurance market in Texas? It is up to the reader to decide.

Editor’s Note: If school districts were to consider a self-funded athletic insurance program, why not form an Interlocal Agreement, band together regionally, procure stop loss, hire a plan administrator, and self-fund their student athletic insurance?

Amfels Changes Plan Administrator

Amfels, the second largest employer in South Texas located in Brownsville, Texas, has moved their self-funded health plan administration to Group & Pension Administrators Inc. (GPA). The move is signficant since GPA is known in the industry as one of the most progressive and agressive health plan administrators in the country, achieving significant savings for their clients by utilizing unique risk management techniques.

Another large Brownsville, Texas based employer contracted with GPA last year, moving from a local HMO plan. A recent claim study shows that claim costs on a PEPM have been cut in half.

Observers speculate that the Brownsville Independent School District will take note and apply similar strategies to reduce their +$40,000,000 employee health plan expenses.

Editor’s Note: GPA has received national publicity in the past year on their success in reigning in health care costs for their clients. The Dallas Morning News ran a front page article on GPA –  Forbes picked up the story as well as other national news sources.

February 26, 2010
2:31 pm EDT
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Critics Slam CVS Caremark

In an Employee Benefit News, February 2010 issue, front page article, “Report Calls PBM Merger Into Question”, critics acuse CVS Caremark of driving up costs for health plans and lowering quality for patients, reducing transparency and hampering oversight for health plans, and compromising the privacy of health plan participants.

“CVS Caremark is currently the only major PBM that is owned by a retail pharmacy chain, and this combined business model has an inherent conflict of interest. As a retailer, CVS Pharmacy has an incentive to drive customers into its stores, fill as many prescriptions as possible, particularly those with high markup, and has little interest in saving health plans money.”

“Of particular interest to health plans and sponsors is the report’s contention that CVS Caremark promotes the use of more expensive brand name drugs over cheaper generics. ”

The article also advises plan sponsors on how to negotiate with their PBM, listing four major points to consider.

Editor’s Note: If you wish to recieve a copy of this article, email Riskmanager@sbcglobal.net

Humana Broker Update – ObamaCare

The latest on health reform for Humana brokers
February 24, 2010

Bipartisan summit or partisan theater?
The big story out of Washington for the past week has been that Washington is broken – or, as Time magazine’s cover story puts it, “Washington is frozen.” The morning news shows, the Sunday news shows, the newspapers and magazines are full of stories saying that Congress and the administration are too polarized, too partisan, too politicized for any real work to get done.

In fact, the President, in his weekly address, focused on the problem of doing “what it takes, all of us – Democrats and Republicans – to build a better future for ourselves, our children, and our country.”

“What’s being tested here,” he said, regarding health care reform, “is not just our ability to solve this one problem, but our ability to solve any problem. Right now, Americans…want to see us focus not on scoring points, but on solving problems; not on the next election but on the next generation.”

This highly charged atmosphere, then, is the backdrop for Thursday’s so-called “bipartsian summit” on health reform. The President and congressional leaders from both parties will meet at Blair House starting at 10 a.m. EST. The President’s purpose in calling this meeting, he said, is to make some progress on health reform. He can do that either by winning over some Republicans or by convincing Democrats of the need to go ahead and act alone. He has said he’s open to Republican ideas, but his starting point and focus are on the Democratic plans. The event will be covered by CSPAN.

There are few people who believe the summit will produce any real bipartisan progress. Most believe it will produce partisan theatrics instead.

But the President has posted his plan online, and has urged Republicans to do the same. His plan is a framework that includes mostly provisions already passed by the Senate and the House (see below). Meanwhile, Democrats in the House and Senate are working to come up with a plan that both chambers can pass in the budget reconciliation process without a single Republican vote. Passing a bill through reconciliation would require 218 House votes and 51 in the Senate (budget reconciliation bills cannot be filibustered).

Republicans do not seem compelled to do what the President asked: deliver a comprehensive plan that “protects people from insurance problems, makes sure that the costs are controlled and people who don’t have health insurance are covered.” In fact, they have said they believe changes should not be comprehensive but incremental – that the country can’t afford the cost of a comprehensive bill.

Last Thursday, Senate Minority Leader Mitch McConnell also told the Louisville Rotary Club that he wasn’t afraid of Republicans being called “the party of ‘no.’ ” “I make no apologies for saying, ‘no,’ ” he said. He criticized the reform bills’ costs and the deals cut with members of Congress to win votes, and he argued that Republicans were fighting “an agenda designed to turn us into a Western European country,” implying that the Democrats’ plan is socialized medicine.

What is the President’s plan?
First of all, the President’s “plan” is a framework or a statement of principles. It contains no legislative language. It doesn’t include enough detail for the Congressional Budget Office to be able to score it – that is, to assign it a price – although the White House estimates the cost at $950 billion over 10 years.

The President’s plan sticks largely to the version passed by the Senate on December 24, but offers some concessions to the House. For example, the Senate’s tax on so-called Cadillac health plans – which House Democrats opposed, largely because it would hit union members – has been scaled back. It would be delayed from 2014 to 2018 and wouldn’t kick in for a family of four until the health insurance benefit is worth $27,500 instead of $23,000.

The Obama plan also:

Contains no public plan
Removes the Medicaid deal Ben Nelson got for Nebraska; improves reimbursement rates for new Medicaid eligibles to all states
Offers the same basic insurance reforms that are in the Senate and House bills: no more excluding people for pre-existing conditions; no more charging people more because of health status or gender; no more lifetime limits on benefits; imposes medical loss ratios of 80 to 85 percent
Although the details vary slightly, the overall approach is the same: Everyone must have insurance, with government subsidies for those who make less than $88,000 for a family of four
Does not require businesses to provide health insurance to employees, but penalizes those with more than 50 employees that don’t
Closes Medicare drug benefit “donut hole” coverage gap by 2020
Contains a new provision in neither the House or Senate bill: the creation of a Health Insurance Rate Authority to provide “assistance and oversight to states in conducting reviews of unreasonable rate increases and other unfair practices of insurance plans”
Appears to contain administered pricing for Medicare Advantage plans, with some bonuses for quality and enrollee satisfaction, although no specifics were given
Includes pilot and demonstration projects for delivery system reforms and cost savings
Delays until 2014 the premium assessment on health plans
Create a side-by-side comparison of House, Senate and Obama plans here.

Read the summary of the Obama plan here.

Rate hikes the focal point
The proposed 39 percent rate hike by Anthem Blue Cross of California has had a huge impact on the run-up to the President’s health care summit. In fact, it has provided the administration with a new rallying point for why comprehensive health reform is necessary.

In response to Anthem’s announcement, Secretary of Health and Human Services Kathleen Sebelius released a report called “Insurance Companies Prosper, Families Suffer.” “Leading experts have predicted that, without reform, these increases will continue,” her report says. “All the while, insurance companies and their CEOs continue to thrive… While insurance companies enjoy increasing profits and CEOs take in millions, American families struggle to find and maintain affordable, quality insurance coverage.” Read Sebelius’ report here.

The next day, Sen. Dianne Feinstein, D-Calif., announced she would introduce legislation “to create a Medical Insurance Rate Authority to prevent egregious premium rate increases, like the one recently announced by Anthem Blue Cross of California.”

She called the rate hike “unconscionable…The insurance industry reaps soaring profits by piling massive financial burdens onto consumers.” Then over the weekend, the Obama administration said it would include Sen. Feinstein’s Rate Authority in its health care plan.

From coast to coast, the media jumped on the rate-hike story, saying, as the Louisville Courier-Journal did last weekend, that “Despite a struggling economy, the nation’s five largest health insurance companies increased their profits by a combined 56 percent last year, to $12.2 billion.” But as Alwyn Cassil, public affairs director for the Center for Studying Health System Change, told the writer of that story, the five companies’ profits amounted to less than half a percent of the total spending, “less than a rounding error.”

“I am no apologist for the insurance industry, believe me,” she said. “But this idea that (taking) this $12 billion that they have in profits…would fix our health-care spending problems is just a pipe dream.” Read the Courier-Journal story here.

On Monday, Karen Ignagni, president and CEO of America’s Health Insurance Plans, responded, “There is an enormous amount of attention being paid right now to premium increases for people who obtain coverage in the individual insurance market…The central policy question that should be asked is: What is driving these increases and whether the measures being proposed will work.”

She continued, “But there is a heavy dose of politics at work here. There has been a strenuous effort to focus on health plans because very few policymakers want to take on the real issue of why costs are rising…” Those reasons, she said, include the poor economy, which is causing young and healthy people to drop their insurance; increased utilization of medical care (the Centers for Disease Control announced last week that the use of high-tech diagnostic imaging had tripled between 1996 and 2007); and increased spending for hospitals, physicians and clinical services.

Ignagni continued, “To suggest that cost containment can be achieved by singling out health plans ignores the very inconvenient truth that premium increases reflect increases in the underlying cost of medical services. Regulating premiums won’t do anything to reduce the soaring costs of medical care. This would be like capping the prices auto makers can charge consumers, but letting the steel, rubber, and technology manufacturers charge the auto makers whatever they want.” Read her entire statement here.

Fortune magazine’s list of the 53 most profitable industries placed health insurance and managed care at No. 35, based on 2008 profits that were 2.2 percent of revenue. Yahoo! Finance ranked the 3.4 percent profit margin for health care plans as 88th among 215 industries.

Meantime, two important opinion pages took the rate hikes as evidence of opposite things. A New York Times editorial saw the rate hikes as proof that the Democratic reforms should be passed, while a Wall Street Journal editorial saw them as evidence of what is to come if those reforms do pass, since they don’t address underlying costs.

On the horizon
Medicare Advantage plans would see a small increase in payments from the federal government under preliminary rates released last Friday. The Centers for Medicare and Medicaid Services announced that it estimates a 1.38 percent increase in payments for 2011 prior to any regulatory reductions or adjustments. The final rate will be announced in early April.
Get involved. Contact Congress about health reform at MyHealthReform.org.

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Aetna – Weekly Update

The White House on Monday released President Obama’s newest health care reform proposal, which the President intends to use as the starting point for discussions at a bipartisan health care reform summit scheduled for Thursday. The White House says the proposal bridges the gap between the Senate and House bills and includes new provisions meant to “crack down on waste, fraud and abuse.” Among the provisions in the President’s plan: increasing the threshold for the excise tax on health plans from $23,000 to $27,500 for a family plan, and implementing the same threshold for all plans in 2018; closing the Medicare prescription drug “donut hole;” and creating a new Health Insurance Rate Authority. Close on the heels of the White House website posting, House Republican Leader John Boehner (R-OH) issued a statement that said: “The President has crippled the credibility of this week’s summit by proposing the same massive government takeover of health care based on a partisan bill the American people have already rejected. The best way to protect families and small businesses in this time of economic uncertainty is to start over with a step-by-step approach to health care reform focused on lowering costs, and that’s exactly what Republicans are fighting for.”


With Congress in recess last week, there is no federal report this week.


CALIFORNIA: The federal government has announced $101 million in grants aimed at boosting the use of health information technology in California and training more workers for health care careers. The grants will provide $38.8 million to the California Health and Human Services Agency to develop a health information exchange; $31 million to a variety of organizations statewide for the Cal-REC effort aimed at helping primary care providers adopt electronic health records; and $31.4 million to California community colleges and not-for-profit organizations to train people for health care careers. The Assembly Health committee will hold an informational hearing on February 23 to discuss premium rate increases. Anthem Blue Cross has been asked to testify at the hearing. The chair of the committee, Assembly Member Dave Jones, is expected to introduce legislation to require prior approval before health insurance premiums, co-payments, coinsurance obligations and deductibles can be increased. Similar legislation has been introduced in the past and failed to make it out of the legislature. Jones is running for State insurance Commissioner.

COLORADO: A bill has been introduced that would prohibit insurers from subrogating against liable third parties to recoup medical expenses. Initiated by the Colorado Trial Lawyers Association and supported by the governor, this proposal is anti-consumer and flies in the face of calls for more affordable insurance premiums. The proponents are focusing on the need to make the injured party “whole” by retaining as much of any applicable damage settlement or award without addressing the option of reducing attorney fees. Aetna is working with the National Association of Subrogation Professionals, business groups and other insurers to highlight the adverse impact the bill would have. Also introduced was a bill that would require the Department of Health Care Policy and Financing to create an advisory committee to make recommendations regarding the creation of an all-payer health claims database, and to appoint an executive director to establish the database if sufficient grants, gifts, and donations are received by 2012 to pay for its creation and maintenance. The database will be made available to the public, state agencies, and private entities. Aetna will provide comments based upon its experiences in other states.

CONNECTICUT: In the early rounds of Senate Insurance Committee voting, legislation that would prohibit co-pays for preventive care was defeated. However, the Chair, Sen. Joe Crisco is appealing to his fellow members to change their votes and keep the bill alive as a work in progress. In addition, “prior approval” legislation put forth by the Attorney General and the Health Care Advocate was introduced as expected after the recent media coverage of individual rate increase requests in Connecticut. The bill would require a public hearing prior to any rate approval for individual health insurance policies. It also would authorize the Healthcare Advocate (HCA) or the Attorney General (AG) or both to be a party to the hearing and allow the AG and HCA to charge the payers for any attorneys, actuaries, accountants or other experts the AG and HCA retain in relation to the hearing, at a cost of up to $200,000. The bill would also require plans to give the Commissioner of Insurance 180 days’ written notice of any proposed rate changes, with the hearing to be held no later than 120 days prior to the effective date of the change. A final determination must be issued by the Commissioner no later than 30 days after the hearing. The Commissioner may only approve an individual product rate that is “reasonable.” The bill defines “reasonable” to mean a rate that provides “a fair rate of return to the filer,” taking into account the previous 5 years’ average net income and rate of return not only for the filer, but for the industry as a whole. The bill as currently drafted is the most onerous prior approval proposal to be proposed in the Northeast states. The industry is working to defeat the bill.

GEORGIA: A hearing was held last week regarding the Governor’s proposal for a tax on health plans and hospitals in the state. Many interested parties testified, including the Georgia Association of Health Plans, in opposition to the tax. No vote was taken, and Aetna expects another hearing in two weeks. The legislature has taken a two-week recess to address the budget.

MINNESOTA: The Minnesota legislature convened for the second year of its 2009-10 biennial session on February 4. During the interim, lawmakers focused on ways to reduce the state’s anticipated $1.2 billion budget deficit and how to address cuts in General Assistance Medical Care (GAMC). Based on that work, a bonding bill to establish $1 billion in general obligation bonds and a bill related to jobs and economic development have already been introduced, as have bills related to the GAMC. As usual, several bills to mandate coverage have been introduced including autism, prosthetics, oral chemotherapy drugs on par with intravenous chemotherapy drugs, and routine patient care during clinical trials. Other bills of note include a mandatory extension of COBRA benefits, a bill allowing cross border sale of insurance and expansion of Medicaid programs. We will continue to monitor these bills and other legislative activity until the session adjourns May 16, 2010.

MICHIGAN: This week, Governor Jennifer Granholm introduced an executive order, her first executive directive, to take steps to open the state’s health insurance system to other public employees. Governor Granholm told the Office of the State Employer and the Department of Management and Budget to identify and remove any barriers to other public workers becoming part of the state’s health insurance system that could help reduce employee costs for both the state and local governments. Opening the state’s health care system was part of Ms. Granholm’s proposals to reform retirement and employee costs that she announced last month. School districts, as well as counties, cities, villages and townships, would be able to enroll their workers in the state plan, she said. All of the various state health care systems, including its PPO and health maintenance organizations, would be open to enrollment from public employees.

NEW MEXICO: New Mexico adjourned its 30-day legislative session on February 18, 2010. Two key bills headed to Governor Bill Richardson are SB 148, eliminating the use of gender as a rating factor in individual policies, and HB 12, establishing a minimum benefit ratio of 85 percent for group policies and 75 percent for individual policies less the 4 percent premium tax; resulting in 81 percent and 71 percent, respectively. The latter bills were part of the administration’s health reform package. The governor withdrew a third bill which would have required guarantee issue in the individual market. He has until March 10 to sign the bills.

TEXAS: Gov. Rick Perry, Lt. Gov. David Dewhurst and House Speaker Joe Straus have asked state agencies to identify possible budget savings that could be applied during the current two-year budget cycle. The move is in anticipation of a multi-billion-dollar budget shortfall expected when lawmakers meet in 2011 to craft the next two-year budget. Health and Human Services Executive Commissioner Thomas Suehs released options and held a hearing last week, saying he “absolutely” is concerned about the potential effect of possible cuts at health and human services agencies. However, the directive for each agency to cut budgets by 5 percent is forcing him to consider the possibility of a provider rate reduction. They total $303.5 million in state funds but would cost Texas another $238 million in federal matching funds. Doctors and advocates for lower-income Texans said cutting reimbursement rates would discourage care providers from taking new Medicaid patients. The cuts would be at least 1 percent and rise to 2 percent for some. After receiving each agency’s proposed cuts, State elected leaders will consider whether the options should be finally implemented. Aetna will continue to follow and have input on this issue as it develops.

Editor’s Note: We get daily emails from numerous insurance companies and other entities giving us continued updates on the insurance industry. This valuable information helps us keep informed and we appreciate the daily emails very much.

Half Guilty, Half Pregnant Insurance Agent Seeks Separate Sentencing

Half Guilty, Half Pregnant insurance agent, Arnulfo C. Olivarez, filed an Unopposed Motion for Separate Sentencing on February 1, 2010. His current sentencing date is March 4, 2010. The petition reads “Defendent Arnulfo Cuahtemoc Olivarez respectfully requests that he be sentenced alone and separate from all other defendents in this case. This request is made not for the purpose of delay but so that justice may be done.”

Under seal, the court has received a “Confidential Sentencing Recommendation” dated February 5, 2010.

Editor’s Note: For more information on this felon, type in “Olivarez” in the search box on this blog.

Medicaid Feels Pinch of Economy

More than half the states are reducing Medicaid services and payments to health care provider this year as the recession propelled enrollments to record levels and sapped money from treasuries.  Many states are threatening bigger cuts starting in July unless Congress extends a higher federal contribution incuded in last year’s $862 billion economic stimulus law. Some of those custs would make it harder to low-income people to qualify.

California plans to close adult day health care centers next month. Nevada is cutting coverage for eye glasses, dentures and hearing aids.

Medicaid enrollment rose by 3.3 million people or 7.5% in the 12 month period ending June 2009 for example. Enrollments rose in every state for the first time since the early 1990’s. Medicaid, on average, 21% of state budgets, equal to education, and is expected to increase even more as the recession continues.

XYZ Insurance Company Hospital Contract – Guaranteed Cash Flow Mechanism


Below is actual language found in an insurance company’s  Hospital Contract which in effect gives the participating hospital an annuity contract of sorts. The participating hospital is guaranteed a weekly cash payment whether they see a member patient that week or not.

XYZ Insurance Company will adjust the weekly Uniform Payment Plan (UPP) for all applicable allowances for Covered Services rendered to XYZ Insurance members. The UPP means the weekly payment that shall be made from XYZ Insurance Company to Hospital representing the average weekly claims volume incurred in the previous running quarter.  The adjustment to the UPP check will be the estimated difference between the Net Covered Charges and the applicable XYZ Insurance Company liability based upon the agreed upon rates attached hereto for each Hospital as a separate Exhibit and incorporated by reference herein. Net Covered Charges means Covered Charges for Covered Services rendered to XYZ Insurance Company members less deductibles and co-payments, less coordination of benefits amounts.

The estimated XYZ Insurance Company liability for Covered Services rendered to XYZ Insurance Company members will be determined based on the amounts reflected in the Rate Exhibits attached hereto.

Adjustments will be reviewed and recomputed by XYZ Insurance Company only as necessary to reflect actual XYZ Insurance Company claims and/or contractual allowances for XYZ Insurance Company Covered Services rendered to XYZ Insurance Company members by the Hospital during the particular year as evidenced by XYZ Insurance Company processed claim data and/or Rate Exhibits. In the event of termination of this Agreement any indebtedness of Hospital to XYZ Insurance Company may be offset and/or recouped via reductions to or elimination of UPP payments during the month prior to the effective date of termination. In addition, XYZ Insurance Company has the right to offset 100% of any claims liability due the Hospital beginning on the effective date of the termination until XYZ Insurance Company has been paid in full, regardless of whether Covered Services were rendered prior to or subsequent to the date of termination.

XYZ Insurance Company will periodically reconcile for each year during the term of this Agreement the payments made by XYZ Insurance Company to Hospital, and the weekly adjustments to UPP.

Editor’s Note:  Many hospitals are dependent upon the cash flow advantages of this and similar hospital contracts. With up-front health care financing, reconciliation strategies employed may very well reward the insurance company with higher fees than are normally  paid to competing payers. However, consumers will never be able to learn the truth because, as is the case with all the various hospital contracts we have  been able to review, invaribly there is the famous paragraph that reads something like this: The hospital certifies that unless otherwise required by law, the specific compensation rates and discounts under this Agreement have not been, and will not be, disclosed by Hospital, its employees, agents or independent contractor, to any third parties including Hospitals or competitors of XYZ Insurance Company.

Swing Votes on Healthcare





We don’t believe that there is any chance of stopping Obama’s renewed push for his horrible healthcare changes in the Senate. Harry Reid is going to use the reconciliation procedure to jam it through with 51 votes — and he will get them. All the hype about how difficult it will be is to distract us from the real battle which will come in the House.

There, where every member faces re-election, it will be a lot harder for Pelosi to round up the vote she needs.

Last time she passed healthcare by 220-215. This time, it won’t be so easy.

The League of American voters has produced ads targeting these swing Congressmen and we urge you STRONGLY to CLICK HERE to send them money to help fund these ads.

But please do more. If you live in any of the states from which these swing Congressmen come, please call them. Let them know your opposition to healthcare changes. The phone for Congress is 202-224-3121. Here’s the list:

Vulnerable Democratic Congressmen Who Voted FOR Obamacare The First Time Around

These are the folks we need to pressure to switch their votes!


Harry Mitchell (Phoenix suburbs)
Gabrielle Giffords (Tucson)
Ann Kirkpatrick (most of rural Arizona, NE part of state)


Jerry McNerney (Stockton and Pleasanton)


John Salazar (Pueblo)


Jim Hines (Fairfield County)


Alan Grayson (Orlando)


Bill Foster (Dixon, Batavia, and Geneseo)


Baron Hill (from Kentucky border up to Bloomington)


Mark Schauer (Branch, Calhoun, Eaton, Hillsdale, Jackson, Lenawee & Washtenaw counties)
Gary Peters (Oakland County)


Dina Titus (Las Vegas)

New Hampshire:

Carol Shea-Porter (Portsmouth, Manchester, Lakes Region)

New York:

Tim Bishop (Suffolk County)
John Hall (Northern Westchester)
Bill Owens (Plattsburgh up along Vermont border to Canada)
Mike Arcuri (Utica and south central NY)
Dan Maffei (Syracuse)

North Dakota:

Earl Pomneroy (at large)


Steven Driehaus (Cincinnati west to Indiana border)
Mary Jo Kilroy (Columbus and west to Indiana border)
Zach Space (Dover, Zanesville, Chillicothe)


Kathy Dahlkemper (Erie)
Patrick Murphy (Bucks County)
Christopher Carney (NE Penn)
Paul Kanjorski (Scranton, Wilkes-Barre)

South Carolina:

John Spratt (rural SC between Columbia and Charlotte)


Tom Perriello (Charlottesville, Bedford, Timberlake, Martinsville & Danville)

West Virginia:

Alan Mollohan (Wheeling, Morgantown)
Nick Rahall (Huntington)


Steve Kagen (Green Bay)

Let’s get busy to save healthcare in America!

Please support the League of American Voters in their efforts to stop Obama — Go Here Now.

SPBA Email Alert – Message from Fred Hunt

Personal observations from SPBA President Fred Hunt      

The descriptions in my recent e-mails about the intents of the various players in health reform right now and heading into the Summit on Thursday all still apply, so take what I say and what you see and hear in the media in that context.  

The $200 billion Congressional Democratic “ping-pong” plan to ram through a Reconciliation version that would make the corrections the House wants to the Senate bill, and then the House pass the Senate bill (meaning that they would pass a superceding corrections bill before passing the underlying bill), thus meaning that both chambers would have passed the Senate version, and it could go directly to the President for signing into law) is still trying, but it assumes a lot of wishful thinking that 51% of the two chambers of  Congress will go along.

Major newspapers are giving pretty good charts & descriptions of the Obama “starting point” proposal for the Thursday Summit.  Don’t drive yourself nuts trying to micro-analyze each provision.  It is essentially like a dealer reshuffling the cards of the existing House & Senate bills and dealing you a new distribution of cards.  Besides, it is just a brainstorming vehicle. 

So, instead of an item-by-item analysis, let me just share some insights about things to which you should be alert during & after the Summit, and the net outcome.

1.  Democrats are approaching the new Obama proposal very cautiously.  It was written in secret within the White House without  Congressional input.  This is a double insult for Congressional Democrats.  First, because Obama is asking them to stake their political futures on something unknown and untested, and features they desire, Obama might abandon.  Second, Congressional Democrats are still resentful that for the past 9 months, Obama kept arm’s-length deniability from the specifics of the Congressional bills,  so they have been battered by angry constituents without any progress to show for it, because Obama never laid out precisely what was and was not his priority items.

2.  The most fierce and divisive issues among Democrats have not been resolved in the Obama proposal, and would tend to generate some “no” votes from needed Democrats in the House & Senate.  For example, the Obama abortion restrictions mirror the Senate bill (which are not acceptable to many House Democrats)  Also, there is no Public Option, instead steering more people into private insurance company policies (via the mandate to have coverage). for regulated MEWA-like self-funded plans for small employers to be allowed.  No such solutions are provided. .   This is one of the Catch-22 provisions in the proposal.  Small employers are forced to have health coverage ….but without any new or streamlined ways for employers to do so.  For example, Republicans for 20 years have been pushing for regulated MEWA-like self-funded plans for small employers.  No such options are made available.

3.  There are more subsidies for low & medium income people, but the trade-of is to subject investment income to Medicare 2.9% taxation for individuals with incomes above $200,000 and couples over $250,000.

4.  The Cadillac tax has become sort of a vestige joke.  To keep unions happy, the family-premium trigger rises to $27,500, but (here’s the kicker) it would not take effect until 2018.  Eight years is a lifetime in politics , so this is mainly window-dressing apt to never happen or in riddled with exceptions. 

5.  The employer mandate is tougher than the Senate version.  Employers with more than 50 employees would be mandated to offer employee health coverage or pay a $2,000 annual fine per employee if even one employee sought federal subsidies. The mandate penalty phases in higher for employers in the 50-80 worker size.

6.  The special deals to Nebraska & Louisiana to subsidize the state’s Medicaid load has been “eliminated” and transformed into more subsidy for all states for Uncle Sam’s share of Medicaid. 

7.  After all the hand-wringing about the necessity to have CBO scoring on every bill & provision, CBO has said that this version is so vague they can’t really issue a precise figure.   You’ll hear the number $950 billion over 10 years and that it does  not add one penny to the deficit, but all of this is like playing with Monopoly money.

A BIG PICTURE LONG-RANGE THOUGHT:  For months, I have had the nagging feeling that  a long-range strategy or outcome of this process will be to drive the insurance companies out of the health market.  If they force mandates of who must be covered and in what conditions, and they impose politically-sensitive veto power over what insurers can charge for that coverage, and they funnel more and more people onto the insurers (such as the mandates) ….does it make business sense and/or can insurers survive for long?  Will insurers voluntarily drop out of the health market state by state or altogether?  That will leave a giant vacuum, and most of self-funding is restricted to employment-related health plans, because ERISA is employment-related law.  Amid much uproar in the country, Uncle Sam would be called upon to come to the rescue with a public option.  This may seem like wild imagination, but I know that single-payer reformers in the past have envisioned this kind of scenario as a strategy if they could not get an instant governmental plan.  I mention this just to have on your radar.


Health Care Service Corporation Issues 2009 ERISA Disclosure Report


The Department of Labor, Department of the Treasury, and the Pension Benefit Guarantee Corporation have issued new regulations effective with the 2009 Plan Year for new disclosure requirements needed to complete ERISA Form 5500.

Attached (Blue Cross Erisa5500-2009_supp_disclos) is the 2009 ERISA Disclosure Information Form issued by Health Care Service Corporation (HCSC). HCSC operates through its Blue Cross & Blue Shield plans in Illinois, Texas, New Mexico, Oklahoma and several subsidiaries.

Page 4 of the report is interesting. A careful read may bring to mind more quesitons than answers. The report states “Additional information about those types of fees, the amount of those fees and the sources of these fees is available upon request.”

Editor’s Note: Are 100% of PPO discounts passed on to the consumer? 

Molly Mulbrier, famed sci-fi novelest and fictional writer of Hollywood fame writes, “For example, suppose the hospital bills an insurance company $100,000 for John Doe’s recent hospital admission. If, for example,  the insurance company has an agreement with the hospital to charge a fee of up to 15% of billed charges, then the insurance company would earn up to $15,000 in fees on this claim. But, the billed charge of $100,000 has to be re-priced through the PPO network and that is reduced to $65,000 in this example (35% discount off billed charges). In this fictional and probably completely untrue scenario, the insurance company would then pay the hospital $50,000 but draft $65,000 from the employer’s self-funded claim account. ” Mulebriar continues “But this is so obscene and irrational, it could not be true and would never ever happen in the real world.”

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Level funding is a unique type of self-funding solution that balances control and information with a degree of predictability. Payments are preset, and employers can benefit from a positive claims experience when claims are less than the annual claims funding. Clients also have access to detailed reports on how their health care dollars are being spent.

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SPBA Alert – Health Care Reform – What is Really Happening


SPBA Email Alert – February 12, 2010

Health Reform Insights & Talking Points
Personal observations from SPBA President Fred Hunt

Sorry; this is a long e-mail, because there is so much swirling around right now.

COBRA ARRA Extension in the Works – The draft bill would extend the eligibility period from February 28, 2010 to May 31, 2010.

Announcement:  SPBA is moving to a new broadcast email system.  TPA firms will need to tell their technology people to permit SPBA emails from the following email address: spba@XMR3.com.  Today’s email will be sent twice: once from the old system and another one from the new system.     
SPBA has been involved in about a dozen sure-to-pass health reform wars over the years, dating back to 1975.  This one takes the prize for most twists & turns and characters reinventing themselves.  It is like one of those TV series like “Lost” or a reality show, in which there is a new plot every week.  Here is the new show:
THE BIPARTISAN SUMMIT scheduled for February 25th for half a day with Democrat & Republican Congressional leaders has a warm-fuzzy sound to it.  We envision the leaders finally coming together, putting aside the old points of national divisiveness, and working out a deal.  However, it is only a political posturing PR event.  Why?  First of all, President Obama has already said that the end result will be no significant change to the mega 2,700 page bill now stuck in Congress.  Second, how much can be done in half a day if a year’s work has ended in deadlock even with only one party involved??  Third, it will be fully on TV, and politicians always gear every words and actions for the cameras, not constructive negotiation.  Both liberal Democrats and Republicans are very leery of this Summit because they don’t trust Obama’s motives.
For PRESIDENT OBAMA, this tactic has multi-win potential.  He will have half-a-day of TV coverage to portray himself to the American public as an open-minded post-partisan statesman, and since he is the host of the meeting, he can set the agenda and way the meeting plays out.  He can then claim that he and his health reform effort listened carefully to Republican input.  He also hopes that his new warm-fuzzy aura can attract even one or a few Republican votes for the mega bill.  Even one Republican would allow the bill to be called “bi-partisan” and would give several worried Democrats political cover if they vote for it.  If he can’t lure any Republicans, he can at least try to use the event to paint the Republicans as the “party of no”.
He can also say he is fulfilling his campaign promise to have health reform deliberations on TV.  (He seems to like TV coverage of these deliberations when there are Republicans around.  He is the one who surprised House Republicans at the last moment at their retreat in Baltimore by saying that he wanted to bring TV with him.)
As I alerted you last week, he also is hoping for a slam-dunk to be ready for him right after the Summit .  I described the secret dealings going on to have the House Democrats pass a Reconciliation version with the changes they would want if they were voting on the Senate-passed version of the mega bill. Pass that, get the Senate to pass it, and then the House would be happy to vote on the Senate-passed version of the mega bill (because they would have already changed the net outcome to their liking via the Reconciliation).  Since House & Senate would be in agreement on the same bill (Senate/Reid version), there is no need for another Senate vote (so Brown is irrelevant), so it can “ping pong” straight to the President and be signed in 24 hours.  Done.  (Funny formality:  Even though the Reconciliation “correcting/changing the main bill will be passed first, the mega bill would need to be signed by the President first, because you can’t have Reconciliation corrections to a bill that had not yet been signed.)

This ping-pong + Reconciliation scheme assumes several wishful thinking scenarios, but Obama & staff + Pelosi are pushing hard to make it happen.  It would mean that Obama would know that he could activate it right after the Summit .  It would allow him to either praise his Summit and claim that the legislation had bi-partisan participation ….or ….say that Republicans are obstructionists against helping people.  Even if the scheme failed because the Senate Democrats could not muster even 51 votes, Pelosi would still get bragging rights that the House is better than the Senate.  (Remember: never underestimate the side effects of the fierce ego competition between the House & Senate.)
DEMOCRATS, especially liberals and early proponents of health reform, are worried or angry on several levels.  First, they are angry that several of their most prized provisions have already been thrown aside (such as public option).  Second, they are angry & frustrated that unlike past Presidents, Obama has never put his personal clout on the line to tell Congressmen precisely what he wants.  He talks the talk, but always keeps arm’s-length deniability, so he can disclaim anything that causes voter anger later, and he can and does throw his Democrat Congressmen under the bus.  They feel he has fumbled a once-in-a-lifetime opportunity to get major health reform.   Third, they fear that if Obama does allow Republicans to have some say in the bill to make changes, add, or delete anything, it will probably be things important to liberal Democrats …and paying attention to Republicans heightens the resentment of the lack of interaction Obama had with Democrats on specifics. They still believe that the public opinion will change, and that if passed, Americans will love health reform by the time  of the November election, and they don’t want to share the credit with Republicans.
REPUBLICANS are leery for all the reasons mentioned above in the Obama description.  The odds are stacked against them for being “had”.  One thing in their favor is that the White House and Congressional Democrats apparently believed their own press releases that the Republicans had no ideas to offer.  Instead, Obama has been caught off-guard with a long list of Republican solutions based on tax incentives and state innovations, but little new federal action.  Their ideas rely on the market.  Republican leaders hope to get these ideas some visibility in the big national bi-partisan Summit TV audience.  Of course, the President & Democrats don’t want that to happen.
So, the Summit will be like a strange play in which the characters’ strategy is perfect for them …but in major conflict with all the other players.  If it weren’t going to be so boring, it would be a good TV show.

One thing to keep in mind is that any bill based on the Senate or House mega-bill versions would probably continue to include the various “incentives” (such as the Nelson, Landrieu, etc. etc. etc. special deals).  Senator Kerry has very righteously said that they should be pulled out ….except, of course for the $500 million in there as a special goodie for his state.

If you think that the President & Congressional leadership got the wake-up call from the Scott Brown Massachusetts election and VA & NJ, think again.  Last week, the White House and some Democrat House members negotiated a deal to exempt federal workers (but not Congressmen or political appointees) from the Cadillac tax.
(1).  HEALTH COMPANY BUSINESS WORRIES:  If the mega-bill fails and there is some last-minute thrown-together bill passed to be claimed as “health reform” (and/or if there are state-by-state reforms), there will be plenty of mandates and prohibitions and restrictions on insurers, HMOs, (and snagging self-funding by accident or on purpose??), it can cause chaos both in functions as well as the business/financial stability of insurers, health companies, HMOs, drug companies, and hundreds of other health businesses.  All the insider deals insurers, drug companies hospitals etc. etc. made with the White House or Congress would be null and void.  The executive offices of those insurers & businesses are probably biting their fingernails now.

On the other hand, some health industry businesses will be helped by the jobs bill’s emphasis on helping small innovative companies.  Most of the new companies exploring new types of treatments are small businesses, so they will not only see their markets growing, but also some government business & hiring benefits.

(2).  Anthem’s large price increases in California has renewed the emotional argument that insurance companies are selfish and charge big prices and pay their execs big bucks, so that’s why we need health reform.  It is a handy scapegoat chant.  This means that everyone involved in self-funding needs to quickly and repeatedly educate their Congressmen and media at all levels that self-funded plans make zero, nada profit and most have no executives getting paid a penny.  They MUST hear this hundreds of times and think of self-funding as different and a good deal for plan participants.  Or else, we’ll get swept up in whatever punitive programs they come up with for insurers.  Do it.
(3). JOBS BILL:  A bi-partisan jobs bill has been in the works.  However, at the last minute, totally without warning, Senate Majority Leader Reid came up with his own bill, blocked the bi-partisan bill from even being introduced, and hopes to ram through his version on a Feb. 22 vote, the day the Senate will be returning from a week recess.  Needless to say, both Democratic & Republican Senators who had been working together are shocked & miffed.  This will be yet another drama to watch unfold. 

The Reid bill seems to be a trimmed-down version of the bi-partisan version (which I note, below, had lots of add-ons). With an eye to his own reelection, he is aiming for instant-job-satisfaction However, it does still include such non-job issues as the “doc-fix” provision described below, which is the pay-off to the AMA to keep them as a supporter of health reform.

The bi-partisan Jobs bill:  Senate Democrats were quietly circulating a 362 page draft Jobs bill.  Ironically, it has very little to create jobs, but has become a gift list for lobbyists of business, doctors, etc.  Reid hopes to introduce the jobs bill this week, before the Senate goes into recess until February 22nd.  The main provisions in the circulating draft are:
(a). Extend the ARRA COBRA Subsidy + unemployment benefits. The draft bill would extend the eligibility period from February 28, 2010 to May 31, 2010.
(b).  Renew the various business tax breaks that expired in 2009.  These are mostly items that are renewed year by year.
(c).  Exempt employers from paying the employer’s share of Social Security taxes for new hires if they are unemployed and hired this year (length of time unknown yet).
(d). The $200 billion “doc fix” (thus undercutting the guts of the 1997 health reform to gradually cut Medicare payments to doctors). This will prevent the scheduled 21% cut until Sept. 30, 2010.   Why such a temporary period??  The doc fix is the sop to the American Medical Association to buy their support for health reform.
(4). PUBLIC OPTION REBIRTH??  Liberal Democrats are actively plotting how to sneak, push, or whatever is needed to get a robust Public Option back into health reform, into a Reconciliation version, or what ever else that will make it law.  I have warned you all along to beware of things that would raise a ruckus if passed in the open, but are quietly slipped into other laws.  For example, the recent Credit Cardholders Bill of Rights had a provision snuck in to allow people to carry guns in national parks.  Go figure!!  Several years ago, there was a major employee benefits provision that had been fought back over an over.  One night, at 3AM, the Federal Boat Safety Act was coming up for final vote. The boat act was “amended” by removing all the boating language and simply replacing it with the employee benefits language.  No hearings, nothing.  It passed a few minutes after the “amendment”.  
So, the moral of this story is that bad things have a way of sneaking back, so you need to have your Congressmen so well educated on what is important to the employers and workers in his state or district that if something comes up, even at 3AM in the morning, alarms will go off in his/her head.  The power rests with you.
(5).  UNCEL SAM CIRCUMVENTING FEDERAL LAW:  CMS and CDC are not allowed to use data such as hospital-acquired infection rates as a measure of hospital performance.  However, CMS is considering ways to make CDC information available to states who will then use it for the hospital performance ratings. The moral of this story is that the federal government will find a method to have its way, even if federal law seems to prohibit it, so be alert, and never assume “it’s over”.

(6).  US BECOMES MAJORITY HEALTH PAYER:  Next year, Uncle Sam will be the majority health payer in the nation; projected to pay 50.4% of all health spending in 2011. 

By 2020, it is projected that 1 in 5 of every dollar spent in the US will be for health care ….soon approaching put-up-or-shut-up of raise taxes or cut benefits.

By 2030, when all of the baby boomers will be over 65, Medicaid, Medicare & Social Security will be 60% of federal spending, which will crowd out almost anything else the government wants to do. 

At the start of this e-mail I mentioned that this is about the 12th time that SPBA has guided members through a major health reform onslaught.  That gives SPBA, and thus you great historical perspective.  For instance whenever anyone tells you that the current proposal is the one-and-only solution, ask them how come all the other times reform has been pushed, there has been a completely different solution each time proclaimed to be the one-and-only solution.  So, tell them that with your psychic powers, you can pr4edict that the next time there will be a big push for health reform, the proponents will scoff at the current proposal (as they do at all the other past ones), and proclaim some very different approach as the one-and-only perfect solution.  (See, with SPBA membership you also get psychic powers J )

P.S. – After all this gloomy foreboding talk, it may give you comfort to know that the U.S. Government has been closed Monday, Tuesday, Wednesday and Thursday due to our double-whammy of snow.  Maybe lobbying dollars should be spent, instead, on snow-making machines.

P.P.S – To keep yourself on the cutting edge of developments on all issues, so you can look like a brilliant guide to your clients, and you have the inside advance knowledge to best guide your firm to survive and thrive, register to attend the SPBA Spring Meeting, April 14 -16, 2010 in Washington DC.  The sessions start promptly at noon on the 14th, and should end by 11 AM on Friday the 16th.  REGISTRATION INFORMATION IS ON THE MEMBER WEBSITE.


Class Action Lawsuit – Undisclosed Insurance Compensation


A class action lawsuit filed in August 2005 makes for fascinating reading. The suit purports that insurance agents and brokers receive significant undisclosed compensation.

Some excerpts within the pleading include: “The broker defendents put their interests above their clients by refusing to place their business with insurance carriers that do not pay overrides even if the carrier provides the most cost effective insurance or superior service.”………………”Aetna’s refusal to pay undisclosed Contigent Commissions has had a direct result on its business with brokers”…………………………”But he gives business to Blue Cross because of commissions”…………………….”He told us to load our rates 5-10% (give him half) and we get all his business”.

The pleading purports that insurance companies pay brokers and agents fees above and beyond commissions. Profit sharing agreements include fees for (1). Volume of business – Volume Contingency Fee, (2). Renewals – Persistance Contigency Fees, (3). Profitability – Profitability Contingency Fees.

Specifically, the pleadings state that AIG’s 2003 Broker Agreement provides Marsh a 1% renewal bonus (fee) if renewal premium renews at 85%, 2% bonus if renewal renewas at rate of 90%, and 3% fee if renewal rates renew at 95% or more. AON’s Broker Agreement is purported to include a Performance Enhancement Fund Fee of 17% for new business, 10% fee for renewals, and when total book of broker’s business hits $10,000,000, an additional 1.5% fee is paid.

In addition to these fees/Agreements, the suit offers that some insurance companies pay (1) Communication Fees, (2). Enrollment Fees, (3). Finders Fees and (4). Administration Fees.

To review the entire pleading, click here:  Class Action – Undisclosed Compensation

Editor’s Note:  We can show how a broker can make +$200,000 on a 150 life case without the employer knowing about it. The cavaet is that the employer must be fairly stupid and non-inquisitive by nature.

How To Choose A Trend Factor

Coin Flip

“The selection of a trend factor is often the most important component of rate indications and rate filings (and certainly always an important component). Indeed, it is often the first and primary number to be contested by, e.g., consumer advocates: presumably because of both its leverage impact, and the fact that the data itself frequently leaves room for multiple interpretations with divergent conclusions. I wish here to delineate the various considerations which go into choosing a trend number. As shall be seen, and as one might expect, the selection process is a synthesis of theoretical and practical considerations.”

Editor’s Note: This is an excerpt from “How to Choose a Trend Factor” by Israel Krakowski. For a complete copy of his White Paper write to RiskManager@sbcglobal.net

Watch Out For Trend Factors

Medical Trend

“Trend” is a fancy name for medical inflation. And, it is a driving force in ever increasing medical insurance rates. Year after year employers are hit with rate increases of 10%, 20%, 35% or more, consistantly. Brokers and insurance consultants point to “trend” as the main culprit.

The sales pitch is that medical inflation (trend) is fueled by ever increasing cost of new and modern technology, an aging population, research costs for new and innovative treatment, R&D for expensive prescription drugs, etc.

But, suspicions abound that trend is primarly driven by secretive PPO – managed care contracts. In every managed care contract we have review, there is invariably an “escalator clause” that insures providers a pay raise as high as 12% per year, compounded year after year.

Recently, we reviewed a renewal from a major insurance carrier. The renewal was early out, six months prior to the anniversary date, based on claims incurred and paid eight months out. Trend was shown as +14%, which produced an effective trend factor for the renewal of +23%.

However, current industry trend factor is about 11%, which if used in this renewal would produce an effective trend factor of about 18%, a 5% differential.

A 5% differential to be loaded as premium, would produce a higher number due to premium tax and reserve requirement. This could be a case where 5% may really be equal to 7-8% premium load, or even higher if commissions need to be factored into the equation. 

Some employers have been successful in reversing trend. Using a 0% trend factor along with sound and common sense logic, is not within the realm of the impossible.

Humana Announces New Form 500 Reporting Requirements

Revisions to Department of Labor regulations require carriers to disclose more information to ERISA employers about broker compensation. The goal is to provide more transparency about what carriers pay for services. As a result, Humana now must include the value of indirect expenses such as trips and entertainment along with reporting on direct expenses such as commissions and bonuses. Employers must report this information when they file their ERISA Form 5500.

Humana’s reporting on Form 5500

We modified our systems to start reporting Jan. 1, 2010.

We will implement the new regulations using these guidelines:
  • For each expense related to a broker or a consultant, Humana will determine what portion of the expense is related to existing accounts and assign the percentage of the total expense that is reportable.
  • If the reportable portion of the expense is related to a general discussion of many existing clients, then the expense will be allocated across the entire book of business, then only the portion allocated to ERISA employers will be reported.
  • Humana will report on indirect expenses related to existing customers. If the expense is related to general education, new business development, or a specific new business prospect, the expense will not be allocated to other customers.
  • The last step is to aggregate all of the reportable expenses to each ERISA eligible employer to see if the total meets the minimum expense test provided by the Department of Labor for reporting. With the new regulations, we now must also report the value of:
    • Gifts, meals, and entertainment valued $10 or more if the total equals at least $100 per person, per calendar year
    • Individual items valued at $50 or more regardless of the total annual value

Examples of how expenses will be reported

Dinner to discuss specific ERISA accounts

A Humana associate has dinner with “Broker Jones” to discuss the renewals for three accounts. All of the accounts are ERISA accounts. The total expense is $300. The Humana associate will report the $300 expense, and at the end of the plan year Humana will report the $100 expense to each of the three ERISA account on their 5500 information.

Dinner to reward business

A Humana associate spends $300 taking “Broker Smith” and his wife out to dinner and entertainment to thank him for his business. The $300 will be divided by the total number of accounts in the broker’s book of business. Broker Smith has 10 accounts with Humana, so the reporting basis is $30 per account. Only four of Broker Smith’s accounts are ERISA eligible; those four will receive $30 reporting of indirect expenses at the end of the plan year.

Educational seminar about Humana’s new products and services

Humana hosts 15 brokers at a daylong seminar to learn about healthcare reform as well as Humana’s products. Some of the brokers are new to Humana and some have long-standing relationships. The event costs $15,000. Since the event is educational and not related to specific customers, the expense is not reportable on any customer’s 5500 information.

Top Health Insurers Profits Climbed 56% in 2009

08:27 AM CST on Friday, February 12, 2010

Los Angeles Times

WASHINGTON – As the nation struggled last year with rising health care costs and a recession, the five largest health insurance companies racked up combined profits of $12.2 billion – up 56 percent over 2008, according to a new report by a liberal health care coalition.

Based on company financial reports for 2009 filed with the Securities and Exchange Commission, the report said insurers WellPoint Inc., UnitedHealth Group, Cigna Corp., Aetna and Humana Inc. covered 2.7 million fewer people than they did the year before.

The report Thursday also said three of the five insurers cut the proportion of premiums they spent on their customers’ medical care, committing relatively more to salaries, administrative expenses and profits.

Prepared by Heath Care for America Now, a coalition of liberal advocacy groups and labor unions, the report was aimed at bolstering the drive by Democrats to complete work on a health care overhaul, which insurers have vigorously opposed.

Industry representatives Thursday criticized the report’s approach, pointing out that 2008 was a bad year financially across many industries, skewing the 2009 comparison.

“It is disingenuous to look at the profits at one company today compared to where it was in the depth of a recession,” said Robert Zirkelbach, a spokesman for America’s Health Insurance Plans, the industry’s Washington-based lobbying arm. The companies’ 2009 profits are nonetheless intensifying pressure on an industry already under attack for raising premiums and denying coverage to millions of Americans.

“That’s why we need health insurance reform today in this country and why we are going to continue in the Congress to work on this until we see it through,” said Rep. Rosa DeLauro, D-Conn.

Editor’s Note: This article was sent to us by our undercover operative in Dallas, a San Benito native who has made good in the Big City. Rumor has it that he is directly related to Baldimar Huerta, better known as Freddy Fender of country western fame. Forgoing a lucrative career as a professional bull fighter based out of Tamulipas, Mexico, Big Al heads up the Dallas office of a major stop loss carrier. Keep them coming Al!

BISD To Audit Health Claims?


The Brownsville Independent School District  (BISD) is concerned that their employee health care costs have increased over the past two years. Upon the advice of their insurance consultant, the BISD terminated their contract with HealthSmart PPO network and moved to the Texas True Choice PPO network. According to their insurance consultant, estimated claim savings to the district will be $4-$5 million in claim costs (see previous posts on this blog).

According to the BISD, annual claim costs through the Texas True Choice network in the four years prior to changing to the HealthSmart network were approximately $26 million, $23 million, $27 million and $28 million. With the change to the HealthSmart network for a two year period the claims spiked to $35 million and +$40 million.

In a January 2010 Board Meeting the BISD considered an action item to hire Claim Technologies Inc. to audit the BISD health plan for a fee not to exceed $143,880. We do not know if this item was approved.


Editor’s Note: BISD would be wise to hire an independent insurance consultant with expertise in forensic auditing and who has no ties to South Texas. The +$50 million budget item deserves close scrutiny.

Cost-Plus Versus Value-Based Hospital Pricing


There is little or no competition among hospitals in the United States. Consumers generally have absolutely no idea what hospitals will charge them when they seek care. Their perception of health care costs is that costs are high. But consumers really dont care about cost since someone else will be paying the bill for them.

Therefore, when hospitals advertise for customers, they focus on value and outcomes, and do not address cost at all. How many times have you seen a hospital advertise – “Come Here and Have Your Baby Delivered for $1,500″. Or, Special Price in May for Open Heart Surgery – $15,000 All Inclusive”. Or, “Call us today and we will send you our menue of services with pricing, sent directly to your home.”

Cost-plus pricing

This can apply to any business. This method takes  the cost of producing products or services and adds an amount needed to make a profit. This is usually expressed as a percentage of the cost. This seems to make sense. For years realtors have been getting 6% as their “profit”, general building contractors have been getting 25%, group health insurance brokers have been getting 5-10% of premium, mutual fund operators get 1 or 2 basis points, etc.

It is generally more suited to businesses that deal with large volumes (hospitals?) or which operate in markets dominated by competition on price (Competition among hospitals ? – What a novel idea!).

Since there is little or no competition in today’s hospital services market, any attempt to change reimbursement methodology is met with strong resistance by hospitals, and their partners. Those partners include insurance companies and PPO networks whose allegiance and profit margins are driven by lucrative agreements with medical care providers.

Recently,it has been rumored,  a PPO network, upon learning that they were not going to get the business of a local employer (who instead was going to implement a cost-plus program for his self-funded employee health plan), called the local hospital administrator to forwarn them of this impending “disaster.” The hospital then allegedly called the employer and warned that if they were going to move forward to a cost-plus hospital reimbursement approach,  the hospital would stop seeing the employer’s employees and would demand full payment up front for services to be rendered (Where is the 60 Minutes Camera Crew?)

Collusion between a PPO vendor and a hospital is evident here, if true. Could this be the beginning of GodFather Part IV?

Value-based pricing

This focuses on the price you believe customers (PPO Networks, Insurance Companies) are willing to pay, based on the benefits your business offers them (kick backs?). The scheme here is to make behind-the-curtain deals, then advertise value and outcomes to entice customers, to hell with the cost.

Editor’s Note: The purpose of this posting is to get the reader to think and question. What is the truth and what is fiction? Does everyone lie, or does everyone tell the truth?  Money motivates behaviour.

My Hospital Discounts are Better Than Your Discounts


Well trained health insurance salesmen and company representatives derive sales by convincing prospective clients that their hospital contracts are better than any other out there. “My discounts are better than your discounts, and I can prove it” exclaim many in the business. “Just give me a sample of your old claims and I will re-price them through our PPO network. Since you have XYZ Company currently, I know through experience that I can save you 20% or more off your claims.”

And so the disco-discount games begin.

Editor’s Note: Brownsville Independent School District was promised a $4-5 million claim savings by changing from the HealthSmart network to the Texas True Choce Network last year.  Has that happened?

ObamaCare on Hold (For Now)


The suspension of action on health care reform in the Senate, triggered by the upset election of Scott Brown to the Senate from Massachusetts, is now in its second week with no end in sight.  What started out as a methodical, plodding health reform effort in 2008 and then became an every-committee-for-itself approach in the summer of 2009 is now in Limbo. Democrats can’t figure out how to actually pass something without offending the anti-incumbent, anti-Congress mood of the electorate, with November’s elections a scant nine months away. Republicans can’t figure out whether to hold the line against any health reform or join with moderate Democrats to stand behind a truly bipartisan bill. The State of the Union speech did little to move the needle on health reform as the President gave no specifics on policy and nothing on process. Congress returns this week from the party “retreats” (get out of town to caucus privately), and the next week or two may provide some indication on which health care reform pathway Congress will choose. Right now, the prospects for something passing are still above 60 percent, but the content of a bill is totally up in the air. 
To take some pressure off, Speaker Nancy Pelosi is suggesting passing a number of narrowly focused health bills to accomplish something and, if crafted carefully, to garner Republican support on a health care item or two. First up seems to be the effort to repeal parts of the industry’s McCarran-Ferguson antitrust exemption, as to health and medical malpractice insurers. It seeks to outlaw price-fixing, bid-rigging and market allocations. Truth be known, the bill is a hollow gesture in that it neither repeals McCarran-Ferguson nor outlaws anticompetitive
practices that are not already prohibited by McCarran- Ferguson. Unfortunately, it may hurt small insurers who need pooled claim and loss data to fairly assess risk, and it could chill quality initiatives. 
Senate Democrats last week passed a ”pay-as-you-go” budget restraint law to require that new bills not go forward unless fully funded, i.e., new revenue must be found or some other program’s funding curtailed. But the very same bill exempts upwards of $250 billion from the rules, just in case Congress wants to permanently eliminate reductions in reimbursement for Medicare physicians but doesn’t want to pay for that.

Editor’s Note: This is an excerpt from today’s Aetna Report to their agency force

Hospital Agrees to Cost-Plus 12%

A Texas hospital has signed a direct contract with a local employer and has agreed to accept cost-plus 12% as payment in full for services rendered. Specialty items, such as implants, will be paid based upon the hospital’s invoice from the manufacturer, plus a 12% margin.  There are no outlier (gotcha) provisions.  Certain in-hospital services will be reimbursed at 80% of RBRVS (20% below Medicare rates).

This is a very encouraging sign that hospitals will negotiate in good faith for the benefit of their customers.

States Seeking to Ban Mandated Health Insurance

By DAVID A. LIEB, Associated Press Writer David A. Lieb, Associated Press Writer 1 hr 57 mins ago

JEFFERSON CITY, Mo. – Although President Barack Obama‘s push for a health care overhaul has stalled, conservative lawmakers in about half the states are forging ahead with constitutional amendments to ban government health insurance mandates.

The proposals would assert a state-based right for people to pay medical bills from their own pocketbooks and prohibit penalties against those who refuse to carry health insurance.

In many states, the proposals began as a backlash to Democratic health care plans pending in Congress. But instead of backing away after a Massachusetts election gave Senate Republicans the filibuster power to halt the health care legislation, many state lawmakers are ramping up their efforts with new enthusiasm.

The moves reflect the continued political potency of the issue for conservatives, who have used it extensively for fundraising and attracting new supporters. The legal impact of any state measures may be questionable because courts generally have held that federal laws trump those in states.

Lawmakers in 34 states have filed or proposed amendments to their state constitutions or statutes rejecting health insurance mandates, according to the American Legislative Exchange Council, a nonprofit group that promotes limited government that is helping coordinate the efforts. Many of those proposals are targeted for the November ballot, assuring that health care remains a hot topic as hundreds of federal and state lawmakers face re-election.

Legislative committees in Idaho and Virginia endorsed their measures this past week. Supporters held a rally at the Pennsylvania Capitol. And hearings on the proposed constitutional amendments were held in Georgia and Missouri. The Missouri hearing drew overflow crowds the day after Obama urged federal lawmakers during his State of the Union address to keep pressing to pass a health care bill. The Nebraska Legislature plans a hearing on a measure this coming week.

Supporters of the state measures portray them as a way of defending individual rights and state sovereignty, asserting that the federal government has no authority to tell states and their citizens to buy health insurance.

“I think the alarm bell has been rung,” said Clint Bolick, the constitutional litigation director at the Goldwater Institute in Phoenix, which helped craft an Arizona amendment on this November’s ballot that has been used as a model in other states.

“These amendments are a way to manifest grass roots opposition” to federal health insurance mandates, Bolick said. “They kind of have a life of their own at this point. So while some of the pressure may be off, I think that this movement has legs.”

Separate bills passed by the U.S. House and Senate would impose a penalty on people who don’t have health insurance except in cases of financial hardship. Subsidies would be provided to low-income and middle-income households. The intent of the mandate is to expand the pool of people who are insured and paying premiums and thus offset the increased costs of insuring those with preexisting conditions or other risks.

The federal bills also would require many businesses to pay a penalty if they fail to provide employees health insurance that meets certain standards, though details and exemptions vary between the House and Senate versions.

Obama and Democratic legislative leaders were working to merge the two bills when Republican Scott Brown won the Massachusetts Senate seat long held by the late Edward M. Kennedy on Jan. 19, leaving Democrats one seat shy of the number needed to break a Republican filibuster.

Since then, the federal legislation has been in limbo. But state lawmakers have not.

“We need to move ahead no matter what kind of maneuvering continues in Washington, D.C.,” said Missouri Sen. Jane Cunningham, a Republican from suburban St. Louis.

Since suffering resounding defeats in the 2008 elections, Republicans have seized upon voter unease over the federal health care legislation to help revitalize their fortunes.

A USA Today/Gallup poll conducted the day after the Massachusetts vote found that about 55 percent of respondents — including a majority of self-described independents — favored putting the brakes on the current health care legislation. The poll had a margin of error of plus or minus 4 percentage points.

State laws or constitutional amendments clearly could bar lawmakers in those states from requiring individuals to purchase health insurance, such as Massachusetts has done. But it’s questionable that such the measures could shield state residents from a federal health insurance requirement.

“They are merely symbolic gestures,” said Michael Dorf, a constitutional law professor at Cornell University. “If this Congress were to pass an individual mandate, and if it is constitutional — which I believe it is — the express rule under the supremacy clause (of the U.S. Constitution) is that the federal law prevails.”

Many Democratic lawmakers are skeptical of both the intent and the effect of the state measures, entitled in many states as the “Freedom of Choice in Health Care Act.” Some have derided it as “political theater” or an attempt to merely shape the public debate.

“We need to do something about health care,” said Idaho Rep. Phylis King, a Boise Democrat. “And the federal government is trying to do something. It hurts our companies and it hurts our people to be uninsured.”


Associated Press writer John Miller in Boise, Idaho contributed to this report.