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Supporting a State-Based Mandate for Health Insurance – A Bi-Partisan Approach

Supporting a State-Based Mandate for Health Insurance - A Bi-Partisan ApproachEvery now and then, I will read something relating to healthcare policy that makes some sense to me, regardless of the writer’s political perspective. I don’t spend much time writing about healthcare policy issues, primarily because the politics of enacting anything that makes sense is, at best, a crapshoot, and, at worst, a waste of my time – and yours! I’ll leave this discussion to the ‘policy wonks.’ Additionally, the legacy lobbyists are thick in Washington and state houses determined to control the process of what eventually becomes policy – usually for the betterment of their own interests. They also have a stockpile of financial resources to ensure their insulated world does not become too disrupted anytime soon.

There, I said it.

The new tax law ends Obamacare’s requirement that nearly all Americans purchase health insurance coverage or pay a fine. With this, I do expect to see some states search for ways to shore up their individual health insurance markets by passing their own state-level mandates to keep many of their residents insured. In addition to Massachusetts’ mandate dating back to 2006, other states such as California, Washington, Maryland, and the District of Columbia may take measures to pursue their own specific mandates.

In the December 28 ‘Editorial Counterpoint’ found in the StarTribune, Minnesota state senator (and physician), Scott Jensen, a Republican from Chaska, wrote a piece, ‘Why we should start talking about a state mandate.’ Jensen suggests that Minnesota-elected leaders begin discussion on establishing a state mandate for individual healthcare insurance coverage – because it is the right thing to do. Jensen does a wonderful job of reaching across the aisle to do something they were elected to do.

I particularly appreciate the bipartisanship approach Jensen gives to this discussion – which is a great way to begin 2018. Instead of paraphrasing his editorial, I have included the entire article. By the way, for those of us from Iowa, just insert ‘Iowa’ whenever you see ‘Minnesota’ – including references to the Governor. Do I advocate that Iowa embrace all of the specifics as described by this elected MN official? Not necessarily. But I do support his attempt to find common ground on a topic that has become too polarized and unsustainable for most every state.

Scott Jensen’s Editorial

Helping someone at the scene of a recent auto accident sparked in me a resolve to publicly address health care costs and universal critical care coverage. I firmly believe Minnesotans want their elected leaders to stop drawing lines in the sand, stop the partisan quibbling, redouble their efforts to get something done with the health care crisis and do it in the coming 2018 session.

I have been asked if I would support a discussion regarding a state-based mandate for health care (“After lost mandate, what’s next for care?” editorial, Dec. 24). Yes, I would engage such a conversation — why wouldn’t I? Health care is infected with big problems, and easy solutions are not looming on the horizon. Legislators are in no position to close their minds to an idea that has received support from both sides of the aisle over the last 30 years.

In 1989, an individual mandate to purchase health care insurance was championed by the politically conservative Heritage Foundation when Stuart Butler wrote: “If a young man wrecks his Porsche and has not had the foresight to obtain insurance, we may commiserate, but society feels no obligation to repair his car. But health care is different. If a man is struck down by a heart attack in the street, Americans will care for him whether or not he has insurance.”

An individual mandate resonates with conservative principles of personal responsibility, and comparisons are often made to similar requirements for auto insurance. But it is crucial to realize that an individual mandate requiring insurance companies to include too many “essential” benefits will likely sabotage the affordability and sustainability of such a mandate. Patients are capable of championing their own health care, and they should be allowed to choose what they want to buy. Teetotalers should not be forced to buy inpatient chemical dependency coverage, and seniors may want to invest their dollars on maladies of aging rather than prenatal care. Choice matters!

Public and private entities have both indicated strong support for a health care insurance mandate. Brainstorming and discussion may help create a blueprint for catastrophic coverage for such essentials as hospitalization, access to generic and select trade name medications, emergency room visits for true emergencies and mental health problems. (Please trust my 30 years in the trenches on at least this one point — no one knows when a mental health crisis might occur, so coverage of some sort is indeed essential.)

Let’s not forget that Medicare started in 1965 as a limited part A hospital-only plan and it grew thereafter. We can take a lesson from this initiative. Just because we can’t do everything doesn’t mean we shouldn’t do something. Indeed, we should do it now.
As a starting point, maybe everyone can agree that people should not die on the streets from heart attacks — but also that not every wart, runny nose or incidental hernia needs to be paid for by a third party.

But a mandate for health insurance is just one idea needing to be explored in the coming months, and individual coverage is not the only sector of the insurance marketplace clamoring for attention. Employer-based insurance is experiencing its own escalating affordability crisis. Some earnest soul-searching needs to happen at the Capitol — soon!

The Senate Select Committee on Health Care Consumer Access and Affordability has deliberated on numerous cost-reduction issues, including pharmaceutical prices, narrow networks, transparency of fees, low-value services, end-of-life decisions and protecting patient-doctor relationships.

As elected leaders, we need to roll up our sleeves and get the job done. If we don’t, we will have failed our constituents.

Hospitals all over the state are in trouble financially because too many bills go unpaid and charity care is crippling their ability to respond to community needs.

Parents and patients are being forced to make impossible choices as to whether critical medical care for their children or themselves should be subordinated to paying bills or house payments — a health crisis should not invoke fear of bankruptcy or a second mortgage.

Home health aides work for $12 per hour with no benefits, and the shortage of these compassionate servants intensifies while the sick and infirm pray for help and a bath.

The time has come for statesmanship — and this will require attention to patient choice, unintended consequences, sustainability, representation from both parties, civil tongues, and a passion for what best serves our state, our nation and the common good.

(Maybe now is the time for Gov. Mark Dayton to take the lead and host a breakfast with Senate and House leaders from both sides of the aisle to determine the level of resolve for addressing our health care crises in 2018. I suspect such a meeting would be more fruitful if cellphones, egos and sound bites are checked at the door.)

Final Comment

The best way to help individuals buy health insurance is to find ways to reduce the cost of it, such as disrupting how healthcare is both delivered and paid. This will require consensus from both sides of the aisle and willing stakeholders to disrupt the status quo.

In the meantime, we can periodically learn from our neighbors to the north.

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Was Grandma Ahead of Her Time?

It’s early Friday morning, a day that marks the beginning of a long holiday weekend, which will culminate on Monday – Christmas Day. In my office, I’ve just poured my third cup of java and started perusing newly-arrived emails from last night and this morning. One particular email caught my eye and I naturally opened it to learn more.

The content was about…coffee.

Grandma and Coffee

The aroma and taste of coffee, at least for me, became an acquired and ‘necessary’ habit over the years, beginning while I was in college. Late night cramming required that I not doze during the precious remaining critical hours prior to the exams. Caffeinated coffee became my best late-night friend.

The origin of my eventual coffee ‘addiction’ can be traced back to my grandparent’s farm – an acreage north of Detroit Lakes, MN. During the summer months in the late 1960s, my siblings and I would have the opportunity to spend time at the farm helping with chores and experience rural living – working in the garden, hitching a ride on a tractor, playing by the slough, and enjoying some of the best home-grown beef and vegetables at dinner. Without a doubt, the time spent on the farm provided some of my best childhood memories!

To begin their day, I noticed that my grandparents enjoyed a hot beverage that was prepared on their wood-burning stove. While percolating, the aroma of the black brew seemed somewhat odd to me, but my grandparents relished the benefits coffee provided to them when beginning their day. As an impressionable boy, I remember asking Grandma if I could have a sip of this ‘black magic,’ and she, very prudently, complied. I remember her telling me, “Someday, you may like the taste of this, David!” The taste, I quickly learned, was not what I had expected, and that was my first and last sip of coffee – until my college days.

Recent Findings about Coffee

The email I received about coffee came from Harvard T.H. Chan School of Public Health. According to a study recently published by Harvard, people with colorectal cancer (CRC) who drank at least four cups of coffee per day after their diagnosis had a ‘significantly lower’ risk of early death – either from this cancer or any cause – than those who didn’t drink coffee. According to the American Cancer Society, CRC is the second-leading cause of cancer in the U.S.

Just four days earlier, I had successfully completed my fourth colonoscopy since 2003. Needless to say, I instinctively poured myself another cup of java and continued reading.

Previous evidence suggested that coffee may help lower the risk of mortality, in addition to several chronic diseases, possibly due to its ability to fight inflammation and insulin resistance. Coffee contains anti-carcinogenic compounds that can benefit us in other ways. Although this newest finding cannot claim causality between drinking coffee and reduced mortality risk, the findings are nevertheless encouraging and are worth further exploration.

My grandparents have long since passed away, but what they shared with their grandson some 50 years ago continues to add to the priceless memories I have of them today. Without realizing it, perhaps grandma was ahead of her time regarding coffee’s taste and health benefits!

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Employer-Sponsored Health Insurance – An Impending Decline?

Americans partake in a variety of traditions. We throw tailgate parties, both before and after football games. During Halloween, our tradition involves children going door-to-door begging for candy, using the words, “Trick or treat!” Before Thanksgiving, our president and many state governors will pardon hand-selected turkeys from becoming the next meal. After Thanksgiving, Americans find the energy to start their annual Christmas gift list and go shopping on Black Friday…and/or wait until Cyber Monday.

During this time of year, millions of Americans will also perform the ritual of selecting a health plan for the new year – based on how much the new insurance plan will now cost them. In addition to the increased insurance premiums, Americans are forced to wrestle with climbing deductibles, copayments and out-of-pocket maximums. In some cases, working families are spending more of their income on insurance coverage that may not protect them compared to insurance plans from yesteryear.

Employer-sponsored health insurance is the largest-single source of health coverage in the U.S. – covering more than 150 million American workers and their dependents. By comparison, Medicaid, the second-largest source of coverage, insures about 70 million Americans, or less than half of job-based coverage. Medicare, health coverage for our seniors, covers 50 million Americans. Finally, the other 17 million American who have health coverage are enrolled in the Affordable Care Act marketplaces and individual markets offered in each state.


As mentioned, adults with job-based health coverage are seeing higher deductible and out-of-pocket costs compared to prior years. In fact, relative to their income, a recent Commonwealth Fund report has found that working Americans are effectively “underinsured” – they spent more than 10 percent of their income, excluding premiums, on healthcare; spent more than five percent if they were low income; or they had a medical deductible that exceeded five percent of their income. According to the report, this is more than double what it was in 2003, and up sharply from just three years ago (2014).

The major factor for the rise in the underinsured is that employer plans (both small and large employers) are increasingly fighting rising healthcare costs by super-sizing their deductibles to keep the cost of premiums relatively reasonable. Commonwealth estimates that the number of ‘underinsured’ American adults (ages 19 to 64) is 41 million, or 28 percent of U.S. adults. This number is double the rate in 2003 and is up by 10 million since 2014.

In the U.S., health spending increased by 4.3 percent in 2016, outpacing overall spending for goods and services, which increased by 2.8 percent that same year. Additionally, healthcare costs continue to grow faster than American workers’ wages. Over time, this cost pressure recedes the workers’ paychecks, which negatively impacts other purchases workers need or desire to make. In Iowa, as an example, the average deductibles offered by employers has increased drastically, up 185 percent between 2004 and 2016. Using a linear regression equation, the average single and family deductibles could climb to $2,000 and $4,500 respectively, by the year 2020.

Despite being large purchasers of healthcare services for employees and their dependents, employer-sponsored plans run the long-term risk of being unable to control rising healthcare costs – which can exacerbate the rising discontent workers have of paying more but getting less in return. Unfortunately, employers seldom work together to increase their leverage with health providers – primarily due to employers lacking the staff and expertise to combat the complexities of healthcare markets. First and foremost, employers are in the business of focusing on their own core products and services and the associated challenges found within the markets they operate. By fiat, insurance companies continue to play the role of the purchaser on behalf of most employers and their employees.

Employee Discontent?

What will the future hold if more workers become dissatisfied about their receding take-home wages? Dr. David Blumenthal, President of the Commonwealth Fund, recently wrote: “With that discontent will likely come increased calls for dramatic reforms in our health insurance system, reforms that will better protect the millions of Americans who have long depended on protections they receive in the workplace. Some of these discontented Americans may become more receptive to government interventions in private health insurance markets.”

Assuming this discontentment is real, and it appears to be, employers will need to find new approaches to apply additional leverage when making future health coverage purchasing decisions. Being a reluctant purchaser may only prolong the inevitable. For employers, there’s no better time than the present to engage in activities that will provide value for their workforce. Otherwise, external cost pressures may eventually jeopardize health coverage at the workplace.

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