6 AM Pacific

Why Pre Existing Conditions Must Go

In response to my previous post on healthcare reform, a reader writes in from India

…Why should an insurer agree to insure a pre-existing condition? It does not make sense to expect a business to agree to a proposition wherein it knows it will have to pay out 10x on a premium of x….

Insurance by its very definition is protection against the unknown. If the condition and its medical costs are known why take such a customer on board?

Methinks that the reason insurance premiums went up at your small business is because these guys figured out that they will now have to shell out treatment money for everyone and hence they are trying to do a CYA before overall costs go up.

For medical issues, I think either
- a public run healthcare or
- government rights to a percentage of facilities/medicines at institutions that it then distributes among the needy works best.

If there is no government healthcare in the US, it is only logical that average insurance premiums will go up for everyone if the insurance business is expected to mix humanitarian issues with cold-hearted business decisions.

The humanitarian side is actually the governments job. Making money is the private insurance business’s job. Why mix the two?

The main argument the reader makes is perfectly rational. Why should an insurer take on a pre-existing condition when they know they are going to make a loss on it?

They don’t have to today. And that is why we have over 30 million people uninsured. More »

My Personal Tale of Healthcare Insurance

I wanted to get this story out before the Sunday vote in the House. If you believe in healthcare reform, call your Congressman. Most of them will have their offices open tomorrow.

Here’s my personal experience with healthcare from this week. Our healthcare insurer Aetna informed the company that our premiums were almost tripling. For a family of four, our premiums would go up from just over $1000 to over $3000. Why?, we asked. That’s just the way it is, they said. We’re going to have to drop our insurance, we said. Yes, they said, we expected that. And that was that. If you are a business with a small payroll, you and your employees are at the mercy of the healthcare insurer.

So, now I have to go out and get insurance for the family. My wife’s employer, also a small business, offers insurance, but I thought I’d go out and see if I could get insurance directly.

I called Anthem Blue Cross. Nice lady at the other end. Took down all the details. Then we came to pre-existing conditions. I said my son had one and described it. She said that she’d have to put me on hold. She was back in less than 10 seconds. Anthem Blue Cross could not offer any insurance at all. Sorry.

I then called Kaiser Permanente. My wife’s employer offers Kaiser and I thought I’d see if I could something directly with them. Kaiser doesn’t decline on the phone, you have to put in an application, which may be declined (it’s more polite, but everyone spends much more time making and reviewing applications). The guy on the phone was helpful. If you get Kaiser at your wife’s company, take it, was his advice.

Now, we have options. Even if we didn’t have my wife’s insurance, we wouldn’t be out on the streets, if something were to happen. But for many Americans (over 30 million of them) there are no options. If they don’t have a job or they have a job that doesn’t offer insurance, and they have a pre-existing condition, they won’t get insurance. Hospitalization in this country can cost $20,000 and up. Which means that they could be just one major illness away from bankruptcy.

Now, about this bill. It’s a very, very long bill. If you really want to understand the issues it tackles, go read Ezra Klein. But basically it boils down to a few things. Health insurers should not be able to deny insurance based upon pre-existing conditions. It also bans recissions (kicking an insured person out) and life time caps (another cute trick to limit payouts). To make this work for insurance companies there has to be an individual mandate (everyone must get insurance).

Six months after the bill is passed, denying insurance based upon pre-existing conditions for children will become illegal. That’s when I’m going to call Anthem Blue Cross again. I can only imagine how many people are waiting with far more desperation for that six month boundary to be crossed.

Here’s where you find out who to call http://www.congress.org/

If you are calling right now, call your Congressman. If you read this blog, and you live in the US, you probably have a nice job and healthcare at work. If I were you, here’s what I would say to his or her aide on the phone:

Congressman (or Congresswoman) I have a nice job and healthcare insurance. I am calling you in spite of the fact that I have nothing to gain if this bill passes. That’s because I feel for those people who do not have insurance today or can’t get it. We cannot be a great country if we let our people sink into misery because we’ve let healthcare become the monster it is today.

Please fix healthcare by voting yes on healthcare reform.

Make Work Homework

A few years ago my son who is now in middle school got some vocabulary homework for English. It was a pretty long list of words. He was supposed to write the meaning of each word and then use it in a sentence. And then, get this, draw or download a picture from the internet that illustrates the word. The homework took thrice as long as it would have without the illustrations.

Now if you think about it, if the child has learnt to use the word in a sentence, there is little value in an illustration. Especially, since most of the words pertained to intangible things like “blatant”. If it were an art class I can still see some value in an exercise where students reflect and then draw a picture depicting “blatant”. But not for 50 such words and not for an English class.

There is a phrase for this kind of work. Its called “Make Work”. Basically teachers are giving homework just to make up the 3 hours or whatever of homework they need to give per day. Like many issues, there is economics behind Make Work Homework.

Public schools and most private schools in the US have a student-teacher ratio that has gotten higher and higher over time. Obviously, there are cost reasons for this. The primary driver of cost efficiencies in a school is the average number of students in a class.

A teacher spends time on preparing for class, grading homework and other small activities. The time required for preparing for class does not vary by the number of students in class. It also goes down with experience. But grading homework varies directly with the number of students. And it can add up to quite a lot of work. If the teacher is hard pressed for time, she can’t reduce the amount of homework given to students. But she can give the kind of homework that takes less time to check. The example I cite above is exactly that kind of homework – with asymmetric workloads for student and teacher.

I believe this is the root cause of Make Work Homework. It takes a lot of time for the student to draw an illustration and very little to eyeball it while grading. This asymmetry works in favor of the teacher. She can give the prescribed amount of homework and still keep her grading workload low.

This is not to say that anything requiring an illustration is Make Work. Not at all. Sometimes it is absolutely necessary. Visual learning can be very powerful. And sometimes it can be justified with the argument that children learn in different ways and at different paces. What may seem like gratuitous drawing and coloring to one student may be essential reinforcement of what is being taught in class for another student.

But a lot of what passes as homework for our children, is the product of a teacher trying to reduce his workload.

Copenhagen – the Mother of all Negotiations

Who hasn’t been in a tough negotiation? If nothing else, negotiating with your kids can often be most difficult. But the negotiations at Copenhagen summit and next year on climate change are going to be the hairiest negotiations you can ever imagine.

An FT article [pay wall] shines some light on why the negotiations were so difficult. The biggest reason is of course that these are multi-lateral negotiations. And different groups have different interests. Developed countries want developing countries to make commitments on emission reductions while not over committing themselves. They also want transparency in developing country emission measurement.

Developing countries don’t want emission reductions to get in the way of development. They want developed countries to pay for clean technology.

There are a also a whole bunch of developing countries in Africa who are not significant emitters but will feel the brunt of climate change. They have nothing to give in the negotiations but a lot is at stake for them.

And then there are also a few heads of state like Chavez, Morales and Ahmadinejad, who simply use the stage to take potshots at the US and the West. But they still have to be invited to party.

Obviously, 170 independent actors can never achieve any consensus. So groups were formed. US, UK, Germany, France as representatives of the developed countries and China, India, Brazil and South Africa as representatives of the developing world. But this still wasn’t enough to get an agreement. The bulk of the world’s emission in the next 20 years is going to come out of the US and China. If only these two countries had sat down and thrashed it out, we would have had a deal.

The world is not going to be happy with their leaders if they don’t put their shoulders to the wheel and get a deal together soon in the new year.

The Numbers Behind the Numbers

This week’s big news was that the US economy lost the fewest jobs in a month since the beginning of the recession. There were reams and reams of news and opinion on the matter. Quotes from the White House, Republicans, Democrats, Wall Street and Economists. But I got stuck on the third paragraph of the first news item that I read on the matter on NYT

In the best report since the recession began two years ago, only 11,000 jobs disappeared last month, the government said on Friday, and the unemployment rate actually dipped, to 10 percent, from 10.2 percent the previous month.

What’s the math that allows the unemployment to go down when 11,000 jobs were lost? Did the denominator suddenly go up? Did all the returning Indians suddenly decide to go back to the US like Shiva Ayyadurai?

The answer seems to be

Not only did the rate of job losses drop to 11,000 but losses in the previous two months were revised down by 159,000.

which is not really offered as an explanation but as an aside by FT. But the numbers look like they should be able to explain the drop in unemployment. Does anybody have the official explanation?

Economics by its nature is complex. Good reporting should make it more accessible. Not leaving obvious questions unanswered would be a start.

Here’s How You Manage Healthcare Costs

There is a terrific piece in the WSJ today about Narayana Hrudalaya and Dr. Devi Shetty called The Henry Ford of Heart Surgery. Narayana Hrudalaya has successfully “mass produced” heart surgery, in the process reducing its price by an order of magnitude. More »

Wall Street Bonuses are Not the Real Issue

This month the biggest Wall Street companies reported their quarterly earnings. JP Morgan Chase and Goldman Sachs reported bumper earnings, Citgroup and Bank of America, not so good. But if you leave out write downs on debt, everyone had a great quarter in their capital markets businesses. Billions have been budgeted for year end bonuses.

As could be expected, the issue of Wall Street compensation raised its head again. And this time there is the weight of the federal government behind it. Banks that have taken TARP money will see their executive compensation capped. And the Federal Reserve has suggested that all large banks that fall under its jurisdiction will be reviewed on on going basis to ensure that executive bonuses do not produce risk taking behavior that could put the banking system at risk.

There are several memes that get mixed up in any discussion about Wall Street compensation in the media. Add a lot of emotion from a distraught public and it becomes for a tangled mess where the media feeds the furore but there’s no real understanding of the underlying issues. Let’s see if we can parse the issues out. More »

Financial Transaction Tax

Philippe Douste-Blazy, the Chairman of Unitaid and the former French foreign minister writes in an op-ed in the New York Times about how the world could come up with the funds to meet the United Nations Millennium Development Goals

The one untapped source that could easily provide the amount of money needed is the foreign currency market, which handles almost $800 trillion in trades annually, all of which is untaxed. A tiny levy of 0.005 percent on transactions involving the world’s most traded currencies — the dollar, the euro, the pound and the yen — would raise more than $33 billion annually for development, while not hurting the market or affecting the average international traveler.

More »

What’s So Difficult About a Gas Tax?

Tom Friedman in his latest column Real Men Tax Gas writes about a gas tax that could potentially fund healthcare, reduce the deficit and still have some leftover to make it up to people who can’t afford the tax:

Such a tax would make our economy healthier by reducing the deficit, by stimulating the renewable energy industry, by strengthening the dollar through shrinking oil imports and by helping to shift the burden of health care away from business to government so our companies can compete better globally. Such a tax would make our population healthier by expanding health care and reducing emissions. Such a tax would make our national-security healthier by shrinking our dependence on oil from countries that have drawn a bull’s-eye on our backs and by increasing our leverage over petro-dictators, like those in Iran, Russia and Venezuela, through shrinking their oil incomes.

More »

Does Complexity Have Regressive Social Effects?

I have written about the virtues of simplicity in business before. But when I look around things are getting more and more complex.

Take the tax code for instance. The US tax code is so complex it is almost impossible to deal with for the average tax payer. An example of this is the Flexible Spending Account.

The FSA is supposed to give the tax payer a tax deduction on healthcare expenses that are not covered by their health insurance. It includes deductibles, co-pays and some kinds of health care expenses that are typically not covered by health insurance.

So far there’s not much you can object to. But the implementation is where it gets tricky. At the beginning of the year the employee must elect the amount to be deducted from their pay towards funding their FSA account. They can’t spend more than what is pre-funded in their accounts. If they spend less, they lose the money!

To me this seems hare-brained. If you are expenses go way over say because of some dental surgery expenses where the copays are high, you are out of luck if you didn’t foresee this at the beginning of the year. If your expenses are well under at the end of the year, you either lose the money or in the last month go hog wild buying OTC drugs that you don’t need. Who wants to see their own money go waste?! More »