Archive for the ‘Healthcare’ Category

Religion Inc.

Thursday, July 3rd, 2014

samuel-alito-jr-2009-9-29-10-13-28Is Justice Samuel Alito really that clueless? During the 2010 State of the Union address, he nervously mouthed the words “not true” when President Obama warned that the Supreme Court’s Citizens United ruling would allow corporate special interests to dominate U.S. elections. A few days ago, Alito wrote an outrageous opinion in the Hobby Lobby case affirming the religious rights of corporations but insisting this would not do much other than prevent a few companies from having to include several kinds of birth control in their health insurance plans.

Alito’s claim about the narrow scope is already beginning to unravel. Although the written opinion suggested that only four types of contraception such as IUDs that religious zealots view as tantamount to abortion would be affected, the Court subsequently ordered lower courts to rehear cases in which employers sought to deny coverage for any form of birth control.

Business owners with other religious views contrary to federal policy will undoubtedly soon speak up. This is exactly what Justice Ginsburg warned about in her powerful dissent, calling Alito’s opinion “a decision of startling breadth” that enables “commercial enterprises, including corporations, along with partnerships and sole proprietorships, [to] opt out of any law (saving only tax laws) they judge incompatible with their sincerely held religious beliefs.”

Alito was apparently so shaken by Ginsburg’s accusation that he felt a need to deny it at length. The denial is not only unconvincing, it is clumsy and takes Alito into some strange territory for a supposed business-friendly conservative.

In their religious zeal, Alito and the other conservatives on the Court apparently forgot that corporations have been trying for the past century to depict themselves as totally apart from religious and moral concerns. Business enterprises are amoral institutions, laissez-faire proponents such as Milton Friedman repeatedly told us—they exist only to maximize their profit. It has often been corporate critics who have brought religious and moral issues into disputes over business practices.

Alito seems to embrace the notion of corporate social responsibility (CSR) when he writes (p.23):

Modern corporate law does not require for-profit corporations to pursue profit at the expense of everything else, and many do not do so. For-profit corporations, with ownership approval, support a wide variety of charitable causes, and it is not at all uncommon for such corporations to further humanitarian and other altruistic objectives.

Alito even makes reference to growing acceptance of the benefit corporation, which he describes as “a dual-purpose entity that seeks to achieve both a benefit for the public and a profit for its owners” (p.24).

It’s unclear whether Alito sincerely believes in the validity of CSR initiatives or is simply using this comparison to try to make his assertion of corporate religious rights more palatable. Oddly, he describes as “unlikely” the possibility that a large publicly traded company would ever make a religious claim, even though such firms are among the biggest promoters of CSR.

Whatever Alito really thinks, his reference to CSR does not make the ruling any more convincing. CSR is already problematic to the extent that its practitioners try to use their supposedly high-minded voluntary initiatives to discourage more stringent and more enforceable government regulation. But at least these corporations are simply trying to influence government policymaking rather than asserting an absolute right to be exempt because of supposed religious convictions.

As much as Alito tries to deny it, his ruling has the potential to cause a great deal of mischief. A religious component can already be seen in the climate crisis denial camp; what will prevent companies from asserting that their beliefs prevent them from complying with environmental regulations? Is it that hard to imagine that business owners holding a scripture-based belief that women should be subservient to men may claim they should not be subject to anti-discrimination and equal pay laws?

Alito seems to be opening the door to such aggressive stances when he insists that “federal courts have no business addressing” the question of whether a religious claim by a corporation is reasonable (p.36). It’s true that, in general, government should not be passing judgment on matters of faith, but that principle falls apart when special interests try to use religion to undermine democratically adopted public policies. It’s even worse when those interests are employers asserting their beliefs at the expense of their workers.

The Supreme Court has done considerable damage by elevating the free speech rights of corporations; now it is compounding the sin by giving those corporations special religious rights as well.

Will Big Pharma Cripple Healthcare Reform?

Thursday, April 24th, 2014

big-pharma-pills-and-moneyFor those of us who criticized the Affordable Care Act for not going far enough, a big part of the concern was the law’s reliance on the private insurance industry to handle much of the expanded coverage. That industry, with its history of denying coverage and inflated premiums, deserved to be phased out rather than being awarded a large new captive customer base.

It now looks like an even more serious problem for healthcare reform will be another industry with a checkered past: Big Pharma. The drugmakers are generating a growing crisis not only for Obamacare but also for more established programs such as Medicare and Medicaid.

When the federal government recently released data on Medicare billings by individual providers, many of the top amounts were linked to doctors who administer expensive drugs in their offices and thus include the cost of those treatments in their Medicare claims. For example, some 3,000 ophthalmologists billed an average of $1 million each (one billed $21 million by himself), reflecting heavy use of an expensive medication for macular degeneration injected into the eye.

Another challenge comes from Sovaldi, a new hepatitis C drug sold by Gilead Sciences with a list price of $1,000 per pill, or $84,000 for a typical course of treatment. The product is doing great things for Gilead, which recorded $2.3 billion in sales for the drug’s first full quarter on the market — a pharmaceutical industry record.

It is causing problems for those entities that have to pay for use of the drug, including state Medicaid programs, the Department of Veterans Affairs and private insurance companies. One of the largest of those companies, UnitedHealth Group, recently cited the cost of hepatitis C treatments such as Sovaldi as one of the reasons for a drop in its earnings in the first quarter of 2014.

Earlier, several members of Congress, including Rep. Henry Waxman of California, sent a letter to Gilead expressing concern about the price of Sovaldi, but it generated little concern on the part of the company or the rest of the industry. One pharma industry analyst was quoted as saying: “We just look at this letter as a little bit of noise.”

Unfortunately, the dismissive tone was justified. Congress has done little to rein in the cost of prescription drugs and even took the absurd step of barring the federal government from negotiating with pharmaceutical providers in the Medicare Part D program.

The cost problem will only get worse. Patents are expiring on many major drugs, and the industry is creating fewer new ones, prompting companies to squeeze everything they can out of their shrinking product lines.

That means higher prices and other shady practices such as promoting drugs for uses for which they have not been approved. Many of the industry’s largest companies have paid large amounts to settle illegal-marketing charges brought against them by the Justice Department, among them Eli Lilly ($1.4 billion relating to Zyprexa), GlaxoSmithKline ($3 billion relating to Paxil and Wellbutrin) and Pfizer ($2.3 billion relating to Bextra and other medications).

Illegal marketing is just one of the serious charges brought against Big Pharma in recent years. The $3 billion GlaxoSmithKline settlement also covered allegations that it withheld crucial safety data on its diabetes drug Avandia from the U.S. Food and Drug Administration. Merck paid the federal government more than $650 million to settle charges that it routinely overbilled Medicaid and other government programs and made illegal payments to healthcare professionals to induce them to prescribe its products. Eli Lilly paid $29 million to settle foreign bribery charges.

It remains to be seen whether these cases have prompted Big Pharma to clean up its act. I remain skeptical, especially in light of recent signs that the industry is engaged in more concentration designed to allow companies to narrow their focus and thus gain bigger market share in particular sectors.

More specialization will mean less competition, which in turn will mean fewer choices and rising prices. When it comes to drugs, the Affordable Care Act will have increasing difficulty living up to its name.

Healthcare Redlining

Thursday, February 13th, 2014

Protest-against-insurance-companies-in-Washington_3951547284_m-250x176Media coverage of the Affordable Care Act these days bounces back and forth between good news and bad. One day the Obama Administration signals that there are more problems with the employer mandate and once again changes the rules. Two days later, federal officials are bragging that ACA enrollment is booming and that even the Young Invincibles are signing up.

Yet perhaps the most significant recent development is the analysis just published by the Wall Street Journal on the limited range of plan options in the ACA exchanges. The newspaper found that in 515 counties across 15 states there is only one insurer selling coverage through the online marketplaces. In more than 80 percent of those counties, the sole insurer is a local Blue Cross/Blue Shield plan.

For the residents of those counties who seek coverage through the exchanges, the ACA is forcing them to do business with a de facto monopoly that can get away with charging inflated premiums. The Journal cites the example of rural, low-income Hardee County in Florida, where comparable exchange-based coverage can cost $200 a month more than in nearby Tampa.

The ACA is premised on the idea that competition would bring down costs and provide better coverage. The Administration and most Congressional Democrats bought into that notion so deeply that they were willing to exclude a public option as unnecessary. That decision looks increasingly bone-headed.

It is true that those who qualify for federal subsidies may be shielded from the cost differentials, but a substantial portion of the uninsured earn too much to qualify for that assistance but are still far from affluent.

A big part of the problem is that major for-profit insurers such as Aetna and UnitedHealth Group have been participating in the exchanges on a very selective basis. The Journal noted that Aetna, for instance, has “targeted areas with stable levels of employment and income to attract desirable customers to its marketplace offerings.”

This is, to put it mildly, infuriating. The ACA was supposed to put a stop to the tendency of Aetna and the other insurance giants to decline coverage to certain categories of people, usually because of pre-existing medical conditions. Now the insurers were supposed to take on all comers, with the federal government functioning in essence as their marketing arm.

It turns out that the national insurers had found another way of cherry-picking. They are simply choosing not to participate in the ACA market in less affluent parts of the country, where they apparently assume that residents are going to have too many medical needs. In a presentation to investors, Aetna admitted that it was participating in exchanges in fewer than one-third of the states.

The decision to limit the scope of their involvement does not result from any financial distress on the part of the major players. In recent weeks Aetna, Humana and Wellpoint have all reported healthy gains in profits for 2013. The big boys are also getting bigger. Aetna swallowed competitor Coventry Health Care, which added $14 billion to its annual revenue stream.

For those of us who advocated a single payer approach, or at least a public option, the behavior of the insurance companies comes as no surprise. These companies have always found ways to increase profits at the expense of coverage, and they always will. Now that they cannot discriminate explicitly against those in poor health, they will discriminate against communities in which think there is likely to be larger numbers of less healthy residents. It is an insidious new form of redlining.

It is disappointing that the Obama Administration, which is going to such great lengths to help businesses adjust to the ACA, seems to have little inclination to help individuals contend with the substandard offerings in some of the exchanges.  For them the Affordable Care Act may be far from affordable.

Challenging Wal-Mart’s Freeloading Ways

Thursday, November 21st, 2013
from Cleveland.com

from Cleveland.com

Countless words have been published about the retrograde labor practices of Wal-Mart, but none of that writing conveyed as much as the short message recently reported to have been taped to a bin in an employees-only area at one of the company’s stores in Ohio: “Please donate food items here so Associates in Need can enjoy Thanksgiving Dinner.”

My first reaction was that this was a stunt staged by the Yes Men to embarrass the giant retailer. Yet it was all too real. In fact, a corporate spokesperson saw nothing amiss, saying it showed how much the company’s employees care about each other. No doubt they do, but the problem is that Wal-Mart is so deliberately obtuse about its obligation to provide a decent living to those on its payroll.

Leaving it to hard-pressed workers to support their colleagues is just one of the ways Wal-Mart shifts its costs to others. The company puts a much bigger burden on taxpayers, who end up paying for the healthcare coverage that so many of its employees must get from public programs such as Medicaid.

In the early 2000s some states began to disclose which employers accounted for the most low-wage workers and their dependents in these programs. Wal-Mart was invariably at or near the top of these lists. (See the Good Jobs First compilation here.)

Unfortunately, fewer of these lists are being released (and the Affordable Care Act will apparently do nothing to help). Yet the few recent disclosures show Wal-Mart is still creating more of these hidden taxpayer costs than any other company. For example, in July the Dayton Daily News obtained data from the Ohio Department of Job and Family Services indicating that Wal-Mart had more employees or household members on Medicaid or food stamps than any other employer in the state. The most recent compilation of employers accounting for the largest number of recipients in Connecticut’s Husky program (its version of Medicaid) also had Wal-Mart as number one.

Another approach was taken in a recent report by the Democratic staff of the U.S. House Committee on Education and the Workforce, which estimates that the workforce of a typical Wal-Mart Supercenter costs taxpayers some $250,000 a year for Medicaid services (as part of at least $904,000 a year in overall federal safety net costs per store).

These hidden costs are not the only way Wal-Mart sticks taxpayers with the bill. The company has traditionally also been shameless in demanding special tax breaks and other forms of financial assistance when it opens a new store or distribution center. My colleagues and I at Good Jobs First have been tracking this practice since 2004, when we published a report estimating that the company had collected some $1 billion in such subsidies. We later updated the report, finding that the total had risen to $1.2 billion, and we assembled all the data in a website called Walmart Subsidy Watch.

In many of its more controversial urban siting efforts in recent years, Wal-Mart has put less emphasis on special subsidies, which we like to think is because we made the practice more radioactive. Yet the company cannot resist its giveaway demands entirely.

Recently, for example, the company sought tax breaks totaling some $5.4 million for a Supercenter and Sam’s Club it is proposing to build in the Chicago suburb of Tinley Park. Thankfully, the plan was shot down by the board of the Summit Hill School District, which took its vote after a hearing in which one resident described Wal-Mart as a “corporate monster.”

In Texas, however, Wal-Mart seems to be on track to receive a property tax abatement worth $3 million in connection with its plan to build an e-commerce distribution center near Fort Worth Alliance Airport. (For other recent awards, see the company’s entries in the Good Jobs First Subsidy Tracker database, which covers all companies; be sure to search under the official corporate name Wal-Mart as well as the brand name Walmart).

The spirit of the Summit Hill School District is reflected in the activism of rank and file workers, who with the assistance of OUR Walmart are planning to resume protests at company stores on Black Friday. Their efforts will help replace food drives with a living wage and eventually get Wal-Mart to change all its freeloading ways.

Where Healthcare’s Bare Bones are Buried

Wednesday, November 6th, 2013

junk_insurancePresident Obama may very well have blundered in leaving out the nuances when he pledged during the Congressional deliberations over the Affordable Care Act that “if you like what you have, you can keep it.” Yet it would have been difficult to anticipate in 2009 that only a few years later the opponents of the ACA would succeed in creating an atmosphere in which much of the public has been made to believe that the government can do nothing right and the private sector nothing wrong when it comes to healthcare reform.

It is amazing how little attention is being paid to the insurance companies whose cancellation notices are what created the current furor over Obama’s supposed betrayal. These companies, with the encouragement of penny-pinching employers, created the substandard plans that must now be eliminated to comply with the minimum coverage provisions of the ACA.

One of the original culprits was Aetna, which in 1999—not long after merging with the controversial HMO pioneer U.S. Healthcare, introduced one of the first bare-bones plans under the name Affordable HealthChoices. The plan, put forth as way to reduce the ranks of the uninsured, was rolled out with the support of groups such as the U.S. Chamber of Commerce and the National Federation of Independent Businesses, which were eager to have an alternative to greater government involvement in healthcare coverage.

Affordable HealthChoices was indeed more affordable than conventional insurance, but that was because it was full of holes.  At the time of Aetna’s announcement, the Wall Street Journal (5/4/1999) quoted consumer advocate Ron Pollack of Families USA as saying: “The bottom line for anybody who buys [this plan] is, ‘Don’t get sick,’ because if you get sick you are going to wind up with enormous bills.” Some states barred Aetna from selling the plans.

Another proponent of cut-rate coverage was Wal-Mart, which in the early 2000s, was putting its workers in plans with deductibles that were far above the norm and which excluded many kinds of preventive care. In many cases, the plans did not pay for any treatment of pre-existing conditions during the first year of coverage (Wall Street Journal, 9/30/2003). These provisions, along with premium costs that were difficult for many of the company’s low-wage workers to handle, prompted many Wal-Mart employees to turn to taxpayer-funded programs such as Medicaid. Nonetheless, Wal-Mart touted its high-deductible approach as a model for other employers.

Unfortunately, other companies followed Wal-Mart’s lead. By 2006 there were estimates that nearly one million people had enrolled in what were often called mini-medical plans, while millions more were in plans with more extensive benefits but high deductibles. Other major insurers such as WellPoint, UnitedHealth Group, Cigna and Coventry (now owned by Aetna) jumped into the market to sell what Consumer Reports has called “junk insurance.”

These companies targeted their bare-bones offerings not only at parsimonious companies but also at those with no employer coverage who turned to the individual insurance market, especially younger people more inclined to take a chance on getting by with catastrophic benefits.

Mini-meds contributed to the epidemic of bankruptcies among people with serious health conditions and helped drive home the reality that underinsurance was becoming as serious an issue as those who lacked coverage entirely.

This threat was highlighted by Democrats on the Senate Commerce Committee, led by Jay Rockefeller of West Virginia, who held a hearing in late 2010 entitled “Are Mini Med Policies Really Health Insurance?” Sen. Rockefeller took special aim at the mini med offered by McDonald’s, which capped benefits at $2,000 per year. At the hearing several Aetna customers described how they were covered for only a small portion of their expenses when they had major health problems. For example, a woman who had to go to the emergency room when she lost feeling in one of her arms and ran up more than $16,000 in bills received only $500 in coverage from Aetna.

The ACA was designed to reduce the number of people in bare-bones plans, but the law did not call for their complete elimination. Insurers can no longer cap the dollar value of annual benefits, but strange as it sounds, larger employers can offer low-cost plans that exclude categories of coverage such as hospitalization and still qualify under the new law. In other words, the real problem may be that not enough policies are being cancelled.

Whatever falsity was involved in President Obama’s pledge does not begin to compare with the deception practiced by insurance companies and miserly employers when they make holders of bare bones policies think that they have something that deserves to be called coverage.

Note: This piece draws from my new Corporate Rap Sheet on Aetna, which can be found here.

UnitedHealth Group Haunts Obamacare

Thursday, October 31st, 2013

unitedhealth_100121_mnKathleen Sebelius’s “hold me accountable” line at the latest House hearing on the botched rollout of Healthcare.gov was a deft political move. It flummoxed Republican interrogators who expected the HHS Secretary to pass the buck.

Yet the line was dismaying in that it continued the Obama Administration’s practice of deflecting most criticism away from the contractors that were responsible for building the portal, at a cost of hundreds of millions of dollars.

Not only have the contractors been shielded, but one of those at the center of the debacle was just chosen to head up the rescue of the project. In the world of government outsourcing, failure is no impediment to getting rehired with even more responsibility.

The anointed company is QSSI, previously an obscure player in the world of healthcare IT. What makes the kid-glove treatment of this firm all the more galling is that QSSI is owned by UnitedHealth Group, also the parent of UnitedHealthcare, one of the two behemoths (the other is WellPoint) of the private health insurance industry.

In other words, one of the large corporations that the Affordable Care Act is propping up (despite their abysmal record) is now profiting from cleaning up the mess that one of its unit caused in trying to create a system designed to help people enroll in plans sold by its own parent company and its competitors.

If this were not bizarre enough, it is worth recalling that this is not the first time a UnitedHealth subsidiary has been involved in a scandal involving a healthcare database. In 2008 the company’s Ingenix unit was the target of allegations that its tool for determining how much patients should be reimbursed for out-of-network medical expenses was seriously flawed. Then-New York Attorney General Andrew Cuomo brought suit against UnitedHealth, calling the widely used Ingenix database part of a scheme to “to deceive and defraud consumers.”

In 2009 UnitedHealth settled with Cuomo by agreeing to spend $50 million to build a new database and then agreed to pay $350 million to settle class action lawsuits that had brought over the issue. Ingenix subsequently changed its name to Optuminsight, which by the way is now the parent of QSSI.

Another UnitedHealth subsidiary, Lewin Group, has generated controversy of another sort: presenting itself as an impartial healthcare consulting company when it is part of a corporation with a big vested interest in the policy options Lewin evaluates. During the Congressional deliberations over healthcare reform in 2009 Lewin produced analyses concluding that the adoption of a public option would result in a mass exodus from private plans and jeopardize their future. A Lewin executive made the alarmist statement that the private insurance industry “might just fizzle out altogether” and helped to sway lawmakers to omit the option from the Affordable Care Act. Like QSSI, the Lewin Group is a unit of Optuminsight.

UnitedHealth is also tied to what is emerging as the new focus of anti-Obamacare rage: reports that insurance companies are cancelling large numbers of policies. This is being portrayed as a betrayal of Obama’s earlier promise that people with coverage would be able to keep it. Yet what is really going on is that insurers are complying with provisions of the ACA that bar them from continuing to sell substandard policies.

Those policies—with huge deductibles and big holes in coverage—were sold not only by fly-by-night companies. Aetna, for example, was pushing these bare-bones plans as early as 1999. UnitedHealth Group made a big push into this market in 2003 when it acquired Golden Rule Financial, which specialized in low-cost individual plans, for $500 million. The spread of such policies was one of the main justifications for healthcare reform.

The repeated appearances of UnitedHealth subsidiaries amid the tribulations of the ACA are reminders that the Obama Administration made a Faustian bargain with the private sector in designing healthcare reform. The question now is whether it can reclaim its soul.

Note: This piece draws from my new Corporate Rap Sheet on UnitedHealth Group, which can be found here.

The Outsourcing Customer is Always Wrong

Thursday, October 24th, 2013
Image from OptumInsight website

Image from OptumInsight website

The corporate executives who testified at a House hearing on the botched rollout of the federal healthcare portal apparently sprayed themselves with Teflon before heading to Capitol Hill. Blame for the fiasco did not stick to these contractors as Republican members of the Energy & Commerce Committee sought to implicate the Obama Administration and the Democrats focused on defending the Affordable Care Act.

Representatives from four contractors — CGI Federal, QSSI, Serco and Equifax — took advantage of the situation by denying any serious shortcomings on their part. In fact, they each claimed that their individual pieces of Healthcare.gov were working fine and claimed to be puzzled as to why the overall system was not working properly. When pressed, they implied that the federal agency that had commissioned their work — the Centers for Medicare and Medicaid Services — had not given them adequate time for testing. In other words, they acted as if they were innocent bystanders at someone else’s train wreck.

Yet these were companies that received the lion’s share of the lucrative contracts awarded by CMS for the creation of the federal portal. CGI and QSSI alone received a total of $143 million. They were not the people who delivered the Chinese food or emptied the wastebaskets while the real work was being done by others.

These contractors present themselves quite differently when touting their services. On its website, CGI brags: “With deep experience in developing and integrating business, clinical and IT solutions for public and private sector health organizations across Europe and North America, CGI helps clients anticipate challenges and achieve real transformation.” Speaking specifically about health insurance exchanges (HIX), the site says: “Because exchanges must provide many different functions, the soundest approaches bring together expertise and best practices in federal and state health programs, commercial insurance, data exchange, portals, e-commerce over the cloud, and financial management. CGI brings all of this expertise to the table, along with direct experience in developing sustainable HIX programs.”

Similar boasts are made by QSSI, which stands for Quality Software Services Inc.: “Bringing together the most talented personnel in the industry, QSSI collaborates with both the public sector and private sector to maximize performance and create sustainable value for our customers.” The website of QSSI’s parent OptumInsight declares: “We’re making the most of our leadership position in health and human services technology by helping to transform government agencies into efficient, cost-effective programs with decision support, informatics, and program analysis.”

There is a special irony in the presence of QSSI and OptumInsight at the center of this scandal. OptumInsight, which purchased QSSI last year, is a unit of UnitedHealth Group, whose UnitedHealthcare unit is one of the country’s largest health insurance providers.

In other words, one of the for-profit insurers that the Affordable Care Act went to such great lengths to preserve — despite their countless abuses — is closely linked to the mess surrounding the web portal that is supposed to help people in 36 states sign up for the coverage that it and its counterparts will provide.

Last year Iowa Sen. Chuck Grassley and House Energy Chair Fred Upton, both Republicans, raised questions about potential conflicts of interest in the wake of UnitedHealth’s purchase of QSSI, but that issue seems to have been forgotten in the quest to blame the Obama Administration for all the ills of Healthcare.gov. Also largely overlooked is the fact that the Inspector General of the Department of Health and Human Services has criticized QSSI, whose employees have access to sensitive information on individuals, for not sufficiently implementing CMS security protocols with regard to thumb drives.

In his testimony before the House Energy committee, Andrew Slavitt of QSSI’s parent company, said: “We do understand the frustration many people have felt since Healthcare.gov was launched,” yet he in effect denied any responsibility for causing that frustration.

So it goes in the world of outsourcing: the customer is always wrong and the company, whatever its shortcomings, gets off scot free.

The Beltway Bandit Behind the Healthcare.gov Debacle

Thursday, October 10th, 2013

Healthcare.gov website downA January 2011 article in Canada’s Globe and Mail was headlined “CGI Spies Opportunity in Obama’s Call for Efficiency.” A new story in the same newspaper about the same company has the title “Canadian IT Firm at Centre of Obamacare Foul-Up Furor.”

U.S. critics of the Affordable Care Act are depicting the widespread computer problems that have accompanied the launch of the ACA’s online healthcare exchanges as a major government failure. To be more precise, it is a failure of government contracting. And the contractor at the center of the mess is CGI Group, a Canadian outsourcing corporation that is little known outside information technology circles.

According to a Government Accountability Office report published in June, CGI’s U.S. subsidiary CGI Federal received the largest share (totaling $88 million) of the contracts awarded for the creation of the Healthcare.gov website, the ACA enrollment portal in the 36 states that declined to create their own exchanges. That report, by the way, warned of possible “implementation challenges.”

The glitches in the ACA rollout are shining an unfavorable light on the widespread practice by governments at all levels of contracting out information technology to the private sector. The Washington Post just published a front-page story reporting that the federal government, which spends some $80 billion a year on outside IT services, ends up purchasing “outdated, costly and buggy technology.” This may be an indication of cluelessness on the part of federal IT procurement officials, but it is also a sign that the private sector is all too willing to take taxpayer dollars for inferior products.

It is not yet clear whether CGI tried to use sub-standard technology for Healthcare.gov or whether it just failed to meet the challenges of creating a complex new system. The company and the feds are saying little about the reasons for the glitches, preferring to issue assurances that everything will soon be running smoothly.

The Post notes that “Federal officials have not yet explained why CGI was given the contract or why it was awarded on a sole-source basis.” They might also want to explain why the contract was given to a company linked to some earlier contracting scandals.

CGI has built its U.S. operation in large part by acquiring existing federal contractors. One of those was Stanley Inc., which it purchased in 2010 for about $900 million. Two years earlier, Stanley found itself under fire when it was reported that some of its employees working on a contract with the U.S. State Department had improperly looked at the passport records of several Presidential candidates, including Barack Obama.

Stanley was also involved in a controversy over its labor practices at the 400-worker processing center of the U.S. Citizenship and Immigration Services in St. Albans, Vermont. As it was about to assume control over the facility, which handles citizenship applications, Stanley announced that it would change job classifications at the facility, resulting in a pay decrease of about 12 percent for up to half the workers. Vermont Sen. Bernie Sanders called on the Labor Department to investigate what he charged was a violation of the Service Contract Act.

Stanley’s move also prompted a union organizing drive by the United Electrical workers. UE official Chris Townsend told me at the time that Stanley was employing a variety of union-busting tactics—from hiring the union-avoidance law firm Seyfarth Shaw to forcing workers to watch propaganda videos. Townsend said workers were held in captive-audience meetings for up to one-quarter of their shifts in the period leading up to the elections—this at a time when the backlog of citizenship applications was a serious problem. Despite these obstacles, UE managed to win representation elections covering most of the workers. In 2011 the U.S. Department of Labor announced that Stanley (by then owned by CGI) and several subcontractors would pay nearly $2.9 million in back wages for workers who had been misclassified.

CGI itself has also had its share of scandals, including a 2007 furor over a C$400 million contract it received from the Canadian government at a time when the Public Works Minister was Michael Fortier, who had been an investment banker for CGI during his time working for Credit Suisse. A 2010 report by the Hawaii State Auditor found that what was supposed to be a five-year contract awarded in 1999 by the state department of taxation to a company later purchased by CGI had been repeatedly extended through non-competitive awards, costing the state far more than originally planned.

The federal government long ago chose to depend on contractors for its vast information technology needs. That decision periodically results in debacles like those surrounding the rollout of the ACA exchanges. It remains to be seen whether fiascoes will also mar the actual insurance coverage being provided through the ACA, which also relies on the supposedly efficient private sector.

UPDATE: I subsequently learned that in September 2012 the Toronto Star reported that the government of Ontario had canceled a C$46 million contract awarded to CGI to create a diabetes registry after the company failed to meet deadlines.

The ACA Employer Penalty Gap

Thursday, August 15th, 2013

walmart_jwj_subsidiesAlong with the scandalous number of the uninsured, one of the biggest healthcare outrages in the United States is the ability of large companies employing low-wage workers to avoid providing reasonable group coverage, letting those employees enroll instead in public programs such as Medicaid.

Those programs were meant for poor people not in the labor force or those working for marginal employers.  In the absence of any legal obligation to provide workplace coverage, giant prosperous corporations such as Wal-Mart exploit the public programs and thus shift costs onto taxpayers.

A recently updated report by the Democratic staff of the U.S. House Committee on Education and the Workforce estimates that the workforce of a typical Wal-Mart Supercenter costs taxpayers some $250,000 a year in Medicaid costs (as part of at least $904,000 a year in overall safety net costs per store).

One might think that this is going to change under the Affordable Care Act that is gradually taking effect. While the law contains a requirement for individuals to have coverage, there is no real employer mandate to provide that coverage to workers. Instead, the ACA imposes penalties on certain employers for failing to provide affordable and inadequate coverage. Yet there are no fines levied when a boss pushes a worker onto the Medicaid rolls.

In fact, the ACA’s provisions encouraging states to adopt expanded Medicaid coverage, while a good thing for the uninsured, will make it easier for low-wage employers both to avoid providing group coverage and to escape penalties for doing so. This largely overlooked fact is worth keeping in mind when businesses complain about the supposedly onerous employer penalties in the ACA—penalties whose implementation the Obama Administration announced in July will be delayed for a year. (Also being delayed, we just learned, are provisions limiting the out-of-pocket costs insurance companies can impose.)

The ACA’s employer penalties have an exceedingly narrow scope. They will apply only when an employee of a firm with 50 or more full-time workers (the law’s definition of a “large” employer) seeks non-group coverage from an insurance company through one of the new state Exchanges that are being constructed and the employee qualifies for a premium or cost-sharing subsidy based on his or her household income.

Those individual subsidies are available only for workers whose household income is between 100 and 400 percent of the federal poverty line (FPL) for their family size and whose employer either fails to provide any group coverage or provides coverage that is unaffordable or inadequate. Coverage for people in that income range is deemed unaffordable if the premium (for self-only coverage) exceeds 9.5 percent of household income or the plan covers less than 60 percent of medical costs.

This means that employers of people earning less than the FPL or more than 400 percent of the FPL face absolutely no risk of penalties for failing to provide decent coverage, while the workers in those income ranges are denied subsidies from the Exchanges. Those earning less than the FPL may or may not be eligible for Medicaid, depending on the state. Those earning more than 400 percent of the FPL are not eligible for Medicaid in any state.

Penalties may also not apply when “large” employers fail to provide affordable coverage to those in the 100-400 percent of FPL range. That’s because some of those workers will for the first time qualify for Medicaid if they live in a state that accepts the optional federal incentives in the ACA for expanding Medicaid eligibility.

Do those conservative state legislators refusing to go along with Medicaid expansion realize that they are increasing the likelihood that employers will have to pay ACA penalties?

Some concern has been expressed about the potential coverage gap for those low-income families which are not eligible either for an Exchange subsidy or Medicaid, but much less attention has been paid to what amounts to an employer penalty gap.

A primary aim of the ACA is to reduce the ranks of the uninsured, but the rejection of a single-payer system means that workplace-based coverage needs to be strengthened. That should have meant a rigorous employer mandate. Instead, the ACA went with a pay-or-play system whose penalties turn out to be full of holes. Companies such as Wal-Mart may thus find it easy to continue shifting their healthcare costs onto the public.

At the state level, one of ways activists have sought to fight such cost-shifting has been to push for the disclosure of data showing which companies account for the largest number of enrollees in Medicaid and other public plans. Such shaming lists have been published for about half the states, with Wal-Mart or McDonald’s typically appearing at the top.

The ACA will require “large” employers to file reports indicating whether they provide group coverage (the effective date of this has also been pushed back). There is no indication in the ACA itself whether these reports can be made public, but given that they will be submitted to the IRS, it is likely that they will be treated as confidential. Not only does the ACA fail to impose a real employer mandate; it also appears to miss an opportunity to shame those freeloading employers which expect taxpayers to pick up the tab for their failure to provide decent coverage.

Cadillacs versus Corollas in the Healthcare Debate

Thursday, August 8th, 2013

solidgoldcadillacOver the past couple of years it has appeared that critics of the Affordable Care Act were virtually all die-hard Tea Party types who couldn’t accept reality, including a ruling of the U.S. Supreme Court.

We are now seeing reminders that those who have misgivings about the ACA are not only those misguided souls who believe it amounts to a government takeover of healthcare.

One group that had raised objections to at least part of the plan are now finding that a compromise they made is coming back to haunt them. That group is the labor movement, particularly public sector unions, which had questioned the dubious decision of Senate Democrats and the Obama Administration to include an excise tax on higher-cost health plans when drafting the ACA; the provision was designed to help fund the costs of subsidizing new coverage for the uninsured.

That decision was particularly galling because Obama had strongly opposed John McCain’s proposal for health plan taxation during the 2008 Presidential campaign. Unions denounced the provision, but in early 2010 they agreed to support a modified version of it. The modifications included a delay in its effective date (until 2018 for plans covering state and local government employees or ones covered by collective bargaining agreements) and an increase in the threshold levels above which the tax would apply.

The issue has been little discussed during the past three years, but now there are reports that local governments across the country are using the coming excise tax to pressure public employee unions to accept less expensive coverage—i.e., plans in which the worker pays more and gets less—or face the prospect of other contract concessions or layoffs.

What the proponents of the excise tax chose to ignore is that unions, especially in the public sector, have often focused on negotiating better benefits because significant wage increases were not possible, either for political or fiscal reasons. In other words, better benefits were not a giveaway to public unions, as anti-government types like to claim, but rather a form of compensation for insufficient pay rates.

When the excise tax was being debated in 2009, proponents misleadingly referred to it as applying only to “Cadillac” plans. It was meant to give the impression that only luxurious coverage of the type offered to corporate executives would be affected. Now it appears that those who drive Corollas may get hurt most by the provision.

The labor movement is also worried that the ACA will weaken the multiemployer benefit plans that some unions negotiate for their members. The concern is that unionized small employers participating in those plans will be end up in a competitive disadvantage compared to non-union competitors which will be able to purchase lower-cost group coverage through the Exchanges being created by the ACA.

Last month the Wall Street Journal reported that the heads of three major unions—the Teamsters, the Food and Commercial Workers and Unite Here—were trying to get the Administration to do something about ACA’s impact on multiemployer plans but were being “stonewalled.” The unions are also concerned that the law prevents low-wage workers in group plans from gaining access to the premium and cost-sharing subsidies that will be available to those who purchase individual coverage through the Exchanges.

The lack of action in response to labor concerns contrasts with the surprise announcement last month by the Administration that it was delaying the implementation of the ACA provisions imposing financial penalties on certain employers that fail to provide affordable group coverage to their workers. The post on the White House website was entitled WE’RE LISTENING TO BUSINESSES ABOUT THE HEALTH CARE LAW.

Despite the scare-mongering that has been going on in parts of the media, the penalties for failing to provide group coverage (or for providing unaffordable coverage) are far from onerous. To begin with, they don’t apply to employers with fewer than 50 full-time workers, and the penalties don’t actually kick in unless there are more than 80 full-timers. Penalties are calculated according to the number of full-timers only, ignoring part-timers and seasonal workers.

And the penalties don’t apply at all unless one of the workers denied affordable group coverage on the job qualifies for a premium or cost-sharing subsidy when purchasing individual coverage through an Exchange. Those subsidies will not be available to anyone with household income above 400 percent of the federal poverty line. This means that even larger employers that fail to provide decent coverage but whose pay rates are somewhat above poverty levels may be able to skirt the penalties entirely.

Perhaps the Obama Administration should be listening a bit less to business and more to workers and their unions.