The Affordable Care Act and Employer Provided Health Bennies

Paul Krugman and Greg Sargent are following a report from McKinsey that says up to 30% of employers are planning to drop health insurance for their employees as a result of the Affordable Care Act.  As you can imagine, Democrats are quite concerned with the validity of this study and whether the predictions are true.  While the jury is still out on whether the study is true or just a carefully planted right wing talking point, let’s look at some unsettling trends that many of us in the R&D industry are starting to see.

A lot of us are getting laid off and can only find jobs as contractors.  Contractors do not usually receive benefits like health insurance from their employers.  If they work for a CRO, they can sometimes buy health insurance coverage but this is typically more expensive than employer provided health care.  Bennies come out of the pockets of the employee contractor, not the corporation that is hiring them.  That saves big companies a lot of money in the end even if they have to pay a fee to the contracting company, which also comes off of the employee’s salary.  It sounds like a sweet deal for everyone but the employee.  Companies get out of those tiresome obligations and the middle man gets a cut of the employee’s salary.  Awesome.

Now, suppose there is a healthcare bill that comes along that mandates universal coverage.  Actually, universal coverage is something you want in a successful national health program but that assumes that costs are controlled elsewhere, otherwise it’s hugely expensive for the insured.  Ok, so universal coverage is mandated.  The burden of covering healthcare is now shifted to the employee.  An employer mandate might be necessary to make sure the group rates are affordable but if an employer can shed their employees and hire them back as contractors, doesn’t that circumvent the employer mandate?  So, should we be surprised that we are seeing a shift from regular full time employment with bennies to contracting work without bennies?  The companies are not incentivized to retain full time workers but to shed them and to do it as quickly as possible.  It’s nothing personal.  It’s just the way the laws are written.  If there’s nothing to stop you from taking advantage of the system, why wouldn’t you?  In a way, the new law gives them a free pass that they might not have considered before.  The new law makes it legal and profitable to ditch your bennies.  And if your primary obligation is to increase shareholder value, what would *you* do?

It’s not a bug.  It’s a feature.

So, if it turns out that the McKinsey study results are real, color me unsurprised.

Disclaimer: I am not a Republican and generally despise right wing talking points.  But you don’t have to be a right wing lunatic to have a problem with Obamacare.

More on the employer mandate: This Time article discusses the employer mandate of the Affordable Care Act and cites San Francisco as an example where the employer mandate has been adopted successfully.  The difference between San Francisco’s plan and what we got with the Affordable Care Act is a public option.

But according to the new report co-authored by Dube, 61% of San Francisco restaurants are very or somewhat supportive of the mandate. This may be because restaurants in the city have found a way to pay for their increased benefit costs without absorbing the expense: many have added a 3% to 4% health care surcharge to customers’ bills. In addition, at the same time that the mandate was passed, a de facto public option was implemented. Employers that opt not to provide coverage must pay $1.23 to $1.85 per hour per worker to help fund the public plan. This public option, which only covers care from some doctors and facilities in the city of San Francisco, has proven popular with employers, with 21% using it for workers. Already the San Francisco public option has enrolled a majority of the city’s previously uninsured residents, more than 50,000 people. And according to a survey conducted by the nonpartisan, nonprofit Kaiser Family Foundation, 94% of those participating in the program are satisfied with the results.

Um, we didn’t get a public option in the Affordable Care Act.  So, the high price of insurance will be borne by the person forced to buy insurance on the open free market.  Technically, I don’t think that’s the employer’s problem anymore as long as it can get by with contracted employees. I think it’s possible to legislate social responsibility but our Congress didn’t do it in the Affordable Care Act. So, expect a lot more layoffs and a lot fewer bennies.

Yet another reason to get rid of incumbents in 2012.

Saturday: round up

What else was in the air over Joplin?

Thank you all who were concerned with my big purple toe.  It’s still swollen but I can walk on it now without wincing so I think it will be OK.

This post contains random stories collected from around the web that provoke me.  Forget that.  There’s only one story that got my attention this morning and made me cranky.

I am not an epidemiologist but this story in the NYTimes about the fungal infections popping up in Joplin, MO post tornado leaves something to be desired.

Several people who were injured when a tornado devastated Joplin, Mo., last month have become sickened by an uncommon, deadlyfungal infection and at least three have died, although public health officials said Friday that a link between the infection and the deaths was not certain.

Also on Friday, the death toll from the tornado was raised to 151.

Eight tornado victims have fallen ill from the mysterious infection, and each had “multiple injuries and secondary wound infections,” said Jacqueline Lapine, a spokeswoman for the Missouri Department of Health and Senior Services. Citing confidentiality rules, officials declined to discuss the treatment or condition of the patients.

The fungus that causes the infection, which is believed to be mucormycosis, is most commonly found in soil and wood, according to the Centers for Disease Control and Prevention, which is studying samples from the eight Joplin patients. “It is a very aggressive and severe infection,” said Dr. Benjamin Park, chief of the epidemiology team in the C.D.C.’s Mycotic Diseases Branch. “It is also very rare.”

Mucormycosis enters the body either via a puncture wound or when a victim breathes in its mold spores, officials said. Those who have weakened immune systems have a mortality rate as high as 90 percent. Other people at risk include those with diabetes or cancer and burn victims.

Mucormycosis is a rare fungal infection that makes death by any other method look like a cakewalk.  Normally, hospitals see only one or two cases a year.  The cluster in Joplin is very disturbing.  When I read the Times article, I got the impression that these infections were the modern day equivalent of the bubonic plague.  No one knows the source of the infection.  It’s a horrible way to die.  Very unsettling.  It’s yet another mystery disease that popped up in the couple of weeks.  Earlier, we heard about the antibiotic resistant ecoli infections in Europe.  Diseases and random acts of microbes, out of control.  OMG, we’re all going to die!  Why so many scary biological stories lately without the cause, effect and perspective?

The Times reporter suggests that the cluster of fungal infections was caused by the incomplete disinfection of wounds at emergency triage centers that we erected immediately after the storm passed through Joplin.  You may recall that one of Joplin’s hospitals was destroyed during the tornado so makeshift medical treatment facilities had to be erected quickly.

Ok, let’s back up for a minute.  When I read this story, I suddenly remembered a pseudo-science cable channel medical voyeur special about a man without a face (cue the Billy Idol).  From what I can remember, Mark Tatum starting experiencing severe headaches, which his doctors determined was caused by a massive mucormycosis fungal infection in his sinuses and behind his eyes.  The infection is 90% fatal.  The only way to save his life was to treat him with anti-fungal medications and to cut out the infection.  That meant removing his eyes, nose and upper jaw.  Imagine having that conversation with your doctor.  Once you decide, there’s no going back.

Anyway, back to Joplin.  What I find so unsatisfying about this story of the mucormycosal infection cluster in Joplin is that there are so many moving parts that could have made it more informative and interesting.  Isn’t this what the paywall is supposed to promote?  For example, I read recently that meteorologists are studying this year’s severity of the tornados and locations with interest because they are working on a theory about dry soils and moist soils and the generation of tornadic activity.  Oddly enough, there is a new article about this theory in earthzine that was posted today, and speculation, not yet proven, that the shift in location and severity of this year’s tornados could be the result of global climate change.  From the article, Seasonal Predictability of Tornadic Activity Using Antecedent Soil Moisture Conditions:

If Intergovernmental Panel on Climate Change (IPCC) [1] projections are accurate, the frequency and severity of extreme water cycle events (e.g. droughts, floods) will increase as a consequence of climate change. The IPCC notes that hydrological extremes such as flooding and drought occurrence have increased markedly in the last three decades, with more intense and longer episodes. Large variability in the atmospheric component of the water cycle is directly linked to terrestrial soil moisture distributions. The consensus on soil moisture-atmospheric feedbacks is that surface heat fluxes and moisture gradients can influence convective development (e.g., [2],[3], [4], [5], [6], [7], [8], [9], [10], [11], [12]).

These studies and others have discussed the following connections between soil moisture and convective storm development: (1) Partitioning of surface energy into latent and sensible heating, which in turn affects the atmospheric boundary layer and regional convergence through moisture and energy exchanges; (2) Higher evaporative fraction; (3) High concentrations of entropy (or moist static energy) in the lower atmosphere; and (4) Development of mesoscale (e.g., sea breeze-like) circulations.

However, there is a lack of literature on the extension of soil moisture-atmospheric feedbacks to extreme hazards like tornadoes. At the same time, there is convergence of hydroclimate processes scales and weather-climate model resolutions, such that explicit feedbacks and connectivity between soil moisture and the atmosphere should be resolved [13]. Further, seasonal predictability of tornados has clear societal implications for safety, insurance companies, the construction industry, and even retailers like Home Depot or Lowes.

I’ve underlined the last line because it doesn’t seem outside the realm of possibility to me that the dry soil/moist soil theory might also be applied to the outbreak of mucormycosis in Joplin.  Is there a connection?  Let’s start with the fungus and disease that it causes.  Mucormycosis is spread by spores, presumably airborne.  The deadliest of these fungal infections is the rhinocerebral variety involving the nasal cavity, behind the eyes and in the maxilla, or upper jaw.  The infection is most commonly found in people with compromised immune systems and in diabetics but the wiki on mucormycosis says that “traumatic innoculation” is also a possible route to infection.  But even though the Times srticle doesn’t go into detail, the number of cases in Joplin suggests that the epidemiology of the disease there is unusual and doesn’t follow the normal rules.  Maybe the people affected are not immunocompromised.

So, here’s my hypothesis: the dry soil/moist soil theory says that tornados form along the boundary between dry soil conditions and moist ones.  We know that parts of the midwest and southwest have been suffering from droughts this year.  If spores are airborne, would dry soil/moist soil boundary areas have a greater number airborne spores?  Think weaponized anthrax.

Ok, so along comes this massive tornado packing walloping winds and in a place like Joplin, there aren’t many places to hide.  The nature of the fatal infections suggests that it gets into the body through the respiratory tract.  The nose and sinus cavities seem to be the primary location of the “fungal ball”.  Is it possible that the route of infection was through the nasal cavity from exposure to tornadic winds or their aftermath?

How might we test this hypothesis?  Here are some of the questions I might have asked if I were the Times reporter:

Were any of the victims immunocompromised?  Did any of them have diabetes?  Is the infection the rhinocerebral variety, suggesting that the spores were inhaled, or are the infections somewhere else?  The mortality rate due to mucormycosis in Joplin suggests inhalation rather than skin infection.  Presumably, you can remove parts of skin without killing the patient.  It’s not so easy to remove sinuses and, potentially, parts of the brain.  Where did the survivors ride out the storm?  Does their location and level of exposure to disturbed air currents correlate to the level of infection?  Were they in an enclosed area during the storm or was the wind in their faces?  If wind wasn’t forced up their noses, that might suggest that the spores remained airborne after the tornado passed through the area. If we look at the region where tornados occurred this year, are there additional cases of mucormycosis?  If we plot these cases on a map, is there a pattern?  Does it correlate with the dates of tornados?  For example, is there an increased number of cases of mucormycosis in Alabama?  How about further east?  Does the rate of mucormycosis increase directionally?  If the infection is caused by airborne spores that are inhaled, does it seem correct to place the blame for the infections on emergency workers who tended to skin wounds and not nasal cavities?  If we discover that the number of mucormycosis infections increase after tornados in general, what course of emergency treatment would be appropriate?  Saline rinses?  An immediate course of anti-fungal medication?

I only ask.  Call me a ‘satiable Elephant’s Child and spank me but the NYTimes article could have presented us with a grim but fascinating medical mystery that might be linked to climate change.  Instead, we get the equivalent of an inexplicable horror story.  Maybe a different information provider, like  Chris Smith and the other NakedScientists, could do a better job of exploring this story.  Chris??

The reason this story bugs me is that the reporter seems so incurious.  The story and investigation goes nowhere.  It’s just a big question mark.  There are so many unanswered questions, some of them due to confidentiality rules, that I might not have put it on the front page.  It makes me irritated that there are so many stories like this that reporters fail to explore.  Journalists are notoriously bad at explaining science and frequently let their biases show.  The reporting on the reactors in Japan after the earthquakes and tsunamis was particularly egregious.  Yes, radiation readings a million times greater than normal are indeed disturbing- until you consider how many zeros follow the decimal point in a normal reading.  That doesn’t mean the situation wasn’t serious or that every nuclear regulatory agency in the world shouldn’t be studying Fukushima very carefully.  It’s just that the level of panic generated by the media was disproportional to the risk to the target audience of that breathless reporting.

I guess I’m just disappointed at what passes for expertise in any field these days.  How many journalists, or members of any profession for that matter, get their jobs through patronage instead of merit?  What is the energy penalty that we pay for this kind of selection process?  Is sensationalism more important than investigation and does that affect how journalists are hired? Do we as a society value loyalty and conformity to our master’s point of view more than independence, diligence and curiosity?  And what does this tell us about the future prospects of Americans without a network, or what Jane Austen would call “connexions”?  How would Edison do in this environment, with a homeschool education and lacking a degree from a prestigious university?  Is there a connection between the lackluster reportage and our stratified society or am I just rambling?  I’m rambling, aren’t I?

Ok, I’m done now.