Friday, December 27, 2013

Hospice companies make too much money off Medicare with long-term "survivors"

Hospice firms are draining Medicare and straining the budget process, according to a front page story in the Washington Post on Friday, December 27, 2013 by Peter Whoriskey and Dan Keating, link here
   
Hospice companies, while they say they follow the guidelines by taking on clients whose life expectancy is six months or less, have an incentive to stretch things.  Patients who “survive” longer add to their earnings.  They have to review “survivors” every two months and show medical evidence of further decline. 
  
The issue appears to occur mainly with in-home care, not with patients who go to hospice facilities for the last few days of their lives.  But it is conceivable for a patient to live longer than expected even there and then wind up in a nursing home.
   
The article mentions vague diagnoses like "adult failure to thrive".
 
My own mother entered in-home hospice in November 2009 and survived until December 14, 2010.  She entered the facility on the afternoon of Friday, December 10, 2010 and passed away at noon on December 14.  

Tuesday, December 17, 2013

CNN article on "bad value" for US health care disappears mysteriously; we spend too much at end of life, we sponsor processed foods

On Monday, Dec. 16, CNN’s Global Public Square Blog offered a perspective by Jody Heymann and Douglas Barthold, posted by CNN’s Jason Milks, “Why U.S, health care is a bad value for the money”.  Many sites linked to it, but the article disappeared.  I read it on my cell phone while on the road yesterday.
  
It did say a couple important things.  One of the most important points is that about a third of our healthcare costs are incurred at end of life, when desperate efforts are made to keep people alive as long as possible.  That certainly bears on the eldercare debate.
  
The other problem is that corporate America invests in “unwellness”.  The article mentioned that Iowa is always an early political caucus state, so politicians placate voters with farm subsidies encouraging the production and consumption of corn syrup, which contains a form of sugar that tend to promote obesity in people with genetic susceptibilities.   The processed food business has tremendous lobbying power with Congress.  So we invest in practices that promote chronic disease and “pre-existing conditions” in many people. 
   

Does anybody know why this article, so convenient to read at a McDonalds as a “roadside attraction” disappeared?

Monday, December 09, 2013

Politicians ignore the 'generational wars" because seniors make up so many votes

Here’s another perspective, this time by Robert Samuelson, on how politicians are blinded to population demographics, in the Washington Post on Monday, December 9, 2013, “America’s clash of generations is inevitable”, link.  

Samuelson says that within families and extended families, the proper personal responsibilities are still clear. “Parents are supposed to care for their children, and children are supposed to care for their aging parents. For families, these collective obligations may work.”  But politicians, spurred by the voting power of seniors, keep taxing the young to pay for longer retirements and deference to the old.
  
I was in the middle of this, when my mother was in her mid-nineties, but I was in my sixties myself, creating a dynamic that seemed almost unprecedented.
   
Samuelson sees Obamacare as part of the generational clash, as younger healthier adults pay for seniors just under 65 (Medicare).  But they could be seen as paying for their own health care in the early senior years. 



Wednesday, December 04, 2013

Detroit bankruptcy said to said new legal precedent in ability to cut back pensions, stiff bondholders

Federal bankruptcy law will trump over Michigan state law protecting pensions, but a Detroit Free Press (Gannett) article about the options available to emergency Kevyn Orr leave a lot of wiggle room for how pensions would be affected.  There could be a means-testing concept, or police and fire unions might fare better.  The Free Press analysis is here
    
The Washington Post on December 4, in a detailed story by Michael A. Fletcher and Reid Wilson, reported “Detroit eligible for bankruptcy filing; pension ruling could set precedent; unions vow to fight plan to shed $18 billion debt”, link here.  The story indicates that Judge Rhodes is setting a precedent in allowing municipal worker pensions, including those already retired, to be cut, as well as stiffing bondholders.  The main story is here  and there is some supplementary video.
There have been some other spectacular bankruptcies, such as Stockton CA, as reported by Morgan Spurlock.
     
Anthony Bourdain recently covered the plight of Detroit in his "Parts Unknown" series for CNN.  The city went into rapid decline after riots in the late 1960's, followed by departure of many employers to the suburbs or to southern cities or overseas.  
  

Retirees who hold a lot of tax-free municipal bond funds could see values go down, as more funds are seen as possibly at risk.  Less risky are holdings of specific securities, where the retiree or investment advisor knows the reputation of the local government or utilities authority

I visited the city on a Sunday morning in August 2012 and found the downtown area (near the new stadium for the Tigers) kept up, and did not see the blighted areas that are widely reported.  

Friday, November 22, 2013

New York Times questions conventional wisdom on Social Security reform proposals

Paul Krugman offers an important op-ed in the New York Times Friday, “Expanding Social Security”, link here
  
Krugman challenges some conventional conservative debate points on entitlement reform.
One bullet point is that the longer lifespans argue for raising eligibility age. Longer lifespans occur largely with higher income individuals, whereas poorer people, who may have worked in dangerous occupations involving manual labor and hazardous conditions and who may “need” benefits more, have seen relatively little increase in life span.
       
The other argument is that conservatives tend to understate poverty among seniors, and that such poverty is likely to increase in the future because lifelong stable employment with one or few employers offering defined benefit pensions is going away.  He describes the conversion to defined contribution 401(k)’s as a failure.  My own worked out all right, although some of the value of my own employer’s stock (ING) had lost value (after 9/11) before I sold it.  

Monday, November 18, 2013

Why not subject all wages to FICA, some Democrats ask

The Washington Post has an important editorial on Monday November 18, 2013, “Liberalism gone awry: Why not spend more money on poor children instead of seniors”, and online it is titled “Social Security proposals are wrongheaded”, link here
The editorial refers to a proposal by Sen. Tom Harkin (D-IA) and Rep. Linda Sanchez (D-CA) to make all wages, without limit, subject to Social Security FICA “tax” even though much of it would go way above what would support one’s own future income from Social Security.  The editorial suggests that this would be a “massive transfer of wealth from upper income Americans to the retired” and would further penalize wages at the expense of other income.  If you’re going to increase taxes, why not help poor children, it asks.  But should FICA really be viewed as a “tax” even if the Supreme Court says it is so, technically?

Sunday, November 17, 2013

Do bitcoins belong in a retiree's portfolio?

According to the Wall Street Journal’s Marketwatch, it’s possible to put bitcoins into your IRA, with a “Bitcount Investment Trust”, with story link here
  
The best advice I find today is that retirees with ample assets (at least a few hundred thousand dollars saved) could well consider putting about 1% of their portfolio into bitcoins, in order to learn the market, and possibly as a future hedge against loss of confidence in the dollar because of US political brinksmanship (the Stansberry theory).  US News has a discussion here and there are a lot of conversations about the matter on Reddit.  

Remember, when capitalized, "Bitcoin" requires to the system; the units of digital currency are called bitcoins.  

Friday, November 15, 2013

ABC reports on over 1 million teen caregivers in the US

ABC News reported tonight, after noting that November is national caregiver’s month, presented a teen as person of the week, Chris Miller, in West Palm Beach, FL, who, at age 13, takes care of a 63 year old grandmother. The report said that 1.4 million teens under 18 serve as primary caregivers.  The link to the story (with video) is here. Obviously, keeping up with school could be a problem.  I recall a scene in the movie "October Sky" where the oldest brother volunteers to go to work in a coal mine when the father gets black lung.  That's how it is for some families. 

The report introduced the American Association of Caregiving Youth (AACY), link here
   
Chris was also shown practicing the violin, with considerable talent.  

Tuesday, November 12, 2013

Medicare Advantage cuts with Obamacare might hurt some seniors (probably not me)

Free Enterprise has an interesting perspective on the cuts that are likely in Medicare Advantage programs, meaning that seniors who buy these programs may face higher premiums and have fewer benefits.
  
I have occasionally been contacted about the idea of buying one, and was approached a couple times a few years ago about selling them.  No, I don’t like to peddle things. 
  
It could make sense, to have some dental care added (I seemed to get the vision care I need with regular Medicare and supplemental). 
  
An article by Sean Hackbarth is arguing that many seniors even on regular Medicare will see premiums rise (perhaps means testing), but Obama is saying that preventive screening is improved.  Hackworth writes that part of the funding of the Patient Protection and Affordable Care Act came from cuts to subsidies of Medicare Advantage.
   
The link for the article is here.
    

I just got my own annual physical results back, and they were OK.  I have not taken advantage of the colonoscopy, because of the prep; but the standard bloodwork is quite extensive (all the various sugars and various cholesterols; liver and kidney function;  PSA;  a pancreatic cancer protein test probably will be available and standard in maybe three years).   Electrocardiogram was included.  

Saturday, November 09, 2013

Forced guardianship could be forced on seniors who live alone and get into trouble

It is possible for a local government to order guardianship for an “incompetent” (older) citizen living alone, as shown in a front page Washington Post story Saturday, November 9, 2013 by Amy Brittain, about a 58-year-old woman with excessive 911 calls, the story link here

The case occurs in Washington DC and the case is being pressed by the city’s Department of Behavioral Health.  In many jurisdictions, the relevant agency would be Adult Protective Services. There are other issues that might create this sort of situation, such as hoarding. 

Monday, November 04, 2013

Would Obamacare affect retiree health insurance from ex-employers before Medicare eligibility?

Are retirees who buy health insurance from their former employers (as I did until I went onto Medicare) affected by Obamacare? 
  
It’s a good question.  My own individual policy from ING with United Health Care cost about $165 a month and covered only 70% if hospitalization, which I never needed.  It did get good pre-discounts on outpatient tests (about 70% off).  I doubt that it covered maternity, mental illness, or drug addiction issues.  Would it have to now?
  
NPR has a link  on how Obamacare affects people already on Medicare – not a lot.  They may have more coverage on annual physicals and by 2020 some closure of the doughnut hole in prescription drug coverage.
    
Self-employed seniors under 65 who are self-employed (that’s a lot of people) may want to check the article Monday morning November 4, 2013 I the Washington Post by Arianna Eunjung Cha and Lena H. Sun about the “sticker shock” and “anger” about higher premiums for many who aren’t likely to use all the services and qualify for aid, link here. Again, it sounds as though maternity and drug abuse coverage, of no value to many in this population, could be an issue.  The print version refers to the health care law’s “losers”.
Okay, in the Army, we used to make fun of the adage, “From each according to his ability, to each according to his needs”.   

Thursday, October 31, 2013

Social Security announces COLA; similar increases for federal retirees; more on the 35 highest years rule

Whatever the doomsday predictions of Social Security cutoffs a few weeks ago during Congressional brinksmanship, now we’re reassured of a 1.5% COLA increase in benefits starting January, 2014. 
Social Security (whose website is rather popular, in great contrast to Obamacare’s “healthcare.gov”) has an account of the modest COLA increase here
  
Eric Yoder, of the Washington Post, discusses the varied Social Security benefits for federal employees on p. B4 (“The Federal Page”) of the Post Thursday, October 31, 2013, where the discusses COLA and CERS and FSRS, systems which replace some or all of Social Security income. 
  
In 1971-1972, when I worked for the Navy Department, I contributed to the Federal retirement system but did not pay FICA taxes.  That may have reduced my benefit slightly by lowering the average of my top 35 years (as explained here at the “About” site, link ).  These years get replaced by years of lower wages, like when I worked as an instructor at the University of Kansas, or later when I worked as a caller or debt collector, or substitute teacher.  Still, my benefit, reduced further by starting at age 62 (because of the way my employer handled Social Security offset) is significant to my financial stability at age 70.
   
It’s not clear that those workers who benefited for two years from a 2-year FICA payroll tax cut could eventually see reduced benefits, especially after Congressional reform.  I’ve advocated that Congress should protect legal ownership of some benefits based on lifetime FICA contributions (including legal spouses in some cases).  But that would be a somewhat different actuarial concept from the “top 35 years” notion.  Reform, in giving legal protection of benefits already earned from future partisan battles, is much in order during the budget negotiations that must be completed by Dec. 13.  

Wednesday, October 23, 2013

My own annual Medicare physical approaches, momentum is my best ally, as always

My own annual Medicare physical comes up pretty soon.  There’s the 12-hour fast, the early morning blood tests.
  
No, I haven’t even done the colonoscopy yet.  I had a high PSA in 2010, but it was back down in 2011 and 2012, probably because the stress of eldercare was gone, and because when I’m alone I eat less fat.
  
I think that for someone without a lot of personal social support, momentum is the best strategy,  Lots of tests can find things, that can lead to more tests, biopsies, surgeries, hospitalizations, infections, a vicious cycle, let alone the waste to Medicare.
  
Mehmet Oz has even said that he doesn’t like to do open heart surgery on someone who doesn’t have a partner (preferably marriage) to live for who “loves you back”.  I don’t like the idea of having a relationship “to be loved back” – but that’s what “in sickness and in health” means.
  

There is something to be said for more aggressive medical testing, though, to find out why I was “behind” as a boy.  Was it neurological, like a very mild form of autism?  Was it hormonal?  Circulatory?  Given my karma, I probably owe the world a willingness to delve into this to find out.  

Sunday, October 20, 2013

Nursing home patients find trust funds embezzled by employees, sometimes

Employees have stolen money from the trust funds of nursing home residents, according to a stunning story Wednesday, Oct. 16, 2013 in USA Today, on the front page, in a “USA Today Investigation” story by Peter Eisler, link here
  
The story starts with the case of Lee Martin at the Vicksburg Convalescent Center in Mississippi.  Money had been diverted to buy jeans for a patient who had lost both legs, possibly to complications of diabetes.
   

The story reiterates the pressure on family members not to place non-intact elders (often with Alzheimer’s) into nursing homes, because of fear of abuse.  Hiring 24 hour care costs about $13000 a month; a nursing home typically costs about $7000 a month.   Hiring a live-in costs much less but raises other ethical questions.  I recall lots of discussions with the hospice social worker during the last year of my own mother’s life, 2010.  

Wednesday, October 16, 2013

AARP lobbies against COLA cuts in Social Security

AARP has a short posting on the proposed COLA adjustments and chained CPI proposals, which will certainly come up in budget negotiations this winter.  It has a chart on how the COLA proposals “could affect you”, here
  
Of course, changes in the COLA formulas could be implemented gradually, and will seem less drastic than many other proposals that will come up with entitlement reform, like means testing, some of which could come quickly, and which might even have been proposed in a default environment as an emergency.
  

So it’s not possible just to protect one group’s interest when there is a crisis.  But this crisis was self-inflicted. 

Wednesday, October 09, 2013

Bank of America and Merrill Edge offer a half-hour video on the future of Social Security

The Bank of America is presenting a 29 minute video to visitors who sign on to its website, titled “Your Money At Risk”, based on a Merrrill Edge webast, with this URL.

The webcast explains the long term outlook for Social Security. 

One-third of the beneficiaries of Social Security are not retired, which means that these must be on the disability program.  That would mean that your FICA taxes support this disability insurance also, so not all of your FICA contributions would support an earned retirement “annuity” if politicians look at it that way.

If you take Social Security at age 62, you get about 75% of full retirement age benefit for life, which means it results in diminished lifetime payments at about age 78.  If you can wait to age 70-1/2, you get 132%.  43% of beneficiaries start at 62, and about 75% start early.

If you reach age 70, a male has a slightly less than 50% chance of reaching age 92, a female slightly more.
  
Social Security has an actuarial information page here

Merrill Edge has a website with this video and others, here.

The video explains that Social Security can pay 100% of promised benefits until 2033, but then would have to cut down to 75% of benefits.  It talks about various ways to improve FICA tax collections, and reducing outlays by raising retirement ages or increasing the number of years of work experience evaluated.

The video mentions the idea of a total economic collapse at one point, as the only event that could stop Social Security payments to current beneficiaries (who would include disabled as well as retirees).  

Monday, October 07, 2013

"Better off" Social Security beneficiaries (and future recipients) could be cut off suddenly as part of GOP strategy to mitigate debt "default"; Is Trust Fund a "real creditor"?

If the debt ceiling is not raised and if indeed the federal government is not able to pay all bills on time starting in late October (or probably November 1), some current and future Social Security beneficiaries could lose their benefits forever, of have them reduced, based on immediate but permanent means testing. 
    
Here’s why it could happen.  I had covered this idea with a blog posting here on January 16, 2013, coordinated with a posting on January 15, 2013 on my  Issue blog, where I linked to a Wall Street Journal article by Rivkin and Casey.   That particular law firm argued that, according to the Constitution, only public debts must be paid.  That generally means interest (and principal, with caveat) on bonds owned by individuals, companies, organizations, and especially outside of the US (like China).  If the president must borrow under the 14th Amendment to pay these, he very likely has the power to do so.  The law firm argues that there is no constitutional duty to continue paying entitlements, even though they were promised.  Failing to pay them as promised so may sound grossly unethical or unfair, but the president (or Treasury) cannot pay them after running out of money without permission from Congress.  The courts are likely to concur with this position.  Continuing to pay entitlements, even those that had been promised, becomes a matter of political pressures, as do most issues.
  
But enriching this debate is the idea that Social Security is a bondholder.  Failure to pay the entire amount – the next big repayment to the Trust Fund is due Nov. 1 – technically constitutes default.  But the rest of the world looks at this as an internal matter.  Markets would not be affected by a default on the Trust Fund as it would on a default to China.  This sounds offensive, but it is true.  In fact, some parts of the world (most recently Russia) look at our entitlement mess as a sign of evasive, non-committal personal morals.
  
There is a good legal question as to whether the president has the authority, under the 14th Amendment, to reimburse the Trust Fund, without permission from Congress.   A couple of postings by law professors from California in the New York Times in January maintained that he would.  Medicare is even murkier, but it’s possible that similar arguments will be made.  Even if the Social Security Trust Fund is a legal bond holder, investors overseas could see it as a largely internal "funny money" matter.  The Wall Street Journal has already hinted at this idea when discussing past proposals (like Toomey's) to guarantee the liquidity necessary to pay off bondholders if the debt ceiling is exceeded.  

If in fact the administration cannot make its full repayment to the Social Security trust fund, Congress could move quickly to lighten the burden on Social Security by cutting off at least better off beneficiaries. (The House, of course, would have trouble getting the Senate to go along with this, Ted Cruz notwithstanding.)  The only ready-to-use tool available for emergency means testing would be income tax returns.   In the past, in my own life, I’ve met people who want to expropriate “inherited wealth”, but it would not be very easy for the federal government to base such a scheme on accumulated wealth, as opposed to income, very quickly. 
  
It’s important to remember that, according to Supreme Court rulings in the past (Flemming v. Nestor), social security recipients have no contractual “ownership rights” to future benefits based on FICA "contributions".  Legally, Congress can not only delay them (by upping retirement ages) but in a national emergency (even if self-inflicted) also cut them off  (for current and future beneficiaries).  Conservatives have actually used this reasoning to mitigate the effects of default, and often privately recommended that better-off Americans move their money overseas (as many of them do themselves).  On the other hand, George W. Bush’s neocons proposed privatization to protect legal ownership of benefits, as have libertarian think tanks like Cato.  It would be more in classical GOP spirit to propose accounting of the actuarial value of FICA “premiums” (taking out the startup and disability insurance component – ironically mandatory and uncontroversial) and guaranteeing them to all current and future beneficiaries, but immediately means-testing the rest.  
   
Back in the 1990’s, the now late Harry Browne of the Libertarian Party did warn that, for freedom, a generation of people would have to give up their social security benefits, a one time shock. I didn’t take it seriously then.
  
My next social security deposit occurs on Oct. 9. I’m even doing a withholding tax.  It could  be my last benefit check ever if this analysis is correct and the worst happens.  There is a silver lining of sorts, from corporate America’s old “playbook”.  That is, I took benefits early, at Age 62, starting in September 2005.  Were there to be a cutoff, I would have accumulated more than I could have if I had waited to full retirement age at 66-1/2.  And I could have wound up with zero had I waited until 70-1/2.  This sounds appalling, but legally I may have made the right choice.  I can recall after “retiring” from ING with a layoff, that HR and the outplacement companies recommended taking retirement early, to give people more time to work on what they wanted to do, and fend off pressure to get into less desirable jobs (that is, the hucksterism that is so common).  Companies built their pensions around the idea that employees take Social Security early and many defined benefit pension plans had Social Security offsets which were predicated on this strategy.  So people on pensions built this way get hit twice, but legally there could be nothing they can do.  It’s all “political”.  
  
Atlantic has an analysis by Matthew Brian that calls a potential debt default “a crisis if we’re lucky and historic calamity if we’re not” here.  But the worst of the calamity is long term, that the US becomes perceived as a cronyistic “banana republic” which is no longer safe enough for investment because moral failure of the people allowed them to be taken over by self-serving special interests. 
  
There is a hard edge within the “Tea Party” that opposes not only “Obamacare” but entitlements in general.  It maintains that care of the vulnerable belongs in families and communities and not with government at all.  It sounds incredible when you look at the fact that most of the western world uses public funding for a lot of healthcare, but conservatives are quick to point out that “demographic winter” is deep-sixing economies in Europe.  If we could go “cold turkey”, there might be a lot of personal sacrifice, but future generations would have it better.   Conservatives make the argument that we don’t care enough about future generations, particularly by not being willing to take on the “responsibility” of having enough children, but then they contradict themselves by denying global warming. As shocking as it sounds, this sort of thinking pervades Russia’s recent anti-gay laws.  (Michele Bachman and Valdimir Putin think a lot alike.)  This sort of thinking has profound meaning for how we perceive “family responsibility” and how much of it is separate from just choosing to have children. It certainly sets the granularity of individualism.  There was a New York Times article Oct. 5 that touched on this “natural family” idea by Jonathan Wiesman Oct. 5. 
     
It’s hard to see any radical GOP endgame that makes a lot of sense. It reminds me of a gambit-style attack in a chess game without followup, resulting in a lost position according to the normal rules.  I certainly feel like a pawn that the GOP feels it can sacrifice for its speculative takeover plans.  It claims new prosperity because America will just get rid of its debt by throwing less "self-sufficient" people off the cliff (all of it “constitutionally”), although if you do all the math, even this plan can't work for too long.  It can’t win a legitimate election this way.  But it could try to plot a fascist takeover.  


Update:

CNN Money has a story predicting that Social Security checks, starting November, could be cut 16% across the board, until the debt limit is increased (if ever).  Oh. I could stop the IRS withholding.  I won't owe much tax. Play Grover Norquist's game. 




Thursday, October 03, 2013

Boehner as promised not to let the nation default over Obamacare fight (apparently)

Late on Thursday afternoon, October 3, 2013, as the security incident on the Capitol grounds was winding down, the Washington Post, in an online article by Lori Montgomery and E O’keefe, reported that high level aides in the House of Representatives of GOP congressmen have been told that Speaker John Boehner will not take this fight with Obama (over Obamacare, largely) to defaulting on required debt payments.  The implication is that he will support an up-down vote on raising the debt ceiling before long.  Apparently these persons were told this by Boehner directly.  There was some talk that Boehner is testing the waters, setting up a politically acceptable exit from a horrible deadlock by settling the dispute over the shutdown and debt ceiling at the same time.  The link for the story is here

Ezra Klein even tweeted that he hoped that the debt default risk was now over.  It’s a little hard for me to believe that it will be that easy.

The details of the story, however, suggest that Boehner might agree to call votes only on very short term extensions, to pay the nation's bills a week or so at a time, putting the president and Democrats again in a box, challenging their "no negotiation" position and still keeping the nation on edge (especially Walll Street) until Democrats make major policy concessions.  Later, some commentators on CNN said that Boehner, will willing to accept Democratic support to pay the nation's bills (and Social Security, by the way), still wants some kind of policy concession, especially in future entitlements (possibly even present) before he will even do that. 
   
Later this evening, CNN confirmed the report in a story by Tom Cohen, Deidre Walsh, and Greg Botello, here. As I was at an HRC event this evening, a few people seemed to be following this on their smart phones.  It seemed like following football scores.

However, real entitlement reform will be necessary, as we keep borrowing larger amounts to pay off previous obligations.  Inevitably, the conservatives may be right: we cannot borrow money or print or coin money forever, without risking a crash in the dollar as reserve currency itself, and major entitlement reforms, some of them rather sudden, have to be faced.  I think it is inevitable that means testing will come up soon again, and for starters, Social Security recipients should told the actuarial value of their historical FICA tax contributions, taking into account that a portion of that tax pays for disability insurance as well as retirement (a curious foreshadow of the mandatory insurance debate, which can certainly spread to other areas) and that a small portion is due to the fact that the first beneficiaries in the 1930’s had not paid into the system. 


See a related story today (and yesterday) about the House Hastert Rule on my Issues blog.  

Wednesday, October 02, 2013

Some of my own case histories with retiree health care, Medicare, and providers not taking Medicare

Today, at a post-op visit to a dental surgeon (I did the “clear choice” thing, but with private dentists and surgeons, at pretty much the same, or maybe slightly lower, price).  The surgeon had previous biopsied a periodontal cyst.  The biopsy analysis (done in Richmond) had been covered by Medicare Part B but the actual cost was pretty low (about $100). 
  
Today, I asked if the cyst obliteration during surgery might be Medicare covered.  The surgeon though maybe, but the office said that it doesn’t take Medicare at all.  That’s interesting.
  
Back in early 2005, after a major infection when I think the cyst formed, I did get a cat scan.  It was covered by my retiree health insurance, after deductible, but because it was covered, the Virginia Hospital Center in Arlington did it for a list price of about $350 (about a 70% discount, according a contract with United Health Care).  Also, the visit to an oral surgeon in Reston then was covered (we didn’t do much).  Maybe it was a matter of ING’s retiree policy and its being fairly generous with dental-associated problems.
  
Generally, Medicare doesn’t cover problems of dental origin (like cysts) but there are gray areas if there are health implications (like secondary heart disease) that seem likely.  It may well be that some Medicare Advantage (replacement) policies will cover these, but then again, Obamacare has cut back on some things Advantage plans can cover. 
  
I do have United Health Care through AARP as my supplemental policy, and I’ve never run into any complications with any claims yet.  Again, during this debate on Obamacare, remember, once you have insurance at all, the list price (which does affect out-of-pocket costs) for most procedures will be much lower, because it is determined by a contract between the insurance company and provider, who wants enough patients to make a profit.
  

Let me add another aside.  In 1998, I fell in a convenience store, and sustained an acetabular fracture.  I received a new operation at the University of Minnesota on the East Bank campus.   I never saw a bill for the new medical device (almost one of the first installed) or the surgeon’s labor, just the OR and anesthesiology.  It looks like the surgery was almost free because it was subsidized by the medical device company, to prove that the new appliance worked (it did, healing very quickly). There was an insurance squabble for a while over some things, but they were eventually resolved.    Surgery was on January 8, 1998 (it took 6 hours).  I could walk without crutches some distance on March 1.  I was completely off crutches the night of an academy awards fundraiser for the Minnesota AIDS Project at the Orpheus in downtown Minneapolis in late March.  A wonderful night that was.  Maybe “conservatives” would love this story.  In this case, the market actually worked.  

Picture: Minneapolis, 2011.  My pelvic titanium "implant" does not trip TSA machines.  

Tuesday, October 01, 2013

Obamacare helps young woman with "filial responsibility" go to college

Today, in his 1 PM speech (Oct. 1, 2013), President Obama mentioned that a young woman had been able to obtain health insurance for her mother today under the Patient Protection and Affordable Care Act (“Obamacare”) under the slick but overloaded website “Healthcare” (link).   Ironically, Obamacare’s website is up now while many government department sites are down, and the whole Tea Party effort shut down practically everything else besides Obamacare..
  

The case that the president mentioned is important because the young woman was going to have to give up ever going to college to pay for her mother’s health care.  And apparently this was regular healthcare, not custodial care (and the mother may have been under Medicare age).  That sounded like the ultimate case of filial piety or filial responsibility that some social conservatives see as part of “social capital” and “the common good”.  

Monday, September 30, 2013

Predictions on how debt default would play out and affect retirees appear on web

Here we go again.  There’s rhetoric around (as on the Issues blog), that a shutdown, while painful for some people, will make a default over the debt ceiling in mid October less likely.  In fact, the New York Times just published some new analysis on how a default might play out and “escalate” this morning, link here. The article gives a link to the Alphaville blog (link  for details – just x-out the pop-up to see the content. Essentially, the second blog warns that it will be impossible for the Treasury to distinguish among valid and defaulted securities, “throwing sand into the gears” of the financial system. 

But in fact, I think there is every reason to think that Treasury would indeed pay bond holders first.  Still, this leaves “Tea Party” Republicans to explain why they are so willing to make others sacrifice for their own ideological goals (and, yes, there are some people – constituents – who can lose jobs to Obamacare). 
  
The most dangerous rhetoric came from Boehner himself in 2011 when he suggested that Congress should just stop paying better-off retirees Social Security and Medicare benefits,  as part of a way (in his mind) to handle “default”.  It doesn’t work that way, since a Trust Fund is involved, and the Social Security Trust Fund is effectively a bond holder.  Furthermore, he is ignoring the fact that retirement assets might suddenly become worth a lot less in fiscal chaos.  It sounds like a kind of bullying of seniors. Politicians can impose stiff means testing as a deficit reduction means even in the near future, but that would occur outside the scope of the debt ceiling debate. Again, that's why some of us would like legal ownership of our benefits -- "privatization".  


Friday, September 27, 2013

Fortune mag editor writes that debt ceiling debacle could turn Social Security into a "Madoff scheme", but he doesn't sound right on how the law really works

Allan Sloan, of Fortune, has an op-ed in the “Deals” page “A payment plan no better than Madoff’s”, p. A19, of the Washington Post Friday morning, Economy and Business section. The link is here. 
  
Of course, he’s referring to Social Security payments in case of a failure to raise the debt ceiling by mid October.
  
However, Social Security is a preferred bond holder, and could probably litigate to get first in line to get its regular payments.  
  
Even so, a few reckless politicians have suggested that better off retirees give up their benefits to help solve the crisis.   This is no way to run a democracy; it’s the way a warlord works.  Technically, Congress could pass a law to cut off benefits even for retirees receiving benefits now if they have over certain incomes or certain assets.  That sounds like expropriation, which is a favorite cry from the Left, not the Right.  But a few reckless politicians have suggested ideas like this. The problem is that, as we have covered, retirees don’t “own” their benefits the way they own private annuities. Even so, a law like that would not, as I understand things, do anything at all about a federal default.  And retiree asset values would plunge after a default, so the idea of asking for sacrifice is particularly galling.  But I have heard talk like this. 



Thursday, September 26, 2013

Orrin Hatch warns that raising debt ceiling alone won't stop a sudden financial crisis

Orrin Hatch (R-UT) has an op-ed in today’s Wall Street Journal that needs a read, “Obama’s Debt-Ceiling Stonewall”.  The link (paywall enforced) is here
  
Hatch doesn’t get into Obamacare; instead he goes right to the heart of entitlement reform.  To be honest, the proposals he makes are reasonable and gradual, and pretty much in line with what we have already heard.  
  
Hatch doesn’t specifically mention Stansberry’s theories on the “dollar as reserve currency” problem, but it isn’t hard to see it reading between the lines.  At some point, a financial crisis can erupt suddenly anyway, he maintains, because the current entitlement system is unsustainable. 

There is some debate on this, as with Social Security, but the math seems to be getting worse, as we noted recently with the disability payment system ambiguities.   

The significance to retirees is not just in Social Security payments, but the value of assets underlying savings of retirees.  

Sunday, September 22, 2013

For long-term care, CLASS evaporates; do we need a debate on "sacrifice"?

Michelle Singletary, in a syndicated business column, writes in the Washington Post Sunday morning about “Our looming long-term care crisis”, link here. The column concerns the demise of the CLASS Act, which would allowed voluntary payroll deductions to save for future long term care.  The problem was, as always, that people most likely to need it can’t afford even the deductions.
  
The key interim step was a “commission” or committee, kicking the can down the road.
  

Singletary points out that Medicare doesn’t normally pay for custodial care, and that people are forced to depend on “family and friends”, often requiring unelected sacrifice from them.  (I can remember some Sunday School sessions in the fall of 2008 about “sacrifice”.)   But that seems to be what social conservatives (of the Rick Santorum ilk) want to see, more “social capital”.   But the moral responsibility of people, outside of their scope of choice in having their own children, to step up to these sacrificial challenges does need to be debated, formally. 

Saturday, September 21, 2013

Social Security disability benefits program use grows, pressuring a sooner "day of reckoning" for retirement benefits

Social Security disability benefits, which are available to workers who become unable to work for medical reasons, have increased markedly and threaten the sustainability of the retirement program, which is, of course, much better known.  The Washington Post has a major front page story Saturday morning by Michael A. Feltcher, link here.
    
Social Security disability income should not be confused with SSI, which is totally separate and not funded by FICA.  SSA explains the difference (web url) here
  
The Post story focuses on eastern Maine, which I have visited myself in 1974 and 1995. 
As a weaker blue collar job market, especially in manufacturing, takes over, employers are less willing to hire mildly disabled workers. I would have thought that such practice was illegal under the ADA.  
  
That may be part of the problem.  Qualification for disability benefits seems to be a gray area and loosely defined, so employers and workers may “abuse it”.  Growing use of the disability program can threaten the actuarial sustainability for retirees in the long run, hastening the date when SSA can no longer pay full benefits, and increasing pressure to raise FICA taxes or wage ceilings and delay retirement age, or perhaps prohibit “early” retirement.
  
But FICA taxes also pay for the disability benefits program, and law firms specialize in helping workers get them (they even advertise on daytime television).  When people collect disability benefits, they generally have not paid as much into the system relative to benefits as retirees.  Therefore, the disability program can contribute to the notion of the Social Security program as a kind of “welfare” rather than an “annuity”, which is how most retirees see it.
   
As noted here before, the debt ceiling issue probably would not stop the Social Security Trust Fund from being “reimbursed” by the Treasury since SSA is a legal priority bond holder. But Congress, according the Supreme Court ruling (Flemming v. Nestor) does not have to honor the value of FICA paid as “property” and could implement means testing (even based on wealth as well as income) if it had the political desire to do so.


Wednesday, September 18, 2013

Home health caregivers will be protected by federal minimum wage, overtime rules by 2015

Amanda Becker, of Reuters, is reporting that the Obama administration has decided to apply the federal minimum wage law for home health aides, starting in 2015.  The federal minimum wage now is only $7.75 an hour.  The link is here. The New York Times has also reported on the matter Wednesday (Steve Greenhouse) here
  
If you do the math, it appears that 24 hours of hired caregiving would cost about $200 a day or a little over $6000 per month.  With Mother, who passed away in December 2010, the 24-hour bills in the last three months were about $12000 a month with two different home health agencies, so I know that the minimum wage could have reasonably been paid.  Minimum wage laws for caregivers do exist in 21 states and in Washington DC. 
  
The article says that exemptions will still apply for some workers hired directly by the family.  That part sounds murky to me.  However, it has long been true that families can save money by hiring home health themselves, but then they have to deal with all the employment paperwork, deductions, and immigration status verification.  Hiring directly can sometimes present other legal conflicts, since one is directly the caregiver’s “boss”. 
  
It's not immediately clear how this change would apply to "live-in's",  

Of additional concern is overtime for home health workers.  The article implies that Fair Labor Standards Act overtime rules will apply, so it could take up to five workers on rotating shifts to cover an entire week without an agency’s incurring overtime liability.  The agencies I used charged time-and-a-half on holidays and slightly more on weekends and evenings, but the rates did not appear to follow overtime rules as in the FLSA.  The Supreme Court had ruled on this with an important case in Long Island, covered earlier, in 2007.
  
Lawyers had told me that it is possible for a client to be held responsible for overtime directly if he or she knows or reasonably suspects (from the math) that a home health agency is breaking the law.  Home health agencies normally must check and verify immigration or “green card” status, and have become much more careful about this since 9/11.  Still, a family that knows that immigration law has been broken might be criminally liable. 


Monday, September 16, 2013

Current Medicare beneficiaries do not need to change anything under Obamacare; don't allow sales people to "trick" you, that's against the law

Susan Jaffe, of Kaiser Health News, has a story on p. A15 of the Monday, September 16, 2013 Washington Post, p. A15, reporting that selling health exchange coverage to current beneficiaries is illegal because they are already covered according to the law and do not need duplicate coverage.  It is not illegal, of course, to sell Medicare Supplemental or Medicare Advantage plans, as they are now and have been for a long time.  The link is here .  It is lawful for Medicare beneficiaries to buy exchange coverage on their own, but it would not make economic sense.
  
The government is concerned that sales people could actually mix the plans up.
  
If I were still in the job market, I think I would be getting solicitations to go to work selling these.  Maybe some of the email I don’t open deals with this.   


Tuesday, September 10, 2013

Assisted living group provides some important references for family caregivers

A company called “Assisted Living for Today” has passed on some information to me recently.
   
One item is a list “10 Essential Tips for Caregivers”, link here.  There is discussion of respite care.
  
eHealth has a blog posting on the financial impact of caregSurveys show a lot of adult children providing their parents with direct financial support. here.
  
The company provided a link for drug rehabs and addiction treatment (website url) here
  
It also provided a reference to physicians search by specialty, Zocdoc, (url) here

I’m told that Medicare has changed its hyperlink for forms, help and resources, to here
   
These items came from “Assisted Living for Today”. 

Thursday, September 05, 2013

Could collapse as dollar as world "reserve currency" wipe out retiree's assets?

Should retirees fret over Porter Stansberry’s theory that most US financial assets (cash, stocks and bonds) – retirement savings – could implode suddenly (like overnight) if the rest of the world no longer accepts the dollar as a reserve currency?  Stansberry says that this can happen because the US continues to print money, Weimar-like, to cover up its debts which are even larger than what politicians will admit to.
  
I discussed this on the Issues blog Aug. 30 and the “cf” blog Sept. 1.   But the current flack over the debt ceiling, which could crash down in mid October, seems to make his ideas relevant again.
    
I don’t see why such an event would stop the domestic economy, but it could make overseas goods and services much more expensive overnight.
    
Stansberry seems to favor owning gold and silver, overseas and offshore assets, and even barter (he’s vague – you have to buy a “discounted” subscription to his e-newsletter).  There certainly is a push to consider living overseas, particularly in Central America, especially Belize or Panama.  Real estate is said to be reasonable there, as is health care.  A local Arlington VA church sends its teens to Belize on a mission for ten days every summer. 


Tuesday, September 03, 2013

Northwestern University assigns patients with Alzheimer's to medical students as mentors; a note on the "senior moment"



NBC News reported, with Maria Shriver, that 5.5 million people in the US have Alzheimer’s. Northwestern University has set up a “buddy” program where Alzheimer’s patients, still in milder stages of progression, act as mentors of first year medical students.
  
Visit NBCNews.com for breaking news, world news, and news about the economy
   

One question that comes up is the “senior moment”, or “literal paraphasia”.  An example is trying to recall a word or name and not being able to recall it, until it pops into mind moments later.  There is an “About” explanation here. It is hard to predict if this process in normal aging can become progressive to the point that it interferes with daily life (frank dementia) or “Mild cognitive impairment” (MCI).   One tip:  when you have a dream, try to jot down what it was and keep a list (don’t post it online!)   That’s a good short term memory strengthening exercise.  

Tuesday, August 27, 2013

Debt ceiling debate is back; Social Security trust fund is on the priority list (as a bondholder)

The debt ceiling debate, like my drain fly colony, is back, as the Treasury department now says that accounting tricks can keep going only until mid October, 2013.  Zachary Goldfarb has the story in the Washington Post today here 
  
As “we” argued last winter, some daily federal income would continue, and the Social Security Trust Fund, according to the best legal information, would have as legally valid a “first claim” as any bond holder.  So the threat to existing Social Security recipients, in the short term, may have been overblown.  But there is nothing “constitutionally relevant” to stop Congress from implementing means testing, even for current recipients, according to Flemming v. Nestor, as we have covered.  There is only political clout.
  

Retirees could also be affected by economic instability – rising interest rates affecting bond portfolios, and possibly lower corporate earnings and future stock prices because of the pressures from Obamacare, which, however, also has many economic benefits (spreading pressure on health care costs, and many more I.T jobs).  Curiously, markets are skittish today over fears over a Syria strike, and that doesn’t sound rational.   

Thursday, August 22, 2013

Workers in 50s and early 60s: savings rate has plummeted in past year

AARP is reporting that retirement savings are down for people aged 50-64 considerably in just the last year, at least since the beginning of 2012.  No doubt, this report will provoke a column by Michelle Singletary.  The link is here
  
I was actually pretty lucky during my last years at ING-ReliaStar.  (I was forced to “retire” by that “Fourth Floor Massacre” in December, 2001.)  I got statements from the company every quarter, based on 401(k) accumulations, and they did show the “nest” egg growing.  The company froze its pension in 2000 but had a healthy 401(k) full match.  ("Freezing" is not the same as "terminating".)
   

If you are involved in receiving money from an estate, you want to know what you accumulated on your own, first.  You want to keep track of your “numbers” with a number of different views, including liquidity.  

Tuesday, August 20, 2013

Is AARP quiet on filial responsibility out of "practical necessity"? Would a policy debate cause more states to enforce it?

Last week (on Monday August 12), I reported that I had discovered that a valuable AARP state map giving linkable details on filial responsibility laws had disappeared.  I contacted AARP, and the only response I got was that they have another posting from 2009 explaining the concept That article does have a link to a 2007 study by Evercare on the sacrifices made by family caregivers, here.
  
I wonder why the map link was taken down and has not been replaced. 

I can appreciate that maintaining it accurately could be a problem.  State laws in this area are tricky.  For many of the 29 states that have them, they are hard to find online, and hard to interpret. AARP could have felt that it was taking a “risk” of giving wrong legal advice by keeping it.  In any case, any adult child in this situation should talk to an eldercare lawyer in his own community and state.

Back in 2007, I researched the laws in a few states: Virginia, Maryland, California, Massachusetts, Connecticut, Iowa, South Dakota, Iowa, and particularly Pennsylvania.  The findings are in this blog during that month.   I have not checked recently to see how current this information is, because it would be so time consuming to maintain (as AARP must know).  The last of these states (that is, PA) moved its filial responsibility law from the welfare code to the family code in 2005, a step that could have been seen as socially provocative.  I was in contact with a few experts in the subject in 2007.  One of them, a professor in Pennsylvania, expressed then in an email a concern that amateur’s publishing on the matter could provoke states (or other parties, like nursing homes) into trying to invoke them.   That is the mentality we used to accept with sodomy laws in the gay world;  in many states, they were on the books, but almost never enforced against private consenting adults,  But they were still there, ready for use as a political weapon.

Could AARP feel that remaining quiet on the matter is safer “practical” political strategy? I wonder. 
It is true that not many states have tried to use them recently, but we saw a case reported here in May 2012 where a nursing home went after an adult child directly rather than going to Medicaid, in Pittas case – in guess what state?  Rick Santorum’s Pennsylvania.

States, as their budgets (and particularly their public employee pension funds) get squeezed, may very well turn to these laws in the future, at least to save money in the Medicaid area. 

There is no question that as a policy matter we must debate it.  If we value keeping human beings alive as long as possible, and there are fewer children being born (especially in some populations) to support previous generations (an issue we touch all the time with the Social Security and Medicare debates), we have to consider the unelected moral and legal responsibilities of adult children as individuals.  And the debate has double-edged areas in many areas, such as childlessness, public policy supporting parents, and most of all how we look at marriage itself, and the responsibilities that go with it.  Because some of those responsibilities can exist anyway. 

Note also that on March 17, 2013 on this blog, I linked to an original article I wrote for Wikipedia on the matter.



Monday, August 12, 2013

PBGC publishes reminder that it does not insure public pension plans; filial responsibility could come into play after bankruptcies

The Pension Benefit Guaranty Corporation (PBCG) has reminded the public that it doesn’t insure the pension plans of governments – municipal, county, or state.  It only backs up the pensions of (most) private-sector plans.  The posting is here

The question began to circulate Sunday night after a television broadcast by Morgan Spurlock about a municipal bankruptcy (in his “Inside Man” series) mentioned that the pension payments of one California town (not Stockton, but a smaller town) had been cut by 90% by the bankruptcy court.  That means the pensioners have been stiffed and are out of luck for life.   That is obviously a big upcoming issue in Detroit.  Here’s another potential complication.  California, like many states (I’m not sure about Michigan) has a filial responsibility law.  It’s possible that when a parent who had beenan affected municipal employee loses most of his or her pension, an adult child could be forced to support him or her.

By the way, the AARP map (linked on this blog March 8) seems to have disappeared.  I’ll try to find out where it is. AARP does have a text article on the filial responsibility issue here.   It is by Beth Baker and dates back to January 2009.  

Wednesday, August 07, 2013

Lessons from Bezos and the Washington Post: if you're near retirement and you company is sold, don't cry (but learn to use EDGAR)

Michelle Singletary, a syndicated columnist often appearing in the Washington Post with her “Color of Money” article, wrote today that she knows what it feels like to learn that your employer has been sold (link). 

Of course, she is referring to Jeff Bezos’s singlehanded purchase of the Washington Post, held and protected eight decades by the Graham family.

I don’t know why a syndicated writer would feel tied to one newspaper;  but it certainly will get attention of people for whom the Post really does mean a journalism career – for example, Timothy B. Lee, who moved over to the Post from Ars Technica and has started a new technology series called the Switch Blog.

Singletary takes us, in this piece, through her calculations of what retirement would mean.  It appears that the Post has funded its pensions pretty well.  What’ interesting is that Singletary names the filings at the SEC and on EDGAR that any stakeholder, especially someone near retirement, should look at, as well as the specific form 8-K.


I would have done all this with ReliaStar and ING before “retiring” in the post-9/11 period at the end of 2001, when many companies were stressed.  I was taken care of OK, but since then I have learned that I was luckier than most people.  Look this stuff up yourself,  “Guys and Dolls”.  

Tuesday, August 06, 2013

Hospital advertises prostate treatment on DC Metro billboards; "W." escapes being cracked open like a lobster

While on the Metro to Nationals Park last night, I saw a bizarre ad in one of the cars for prostate care, from Georgetown University Hospital.  Two “friend” had both shared the experience of “CyberKnife” (link) , which reduces the number of radiation sessions from 40 to 5.
   
My own PSA numbers went down the year after mother died, probably because no caregiver was cooking, so I tended to consume less fat.  Reducing fat intake and perhaps weight will probably reduce PSA in some men, and greatly lengthen the period of “watching and waiting” with no intervention (possibly leading to incontinence or impotence). 
    
There’s always an issue – whether your own momentum can keep you going without stopping for cacer screening and the possibility of mutilative surgery and dependence on others.
  
Former President George W. Bush didn’t get to go home to his ranch near Austin, TX yesterday, when a “routine” physical found a blocked artery.  He had an angioplasty and stent this morning despite not having many symptoms.  I don’t know how a “routine” physical finds something like that. At least “W.” came out of this better than David Letterman; he didn’t have to join the zipper club. 
   

But, at 70, I suspect I will be pressured to accept more invasions and humiliation for Medicare-paid tests next go round.  After all, I have a moral obligation to find out why I was so far behind physically as a youngster.  With me, it remained a moral issue, not a disability.  


There was a media report today that breast-feeding may reduce a woman's chances of devleoping Alzheimer's Disease later in life by as much as 65%.   Does this mean that women who don't have children are at greater risk?

Monday, August 05, 2013

Moderates call for Congress to develop a municipal bond insurance program to stabilize public pension accounting

Congress should develop a federal municipal bond insurance program, which would establish uniform national standards for actuarial projections of returns on pension investments.  That is a suggestion made on p. A17 of the Monday, August 5, 2013 New York Times, by Richard J. Riordan an Tim Rutten, title "A Paln to Avert the Pension Crisis", link here.

This would not overlap the responsibilities of the Pension Benefit Guaranty Corporation (PBGC).

The GOP would probably resist a proposal like this, but would have a hard time not looking silly.
  

The entire tax-free municipal bond world could be at risk without more uniform standards of actuarial accounting, which generally already exist in the life insurance industry.  

Saturday, August 03, 2013

Moody's places some local, state employee pension funds under review; Conservative group in Minnesota weighs in

When I lived in Minneapolis from 1997 to 2003, I sometimes went to seminars or luncheons held downtown by the conservative-to-libertarian group Center for he American Experiment, run by Mitchell B. Pearlstein and Katherine A. Kersten.   Speaker ranged from John Stossel (libertarian-oriented ABC 20-20- reporter at the time) to Cato Institute policy researchers (David Boaz once, if I recall right).
   
Sometimes the writings could take on a socially conservative side, as with the 2000 essay anthology book by the couple, “Close to Home: Celebrations and Critiques of America’s Experiment I Freedom”, where Kersten, in one essay (“Textbooks Push the Needs of ‘Self’ ove Marriage”) criticizes a hyper-individualistic outlook on life that disregards the importance of learning to take care of other people (before being married with kids, or not).  I recall the coined term, “self-date”. In more recent years, some libertarian writers like Charles Murray have noted a gradual erosion of "social capital" and the effect this can have on the needy.
    
In fact, that point certainly translates into today’s concerns about eldercare, aging population, lower birthrate, and filial responsibility.

A recent policy article by the group points out that in many states (in their case, Minnesota, particularly the city of Minneapolis or Hennepin County), taxpayers have to pay more and face higher interest rates (or their local governments face them with bonds) because accounting for pension funds for public employees was not done properly in the past.  The link is here.
     
The article does favor the practice by employers (public and private) to convert employees over to defined contribution plans (from defined benefit plans) in the way of various 401(k)’s and annuity products. 
  
The article also mentions Virginia (the entire Commonwealth) as having problems, as well as over twenty local or state systems, “under review” by Moody’s.