Health Insurance – Open Mind http://open-mind.org/ Sat, 17 Jul 2021 03:12:06 +0000 en-US hourly 1 https://wordpress.org/?v=5.7.2 https://open-mind.org/wp-content/uploads/2021/06/icon-6-150x150.png Health Insurance – Open Mind http://open-mind.org/ 32 32 Finding Health Insurance Before Medicare https://open-mind.org/finding-health-insurance-before-medicare/ https://open-mind.org/finding-health-insurance-before-medicare/#respond Wed, 07 Jul 2021 14:10:35 +0000 https://open-mind.org/?p=770 Eric Galler retired early, but he has a big job ahead of him: finding high-quality health insurance for less than a king’s ransom. This year, Galler is paying $17,000 in premiums for a plan that covers himself, his wife and his 20-year-old son—and that’s with a $13,000 deductible. In the past two years, the premium […]]]>

Eric Galler retired early, but he has a big job ahead of him: finding high-quality health insurance for less than a king’s ransom.

This year, Galler is paying $17,000 in premiums for a plan that covers himself, his wife and his 20-year-old son—and that’s with a $13,000 deductible. In the past two years, the premium has climbed more than 40%, and the deductible has roughly doubled. “Inflation has been through the roof,” says Galler, a former General Mills executive.

At 52 years old, Galler has 13 years to wait before he reaches Medicare eligibility at 65. So he’s hashing out his health coverage options. He’s closely watching the development of new association health plans, authorized by a U.S. Department of Labor rule finalized in June, that can offer coverage to sole proprietors and small businesses while skirting some of the ACA’s requirements for non-group health plans. And Galler has looked at health care sharing ministries, which are actually not insurance but simply groups of people who agree to share each other’s health costs.

When Galler turns 55, he can also switch to his former employer’s retiree health plan and cut his premiums in half, he says—but that’s three costly years down the road. The challenge, he says, is “how do I get through those years?”

That’s a daunting challenge indeed—and many early retirees and self-employed people in their pre-Medicare years face a similar struggle. Although the Affordable Care Act has been a boon for this group, guaranteeing them access to coverage even if they have preexisting conditions, many of those who don’t qualify for subsidies on the ACA exchanges have faced skyrocketing premiums. And while opponents of the ACA are moving to expand marketplace-plan alternatives, including association health plans and short-term health plans, these options lack some of the consumer protections that are built into ACA plans.

The future of marketplace plans, meanwhile, looks less and less certain. Next year, the penalty for going without health insurance drops to zero, which may cause more healthy people to abandon marketplace plans and inflate premiums for those who remain. And the Trump administration said in June that it would no longer defend key provisions of the ACA that protect people with preexisting conditions.

People in their fifties and sixties who lack group health coverage are among the hardest hit by the upheaval. As they age and develop more serious health conditions, going uninsured or opting for bare-bones coverage is a big risk—but if they don’t qualify for marketplace subsidies, comprehensive coverage is often unaffordable. This is “the group that is really struggling the most,” says Ronnell Nolan, president and chief executive officer of Health Agents for America.

What’s an early retiree to do? Some may have access to COBRA coverage, allowing them to stay on their former employer’s plan for a limited period. But that tends to be an expensive option: You have to pay both the employer and employee share of the cost. Others have made life-altering decisions, such as going back to work full-time to get employer health coverage or moving to a country that offers free universal health care. But such drastic steps may not be necessary. Here’s how to protect your health—and your pocketbook—in early retirement.

1. Start With the Marketplace

Yes, marketplace premiums give many early retirees sticker shock, and the political brouhaha around the ACA creates considerable uncertainty about the pricing of 2019 plans. But don’t ignore the marketplace—it may offer some surprisingly affordable options.

In most states, marketplace open enrollment for 2019 coverage runs from November 1 through December 15. But you can still get 2018 coverage if you’ve had certain life events, such as losing health coverage.

Need some motivation to visit healthcare.gov, where you can find marketplace coverage? Consider this bit of good news from HealthSherpa, which helps consumers sign up for marketplace plans: After factoring in the premium tax credits and cost-sharing reduction subsidies that many marketplace enrollees receive, the median premium paid by consumers 50 and older enrolling through HealthSherpa has actually dropped 36% in the past three years, to about $60 per month.

Last year, nearly 9 million people who bought coverage through the marketplace received subsidies and were insulated from the sharp premium increases that have so often made headlines, according to the Kaiser Family Foundation. “Whatever happens to premiums, people who are eligible for premium tax credits will be largely protected,” says Karen Pollitz, senior fellow at the Kaiser Family Foundation. “When premiums go up, the tax credit goes up dollar for dollar.”

To be eligible for subsidies, your annual income must be below 400% of the federal poverty level. For 2018, a one-person household falls below that threshold if annual income is less than $48,560, and for a two-person household, the cut-off is $65,840.

If your income is just above the threshold, talk to a tax adviser about potential ways to qualify for the subsidies, Pollitz says. Perhaps making a larger IRA contribution or strategically timing retirement account withdrawals could help you qualify. To see how various levels of income might affect your premiums and subsidies, use the Kaiser Family Foundation’s calculator at kff.org/interactive/subsidy-calculator.

Recent political maneuvering adds some new wrinkles to marketplace-plan shopping. To understand why, first recall that marketplace plans fall into one of four metal categories—bronze, silver, gold and platinum—based on how costs are split between consumers and insurers. Late last year, the Trump administration said it would end federal government payments that compensate health insurers for offering cost-sharing reductions to lower-income enrollees. In response, insurers raised premiums on the silver plans that are used to calculate ACA subsidies—a move that became known as “silver loading.” When those premiums rose, consumers’ subsidies also rose. And because consumers can use premium subsidies to buy plans in any metal category, many are now able to buy higher-deductible bronze plans at very low or even zero premiums—or purchase lower-deductible gold plans for less than the cost of a silver plan.

If you check out your marketplace options and find that you’re not eligible for subsidies and the premiums seem unaffordable, don’t give up. Look for ACA-compliant plans that you can purchase off the exchange, either directly from the carrier or through a broker. In some states, insurers are offering silver plans outside the exchange without the “silver loading” surcharge. So a silver plan may cost “a lot less off the exchange if you’re not subsidy-eligible,” says Betsy Imholz, special projects director at Consumers Union.

2. Approach Bare-Bones Plans With Caution

The Trump administration has taken a number of steps to promote plans that skirt the ACA’s requirements. Some of these plans may be considerably cheaper than marketplace options, particularly if you don’t qualify for subsidies on the exchange. But in some cases, they can deny sick people coverage, refuse to cover preexisting conditions or exclude coverage of essentials, such as prescription drugs. Such restrictions are prohibited in marketplace plans.

Short-term health plans, designed for people who have a temporary gap in coverage, currently offer coverage for up to three months—and the administration has proposed extending that term to 12 months. The plans are relatively cheap. A typical 55-to-64-year-old can pick up a short-term plan for about $250 a month, says Sean Malia, senior director of carrier relations at online insurance broker eHealth, compared with about $800 a month for a marketplace plan.

But unlike other individual health plans, short-term plans are not renewable. When your policy ends, you have to apply for a new one—and if you’re sick, you may be denied. These plans can also charge you higher premiums based on your health, gender or age; refuse to cover preexisting conditions; exclude coverage of prescription drugs, preventive care and other basic benefits; and impose caps on coverage.

Because of such restrictions, the plans “tend to be bad deals for people who are older,” says Ning Liang, co-founder of HealthSherpa. “You’ll pay each month, and when you actually need the insurance, it’s not going to be there for you.”

Yet some early retirees have found these plans are the only affordable option for bridging a short coverage gap. Late last year, Paula Smith, a 64-year-old retiree in Baton Rouge, La., was shopping for a plan to cover herself and her husband, Coy. An ACA-compliant plan would cost them about $1,500 a month, with a $4,500 deductible—an expense that seemed “just ridiculous,” Paula says. Because Coy was turning 65 and switching to Medicare in February of this year, they opted to get an ACA plan to cover only Paula, for about $960 per month, plus a $291-per-month short-term plan that would cover Coy for the month before he enrolled in Medicare. They found the short-term policy acceptable “because it was such a short period of time,” Paula says. “If I had known we’d have to have it for even three to six months, I’d have been more concerned.”

The new association health plans authorized by the Labor Department in June, meanwhile, will also allow self-employed individuals and small employers to buy less-regulated plans. These plans must follow some ACA rules—they can’t refuse to cover sick people, for example. But they can offer skimpy benefits. They don’t have to cover prescription drugs, and they may put a cap on hospital coverage.

And while marketplace-plan premiums can be up to three times higher for older people than for younger people, association health plans can make larger age-related premium adjustments. “So people over 50 might not find better rates” through these plans, Pollitz says. The plans can also vary premiums based on gender or occupation.

What’s more, association health plans have a checkered history, insurance experts say. The plans have been plagued by scams and financial instability, leaving enrollees stuck with unpaid medical bills.

3. Consider the Direct Route

Some patients are taking matters into their own hands, seeking to sidestep insurance altogether.

One approach: contracting directly with physicians for health care services. In this “direct primary care” model, doctors charge a flat monthly fee that covers at least a portion of primary-care services, such as regular checkups and preventive care. Although fee structures vary from one practice to the next, a typical monthly fee might be $65 or $70, says Dr. Phil Eskew, a direct primary care physician and lawyer in Wyoming who tracks the industry. Patients may also pay a small per-visit fee, such as $10.

Direct primary care doctors often contract directly for lab services and radiology and offer those services to patients at a significant discount, says Dr. John Cullen, a family physician in Valdez, Alaska, and president-elect of the American Academy of Family Physicians. In many cases, they can also get medications from wholesalers and sell them to patients at cost.

Direct primary care differs from concierge care—another retainer-fee-based model—in that the monthly fees tend to be lower and the physicians typically don’t bill insurance at all.

Patients are generally encouraged to pair direct primary care with a high-deductible health plan that can cover them if they are hospitalized or face other hefty health costs. But there’s a catch: In many cases, “even the high-deductible health plans are astronomical,” Nolan says. But for those who can find an affordable high-deductible plan, “the overall cost should be less, especially if you’re preventing higher-cost medical services” with direct primary care, Cullen says.

Note that health savings accounts, which allow high-deductible plan enrollees to pay certain medical expenses with tax-free money, currently can’t be used to cover direct primary care fees. Several bills introduced in Congress, however, would make HSAs more compatible with direct primary care.

There are roughly 850 direct primary care practices nationwide, and about 200 new ones open each year, Eskew says. You can find a direct primary care practice in your area using the map at dpcfrontier.com. Since various direct primary care practices in your area may operate differently, make sure you understand exactly what services are offered and what’s included in the monthly fee before you sign up.

Direct primary care is one option that Ed Ditto, 49, a retired commodity trader in Chattanooga, Tenn., is considering to rein in his expenses. As the husband of a breast-cancer survivor, he knows the value of good health coverage. But his current marketplace plan has a sticker price of about $1,200 a month, and because his annual income fluctuates, he’s not yet certain whether he’ll qualify for subsidies this year. His premium has climbed about 10% annually in recent years, says Ditto, who blogs at EarlyRetirementDude.com.

In addition to direct primary care, Ditto is also reluctantly considering plans that offer fewer consumer protections. He doesn’t think non-ACA-compliant policies offer adequate coverage, but if premiums continue to climb and the choice comes down to a non-compliant policy or foregoing coverage altogether, he’d go with the non-compliant policy, he says. “There’s so much uncertainty,” Ditto says. “We’re considering all our options.”

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Long-Haul COVID Renews Push to Expand Palliative Care https://open-mind.org/long-haul-covid-renews-push-to-expand-palliative-care/ https://open-mind.org/long-haul-covid-renews-push-to-expand-palliative-care/#respond Tue, 06 Jul 2021 03:11:32 +0000 https://open-mind.org/?p=753 The COVID-19 pandemic, which has left an estimated tens of thousands of Americans with long-term debilitating symptoms, has prompted a renewed push to provide full palliative care services to seriously ill patients in their homes. Palliative and hospice organizations are in talks with the Biden administration to create such a benefit as a demonstration project […]]]>

The COVID-19 pandemic, which has left an estimated tens of thousands of Americans with long-term debilitating symptoms, has prompted a renewed push to provide full palliative care services to seriously ill patients in their homes.

Palliative and hospice organizations are in talks with the Biden administration to create such a benefit as a demonstration project in Medicare, the health plan for older Americans. If successful, they hope it would become a permanent benefit in Medicare and then be offered under Medicaid, the federal/state program that covers lower-income Americans, and commercial insurance plans as well.

Advocates point to numerous studies showing that palliative care results in a higher quality of life for patients, better management of their pain and symptoms and lower health care costs as a result of fewer hospitalizations.

But most insurance plans, including Medicare and Medicaid, only cover comprehensive home- or community-based palliative care services for people in hospice care, which generally means they have a prognosis of six months or less to live and are forgoing treatment intended to prolong their lives.

Those pushing for changes say many who are not in hospice but who are afflicted with illnesses such as cancer, heart disease and Alzheimer’s would benefit from a full array of palliative care services delivered to them at home.

Added to that list now are COVID-19 long-haulers who, months after becoming infected, continue to suffer from lingering, life-limiting symptoms such as mental confusion, nausea, dizziness, blurry vision, hearing loss, paralyzing fatigue and dizziness. Approximately 10% of people who test positive for COVID-19 remain unwell for more than three weeks and a smaller proportion for months, according to an August study in The BMJ, a medical trade journal published by the British Medical Association.









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The pandemic sparked the National Hospice and Palliative Care Organization’s latest push in its talks with the federal Centers for Medicare and Medicaid Services (CMS) to create a home- and community-based palliative care benefit, said Edo Banach, the group’s president.

“Early on, it was clear to me that we are going to have a ton of seriously ill people, and almost none of them will qualify for hospice care,” Banach said.

The contagiousness of the coronavirus also is an impetus for action, he said, since many people who might benefit from palliative care are particularly vulnerable to infection. They shouldn’t risk a trip to the hospital during a pandemic if they can avoid it, he said.

“Anything that can bring home based palliative care to patients who are not hospice eligible (or desiring) is essential,” James Tulsky, co-director of the Harvard Medical School Center for Palliative Care, said in an email. “There are many patients with significant needs (medical, psychosocial) who are primarily homebound and could benefit from closer monitoring and more in-home services. Currently, the resources available for them are limited.” 

Home Care During a Pandemic

When Shelenea Harris invited a palliative care team into her western Virginia home last fall to help care for her father-in-law, Roy Harris, she made something very clear. “I told them I was adamant that I wanted the best care for him, and if they couldn’t do that, I didn’t want them to waste their time or mine.”

She got what she asked for. The team kept Roy living at home and surrounded by family, free from pain and the medicines that made him sick, and out of the hospital and doctors’ offices, as he fervently desired.

“He wanted to have peace, and that’s what they gave him,” Shelenea Harris said.

It brought peace to the family as well, she said. During the pandemic, the last thing the family wanted was to place 85-year-old Roy in a congregate setting such as a residential rehabilitation center.






Roy Harris with his granddaughter Anna Harris in Eagle Rock, Virginia, in 2020. He received hospice care services at home in the last six months of his life. He died in February.

Provided by Shelenea Harris




In one way—a grim way, to be sure—Roy, a retired trucker and grandfather known to his family as “Pawpaw,” was fortunate: He was able to receive a raft of services at home since he was eligible under Medicare for hospice care. But that’s only because he had a prognosis of six months or less to live.

The prognosis was correct almost to the day. He died in February at home with his family, half a year after beginning hospice care.

Without the hospice eligibility that came with his six-month prognosis, Harris likely would have had to endure the hospitalizations he dreaded, leading to higher health care costs and more stress for all involved.

“A lot of frail elderly and chronically ill fall into that category. They have a year or two to live but don’t qualify for hospice,” said Dr. Balu Natarajan, chief medical officer of Seasons Hospice, a palliative and hospice care provider based in Illinois that operates in 19 states.

Others who are seriously ill now but who might recover, such as COVID-19 long-haulers, also could benefit from palliative care.

Medical groups and hospice and palliative care providers have long argued for more community-based palliative care options, but Banach said they redoubled their efforts in March 2020 as coronavirus cases began multiplying. The urgency grew after it became clear that many of those infected were still incapacitated with a variety of life-limiting symptoms months after first falling ill.

The hallmark of a comprehensive palliative care is an interdisciplinary team of providers who address the medical, social, psychological and spiritual needs of the patient, including management of pain and symptoms.

In recent years, a number of states have adopted measures to improve access to palliative care, but California appears to be the only state with a Medicaid program that covers comprehensive palliative care services at home for patients not eligible for hospice.

Advocates say the biggest roadblock to expansion of palliative care services is that many patients, policymakers and even medical providers continue to believe that palliative care is meant only for the dying.

“Our health care system tends to do pretty well at treating disease, but where it often falls down is truly taking care of the person—helping them with the physical, emotional, and practical burdens of their disease,” said Kate Meyers, a senior program officer with the California Health Care Foundation, which works to improve health care delivery in that state.

“It’s not enough to only provide that kind of support to people at the very end of their lives through programs like hospice,” Meyers said. “We need to provide them with those supports much earlier, while they’re getting treated for their disease, while they’re making decisions about what treatment approach is right for them.”

A Problem of Definitions

Hospice and palliative care overlap, but they are not the same, even as many lay people often use the terms interchangeably. Palliative care can be administered apart from hospice, for patients not deemed terminal but still living with chronic, serious and life-limiting conditions.

If hospice-eligible, a patient can tap a range of services, both medical and otherwise, which can be provided in a hospital, at home or elsewhere in a community, such as a residential hospice, assisted living facility or nursing home.









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The services can encompass help with pain relief and symptom management, in-person medical care, personal care, patient and caregiver education and advance life planning, respite care and social services, as well as psychological, spiritual and grief counseling for the patient and family members.

Palliative care often delivers a similar set of services, but it is not time limited.

Often patients get a patchwork of palliative care at home, advocates say, but not comprehensive services delivered by a team.

“We need to reach upstream of what is hospice eligible to provide support for people,” said Bob Parker, chief clinical officer and chief compliance officer at Intrepid USA Healthcare, a Texas-based company offering health care and hospice services in homes and congregate settings in 18 states.

Some Medicare managed care and commercial plans offer limited home- and community-based palliative services, but Medicare fee-for-service programs do not. While California is the only state to offer full community-based palliative care services through Medicaid, proponents in Arizona, Colorado, Florida and Oregon are pushing those states to follow suit, according to the National Hospice and Palliative Care Organization.

Demonstration Model

Providers would apply to the federal Centers for Medicare and Medicaid Services to participate in the new model advocates are seeking.

Banach said he and allies have had fruitful conversations with CMS about embarking on such a model. CMS declined a request from Stateline to talk about the proposal.

The group’s proposal calls for the expansion of a demonstration that CMS has been funding since 2016 called the Medicare Care Choices Model. Under that model, patients with terminal illnesses who did not want to abandon medical treatments intended to prolong their lives can receive hospice services through participating hospice organizations.

The model resulted in a 25% savings to Medicare, largely by reducing hospitalizations, according to a CMS evaluation published in October. Most caregivers also reported high satisfaction with the treatment provided.

If deemed successful, the demonstration could result in the expansion of the current Medicare palliative care benefit.

And that likely also would result in the extension of those benefits in state Medicaid programs. Medicaid and commercial insurance carriers often adopt benefits first adopted by Medicare.

Proponents also want the demonstration project to develop a baseline standard for what constitutes palliative care services.

California passed its law to provide a Medicaid benefit for home- and community-based palliative care for patients who are not hospice eligible in 2014. That law was an expansion of an earlier law providing home palliative care Medicaid benefits to children.

The need for such services, said Meyers of the California Health Care Foundation, is only going to grow.

“As the country faces an aging population and the need for people to be well supported at home and avoid unnecessary hospitalizations, palliative care is one of the tools to help keep people as well as they can be for as long as they can be,” she said.

“It isn’t just meant for people at the end stage of their lives, and we still have a long way for that to be widely understood.”

Roy Harris was eligible for the full array of palliative care services at his son’s Virginia home, which he received from Intrepid USA, the Texas-based provider. Harris suffered from a multitude of health conditions: congestive heart disease, chronic obstructive pulmonary disease, neuropathy and dementia.

His daughter-in-law said his caregivers got his breathing sorted with oxygen and kept him comfortable. They bathed and gently shaved him. They did physical therapy to help with his walking and balance and taught family members exercises to help with his memory. They brought in a chaplain who prayed with him and sang hymns with the family.

“They allowed him to keep his dignity,” said Shelenea Harris. “He did not want to be in and out of hospitals. He was able to reminisce, spend quality family time, make memories.

“He was able to live the life he wanted to live.”

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hellsite.austin.gov: Everything needs to be online now. Austin is a world-renowned tech capital. Why can’t the city get it right? – News https://open-mind.org/hellsite-austin-gov-everything-needs-to-be-online-now-austin-is-a-world-renowned-tech-capital-why-cant-the-city-get-it-right-news/ https://open-mind.org/hellsite-austin-gov-everything-needs-to-be-online-now-austin-is-a-world-renowned-tech-capital-why-cant-the-city-get-it-right-news/#respond Sun, 04 Jul 2021 05:19:02 +0000 https://open-mind.org/?p=737 Illustration by Zeke Barbaro / Getty Images For the thousands staring anxiously at their computer screens for hour after hour, the message came like a slap to the face. “There are currently no appointments available. As of 11:40pm, our scheduling system has run into technical issues resulting in massive delays. After working with our vendor […]]]>

Illustration by Zeke Barbaro / Getty Images

For the thousands staring anxiously at their computer screens for hour after hour, the message came like a slap to the face. “There are currently no appointments available. As of 11:40pm, our scheduling system has run into technical issues resulting in massive delays. After working with our vendor for multiple hours, it appears there is no immediate fix we can make.”

With that, thousands waiting through the evening of March 15 to make appointments for the COVID-19 vaccine on Austin Public Health’s webpage were kicked out of the sign-up process. Many immediately began typing:

“We sat here for six hours. This is unacceptable.”

“I was literally at the screen selecting an appointment time. Does this mean that I lose this spot and start completely over in the queue tomorrow?”

“They can’t keep the lights on. They can’t keep the water running. They can’t even handle a basic scheduler. What a waste of space.”

It wasn’t the first time APH’s COVID pages had crashed, or randomly kicked people out of its database, or confounded their attempts to register in the first place. And while the dysfunction was shocking to some, many of the city’s own IT workers were definitely unsurprised. They had been predicting the mess for months before watching it unfold.

Tori Breitling was one. Breitling left the city in January after three years of trying to reinvent, or just improve, its website, which has fallen short of tech-friendly Austinites’ expectations since the city first went online in the 1990s. She spent the last weeks in her position watching the city try to make the vaccine portal work, offering her advice in vain to confused bosses. It makes her angry to talk about.

“Just try to sign up,” Breitling said. “It’s a nightmare. I mean, it’s barely usable. If you look at the APH Facebook page, in the comments, you will see people complaining about how horrible it is. You know, we’re supposed to be this tech city? And Austin has not hired one person who knows what they’re doing and put them in control. It’s embarrassing. They all should be really embarrassed and frankly I can’t believe that they’ve managed to get away with it for this long.”

Tori Breitling (Photo by Jana Birchum)

“You know, we’re supposed to be this tech city? And Austin has not hired one person who knows what they’re doing and put them in control. It’s embarrassing. They all should be really embarrassed and frankly I can’t believe that they’ve managed to get away with it for this long.” – Tori Breitling

The city of Austin’s Communications & Public Information Office is, among other things, in charge of the content on the city’s website. Another department, Commun­i­ca­tions & Technology Management, is, among other things, in charge of providing technical support for the website. Both CPIO and CTM employ web developers and other in-house technical experts. However, neither department created APH’s COVID-19 vaccine portal. Instead, the city contracted with third-party vendors using software from Salesforce, the Fortune 500 tech giant that dominates the customer relationship management market.*

The Chronicle interviewed a dozen former and current tech workers with the city to compile this report, many of whom preferred to speak off the record. They say that the vendors implementing the Salesforce platform did not test the vaccine portal to see how many users it could handle before the site went live. So when thousands tried to sign up for vaccines, it crashed. This failure to “load test” the portal, our sources say, was one of several serious blunders made in its design.* But the workers share the conviction that though a vendor built the vaccine portal, its failure is the responsibility of city leaders. As one said, “If you’re going to use a vendor, you still need to tightly control the process.”

City leaders have shown no eagerness to embrace responsibility for what happened on March 15, or before, or since. Chris Stewart, the chief information officer of CTM, made it clear after a prior crash in February that though he is the city’s top technology manager, he wants no blame for the malfunctions. After KXAN ran a critical news piece on the February crash, Stewart sent memos to the City Manager’s Office and to his workers, both obtained by the Chronicle.

Stewart wrote to management: “The portal platform used for Austin Public Health’s COVID-19 vaccine and testing registration system is entirely separate to the City’s main website, austintexas.gov, and is managed by an external vendor. KXAN’s conflation of the two is unfortunate and misleading.” To his workers, Stewart wrote: “As many of you are aware, that platform and the City’s website are completely independent and have nothing to do with each other.” He then reminded his workers not to talk to reporters.

Sarah Rigdon is another tech worker who recently left the city’s employ. She points out that Stewart’s memos show the city’s IT department disavowing responsibility for a city webpage, one crucial to saving lives. “The fact that this detail is something they considered important enough to single out, in a huge list of things they could have addressed, is exactly the problem,” Rigdon said. “They are so separate from their users that it doesn’t occur to them that it doesn’t matter who manages each website. For the user, it’s the same thing. And their lack of understanding and lack of interest in learning has endangered public health, and continues to make it harder on residents just trying to get the services they need every day.”

The City Knows What’s Up

There’s a reason the heads of APH looked for a third-party vendor to design their vaccine portal. It’s because the city’s website, austintexas.gov, is fragile, tangled, and a general mess.

This has long been the view of many Austinites, who like Breitling have been amazed, and not in a good way, that a city known worldwide as a tech capital could do such a poor job establishing a useful online presence. The Chronicle‘s Richard Whit­tak­er reported in February 2012 on the launch of austintexas.gov – four years in the making, after the city abandoned plans to use an outside vendor and moved the job in-house – to replace the original cityofaustin.org, which was launched in the early days of the World Wide Web and also clunky and buggy. The then-leaders of CTM and CPIO acknowledged that the new site was incomplete, that there were many bugs still to be worked through, that large sections of it had to be pulled back for retooling, and that its search functions were inadequate. But they were optimistic that, moving forward, all these issues would be resolved.

They were not. Nearly five years later, an October 2017 report by the Office of the City Auditor told much the same story. The report compared austintexas.gov to websites in nine other large cities and found that it was poorly organized and difficult to navigate. “This, coupled with the website not meeting accessibility guidelines, means that services are more difficult for people of all abilities to find and use,” the report’s authors wrote.

The audit zeroed in on the way that austintexas.gov presents information. It explained that visitors to the city’s website are looking for services – they want to pay parking tickets, apply for building permits, adopt pets, learn about rebate programs. But when they logged on, they weren’t asked what kind of service they were looking for. Instead, they were greeted by a list of departments. Rigdon says this is not the way information on modern websites is arranged, because people don’t think like that: “The primary mental model of residents – and we know this from research – is that they want their services. They have a task, they go to the city website, and they just want to complete their task. They don’t care what departments are involved, or which managers are in charge.”

The audit also found that austintexas.gov didn’t comply with Americans With Dis­abil­i­ties Act requirements that public websites be accessible equally to people with visual impairments, because screen readers (used to convert text to speech) couldn’t make sense of all of austintexas.gov’s information. In addition, the language on some pages is written at a college reading level, instead of at the maximum eighth-grade reading level recommended by federal guidelines.

The audit recommended that the city devise a plan for providing online services (something that our sources say was done, but that the city has not implemented); that it assign responsibility for austintexas.gov to a single manager (something that our sources say was never done); that it designate a manager to help each department identify the online services they offer and assure they are accessible (never done); and develop a plan for ADA accessibility (never done).

When asked for comment on our sources’ assessment, the city said that it is making “significant progress” on the audit’s recommendations. A spokesperson told the Chronicle that the city continues to develop its online services plan, but CPIO and CTM still share responsibility for austintexas.gov, rather than a single manager. The spokesperson said that work is complete on 66 of the more than 500 services identified for digitization; as for complying with ADA requirements, the city plans to continue improving the website and has set a goal of meeting the requirements by 2022.

These good intentions are what’s left of the plan agreed to by the leaders of CPIO, CTM, and the City Manager’s Office back in 2017 that they hoped would address austintexas.gov’s issues. They agreed to continue using CTM to maintain it, but also created a separate team within the department to simultaneously develop a new city website. This new team was named the Office of Design and Delivery – ODD.

ODD People at Work

Breitling was one of ODD’s first employees. She’s been working in tech since the late 1990s, an expert at user experience design – that is, understanding and improving how people use a website. Breitling joined 10 or 12 other idealistic web experts in the spring of 2018.

The new hires at ODD had moved over from the private sector and were taking a pay cut. They signed on as temp workers, ineligible for holiday or vacation pay. Health insurance wasn’t offered until they’d worked for the city for a year. But the ODD workers were motivated by something besides money or job security. For Breitling, it was Donald Trump’s election in 2016. “I was really upset at the part that technology had played – Facebook especially – in that turn of events,” she said. “And I wanted my next job to feel like I was doing good in the world.”

Andrew Do, who worked as a service designer from 2018 to 2020, also wanted to create positive change. “I’m a big believer that government is one of the few institutions that can help solve our collective problems,” Do said. “All of my colleagues, we talked philosophically like, ‘What is the role of government, why are we in this game?’ All of us wanted to work a job that aligned with our values.”

For Sarah Rigdon, hired as a content strategist in 2018, working at ODD was an opportunity to help the city deliver services more efficiently. “We wanted to get a modern digital services program,” Rigdon said, “which is different from a bunch of people who work on a website and have skills in web design. It’s more like asking the city, ‘What services do we offer?’ And getting them to think about offering services as effectively as possible.”

Sarah Rigdon (Photo by Jana Birchum)

“There’s no acknowledgment that the current website is broken a lot of the time, because they take that as a personal affront. There’s really no collective acceptance of reality. And we were trying … to get to that shared reality, but it’s just chaos. So it’s a really sad story.” – Sarah Rigdon

Central to ODD was the concept of equity. The website it would create would prioritize Austin’s most vulnerable citizens. It would work well for those with lower levels of education, for those with limited internet access, for those with limited English proficiency, for the visually impaired.

To make a website that met those equity goals, the ODD workers rewrote existing austintexas.gov pages, stripping away the jargon of city government and emphasizing services over departments. But offering services effectively involves more than making a cleaner and more streamlined front-facing webpage. It requires really understanding how a service is provided and then eliminating any barriers that hinder its provision. Web developers call this “service design,” and it begins before writing a single line of code.

“The way service design works is you interview a smaller group of people but you understand their experience deeply,” Do said. “With big data, you have your large sample size. With us, you have your small sample size, but we’re really trying to understand people’s experience deeply, start to finish.”

Service design is rarely overlooked in major digital projects in the private sector, but it had never been part of the creation or management of austintexas.gov. So ODD’s foregrounding of the concept was an innovation, something that distinguished it from the existing web teams at CTM and CPIO. The Service Design Lab, a group of experts within ODD, played a part in every project the office undertook, internally and for departments and programs throughout city government.

Food Trucks, Parking Fines

One was the creation of a guide for people applying for a food truck license. “The food truck permitting was notoriously bad,” Breit­ling said. “If you talked to the people who were trying to get permitted, they basically had their own Google Groups to help each other. They talked about, ‘If you go to the city, you’re going to get a different story every time, depending on who you talk to.'”

Getting a license to operate a food truck is not simple. There are requirements related to the siting of the truck; to its use of electricity, generators, and propane; to cooking surfaces; to refrigeration; to water sources. The truck must be inspected by Austin Public Health, Austin Water, and the Austin Fire Department. ODD’s service designers found that these departments operated in silos, reluctant to engage with one another. So they brought the heads of the departments, their front-line workers, and the people trying to get licenses into the same room and got them to agree on what the actual process should be.

“It was almost like therapy,” said Taylor Cook, who managed the Service Design Lab from 2018 to 2019. “Just making sure that everybody, together, on both sides of the service, are seeing each other, are collectively seeing the problems together. And then we do a co-creation process – think about our shared goals, think about the services that we need, and then collectively think about what we could do to improve those processes.”

Once that consensus was achieved, ODD organized the information and wrote up a guide in English and Spanish. This mobile food vendor permit guide was one of the early success stories incorporated into the website ODD had begun to build – alpha.austin.gov, which most people just called “Alpha.” The guide still exists; a link to it is buried on the austintexas.gov landing page for mobile food vending. Clicking it shows one immediately how the Alpha interface differs from the existing page.

Another of ODD’s early projects was the creation of the website for the Office of Police Oversight, created in the fall of 2018 to replace the former Office of the Police Monitor – itself created by the city’s contract with the Austin Police Association. City Manager Spencer Cronk installed the police monitor, Farah Muscadin, as director of the new office, independent of the union and APD. (In the May 2021 special election, voters approved making the OPO more independent still, moving it under Council’s direction.)

With APD’s history of brutalizing Black and brown people on the city’s Eastside, Muscadin wanted to change how people could complain about police misconduct, as the police monitor process (again, approved by the union) was difficult and frightening for anyone who’d been subjected to force. Chris Luedtke* researched the process as a member of the Service Design Lab. “We went through the experience,” Luedtke said. “And you had to take a bus up to [APD’s Northeast substation off] Rundberg, you had to walk between police cars, show your ID, be escorted to a room. There were all these blockers that were physical, that didn’t need to be there for someone to make a complaint.”

Using Luedtke’s research, Rigdon helped Muscadin create a form to allow Austinites, for the first time, to criticize or thank officers anonymously. The process occurs completely online, on Alpha. Disciplinary reports by APD’s chief of police and complaints from citizens are available on the site as well and, because the information is on Alpha rather than austintexas.gov, these documents can be searched by keywords and date ranges.

ODD also rewrote the Municipal Court’s website. As the place where low-level infractions are handled, such as parking and traffic tickets, Municipal Court is one of the city’s busiest customer service departments. Many who need services from the court have lower levels of education and English proficiency. Yet they are forced to grapple with concepts like “affidavit of indigency,” “motion to expunge,” and “petition for deferred disposition.”

From time immemorial, it has fallen to the court clerks to make such things understandable. “The way that Municipal Court traditionally operated was that people would either have to call in, or go in, and they would get a very helpful court clerk that would guide them to austintexas.gov/courtforms, which was like a filing cabinet of different forms,” explained Gabriela Perez, a former ODD worker who helped rewrite the Municipal Court pages. “And they would tell you which one you needed and you would fill it out. But if you didn’t have that person on the phone, you just had a list of dozens of PDFs [documents to be downloaded and, often, printed out] that didn’t necessarily make sense to you.”

Those who searched austintexas.gov to find the document they needed might come upon outdated, contradictory PDFs from 2002, 2006, or 2012, because the administrators running the Municipal Court site had never removed the older documents. ODD set about digitizing the documents; then they created software that would help Austinites find the documents on their own.

ODD also simplified the website’s language and reorganized its content so that services like “Handle a Ticket” and “Appeal a Municipal Court Case” appear at the top of the page. And as they simplified and streamlined content, they worked on bringing another cutting-edge digital enhancement to the city’s residents – a translation tool that would accurately convert English to Spanish and other languages.

Websites in most cities use Google Translate to render English into other languages. But Google Translate is not as accurate as more sophisticated translation software. It might translate “court” as a judicial court or a basketball court. So ODD chose a higher-quality software product that could corrected and trained to translate better over time. In the interim, they used human translators to recreate the Municipal Court content; ODD’s version of the site radically improved access for Span­ish speakers and reduced the need for workers to answer questions over the phone.*

Top: The austintexas.gov page for Mobile Food Vendors leads with the program’s bureaucratic mission statement. It includes a long list of links with terse explanations but not an overview of how or why to use them. It is flanked, as are most pages on austintexas.gov, with cryptic and irrelevant information about other duties and programs of this department (in this case, Austin Public Health) that takes up a huge amount of screen space. And it greets people wanting to obtain a mobile food permit – the main users of the page – with a boldface scolding telling them to make an appointment.
Bottom: Buried in that list of links – not under its “Guides” sub-heading, but below that, under “FAQs” – one can still get to Alpha’s version of its Mobile Food Vendor Permit Guide. It’s free of extraneous information, organized as a step-by-step walkthrough of the process, and written in much friendlier language that conveys that the city wants you to be able to get the help you need.

Non-Fixing Austintexas.gov

As the ODD workers moved content from austintexas.gov onto Alpha, they marveled at the state of the city’s old website. “On some pages, we learned that it had been maybe a decade since anyone had done maintenance – or never,” Rigdon said. “It was like walking into a giant mansion and every breath you take is blowing a bunch of cobwebs.”

Back in 2012 when it debuted, austintexas.gov was already behind the times. It was built with Drupal, a then-popular open-source platform that theoretically would allow content managers throughout city government to easily and effectively update the site, as the CPIO’s then-Director Doug Mat­thews told the Chronicle at the time. This was when the use of mobile devices – the new generation of tablets and smartphones – to access websites was expanding exponentially, and becoming the primary interface for many Austinites. But austintexas.gov’s Drupal pages didn’t adapt well to mobile, and its multi-lingual functionality was poor in a city where a quarter of the residents speak Spanish as their first language.

Drupal also proved to be more complicated than anticipated for administrators to use, which became a real problem as the city’s 51 different departments with webpages decided on their own what to post and what to delete. “You have all these people adding content to the website that basically have no training,” Breitling said, “whose primary job is not writing for the web. They’re doing their other jobs, so maybe they’re contributing to the web once a week, once a month, right?”

Because the content management system is so hard for nonspecialists to use, most departments only add content to austintexas.gov when they must and avoid removing old content entirely. Over the years, the website has accumulated 17,000 pages, when it should have no more than 5,000; 45,000 PDFs, when it should have 3,000; and 27,000 images, when it should have 2,000. As one developer said, “We have much more unwanted content than content we want.” (Back in 2012, this was already a problem; Matthews told the Chronicle the prior cityofaustin.org had 10,000 pages, of which only 500 saw much traffic.)

Whatever functionality austintexas.gov had when it debuted in 2012 was reduced by 2018, after several teams of developers did maintenance on the site and it became tangled with programming hacks. Meanwhile, the staffers who’d been in place in the system’s early years moved on, leaving CTM and CPIO with no in-house experts. So when city leaders decided to update austintexas.gov from Drupal 7 to Drupal 8 in 2018 – as ODD continued to develop Alpha – they decided not to use CTM to do the work, and instead hired an outside company, a third-party vendor named Zilleem.

Those the Chronicle spoke with emphasized that their bosses at CTM and CPIO were warned not to use the company. Nonetheless, the city paid Zilleem to freshen up austintexas.gov over a three-month span; it was to debut in August 2019. That launch was delayed several times, but the updated austintexas.gov finally appeared in the spring of 2020. However, when the site went live, employees at CTM and CPIO discovered literally thousands of bugs.

Our sources say that Zilleem didn’t follow best practices in updating austintexas.gov. “Zilleem simply took the existing Drupal 7 site and shoved it poorly into Drupal 8, which broke a lot of basic functionality,” one worker said. “To explain how bad this is, a good process has planning, building, testing, launching. Our process was to break a very complex system and then try to fix it little bug by little bug. That process began in 2019 and continues today, as basic elements of the site are still not working.”

These bugs are observed easily enough. A search for “City Council minutes” returns a list of pages, none of which link to the current minutes of the City Council. (A Google search, on the other hand, will turn up austintexas.gov’s Council Meeting Information Center as the first link.) A search for “Parks and Recreation” may return the department’s homepage or it may return links to duplicate pages with no actual information on them. When users click on pictures, they open in a new window, uncompressed and far too large. If you’re visually impaired, you won’t even know the image is there because screen readers can’t interpret it.

Those the Chronicle spoke with said it could take the city’s tech workers years to fix all the many bugs littered throughout austintexas.gov. At the rate they’re going, they say, they probably never will.

Who Shut Down Alpha?

The successful Municipal Court rollout on Alpha coincided with a shake-up in the city bureaucracy. Nuria Rivera-Vandermyde had been hired in 2019 as deputy city manager, with direct oversight of city administrative departments such as CPIO, CTM, and ODD. Within months, she learned that Austin was, as the administrators later characterized it, “funding two websites.” Pressure built on CPIO, CTM, and ODD through the spring and summer of 2020 to begin transferring content from austintexas.gov to Alpha and finish the project. Then, in late August, ODD’s main advocate in city management – the head of CTM, Stephen Elkins – suddenly retired. Many believe he was pushed out by Rivera-Vandermyde. Within a week, the new head of the department, Chris Stewart, alerted workers that management would soon choose one website to keep. The other would be abandoned.

Stewart, Rivera-Vandermyde, and Jessica King, Mat­thews’ successor at CPIO, began, ostensibly, to collect the information necessary to make that choice. Yasmin Wagner, a CPIO manager and crucial link between the tech workers and the higher­-ups (and familiar to many as an Austin ISD trustee), was a big part of that process, which can be viewed as it happened in many emails obtained by the Chronicle through public information requests. In these, management portrays itself as doing its due diligence. The workers, aware of the shifting ground beneath their feet, earnestly make the case for Alpha.

The city’s decision “can be described as committing to the product that was both furthest in development and that presented the best long-term opportunity for success,” a city spokesperson told us. “The work completed on Alpha over the years was not sufficient to prove success or to instill confidence in the product.”

The arguments they used are documented in a complaint filed with the City Auditor’s Office by former ODD employee Joanna Dwyer. The complaint links to a spreadsheet comparing austintexas.gov and Alpha, sent to King, Stewart, Wagner, and Rivera-Vandermyde, and displaying 21 categories such as “accessibility,” “document management,” and “reading level.” In 19 of the 21 categories, the spreadsheet shows that austintexas.gov “doesn’t meet expectations,” while Alpha’s performance is described as “good.” Dwyer’s complaint also links to a 100-page document that ODD released in August 2020 promising that they could migrate austintexas.gov to Alpha in six months. With these documents and in communications with their superiors, the workers sought to drive home the point that austintexas.gov was old, broken, and expensive to maintain, while Alpha was smart, equitable, and ready to deploy.

King, Stewart, Rivera-Vandermyde, and ODD manager Marni Wilhite met on Oct. 6, 2020, to decide which website to go with. Within an hour of the meeting’s conclusion, they sent an email to the staff announcing that they had chosen austintexas.gov. Rigdon, her co-workers, and Wilhite processed the news in a video call where, Rigdon told us, Wilhite reported that Wagner – invited by King to the meeting at the last minute – spoke against Alpha, calling it a risky choice. “That kind of framing doesn’t make any sense unless her goal was to scare Nuria and Chris into agreeing with the choice she wanted, which conveniently keeps control of the website under her purview,” Rigdon said.

The city says it has no record of who said what at the Oct. 6 meeting, but that the choice was made by Stewart and King – and that it stands by it. “The 2020 decision to continue with Drupal can be described as committing to the product that was both furthest in development and that presented the best long-term opportunity for success,” a city spokesperson said. “The work completed on Alpha over the years was not sufficient to prove success or to instill confidence in the product.”

Three weeks later, on Oct. 27, the leaders and the workers met to discuss the decision. According to Dwyer’s complaint, Tim Ziegler, a content strategist with CPIO who had advocated for Alpha, reiterated the warnings about austintexas.gov. “The truth is that our Drupal implementation is actually very much still broken,” Ziegler told the bosses. Stewart replied that he didn’t agree. King said that austintexas.gov was being fixed by yet another third-party vendor. Ziegler explained that vendor was just trying to keep the site afloat, not fix it. He said: “This is my area of expertise and I’d be happy to do a deep dive with anyone who wants to at any time.” According to our sources, the bosses never requested more information from Ziegler.

Again and again, our sources emphasized that the leaders weren’t experienced enough, or interested enough, to process the information they had been shown. They point out that Stewart had been the head of CTM for only a month when he agreed to abandon Alpha; that King has no background in website development; and that Rivera-Vandermyde, who recently left Austin to become the city manager of Boul­der, Colo., is similarly inexperienced.

After the Oct. 27 meeting, Dwyer submitted her complaint to the Auditor’s Office. Emails reviewed by the Chronicle show that they punted it to the City Manager’s Office, a seeming conflict of interest that will allow Rivera-Vandermyde’s former colleagues to decide if her choice of austintexas.gov over Alpha was appropriate.

l-r: Tori Breitling, Sarah Rigdon, Chris Luedkey, Gabriela Perez (Photo by Jana Birchum)

Better Than the Other

The regret in Rigdon’s voice is unmistakable. “All of our design approaches worked for people who have capped data plans. They worked for people with low internet access. This was true before COVID, but now with COVID it’s way more clear – you have to access city services online. If you’re poor and you’re relying on a government program to log on to WIC [food assistance], for example, you don’t have time to go into an office anyway. This is a huge equity issue.”

ODD has been shut down since February. All of its employees quoted in this story have now left city employment. Rigdon’s last day was May 28. The website that she tried to build is still up, but workers at CTM have begun moving it into austintexas.gov.

The leaders don’t seem to realize, our sources say, that inserting Alpha into austintexas.gov will destroy many of its innovations. At the Office of Police Oversight, which for now is still on Alpha, users will no longer be able to search police officer discipline and complaint documents by keywords and date ranges. On the Municipal Court page – already transferred over from Alpha – they won’t see document titles or descriptions in Spanish. Those with vision impairment won’t hear everything on the city’s webpages with their screen readers.

When KXAN ran its piece on the APH web crashes in February, it detailed the creation and dissolution of ODD, relying on a familiar framing – that government bureaucracy had wasted millions of dollars. The station tacitly accepted the city’s explanation that it was ODD that had done the wasting, and treated that mismanagement as something that was in the past. The ODD workers say that yes, the project cost somewhere around $4 million over its four-year lifespan, and no, there wasn’t enough gained for the money spent. They insist, though, that the project was much closer to completion than city leaders realized. They reiterate that if those leaders had simply told the city’s departments to work with ODD, Alpha would have been complete in six months.

They also emphasize that the cost of keeping austintexas.gov afloat over the last four years has not been cheap either. The Zilleem contract wound up costing $540,000. The city spent $124,000 more when another third-party vendor, the well-regarded Favish, was brought in to clean up austintexas.gov. Add to that the salaries that the city has been paying two Drupal developers and a contract manager to work alongside Zilleem and Favish for the last few years, and the fact that workers in CPIO and CTM are still fixing the thousands of bugs that went unfixed or were created anew by the 2020 relaunch, and the cost of continuing with austintexas.gov rises into the millions.

That meter is still running, because austintexas.gov is nowhere near being fixed. “Workers in CTM and CPIO spend their days trying to help city departments get their content onto the site, or make it work, or fixing bugs,” one worker said. “They’re not developing multi-language capabilities or changing the way the pages are presented to help users find forms or services. They’re just putting out fires.”

Our sources say the city still has no realistic plan to fix austintexas.gov. “There’s no acknowledgment that the current website is broken a lot of the time, because they take that as a personal affront,” Rigdon said. “There’s really no collective acceptance of reality. And we were trying, our team, everyday, to get to that shared reality, but it’s just chaos.

“So it’s a really sad story. Because you had this team of people that were there for the right reasons, willing to do the work, actually building something. Which is hard to do. And we were 90% of the way there in terms of functionality. It could have happened. And it was obvious – one was better than the other.”


* Editor’s Note: This story has been updated since publication to clarify that the APH Salesforce install was implemented by third-party vendors and not Salesforce itself; to more accurately reflect the progress made by the Alpha team on the site’s translation tool; and to correct the spelling of Chris Luedtke’s name.

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https://open-mind.org/hellsite-austin-gov-everything-needs-to-be-online-now-austin-is-a-world-renowned-tech-capital-why-cant-the-city-get-it-right-news/feed/ 0
North Carolina health insurance marketplace: history and news of the state’s exchange https://open-mind.org/north-carolina-health-insurance-marketplace-history-and-news-of-the-states-exchange/ https://open-mind.org/north-carolina-health-insurance-marketplace-history-and-news-of-the-states-exchange/#respond Fri, 25 Jun 2021 08:21:23 +0000 https://open-mind.org/?p=594 What type of health insurance exchange does North Carolina have? North Carolina uses the federally run exchange (HealthCare.gov), and has not yet expanded Medicaid under the ACA. 535,803 people enrolled in qualified health plans (QHPs) through North Carolina’s exchange during the open enrollment period for 2021. Only California, Florida, and Texas had higher QHP enrollment […]]]>

What type of health insurance exchange does North Carolina have?

North Carolina uses the federally run exchange (HealthCare.gov), and has not yet expanded Medicaid under the ACA. 535,803 people enrolled in qualified health plans (QHPs) through North Carolina’s exchange during the open enrollment period for 2021. Only California, Florida, and Texas had higher QHP enrollment in their marketplaces.

Which companies offer coverage in North Carolina’s exchange?

There are a total of six insurers that offer coverage in North Carolina’s exchange as of 2021, although as described below, two additional insurers are expected to enter the exchange for 2022.

Nearly all of the state has at least two carriers offering coverage in the exchange in 2021, and much of the central and western portions of the state have four or five carriers offering plans. Cigna joined the exchange starting in 2017 in the Raleigh/Durham area (Chatham, Johnston, Nash, Orange, and Wake). Ambetter (Centene) entered the ACA-compliant individual market in Durham and Wake counties in North Carolina for 2019 coverage, and Bright Health began offering plans in the Charlotte and Winston-Salem areas as of 2020. Oscar joined North Carolina’s exchange as of 2021, and UnitedHealthcare rejoined as of 2021, bringing the total number of participating insurers to six.

AmeriHealth and Friday Health Plans joining North Carolina’s marketplace for 2022

As of 2021, there are six insurers that offer plans in North Carolina’s marketplace. Rate filings for 2022 coverage were due on May 19, 2021 in North Carolina. For most insurers, the only publicly available information is a confirmation that the filings have been submitted.

But there are filings in SERFF for two new insurers that plan to join North Carolina’s marketplace in 2022, with plans available for purchase as of November 2021: Friday Health Plans (SERFF tracking number COHP-132831771) and AmeriHealth Caritas (SERFF tracking number AHCR-132832084).

Friday Health Plans currently offers coverage in Colorado, Texas, New Mexico, and Nevada, and is also expanding into Oklahoma for 2022. AmeriHealth Caritas is already a Medicaid managed care organization in North Carolina, and plans to expand into the individual/family market for 2022.

As far as rate filings go, the only publicly available rate data as of May 2021 is Bright Health’s filing. Bright has proposed an 8.2% average rate increase, affecting 81,722 members. Bright’s filing also notes that they plan to expand their coverage area as of 2022.

With regards to the new filings, it’s worth noting that a filing in SERFF does not guarantee that a company will ultimately offer coverage in the marketplace. Sentara/Optima (which offers individual market coverage in Virginia) had a North Carolina filing in SERFF in 2020 (tracking number OPHL-132383120) for new plans that would be available in North Carolina’s individual market, on- and off-exchange, as of 2021. But neither Sentara/Optima nor the North Carolina Department of Insurance was able to confirm the carrier’s entry into North Carolina’s market, and the filing in SERFF was ultimately marked as disapproved.

UnitedHealthcare and Oscar join North Carolina’s marketplace for 2021

UnitedHealthcare, which previously offered coverage in North Carolina’s marketplace but exited after the end of 2016, returned to the state as of 2021 (details are in SERFF tracking number UHLC-132377671). UnitedHealthcare’s plans are only sold on-exchange, and are available in all of rating areas 2, 7, 9, and 13, plus parts of rating areas 1, 11, and 15 (North Carolina’s rating areas are detailed here, and shown in map format here).

Oscar also joined the North Carolina marketplace for 2021, with plans available in the Asheville area.

How did premiums in North Carolina’s individual market change for 2021?

The four existing insurers in North Carolina’s marketplace all continued to offer coverage for 2021, so there are a total of six participating insurers. The following average rate changes were implemented for 2021 (note that some are different from the rate adjustments that the insurers initially proposed):

  • Blue Cross Blue Shield of North Carolina: Average rate decrease of 1.03%
  • Cigna: Average rate decrease of 14.3%
  • Ambetter/Centene: Average rate increase of 6.2%
  • Bright Health: Average rate increase of 2%
  • Oscar: New for 2021
  • UnitedHealthcare: New for 2021 (after exiting at the end of 2016)

How did North Carolina’s health insurance premiums change in 2020?

All three of North Carolina’s exchange insurers – Cigna, Ambetter (Centene), and Blue Cross Blue Shield of North Carolina – reduced their average premiums for 2020. The final approved rate changes ended up being very similar to what the insurers initially proposed, although Ambetter implemented a more significant rate decrease than they initially filed.

In addition, Bright Health entered the North Carolina marketplace, offering coverage in Charlotte and Winston-Salem.

Insurers in North Carolina’s individual market implemented the following average rate changes for 2020:

  • Blue Cross Blue Shield of North Carolina: An average decrease of 5.5 percent. BCBSNC has the lion’s share of the ACA-compliant individual market in North Carolina, with about 489,000 enrollees in 2019. Blue Cross Blue Shield of North Carolina decreased their premiums by about 4 percent for 2019, so the 2020 rates represent two straight years of declining rates.
  • Cigna: An average decrease of 4.6 percent. Cigna has 5,806 enrollees in 2019. The premium decrease for 2020 came on the heels of a very slight (0.4 percent) average increase for 2019. Cigna’s plans are available in the Raleigh area, in Chatham, Johnston, Nash, Orange, and Wake counties.
  • Ambetter: An average decrease of 11.1 percent (Ambetter initially proposed an average decrease of 8.73 percent). Ambetter was new to North Carolina in 2019, with plans available in Durham and Wake counties.
  • Bright Health: New to North Carolina for 2020, so no applicable rate change. Bright is offering coverage in the Charlotte area and the Winston-Salem area.

The average benchmark plan premium in North Carolina’s exchange was 10 percent lower in 2020 than it was in 2019. But overall average premiums for the three existing insurers only dropped by 5.6 percent. Premium subsidies are based on the cost of the benchmark plan, so average subsidies were smaller for 2020, assuming enrollees’ average incomes remained unchanged.

But because the cost of CSR continues to be added to the premiums for silver plans, after-subsidy premiums for bronze and gold plans are still lower than they were in 2017. These low-premium plans are available because the cost of CSR has been added to the premiums for silver plans, which makes the benchmark plan disproportionately expensive, compared with plans at other metal levels. That results in a disproportionately large premium subsidy, which can then be applied to any metal-level plan in the exchange, making some of them nearly free.

A look at North Carolina’s average rate increases since 2014

ACA-compliant plans debuted in 2014, and premiums were essentially insurers’ educated guesses, since they had no claims experience with these plans.

For 2015, PricewaterhouseCoopers LLC determined a weighted average rate increase of 9.8 percent for individual coverage in North Carolina, including on and off-exchange carriers (nine carriers total in NC).  This was higher than the national average of 5.4 percent.

The Commonwealth Fund’s analysis of exchange plans in North Carolina came up with an average rate increase of 12 percent for 2015.

Among the 34 states with fully-HHS-run exchange, only four states (Alaska, Indiana, Maine, and Wyoming) had average 2015 premiums for the second-lowest-cost silver plans that were as high or higher than North Carolina’s average.

For 2016, the weighted average rate increase in the North Carolina exchange was about 29 percent across all plans (32.5 percent for Blue Cross Blue Shield of North Carolina, 23.6 percent for Aetna/Coventry, and about 20 percent for UnitedHealthcare. North Carolina’s Insurance Commissioner Wayne Goodwin blamed the state’s spiking premiums for 2016 on the General Assembly, because they refused to establish a state-based exchange or expand Medicaid.

Goodwin explained that “if [North Carolina] had a state-based system, we would have had more companies competing. There would have been more leverage on my end as the Insurance Commissioner and rates would have been lower. If there had been Medicaid expansion, rates would have been lower.”

United and Aetna exited the exchange at the end of 2016, which exacerbated the increase in the average benchmark (second-lowest-cost silver plan) premium in North Carolina’s exchange for 2017. HHS reported in October that the average benchmark premium in North Carolina would be 40 percent higher than the average benchmark premium in 2016 (for reference, the average benchmark premium increase across all the states that use HealthCare.gov was 22 percent).

Blue Cross Blue Shield of North Carolina raised their premiums by an average of 24.3 percent in 2017, and Cigna raised theirs an average of 15.3 percent (30 percent for bronze plans).

For 2018, Blue Cross Blue Shield of North Carolina increased their premiums by an average of 14.1 percent, while Cigna’s premiums grew by an average of 24.6 percent. As described below, much of that was due to the Trump administration’s decision to stop funding cost-sharing reductions.

By 2019, rates were much more stable. Blue Cross Blue Shield of North Carolina decreased their premiums by an average of 4.1 percent, and Cigna increased theirs by just 0.4 percent.

And for 2020, average premiums for the three existing insurers dropped by more than 5 percent, and average benchmark premiums dropped by 10 percent.

New law expands AHPs in North Carolina, but some provisions depend on federal AHP lawsuit (which has now been stayed under the Biden administration)

North Carolina lawmakers passed S.B.86 by a wide margin in 2019, and although Governor Roy Cooper did not sign it, the bill became law without his signature. (Cooper considered a veto, and Lt. Gov. Dan Forest urged him to do so, but he opted to let the bill become law without his signature).

The NC legislation essentially mirrors the federal guidelines for association health plans (AHPs) that the Trump administration finalized in 2018, allowing small businesses to join together and obtain large-group health insurance based on either a common industry (eg., numerous small bakeries joining together) or a common geographical area (eg., a group of unrelated small businesses that are all based in the same state). The legislation also calls for allowing sole proprietors to join AHPs, as is the case under the federal guidelines.

In March 2019, a federal judge blocked some provisions of the federal AHP rules, calling the regulations an “end-run around the ACA.” Specifically, the judge overturned the provisions that allow sole proprietors to join AHPs, as well as the provision that allowed unrelated small businesses that share only a geographical location (and not a commonality of interest) to join AHPs. The Trump administration appealed the decision in April 2019; oral arguments were heard by the U.S. Court of Appeals, DC Circuit, in November 2019, but a ruling had not yet been issued as of February 2021, when the Biden administration asked the court to stay the appeal, and the court agreed.

So S.B.86 also notes that if those provisions in the federal AHP regulations are struck down by the appeals court, North Carolina would “conduct a study on the feasibility of submitting a 1332 waiver request” to CMS in order to seek approval for allowing sole proprietors and unrelated small businesses (that share only a geographical location) to join AHPs.

If sole proprietors and small businesses are ultimately allowed to join together to obtain AHP health coverage that follows large group rules (instead of individual market and small group rules), the health plans issued under those rules are expected to be less expensive, since they could be less generous. There’s no requirement, for example, that large group plans cover essential health benefits. Most current large employers do cover EHBs, but an AHP would have less incentive to do so (compared with large employers, for whom robust employee benefits are a key part of compensation, recruitment, and retention).

North Carolina exchange enrollment peaked in 2016, but enrollment in 2021 is higher than it’s been since 2017

How many people are enrolled in North Carolina’s exchange?

535,803 people enrolled in private individual market plans through North Caroliana’s exchange during the open enrollment period for 2021 coverage, up from 505,275 the year before. Among the states that use HealthCare.gov, only Florida and Texas have higher enrollment than North Carolina (California, which has a state-run exchange, is the only other state with higher enrollment). And North Carolina is one of just a handful of states that use HealthCare.gov where enrollment increased from 2019 to 2020 (it grew in 2021 in numerous states, including North Carolina).

Like most states that use HealthCare.gov, enrollment in North Carolina’s exchange peaked in 2016. And although enrollment is higher in 2021 than it has been in any year since 2017, it’s still nearly 13 percent lower than it was in 2016. Here’s a summary of total enrollment in individual market plans through North Carolina’s exchange during open enrollment each year:

Across all the states that use HealthCare.gov, enrollment declined by about 5 percent in 2017, likely due to uncertainty about the future of the ACA, combined with the Trump administration’s reduction in advertising and outreach for HealthCare.gov in the final week of open enrollment.

And for 2018, enrollment in HealthCare.gov states was about 5 percent lower in 2018 than it was for 2017, due in part to continued funding cuts for advertising and outreach, combined with an open enrollment period that was half as long as it had been in prior years.

Enrollment dropped again in 2019 in most HealthCare.gov states, thanks in part to the elimination of the federal penalty for being uninsured, as well as the Trump administration’s expansion of short-term plans, which serve as an attractive alternative to ACA-compliant plans for some healthy consumers.

Enrollment dropped again in 2020 in most states that use HealthCare.gov, although North Carolina bucked that trend, with more than 4,000 additional enrollees for 2020.

Nationwide exchange enrollment grew by more than 2 percent in 2021; North Carolina was among the majority of the states where enrollment was higher for 2021 than it had been for 202o.

Insurer participation in North Carolina’s exchange: 2014-2022

In 2014, plans were only available through two carriers in North Carolina’s exchange: Blue Cross Blue Shield of North Carolina and Coventry Health Care of the Carolinas (Aetna). But nearly two-thirds of the state’s 100 counties had only Blue Cross Blue Shield as an option, because Coventry only offered plans in 39 counties.

United Healthcare joined the individual health insurance exchange in North Carolina in 2015 (United already had a strong market share in North Carolina, outside the exchange), and the three insurers continued to offer plans in the exchange in 2016 as well. BCBSNC plans were available statewide, United’s plans were available in 77 counties, and Aetna’s plans were available in 39 counties (Humana had planned to join the exchange in four counties in the Charlotte and Winston-Salem area, but ended up withdrawing their application in 2015)

UnitedHealthcare exited the individual market entirely in North Carolina at the end of 2016, as was the case in the majority of the states where United offered exchange plans in 2016. Aetna also exited the exchange in North Carolina, along with most of the other states where they were participating in the exchanges.

North Carolina Insurance Commissioner, Wayne Goodwin, expressed his dismay at Aetna’s announcement, saying “I am shocked and disappointed that Aetna and its executives have chosen to abandon their Exchange members. We at NCDOI were in the middle of reviewing Aetna’s rate requests for 2017.  Never during the review did the company indicate any concern that the requested rates would not solve. I am angered by the impact Aetna’s decision will have on Tar Heel families and our market.”

But Cigna joined the North Carolina exchange as of 2017, offering exchange plans in five counties in the Raleigh/Durham area. For 2019, Ambetter/Centene joined the North Carolina exchange in Durham and Wake counties. And for 2020, Bright Health joined the exchange in the Charlotte and Winston-Salem areas.

For 2021, UnitedHealthcare rejoined North Carolina’s exchange, and Oscar also joined the exchange, offering plans in the Asheville area.

For 2022, Friday Health Plans and AmeriHealth Caritas have filed rate proposals with the state. Both insurers plans to join the marketplace with coverage available for purchase as of November 2021.

Virtually all of BCBSNC’s 2018 rate increase was due to Trump Administration’s elimination of CSR funding

The Trump Administration waffled throughout 2017 in terms of whether they’d continue to fund cost-sharing reduction (CSR) payments to insurers, and Congress failed to take action to appropriate funding. Under the ACA, insurers are required to provide more robust coverage to eligible low-income enrollees, and the federal government is supposed to reimburse insurers for the cost. House Republicans sued the Obama Administration in 2014 over the legality of the federal payments to insurers (which weren’t specifically appropriated by Congress), and a judge sided with House Republicans in 2016. The Obama Administration appealed, however, and cost-sharing reduction payments continued to flow to insurers for more than a year.

But President Trump repeatedly threatened to cut off funding for cost-sharing reductions, and in mid-October 2017, he announced that CSR funding would end immediately. By that point, rates were already finalized for 2018, and both North Carolina insurers had already based their premiums on the assumption that federal funding for CSR would not continue in 2018 — a prescient decision, in hindsight.

Blue Cross Blue Shield of North Carolina filed 2018 rates in May 2017, and the filing painted a clear picture of the importance of the CSR issue: Blue Cross Blue Shield of NC proposed a 22.9 percent rate increase, but they noted that 14 percentage points of that rate increase were based on an assumption that cost-sharing reductions (CSRs) wouldn’t be funded in 2018. They said they would re-file lower rates if the federal government were to provide “firm commitment to fully fund CSR payments in 2018 in a timely manner.” Had that commitment been forthcoming — which it wasn’t — the new rate filing would presumably have been in the range of 8.9 percent.

But Blue Cross Blue Shield of North Carolina filed new rates in early August, noting that “the individual market in North Carolina has become less volatile…we got information in June and July that made us confident we could reduce our requested rate increase for 2018” The new rate filing was for an average increase of 14.1 percent. That rate filing was ultimately approved by regulators, and BCBSNC clarified in October that if CSR funding had continued, the average rate increase for 2018 would have been “near zero.”

Cigna also filed rate proposals for 2018, but they had — and continue to have — a much smaller membership in North Carolina, due to their limited coverage area. Their initial rate filing was for an average increase of 32 percent, but a subsequent filing, dated in late July, proposed a rate increase of 24.61 percent. In both cases, the cost of CSR had been added to premiums, as Cigna had based their rate proposal on the assumption that CSR funding would not continue.

So for 2018 coverage, the average approved rate increases for North Carolina were:

  • Blue Cross Blue Shield of North Carolina: 14.1 percent (502,000 members; coverage available statewide). BCBSNC confirmed that virtually all of their rate increase for 2018 was due to the elimination of federal funding for CSR.
  • Cigna: 24.61 percent (21,968 members; coverage available in the Raleigh-Durham area, in Chatham, Johnston, Nash, Orange, and Wake counties)

As always, it’s important to note that these premium increases refer to full-price premiums. For people who receive premium subsidies (which included 93 percent of the people who were enrolled through North Carolina’s exchange in 2017), the subsidies grow in order to keep after-subsidy premiums affordable. In 2017, the average BCBSNC premium was $655/month, but for subsidized enrollees, the average after-subsidy premium was just $155/month. People who are eligible for premium subsidies began receiving larger subsidies in 2018 to offset all or most of the rate increase due to CSR defunding, although some enrollees may have had to switch plans in order to get the most value from their premium subsidies. But people who pay full-price for their coverage, which included 7 percent of exchange enrollees in 2017, as well as anyone who has off-exchange coverage in North Carolina, felt the full impact of the premium increases as of January 2018.

50,000 with grandfathered BCBSNC plans needed to transition to ACA-compliant coverage for 2018

Blue Cross Blue Shield of North Carolina announced in August 2017 that they would terminate their remaining grandfathered plans at the end of 2017. The insurer noted that while they initially had 330,000 grandfathered plan members in 2010, enrollment had dropped to 50,000 in 2017. And since nobody was able to join the insurance pool for those plans since the ACA was enacted in 2010, the risk pool got older and sicker — and thus more expensive — over the ensuing seven years.

Members with BCBSNC grandfathered plans were able to select from all of the available ACA-compliant plans in their area during open enrollment, including on and off-exchange plans. And while open enrollment ended on December 15, there was a special enrollment period (SEP) that continued through March 1, 2018 for anyone whose plan was terminated on December 31, 2017. The special enrollment period allowed former BCBSNC grandfathered plan members to enroll in a replacement plan on or off-exchange.

Blue Cross Blue Shield stayed in the exchange in 2017, but sued feds over risk corridor shortfalls. Supreme Court ruled in favor of insurers in 2020.

Blue Cross Blue Shield of North Carolina covers the majority of the state’s exchange enrollees, and they were the only exchange carrier that offered plans state-wide in 2016. In early 2016, they were considering the possibility of pulling out of the exchange in 2017. By May 2016, they had tentatively confirmed that they would continue to offer plans in the exchange in 2017, despite the losses they had incurred by that point. They had until September 24 to make a final decision; on September 22, they reiterated their commitment to remaining in the exchange in every county in North Carolina in 2017.

Their initial rate filings for 2017 included 24 plans, and an average rate increase of 18.8 percent. But in late August, BCBSNC filed new rates, with an average rate increase of 24.3 percent. The carrier noted that exchange enrollees (not just in NC, but nationwide) have been sicker than expected, and using more health care services than other insured populations. So the new rate filing in late August was in response to the announced departure of Aetna from North Carolina’s marketplace and the expected influx of new (potentially high-cost) enrollees for BCBSNC.

For perspective, the state approved an average rate increase of 32.5 percent for BCBSNC plans heading into 2016, so the requested rate increase for 2017 (which was approved) was not as steep as it was a year earlier.

In 2014, BCBSNC lost $123 million on their exchange business, and that figure spiked to $282 million in 2015. The carrier filed a lawsuit against the federal government in June 2016, alleging that the government failed to live up to its obligations under the ACA’s risk corridor program.

Several other carriers had already filed similar lawsuits; carriers found out in the fall of 2015 that their payouts would be less than 13 percent of the total amount they were owed under the program. And in September 2016, HHS announced that risk corridor revenues from 2015 would all have to be allocated towards the 2014 shortfall, and that there would be no funding left to cover any of the money that carriers are owed under the program for 2015. The risk corridor debacle eventually made its way to the Supreme Court, and in 2020, the Court ruled in favor of the insurers, stating that the federal government is obligated to pay insurers the risk corridor money that was owed to them.

Although BCBSNC lost $405 million on ACA-compliant plans in 2014-2015, growth in investment income and Medicare Advantage during 2015 offset the losses in the exchange market, giving BCBSNC net earnings of $500,000 in 2015, as opposed to a $51 million loss in 2014 (Wendell Potter recently detailed how carriers can be losing money in the exchanges but still doing well overall). And BCBSNC’s ACA-compliant market losses were much smaller ($38 million) in 2016.

Hands-off approach from state leaders

While the federal government is running the marketplace in North Carolina via Healthcare.gov, the state department of insurance reviews the rates proposed by insurers who want to sell policies in North Carolina through the federal exchange. Much to the dismay of state Insurance Commissioner Wayne Goodwin, this is the only involvement that the state has with the exchange.

North Carolina has also continued to reject federal funds to expand Medicaid. There are an estimated 194,000 North Carolina residents in the coverage gap (ineligible for Medicaid, and also ineligible for premium subsidies in the exchange) due to the state’s decision to reject Medicaid expansion.

Support for the ACA in North Carolina is relatively low, no doubt a result of the clear opposition to the law voiced by the state’s leaders.  The state is not doing any marketing or outreach to explain the insurance marketplace to state residents. Instead, the federal government and insurers themselves have taken on that responsibility. Blue Cross and Blue Shield of North Carolina dominates the individual insurance market in the state, and the organization took a lead role in promoting the marketplace from the beginning. Its outreach efforts include operating retail stores and taking a trailer to fairs, farmers markets, and other community events across the state.

North Carolina’s legal aid program has also been very instrumental in getting people enrolled, and has established a phone number (855-733-3711) where residents can call to get help with their insurance questions.

Exchange history and legislation

North Carolina’s path towards ACA implementation was a complicated one that covered all bases.  The state took official actions toward each one of the options for a health insurance marketplace: state-run, partnership, and federally operated. In June 2011, North Carolina passed a law stating an “intention” to develop a state-run health insurance exchange.

The House at one point authorized a state-run exchange, but the Senate did not. Outgoing Gov. Bev Perdue announced in November 2012 that the state would partner with the federal government to run the marketplace. Finally, new Gov. Pat McCrory announced in February 2013 that North Carolina would default to the federal marketplace.

North Carolina health insurance exchange links

HealthCare.gov
800-318-2596

State Exchange Profile: North Carolina
The Henry J. Kaiser Family Foundation overview of North Carolina’s progress toward creating a state health insurance exchange.

North Carolina Institute of Medicine (NCIOM)

Health Insurance Smart NC
Assists people insured by private health plans, Medicaid, or other plans in resolving problems pertaining to their health coverage; assists uninsured residents with access to care.
Toll free: 1-877-885-0231

Managed Care Patient Assistance Program
Serves consumers who are members of managed health benefit plans.
(919) 733-6272 / Toll-Free: 1-866-867-6272 (in North Carolina only)
MCPA@ncdoj.com

Community Care of North Carolina

Legal Aid of North Carolina (855-733-3711)


Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

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Why aren’t voters more willing to abandon a health system that’s failing? https://open-mind.org/why-arent-voters-more-willing-to-abandon-a-health-system-thats-failing/ https://open-mind.org/why-arent-voters-more-willing-to-abandon-a-health-system-thats-failing/#respond Fri, 18 Jun 2021 18:18:15 +0000 https://open-mind.org/?p=471 What does it mean to say “if you like your health insurance, you can keep it”? Some will remember this as a defining debate around the Affordable Care Act. One lesson Democrats took from the collapse of the Clinton administration’s 1994 reforms was that Americans hated the idea of the government canceling their insurance plans. […]]]>

What does it mean to say “if you like your health insurance, you can keep it”?

Some will remember this as a defining debate around the Affordable Care Act. One lesson Democrats took from the collapse of the Clinton administration’s 1994 reforms was that Americans hated the idea of the government canceling their insurance plans. In deference to that view, the ACA was designed to leave most existing health coverage intact, and President Obama repeatedly promised that no one would lose insurance they liked. Even so, about 3 million plans did get canceled because they were beneath the ACA’s minimum standards for health insurance, and the political backlash was fierce.

This debate has reemerged in the runup to 2020. Bernie Sanders’s Medicare-for-all plan, as currently written, would cancel every private insurance plan in the country. Polling suggests that’s lethal: When told that Medicare-for-all would abolish private insurance, respondents flip from favoring the plan by a 56 percent to 38 percent margin to opposing it by a 58 percent to 37 percent margin. These numbers, when combined with the Obamacare backlash and the Clintoncare experience, have underscored reformers’ view that a plan that takes away the private insurance people have and like is doomed.

In response, supporters of Medicare-for-all have struck back with an ambitious reframing: The idea that anyone can keep the health insurance they like under any system but Medicare-for-all is the true lie, they say.

Matt Bruenig, of the People’s Policy Project, is the most aggressive proponent of this view. “The truth is that people who love their employer-based insurance do not get to hold on to it in our current system,” he writes. “Instead, they lose that insurance constantly, all the time, over and over again. It is a complete nightmare.” The only way to enjoy true health security, where your insurance can never be taken away, is “a seamless system where people do not constantly churn on and off of insurance. Medicare for All offers that.”

There’s power to this argument. As a comparison between Medicare-for-all and the status quo, there’d be far more security under Medicare-for-all. But even as he accuses others of dishonesty, Bruenig is weaponizing this point against plans that it doesn’t apply to — most recently, the Center for American Progress’s Medicare Extra plan — and doing so in ways that confuse the underlying issue.

If this were just an internecine debate between supporters of different health reform plans that would all be vast improvements over what we have now, it wouldn’t much matter. But it raises some of the hardest issues in health politics. Private health insurance isn’t theoretical. More than 150 million Americans get insurance through their employers right now. They live in the world that pundits and think-tankers are arguing over. So if the private insurance market as it exists is such a nightmare, then why are people so loath to see it replaced?

This is a question that has crushed past efforts at health reform — and not just federally. In the past few years, Vermont saw its effort to pass single-payer collapse and 79 percent of Coloradans voted down a single-payer ballot initiative.

So why aren’t voters more willing to abandon a system that’s clearly failing? And what kinds of reforms will they accept?

The two types of “insurance churn”

The key idea in Bruenig’s argument is something experts call “insurance churn.” Importantly, though, the term is being used to refer to two different things:

  • Researchers use insurance churn to refer to any change in health insurance plans. If I lose my job and become uninsured, that’s churn. If my employer switches insurance providers, that’s churn. If I move from my current job and insurance coverage to another job with a different insurance plan, that’s churn. And so on.
  • In punditry, though, people will often simplify churn to the question of losing and gaining health insurance. In this meaning, it’s not churn if my employer switches coverage providers, but it is if my employer fires me and I become uninsured.

You can see the way one definition slides into the other in Bruenig’s post. For most of the analysis, he’s using the first, more technical, definition of churn. He relies on a study of insurance churn in Michigan, for instance, to write:

Among those who had employer-sponsored insurance in 2014, only 72 percent were continuously enrolled in that insurance for the next 12 months. This means that 28 percent of people on an employer plan were not on that same plan 1 year later. You like your employer health plan? You better cross your fingers because 1 in 4 people on employer plans will come off their plan in the next 12 months.

The study he’s referencing found that “Ninety-four percent of respondents with employer-sponsored plans maintained coverage continuously all year.” The lower, 72 percent number includes data showing that “16 percent directly switched to a different employer-sponsored plan and 6 percent gained coverage through either an individually purchased plan, Medicaid, or Medicare.” So that’s the first type of churn, which includes changes to the plans people use, not just changes to whether people are insured or not.

But at the end, when Bruenig says that Medicare-for-all is “a seamless system where people do not constantly churn on and off of insurance,” he’s quietly switching to the second definition of churn.

The core insight here is real: So long as a third party is providing your health insurance, you don’t have full control of its future. You may like the health plan your employer provides now, but they could change that plan, or you could change jobs, or be laid off. The problem is that point applies to public insurance too.

Imagine President Bernie Sanders passes Medicare-for-all in 2022. In 2024, amid a backlash to rising tax rates, Sanders loses reelection to Ohio Sen. Rob Portman. Working with a Republican Congress, Portman restructures Medicare-for-all in a few ways. Where Sanders included coverage for abortion, Portman bars it totally. Where Sanders designed the program to avoid copays and deductibles, Portman, a believer in health savings accounts, reworks it to frontload the cost-sharing. Where Sanders guaranteed coverage to everyone, including unauthorized immigrants, Portman restricts it to legal residents, and adds a work requirement for able-bodied adults.

If any of that sounds far-fetched, consider that Republicans were a single vote away from repealing Obamacare in 2017, and the Trump administration approved Wisconsin’s request to add premiums and a work requirement to its Medicaid program in 2018.

The skepticism Bruenig brings to private insurance is the same skepticism many bring to single-payer insurance. You like your government-provided health plan? Better cross your fingers, because your side just lost the White House, and the incoming administration wants to slash health care spending by 15 percent, drug-test all beneficiaries, and turn the whole thing over to private contractors.

Not all churn is equal

A problem with the term “churn” is that it collapses both good and bad dynamics into the same label. Involuntary churn is a problem. But voluntary churn typically goes by another name: choice.

Take Medicare Advantage, the suite of private insurance options offered inside the Medicare program. About a third of Medicare enrollees choose Medicare Advantage, and about 10 percent of Medicare Advantage members voluntarily choose to switch to another plan each year. Medicare Advantage’s enrollees are slightly more satisfied with their coverage than those in traditional Medicare, so it’s reasonable to assume they appreciate the opportunity for churn.

Last week, I wrote about the Center for American Progress’s Medicare Extra plan. I won’t recap the entire piece here, but the short version is that Medicare Extra rebuilds the health system around a revamped Medicare plan, but it allows people to remain in employer-sponsored insurance, traditional Medicare, or VA care if they so choose. It also preserves some private options in Medicare for those that want them. It’s an effort to capture the main benefits of single-payer — universal, guaranteed coverage alongside Medicare-based pricing — without taking away the insurance plans most people have and like. Bruenig was, to say the least, not happy with my description:

This is a good example of the slipperiness in the way Bruenig deploys this argument. Under Medicare Extra, there’s no churn on and off health insurance: it’s a universal program. If you chose to remain on your employer-sponsored insurance and then you got fired, you’d just be added to Medicare Extra.

Bruenig’s claim that this is a lie rests on switching his definition to the first type of churn, the one that counts any change in plan. Under Medicare Extra, it’s true, you could end up switching from one employer-sponsored insurance plan to another, or from an employer who offered Cigna to one who bought into Medicare. Or you could choose to switch from Medicare to your employer’s insurance, or to the private options offered under Medicare Choice.

Bruenig says this would be “entirely out of your control.” That’s true in some cases, and not in others. Either way, Medicare-for-all is just as vulnerable to that critique: You can keep Bernie Sanders’s Medicare-for-all plan until the moment some other president and Congress decides to change the law. It’s also outside of your control. (And in a system where the White House and the Senate are both held by the party that won fewer votes, the idea that it is in your control because the government reflects the will of the people isn’t particularly convincing.)

This is the problem with the rhetorical game Medicare-for-all’s supporters are playing. If you narrow the definition of insurance churn to whether or not you have insurance, the argument doesn’t work as a cudgel against some of the competing plans like Medicare Extra. If you widen the definition of insurance churn to any change in your insurance plan, then it becomes a cudgel against Medicare-for-all too.

You can’t talk yourself out of public opposition

This gets to the broader context of this debate. There’s an effort among Medicare-for-all’s supporters to argue that nothing but pure single-payer can solve the problems of the health care system, and so any other plan, even if it’s more aligned with what the public wants, is an unacceptable half-measure. Since those plans make a virtue out of offering people more insurance choices, and since Medicare-for-all suffers in polls for abolishing private insurance, you need to make the offering of those choices into a weakness.

But in doing, you end up sidestepping the hard political question here, the one those other plans are trying to respond to: If the private insurance market is such a nightmare, why is the public so loath to abandon it? Why have past reformers so often been punished for trying to take away what people have and replace it with something better?

It’s simply not the case that when you say, in normal English, “if you like your X, you can keep it,” people believe you’re protecting them from all exigent circumstances. People live in the employer-based health insurance market now. They’re dealing with the instability Bruenig and others are pointing out as we speak. The fact that they’re not clamoring for the government to take it over demands exploration, not rebuttal.

Trying to redefine “it’s possible to lose the insurance you have now” as equivalent to “the government will take away the insurance you have now and move you to something different” isn’t a way of answering the concerns people have — it’s a way of trying to talk yourself out of answering them. And that’s a dangerous strategy.

It’s particularly unwise when the public’s views are as clear as they are here. A new Marist/NPR poll tested support for both “Medicare for all that want it — that is, allow all Americans to choose between a national health insurance program or their own private health insurance” and “Medicare for All — that is, a national health insurance program for all Americans that replaces private health insurance.” “Medicare for all that want it” polled at 71 percent. Medicare-for-all that replaces private insurance polled at 41 percent. Supermajority support becomes a minority position. Why?

There are different interpretations of what’s going on here. Many Americans simply don’t trust the government. Others don’t much like radical change, even if they do trust the government. Some reasonably want private options as escape hatches if the government option is wrecked by a future Congress, or marred by incompetent administration. Many don’t realize how much their insurance costs, because employers pay, on average, 70 percent of premiums, even if that quietly comes out of wages. And while about 60 percent of Americans think it’s the government’s responsibility to ensure everyone can access health care, that leaves 40 percent of the country that disagrees.

Indeed, the political risk of a plan like Medicare Extra isn’t that it changes too little for the public’s comfort, but that, like Medicare-for-all, it changes too much. Everyone on Medicaid gets forced into the new system. Everyone on Obamacare’s individual markets gets forced into the new system. The new plan will be better and more comprehensive than what came before it, so in theory, it should be a welcome change. But if “in theory, it should be a welcome change” always cashed out in practice, we would have fixed the health system long ago. The political upsides of Medicare Extra are that it won’t require as large tax increases, it won’t upend employer-based insurance, and it can at least claim that private choices will be available, but for all that, it will still mean huge disruption, far more than attended Obamacare.

For the record, I’m not opposed to Medicare-for-all. It’s one of many health systems that I think would be a vast, vast improvement on what we have now. I want more people to have better health care, and my fear is that in treating public opinion as infinitely malleable or simply confused, Medicare-for-all’s supporters will trigger a backlash that destroys the effort, just as so many health reformers have before them.

Risk aversion here is real, and it’s dangerous. Health reformers don’t tiptoe around it because they wouldn’t prefer to imagine bigger, more ambitious plans. They tiptoe around it because they have seen its power to destroy even modest plans. There may be a better strategy than that. I hope there is. But it starts with taking the public’s fear of dramatic change seriously, not trying to deny its power.

Further reading:

The lessons of 1994. It’s been 25 years since the Clintons tried, and failed, to fundamentally restructure the American health care system. What went wrong then is worth studying.

How to get to universal coverage without single-payer. How Medicare Extra works, and where it does and doesn’t differ from Medicare-for-all.

7 health care questions the 2020 Democrats should answer. I argue in this piece that centering the entire Democratic health reform debate on where or not you want to abolish private insurance is the wrong question. Here are some better ones.

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A Beginner’s Guide to Social Media Marketing: A U.S. News Guide | Education https://open-mind.org/a-beginners-guide-to-social-media-marketing-a-u-s-news-guide-education/ https://open-mind.org/a-beginners-guide-to-social-media-marketing-a-u-s-news-guide-education/#respond Thu, 17 Jun 2021 05:47:43 +0000 https://open-mind.org/?p=423 If you are interested in growing an engaged audience for your business or gaining loyal customers for your product, it might be time to learn social media marketing. (Getty Images) Social media used to be one option in a sea of marketing opportunities, but now it’s a huge resource for businesses of all sizes. Social […]]]>

If you are interested in growing an engaged audience for your business or gaining loyal customers for your product, it might be time to learn social media marketing.

(Getty Images)

Social media used to be one option in a sea of marketing opportunities, but now it’s a huge resource for businesses of all sizes. Social media marketing is much more than sending out a tweet or posting a product image to Instagram – it takes time, money and strategy to grow brand recognition.

Social media marketing connects consumers with brands through platforms that include Facebook, Instagram, Twitter, LinkedIn, Pinterest, YouTube and Snapchat to drive engagement, sales and brand recognition.

From choosing the right social media channel to deciding what kind of campaign your business would like to run, learning how to utilize social media marketing can be crucial for success in today’s world.

Coors Light found success during the COVID-19 pandemic when a tweet from 93-year-old Olive Veronesi of Seminole, Pennsylvania, using a whiteboard to ask her neighbors for more beer through her window went viral. The company responded, engaging directly with one of its consumers, and the interactions garnered thousands of likes. It made the company relatable, likable and relevant on Twitter.

There are many ways to use social media marketing, and as companies rely more heavily on these platforms for growth, career opportunities in the social media marketing field are on the rise.

Small-business owners interested in promoting their businesses to new audiences should know the basics of social media marketing. Creating and sharing content with social media users can increase the potential for revenue and yield data to help you better understand your consumers.

Business owners looking for a way to connect with potential customers might also use social media to connect personally and gather feedback on products or services.

“Knowing more about their customers through social media engagement and metrics can allow a small business to allocate their marketing budget in an informed way and truly know who and where their customers are, which can save time and money,” says Sarah DeGeorge, a freelance digital marketing specialist.

Those working in print and digital marketing can also benefit from knowing social media marketing. As the marketing field diversifies, learning how to use new platforms could come in handy when looking for job opportunities.

And social media marketing skills could help beginners or those wishing to pick up an online side gig. Having basic skills and knowing how to engage with an audience are good for those wishing to create a hobby, but it will require time and energy.

“Social media marketing is a larger blanket item that covers so many different platforms, interfaces and other learning curves,” DeGeorge says. “If you want to approach being a social media marketer from a larger scale, you will want to invest a decent amount of time understanding both social media marketing as a concept and also learning each platform in which you will be offering your services to businesses.”

Social media marketing isn’t cut and dry – it can require trial and error, since social media itself is constantly changing. Learning a new platform can be as simple as watching a tutorial about a new platform online or as complex as learning a whole new system, DeGeorge says.

“Social media marketing is one of those areas in which it feels like a living, breathing creature that is constantly changing based on customer needs and suggestions of the platforms,” DeGeorge says. “If you fall behind or decide not to continuously keep informed, you can fall behind very quickly and lose your footing in the industry.”

Beginners may face a social media marketing learning curve. Professionals can have experience in multiple disciplines and skill sets ranging from communication to basic graphic design knowledge to data analysis.

Social media marketing is done best when you can be creative, strategize, manage a community, write clearly and concisely, stay up to date on trends and features, understand how content works on social media and establish a brand to keep users coming back.

To get started in social media marketing, first you must know what you’re trying to accomplish. Social media can appear daunting for business owners if they don’t have a plan in mind.

Some common social media goals include creating custom content, directly engaging with consumers, growing your audience, developing a posting schedule and tracking how your business’ content performs. Without goals or direction, social media marketing can be overwhelming and lead to wasted time.

“The biggest mistake I see is being too focused on doing too much at once or trying to learn it all,” says DeGeorge. “Social media marketers need to know a lot, but building off of the core building blocks of social media marketing should be your first goal.”

Defining who your audience is or who you want it to be is the next step. Your business will have a better chance of accomplishing its goals if you listen to what consumers are saying and who they’re engaging with on social media.

“It’s so important, especially when you’re first starting out, to go to a platform where you are welcome,” says Caitlin Durning, owner of Meraki Media Management. “This allows you to easily get used to outreach, engagement and connecting with your ideal client.”

Popular Social Media Marketing Channels

Not all social media platforms are equally suited for your business, so it’s important to know what each one prioritizes, rewards and highlights.

First, you must identify where your audience is spending the majority of its time. Are they watching short videos or long ones? Are they scrolling for a variety of content? Are they focused on the aesthetic of the content? These are all valuable insights that can help you choose the best platform for your brand and avoid throwing resources into one that does not fit your needs.

Facebook is one of the largest social media platforms, with more than 1.8 billion daily users. You might want to use Facebook if your business plans to provide a variety of content such as images, video, text, tangible products or livestreams. Facebook may also be right for you if you plan on sharing a lot of links. As of October 2020, more than 32% of Facebook users worldwide were between the ages of 25 and 34, according to Statista.

Instagram emphasizes sharing visual content, and it’s best when your content is well designed and aesthetically pleasing. More than 56% of Instagram audiences in the U.S. are female.

Instagram’s short-form video feature, Reels, allows users to post 15-second videos. If short-form video, the shop feature and lots of communication between business and consumer fits your needs, Instagram could be right for you.

Twitter is made for short, character-limited bursts and is designed for quick thoughts and breaking news. In November 2020, the platform released “Fleets,” a feature similar to Instagram and Snapchat Stories that allows messages to disappear 24 hours after they are posted. Twitter is centered around social messaging, humor and news.

Almost 30% of global Twitter users are between 25 and 34 years old. Twitter might be a good choice if you plan to provide concise messages while engaging with your audience.

LinkedIn specializes in professional and business-to-business connection. It’s the virtual edition of cold-calling or networking events.

Starting on LinkedIn can be a smart move if you’re interested in expanding your team or partnering with others in your industry.

YouTube is a good platform if you are interested in video content for your brand. Video plays an important role in the social media marketing world, and YouTube has more than 2 billion monthly users.

Social media advertising is not too different from digital advertising, except that it uses social media platforms to reach target audiences where they spend much of their personal time. You have seen it in action if you’ve noticed posts on Facebook or Instagram labeled “Sponsored” or “Paid for Partnership.”

Social media advertising can reach untapped audiences with a consistent campaign strategy, and there are two ways to get there: paid social advertising campaigns and organic social advertising campaigns.

Paid campaigns involve budgeted money going to the social media platform of your choosing to put your content in front of more users. Some platforms allow you to choose your audience based on demographics like age, location and interests.

Organic social advertising is free and its success completely relies on users, the platform’s algorithm and the quality of your content.

Both methods, paid and organic, should have the audience in mind and be driven by a goal. Organic social advertising campaigns are valuable, but paid campaigns may help you reach a wider audience.

“Paid advertising comes when you’re ready to push the market, not organically connect,” Durning says. “For Instagram, this comes at times with a certain amount of growth, or if there is a sale or event coming up for the business.”

Once your paid campaign has ended, you can track who interacted with the content and get information about your audience. Organic campaigns are a bit harder to analyze and are subject to the ebbs and flows of the platform.

Success in social media marketing can mean different things to different people, which is why it is important to equip your business with the tools needed to understand what’s working and what’s not.

Social media tracking tools have access to your accounts as well as the data and insights of each post, and they analyze your viewers’ actions. Other tools allow you to schedule posts in advance to publish at a certain time. Some analytics tools cost money, but there are free options as well. Here are a few analytics and scheduling tools available:

  • Google Analytics is a free web analytics tool that tracks traffic on your website and compiles its findings into reports. Google offers free training videos on how to use the program.
  • Mixpanel is a web analytics tool similar to Google Analytics. The company offers a free plan, a monthly plan starting at $17 and a personalized plan with varying rates.
  • Hootsuite is a social media and web analytics tool with four pricing plans listed here. Hootsuite can be good for beginners and those who manage multiple platforms.
  • TweetDeck is a browser-based program that allows users to tweet from and manage multiple Twitter accounts in one place. It is free and only for Twitter. Its management abilities can be good for beginners.

Helpful Social Media Industry Resources and Courses

There are multiple publications, online courses and conferences to help you get started in social media marketing.

Learn more about the newest tools and tricks in social media marketing from industry publications and blogs like:

Here are a few social media marketing conferences that might interest you as you build out your professional network:

Here are a few social media marketing courses:

Other online resources that might be useful to you include:

To qualify for a social media marketing position, you must have experience in trying multiple techniques on different platforms, Durning says. And that kind of experience comes from learning by doing and staying up-to-date on how social media platforms and users are changing.

While companies looking for a social media marketing manager may expect or require certifications, most of the requisite skills can be obtained for free.

“While a solid time commitment is hard to answer, you will want to make this your job to learn and build your skills,” DeGeorge says. “This can look like taking an online course, watching tutorials, working or interning and continually building out your knowledge.”

Other skills that are useful for someone pursuing a social media marketing career include copywriting, graphic design, shooting and editing video, public speaking for live appearances, customer service and strategy building.

You’ve decided on a career in social media marketing. Here are some tips for landing that first job or internship.

Beginners should look for internships in brands needing social media marketing employees. In these positions, you could be expected to run campaigns, manage reports from social media tracking applications and do consumer research. Learning some of these skills ahead of time through free online courses could set you apart from other applicants.

Intermediate learners seeking jobs in social media marketing could look to smaller brands or nonprofits for social media management positions, or large companies with assistant positions on their marketing teams. Managers hiring for entry-level positions in social media marketing will be looking for candidates who have time management skills, more than a basic knowledge of social media platforms and a strong understanding of how to identify business needs.

“Social media is constantly changing,” Durning says. “As a social manager, it is so important to be fluid, always learning and adapting.”

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Scorned girlfriend who exposed married Texas police chief of living a ‘triple life’ speaks out https://open-mind.org/scorned-girlfriend-who-exposed-married-texas-police-chief-of-living-a-triple-life-speaks-out/ https://open-mind.org/scorned-girlfriend-who-exposed-married-texas-police-chief-of-living-a-triple-life-speaks-out/#respond Thu, 17 Jun 2021 05:14:53 +0000 https://open-mind.org/?p=376 Former Stinnett Police Chief Jason Collier was not only a married man with a girlfriend and fiancee, but was dating at least eight women at the same time, DailyMail.com can reveal.   Cecily Steinmetz, 39, a divorced mother of two young children was one of the eight women and when she discovered Collier’s triple life, she […]]]>

Former Stinnett Police Chief Jason Collier was not only a married man with a girlfriend and fiancee, but was dating at least eight women at the same time, DailyMail.com can reveal.  

Cecily Steinmetz, 39, a divorced mother of two young children was one of the eight women and when she discovered Collier’s triple life, she exposed the cheating police chief to the world on Facebook.

Her post went viral with more than a hundred thousand views, he was put on administrative leave by the Stinnett city manager, and then resigned days later after he was arrested for falsifying a government document.

And on Monday Collier’s wife Opal Collier filed for divorce in light of the public cheating scandal.   

In an exclusive interview with DailyMail.com, Steinmetz tells about their whirlwind two week romance and how she caught the cheat in several lies before exposing him to the world. 

In an exclusive interview with DailyMail.com, Steinmetz tells about her whirlwind romance with Collier and how she caught the cheat in several lies

Stinnett Police Department chief Jason Collier, 39, resigned after the married father-of-four was discovered to be living a 'triple life'. In a Facebook post, Cecily Steinmetz claimed they'd been in a relationship until she learned he was married and also engaged to another woman

Stinnett Police Department chief Jason Collier, 39, resigned after the married father-of-four was discovered to be living a ‘triple life’. In a Facebook post, Cecily Steinmetz claimed they’d been in a relationship until she learned he was married and also engaged to another woman

Steinmetz shared text messages with DailyMail.com showing the depth of their whirlwind romance

Steinmetz shared text messages with DailyMail.com showing the depth of their whirlwind romance 

Steinmetz tells DailyMail.com in an exclusive interview, ‘I met Jason on a dating app in mid- December, our profiles matched each other and one day I received a ”like” from him. I responded back and we chatted via the web a few times. He told me he worked in law enforcement but wasn’t really specific about it.’

But Steinmetz said she deleted her dating profile after deciding she really wasn’t ready to date and just wanted to get through the holidays before starting a relationship.

But the first week in January she got back into the dating game and created a new profile. Within a few days she said she got a message from Collier and within hours they had exchanged phone numbers and ‘were talking on the phone, texting and everything.’

Collier was arrested for faking a marriage annulment document after his girlfriend accused him of living a 'triple life' with her, his wife, and a fiancee

Collier was arrested for faking a marriage annulment document after his girlfriend accused him of living a ‘triple life’ with her, his wife, and a fiancee

‘There was an immediate connection, it was just comfortable talking to him, and he’s charming and disarming at the same time as well as calming. He made a really big deal to tell me that he had been divorced since 2016 and spent the past four years working on himself, personal insight type of work and he was finally ready to get out and have a relationship,’ she said. 

‘I felt really good on the phone, he seemed very polite, respectful, and I thought with his job that he would definitely be trustworthy. That put me at ease that he was a police officer and not just a police officer, but a chief of police, and I thought they definitely were held to a higher standard. So I thought I should be able to believe him – at the time I had no reason not to believe him.’

During that first conversation Collier asked her to download the Marco Polo App a video based instant messaging system.

She said it was because he had an Android and she had an iPhone and they couldn’t FaceTime unless they used this App.

Steinmetz said Collier told her during their first conversation he was the Chief of Police in Stinnett, Texas, a small city in the panhandle of northern Texas about 60 miles north of Amarillo. The rural town has a population of almost 1,900 people and a police force of four officers and three reserves.

He told her that if she came across an article where it mentioned he was married and had four kids, to ‘ignore it, that it was incorrect and he’s contacted the news organization who wrote the article to change it but haven’t as of yet.’

She said he told her check to out the Facebook page for the Stinnett Police Department and that’s where she’ll find the corrected version – showing that he wasn’t married.

Steinmetz said things were moving quickly in their relationship. He was suddenly bombarding her with compliments, telling her how beautiful she was and how lucky he was to have met her.

Opal Collier’s lawyers put out a statement Monday announcing the divorce filing and said, ‘Mrs. Collier has discontinued the use of all social media accounts in her name for the foreseeable future. She respectfully requests that members of the media and community respect her privacy and the privacy of her family at this time.’ 

This is Collier's dating profile which says he's 'look for friendship and then more from there!' and 'Not looking for a hook up'

This is Collier’s dating profile which says he’s ‘look for friendship and then more from there!’ and ‘Not looking for a hook up’ 

Steinmetz says Collier told her his marriage to wife Opal (pictured together) had been annulled, despite him celebrating his anniversary in a touching Facebook post in September. His wife filed for divorce on Monday

 Steinmetz says Collier told her his marriage to wife Opal (pictured together) had been annulled, despite him celebrating his anniversary in a touching Facebook post in September. His wife filed for divorce on Monday 

Fiancee: After Steinmetz discovered that Collier had been lying to her, she was contacted by Kristi Shaffer, who said she had actually been engaged to the police chief since December

After Steinmetz discovered that Collier had been lying to her, she was contacted by Kristi Shaffer, who said she had actually been engaged to the police chief since December

Steinmetz revealed on Facebook last week that she'd been in a long-term relationship with Collier and has since found out that he is dating other women, too

Steinmetz revealed on Facebook last week that she’d been in a long-term relationship with Collier and has since found out that he is dating other women, too

The first time they saw each other was on Sunday, January 17. He told her that he was going to be in Lubbock, Texas that weekend for work and he would drive to meet her after he was finished.

‘Jason told me he was going to meeting with the Secret Service in Lubbock. He had a side job being dispatched to national emergencies, like the Nashville bombing on Christmas and the Portland and Minneapolis riots. He said he was a tactical consult for these type of national emergencies and he was going to school to get his master’s degree in emergency management. Jason said he contracted with the government to do emergency management planning with other law enforcement agencies.’

Steinmetz said, ‘Jason told me he flew to Nashville to work the Christmas day bombing and worked on riots in Minneapolis after George Floyd. 

Steinmetz met Collier at a local restaurant in Amarillo and she said the night was great.

Texas Rangers took Collier into custody on Thursday after he resigned, and he is now facing a charge of tampering with a government record with the intent to defraud or harm

Texas Rangers took Collier into custody on Thursday after he resigned, and he is now facing a charge of tampering with a government record with the intent to defraud or harm

‘He was everything I could have hoped for, he was nice, polite,’ she said. 

‘At dinner Jason told me he had been previously married, one time, for 16 years and has two kids and got divorced in 2016. He also told me that I was the first women he has met since then.

‘It made me feel great to hear this guy say this stuff to me,’ added Steinmetz.

Steinmetz said they both had salads and a soft drink, but when the bill came, Collier took the check and asked her to sign both her married last name and maiden name. 

She thought this was odd, but did it anyway.

‘Jason explained to me that he was trained by the FBI to do handwriting analysis and told me that he could tell a lot about a person by their handwriting, which I had never heard of before. But I had no reason to doubt him. I remember it said something on his profile about having some type of FBI certification. Jason said he was trained by the same person in the FBI who analyzed the Jon Benet Ramsey ransom letter.’

After she signed both of her names on the dinner ticket, she gave it back to him.

‘Jason was acting like he was analyzing both signatures, drawing lines at the top and at the bottom, scribbling on it, etc. Now I know he was just pretending, but at the time I thought he was legit.’

Then came his handwriting analysis, ‘He told me that I was completely detached from last name by the slanting of my writing and I was much more connected to my maiden name. I didn’t understand what he was saying and it didn’t really make any sense to me.

‘The point he was trying to get across was he said he was worried that my ex-husband was going to see how happy I was in my current relationship that he would want to get back with me.

‘But I assured Jason that relationship had sailed and we have a good working relationship because of our children and we were never going to get back together.

‘It was a constant theme of our short lived relationship that he needed constant reassurance.’

 

Collier would give Steinmetz excuses as to why he couldn't talk on the phone when she would question him about his marriage

Collier would give Steinmetz excuses as to why he couldn’t talk on the phone when she would question him about his marriage

Steinmetz has changed Colliar's name in her phone from 'Jason' followed by a heart emoji, to 'Jason LIAR'

Steinmetz has changed Colliar’s name in her phone from ‘Jason’ followed by a heart emoji, to ‘Jason LIAR’

Collier sent Steinmetz several mirror selfies during their relationship, which she shared with DailyMail.com. In one photo, his police badge is clearly visible

Collier sent Steinmetz several mirror selfies during their relationship, which she shared with DailyMail.com. In one photo, his police badge is clearly visible

Collier sent Steinmetz several mirror selfies during their relationship, which she shared with DailyMail.com. In one photo, his police badge is clearly visible 

Steinmetz said the next night he picked her up at her house and they went to dinner.

‘When we went to sit down in a booth and he wanted us to sit together instead of across from each other. He said he wanted everyone to know that we were a couple.’

‘Things were going fast in our relationship, at dinner that night we both said that we were going to be exclusive to each other. I was so excited about him. We had a picture taken of us and I told him I was going to post it on Facebook and that made him really happy.’

But after Steinmetz posted the picture of them on Facebook and changed her status as ‘in a relationship’, things starting to unravel.

‘After I posted the picture of us on Facebook things kind of hit the fan. The next morning, (Tuesday, January 19th) a friend of mine texted me asking for his name. I told her his name and she said he looked very familiar. But I reassured my friend I already knew about his ex-wife’s name and had checked him out.

‘But within minutes my friend started to bombard me with multiple screenshots of his wedding, with a women who was not the ‘wife’ he told me of. She sent me a post where Jason wished his wife, happy anniversary in September 2020.’

It’s still hard for me to reconcile who he was and who he actually is. Everything single thing out of his mouth was a lie. 

Steinmetz said her friend was also friends with Jason’s current wife, Opal, and they had been Facebook friends for years, albeit not great friends.

‘I was crushed. I was also humiliated because I literally just had posted this the night before and I didn’t want to have to backtrack and look stupid basically that I posted a picture of being in a relationship with a married man. I immediately texted him forwarding him all of these screenshots from his wife’s Facebook account that my friend had sent to me.

‘He finally admitted that that was his ”other” ex and the marriage was ”annulled.”’

‘Jason said her name was Opal and that their marriage was short-lived because of a ”bad incident.”’

‘But I told Jason if the marriage was annulled why were these posts about their marriage from as early as September 2020 if it was annulled in 2016.’

Steinmetz said she was livid and wanted to talk on the phone with Jason about it, but he said he couldn’t talk because he was working in a ”school zone” at the time. He finally called her but got off the phone with a work excuse within minutes.

‘Jason then texted me back and said that he’s trying to get his annulment paperwork and he was going to send it to me. That made me feel a little better, knowing that the marriage was actually annulled and he was going to send me the paperwork.

‘A few minutes later Jason sent me the document. I told him I was going to do an open records request just to make sure, he was taken back that but said okay.’

Still not trusting of her new boyfriend, Steinmetz asked him if there was anyone else who could ‘vouch’ for him.

‘I asked Jason for him to put me in touch with his brother, but he said he was in a meeting. Then he suggested that I speak directly with Opal.

‘Jason then sent me her number and I started to text her asking about the relationship. Opal confirmed back that they have been divorced since 2016. I told this person I just wanted to make sure Jason wasn’t married because I didn’t want to be a homewrecker. This Opal assured me they weren’t together and said he was a great guy and I should go ahead and go for it with him.’

Collier and Steinmetz went on a weekend getaway to New Mexico where she said he spoke of marriage at lest 50 times

Collier and Steinmetz went on a weekend getaway to New Mexico where she said he spoke of marriage at lest 50 times  

Steinmetz called him a ‘poor representative’ of the town he served, alleging that he would drive to visit her an hour away in Amarillo when he was on shift

‘I then asked this person who I thought was Opal about the Facebook posts from the past four years. She responded back that she was embarrassed for her failed marriage and was concerned about it affecting her job and wanted to keep up the appearance for social media purposes.

‘After talking to ‘Opal’ and she confirmed they weren’t married or together I really couldn’t doubt him on it anymore. Later I confirmed that the number I received a call from was actually Opal’s number. I’m not sure if he cloned the number or had a friend cover for him, I know I was actually talking to a woman.’

‘After I got off the phone with ”Opal” I talked to Jason, I apologized to him, and he made me feel bad for questioning him. He told me, ”I told you so. I showed you the document.” I apologized to him and said let’s just forget it and move on.

‘But after hanging up with Jason, the Potter County Court clerk called me back and I asked her about the document, I gave her the case number, name, etc. But she couldn’t locate any annulment document.

‘There weren’t any records, but I asked if the record could be sealed or something, which the clerk said there was a possibility but not probable.’

When she told Jason that the county clerk couldn’t locate his annulment he said to her, ‘it’s signed off by Judge Lopez, I’ve got it in my safe. Its news to me if it’s not legit.’

A few hours later Steinmetz said she received a video of Jason apologizing to her for lying about not disclosing his annulment.

Still feeling that something wasn’t quite right, Steinmetz told him she wanted to come up to his house and see him for a face to face talk. He agreed but conveniently a few hours later he told her that he had to serve a search warrant that night .

His wife Opal often posted loving family photos on Facebook. Steinmetz shared the photos with DailyMail.com 

Collier posted about his 'beautiful bride' in 2019 and tagged Opal. When he was confronted, he said he was divorced

Collier posted about his ‘beautiful bride’ in 2019 and tagged Opal. When he was confronted, he said he was divorced 

DailyMail.com reached out to Jason and his wife, Opal and they have yet to reply

'I soon found out I was dating a married man. I was sickened by it. I wanted everyone to know this man is a cheater so I posted about him on the Stinnett Police Department Facebook page and it went viral,' Steinmetz said. Collier is pictured with his wife

‘I soon found out I was dating a married man. I was sickened by it. I wanted everyone to know this man is a cheater so I posted about him on the Stinnett Police Department Facebook page and it went viral,’ Steinmetz said. Collier is pictured with his wife 

Steinmetz told him that she could come up afterwards, but he told her that he didn’t know how long it would take.

‘He was making excuse after excuse for not wanting me to come up to his house. Throughout the later afternoon and evening he was texting me with updates on the search warrant. He told me when they were about the ”breach the door” after their debriefing.’

But he never called her until the next morning, he told her that he didn’t finish up until 1am and they had to call in the DEA because ‘there were so many guns, weapons and drugs – it was just a big ordeal.’

‘I chose to believe him again, I didn’t want to be the nagging girlfriend constantly questioning him.’ 

On Wednesday, January 20, Collier told her he couldn’t see her because he had a city council meeting.

On Thursday, January 21, Collier invited her up to Stinnett for a ‘ride along.’

‘When Jason invited me up for a ride a long I felt pretty confident. I felt he wouldn’t invite me up to his work if any of this stuff was untrue.

‘Steinmetz said she rode in his car for a few hours, he even pulled someone over. I was feeling great.

‘Then we went back to the police station. There were two women in the front and we just walked past them. I asked him if he was going to introduce me to his coworkers. He said, no, they are bi**hes, and one of them is upset that he won’t date her sister. He said he didn’t want to put me through that so we just walked past them back to his office.’

Jason had previously sent Cecily a picture of them together hanging in his office taped to his desk, but when she went back there, the picture had been taken down and placed face down on his desk.

When she asked him why he took it down, he told her that he didn’t want the tape on it to ruin the picture so he took it down until she brought him a picture frame, which she did.

‘Jason put our picture in the frame and put it back up on the shelf.’

‘I soon found out I was dating a married man. I was sickened by it. I wanted everyone to know this man is a cheater.

The next morning, Jason arrived at her house in Amarillo with donuts in hand for their weekend trip to Taos, New Mexico. For the past several days Jason had been telling me he was in love with me, and how he wanted to spend the rest of his life with me.

‘After he told me he loved me a few times, I finally said it back to him.’

Steinmetz said they dropped her kids off at school, ran a few errands and then hit the road for the 5-hour drive.

‘Since the restaurants where closed because of COVID we had to order take-out. We ate dinner in our room. Later that night we consummated our relationship. I felt in love with him that weekend. He was everything I had hoped for, I loved him for him. I was attracted to his love and affection more than his physical appearance. I never said anything but when he first took off his clothes I could tell he had lost a lot of weight because he had sagging skin hanging all over his body, but I didn’t care, I’m not in the best shape either.

‘And his love-making was not the best and, especially now knowing all of the practice he had, he should have been better. But I loved him for who I though he was.’

On that Saturday January 23, they were driving to a famous bridge in Taos when they saw a man who appeared on drugs and was threatening to jump.

They called 911 and the meantime, Jason went into action.  

‘He basically saved the guys life, the drugs were taking effect and the guy started to vomit. Jason turned him on his side and helped him out until the medics and cops arrived. It was a stressful experience but Jason remained calm the entire time.

‘It felt great to see him in his element rescuing and saving people’s life. It made me really admire him, the way he was asking the guy questions.

‘During the entire weekend Jason was talking about marriage, by the end of the weekend together I was more than willing to marry the guy. He told me I was a blessing, that I’m the answer to his prayers, how he’s never met anyone like me and he’s waited his entire lifetime to meet someone like me. He showered me with compliments.

Collier's alleged infidelities were exposed by his girlfriend Cecily Steinmetz, who also shared an image of the fraudulent marriage annulment document he sent her (pictured)

Collier’s alleged infidelities were exposed by his girlfriend Cecily Steinmetz, who also shared an image of the fraudulent marriage annulment document he sent her (pictured) 

Initially, the City of Stinnett placed Collier on administrative leave pending an investigation on January 27 - however he has now resigned and been arrested

Initially, the City of Stinnett placed Collier on administrative leave pending an investigation on January 27 – however he has now resigned and been arrested

‘He never officially asked to marry me. He said he wanted to wait until he got me the ring I wanted. He asked me to send him pictures of rings that I liked and he was going to get me one and propose. He was also talking about moving down to Amarillo and commuting to Stinnett every day.

‘He even mentioned Las Vegas as a potential place for us to get married.

‘During the weekend to Taos he probably mentioned marriage about 50 times and asked if I was still okay with getting married, which I told him, yes.’

‘We returned from Taos on Sunday night and I still had a gut feeling about him, that something wasn’t right. I just didn’t know what. He had an answer for everything.

‘He dropped me off and we were planning on him spending the week with me in Amarillo starting on Monday, January 25.

‘Thirty minutes later I got a text from him saying he missed me already. I replied back that I missed him as well. Then another 30 minutes went by and I get another text, he said we needed to slow this way down and we have some differences.

‘I was devastated, hours earlier he told me he wanted to spend the rest of his life with me and now he wants to put the brakes on our relationship.

‘He told me that he didn’t think I had a close relationship with God.

‘I was confused as it’s never really been a topic of discussion. He brought it up when we first starting talking but then never mentioned a word about it since. I didn’t respond to him anymore that night. I was hurt.’

The next morning Steinmetz said she didn’t receive a text from him and went about her day, when mid-morning he sent her a text telling her they have some things to work through. He had complaints or differences about her including that she didn’t drink coffee and didn’t like seafood.

She was flabbergasted that those small things were going to be a deal breaker in their relationship.

He then told her he didn’t know if he wanted to move to Amarillo, so she told him she was going to do him a favor and get out of his life. She told him she was done with their relationship.

She then had a heated conversation with him on the phone where he told her she was rude and played the victim role.

‘I unloaded on him with all of the questions and red flags I had. He still claimed the annulment was legit. He was defensive, He told me that I was belittling him and he wasn’t going to put up with it. I told him that he’s nothing but a liar and not to contact him ever again and hung up on him. 

‘I was done with him and chalked it up to a bad memory and was just going to let the whole situation go and forget about it.

Steinemetz said she's glad she came forward because she never wants him to do this to anyone again. 'Jason downfall was because he had a relationship with someone who lived near him

Steinemetz said she’s glad she came forward because she never wants him to do this to anyone again. ‘Jason downfall was because he had a relationship with someone who lived near him

'He asked me to send him pictures of rings that I liked and he was going to get me one and propose. He was also talking about moving down to Amarillo and commuting to Stinnett every day,' Steinmetz said

‘He asked me to send him pictures of rings that I liked and he was going to get me one and propose. He was also talking about moving down to Amarillo and commuting to Stinnett every day,’ Steinmetz said 

‘Until I spoke with my friend who had been friends with Jason’s wife on Facebook. I filled her in on the entire situation and she told me that she had found a post on the Stinnett Police Department Facebook page from a Kristi Shaffer about two weeks ago. The post said something like this is the most fair and equitable man I’ve ever met, etc. This Kristi’ profile picture was of Jason and her. 

‘So I quickly message Kristi and within 20 minutes she called me and we both realized we’ve been played by the same man. We compared notes, dates, times, etc.

She discovered that Shaffer had been engaged to Collier since December.  

‘After my conversation with Kristi I sent Jason several screenshots of my conversation with her and told him I’m telling everyone about him. He didn’t respond.

‘I soon found out I was dating a married man. I was sickened by it. I wanted everyone to know this man is a cheater so I posted about him on the Stinnett Police Department Facebook page and it went viral.

‘I’ve been contacted by several women, there are at least eight of us that I know of. I want everyone out there to know this man is a liar and cheater.

Steinmetz still says she's still processing her whirlwind romance, she said she's overwhelmed, embarrassed, humiliated and angry

Steinmetz still says she’s still processing her whirlwind romance, she said she’s overwhelmed, embarrassed, humiliated and angry

‘On Tuesday I was contacted by the Texas Rangers, I met with one of them in person and told them my story and gave them the document Jason sent to me.

On Thursday Jason was arrested by the Texas Rangers for falsification of a government document and released on $10K bond.

Steinmetz still says she’s still processing her whirlwind romance, she said she’s overwhelmed, embarrassed, humiliated and angry.

‘It’s still hard for me to reconcile who he was and who he actually is. Everything single thing out of his mouth was a lie.

‘I’ve spoken with several of them women he dated and we compared dates and notes, he would often send several of the women the same video via the Marco Polo App.

‘Jason used the same lines with all of the women, he told them he was ready to get back into the dating world, how he was a Godly, he appeared to be kind and sincere, told them he was looking for marriage.’

Another women he dated, Katie Berry told DailyMail.com that she had meet Jason on the same Facebook dating site and he drove down to Abilene, TX to spend the weekend with her on January 16 and January 17.

Katie said, ‘He stayed at a local hotel and we met for lunch. He was charming and very polite. He told me that he was not only a Chief of Police of Stinnett but he some sort of police chaplain and how he was a Godly man and always praying for me and over me.

‘He never was inappropriate with me, I thought I was talking to a really good man, he turned out to be the complete opposed of that. He is a predator whose goal was to feed his narcissistic ego whatever the cost. I’m thankful that they were enough red flags that I had my guard up and didn’t become emotionally invested in him, but I still feel betrayed and publicly humiliated. I pray for his wife and kids.’

She thought it was strange when he started talking about moving down to her area and wanting to look for a job when they had only been talking for a week or two.

Katie said on Tuesday morning, January 26, she received a text from him saying he needed to step back from our relationship because he was in a bad place mentally.

‘I never responded back to him because I wasn’t that emotionally invested in him.’

The next day is when she saw on Facebook about the cheating chief.

Steinmetz said she would like to ask Jason, ‘Why would you do this to so many women? If you are just looking for a fling there are plenty of people and websites out there to find one at. Why did you tell so many women that you are a Godly man and you want a relationship? When it’s nothing more than a lie. You pushed the idea of marriage on so many women when clearly you had no intentions of it.’ 

Steinmetz feels sorry for his wife, Opal. 'She's a victim in this as well, he used his nonexistent 'side job' to cheat on his wife,' she said

Steinmetz feels sorry for his wife, Opal. ‘She’s a victim in this as well, he used his nonexistent ‘side job’ to cheat on his wife,’ she said

Steinmetz feels sorry for his wife, Opal. ‘She’s a victim in this as well, he used his nonexistent ‘side job’ to cheat on his wife,’ she said

She also feels sorry for his wife, Opal. ‘She’s a victim in this as well, he used his nonexistent ‘side job’ to cheat on his wife.’

She has a theory on maybe why he cheated and lied to so many women. ‘I saw previous pictures of him and he was a lot heavier, maybe when he was young and a lot of women wouldn’t give him the time of day and now he’s ‘revenge dating.’

She’s glad she came forward because she never wants him to do this to anyone again. ‘Jason downfall was because he had a relationship with someone who lived near him.

‘All of the other women he had dated lived out of state or several hours away. If it wasn’t for my friend being friends with Jason’s wife on Facebook, and bringing it to my attention who knows what would have happened?’

DailyMail.com reached out to Jason and his wife, Opal and they have yet to reply.

Mark W Snider District Attorney for Hutchinson County, Texas told DailyMail.com ‘The case involving Jason Collier is still under investigation. Once the investigation has been completed and if the elements of the case meets the criteria it will be presented to a grand jury for an indictment as per Texas law for all felonies. There is no time frame for the investigation to be completed.’ 

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US Health and Healthcare is a Chaos: Now What? https://open-mind.org/us-health-and-healthcare-is-a-chaos-now-what/ https://open-mind.org/us-health-and-healthcare-is-a-chaos-now-what/#respond Thu, 17 Jun 2021 01:14:41 +0000 https://open-mind.org/us-health-and-healthcare-is-a-chaos-now-what/ The report of the lancet Public Order and Health Commission in the Trump Era 1 Wool merchant S Himmelstein YOU Ahmed S. et al. Politics and Health in the Trump Era. is a tour de force chronicle of the failures of both the US healthcare system and the society and public institutions that cause and […]]]>
The report of the lancet Public Order and Health Commission in the Trump Era

1

  • Wool merchant S
  • Himmelstein YOU
  • Ahmed S.
  • et al.
Politics and Health in the Trump Era.