Getting “Hip” With HIPAA

Since we are on a bit of a statutory roll here, we thought we would continue to knock out a few more primers on some of the most important statutes that impact our business. Starting with this “strange animal.” Word to the wise, it has nothing to do with African semi-aquatic mammals of a similar sounding name.

This statute (known formally as the Health Insurance Portability and Accountability Act) was passed in 1996 during the Clinton era discussions about healthcare reform. It covers many areas important to everyone who needs healthcare, but there are some particular aspects of this law that we wanted to highlight, specifically as they interact with both Privacy Act requirements (a topic for a blog post coming soon), and of course our favorite two civil rights bills, the ADA and the Civil Rights Act of 1991.

Title I of HIPAA was the first real attempt to limit the ability of health insurers to exclude individuals for coverage based on pre-existing conditions. It is nowhere near as declarative in this regard as Obama’s current law, which is why we support this critical aspect of healthcare reform. This however, we anticipate will become less of an important piece of this statute as some form of Obamacare comes into practice.

Title II of HIPAA however, still has a lot of teeth, and we anticipate that this segment of the legislation will only grow in importance. Specifically, this section deals with the creation of standards for the dissemination of healthcare related information. Again this is tied into Privacy Act issues we’ll discuss another day, but these provisions are critical in maintaining not only medical privacy for individuals but their basic Constitutional Rights under both the ADA and The Privacy Act which include not only privacy but the right of due process. In the former, for one, it directly addresses the right of a PWD, for example, to better control who knows what about their disability. As the ADA is very clear on the rights of individuals who are “perceived” to have disabilities (whether they have them or not), this statute compliments that legislation for this demographic in very positive ways.

The so-called “Security Rule” deals with electronically transmitted medical information specifically. In other words, one has to be very careful where and how medical records are transmitted and stored on what databases and who should have access to them. This is the part of HIPAA that has proved to be particularly problematic for some of the larger IT players (and indeed some state actors, starting with North Carolina) to comply with.

Our service provision model we believe not only creates an answer for some of those ongoing issues and problems, we also plan to give access to advertisers to a very valuable demographic while protecting our customers’ medical privacy. We believe our model is unique among IT players who are entering this space or have wanted to for some time (such as Google and Facebook). What the specifics are we will decline to elaborate upon further at this time, but we have provided one model we intend to use on this site. Click on the taxi to the left of the blog post and we hope readers will see what we mean.

We as a company will be operating in some very highly regulated waters. We actually think its a very good thing. One of what we believe to be the value adds we bring to the table is a profitable operating model that actually makes its business case BECAUSE of regulation rather than in spite of it. While this may not be the case for every private enterprise out there, we think that some of the ideas and models we have created set new benchmarks and open new doors to profitability and innovation.

A Primer on The Civil Rights Act of 1991

Along with the passage of the ADA, another piece of legislation passed about the same time (The Civil Rights Act of 1991) guarantees PWDs the same Constitutional protections as minorities – specifically that they are worth the full “value” of a white man.

The Act was originally passed in the Reconstruction Era and until 1991 only applied to minorities. Ever afterwards, it also applied to the PWD community, even though legal challenges if not a broad understanding of the statute remains oblique and largely untested.

What the statute also essentially does is address not only the “contractual worth” of PWDs, it also ostensibly creates economic “rights” or an economic “floor” for PWDs. This means that, for example, a PWD may not be hired at less than the minimum wage (for example).

What it also does, however, is create mandates for the government where goods and services vital to maintaining that “contractual” worth are provided to this community.

Starting with, of course, healthcare.

While a great many of the failings of the ADA remain to be addressed thanks to aggressive federal push back in the courts (for example), one of the most instructive things to come out of the last twenty years of litigation under the Act was attempts to “define” a covered disability.

The ADA Restoration Act will address many of these issues, we hope, but taking from that line of reasoning, we contend that in fact, since so many people with disabilities require medication to manage their disabilities so as to not meet the federal standards of being “disabled” that this is actually a very interesting legal space right now. Specifically, using that logic, a person with a disability who can manage their disability with medication (starting with diabetes) is therefore guaranteed a certain “floor” of medical service. Without such service (including access to medication, regardless of the ability to pay), such a person very well may be “disabled.” With it, they will be a PWD, able to take their rightful place in society in every place the “able-bodied” now participate. As such, the state has a vested interest if not obligation (starting with a fiscal one if not a civil rights based one) to insure, if not is forced to require, unimpeded access for every PWD to state provided medication to preserve their “contractual value.”

We realize that for the non legal eagles reading this, this may all sound like complicated legal mumbo jumbo.

However in the middle of budget battles, from the federal to the state level, we think this is an important point to raise.

Particularly as we have a service provision model which not only addresses it but creates a very powerful “fix” that will reverberate both directly on the bottom line and in indirect costs that we anticipate will become increasingly obvious as we begin service provision.

The Missing 20%

According to data we have seen, the “disabled” (or PWDs) account for a full 5% (or one third) more of the Medicaid (or government healthcare benefit) recipients in North Carolina than the “elderly” (those over 65). The former are about 15% of recipients, the latter only 10%. We are going to extrapolate this data as a roughly equivalent “national” average even if the numbers in other states are higher or slightly different.

However, in light of just this fact, it boggles the mind that the most frequently cited users of government health benefits are “the elderly.” This is in fact how so much of the current budget debates and fights over “Medicare” or “Medicaid” are framed.

The reality is that the people most affected, for the longest period of their lives by both government benefits and “Medicare” (which is essentially the same as “Disability”) are in fact completely left out of the debate if not invisible. That’s a pretty big exclusion. National figures of PWDs put this population statistically at 20% of the country. About twice as large, we add, as the African-American or LGBT population and certainly one, across all age demographics, that will compete with the Boomers in terms of size if not wealth or relative health.

These are also people that, in fact, the Boomers have systematically ignored for the last 20 years since the passage of the ADA.

As both populations reflected in the data sets are relatively “stable” (in other words, most people over 65 receive Medicare and unfortunately most PWDs under 65 are still kept out of the job market, so this figure is also fairly reflective of overall PWD numbers), these two figures are a fairly reliable indicator of the total size of the population itself and “steady-state” recipients (in other words people who are not likely to move off the roles without significant policy in place to address it). The reason why PWDs have such an appallingly high rate of poverty if not unemployment (90%) is an issue we won’t discuss here, but we want to put our stake in the ground as recognizing it.

However more to the point, PWDs are also the largest “consumer” of government benefits of all those that receive them. Over 40% of the money spent on government healthcare in-state flows to this population. To put this in comparison, the “elderly” only account for about 26%.

This means a couple of things. It means that current efforts to “reform” the system, whatever it is called, must be systematic.

It also means that nobody is going to really affect the budget all that much if the debate only focuses on the recipients of government health benefits over 65. No matter how big and bad the Boomers like to think they are. Specifically, “vouchering” care is a drop in the bucket to the real, ongoing needs of a large segment of the population which statistically also uses such benefits, conceivably, for most of their lives – not just post-retirement.

For the uninitiated, this could seem like one of those “kick the can down the road” discussions. Unfortunately, anyone concerned about the budget these days (and let’s face it, we all are) needs to understand how imperative real reform is. It literally affects the Constitutionally defined “worth” if not “contractually defined value” of many human beings in this country. We’ll skip the wonky discussion of the implications of the 1991 Civil Rights Act in this blog post and how it intersects with the ADA, but we’ll come back to it later. The reality is that government healthcare benefits, particularly for PWDs are in fact part of such individuals’ implied contractual rights with the state if not tie into the perceived “worth” of a PWD per the Constitution.

Starting with, we argue, allowing as many of those currently on “Disability” to have every opportunity, including training, education and structural access to employment (if not real prosecution of their rights under the ADA) so that America may finally address its last great discrimination story. Not to mention start to address budget cuts in a real way and “right” the structural problems with the economy. Nothing close to this mindset exists right now in the official halls of power. One of the many reasons we decided to start this company (apart from the business case that exists) is to also bring attention to the unbelievably horrific realities of most of this population – suffering that is absolutely unnecessary if not immoral.

The reality also is that the many problems of “Medicaid/Medicare” actually work in concert to also rob PWDs of the ability to work, simply because the system is so beyond awful at the moment that it usually takes a significant amount of time to get care – so much so that it could easily impinge on the ability to find and keep employment (of any sort.)

The hidden story of the “missing 20%” in current budget discussions is also one we are working to highlight simply because it is also another “fix” that we support. It’s a far more complicated one to address, however, from the policy level, particularly in such a highly-charged debate where brinksmanship and lack of details about goals seems to be more important than focusing on the underlying issues required to create real change.

For those used to Washington politics, the response to this assertion may very well be “what’s new?”

In such a cynical and jaded echo chamber, we do actually think we do have something new.

We also think however, particularly for an administration that promised “change we can believe in,” that this is a very good place to start listening.

Disingenuous “Budget Cuts” For “Medicare”

We, like just about anyone alive with access to media (old, new or somewhere in between) know that the hunt is now on for savings. And as usual, everyone is looking to “Medicare.”

We do feel we need to weigh in on this issue at the moment from what we hope is a strictly non-partisan “green” stance, however it is apparent to us that despite all the rhetoric, as usual, to date, there is more hot air than substance on all sides. We would say gas, but, well, we think savvy readers get the point and we wouldn’t want to get into any confusion about “good” gas and “bad.” We run into that problem enough as it is.

However, the reality is, beyond Beltway Contortions, is that “Medicare” actually refers to all government-sponsored health insurance. While the VA (this time) is apparently being saved from all consideration, in general, VA covered medical care is the same thing as HHS covered “Medicare” – as are “Disability benefits” and of course “Medicaid.” When it comes to healthcare, the benefits are all the same. We won’t confuse the uninitiated with a further discussion of the “dually eligible.” So many monikers, all the same deal.

This means, however, for example, that doctors are compensated under the same rate, and, to get to a point, so are drivers. Even more to the point, according to some interesting figures we have seen, historically, “the disabled” or as we refer to them, “PWDs” have actually been a higher driver of care costs than the “elderly.” (We refer to those folks these days as, um, “Boomers” however much we know they really hate that. No matter how cute Robert Redford looked on the cover of AARP’s national mag not too long ago.)

Snarking aside, that’s an awfully big segment of the population that is being rather systematically ignored. Annually, not just cumulatively.

Oops.

What this also means of course is that the current calculations of “getting rid” of Medicare if not “voucherizing” it essentially means that people who have had “Medicare” all of their lives or after a disabling situation or illness, will be essentially cut off after they reach 62. Sort of like a “Logan’s Run” on the far, far, side of 30.

We won’t even begin to think of weighing in on that score, however we did think it was appropriate to bring up a topic that is directly at our core mission and one which is directly related to that problem we just mentioned. Specifically, added to this very grim situation already is that there is a great deal of transportation now (supposedly) reimbursed by HHS.

We say “supposedly” because that is really what it means. And while we don’t want to get into any Title II discussions (for one) we believe that many areas are actually in danger of (unintentionally) violating Title II of the ADA with “budget” but not civil rights law compliant service cutbacks that affect the (unfortunately still too high) 90% of the 20% of the country with a disability who is also forced, for whatever reason, to also receive government benefits (known broadly as “disability”).

That’s where we hope we can really make our first impact. We also hope that we begin to make enough “noise” on the policy level (and we don’t care where, how, or with whom, as long as we can make our point) that draining the petroleum out of Medicaid (the blanket default medical insurance program we should probably all get used to referring to) is one of the best ways to immediately figure out ways to “cut it” while planning longer term service models (like ours we not so modestly suggest) to actually make the service itself if not the transportation that serves this community, the most efficient, best and cost-effective it can be.

After all, Title II of the ADA was designed as the “no separate but unequal” clause of the statute. In “Title VII” terms (which also apply here we hasten to remind any legislators reading this), this is essentially the “no white drinking fountain” clause of the ADA.

We think this makes the point without, say, sitting in any cafeterias marked “able-bodied only” and most certainly without posting a cartoon somewhere effective with two (non ADA compliant) drinking fountains – one for the “able-bodied” and the other for “gimps.”

Green Tipping Points

There is an inevitability to the direction we are headed, even if for example “we” as Freedom Riders do not succeed in our current venture. The realities if not greenbacks of “real-politik” if not directly in consumer’s (and government’s) wallets are dictating the lockstep of our strategic guidance.

This is no-where more true right now than in the “green” action that is going on in Washington D.C. at the moment, ostensibly even with cutbacks at such agencies as the EPA. In another classic “behind the scenes,” not to mention “I’m not an insider but I play the game” hall and vote jockeying move by Obama, there are some political realities lining up that are decidedly bipartisan and seem to meet everybody’s goals at the moment. This starts with all the careful posturing of the President yesterday about the cuts he has “allowed” in the budget to date along with the “invest in the future” rhetoric. It also happened about a week ago with far less drama on the (mostly) Republican side of the House with the introduction of H.R. 1380, the so-called “Natural Gas Act.” We will examine that piece of nascent legislation in another post no doubt. The White House has already praised the vehicle we plan to use (the MV-1) in a press statement we link to elsewhere on this site. It boggles the mind in the spider-web sensitivity of the White House to the Hill, particularly in this administration, that this legislation didn’t at least make a mention at some White House briefing in the last week. Nor, we surmise, was it entirely unrelated to Obama’s subsequent remarks and actions on the federal budget negotiations.

On the local level, we see these federal developments as a boon (not the one in Watauga County) for North Carolina and even more specifically Charlotte. The region is staggering right now under a very high 11% unemployment rate (the fourth highest of any city in the country), that will prove to be stubborn to combat unless some kind of investment and retraining of a large segment of the population occurs quickly. It will also be inevitably helped by creating opportunities for this cash-strapped (and very petroleum dependent) region to cut their transportation energy costs dramatically. Charlotte is also, for those without the regional knowledge, one of the major North-South transportation hubs for long-haul truckers on the East Coast. This legislation and Charlotte’s early mover advantage in converting to CNG city-wide, could directly (and positively) impact the price of many different commodities (starting with food) on a regional (as in East Coast) basis if not nationally.

If there was ever a “ground zero” for the “green tipping point” to make an (excuse the mixed metaphors) economic “atomic blast” the size of both Hiroshima and Nagasaki domestically with the least amount of other kinds of investment (both public and private), we believe that Charlotte would be it.

We continue to push forwards on all fronts to help make our company one of the ones that is in the forefront of the coming “green” revolution that we hope begins to bloom right along with the azaleas this year.

The “Greening” of Medicaid

It’s no accident that the real targets of “Republican” attempts to cut the federal budget focused on the environment (EPA) and of course “entitlements” (which always includes government-funded health insurance of some sort).  These are both complicated issues which of course our company is designed to address.  That said, we aim to tackle the problem as a private sector, bottom-line and profit-focused business.  As such of course we straddle a lot of divides, starting with “partisan identification.”

We aim to avoid that.  To create our business case, we have assumed that just about everyone needs clean air to breath, clean water to drink and well, when you get sick, you need care.

That doesn’t mean that you can always throw money at the problem, which is why we are attempting to be so bi-partisan.  The reality is that our first service model aims to actually increase and improve service while reducing the annual expenditure by the federal and state government of North Carolina by about $300 Million a year.  At present, the state only picks up about 1/3rd of the cost of Medicaid/Medicare in-state, so we are pretty confident that no matter what impact we have, the Feds, logically, will be twice as enthused as the neighbors.  We think also it’s hard to argue with our motives, no matter where on the political spectrum you place yourself.

The fact is that Medicaid, like most government services (and let’s face it, the private sector) is shot through with the costs of petroleum that until recently were all but invisible to both policymakers and advocates alike because of the drum-beat of pro-petroleum forces.  With the cost of petroleum now over $100 a barrel (again), and of course alternatives like ours readily available, there is no getting around this 600lb guerrilla in the living room.

As we were recently tasked to do, our first guidepost is to remove about 240,000,000 BTUs of petroleum-based energy (annually) from Medicaid (in Department of Energy lingo).   That’s only from our Charlotte HQ, FYI, at the smallest number of taxis we plan to operate.  The demand is so great that we could easily save far more than that.  Our first service model is so efficient, in fact, that it will also drastically reduce the amount of energy it takes (from a strictly scientific perspective) for the government to help Medicaid patients get their meds refilled (a requirement under both the ADA and Title VII).   As much wind that blows from Washington on the “people’s mandate” to cut the budget, when it comes to some government services (such as Medicaid) there is no getting around the reality that civil rights cost money.  That’s something that is always left out of these discussions.  It can’t be anymore.  It creates a “floor” of service provision that the federal government is required to meet per the Constitution.  The states must also follow under some “tricky” legal quirks, known broadly as “Title II.”

We know that this is an awfully academic subject filled with tiring legal mumbo jumbo, so in the interests of brevity, we are used to just saying “it’s required.”  Unlike say strict “treehuggers” however, we have the luxury of pointing to a document that can’t be dissed (too much), although it appears these days that everyone and their little sister is a Constitutional scholar (no matter how much some people also seem to think that other historical dates enshrined in paperwork, such as the 14th Amendment, happened at the time of George and Tom.)

We do advocate the recycling of paper and other appropriate items, but we are rather partial to the Constitution and think it shouldn’t be shredded for inclusion in the local landfill.  For that reason, we are taking the stance that we are.  We think ultimately, it will be seen as no more inciteful of anything other than a very comfortable and healthy if not “green” bottom line.