The Community Living Assistance Services and Supports (CLASS) Act, a program championed by the late Sen. Edward M. Kennedy, has been criticised by Republicans and the employer community, who disputed claims that it would be fully funded by enrollees.

For 19 months, experts inside and outside of government have examined how HHS might implement a financially sustainable, voluntary, and self-financed long-term care insurance program under the law that meets the needs of those seekig protection for the near term and those planning for the future,” Secretary Kathleen Sebelius wrote in a letter to congressional leaders. “But despite our best analytical efforts, I do not see a viable path forward for CLASS implementation at this time”

Doctors have long known that obesity increases a person’s risk of heart disease, but in recent years the picture has grown more complicated.

Several studies have found that a high body mass index is associated with a lower risk of dying from heart disease and other chronic illnesses — a mysterious phenomenon that has come to be known as the “obesity paradox.” (Body mass index, or BMI, is a ratio of height to weight used to define obesity.)

According to a new analysis in the Journal of the American College of Cardiology, the paradox appears to be explained by the simple fact that BMI is a very flawed measure of heart risk. Waist size provides a far more accurate way to predict a heart patient’s chances of dying at an early age from a heart attack or other causes, the study found.

Health.com: 10 best foods for your heart

As in previous studies, a high BMI was associated with a lower risk of death. But researchers found that heart patients with a high ratio of waist-to-hip circumference or a large waist size — greater than 35 inches for women, or 40 inches for men — were 70 percent more likely to die during the study period than those with smaller waists. The combination of a large waist and a high BMI upped the risk of death even more.

“What matters probably the most is the distribution of fat, more than anything else,” says the lead researcher, Francisco Lopez-Jimenez, M.D., a cardiologist at the Mayo Clinic, in Rochester, Minnesota.

The new study provides more evidence of BMI’s shortcomings in assessing heart risk, says Jean-Pierre Després, Ph.D., the director of research at the Quebec Heart and Lung Institute at Laval University, in Quebec City.

“If you measure body mass index, you don’t assess body shape, you don’t assess body fat distribution,” says Després, who wrote an editorial accompanying the study. “I’m not saying BMI is useless. It’s just that we need to go beyond that. BMI is the total cholesterol of lipids: We know that there is good and bad cholesterol, and there is good and bad fat.”

Health.com: Good fats, bad fats: how to choose

Nor does BMI distinguish between fat and muscle, Després adds. Heart patients who lead a sedentary lifestyle may see a drop in BMI as they lose muscle mass, he explains, while heart-disease patients who become more active may actually put on weight and raise their BMI because they are adding lean muscle.

The findings also add fuel to the debate surrounding body type and the risk of developing heart disease. Several studies have suggested that people with an apple-shaped body who accumulate fat in their belly are more likely to develop heart disease than their pear-shaped counterparts, but that theory has been called into question by recent research.

Lopez-Jimenez and his colleagues analyzed data from nearly 16,000 heart patients who participated in one of four previously conducted studies or the Mayo Clinic’s Cardiovascular Rehabilitation Program. More than one-third of the patients died during the studies, which ranged in length from six months to more than seven years.

Health.com: Heart-healthy rules to live by

A high BMI was associated with a 35 percent lower risk of death, but having a large waist in addition to a high BMI nearly doubled the risk of dying, the researchers found. (To zero in on waist size, they controlled for age, hypertension, diabetes, and other risk factors for heart disease.)

Even heart patients with apple-shaped bodies and BMIs in the normal range were at increased risk of dying sooner, which drives home the fact that normal-weight heart patients may need to lose some weight in their bellies too, Després says. “That’s why it’s so important for clinical cardiologists to measure waist circumference.”

Health.com: Your A-to-Z guide to a flat belly

Why is belly fat so bad? It tends to be a sign of visceral fat, or fat that gathers around the organs in the abdomen, the study notes. This fat seems to promote insulin resistance and unhealthy cholesterol numbers, and may also boost inflammation.

Genetics plays a “very strong” role in whether a person gains weight around the waist, Després says. He estimates that about 30 percent of the population has this tendency to put on fat in these “undesirable sites.”

Copyright Health Magazine 2010

As reported in our last issue, pressure was mounting within all three branches of government for a compromise to the most significant change imposed by the Patient Protection and Affordable Care Act (PPACA); the personal mandate President Obama extended an olive branch to governors meeting at the National Governors Association in Washington this week, when he announced that he supported amending the 2010 health care law to allow states to opt out of its most burdensome requirements three years earlier than currently permitted.

Specifically, the President said he would back legislation that would enable states to request federal permission to withdraw from the law’s mandates in 2014 rather than in 2017 as long as they could prove that they could find other ways to cover as many people as the original law would and at the same cost.

The earlier date is when many of the act’s central provisions take effect, including requirements that most individuals obtain and that employers of a certain size offer coverage to workers or pay a penalty. This concession is significant as there are already states that have developed or are in the process of developing there own state-run alternatives to the PPACA.  The Commonwealth of Massachusetts began offering its own alternative three years before the passage of the PPACA.  As mentioned here last week, Vermont Governor Shumlin has proposed a “single-payer” system.  In this system, all Vermont residents would receive health benefits paid for by the state, regardless of their employment status or income. The plan is designed to help stem rising health costs, which state officials say have become unsustainable.

The President told the governors that his concession “will give you flexibility more quickly while still guaranteeing the American people reform.”

The pressure of the divergent rulings, issued by federal district courts throughout the country, on the constitutionality of the mandate and the protracted appeals process, coupled with mounting budgetary crises at the federal and state level, and employer unrest caused the President to, for the first time, call for changing a central component of his signature health care law.

Although he has previously backed removing the penalty imposed on employers when any of its employees used one of the proposed Exchanges, the bipartisan amendment that Mr. Obama is now embracing was first proposed in November, eight months after enactment of the Affordable Care Act, by Senators Ron Wyden, a Democrat from  Oregon, and Scott Brown, a Republican from Massachusetts. Senator Mary Landrieu  of Louisiana, a Democrat, is now a co-sponsor of the bill.

While the legislation would allow states to opt out earlier from various as long as they could prove that they could find other ways to cover as many people as the original law would and at the same cost.   If states can meet those standards, they can ask to circumvent minimum benefit levels, structural requirements for insurance exchanges and the mandates that most individuals obtain coverage and that employers provide it. Washington would then help finance a state’s individualized health care system with funds earmarked for insurance subsidies and tax credits.

This initial movement is not likely to be the last; give and take will continue—hopefully yielding a bipartisan solution.♦

Congress

As part of legislation to keep the government funded through March 4, House Republicans passed a series of amendments this week aimed at defunding implementation of the health care law.  The House proposed a freeze on any money that would be used to implement the health care reform law.  Specifically, the House proposed  that there be no funding for:

• any employee of the Department of Health and Human Services, the Department of Labor to implement the health care law;
• anyone at the Internal Revenue Service to implement the individual mandate; and
• any employee to work on the health insurance exchanges or the medical loss ratios.

House Republicans dislike the law. They already voted symbolically to repeal the law but were defeated by the Democratic controlled Senate.  Now they want to make sure there is absolutely no money to fund it.  A denial of funding is also likely be defeated by the Senate.

Courts

A federal judge in Washington, D.C. became the third U.S. trial judge to uphold the constitutionality of the new health-care law’s requirement that individuals maintain health coverage or pay a penalty.

In Tuesday’s ruling, U.S. District Court Judge Gladys Kessler said Congress was within its constitutional authority under the Commerce Clause to regulate  when it chose to penalize people who forgo health insurance.  The Court  held that “Congress had a ‘rational basis’ for its conclusion that an individuals decisions not to purchase health insurance substantially affects the national health insurance market.” 

Two other judges, most recently U.S. District Court Judge Roger Vinson in Florida, have ruled the insurance mandate provision as unconstitutional. Judge Vinson, who ruled on a legal challenge brought by a group of 26 states, voided the entire law.

While trial judges continue to consider challenges to the health law, the legal fight over its constitutionality will find its way to the Supreme Court before the matter is finally resolved.

States

States have a complicated shared-power relationship with the federal government in regulating various aspects of the health insurance market and, specifically, the PPACA.

In response to the passage of the PPACA, at least 40 state legislatures proposed legislation to limit, alter or oppose selected state or federal actions that mandate a citizen’s purchase of insurance. 

Other states have sought to keep in-state health insurance optional, and instead allow citizens the opportunity to purchase any type of health services or coverage they may choose.  

In 30 of the states, the filed measures included a proposed constitutional amendment by ballot question.  In a majority of these states, their constitution includes an additional hurdle for passage–requiring either a “supermajority” of 60 percent or 67 percent for passage, or requiring two affirmative votes in two separate years, such as 2010 and 2011, for passage.♦

The Affordable Care Act bans any annual dollar limit on essential benefits beginning in 2014. Last month, the Department of Health and Human Services (HHS) issued additional guidance clarifying the process for a group health plan (or health insurance carriers) to seek a waiver for a limited benefit plan or “mini-med” plan of the restrictions on the imposition of annual limits on the dollar value of essential health benefits under the Patient Protection and Affordable Care Act (PPACA).

A group health plan (or health insurance carrier) may seek a waiver from the annual limit requirement on essential benefits if the plan can demonstrate that compliance with the requirement would result in a “significant decrease in access to benefits” or a “significant increase in premiums” for affected individuals.

For more information, see:

http://www.healthcare.gov/center/regulations/guidance_limited_benefit_3rd_supp_bulletin_120910.pdf

http://www.hhs.gov/ociio/regulations/annual_limit_waivers.html♦

The Affordable Care Act imposes, non-discrimination rules on non-grandfathered, insured group health plans similar to those that apply to self-insured plans under Section 105(h) of the Internal Revenue Code (the Code). This new provision could have a significant impact on an insured health care benefit structure.
The new rules were to be effective on the first day of the first plan year beginning on or after September 23, 2010 (or January 1, 2011 for calendar year plans). However, no guidance was issued prior to the effective date with respect to these new rules. Therefore, employers were faced with complying with the new nondiscrimination rules, without knowing how to comply. Fortunately, the Internal Revenue Service issued IRS Notice 2011-1. This notice provides that because regulatory guidance is essential to the operation of the nondiscrimination rules, the agencies have determined that compliance should not be required until after guidance has been issued and that compliance with the nondiscrimination rules is delayed at least until January 1, 2012 for calendar year plans, and potentially later.♦

As a result of the Health Care Reform Act there are significant changes to the eligibility of over-the-counter (OTC) drug expenses through Flexible Spending Accounts (FSAs). Effective January 1, 2011, FSA, participants will be required to obtain a prescription from a licensed health care professional for all OTC drugs or medicines in order to assure eligibility.

On December 23, 2010 the IRS has provided additional clarification on how health debit cards may be used to pay for prescribed over-the-counter drugs. IRS Notice 2011-5 clarifies that participants have the following two options available to obtain reimbursement:

Option 1: Purchase the prescribed over-the-counter drugs or medicines at the pharmacy – Health FSA debit cards may be used for OTC medicines and drugs if:

Prior to the purchase, a prescription is presented to a pharmacist
The pharmacist then dispenses the drug in accordance with applicable law
Rx number is assigned (The health debit card system will not work unless an Rx number is assigned)
The pharmacist retains certain records (the Rx number, the name of the purchaser or the name of the person for whom the prescription applies, and the date and amount of the purchase), and the records are accessible by the employer’s plan or its agent.

Option 2: Purchase OTC drug or medicine over-the-counter – Should the participant obtain the appropriate prescription for the OTC drug or medicine, he or she can pay out of pocket at the normal register and then submit for reimbursement. To be reimbursed through their FSA the participant must submit a completed claim form, receipt of purchase and a legal prescription that corresponds with the OTC drug or medicine purchased to a plan’s FSA Vendor for review.

http://access.usi.biz/usi_files/docs/Legislative%20Brief%2011-9-10.pdf

Woburn, CT, September 30, 2010 – USI New England CEO J. Thomas Stiles has announced that Thomas Mangan, CMCE has assumed the role of Regional President of the region’s Employee Benefits Operation. Mangan assumes the role of Practice Leader for USI New England’s Employee Benefits sales force and service team, strategic development, and carrier market relationships. He is an insurance veteran with more than 20 years experience. Prior to joining USI New England, Mangan served as the CEO of Corporate Synergies, the president of the Employee Benefits Division at HUB International as well as the National Practice Leader/Chief Sales Officer of Employee Benefits of HUB International Limited. His expertise includes Insurance Carrier and Brokerage Management, Carrier Relations, Industry Affairs, Media Communications, Government Lobbying, Mergers & Acquisitions, Due Diligence, Wellness, Health Insurance Consulting, COBRA, HIPPA, Pension and Sales Management.

A graduate of Westminster College, Mangan earned an MBA from Troy State University and completed the Insurance Executive Leadership Program from the University of Pennsylvania’s Wharton School of Business. He currently sits on the board of trustees of his alma mater.

A member of the Council of Employee Benefit Executives (a division of the Council of Insurance Agents and Brokers), he serves as a board member and is also chairman of the Industry Affairs Committee. Additionally, he serves, or has served on the National Consultant Advisory Boards with insurance carriers such as CIGNA, Aetna and UnitedHealthcare.

He resides in South Glastonbury with his wife, Karen, and daughter.

About USI
Founded in 1994, USI is a leading distributor of property and casualty insurance and employee benefits products to businesses throughout the United States. Ranked as the 3rd largest1 of independent insurance brokerage in the nation, USI is headquartered in Briarcliff Manor, NY, and operates out of 79 offices in 22 states.

USI is a portfolio company of Goldman Sachs Capital Partners, a private equity affiliate of Goldman Sachs & Co. Additional information about USI may be found at www.usi.biz.