500 Million Lines of Code

[Turdacious]

On a crisp California morning in February 2012, my sister-in-law, Marcella Wagner, was driving down the interstate toward Chico State University, where she had just entered the nursing program. She was thinking about the day ahead when suddenly another driver swerved in front of her. To avoid a collision, she jerked the wheel hard, and her car veered off the freeway. It rolled over, crushing the roof. The other driver sped off, never to be found. Marcella was seven-and-a-half months pregnant. Miraculously, the baby survived and was not harmed. But Marcella was left a quadriplegic, paralyzed from the chest down and with little use of her hands. She will need a wheelchair and round-the-clock personal care assistance indefinitely.
Key points: Marcella and Dave's story

1) Marcella was paralyzed in a car accident while she was 7.5 months pregnant.

2) She had to go on Medi-Cal, California's version of Medicaid, to get health insurance.

3) Medi-Cal has strict asset limits. Marcella and her husband, Dave, can own a home and one car. Beyond that, they can have only $3,150 in assets.

The accident caused more than the physical and emotional devastation that upended Marcella's career plans. It also brought about an economic tragedy that hurtled her young family into the world of means-tested social assistance programs, the "safety net" of public programs for the poor. My brother, Dave Campbell, works for a small company that doesn't offer employee benefits. Nonetheless, before the accident Marcella had managed to secure health insurance for both her and the baby. Her pregnancy and 60 days' postpartum care was being covered by Access for Infants and Mothers, California's health insurance program for middle-income pregnant women. After the birth, Marcella would have been able to join the university's student health plan. The baby would be covered by the Children's Health Insurance Program, the federal-state plan for lower-income children. Marcella and Dave thought they were all set. And then, with the accident, they fell down the social assistance rabbit hole.

Essentially, the way they meet the income test is for Medi-Cal to skim off Dave's income until they are in fact poor. Brian noted that they are "lucky" that they are allowed to retain that much income; if Marcella weren't disabled, the amount they'd be allowed to retain would be even lower than $2,100. And this is how things will be indefinitely. In order to get poor people's health insurance, Dave and Marcella must stay poor, forever.

http://www.vox.com/2014/12/9/7319477/me ... disability
Health insurance and poverty or crap health insurance and an income-- there's a reason other countries don't have this type of safety net when it comes to health care.

[Turdacious]

Nobody thinks the math works, even CMS:

Among the most important factors in projecting Medicare expenditures are the annual payment
updates to Medicare providers. The estimates based on current law are complicated substantially by
mandated reductions in these payment updates for most Medicare services. In particular, Medicare payment rates for physician services as determined by the Sustainable Growth Rate (SGR) system are scheduled to be reduced by almost 21 percent on April 1, 2015. For most of the other categories of Medicare providers, the Affordable Care Act (ACA), as amended, calls for a reduction in payment rate
updates equal to the increase in economy-wide multifactor productivity.2

As described in more detail below, in our view the scheduled physician payment reduction is implausible, and there is a strong likelihood that the productivity adjustments will not be sustainable in the long range. It is reasonable to expect that Congress would find it necessary to legislatively override or otherwise modify the reductions in the future to ensure that Medicare beneficiaries continue to have access to health care services. If these payment reductions were moderated or removed, estimated Medicare costs would exceed the thresholds that would require the Independent Payment Advisory Board (IPAB) to develop proposals to reduce the growth rate below the threshold.

http://www.cms.gov/Research-Statistics- ... enario.pdf
So either the cost projections are not accurate, or it requires getting the IPAB up and running in a hurry-- something the Obama administration hasn't even started and that the latest FY budget proposal guts funding for.

[Turdacious]

The Affordable Care Act is injecting billions upon billions of dollars to provide Medicaid to previously uninsured people. More money should help healthcare providers’ finances, not hurt them. So what’s going on?

To summarize, Medicaid reimburses for services at only about half the rate of what commercial health plans pay. A doctor in the article receives just $80 to see a Medicaid patient compared to $160 for a commercial patient. That’s typical.

If all providers had the same mix of patients, this wouldn’t be such a problem. Well reimbursed commercial patients would make up for poorly paid Medicaid patients. But in today’s world, that’s not how it works. Some health systems concentrate their resources in wealthy communities with lots of commercial patients. Other providers end up with a much higher share of Medicaid patients and enter a vicious cycle that depresses their earnings, makes it hard for them to compete, and leads eventually to financial distress. To make matters worse, some of these “Medicaid” hospitals receive lower rates from commercial plans than fellow hospitals who avoid Medicaid.

http://healthbusinessblog.com/2014/11/1 ... d-for-all/
A more detailed explanation: http://healthcaremassachusetts.files.wo ... report.pdf

[Turdacious]

Just six states will use their own money in 2015 to sustain the federal Medicaid pay raise to primary care doctors, which was a key provision of the Affordable Care Act intended to make sure millions of low-income people enrolling in the expanding insurance program have access to a physician.

Interestingly, two of the states extending the pay raise are Alabama and Mississippi — neither of which expanded Medicaid under the health law. The other states extending the pay raise next year are Colorado, New Mexico, Iowa and Maryland, according to interviews with state officials and the American Medical Association. Those four states expanded their Medicaid eligibility to cover everyone with incomes less than 138 percent of the federal poverty level, or about $15,900 for an individual

http://www.kaiserhealthnews.org/news/6- ... e-doctors/

Of the 28 states that expanded Medicaid, only four are willing to do what it takes to make it work (i.e. incentivize physicians to take it).

It probably won't matter much in NM unfortunately-- they have a poverty rate over 40% and one of the lowest physician/population ratios in the country. CO and MD have below average poverty rates and above average physician/population ratios-- they might be ok. IA has the lowest physician/population ratio in the country, but a below average poverty rate-- that one will be interesting, but difficult.

Of course it would help if Medicaid paid faster, had simpler and more straightforward paperwork requirements, and lower claim rejection rates-- but those are largely federal issues.

(EDIT-- link fixed)

[Turdacious]

And we're back to page 1...

Trying to head off a new round of consumer headaches with President Barack Obama’s health care law, the insurance industry said Tuesday it will give customers more time to pay their premiums for January.

America’s Health Insurance Plans, the main industry trade group, says the voluntary steps include a commitment to promptly refund any overpayments by consumers who switched plans and may have gotten double-billed by mistake.

Though the HealthCare.gov website is working far better this year, the industry announcement highlights behind-the-scenes technical issues between the government and insurers that have proven difficult to resolve. Last year’s enrollment files were riddled with errors, and fixing those has been a painstaking process. As a result, renewing millions of current customers is not as easy as it might seem.

http://bigstory.ap.org/article/59e89fb8 ... e-deadline

[Turdacious]

The Affordable Care Act (ACA) is designed to increase access to health insurance coverage in part through an expansion of eligibility for states’ Medicaid programs. To date, 27 states and the District of Columbia have expanded eligibility for their Medicaid programs, and those states have reportedly added more than 7.5 million Medicaid enrollees since the third quarter of 2013 (Centers for Medicare and Medicaid Services (2014). Because of long-standing concerns about the level of physician reimbursement in the Medicaid program and its effect on physicians’ willingness to accept Medicaid patients, the ACA also includes a mandatory two-year increase in Medicaid fees for primary care services to Medicare levels. This increase is fully funded by the federal government and raises fee-for-service and managed-care Medicaid fees for certain primary care services provided by family physicians, internists, and pediatricians from January 1, 2013, through December 31, 2014. Using fee-for-service data from 2012, the Urban Institute estimates that this primary care “fee bump” would increase fees by approximately 73 percent on average (Zuckerman and Goin 2012). As of June 2014, the federal government had spent an estimated $5.6 billion on the fee bump (Medicaid and CHIP Payment Access Commission 2014).
Delays in federal rulemaking and implementation difficulties at the state level meant that most states
did not have a clear policy in place until mid to late 2013, although the higher Medicaid fees were required to be paid back retroactively to the start of the year. Even if the implementation had gone smoothly, a long lag in the availability of survey data about physician acceptance of Medicaid patients would have complicated assessments of the effect of this policy on provider availability for Medicaid enrollees. To date, it is unclear whether the increase in Medicaid primary care payment has had an effect on the number of physicians accepting Medicaid or the number of Medicaid patients that physicians are willing to see, and anecdotal evidence is mixed (Crawford and McGinnis 2014). For example, although Connecticut has reported a significant increase in the number of participating physicians after the fee bump, other states expect little or no effect (Snyder, Paradise, and Rudowitz 2014).

http://www.urban.org/UploadedPDF/200002 ... e-Bump.pdf

As of 2008, Medicaid paid, on average, 58% what private insurance did (this ratio is considered stable by HHS). This policy, if implemented well by federal and state bureaucracies, would have made Medicaid much more competitive over a short term period.

When 49/50 states have problems, it's hard to blame the states, and CT (the lone success story) had a different deal with HHS regarding Medicaid than any other state and pays a lot faster than anyone else.

Moar on how Medicaid sucks compared to everyone else: http://www.athenahealth.com/_doc/pdf/at ... lth.3e.pdf

Also, the two largest states to accept the Medicaid expansion, CA and NY, consistently pay among the lowest rates and are are among the worst payers. CA pays less per patient than GA and TN-- two states with much higher poverty rates and significantly lower costs of living.

[Turdacious]

Although much of Medicaid’s expenditure growth (both past and future) is due to expansions of eligibility criteria, the per enrollee costs for Medicaid have also usually increased significantly faster
than per capita GDP. This growth pattern is not unique to Medicaid. Costs for virtually every form of
health insurance, public and private, have increased rapidly, reflecting growth in the number of insured persons, wage increases and price inflation in the medical sector, provision of a greater number of medical services, and the development of new, better, more complex, and generally more expensive services. Together, these cost factors have increased at a faster rate than the number of workers, general inflation, and productivity underlying economic growth. Determining how to optimally
balance our collective demand for the best possible health care with our not-unlimited ability to fund such care through private and public efforts represents one of the most challenging policy dilemmas facing the Nation. The unusually slow rate of growth of Medicaid expenditures in 2012 does not necessarily contradict these trends. Following the expiration of temporary increases in the Federal matching rate, the States’ share of Medicaid expenditures have grown rapidly over the last 2 years—nearly 40 percent—and the States have acted to reduce provider payment rates and/or optional benefits. Their actions had a substantial impact in 2012 and emphasize the difficulty in balancing Medicaid against other government programs in the context of States’ budgets.

http://medicaid.gov/Medicaid-CHIP-Progr ... t-2012.pdf

Not sure how they came to that conclusion. Federal Medicaid expenditures decreased by 7% and 4% respectively in 2011 and 2012, while state Medicaid expenditures increased by 22% and 15%. For the period of 2007-12, total Medicaid spending is up 22.1%. While federal Medicaid spending is up 16.9%, state Medicaid spending is up 29.6%-- that period includes the temporary Recovery Act bump. Even by federal standards, that's fuzzy math.

[Turdacious]

Long before revelations in the spring that the Veterans Affairs hospital in Phoenix had manipulated waiting lists to hide that veterans were facing long delays to see doctors, senior department officials in Washington had been made aware of serious problems at the hospital, according to filings before a federal administrative board.

The documents in the case of the Phoenix hospital director Sharon Helman, who had been contesting her Nov. 24 firing, provided new details of how much officials knew about the medical center, including patient backlogs, shortages of medical personnel and clinic space, and long waiting lists.

The filings included the sworn statement of Susan Bowers, the executive in charge of dozens of hospitals and clinics from West Texas to Arizona, that she had warned her superiors in Washington that if any V.A. medical center was going to “implode,” it would be Phoenix.

Ms. Bowers, who retired one month ahead of schedule in May as the scandal emerged, said that before Ms. Helman became the head of the Phoenix facility in 2012, an audit showed the hospital was out of compliance with a directive requiring patients to be placed on an official electronic waiting list. There was, in fact, no such active list for primary-care patients in Phoenix, even though a previous hospital director had certified compliance, she said.

Ms. Bowers said that when she submitted a report stating that the Phoenix hospital was out of compliance, she was pressured by other officials to say that it was compliant.

The documents are not the first indication that senior officials knew of the Phoenix problems. In 2008, the inspector general found that it was “an accepted past practice” there to alter appointments to avoid waits over 30 days.

Two years later, a deputy under secretary warned regional directors in a memo to eliminate improper practices being used to “improve scores on assorted access measures.” In a telephone interview after the judge’s ruling in the case, Ms. Bowers said that 2010 memo was written after she told the official of scheduling problems in Phoenix.

When she briefed Mr. Shinseki about problems, she added, he would say, “There’s a process, and we need to follow through on the process.”

http://www.nytimes.com/2014/12/26/us/po ... c=rss&_r=0

[Turdacious]

Risk Corridor bailouts for insurance companies? Looks like taxes on federal exchange policies will have to go up to fund that.

[Turdacious]

2014 marked the largest one-year increase in enrollment in high-deductible consumer-driven health plans (CDHPs), from 18% to 23% of all covered employees, per the Mercer survey. In addition, 3% of large employers (those with 500 or more employees) moved to a private exchange in 2014 (or will in 2015) to provide benefits to active employees, and 28% said they are likely to do so within the next five years.

As CDHPs cover more employees, they offer employers a way to mitigate growth in spending. The average cost of coverage in a CDHP paired with a tax-advantaged health savings account, $8,789 per employee, is 18% less than coverage in a PPO and 20% less than an HMO.

These plans are also a top strategy for employers looking for ways to avoid paying the “Cadillac tax” in 2018 — a 40% excise tax on health coverage that costs more than $10,200 for an individual or $27,500 for a family. Mercer estimates that about a third of employers are currently at risk for triggering the tax in 2018 if they make no changes to their most costly plan.

http://ww2.cfo.com/health-benefits/2014 ... ism-grows/
Passing the cost burden onto middle class families and primary care physicians is the solution to health care problems-- Winning!

[Turdacious]

Because there wasn't a cheaper way to get to where we were in 1982.

[Turdacious]

The Gold ‘N Silver Inn in Reno, Nev., has long offered health coverage to its employees — but many of the cooks, dishwashers and waiters who make close to minimum wage can’t afford the $100 monthly premium.

Last January, when Nevada became one of more than two dozen states to expand Medicaid under the Affordable Care Act, 10 of the diner’s 55 employees qualified for the government insurance program for low-income Americans. None of them realized it, however, until the family-run restaurant hired BeneStream, a New York-based start-up funded partly by the Ford Foundation.

The goal is to help employers and workers make the most of two key provisions of the health law — the Medicaid expansion that’s making millions of working adults eligible for Medicaid and the requirement that medium and large-sized employers provide coverage in 2015 or face a penalty.

“Most employers do not understand Medicaid and the eligibility requirements,” said BeneStream CEO Benjamin Geyerhahn. “We are a way to help employers manage this cost and resolve a big issue for their low-income workers.”

By enrolling in Medicaid, low-wage workers benefit from low- or no-cost health coverage since the program typically has no monthly premiums and few out-of-pocket costs. Employers benefit because they don’t have to pay a share of workers’ insurance premiums or risk incurring penalties.

http://kaiserhealthnews.org/news/might- ... -find-out/
Obamacare-- helping keep wages low.

[Turdacious]

Based on ADP's new white paper, Affordable Care Act and Employer Confidence: Navigating a Complex Compliance Challenge, more than half of large employers (1,000+ employees) are unprepared to comply with all ACA regulatory requirements.

"As we meet with large employers, it has become clear that many don't have the systems or processes in place to meet ACA compliance requirements, highlighting a need for a cohesive internal effort and perhaps a third-party partner," said Vic Saliterman, senior vice president, ADP. "With reporting requirements based on 2015 data and subsequent penalties going into effect in 2016, the decision to go it alone on ACA compliance could prove risky based on current levels of preparedness."

While the majority of large employers (70%) handle ACA compliance internally, the study revealed that these employers do not feel fully prepared to manage several critical compliance requirements, including Exchange notices (62%), ACA penalties (60%) and annual health care reporting (IRS Forms 1094/1095-C) (49%).

In response to ACA compliance requirements, large employers also plan to take a number of strategic workforce management and cost containment actions, including:

Change employee benefits plans
As a result of the ACA Excise Tax on high-value health care plans that becomes effective in 2018, employers are continuing to employ benefits strategies that shift more costs to employees. Nearly two-thirds of large employers (63%) plan to increase employees' share of costs through changes to employee deductibles, employee co-pays or employer contributions.

http://mediacenter.adp.com/releasedetai ... eID=891074
Employers are as ready to comply with it as the government is ready to enforce it.

[Turdacious]

Eliminating discrimination on the basis of preexisting conditions is one of the central features of the Affordable Care Act (ACA). Before the legislation was passed, insurers in the nongroup market regularly charged high premiums to people with chronic conditions or denied them coverage entirely. To address these problems, the ACA instituted age-adjusted community rating for premiums and mandated that plans insure all comers. In combination with premium subsidies and the Medicaid expansion, these policies have resulted in insurance coverage for an estimated 10 million previously uninsured people in 2014.

There is evidence, however, that insurers are resorting to other tactics to dissuade high-cost patients from enrolling. A formal complaint submitted to the Department of Health and Human Services (HHS) in May 2014 contended that Florida insurers offering plans through the new federal marketplace (exchange) had structured their drug formularies to discourage people with human immunodeficiency virus (HIV) infection from selecting their plans. These insurers categorized all HIV drugs, including generics, in the tier with the highest cost sharing.

http://www.nejm.org/doi/full/10.1056/NEJMp1411376

In other words, nothing's really changed. Be interesting to see which plans have formularies that include cancer drugs.

[Turdacious]

Obamacare discourages lower middle class women from having children.

Fun fact-- studying the expansion of maternity benefits, the most popular mandated health care benefit, is what made Gruber famous in the first place.

[Turdacious]

In its economic forecast last week, the Congressional Budget Office revealed a quandary about Obamacare’s “Cadillac tax”: To make the underlying law fiscally sustainable, the tax may end up increasing at a rate that becomes politically unsustainable.

The nugget about the tax, formally known as a high-premium excise tax and set to take effect in 2018, came in CBO’s updated estimates for the law as a whole, which noted:

“CBO and [the Joint Committee on Taxation] expect that premiums for health insurance will tend to increase more rapidly than the threshold for determining liability for the high-premium excise tax, so the tax will affect an increasing share of coverage offered through employers and thus generate rising revenues. In response, many employers are expected to avoid the tax by holding premiums below the threshold, but the resulting shift in compensation from nontaxable insurance benefits to taxable wages and salaries would subject an increasing share of employees’ compensation to taxes. Those trends in exchange subsidies and in revenues related to the high-premium excise tax will continue beyond 2025, CBO and JCT anticipate, causing the net costs of the ACA’s coverage provisions to decline in subsequent years.”

In other words, under current projections the tax will grow so quickly that it will exceed the annual rising costs of the law’s new entitlements, causing net spending on Obamacare actually to decline.

http://blogs.wsj.com/washwire/2015/02/0 ... cal-cliff/

[Turdacious]

The 'family glitch':

The Affordable Care Act is written so that individuals who are offered adequate insurance through their jobs are not eligible for subsidies if they choose instead to buy plans from the exchanges. This is true even if the individual’s employer offers coverage only for the employee and not for the employee’s family. In that case, employees who want a family plan, or a plan for their child, must pay the full exchange price.

http://www.nytimes.com/2014/12/30/upsho ... abg=1&_r=0

[cleaner464]

I'm calling bullshit on the 500 million number, however I'm not all that surprised that they fucked up on the IT management.

I have done this shit for nearly 30 years, and I have never been involved with a project that I didn't run myself that came in on time. Scope creep is a killer. Undisciplined users too.

[Turdacious]

Y'all might want to switch plans if you get cancer:


http://avalere.com/expertise/life-scien ... medication

[Turdacious]

Re King v. Burwell:

The average cost-per-enrollee for all 50 states plus DC was $922. For the 15 jurisdictions running their own Exchanges it was $1,503, while for 36 states in which the federal government operates the Exchange it was $647. Cost-per-enrollee in states running their own Exchanges was thus 2.3 times as much as the cost-per-enrollee in the 36 states in which the federal government runs the Exchange.

http://www.cchfreedom.org/files/files/M ... 202014.pdf

There are some pretty serious economies of scale. The idea that Hawaii (with a cost per enrollee of $23.9k on the federal exchange) can run it's effectively run it's own exchange at that cost is ridiculous.

[Turdacious]

The first major casualty among the new non-profit health plans created by the Affordable Care Act was both swift and surprising.

The demise of CoOportunity Health in Iowa and Nebraska does not signal the end for the nation’s 22 other Consumer Oriented and Operated Plans (CO-OPs). But CoOportunity’s fast descent from exchange success to collapse should give CO-OPs pause about growing too fast or lowering rates too steeply.

Between its two states, CoOportunity had exceeded 100,000 members, a staggering figure for a new health plan. Denied additional federal funding needed to pay claims in December, Iowa Insurance Commissioner Nick Gerhardt took over CoOportunity. After reviewing its operation, Gerhart opted to liquidate the plan on Jan. 23.

CoOportunity Health got strong reviews from its enrollees, but that doesn’t change the fact that it was undercapitalized.
With CoOportunity finished, it might be tempted to see buzzards circling the remaining CO-OPs. So far, only Maine Community Health Options posted a profit, which isn’t a ringing endorsement.

http://hl-isy.com/Healthcare-Reform-Blo ... for-CO-OPs
Hard to believe that undercapitalized, actuarially challenged insurance plans with tiny risk pools would fail in a market where these things are actually important.

And the feds aren't bailing the 2nd largest COOP out, Iowa and Nebraska policyholders are:

Both Iowa and Nebraska have insurance guaranty associations that provide up to $500,000 in total protection per covered person to customers and providers if the company’s asset are unable to meet its obligations. As per the guaranty system statutes, any payments from the guarantee associations will be funded through assessments on surviving insurers in each state.

http://www.rwjf.org/content/dam/farm/re ... rwjf417873

[Turdacious]

The federal 340B program gives participating hospitals and other medical providers deep discounts on outpatient drugs. Named for a section of the Veterans Health Care Act of 1992, the program’s original intent was to help low-income and uninsured patients. But the program has come under scrutiny by critics who contend that some hospitals exploit the drug discounts to generate profits instead of either investing in programs for the poor or passing the discounts along to patients and insurers. We examined whether the program is expanding in ways that could maximize hospitals’ ability to generate profits from the 340B drug discounts. We matched data for 960 hospitals and 3,964 affiliated clinics registered with the 340B program in 2012 with the socioeconomic characteristics of their communities from the US Census Bureau’s American Community Survey. We found that hospital-affiliated clinics that registered for the 340B program in 2004 or later served
communities that were wealthier and had higher rates of health insurance compared to communities served by hospitals and clinics that registered for the program before 2004. Our findings support the
criticism that the 340B program is being converted from one that serves vulnerable patient populations to one that enriches hospitals and their affiliated clinics.

http://blog.communityoncology.org/userf ... 0-6-14.pdf
The big change was in 2012.

A good write-up from the NYT on how it works now.

[Turdacious]

Technology entrepreneur Jonathan Bush says he was recently watching a patient move from a hospital to a nursing home. The patient's information was in an electronic medical record, or EMR. And getting the patient's records from the hospital to the nursing home, Bush says, wasn't exactly drag and drop.

"These two guys then type — I kid you not — the printout from the brand new EMR into their EMR, so that their fax server can fax it to the bloody nursing home," Bush says.

In an era when most industries easily share big, complicated, digital files, health care still leans hard on paper printouts and fax machines. The American taxpayer has funded the installation of electronic records systems in hospitals and doctors' offices — to the tune of $30 billion since 2009. While those systems are supposed to make health care better and more efficient, most of them can't talk to each other.

Bush lays a lot of blame for that at the feet of this federal financing.

"I called it the 'Cash for Clunkers' bill," he says. "It gave $30 billion to buy the very pre-internet systems that all of the doctors and hospitals had already looked at and rejected," he says. "And the vendors of those systems were about to die. And then they got put on life support by this bill that pays you billions of dollars, and didn't get you any coordination of information!"

[Turdacious]

CBO revises update, saying employers will drop less fewer employees from health coverage than they did two months ago despite rising costs, but won't say how.

[Turdacious]

Amid the national debate over raising the federal minimum wage to $10 per hour, Scott Leavitt of Boise says he and his fellow advisors have been enrolling clients in their state’s health insurance exchange for an hourly wage that works out to about $4.50 – and sometimes even less.

"What is happening is that agents are making half the commission they previously made and doing twice as much work on the front end enrolling people in coverage," he said, adding that many exchanges were still not functioning well. "If you’re earning $9 for each client you enroll and you have to spend two hours with each client to sign them up for a plan and you have 10 hours in a day – you do the math."

Leavitt, past president of the National Association of Health Underwriters (NAHU), said the combination of additional work plus lower commissions brought about by the Affordable Care Act (ACA) has prompted about 25 percent of health insurance agents nationwide to leave the business since the law took effect.

http://www.insurancenewsnetmagazine.com ... is-on-2880