Tuesday, March 14, 2017

It Should Be My Choice

I want more choices.

Damn Right!

The government limits what I am allowed to buy. It isn’t up to Washington to tell me what I need.


All those extras just add to the cost.

Yes, make it cheaper.

I’m tired of the nanny state. Too many politicians are butting in. They are taking money out of my wallet. Let me make my own decisions. I want more choices.

I’m with you.

Yep. I’m going to call my Congressman and demand change.

Me, too.

I’m tired of Washington adding thousands of dollars to the price of a car. I don’t want to pay extra for air bags. Seat belts are a waste of my money. I never wear them. Man, there’s a bunch of stuff like this. Anti-lock brakes? Really? I want to get rid of all this unnecessary crap and get a better price on my next car.

Cars? I thought you were talking about health insurance.


When Tom Price, Secretary of Health and Human Services (HHS) says that he wants Americans to have more choices what he is really saying is that the current policies are too expensive because they are too comprehensive. Americans no longer have the opportunity to purchase inadequate health insurance policies. All policies are now required to cover the ten Essential Health Benefits (EHB). Which of the following would you like to leave off your next policy? Are you sure?
  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Pregnancy, maternity, and newborn care
  5. Mental health and substance use disorder services
  6. Prescription Drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services
  10. Pediatric services
How could you know that you’ll never have cancer or a chronic back problem? Which benefits can you eliminate? The easy one is maternity. How much does a 60 year old pay for maternity? About the same amount as a 22 year old pays for prostate cancer. The truth is that you can’t make an informed decision. You can’t guarantee that you will never suffer from depression or get hooked on opioids after major dental work. And none of that really matters because it assumes that you would be making these choices with your eyes wide-open and know exactly what types of coverage you would be eliminating. You won’t.

This whole push to get policies sold across state lines is about removing care. Ohio, for example, recently passed legislation guaranteeing coverage for the treatment of autism. That is a Republican governor, a Republican controlled senate, and a Republican controlled house voted to grant this benefit for all of Ohio’s children. Tom Price wants you to have the opportunity to purchase a cut-rate policy from Tulsa based Shaky Ground Mutual. Minnesota may be leading the way towards the new, useless policies. More importantly, it won’t be until you go to the doctor that you will find out that your child’s autism or your cancer isn’t covered.

It may be difficult to read today’s heavily regulated health insurance policies, but these have much less fine print and legalese than what we used to provide. Remove the regulations and we immediately return to the gobbledygook of the past. If locked doors keep honest people honest, than regulations are the locked doors that protect the consumer from our insurance providers.

Please don’t confuse this post as a full-throated endorsement of the Patient Protection and Affordable Care Act. It is not. The PPACA is a badly written law that needs significant changes if it ever has a chance to succeed. Most of our representatives in Washington know this. That’s not repeal. That’s repair.

Will the Republicans overcome their obsession with our last president and choose to do what’s in the country’s best interest? I don’t know. It is the one choice they didn’t want.





Wednesday, March 8, 2017

Our New Law Is Better Than A Poke In The Eye With A Sharp Stick

Our friend Paul inherited a car. It only had a few miles and still had that new car smell, but it wasn’t brand new, it wasn’t the exact car Paul wanted, and he hated the color. Paul despised the car. The Check Engine light came on as Paul took the car out for his first drive. He cursed the car and threatened to drop it off at the junk yard. He didn’t fix the problem. He never even looked to see why the idiot light was on. Paul continued to drive the car without bothering with routine service after other warnings lit up his dashboard. The Check Oil light had only elicited more curses and more threats of the compactor at the junk yard. But no matter how badly Paul abused the car, the damned vehicle started every day and managed to get him wherever he needed to go. Now, a couple of years into Paul’s ownership, the car is starting to stall and it has difficulty going up hills. Paul is telling everyone that this car, this worthless piece of garbage, needs to be replaced. And that is our friend Paul Ryan’s relationship with Obamacare.

The Chairman of the House Ways and Means Committee, Kevin Brady (R-TX), introduced the Republican alternative to the Patient Protection and Affordable Care Act (Obamacare) yesterday on TV. His main thrust was that Obamacare is failing, a disaster, and that the Republicans have to do something. Anything would be better! And to test that theory we have the American Health Care Act.

Seven years in the making! And, as White House Press Secretary Sean Spicer was quick to point out yesterday, the American Health Care Act is only 123 pages as opposed to the PPACA that is a whopping 974. That alone makes it a better law.

There will be any number of analyses published over the next week. My peers and I have received countless calls and emails about this first stab at (in) replacing Obamacare. Before we spend too much time on this, we need to acknowledge that there are serious divisions within the Republican Party and that much of this will be changed. Senators from states that expanded Medicaid have no interest in explaining to the folks back home why they lost their health care. Congressmen on the conservative fringes have had the luxury of passing bills that could never become law. They have no interest in supporting anything that might even appear to be pragmatic. So no, don’t get too worked up about the American Health Care Act. Senators like Bill Cassidy (R-LA) have already declared it DOA.

A more relevant question may be whether this is a serious piece of legislation or simply one more opportunity to pander to the Republican base. Both Congressman Brady and Congressman Ryan suggested that the public should read the law. Part of this is bluff. They are hoping that the average American’s eyes glaze over while reading the highlights on the lead page. News organizations, researchers, and the author of this blog accepted their challenge.

Let’s explore priorities. Health care is almost 20% of the U S economy. Any replacement of the PPACA would have to provide for the seamless transfer of one payment system for health care to another. Billions of dollars (and millions of lives) are at stake. So the Republican bill would have to address all of these issues thoughtfully, carefully. How did they do?

The first issue, the most important task of this legislation, appears on Page 2. Yes, before we can tackle the individual mandate, preexisting conditions, or even Medicaid expansion, the first thing we have to do is defund Planned Parenthood. The AHCA goes to great pains to describe Planned Parenthood without mentioning it by name. It isn’t till the bottom of Page 4 that we move on to Medicaid.

Much has been made of the possible changes to Medicaid. The simple explanation is that the states that expanded Medicaid would have to do more with a lot less. The real pressure points are 2020 and after which at first seems far away, but is actually less than 3 years till implementation.

Our next section dealt with the payments that hospitals receive for uncompensated care (DSH). The idea is to improve access for the uninsured and Medicaid patients. These payments were reduced due to the anticipated success of Obamacare. The goal was to have everyone insured. The AHCA reinstates the payments.

On Page 10 we arrive upon the other issue that appears to have been keeping Speaker Ryan up at night. The next 7 pages deal with preventing lottery winners from accessing Medicaid. Seven! This change should guarantee that our budgets will now be balanced.

The next few pages guarantee that states aren’t forced to pay for aliens (international or intergalactic) and how home equity loans impact Medicaid qualifications. By Page 25 we get to Medicaid funding which kills another 20 pages. On Page 45 we finally get to Subtitle D – Patient Relief and Health Insurance Market Stability, a nine year $100 billion funding mechanism to the states to expand coverage options. Finally, some meat.

The rest of the document details which taxes are to be repealed, which repurposed, and which just simply delayed till someone else is in office. The individual mandate is eliminated in favor of a different penalty for opting out of coverage. Older adults are charged higher premiums with the hope that young, healthy individuals will sign up in droves and make the system work. And, of course, there are a number of favors included to make some donors happy such as the repeal of the tanning tax and the reinstatement of the deduction for insurance executive compensation.

The media, both right and left, will hit the high points. And more importantly, most of those points will be the ones debated and changed in the weeks/months to come. I wanted to focus on the issues that the Ways and Means Committee thought were most important, the issues that they hit first. There is one other issue that I thought was unusual. Section 6, about 80 pages or so into this bill, repeals the employer mandate, the rule that forced employers with more than 50 employees to provide health insurance as of December 31, 2015. Not the end of last year. Not the end of this year. Obviously, one of the Congressmen has a very important constituent who didn’t bother to cover employees in 2016. Perhaps Chairman Brady? Gosh it is always great to know a Congressman. Heck, it is better than a poke in the eye with a sharp stick.



Friday, February 24, 2017

Lucky, Again

This just in – Grandmothered Policies are now extended to the end of 2018

This is called Transitional Relief. Grandmothered policies were issued with an effective date between April 2010 (right after the passage of the Patient Protection and Affordable Care Act) and December 31, 2013 when the law was completely implemented. Grandmothered policies were underwritten and based on an age ratio of 5:1 or higher.

Healthy and/or young people got a good deal in 2013. If you didn’t, if you were charged extra or if you needed a policy that covered maternity or a pre-existing condition, you purchased a new, compliant policy in 2014. The only people left were the cheapest to insure. And though we haven’t added any new, healthy, people to this pool, the Grandmothered policies are still a better risk than the general population. Grandmothered policies are cheaper!

This rule from CMS will allow each state to decide whether impacted individual policies, group policies, or both may be retained until 2018. Mary Taylor, Lt. Governor and Insurance Commissioner, has been willing to extend Grandmothered policies in the past. There is no reason to believe that she would block this now.

And yes, we did talk with our elected officials about this while in Washington, but I don’t know that we can claim credit for it. This may fall under the area of keeping the waters calm while the storm is brewing on Capitol Hill.

Quick Example:

My current policy – Anthem HSA Qualified, $5,500 Deductible - $428.99 per month

2017 policy – Anthem HSA Qualified, $6,500 Deductible - $863.74 per month

If you have a Grandmothered policy you are lucky, again.



Friday, February 17, 2017

The Rescue Call, Market Stability, And How I Failed At UBER

It appears that it is common, when someone is on a blind date, to arrange a “Rescue Call”. There is even a commercial on TV that references this. A friend calls you and provides you a reason to cut the date short. I actually saw it in action on Wednesday.

I was in a Congressman’s office. Seven Ohio health insurance brokers were in his office to discuss the Patient Protection and Affordable Care Act (Obamacare) and what we were going to do now. Fifteen minutes into a positive / routine meeting we were interrupted by one of his aides. After one quick knock on the door, the aide poked his head into the room and told the Congressman that he had another meeting. The Congressman waived him off and we all got another fifteen minutes. If this had been a date, we would have just qualified for a second cup of coffee. Welcome to How To Visit Washington DC 2017.

Over a thousand members of the National Association of Health Underwriters (NAHU) gathered this week in Washington to hear from a variety of experts and to talk with our states’ elected representatives. Most of us are there on our own dime. It is that important for us to get the most up to-date information and to make certain that our lawmakers understand how our clients will be impacted, both positively and negatively, by any changes in the way Americans pay for their health care.

The Law of Unintended Consequences.

There are a lot of ideas that sound absolutely fantastic on TV but will be irrelevant, or even worse disastrous, in practice. Insurance agents are uniquely positioned to explain the real world impact of these programs.

We were in Washington to deliver one important message for our clients – Market Stabilization. It is already mid-February. Nothing can really be changed for 2017 and the insurers only have eight weeks left to prepare for 2018. Yes, eight weeks. Insurers are currently working to file their plans and rates for 2018 and they, as well as our clients, need to know what the market will look like on both the state and federal levels.

Our key points centered on the individual (non-group) market.
  • Allow the tax credits that help so many Americans to afford coverage to remain intact for at least two more years or until a comparable replacement can be put in place.
  • Allow tax credits to be used outside of the Marketplace if fewer than two choices are offered in a state.
  • Allow any person to purchase a catastrophic-category coverage regardless of age or income status.
  • Tighten both the open-enrollment and special-enrollment periods to reduce adverse selection.
  • Allow states to be eligible for a new hybrid high risk pool that would serve as a reinsurance mechanism while still providing the same level of coverage for even the highest risk individuals.
  • Preserve employer-sponsored health insurance by retaining the employer exclusion.
Yes, this is a lot of process and almost nothing that would make a good sound bite. These points and others would help secure the promise of health insurance coverage for the next couple of years.

Armed with individualized packets, we set off to meet our Senators and Members of the House. I had a chance to visit offices in the Senate and the House, Democrats and Republicans. Some of my meetings were with the actual lawmaker. Some were with staff. And though it is always gratifying to have a Congressman make time to speak with a visiting constituent, some of the best meetings can be with a Chief of Staff or a knowledgeable legislative aide, especially one who specializes in public health. I found this year’s meetings productive. The Congressmen and their staffs were totally engaged. They asked good questions. They took notes. I honestly felt that my time and expertise were valued.

** ** ** ** **

I was in geek heaven. Cigars. Scotch. Politics. I was with two of my peers and a lobbyist in Shelly’s Backroom doing a deep dive on the current state of affairs. The hours flew by and it was past midnight when I called us an UBER. We walked outside, ignored the parked cab, and looked for Mohammed and his Toyota Camry. A Camry stopped, right in front of us, in the middle of the street. We walked up to the car and tried to get in as the driver frantically waived at us. We had failed to notice that there was a traffic light, here in the middle of the block, and he had been stopped for a red light. He wasn’t an UBER! We stepped back and he sped off.

Another Camry, one with an UBER decal, came up a couple of minutes later. This time we verified that it was an UBER and got in. Sitting shotgun, I noticed that the driver was a little confused. We had only traveled a few blocks before his phone rang. It was Betsy. She wanted to know where the Hell he was. They started arguing. This wasn’t Mohammed and we were in the wrong UBER. In the end I cancelled my order, paid the penalty, and slipped the driver a $10 for a $7 ride. His last ride as an UBER drive might as well include a tip.

This is either the office of Rep. Don Young of Alaska or a Betsy DeVos elementary school.

The view from the train beneath the Capitol.



Wednesday, February 1, 2017

The Nice Guy Finished Last / First

Robby is the nicest guy I know. No exaggeration. Robby is just a great guy. And right now Robby is losing and winning the health insurance battle.

Robby was referred to me by his employer at the very beginning of the full rollout of the Patient Protection and Affordable Care Act (Obamacare). So I have never asked him any health questions, but I have no reason to believe that he has any medical issues or ongoing prescriptions. He is just a laborer, single and a non-smoker, in his early 50’s, living in Parma. There are thousands of guys just like him throughout Greater Cleveland.

Robby has gone years without health insurance. His employers seldom provided coverage and he couldn’t possibly afford it on his own. The PPACA guaranteed access to coverage AND included a penalty for non-compliance. The penalty was an important factor in his request. It would be unthinkable for Robby to jaywalk, he certainly wasn’t going to do anything penalized by law.

And Robby got a policy. It was a terrible policy with a $6,000 deductible and it cost him $110 a month after his tax credit subsidy of $187, but he was covered and if, G-d forbid, he got really sick or injured he would have easy access to world-class facilities right here in Cleveland. He even got a free routine annual exam, if he ever had a chance to get to a clinic on a day he wasn’t working. So, Robby won. We all did. We had one less uninsured American worried about a major illness and a society less concerned with the inevitable bill for his care.

Robby’s insurance went up $30 a month beginning January 1, 2015. Robby’s victory wasn’t quite so sweet.

The price of insurance was going up. The subsidies were going down even though his income had hardly changed. The invasion of low-cost Medicaid providers into the Exchange severely impacted Robby’s subsidy. If he would allow the Exchange to force him to Metro and Charity hospitals he would pay less. He hung on to the Cleveland Clinic and the price went up to over $250 with his subsidy for 2016.

In 2017 his premium is $325 and his deductible is $6,400. Robby is losing.

I got a call today from Robby. He wants to drop his policy now that he is no longer required to keep it. I let him know that he can drop the policy but that he would still be liable for the penalty. He thought that it was over. I had to break the news to him that the individual mandate, both a Republican idea traceable to the Heritage Foundation in 1989 and Republican strawman, was still the law.

President Trump’s Executive Order gives the Secretary of Health and Human Services and other department heads the ability to reduce the “burden” of complying with Obamacare. Congressman Price’s confirmation for Health and Human Services has been stalled due to what appears to be insider trading. More importantly, the insurance companies are scared to death of adverse selection. Without the individual mandate, the only people who will buy insurance are the sick and the responsible. That could be disastrous.

With no immediate viable replacement, a nice guy like Robby has no place to go. He’s winning. He’s losing. Nothing has really changed.



Monday, January 23, 2017

The Number One Priority

You may have seen the picture of the new president rushing into his office to sign his first Executive Order. It was Friday, January 20, 2017, after the parades and before the inaugural balls. Chief of Staff Reince Priebus put the paper in front of him, and like a homebuyer whose eyes have glazed over from thirty pages of gobbledygook, President Trump quickly signed the document without a moment’s hesitation. Now if you or I were about to make history, and everything a president does, by definition, is historical, we might have looked at the document, maybe ever READ the document, prior to affixing our name to it.

Since we aren’t on our way to any formal dinners or balls, we have plenty of time to read the Executive Order. Please take a moment. It is only one page.

It is important to note that this was the first Executive Order. So what does it mean?

Option One – If the repeal, replace, demolition, or rebranding of Obamacare succeeds, this Executive Order will be hailed as the important first step President Trump made to keep his promise and to deliver a better program. That is a huge if.

Option Two – This Executive Order opens the door for major changes. Once a Secretary of Health and Human Services (HHS) has been confirmed by the Senate, he (Don’t judge me. All of the nominees are male.) will be able to determine what regulations are burdensome. Here’s a hint – All regulations are a burden to someone. The current nominee is Congressman Tom Price (R-GA). States looking to modify the cost of Medicaid by reducing benefits or access will find Mr. Price supportive. In fact, a quick read of his positions over the years will yield the impression that Mr. Price might happily remove any requirement that the poor and middle class have comprehensive insurance coverage.

And though all of the above might seem like enough of a motivation to sign this Executive Order, I still think that it isn’t enough to be #1. So allow me to offer another explanation.

The Patient Protection and Affordable Care Act (Obamacare) was structured in broad strokes with the details to be fleshed out in the form of regulations. This is not unusual. Major legislation like the Patriot Act are designed this way. The PPACA requires health plans to cover annual routine preventive care visits. These visits are covered at 100%. No deductible. No copays. It was HHS that determined that routine preventive care included a colonoscopy for those of us over 50. This has undoubtedly saved lives. It was also HHS that determined that preventive care included birth control pills, the IUD, and the morning after pill. That made the lives of countless Americans easier. And now that this Executive Order has been signed, it will be HHS that will decide birth control, the IUD, and the morning after pill are no longer part of preventive care.

This change could apply to both individuals and groups. The current court cases dealing with this will be dropped immediately. This will be seen as a victory for those employers who are opposed to these services. And to those who needed these benefits. Well, they aren’t the priority.


Friday, January 20, 2017


Michael Lewis’s recent book, The Undoing Project, details the groundbreaking work of two Israeli psychologists, Daniel Kahneman and Amos Twersky. Their work explored the way we make decisions and how we justify, after the fact, those decisions. Mr. Lewis helps us to understand how these two scientists moved our decision making towards data and away from intuition.

In late 1973 or early 1974, Danny gave a talk, which he would deliver more than once, and which he called “Cognitive Limitations and Public Decision Making.” It was troubling to consider, he began, “an organism equipped with an affective and hormonal system not much different from that of the jungle rat being given the ability to destroy every living thing by pushing a few buttons.” Given the work on human judgement that he and Amos had just finished, he found it further troubling to think that “crucial decisions are made, today as thousands of years ago, in terms of the intuitive guesses and preferences of a few men in positions of authority.” The failure of decision makers to grapple with the inner workings of their own minds, and their desire to indulge their gut feelings, made it “quite likely that the fate of entire societies may be sealed by a series of avoidable mistakes committed by their leaders.”

I can’t think of a more important paragraph to share with you today, January 20, 2017. Health Care, Nuclear Proliferation, Trade – all of these decision will affect us all.