Thursday, November 8, 2018
The elections are over and most of the results are in. Most, but not all. A few races won’t be decided for several weeks. For good or ill, none of Ohio’s contests were that close. The winners can now begin to deliver on their promises.
The television ads for our new governor, Mike DeWine, were clear. Mr. DeWine may have had a checkered past in his defense of protecting affordable access to health care for Ohioans with preexisting conditions, but he is now prepared to champion their cause. We have his daughter’s word on it. It is time for all of us, in and out of the insurance industry, to ask “HOW?”
President Trump and his administration continue to work against one of the cornerstones of the Patient Protection and Affordable Care Act (Obamacare), coverage for Americans with preexisting conditions. The ongoing Texas lawsuit, supported by the president, is still a threat. Other actions taken last year, the defunding of the Cost Sharing Reduction and the elimination of the penalty associated with the Individual Mandate, continue to disrupt the health insurance market. And now, Mr. Trump has taken the next step to destroy your access to health insurance with new rules to allow the sale of stripped down policies.
We are looking at new rules that will make it easier to purchase short term major medical policies. These policies, which really do have a place in the market, are issued for a specific period of time, usually no longer than 6 – 12 months in duration. These policies are usually limited in nature, designed to exclude coverage for preexisting conditions, maternity, and mental health. If you push the young and, more importantly, the healthy to short term policies, then you are left with a health insurance system focused strictly on the sick and the responsible.
As an Ohioan, as an insurance agent, I wish Mr. DeWine luck. But it is time, Mr. DeWine, to tell us your plan. Protection for preexisting conditions? How?
Picture – David L Cunix – At Least The Parking Is Free
Monday, October 29, 2018
I was lying face down on a massage table in the Beachwood Mall Comfort Zone. My lower back was giving me grief and this was the place to go. The place was packed. Every table and massage chair was filled. The shop does a good business, but there is normally one or two employees standing on the lease line asking for people to come in. Not today. Could this many people also have old basketball injuries? Exertion? Stress? Who knows?
Face down. My mind started to wander as he started to work his fingers into my shoulders. It certainly has been a stressful week. We were transfixed to our televisions as over a dozen bombs were mailed to a past-president and other government officials. Then there were the two elderly Black people executed at a grocery store in Kentucky. And then there was the horrific assault at the synagogue in Pittsburgh. I have been in that synagogue. Since it occurred on a Saturday morning, I was in a synagogue when the attack occurred. And if all of that wasn’t enough, we are less than two weeks from an election so the commercial breaks inserted between these terrible news stories were negative political ads.
Is he trying to pull my spine apart?
I thought about all of those ads. It seems like every candidate is claiming to be the number one champion of those of us with preexisting conditions. Every one of them. If that is the case, how come we’re so concerned? This is a good time to do the fire department test. Do you worry about the fire department coming out if your house was burning? Of course not! It is a given. Coverage for preexisting conditions is not a given. Our health insurance system prior to The Patient Protection and Affordable Care Act (Obamacare) offered little protection for those with chronic illnesses. Those guarantees are only five years old, not long enough to forget the way it was.
Is that his elbow in my back?There are people running for reelection who have voted to repeal Obamacare over 60 times. That, in of itself, does not mean that they were unconcerned about preexisting conditions had they had a viable replacement. An actual repeal with an immediate replacement would have opened the door for a discussion on the merits of their proposal. But there wasn’t a replacement, a real, viable plan, was missing throughout the fight. From 2011 through 2016 we had grandstanding and campaign fundraising and votes, lots of votes, but no plans. Repealing Obamacare meant returning to a process that provided little to no security.
Repealing the PPACA wasn’t just the focus of the Republican controlled Congress. The governors and attorney generals from a number of red states attempted to have the courts declare the law unconstitutional. One case made it to the Supreme Court where Chief Justice Roberts was the deciding vote. Our current attorney general/ gubernatorial candidate Mike DeWine joined a lawsuit in 2011 to gut the law. This blog noted the current suit in Texas, supported by the Trump administration, designed to eliminate the coverage for preexisting conditions. Some of the litigants are running in their respective states as if their lawsuit didn’t exist!
Man that hurts! Deep Yoga breaths.So how can many of our politicians claim to have any interest in protecting our access to care? The only possible answer is the 2017 American Health Care Act (AHCA). If you don’t feel like reading the entire bill, the link to the summary is here. Most people remember the AHCA because of the beer celebration at the White House after the bill passed the House and the late night votes by Lisa Murkowski (R-AK), Susan Collins (R-ME), and John McCain (R-AZ) that saved the country from this disastrous legislation. Did the AHCA provide coverage for preexisting conditions? Sort of. An amendment was included to “allow states to seek a limited waiver to allow the insurance companies to charge higher premiums for a person with a health condition only if they do not maintain continuous coverage”. How much? 30%! That and other holes would have doomed the law had there been the normal process with public hearings and amendments that we expect with any legislation, much less a bill that would impact 20% of our economy and our access to health care. But this bill was still better than nothing.
My half hour was over and it was time to pay and return to the real world. My back felt better but I couldn’t say whether it was due to the massage therapist’s efforts or 30 minutes without TV, Facebook, and the trouble we seem to be in as a country. One thing for sure, the therapist was certainly better at massaging my back then the politicians are at massaging their message.
Picture – We all need a little Chutzpah – David L. Cunix
Sunday, October 7, 2018
November 4, 1995 was a warm fall day in Northeast Ohio. I was driving to Kidron to talk to some Amish craftsmen about a dining room table. I remember the day because that was when the news broke that Art Modell was moving the Browns to Baltimore. That next day, when I chaperoned a group of Cub Scouts to the game, was my last as a Browns fan. We have heard any number of reasons why The Move was necessary. But one excuse, briefly floated, was that the move would be good for the City of Cleveland, too.
We are witness to any number of self-serving actions that are sold to us as being good for everyone, perhaps even better for us than the obvious beneficiary. These actions might have financial benefits. These actions might have political benefits. Of course, sometimes the benefits are strictly entertainment, such as watching some politicians now trying to weasel out of their actions and votes over the last eight years.
Turn on the TV and marvel at the advertisements from Republican candidates for both State of Ohio offices and seats in Congress. Sure, they were voting to eliminate the Patient Protection and Affordable Care Act (Obamacare) last year with its guarantee of coverage for preexisting conditions. And no, there were never any alternatives that provided the same assurance that insurance, our method of accessing and paying for health care, would be available to anyone, regardless of health. But that is ancient history. Every one of them now supports coverage for preexisting conditions. Honest. Just don’t ask how.
This dissembling starts at the top. It was, after all, President Trump who said, “I will always fight for, and always protect, patients with pre-existing conditions” as his Attorney General Jeff Sessions argues that rules mandating the insuring of people with preexisting conditions and the guaranteed access to coverage are not constitutional. The cynicism of the last eight years has been taken to its illogical extreme.
Congressmen who were campaigning and fundraising last year on their personal mission to eliminate Obamacare are now running as the champions of the chronically ill and infirmed. I won’t link you to the commercials. And this is not an Ohio phenomenon. You can find this level of hypocrisy across the country. Some of the very same Attorney Generals mentioned in my last blog, Deep In The Heart(less) Of Texas, are campaigning on their concern for those with preexisting conditions.
It is important to remember that Mike DeWine and his cohorts really don’t want to throw sick people off insurance. They certainly don’t want to bar the poor and unhealthy from access to medical care. They don’t. They just don’t give a damn about how it gets done. They are sure that everything will work itself out. Meanwhile, being anti-Obamacare has been a terrific issue, a cash cow for fundraising, and gold at the polls on elections day. The very people who have benefited the most have, at times, been the most hostile to the law.
The Republicans have been playing Hide and Seek with preexisting conditions. And now, months before the 2018 mid-term elections, they have found the issue. But preexisting conditions have always been right here, in the middle of the entire health care / health insurance debate. It wasn’t that the issue was hiding. The Republicans simply weren’t looking.
Picture – David L Cunix – Hiding in plain sight
Sunday, September 9, 2018
We don’t need no health insurance
We don’t need no safety netThe political leaders, all of them well-insured, have the people of Texas singing a bastardized version of Pink Floyd’s Another Brick in the Wall, Part 2. “We don’t need no health insurance.” It must be working. Texas leads the country with the most people age 18 - 64 without insurance. And they keep electing people who see no reason change their status.
Bloomberg News recently published an article entitled, “Fewer Americans Without Health Plans Since Obamacare Debut”. The article features a map showing which states had the lowest percent of uninsured and which had the highest. The highest, to the surprise of no one, were Texas, Oklahoma, Arkansas, and Louisiana. Close behind were Kentucky, Tennessee, Alabama, and Mississippi. Of course, the Pacific Coast States and the states in the Northeast had the highest percentage of insureds.
These reports tend to pretty repetitive. A look at life expectancy in our country reveals similar results. Here are the bottom 10:
West Virginia - 63.8 years
Kentucky - 64.3
Oklahoma - 64.5
Alabama - 64.6
Mississippi - 64.9
Louisiana - 65
Tennessee - 65.4
Arkansas - 65.5
South Carolina - 65.8
Indiana - 66
Is there a corollary between health insurance, our system to access and pay for medical coverage, and life expectancy? I can’t say definitively, but it couldn’t hurt.
I bring this to your attention because there are a group of people who find the promise of the Patient Protection and Affordable Care Act (Obamacare) disturbing and disruptive. Why should everyone have access to health insurance? Why should Americans with preexisting medical conditions be guaranteed the opportunity to purchase health insurance? Why should access be available to just anybody?
Texas vs. The United States of America
The State of Texas has filed a lawsuit to invalidate the PPACA. The suit was filed in February 2018 in federal district court of Northern District Texas. There are 18 attorneys general and two governors associated with this lawsuit led by Ken Paxton of Texas. All of the attorneys generals are Republicans as are the two governors. The goal of the suit is to have the judge to declare Obamacare unconstitutional and to prohibit the federal government “from implementing, regulating, enforcing, or otherwise acting under the authority of the ACA.” A preliminary injunction was filed to immediately end the PPACA pending the outcome of the trial. Abruptly terminating the PPPACA would result in unimaginable turmoil. Let’s be clear, the following individuals could not possibly care less.
The Attorney General of:
- North Dakota
- South Carolina
- South Dakota
- West Virginia
There is no doubt that the Patient Protection and Affordable Care Act is imperfect law. Surely it needs adjustments and changes, but few laws, and certainly one as all-encompassing as the PPACA, don’t. While this lawsuit, much like the 60+ bills passed by US House of Representatives over the last 8 years, doesn’t lack from political ambition, it fails to offer any alternative. This lawsuit hopes to not be successful. Success would be disastrous. But what would happen if they did succeed? Like President Trump’s elimination of the funding for the Cost Sharing Reduction or last year’s tax bill that effectively killed the Individual Mandate, their indifference to the consequences of their actions should give us all pause. Please don’t ask Mr. Paxton or Mr. Sessions about the sick, the injured, or the uninsured. Their focus is strictly on the next sound bite, the next fundraising letter. And as per Mr. Paxton, he’s safe. He lives in Texas.
We don’t need no health insurance
We don’t need no safety net
Picture – David L Cunix – With Your Boots On
Tuesday, August 21, 2018
The old definition of Chutzpah – A man kills his parents. He is tried and convicted. As the court is about to announce his sentence, he stops the judge and begs for mercy because he is an orphan. That’s Chutzpah.
The new definition of Chutzpah – After the Trump Administration has spent the last eighteen months intentionally destabilizing the health insurance marketplace, Alex Azar, the Secretary of Health and Human Services, publishes an article in the Washington Post with the headline “Obamacare forgot about you. But Trump didn’t.” That’s Chutzpah.
Mr. Azar uses about a thousand words to trash the Patient Protection and Affordable Care Act (Obamacare), decry the rising premium costs that only some people have to pay, and tout the expansion of short term health insurance options. He unfortunately ran out of space before he had an opportunity to mention any of the consumer benefits of the PPACA (guaranteed issue, coverage for preexisting conditions, etc…) or how President Trump and his administration have played a significant part in the premium increases for 2018 and 2019.
One of the points that Secretary Azar hammers is that people who get subsidies through the marketplace aren’t as negatively impacted by premium increases as those of us who pay the full premium. Yes, and the sun rises in the east daily. This blog detailed how Mr. Trump’s Executive Orders and Trumpcare would balloon the deficit and raise premiums. This was all explained last October. Eliminating the funding for the Cost Sharing Reduction and the penalty for healthy people choosing to forego coverage (Individual Mandate) have had the predictable results. The creation of an alternate health insurance marketplace for the young and healthy (Short terms on steroids) will only escalate the pricing crises. It is hard to believe that someone with Mr. Azar’s resume wouldn’t know all of this, wouldn’t be able to explain this better than me, were he not a member of this Cabinet.
Mr. Azar wants us to know that President Trump didn’t forget us. This may a good time to pray for amnesia. That and that Chutzpah is only fun to watch when you aren’t involved.
Picture – David L Cunix – He Had 4 Of A Kind
Tuesday, August 14, 2018
I felt like a time traveler. I was in a Mayfield Heights home, standing in a packed living room, listening to a political candidate dismantle the current administration’s (mis)handling of our country’s health care system. Point by point the candidate highlighted the president’s statements and actions. It was like shooting fish in a barrel. The audience agreed with every point. Many of those in attendance volunteered to take yard signs and campaign.
I would have had a difficult time disagreeing with the generalities. I even found some of the details and potential solutions realistic. But I still felt that I had been here before.
The advantage/disadvantage of a blog is the existence of a paper trail. OK. Now What? was published on November 3, 2010, the day after the Republicans regained control of the U.S. House of Representatives.
The Patient Protection and Affordable Care Act succeeded in energizing the opposition. Even centrist Democrats and Republicans were outraged by this combination of government overreach and intellectual dishonesty. Democrats representing swing districts, like John Boccieri, were pressured into supporting a bill that almost single-handedly caused their defeat.
Republicans have campaigned against the PPACA. Some have implied, some have even promised, to repeal this legislation. Can this legislation, passed only seven and a half months ago, be reversed? And, more importantly, do the Republicans want to?
NO and NO.The Patient Protection and Affordable Care Act is not going to be repealed or reversed anytime soon. Oh, I’m sure Speaker-designate John Boehner will run a bill through the House. It will be great political theater. And, it will be risk free. The legislation won’t get through the Senate, and even if it did, it would be vetoed by the President.
I sincerely doubt that the Republicans would want to repeal this legislation. This is a fundraising bonanza. Campaigning against PPACA is far more profitable than solving the problems that necessitated the law.
So, we have a bad bill and the real possibility that cynicism may rule the day. Plus, we have yet to mention the insurers who have already spent millions to comply with the new rules and regulations. I firmly believe that the insurers have devised a path to real success under a government run health plan where they provide supplementary coverages. The major insurance companies would then have no desire to repeal the law.
We are quickly approaching the next calendar triggers of the health care legislation. It is possible that the Republican lead House of Representatives, far more interested in extending the Bush era tax cuts than anything else, might tackle meaningful reform in early spring. In a yet to be exhibited act of political maturity, the House could even draft a bill to limit and refine the PPACA. Such legislation could be passed by the Senate and signed by the President. It is possible. I leave the question of probability to you.
That was eight years ago. We are on the verge of a Blue Wave. Some of the people swept into office will be as prepared as the candidate I heard Sunday afternoon. Some will just be talented at pointing out President Trump’s obvious shortcomings. Now, before the election, is the time to talk to the candidates. Help them understand that health care is more than just a fundraising vehicle and that talking points don’t pay for medical bills.
Pray that we don’t get fooled again.
Pictures – David L Cunix - New Boss and Old Boss
Thursday, August 2, 2018
The Wall Street Journal has never been a big fan of the Patient Protection and Affordable Care Act (Obamacare). The paper has added gravitas to even the flimsiest of the alternate plans offered by the Republicans over the last few years. But, the WSJ has also featured some of the deepest thinkers of the Conservative Movement. One of these brighter stars is John C. Goodman, president of the Goodman Institute for Public Policy Research.
The Goodman Institute has been the intellectual force behind such policies as the recent Paul Ryan “Better Way” tax reform and other tax and health initiatives promoted by Republicans over the last twenty plus years. I confess that I have not been a big fan of their work. A recent Opinion/Commentary piece from Mr. Goodman appearing in the WSJ did nothing to change my opinion. Here is the link to the article.
My initial impression was that Mr. Goodman had strung together an interesting collection of non-sequiturs. Texas, the state that had the nation’s highest rate of uninsured, 27%, prior to the inception of Obamacare, appears to be a hot mess where the insurers and providers are still trying to get onto the same page. We in Ohio are happy to not be Texans! In Greater Cleveland we have watched the Cleveland Clinic partner with New York based Oscar to form a new partnership and Medical Mutual of Ohio cement a new relationship with University Hospitals. It is a process and it is not without flaws. 2019 could be better.
I would have dismissed Mr. Goodman’s musing had it not been for this:
What’s driving this race to the bottom? The problem starts with the community rating system, which requires insurers to charge the same premiums to all comers regardless of health status.
Do you want cheap insurance? Do you want great coverage with access to the world’s best doctors? According to Mr. Goodman and the politicians promoting his agenda, all we need to do is to return to medical underwriting. We can save you a lot of money, if we are allowed to price our policies based on your health. Of course, that only works, you only save money, IF YOU ARE HEALTHY AND STAY HEALTHY. If you aren’t? Oh well.
This blog started discussed the pitfalls of Community Rating in October 2009. We, the insurance industry, can base our rates on you and the risk you present. We have the statistics. Age, gender, location, health status, hobbies, occupation, and even driving habits can impact your likelihood of having a claim. One hundred years ago the insurance companies even charged premiums based on race. The numbers, the math, determines the premium. If we, as a society, choose to ignore or minimize these factors, the premiums are deemed to be fairer, especially if you are getting a lower rate. The PPACA has insurers ignoring gender, health conditions, occupations, and hobbies. The premium ratio between a 62 year old and a 22 year old was about 5 to 1 in 2013. The PPACA limits that ration to 3 to 1. All of these changes impact premiums. Some people pay more. Some people pay less. And some now qualify for coverage when they would have been turned down a few short years ago.
Do we want to return to medical underwriting?
The Kaiser Family Foundation estimated that 52 million Americans would be declined for insurance if forced to submit to medical underwriting. G-d knows I would be declined if my insurer was given a chance to ask me health questions. And I remember what it was like to tell my clients that they were not eligible for regular health insurance coverage. Is that the solution?
Maybe it is just different in Ohio. Maybe the concept of 27% uninsured seems like a bigger deal here, a place where a Republican governor fought to expand Medicaid to provide coverage for the working poor. Taking insurance away from other people doesn’t make your insurance cheaper, not in the long run, not if we are going to treat the sick and injured. Insurance is simply the way most Americans access and pay for care. There can’t be cheap insurance paying expensive health care. The two go hand in hand. Managing health care costs, whether that is through provider networks or other limitations, will have to be part of the discussion.
Make Insurance Cheap Again? It was never cheap for some of us.
Picture – David L Cunix - Turning Back The Clock