Monday, June 19, 2017
I felt the first large drops of rain before I had managed to get in four miles. I had planned to golf, but there had been an 80% chance of thunderstorms. So I was walking. I was now in the Mayfield Village Wetlands, a mile long circle of bridges and gravel. I tried to stay on dirt and gravel paths to keep my focus on where I stepped as opposed to how far I was walking or the hot, sticky air. This particular trail was designed to be walked clockwise. I, of course, was going counterclockwise. I laughed at the thought. NO ONE WAS IMPACTED BY MY CHOICE. One path was as good as another.
Senate Majority Leader Mitch McConnell (R-KY) is engaged in a different type of exercise. He and his new best friends aren’t trying to lose a couple of pounds. President Trump, Speaker of the House Paul Ryan, and McConnell are trying to eliminate a legacy. They are not alone. There appears to be plenty of Republicans who would like to return to 2005, a time when they controlled the House, the Senate, and Bush was the president. A time before their failures. A time before Obama.
Many of their actions are petty and/or irrelevant. Then there is healthcare. For seven years McConnell and Ryan cynically fanned the flames of hatred and resentment of Obamacare, the Patient Protection and Affordable Care Act. Now it is Trumpcare and they own it.
Some paths lead nowhere. Some are dead ends.
Somewhere in Washington, behind locked doors, thirteen Republican Senators are creating the Senate version of Trumpcare. No hearings. No amendments. No debate. We are discussing how Americans access and pay for healthcare. We are talking about nearly 20% of the economy. We are talking, but they aren’t talking to us.
One of the senators is Rob Portman (R-OH). I have contacted his office about the secrecy. I have asked about specifics. What I’ve received, to date, was a form letter about his commitment to the treatment of opioid addiction. He is clear that he doesn’t support the House bill (The American Health Care Act) that doesn’t do enough to protect Ohioans dependent on the Medicaid expansion. Our governor and my local congressman, David Joyce (R-OH) have also voiced concerns.
OK, now what?
This secret bill is being cobbled together to garner 50 Republican votes in the Senate. That is all McConnell needs. Fifty, and then Vice-president Pence casts the tiebreaker. And the fate of millions of Ohioans depends on Rob Portman having more influence in the Senate than Senators Ted Cruz, Rand Paul, and Mike Lee. This dangerous path leads us to a cliff. Who are we willing to lose?
Wednesday, June 7, 2017
The coroner was ready to address the press. She stood behind the podium with its bank of microphones, looked directly into the cameras, and delivered her judgement. “The cause of death was thin skin.” Several reporters nodded in agreement. They had been predicting this would be the answer. But one journalist refused to close his notebook and felt compelled to get a clarification. “Pardon me, Madame Coroner, but you are saying that the deceased perished from thin skin?” “Yes”, she replied without even a hint of emotion. “So the 27 stab wounds had nothing to do with his death?” “Well”, the coroner replied, “if he had had stronger skin he’d still be with us today, wouldn’t he?”
There was a rumor in 1897 that Mark Twain had died. A newspaper printed an obituary. Twain’s response was “The reports of my death are greatly exaggerated”. I was thinking of this earlier today as President Trump was again telling the American public that Obamacare is imploding. It is true that our current health insurance system seems to be having difficulty breathing, but the first step might be to convince Trump to stop choking it.
Yesterday’s big news was Anthem Blue Cross and Blue Shield’s announcement to abandon the exchange market in Ohio for 2018. This was not a shock to those of us following the shenanigans in Washington. This business decision by Anthem will be spun more than a dreidel during Hanukkah, but their simple words tell the real story:
Anthem has a long history of serving individuals in our communities. Customers have grown to expect great value and access to health care coverage from us. And our desire to meet those needs has not changed. But the current regulatory climate and the uncertainty it has produced in our industry do not give us the clarity and confidence we need to commit to offering broad-based, affordable health plans for 2018. So, while we wait for new regulations to be released, we’ve made the difficult decision to reduce the number of Individual health plans we’ll offer next year.Please note that Anthem isn’t crying poverty. There are no claims of insurmountable losses. Washington seems determined to play politics with Anthem’s clients and gamble with Anthem’s money. Anthem walked. My clients have been calling all day, mostly elderly, Medicare beneficiaries who aren’t impacted, to ask what they need to do. The answer today is – NOTHING. We may need to take action in November, but there is absolutely nothing to do today.
There have been members of Congress and various Republican state officeholders who have been attempting to kill the Patient Protection and Affordable Care Act (Obamacare) since its inception. There were the 60+ votes in the House that we’ve discussed ad nauseum. There have been various law suits from red states. Some of the suits have been more effective than others. We don’t have Medicaid expansion in all 50 states, thus blocking millions of Americans from access to healthcare. Other cases involve subsidies, who gets them and how much.
CWRU Professor J. B. Silvers, the former CEO of QualChoice, published an article on January 4th of this year on MarketWatch year about the dangers of repealing Obamacare without a comprehensive plan. He returns again and again to market uncertainty. The insurers have to trust the government to not change the rules in the middle of the game. AND THEY CAN’T.
One example he (and others) cited was an initial risk reduction program built into Obamacare to defray the high cost of claims anticipated during the first three years of the program. The claims were significantly higher than anticipated, “But when the time came to pay for the risk reduction in the Obamacare exchanges, Congress reneged and paid only 12% of what was owed to the insurers.” This shortfall chased some insurers out of the market and forced those remaining to raise rates significantly last year.
And now we are in the middle of another bait and switch.
One of the lawsuits the Obama administration had been fighting was designed to eliminate a special subsidy for those Americans earning between 138% and 250% of the federal poverty level. This additional benefit not only helped to make the premium affordable, it also reduced the deductibles and out of pocket limits for these insureds. The Obama administration had won a stay while the fight went on in the courts. Trump could simply drop the fight. He has been threatening to do this for months. The insurers would be left holding the bag. This is a link to an April Forbes article on the issue. Katherine Hempstead of the Robert Wood Johnson Foundation is quoted in the article. “It probably was inevitable that the threat of cost-sharing reduction non-payment would be dangled for leverage.”
What we learn, time and again, isn’t that Obamacare is imploding. It is being sabotaged. It is under attack. And if the way we deliver and pay for healthcare, nearly 20% of our economy, suffers an untimely demise it won’t be from thin skin. I think we have to see who is holding the knife.
Tuesday, June 6, 2017
It happened again last week, this time on a golf course. A fourth was added to our group. Our new friend, Ken (name changed), is a businessman from the Akron area. It only took a couple of holes for him to learn what the rest of us did for a living and only another before he started to complain about Obamacare.
I can’t offer my employees health insurance because of Obamacare.
My Insurance went up 400%!
That seems odd.
My premium jumped to $3,000!
For just you?
And my deductible was $10,000. It was worthless insurance.
You had an individual deductible of $10,000? That’s not possible.
What really ticks me off is how all those people are getting free insurance, great insurance, for doing nothing!
It always devolves to a complaint about the poor. There are winners and losers in the Patient Protection and Affordable Care Act (Obamacare). There had to be. We can look back to September 1993 when then President Bill Clinton went before Congress to explain that it was inevitable that some people would be forced to pay more if we were to overhaul our healthcare system for the betterment of most.
The Obamacare winners are easy to list:
- The unhealthy
- The poor
- The working poor
- Anyone stuck in a job or marriage to retain health insurance
- Young women
- Young healthy males
- Businesses employing unskilled, low income workers
- Individuals earning over $200,000
- Healthy middle income wage earners purchasing their own coverage
But what galls me are the politics of resentment. Being poor is a full-time job. I recently helped a young woman apply for coverage. She had aged off her parents’ policy and we went through healthcare.gov to get her a new policy. She qualified for Medicaid. This was a huge relief. Her expensive prescription would be covered. Her premium - $0. That was in March. Today is June 6th. She is still waiting. No word from the State of Ohio. No Rx card. No help.
Not only are my tax dollars helping to provide Medicaid to the poor and the working poor, I am also losing commissions. Some of those people were or would be clients. I am no longer paid to be their agent. That’s a trade I’m happy to make. Do we really believe that people want to be poor? Are we better off as a society by punishing the sick and the hungry?
The problem with Obamacare isn’t that the Medicaid expansion extended access to healthcare to millions of Americans. The problem is that millions of Americans are still uninsured. The problem with Ken? Who cares?
Sunday, May 21, 2017
Paul Ryan triumphantly moved his pawn to the last square. “Hey Nancy, queen me!” His gallery went wild. He jumped out of his chair and high-fived his backers. “You da man”, his new friend, Donald Trump, shouted from the front row. It wasn’t until he returned to his seat that he noticed that his opponent had remained silent, oddly silent, throughout the celebration. But that didn’t matter to Paul. He leaned back in his chair and didn’t even bother to hide his smirk. Nancy Pelosi reached for her rook, pushed it three blocks to the right, and said “Checkmate”.
While the TV has been Trump 24/7, there are other news sources helping to bring important info to the American public. Excellent reporting from Bloomberg Politics on May 18th revealed that “the American Health Care Act, H.R. 1628, hasn’t been transmitted from the House to the Senate, according to Senate Bill Clerk Sara Schwartzman”. Confirmed by CNN, House Bill 1628, the American Health Care Act is sitting in Paul Ryan’s desk while he sweats out a Congressional Budget Office report.
The danger of creating a piece of legislation that is designed more to punch your opponents in the nose than to solve a particular policy problem is that the House can pass just about anything by a simple majority but that the Senate’s rules are a lot more complicated. The Senate’s filibuster and reconciliation rules shaped the final structure of the Patient Protection and Affordable Care Act (Obamacare). And Trumpcare will only become law if the legislation meets these same arcane regulations. And we won’t know until Wednesday, when the Congressional Budget Office releases their scoring, if the AHCA complies.
The minimal requirements are that the American Health Care Act must reduce the deficit by at least Two Billion Dollars. That removes the possibility of a Democratic lead filibuster and allows the Senate to pass legislation by simple majority. The bill must also provide the proper optics. If the CBO report comes back with too many people losing their coverage, that too could bury the legislation. The original House version had only 24 million Americans losing their coverage, not nearly enough to slow Speaker Ryan. The uninsured issue could cause real concern in the Senate, but doesn’t force the House to act. But if the deficit reduction goals weren’t met, the House will be forced to retool the AHCA and then VOTE AGAIN. President Trump and Speaker Ryan twisted an awful lot of arms to get those 217 votes a few weeks ago. Could he get them again?
The biggest problem with the AHCA isn’t that it fails to answer how all Americans can access and pay for healthcare. The biggest issue is that its starting point is the repeal and replacement of Obamacare. The goal is to eliminate President Obama’s legacy, not affordable healthcare and certainly not patient protection. There can’t be any real progress or any true bipartisan effort until our elected representatives choose to fix the existing law. There are responsible Democrats and Republicans who will privately acknowledge that there are ways to improve the PPACA that both sides could accept once the focus changes from the name to the content.
Mark Bertolini, the chairman and CEO of Aetna, was recently quoted as saying “Single-payer, I think we should have that debate as a nation”. In the attached article Bertolini describes the public/private partnership that already exists in both Medicare and Medicaid. He also notes that the insurers already run many of these programs and process the paperwork. Some are viewing this as expanding Medicare Part C, the Advantage Plans, to all Americans both under and over 65. I look at this as a direct extension of my blog post of April 2010 where I claimed that the insurers would eventually push for a single-payer type of system.
Democrats like Pelosi wanted a single-payer program in 2010. Republicans have long promoted market-based solutions such as the Advantage Plans. It is difficult to predict how soon the adults in Congress gain control of the news cycle, much less the legislative agenda. But no one wants to campaign on the value of taking access to healthcare away from Americans. Paul Ryan had a minor victory two weeks ago. Nancy Pelosi appears to still be winning the chess match.
Monday, May 15, 2017
I visited the Senate day care center on Friday. The room was filled with Screaming Meemies. One little girl had the word Protocol on her t-shirt. She was standing in the middle of the room, hitting herself in the head with a wooden spoon. It was a big room. On the south side there were several old men in rockers with sobbing babies sitting on their laps. The old men were crying about a past that might not have ever happened. The babies were crying about a future that never will. And in one corner a child kept wailing “nobody likes me” as tears flowed down his face. “Who’s that” I asked Mitch, the facility director. “Oh, him? That’s the health care bill. We found him in a basket on our doorstep a week or so ago. Nobody likes him!”
There are days were it feels like we are all stuck in the Senate day care center. The unexpected firings and resignations, alone, could fill the daily news cycle. Add the Russians, the specter of war, and all of the questions about the economy, taxation, and regulation and we are on overload. Wouldn’t a nap sound good right now? Perhaps a vacation? But we are adults and we don’t have the luxury of allowing ourselves to be distracted. And since this is Health Insurance Issues With Dave, we are going to spend some time with that lonely unloved health care bill.
That also means that we are stuck spending more time with Mitch.
The Senate Majority Leader opened the door and brought into his chamber the bill he never wanted. He could have turned to Senators Susan Collins (R-Maine) and Bill Cassidy (R-Louisiana) who have been working for months on legislation. Both have years of experience on this issue. Or, the Majority Leader could have attempted to create a bipartisan group to draft meaningful legislation like the gang of six in 2009 that worked on the original bill. Instead, McConnell assembled 13 other Republicans, all male, who represented the full diversity of Republican thinking from Conservative to VERY Conservative.
The current fight in the Senate, in those rare moments when they can focus on something other than the President’s antics, has not been about healthcare or preexisting conditions. This being Republican legislation, the first big issue is Medicaid.
Senator Rob Portman (R-Ohio) is being portrayed as a moderate since he has expressed real concern about slashing Medicaid. The Wall Street Journal is reporting that Senator Mike Lee (R-Utah) and others are “weighing faster and steeper cuts in Medicaid”. The question is never about who is served by Medicaid and how much is really needed to provide for their care. That doesn’t appear to be relevant. The issue is strictly how soon can Medicaid funding be cut and by how much.
We might want to remember that Medicaid serves a number of communities. The schools depend on Medicaid funding to help defray the cost of educating children with disabilities. The AP quoted Kriner Cash, superintendent of the Buffalo, New York public schools. 80% of his students are low income and 22% have disabilities. The district currently receives approximately $2.5 million annually from Medicaid.
…individual student care comes with highly variable costs, especially in the case of students with disabilities.Those costs would not be considered in a system where money is allocated on a per person basis regardless of need. And need does not appear to be relevant to our senators.
At some point our senators may resolve the Medicaid issue to their satisfaction and then move on to preexisting conditions, maternity care, and the Essential Health Benefits. Or not. The Senate may just cobble together something as unsatisfactory as the American Health Care Act, but set it up where their bill wouldn’t go through reconciliation so that the Democrats can kill it with a filibuster. That is a scenario only someone as cynical as Mitch McConnell could orchestrate.
The reporters are trying to get details about the latest Trump debacle and Senator Collins just plaintively asked if we could have just one day without chaos. There is a lot of unhappiness in the Senate day care center, but it is time for our friends in Washington to finally work across the aisle to fix the way we deliver and pay for healthcare in this country. Soon, before we all become a bunch of Screaming Meemies.
Wednesday, May 3, 2017
They didn’t look 74. He was reading, sitting mostly in the shade, his skin dark and leathery. And, he still had a full head of hair, though it appeared very white against his well-tanned face. His wife was still working on her tan. She wasn’t that far behind. She was filling out a yellow bikini and, like Sally, frequently moving her beach chair to catch the best rays. We talked for a few minutes before he asked my occupation. Once I said health insurance he began to ask questions.
We just got back from a week in Mexico. (Feel free to insert your wall joke here!) We talked with Europeans, Canadians, Mexicans, and lots and lots of US Citizens. World affairs dominated our conversations with the Europeans. Canadians wanted to know “What the Hell is going on?” The Mexicans seemed to politely concentrate on their culture. Americans immediately asked healthcare questions as soon as they learned that I was an agent. Thank G-d for the NFL Draft. It was my major break from shop talk.
I talked with business owners overwhelmed by changes in the group health insurance market. There were hospital workers worried about facility consolidations and closings. Republicans sought reassurance. “It is going to get better, right?” Dems seemed worried about everything. Cost? Coverage? Preexisting Conditions? Americans, now accustomed to simple answers to complex questions, wanted to know what was going to change and when it was going to happen.
There are no simple answers.I left for vacation as the Republicans struggled with their amended American Health Care Act (Trumpcare). In a rush to accomplish something/anything within the first 100 days of this term, a stab was made at both healthcare and at the budget. Neither got done. Nothing changed while I was gone. There was a lot of grandstanding in Washington and Harrisburg. Lots of angst everywhere else.
There are Congressmen on TV declaring that the new, new, new plan still doesn’t protect their constituents with preexisting conditions. Other Congressmen are pooh-poohing the issue. And the President is unclear, at best. Worse, all of these elected officials are Republicans. Somehow the Democrats have extricated themselves from this circular firing squad. Would that the American people were so lucky.
Today is Wednesday, May 3rd. The President and Vice-President are busy twisting arms and begging for votes. They hope to have a vote tomorrow afternoon. Why? Surely it isn’t because they have a solution. Trump needs a victory. The Republican controlled Congress needs to prove that it can pass a bill.
The current sticking point appears to be preexisting conditions. The MacArthur Amendment appears to open the door to shuttling the sick to an insurance Siberia of underfunded high risk pools. According to FamiliesUSA, there was a fund of $13 billion per year for ten years to help protect high risk individuals from higher premiums. An additional $8 billion dollars was dumped in yesterday to help make the final push for approval. That isn’t $8 billion per year. No, that is $800,000 per year, essentially no change at all.
We have already seen what happens when you underfund high risk pools. Over 30 states tried one version or another prior to the Patient Protection and Affordable Care Act (Obamacare). Even the PPACA had a high risk pool to help during the transition. The $5 billion dollar fund quickly evaporated.
Conservatives James Capretta and Tom Miller tackled this issue in the Spring 2010 edition of National Affairs. They lay out a compelling argument for high risk pools and a well-regulated insurance market. They also call for reasonable funding - $15 - $20 billion per year. That was in 2010. The current bill calls for less money, not more. It also calls for less regulation. It is a recipe for disaster.
The elderly couple on the beach asked if they should finally purchase a Medicare Supplement. I took a few minutes to explain the basics of Medicare Part A and Part B, the drug benefits of Medicare Part D (Rx), and even Medicare Advantage Part C. That’s when their faces lit up and they remembered that they had advantage plans through UnitedHealth Care. I confirmed that their coverage was working for them and congratulated them on the choice. They are lucky. They don’t need to do a thing.
If you are under age 65, you aren’t that lucky.
Picture by David L. Cunix
Saturday, April 22, 2017
Thirteen. At thirteen, a milestone, a Jewish boy is viewed to be a man. He has a Bar Mitzvah, becomes responsible for his actions, and three days later is reprimanded by his parents for failing to do his homework. So which is it? Is thirteen a milestone or is it really miles from nowhere?
We have a lot of artificial milestones, deadlines to get something accomplished, a deadline to be somebody. Twenty-one seems to be the threshold to adulthood. Fifty to being whatever we might actually accomplish professionally. Retirement at 65. But these are just numbers, an average, perhaps, maybe even a goal for some, but these numbers. These milestones are not law, not mandatory, and the first true sign of maturity is to understand that in our quest to achieve our best we must first discard artificial, imposed timelines. While some may peak at 23, others are still honing their skills in their 70’s. Limiting oneself to someone else’s milestones might even force someone into foolish actions.
And that brings us to Donald Trump and the rush to pass a healthcare bill next week.
Donald Trump has decided that he must repeal and replace Obamacare (The Patient Protection and Affordable Care) within his first 100 days. This is not because he has a prescription for better, cheaper, or even easier access to healthcare for most Americans. It is strictly because the first 100 days is a milestone. He has no concern about leaving us miles from nowhere.
President Trump is trying to get the House Republicans to pass a bill by next Friday. And though the legislation hasn’t been written, the Congressional Budget Office hasn’t revised its scoring, and no House committee has held a single hearing, Trump thinks he can get a bill passed. Of course, it could be passed if the details don’t matter. Just a reminder – we are talking about close to 20% of our economy and how the doctors and hospitals get paid if you happen to get sick or injured. The details are important.
Trump’s latest partners are two Republican House members representing two different wings of the party, House Freedom Caucus Chairman Mark Meadows and Tuesday Group co-chairman Tom MacArthur. Together they have crafted a compromise that is more likely to anger the members of their caucuses than to garner their support. The MacArthur Amendment (draft provided to Politico) to the American Health Care Act does not fulfill the Republican promise of repealing and replacing Obamacare, guarantee that Americans won’t lose their healthcare coverage, or even deliver more coverage for less. They have shuffled the deck, added a couple of jokers, and then mistakenly dealt the cards face up.
The MacArthur Amendment reaffirms the value of having real standards of insurance. The Essential Health Benefits, a list of ten benefits delineated under the PPACA, were scheduled to disappear under the original Republican plan. This amendment brings the EHB back, but only for a moment. Section 1 reinstates the EHB. Section 2 allows states to seek a waiver to eliminate the EHB if they claim that this would lead to lower premiums or the possibility of more insureds. And it isn’t just the Essential Health Benefits. Section 1 guarantees useful insurance and Section 2 guarantees that usefulness won’t be around for long.
We are rushing towards a milestone – Trump’s first 100 days. It is an artificial deadline. But healthcare, taxes, war and peace are not artificial. These issues are real. And when it comes to reality, he is miles from nowhere.