Friday, May 22, 2015

The Blind Men And The Elephant



“You have no idea”, the doctor muttered beneath his breath. He repeated the comment. “You have no idea”. Realizing that his statement had had little impact, the doctor decided that a stage whisper might be more effective. “None of you have any idea”. Success! He had our attention. It appeared that it was up to me to ask him what he was talking about.

The doctor explained the new reality of hospital emergency room care. E/R units, equipped with suites of examination rooms, were now limiting patients for a specific period of time, 13 to 16 hours, to maximize charges. If the patient’s conditions didn’t warrant admission, he/she was sent home. It didn’t matter if the clock ran out at 2 PM or 2 AM. When 16 hours hit, the patient was cut loose.

Payment dictates care.

The doctor is a first person observer of how the new law, the Patient Protection and Affordable Care Act (PPACA), has altered the delivery of hospital based care. He declared himself an expert on the PPACA.

* * *

I got a call from a chiropractor. His patient, one of my clients, was no longer covered for indefinite once a month visits. The government (Medicare) has sharpened the definition of medically necessary. The insurance companies quickly followed. Conditions need to be clearly defined and treatment plans must have a beginning, a middle, and a predictable ending.

The chiropractor is a first person observer of how the Patient Protection and Affordable Care Act has altered the delivery of ongoing care. He declared himself an expert on the PPACA.

* * *

The psychiatrist described her newest challenge. Treatment might be covered by Medicare and the insurers, but the tests to determine the most effective form of treatment might not. What’s covered and what’s not seemed like a moving target. The culprit had to be the PPACA.

* * *

I am reminded of the story of the blind men and the elephant. In the ancient Jain version, six blind men are asked to describe an elephant. They each feel a different part of the animal. Each is convinced that he, and he alone, understands the nature of the beast from his limited contact.

But the elephant is more than just the one part each encounters.

Insurance agents are first person observers of the PPACA. We see who can now access and afford insurance and who has been exiled from the market. We talk with doctors and hospital administrators. We fight with our insurers over claims. In February I was in Washington to meet with members of Congress and last week Columbus to talk with our representatives in the Ohio House and Senate. But like my friends the doctor, the chiropractor, and the psychiatrist, we too are simply describing the parts of the elephant we’ve encountered.



Monday, May 11, 2015

Psst, Would You Like To Hear A Secret?

Mayfield Heights-20150511-00515

Senator Ron Johnson (R-WI) has a secret. The secret is that he is a realist. As such he has to balance competing interests on a daily basis if he would like to keep his job. And yes, he really wants to keep his job.
  • The most vocal members of his party want to repeal Obamacare (The Patient Protection and Affordable Care Act) immediately.
  • Americans, even Wisconsinites, seem evenly divided between repealing and reforming the new health care law.
  • Millions of Americans have directly benefited from key provisions of the law such as Open Enrollment, coverage for Preexisting Conditions, and the Tax Credit Subsidies.
  • The Supreme Court will rule on King v Burwell in next month. There is a very real possibility that the court may eliminate the subsidies for those Americans who purchased coverage through the federal exchange ( as opposed to a state run exchange.

The Supreme Court may help the coyote catch the roadrunner.

Senator Johnson has a solution. He has crafted a plan where Americans would keep their new coverage, and more importantly their tax credit subsidies, until after the next election. By kicking the can down the road till 2017 he solves two problems.
  1. It is after (he hopes) his reelection
  2. A new Republican president will be able to put forward a real plan.
Are you interested in the details? Do you what to know about the elimination of the individual mandate and other items on the Republican wish list? This post provides links the The Hill and other publications. Just don’t waste any time looking at the Senator’s website. There is nothing to be found there. See, this plan is a secret.

Senator Johnson’s most vocal constituents on the right can’t stomach anything less than complete repeal. And his constituents on the left will treat the Johnson plan like a piƱata.

Senator Johnson isn’t alone. Senators Orrin Hatch (R-UT) and Richard Burr (R-N.C.) and Congressman Fred Upton (R-MI)are already touting the second version of the Patient Care Act. According to Forbes, it’s terrific. Much like the Johnson plan, details, the real specifics of how this will affect you, are hard to come by. Their Press Release, however, is filled with glowing generalities and buzz words.

The Hatch plan solves many of the Republican issues with Obamacare by giving them new names. Don’t like the Cadillac Tax? The Hatch plan reduces “the distortions in the tax code that drive up health care costs (by) capping the exclusion of an employee’s employer-provided health coverage”. Hate the Tax Credit Subsidies? The Hatch plan would “Empower Small Businesses and Individuals with Purchasing Power (by providing) Targeted tax credit to buy health care”.

None of this is on Senator Hatch’s website. There just isn’t space for stuff like that. Besides, it’s a secret.


Monday, April 20, 2015

The Disqualifier

Asking permission


The couple desperately needed health insurance. Their current health policy, purchased through COBRA, was about to end and the woman was pregnant. She was a former banker and he was a private money manager. Even though I had found a way to solve their problem, they still had one question to ask me before they would allow me to help them.

“What type of annuities do you sell”?

There were some really terrible annuities on the market twelve years ago and they viewed the sales of these products as a disqualifier. It wasn’t a problem for me. I didn’t sell any annuities, the good or the bad ones. They are still clients.

We all have disqualifiers, reasons why we won’t do business with certain people or companies. Some are logical. Some aren’t. Some, like the example above, speak to an individual’s honesty and professionalism. And some disqualifiers are simply excuses covering a darker motivation.

This edition of Health Insurance Issues With Dave will address my Number 1 disqualifier – REFERRALS.

The insurance companies are under intense pressure to control health care costs. The Patient Protection and Affordable Care Act (PPACA) has instituted a number of changes in the marketplace. Many of these changes have negatively impacted the way the insurers price and market their products. The very design of the new policies can, at times, seem counterproductive. Finding a way to control costs is a major priority. Many insurers have embraced the concept of requiring referrals.

How does this work? When you purchase a policy through some carriers you will be required to name a Primary Care Physician (PCP). We are used to this procedure with a Health Maintenance Organization (HMO) such as HealthSpan, the former Kaiser Permanente. But in this example we are talking about a traditional network driven PPO (Preferred Provider Organization). It has been about twenty years since this was common in our area.

Your Primary Care Physician serves as your health care quarterback. You will need a referral from him/her to have any treatment by a specialist, lab, or facility covered by your policy. No referral – no coverage.

Your first question might be, “How much will my family doctor be paid for this additional responsibility and paperwork?” The answer is NOTHING. The government is projecting a shortage of over 20,000 primary care doctors in the next five years. More and more services are being provided by physicians’ assistants and nurse practitioners. Weighing down physicians with uncompensated paperwork is not a good idea.

What happens once you get your referral? Let’s skip the issue of fighting to be referred to the doctor of your choice. We’ll pretend that you have diabetes and that your doctor (Smith) is willing to refer you to your family’s endocrinologist (Jones). Dr. Jones conducts a thorough examination and decides that he needs a few more tests and that you should see the ophthalmologist (Swenson). Dr. Jones isn’t authorized to refer you and you can’t just make an appointment. If you want the visits covered you will need to return to Dr. Smith to secure another referral. And another. And another.

Is the insurer hoping to control costs by eliminating unnecessary doctors’ visits and tests or is the goal to sidestep the payment of unauthorized care? That’s what it looked like the last time this practice raised its ugly head.

You are your best advocate. You should be in charge of your health care.

I refuse to market any non-HMO policy that requires a referral to see specialists. Many of these policies are purchased by the unsuspecting public through It is very difficult to determine whether a policy requires referrals if you are buying a policy on the government’s exchange without an agent present. Too many will not find this out until their claims are denied.

I see the problem as a sin of omission rather than a sin of commission. But sin is sin. It’s a disqualifier.


Sunday, March 22, 2015

Another Bite Of The Apple

Apple 2

Are you feeling left out? Do you long for the warm afterglow only experienced by the properly insured? Are you ready to come in from the cold? If you answered YES then you may be in luck. The federal government has created a Special Enrollment (SEP) just for you.

This new SEP ends April 30, 2015. This will be the last chance for many individuals and families to purchase health insurance coverage for 2015. To qualify you must:
  • Currently be uninsured for 2015
  • Filed your 2014 tax return and paid the Patient Protection and Affordable Care Act (PPACA) penalty for being uninsured in 2014
  • State that you first became aware of the tax penalty while completing your 2014 tax return
Policies may be purchased on and off the Exchange.

Many of my clients have done the math and have opted out of the PPACA. They are purchasing less expensive short term major medical policies and will pay the tax penalty if assessed. Others will jump at this opportunity to finally purchase compliant coverage.

There won’t be another chance.


Saturday, February 28, 2015

Shopping At Garage Sales In Alternate Universes

Senate cufflinks

February 2015 – Washington DC

There are only two groups of tourists to our nation’s capital in the dead of winter, 8th graders with their teachers and chaperones and constituent visitors otherwise known as unpaid lobbyists. It has been a long time since I had an 8th grader, so you know why I was wandering around the halls of Congress last week.

The National Association of Health Underwriters (NAHU) is the health insurance agents’ trade group. NAHU holds a conference annually in Washington and I was here to listen to regulators, members of the Administration, and members of Congress address hundreds of agents from around the country. I have to admit that I was impressed that not only did the new CEO of the Federal Marketplace ( come to talk with us, he even answered questions and promised to follow-up on specific issues.

And that was why we were in Washington. At the risk of sounding almost altruistic, our main mission was to make the Patient Protection and Affordable Care Act (PPACA) work better for our clients. Each of us has more than a few stories of clients who have benefited by the new law. But, we can also cite plenty of examples of families and businesses who are no longer adequately insured due to correctable problems with the law and its administration. Things have gotten better. Last year was a disaster. But I still spent almost 5 hours online and on the phone February 15th to enroll one family. There is plenty of room for improvement.

Improvement requires the assistance of Congress.

I had appointments with members of both the House and the Senate in their offices. These are always a crap shoot. Sometimes you get to meet with the elected official. Sometimes it is the legislative aide. Some are prepped and ready. And some are meeting with you out of courtesy. There are only so many minutes in the day, only so many constituent visits our elected officials and staff can attend. The halls were filled with Disabled American Veterans, a well coifed group of broadcasters, and a contingent of the blind. The realtors and countless other groups, some with identifying name tags and some just with nice suits that were last worn at a relative’s wedding, preceded or quickly followed us into every office. And each group came with a perfectly reasonable request, one of remarkable fairness that couldn’t help but move our country forward.

Our big get was a bi-partisan letter, authored by Congressmen John C Carney, Jr. (D-DE) and Daniel Benishek (R-MI), to Secretary Sylvia Burwell of the Department of Health and Human Services. The key provision was the request to “create a dedicated customer service hotline for certified agents and brokers, navigators, marketplace assistors and state health officials to ensure that problems with enrollment are addressed quickly and effectively.” In other words, we want to be able to call someone who has been trained to understand the issues and empowered to fix a problem once discovered.

One legislative aide finally asked me what else we wanted.

There are members of Congress, in both parties, who are dedicated to constituent service and have instructed their staffs to solve problems. This blog has noted the help I have received from Senator Sherrod Brown’s (D-OH) office. Other Democrats have little to no interest in problems. They only want to hear success stories. And some Republicans are collecting tales of woe.

I was in a Republican’s office (Don’t ask who!). I was just one of seven in our delegation and I can’t even tell you why I had been included. But I was there and my main job appeared to be to nod my head authoritatively. I can do that. His constituents brought a couple of important examples where the law of unintended consequences had caused significant harm to individuals and small businesses in his district. He welcomed their report and arranged for his staffer to collect more. It was at this point that I realized that he had no interest in solving any of these problems, just amassing a collection, a weapon for future debates and campaigns.

This was not the time to express my outrage. (Cue up Mr. Cunix goes to Washington.)

I pushed my thumbnail hard into my index finger and looked around the room. I saw awards and tchotchkes, the kind that you might find in most offices, and I was beginning to worry that I wasn’t going to be sufficiently distracted. And then I focused on a picture on the wall right behind the Congressman. There were eight Republican Presidents playing poker! Really. Teddy Roosevelt was glancing with admiration at Richard Nixon. Reagan had a Bush on either side of him and Ike was standing in the background. Abraham Lincoln had his back to us. I don’t know if Abe Lincoln would play poker with Ronald Reagan or Richard Nixon if he had chance to come back to the living, but I do know that he would always sit with his back against the wall. The name of the picture is Grand ‘Ol Gang.

Lincoln Memorial

My favorite Lincoln

The picture summed up everything I needed to say about this Congressman. Republican first. Not problem solver. Not legislator. But he is not alone. There is a Congressman representing a district only a few hundred miles away with the corresponding picture of Democratic Presidents. True Blues has Lyndon Johnson leaning over Harry Truman to talk with Woodrow Wilson. JFK appears to be watching Jimmy Carter play poker with FDR and Bill Clinton. And the picture’s owner is just as partisan, just as dedicated to his career.

Library of Congress

Library of Congress

Walking the halls of the utilitarian office buildings of the House of Representatives or the majestic buildings of the Senate, the Capitol, or the Library of Congress I began to wish that our elected officials simply aspired to be worthy of these buildings and the ideals that built them. But these Congressmen and Congresswomen are no different than the men and women we revere from 50, 100, or even 150 years ago. They had moments of greatness and reprehensible pettiness. They lead and they followed. Some of the giants of the Senate were not necessarily thought to have been giants in their own time. Our grandchildren may one day be taught that George W. Bush and Jimmy Carter were great visionaries. I doubt it, but it could happen.

And with that I joined a couple of my peers in one more meeting with a legislative aide. She (the staffer) was fully up to speed on the issues and actually kept the broadcasters waiting. And there were no poker pictures on the wall.


Tuesday, February 10, 2015

Freeze Tag


Today’s edition of Health Insurance Issues With Dave may provide relief and cause panic. Many of you will be relieved to know that the title is not a Frozen reference. This is a Disney-free zone. And way too many of you will become panic-stricken as I remind you that the Open Enrollment Period ends February 15th.

If you are under 65 and are not covered by the government or an employer sponsored group health insurance policy, you will have until Sunday night to either change your existing coverage or to purchase a policy. A great national game of Freeze Tag begins at 12:01 AM Monday morning. You are where you are until the government tags you again on November 15th.

Are you ready? Are you in the right place? FREEZE


Sunday, February 1, 2015







We’ll return to Health Insurance Issues With Dave after this quick ethics test:

You are standing at the corner of Mayfield Road and SOM Center at 2 AM. The light is red and the crosswalk sign is against you. There isn’t a car in sight.

1. Do you cross the street?
  • Yes
  • No
Three people cross the street, two not even bothering to come to the corner. A police car drives by and doesn’t stop to even warn the scofflaws.

2. Do you cross the street now?
  • Yes
  • No
The above is brought to you courtesy of the U.S. Government and your friends at the Internal Revenue Service. Would you like to rethink your answers?

The Individual Mandate is a core element of the Patient Protection and Affordable Care Act (PPACA). The requirement of universal participation is an important component of any serious proposal that would extend coverage, without underwriting, to everyone. It is an unfortunate part of human nature that many people would opt out of coverage until 5 minutes AFTER they suffered a major accident or experienced chest pains.

It is only under the threat of penalty that some people feel compelled to act responsibly.

Americans were required to have health insurance in 2014. And not just any insurance. Compliant, approved insurance. The penalty free options for someone under 65 in 2014 were:
  • Employer provided group health policy
  • Individual policy purchased on the Exchange with an effective date of January 1, 2014 or later
  • Individual PPACA compliant policy purchased off the Exchange with an effective date of January 1, 2014
  • Individual policy purchased prior to March 2010 – Grandfathered
  • Individual policy purchased with an effective date between March 2010 and December 31, 2013 – Grandmothered
  • Medicaid, Medicare, or Veterans Administration provided
  • Granted a Hardship Waiver from the government
The Grandmothered policies are the special contracts that fall under the “If you like your coverage you can keep it” compromises of 2013 and the spring of 2014. We are good for another year on most of them.

Those are acceptable options. If you have one of these you don’t have to pay the Shared Responsibility Fee that I just mentioned in the blog and client update last week. Are you in compliance?

Line 61 on Form 1040 is of little help. Health care: Individual responsibility (see instructions) Full-year coverage (___). Unless you purchased a policy on the Exchange, the government has no idea whether or not you had a compliant policy. We just learned this past week that the insurers will not be providing Form 1095B confirming compliant coverage in 2014. As UnitedHealth Care stated in an update to agents:
“The IRS has indicated that taxpayers will not need specific documentation to “check the box” in good faith and avoid the shared responsibility payment.”

The IRS has to trust us to voluntarily confess non-compliance.

This is not a big surprise. As I noted several months ago, the forms needed to verify compliant coverage have yet to be created. Too complicated. Too many moving parts.

Did you have any health insurance in 2014? Did you save money and purchase short term coverage for the year? Time for that ethics test. Will you turn yourself in when the possibility of detection is almost nil?

Instead of simply waiting a year to impose the Individual Mandate, the Obama Administration has chosen to collect from the intensely honest or the poorly advised. And in the end that is the real ethics test. And the government failed.