Thursday, January 5, 2017
ALL IN! Crap, all in with a pair of sevens. But he had to do it. It had been so long since he had had a hand, any hand, that he was forced to go all in with a pair of sevens. He had been pushed around long enough. He remembered his last chance, the last time he had been really good hand. Thought he had a winner. The first two cards – King and Queen of Hearts. He bet and his opponent called. Next the Jack and then the ten. Both hearts! He bet big. Call. And then came the ACE! But it was the ace of clubs and all he had was a high straight. He bet and his opponent raised. The warning bells went off in his head as he called. He had a straight, but his opponent had drawn a full house. Now he was all in with a pair of sevens. And his opponent looks like he may call…
It takes a certain amount of courage to put your money on the table and ask to be dealt into the game. Though some may always lose, no one always wins. So you better enjoy the game, revel in the risk, and be prepared to accept the outcome win or lose. And there is one more similarity between poker and politics. You must be prepared to bluff.
In March of 2010 the Democrats went all in. They didn’t have a great hand. This wasn’t the early 90’s when they thought that they had a winner. They didn’t have the National Single Payer plan that they really wanted. They had compromised with their fellow legislators from across the aisle to cobble together a plan that would garner bipartisan support. And they failed. They were all in and they were exposed and alone. On March 23, 2010 the Dems won with a pair of sevens and the Patient Protection and Affordable Care Act (Obamacare) was signed into law.
March 23rd wasn’t the end of the game, just the biggest tournament to date. The Republicans have been very busy since that loss. They had no respect for the gambler, President Obamacare, and hated to have been bested by such a weak hand. It took almost seven years, but here they are, back at the table. The Republicans had spent almost every waking hour since the defeat preparing for this day. A poker player needs a bankroll. The Republicans needed votes – a solid majority in the House of Representatives, the Senate, and a Republican in the White House. And on Friday, January 20, 2017 it will all come together.
For almost seven years the Republicans have told everyone who would listen that they were the better choice. “Bet on me”, they said to the American public. Their focus, the game, scheduled for 1/20/2017 was impressive. We all knew that if they were given the chance they would repeal and replace Obamacare. They just needed their bankroll. And now they’ve got it. There is only one problem.
We are about to see how Paul Ryan plays a bluff. He’s got the votes. But he doesn’t have the cards. There is no viable Republican alternative. Even Republican governors want/need to retain the expansion of Medicaid built into the law. Nobody wants to reinstate medical underwriting, exclude preexisting conditions, or kick kids off their parents’ policies. Everyone wants cake and ice cream for dessert, but no one wants to be forced to eat the liver and onions entrée.
The players are about to be seated. We’ve already taken a peek at the Republicans’ hand. Wonder what the Dem’s have? Wonder how they’ll play their cards? More importantly, who is going to tell all of them that this isn’t just a game?
Sunday, January 1, 2017
Irritated. My right eye was irritated. So was I. My eye had been bothering me for a couple of days. I didn’t know if it was allergies, a sty, or an infection. I had been determined to rely on eye drops and to just tough it out, but that was before I had needed a warm compress in the middle of the night. Time to get medical attention.
As previously noted, I was a touch irritated. Before I could deal with my issues I had to solve a client’s problem with UnitedHealth One. I was on hold for 52 minutes! My phone has a timer. Staffing cuts reflect the company’s losses over the last few years. Once that was completed I could focus on me.
I contacted the Cleveland Clinic facility in Beachwood. It only took 30 seconds for me to clearly state that I didn’t need to see my doctor, or any doctor. I would be perfectly happy with a nurse practitioner as long as I got to come in today. I had also detailed my eye problems. If I was having a heart attack or bleeding to death the scheduling tech would have been able to send me to the E/R and hang up. No, she had to talk to me.
I have been a Cleveland Clinic patient for years. The clerk had all of my information on her screen. Still, she needed to verify ALL of the information from my Anthem card, front and back. I said that I’ve had this policy for over three years. Nothing has changed. It didn’t matter. She plowed on. Next, where do I work? What is my job title? At the eight minute mark, remember my phone has a timer, I noted that we had spent more time confirming how the Cleveland Clinic would be paid than my health problem. She persisted.
Ten minutes into the call I asked her again who was going to see me. She said, “We don’t have any openings today”. “Then why did you waste my time”? She began to offer appointments for the following week, but I had had enough and hung up.
I hear it all of the time. Every negative encounter with the medical industry is blamed on Obamacare (the Patient Protection and Affordable Care Act). Sometimes the complainer is correct, but not always. Failure can be traced to a number of sources.
The staff cuts and financial losses at UnitedHealth One are due, in part, to some really awful decisions. And UH1 cut their marketing and service staff when the going got tough. They succeeded in making it harder to do business with them. UnitedHealth One will get better. This is just a bump in the road.
And the Cleveland Clinic’s failure can’t be blamed on Obamacare. This insatiable push for more money, more donors, and more buildings occasionally leaves the patient as nothing more than a necessary evil. We are in the way. Soon we will be diagnosing and treating our own ailments and simply sending tribute payments to the Cleveland Clinic.
Two websites and a phone call later I had an appointment at a Minute Clinic in a CVS. These clinics are somehow affiliated with the Cleveland Clinic. The nurse checked my vitals, noted my agitation, and gave me a prescription for some eye drops.
So what was it? Allergies? Sty? Infections? I’m still not sure. I took an antihistamine and have religiously put in the eye drops as prescribed. I’m sure I’ll be OK in another day or so.
Thursday, December 22, 2016
Dana Milbank, opinion writer for the Washington Post, was featured on some of the news shows yesterday to discuss Trump voters who desperately rely on Obamacare (The Patient Protection and Affordable Care Act). His article appeared Tuesday and was creating quite a buzz. I, for one, enjoyed 20 minutes of TV that didn’t feature Putin or the words “Conflict of Interest”. Still, this is a serious issue, and we will treat it with a little more respect than Mr. Milbank.
There are and always will be Americans who vote against their personal interest. This is a link to a Forbes article on the issue. But as this article and many like it point out, it is not necessarily that simple. Poor people in Kentucky didn’t decide on Election Day to screw themselves. The previously uninsured didn’t vote for Donald Trump because he vowed to repeal Obamacare. Interviewing them now, a month after the election and a month before anything has changed is unfair to them. It is bad enough to be poor. We don’t need to make them look stupid.
I have a number of clients who have benefited from the PPACA who still voted for Trump. Let’s take a quick look at some of the possible reasons for their choice.
It Didn’t Matter – There are many people who feel that Obamacare will be repealed loudly and retained quietly. We may end up with Trumpcare, a modification that fixes some issues while creating new problems. The Republicans declare victory and the Democrats cede the next 5 years of glitches and complications to the other side.
The Bright Side – I have at least one client predicting a major economic recovery that will result in more jobs with benefits. If they score better gigs, they won’t need individual coverage and all of this will cease to be relevant to THEM.
A Better Way – There must be a better option and their team’s got it. No matter how many times they have been let down by politicians of both parties in the past, this could be the time they get it right.
There Are Other Issues – Health Insurance is really important to me, but I doubt that there are many single issue Health Insurance voters. Abortion, Pro-Life or Pro-Choice, seems to drive people to the polls. Immigration and jobs, too. People were riled up and voted AGAINST Obamacare, often without understanding its positive impact on them personally, but I think that they saw it as part of a whole, a failure of Washington to properly serve and protect them.
Regardless of why or who voted for Donald Trump, the election is over and about 40% of us have spoken. Donald Trump will be the next president and he has a Republican controlled Congress. He has nominated Tom Price (R-GA) to be the next Secretary of the Department of Health and Human Services. Mr. Price is famously anti-Obama and anti-Obamacare. His solutions are radically different and concerning. Will the Price plan or something like it be implemented? No one knows at this point.
Congress will be very active in January and February. It will be important for all of us to watch them closely and share our thoughts with our elected officials. I don’t think that we will see any major changes in 2017, but that is my guess. I will be in Washington in February, in part to discuss my clients’ needs and how the actions of Congress can help or hurt my people.
Until then, if you need a liver transplant like Mr. Mills of Whitley County, Kentucky, I strongly suggest that you get this scheduled soon. The press may paint you as a victim of your own folly for being in this mess, but if you put it off too long this really could be a tragedy of Shakespearean proportions.
Wednesday, December 7, 2016
Editor’s Note: All articles, blogs, and news reports about Obamacare (The Patient Protection and Affordable Care Act) must, per the edict from the incoming president, begin by stating that Obamacare is a terrible burden on the American public and that it needs to be repealed immediately. If you have benefited by the law because of the subsidies, preexisting conditions, or access to care, please have the good sense to keep that to yourself. You wouldn’t want the most powerful man in the world to tweet about you at 3 AM.
The election was about a month ago. Each day brings new proclamations and trial balloons. The Congress beat at Health Insurance Issues With Dave has been working overtime to monitor all of the pronouncements coming from our elected officials. Today’s post will serve as an update.
Republicans in both the House and Senate are eager to repeal Obamacare. The repeal may even be HB 1, the first bill of the new legislative session. It will be a great moral victory. The newspapers, Facebook, and TV news will talk about it that night. The details are more important. Some in Congress want to have the replacement bill be introduced as soon as the celebration and back-slapping dies down. Others believe that the replacement package is still 1, 2, EVEN 3 years away. This is known as Repeal and Delay.
There are advantages and disadvantages to both strategies.
On June 22, 2016, Speaker of the House Paul Ryan released his health care plan, A Better Way. His proposal begins with the repeal of Obamacare. “…This law cannot be fixed…We need a clean start in order to pursue the patient-centered reforms the American people deserve”. That has been the Republican line of attack since the bill was passed in March 2010. No compromise. No tweaking. No amendments. The Republicans have bludgeoned the Democrats with Obamacare to the point that even those Americans who have benefited the most from the new law might not understand or appreciate it.
If Obamacare is repealed and immediately replaced we, the American people, would be able to quickly identify winners and losers, the before and after of the Republican’s actions. The insurance companies and the medical providers would also know their places in the new market. Unfortunately, that is not going to happen. There is no Republican alternative plan. There never was one. Speaker Ryan’s recent interviews confirm that. Reality: What a Concept.
So we are looking at Repeal and Delay. The concept is simple. As detailed by the Urban Institute, the partial repeal of Obamacare could be done through the process of reconciliation. The Senate Democrats could not stop this since reconciliation only needs a simple majority in the Senate. Congress would starve Obamacare by cutting off the funding for Medicaid, tax credit subsidies, and eliminate the individual and employer mandates. Doing that immediately would be the equivalent of dropping a bomb in Times Square. But it could be phased in over a three year period.
Why three years? For one, Paul Ryan, Mitch McConnell and the entire Republican team want to take a victory lap for killing Obamacare even before it is really gone. The real impact of their actions wouldn’t hit until after the 2018 election, just the press releases. The other reason is that they need several years to come up with a viable option that can be phased in properly. Mr. Ryan doesn’t want to take health insurance away from 20 million Americans. That is not his goal. Plus, some of them vote! And, if they can buy three years they have enough time to find a Democrat or two to sign on to their final legislation which will provide the illusion of bipartisanship. The Democrats tried the same thing in 2009 and 2010. But in the end Senator Chuck Grassley and Senator Olympia Snowe still walked away from the negotiations.
The insurance companies, already losing money in the individual market, and the medical providers aren’t real excited. Eliminating Medicaid expansion will force millions of Americans out of the health care system. No routine care. No access to maintenance prescriptions for diabetes, high blood pressure, and other common easily treated illnesses. The E/R waiting rooms will again be filled with people seeking care for minor ailments better treated in a doctor’s office. Would the Republican controlled Congress reinstate reimbursements for charity care? Who knows?
The insurance side is worse. The law would still require insurers to cover anyone who applied, regardless of preexisting conditions. But healthy people would not be required to retain coverage. Only the unhealthy and the responsible would seek coverage. Insurers would be foolish to offer coverage under those circumstances. Major insurers, now publicly owned, would be forced to leave markets or face the ire of their shareholders.
Other alternatives? Darned if I know. You can’t have health insurance if there isn’t an insurance company to sell it. I am scheduled to go to Washington in February to meet with our members of Congress. I have no idea what I’m going to find when I get there.
Oh, and did I mention that Speaker Ryan would like to change Medicare?
Sunday, November 13, 2016
Wednesday was a terrible day in the office. I was a mess. I had been awake most of the night, my worries as dark as the bedroom. Clients called. Clients texted. Everyone, all through the day, wanted to know how this election would affect them. I was too busy to write this update. And I was too concerned about the possible impact to prepare a full report. A friend came in around 5:30. He asked me how I was doing. I told him. I probably did ten minutes on where we were and how worried I was about my clients. He was very patient. Then he asked me, again, how I am. I had completely forgotten that my friend David is totally apolitical. He was asking about my health!
We’ve had a couple of days to watch the president-elect articulate his vision and the current Congressional leaders voice theirs. They are not the same. The future of health insurance will be determined by both the new president and Congress. And the courts may also play a part in our future.
This blog is Health Insurance Issues With Dave. It is not my interest nor place to discuss any part of the election that does not deal with health insurance. And health insurance is our method of compensating medical providers for their products and services. Health insurance is regulated on both the state and federal level, which means that decisions are influenced by finances and the public good. Finances are in black and white. The public good is open to discussion.
The president-elect campaigned on the promise to Repeal and Replace Obamacare (The Patient and Protection and Affordable Care Act). The Republicans who control Congress have promised this for years. On Tuesday the coyote caught the roadrunner.
First, Mr. Trump. As discussed in March, there wasn’t a detailed Trump alternative. We had no idea, prior to the election, what his priorities were or how he would accomplish them. Our closest peek into his thinking came at his Gettysburg speech in late October when he spoke of selling insurance across state lines and of increasing access to Health Savings Accounts, both Republican ideas. This week he expressed his view that the Repeal and Replace would take place simultaneously and that two key provisions of Obamacare – coverage for pre-existing conditions and the ability of children to retain their parents coverage till age 26 – would be continued.
Congress has a different view. Some in Congress have PRIVATELY admitted that Obamacare couldn’t be repealed. Amended? Sure. Changed? You bet. But the idea of repealing the law and blowing up our system, and 20% of our economy, and then eventually replacing the law would be a disaster. Passing repeal bills was safe and easy. There was no danger as long as a Democrat was in the White House to veto the law.
We have had a chance to review the various alternatives. Over the las few years I have covered plans from Governor Scott Walker, Speaker of the House Paul Ryan, and Senator Orrin Hatch. Some have been exercises in ideology and others are closer to marketing projects, the rebranding of Obamacare to a Republican name. You will hear a lot more about this in the coming months.
Let’s quickly hit a couple of the major talking points.
Selling Insurance Across State Lines – I have tackled this a number of times. This is a link to the Kaiser Foundation’s explanation.
Covering Pre-existing Conditions – Everybody loves this, but it doesn’t work unless we have everyone participating. Given the opportunity, lots of healthy people would choose to save their money until they needed coverage. Health insurance is really expensive if only the unhealthy buy it. That means that any law, Obamacare or its replacement, needs to have some form of mandated participation.
Subsidies – The current Tax Credit Subsidy is complicated. There is a lot of room for improvement. Some of the Republican plans will give you a tax credit in 2018 for what you paid in 2017 on insurance. That only works if you can afford the premium in 2017. That eliminates millions of Americans.
Health Savings Accounts – Another great idea if you’ve got disposable income and could us a tax break. Otherwise, no big deal.
Preventive Care – This is really important, especially for children. There is an upfront cost, but long term savings. How preventive care is defined may be changed under the new administration. This has been very contentious.
This has been a very long post and I truly appreciate your patience. There are no simple answers for complex questions. I am very concerned about what the next year holds for us.
I leave you with a thought about a Ferris Wheel. The ride stops when you get to the top. The view is incredible. You are filled with joy. The ride begins to move again and eventually you are at the bottom and forced to leave. The world, even our little world of health insurance, is never as euphoric or bleak as it might seem. We will get through this together.
Monday, October 17, 2016
October 16, 2016
I got to the office in the middle of the second quarter of the Browns’ game. I left a 7:30. It was time. I had spotted a unicorn.
Open enrollment for Medicare Part D (Rx) and Medicare Advantage products technically began yesterday. It will officially start at 9 AM tomorrow morning in my office. Most of my Medicare visitors will be coming to confirm that they don’t need to do anything. No changes, just a cup of coffee and some conversation.
My real challenge is the open enrollment for individuals under age 65. Most of my clients received their renewal packet on Saturday, October 1st. They began calling my office that day. Unfortunately, we, the agents that service these insureds, never got our copy. We were told that the packets were in the mail. We were also told that we could download, one 8 page renewal at a time, from the insurer’s website. Hundreds and hundreds of renewals. I gave up and started to pull and print these a few days ago.
And today I am in my office to work on these renewals.
I am not complaining. I am not telling you about this process because I am some kind of insurance martyr. I love this gig and I’m not the only guy working on a Sunday. Successful agents throughout this country are evaluating their clients’ 2017 health insurance options.
One by one I review each renewal. Should the client stay with his/her current insurer or move? Would a higher deductible save enough money to be worth the additional exposure? Is this the year we should try for a tax credit subsidy? And then, once I know what I would like for them to do, I send them an email or a hand-written note.
This process isn’t fast and it can’t be delegated. The insureds are counting on the agent’s experience and expertise. The health insurance premium may be someone’s second or third largest monthly bill. My goal is to have all of these processed before November 1st. My fellow agents are working just as hard.
I had predicted a tough year. I expected increases of 15% - 20%. Policies that have Rx and office visit copays are coming in around 17%. My HSA policies seem to be averaging a few percent less. The highest HSA deductible plans, now $6,400, were renewed at the best rates. Those policies may work for some people, but not for everyone. Analyzing the options, not simply choosing the cheapest, gives us a better claims experience should you ever get sick or injured.
One of the clients that contacted me on the 1st was particularly concerned about his increase. He and his family got hammered. 25%! It took some time this afternoon to figure out why. What happened? I determined that his son was the main reason for the price jump. He turned 21 this year and will now be rated as an adult, not a child. Just to be sure, I went to the insurer’s website and ran a quote as if he was only 20. I don’t know if this family will be any happier about their new rate, but at least they will understand why.
A unicorn is a mythical creature. They supposedly exist, but no one has ever seen one. My insurers said that the renewal rates were the best that they could offer. Heck, some people might even see a rate reduction as the deductible on the HSA qualified policy drifts from $6,000 to $6,400. It was about 7 PM when I found a renewal with a 7% decrease. A decrease! I rerated the family just to be sure. I sent the client an email, packed up my stuff, and locked up.
Once you spot a unicorn, it must be time to go home.
Thursday, September 29, 2016
I was licensed with over fifty different insurers. Sure, most of my Cuyahoga County clients acquired their health insurance from one of the half-dozen major carriers, but Gosh there were a lot of choices. That was 10 years ago. Now we have two or three good options in Greater Cleveland. And we’re the lucky ones.
Ohio’s population is spread across eighty-eight counties. We have major metropolitan regions, cities, towns, and rural areas. We all may share the same state government, but we do not share the same health insurance options. Cleveland, Columbus, and Cincinnati have choices. Nineteen Ohio counties will have only one health insurer participating on the Exchange in 2017. One! Twenty-eight Ohio counties will have twice as many insurers, Two.
In nineteen counties, if you don’t like Anthem Blue Cross, you can still choose Anthem Blue Cross. That’s it. And by the way, thank G-d it is Anthem and not some tier 3 level Brand X insurer. But one choice is no choice. Will Anthem’s network cover Your doctor? Your hospital? Be affordable? I can’t answer that until the final rates and plan information are released.
And yet we are still considered fortunate in Ohio. Less than 15,000 current Exchange enrollees reside in a single-insurer county according to the Iowa City Press-Citizen. The national picture is much worse. Five states – Alabama, Alaska, Oklahoma, South Carolina, and Wyoming – are limited to a single insurer for the individual health insurance Exchange. That is five entire states. Several others are limited to a single insurer for most, but not all, of the state. According to a recent New York Times article, 17% of the U.S. population will have only one individual health insurer available in 2017.
Where are the other insurers? We’ve seen companies fail (the government created Co-ops, HealthSpan) and we’ve seen companies abandon the market. Aetna and UnitedHealth Care have been the most vocal about leaving the individual market. UHC and Aetna both reported incredible profits this year. It is important to note that these profits are in spite of, not because of, their individual Exchange business. UnitedHealth Care reported a loss of close to $500 million in 2015 on new individual health policies compliant with the Patient Protection and Affordable Care Act (Obamacare). An Aetna press release of August 15, 2016 details a Second Quarter pretax loss of $200 million.
Neither Aetna nor UnitedHealth Care see any reason to continue to bleed money by selling individual policies on the Exchange. They have a duty to their shareholders to market products that make money. Individual policies do not appear to be profitable under the PPACA.
Where does that leave us? In truth, we are right where I predicted we’d be when I wrote Over The Tree, Close To The Front Of The Green in April 2010. Our “Grandfathered” and “Grandmothered” policies are getting too expensive to keep. The new policies, even with a tax credit subsidy, are too expensive for many Americans. And we have few choices. What is the solution? The answer, for many, is the Public Option.
According to USA Today and the Huffington Post, to cite a couple of sources, the Senate Democrats are pushing for an alternative to the private insurance market, a Public Option. And this isn’t just Bernie Sanders (I-Vt.). Senator Chuck Schumer (D-NY) and Senator Patty Murray (D-WA) are involved in this effort to offer a government plan to all Americans. There is also a parallel concept of expanding Medicare from age 65 to age 55.
As we learned from the disastrous Co-op experiment, the government, and the people the government empowers to run business-like entities, will over-promise and underprice the product. The insurers will not reduce their premiums and increase their losses to compete. They will abandon the market completely and let the public option drown. And then? And then the government will be forced to ride in and save us with a true, Medicare-like product for all of us.
And we will be left with one choice. And one choice is no choice at all.