Sunday, September 9, 2018

Deep In The Heart(less) Of Texas


We don’t need no health insurance

We don’t need no safety net

The 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:
  • Texas
  • Wisconsin
  • Alabama
  • Arizona
  • Florida
  • Georgia
  • Indiana
  • Kansas
  • Louisiana
  • Missouri
  • Nebraska
  • North Dakota
  • South Carolina
  • South Dakota
  • Tennessee
  • Utah
  • West Virginia
The Governor of:
  • Maine
  • Mississippi
It isn’t enough that their own population may have difficulty accessing health care. The above elected officials want to disrupt YOURS! And who is defending the suit? The Justice Department has taken a pass. Attorney General Jeff Sessions has already decided that eliminating the Individual Mandate last year effectively eliminates the need to cover people with preexisting conditions and any of the other beneficial provisions of the PPACA. The defense is being led by Xavier Becerra, the Attorney General of California.

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

Meet The New Boss

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

Make Insurance Cheap Again

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


Wednesday, July 25, 2018

Attacked With A Dull Knife

The Patient Protection and Affordable Care Act (Obamacare) is under siege. There is no need for a link here to back that up. You already know this if you haven’t been asleep for the last eight years. The law has withstood the faint-hearted assaults of the Congressional Republicans and a variety of presidential candidates. And now health insurance, the way most Americans pay for and access care, is being attacked by a guy wielding nothing but bluster and a dull knife. Obamacare vs. Trumpcare. In the eternal battle between something and nothing, something always wins.

It has been a little over two weeks since the Trump administration, specifically the Centers for Medicare and Medicaid Services (CMS) announced that it would stop collecting and distributing money from the Permanent Risk Adjustment Program. The government decided to retain $10,400,000,000 of the insurance companies’ money. There are no taxpayer subsidies involved.

That has now been reversed.

In an email release Tuesday (because Tweets are reserved for the really important stuff!) CMS announced that it would release the money and reaffirm one of the basic pillars of Obamacare. Here is a link to the final rule.

In CMS Administrator Seema Verma’s press release she notes, “Issuers (sic) that had expressed concerns about having to withdraw from markets or becoming insolvent should be assured by our actions today”.

The Cliff Notes Version: Nothing has changed! Sure there were a couple of weeks of unneeded aggravation and another attempt to undermine the stability of the insurance markets, but in the end… It is as if there really are adults, somewhere in Washington, who step in and stop Donald Trump before he can do too much damage.

We are a little over 90 days from the next Open Enrollment Period, the first without a penalty for failing to carry compliant coverage (Individual Mandate). We are bracing ourselves for the last acts of sabotage, the last attacks on our system prior to facing our clients. Thankfully, all he’s got is a dull knife.


Picture – David L Cunix – The Weapon


Monday, July 9, 2018

Naked Aggression

Vladimir Putin was embarrassed on the world’s stage. Thousands of journalists, from print, TV, and online, were in Sochi for the 2014 Winter Olympics. The pictures and stories of inept plumbing and shoddy construction made Putin look foolish and unprepared. He changed the narrative and the world’s focus. He invaded Crimea. His attack of Crimea eliminated all discussion of the Sochi debacle.

Donald Trump appears to hold dictators and strongmen in high esteem. He has noted that Xi Jinping of China has a lifetime gig. He is outspoken in his appreciation of Rodrigo Duterte of the Philippines. And he appears to have learned a lot from Putin. Where Putin attacked Crimea, Donald Trump attacks our access to health care. Last week was a particularly challenging week for the administration and the President again attacked our health care system.

CMS Stiffs the Insurance Companies

On Saturday, July 7, 2018, the Centers for Medicare and Medicaid Services (CMS) announced that it on would stop collecting and distributing money from the Patient Protection and Affordable Care Act’s (Obamacare’s) Permanent Risk Adjustment Program. The Permanent Risk Adjustment Program had the insurers collect fees from everyone covered by insurance that would be distributed to the insurers proportionately to mitigate the costs associated with higher risk/claim clients. From The Center for Consumer Information & Insurance Oversite on the CMS website:

“Reducing the incentives for health insurance issuers to avoid enrolling people with pre-existing conditions: The permanent risk adjustment program will assist health plans that provide coverage to individuals with higher health care costs and will help ensure that those who are sick have access to the coverage they need.”

This is an integral part of the market stabilization built into the PPACA.

In an act of naked aggression, the Trump administration is holding $10,400,000,000 of the insurance companies’ money.

Are you distracted? Will you forget about Scott Pruitt or the future of the Supreme Court or the needless fights with our allies when your health insurance premiums spike again? The PPACA is surprisingly resilient. The attempts to repeal it, though often just for show, have not been successful. The sabotage from this Congress and President Trump have resulted in fewer choices and higher prices. Their goal has been to destabilize the insurance markets. Here is a record of their achievements:
  • Remove the penalties of the Individual Mandate as of 2019
  • Shorten the Open Enrollment Period
  • Remove almost all funding for promotion and community outreach
  • Threaten to eliminate the funding for the Cost Sharing Reduction and when that failed to do enough damage, follow through with the threat
  • Attempted to eliminate or limit guarantees built into the PPACA
  • Encourage the creation of association policies and other options designed to cherry-pick the healthy from the general insurance pool.
  • Withhold money due the insurers and eliminate the future benefits of the Permanent Risk Adjustment Program.
Insurers, agents, and a variety of industry groups were surprised by the Saturday announcement. The 2019 rates need to be filed now. How should the industry respond to naked aggression?

There may not be a tank rolling into my parking lot, but I know when my clients and I are under attack.


Picture – Aggression – David L Cunix

Wednesday, June 20, 2018

Having It Both Ways

The most cynical man in Washington was, once again, counting on the American public to believe his words and to ignore his actions. “Everybody I know in the Senate, everybody is in favor of maintaining coverage for preexisting conditions…There is no difference in opinion whatsoever”, said Senate Majority Leader Mitch McConnell last week. Senator McConnell feverishly tried to block the passage and implementation of the Patient Protection and Affordable Care Act (Obamacare), and he has spent the last eight years trying to repeal it without a workable alternative, but please believe him when he says that he is concerned about your access to health care. Worse, a certain percentage of the American public are prepared to dry Mitch’s crocodile tears.

This blog has discussed the political strategy of Republican-led states to sue the federal government over Obamacare. The Justice Department recently decided that it will no longer defend such provisions as the Individual Mandate and preexisting conditions in a district court case brought by Texas and a group of nineteen states.

Actions speak louder than words. We have eight years sabotage and poison pills (see the abortion provision placed in last year’s Alexander / Murray negotiations). Senator McConnell tells us that he is 100% in favor of protecting access to health insurance for the 52 million Americans under age 65 who have preexisting conditions, while simultaneously touting the Trump Administration’s new moves towards Association Health Plans and the destruction of the guarantees of the PPACA. Mitch thinks that he can have it both ways.

There are, of course, responsible American leaders fighting Senator McConnell and Donald Trump. It is easy to point to Senator Sherrod Brown (D-OH) who recently said, “Families in Ohio will likely face higher premiums next year because of the actions taken by President Trump and Republicans in Congress. Instead of working in a bipartisan way with Democrats to lower costs and expand access to care, we’ve seen this administration create instability in our health care system and it is hurting millions of hardworking families.” Easy, but the truth is that Senator Brown is running for reelection and too many will dismiss his comments, even though factual, as purely partisan. We also need to hear from members of both parties who have shown as much interest in solving problems as scoring political points.

We need to hear from the governors.

A statement was released on Monday, June 18, 2018, from a bipartisan group of governors. And yes two of them, John W. Hickenlooper (D-CO) and John R. Kasich (R-OH), seem to relish the opportunity to appear on the top of any bipartisan press release, but the other governors are new to this club of problem solvers. The following statement was also signed by Bill Walker (I-AK), Tom Wolf (D-PA), Brian Sandoval (R-NV), Roy Cooper (D-NC), Steve Bullock (D-MY), Jay Inslee (D-WA), and Larry Hogan (R-MD).

Everyone in this country deserves access to affordable, quality health insurance. The Administration’s disappointing decision to no longer defend this provision of federal law threatens health care coverage for many in our states with preexisting conditions and adds uncertainty and higher costs for Americans who purchase their own health insurance.

Helping our neighbors get health insurance even though they have a preexisting condition is something Americans support and the Administration’s actions will hurt families in our states. This is not right. We’re asking the Administration to reverse their decision and instead work with Congress and Governors on bipartisan solutions to protect coverage and lower health care costs for all Americans, all while protecting those with preexisting conditions.

Governors Kasich and Hickenlooper have been consistent in their efforts to make health insurance, our system of accessing and paying for health care, work for all Americans. They were fighting for sensible reforms last summer while Congress was attempting to dismantle the PPACA. Where was Mitch McConnell last August while Kasich and Hickenlooper were discussing solutions? By all accounts he was in his office licking his wounds after the defeat of his fictitiously named Better Care Reconciliation Act of 2017.

Joining the governors in this fight are business leaders, insurance executives, and any number of representatives of the doctors and hospital associations from around the country. Andrew Dreyfus, CEO of the non-profit Blue Cross Blue Shield of Massachusetts, is in Washington this week to discuss the importance of the consumer protections built into the PPACA. According to the Boston Globe, Mr. Dreyfus will be pressing his case with a variety of congressional leaders. I’m willing to bet money that he won’t get a chance to talk to Mitch.

And that is the question. Are Kasich, Hickenlooper, and Dreyfus simply spitting into the wind? Is there a serious interest in Washington to help Americans to better afford and access health care? That is an honest question in 2018. And we won’t get any solutions as long as Congress and this President try to have it both ways.


Picture - Clip Art