Saturday, April 22, 2017

Milestone / Miles From Nowhere

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.


Thursday, April 13, 2017

Donald Trump Needs A Friend

It may be a little late in the game, at age 70, to finally make a friend, but Donald Trump needs a friend. A real friend. This is becoming a priority. I’m not volunteering, but I would at least try if no one else is available.

It is obvious that our current president has never had a friend. He has never learned the importance or value in real friendship. Instead his relationships, with people or the truth, have been of convenience. He is transactional and of the moment. In the last few weeks he has demoted Steve Bannon, Michael Flynn, and Paul Manafort. The president now claims that these three men, previously among his closest advisors, played small, insignificant rolls in his campaign. Let’s be clear. Removing Bannon, Flynn, and Manafort from the executive branch of our government is a good thing. The issue is how it happened and what that means for other areas affected by President Trump’s leadership “process”.

Let’s look at healthcare. Candidate Trump campaigned in superlatives. He was going to replace Obamacare with something BETTER. It was going to be GREAT. Only Mr. Trump’s biggest fans believe that he ever had any plan or knows anything about our healthcare system. The less charitable might also point out that he probably doesn’t give a damn about any of the details. His relationship with the healthcare issue is strictly one of convenience. All of the details are negotiable since the only, I do mean only, goal is the opportunity to declare victory. This was supposed to be a series of transactions.
  1. He told the American people what they wanted to hear – He got votes
  2. He tells Congress to give him a bill, any bill – He signs it
  3. He then declares victory and claims to have killed Obamacare – He then moves on to the next victory
The issues are not relevant to him. And whether you are accusing the Chinese of currency manipulation or bargaining away coverage for preexisting conditions, details matter. Bluff and bluster might work in the real estate market where it may be assumed that little of what he said was true or relevant. Governing is different. At some point they either call his bluff (see Freedom Caucus) or just ignore him.

Monitoring the rumors swirling around Washington could become a fulltime job. One day President Trump is all in on the American Health Care Act, the hastily assembled Republican healthcare bill. It quickly devolved into Trumpcare, a collection of disparate bargaining chips unloved by even its creators. The AHCA didn’t have a champion, just Trump offering one more deal to find a vote or two. The AHCA died without a vote. And who was the first to kick dirt on the grave? Donald Trump!

I'm a little surprised, to be honest with you. We really had it. It was pretty much there within grasp. But I'll tell you what's going to come out of it is a better bill -- I really believe a better bill. Because there were things in this bill I didn’t particularly love. And I think it's a better bill.

The big rumor today is that Trump is threatening to undermine the tax credit subsidies in an effort to torpedo The Patient Protection and Affordable Care Act (Obamacare). The other alternative is that this is a bluff to force Democrats, legislators that have exhibited a certain level of seriousness on the healthcare issue, to come to the table. This would not be to discuss improving the way we pay for healthcare. No, this would be about the dismantling of Obamacare. It is important to remember that repealing Obamacare does not get one more patient admitted to a hospital nor does it guarantee the payment of a single doctor’s fee. Repealing Obamacare is the political exercise of the intellectually flabby.

Jeffrey Lord has represented Donald Trump on CNN for the last year. Today he declared Trump to be the Martin Luther King, Jr. of healthcare. Honest. I can’t make this stuff up. Two days ago Sean Spicer lauded Adolph Hitler’s restraint with poison gas as compared to Assad in Syria. Why appropriate other people’s heroes or minimize other people’s suffering unless they are simply means to an end. Why shift positions on ALL issues unless no position has any value save as a stepping stone to a deal, regardless of the terms. And why pledge loyalty to someone who places no value in relationships that fail to yield results.

Loyalty. Truth. The ability to look someone in the eye and tell him when he is wrong and demand a heartfelt apology. Friend, the person that brings out the very best in each of us. American needs Donald Trump to find a friend.



Monday, March 27, 2017

Let Me Help You To Hurt Me

You never write about medical issues. Why don’t you ever talk about heart conditions or even cancer other than yours? How about the latest prescriptions? You never cover any of them in your blog.

This is Health INSURANCE Issues With Dave. This blog covers health insurance, an organized method of compensating medical providers. It is not about health. In fact, our system has never been about your health.

Blue Cross was created in 1929 as a way to prepay days in the hospital. Blue Shield soon followed to prepay for the services of doctors. Health insurance, pooled risk and shared responsibility, was also created in the 1930’s to cover medical expenses. Congress gave us Medicare in 1965 to help pay for the medical bills of the elderly. And even Medicare Part D (Rx) was designed, in part, to cover the high cost of prescriptions for senior citizens. The focus has never been on health, just the COST of health care.

The Patient Protection and Affordable Care Act (PPACA) was passed in 2010 to provide health insurance for every American. That was the goal. The combination of expanding Medicaid, tax credit subsidies, and the elimination of medical underwriting was supposed to remove every obstacle from our country achieving universal coverage. That didn’t happen. We have fewer people uninsured, but there have been significant problems with the PPACA.

Last week the Republicans attempted to pass the American Health Care Act (AHCA). This was a first. For ninety years we have tried to find better ways to pay for health care. This law wasn’t about that. Trumpcare’s only goal was the repeal of Obamacare. The vote was scheduled on the seventh anniversary of the passage of the PPACA to emphasize the point.

This blog reviewed the original AHCA when it was first released a couple of weeks ago. This half-baked compilation of grudges and campaign rhetoric found few friends outside of the party leadership. Governors and members of Congress of states that had expanded Medicaid worried about the citizens who would lose coverage. The absolutists on the far right, the Freedom Caucus, derided the bill as Obamacare-light. Last week President Trump, Speaker Ryan, and various Congressmen negotiated the dismantling of consumer protections and coverage guarantees. But it wasn’t enough. With nowhere near enough votes for passage, both Trump and Paul Ryan now each claim responsibility for pulling the bill. Neither could have afforded another embarrassing defeat.

And who did Trump blame for his failure to repeal Obamacare? The Democrats!

The Republicans have been beating the Democrats over the head with a baseball bat for the last seven years. The bat broke on November 8, 2016. President Trump is mad that the Dems didn’t buy him a new bat.


Tuesday, March 14, 2017

It Should Be My Choice

I want more choices.

Damn Right!

The government limits what I am allowed to buy. It isn’t up to Washington to tell me what I need.


All those extras just add to the cost.

Yes, make it cheaper.

I’m tired of the nanny state. Too many politicians are butting in. They are taking money out of my wallet. Let me make my own decisions. I want more choices.

I’m with you.

Yep. I’m going to call my Congressman and demand change.

Me, too.

I’m tired of Washington adding thousands of dollars to the price of a car. I don’t want to pay extra for air bags. Seat belts are a waste of my money. I never wear them. Man, there’s a bunch of stuff like this. Anti-lock brakes? Really? I want to get rid of all this unnecessary crap and get a better price on my next car.

Cars? I thought you were talking about health insurance.


When Tom Price, Secretary of Health and Human Services (HHS) says that he wants Americans to have more choices what he is really saying is that the current policies are too expensive because they are too comprehensive. Americans no longer have the opportunity to purchase inadequate health insurance policies. All policies are now required to cover the ten Essential Health Benefits (EHB). Which of the following would you like to leave off your next policy? Are you sure?
  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Pregnancy, maternity, and newborn care
  5. Mental health and substance use disorder services
  6. Prescription Drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services
  10. Pediatric services
How could you know that you’ll never have cancer or a chronic back problem? Which benefits can you eliminate? The easy one is maternity. How much does a 60 year old pay for maternity? About the same amount as a 22 year old pays for prostate cancer. The truth is that you can’t make an informed decision. You can’t guarantee that you will never suffer from depression or get hooked on opioids after major dental work. And none of that really matters because it assumes that you would be making these choices with your eyes wide-open and know exactly what types of coverage you would be eliminating. You won’t.

This whole push to get policies sold across state lines is about removing care. Ohio, for example, recently passed legislation guaranteeing coverage for the treatment of autism. That is a Republican governor, a Republican controlled senate, and a Republican controlled house voted to grant this benefit for all of Ohio’s children. Tom Price wants you to have the opportunity to purchase a cut-rate policy from Tulsa based Shaky Ground Mutual. Minnesota may be leading the way towards the new, useless policies. More importantly, it won’t be until you go to the doctor that you will find out that your child’s autism or your cancer isn’t covered.

It may be difficult to read today’s heavily regulated health insurance policies, but these have much less fine print and legalese than what we used to provide. Remove the regulations and we immediately return to the gobbledygook of the past. If locked doors keep honest people honest, than regulations are the locked doors that protect the consumer from our insurance providers.

Please don’t confuse this post as a full-throated endorsement of the Patient Protection and Affordable Care Act. It is not. The PPACA is a badly written law that needs significant changes if it ever has a chance to succeed. Most of our representatives in Washington know this. That’s not repeal. That’s repair.

Will the Republicans overcome their obsession with our last president and choose to do what’s in the country’s best interest? I don’t know. It is the one choice they didn’t want.




Wednesday, March 8, 2017

Our New Law Is Better Than A Poke In The Eye With A Sharp Stick

Our friend Paul inherited a car. It only had a few miles and still had that new car smell, but it wasn’t brand new, it wasn’t the exact car Paul wanted, and he hated the color. Paul despised the car. The Check Engine light came on as Paul took the car out for his first drive. He cursed the car and threatened to drop it off at the junk yard. He didn’t fix the problem. He never even looked to see why the idiot light was on. Paul continued to drive the car without bothering with routine service after other warnings lit up his dashboard. The Check Oil light had only elicited more curses and more threats of the compactor at the junk yard. But no matter how badly Paul abused the car, the damned vehicle started every day and managed to get him wherever he needed to go. Now, a couple of years into Paul’s ownership, the car is starting to stall and it has difficulty going up hills. Paul is telling everyone that this car, this worthless piece of garbage, needs to be replaced. And that is our friend Paul Ryan’s relationship with Obamacare.

The Chairman of the House Ways and Means Committee, Kevin Brady (R-TX), introduced the Republican alternative to the Patient Protection and Affordable Care Act (Obamacare) yesterday on TV. His main thrust was that Obamacare is failing, a disaster, and that the Republicans have to do something. Anything would be better! And to test that theory we have the American Health Care Act.

Seven years in the making! And, as White House Press Secretary Sean Spicer was quick to point out yesterday, the American Health Care Act is only 123 pages as opposed to the PPACA that is a whopping 974. That alone makes it a better law.

There will be any number of analyses published over the next week. My peers and I have received countless calls and emails about this first stab at (in) replacing Obamacare. Before we spend too much time on this, we need to acknowledge that there are serious divisions within the Republican Party and that much of this will be changed. Senators from states that expanded Medicaid have no interest in explaining to the folks back home why they lost their health care. Congressmen on the conservative fringes have had the luxury of passing bills that could never become law. They have no interest in supporting anything that might even appear to be pragmatic. So no, don’t get too worked up about the American Health Care Act. Senators like Bill Cassidy (R-LA) have already declared it DOA.

A more relevant question may be whether this is a serious piece of legislation or simply one more opportunity to pander to the Republican base. Both Congressman Brady and Congressman Ryan suggested that the public should read the law. Part of this is bluff. They are hoping that the average American’s eyes glaze over while reading the highlights on the lead page. News organizations, researchers, and the author of this blog accepted their challenge.

Let’s explore priorities. Health care is almost 20% of the U S economy. Any replacement of the PPACA would have to provide for the seamless transfer of one payment system for health care to another. Billions of dollars (and millions of lives) are at stake. So the Republican bill would have to address all of these issues thoughtfully, carefully. How did they do?

The first issue, the most important task of this legislation, appears on Page 2. Yes, before we can tackle the individual mandate, preexisting conditions, or even Medicaid expansion, the first thing we have to do is defund Planned Parenthood. The AHCA goes to great pains to describe Planned Parenthood without mentioning it by name. It isn’t till the bottom of Page 4 that we move on to Medicaid.

Much has been made of the possible changes to Medicaid. The simple explanation is that the states that expanded Medicaid would have to do more with a lot less. The real pressure points are 2020 and after which at first seems far away, but is actually less than 3 years till implementation.

Our next section dealt with the payments that hospitals receive for uncompensated care (DSH). The idea is to improve access for the uninsured and Medicaid patients. These payments were reduced due to the anticipated success of Obamacare. The goal was to have everyone insured. The AHCA reinstates the payments.

On Page 10 we arrive upon the other issue that appears to have been keeping Speaker Ryan up at night. The next 7 pages deal with preventing lottery winners from accessing Medicaid. Seven! This change should guarantee that our budgets will now be balanced.

The next few pages guarantee that states aren’t forced to pay for aliens (international or intergalactic) and how home equity loans impact Medicaid qualifications. By Page 25 we get to Medicaid funding which kills another 20 pages. On Page 45 we finally get to Subtitle D – Patient Relief and Health Insurance Market Stability, a nine year $100 billion funding mechanism to the states to expand coverage options. Finally, some meat.

The rest of the document details which taxes are to be repealed, which repurposed, and which just simply delayed till someone else is in office. The individual mandate is eliminated in favor of a different penalty for opting out of coverage. Older adults are charged higher premiums with the hope that young, healthy individuals will sign up in droves and make the system work. And, of course, there are a number of favors included to make some donors happy such as the repeal of the tanning tax and the reinstatement of the deduction for insurance executive compensation.

The media, both right and left, will hit the high points. And more importantly, most of those points will be the ones debated and changed in the weeks/months to come. I wanted to focus on the issues that the Ways and Means Committee thought were most important, the issues that they hit first. There is one other issue that I thought was unusual. Section 6, about 80 pages or so into this bill, repeals the employer mandate, the rule that forced employers with more than 50 employees to provide health insurance as of December 31, 2015. Not the end of last year. Not the end of this year. Obviously, one of the Congressmen has a very important constituent who didn’t bother to cover employees in 2016. Perhaps Chairman Brady? Gosh it is always great to know a Congressman. Heck, it is better than a poke in the eye with a sharp stick.


Friday, February 24, 2017

Lucky, Again

This just in – Grandmothered Policies are now extended to the end of 2018

This is called Transitional Relief. Grandmothered policies were issued with an effective date between April 2010 (right after the passage of the Patient Protection and Affordable Care Act) and December 31, 2013 when the law was completely implemented. Grandmothered policies were underwritten and based on an age ratio of 5:1 or higher.

Healthy and/or young people got a good deal in 2013. If you didn’t, if you were charged extra or if you needed a policy that covered maternity or a pre-existing condition, you purchased a new, compliant policy in 2014. The only people left were the cheapest to insure. And though we haven’t added any new, healthy, people to this pool, the Grandmothered policies are still a better risk than the general population. Grandmothered policies are cheaper!

This rule from CMS will allow each state to decide whether impacted individual policies, group policies, or both may be retained until 2018. Mary Taylor, Lt. Governor and Insurance Commissioner, has been willing to extend Grandmothered policies in the past. There is no reason to believe that she would block this now.

And yes, we did talk with our elected officials about this while in Washington, but I don’t know that we can claim credit for it. This may fall under the area of keeping the waters calm while the storm is brewing on Capitol Hill.

Quick Example:

My current policy – Anthem HSA Qualified, $5,500 Deductible - $428.99 per month

2017 policy – Anthem HSA Qualified, $6,500 Deductible - $863.74 per month

If you have a Grandmothered policy you are lucky, again.


Friday, February 17, 2017

The Rescue Call, Market Stability, And How I Failed At UBER

It appears that it is common, when someone is on a blind date, to arrange a “Rescue Call”. There is even a commercial on TV that references this. A friend calls you and provides you a reason to cut the date short. I actually saw it in action on Wednesday.

I was in a Congressman’s office. Seven Ohio health insurance brokers were in his office to discuss the Patient Protection and Affordable Care Act (Obamacare) and what we were going to do now. Fifteen minutes into a positive / routine meeting we were interrupted by one of his aides. After one quick knock on the door, the aide poked his head into the room and told the Congressman that he had another meeting. The Congressman waived him off and we all got another fifteen minutes. If this had been a date, we would have just qualified for a second cup of coffee. Welcome to How To Visit Washington DC 2017.

Over a thousand members of the National Association of Health Underwriters (NAHU) gathered this week in Washington to hear from a variety of experts and to talk with our states’ elected representatives. Most of us are there on our own dime. It is that important for us to get the most up to-date information and to make certain that our lawmakers understand how our clients will be impacted, both positively and negatively, by any changes in the way Americans pay for their health care.

The Law of Unintended Consequences.

There are a lot of ideas that sound absolutely fantastic on TV but will be irrelevant, or even worse disastrous, in practice. Insurance agents are uniquely positioned to explain the real world impact of these programs.

We were in Washington to deliver one important message for our clients – Market Stabilization. It is already mid-February. Nothing can really be changed for 2017 and the insurers only have eight weeks left to prepare for 2018. Yes, eight weeks. Insurers are currently working to file their plans and rates for 2018 and they, as well as our clients, need to know what the market will look like on both the state and federal levels.

Our key points centered on the individual (non-group) market.
  • Allow the tax credits that help so many Americans to afford coverage to remain intact for at least two more years or until a comparable replacement can be put in place.
  • Allow tax credits to be used outside of the Marketplace if fewer than two choices are offered in a state.
  • Allow any person to purchase a catastrophic-category coverage regardless of age or income status.
  • Tighten both the open-enrollment and special-enrollment periods to reduce adverse selection.
  • Allow states to be eligible for a new hybrid high risk pool that would serve as a reinsurance mechanism while still providing the same level of coverage for even the highest risk individuals.
  • Preserve employer-sponsored health insurance by retaining the employer exclusion.
Yes, this is a lot of process and almost nothing that would make a good sound bite. These points and others would help secure the promise of health insurance coverage for the next couple of years.

Armed with individualized packets, we set off to meet our Senators and Members of the House. I had a chance to visit offices in the Senate and the House, Democrats and Republicans. Some of my meetings were with the actual lawmaker. Some were with staff. And though it is always gratifying to have a Congressman make time to speak with a visiting constituent, some of the best meetings can be with a Chief of Staff or a knowledgeable legislative aide, especially one who specializes in public health. I found this year’s meetings productive. The Congressmen and their staffs were totally engaged. They asked good questions. They took notes. I honestly felt that my time and expertise were valued.

** ** ** ** **

I was in geek heaven. Cigars. Scotch. Politics. I was with two of my peers and a lobbyist in Shelly’s Backroom doing a deep dive on the current state of affairs. The hours flew by and it was past midnight when I called us an UBER. We walked outside, ignored the parked cab, and looked for Mohammed and his Toyota Camry. A Camry stopped, right in front of us, in the middle of the street. We walked up to the car and tried to get in as the driver frantically waived at us. We had failed to notice that there was a traffic light, here in the middle of the block, and he had been stopped for a red light. He wasn’t an UBER! We stepped back and he sped off.

Another Camry, one with an UBER decal, came up a couple of minutes later. This time we verified that it was an UBER and got in. Sitting shotgun, I noticed that the driver was a little confused. We had only traveled a few blocks before his phone rang. It was Betsy. She wanted to know where the Hell he was. They started arguing. This wasn’t Mohammed and we were in the wrong UBER. In the end I cancelled my order, paid the penalty, and slipped the driver a $10 for a $7 ride. His last ride as an UBER drive might as well include a tip.

This is either the office of Rep. Don Young of Alaska or a Betsy DeVos elementary school.

The view from the train beneath the Capitol.