Sunday, June 10, 2018

Sunset Of The American Dream

The United States is often called a nation of immigrants. Many of our families made the choice to leave their homes and make the arduous journey to a land that promised a better life, if not for them then at least for future generations. A better life for some meant the right to practice their religion without government interference. The American Dream included food for the hungry, prosperity for the impoverished, and freedom, a concept so alien that most could not define it, for all.

The American Dream is under attack.
Security. The American Dream is dependent on us feeling secure. Secure in our faith in the rule of law. Secure financially with a stable economy. Secure with access to quality health care paid, for the most part, by someone else. Yes, someone else. Most Americans have private self-paid health insurance, employer sponsored group coverage, Medicaid for the poor and working poor, Medicare for the disabled and elderly, or some combination of a couple of those. This is hardly a perfect system, but it is ours. Tampering with our process of compensating medical providers should only be done with the goal of improving the system. Someone needs to explain that to the Trump administration.

The Trump Justice Department is actively trying to sabotage the Patient Protection and Affordable Care Act (Obamacare). A main feature of the PPACA is the protection the law provides for those of us (about 52 million Americans under age 65 according to the Kaiser Family Foundation) who have preexisting conditions. Unsatisfied with the destabilizing impact of removing the penalty associated with the Individual Mandate, the Justice Department has upped the ante and asked a district court to open the door to medical underwriting. Donald Trump believes that we should return to the days when unhealthy people were charged more for their health insurance. Denying coverage can’t be far behind.

This blog predates the PPACA by over a year. The Patient Protection and Affordable Care Act was a compromise bill created by Republican and Democratic lawmakers. It both suffers and benefits from those compromises. But it was still being drafted right up to the vote and this blog has been clear that the PPACA was poorly written and much, too much, was left in the hands of the regulators. This blog is neither defending the law nor the process. But, our system was working to adjust to the changes initiated by the law.

There have been two types of Republicans since the passage of the PPACA, those who understand the nature of the law and cynically campaign and fundraise against it, and those who really don’t understand our health care system. There was never been a comprehensive Republican alternative to Obamacare. But the Republican tax bill that eliminated the penalty, as of next year, for failing to carry insurance, Trump’s decision to eliminate funding for the Cost Sharing Reduction, and this new effort to reduce access for Americans with ongoing health issues, usher in the era of Trumpcare.

Trumpcare                                                                              Obamacare 

Erase a legacy                    Goal                                      Access to care

Destabilize                         Markets                                Adjusted in time

Price based on health         Underwriting                   Community pooling

Short term politics              Vision                                    Focused, if flawed

Guaranteed to fail               Success                                  Needed to evolve

Some states are trying to stave off the disaster of Trumpcare. Governor Phil Murphy (D-NJ) and Governor Phil Scott (R-VT) have recently signed legislation that will codify the Individual Mandate in their states. New Jersey has also passed legislation that will take the money raised by the penalty to form a reinsurance fund to further help stabilize the market. Several other states are reviewing similar actions. Ohio, this being an election year, is marching in the opposite direction.

I cannot sit silently and watch the American Dream being attacked. How much worse it is when that attack is from within?


Picture – David L Cunix – Sunset Of The American Dream

Tuesday, May 29, 2018

Out Of Sight. Out Of Mind. Out Of Money.

You may be forgiven if you haven’t been focused on the looming health insurance crises. Most of us are on information overload. With the daily revelations of inappropriate business deals and the on again / off again nature of the summit with North Korea, who has time to contemplate the administration’s ongoing war with Obamacare (Patient Protection and Affordable Care Act)? That’s our job.

Over 150 million Americans get their health insurance at work. The premiums are paid by their employers. The employees’ portion, if any, is deducted from their paychecks. Most of our clients on individual coverage (non-group) have the premiums deducted automatically from their credit cards or checking accounts. The premiums are a huge issue in November, when the clients see next year’s price, and January, when that first higher amount comes out of the account. Otherwise, the cost of insurance is just another part of that great American mystery, “I work hard, but I can’t seem to save any money!”

There are, of course, lots of Americans challenged by the recent changes in health insurance, our method of accessing and paying for health care.

It is fair to say that President Trump and the Republican-controlled Congress, having failed at repealing Obamacare, have quietly settled on sabotage. The strategy might work.

The first salvo was President Trump threatening last spring to eliminate the funding for the Cost Sharing Reduction. The risk of losing millions of dollars chased insurers like Anthem Blue Cross out of the market. He can play politics with the health care of millions of Americans, but the insurers who must answer to shareholders cannot. Those insurers that remained in the market were forced to substantially increase their premiums. Anthem’s decision to leave as well as the pricing moves by those that stayed were confirmed when Trump eliminated the funding in October.

Premiums are about to take another unnecessary jump. The Congressional Budget Office is projecting a 10% annual increase due to the most recent tax bill that eliminated the penalty for failing to carry compliant health insurance beginning 2019. Killing the Individual Mandate will cost us 10% per year! Without the (negative) incentive to retain coverage, many healthy Americans will drop their major medical policies and either go bare or purchase short term policies. You can’t fund a health care system with just the sick and the responsible. Premiums will rise exponentially. The CBO estimates that this alone will cause 4 million more Americans under age 65 to join the ranks of the uninsured in 2019.

The increase in premiums has been forcing more Americans to choose less comprehensive policies. Our top selling contracts may cover preventive care at 100% without copays or deductibles, but your child’s strep throat, with office visits, testing, and Rx, may cost you $100 or more. It is not unusual for someone to have a $5,000 or $6,500 deductible. That amount seems incidental if you have a major claim over $100,000. But lots of people have smaller claims, under $10,000, and find that they are paying the entire bill.

The average American has about $1,000 in savings. Where will that person find $4,000 or $5,000 the next time he/she slips on the ice or trips on an uneven sidewalk?

The limitations, restrictions, and network reductions of our new health plans are ignored or forgotten until you get sick or injured. And then it is too late. And then no amount of stories about Korean missiles will get your mind off your bills.


Picture – Surprise! – David L Cunix

Monday, May 14, 2018

There Is A Doctor In The House

Health Insurance Issues With Dave has interviewed doctors, hospital executives and other members of the health care industry. Today is the first time I’ve handed the keys to a guest columnist.

I am proud to introduce my high school friend Gregg M. Gaylord MD. Dr. Gaylord is a Fellow in the Society of Interventional Radiology and is in the independent practice of medicine in Milwaukee, WI. He graduated U. of Cincinnati College of Medicine in 1981, and is Board Certified in Diagnostic/Interventional Radiology.

“I’m mad as hell…”

This famous line from the movie “Network” pretty much sums up how I feel about the now ubiquitous health care “network”. Nearly every health insurance plan comes with some form of network that either pays only for services provided by physicians, hospitals, and other providers in-network (IN), or has a higher copay and deductible if you choose to go out-of-network (OON).

Networks of providers are formed by payers such as Medicare Advantage and health insurance plans who solicit special pricing from major medical centers and professional medical groups as well as medical labs, surgery centers, hospitals and other entities. In exchange for accepting what are usually lower fees, the IN providers gain exclusivity under the insurance plan. If you aren’t accepted into the network or won’t accept their contract, you can’t treat patients and expect to get paid by the insurance plan. Independent individual providers are often excluded from networks, particularly on the individual “Obamacare” exchange plans. Some plans will pay for OON benefits, but at a much higher cost to the patient. Deductibles are often doubled and depending on the type of plan, coverage can also be reduced by a significant percentage. In many cases, a plan pays ZERO for out-of-network care except for emergencies. And many of these plans have no network providers – therefore no coverage - outside of the state where you purchase the plan (again, unless there is an emergency, though once the emergency subsides you once have to use an IN provider).

Not every plan has a narrow network. Some plans still offer a broad choice, but these are often group policies provided at your job or through Medicare and Medicaid programs that offer a variety of options though at vastly different premium pricing. If you are fortunate enough to have a broad choice of providers, you can usually keep your doctor. But this is not always the case, and many employers are also limiting their plans to those with a narrow network in order to stave off – at least temporarily - large premium increases.

So what’s the beef? Purchasing a plan in the individual market usually comes with a narrow network plan with a narrow list of IN providers that has no OON benefits. If your doctor is not in the network, too bad. Pay for your own care out of pocket. Don’t like the hospitals in your plans network? Again, too bad. Pay for it yourself. The sales pitch is that your plan will reduce costs and therefore reduce premiums, and that by narrowing the network, health care providers will work together to provide higher quality of care.

But is it working? No one is sure at this point. Some plans are showing a relative premium reduction of 6-7% compared to plans with broader networks. But premium prices are still headed up. Predictably, by narrowing networks there is an incentive for hospitals and health providers to merge and consolidate services – a trend that started during the early Clinton years but is now accelerating. This has led to upward price pressure in many markets. And perhaps even worse, these consolidated models have yet to prove long-term quality improvement on a broad scale. Unfortunately, we know that failure to prove better quality has not prevented this model from moving forward. One example of failure to prove benefits prior to implementation of policy is the requirement for nearly all physicians and hospitals to utilize Electronic Health Records. The benefits of EHR’s have yet to fully materialize, but the unintended consequences have included physician burnout, less time for nurses and doctors to interact with patients, and more and more reporting requirements that seem to add nothing to quality health care at this point.

Will narrow networks also lead to unintended consequences? In 2017 for the first time in the United States, independent physician-owned practices are no longer the majority. Employed physicians and independent physicians each constitute about 47% of physician practices. In many cases, employed physicians are seeing drastic income reductions – something that may or may not prove beneficial to the system as a whole. But a disturbing trend is the loss of autonomy in decision making which is being replaced by decision-making algorithms, management economic decisions, and incentives to increase referrals and therefore income “within the network”. Worse yet, in some cases physicians are being punished for not generating sufficient income to the system. Perhaps this will end with newer models of health care that shift responsibility and risk to the providers and the incentives will be to provide less care at lower cost. Will higher quality result? No one knows.

Bottom line? As networks narrow there is an incentive for providers to merge, and there will be fewer and fewer networks and hence physicians and hospitals to choose from. The doctor-patient relationship is being fractured ever more by third party payers and managers. Patient choice might become a thing of the past, and in some case already has.

What will the response be by the very human providers? There seems to be a reversal brewing from the employed physicians who are seeking to go back to the independent physician or independent physician group model as they feel less and less valued in a system that places remote management in charge of decision making. Some call this the “corporatization” of medicine – something that is already highly developed in the United States.

Until then, many providers are “Mad as hell”. And at some point – I wonder – will they “Not take it anymore”?

Gregg M. Gaylord MD

Special thanks again to Dr. Gregg M. Gaylord for providing us with his insight to the changing landscape of the health care industry.

Picture provided by Dr. Gaylord




Friday, May 11, 2018

The Truth, And Getting Fired, Will Set You Free

Here is the key question: Did Dr. Tom Price, a longtime Republican Congressman from Georgia and, most recently, the Secretary of Health and Human Services (HHS), know that dismantling the Patient Protection and Affordable Care Act (Obamacare) was a terrible idea for all of the last eight years or did he just now realize the negative impact of his actions and advocacy?

Dr. Price recently spoke at the World Health Care Congress, an important meeting of the major stakeholders of the health care industry. In a moment of clarity, the former champion of the repealing of all that is Obamacare said this about eliminating the Individual Mandate:

There are many, and I’m one of them, who believes that that will harm the pool in the exchange market. Because you’ll likely have individuals that are younger and healthier not participating in that market, and consequently that drives up the costs for other folks within that market.
Don’t worry. Within in a day he was walking back his statements, claiming that he was being quoted out of context. As this blog has long contented, the first casualty of the creation of the PPACA was intellectual honesty. Dr. Price is now hoping that nonpoliticians, such as his current employer, a health care staffing company, will focus on his new understanding of insurance basics. Dr. Price is also hoping that his old buddies in the Republican controlled Congress will ignore his moment of candor and welcome him back in the club when he comes calling.

There are any number of Republicans who, now that they have chosen to not run for reelection, have suddenly been gifted with clarity and/or honor. Exhibit one for most people was John McCain’s July 2017 thumbs down, the final vote to defeat the Republican’s attempt to repeal Obamacare. Most Americans forget that two other Republican Senators, Susan Collins of Maine and Lisa Murkowski of Alaska, had already voted against the poorly crafted measure. Were they the only three members of the majority who knew how disastrous repealing the PPACA without a real replacement would be for American, or did a number of cowards and hacks breathe a sigh of relief when McCain stood up in their place?

Now the airwaves are filled with the brave and honorable. Charlie Dent (R-PA), Jeff Flake (R-AZ), and Bob Corker (R-TN) are just a few of the guys who suddenly feel compelled to share their thoughts on a variety of issues. And, one by one, as members of Congress and this administration become ex-Congressmen and ex-federal employees, we will get more honesty about both domestic and foreign policy. The input from insiders, no longer shackled by partisan talking points may help us to create better health care regulation.

First, we will have to forget so much of what these politicians said in the past. We need to say that it is all right now. Because the truth, no matter when it is delivered, should be welcomed. And it will set you free.


Picture – The Adult in the Room – David L Cunix

Tuesday, April 10, 2018

Just One Victory

Our current political climate celebrates All or Nothing. You are either on my side, for every issue, or you’re on the other side, one of the bad guys. There is little to be gained by that thinking. Over the long haul we are better served by finding ways where we can work together, to find middle ground, to search for just one victory on the path to a greater good. Today is one of those days to celebrate a win.

My March 4th post, (Un)Comfortably Numb, detailed my annual trip to Washington DC and my meetings with members of Congress and their staffs. As noted, my fellow insurance agents and I felt more welcomed this year, as if there was a general consensus that the status quo was no longer acceptable to any of the participants. Our credibility, our reputation as problem solvers with a long history of representing our clients in this battle, helped our elected officials focus on issues that we were bringing to their attention.

Many of us were particularly concerned with Transitional Relief, the ability to retain health insurance policies written and issued in 2010 after the Patient Protection and Affordable Care Act (Obamacare) was passed until the end of 2013 when the law was fully implemented. Many of us are dependent on our ability to retain these policies, both group and individual contracts, and wait nervously for the annual announcement. We were in Washington at the end of February. Last year’s announcement had been in early February. Would the Centers for Medicare and Medicaid Services (CMS) remember us this year or drop the ball?

This blog has mentioned the assistance my clients and I have received from Senator Sherrod Brown’s office, both with problems on the Federal Marketplace as well as with specific issues. One of the Senator’s senior legislative aides, a woman who specializes in public health financing, has met with us the last couple of times we were in Washington. We have kept in touch. She has a real interest in our issues and has sought our input about improving the PPACA. I sent a follow-up email to her yesterday morning. This was her response:

Hi Dave,

It’s like your ears were ringing! CMS just finalized the NBPP for this coming year and extended the transitional plans for another year. More information can be found here: and here: Please let me know if you have any questions or if I can get you any additional information.

I’m still trying to learn more about the COBRA issue – I think one way we might be able to do a better job of making sure folks don’t fall into this trap is by better educating individuals as they get closer to Medicare eligibility. What do you think?

SUCCESS! The links will take you to the CMS documents. The key for so many of us is the granting of Transitional Relief for another year. There is our victory.

There is also a link to five pages of modifications for 2019. Some appear to be purely cosmetic. Some of the changes may move us forward while others may serve to further destabilize the markets. It is way too early to predict how these changes will be interpreted by the various states. That will need to wait until we see what actions Idaho, Iowa, and others take based on these rules.

We go to Washington and Columbus to help our legislators understand how our clients are impacted by their laws, their rules, and their regulations. Today we celebrate a victory.


Picture – The Road To Victory – David L Cunix

Wednesday, March 14, 2018

You Can Rent Your Own Private Idaho

The Patient Protection and Affordable Care Act (Obamacare) is the law the Republican love to hate. They have spent eight years campaigning on the promise to Repeal and Replace or simply to Repeal the PPACA. The Republican controlled Congress passed over 60 meaningless bills, some just so that newly elected members could have the opportunity to cast a vote. It was only after the 2016 elections, when the R’s retained control of Congress and captured the presidency, that real action seemed unavoidable. We know how that worked out.

The strategy has shifted from repealing the PPACA to simply sabotaging the law. The recent tax law, with the elimination of the financial penalties for failing to own compliant coverage, is instructive in its construction. The Republican controlled Congress determined that it could not repeal Obamacare, nor could they remove the Individual Mandate from the law. They were forced to remove the penalty for not complying with the law. The law still stands.

And that brings us to Idaho

We have been talking about Idaho Governor C. L. “Butch” Otter (real name!) and his decision to create a whole new class of health insurance policies, one that looks suspiciously like the health insurance policies the PPACA eliminated. Governor Butch wanted to return to a time of medical underwriting, limited benefits, and policy caps. You know, the good old days. The details can be found in the blog post Rotten Potatoes. With the help of his insurance commissioner and our friends at Blue Cross of Idaho, Governor Butch was trying to leave the ultimate destruction of the individual health insurance market as his legacy.

Blue Cross of Idaho was prepared to announce plan designs for the new policies within weeks of the announcement that the walls had been breached and that the PPACA was about to fall in Idaho. And that is when the U.S. Department of Health and Human Services decided to do its job. This is the link to the letter to Idaho’s Governor.

The letter, signed by Seema Verma the current Administrator of the Centers for Medicare and Medicaid Services (CMS), echoed the Trump Administration position that the Patient Protection and Affordable Care Act is the worst thing that ever happened to Americans, “However, the PPACA remains the law and we have a duty to enforce and uphold the law”. And since the law is the law, you can cut corners but you can’t stage a blatant frontal attack.

Ms. Verma’s letter noted that the plans that Idaho wanted to create failed to comply with the law on numerous levels and that CMS, her agency, would be required to step in if Idaho chose to ignore the issues. She also detailed the fines that could be levied against any insurer who chose to participate in the Idaho scheme. Her public protection train doesn’t derail until the 4th page of her letter when she suggests that Idaho should focus on “short-term, limited duration health insurance”. You can’t own your own Private Idaho, but you can rent it.

This blog has discussed the value and problems of short term major medical policies. I normally have between 20 and 25 clients on short term policies. These contracts serve as the safety valve for

  • Individuals who accidently missed the enrollment period
  • Make too much to qualify for a subsidy but find the premiums too expensive
  • Make too little for a subsidy, don’t want to be on Medicaid, and couldn’t afford a regular policy
Short term policies ask a few underwriting questions, are for a limited number of days, and don’t cover preexisting conditions. These plans are not designed to be a permanent health insurance solution. The Idaho plans were. Idaho was trying to syphon off the healthiest risks to policies that would be useful – until they weren’t. As soon as an insured got sick, pregnant, or injured, the plan was to move them to the guaranteed issue, preexisting condition covering, safe haven policies of Obamacare. The healthy and lucky could stay on the special Blue Cross of Idaho policies forever, protected from the responsibility of being part of the general population risk pool.

There are ways to make the PPACA work better. Undermining the law, whether directly or indirectly, will not help us in the long run. Destabilizing the individual insurance market by eliminating the funding for the Cost Sharing Reduction Subsidies, defanging the Individual Mandate, or promoting short term contracts in lieu of comprehensive health insurance, hurt the American consumer. The residents of Idaho, and all of the other states, would be better served with an administration that was less focused on short cuts and work-arounds and more prepared to help the law achieve its stated goals – patient protection and affordable care.


Photo – Lost in my Private Idaho – David L Cunix


Sunday, March 4, 2018

(Un)comfortably Numb

There was quite a to-do at the Capitol last week. I happened to be walking by as the body of the late Reverend Billy Graham was being carried up the steps into the Capitol. Thousands of people waited in line over the next few days to pay their respects and celebrate his life.

I was in Washington last week for my annual meeting of the National Association of Health Underwriters and for the opportunity to talk with members of Congress and their legislative aides. The supporters of Reverend Graham seemed to be the only people celebrating anything in Washington DC. Last year’s trip was only a few weeks after the inauguration. The mood in Congress was “What are we going to accomplish FIRST?” This year the mood seemed to be closer to “What the Hell just happened?”

Over the course of four days I spoke with people from all across the political spectrum. To be clear, the federal employees (Congressmen, aides, and security personnel), the insurance agents, and the political professionals are all patriots who love our country and are trying to do what they think is best. That seems to be the first thing lost in these debates and smear campaigns. One may question whether self-interest sometimes clouds one’s judgement. We are all human. But constantly questioning someone’s patriotism gets us nowhere.

Why Bother – There were fewer people participating this year. I could be wrong, but I felt like our annual meeting of hundreds of insurance professionals from around the country was down 10% to 15%. This is understandable since most of us are paying own way and all of the instability of the last year has taken a toll on us. Still, the huge ballroom at the Hyatt is normally SRO. What really got my attention were the empty halls of Congress. Our appointments are usually shoehorned in right after one group and just before another. That was not the case this year. One Congressman might still be meeting with us had he not had to leave, well over 30 minutes into our meeting, to cast a vote. The smaller numbers of groups meeting with members of Congress speaks to the general questions of how or why anything is getting done while this administration is in the White House.

News – A Columbus area friend is running for the Ohio House of Representatives. He held a fundraiser at the Dubliner, a famous Irish pub a few blocks from the hotel. I mentioned to a woman from Middleburg Heights that the Dubliner has served as the Washington home for Morning Joe. She made a face and made clear her disdain for all things MSNBC. I thought of my westside friend while in the office of one of our Ohio Republican Congressmen. His reception area had FOX News on the wall-mounted TV. His inner office was running MSNBC. With this administration, where the position du jour may be blurted out on live TV or a tweet, you have to be open to receiving your news from all possible sources.

Why Bother 2 – We record both small victories and minor setbacks each year. This year will be no different, but I have reason to be hopeful. For one, both the Congressmen and their aides had the time to conduct meaningful policy discussions. For another, the silliness and intellectual dishonesty of Repeal and Replace may have finally been laid to rest. Here are a couple of things that we discussed last week:
  • COBRA as Medicare Credible Coverage – This is one of those down in the weeds issues that had no champions, only victims. COBRA doesn’t count as credible coverage. Senior who retain their COBRA coverage instead of enrolling in Medicare when they become eligible, are considered to be “late enrollees”, subject to a waiting period, and will pay a penalty for the rest of their lives! It is normally just a mistake. Retirees over 65 may not have access to good, free information. We can correct this. I am happy to announce that our efforts have been rewarded with the introduction this past week of H.R. 5104 - Medicare Enrollment Protection Act.
  • Transitional Relief – With all of the confusion at Health and Human Services (HHS), it is not surprising that the Grandmothered health policies have fallen through the cracks. These policies were written and issued in 2010 after the Patient Protection and Affordable Care Act (Obamacare) was passed until the end of 2013 when the law was fully implemented. Many of us are dependent on our ability to retain these policies and wait nervously for the annual announcement. There aren’t any policies sold in Ohio that can match the network access of the Anthem, Medical Mutual, and Golden Rule Grandmothered contracts. Every Congressman and legislative aide quickly grasped the importance of granting transitional relief for these policies. Some even thought that this should be simply granted permanent status. As with so many other issues, this would disappear without our constant vigilance.
  • Retain the employer tax exclusion – More than 175 million Americans get their health insurance at work. There were some proposals being floated to either cap the maximum amount of premium the employer could deduct or eliminate the deduction completely. Talk about destabilizing the market! There seemed to be little interest in overturning our markets in the offices I visited.
Politics in the Real World – The topic of Congressional Hearings came up during a conversation with a Republican Congressman. He brought it up, not me. He mentioned the lack of hearings as part of the overall failure of last year’s efforts to repeal Obamacare. He noted that “We’ve done nothing to bring the cost of health care down”. He had a real grasp of some of the nuts and bolts of the health care funding debate and expressed his regrets with the lack of tangible results. In many ways it mirrored the conversation I had with the Senior Legislative Assistant of a local Democratic member of Congress. I have met this particular aide several times and knew her to be a straight shooter. We discussed the anticipated November 2018 wave election. She expressed a sincere desire to not replicate the mistakes of this past year, to be inclusive, and to get things done. One party having significant majorities in the Senate, House, as well as the Presidency has been a shock to the system. The question is whether the ideologues will win out and the politics of Washington will careen wildly from one extreme to another or if the pragmatists from both sides of the aisle can regain control of the House and the Senate and return order, decorum, and respect to our institutions.

I was standing in a Senator’s office when President Trump announced on live TV an entirely new gun control policy. The staff didn’t even bother to look up knowing full well that he would reverse himself tomorrow. I get that. We’re all (un)comfortably numb.


Picture – There Had To Be A Moon Involved – David L Cunix

Picture – The Reverend Billy Graham – David L Cunix

Picture – Fighting The Crowd In The Hart – David L Cunix