Friday, December 21, 2012

Buried Deep Within The Law

December is my busiest month. The majority of my business clients prefer to renew or change their coverages as of January 1st. New deductibles. New Benefits. New Year. So wasting forty-five minutes of my time by taking a meaningless class and test were not on my agenda. But there I was, staring at the computer screen, plowing through the mindless drivel that the federal government feels every agent needs to review annually. AML training – anti-money laundering for the uninitiated.

Long before then Speaker of the House Nancy Pelosi told her colleagues that they needed to vote for the Patient Protection and Affordable Care Act “we have to pass the bill so that you can find out what is in it, away from the fog of controversy”, we were given Uniting and Strengthening America by Providing Appropriate Tools Required To Intercept and Obstruct Terrorism Act of 2001. You know it as the USA Patriot Act. A reaction to 9/11, it was signed into law by President Bush on October 26, 2001. It wasn’t until years later that the American people and the Congressmen who voted for it learned about the government’s new ability to legally spy on US citizens and the provisions concerning torture. And for the financial services industry – AML, the anti-money laundering rules.

Section 352 of the USA Patriot Act includes the requirement that financial institutions establish anti-money laundering internal enforcement. Each company must:
  • Develop internal policies, procedures, and controls

  • Designate an AML compliance officer

  • Institute ongoing training

  • Install an independent audit function to test the program

  • The insurance industry regulations went into effect on December 5, 2005, over four years after the law’s passage. Some of the rules make sense. Some are the result of regulators gone amok. Let’s be serious. Prudential is not worried that I am going to take three non-sequentialed numbered money orders, each for $5,000, and open up a life insurance policy for some drug kingpin. Pru is petrified that a federal regulator would find an agent operating without an up-to-date AML certificate.

    Rome is burning and we are too busy inspecting the fire extinguishers to have time to use them.

    The Patient Protection and Affordable Care Act (PPACA) is a complex law. It has to be. You can’t rework a sixth of our economy with a short paragraph and an emoticon. The new fees (taxes) to give this a chance to succeed are just about to begin. Rules and regulations are being written and promulgated. The exchanges are to be up and running in less than a year. Everyday brings something new.

    One of the new taxes, creatively named the Health Insurance Tax (HIT) is designed to raise $100 billion over the next ten years. This is a tax on health insurance companies levied, in part, on market share. A study conducted by Oliver Wyman for the industry group America’s Health Insurance Plans (AHIP) predicts that this excise style tax will result in significantly higher premiums. This should come as no surprise to anyone who has been paying attention.

    Other new taxes and fees debut next month.

    The major insurers are trying to learn not just what the new rules will be, but when these rules will begin. Does your current policy, purchased under a different set of regulations, end on December 31, 2013? Or, will you be allowed to keep your current policy till its annual renewal or even longer? Do you care? YES!

    If you are young. If you are healthy. If you don’t need any of the new benefits required of all future individual (self-pay) policies such as maternity or habilitative care, you will want to hold on to your current health insurance with both hands. Will you be allowed to retain your current policy? For most of you the logical answer is “Not for long.” These are the issues I’m asked about daily.

    Over the next ten months we will get a clearer picture of the new health insurance market, the policies, the distribution system, and eventually, the pricing. This has always been, first and foremost, about paying for medical services, not about the practice of medicine. But the delivery of health care will change as the money changes.

    Look around you. It would be very crowded here in Greater Cleveland if our population grew at the same rate as our hospitals and clinics expanded. Kaiser Permanente, The Cleveland Clinic, and University Hospital must believe that they know how to make the Patient Protection and Affordable Care Act pay off for them.

    The potential to build health care empires must be buried deep within the law. We, however, are probably just working the mine.

    Thursday, December 6, 2012

    Still Stuck Inside

    Will you indulge me? Will you return with me to a post I wrote on August 21, 2009? That post, Stuck Inside, was about an insurance agent, me, trying to give a quick, off-the-cuff answer to the question, “So, what would you do?”

    What would you do? That is the real question. It is incredibly easy to shoot down everyone else’s ideas. All ideas, born from the minds of imperfect humans, have flaws. And the more complicated the ideas, the more potential there is for mistakes. All of our plans have big, gaping holes. So designing a solution to any problem opens you up to derision. It is easy to do nothing. It is even easier to do nothing but snipe at those flawed ideas and the people who created them.

    This blog has consistently held that the Patient Protection and Affordable Care Act (PPACA) is a poorly written law that lacks both transparency and logical goals. Either the eventual plan is to have us in a national health plan or our guys in Congress are getting directions from Moses’s map maker. Flaws? We got ’em. But most of the people fighting the PPACA have spent their time picking the low hanging fruit and defending the status quo.

    This blog has contended that the PPACA is not only the law of the land, but that it was never going to be overturned. Deal with it. Kathleen Sebelius, Secretary of Health and Human Services, is busily churning out new rules and regulations. Some of these edicts from on high will help the American people. Some are patently absurd and will, hopefully, be changed. No matter, we need to start to prepare for a future that will soon be upon us whether or not we want it or are prepared.

    My August 2009 post, seven months prior to the passage of the PPACA, laid out a program where health insurance would be guaranteed issue, would cover all preexisting conditions, and would be mandatory. My off-the-cuff solution also included the concept of creating a limited number of uniform plans that would be easier for the consumer to understand, easier to compare, and would include preventive care.

    The President’s plan includes many of these ideas. I may quibble with what is included in the standardized plans and what all was thrown in to the preventive care catch-all, but THEY DIDN’T ASK ME. And you might not be a huge fan of the specifics had I been the author of the plan.

    The Exchanges are currently designed to offer four levels of coverage – Platinum, Gold, Silver, and Bronze. We are still getting information on plan design and specifics. My last post covered the Essential Health Benefits that each plan must include. The difference will simply be the percent of coverage paid by the insurer and you.

    The Cunix option included the idea of Medicaid being opened up to people earning up to 300% of the poverty level, paid on a sliding scale. The PPACA provides premium support and/or tax credits through the exchanges for people who earn up to 400% of the poverty level. That would mean a family of four may receive a tax credit for purchasing a policy through the exchange even though they have a family income of $92,200 (2012). By pushing individuals to the exchanges and making the premium support federal money, Washington has eliminated any potential problems or fights with recalcitrant Republican governors.

    My program included a number of starting places to create cost controls. The PPACA is eerily silent when it comes to controlling costs. But then again, there is a lot of wishful thinking built into the PPACA.

    The HHS has been dropping new rules on an almost daily basis. Last week it was announced that the federal government will be charging user fees to the insurers who market policies through the exchanges. These (premium taxes) fees, approximately 3.5%, will be on top of the new taxes imposed on a national basis to all health insurers as determined by their market share, and any state and local insurance tax. Some of this makes sense. This is how the Obama administration expects to pay for this transition and the ongoing process.

    Here is the fun part as it appeared in the New York Times:

    Erin Shields Britt, a spokeswoman for Ms. Sebelius, predicted that insurers would not raise prices. “Exchanges will provide already profitable insurance companies with access to 30 million new customers while cutting down insurers’ marketing and advertising expenses,” Ms. Shields Britt said. “Exchanges force insurance companies to compete and drive down costs for consumers. The congressional Budget Office has estimated consumers will save up to 20 percent on their premiums.

    And J. R. R. Tolkien wrote non-fiction.

    But sniping on the sidelines isn’t going to help. Jumping up and down and threatening to repeal the PPACA (attn: Republican run House of Representatives) only made things worse. Now is the time to talk to your Congressional Representative. The course can’t be reversed, but it can be modified. The Patient Protection and Affordable Care Act is an open-ended medical spending spree guaranteed to make private insurance untenable. Will our elected officials, Democrats and Republicans, work together to create effective cost controls, common sense limitations, and robust fraud enforcement? Those are just for starters.

    Now, before we’re stuck.


    Thursday, November 22, 2012

    It's Novermber and Everybody's Busy (Too Busy to Talk)

    The days before Thanksgiving are a time of unrelenting activity. Some people are finalizing the big meal for Thursday. Others are preparing for the December holidays. In fact, I’ve been told that there are even elves working overtime somewhere near the North Pole. Thanks to climate change they are wearing Hawaiian shirts, but they are still working hard.

    Speaking of working hard, the folks at the Department of Health and Human Services (HHS) have been very busy this week. On Tuesday, November 20, 2012, our busy elves at HHS released a new set of rules and regulations designed to flesh out the Patient Protection and Affordable Care Act (PPACA).

    Tuesday’s new rules and regs cover a host of areas from defining the benefits to creating the framework for future premiums and options. You can find the public relations version of all of this at Don’t worry about going to the government’s website. This will all be coming to you – on TV, on billboards, and door-to-door solicitation, if necessary – thanks to a special campaign.
    The new rules reaffirm the definition of the Essential Health Benefits (EHB). The PPACA demands that all policies offered for individuals and small groups provide coverage for a “core package of items and services known as Essential Health Benefits. EHB must include items and services within at least the following 10 categories”:
      1. Ambulatory patient services
      2. Emergency services
      3. Hospitalization
      4. Maternity and newborn care
      5. Mental health and substance use disorder services, including behavioral health treatment
      6. Prescription Drugs
      7. Rehabilitative and habilitative services and devices
      8. Laboratory services
      9. Preventive and wellness services and chronic disease management
      10. Pediatric services, including oral and vision care
      Most of this looks pretty reasonable. Though you may wonder how much that maternity benefit will add to the cost of a woman’s policy. And if that woman can’t have children, how much is she wasting?

      Employer sponsored group health policies have included maternity “covered as any other illness” for years. We know how to evaluate the risk and how much each policyholder needs to pay. That is, after all, the concept of insurance – evaluate risk and share the cost. What happens when the risk is open-ended? How do we share an unknown cost?
      #7, above, is coverage for rehabilitative and habilitative services and devices. We are all familiar with rehabilitative care such as physical therapy which is designed to restore the patient to his/her former state of health and previous level of skills. The current fight over rehabilitative care is about the number of treatments. Today’s policies cover 15, 20, or maybe 25 visits to the physical therapist. We don’t know if future policies will be allowed to have such limitations. But rehabilitative coverage is much easier to assess than habilitative.

      Habilitative therapies create skills. Teaching an autistic child to interact with his/her peer group is a wonderful thing. In fact, improving social skills and communication is life-changing for the children and adults touched by autism and certain forms of mental illnesses. Those suffering from other illnesses or conditions, such as cerebral palsy, have had their lives improved through habilitative care. Much of this has been open-ended, where patients weren’t actually cured, just made better. So as long as someone was willing to pay for services, another appointment was warranted.

      Both the government, through Medicare and Medicaid, and the insurance industry have fought habilitative care for decades. The insurance industry lives by black and white. Habilitative therapies exist in a grey area. The industry has avoided paying for much of these services by labeling them experimental or educational. That may end soon.

      Do you care? Is this good? As always, the answer is Yes and No.

      Please don’t get distracted by the pictures of your neighbor’s autistic child. This has very little to do with her. It is important to remember that the healthcare debate has very little to do with health. With the possible exception of someone personally touched by a particular condition, this is, and always has been, a discussion of how we compensate doctors and hospitals. Who gets paid from the deep pockets and who doesn’t.

      The insurance industry is still trying to retain the right to offer a stripped down contract that will exclude some of the open-ended coverages. It is far easier to price a policy that has fewer gray areas. A policy that doesn’t cover habilitative services; a policy that doesn’t pay for infertility treatments; a policy that included some limitations for rehab, would be significantly less than the federally mandated coverage. My guess is that we won’t have that option for long, if ever.

      Seeing how much these other benefits add to the cost of coverage would force us to finally have a national discussion about our priorities. What are we willing to pay for? It still appears that no one in Washington, Democrat or Republican, wants to have that discussion.

      And who can blame them? It’s November and everybody’s busy. Way too busy to talk.

      Wednesday, November 14, 2012

      Sorry, You're Screwed

      The letter came from The State of Ohio, The Ohio Department of Insurance, and Medical Mutual. Good news never comes with that many names on the top of the letter.

      We are sorry to inform you that your Ohio High Risk Pool coverage will be canceled at the end of the day on November 30, 2012.

      The letter was dated November 12, 2012.

      Some of the unhealthiest residents of the State of Ohio were being tossed off their insurance policy, the Ohio High Risk Pool. In less than three weeks they would no longer be insured. And nobody is standing in line to cover them. How could this happen?

      The Ohio High Risk Pool is part of the Patient Protection and Affordable Care Act (PPACA). A stop gap measure, the states were charged with the duty of offering coverage for the chronically uninsured suffering from significant preexisting conditions. The federal government also provided five billion dollars of which Ohio received $152,000,000 for the four year program.

      To qualify for the Ohio High Risk Pool you must prove:
      1. Citizenship
      2. That you have not been credible insurance coverage for at least six months
      3. That you have been declined by two insurers within the last six months
      4. You may skip #3 if your medical records show that you have a major illness that would have gotten you declined
      You can not have had credible insurance coverage in the six months leading up to your application for coverage under the Ohio High Risk Pool. This is a federal requirement. Neither the State of Ohio nor Medical Mutual of Ohio, the insurer running our plan, has anything to do with this rule. Some people who are not easily insured have purchased supplements, a better than nothing option. If something happened while they were attempting to find real insurance or qualify for an affordable program, these responsible people were trying to do what they could.

      My friend Dave is a conscientious insurance agent. He took a letter from American Medical and Life Insurance Company (AMLI) to the Ohio High Risk Pool. The letter, dated February 11, 2011 was sent to clients to advise them that their policy was no longer HIPAA credible coverage. Dave verified that since the AMLI CoreValue policy was no longer credible coverage, his clients, including family members, could retain this minimum semblance of coverage until they had six months of no real insurance and could enter the Ohio High Risk Pool. NO PROBLEM.

      It is those people, those responsible people who attempted to have some coverage, no matter what, who are being kicked to the curb. The letter from the State specifically notes:

      Our records indicate you were enrolled in an AMLI policy in the six months prior to enrolling in the Ohio High Risk Pool Program. Therefore, CMS directed us to cancel your coverage because you are not eligible for this program.

      The PPACA is a poorly written law. We know that. Worse, the rules and regulations are being written on the fly. What complies one day is non-compliant the next. We went through this with the grandfathering rules. The costs, both human and financial, can’t possibly be calculated.

      The Ohioans being kicked out of the High Risk Pool did nothing wrong. They followed the rules of that moment. We are talking about individuals who are gravely ill. What do they do now? 


      Sunday, October 28, 2012

      The Sky Is Not Falling

      A Power of Attorney. The elderly couple wanted to give me a Power of Attorney. They were convinced that President Obama is going to win re-election and that their Medicare coverage is in jeopardy. What happens when(!) he changes Medicare and they don’t get into my office fast enough to be protected?

      Can we give you a Power of Attorney to change our policies so that we have the right coverage?

      It was Republican Week at my office. I can normally tell whether my clients are Democrats or Republicans just by the questions they ask. The talking heads on FOX create a climate of fear and misinformation on some parts of the Patient Protection and Affordable Care Act (PPACA). Rachel Maddow and Ed Schultz create a competing sense of dread and foreboding amongst their viewers.

      I watch both channels so that I can anticipate my clients’ concerns.

      My last post, Collateral Damage, noted the unintended consequences of a badly written piece of legislation. But, the PPACA has helped a lot of people. In the interest of fairness, we should spend a moment or two discussing a few of those victories. All of these examples are from last week. And all involved Republicans. Key details have been changed to protect the identities of all involved.

      Bruce has been self-employed for over ten years. He was covered under his spouse’s health policy. When they divorced, he took full advantage of COBRA for the entire thirty-six months. The story then gets murky. Either a bad agent sold him a crappy policy or he cheaped out and purchased something that did not meet his needs. Either way, his health got worse, the mediocre policy didn’t pay for his care, and the premium became unaffordable. Bruce is now an unhealthy 56 year old with no insurance facing possible surgery.

      Bruce will qualify for the Ohio High Risk Pool policy. The premium isn’t cheap, $428 per month. It would be far worse if there wasn’t premium support built into the legislation. The Ohio High Risk Pool is not for everyone. Not everyone qualifies. The rules are complicated. But the PPACA is a lifeline for Bruce and he wasn’t the only winner last week.

      Jane is another Ohio High Risk Pool winner. She is 61. Jane was terminated by a major local employer last November. She could have been covered through COBRA if she could have afforded it. She couldn’t. She has a number of preexisting conditions that would result in an automatic decline if she applied for individual health insurance. Jane qualifies for the Ohio High Risk Pool policy and the $428 premium may be a challenge, but she has had a year without insurance. $428 is a gift.

      The Ohio High Risk Pool plan is not placed through an agent’s office. I have nothing to do with it and I am not compensated for helping people access this insurance. Educating the uninsured is just part of doing the right thing.

      Amanda has four sons, two in college, one in middle school, and her youngest is only 8. They are all healthy except for Billy, age 14. Billy is in remission, thank G-d, but he has had hundreds of thousands of dollars of medical care. He might not require additional expensive care. Who knows? I would have had a very hard time covering Billy three years ago. Today? No big deal. Amanda is healthy. The insurers will readily approve her. Billy and his brothers will go through underwriting to determine price, not insurability. The price will be a little higher, but the cost of insurance won’t even begin to reflect the potential cost of care.

      The PPACA allows Amanda to purchase affordable health insurance for her entire family. To deny this is to deny reality.

      I completely understood why the elderly couple was afraid. All day long they are bombarded with solicitations for different Medicare plans, pleas to support candidates who will fix Medicare, and television reports that the sky is falling. Whatever healthy skepticism they may have once had has been beaten down by the constant repetition of the same facts.

      The elderly couple came to my office to be protected. What they need was to be reassured.  


      Monday, October 1, 2012

      Collateral Damage

      It was 1986. A bank opened about ten new locations in the Cleveland area. Somehow or another I ended up as the life insurance agent for many of the branch managers. The bank’s marketing department decided to brand these guys as Financial Planners. I was sitting with one of my clients in his branch, a kiosk inside the Kmart at 260th and Euclid (did I forget to mention that all of these new branches were inside Kmart’s?) and laughed at the idea that he and his peers were Financial Planners.

      A Financial Planner is a stock broker with delusions of grandeur or an insurance agent with low self-esteem.

      It would be years and years before financial professionals like my partners Jeff Bogart and Kathy Browning would embrace the concept of fee based money management and financial planning would no longer be just another way to sell a policy, a loan, or an annuity.

      I bring this up not to laugh at the wide variety of people, qualified or not, who call themselves Financial Planners, but to remind you, dear readers, that in America anyone can claim to be an expert on anything. And in this age of disinformation overload, your email inbox and Facebook news feed are a constant source of rumor, innuendo, and out right lies.

      The health care debate is a prime example.

      This blog has consistently contended that the Patient Protection and Affordable Care Act (PPACA) is a poorly written law that fails to address our biggest problem, the cost of care. Badly written laws lead to poorly crafted regulations which are a disaster in execution. The unintended consequences are the people who fall through the cracks, in essence, the collateral damage. Today’s post is about a couple of these casualties.

      But it is important to note that the way to solve the inherent problems of the PPACA isn’t to scrap it (which isn’t going to happen) but to amend it. If you got lost on the way to Cedar Point would you turn the car around and take your kids back home, or would you stop, get directions, and get on the correct road? We need to correct our path. We need to amend the bill.

      The politicians and functionaries that created and backed the PPACA either have a different, unstated agenda or are just lost. Twice in the last few months I have had to deal with the consequences of a health care bill that ignores health care and costs and instead focuses on insurance reconstruction. They are my examples of collateral damage.

      The new law made insurance coverage on children guaranteed issue. We can’t deny any child coverage regardless of his/her preexisting conditions. So if we are taking the parents, we have to take the kids. That part is fine, but the other part, the part that was easily predicted by anyone who understands the process, was that the legislation eliminated “Children, only” policies. That is a huge problem.

      Some employers don’t choose to pay for the health insurance coverage of dependents. I was able to save families, usually lower income or middle class, a lot of money by writing policies that covered just the kids. If there was an unhealthy child, he/she would stay on the parent’s coverage. That, however, is a discussion of choice and savings. What if there isn’t a choice?

      What happens if someone is a single parent? What if that individual is severely ill or injured and after a year plus of treatment is granted Medicare? Who covers the kids? The quick answer – NO ONE. There isn’t a regularly priced major medical policy in the marketplace for a couple of healthy children. After considerable time and research I was able to find a short term catastrophic major medical policy. I have used this option twice in the last few months and shared the information with my peers.

      The new Summary of Benefits and Coverage (SBC) regulations kicked in last week. We are just learning how this will impact employer based health insurance policies. We know that this regulation will help people find out what is and isn’t covered under their health insurance policies. We also know that it will prevent employers from changing policies quickly if their business environment forces them to cut costs. That second point is significant. Restructuring benefits, with the same insurer or with a different company, is how many of my clients were able to retain employee benefits during this last recession. What do we do now? No one knows.

      The PPACA is a classic example of the blind leading the visually impaired. The experts in Washington, like many so-called Financial Planners, are self-anointed. Without a clear understanding of how their goals impact the average American’s realities, we have laws that may be well-intentioned, but have real, negative consequences for lots of us.
      And do you know what we call those Americans, the ones who suffer from the mistakes of others? Collateral Damage. 


      Monday, September 10, 2012

      A Spoonful of Sugar, The One Hundredth Post of Health Insurance Issues With Dave

      Before we get started, this is the one hundredth post of this blog. It started in February 2009 as one of my leadership tasks as president of the Beachwood Chamber of Commerce. I have had tremendous assistance along the way from David Toth and Brad Kleinman, who got me started, and my faithful team of proofreaders and kibitzers: Sally Mandel, Jennifer Kuznicki, Jeff Bogart, Felicia Martinez, Susie Sharp, and my blogging buddies at the Lake Erie Moose Society. This blog now appears in three formats and has readers across the country.

      Mitt Romney, former Massachusetts Governor and GOP candidate, has decided to re-embrace his Romneycare. On yesterday’s Meet The Press, Mr. Romney again told us that he would repeal Obamacare on his first day in office. That’s not new. David Gregory then asked him about the people who have benefited from the Patient Protection and Affordable Care Act (PPACA) such as adult children in their 20’s and people with preexisting conditions.

      I’m not getting rid of all of health care reform. Of course there are a number of things that I like in health care reform that I’m going to put in place. One is to make sure that those with pre-existing conditions can get coverage. Two is to assure that the marketplace allows for individuals to have policies that cover their family up to whatever age they might like.

      We haven’t learned a thing. The first edition of this blog discussed the difficulty of making tough, adult decisions. It has been three years, countless pages of legislation, rules and regulations, and a couple of election campaigns and we haven’t begun to move forward. It is one thing to use a spoonful of sugar to help the medicine go down. It is quite another to skip the medicine and eat all of the sugar.

      Before Mr. Romney’s surrogates have a chance to take to the airwaves to tell us that he isn’t backsliding and that their candidate really, really hates Obamacare, all of it, let’s go over a few of the basics:

      • We can ask questions and underwrite with the option of pricing based on the risk or we can insure everyone and come up with an average price.

      • Healthier and younger people will pay more under an average price system.

      • Many of the healthiest and youngest would pass on coverage until they needed it, if given the chance.

      • The current healthcare legislation and debate has almost nothing to do with healthcare. We are simply discussing how we pay providers.

      • Inaction is a whole lot easier than action. Specifics are down right dangerous.

      Elected Republicans have little interest in repealing the Patient Protection and Affordable Care Act, not because they like it or agree with it, but because the alternative is worse. The alternative would be the responsibility to create a better program! The PPACA created a bridge plan that insures the previously long-term uninsured. It was (is) a costly program that is helping individuals with expensive, life-threatening preexisting conditions. Repeal the law first and then create the alternative? What happens to those people? If the law is repealed, or if the House Republicans simply carried out their threat to defund the PPACA, these people are no longer insured.

      Less dramatic, the number of uninsured twenty-somethings has also declined in the last year. The PPACA is the only reasonable explanation. Dump the law and there is no guarantee that the insurers won’t dump the 25 year old still clinging to mom and dad’s policy.

      If the Republicans had ever been serious about changing and improving the Democrat’s legislation, there would have been an honest effort to amend it. Instead the second bill to be pushed through by the House Republicans was H.B.2 Repealing the Job-Killing Health Care Law Act. So nothing got done. But doing nothing was the goal. It is far easier to campaign and raise funds in opposition to legislation than to create and defend your own solutions. If Mr. Romney wins the White House and the Republicans won the House and Senate, the most popular guy in Washington would be the Democrat responsible for the filibuster in the Senate that would save the Republicans from themselves.

      So where are we? We still have a system that is based on demand, not care, and certainly not about outcomes. Our hospital buildings multiply like rabbits. Television and radio feature an almost endless barrage of ads for medications and treatments, many with the promise of little to no charge for the insured or aged. And we have become addicted to free stuff, whether it free exams, free pills, or free scooters for those who are no longer mobile. We want to tax others and limit access to care as long as we get to choose how and how long we live.

      Where else but in the United States would you have attorneys advertise how to shift your assets to your children so that the government (Medicaid) will pay for your nursing home expenses?

      So it may be time to bring healthcare into the healthcare debate. What care are WE willing to fund? What care are we willing to forego? Will the rich be able to get better care than everyone else? Of course. We don’t pay for cosmetic surgery now. In the future we might not pay for heart transplants for 70+ year olds. Or maybe we will have a national discussion and make that choice.

      I just hope that we’re doing better before the 200th edition of this blog.


      Thursday, August 30, 2012

      A Basic Principle

      A basic principle of politics is that the rules don’t matter if they inhibit your progress or agenda, but the rules are sacrosanct if they inhibit your opponents’ agenda or progress.

      The Republicans have installed a Debt Clock at their convention in Tampa as a way to visually highlight their disdain for fiscal irresponsibility. The Republicans, with a Democrat in the White House and Harry Reid leading the Senate, are now deficit hawks. Even Condoleezza Rice, in her speech last night to the delegates, stressed the importance of getting our financial house in order. But it has only been a few years since Paul Ryan was voting for Medicare Part D and bailouts and Vice-President Dick Cheney famously declared that “Deficits don’t matter”.

      Hypocrisy and the total absence of intellectual honesty are just as common on the other side. Up is down and down is up when it is politically expedient. The current Medicare debate is a perfect example.

      Let’s take a two second detour to the “Bush Tax Cuts”. Congress, especially Republicans, like to pretend that revenues will increase if the tax rates decrease. But knowing that that is all BS, the cuts of 2001 and 2003 were made temporary and designed to end within ten years. This allowed Congress to ignore the fact that the legislation was not revenue neutral. They didn’t have to acknowledge the debt they were creating. Congress has been fighting about retaining those cuts for the last few years.

      The Patient Protection and Affordable Care Act (PPACA) was billed as revenue neutral, too. It never was. Part of the funding for the PPACA came from the CLASS program, the ill-fated long term care policy that has already been eliminated. Part of the funding was to come from the new 1099 rules, which have also been repealed. There are still numerous fees and taxes sprinkled like fairy dust throughout the law. And 716 million dollars comes from future Medicare spending.

      Ah Ha! The Republicans are right. He is gutting Medicare.

      No, not really. As David Wessel notes in today’s Wall Street Journal, both Obama and Ryan remove a similar amount of future funding from Medicare. Mr. Romney has now backed himself into a corner and pledged to restore the money. That too will change.

      The problem is that none of these men are at all credible when discussing this issue. The numbers never add up. The details never include the HOW something will work.

      Where are we now?

      1. Medicare was designed to pay about 75% of a senior’s health care expense

      2. Our current system incentivizes care

      3. Our current system creates an environment where fraud and abuse are almost inevitable

      4. We have no way to cap expenses currently

      5. About 30% of Medicare dollars are spent on a person’s last year of life

      How do you control costs? The obvious answer is to reverse as much of the above as possible. How do you lose an election? The obvious answer is to attempt to reverse any of the above.

      The President has proposed the creation of the Independent Payment Advisory Board (IPAB). By setting standards in both care and pricing, the government would begin to get a handle on unnecessary procedures and costs. The IPAB will classify certain questionable treatments as elective or self-pay. If you want it and can pay for it – go ahead.

      Mr. Ryan would have you buy a private insurance policy. He would give you just enough to purchase a basic policy, the second worst in the marketplace. If you want more coverage, a plan that might pay for certain physicians or medications, you will make up the difference. The insurer will classify certain questionable treatments as elective or self-pay. If you want it and can pay for it – go ahead.

      The results are about the same. The wealthy will always have access to care. The rest of us should be OK. If all of this looks vaguely familiar, think about the number of prescription medications that are now available over the counter. OTC doesn’t require a prescription, so the government (Medicare, Medicaid, and government employee coverage) and the insurers save money. No doctors’ visits. No coverage for the cost of the drug. If you want Prilosec, pay for it.

      Albert Brooks, in his dystopian novel 2030, offered a vision of the U.S. where the Right To Life movement shifts its focus from abortion to preserving, at any cost, the lives of the elderly. Is it that far fetched to envision warehouses of comatose elderly connected to expensive hardware, alive in name only? Would a Republican Party ready to extend the protections of the 14th Amendment to the unborn require unlimited care for the brain dead? And if that care is mandated by the government, will it also be unfunded?

      The answer – Perhaps. See all of those rules about small government vs. large government; regulations vs. the free market are only as strong as the special interests pushing our politicians. The good news is that our politicians occasionally surprise us.   DAVE

      Wednesday, August 15, 2012

      Lie To Me

      So, which is better? Would you prefer a politician who tells you whatever he thinks you want to hear, whose only core commitment is to his own election? Or would you rather have someone who is clear-voiced and unashamedly direct in his pursuit of an agenda that even his followers consider unyielding?

      My friend Bill (name changed) has a problem. Four years of President Obama are more than enough for Bill. Health Care. Foreign Policy. The Economy. There have been few bright spots for Bill, a moderate Republican. And moderation is the issue. He could vote for Mitt Romney, he told me and anyone else that would listen, because once in office Romney was the candidate most likely to rein in the whack jobs in the House.

      In other words, he was hoping that the guy running for President was a pendulum. He has been left of Kennedy and right of Gingrich. Once elected, he should just flop into the middle.

      This past Saturday morning, Mitt Romney chose Paul Ryan to be his running mate. On Saturday afternoon, Bill threw up his hands in disgust.

      Since this is Health Insurance Issues With Dave, we should take a look at what will be the key issue of the campaign and the subject of millions of dollars of TV ads – Medicare.

      Does Paul Ryan want to end Medicare as we know it?

      Yes and No. The 2011 budget Mr. Ryan prepared and packaged as The Path to Prosperity: A Blueprint for American Renewal originally replaced the current Medicare program for all seniors in the year 2022. The Democrats beat that proposal like it was a piñata at a ten year old’s birthday party. The 2012 version, crafted in part with Ron Wyden (D-Ore), retains traditional Medicare as an option, thus killing it more slowly over time.

      This blog has covered Medicare numerous times. It is important to note that Medicare was never designed to cover 100% of a senior citizen’s hospital or doctors’ bills. The first anniversary post of this blog included a complete breakdown of what Medicare does and doesn’t cover.

      We should also note that the only time Either Side is telling the truth is when they are deriding the other guy’s plans for Medicare. The President does cut (mostly in future growth) over 700 billion from Medicare. But Mr. Ryan’s plan does not restore the cuts. Mr. Romney initially endorsed the Ryan budget while offering a vague statement of ideals designed to give the impression that he has a different plan.

      The current Medicare spending for a typical 66 year old is currently around $5,700 per year. Both the President's plan and Mr. Ryan's assume a significant rise in cost to the government over the next 18 years.

      The cuts aren’t the only detail the two plans share. Insurance Exchanges, the expensive new marketplace to purchase insurance, may be a sore spot for Republican governors, but Mr. Ryan is a big fan. The Patient Protection and Affordable Care Act (PPACA) utilizes exchanges for all ages. Mr. Ryan wants to set up exchanges, too, but only for senior citizens.

      So what are the differences between the President’s plan and Mr. Ryan’s? According to The Path to Prosperity website, the most important element is that the PPACA creates the Independent Payment Advisory Board (IPAB) to orchestrate Medicare cuts. Mr. Ryan’s site raises the possibility of faceless bureaucrats rationing access and randomly denying needed health care. It is very scary.

      The Ryan solution? Premium Supports / Vouchers. Starting in 2023, new Medicare beneficiaries will be guaranteed a ticket to the next to the cheapest (not the cheapest, the next one up!) insurance option in the marketplace. There will be more comprehensive plans available to those willing and able to pay the difference. Mr. Ryan envisions doctors, hospitals and insurers fighting for your partial payment.

      You won’t be denied the opportunity to have access to any cure, any doctor, any hospital – which you can pay for.

      But the 2012 plan keeps Traditional Medicare as an option.

      If you like your current insurance, you will keep it”, President Obama said during the health care debate. Those of us in the business knew that that was impossible. The grandfather rules were confusing and contradictory. The insurers could only maintain policies operating under separate regulations for so long. Medicare Part D, the underfunded Republican Rx program introduced in 2003, eliminated Medicare Supplement Plan F which was saving my clients a lot of money. It is hard to pretend that traditional Medicare, Medicare as we know it, would survive the Ryan plan.

      Under the Ryan program, people who turn 65 prior to 2023 (such as Dave Cunix, class of 2020) will be allowed to stay on the current system. New beneficiaries will be offered the new system or an updated version of what we now have. How will funding for these different options be maintained? What will actually be the mandated minimum coverages? How much more will it cost for the government to regulate two systems? With no new healthy retirees coming into traditional (pre-2023) Medicare, how long will it be before we have a death spiral?

      The possibility of capping our current Medicare system with no access to new, healthier members is why this debate is not limited to Americans under the age of 54. We, anyone who has the hope of seeing 2030, would be impacted by the Ryan plan.

      Where does that leave us? We have out-of-control costs, no idea what we should and shouldn’t cover, and little willingness to pay what it would really take to get the job done. It doesn’t solve any problems, but sometimes, I guess, it does feel better when they just lie to me.


      Sunday, July 29, 2012

      One Hundred Days

      The woman on the phone was adamant. She demanded to know what benefits are now a part of new health policies and what does she have to do to change her old contract to a new one. Damn it, she wants her share of all of the free stuff. It was the second one of these today. I told her that she was already getting the no copay annual preventive care visit. Neither she, nor her twelve year old, had any need for the new birth control, IUD, and Morning After Pill benefit. And since her daughter is only twelve, the opportunity to stay on her parents’ policy to age twenty-six is hardly relevant. It didn’t matter. She KNEW that there was something that someone was getting that she wasn’t.

      We have reverted to a nation of ten year olds, jealous of the kid who broke his arm and now has a cast. Where is our cast? I want my cast, and crutches, too.

      And so we begin the next stage of the Patient Protection and Affordable Care Act (PPACA), the over-promise and under-deliver phase. The calls come in daily from people who believe that they are suddenly going to get fabulous coverage for free. “The doctor told me that I can’t be turned down or charged extra even though I have Type I Diabetes and a stent”, the gentleman insisted last week.

      I have begged physicians to honor a simple agreement. I won’t practice medicine and they shouldn’t practice insurance. It makes sense to me.

      It is important to again point out that we are not talking about health care. We are discussing the payment of health care services. Who is going to pay for the doctors, hospitals, and other medical providers and products?

      In this highly politicized environment, this issue may be the most contentious of all. There are a couple of reasons for the heat:
      1. We are talking about almost 20% of the economy
      2. We are potentially discussing life and death
      3. We all have a stake in the final product
      4. We all think we know what we are talking about
      Heat, but no light. The truth is that the differences between the real actions on the right vs. the left are hard to find. So the fight isn’t about real differences, but about vague notions of entitlement. The Republicans promise to repeal “Obamacare” and institute patient-centered health reform, a term that happens to test well in focus groups but means more than simply eliminating malpractice suits.

      Look at Medicare Part D (Rx), a program that was created by a Republican controlled House, passed by a Republican controlled Senate, and signed into law by a Republican President. Here is a law that trampled on patients’ rights, states’ rights, and common sense. But it did help certain people get reelected and did a world of good for both the insurers and the drug companies.

      When buying and selling are controlled by legislation, the first things to be bought and sold are legislators. - P. J. O'Rourke

      So one side has a large segment of the population frothing at the mouth in anticipation of more free stuff, while the other side is desperately trying to convince Americans that the current system is a stone’s throw away from perfection. Of course, the only perfection is the cynicism that both sides have mastered.
      Medical costs are rising as doctors and hospitals adjust pricing in anticipation of more government involvement. New fees, like facility charges, are appearing on our bills. Medical buildings are now hospitals, and that increases all charges. Your insurance premiums reflect those increases. There isn’t anything complicated in this. Every time the cost of care increases, every time you are given a new ‘free” benefit, every time the definition of what constitutes preventive care is expanded, your premium has to increase.

      And if the government, an organization incapable of comprehending the concept of a balanced budget, prevents the insurer from raising the premium as the costs increase, the policy is terminated. Governments can print money. Insurers can not.

      We have just less than 100 days till the election. Just under 100 days of exaggeration, distortion, and out-right lies from both sides. But one day, a year from now or maybe two, you will need to go to the doctor. Who negotiates the fees, who processes the paperwork, and who writes the checks will matter that day. If you happen to talk to any of the people running for office, ask them who is going to be doing that for you.

      And more importantly, ask them where the money is coming from.


      Tuesday, July 17, 2012

      Follow The Money

      This may come as a total shock to some of my readers, but even here, in the USA, the greatest country EVER, there are poor people. For the purposes of this blog post, it doesn’t matter why some Americans are poor. It is irrelevant as to whether the poor have had access to help or if they have abused the programs designed to lift them from poverty. It doesn’t even matter if there aren’t enough jobs or if they are too lazy to work.

      I simply need for you to admit that there are poor people. Nod your head if you are with me.

      Great. Now that we all accept that there are poor amongst us, we are no longer capable of pretending that they don’t exist. They do exist and the poor – adults and children – have health care needs. They can’t help it. They are human. The poor get sick. Their children suffer injuries.

      Who pays for the health care of the poor? We do. We pay in the higher taxes that fund Medicaid. Our costs for doctors’ visits, hospital stays, and major testing are inflated to help cover the costs of the uninsured and the lower reimbursement rate of Medicaid. And hospitals bear the burden of “charity” care.

      Medical providers may not like Medicaid, where their payments are a political football, but some compensation is better than none. That’s why our major local hospitals are counting on the Medicaid expansion of the Patient Protection and Affordable Care Act (PPACA). The possibility of extending coverage to 133% of the federal poverty level, which is about $30,000 for a family of four, would protect a lot of people.

      Two other key elements: The PPACA adds childless adults to Medicaid, people usually not covered by this program. And, in an effort to encourage more primary care doctors to accept Medicaid patients, family doctors will now be paid at the Medicare rate.

      The recent Supreme Court ruling made that expansion optional. Some states may participate. Some may not. Governor Kasich is still weighing his options. There are reasons, beyond the political, for each state to participate or to pass on this program.

      The negatives are easy: Yes, the federal government is committed to covering the bulk of the initial cost, but what happens if the money stops? Can the federal government, regardless of who is in the White House, be counted on to honor this obligation? History casts doubts on Congress’s willingness to fund Medicaid, cut expenses, or resolve issues. Worse, the money, if it does come, isn’t forever. No one really knows how much this will cost the states after 2020.

      Another issue is the increase in pay to primary care physicians. There was a real interest in funding this provision when the Democrats controlled the House of Representatives. Today, none at all. If this is initiated and funding for this part of the program ends, can the Ohio legislature, for example, screw the Cleveland Clinic and cut physician compensation? Congress budgeted $11 Billion for 2013 and 2014. It takes a willing Congress to allocate another penny.

      It is important to remember that all cost estimates are, at best, guesses. New diseases, new treatments, new rules, and greed will all affect the final taxpayer outlay. Did anyone predict the AIDS epidemic in 1980 and the costs associated with the treatments? New and expensive medications and treatments are being developed here, in Cleveland, and around the world. It is impossible to predict, with certainty, the costs for care three, four, or eight years from now. We are writing Blank Check commitments.

      Rule changes must also be a major concern. Did any member of the House or Senate know in March 2010 that the Preventive Care Benefit of the PPACA would include free birth control pills, IUD’s, and the Morning After Pill? Of course not. What will suddenly be covered, for free, under the Medicaid expansion?

      So what are the positives? There is only one. If we accept that there are, and always will be, poor amongst us, then we have to make a decision as to whether or not we care. Are the poor our responsibility? If so, then we must craft a proper plan designed to meet their needs. If not? Well, I prefer to not think about a country that chooses “If not”.

      This program, the Medicaid expansion, fails like so much of the Patient Protection and Affordable Care Act because of its lack of straight forward purpose. It is time to stop pretending that spending money will save us money. The Obama Administration needs to sell its vision to the American public. Tell us why we need to take action and how much it will cost.

      This isn’t about health care. It is about how doctors, hospitals, and other medical providers get paid. And if you want to understand this, you have to follow the money.


      Monday, July 2, 2012

      A Rose By Any Other Name

      “As a Democrat, you should be outraged”, the client said in lieu of “Hello”. I paused for a moment and he identified himself. I replied that I’m seldom outraged. “Weren’t you shocked by the decision?” Of course, if he had ever read this blog he would have known the answer. “Nope, I’m not shocked.” “You knew that Roberts would do this”, he asked incredulously. “No”, I replied. “I had no idea. No one did. The pundits and blowhards on both sides told their audiences what they wanted to hear. No one really knew. I never wasted a moment worrying about the Supreme Court or guessing the outcome. You can only be shocked if you believed in the prognostications of a bad guesser.”

      “But it is a tax! Obama said it wasn’t a tax, but it is. This is the largest tax hike in U.S. history.”

      If I may quote the hero of the right, Ronald Reagan, “There you go again.” Every time a Democratic president raises revenue, it is the largest tax hike in U.S. history. What possible pleasure could they derive from yelling “Wolf!” so often? When will even they grow tired of this refrain?

      And so I reminded the client and others that I’ve talked with over the last few days that a rose by any other name would smell as sweet. Governments tax us. Period. Sometimes the legislators use the word TAX. Sometimes we are treated to the threats of penalties or fines. We are forced to purchase licenses and permits for everything from driving a car, to fishing, to installing a new hot water heater in certain suburbs. They are all taxes.

      A new law was recently passed in Beachwood forbidding the use of a hand operated cell phone while driving. Does Beachwood really care? Get serious. How often have you seen a Beachwood patrol officer driving while talking on a cell phone? But this new law carries a fine (tax) of $101 and two points on your driving record. This is just another way to fill the depleted coffers.

      I view all taxes, fees licenses, etc… the same. They feed the addiction politicians have to other people’s money. Some of us place a great value on defense and military spending. Some of us feel that more help should be given to the poor and less fortunate. And of course, there are those that believe that our job creators need more help and incentives. If funds are unlimited, there is no conflict. But funds aren’t unlimited, so the arguments continue. What we have not had is an honest debate about priorities. Do we care enough about defense, healthcare, poverty, et al to spend some of our own money to solve these problems?

      So, let’s stop the silliness about taxes and get back to the matter at hand. Does the Patient Protection and Affordable Care Act (PPACA) cover the uninsured (allegedly 50 million Americans) and control costs? My answer is still NO. Have the Republicans put forth a comprehensive alternative? Also, still NO.

      You can’t beat something with nothing.

      Millions of dollars have been spent by insurers, government entities at every level, and businesses to comply with the PPACA. Simply repealing the law makes all of that money wasted. Though some Americans have been hurt by the law, others have benefited. Repealing the law runs the risk of eliminating their insurance coverage. Repeal without a better, more comprehensive solution, is irresponsible.

      Repeal and Replace is cynical political rhetoric if there isn’t another option ready to fill the void. Responsible lawmakers, more focused on governing and the public good, might consider a different R word, Revise.

      Working together, something that has yet to be tried, our legislators could attempt to create an amended PPACA that might have a better chance at accomplishing a couple worthwhile goals. That law might not be as useful as a fundraising tool, but could help to deliver affordable care to more Americans.

      What will it take? The first step may be a little intellectual honesty. The second is to notice the flowers hiding amongst the thorns.


      Sunday, June 24, 2012

      And Now, A Word From Our Sponsor

      My favorite, my absolute all time favorite, involved a spaceship hovering over a farm house. As a tractor beam guided bottles of Stroh’s Beer from the refrigerator to the vehicle above, the farmer deadpans, “Don’t surprise me none.”

      What are some of your favorite television commercials? Do you like the new La Quinta spots that parody tired sales clichés? Are you a fan of locally produced ads? The Cleveland market has several ads of young girls asking you to love your floor or Chevy as much as they love their daddies.

      Which ads are you going to miss?

      It all ends today. Local commercials were already being crowded out of the market by ads for and against President Obama, for and against Governor Romney. The candidates and their super PAC’s have an almost endless supply of money to run ads in a swing state like Ohio. But the Supreme Court decision is due today, June 25, 2012. The Court’s decision on the constitutionality of the Patient Protection and Affordable Care Act (PPACA) will dominate the airwaves for the rest of this year.

      The Verdict? I have no idea. You will have that answer by the time you read this. The Court’s decision is just one piece of the puzzle. It is what the President, the Congress, the individual states and the American people do over the next eight months that will give us the entire picture.

      The first actions will be the most meaningless. Unless the decision is completely, totally on one extreme or the other, both sides will declare victory. Both sides will treat that part of the ruling that favors the other side as an insignificant set-back that can be easily remedied. In the unlikely event, in my opinion, that one side or the other completely wins; the losing side will vow revenge and cry politics.

      In any case, the ads start tomorrow. Both the Democrats and the Republicans will use the Supreme Court’s decision as the main reason to vote for their guy and the rest of the ticket.

      The first victim of the Supreme Court’s ruling won‘t be any section of the PPACA. The first casualty will be the Truth. Black will become white. Day will become night. If you become confused, so much the better. And, if you are undecided and choose to stay home on Election Day, then they will have won. The hard-core of both parties, the people who are so sure, will always turn out. It’s you, the people who are up for grabs, that can’t be trusted to vote for the right guy.

      So there will be ads, non-stop, till Election Day. And you will hear claims and counterclaims. You will be bombarded with meaningless statistics and weepy old people. What you won’t get is any nuance or a whole lot of truth. What will be missing are young girls that love their daddies and wall to wall carpet.

      And now, a word from our sponsor.


      Wednesday, June 6, 2012

      A Pack Of Wild Dogs

      Your ten year old comes crashing through the door with a story of being chased home from school by a pack of wild dogs. Do you
      1. Grab a shot gun and your copy of Old Yeller
      2. Call 911
      3. Pour a glass of milk, hand him a cookie, and return to whatever you were doing.
      All of the parents out there smiled and chose option #3.

      However, if you child would have burst through the door and said that a dog had chased him home, you would have gone to the door fully expecting to see a neighbor’s German shepherd, collie, or great Dane.

      My favorite ten year olds are Doctors Arthur Lavin and Michael Devereaux the co-chairmen of a local lobbying group, Doctors for Health Care Solutions. Longtime readers of this blog remember this group as the stage props who show up with their white lab coats whenever a politician endorses the President’s health care plan.

      Doctors Lavin and Devereaux, along with their own pack of wild dogs, surfaced again in last Sunday’s Plain Dealer. Appearing, fittingly, on Page 3 of the Forum (opinion) Section, they weaved a fact-less tale of illness, greed and desperation.

      It is tempting to disassemble their article one line at a time. Several clients, one a young woman with a serious insurance issue and a far more serious health problem, have already participated in this exercise. I will try to keep this down to only a few of the obvious flaws.

      The plot: A forty-five year old healthy female, a middle class Greater Clevelander with a good job and “excellent health insurance”, suddenly comes down with multiple sclerosis. Her insurance company drops her. Without insurance, her doctor the alleged hero of this story, drops her. Bills pile up. Treatments fail to keep her healthy enough to work. She loses her job and ends up on Medicaid. Now the government spends $40,000 a year for the doctors to treat her.

      WOW! It is too gruesome to imagine. It’s like a pack of wild dogs chasing a ten year old home from school.

      She lost her insurance? How? You can not be cancelled by your insurance company due to a health condition. Was this “excellent health insurance” from her employer? How did she lose the coverage BEFORE she lost her job?

      The article is filled with random falsehoods and exaggerations. At one point our creative doctors claim that women pay roughly double the price of men. The key is the word roughly as in at 6’3” I am roughly 10 feet tall. I will be happy to bore you with the specific rates of where women are more expensive than men and where men are more expensive than women upon request.

      The truth is stretched beyond recognition when the doctors deal with the number of uninsureds, the difficulty in acquiring insurance, and the benefits of the Patient Protection and Affordable Care Act.

      Why does this matter? Even the most casual, neutral observer will see this for what it is, propaganda. And that is the problem. Most of what we are seeing is either hysteria from the left, like this, or hysteria from the right that would lead you to believe that the sick are dying on the streets in Canada. It is all so extreme and so unlikely that we start to ignore everything. It is understandable to scream “A plague upon both houses”, but the health care system affects all of us. We ignore this mess at our own peril.

      There are real problems with the status quo. There are people falling through the cracks. Doing nothing solves nothing. Unfortunately, the PPACA does not adequately address many of these issues. But we will never get anything done if we are spending all of time fleeing from packs of wild dogs.


      Monday, May 28, 2012

      Isn't That Convenient?

      The client was adamant. He didn’t want birth control covered and he didn’t want abortion. And because he had over fifty employees and because the year was 1991, I could get his group health insurance policy issued to his specifications. Was this a decision based upon his values and personal religious beliefs? Not hardly. The elimination of these benefits reduced his premium. He was not concerned about the needs of his female employees. The spouses and children of his male employees were not his problem. His daughter-in-laws could afford birth control pills and his granddaughters were still in elementary school.

      If that same conversation were held today, his request would be couched with religious overtones. But truth be told, he would have pretended to have been Catholic if it would have saved him 2%.

      The Sunday Plain Dealer had a half dozen letters to the editor about the recent lawsuit. A group of forty-three Catholic organizations including the archdioceses of New York and Washington, the University of Notre Dame and Catholic University of America, are suing to block requirements of the Patient Protection and Affordable Care Act to provide birth control, IUD’s, and the morning after pill. The letters feature Catholics defining Catholicism, Catholics attacking anyone out of step with the current Pope, and Catholics clarifying their belief that theirs is the only true version of Christianity.

      As a non-Catholic, non-Christian, I have the opportunity to observe what appears to be a lot of heat, but very little light.

      The fun part of this is that the PPACA does not guarantee these benefits, just the fight.

      Free Preventive Care, no copays, deductibles, or coinsurance, is a key element of the Patient Protection and Affordable Care Act. It is the Obama administration and Kathleen Sebelius, the Secretary of Health and Human Services, who chose to define birth control pills, IUD’s, and the morning after pill as part of Preventive Care. That was a deliberate choice.

      But when it comes to the PPACA, almost everyone is pro-choice. The Democrats chose to ignore the parts they don’t like. Republicans choose to ignore the parts that they once endorsed or created.

      Are there people truly offended by the birth control provision or the individual mandate? Of course. But like my client of twenty years ago, much of this appears to be convenient agitation. They don’t want to implement the program and this is the excuse du jour. There are costs involved with any improvement in access to care or treatment. In our system, it will be the employers who will bear that burden. There are also some Americans who will disagree with this President no matter what. Some of those people are now, for the first times in their lives, rooting for Notre Dame.

      Will the Supreme Court drop-kick the individual mandate? Will the Catholic Church have its day in court? Your guess is as good as mine.

      I still contend that none of this really matters.


      Tuesday, May 22, 2012

      Facts? We Don't Need No Stinkin' Facts!

      Governor Ted was on a roll. Ted Strickland, our previous governor, is a national co-chairman for President Obama’s reelection campaign. It is his job to tell one side of the story. It is his job to shape the issues to his candidate’s advantage. And, if necessary, it is his job to bypass a fact or two en route to his desired destination. Governor Ted was born for this job. Lucky for him, the reporters were the Plain Dealer’s Sabrina Eaton and Stephen Koff.

      The article, Health care law may be big issue for young voters, appeared in last Sunday’s Plain Dealer. The online version linked here is slightly different from the version that appeared in the Plain Dealer. The crux of the article was that young adults are thrilled to be able to stay on their parents’ group health insurance policies. Dumping the Patient Protection and Affordable Care Act (PPACA) could cost the Republicans the votes of everyone under age 28.

      This is where Governor Ted comes in.
      Without the health care law, this group could lose coverage under their parents’ plans and “it’s impossible to be able to afford an individual policy unless you’re a wealthy or semi-wealthy person,” Strickland says.
      It’s impossible? Balderdash!

      This act of journalistic sloth, printing that claim by the President’s reelection campaign without question, is inexcusable. The Plain Dealer reporters could have interviewed any health insurance agent. They could have contacted an insurer, like Medical Mutual of Ohio who, unlike the Plain Dealer, is still headquartered in downtown Cleveland. Or, they could have gone online and run a couple of quick quotes.

      They chose to do nothing.

      And speaking of nothing, covering your children on your employer’s group policy is not nothing. The employer may be paying some or even the entire premium. The parent may be paying all of the cost. Ask your boss how much, if anything, you are paying to cover your children.

      Let’s look at some numbers. Medical Mutual of Ohio. Elite policy with an office copay, Rx card, and a $2,500 deductible. Cuyahoga County (most expensive in Ohio). Healthy non-smoker.


      There are less expensive policies. You would never know any of this if your only source of information is the Plain Dealer.

      Is $107.95 a month less than your employer’s policy? Most definitely. And if you are paying for this coverage, you may be able to save money by ignoring Governor Ted.

      I am not running a campaign, so I will tell you the whole story. Some adult children are benefitting from the PPACA. If your child is unhealthy, if your child has had a major illness or injury, or if your daughter is pregnant, your employer’s group health coverage and the law that allows your child to remain on your policy, is a godsend. That is not dramatic or scary, but it is real.

      We need more access to quality health care, not less. We need more facts, not less.


      Monday, April 30, 2012

      I Like My Funds Extra Slushy

      Readers of this blog are aware of my fixation on transparency. Readers of my other blog, Again? Really?, know that I am particularly offended by slush funds, large amounts of taxpayer money redirected by government entities to surreptitiously benefit pet causes or personal gain. The slush finds of a local government might be in the thousands or possibly a million dollars or so. It takes the federal government to create a billion dollar boondoggle.

      Insured Americans will be paying a new fee as of October 1, 2012. Anthem Blue Cross sent a warning announcement last week to advise us that they will be adding the charge to our bills. “The Affordable Care Act (PPACA) established the Patient-Centered Outcomes Research Institute (PCORI) to explore the effectiveness, risks, and benefits of medical treatments. This study is also known as Comparative Effectiveness Research (CER). PCORI is a nonprofit, nongovernmental organization supported by a trust fund that is financed in part by fees from health plan insurers.”

      The fees are $1 per covered person in the first year. $2 per person in the second year. And after two years? The $2 per person per year will be adjusted for medical inflation.

      Bureaucracies, in general, like acronyms, but the combination of acronyms and money make for a government love affair.

      Comparative Effectiveness Research came into prominence as part of President Obama’s American Recovery and Reinvestment Act of 2009. $1.1 Billion was allocated.
      • $300 Million for the Agency for Healthcare Research and Quality.
      • $400 Million for the National Institutes of Health.
      • $400 Million for the Office of the Secretary of Health and Human Services.
      This wasn’t a beginning, middle and end. This was seed money.

      The Department of Health and Human Services (HHS) explained that CER “compares treatments and strategies to improve health. This information is essential for clinicians and patients to decide on the best treatment. It also enables our nation to improve the health of communities and the performance of the health system.”

      Gosh that sounds good.

      According to the National Cancer Institute, CER has both its proponents and detractors. One key issue was brought up by Jeffrey Kindler, CEO of Pfizer, who wondered whether the results from Comparative Effectiveness studies would be “automatically linked” to insurance coverage decisions. In other words, will healthcare in the future become one size fits almost all and too bad about the rest.

      In his paper “Comparative Effectiveness Research and Kindred Delusions”, Norton Hadler, MD expanded on the difference between efficacy and effectiveness.

      I have nothing to add to that debate. My only question is “How Much?” How much money, your money in taxes and your money in fees, are we spending on this and who is getting it?

      Billions of dollars funneled through the Department of Health and Human Services became even more of an issue last week when the Government Accountability Office (Yes, that GAO) found that the Obama administration was wasting $8.3 Billion on a questionable Medicare program.

      As part of a “Demonstration Project”, HHS has created an experimental program to study the effects of money on the insurance market. This experiment is to award bonuses to high quality managed care Medicare policies known as Medicare Advantage. High quality, like intellectual honesty, was one of the first victims of this scheme. To make a long story short, the money, most paid out in the next three years, covers the cuts that were made in these popular programs by the President’s health care law. The PPACA took money away, but Health and Human Services put the money back in through the back door.

      The independent Medicare Payment Advisory Commission panned the misdirection. The Republicans think that this looks suspiciously like a re-election driven decision. The New York Post didn’t bury the lead. They labeled it a political slush fund.

      What we are talking about is money. We know where it comes from, US. What we don’t know is where it is going and why. Unlimited funds funneled through Kathleen Sebelius and her politicized Department of Health and Human Services are sure to arouse suspicions. Add to this an $8.3 Billion experiment and you have the potential for a real problem.


      Monday, April 23, 2012

      It Sucks To Be Poor

      It sucks to be poor. It is nobody’s goal in life to be poor, to wonder how you are going to feed your family, keep a roof over your head, or to be unable to afford the most basic of needs or wants. I’ve been poor, not homeless or destitute, but close enough to appreciate the fear and uncertainty that comes with an overdrawn back account and a baloney and tater tot dinner.

      I’ve never received government assistance, not even unemployment compensation. So I have never had to check in with a government employee, told where I could live, or what groceries I could buy. And when I needed to take my children to the doctor, I’ve always had my choice of all of the pediatricians in town.

      The poor have Medicaid.

      Medicaid. Fraud ravaged. Doctor hated. Taxpayer resented. Medicaid. And no one likes Medicaid less than the people it was designed to help.

      There are 1.7 million Ohioans receiving state funded medical assistance. Ohio is revamping Medicaid, again.

      Eleven companies recently participated in a complex bidding process to win a piece of this action. Five won the opportunity to provide coverage. Five lost and are filing appeals. One, Anthem Blue Cross the #1 insurer of Ohioans, shrugged off its loss and walked away.

      Medicaid, the State of Ohio’s single payer health care system for the poor, appears to be mired in controversy. As reported in the Columbus Dispatch, there are charges of more than just irregularities, mistakes, and a shocking lack of transparency. There may have been actual fraud and false statements on the applications.

      Some of the companies that were shut out contacted London based Barclays to analyze the process. They found “Scoring results indicate considerable inconsistencies among bidders…Scoring processes are always complex, especially in markets this large, but typically not to this degree.”

      In a rush to save $1.5 Billion (real or imagined) in the next two years, the state may have selected up to three vendors thanks to applications enhanced with inflated statistics. Though the process was supposed to “improve the coordination of care for 1.7 million recipients and improve health”, it may, instead, have been just one more arbitrarily awarded government contract.

      It is one thing to entrust your children’s health to the lowest bidder. It is even worse to be herded to a facility or provider that lacks the integrity to compete fairly. But when you are a football, when you are tossed from one player to another, you don’t have much say in the process.

      But then again, it sucks to be poor.


      Wednesday, April 11, 2012

      The Fixer

      Her Nationwide guy suggested that she call me. And though I appreciate Mike’s confidence, I also know that his referrals are often people who have somehow fallen through the cracks of our system. This woman epitomized the permanent flaws in this and any system of health care. And more to my frustration than hers, I could not fix her problem.

      Much like Eddie Vedder’s The Fixer, I have always been obsessed with making things right, of solving everyone’s problems. That empathy works well in what I do for a living. But I am deeply frustrated when I encounter a situation that can’t be fixed. Here is hers:

      The woman, we’ll call her Maria, has group insurance through her employer. The cost of the policy has increased over the years, but the employer is still paying the vast majority of the premium. This year the employer changed the coverage to a High Deductible Healthcare Plan, in other words, a policy that qualifies for an HSA. Maria no longer has an office visit copay. Maria no longer has an Rx card. All of these expenses are applied towards her $4,000 deductible. In theory, this might save her money. In reality, she is screwed. She is on two very expensive medications. One is $885 for a three month supply. The other is $1,400!

      Where does she come up with the money for these prescriptions? She makes just enough per month that she won’t qualify for any help from the drug companies. She makes too little to be able to afford the medications she needs to be able to work.

      Got an answer? Neither do I?

      No system could possibly sustain the cost of paying for everyone’s doctors’ visits, prescriptions, and hospital stays. We must contribute. We must either pay for insurance or be taxed by the government (or both) to fund the system that pays most of the bills. The balance, whether that structure includes copays or deductibles, must be paid by the person receiving treatment. Should we all be responsible for the same amount? Will there be a sliding scale based on income, location, or family size?

      No matter the final outcome, most people will be offended when it is their turn to pay. Worse, many people will be forced to pay more than they feel that they can afford. And some will be buried in debt. The other choice is to simply limit the most expensive care based on survivability and efficacy. And that opens another set of worries.

      In a recent Forbes article, Richard Grant argues that what we need is less regulation, not more. “Government’s main role has been to serve as the enforcer of a cartel that limits the supply of doctors, of hospitals, of drugs, and of innovative alternatives.” There is truth to all of that. And if we reversed our course and somehow made it to a completely open market, the well-off and educated, like Mr. Grant, might receive better care for less. Unfortunately, the Maria’s of our world would be collateral damage. I’m not sure which regulations Mr. Grant would like to eliminate. Do we want to trust the marketplace to license doctors and approve prescriptions?

      The HSA policy is a half-hearted attempt at empowering the patient and controlling costs. It succeeds at neither. Does Maria need to be on these expensive medications? Would more common, less expensive drugs, be almost as good? Since at least one of these drugs is for a mental condition, would she have the needed faith in a new prescription that was purchased not because her doctor thought it was better for her, but because she can’t afford the good one? The experiment is doomed to failure.

      And I can’t help her. And there is no moment worse for a Fixer than when he realizes that there is nothing that he can do.

      Tuesday, March 27, 2012

      One Ballot, Two Votes

      Dave Cunix – surrogate. I was asked to represent Al Gore during the 2000 presidential campaign. I presented his positions at candidate forums and spoke to citizens’ groups. Based on Mr. Gore’s success, I was recruited four years later to serve on the John Kerry campaign. We know how well that went.

      The candidate forums were very inclusive. Surrogates were invited from all of the major campaigns. The Bush representative and I were often joined by men and women prepared to advance the agendas of Pat Buchanan (Reform), Ralph Nader (Green), and Harry Browne (Libertarian). At the end of these forums I would say something that though incredibly true was sure to agitate the Libertarians and the Greens. “A vote for Ralph Nader is a vote for George Bush. A vote for Harry Browne is a vote for no one”.

      Gosh that would torque them off. Worse, as we now know, I was totally correct. Here are the results of a few of the states:

      Fl........16,414.....17,484.......2, 912,790....2,912,253....97,488

      Emotion plays a huge roll in politics. The politicians, our leaders, use our emotions to push us in one direction or another. Our first task must be to remove all emotion from political discussions. Once we get down to facts, to cause and effect, we can determine what we really want to do and how to create a logical course of action.

      My issue with government in 2012 is the inherent laziness of our politicians. Speaking in snippets and sound bites and relying on emotion laden advertisements, candidates and elected officials don’t debate solutions, just fears. They exploit our fear of spending money. Our fear of the “Other”. Our fear of losing what little peace or privacy we have left.

      The President’s health care program, the Patient Protection and Affordable Care Act (PPACA), was initially sold as a way to insure the uninsured, all 50 million of them. The American public was told that not only wouldn’t it cost more to do this, but that premiums would go down. And we were going to get better coverage (free stuff!) at no additional cost.

      The Republicans were asking for a birth certificate from the tooth fairy.

      And what were the Republicans doing during all of this? They defended the status quo and promised to respect the doctor/patient relationship. They assured us that they would protect the world’s best health care system. And we do have a great system. And we do have great doctors and hospitals. But G-d help you if get really sick and are stuck with inadequate insurance coverage.

      So here, again, is the truth. We aren’t going to return to 2007. No one in power wants to replace the PPACA. No one wants to fix it. The Republicans took control of the House of Representatives over a year ago. Repeal Obamacare? How? To what end? If the Republicans had a constructive option they would have advanced it by now. As in any successful negotiation, common ground and saving face are keys to victory. Mr. Boehner, Mr. Cantor, Mr. Romney, and even Mr. Gingrich, a legislator who has promoted the individual mandate for most of the last twenty years, have not offered a path to modify the PPACA to make it work. They have no solutions, just campaign issues.

      The Democrats have a program that won’t work as a privately insured system, but could lead to single payer. The Republicans have a fundraising gold mine. You? You have debates about birth control pills and a lifetime supply of smoke and mirrors.

      The numbers are real, everything else is, as Rick Santorum would say, “BS”. The PPACA had to have gimmicks built in to it to cover the exorbitant costs. One by one these income generators are disappearing. The 1099 silliness is gone. The Long Term Care program (CLASS) is gone. The tax on Cadillac Health Plans will disappear, too. The Supreme Court is hearing arguments TODAY about the constitutionality of the individual mandate. We will get the verdict in a couple of months. Regardless of the outcome, the Patient Protection and Affordable Care Act will move forward.

      So which party deserves your support? Who is going to get our health care system on to firm financial ground? Will a vote for one guy really be a vote for someone else?

      I need a ballot that offers “None of the Above”.