Thursday, December 22, 2016

A Tragedy Of Shakespearean Proportions

Dana Milbank, opinion writer for the Washington Post, was featured on some of the news shows yesterday to discuss Trump voters who desperately rely on Obamacare (The Patient Protection and Affordable Care Act). His article appeared Tuesday and was creating quite a buzz. I, for one, enjoyed 20 minutes of TV that didn’t feature Putin or the words “Conflict of Interest”. Still, this is a serious issue, and we will treat it with a little more respect than Mr. Milbank.

There are and always will be Americans who vote against their personal interest. This is a link to a Forbes article on the issue. But as this article and many like it point out, it is not necessarily that simple. Poor people in Kentucky didn’t decide on Election Day to screw themselves. The previously uninsured didn’t vote for Donald Trump because he vowed to repeal Obamacare. Interviewing them now, a month after the election and a month before anything has changed is unfair to them. It is bad enough to be poor. We don’t need to make them look stupid.

I have a number of clients who have benefited from the PPACA who still voted for Trump. Let’s take a quick look at some of the possible reasons for their choice.

It Didn’t Matter – There are many people who feel that Obamacare will be repealed loudly and retained quietly. We may end up with Trumpcare, a modification that fixes some issues while creating new problems. The Republicans declare victory and the Democrats cede the next 5 years of glitches and complications to the other side.

The Bright Side – I have at least one client predicting a major economic recovery that will result in more jobs with benefits. If they score better gigs, they won’t need individual coverage and all of this will cease to be relevant to THEM.

A Better Way – There must be a better option and their team’s got it. No matter how many times they have been let down by politicians of both parties in the past, this could be the time they get it right.

There Are Other Issues – Health Insurance is really important to me, but I doubt that there are many single issue Health Insurance voters. Abortion, Pro-Life or Pro-Choice, seems to drive people to the polls. Immigration and jobs, too. People were riled up and voted AGAINST Obamacare, often without understanding its positive impact on them personally, but I think that they saw it as part of a whole, a failure of Washington to properly serve and protect them.

Regardless of why or who voted for Donald Trump, the election is over and about 40% of us have spoken. Donald Trump will be the next president and he has a Republican controlled Congress. He has nominated Tom Price (R-GA) to be the next Secretary of the Department of Health and Human Services. Mr. Price is famously anti-Obama and anti-Obamacare. His solutions are radically different and concerning. Will the Price plan or something like it be implemented? No one knows at this point.

Congress will be very active in January and February. It will be important for all of us to watch them closely and share our thoughts with our elected officials. I don’t think that we will see any major changes in 2017, but that is my guess. I will be in Washington in February, in part to discuss my clients’ needs and how the actions of Congress can help or hurt my people.

Until then, if you need a liver transplant like Mr. Mills of Whitley County, Kentucky, I strongly suggest that you get this scheduled soon. The press may paint you as a victim of your own folly for being in this mess, but if you put it off too long this really could be a tragedy of Shakespearean proportions.


Wednesday, December 7, 2016

Reality What a Concept

Editor’s Note: All articles, blogs, and news reports about Obamacare (The Patient Protection and Affordable Care Act) must, per the edict from the incoming president, begin by stating that Obamacare is a terrible burden on the American public and that it needs to be repealed immediately. If you have benefited by the law because of the subsidies, preexisting conditions, or access to care, please have the good sense to keep that to yourself. You wouldn’t want the most powerful man in the world to tweet about you at 3 AM.

The election was about a month ago. Each day brings new proclamations and trial balloons. The Congress beat at Health Insurance Issues With Dave has been working overtime to monitor all of the pronouncements coming from our elected officials. Today’s post will serve as an update.

Republicans in both the House and Senate are eager to repeal Obamacare. The repeal may even be HB 1, the first bill of the new legislative session. It will be a great moral victory. The newspapers, Facebook, and TV news will talk about it that night. The details are more important. Some in Congress want to have the replacement bill be introduced as soon as the celebration and back-slapping dies down. Others believe that the replacement package is still 1, 2, EVEN 3 years away. This is known as Repeal and Delay.

There are advantages and disadvantages to both strategies.

On June 22, 2016, Speaker of the House Paul Ryan released his health care plan, A Better Way. His proposal begins with the repeal of Obamacare. “…This law cannot be fixed…We need a clean start in order to pursue the patient-centered reforms the American people deserve”. That has been the Republican line of attack since the bill was passed in March 2010. No compromise. No tweaking. No amendments. The Republicans have bludgeoned the Democrats with Obamacare to the point that even those Americans who have benefited the most from the new law might not understand or appreciate it.

If Obamacare is repealed and immediately replaced we, the American people, would be able to quickly identify winners and losers, the before and after of the Republican’s actions. The insurance companies and the medical providers would also know their places in the new market. Unfortunately, that is not going to happen. There is no Republican alternative plan. There never was one. Speaker Ryan’s recent interviews confirm that. Reality: What a Concept.

So we are looking at Repeal and Delay. The concept is simple. As detailed by the Urban Institute, the partial repeal of Obamacare could be done through the process of reconciliation. The Senate Democrats could not stop this since reconciliation only needs a simple majority in the Senate. Congress would starve Obamacare by cutting off the funding for Medicaid, tax credit subsidies, and eliminate the individual and employer mandates. Doing that immediately would be the equivalent of dropping a bomb in Times Square. But it could be phased in over a three year period.

Why three years? For one, Paul Ryan, Mitch McConnell and the entire Republican team want to take a victory lap for killing Obamacare even before it is really gone. The real impact of their actions wouldn’t hit until after the 2018 election, just the press releases. The other reason is that they need several years to come up with a viable option that can be phased in properly. Mr. Ryan doesn’t want to take health insurance away from 20 million Americans. That is not his goal. Plus, some of them vote! And, if they can buy three years they have enough time to find a Democrat or two to sign on to their final legislation which will provide the illusion of bipartisanship. The Democrats tried the same thing in 2009 and 2010. But in the end Senator Chuck Grassley and Senator Olympia Snowe still walked away from the negotiations.

The insurance companies, already losing money in the individual market, and the medical providers aren’t real excited. Eliminating Medicaid expansion will force millions of Americans out of the health care system. No routine care. No access to maintenance prescriptions for diabetes, high blood pressure, and other common easily treated illnesses. The E/R waiting rooms will again be filled with people seeking care for minor ailments better treated in a doctor’s office. Would the Republican controlled Congress reinstate reimbursements for charity care? Who knows?

The insurance side is worse. The law would still require insurers to cover anyone who applied, regardless of preexisting conditions. But healthy people would not be required to retain coverage. Only the unhealthy and the responsible would seek coverage. Insurers would be foolish to offer coverage under those circumstances. Major insurers, now publicly owned, would be forced to leave markets or face the ire of their shareholders.

Other alternatives? Darned if I know. You can’t have health insurance if there isn’t an insurance company to sell it. I am scheduled to go to Washington in February to meet with our members of Congress. I have no idea what I’m going to find when I get there.

Oh, and did I mention that Speaker Ryan would like to change Medicare?


Sunday, November 13, 2016

The Post-Election Update


Wednesday was a terrible day in the office. I was a mess. I had been awake most of the night, my worries as dark as the bedroom. Clients called. Clients texted. Everyone, all through the day, wanted to know how this election would affect them. I was too busy to write this update. And I was too concerned about the possible impact to prepare a full report. A friend came in around 5:30. He asked me how I was doing. I told him. I probably did ten minutes on where we were and how worried I was about my clients. He was very patient. Then he asked me, again, how I am. I had completely forgotten that my friend David is totally apolitical. He was asking about my health!

We’ve had a couple of days to watch the president-elect articulate his vision and the current Congressional leaders voice theirs. They are not the same. The future of health insurance will be determined by both the new president and Congress. And the courts may also play a part in our future.

This blog is Health Insurance Issues With Dave. It is not my interest nor place to discuss any part of the election that does not deal with health insurance. And health insurance is our method of compensating medical providers for their products and services. Health insurance is regulated on both the state and federal level, which means that decisions are influenced by finances and the public good. Finances are in black and white. The public good is open to discussion.

The president-elect campaigned on the promise to Repeal and Replace Obamacare (The Patient and Protection and Affordable Care Act). The Republicans who control Congress have promised this for years. On Tuesday the coyote caught the roadrunner.

First, Mr. Trump. As discussed in March, there wasn’t a detailed Trump alternative. We had no idea, prior to the election, what his priorities were or how he would accomplish them. Our closest peek into his thinking came at his Gettysburg speech in late October when he spoke of selling insurance across state lines and of increasing access to Health Savings Accounts, both Republican ideas. This week he expressed his view that the Repeal and Replace would take place simultaneously and that two key provisions of Obamacare – coverage for pre-existing conditions and the ability of children to retain their parents coverage till age 26 – would be continued.

Congress has a different view. Some in Congress have PRIVATELY admitted that Obamacare couldn’t be repealed. Amended? Sure. Changed? You bet. But the idea of repealing the law and blowing up our system, and 20% of our economy, and then eventually replacing the law would be a disaster. Passing repeal bills was safe and easy. There was no danger as long as a Democrat was in the White House to veto the law.

We have had a chance to review the various alternatives. Over the las few years I have covered plans from Governor Scott Walker, Speaker of the House Paul Ryan, and Senator Orrin Hatch. Some have been exercises in ideology and others are closer to marketing projects, the rebranding of Obamacare to a Republican name. You will hear a lot more about this in the coming months.

Let’s quickly hit a couple of the major talking points.

Selling Insurance Across State Lines – I have tackled this a number of times. This is a link to the Kaiser Foundation’s explanation.

Covering Pre-existing Conditions – Everybody loves this, but it doesn’t work unless we have everyone participating. Given the opportunity, lots of healthy people would choose to save their money until they needed coverage. Health insurance is really expensive if only the unhealthy buy it. That means that any law, Obamacare or its replacement, needs to have some form of mandated participation.

Subsidies – The current Tax Credit Subsidy is complicated. There is a lot of room for improvement. Some of the Republican plans will give you a tax credit in 2018 for what you paid in 2017 on insurance. That only works if you can afford the premium in 2017. That eliminates millions of Americans.

Health Savings Accounts – Another great idea if you’ve got disposable income and could us a tax break. Otherwise, no big deal.

Preventive Care – This is really important, especially for children. There is an upfront cost, but long term savings. How preventive care is defined may be changed under the new administration. This has been very contentious.

This has been a very long post and I truly appreciate your patience. There are no simple answers for complex questions. I am very concerned about what the next year holds for us.

I leave you with a thought about a Ferris Wheel. The ride stops when you get to the top. The view is incredible. You are filled with joy. The ride begins to move again and eventually you are at the bottom and forced to leave. The world, even our little world of health insurance, is never as euphoric or bleak as it might seem. We will get through this together.


Monday, October 17, 2016


October 16, 2016

I got to the office in the middle of the second quarter of the Browns’ game. I left a 7:30. It was time. I had spotted a unicorn.

Open enrollment for Medicare Part D (Rx) and Medicare Advantage products technically began yesterday. It will officially start at 9 AM tomorrow morning in my office. Most of my Medicare visitors will be coming to confirm that they don’t need to do anything. No changes, just a cup of coffee and some conversation.

My real challenge is the open enrollment for individuals under age 65. Most of my clients received their renewal packet on Saturday, October 1st. They began calling my office that day. Unfortunately, we, the agents that service these insureds, never got our copy. We were told that the packets were in the mail. We were also told that we could download, one 8 page renewal at a time, from the insurer’s website. Hundreds and hundreds of renewals. I gave up and started to pull and print these a few days ago.

And today I am in my office to work on these renewals.

I am not complaining. I am not telling you about this process because I am some kind of insurance martyr. I love this gig and I’m not the only guy working on a Sunday. Successful agents throughout this country are evaluating their clients’ 2017 health insurance options.

One by one I review each renewal. Should the client stay with his/her current insurer or move? Would a higher deductible save enough money to be worth the additional exposure? Is this the year we should try for a tax credit subsidy? And then, once I know what I would like for them to do, I send them an email or a hand-written note.

This process isn’t fast and it can’t be delegated. The insureds are counting on the agent’s experience and expertise. The health insurance premium may be someone’s second or third largest monthly bill. My goal is to have all of these processed before November 1st. My fellow agents are working just as hard.

I had predicted a tough year. I expected increases of 15% - 20%. Policies that have Rx and office visit copays are coming in around 17%. My HSA policies seem to be averaging a few percent less. The highest HSA deductible plans, now $6,400, were renewed at the best rates. Those policies may work for some people, but not for everyone. Analyzing the options, not simply choosing the cheapest, gives us a better claims experience should you ever get sick or injured.

One of the clients that contacted me on the 1st was particularly concerned about his increase. He and his family got hammered. 25%! It took some time this afternoon to figure out why. What happened? I determined that his son was the main reason for the price jump. He turned 21 this year and will now be rated as an adult, not a child. Just to be sure, I went to the insurer’s website and ran a quote as if he was only 20. I don’t know if this family will be any happier about their new rate, but at least they will understand why.

A unicorn is a mythical creature. They supposedly exist, but no one has ever seen one. My insurers said that the renewal rates were the best that they could offer. Heck, some people might even see a rate reduction as the deductible on the HSA qualified policy drifts from $6,000 to $6,400. It was about 7 PM when I found a renewal with a 7% decrease. A decrease! I rerated the family just to be sure. I sent the client an email, packed up my stuff, and locked up.

Once you spot a unicorn, it must be time to go home.


Thursday, September 29, 2016

One Choice Is No Choice


I was licensed with over fifty different insurers. Sure, most of my Cuyahoga County clients acquired their health insurance from one of the half-dozen major carriers, but Gosh there were a lot of choices. That was 10 years ago. Now we have two or three good options in Greater Cleveland. And we’re the lucky ones.

Ohio’s population is spread across eighty-eight counties. We have major metropolitan regions, cities, towns, and rural areas. We all may share the same state government, but we do not share the same health insurance options. Cleveland, Columbus, and Cincinnati have choices. Nineteen Ohio counties will have only one health insurer participating on the Exchange in 2017. One! Twenty-eight Ohio counties will have twice as many insurers, Two.

In nineteen counties, if you don’t like Anthem Blue Cross, you can still choose Anthem Blue Cross. That’s it. And by the way, thank G-d it is Anthem and not some tier 3 level Brand X insurer. But one choice is no choice. Will Anthem’s network cover Your doctor? Your hospital? Be affordable? I can’t answer that until the final rates and plan information are released.

And yet we are still considered fortunate in Ohio. Less than 15,000 current Exchange enrollees reside in a single-insurer county according to the Iowa City Press-Citizen. The national picture is much worse. Five states – Alabama, Alaska, Oklahoma, South Carolina, and Wyoming – are limited to a single insurer for the individual health insurance Exchange. That is five entire states. Several others are limited to a single insurer for most, but not all, of the state. According to a recent New York Times article, 17% of the U.S. population will have only one individual health insurer available in 2017.

Where are the other insurers? We’ve seen companies fail (the government created Co-ops, HealthSpan) and we’ve seen companies abandon the market. Aetna and UnitedHealth Care have been the most vocal about leaving the individual market. UHC and Aetna both reported incredible profits this year. It is important to note that these profits are in spite of, not because of, their individual Exchange business. UnitedHealth Care reported a loss of close to $500 million in 2015 on new individual health policies compliant with the Patient Protection and Affordable Care Act (Obamacare). An Aetna press release of August 15, 2016 details a Second Quarter pretax loss of $200 million.

Neither Aetna nor UnitedHealth Care see any reason to continue to bleed money by selling individual policies on the Exchange. They have a duty to their shareholders to market products that make money. Individual policies do not appear to be profitable under the PPACA.

Where does that leave us? In truth, we are right where I predicted we’d be when I wrote Over The Tree, Close To The Front Of The Green in April 2010. Our “Grandfathered” and “Grandmothered” policies are getting too expensive to keep. The new policies, even with a tax credit subsidy, are too expensive for many Americans. And we have few choices. What is the solution? The answer, for many, is the Public Option.

According to USA Today and the Huffington Post, to cite a couple of sources, the Senate Democrats are pushing for an alternative to the private insurance market, a Public Option. And this isn’t just Bernie Sanders (I-Vt.). Senator Chuck Schumer (D-NY) and Senator Patty Murray (D-WA) are involved in this effort to offer a government plan to all Americans. There is also a parallel concept of expanding Medicare from age 65 to age 55.

As we learned from the disastrous Co-op experiment, the government, and the people the government empowers to run business-like entities, will over-promise and underprice the product. The insurers will not reduce their premiums and increase their losses to compete. They will abandon the market completely and let the public option drown. And then? And then the government will be forced to ride in and save us with a true, Medicare-like product for all of us.

And we will be left with one choice. And one choice is no choice at all.


Cunix Insurance

Tuesday, September 6, 2016

We Don't Need No Regulations


They were at it again. The politicians were railing against unnecessary regulations. Their #1 villains are those damn government bureaucrats who make our products uncompetitive and cost us jobs. They can pontificate for hours but become strangely quiet when pressed to address the benefits of regulation.

We aren’t going to waste time discussing the recent Olympics in Rio, the air quality in Beijing, or the new interest in earthquakes in Oklahoma. This being Health Insurance issues With Dave, we are going to look at prescriptions.

Insurance applications used to ask health questions. EpiPens, like inhalers, appeared on a few applications each year. That changed about ten years ago as more and more clients kept an EpiPen or inhaler just in case. The inhalers were for a sudden asthma attack. The EpiPen was designed to inject the generic hormone epinephrine to prevent anaphylactic shock from an allergic reaction.

What was once rare was now common. By 2013 the federal government was strongly encouraging schools to have an emergency supply of epinephrine (EpiPens).

We have a product that has been around for decades, cost next to nothing to make, and does great business. These things should sell for about the price of a bottle of ketchup. OK, it is a prescription so maybe the price of a case of ketchup.

The EpiPen is sold in two pen sets. Ten years ago a set was a little over $100. Today, over $600. Is the drug more effective? No. Are the ingredients more expensive? No. What changed?

The biggest single change was Medicare Part D (Rx). The 2003 law “exempts Part D drugs from ‘best price’ rebates that drugmakers have been required to give to the state Medicaid programs since 1991” (The Hill). While some may argue that this provision has caused a large increase in the development of senior-related medications, many of us have also noticed that there is a huge market for senior-related products since 10,000 baby boomers turn 65 daily. I believe that the R & D would have come with or without the government handing the pharmaceutical companies the keys to the vault.

The last thirteen years have given us drug company mergers, hostile takeovers, and even a hedge fund guy who increased a little known HIV drug by 5000%. And that takes us back to Mylan Pharmaceuticals and their EpiPen.

Did Mylan develop the EpiPen? Hell No. Mylan purchased a generic drug manufacturer in 2007. The EpiPen was just one of the products they acquired. R & D cost – Zero. Current price? Whatever the market will bear. There is very little that can be done about this. Oh sure, there will be a lot of harrumphing in the Senate. But in the end, there will be some coupons, a slightly lower price, and a promise from Mylan’s CEO to be a better corporate citizen.

What we need is both more and more effective regulation. There are thousands of generic drugs waiting for final approval. This is not effective regulation. And, at the very least, we need to create a pricing formula for decades’ old generic medications.

The EpiPen problem reminds us that we have no way to prevent price gouging and other unscrupulous business practices without regulations. Regulations can be the locked doors that keep honest people honest.


Monday, August 15, 2016


It happened again on Friday. Another COBRA victim. I have talked with three people in the last few months who lost money due to COBRA. There is talk of ending or, at the very least, amending the Consolidated Omnibus Budget Reconciliation Act (COBRA). That should be a goal for the spring of 2017.

What is COBRA? This is from the Department of Labor:

The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances such as voluntary or involuntary job loss, reduction in the hours worked, transition between jobs, death, divorce, and other life events. Qualified individuals may be required to pay the entire premium for coverage up to 102 percent of the cost to the plan.

COBRA generally requires that group health plans sponsored by employers with 20 or more employees in the prior year offer employees and their families the opportunity for a temporary extension of health coverage (called continuation coverage) in certain instances where coverage under the plan would otherwise end.

In English – You get to keep your health insurance policy if your ex-employer 1) had a policy, 2) had more than 20 employees, and 3) if you pay the full monthly premium plus up to 2% for processing. You may keep the policy for up to 18 months, 36 months if you are losing coverage due to death or divorce.

COBRA was very important. Prior to the Patient Protection and Affordable Care Act (PPACA or Obamacare), unhealthy individuals and families could be declined for coverage due to preexisting conditions. COBRA guaranteed 18 months to find an acceptable option.

COBRA also allowed someone who had already met an annual deductible to retain coverage for the balance of that calendar year. This may still prove useful even under the new law.

COBRA, retaining the ex-employer’s policy, may also be less expensive than purchasing a new policy. This is more likely if the individual is in his/her late fifties or early sixties.

So far, so good. What could be bad?

Christopher (name changed) worked for over twenty years at a local service organization. His position was consolidated with two others and he was let go. This was in October. The first six months of COBRA were paid by his ex-employer as part of a generous severance package. Chris was shocked by the $1,100 bill he received in late April for his May premium. He had no idea. He was referred to me and we met a few days later. I was forced to deliver terrible news. Chris missed the Annual Open Enrollment. Discovering that you have expensive COBRA does not qualify for a Special Enrollment Period. Christopher must keep this policy for the balance of 2016 if he wants to retain PPACA compliant coverage. What looked like a lifesaver had become cement shoes. His ex-employer didn’t understand how COBRA works in this new environment.

Another issue is that COBRA and Medicare are like oil and water. If you are over 65 and work for a business that has over twenty employees, your group health insurance is primary. Medicare is secondary. Most of these people save their money and don’t enroll in Medicare Part B. But, COBRA doesn’t count. Failing to enroll in Medicare Part B when you become eligible may result in a penalty and being forced to wait until the annual enrollment period the following January. This is an expensive common mistake.

Angela (name changed) made the above mistake. She was supposed to enroll in Medicare Part B six years ago, a few months into COBRA. She didn’t. Angela got a new job with benefits about a year later. Now, at age 71 and ready to retire, she will be forced to wait until next July for Medicare to begin. Angela will pay more than twice as much for inferior coverage due to her error six years ago.

My last example is Charlotte (ditto) who visited my office on Friday. Her last day at a major Cleveland employer was June 30th. She spent twenty-nine years at a really big company. Charlotte signed up for Medicare Part B. Since she didn’t have the time to do any research and had zero help from H.R., she enrolled in her employer’s retiree COBRA plan, a mediocre $400 Medicare Supplement-like policy. A month later she realized that her friends all have better coverage for a lot less.

Charlotte paid a price for convenience. Even though she is 66, this was her Medicare Initial Enrollment Period. You have just one bite of the apple and she picked a bad one. She still has options, but she has forfeited some of the flexibility and guarantees that had been available in June.

There is still a place for COBRA under Obamacare, but it is not as important as it once was. So maybe it is too early to unleash the mongoose, but I’m keeping mine fed and ready.


Sunday, July 24, 2016

A Cheap Date


There was a time, back when I was in high school, when a boy asked a girl out for a date and paid for the evening.  Movies, a dance, even dinner – he asked and he paid.  A cheap date was a girl who didn’t insist on the fanciest restaurant for every date and didn’t search the menu for the most expensive meal.   When we got into our twenties, a cheap date was someone who might only order one or two glasses of wine and didn’t view dating as a competitive drinking sport.
The young woman in my office last week has never been a cheap date, at least not from an insurance perspective.  Millie (name changed) is an insulin-dependent diabetic, has been most of her twenty-four years.  She has lots of claims every year.  There was a time, about ten years ago, when her mother and I had real concerns about finding health insurance for her.  Now it is no big deal.
I used to be a cheap (insurance) date.  The only time I saw the doctor most years was for my annual physical.  No Rx.  No issues.  This year has permanently changed my status.  University Hospital and the doctors have submitted bills for over $550,000 for my care.  Millie and I now have something in common.  No Insurance company would take us if they had a choice.
We are not alone.  Many of you have pre-existing conditions from an illness or injury.  You used to be cheap dates.  You paid your premiums and seldom filed a claim.  An accident or ailment changed that.  The most important benefits of The Patient Protection and Affordable Care Act (Obamacare) are the absence of medical underwriting and that all policies cover pre-existing conditions.  Millie and I can apply for coverage with no fear of being turned away.
Are those benefits safe?
I get the calls at least once week:
  • Are they going to repeal Obamacare?
  • What happens if the Republicans win?
  • Is my policy going to be cancelled?
My standard answers are:
  • No.
  • Nothing.
  • Probably not, but if it is we’ll find a new one.
We just watched the four day infomercial for the Republican Party and are moments away from the Democratic Party’s version.  Did you hear a substantive discussion about healthcare, 20% of our economy?  Of course not.  Six years of Obamacare have yielded millions of dollars of negative political ads but not even one serious alternative proposal.  Even if we wanted to, we can’t magically return to February 2010.  We can’t just repeal the PPACA and then begin the difficult process of creating a new program.  If there is to be an alternative, it must be designed with a seamless transition.
That is, of course, just my opinion.  This blog has reviewed all of the Republican plans including Speaker Ryan’s latest last month.  I have been trying to include coverage of the Libertarian Party’s proposal.  In May I interviewed one of the candidates who had been running to be the standard bearer for the Libertarians.  His suggestion was to eliminate the PPACA and to make charitable donations a dollar for dollar tax reduction.  People would then donate to hospitals and everyone would receive the care they needed without any government involvement.  I laughed until I realized that he was serious.  Their official platform has no information or details.
But with no disrespect to either the Libertarian or the Green Parties, our next president will most likely be either a D or an R.  But that doesn’t mean that there aren’t major issues with the PPACA.  The insurers have not found a way to make money under this new system.  They will continue to tinker with their networks and plan designs.  Hospital and doctors are looking at different business models to reduce expenses and maximize payments from the government and insurers.  A new president may be more successful working with a new Congress to make the needed changes to Obamacare.  Perhaps, under new leadership, we can get a bipartisan buy-in once we change the name.
It is important to remember that we are talking about 20% of our economy.  Our population is aging.  Our cost of care is rising.  Americans demand the very best of care.  And we are never a cheap date.

Wednesday, June 29, 2016

The Publicity Stunt

The Speaker of the House, Paul Ryan (R-WI), was clearly agitated. The Democrats were holding a sit-in on the House floor in order to push for a vote on gun control legislation. He later labeled the protest, led by civil rights icon John Lewis (D-GA), a publicity stunt. And he was right. The Democrats became the major story of the day thus overshadowing a different publicity stunt, Speaker Ryan’s attempt to grab attention earlier in the day.

This being Health Insurance Issues With Dave, we will give Speaker Ryan the attention he craves. Announcing the G.O.P.’s A Better Way. Our Vision For a Confident America.

Yes, it’s here. Thirty-seven pages of pure Conservative legislative joy. Here is the link. Better yet, here is the link to the one page summary. You probably won’t want to waste your time on the long version once you’ve taken a peek at the summary.

The summary is one page, bullet point laden, and facts optional. It promises a Republican Plan that retains all of the things you like from the Patient Protection and Affordable Care Act (Obamacare), such as guaranteed access and dependent care to age 26, without any of the costs. Really, no tax increases. Zero! The Republicans feel that codifying the Hyde Amendment is also a major selling point. And speaking of selling points, the summary never mentions President Obama or Obamacare. Instead, Obamacare is renamed “Speaker Pelosi’s Bill”. The full version isn’t much better.

Speaker Ryan is very proud to announce that this 37 page outline of ideal, goals, and wishful thinking is the first plan universally endorsed by all of the Republican leaders in the House. It isn’t really supposed to be a plan. When asked, leadership has labeled it a “White Paper”. I actually printed out and read the full presentation. It is the only way to know that Speaker Ryan forgot to estimate the cost of his programs or that he is pushing Medicare to age 67 (page 36).

A Better Way is really an organized collection of the Republican’s greatest hits of the last six years. We rejected most of these ideas as inconsequential then. They aren’t more relevant repackaged today. Part of the problem is the refusal to face the realities of the insurance marketplace and the inclusion of information that is laughably false.

Here are the five principles of A Better Way:
  1. Repeal Obamacare
  2. Provide All Americans with more choices, lower costs, and greater flexibility
  3. Protect our nation’s most vulnerable
  4. Spur innovation in health care
  5. Protect and preserve Medicare
Protect our nation’s most vulnerable. Patients with pre-existing conditions, loved ones struggling with complex medical needs, and other vulnerable Americans should have access to high-quality and affordable coverage options. Obamacare’s solution was to force millions of people onto Medicaid…
No, it didn’t.

The PPACA eliminated medical underwriting. We no longer ask health questions when you apply for coverage. Pre-existing conditions are covered completely. And the premium for your insurance policy no longer reflects your previous claims or medical conditions. Medicaid, where expanded, allowed additional lower income individuals and families to acquire coverage regardless of their health. Statements like the one above call into question the seriousness of the document.

And how does A Better Way deal with our most vulnerable? Badly. This plan reintroduces medical underwriting and suggests that we reinstate state run High Risk Pools. The Republicans strongly criticized the transitional High Risk Pools of Obamacare. They were, in part, correct. Five Billion Dollars wasn’t enough even though this was just for the transition to the full implementation of the new law. This program offers Twenty-five Billion Dollars (from where?) and walks away from the unhealthy.

Here are a few of the other highlights of Speaker Ryan’s plan:
  • No requirement to have any health insurance policy
  • No Coverage Standards (under or over age 65!)
  • An age based refundable tax credit to replace the income based subsidies
  • Adjust premium ratio to 5 – 1
  • A significant overhaul of Medicare
  • Changing the onset of Medicare to that of the Social Security Retirement Age.
It is important to note that Obamacare is far from perfect and that some of the ideas included in A Better Way might help the law to work better. That is, of course, ruled out immediately by Speaker Ryan and his team. It is this unwillingness to work with the President that makes all of these documents wasteful publicity stunts.



Monday, June 13, 2016

June 2016 Update

There is a lot going on. Today’s blog post will also be sent separately to my clients. The next blog will deal with high concepts, today we tackle some of the basic issues that affect most of you. But as I said, this blog will be duplicated as my current client letter. Read this and you get to skip the letter.

This isn’t as easy as it looks. Running a health insurance company is a lot than it appears. Any number of hospitals, medical organizations, not-for-profits, and government entities have invaded my business over the years. On paper it doesn’t look like that big a deal. Collect a lot of money (premiums) and pay the doctors and hospitals for services rendered (claims). We’ve recently lost InHealth, one of the government created CO-OP’s, and Catholic Health Partners’ foray into insurance, HealthSpan. Both entities were spectacular flops that failed to survive five full years.

Unfortunately, even the pros are having their struggles. I have seen a massive increase in insurance company errors. This may be, in part, due to the Patient Protection and Affordable Care Act (PPACA or Obamacare). As the companies expend millions of dollars to comply with new regulations, they are also limited in how much of each premium dollar can be spent on infrastructure (Medical Loss Ratio). Something has to give. The problems created y insufficient staffing and quick fixes directly affect you.

Quick example – A client recently purchased a policy with a $5,000 deductible. The application was accidentally changed to a $1,000 deductible at the Home Office. Understaffed, this major insurer had no one to catch the error. The system simply spat out the more expensive policy and a bill. The client called as soon as he got the bill. It only took me an hour or so to figure out the problem and to get the insurer to promise to fix it. What a waste of time and money. And yes, cancelling and reissuing the policy costs them a lot of money. These costs will eventually be passed to us.

Billing is a huge issue. Let’s say that you arrange to have your monthly premium electronically withdrawn from your checking account or credit card. Your policy will lapse if the money doesn’t transfer. It doesn’t matter if the insurer screws up and fails to take the money (more common than you’d think). No one cares if Chase gets hacked again. You will get no pity if your check bounces. It is up to you to make certain that the money left your account or was charged to your card. And if it isn’t, you must call your agent or the insurance company immediately. We don’t have the flexibility we once had. I currently have four clients in limbo due to this.

Grace Periods are for emergencies. Too many people think that a 30 day grace period means that their policies are due on the 30th of the month, not the 1st. You know what happens. They are a touch late, miss the end of the grace period, and are then shocked that they are suddenly uninsured. This can be a really expensive lesson. Many of us cannot afford to be without coverage. The first check I authorize each month is my health insurance bill, FOR THE FOLLOWING MONTH.

Short Term Policies are under attack. Many of my clients have been purchasing short term major medical policies. These policies are not compliant. Preexisting conditions are not covered and the policies are not guaranteed issue. The premiums for these policies and the tax penalty for opting out of Obamacare may still be a lot less than a compliant policy. The State of Ohio recently expanded the definition of short term to 360 days, further enhancing this consumer safety valve. The people who purchase these policies tend to be very healthy. And that is the problem.

It took a while but Health and Human Services Secretary Sylvia Burwell has realized that one of the reasons health insurance premiums are skyrocketing is that lots of healthy people are opting out. Sales of short term policies are higher now than in 2013. Secretary Burwell wants to restrict the policies to 90 days in an effort to force healthy Americans back into the general risk pool.

The perspective short term regulations were just announced a few days ago. The next step is a 60 day period for public comment. The final regulations, if any, will be crafted mid-August. I will be monitoring this issue.

As a point of personal privilege, I’d like to thank so many of you for your cards, calls, and emails. The post Shedding Pounds By Shedding Organs is the quick explanation of how I got here. I started radiation on June 6th. 9 weeks. 5x per week. I’m fine. I feel stronger every day.

Open enrollment is still several months away. We will get through this together.



Wednesday, May 25, 2016



I got caught. One of my readers noticed that I had yet to say a word about Senator Bernie Sanders and his health plan. I have reviewed plans from Scott Walker to Donald Trump. I’ve even covered Obamacare-lite plans from the Senate Republicans. But like Secretary Clinton, I just kept waiting for him to go away. But he hasn’t…

I read Senator Sanders’ plan over the weekend. It is very easy to understand, especially if you are five years old. Go to the doctor and Dad pays the bill. You may, or may not, get a lollipop, but no one will ask you, at age five, for any money. Need a prescription? Go to the drugstore. Dad’s got it covered. Hospital? Physical therapy? Inpatient substance abuse? Whatever you need, don’t worry. Dad’s got you covered. Great Dad. Rich Dad. Really rich.

Dad is the federal government.

Senator Sanders plan provides 100% coverage. No deductibles. No coinsurance. No copays. He pulls all of the consumer money out of the system. He eliminates all patient incentives to limit or question care.

Where does the federal government get all of this money?
  • 6.2% income-based health care premium paid by employers
  • 2.2% income-based premium (after deductions) paid by households
  • Tax capital gains and dividends as ordinary income
  • Limit tax deductions for households earning over $250,000
  • Rejuvenate the estate tax
  • Increase marginal income tax rates to 37% for a $250,000 family income to 52% on incomes over $10,000,000
That is a lot of tax. It would take a very different Congress to pass a funding bill that looked anything like the wish list, above.

It is difficult to illustrate an apples to apples comparison. Your average 40 year old has an insurance premium, deductible, coinsurance, and copays. This plan has none of that. The closest I can provide would be Medicare.

My clients love Medicare. They’ll tell you how they don’t pay anything at the doctor’s office and how they never saw a bill after a hospital stay. Even prescriptions are manageable.

Of course, that’s not Medicare. That is traditional Medicare plus a Medicare Supplement Plan F plus a Medicare Part D (Rx) plan. But most people just see it all as Medicare once it is all put in place.

Medicare is not free. We have all been paying into it for years. The doctors and hospitals are paid on a fee schedule that is more subject to politics than market forces. This is what you would pay if you turned 65 next month and went on to Medicare.
  • Medicare Part A - No Charge
  • Medicare Part B - $121.80 per month
  • Medicare Supplement Plan F - @$150 per month
  • Medicare Part D (Rx) - @$20 per month
The total for someone just turning 65 would be about $292 per month or $3514 per year.

The Sanders plan does not factor in age, just income. A 22 year old pays the same as a 72 year old, probably more.

How much would an unemployed/retired 65 year old pay under Senator Sanders’ plan? Assuming a Standard Deduction:
  1. Annual Income of $20,000 - $281.60 per year
  2. Annual Income of $40,000 - $721.60 per year
100% coverage for $281.60, an annual savings of over $3,200! It takes a lot of income tax on rich people to make these numbers work.

Does this prove that the Sanders plan can’t succeed? No, but I believe that it would take a giant leap of faith to make these numbers fly. The lack of consumer/patient involvement dooms the program. I still believe that the Patient Protection and Affordable Care Act (Obamacare) has put us on the path to a single-payer system. I just don’t see how it could be a 100% plan.

Free. We want free. But we’re not five and Dad, even a Dad that can print money, can’t afford to give us everything we want.



Picture is of a dad, but not one who can print money.


Tuesday, May 10, 2016

Cheap At Twice The Price

The University Hospital system is incredibly efficient. I’ve spent a lot of time lately in both the suburban facilities and the main campus. The clerks manning the check-in desks and the schedulers don’t do anything until they make a copy of your photo ID and insurance card. I once went to the same office, same clerk, two days in a row. She didn’t deviate, didn’t skip a step. University Hospital knows how it is going to be paid. And that’s a good thing. I just thought it weird when the gift shop asked for my photo ID and insurance card...

# # # #

The young widow had her own share of nagging health issues. Last May her doctor looked her in the eye and told her that he wanted her to have a heart catheterization. This wasn’t an emergency. He just felt that it was warranted. More importantly, he wanted a specific doctor at U.H. main campus to perform the procedure. This would be fine except that Brenda (name changed) has Medical Mutual of Ohio. MMO’s network includes the Cleveland Clinic and the suburban University Hospital facilities. It is common knowledge that Brenda had great coverage throughout Northeast Ohio. Everywhere but U.H. main campus.

He sent her to U.H. Main Campus.

Brenda should have known better, but she was totally focused on the fact that she needed a heart catheterization. The doctor simply didn’t care. The schedulers, both at the doctor’s office and at U.H. main campus, noted her coverage as they set up her non-emergency appointment. And since it was not an emergency, she had close to a month to worry about this procedure and her health.

Brenda got the call the day before the procedure. It was a courtesy call from University Hospital to let her know that she was going to be out-of-network. Did she still want her heart catheterization? It was too late to turn back. She had worried about this for almost a month. She made a snap decision. How bad could it be?


Brenda paid $11,000 in out-of-network fees. I consider this an abuse of privilege. Everyone involved knew that Brenda was going to the wrong facility. This was not an emergency. And this was too high a price to pay for good news.
# # # #

The bills are coming in for my little adventure. University Hospital, the doctors, and the labs have submitted claims in excess of $250,000. So far. My share, to date, has been my $5,500 deductible. All of my services were rendered by in-network providers. Anthem seems to be doing their job so that I can do mine, recover.

$250,000! I think that it would have been cheap at twice the price.


Monday, May 2, 2016

Sorry To Bother You

Mayfield Heights-20160502-00743

Quick Personal Update – Thanks for asking. I’m feeling stronger everyday. Already spending too much time at the office.

Frank (name changed) knew exactly what he wanted. Frank wanted the kind of policy he used to have twenty years ago when he worked in the family business. He wanted a small deductible, office copays, and an Rx card. A throwback. The policy needed to cover him and his twenty year old son. He wanted Platinum in a Silver or Bronze environment. Frank was insistent.

There was a way. I could put Frank and his son into the Government Exchange. Medical Mutual of Ohio was still offering a Gold Level policy through the Exchange, and even though he didn’t qualify for a tax credit subsidy, we could access this contract for them. I DIDN’T WANT TO DO IT. I warned Frank that accessing the Exchange needlessly simply multiplied our chances for failure. But Frank was insistent.

I can’t tell you how many hours I have invested in this disaster. It is difficult to even explain how messed this up. But they did. The original mistake isn’t the interesting part. It is all of the subsequent steps that leave us today, May 2, 2016, with Frank and his son uninsured.

Let’s skip ahead to April 9, 2016. Frank sat in my office for almost two hours that day. We were on hold for over 40 minutes before we got to talk to anyone. We were lucky. The woman we worked with seemed both knowledgeable and caring. Here is what she told us:
  • I can see where we corrected the initial problem and got Mr. Frank and his son covered as of March 1, 2016
  • I can see where we corrected that mistake and got Mr. Frank and his son correctly covered as of February 1, 2016
  • I can see that the policy then automatically cancelled itself out on March 1, 2016 through no fault of the insured
  • I can see that this was supposed to be expedited
  • I can see that it was never expedited
She promised to get this into the right hands and assured us that there was no reason for this problem to persist. We actually felt pretty good about the process when we finally hung up with her.

Don’t get too comfortable

The rejection letter came three weeks later. The government had decided that he didn’t deserve to have his policy reinstated. The letter helpfully included the marketplace appeal hotline 855.231.1751. Frank came in today.

By the way, this isn’t a specific problem of the Patient Protection and Affordable Care Act (Obamacare). This is a bureaucracy issue. This is a regulatory issue. This is a full-fledged screw up.

Frank sat in my office as I called the hotline. Working through the automated system I finally hit the button to file an appeal. WE WERE IMMEDIATELY DISCONNECTED.

Second call. This time, to the surprise of a Ms. Shannon, I managed to get to a human being. She had no interest in hearing why we were calling. The process demanded that we must first go to, file an appeal, and then, and only then, will anyone talk with us. Maybe. I tried. She wouldn’t budge.

We went to with her on the line. She made sure to point out the next to the last section, Choose an Authorized Representative. Frank had the right to name me as his contact, someone who could easily answer their questions and make sense of this. We got off the phone and completed the appeal form.

And once the appeal form had been completed we hit the link to the special authorization form. The picture at the top is where the link takes you. We’re so screwed…


Sunday, April 24, 2016

Shedding Pounds By Shedding Organs

back home

My new weight loss program

Standing by the hospital bed, the two nurses discussed the patient’s status. They reviewed recent ultrasounds, CT Scans, and the importance of “you have to go before you can go”. At some point I just looked up at the two of them and said, “I am being transformed from a 61 year old man to a 29 year old in the Maternity wing.”

Welcome to a very special Health Insurance Issues With Dave. It must now be obvious that some of the posts of the last year dealing with doctor interaction and cancer treatment were, in fact, about me. I apologize for being less than 100% transparent. I kept waiting for my Emily Litella moment. It just never came. (By the way, the links are footnotes that attempt to make these posts more informational and entertaining. Take a moment to enjoy Gilda Radner).

This post will discuss my last two weeks in stark detail. The picture above was taken Thursday, after I got home. Yeah, Happy Ending. Still, my story is still evolving and so is yours. And though less than pleasant, this is very relevant to you.

My annual physical has always included bloodwork. My PSA started to climb a few years ago. Nothing shocking. Not too high. No spikes. I didn’t have ANY problems, but I could hear my prostate calling. I finally had a biopsy last fall. The news wasn’t good. I had a Gleason Score of 7.

In some countries an otherwise healthy, asymptomatic man in his early 60’s would be monitored. Prostate Cancer moves slowly. In the US we aggressively tackle Prostate Cancer now, while the patient has the best opportunity to not only withstand the process of surgery or radiation, but to lead a long, normal life post-treatment. I opted for a combination of hormonal and radiation treatments. This was detailed in my last post.

I was invited to participate in a clinical study. Part of the protocol was another CT Scan. My last was just outside the timeframe. OK. One more test. The test results were fine, except that there was a shadow on my left kidney. The subsequent ultrasound was not determinant, but it wasn’t good. The next CT Scan was focused on my kidneys. I had a mass, approximately 10 cm wide, on the base of my left kidney. It didn’t matter if it was benign or malignant (probably), it had to come out. The radiation was put on hold for a couple of months so that this could be resolved.


This picture is of me walking into University Hospital Wednesday morning, April 13th. I had to accept that this was to be the first day of my process. It might be a year before I felt this good again.

The goal was to remove the mass and a small part of my left kidney. The surgeon would attempt to utilize minimally invasive techniques. But if he didn’t like what he saw, I had been warned that he wouldn’t hesitate to open me up and take the entire kidney. I should be able to leave the hospital Friday or Saturday. Sunday was my worst case scenario.

The surgeon removed the mass and part of my kidney. The doctors were concerned about my post-surgical bleeding. They took me back in, briefly, early that afternoon. Ten hours later we came close to ending my life as we ended the day. I was bleeding to death. You aren’t supposed to remember these incidents. I recall the room in vivid detail. At some point I attempted, with my left hand, to authorize another complete surgery while keeping my blood-soaked gown away from the form.

Let us at this point finally end the irrelevant notion of patient controlled cost containment. The patient, a 61 year old man who had never had any previous medical issues and was not on any medications, needed a major operation. He had done his part. Do We Save His Life? That is a YES or NO question. What if he had been 71? 81? 91? This is a question that we, as a society, must answer.

So, we all agreed to save my life. Yeah! Now, who’s paying? We have several ways to pay for medical services:
  • Government
  • Private Business (Insurance)
  • Some combination of government and insurance
Self-pay is not an option. Who but a very few could guarantee the availability of liquid assets when needed most? What society would turn away most of the truly ill? And how could the medical industry depend upon us to meet our obligations?

And just as important, who decides how much the medical providers (doctors, pharmaceutical companies, hospitals, labs, etc.…) get to charge for their goods and services?
  • Government
  • Private Business (Insurance)
  • Some combination of government and insurance
  • Or are the medical providers allowed to charge whatever the market will bear?
They rushed me into surgery in the early morning hours of Thursday, April 14th. The surgeons removed the balance of my left kidney and my spleen.

Each patient is connected to an impressive array of computers. Each machine has its own set of bells, horns, and alarms. Sleep and silence have been disrupted by an alarm. Every minute of an alarm feels like an hour. Alone in the darkness you first need to determine if it is your alarm. Why is it ringing? Am I Ok? And if it isn’t you, you relax for a moment before you wonder how that other guy is doing.

I awoke in the intensive care unit. Sally and Jennifer had been through the entire previous 30 hour adventure and were visibly relieved. They were allowed to dab my lips with a wet sponge. I was moved within a few hours to a surgical step-down unit. They gathered my stuff and put a long stainless steel cylinder next to me on the bed. “What’s that”, I asked. “That’s what’s keeping you alive”. I tried to move over and give them room for two.

I had been told that there was an almost sadistic nature to the way nurses and techs woke you up all night to draw blood and take tests. I greeting my nurses, nurse’s aides, and tech by name. Their presence proved that I was still alive. And I was only going to be able to leave the hospital with their help.

I had a great team. I recall these names: Nurses Becky, Sue, Lauren, Jen, Katarina, and Megan. Assistants Dave, Marie, and Debra. The surgeons resolve a problem. The nurses heal the patient.

Mark was one of my nurses in the step-down unit. Mark is in total control of his little corner of the world. Lucky for me, I got to spend about twelve hours there. He was the one to track down XL sized hospital socks, reassure Jen and Sally, and remove the catheter. Mark decided that I had to get out of the bed and take a wheelchair to my room on the 5th floor. There was push back. Didn’t matter. Mark was my first step towards recovery.

Nurses tell the truth. It is sometimes the patient’s responsibility to ask the right questions, but the nurses are your advocates. I was fortunate to have Tom for a couple of days in a row. He answered every question. He helped me to mentally prepare for my recovery.

I got home the afternoon of Wednesday, April 20th. I’m OK. Really. I’m almost fine. I’ve very tired and it will take a while to be back to 100%. I will share the bills with you as they come through. I’m curious as to what this all cost. I bet it would be cheaper and easier to drop a few pounds by going to Weightwatchers.

Thursday, April 7, 2016


Big Bucks

Consumer Directed Health Plan. One of the biggest jokes in the health insurance industry is the illusion of control. We pretend that you, the consumer, can control your medical expenses. We created products that, by law, have high deductibles, no office visit copays, and no Rx card. We know that you will shop for the best deals in primary care doctors and cardiologists. We are counting on you to force the doctors to justify every blood test, CT scan, and procedure. You know that you are a great shopper. Here’s your chance to prove it.

Can you shop for a deal when they are wheeling you in to the hospital with a blocked artery? “Hold up Mr. EMT. I just got a text alert that Hillcrest is having a sale on bypasses this week.”

But of course, none of this is real. There is no way to know the real cost of medical services in advance. And who amongst us wants health care by the lowest bidder? Plus, do we know anyone who is prepared to say to his doctor, “Another surgery? Gosh I don’t think we should spend so much just to save my life.”

The client is in the early stages of his treatment for prostate cancer. He and his doctors discussed the various ways to remove his prostate, external beam radiation, and even radiation seeds that can be implanted. The patient chose external beam radiation. The doctors then suggested that he also have hormone therapy.

Hormone therapy almost appeared to be an afterthought. By taking pills or getting shots the patient would inhibit testosterone production, shrink the prostate, and slow the growth of cancer. What shot? Which pill? The patient was told that the nurse practitioner would tell him when they met.

The client had a shot and got a bill a few weeks later. Ready? The shot cost $34,228.50. Surprise. The Anthem Blue Cross negotiated price for the shot was $18,932.99. The client’s deductible was $5,500. He blew past that. The client maxed out his share and Anthem paid the rest.

I looked at the bill and the first question I had was, “Did they buy you dinner?” I mean for this price he should have received a gift card for The Cabin. Sadly, all he got was an off switch for his libido. My second question was, “Is this some new miracle drug?” No, he was given Lupron which has been in use for over 30 years. The good news that it was a double shot, good for 6 full months.

$34,228.50 for one shot. Who knew? That’s easy. Everyone but the patient.

We have no control. Remember our friend the next time you wonder why your insurance premiums are going through the roof. I wouldn’t have done anything differently. You would have been just as surprised as he was. This shot is just one more example of a broken system in search of a solution.


Thursday, March 10, 2016

Platinum, Gold, Silver, Bronze, Lead



The Metal Tiers were a key component of the Patient Protection and Affordable Care Act (Obamacare). The idea was to force all policies (square pegs) into four levels of coverage (round holes). The metal tier would allow you to purchase a policy that would fit your needs. Each described the percentage the policy would pay of your overall healthcare claims.

Platinum – 90%
Gold – 80%
Silver – 70%
Bronze – 60%


Are these percentages accurate? Do they really represent 90%? 60%? Who knows? If you ask 5 people you will surely get 7 answers. Part of the problem is that everyone, and I do mean everyone, is engaged in the constant struggle to recreate reality. The pricing, the policies, the benefits, the covered doctors and hospitals, and even the insurers change annually. There can’t be an apples to apples comparison when 2014’s apples were replaced by kumquats in 2015 which were replaced this year by frozen pizzas.

The PPACA included an annual cap for out-of-pocket covered expenses. That cap has increased each year. In 2016 it is $6,850 for an individual and $13,700 for a family. This number includes the most you, the consumer, can spend on the deductible, copayments, and co-insurance during the calendar year. It does not include the premiums you pay.

The 2017 maximum out-of-pocket will be $7,150 for an individual and $14,300 for a family. Those numbers apply to Platinum, Gold, Silver, and Bronze policies. But if you have a family, especially a family that has ongoing health issues, the possibility of facing $14,300 of exposure (plus premiums) doesn’t feel like Platinum, Gold, Silver, or Bronze. It feels like lead. And many of these policies will be as valuable as lead pipes in Flint.

The health insurance market is changing rapidly. I can’t find a Platinum level policy in Cuyahoga County. There are only a few available in all of Ohio. Gold level policies are disappearing, too. At some point the metal tiers will need to be redefined or a couple of new ones will have to be added. Or, we will change to letters, such as Tier A, Tier B, Tier C, etc…

Because when all else fails we can always fall back on rebranding.


Thursday, March 3, 2016

Notes On Napkins

Trump health plan


It was a warm spring evening. Warm enough for the guys to sit on the whiskey bar’s patio. The group, a restaurateur, an insurance agent, a physical therapist, a scrap metals guy, and an attorney (isn’t there always an attorney?) were solving the world’s problems over adult beverages, mostly Scotch, and good cigars. But their real focus that evening was Korea. The insurance agent took notes on a couple of napkins as the group formulated a simple, common sense solution to Kim Jong-un and his nuclear paranoia. The only thing these five guys knew about Korea was a good place to get kimchi, but that didn’t deter them.

Last week’s post noted the ignorance of Donald Trump, specifically when it came to the Patient Protection and Affordable Care Act (Obamacare). I was not the only person to notice. Mr. Trump’s opponents, especially Senator Rubio, focused on the emptiness of his rhetoric at last Thursday’s Republican Debate. Even Mr. Trump’s most ardent supporters had to admit that he looked clueless and unprepared. And thus the Healthcare Reform To Make America Great Again plan was created. (That is a real link to the Trump plan)

This blog has reviewed each of the Republican alternatives as they have been released. The Bart Simpson Award for Spectacular Underachievement was presented to Scott Walker last summer for his fifteen page term paper. We have our first entry for 2016.

I want you to imagine Mr. Trump, his shadow Chris Christie, and a few advisors sitting on the patio in Palm Beach. The glasses are full of orange juice and unsellable bottles of Trump Vodka. The ideas are coming fast and furious.

Scotland! We love their health care.

No Americans dying in the streets.

We have to get rid of the artificial lines around the states.

Mandates! OK, maybe not.

No one had time to get a laptop or even a notepad. A junior staffer stopped refilling the glasses and started to take notes on some napkins. And that is how we got the Healthcare Reform To Make America Great Again, two and a half pages of napkin fodder.

The opening paragraphs were borrowed from all of the previous Republican offerings. Obamacare is blamed for all of humanities ills. Words like economic burden, higher premiums, and partisan litter the preamble with the promise that a complete repeal would bring the exact opposite. Obamacare would be blamed for global warming if the Republicans accepted climate change. The opening paragraphs also beg for help from Congress, the first time Mr. Trump has acknowledged that he isn’t officially running to be our dictator.

Here are the seven reforms that the Trump Administration wants Congress prepared to pass on the first day he is in office:
  1. Completely repeal Obamacare and eliminate the individual mandate. “No person should be required to buy insurance unless he or she wants to.”
  2. Allow the sale of health insurance across state lines as long as the plan purchased complies with state requirements.
  3. Allow everyone to deduct their health insurance premiums. Suggest to the various states what they should do about Medicaid and coverage for the poor.
  4. Legalize Health Savings Accounts (HSA)
  5. Require price transparency.
  6. Send the states money for Medicaid (Block Grants)
  7. Allow foreign companies easier access to sell prescriptions in the U.S.
“The reforms outlined above will lower healthcare for all Americans.”

That’s it. I know that you are more surprised by what is missing than what little is there. There is no mention of preexisting conditions. None. What do we do with the people who are now covered who wouldn’t be if the insurers had a choice? Your guess is as good as mine. How could any of this change happen? Don’t ask Donald. He ran out of napkins.

Unfortunately, I don’t have the luxury of running a fact-free presidential campaign. Neither do our friends at Forbes or at the home offices of the major insurers. My clients are already calling and asking how they would be affected by the Trump plan. The quick answer is that they wouldn’t be impacted at all. The seven bullet points simply prove that the candidate doesn’t care about their issue.

We’ve discussed points one and two. Deducting health insurance premium (point 3) is really important to people who want to pay less taxes. It is meaningless to people who want help in paying for their premiums. Donald and his team appear to be confused about the difference between the FSA, Flexible Spending Account, and the HSA, Health Savings Account. You should know that BEFORE you release your paper to make America Great Again. And if we send the states Medicaid Block Grants, we will condemn millions of Americans to substandard care as the money is misdirected elsewhere.

There are times in politics when being attacked from the Left and from the Right means that you really are in a good place. The Healthcare Reform To Make America Great Again appears to be nothing more than random thoughts on a cocktail napkin. And Donald came up empty.




Monday, February 22, 2016

Ignorance Is Bliss


The United States is a true super power. We have wealth, power, and almost unlimited resources. What we lack, what we desperately need, is more intellectual honesty. There is no reason to believe that that is going to change anytime soon.

The debate that led up to the passage of the Patient Protection and Affordable Care Act (PPACA or Obamacare) in 2009 and 2010 was filled with undeliverable promises and sugar-coated fantasies. This blog called out several Democrats by name. And a lack of intellectual honesty seemed pretty bad until we got the debates of 2011, 2012, 2013, 2014, 2015, and now 2016. We have replaced blather with cynicism.

The cynic knows what he is attacking is safely out of reach and what he is proposing wouldn’t really work. It doesn’t matter. It is the House of Representatives voting to repeal Obamacare 60+ times. It is our nation’s most cynical politician, Senator Ted Cruz, shutting down the government in effort to call more attention to himself.

The cynic understands the issue. The ignorant does not. We have devolved to ignorance, an entirely fact-free discussion of an important issue such as our health care and 20% of our economy. This is far more dangerous. And for that we must thank super salesman Donald J. Trump.

We may all have our own opinions about whether Mr. Trump knows what he is talking about when he tackles immigration, national defense, or taxation. But I feel compelled to speak up when he invades my territory, the delivery of paid access to our health care system.

Anderson Cooper conducted town hall meetings with all six Republican candidates on CNN last week. When asked about the PPACA and health care, Mr. Trump agreed to the need for mandates before he moved to his usual self-aggrandizing answer about his large crowds and standing ovations. I was impressed simply because the word mandate means something and his acceptance meant that he might be paying attention to this issue. That impression was short-lived.

Donald Trump appeared on CNN again on Sunday. Jake Tapper interviewed Mr. Trump on The State of The Union. Here is the entire interview. Mr. Trump, fresh off his South Carolina victory, quickly backtracked on mandates. He must have been briefed on the official talking points. Though he kept on detouring to how great his plan will be and that he will make sure that sick Americans aren’t dying in our streets (a real concern), he decided that he really doesn’t like mandates and he wants to eliminate state lines. Watch the interview. Words matter and it was clear that he had no idea what any of the terms meant.

Republicans cite the Tenth Amendment almost as often as the Second. But States’ rights seem to be unimportant when it comes to insurance regulations. Eliminating state lines and having insurers sell wherever they’d like might have some eventual benefit, might, but certainly nothing in the short run.

This blog has discussed the individual mandate numerous times. We all understand that people won’t purchase car insurance unless required. Health insurance is no different. If we want to have guaranteed issue and cover preexisting conditions, we need to have everyone participating. Even the GOP 1993 plan incorporated mandates, mostly because it was a real plan.

So what was Mr. Trump talking about? Nothing! What is the Trump plan? There is none. His gut instincts might have him embracing the core values of Obamacare or its ancestor, the Republican’s 1993 plan, but he hasn’t bothered to learn the details. This isn’t a lack of intellectual honesty. This isn’t cynicism. This is simply ignorance. He doesn’t know anything about Obamacare. One can only hope that a President Trump will.

He may appear angry, but Donald Trump is a really happy guy. Damn near blissful.