Friday, June 23, 2017

Trojan Horse

President Lyndon Johnson declared the War on Poverty in 1964. It was a sincere effort, but poverty persists to this very day. Senate Majority Leader Mitch McConnell, President Trump, and Speaker of the House Paul Ryan have decided that a War on the Poor is a better idea. They are weaponizing healthcare. The opening salvo was the American Health Care Act (AHCA). And yesterday, June 22, 2017, we got the working draft of the Better Care Reconciliation Act of 2017 (BCRA). The names might imply that these efforts are designed to enhance our access and payment of healthcare. A more honest name might have been Bang Bang You’re Dead.

The Senate released a “working draft”. This could be the actual bill. It could be a Trojan Horse. Since McConnell is trying to ram this through under the Senate’s rules for reconciliation, we may not know until the last possible moment.

I apologize for focusing so much on process, but that is where we must start. Leader McConnell is an incredibly cynical politician. He is a master of the game. We need to at least know some of the rules.

Under reconciliation, McConnell only needs 50 votes for a tie. Vice-president Pence would then cast the deciding vote. This “working draft” could be introduced as legislation. Debate will be limited to TEN HOURS. The Democrats would be able to introduce amendments, but debate is limited to TWO MINUTES per amendment. The Republican majority could quickly defeat all of Dem’s motions. Then, at the nine hour fifty minute mark, McConnell could introduce the actual legislation as a replacement amendment. The real bill is then passed before anyone can read or debate it.

Farfetched? Really? Have you been paying attention?

This blog will analyze the “working draft” over the next few days, but we must first focus on the process. Certain key Republican Senators and lobbyists have had advance copies of the BCRA. The first to complain weren’t Senators Portman or Collins. The first to the TV cameras to voice their disapproval were Senators Cruz, Lee, Paul, and Johnson who represent the extreme right wing of their party. They voiced opposition to the concessions made to the moderates. It feels like the fix is in.

I may see a Trojan Horse. The poor and working poor are staring at a tank.


Monday, June 19, 2017

The Path

I felt the first large drops of rain before I had managed to get in four miles. I had planned to golf, but there had been an 80% chance of thunderstorms. So I was walking. I was now in the Mayfield Village Wetlands, a mile long circle of bridges and gravel. I tried to stay on dirt and gravel paths to keep my focus on where I stepped as opposed to how far I was walking or the hot, sticky air. This particular trail was designed to be walked clockwise. I, of course, was going counterclockwise. I laughed at the thought. NO ONE WAS IMPACTED BY MY CHOICE. One path was as good as another.

Senate Majority Leader Mitch McConnell (R-KY) is engaged in a different type of exercise. He and his new best friends aren’t trying to lose a couple of pounds. President Trump, Speaker of the House Paul Ryan, and McConnell are trying to eliminate a legacy. They are not alone. There appears to be plenty of Republicans who would like to return to 2005, a time when they controlled the House, the Senate, and Bush was the president. A time before their failures. A time before Obama.

Many of their actions are petty and/or irrelevant. Then there is healthcare. For seven years McConnell and Ryan cynically fanned the flames of hatred and resentment of Obamacare, the Patient Protection and Affordable Care Act. Now it is Trumpcare and they own it.

Some paths lead nowhere. Some are dead ends.

Somewhere in Washington, behind locked doors, thirteen Republican Senators are creating the Senate version of Trumpcare. No hearings. No amendments. No debate. We are discussing how Americans access and pay for healthcare. We are talking about nearly 20% of the economy. We are talking, but they aren’t talking to us.

One of the senators is Rob Portman (R-OH). I have contacted his office about the secrecy. I have asked about specifics. What I’ve received, to date, was a form letter about his commitment to the treatment of opioid addiction. He is clear that he doesn’t support the House bill (The American Health Care Act) that doesn’t do enough to protect Ohioans dependent on the Medicaid expansion. Our governor and my local congressman, David Joyce (R-OH) have also voiced concerns.

OK, now what?

This secret bill is being cobbled together to garner 50 Republican votes in the Senate. That is all McConnell needs. Fifty, and then Vice-president Pence casts the tiebreaker. And the fate of millions of Ohioans depends on Rob Portman having more influence in the Senate than Senators Ted Cruz, Rand Paul, and Mike Lee. This dangerous path leads us to a cliff. Who are we willing to lose?



Wednesday, June 7, 2017

Thin Skin

The coroner was ready to address the press. She stood behind the podium with its bank of microphones, looked directly into the cameras, and delivered her judgement. “The cause of death was thin skin.” Several reporters nodded in agreement. They had been predicting this would be the answer. But one journalist refused to close his notebook and felt compelled to get a clarification. “Pardon me, Madame Coroner, but you are saying that the deceased perished from thin skin?” “Yes”, she replied without even a hint of emotion. “So the 27 stab wounds had nothing to do with his death?” “Well”, the coroner replied, “if he had had stronger skin he’d still be with us today, wouldn’t he?”

There was a rumor in 1897 that Mark Twain had died. A newspaper printed an obituary. Twain’s response was “The reports of my death are greatly exaggerated”. I was thinking of this earlier today as President Trump was again telling the American public that Obamacare is imploding. It is true that our current health insurance system seems to be having difficulty breathing, but the first step might be to convince Trump to stop choking it.

Yesterday’s big news was Anthem Blue Cross and Blue Shield’s announcement to abandon the exchange market in Ohio for 2018. This was not a shock to those of us following the shenanigans in Washington. This business decision by Anthem will be spun more than a dreidel during Hanukkah, but their simple words tell the real story:

Anthem has a long history of serving individuals in our communities. Customers have grown to expect great value and access to health care coverage from us. And our desire to meet those needs has not changed. But the current regulatory climate and the uncertainty it has produced in our industry do not give us the clarity and confidence we need to commit to offering broad-based, affordable health plans for 2018. So, while we wait for new regulations to be released, we’ve made the difficult decision to reduce the number of Individual health plans we’ll offer next year.
Please note that Anthem isn’t crying poverty. There are no claims of insurmountable losses. Washington seems determined to play politics with Anthem’s clients and gamble with Anthem’s money. Anthem walked. My clients have been calling all day, mostly elderly, Medicare beneficiaries who aren’t impacted, to ask what they need to do. The answer today is – NOTHING. We may need to take action in November, but there is absolutely nothing to do today.

There have been members of Congress and various Republican state officeholders who have been attempting to kill the Patient Protection and Affordable Care Act (Obamacare) since its inception. There were the 60+ votes in the House that we’ve discussed ad nauseum. There have been various law suits from red states. Some of the suits have been more effective than others. We don’t have Medicaid expansion in all 50 states, thus blocking millions of Americans from access to healthcare. Other cases involve subsidies, who gets them and how much.

CWRU Professor J. B. Silvers, the former CEO of QualChoice, published an article on January 4th of this year on MarketWatch year about the dangers of repealing Obamacare without a comprehensive plan. He returns again and again to market uncertainty. The insurers have to trust the government to not change the rules in the middle of the game. AND THEY CAN’T.

One example he (and others) cited was an initial risk reduction program built into Obamacare to defray the high cost of claims anticipated during the first three years of the program. The claims were significantly higher than anticipated, “But when the time came to pay for the risk reduction in the Obamacare exchanges, Congress reneged and paid only 12% of what was owed to the insurers.” This shortfall chased some insurers out of the market and forced those remaining to raise rates significantly last year.

And now we are in the middle of another bait and switch.

One of the lawsuits the Obama administration had been fighting was designed to eliminate a special subsidy for those Americans earning between 138% and 250% of the federal poverty level. This additional benefit not only helped to make the premium affordable, it also reduced the deductibles and out of pocket limits for these insureds. The Obama administration had won a stay while the fight went on in the courts. Trump could simply drop the fight. He has been threatening to do this for months. The insurers would be left holding the bag. This is a link to an April Forbes article on the issue. Katherine Hempstead of the Robert Wood Johnson Foundation is quoted in the article. “It probably was inevitable that the threat of cost-sharing reduction non-payment would be dangled for leverage.”

What we learn, time and again, isn’t that Obamacare is imploding. It is being sabotaged. It is under attack. And if the way we deliver and pay for healthcare, nearly 20% of our economy, suffers an untimely demise it won’t be from thin skin. I think we have to see who is holding the knife.




Tuesday, June 6, 2017

Healthcare And The Politics Of Resentment

It happened again last week, this time on a golf course. A fourth was added to our group. Our new friend, Ken (name changed), is a businessman from the Akron area. It only took a couple of holes for him to learn what the rest of us did for a living and only another before he started to complain about Obamacare.

I can’t offer my employees health insurance because of Obamacare.


My Insurance went up 400%!

That seems odd.

My premium jumped to $3,000!

For just you?

And my deductible was $10,000. It was worthless insurance.

You had an individual deductible of $10,000? That’s not possible.

What really ticks me off is how all those people are getting free insurance, great insurance, for doing nothing!

It always devolves to a complaint about the poor. There are winners and losers in the Patient Protection and Affordable Care Act (Obamacare). There had to be. We can look back to September 1993 when then President Bill Clinton went before Congress to explain that it was inevitable that some people would be forced to pay more if we were to overhaul our healthcare system for the betterment of most.

The Obamacare winners are easy to list:
  • The unhealthy
  • The poor
  • The working poor
  • Anyone stuck in a job or marriage to retain health insurance
  • Young women
  • Hospitals
The losers, mostly due to additional premium or taxes:
  • Young healthy males
  • Businesses employing unskilled, low income workers
  • Individuals earning over $200,000
  • Healthy middle income wage earners purchasing their own coverage
There has to be winners and losers. Republicans constantly cite President Obama’s claim that insurance rates were going to decrease and that if you liked your doctor you can keep your doctor. Yes, Obama oversold Obamacare as he confused goals with deliverables. But these same Congressmen give Trump a pass on his sugarplum and rainbow description of his non-existent health plan. Would there be winners and losers if Trump, Ryan, and McConnell ever pass an alternative to Obamacare? Of course. There has to be.

But what galls me are the politics of resentment. Being poor is a full-time job. I recently helped a young woman apply for coverage. She had aged off her parents’ policy and we went through to get her a new policy. She qualified for Medicaid. This was a huge relief. Her expensive prescription would be covered. Her premium - $0. That was in March. Today is June 6th. She is still waiting. No word from the State of Ohio. No Rx card. No help.

Not only are my tax dollars helping to provide Medicaid to the poor and the working poor, I am also losing commissions. Some of those people were or would be clients. I am no longer paid to be their agent. That’s a trade I’m happy to make. Do we really believe that people want to be poor? Are we better off as a society by punishing the sick and the hungry?

The problem with Obamacare isn’t that the Medicaid expansion extended access to healthcare to millions of Americans. The problem is that millions of Americans are still uninsured. The problem with Ken? Who cares?



Sunday, May 21, 2017

Hey Nancy, Queen Me!

Paul Ryan triumphantly moved his pawn to the last square. “Hey Nancy, queen me!” His gallery went wild. He jumped out of his chair and high-fived his backers. “You da man”, his new friend, Donald Trump, shouted from the front row. It wasn’t until he returned to his seat that he noticed that his opponent had remained silent, oddly silent, throughout the celebration. But that didn’t matter to Paul. He leaned back in his chair and didn’t even bother to hide his smirk. Nancy Pelosi reached for her rook, pushed it three blocks to the right, and said “Checkmate”.

While the TV has been Trump 24/7, there are other news sources helping to bring important info to the American public. Excellent reporting from Bloomberg Politics on May 18th revealed that “the American Health Care Act, H.R. 1628, hasn’t been transmitted from the House to the Senate, according to Senate Bill Clerk Sara Schwartzman”. Confirmed by CNN, House Bill 1628, the American Health Care Act is sitting in Paul Ryan’s desk while he sweats out a Congressional Budget Office report.

The danger of creating a piece of legislation that is designed more to punch your opponents in the nose than to solve a particular policy problem is that the House can pass just about anything by a simple majority but that the Senate’s rules are a lot more complicated. The Senate’s filibuster and reconciliation rules shaped the final structure of the Patient Protection and Affordable Care Act (Obamacare). And Trumpcare will only become law if the legislation meets these same arcane regulations. And we won’t know until Wednesday, when the Congressional Budget Office releases their scoring, if the AHCA complies.

The minimal requirements are that the American Health Care Act must reduce the deficit by at least Two Billion Dollars. That removes the possibility of a Democratic lead filibuster and allows the Senate to pass legislation by simple majority. The bill must also provide the proper optics. If the CBO report comes back with too many people losing their coverage, that too could bury the legislation. The original House version had only 24 million Americans losing their coverage, not nearly enough to slow Speaker Ryan. The uninsured issue could cause real concern in the Senate, but doesn’t force the House to act. But if the deficit reduction goals weren’t met, the House will be forced to retool the AHCA and then VOTE AGAIN. President Trump and Speaker Ryan twisted an awful lot of arms to get those 217 votes a few weeks ago. Could he get them again?

The biggest problem with the AHCA isn’t that it fails to answer how all Americans can access and pay for healthcare. The biggest issue is that its starting point is the repeal and replacement of Obamacare. The goal is to eliminate President Obama’s legacy, not affordable healthcare and certainly not patient protection. There can’t be any real progress or any true bipartisan effort until our elected representatives choose to fix the existing law. There are responsible Democrats and Republicans who will privately acknowledge that there are ways to improve the PPACA that both sides could accept once the focus changes from the name to the content.

Mark Bertolini, the chairman and CEO of Aetna, was recently quoted as saying “Single-payer, I think we should have that debate as a nation”. In the attached article Bertolini describes the public/private partnership that already exists in both Medicare and Medicaid. He also notes that the insurers already run many of these programs and process the paperwork. Some are viewing this as expanding Medicare Part C, the Advantage Plans, to all Americans both under and over 65. I look at this as a direct extension of my blog post of April 2010 where I claimed that the insurers would eventually push for a single-payer type of system.

Democrats like Pelosi wanted a single-payer program in 2010. Republicans have long promoted market-based solutions such as the Advantage Plans. It is difficult to predict how soon the adults in Congress gain control of the news cycle, much less the legislative agenda. But no one wants to campaign on the value of taking access to healthcare away from Americans. Paul Ryan had a minor victory two weeks ago. Nancy Pelosi appears to still be winning the chess match.


Monday, May 15, 2017

Screaming Meemies

I visited the Senate day care center on Friday. The room was filled with Screaming Meemies. One little girl had the word Protocol on her t-shirt. She was standing in the middle of the room, hitting herself in the head with a wooden spoon. It was a big room. On the south side there were several old men in rockers with sobbing babies sitting on their laps. The old men were crying about a past that might not have ever happened. The babies were crying about a future that never will. And in one corner a child kept wailing “nobody likes me” as tears flowed down his face. “Who’s that” I asked Mitch, the facility director. “Oh, him? That’s the health care bill. We found him in a basket on our doorstep a week or so ago. Nobody likes him!”

There are days were it feels like we are all stuck in the Senate day care center. The unexpected firings and resignations, alone, could fill the daily news cycle. Add the Russians, the specter of war, and all of the questions about the economy, taxation, and regulation and we are on overload. Wouldn’t a nap sound good right now? Perhaps a vacation? But we are adults and we don’t have the luxury of allowing ourselves to be distracted. And since this is Health Insurance Issues With Dave, we are going to spend some time with that lonely unloved health care bill.

That also means that we are stuck spending more time with Mitch.

The Senate Majority Leader opened the door and brought into his chamber the bill he never wanted. He could have turned to Senators Susan Collins (R-Maine) and Bill Cassidy (R-Louisiana) who have been working for months on legislation. Both have years of experience on this issue. Or, the Majority Leader could have attempted to create a bipartisan group to draft meaningful legislation like the gang of six in 2009 that worked on the original bill. Instead, McConnell assembled 13 other Republicans, all male, who represented the full diversity of Republican thinking from Conservative to VERY Conservative.

The current fight in the Senate, in those rare moments when they can focus on something other than the President’s antics, has not been about healthcare or preexisting conditions. This being Republican legislation, the first big issue is Medicaid.

Senator Rob Portman (R-Ohio) is being portrayed as a moderate since he has expressed real concern about slashing Medicaid. The Wall Street Journal is reporting that Senator Mike Lee (R-Utah) and others are “weighing faster and steeper cuts in Medicaid”. The question is never about who is served by Medicaid and how much is really needed to provide for their care. That doesn’t appear to be relevant. The issue is strictly how soon can Medicaid funding be cut and by how much.

We might want to remember that Medicaid serves a number of communities. The schools depend on Medicaid funding to help defray the cost of educating children with disabilities. The AP quoted Kriner Cash, superintendent of the Buffalo, New York public schools. 80% of his students are low income and 22% have disabilities. The district currently receives approximately $2.5 million annually from Medicaid.

…individual student care comes with highly variable costs, especially in the case of students with disabilities.
Those costs would not be considered in a system where money is allocated on a per person basis regardless of need. And need does not appear to be relevant to our senators.

At some point our senators may resolve the Medicaid issue to their satisfaction and then move on to preexisting conditions, maternity care, and the Essential Health Benefits. Or not. The Senate may just cobble together something as unsatisfactory as the American Health Care Act, but set it up where their bill wouldn’t go through reconciliation so that the Democrats can kill it with a filibuster. That is a scenario only someone as cynical as Mitch McConnell could orchestrate.

The reporters are trying to get details about the latest Trump debacle and Senator Collins just plaintively asked if we could have just one day without chaos. There is a lot of unhappiness in the Senate day care center, but it is time for our friends in Washington to finally work across the aisle to fix the way we deliver and pay for healthcare in this country. Soon, before we all become a bunch of Screaming Meemies.






Wednesday, May 3, 2017

They Don't Need To Do A Thing

They didn’t look 74. He was reading, sitting mostly in the shade, his skin dark and leathery. And, he still had a full head of hair, though it appeared very white against his well-tanned face. His wife was still working on her tan. She wasn’t that far behind. She was filling out a yellow bikini and, like Sally, frequently moving her beach chair to catch the best rays. We talked for a few minutes before he asked my occupation. Once I said health insurance he began to ask questions.

We just got back from a week in Mexico. (Feel free to insert your wall joke here!) We talked with Europeans, Canadians, Mexicans, and lots and lots of US Citizens. World affairs dominated our conversations with the Europeans. Canadians wanted to know “What the Hell is going on?” The Mexicans seemed to politely concentrate on their culture. Americans immediately asked healthcare questions as soon as they learned that I was an agent. Thank G-d for the NFL Draft. It was my major break from shop talk.

I talked with business owners overwhelmed by changes in the group health insurance market. There were hospital workers worried about facility consolidations and closings. Republicans sought reassurance. “It is going to get better, right?” Dems seemed worried about everything. Cost? Coverage? Preexisting Conditions? Americans, now accustomed to simple answers to complex questions, wanted to know what was going to change and when it was going to happen.

There are no simple answers.

I left for vacation as the Republicans struggled with their amended American Health Care Act (Trumpcare). In a rush to accomplish something/anything within the first 100 days of this term, a stab was made at both healthcare and at the budget. Neither got done. Nothing changed while I was gone. There was a lot of grandstanding in Washington and Harrisburg. Lots of angst everywhere else.

There are Congressmen on TV declaring that the new, new, new plan still doesn’t protect their constituents with preexisting conditions. Other Congressmen are pooh-poohing the issue. And the President is unclear, at best. Worse, all of these elected officials are Republicans. Somehow the Democrats have extricated themselves from this circular firing squad. Would that the American people were so lucky.

Today is Wednesday, May 3rd. The President and Vice-President are busy twisting arms and begging for votes. They hope to have a vote tomorrow afternoon. Why? Surely it isn’t because they have a solution. Trump needs a victory. The Republican controlled Congress needs to prove that it can pass a bill.

The current sticking point appears to be preexisting conditions. The MacArthur Amendment appears to open the door to shuttling the sick to an insurance Siberia of underfunded high risk pools. According to FamiliesUSA, there was a fund of $13 billion per year for ten years to help protect high risk individuals from higher premiums. An additional $8 billion dollars was dumped in yesterday to help make the final push for approval. That isn’t $8 billion per year. No, that is $800,000 per year, essentially no change at all.

We have already seen what happens when you underfund high risk pools. Over 30 states tried one version or another prior to the Patient Protection and Affordable Care Act (Obamacare). Even the PPACA had a high risk pool to help during the transition. The $5 billion dollar fund quickly evaporated.

Conservatives James Capretta and Tom Miller tackled this issue in the Spring 2010 edition of National Affairs. They lay out a compelling argument for high risk pools and a well-regulated insurance market. They also call for reasonable funding - $15 - $20 billion per year. That was in 2010. The current bill calls for less money, not more. It also calls for less regulation. It is a recipe for disaster.

The elderly couple on the beach asked if they should finally purchase a Medicare Supplement. I took a few minutes to explain the basics of Medicare Part A and Part B, the drug benefits of Medicare Part D (Rx), and even Medicare Advantage Part C. That’s when their faces lit up and they remembered that they had advantage plans through UnitedHealth Care. I confirmed that their coverage was working for them and congratulated them on the choice. They are lucky. They don’t need to do a thing.

If you are under age 65, you aren’t that lucky.



Picture by David L. Cunix



Saturday, April 22, 2017

Milestone / Miles From Nowhere

Thirteen. At thirteen, a milestone, a Jewish boy is viewed to be a man. He has a Bar Mitzvah, becomes responsible for his actions, and three days later is reprimanded by his parents for failing to do his homework. So which is it? Is thirteen a milestone or is it really miles from nowhere?

We have a lot of artificial milestones, deadlines to get something accomplished, a deadline to be somebody. Twenty-one seems to be the threshold to adulthood. Fifty to being whatever we might actually accomplish professionally. Retirement at 65. But these are just numbers, an average, perhaps, maybe even a goal for some, but these numbers. These milestones are not law, not mandatory, and the first true sign of maturity is to understand that in our quest to achieve our best we must first discard artificial, imposed timelines. While some may peak at 23, others are still honing their skills in their 70’s. Limiting oneself to someone else’s milestones might even force someone into foolish actions.

And that brings us to Donald Trump and the rush to pass a healthcare bill next week.

Donald Trump has decided that he must repeal and replace Obamacare (The Patient Protection and Affordable Care) within his first 100 days. This is not because he has a prescription for better, cheaper, or even easier access to healthcare for most Americans. It is strictly because the first 100 days is a milestone. He has no concern about leaving us miles from nowhere.

President Trump is trying to get the House Republicans to pass a bill by next Friday. And though the legislation hasn’t been written, the Congressional Budget Office hasn’t revised its scoring, and no House committee has held a single hearing, Trump thinks he can get a bill passed. Of course, it could be passed if the details don’t matter. Just a reminder – we are talking about close to 20% of our economy and how the doctors and hospitals get paid if you happen to get sick or injured. The details are important.

Trump’s latest partners are two Republican House members representing two different wings of the party, House Freedom Caucus Chairman Mark Meadows and Tuesday Group co-chairman Tom MacArthur. Together they have crafted a compromise that is more likely to anger the members of their caucuses than to garner their support. The MacArthur Amendment (draft provided to Politico) to the American Health Care Act does not fulfill the Republican promise of repealing and replacing Obamacare, guarantee that Americans won’t lose their healthcare coverage, or even deliver more coverage for less. They have shuffled the deck, added a couple of jokers, and then mistakenly dealt the cards face up.

The MacArthur Amendment reaffirms the value of having real standards of insurance. The Essential Health Benefits, a list of ten benefits delineated under the PPACA, were scheduled to disappear under the original Republican plan. This amendment brings the EHB back, but only for a moment. Section 1 reinstates the EHB. Section 2 allows states to seek a waiver to eliminate the EHB if they claim that this would lead to lower premiums or the possibility of more insureds. And it isn’t just the Essential Health Benefits. Section 1 guarantees useful insurance and Section 2 guarantees that usefulness won’t be around for long.

We are rushing towards a milestone – Trump’s first 100 days. It is an artificial deadline. But healthcare, taxes, war and peace are not artificial. These issues are real. And when it comes to reality, he is miles from nowhere.


Thursday, April 13, 2017

Donald Trump Needs A Friend

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

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

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

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

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

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

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

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



Monday, March 27, 2017

Let Me Help You To Hurt Me

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

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

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

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

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

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

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

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


Tuesday, March 14, 2017

It Should Be My Choice

I want more choices.

Damn Right!

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


All those extras just add to the cost.

Yes, make it cheaper.

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

I’m with you.

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

Me, too.

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

Cars? I thought you were talking about health insurance.


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

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

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

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

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




Wednesday, March 8, 2017

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

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

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

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

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

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

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

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

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

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

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

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

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

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


Friday, February 24, 2017

Lucky, Again

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

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

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

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

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

Quick Example:

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

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

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


Friday, February 17, 2017

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

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

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

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

The Law of Unintended Consequences.

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

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

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

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

** ** ** ** **

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

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

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

The view from the train beneath the Capitol.


Wednesday, February 1, 2017

The Nice Guy Finished Last / First

Robby is the nicest guy I know. No exaggeration. Robby is just a great guy. And right now Robby is losing and winning the health insurance battle.

Robby was referred to me by his employer at the very beginning of the full rollout of the Patient Protection and Affordable Care Act (Obamacare). So I have never asked him any health questions, but I have no reason to believe that he has any medical issues or ongoing prescriptions. He is just a laborer, single and a non-smoker, in his early 50’s, living in Parma. There are thousands of guys just like him throughout Greater Cleveland.

Robby has gone years without health insurance. His employers seldom provided coverage and he couldn’t possibly afford it on his own. The PPACA guaranteed access to coverage AND included a penalty for non-compliance. The penalty was an important factor in his request. It would be unthinkable for Robby to jaywalk, he certainly wasn’t going to do anything penalized by law.

And Robby got a policy. It was a terrible policy with a $6,000 deductible and it cost him $110 a month after his tax credit subsidy of $187, but he was covered and if, G-d forbid, he got really sick or injured he would have easy access to world-class facilities right here in Cleveland. He even got a free routine annual exam, if he ever had a chance to get to a clinic on a day he wasn’t working. So, Robby won. We all did. We had one less uninsured American worried about a major illness and a society less concerned with the inevitable bill for his care.

Robby’s insurance went up $30 a month beginning January 1, 2015. Robby’s victory wasn’t quite so sweet.

The price of insurance was going up. The subsidies were going down even though his income had hardly changed. The invasion of low-cost Medicaid providers into the Exchange severely impacted Robby’s subsidy. If he would allow the Exchange to force him to Metro and Charity hospitals he would pay less. He hung on to the Cleveland Clinic and the price went up to over $250 with his subsidy for 2016.

In 2017 his premium is $325 and his deductible is $6,400. Robby is losing.

I got a call today from Robby. He wants to drop his policy now that he is no longer required to keep it. I let him know that he can drop the policy but that he would still be liable for the penalty. He thought that it was over. I had to break the news to him that the individual mandate, both a Republican idea traceable to the Heritage Foundation in 1989 and Republican strawman, was still the law.

President Trump’s Executive Order gives the Secretary of Health and Human Services and other department heads the ability to reduce the “burden” of complying with Obamacare. Congressman Price’s confirmation for Health and Human Services has been stalled due to what appears to be insider trading. More importantly, the insurance companies are scared to death of adverse selection. Without the individual mandate, the only people who will buy insurance are the sick and the responsible. That could be disastrous.

With no immediate viable replacement, a nice guy like Robby has no place to go. He’s winning. He’s losing. Nothing has really changed.


Monday, January 23, 2017

The Number One Priority

You may have seen the picture of the new president rushing into his office to sign his first Executive Order. It was Friday, January 20, 2017, after the parades and before the inaugural balls. Chief of Staff Reince Priebus put the paper in front of him, and like a homebuyer whose eyes have glazed over from thirty pages of gobbledygook, President Trump quickly signed the document without a moment’s hesitation. Now if you or I were about to make history, and everything a president does, by definition, is historical, we might have looked at the document, maybe ever READ the document, prior to affixing our name to it.

Since we aren’t on our way to any formal dinners or balls, we have plenty of time to read the Executive Order. Please take a moment. It is only one page.

It is important to note that this was the first Executive Order. So what does it mean?

Option One – If the repeal, replace, demolition, or rebranding of Obamacare succeeds, this Executive Order will be hailed as the important first step President Trump made to keep his promise and to deliver a better program. That is a huge if.

Option Two – This Executive Order opens the door for major changes. Once a Secretary of Health and Human Services (HHS) has been confirmed by the Senate, he (Don’t judge me. All of the nominees are male.) will be able to determine what regulations are burdensome. Here’s a hint – All regulations are a burden to someone. The current nominee is Congressman Tom Price (R-GA). States looking to modify the cost of Medicaid by reducing benefits or access will find Mr. Price supportive. In fact, a quick read of his positions over the years will yield the impression that Mr. Price might happily remove any requirement that the poor and middle class have comprehensive insurance coverage.

And though all of the above might seem like enough of a motivation to sign this Executive Order, I still think that it isn’t enough to be #1. So allow me to offer another explanation.

The Patient Protection and Affordable Care Act (Obamacare) was structured in broad strokes with the details to be fleshed out in the form of regulations. This is not unusual. Major legislation like the Patriot Act are designed this way. The PPACA requires health plans to cover annual routine preventive care visits. These visits are covered at 100%. No deductible. No copays. It was HHS that determined that routine preventive care included a colonoscopy for those of us over 50. This has undoubtedly saved lives. It was also HHS that determined that preventive care included birth control pills, the IUD, and the morning after pill. That made the lives of countless Americans easier. And now that this Executive Order has been signed, it will be HHS that will decide birth control, the IUD, and the morning after pill are no longer part of preventive care.

This change could apply to both individuals and groups. The current court cases dealing with this will be dropped immediately. This will be seen as a victory for those employers who are opposed to these services. And to those who needed these benefits. Well, they aren’t the priority.


Friday, January 20, 2017


Michael Lewis’s recent book, The Undoing Project, details the groundbreaking work of two Israeli psychologists, Daniel Kahneman and Amos Twersky. Their work explored the way we make decisions and how we justify, after the fact, those decisions. Mr. Lewis helps us to understand how these two scientists moved our decision making towards data and away from intuition.

In late 1973 or early 1974, Danny gave a talk, which he would deliver more than once, and which he called “Cognitive Limitations and Public Decision Making.” It was troubling to consider, he began, “an organism equipped with an affective and hormonal system not much different from that of the jungle rat being given the ability to destroy every living thing by pushing a few buttons.” Given the work on human judgement that he and Amos had just finished, he found it further troubling to think that “crucial decisions are made, today as thousands of years ago, in terms of the intuitive guesses and preferences of a few men in positions of authority.” The failure of decision makers to grapple with the inner workings of their own minds, and their desire to indulge their gut feelings, made it “quite likely that the fate of entire societies may be sealed by a series of avoidable mistakes committed by their leaders.”

I can’t think of a more important paragraph to share with you today, January 20, 2017. Health Care, Nuclear Proliferation, Trade – all of these decision will affect us all.


Thursday, January 5, 2017

Pair Of Sevens

ALL IN! Crap, all in with a pair of sevens. But he had to do it. It had been so long since he had had a hand, any hand, that he was forced to go all in with a pair of sevens. He had been pushed around long enough. He remembered his last chance, the last time he had been really good hand. Thought he had a winner. The first two cards – King and Queen of Hearts. He bet and his opponent called. Next the Jack and then the ten. Both hearts! He bet big. Call. And then came the ACE! But it was the ace of clubs and all he had was a high straight. He bet and his opponent raised. The warning bells went off in his head as he called. He had a straight, but his opponent had drawn a full house. Now he was all in with a pair of sevens. And his opponent looks like he may call…

It takes a certain amount of courage to put your money on the table and ask to be dealt into the game. Though some may always lose, no one always wins. So you better enjoy the game, revel in the risk, and be prepared to accept the outcome win or lose. And there is one more similarity between poker and politics. You must be prepared to bluff.

In March of 2010 the Democrats went all in. They didn’t have a great hand. This wasn’t the early 90’s when they thought that they had a winner. They didn’t have the National Single Payer plan that they really wanted. They had compromised with their fellow legislators from across the aisle to cobble together a plan that would garner bipartisan support. And they failed. They were all in and they were exposed and alone. On March 23, 2010 the Dems won with a pair of sevens and the Patient Protection and Affordable Care Act (Obamacare) was signed into law.

March 23rd wasn’t the end of the game, just the biggest tournament to date. The Republicans have been very busy since that loss. They had no respect for the gambler, President Obamacare, and hated to have been bested by such a weak hand. It took almost seven years, but here they are, back at the table. The Republicans had spent almost every waking hour since the defeat preparing for this day. A poker player needs a bankroll. The Republicans needed votes – a solid majority in the House of Representatives, the Senate, and a Republican in the White House. And on Friday, January 20, 2017 it will all come together.

For almost seven years the Republicans have told everyone who would listen that they were the better choice. “Bet on me”, they said to the American public. Their focus, the game, scheduled for 1/20/2017 was impressive. We all knew that if they were given the chance they would repeal and replace Obamacare. They just needed their bankroll. And now they’ve got it. There is only one problem.

We are about to see how Paul Ryan plays a bluff. He’s got the votes. But he doesn’t have the cards. There is no viable Republican alternative. Even Republican governors want/need to retain the expansion of Medicaid built into the law. Nobody wants to reinstate medical underwriting, exclude preexisting conditions, or kick kids off their parents’ policies. Everyone wants cake and ice cream for dessert, but no one wants to be forced to eat the liver and onions entrĂ©e.

The players are about to be seated. We’ve already taken a peek at the Republicans’ hand. Wonder what the Dem’s have? Wonder how they’ll play their cards? More importantly, who is going to tell all of them that this isn’t just a game?


Sunday, January 1, 2017

Fighting For Care


Irritated. My right eye was irritated. So was I. My eye had been bothering me for a couple of days. I didn’t know if it was allergies, a sty, or an infection. I had been determined to rely on eye drops and to just tough it out, but that was before I had needed a warm compress in the middle of the night. Time to get medical attention.

As previously noted, I was a touch irritated. Before I could deal with my issues I had to solve a client’s problem with UnitedHealth One. I was on hold for 52 minutes! My phone has a timer. Staffing cuts reflect the company’s losses over the last few years. Once that was completed I could focus on me.

I contacted the Cleveland Clinic facility in Beachwood. It only took 30 seconds for me to clearly state that I didn’t need to see my doctor, or any doctor. I would be perfectly happy with a nurse practitioner as long as I got to come in today. I had also detailed my eye problems. If I was having a heart attack or bleeding to death the scheduling tech would have been able to send me to the E/R and hang up. No, she had to talk to me.

I have been a Cleveland Clinic patient for years. The clerk had all of my information on her screen. Still, she needed to verify ALL of the information from my Anthem card, front and back. I said that I’ve had this policy for over three years. Nothing has changed. It didn’t matter. She plowed on. Next, where do I work? What is my job title? At the eight minute mark, remember my phone has a timer, I noted that we had spent more time confirming how the Cleveland Clinic would be paid than my health problem. She persisted.

Ten minutes into the call I asked her again who was going to see me. She said, “We don’t have any openings today”. “Then why did you waste my time”? She began to offer appointments for the following week, but I had had enough and hung up.

I hear it all of the time. Every negative encounter with the medical industry is blamed on Obamacare (the Patient Protection and Affordable Care Act). Sometimes the complainer is correct, but not always. Failure can be traced to a number of sources.

The staff cuts and financial losses at UnitedHealth One are due, in part, to some really awful decisions. And UH1 cut their marketing and service staff when the going got tough. They succeeded in making it harder to do business with them. UnitedHealth One will get better. This is just a bump in the road.

And the Cleveland Clinic’s failure can’t be blamed on Obamacare. This insatiable push for more money, more donors, and more buildings occasionally leaves the patient as nothing more than a necessary evil. We are in the way. Soon we will be diagnosing and treating our own ailments and simply sending tribute payments to the Cleveland Clinic.

Two websites and a phone call later I had an appointment at a Minute Clinic in a CVS. These clinics are somehow affiliated with the Cleveland Clinic. The nurse checked my vitals, noted my agitation, and gave me a prescription for some eye drops.

So what was it? Allergies? Sty? Infections? I’m still not sure. I took an antihistamine and have religiously put in the eye drops as prescribed. I’m sure I’ll be OK in another day or so.