Reality Used To Be A Friend Of Mine

 

Quick Note – I sincerely apologize to the five or six of you, my regular readers, who wondered what happened to this blog.  Between the closing of my office and a little health care issue, I have not had the opportunity to address all of the craziness of the last few months.  

 

Vice President Gary Nance, played by Ben Kingsley, talked about how he got started in politics in the movie, “Dave”.  He was motivated to help his community.  He was motivated to do GOOD.  And I wonder, each time I think about that movie and everyday when I watch our politicians, like Speaker of the House Mike Johnson, on TV, when doing GOOD no longer became their defining purpose.  I refuse to believe that the majority of our elected officials have abandoned such basics as honesty, human decency, and the desire to help our fellow citizens, especially those most in need.  But I could be wrong. 

Today’s post is going to get into the details, the details for how Congress passes legislation and the consequences of said legislation.  There will be a lot of links to take you to the source materials.  Of course this is an opinion piece, but I am providing you with the facts to back up my conclusions.  Read the materials.  Please share with me your conclusions.  You may, or may not, agree with me. 

Reconciliation – This must be our starting point.  Per the Brookings Institute:

“Reconciliation is, essentially, a way for Congress to enact legislation on taxes, spending, and the debt limit with only a majority (51 votes, or 50 if the vice president breaks a tie) in the Senate, avoiding the threat of a filibuster, which requires 60 votes to overcome. Because Republicans have 53 seats in the Senate—plus a Republican vice president—reconciliation is a way to get a tax-and-spending bill to the president’s desk even if no Democrats support it.” 

We start with Reconciliation because that is how the Republican controlled Senate was able to pass H.R. 1, The Big Beautiful Bill.  This legislation could not have passed otherwise.  The bill specifically includes certain provisions, such as tax cuts for certain groups, and intentionally reduces the access to benefits, such as Medicaid.  The bill also intentionally chooses to ignore the need to extend the Patient Protection and Affordable Care Act (Obamacare) enhanced tax credits.  These were choices made by the Republicans.  There were no negotiations.  They had enough votes to pass H.R. 1 through Reconciliation. 

The expanded tax credits are addressed at Congress.gov:

“Summary

Although the premium tax credit (PTC) has been available since 2014, there is increased congressional interest in the federal subsidy due to the impending expiration of a provision that enhanced the PTC.

The Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) established the PTC to help eligible households lower their payments toward premiums for qualified health plans offered through health insurance exchanges. The American Rescue Plan Act of 2021 (ARPA; P.L. 117-2) expanded eligibility for and the amount of the PTC for tax years 2021 and 2022. The Fiscal Year (FY) 2022 Budget Reconciliation Law (P.L. 117-169) extended the ARPA provision for three additional tax years, 2023 through 2025.

In general, the enhanced PTC provision allowed more households to become eligible for the credit and provided larger subsidies to all eligible households, compared with ACA-only rules. As a result, federal expenditures for the PTC were larger under ARPA/FY2022 Budget Reconciliation Law rules than under ACA-only rules.

If the enhanced subsidies expire, the Congressional Budget Office (CBO) estimates a decrease in enrollees with subsidized exchange coverage resulting in a reduction in federal expenditures. CBO also estimates that expiration of the enhanced PTC would contribute to a rise in the uninsured rate.

If the enhanced subsidies are permanently extended, CBO and the staff of the Joint Committee on Taxation estimate an overall increase in exchange enrollment leading to an increase in the federal budget deficit.” 

Please note that this current online document from the CURRENT Congress details the importance of the premium tax credits in reducing our rate of uninsureds.  Health insurance is the way most Americans access and pay for health care.  

Let’s go back to the first meaningful and positive tweak to Obamacare, the March 2021 expansion of the premium tax credits to more accurately reflect the realities of the market.  This is the CNN report from March 31, 2021: 

“More help to buy health coverage

The boost in aid is part of Biden’s effort to get more Americans covered by health insurance. The relief package makes two changes to the subsidies to address long-standing complaints that Obamacare plans are not affordable for many people, particularly the middle class.

Enrollees will pay no more than 8.5% of their income toward coverage, down from nearly 10%. And lower-income policyholders will receive subsidies that eliminate their premiums completely.

Also, those earning more than 400% of the federal poverty level – about $51,000 for an individual and $104,800 for a family of four in 2021 – will become eligible for help for the first time.” 

The purpose of the change was to help Americans, to do good.  And it did.  The expanded tax credits really helped our clients over age 55.  Individuals in the early sixties, many suddenly force to purchase their own coverage for the first time, were only able to afford the purchase of health coverage because of the extended premium tax credits. 

The Big Beautiful Bill intentionally allows the extended premium tax credits to end.  Many older Americans, age 55 to 64, will no longer be able to afford comprehensive coverage.  The healthiest of them will opt for short term coverage or to be uninsured.  Both options only work if you never get sick or injured.  The unhealthiest will find some way to stay insured.  This only serves to make insurance even more expensive.  The term is Death Spiral.  In this case, the damage is intentional. 

Sequestration – Per the Congressional Budget Office:

“Sequestration refers to automatic spending cuts that occur through the withdrawal of funding for certain (but not all) government programs. CBO provides estimates of the statutory caps on discretionary funding and an assessment of whether sequestration might be necessary under current budgetary rules, but the Administration's Office of Management and Budget makes the ultimate determination of whether a sequestration is necessary and, if so, how big it should be.”

The Big Beautiful Bill adversely affects your access to health care by intentionally driving up the deficit.  This will, in turn, cause automatic cuts in the budgets of the entire social safety net, INCLUDING MEDICARE.  This is the link to the CBO response to the question, “Would Sequestration impact Medicare?”

We, meaning anyone interested in fighting to preserve our current system of accessing health care, have one last chance – the current fight in the U S Senate.  The Senate Majority Leader, John Thune, is asking the Democrats to just let everything go through for now.  There is plenty of time to address these issues in November.  No, if this isn’t addressed now, it will not be done at all. 

None of this should come as a surprise.  Many of us spent all of the summer of 2024 discussing the Heritage Foundation’s Project 2025.  My blog posts included a link to a searchable online version that helped many of us to fully understand the potential danger.  The Heritage Foundation has removed that online document.  Instead, I can provide you with the link to the Project 2025 Tracker.  Yes, someone is meticulously monitoring the dismantling of the federal government by Russ Vought, the Director of the Office of Management and Budget. 

Few would argue that Obamacare is perfect.  It was perceived to be the best legislation that could be passed through Congress at the time.  It has survived over a decade of political grandstanding and sabotage.  But the core was the attempt to help more people access and pay for coverage.  Steven Brill wrote a thoughtful piece in June 2017 that detailed nine ways to fix Obamacare.  I can’t imagine Mike Johnson having any desire to read the article, much less implement any of the ideas. 

This has been a long article, but I hope that I have put the current government shutdown into perspective.  I would like to believe that our elected representatives have our best interests at heart.  That all of these shenanigans are just a difference in perspective.  But reality used to be a friend of mine.  I’m afraid that we can no longer pretend that we are having an honest difference of opinion of how best to help the American people. 

Dave 

Health Insurance Issues With Dave

Picture – Some Things Must Be Stopped! – David L Cunix

 

When Is The Right Time To Destroy Medicaid?

 

The United States House of Representatives will be busy tonight.  The Rules Committee will be meeting tonight at 1 AM to discuss Donald Trump’s Big Beautiful Bill.  I would provide a link to this legislation, but they are keeping it under wraps.  It is like getting hit by a Tesla.  You won’t hear it coming, but you will feel the impact. 

A key reason for these late night shenanigans is the need to pass a bill that will allow the Republican majority to continue the Trump tax cuts that are expiring without, officially, raising the debt.  There are two ways to accomplish this.  The first is to fudge the actual numbers.  The second is to gut the social safety net.  This is not the kind of debate that is televised to a national audience at 1 PM. 

The Patient Protection and Affordable Care Act (Obamacare) provided for the expansion of Medicaid.  As noted in my post of June 26, 2017 Dayenu, the de-stigmatization of Medicaid and the subsequent expansion to include the working poor may have been the most important part of this legislation.  The Supreme Court ruled on June 28, 2012 that the states could choose to expand Medicaid, or not.  Ten states have yet to expand Medicaid, the most notable being Texas.  So it is no surprise that tonight, a Congressman from Texas, Chip Roy (R-TX), will be leading the charge towards bigger tax cuts and less health care.  It is always Texas. 

It might be instructive to look at some numbers for Texas in general and Chip Roy’s District 21 in particular.  To be fair, Mr. Roy is very clear on his views.  He has posted “The Case for Healthcare Freedom” on his website.  He envisions a world where you have a hundred grand in your HSA so that you could negotiate your appendectomy at the Cleveland Clinic.  The real world, especially for those who live in Texas, is very different.

The population of Texas                                             30,029,577

Percent Uninsured                                               16.6%     #1

Number of uninsured Texans                          4,984,909      #1

Fun fact – There are more people uninsured in Texas than the combined population of Delaware, South Dakota, North Dakota, Alaska, Vermont, and Wyoming.

Number on Medicaid/Chip in Texas                   5,800,000

Chip Roy’s District

Percent of population uninsured & under age 65         14%

Percent of population uninsured age 18 and under        9%

Number of uninsured in District 21                      86,377

Percent of population on Medicaid & under age 65    6.5%

Percent of children on Medicaid/Chip                        15.3%

Number on Medicaid/Chip                                      43,200

The Commonwealth Fund produces The Scorecard For State Health System Performance.  This is the link to the 2023 report.  Texas rates, as usual, near the bottom.  For those keeping score, Texas usually rates in the second half or lower on such charts as life expectancy and health rankings.

There has been an effort to pull Texas away from the likes of Mississippi, Louisiana, and Alabama.  Expanding access to health care has been a real struggle.  The Texas Standard has detailed the benefits of expanding Medicaid and, unfortunately, why it probably won’t happen in 2025.  It is estimated that over 600,000 Texans do not qualify for either Medicaid or a tax credit subsidy under Obamacare.  This is not a problem that the current Texas government nor its Congressional delegation has any interest in solving.  Organizations such as the Heartland Institute work tirelessly to leave Texas where it is.  This is the link to their Research and Commentary: Texas Medicaid Expansion.

Medicaid expansions benefitted insurers, hospitals, and providers while the population’s health worsened and average life expectancy declined in expansion states, Dr. Brian Blasé and David Balat of the Texas Public Policy Foundation found.  “The ACA significantly expanded insurance coverage between 2013 and 2017, but Americans’ health worsened during this period and life expectancy declined for three consecutive years from 2014 to 2017,” the authors write.

Of course, by their logic, if we cancel everyone’s insurance we all live forever.

The clock is ticking.  A bill will come out of the House of Representatives and if you make enough money, you might even find it big and beautiful.  The rest of us are counting on the Senate to protect the rest of America.

Dave

www.cunixinsurance.com      

Picture – Time To Insure – David L Cunix

 

Another Small Victory

 

 

It is the most American of activities, the petitioning of our elected representatives in the hope that we can get our government to enact legislation that will help us to live happier and more productive lives.  This is the essence of Capitol Conference, the annual meeting of the National Association of Benefits and Insurance Professionals (NABIP). 

I recently joined a gathering of 750 health insurance agents and industry employees in Washington DC.  As I have detailed in previous years, we were in our nation’s capital to hear from the heads of regulatory departments such as CMS, Congressmen, Senators, and thought leaders on the issues impacting us and our clients.  This year, the beginning of Trump 2.0, was particularly important.  How would the new administration try to change Medicare, Medicaid, and the Patient Protection and Affordable Care Act (Obamacare)?  Most of us had booked our rooms and flights before DOGE began to focus on Social Security and Medicare.  The news coming from Washington since the inauguration confirmed the need for us to be there in person. 

The focus for me has always been the meetings with our elected representatives.  I was honored to lead delegations to the offices of two of Ohio’s members of Congress.  Due to votes, our meetings were with the legislative aides, not the Members.  I had had the pleasure of talking again with Ms. L. Hannah, Congresswoman Shontel Brown’s Legislative Assistant.  She is well aware of the issues impacting our district.  Our other appointment was with Ms. K. Walker, MPH, Congressman Greg Landsman’s Legislative Aide.  One of the reasons I love wandering around the Halls of Congress is the opportunity to interact with the bright, talented 20 and 30 somethings who choose to devote themselves to public service.  These are our future leaders. 

Our issues – our Ask – our Talking Points are always more focused on our clients than ourselves.  It is odd, but we, the agents, are in the best position to advocate for the health care access of the average American.  Here are a few of the highlights:

·       Codify telehealth benefits for High Deductible Health Plans and Medicare

·       Advance PBM (Pharmacy Benefit Manager) reforms for lower costs and greater transparency

·       Revisit site-neutral payments which will help lower health care costs

·       Preserve tax incentives for employer sponsored benefits.  Over 175 million Americans are covered by employer-sponsored group health insurance.

·        Reintroduce COBRA as Credible Coverage legislation

There were also some suggestions to improve the enrollment process for Medicare Part D (Rx).  I would be happy to discuss any of these topics in greater detail.  That is probably better left to one on one conversations. 

What is important is that these aren’t Democratic or Republican positions.  There is nothing inherently partisan about making sure that Americans of any age can access and pay for health care. 

The House of Representatives voted last week to extend telehealth for six more months.  It wasn’t a standalone bill.  It was part of the continuing resolution.  Telehealth coverage for millions of Americans is still an option until September 25^th.  It isn’t permanent.  It isn’t even till the end of the year, but it is a small victory. 

And we should celebrate every victory, no matter how small. 

Dave 

www.cunixinsurance.com

Picture – Out With The Old – David L Cunix

Is Your Insurer Prepared For 2017?

 

It has only been 8 years, but can you count on your insurer’s institutional memory?  Eight years seems like yesterday to those of us who have been in the health insurance business for decades.  Unfortunately, many of our insurance companies are now run by bean counters.  Eight years?  Eight years ago our C-Suiters may have still been at a major hospital system or doing time at UnitedHealth Care (it appears that many of them pass through UHC), but now they are at their current insurer, the one that you are depending upon.  Are they ready?  I’m not sure.  So much of the business community has been in denial this past year.  There was an assumption within the business community, that Donald Trump, the Heritage Foundation and its Project 2025, and even Elon Musk would do nothing more than shake things up, make a lot of noise, take their cuts, AND LEAVE THEM ALONE.  That is not going to happen.  We will all be involved.    

Health Insurance Issues With Dave had 34 posts in 2017.  Almost all of these post were about the various attempts to repeal the Patient Protection and Affordable Care Act (Obamacare) without a viable replacement or the other efforts by the Trump administration to sabotage the law.  Our insurers may have already forgotten the damage of these actions.  I would like to focus on October 13, 2017, when we learned that the president had terminated the funding for the Cost Share Reduction, an important part of Obamacare.    

Today’s post will be a collection of articles about Trump’s October 2017 actions from a variety of sources.  You will learn about the unintended consequences of Trump’s style of bluster and bullying, that this “Cut” cost the taxpayer, the insurers, and YOU the consumer a lot of money.  There were no savings.  Obamacare survived.  We all paid. 

These are articles from October 2017: 

My post – Playing Chicken

Plain Dealer – Stephen Koff’s What Trump's decision to Obamacare means for you, insurers and Congress

Business Insider - Trump just made a huge move that could blow up Obamacare

NPR - Trump Administration To End Obamacare Subsidies For The Poor

CNN - Trump kills key Obamacare subsidy payments: What it means

FOX tried to put a positive spin - Trump Ends Key Obamacare Subsidies: What You Need To Know

Healthcare Finance - Trump administration ends cost-sharing reduction payments under ACA

Healthcare Triage (Video) - Trump Cuts ACA Cost-sharing Payments, Lawsuits Incoming

By October 27, 2017 the Centers for Medicare and Medicaid Services (CMS), the state insurance departments, and the insurance companies were all working to solve this unplanned for disaster.  In most states the real question was whether all rates would be increased or just the rates for the Silver Level plans.  Would this push low-income enrollees to less comprehensive policies?  How would this impact the tax credit subsidies?

Kaiser Family Foundation - How the Loss of Cost-Sharing Subsidy Payments is Affecting 2018 Premiums  This article includes the actual rate increases in a state by state section.

This last article was published on May 10, 2024 by Fanyu Liu of the Department of Economics of Tulane University in the Frontiers of Public Health.  We are still impacted by the rash decisions of 2017.  The impact of terminating cost-sharing reductions payments on health insurance plan choices

I have been accused of being overly concerned about my clients’ access to health care.  There are those who say not to worry.  Neither Trump nor his minions would really endanger the American public.  What they mean to say is that Donald Trump wouldn’t intentionally endanger the American public.  There is a huge difference. 

##########          ##########          ##########

Two other insurance agents and two insurance company employees were sitting in my office.  Three of them were excited about Elon Musk’s efforts in Washington.  I got them to admit that he hadn’t really found any fraud, but they were still sure that he had found massive waste.  I reminded them that one person’s waste was another’s important value.  After all, there are plenty of people who think that what we do, all five of us, is just waste.  

Musk and Trump talk about Fraud when, at best, they might be finding waste.  Fraud is objective.  Waste is subjective.  I’m not worried about justifying my professional existence.  I suspect that many of the so-called wasteful programs can also be justified, if given a chance.  A Republican Congressman recently said that some mistakes may be made and some worthwhile programs might suffer, but you have to break a few eggs to make an omelet.  That might be true, but Project 2025 is not a cookbook and Elon Musk is not a chef. 

Dave 

www.cunixinsurance.com

Picture – Like Water Flowing To The Lowest Point – David L Cunix

 

 

 

You Deserve The Best

The word “Meritocracy” is more of a weapon than an honest description of how our businesses, government, or even personal lives operate.  The word also directly contradicts a common phrase, “It is not what you know, but who you know”.  What we know, really know, is that the numbers are the numbers, and that in the real world, in this case, insurance, we are sometimes judged as part of a group and sometimes as individuals.  Our merit is not always rewarded.

One of the provisions of the Patient Protection and Affordable Care Act is Community Rating.  Community Rated premiums are calculated based on everyone’s medical claims within a community (or risk pool), as opposed to Experience Rated premiums which are calculated based on each person’s claims history.  Our unhealthy clients are ecstatic.  Our healthy clients complain vociferously about community rating until they endure a serious accident or illness.  We used to experience rate.  We used to underwrite each case.  Lots, really LOTS, of people were declined.  Others were charged extra or had their existing conditions excluded from coverage.  Did people prefer that system?  Yes, right up and until the moment they were told “NO”.  Some agents would like to return to that system.  I am not one of them.  I remember what it was like in 2013 and before to tell a family that we could not insure their child because of a diagnosis of asthma.  I recall underwriters saying, “Their doctor prescribe a breathing machine?  This must be serious.”

Meritocracy is fine if you are part of the favored group.

My start in this business was in Life Insurance.  As a rule, it is clean and neat.  If you die while insured, we write a check.  The process of acquiring life insurance isn’t that simple.  Most of our policies involve significant underwriting.  The issue is mortality.  Do you have a medical condition, dangerous hobby or occupation, bad driving record, risky travel plans?  Have you exhibited a behavior that violates community standards or morality (moral turpitude)?  Do you have a need for the coverage?  These factors determine whether or not you qualify to purchase a life insurance policy and at what price.

I have always been fascinated by life expectancy tables.  This blog has posted information from these tables.  Is it only a coincidence that states with mediocre health care have the lowest life expectancy?  Texas has the highest rate of uninsured adults.  As big and as rich as Texas is, the state normally ranks about 30^th in life expectancy.  Here are two National Vital Statistics Reports.  Each shows the life expectance at birth, rank, and standard error, by sex.  This is for each state, the District of Columbia, and the United States:

·         2020 – Published August 23, 2022

·         2021 – Published August 21, 2024

By the way, the Centers for Disease Control and Prevention (CDC) now has a new heading - CDC’s website is being modified to comply with President Trump’s Executive Orders.

Is there a meritocracy in life insurance?  Yes and No.  Women, as a rule, pay less than men because they have a longer life expectancy.  Accountants tend to pay less than roofers.  Your height and weight will be evaluated.  What isn’t considered is your state of residence.  If this was a real meritocracy, residents of Mississippi would pay a lot more for life insurance than a resident of Hawaii.  Review the tables and see where your state falls.  Ohio was 38^th in 2020 and 40^th in 2021.  Certain states are always near the top.  Others like Alabama, Louisiana, West Virginia, and Mississippi are always at the bottom.  There is no benefit to residents of Massachusetts to have their life insurance risk pool polluted with insurance sales to residents of Kentucky or Alabama.

I am not campaigning to have my clients, most of whom live in Ohio, to pay more for their life insurance.  This is just a reminder that our systems, business and government, are always looking to bring in a little fairness. 

What is the definition of “fairness”?  In truth, it means to give ME a benefit, price, job, or opportunity I might not have been able to access on my own.  The news has a lot of talk about fairness right now.  It might be important to remember that we are all a part of a lot of different groups.  In some of those groups we look like Hawaii.  In some we look like Mississippi.  Let’s all try to be more consistent in our applications of fairness.

May we all be meritorious in all of our endeavors.

Dave

www.cunixinsurance.com

Picture – Read Between The Lines – David L Cunix

 

 

 

 

Bone Of Contention

 

This blog has sounded the alarm.  There is a concerted effort to dismantle regulations, at least those impacting business activity and business behavior.  And though this is Health Insurance Issues With Dave, we have to take a moment to talk about boneless chicken wings. 

Here is the link to the Court News Ohio article.  The two minute version is that an Ohio man, Michael Berkheimer, revisited a local restaurant in 2017 and ordered his usual, boneless chicken wings.  From the article: 

“Berkheimer followed his normal practice of cutting each boneless wing into two or three pieces. He was eating the third piece of a wing when he felt “a piece of meat [go] down the wrong pipe.” He went to the restroom to try to clear his throat but was unsuccessful. Over the next three days, he spiked a fever and had trouble eating. During a visit to the emergency room, a doctor discovered a thin chicken bone lodged in his esophagus. His medical records indicated it was a “5 cm-long chicken bone,” which is about 1-3/8 inches.” 

The Ohio Supreme Court has ruled that Mr. Berkheimer cannot sue the restaurant or anyone responsible for the production of not-boneless boneless chicken wings.  Our courts have decided that you have no right to assume that a product sold as boneless would actually not have any bones.  This faith in the marketplace to self-correct means that anyone can sell you anything.  No matter what, you should know better.

 I am not implying coordination.  Instead, I see a convergence of a particular mindset / political view with those who would exploit weaknesses in the regulatory system.  Specifically, I am looking at the way legislation pending in the Ohio legislature, H.B. 400 and H.B. 587, would work with the Heritage Foundation’s Project 2025. 

H.B. 400 – Changes the way Medicare Supplements are marketed.  The bill would allow Medicare Beneficiaries under age 65 to purchase Medicare Supplement coverage.  It would also allow these Beneficiaries to change their policies annually.  Since they are under 65 and already declared Medicare eligible due to sickness or injury, there can’t be any underwriting.  Key changes:

·         Sale of Medicare Supplements to <65

·         Change Medicare Supplement policies annually, guaranteed issue with Pre-Ex covered

·         A whole new market that is constantly eligible.

·         Pricing locked in to the age 65 rate

·         Medicare Supplement marketing is state regulated

·         NO MENTION OF MEDICARE PART D (Rx) WHICH HAS FEDERAL MARKETING REGULATIONS.

H.B. 587 – Changes the way Medicare Supplements are marketed within the State of Ohio.  Many of Ohio’s current regulations mirror the federal government’s Medicare Advantage / Medicare Part D (Rx) prohibitions.  This bill removes these consumer safeguards while ignoring the need to help the consumer understand and address all of his/her needs.  Someone purchasing a Medicare Supplement would also need a Medicare Part D (Rx) plan.  And that individual might even be better served with a Medicare Advantage Plan.  Current Federal regulations would prevent the marketing of those plans at that time.  Key changes:

·         “Print solicitations such as…door hangers left at residences or on motor vehicles.”

·         “In-person solicitations of individuals at the individual’s residence or in public or common areas such as parking lots, hallways, lobbies, or sidewalks.”

·         “Telephonic or electronic solicitation such as electronic voicemail messages, text messages, or direct social media messages.”

Please note that H.B. 587 does not address the likelihood that many of those solicited would not qualify for the purchase of a Medicare Supplement policy under the current rules due to their preexisting conditions.  Beneficiaries currently covered by a Medicare Advantage Plan would have to answer health questions and would be subject to decline if they have had the MAPD for over 12 months.  This bill does not address the Beneficiaries’ need for Medicare Part D (Rx) coverage.

 

Project 2025 – The Heritage Foundation’s Mandate for Leadership: The Conservative Promise.  If I may skip the 533 times tax and/or taxpayer are mentioned and the 199 times for abortion, the other key focus of Project 2025 is the privatization and / or move to state (non)regulation of federally regulated programs.  The privatization of Social Security and the move of programs such as Medicare to state regulation are an inherent part of Project 2025.  And this is the final connection:

·         If Medicare was regulated by the State of Ohio, we could lose all of the consumer protections:

A.      Minimum standards for MAPD policies

B.      Age restrictions on Medicare Supplements

C.      Meaningful guaranteed issue vs. underwritten times to purchase coverage

D.     All marketing regulations.  Once anyone on Medicare can routinely change plans, marketing restrictions would be ignored (see current call centers with MAPD) and eventually eliminated.

It is important to remember that this mindset is completely convinced that the market will correct any and all excesses.  That faith in market correction ignores the real world consequences of the damage done. 

This same thinking can be applied to their efforts to dismantle the Patient Protection and Affordable Care Act in our industry and countless other examples in other industries.  

Eliminate all consumer safeguards?  I have a bone to pick with that. 

Dave 

www.cunixinsurance.com

Picture – Dependably Boneless – David L Cunix 

Quick footnote – I hope that some of you, especially those of you who are insurance agents, will click on the links to the legislation.  Both bills are only a few pages.  Also, the Project 2025 link is searchable.

It's All Great As Long As You Don't Pay Attention

Warning – Today’s post deals with the controversial Heritage Foundation Project 2025 Mandate for Leadership: The Conservative Promise.  Here’s a hint, I’m not a fan.  If offering my thoughts and quoting from this document might bother you, skip this issue and come back in another week or so.  Dave

One of last month’s posts on Health Insurance Issues With Dave discussed The Republican Study Committee Fiscal 2025 Budget Proposal and how it would, if given a chance, impact health insurance, the way most Americans access and pay for health care.  Today’s post will take a look at the Heritage Foundation’s Project 2025 Mandate for Leadership: The Conservative Promise.  It is important to note that this blog is my opinion on the major issues affecting health insurance, but the links will take you to the source material.  If you doubt my characterization of Project 2025, read it and then get back to me.

First, a little about the Heritage Foundation.  Many of us in the insurance business first became acquainted with this organization in the late 1980’s and/or early 1990’s.  The Individual Mandate, later to become a flashpoint in the Patient Protection and Affordable Care Act (Obamacare), originated with the Heritage Foundation in 1989.  Conservative Republicans including Orrin Hatch (R-UT), Charles Grassley (R-IA), and Newt Gingrich (R-GA) introduced legislation in 1993 that included the Individual Mandate as a counter to “ClintonCare”.   The concept also played a part in the Republican sponsored Medicare Part D (Rx) legislation ten years later.  As I have often noted for my clients, the first casualty of Obamacare was intellectual honesty.

The history is important because there are those who would edit the records based on whichever way the wind is blowing.  I have seen television interviews of the president of the Heritage Foundation, Kevin Roberts.  I’m certain that he will, by this time next year, either affirm or deny everything he’s said, depending on the results of the election.  But for now we can see and hear him say, “We are in the process of the second American Revolution, which will remain bloodless if the left allows it to be”.

There have been many scholarly papers written about using tax policies for social engineering.  Our government encourages marriage, having children, and owning a home through a variety of tax incentives.  So it is no surprise that the 922 page Project 2025 mentions the word tax or taxpayer a whopping 533 times.  For the record, here are how often a few other key words appear:

• Medicaid                      55 times
• Medicare                      51
• Health Insurance        11
• Obamacare / ACA       17
• Abortion                       199

Medicare first appears on Page 283.  This is an unedited excerpt: 

The first year that Medicare spending was visible on the books was 1967. From that point on through 2020—according to the American Main Street Initiative’s analysis of official federal tallies—Medicare and Medicaid combined cost $17.8 trillion, while our combined federal deficits over that same span were $17.9 trillion. In essence, our deficit problem is a Medicare and Medicaid problem. 

Please review your most recent paycheck.  If you are an employee, you and your employer each paid a 1.45% Medicare Tax.  If you are self-employed you paid the entire 2.9%.  Most Medicare beneficiaries also pay $174.90 per month for Medicare Part B.  The Heritage Foundation is pretending that there is no funding for these programs and is simply fudging the numbers.

On Page 463 we finally get to the meat of the Heritage Foundation’s plan.  First this paragraph:

Increase Medicare beneficiaries’ control of their health care. Patients are best positioned to determine the value of health care services, working with their health care providers. They also benefit from increased choice of doctors, hospitals, and insurance plans. Access to reliable information with respect to physicians, hospitals, and insurers is therefore essential.

This was quickly followed on the next page by:

1. Make Medicare Advantage the default enrollment option.

Where is Alanis Morissette when we need her?

Let’s move over to health insurance.  A few pages later, on page 468, we get to individual health insurance.  Over the next few pages they will cover the importance of concierge medicine, pricing negotiations on a case by case basis, and the elimination of the safeguards built into Obamacare (guaranteed issue, preexisting conditions covered, no policy maximum benefits, etc.)  I am posting some of the actual paragraphs for you to read.

AFFORDABLE CARE ACT AND PRIVATE HEALTH INSURANCE 

Remove barriers to direct primary care. Direct primary care (DPC) is an innovative health care delivery model in which doctors contract directly with patients for their care on a subscription basis regardless of how or where the care is provided. The DPC model is improving patient access, driving higher quality and lower cost, and strengthening the doctor– patient relationship. DPC has faced many challenges from government policymakers, including overly exuberant attempts at regulation and misclassification. Changes should clarify that DPC’s fixed fee for care does not constitute insurance in the context of health savings accounts. 

Facilitate the development of shared savings and reference pricing plan options. Under traditional insurance, patients who choose lower cost care do not benefit financially from that choice. Barriers to rewarding patients for cost-saving decisions should be removed. CMS should ensure that shared savings and reference pricing models that reward consumers are permitted. 

Separate the subsidized ACA exchange market from the non-subsidized insurance market. The Affordable Care Act has made insurance more expensive and less competitive, and the ACA subsidy scheme simply masks these impacts.  To make health insurance coverage more affordable for those who are without government subsidies, CMS should develop a plan to separate the non-subsidized insurance market from the subsidized market, giving the non-subsidized market regulatory relief from the costly ACA regulatory mandates.

Strengthen hospital price transparency. In 2020, CMS completed its rule to require hospitals to post the prices of common hospital procedures. Future updates of these rules should focus on including quality measures. Combined with the shared savings models and other consumer tools, these efforts could deliver considerable savings for consumers.

Center for Consumer Information and Insurance Oversight (CCHO).

CMS also plays an outsized role in overseeing the Obamacare exchanges, including managing Healthcare.gov, through the Center for Consumer Information and Insurance Oversight (CCIIO). While Obamacare limits plan options, CCIIO has been overly prescriptive in dictating what benefits and types of health plans may participate in the exchanges, thereby actually stifling market innovation and driving up costs.

Congress should build on the Trump Administration’s efforts to expand choices for small businesses and workers, both in and out of the exchanges, by codifying an expansion of association health plans, short-term health plans, and health reimbursement arrangements (including individual coverage HRAs). CCIIO should also work with the Treasury Department and the Office of Management and Budget (OMB) to give consumers more flexibility with their health care dollars through expanded access to health savings account.

The Heritage Foundation is not a big fan of Group Health Insurance:

Wages vs. Benefits.

The current tax code has a strong bias that incentivizes businesses to offer employees more generous benefits and lower wages. This limits the freedom of workers and their families to spend their compensation as they see fit—and it can trap workers in their current jobs due to the jobs’ benefit packages. Wage income is taxed under the individual income tax and under the payroll tax. However, most forms of non-wage benefits are wholly exempt from both of these taxes. To reduce this tax bias against wages (as opposed to employee benefits), the next Administration should set a meaningful cap (no higher than $12,000 per year per full-time equivalent employee—and preferably lower) on untaxed benefits that employers can claim as deductions. Employee benefit expenses other than tax-deferred retirement account contributions should count toward the limitation, whether offered to specific employees or whether the costs relate to a shared benefit like building gym facilities for employees. Tax-deferred retirement contributions by employers should not count toward this limitation insofar as they are fully taxable upon distribution. Only a percentage of Health Savings Accounts (HSA) contributions (which are not taxed upon withdrawal) should count toward the limitation.  The limitation on benefit deductions should not be indexed to increase with inflation.  Employers should also be denied deductions for health insurance and other benefits provided to employee dependents if the dependents are aged 23 or older. 

My focus is on health insurance.  There is more, a lot more, focused on removing guardrails with the understanding that there is no reason to worry about excesses because the market will self-correct.  But this is health care, not just 20% of the economy but whether or not you get to see a doctor and receive medical attention when you need it.

This is getting long so I will spare you the numerous abortion, LGBTQ+ (12), or gender (111) references.  I had to include the one section that proves that self-described Conservatives have rhythm:

Expand inclusion of fertility awareness–based methods and supplies to family planning in the women’s preventive services mandate.

The ACA requires coverage of and prevents insurance plans from imposing any cost-sharing requirements on women who obtain preventive care and screenings as defined by HRSA. In 2016, HHS included “instruction in fertility awareness-based methods” as part of this requirement. However, in December 2021, HHS removed that language from its list without using the notice-and-comment process or giving any rationale, both of which are mandated by the Administrative Procedures Act. In August 2022, a federal court blocked this attempt to eliminate health insurance coverage for fertility awareness–based methods of family planning from requirements that cover at least 58 million women, and the judge made his ruling permanent in December 2022. HRSA should promulgate regulations consistent with this order. HHS should more thoroughly ensure that fertility awareness–based methods of family planning are part of women’s preventive services under the ACA. FABMs often involve costs for materials and supplies, and HHS should make clear that coverage of those items is also required. FABMs are highly effective and allow women to make family planning choices in a manner that meets their needs and reflects their values.

A lot has been said about Project 2025.  Some on the left have taken these plans to their illogical extreme.  Many on the right are already running away from Project 2025 (unless they win).  There wasn’t a Republican Party platform in 2020.  The recently released 2024 draft is oddly silent on almost everything other than the border.  If we are going to assess the Republican plans for governing this country in general and health care in particular, we must look at the work of the Republican Study Committee and the Heritage Foundation.  Those links will take you to THEIR WORDS and THEIR GOALS.  I am only here to get you started.

We are all in this together.

Dave

www.cunixinsurance.com

Picture – The Gorge – David L Cunix