Dayenu

Passover is my favorite holiday. And my favorite part of the Passover Seder is the singing of Dayenu. As we list each miracle and wonder that was done for us, such as freeing us from slavery or saving us at the Red Sea, we say Dayenu. Dayenu is loosely translated to “That would have been enough for us”.

The Patient Protection and Affordable Care Act (Obamacare) was a poorly written bill. It was compromise legislation that didn’t fully satisfy anyone on the left or the right. But when asked over the last seven years what Obamacare did well, I have always cited the expansion of Medicaid. If the Patient Protection and Affordable Care Act had done nothing but expand Medicaid – Dayenu!

Destigmatizing Medicaid was the first positive step we could take as a society to help the poor and working poor. And Medicaid helps more than just the poor. It also helps the disabled and the elderly. Medicaid is our insurer of last resort, which means that an awful lot of our friends and neighbors rely on this government provided insurance.

In Greater Cleveland Medicaid coverage allows those in need access to our world-class medical facilities, highly trained doctors, and needed prescriptions. Medicaid even covers office visits which are much cheaper and more convenient than the inefficient emergency room.

The Kaiser Family Foundation has done extensive research on Medicaid. Their Medicaid utilization graph has appeared on numerous TV shows as well as in newspapers such as the New York Times and the Plain Dealer. On a national level Medicaid covers:

• 49% of all births
• 76% of all poor children
• 60% of all children with disabilities
• 64% of all nursing home residents
• 30% of all adults with disabilities

Medicaid is helping our most vulnerable. Do we have some people who could/should be paying for their own insurance? Of course. Can we do a better job policing utilization and reimbursement (fraud and waste)? Of course. Can we significantly reduce funding without impacting access to care? NO WAY.

There has been excellent reporting on Mitch McConnell’s Senate “working draft”, the Better Care Reconciliation Act of 2017 (Trumpcare). Steven Koff of the Plain Dealer has delivered some of his best work. The New York Times has again proven why it is the paper of record. The “working draft” is only 142 pages. It is a quick read. Follow this link. We’re talking about the way we, all Americans, access and pay for healthcare. We are talking about nearly 20% of our economy. It is your responsibility to at least read McConnell’s plan. You have the time.

We can discuss the merits of a huge tax cut for the wealthy. We can wonder how eliminating the individual and employer mandates while retaining guaranteed issue won’t destroy the insurance market. We can go page by page through the BCRA and ask “Why?” But for today, I just want you to read the bill. And if you do that, it will be enough for me.

DAVE

www.cunixinsurance.com

 

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.

DAVE

www.cunixinsurance.com

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?

DAVE

http://www.cunixinsurance.com/

 

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 4^th 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.

DAVE

www.cunixinsurance.com

 

 

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.

Really?

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 healthcare.gov 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 6^th. 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?

DAVE

http://www.cunixinsurance.com/