One Hundred Days

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


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

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

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

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

In this highly politicized environment, this issue may be the most contentious of all. There are a couple of reasons for the heat:

1. We are talking about almost 20% of the economy
2. We are potentially discussing life and death
3. We all have a stake in the final product
4. We all think we know what we are talking about

Heat, but no light. The truth is that the differences between the real actions on the right vs. the left are hard to find. So the fight isn’t about real differences, but about vague notions of entitlement. The Republicans promise to repeal “Obamacare” and institute patient-centered health reform, a term that happens to test well in focus groups but means more than simply eliminating malpractice suits.

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

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

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

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

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

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

DAVE

http://www.bcandb.com/

Follow The Money

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

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

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

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

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

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

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

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

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

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

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

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

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

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

DAVE

http://www.bcandb.com/

A Rose By Any Other Name

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

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

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

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

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

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

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

You can’t beat something with nothing.

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

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

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

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

DAVE

http://www.bcandb.com/

And Now, A Word From Our Sponsor

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

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

Which ads are you going to miss?

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

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

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

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

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

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

And now, a word from our sponsor.

DAVE

http://www.bcandb.com/

A Pack Of Wild Dogs

Your ten year old comes crashing through the door with a story of being chased home from school by a pack of wild dogs. Do you

1. Grab a shot gun and your copy of Old Yeller
2. Call 911
3. Pour a glass of milk, hand him a cookie, and return to whatever you were doing.

All of the parents out there smiled and chose option #3.

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

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

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

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

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

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

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

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

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

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

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

DAVE

www.bcandb.com

Isn't That Convenient?

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

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

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

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

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

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

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

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

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

I still contend that none of this really matters.

DAVE

www.bcandb.com

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

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

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

This is where Governor Ted comes in.

Without the health care law, this group could lose coverage under their parents’ plans and “it’s impossible to be able to afford an individual policy unless you’re a wealthy or semi-wealthy person,” Strickland says.

It’s impossible? Balderdash!

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

They chose to do nothing.

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

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

......Male..........................Female
....$107.95..........21........$136.50
....$110.56..........26........$150.57

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

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

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

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

DAVE

www.bcandb.com