Construction vs. Destruction

Ronald Reagan famously said that the most terrifying words in the English language are, “I’m from the government and I’m here to help”.  The line garnered laughs and applause whenever he delivered it.  We’ll never know who wrote the quip or whether he really believed it.  But he had been an actor and he delivered the line with style and it was well received.  People in the southeast, an area ravaged almost annually by hurricanes from the Atlantic or the Gulf of Mexico, failed to see the irony.  The people living in the tornado alley states of Oklahoma, Kansas, Iowa, and others also cheered the line.  And so it became apparent that federal help (money) is good help as long as it is for you and wasted if it is for someone else. 

Some of us are looking for a bigger picture, a way to describe the value of federal help, money, and regulation that can potentially help large segments of the American public.   The expansion of Medicaid, a federal-state partnership to provide health insurance to the poor and working poor, is one of those programs.  The Medicaid expansion was a key component of the Patient Protection and Affordable Care Act (Obamacare).

I had the great pleasure of hearing freshman Congresswoman Lauren Underwood (D-IL) speak while I was in Washington a few months ago.  Prior to her election she had been a nurse.  She drafted H.R. 4996, Helping Medicaid Offer Maternity Services (MOMS) Act of 2019.  Her legislation was designed to expand Medicaid services a full year postpartum.  The logic was clear.  “The majority of pregnancy-related deaths happen after the day of delivery, and nearly one quarter of deaths happen more than six weeks postpartum.”  It took a nurse to bring this to Congress’s attention.  I was so impressed with her presentation that I went to her office and got more information from her legislative aide.  Who benefits from this expansion of Medicaid?  Obviously the families of the women who have just given birth.  These are families in urban, suburban, and, importantly, in rural areas.  This also helps to make sure that medical providers, doctors and hospitals, are compensated in these settings.  Rural hospitals suffer from uncompensated care.  This is a solution.

H.R. 1425 – The Patient Protection and Affordable Care Enhancement Act includes Congresswoman Underwood’s Medicaid expansion.

The House of Representatives passed H.R. 1425 earlier this week.  The goal is to make the PPACA more effective.  Like the bill it is tweaking, this enhancement is neither perfect nor likely to garner a lot of support from the Republicans in the Senate.  The point is to put forth constructive, useful rules to make it easier for Americans to access and pay for health care.

My blog post from eight years ago today scoffed at the intellectual dishonesty of repeal and replace and asked instead for revise.  H.R. 1425 is a good starting point for an honest debate about revising the PPACA.  Sadly, you can only have a serious policy debate if you have participants from both political parties and the attention of the president. 

H.R. 1425 has its detractors.  Some are just the usual suspects who appear to believe that they were elected to Congress simply to disagree with whatever the other side does.  We won’t waste time on them.  Nor will we mention some of our Congressional delegation more intent to have their pictures taken than to ever do anything.  There is a good chance that these Congressmen have not bothered to read the bill.  They have legislative aides for that.

The American Action Forum “is a center-right policy institute providing actionable research and analysis to solve America’s most pressing challenges.”  Christopher Holt, the Director of Health Care Policy, published an executive summary of H.R. 1425 on June 25, 2020.  This is the link.  It is only 7 pages and worth the read.  Spoiler Alert – he is not a fan. 

Mr. Holt’s analysis is instructive.  You may like what he dislikes.  Or, your thoughts find a home in his words.  What is clear is his honesty about how his perspective impacts his view of the law. 

Here are some of the key goals and provisions of the Enhancement:

·       Reduce premiums by bringing healthy people into the insurance pool.  This is done by limiting and/or eliminating short term policies

·       Expand the Tax Credit Subsidy to make insurance more affordable

·       Fix the “Family Glitch”, the problem when the employee has coverage from work, but the coverage for dependents is too expensive.  This was determined to be a huge issue since 2014.

·       Provide funding for reinsurance on the state level.  The states that have done this have shown real savings on insurance premiums.  We keep hoping Ohio would do this.  The funding would help.

·       Incentivize the states that haven’t expanded Medicaid to finally do this.  This might be what it takes to get states like Kansas and Missouri across the finish line.

·       Money for outreach and advertising for the annual open enrollment

·       The Medicaid postpartum expansion

·       The government would be allowed to negotiate with the pharmaceutical companies over pricing.  This was H.R. 3 passed earlier in the term.

Those are some of the highlights.  Mr. Holt has his thoughts.  For a different perspective, you might also want to look at Katie Keith’s article in Health Affairs.  She is a touch more positive.  But whether you are in one camp or the other, an honest reading of H.R. 1425 is to see the beginning of a conversation, a path forward.  It is construction not destruction.  After 10 wasted years where little has been accomplished, wouldn’t it be great if the people we elected to help make our lives better focused on that job?  Health insurance, the way most Americans access and pay for care, is an issue for all of us.  I’d love to hear our Congressmen tell us that they are from the government and that they are here to help and mean it.

DAVE

www.cunixinsurance.com

Picture – Clearing A Path – David L Cunix

It Was All A Game

The Washington Post, CNN, and other news organizations published long, in-depth articles about the 2017 Republican tax bill.  The most cynical man in Washington, Mitch McConnell, needed to find extra money for his tax cut.  And, of course, neither Mitch nor President Trump ever passed up a chance to attack the Patient Protection and Affordable Care Act (Obamacare).  Eliminating the penalty for those people who failed to purchase insurance, the Individual Mandate, could free up as much as $300 billion.  (By the way, this is the very definition of cynicism.  Without the mandate, young and healthy people would skip insurance, prices would skyrocket, fewer people would purchase coverage, and the government would eventually save money since fewer people would get the tax credit subsidy help to pay their premiums!)  If you read the articles or anything else from that time, you will not find any mention of the tax bill making the PPACA unconstitutional.  Senators like Susan Collins (R-ME) and Lamar Alexander (R-TN) were still in discussions with their Democratic counterparts to strengthen other provisions of the law.

Senator McConnell was very aware of the dangerous game he was playing.  When asked in June of 2018 about the potential damage of the Texas lawsuit and the Trump administration’s position, Mr. McConnell said, “Everybody I know in the Senate, everybody is in favor of maintaining coverage for preexisting conditions…There is no difference in opinion whatsoever”.   But Mitch had years and years of actions that directly contradicted his words.  There were dozens of votes to repeal Obamacare.  There was the fictitiously named Better Care Reconciliation Act of 2017.  And that brings us to today.

The Trump administration filed its brief last night for the Supreme Court’s review of the Texas lawsuit.  Trump’s attorneys argue that the entire Patient Protection and Affordable Care Act should be eliminated.  ALL OF IT.  The administration’s position is clear.  Guaranteed coverage for preexisting conditions? Ditch it.  Preventive Care? Nope. Coverage for children to age 26? NO!  The law is irredeemable.  And they say it is all Mitch’s fault.

From Page 13 of the brief:

Nothing the 2017 Congress did demonstrates it would have intended the rest of the ACA to continue to operate in the absence of these three integral provisions. The entire ACA thus must fall with the individual mandate…

Our Republican friends have voted countless times to repeal Obamacare.  The Trump administration just called their bluff.  And yes, it is a bluff.  Always was.  There is no replacement waiting in the wings.  We are talking about nearly 20% of our economy.  We are talking about the way most Americans access and pay for health care.  And by the way, we are in the middle of a pandemic. 

The Supreme Court will hear this case in October and won’t render a decision until after the election.  How convenient.  This may be all a game for some of our elected representatives in Washington. But it is not a game that anyone with preexisting conditions wants to play.

DAVE

www.cunixinsurance.com

Picture – Right Game, Wrong Venue – David L Cunix

Paper Mache Armor

Our Governor, Mike DeWine, is on TV with Dr. Amy Acton, the Director of Health, almost every day.  The Ohio House and Senate are in session and working.  Having our government working for us could be a good thing.  There certainly is no shortage of issues for them to address.

One of those issues is Surprise Billing.  On May 20^th the Ohio House unanimously passed H.B. 388, the legislation specifically designed to address out-of-network care. The legislation was introduced in the Ohio Senate on May 26^th.  It should get passed and be signed by the governor next week.  The Bill is only 14 pages and if you promise to take a quick look I won’t feel compelled to review all of it here. 

The vast majority of H.B. 388 is devoted to the way out-of-network charges are defined and, more importantly, how the providers (doctors, facilities, ground ambulances, and clinical laboratories) will be paid.  There is a definition of the Benchmark or the fair market value for payment.  There is extensive verbiage related to negotiation and, if necessary, baseball style arbitration.  And as was reported in the newspapers, the consumer cannot be billed for the difference between his/her insurance plan’s reimbursement and the providers’ charges.

It looks great, but it is only paper mache armor.

H.B. 388 has the same gaping loophole as some of the other bills introduced in the Ohio legislature.  If you care to read along, turn to Page 6, Line 143 of the bill.  Let me summarize:

• For services covered by the health plan, but are provided by an individual out-of-network provider, an individual cannot be balance billed unless all of the following are met:

a)      The provider informs the individual that the provider is not in the covered person’s health benefit plan.

b)      They provide the consumer with a good faith estimate, including a disclaimer that they are not required to get the services at that location for from the provider.

c)       The covered person consents to the services.

There was no budge on this provision.  A requirement that the disclosure be made 24 or 48 hours prior to the procedure would have been useful.  A requirement that the fees be clearly stated with an explanation of how or why the final price could change with a limit to that change would have been useful.  A prohibition of sticking a form in front of a patient mere minutes before a procedure and “asking” for consent, would have been useful.  My guess is that we will be revisiting this in a year or so once the abuses add up to a point where this has to be taken seriously.  I am sure that the hedge funds that own some of the biggest offenders, the ones whose actions created the need for this whole discussion, will have their consent forms printed before Governor DeWine can affix his signature to the final bill.

Or not.  Those are my concerns.

But our representatives, our senators, and our governor are working to protect us.  I just wish they would take the time to make our armor of stronger stuff.

DAVE

www.cunixinsurance.com

Picture – Ready To Make My Shield – David L Cunix

Sounding The Alarm

The focus of this blog, Health Insurance Issues With Dave, is, first and foremost, insurance, the way most Americans access and pay for health care.  There are three key players in this process: the medical providers, the insurance companies, and the government.  The medical provider section includes doctors, hospitals, pharmaceutical companies and everyone/everything else involved in the delivery of care.  The insurance companies serve both to organize the market and as a useful buffer between the providers and the patients.  And the government writes the rules, pays a huge portion of the bills through Medicare and Medicaid, and significantly impacts the pricing.  There is a natural push and pull in this process.  The American public benefits when all three sectors work towards a common good (Enlightened Self-Interest).  That isn’t easy and it depends on a determined focus and an honest effort.  To be clear, determined focus and honest efforts don’t guarantee success.  A lack of either determined focus or honest effort guarantee failure.

Deep In The Heart(less) Of Texas was posted on September 9, 2018.  This was the first blog dedicated to the Texas lawsuit, the attempt to have the courts declare the Patient Protection and Affordable Care Act (Obamacare) unconstitutional.  Today’s post will be the 14^th warning of the havoc this could cause.  Yes, I keep sounding the alarm.  There isn’t any good will, focus, or honest effort involved in the promotion of this lawsuit.  And it only got worse when Donald Trump decided to champion its cause.

The sudden elimination of Obamacare without a replacement would terminate health insurance for millions of Americans.  This is so important that I was happy to see an article in Sunday’s (5/24/2020) Plain Dealer on the issue.  “If Obamacare was overturned, what would it mean here?” was written by Sabrina Eaton.  Welcome to the conversation!

Please read her article.  There is nothing, absolutely nothing, that contradicts my 13 previous posts.  I will note that Ms. Eaton bothered to contact Senator Portman’s office for the story.  He predictably declined to comment on the court case, but his spokesman did note that premiums have gone up.  I would never contact Senator Portman’s office about a solution or improvement to our health care system for the same reason you wouldn’t bother to call my Rabbi for a ham recipe.  But she tried.

As previously noted, I was both surprised and pleased to see this coverage in the Plain Dealer.  Considering the potential impact on our area, I expected them to sound the alarm regularly.  Imagine my shock when I went to their website to link this article.  It took some effort to find it.  Ms. Eaton’s article was posted on Cleveland.com on May 8, 2020, over two weeks earlier!  I guess Greater Clevelanders are lucky that there was so little going on this Memorial Day weekend that her article finally made it to print.  And though I have readers across the country, I would never compare the reach of my little blog to the readership of the once formidable Plain Dealer or its disorganized website.  An issue that impacts nearly 20% of our nation’s economy, the lives of millions of Ohioans, and the financial stability of our hospitals deserves our attention.  In the old days we could count on our newspapers to bring us the information we needed.

Will the Texas lawsuit succeed?  Stranger things have happened.  I promise to keep you informed.  And to keep sounding the alarm.

DAVE

www.cunixinsurance.com

Picture – Thankfully Loud – David L Cunix

The Fear Before Now

Health insurance used to be hard to get and expensive.  It is no longer hard to get health insurance, but it certainly is expensive.  In that health insurance is the way most Americans access and pay for their health care, it was very important to make it easier for us to become insured.

Too many of us forget what it once was like to purchase insurance.  In ancient times, pre-2014, your agent would ask you questions about your health, occupation, driving record, and hobbies.  If you needed coverage for a spouse or children, we needed all of that information on each of them, too.  As you can imagine, there were plenty of adults with Diabetes (Type 1 or 2), cancers, and sports injuries that either prevented them from acquiring coverage or resulted in higher premiums.  Some policies waived (excluded) preexisting conditions.  Some policies accepted an individual and his/her preexisting conditions after extensive conversations with the underwriters and the insurer had collected all of the pertinent medical records.

Insurance companies hate preexisting conditions, the difference between a risk and a certainty.  Children were an agent’s biggest challenge.  Ask any agent.  We remember the children we fought to cover.  There were children, sometimes babies, with cystic fibrosis, heart conditions, and even adolescents with ADHD.  We fought and we fought and most of the time we succeeded at finding the families health insurance.

No one wants to be responsible for the payment of the costs associated with preexisting conditions.  Not even the government.  Today’s proof comes courtesy of The Military Times.  The Pentagon has confirmed a recently released memo that stated that any recruit who has been diagnosed as having had COVID-19 will be permanently disqualified.  Permanently.  We have no idea what costs may be incurred 5, 10, or even 20 years from now by those who survive the Coronavirus.

We used to worry about getting insurance once we contracting an illness or suffered an injury even if we had a complete recovery.  That fear was real.  Now, thanks to the Patient Protection and Affordable Care Act (Obamacare), we no longer have that concern.  That could change if Donald Trump and 18 Republican governors have their way.

This blog has extensively covered the Texas lawsuit, the effort to declare Obamacare unconstitutional which would eliminate coverage for preexisting conditions and throw our entire system into disarray.  This past Wednesday was an important milepost, the last day for the Trump administration to disengage from the case as it heads to the Supreme Court.  Instead, President Trump said, “We want to terminate health care under Obamacare”.  What would happen if he is successful and Obamacare destroyed?  He has no idea.  What is his alternative, his replacement for our current system?  Trust him, it will be great.

Senator Lamar Alexander (R-TN) was interviewed by Chuck Todd on Meet The Press (5/20/2020).  The Senator expressed disappointment that Trump decided to stay a part of the lawsuit.  It was one thing for Senator Alexander and other Congressional Republicans to cast dozens of meaningless votes to dismantle Obamacare.  It is entirely different to actually be a part of an action that could succeed in harming millions of Americans.

It is amazing that Texas, with almost 25% uninsured, the highest in the country, wants to impose its success on the rest of us.

States suing to immediately end the Patient Protection and Affordable Care Act:

            Texas                                 Alabama

            Arkansas                            Arizona

            Florida                               Georgia

            Indiana                              Kansas

            Louisiana                           Mississippi

            Missouri                            Nebraska

            North Dakota                    South Carolina

            South Dakota                     Tennessee

            Utah                                  West Virginia

These states were part of the lawsuit, but dropped off:

            Maine                                Wisconsin

States defending the Patient Protection and Affordable Care Act (initial filing):

            California                          Connecticut

            District of Columbia          Delaware

            Hawaii                               Illinois

            Kentucky                            Massachusetts

            Minnesota                         New Jersey

            New York                           North Carolina

            Oregon                              Rhode Island

            Vermont                            Virginia

            Washington

These states joined in the defense:

            Colorado                           Iowa

            Michigan                           Nevada

Data courtesy Center on Budget and Policy Priorities

There was fear before now, the fear that we would not be able to get health insurance for ourselves and our families due to a preexisting condition.  It was real.  The question, now in the middle of a pandemic, is whether that fear is about to return.

DAVE

www.cunixinsurance.com

Picture – The Other Side Of The Fence – David L Cunix

How Do You Spell HSA?

Spelling was my Achilles Heel.  I couldn’t spell.  I even got a D in spelling on a report card!  And whether I was at home or school, when I asked an adult how to spell a word I would inevitably get the same answer, “Look it up”.  Looking up a word in a dictionary, decades before AI, meant that you took your best guess, failed, and kept on trying until you bumped into the correct spelling.  It was not efficient.  There was one benefit to this exercise.  Opening up a dictionary was like handing me a car with a full-tank of gasoline and access to the freeways.  There were no dead-ends or wrong turns.  And reading a dictionary was far more interesting than whatever project I had been assigned.

Our computers and phones now have spellcheck.  The big dictionary has been replaced by Google, Alexa, and Siri.  The information you need is at your fingertips or by simply asking your electronic assistant.  So I was very surprised when one of my life insurance clients recently asked me some questions about Health Savings Accounts (HSA).  I told him that the information was readily available and that I had covered this on my searchable blog.  He had little interest in reading the blog(!) and felt that I should put the information into a useable format for him and some of his friends and coworkers at a local large business.  I wrote him a letter.  Not only did I answer his questions he even insisted that I create a special page for this on my website.  Instead, I will just post the letter as part of today’s blog.

April 21, 2020

Dear Roger (Name changed so that my attorney can sleep at night):

It is important to remind you, up front, that I am an insurance agent not a CPA.  You should consult with your professional tax preparer about whether or not anything is deductible for you.  The information I am providing is based on my understanding of how these insurance policies impact my clients’ taxes.

The term H.S.A. is normally used to refer to two very separate things.  Part One is a High Deductible Health Insurance Policy.  Part Two is a Health Savings Account.  You can have Part One without Part Two.  You cannot have Part Two without Part One!  This is very important and has been an area of confusion.

A High Deductible Health Insurance Policy (HDHP):

·         For 2020, the IRS defines a high deductible health plan as any plan with a deductible of at least $1,400 for an individual or $2,800 for a family. An HDHP’s total yearly out-of-pocket expenses (including deductibles, copayments, and coinsurance) can’t be more than $6,900 for an individual or $13,800 for a family. (This limit doesn't apply to out-of-network services.)

·        All covered services must apply to the deductible prior to any copays or coinsurance.

·        The exception has been Preventive Care performed by a network provider.

·        A recently added exception is the diagnosis and treatment for COVID 19 which will be covered without deductible, copayment, or coinsurance.

·        It has been generally ruled that even telemedicine, other than for COVID 19, cannot be provided free or with copayments until the deductible has been met.

Once you have an HDHP, whether it is an individual policy or an employer sponsored group contract, you may open a Health Savings Account.

·        An HSA may be opened through an insurer, a bank affiliated with an insurer, a bank, or an online HSA bank

·        The employer may contribute $0 to the annual maximum

·        An individual or employee may contribute between $0 to the maximum

·         The annual maximum is the same regardless of who is contributing

·        The maximum contribution for 2020 is $3,550 for an individual and $7,100 for a family.

·        The catch-up contribution limit for those over age 55 will remain at $1,000.

Medicare:

A friend of mine, an attorney, had a couple of quick questions about Medicare.  He will be turning 65 soon and needed to confirm that he didn’t have to sign up for Medicare Part B since he plans to stay on his wife’s group health policy.  I verified that his wife works for a company with over 20 employees.  So yes, he doesn’t need Medicare Part B.  But, I asked, is the group plan a High Deductible Health Savings Account (HSA) Qualified Policy and do you contribute to the HSA?  He confirmed that Yes and Yes.  In that case, he must renounce Medicare Part A, too.  You cannot contribute to a Health Savings Account if you have Medicare.  In fact, there is a six month look-back.  He didn’t know.  And if an attorney could have accidentally screwed this up, what are the chances that your average office worker or machinist couldn’t make the same mistake?

The Medicare issue is particularly troubling.  The HR departments do not discuss this with employees.  I have talked with Senator Brown’s office about this. They have looked into correcting this, but there are not enough people pushing on this to see action anytime soon.

I hope that this answers your questions about High Deductible Health Insurance Policies and Health Savings Accounts.

The good news is that now, if you search this blog or ask Google, you might come up with this information.  The bad news is that you won’t spend an hour or two getting lost on other tangents learning all kinds of interesting stuff you wouldn’t otherwise know.

DAVE

www.cunixinsurance.com      

Picture – Old School – David L Cunix

A Tool, Not A Weapon

The Patient Protection and Affordable Care Act (Obamacare) was designed to be a tool, a way to improve healthcare in our country and the health insurance that provides the access and payment for that care.  It certainly wasn’t a great tool.  This blog has detailed many of the PPACA’s flaws and shortcomings, but the goals were always about more care for more people.  Through the last ten years many Americans paid less per month for comprehensive coverage and, unfortunately, many Americans have paid more.  There certainly were ways to improve the law.  Few were ever tried.

As previous national health insurance programs that were designed to cover preexisting conditions such as Medicare Part A, Part B, and even Part D (Rx), the PPACA requires individuals to enroll in a timely manner.  Left to their own devices, many people would delay purchasing insurance until they had an immediate need.

Obamacare has an Open Enrollment Period that currently runs from November 1^st to December 15^th each year.  It used to be a lot longer until the current administration shrunk it to only six weeks in 2017.  There are also Special Enrollment Periods available to Americans who have involuntarily lost their coverage.  The combination of Open Enrollment and Special Enrollments usually meets most people’s needs.

These are not usual times.  States that run their own insurance exchanges have recognized the need to hold an emergency Open Enrollment Period to meet the insurance requirements of their citizens.  Other states, like Ohio, utilize the federal government’s healthcare.gov.  The federal government, read President Trump, is in a position to be a help or a hindrance.  Will Ohioans have an emergency Open Enrollment?  NO!  Donald Trump is happy to convert a tool into a weapon.

Here are some of the people who might benefit from an emergency Open Enrollment:

·         People who never bothered to purchase insurance

·         People who missed the shorter open enrollment period

·         Ohioans who purchased short term major medical and now want comprehensive coverage

·         Ohioans that purchased comprehensive coverage directly from the insurer.  Example – I have a client in her late 20’s.  She is a mechanical engineer making $55K per year.  Since she wouldn’t qualify for a tax credit subsidy, we didn’t have to go through the Exchange to get her policy.  That saves her time and money.  She lost her job.  Too bad.  This doesn’t qualify as a SEP.  If we got the Exchange opened, I could get her a subsidy to help her.

·         Individual policies are HMO contracts that can provide good LOCAL coverage.  If you live in Cleveland and send your child to school in Columbus or Denver or wherever, you will take the child off the Cleveland policy and buy a health plan for the school.  The schools are closed.  The kids are home.  We cannot put the child on the parent’s policy or offer the child a comprehensive policy to purchase.

There is only one reason to not have an emergency Open Enrollment.  By allowing citizens from across the country, many residents of battleground states, to purchase coverage, Trump would be admitting the value of the Patient Protection and Affordable Care Act, the law he is actively trying to invalidate.  His support of the Texas lawsuit which would rule the PPACA unconstitutional and eliminate coverage for, among other things, preexisting conditions has gone virtually unnoticed by the general public.  Much like the Coronavirus, many Americans will ignore the implications of the Texas lawsuit until in impacts them directly.  And again like the virus, when they lose their health insurance coverage it will not be dissimilar to being isolated on a ventilator at the end of a darkened hall.

Without a whole lot of thought or planning, Mr. Trump recently announced that the uninsured would have their COVID 19 related bills covered.  When pressed he declared that the hospitals would have to accept the Medicare funding level, as if that was sufficient.   Worse, the president decided to take the money from the desperately needed funds just allocated to our nation’s hospital systems.  We are back to spending the same dollar a couple of times and hoping nobody notices…

We have tools.  In the hands of the right people, the federal government, in concert with the states and major cities, can marshal the professionals needed to treat our sick, work to reduce our risks, and insure our general safety.  All we need are people who understand how to make our system work for us.  And, we need someone who doesn’t want to convert a tool into a weapon.

DAVE

www.cunixinsurance.com

Picture – Taking A Hammer To The Level - David L Cunix