Buried Deep Within The Law

December is my busiest month. The majority of my business clients prefer to renew or change their coverages as of January 1^st. New deductibles. New Benefits. New Year. So wasting forty-five minutes of my time by taking a meaningless class and test were not on my agenda. But there I was, staring at the computer screen, plowing through the mindless drivel that the federal government feels every agent needs to review annually. AML training – anti-money laundering for the uninitiated.

Long before then Speaker of the House Nancy Pelosi told her colleagues that they needed to vote for the Patient Protection and Affordable Care Act “we have to pass the bill so that you can find out what is in it, away from the fog of controversy”, we were given Uniting and Strengthening America by Providing Appropriate Tools Required To Intercept and Obstruct Terrorism Act of 2001. You know it as the USA Patriot Act. A reaction to 9/11, it was signed into law by President Bush on October 26, 2001. It wasn’t until years later that the American people and the Congressmen who voted for it learned about the government’s new ability to legally spy on US citizens and the provisions concerning torture. And for the financial services industry – AML, the anti-money laundering rules.

Section 352 of the USA Patriot Act includes the requirement that financial institutions establish anti-money laundering internal enforcement. Each company must:

Develop internal policies, procedures, and controls

Designate an AML compliance officer

Institute ongoing training

Install an independent audit function to test the program

The insurance industry regulations went into effect on December 5, 2005, over four years after the law’s passage. Some of the rules make sense. Some are the result of regulators gone amok. Let’s be serious. Prudential is not worried that I am going to take three non-sequentialed numbered money orders, each for $5,000, and open up a life insurance policy for some drug kingpin. Pru is petrified that a federal regulator would find an agent operating without an up-to-date AML certificate.

Rome is burning and we are too busy inspecting the fire extinguishers to have time to use them.

The Patient Protection and Affordable Care Act (PPACA) is a complex law. It has to be. You can’t rework a sixth of our economy with a short paragraph and an emoticon. The new fees (taxes) to give this a chance to succeed are just about to begin. Rules and regulations are being written and promulgated. The exchanges are to be up and running in less than a year. Everyday brings something new.

One of the new taxes, creatively named the Health Insurance Tax (HIT) is designed to raise $100 billion over the next ten years. This is a tax on health insurance companies levied, in part, on market share. A study conducted by Oliver Wyman for the industry group America’s Health Insurance Plans (AHIP) predicts that this excise style tax will result in significantly higher premiums. This should come as no surprise to anyone who has been paying attention.

Other new taxes and fees debut next month.

The major insurers are trying to learn not just what the new rules will be, but when these rules will begin. Does your current policy, purchased under a different set of regulations, end on December 31, 2013? Or, will you be allowed to keep your current policy till its annual renewal or even longer? Do you care? YES!

If you are young. If you are healthy. If you don’t need any of the new benefits required of all future individual (self-pay) policies such as maternity or habilitative care, you will want to hold on to your current health insurance with both hands. Will you be allowed to retain your current policy? For most of you the logical answer is “Not for long.” These are the issues I’m asked about daily.

Over the next ten months we will get a clearer picture of the new health insurance market, the policies, the distribution system, and eventually, the pricing. This has always been, first and foremost, about paying for medical services, not about the practice of medicine. But the delivery of health care will change as the money changes.

Look around you. It would be very crowded here in Greater Cleveland if our population grew at the same rate as our hospitals and clinics expanded. Kaiser Permanente, The Cleveland Clinic, and University Hospital must believe that they know how to make the Patient Protection and Affordable Care Act pay off for them.

The potential to build health care empires must be buried deep within the law. We, however, are probably just working the mine.

Still Stuck Inside

Will you indulge me? Will you return with me to a post I wrote on August 21, 2009? That post, Stuck Inside, was about an insurance agent, me, trying to give a quick, off-the-cuff answer to the question, “So, what would you do?”

What would you do? That is the real question. It is incredibly easy to shoot down everyone else’s ideas. All ideas, born from the minds of imperfect humans, have flaws. And the more complicated the ideas, the more potential there is for mistakes. All of our plans have big, gaping holes. So designing a solution to any problem opens you up to derision. It is easy to do nothing. It is even easier to do nothing but snipe at those flawed ideas and the people who created them.

This blog has consistently held that the Patient Protection and Affordable Care Act (PPACA) is a poorly written law that lacks both transparency and logical goals. Either the eventual plan is to have us in a national health plan or our guys in Congress are getting directions from Moses’s map maker. Flaws? We got ’em. But most of the people fighting the PPACA have spent their time picking the low hanging fruit and defending the status quo.

This blog has contended that the PPACA is not only the law of the land, but that it was never going to be overturned. Deal with it. Kathleen Sebelius, Secretary of Health and Human Services, is busily churning out new rules and regulations. Some of these edicts from on high will help the American people. Some are patently absurd and will, hopefully, be changed. No matter, we need to start to prepare for a future that will soon be upon us whether or not we want it or are prepared.

My August 2009 post, seven months prior to the passage of the PPACA, laid out a program where health insurance would be guaranteed issue, would cover all preexisting conditions, and would be mandatory. My off-the-cuff solution also included the concept of creating a limited number of uniform plans that would be easier for the consumer to understand, easier to compare, and would include preventive care.

The President’s plan includes many of these ideas. I may quibble with what is included in the standardized plans and what all was thrown in to the preventive care catch-all, but THEY DIDN’T ASK ME. And you might not be a huge fan of the specifics had I been the author of the plan.

The Exchanges are currently designed to offer four levels of coverage – Platinum, Gold, Silver, and Bronze. We are still getting information on plan design and specifics. My last post covered the Essential Health Benefits that each plan must include. The difference will simply be the percent of coverage paid by the insurer and you.

The Cunix option included the idea of Medicaid being opened up to people earning up to 300% of the poverty level, paid on a sliding scale. The PPACA provides premium support and/or tax credits through the exchanges for people who earn up to 400% of the poverty level. That would mean a family of four may receive a tax credit for purchasing a policy through the exchange even though they have a family income of $92,200 (2012). By pushing individuals to the exchanges and making the premium support federal money, Washington has eliminated any potential problems or fights with recalcitrant Republican governors.

My program included a number of starting places to create cost controls. The PPACA is eerily silent when it comes to controlling costs. But then again, there is a lot of wishful thinking built into the PPACA.

The HHS has been dropping new rules on an almost daily basis. Last week it was announced that the federal government will be charging user fees to the insurers who market policies through the exchanges. These (premium taxes) fees, approximately 3.5%, will be on top of the new taxes imposed on a national basis to all health insurers as determined by their market share, and any state and local insurance tax. Some of this makes sense. This is how the Obama administration expects to pay for this transition and the ongoing process.

Here is the fun part as it appeared in the New York Times:

Erin Shields Britt, a spokeswoman for Ms. Sebelius, predicted that insurers would not raise prices. “Exchanges will provide already profitable insurance companies with access to 30 million new customers while cutting down insurers’ marketing and advertising expenses,” Ms. Shields Britt said. “Exchanges force insurance companies to compete and drive down costs for consumers. The congressional Budget Office has estimated consumers will save up to 20 percent on their premiums.

And J. R. R. Tolkien wrote non-fiction.

But sniping on the sidelines isn’t going to help. Jumping up and down and threatening to repeal the PPACA (attn: Republican run House of Representatives) only made things worse. Now is the time to talk to your Congressional Representative. The course can’t be reversed, but it can be modified. The Patient Protection and Affordable Care Act is an open-ended medical spending spree guaranteed to make private insurance untenable. Will our elected officials, Democrats and Republicans, work together to create effective cost controls, common sense limitations, and robust fraud enforcement? Those are just for starters.

Now, before we’re stuck.

DAVE

www.bcandb.com

It's Novermber and Everybody's Busy (Too Busy to Talk)

The days before Thanksgiving are a time of unrelenting activity. Some people are finalizing the big meal for Thursday. Others are preparing for the December holidays. In fact, I’ve been told that there are even elves working overtime somewhere near the North Pole. Thanks to climate change they are wearing Hawaiian shirts, but they are still working hard.

Speaking of working hard, the folks at the Department of Health and Human Services (HHS) have been very busy this week. On Tuesday, November 20, 2012, our busy elves at HHS released a new set of rules and regulations designed to flesh out the Patient Protection and Affordable Care Act (PPACA).

Tuesday’s new rules and regs cover a host of areas from defining the benefits to creating the framework for future premiums and options. You can find the public relations version of all of this at healthcare.gov. Don’t worry about going to the government’s website. This will all be coming to you – on TV, on billboards, and door-to-door solicitation, if necessary – thanks to a special campaign.
The new rules reaffirm the definition of the Essential Health Benefits (EHB). The PPACA demands that all policies offered for individuals and small groups provide coverage for a “core package of items and services known as Essential Health Benefits. EHB must include items and services within at least the following 10 categories”:

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services, including behavioral health treatment
6. Prescription Drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care

Most of this looks pretty reasonable. Though you may wonder how much that maternity benefit will add to the cost of a woman’s policy. And if that woman can’t have children, how much is she wasting?

Employer sponsored group health policies have included maternity “covered as any other illness” for years. We know how to evaluate the risk and how much each policyholder needs to pay. That is, after all, the concept of insurance – evaluate risk and share the cost. What happens when the risk is open-ended? How do we share an unknown cost?
#7, above, is coverage for rehabilitative and habilitative services and devices. We are all familiar with rehabilitative care such as physical therapy which is designed to restore the patient to his/her former state of health and previous level of skills. The current fight over rehabilitative care is about the number of treatments. Today’s policies cover 15, 20, or maybe 25 visits to the physical therapist. We don’t know if future policies will be allowed to have such limitations. But rehabilitative coverage is much easier to assess than habilitative.

Habilitative therapies create skills. Teaching an autistic child to interact with his/her peer group is a wonderful thing. In fact, improving social skills and communication is life-changing for the children and adults touched by autism and certain forms of mental illnesses. Those suffering from other illnesses or conditions, such as cerebral palsy, have had their lives improved through habilitative care. Much of this has been open-ended, where patients weren’t actually cured, just made better. So as long as someone was willing to pay for services, another appointment was warranted.

Both the government, through Medicare and Medicaid, and the insurance industry have fought habilitative care for decades. The insurance industry lives by black and white. Habilitative therapies exist in a grey area. The industry has avoided paying for much of these services by labeling them experimental or educational. That may end soon.

Do you care? Is this good? As always, the answer is Yes and No.

Please don’t get distracted by the pictures of your neighbor’s autistic child. This has very little to do with her. It is important to remember that the healthcare debate has very little to do with health. With the possible exception of someone personally touched by a particular condition, this is, and always has been, a discussion of how we compensate doctors and hospitals. Who gets paid from the deep pockets and who doesn’t.

The insurance industry is still trying to retain the right to offer a stripped down contract that will exclude some of the open-ended coverages. It is far easier to price a policy that has fewer gray areas. A policy that doesn’t cover habilitative services; a policy that doesn’t pay for infertility treatments; a policy that included some limitations for rehab, would be significantly less than the federally mandated coverage. My guess is that we won’t have that option for long, if ever.

Seeing how much these other benefits add to the cost of coverage would force us to finally have a national discussion about our priorities. What are we willing to pay for? It still appears that no one in Washington, Democrat or Republican, wants to have that discussion.

And who can blame them? It’s November and everybody’s busy. Way too busy to talk.

Sorry, You're Screwed

The letter came from The State of Ohio, The Ohio Department of Insurance, and Medical Mutual. Good news never comes with that many names on the top of the letter.

We are sorry to inform you that your Ohio High Risk Pool coverage will be canceled at the end of the day on November 30, 2012.

The letter was dated November 12, 2012.

Some of the unhealthiest residents of the State of Ohio were being tossed off their insurance policy, the Ohio High Risk Pool. In less than three weeks they would no longer be insured. And nobody is standing in line to cover them. How could this happen?

The Ohio High Risk Pool is part of the Patient Protection and Affordable Care Act (PPACA). A stop gap measure, the states were charged with the duty of offering coverage for the chronically uninsured suffering from significant preexisting conditions. The federal government also provided five billion dollars of which Ohio received $152,000,000 for the four year program.

To qualify for the Ohio High Risk Pool you must prove:

1. Citizenship
2. That you have not been credible insurance coverage for at least six months
3. That you have been declined by two insurers within the last six months
4. You may skip #3 if your medical records show that you have a major illness that would have gotten you declined

You can not have had credible insurance coverage in the six months leading up to your application for coverage under the Ohio High Risk Pool. This is a federal requirement. Neither the State of Ohio nor Medical Mutual of Ohio, the insurer running our plan, has anything to do with this rule. Some people who are not easily insured have purchased supplements, a better than nothing option. If something happened while they were attempting to find real insurance or qualify for an affordable program, these responsible people were trying to do what they could.

My friend Dave is a conscientious insurance agent. He took a letter from American Medical and Life Insurance Company (AMLI) to the Ohio High Risk Pool. The letter, dated February 11, 2011 was sent to clients to advise them that their policy was no longer HIPAA credible coverage. Dave verified that since the AMLI CoreValue policy was no longer credible coverage, his clients, including family members, could retain this minimum semblance of coverage until they had six months of no real insurance and could enter the Ohio High Risk Pool. NO PROBLEM.

It is those people, those responsible people who attempted to have some coverage, no matter what, who are being kicked to the curb. The letter from the State specifically notes:

Our records indicate you were enrolled in an AMLI policy in the six months prior to enrolling in the Ohio High Risk Pool Program. Therefore, CMS directed us to cancel your coverage because you are not eligible for this program.

The PPACA is a poorly written law. We know that. Worse, the rules and regulations are being written on the fly. What complies one day is non-compliant the next. We went through this with the grandfathering rules. The costs, both human and financial, can’t possibly be calculated.

The Ohioans being kicked out of the High Risk Pool did nothing wrong. They followed the rules of that moment. We are talking about individuals who are gravely ill. What do they do now? 

DAVE
www.bcandb.com

The Sky Is Not Falling

A Power of Attorney. The elderly couple wanted to give me a Power of Attorney. They were convinced that President Obama is going to win re-election and that their Medicare coverage is in jeopardy. What happens when(!) he changes Medicare and they don’t get into my office fast enough to be protected?

Can we give you a Power of Attorney to change our policies so that we have the right coverage?

It was Republican Week at my office. I can normally tell whether my clients are Democrats or Republicans just by the questions they ask. The talking heads on FOX create a climate of fear and misinformation on some parts of the Patient Protection and Affordable Care Act (PPACA). Rachel Maddow and Ed Schultz create a competing sense of dread and foreboding amongst their viewers.

I watch both channels so that I can anticipate my clients’ concerns.

My last post, Collateral Damage, noted the unintended consequences of a badly written piece of legislation. But, the PPACA has helped a lot of people. In the interest of fairness, we should spend a moment or two discussing a few of those victories. All of these examples are from last week. And all involved Republicans. Key details have been changed to protect the identities of all involved.

Bruce has been self-employed for over ten years. He was covered under his spouse’s health policy. When they divorced, he took full advantage of COBRA for the entire thirty-six months. The story then gets murky. Either a bad agent sold him a crappy policy or he cheaped out and purchased something that did not meet his needs. Either way, his health got worse, the mediocre policy didn’t pay for his care, and the premium became unaffordable. Bruce is now an unhealthy 56 year old with no insurance facing possible surgery.

Bruce will qualify for the Ohio High Risk Pool policy. The premium isn’t cheap, $428 per month. It would be far worse if there wasn’t premium support built into the legislation. The Ohio High Risk Pool is not for everyone. Not everyone qualifies. The rules are complicated. But the PPACA is a lifeline for Bruce and he wasn’t the only winner last week.

Jane is another Ohio High Risk Pool winner. She is 61. Jane was terminated by a major local employer last November. She could have been covered through COBRA if she could have afforded it. She couldn’t. She has a number of preexisting conditions that would result in an automatic decline if she applied for individual health insurance. Jane qualifies for the Ohio High Risk Pool policy and the $428 premium may be a challenge, but she has had a year without insurance. $428 is a gift.

The Ohio High Risk Pool plan is not placed through an agent’s office. I have nothing to do with it and I am not compensated for helping people access this insurance. Educating the uninsured is just part of doing the right thing.

Amanda has four sons, two in college, one in middle school, and her youngest is only 8. They are all healthy except for Billy, age 14. Billy is in remission, thank G-d, but he has had hundreds of thousands of dollars of medical care. He might not require additional expensive care. Who knows? I would have had a very hard time covering Billy three years ago. Today? No big deal. Amanda is healthy. The insurers will readily approve her. Billy and his brothers will go through underwriting to determine price, not insurability. The price will be a little higher, but the cost of insurance won’t even begin to reflect the potential cost of care.

The PPACA allows Amanda to purchase affordable health insurance for her entire family. To deny this is to deny reality.

I completely understood why the elderly couple was afraid. All day long they are bombarded with solicitations for different Medicare plans, pleas to support candidates who will fix Medicare, and television reports that the sky is falling. Whatever healthy skepticism they may have once had has been beaten down by the constant repetition of the same facts.

The elderly couple came to my office to be protected. What they need was to be reassured.  

DAVE  

www.bcandb.com

Collateral Damage

It was 1986. A bank opened about ten new locations in the Cleveland area. Somehow or another I ended up as the life insurance agent for many of the branch managers. The bank’s marketing department decided to brand these guys as Financial Planners. I was sitting with one of my clients in his branch, a kiosk inside the Kmart at 260th and Euclid (did I forget to mention that all of these new branches were inside Kmart’s?) and laughed at the idea that he and his peers were Financial Planners.

A Financial Planner is a stock broker with delusions of grandeur or an insurance agent with low self-esteem.

It would be years and years before financial professionals like my partners Jeff Bogart and Kathy Browning would embrace the concept of fee based money management and financial planning would no longer be just another way to sell a policy, a loan, or an annuity.

I bring this up not to laugh at the wide variety of people, qualified or not, who call themselves Financial Planners, but to remind you, dear readers, that in America anyone can claim to be an expert on anything. And in this age of disinformation overload, your email inbox and Facebook news feed are a constant source of rumor, innuendo, and out right lies.

The health care debate is a prime example.

This blog has consistently contended that the Patient Protection and Affordable Care Act (PPACA) is a poorly written law that fails to address our biggest problem, the cost of care. Badly written laws lead to poorly crafted regulations which are a disaster in execution. The unintended consequences are the people who fall through the cracks, in essence, the collateral damage. Today’s post is about a couple of these casualties.

But it is important to note that the way to solve the inherent problems of the PPACA isn’t to scrap it (which isn’t going to happen) but to amend it. If you got lost on the way to Cedar Point would you turn the car around and take your kids back home, or would you stop, get directions, and get on the correct road? We need to correct our path. We need to amend the bill.

The politicians and functionaries that created and backed the PPACA either have a different, unstated agenda or are just lost. Twice in the last few months I have had to deal with the consequences of a health care bill that ignores health care and costs and instead focuses on insurance reconstruction. They are my examples of collateral damage.

The new law made insurance coverage on children guaranteed issue. We can’t deny any child coverage regardless of his/her preexisting conditions. So if we are taking the parents, we have to take the kids. That part is fine, but the other part, the part that was easily predicted by anyone who understands the process, was that the legislation eliminated “Children, only” policies. That is a huge problem.

Some employers don’t choose to pay for the health insurance coverage of dependents. I was able to save families, usually lower income or middle class, a lot of money by writing policies that covered just the kids. If there was an unhealthy child, he/she would stay on the parent’s coverage. That, however, is a discussion of choice and savings. What if there isn’t a choice?

What happens if someone is a single parent? What if that individual is severely ill or injured and after a year plus of treatment is granted Medicare? Who covers the kids? The quick answer – NO ONE. There isn’t a regularly priced major medical policy in the marketplace for a couple of healthy children. After considerable time and research I was able to find a short term catastrophic major medical policy. I have used this option twice in the last few months and shared the information with my peers.

The new Summary of Benefits and Coverage (SBC) regulations kicked in last week. We are just learning how this will impact employer based health insurance policies. We know that this regulation will help people find out what is and isn’t covered under their health insurance policies. We also know that it will prevent employers from changing policies quickly if their business environment forces them to cut costs. That second point is significant. Restructuring benefits, with the same insurer or with a different company, is how many of my clients were able to retain employee benefits during this last recession. What do we do now? No one knows.

The PPACA is a classic example of the blind leading the visually impaired. The experts in Washington, like many so-called Financial Planners, are self-anointed. Without a clear understanding of how their goals impact the average American’s realities, we have laws that may be well-intentioned, but have real, negative consequences for lots of us.
And do you know what we call those Americans, the ones who suffer from the mistakes of others? Collateral Damage. 

 DAVE

 www.bcandb.com

A Spoonful of Sugar, The One Hundredth Post of Health Insurance Issues With Dave

Before we get started, this is the one hundredth post of this blog. It started in February 2009 as one of my leadership tasks as president of the Beachwood Chamber of Commerce. I have had tremendous assistance along the way from David Toth and Brad Kleinman, who got me started, and my faithful team of proofreaders and kibitzers: Sally Mandel, Jennifer Kuznicki, Jeff Bogart, Felicia Martinez, Susie Sharp, and my blogging buddies at the Lake Erie Moose Society. This blog now appears in three formats and has readers across the country.


Mitt Romney, former Massachusetts Governor and GOP candidate, has decided to re-embrace his Romneycare. On yesterday’s Meet The Press, Mr. Romney again told us that he would repeal Obamacare on his first day in office. That’s not new. David Gregory then asked him about the people who have benefited from the Patient Protection and Affordable Care Act (PPACA) such as adult children in their 20’s and people with preexisting conditions.

I’m not getting rid of all of health care reform. Of course there are a number of things that I like in health care reform that I’m going to put in place. One is to make sure that those with pre-existing conditions can get coverage. Two is to assure that the marketplace allows for individuals to have policies that cover their family up to whatever age they might like.

We haven’t learned a thing. The first edition of this blog discussed the difficulty of making tough, adult decisions. It has been three years, countless pages of legislation, rules and regulations, and a couple of election campaigns and we haven’t begun to move forward. It is one thing to use a spoonful of sugar to help the medicine go down. It is quite another to skip the medicine and eat all of the sugar.

Before Mr. Romney’s surrogates have a chance to take to the airwaves to tell us that he isn’t backsliding and that their candidate really, really hates Obamacare, all of it, let’s go over a few of the basics:

• We can ask questions and underwrite with the option of pricing based on the risk or we can insure everyone and come up with an average price.

• Healthier and younger people will pay more under an average price system.

• Many of the healthiest and youngest would pass on coverage until they needed it, if given the chance.

• The current healthcare legislation and debate has almost nothing to do with healthcare. We are simply discussing how we pay providers.

• Inaction is a whole lot easier than action. Specifics are down right dangerous.

Elected Republicans have little interest in repealing the Patient Protection and Affordable Care Act, not because they like it or agree with it, but because the alternative is worse. The alternative would be the responsibility to create a better program! The PPACA created a bridge plan that insures the previously long-term uninsured. It was (is) a costly program that is helping individuals with expensive, life-threatening preexisting conditions. Repeal the law first and then create the alternative? What happens to those people? If the law is repealed, or if the House Republicans simply carried out their threat to defund the PPACA, these people are no longer insured.

Less dramatic, the number of uninsured twenty-somethings has also declined in the last year. The PPACA is the only reasonable explanation. Dump the law and there is no guarantee that the insurers won’t dump the 25 year old still clinging to mom and dad’s policy.

If the Republicans had ever been serious about changing and improving the Democrat’s legislation, there would have been an honest effort to amend it. Instead the second bill to be pushed through by the House Republicans was H.B.2 Repealing the Job-Killing Health Care Law Act. So nothing got done. But doing nothing was the goal. It is far easier to campaign and raise funds in opposition to legislation than to create and defend your own solutions. If Mr. Romney wins the White House and the Republicans won the House and Senate, the most popular guy in Washington would be the Democrat responsible for the filibuster in the Senate that would save the Republicans from themselves.

So where are we? We still have a system that is based on demand, not care, and certainly not about outcomes. Our hospital buildings multiply like rabbits. Television and radio feature an almost endless barrage of ads for medications and treatments, many with the promise of little to no charge for the insured or aged. And we have become addicted to free stuff, whether it free exams, free pills, or free scooters for those who are no longer mobile. We want to tax others and limit access to care as long as we get to choose how and how long we live.

Where else but in the United States would you have attorneys advertise how to shift your assets to your children so that the government (Medicaid) will pay for your nursing home expenses?

So it may be time to bring healthcare into the healthcare debate. What care are WE willing to fund? What care are we willing to forego? Will the rich be able to get better care than everyone else? Of course. We don’t pay for cosmetic surgery now. In the future we might not pay for heart transplants for 70+ year olds. Or maybe we will have a national discussion and make that choice.

I just hope that we’re doing better before the 200th edition of this blog.

DAVE

www.bcandb.com