Thirteen. At thirteen, a milestone, a Jewish boy is viewed to be a man.  He has a Bar Mitzvah, becomes responsible for his actions, and three days later is reprimanded by his parents for failing to do his homework.  So which is it?  Is thirteen a milestone or is it really miles from nowhere?

We have a lot of artificial milestones, deadlines to get something accomplished, a deadline to be somebody. Twenty-one seems to be the threshold to adulthood.  Fifty to being whatever we might actually accomplish professionally.  Retirement at 65.  But these are just numbers, an average, perhaps, maybe even a goal for some, but these are numbers.  These milestones are not law, not mandatory, and the first true sign of maturity is to understand that in our quest to achieve our best we must first discard artificial, imposed timelines.  While some may peak at 23, others are still honing their skills in their 70’s.  Limiting oneself to someone else’s milestones might even force someone into foolish actions.

And that brings us to Donald Trump and the rush to pass a healthcare bill next week.

Donald Trump has decided that he must repeal and replace Obamacare (The Patient Protection and Affordable Care) within his first 100 days.  This is not because he has a prescription for better, cheaper, or even easier access to healthcare for most Americans.  It is strictly because the first 100 days is a milestone.  He has no concern about leaving us miles from nowhere.

President Trump is trying to get the House Republicans to pass a bill by next Friday. And though the legislation hasn’t been written, the Congressional Budget Office hasn’t revised its scoring, and no House committee has held a single hearing, Trump thinks he can get a bill passed.  Of course, it could be passed if the details don’t matter.  Just a reminder – we are talking about close to 20% of our economy and how the doctors and hospitals get paid if you happen to get sick or injured.  The details are important.

Trump’s latest partners are two Republican House members representing two different wings of the party, House Freedom Caucus Chairman Mark Meadows and Tuesday Group co-chairman Tom MacArthur.  Together they have crafted a compromise that is more likely to anger the members of their caucuses than to garner their support.  The MacArthur Amendment (draft provided to Politico) to the American Health Care Act does not fulfill the Republican promise of repealing and replacing Obamacare, guarantee that Americans won’t lose their healthcare coverage, or even deliver more coverage for less.  They have shuffled the deck, added a couple of jokers, and then mistakenly dealt the cards face up.

The MacArthur Amendment reaffirms the value of having real standards of insurance.  The Essential Health Benefits, a list of ten benefits delineated under the PPACA, were scheduled to disappear under the original Republican plan.  This amendment brings the EHB back, but only for a moment.   Section 1 reinstates the EHB.  Section 2 allows states to seek a waiver to eliminate the EHB if they claim that this would lead to lower premiums or the possibility of more insureds.  And it isn’t just the Essential Health Benefits.  Section 1 guarantees useful insurance and Section 2 guarantees that usefulness won’t be around for long.

We are rushing towards a milestone – Trump’s first 100 days.  It is an artificial deadline. But healthcare, taxes, war and peace are not artificial.  These issues are real.  And when it comes to reality, he is miles from nowhere.

Our friend Paul inherited a car. It only had a few miles and still had that new car smell, but it wasn’t brand new, it wasn’t the exact car Paul wanted, and he hated the color.  Paul despised the car.  The Check Engine light came on as Paul took the car out for his first drive.  He cursed the car and threatened to drop it off at the junk yard.  He didn’t fix the problem.  He never even looked to see why the idiot light was on.  Paul continued to drive the car without bothering with routine service after other warnings lit up his dashboard.  The Check Oil light had only elicited more curses and more threats of the compactor at the junk yard.  But no matter how badly Paul abused the car, the damned vehicle started every day and managed to get him wherever he needed to go.   Now, a couple of years into Paul’s ownership, the car is starting to stall and it has difficulty going up hills.  Paul is telling everyone that this car, this worthless piece of garbage, needs to be replaced.  And that is our friend Paul Ryan’s relationship with Obamacare.

The Chairman of the House Ways and Means Committee, Kevin Brady (R-TX), introduced the Republican alternative to the Patient Protection and Affordable Care Act (Obamacare) yesterday on TV.  His main thrust was that Obamacare is failing, a disaster, and that the Republicans have to do something. Anything would be better!  And to test that theory we have the American Health Care Act.

Seven years in the making! And, as White House Press Secretary Sean Spicer was quick to point out yesterday, the American Health Care Act is only 123 pages as opposed to the PPACA that is a whopping 974.  That alone makes it a better law.

There will be any number of analyses published over the next week. My peers and I have received countless calls and emails about this first stab at (in) replacing Obamacare.  Before we spend too much time on this, we need to acknowledge that there are serious divisions within the Republican Party and that much of this will be changed.  Senators from states that expanded Medicaid have no interest in explaining to the folks back home why they lost their health care.  Congressmen on the conservative fringes have had the luxury of passing bills that could never become law.  They have no interest in supporting anything that might even appear to be pragmatic.  So no, don’t get too worked up about the American Health Care Act.  Senators like Bill Cassidy (R-LA) have already declared it DOA.

A more relevant question may be whether this is a serious piece of legislation or simply one more opportunity to pander to the Republican base. Both Congressman Brady and Congressman Ryan suggested that the public should read the law.  Part of this is bluff.  They are hoping that the average American’s eyes glaze over while reading the highlights on the lead page.  News organizations, researchers, and the author of this blog accepted their challenge.

Let’s explore priorities. Health care is almost 20% of the U S economy.  Any replacement of the PPACA would have to provide for the seamless transfer of one payment system for health care to another.  Billions of dollars (and millions of lives) are at stake.  So the Republican bill would have to address all of these issues thoughtfully, carefully.  How did they do?

The first issue, the most important task of this legislation, appears on Page 2. Yes, before we can tackle the individual mandate, preexisting conditions, or even Medicaid expansion, the first thing we have to do is defund Planned Parenthood.  The AHCA goes to great pains to describe Planned Parenthood without mentioning it by name.  It isn’t till the bottom of Page 4 that we move on to Medicaid.

Much has been made of the possible changes to Medicaid. The simple explanation is that the states that expanded Medicaid would have to do more with a lot less.  The real pressure points are 2020 and after which at first seems far away, but is actually less than 3 years till implementation.

Our next section dealt with the payments that hospitals receive for uncompensated care (DSH).  The idea is to improve access for the uninsured and Medicaid patients.  These payments were reduced due to the anticipated success of Obamacare.  The goal was to have everyone insured.  The AHCA reinstates the payments.

On Page 10 we arrive upon the other issue that appears to have been keeping Speaker Ryan up at night. The next 7 pages deal with preventing lottery winners from accessing Medicaid.  Seven!  This change should guarantee that our budgets will now be balanced.

The next few pages guarantee that states aren’t forced to pay for aliens (international or intergalactic) and how home equity loans impact Medicaid qualifications. By Page 25 we get to Medicaid funding which kills another 20 pages.  On Page 45 we finally get to Subtitle D – Patient Relief and Health Insurance Market Stability, a nine year $100 billion funding mechanism to the states to expand coverage options.  Finally, some meat.

The rest of the document details which taxes are to be repealed, which repurposed, and which just simply delayed till someone else is in office. The individual mandate is eliminated in favor of a different penalty for opting out of coverage.  Older adults are charged higher premiums with the hope that young, healthy individuals will sign up in droves and make the system work.  And, of course, there are a number of favors included to make some donors happy such as the repeal of the tanning tax and the reinstatement of the deduction for insurance executive compensation.

The media, both right and left, will hit the high points. And more importantly, most of those points will be the ones debated and changed in the weeks/months to come.  I wanted to focus on the issues that the Ways and Means Committee thought were most important, the issues that they hit first.  There is one other issue that I thought was unusual.  Section 6, about 80 pages or so into this bill, repeals the employer mandate, the rule that forced employers with more than 50 employees to provide health insurance as of December 31, 2015.  Not the end of last year.  Not the end of this year.  Obviously, one of the Congressmen has a very important constituent who didn’t bother to cover employees in 2016.  Perhaps Chairman Brady?  Gosh it is always great to know a Congressman.  Heck, it is better than a poke in the eye with a sharp stick.

It appears that it is common, when someone is on a blind date, to arrange a “Rescue Call”. There is even a commercial on TV that references this.  A friend calls you and provides you a reason to cut the date short.  I actually saw it in action on Wednesday.

I was in a Congressman’s office. Seven Ohio health insurance brokers were in his office to discuss the Patient Protection and Affordable Care Act (Obamacare) and what we were going to do now.  Fifteen minutes into a positive / routine meeting we were interrupted by one of his aides.  After one quick knock on the door, the aide poked his head into the room and told the Congressman that he had another meeting.  The Congressman waived him off and we all got another fifteen minutes.  If this had been a date, we would have just qualified for a second cup of coffee.  Welcome to How To Visit Washington DC 2017.

Over a thousand members of the National Association of Health Underwriters (NAHU) gathered this week in Washington to hear from a variety of experts and to talk with our states’ elected representatives.  Most of us are there on our own dime.  It is that important for us to get the most up to-date information and to make certain that our lawmakers understand how our clients will be impacted, both positively and negatively, by any changes in the way Americans pay for their health care.

The Law of Unintended Consequences.

There are a lot of ideas that sound absolutely fantastic on TV but will be irrelevant, or even worse disastrous, in practice. Insurance agents are uniquely positioned to explain the real world impact of these programs.

We were in Washington to deliver one important message for our clients – Market Stabilization. It is already mid-February.  Nothing can really be changed for 2017 and the insurers only have eight weeks left to prepare for 2018.  Yes, eight weeks.  Insurers are currently working to file their plans and rates for 2018 and they, as well as our clients, need to know what the market will look like on both the state and federal levels.

Our key points centered on the individual (non-group) market.

• Allow the tax credits that help so many Americans to afford coverage to remain intact for at least two more years or until a comparable replacement can be put in place.
• Allow tax credits to be used outside of the Marketplace if fewer than two choices are offered in a state.
• Allow any person to purchase a catastrophic-category coverage regardless of age or income status.
• Tighten both the open-enrollment and special-enrollment periods to reduce adverse selection.
• Allow states to be eligible for a new hybrid high risk pool that would serve as a reinsurance mechanism while still providing the same level of coverage for even the highest risk individuals.
• Preserve employer-sponsored health insurance by retaining the employer exclusion.

Yes, this is a lot of process and almost nothing that would make a good sound bite. These points and others would help secure the promise of health insurance coverage for the next couple of years.

Armed with individualized packets, we set off to meet our Senators and Members of the House. I had a chance to visit offices in the Senate and the House, Democrats and Republicans.  Some of my meetings were with the actual lawmaker.  Some were with staff.  And though it is always gratifying to have a Congressman make time to speak with a visiting constituent, some of the best meetings can be with a Chief of Staff or a knowledgeable legislative aide, especially one who specializes in public health.  I found this year’s meetings productive.  The Congressmen and their staffs were totally engaged.  They asked good questions.  They took notes.  I honestly felt that my time and expertise were valued.

**  **  **  **  **

I was in geek heaven. Cigars.  Scotch.  Politics.  I was with two of my peers and a lobbyist in Shelly’s Backroom doing a deep dive on the current state of affairs.  The hours flew by and it was past midnight when I called us an UBER.  We walked outside, ignored the parked cab, and looked for Mohammed and his Toyota Camry.  A Camry stopped, right in front of us, in the middle of the street.  We walked up to the car and tried to get in as the driver frantically waived at us.  We had failed to notice that there was a traffic light, here in the middle of the block, and he had been stopped for a red light.  He wasn’t an UBER!  We stepped back and he sped off.

Another Camry, one with an UBER decal, came up a couple of minutes later. This time we verified that it was an UBER and got in.  Sitting shotgun, I noticed that the driver was a little confused.  We had only traveled a few blocks before his phone rang.  It was Betsy.  She wanted to know where the Hell he was.  They started arguing.  This wasn’t Mohammed and we were in the wrong UBER.  In the end I cancelled my order, paid the penalty, and slipped the driver a $10 for a $7 ride.  His last ride as an UBER driver might as well include a tip.

The view from the train beneath the Capitol.

The Ways and Means and Committee needs new furniture!

This is either the office of Rep. Don Young of Alaska or a Betsy DeVos elementary school.

DAVE