You may have seen the picture of the new president rushing into his office to sign his first Executive Order.  It was Friday, January 20, 2017, after the parades and before the inaugural balls.  Chief of Staff Reince Priebus put the paper in front of him, and like a homebuyer whose eyes have glazed over from thirty pages of gobbledygook, President Trump quickly signed the document without a moment’s hesitation.  Now if you or I were about to make history, and everything a president does, by definition, is historical, we might have looked at the document, maybe ever READ the document, prior to affixing our name to it.

Since we aren’t on our way to any formal dinners or balls, we have plenty of time to read the Executive Order.  Please take a moment.  It is only one page.

It is important to note that this was the first Executive Order. So what does it mean?

Option One – If the repeal, replace, demolition, or rebranding of Obamacare succeeds, this Executive Order will be hailed as the important first step President Trump made to keep his promise and to deliver a better program.  That is a huge if.

Option Two – This Executive Order opens the door for major changes. Once a Secretary of Health and Human Services (HHS) has been confirmed by the Senate, he (Don’t judge me.  All of the nominees are male.) will be able to determine what regulations are burdensome.  Here’s a hint – All regulations are a burden to someone.  The current nominee is Congressman Tom Price (R-GA).  States looking to modify the cost of Medicaid by reducing benefits or access will find Mr. Price supportive.  In fact, a quick read of his positions over the years will yield the impression that Mr. Price might happily remove any requirement that the poor and middle class have comprehensive insurance coverage.

And though all of the above might seem like enough of a motivation to sign this Executive Order, I still think that it isn’t enough to be #1.  So allow me to offer another explanation.

The Patient Protection and Affordable Care Act (Obamacare) was structured in broad strokes with the details to be fleshed out in the form of regulations.  This is not unusual.  Major legislation like the Patriot Act are designed this way.  The PPACA requires health plans to cover annual routine preventive care visits.  These visits are covered at 100%.  No deductible.  No copays.  It was HHS that determined that routine preventive care included a colonoscopy for those of us over 50.  This has undoubtedly saved lives.  It was also HHS that determined that preventive care included birth control pills, the IUD, and the morning after pill.  That made the lives of countless Americans easier.  And now that this Executive Order has been signed, it will be HHS that will decide birth control, the IUD, and the morning after pill are no longer part of preventive care.

This change could apply to both individuals and groups. The current court cases dealing with this will be dropped immediately.  This will be seen as a victory for those employers who are opposed to these services.  And to those who needed these benefits.  Well, they aren’t the priority.

DAVE

Michael Lewis’s recent book, The Undoing Project, details the groundbreaking work of two Israeli psychologists, Daniel Kahneman and Amos Twersky.  Their work explored the way we make decisions and how we justify, after the fact, those decisions.  Mr. Lewis helps us to understand how these two scientists moved our decision making towards data and away from intuition.

In late 1973 or early 1974, Danny gave a talk, which he would deliver more than once, and which he called “Cognitive Limitations and Public Decision Making.” It was troubling to consider, he began, “an organism equipped with an affective and hormonal system not much different from that of the jungle rat being given the ability to destroy every living thing by pushing a few buttons.”  Given the work on human judgement that he and Amos had just finished, he found it further troubling to think that “crucial decisions are made, today as thousands of years ago, in terms of the intuitive guesses and preferences of a few men in positions of authority.”  The failure of decision makers to grapple with the inner workings of their own minds, and their desire to indulge their gut feelings, made it “quite likely that the fate of entire societies may be sealed by a series of avoidable mistakes committed by their leaders.”

I can’t think of a more important paragraph to share with you today, January 20, 2017. Health Care, Nuclear Proliferation, Trade – all of these decision will affect us all.

DAVE

ALL IN! Crap, all in with a pair of sevens.  But he had to do it.  It had been so long since he had had a hand, any hand, that he was forced to go all in with a pair of sevens.  He had been pushed around long enough.  He remembered his last chance, the last time he had had a really good hand.  Thought he had a winner.  The first two cards – King and Queen of Hearts.  He bet and his opponent called.  Next the Jack and then the ten.  Both hearts!  He bet big.  Call.  And then came the ACE!  But it was the ace of clubs and all he had was a high straight.  He bet and his opponent raised.  The warning bells went off in his head as he called.  He had a straight, but his opponent had drawn a full house.  Now he was all in with a pair of sevens.  And his opponent looks like he may call…

It takes a certain amount of courage to put your money on the table and ask to be dealt into the game. Though some may always lose, no one always wins.  So you better enjoy the game, revel in the risk, and be prepared to accept the outcome win or lose.  And there is one more similarity between poker and politics.  You must be prepared to bluff.

In March of 2010 the Democrats went all in. They didn’t have a great hand.  This wasn’t the early 90’s when they thought that they had a winner.  They didn’t have the National Single Payer plan that they really wanted.  They had compromised with their fellow legislators from across the aisle to cobble together a plan that would garner bipartisan support.  And they failed.  They were all in and they were exposed and alone.  On March 23, 2010 the Dems won with a pair of sevens and the Patient Protection and Affordable Care Act (Obamacare) was signed into law.

March 23^rd wasn’t the end of the game, just the biggest tournament to date.  The Republicans have been very busy since that loss.  They had no respect for the gambler, President Obamacare, and hated to have been bested by such a weak hand.  It took almost seven years, but here they are, back at the table.  The Republicans had spent almost every waking hour since the defeat preparing for this day.  A poker player needs a bankroll.  The Republicans needed votes – a solid majority in the House of Representatives, the Senate, and a Republican in the White House.  And on Friday, January 20, 2017 it will all come together.

For almost seven years the Republicans have told everyone who would listen that they were the better choice. “Bet on me”, they said to the American public.  Their focus, the game, scheduled for 1/20/2017 was impressive.  We all knew that if they were given the chance they would repeal and replace Obamacare.  They just needed their bankroll.  And now they’ve got it.  There is only one problem.

We are about to see how Paul Ryan plays a bluff. He’s got the votes.  But he doesn’t have the cards.  There is no viable Republican alternative.   Even Republican governors want/need to retain the expansion of Medicaid built into the law.  Nobody wants to reinstate medical underwriting, exclude preexisting conditions, or kick kids off their parents’ policies.  Everyone wants cake and ice cream for dessert, but no one wants to be forced to eat the liver and onions entrée.

The players are about to be seated. We’ve already taken a peek at the Republicans’ hand.  Wonder what the Dem’s have?  Wonder how they’ll play their cards?  More importantly, who is going to tell all of them that this isn’t just a game?

DAVE

Irritated. My right eye was irritated.  So was I.  My eye had been bothering me for a couple of days.  I didn’t know if it was allergies, a sty, or an infection.   I had been determined to rely on eye drops and to just tough it out, but that was before I had needed a warm compress in the middle of the night.  Time to get medical attention.

As previously noted, I was a touch irritated. Before I could deal with my issues I had to solve a client’s problem with UnitedHealth One.  I was on hold for 52 minutes!  My phone has a timer.  Staffing cuts reflect the company’s losses over the last few years.  Once that was completed I could focus on me.

I contacted the Cleveland Clinic facility in Beachwood. It only took 30 seconds for me to clearly state that I didn’t need to see my doctor, or any doctor.  I would be perfectly happy with a nurse practitioner as long as I got to come in today.  I had also detailed my eye problems.  If I was having a heart attack or bleeding to death the scheduling tech would have been able to send me to the E/R and hang up.  No, she had to talk to me.

I have been a Cleveland Clinic patient for years. The clerk had all of my information on her screen.  Still, she needed to verify ALL of the information from my Anthem card, front and back.  I said that I’ve had this policy for over three years.  Nothing has changed.  It didn’t matter.  She plowed on.  Next, where do I work?  What is my job title?  At the eight minute mark, remember my phone has a timer, I noted that we had spent more time confirming how the Cleveland Clinic would be paid than my health problem.  She persisted.

Ten minutes into the call I asked her again who was going to see me. She said, “We don’t have any openings today”.  “Then why did you waste my time”?  She began to offer appointments for the following week, but I had had enough and hung up.

I hear it all of the time. Every negative encounter with the medical industry is blamed on Obamacare (the Patient Protection and Affordable Care Act).  Sometimes the complainer is correct, but not always.  Failure can be traced to a number of sources.

The staff cuts and financial losses at UnitedHealth One are due, in part, to some really awful decisions. And UH1 cut their marketing and service staff when the going got tough.  They succeeded in making it harder to do business with them.  UnitedHealth One will get better.  This is just a bump in the road.

And the Cleveland Clinic’s failure can’t be blamed on Obamacare. This insatiable push for more money, more donors, and more buildings occasionally leaves the patient as nothing more than a necessary evil.  We are in the way. Soon we will be diagnosing and treating our own ailments and simply sending tribute payments to the Cleveland Clinic.

Two websites and a phone call later I had an appointment at a Minute Clinic in a CVS. These clinics are somehow affiliated with the Cleveland Clinic.  The nurse checked my vitals, noted my agitation, and gave me a prescription for some eye drops.

So what was it? Allergies?  Sty?  Infections?  I’m still not sure.  I took an antihistamine and have religiously put in the eye drops as prescribed.  I’m sure I’ll be OK in another day or so.

DAVE

Dana Milbank, opinion writer for the Washington Post, was featured on some of the news shows yesterday to discuss Trump voters who desperately rely on Obamacare (The Patient Protection and Affordable Care Act).  His article appeared Tuesday and was creating quite a buzz.  I, for one, enjoyed 20 minutes of TV that didn’t feature Putin or the words “Conflict of Interest”.  Still, this is a serious issue, and we will treat it with a little more respect than Mr. Milbank.

There are and always will be Americans who vote against their personal interest. This is a link to a Forbes article on the issue.  But as this article and many like it point out, it is not necessarily that simple.  Poor people in Kentucky didn’t decide on Election Day to screw themselves.  The previously uninsured didn’t vote for Donald Trump because he vowed to repeal Obamacare.  Interviewing them now, a month after the election and a month before anything has changed is unfair to them.  It is bad enough to be poor.  We don’t need to make them look stupid.

I have a number of clients who have benefited from the PPACA who still voted for Trump. Let’s take a quick look at some of the possible reasons for their choice.

It Didn’t Matter – There are many people who feel that Obamacare will be repealed loudly and retained quietly.  We may end up with Trumpcare, a modification that fixes some issues while creating new problems.  The Republicans declare victory and the Democrats cede the next 5 years of glitches and complications to the other side.

The Bright Side – I have at least one client predicting a major economic recovery that will result in more jobs with benefits.  If they score better gigs, they won’t need individual coverage and all of this will cease to be relevant to THEM.

A Better Way – There must be a better option and their team’s got it.  No matter how many times they have been let down by politicians of both parties in the past, this could be the time they get it right.

There Are Other Issues – Health Insurance is really important to me, but I doubt that there are many single issue Health Insurance voters.  Abortion, Pro-Life or Pro-Choice, seems to drive people to the polls.  Immigration and jobs, too.  People were riled up and voted AGAINST Obamacare, often without understanding its positive impact on them personally, but I think that they saw it as part of a whole, a failure of Washington to properly serve and protect them.

Regardless of why or who voted for Donald Trump, the election is over and about 40% of us have spoken. Donald Trump will be the next president and he has a Republican controlled Congress.  He has nominated Tom Price (R-GA) to be the next Secretary of the Department of Health and Human Services.  Mr. Price is famously anti-Obama and anti-Obamacare.  His solutions are radically different and concerning.  Will the Price plan or something like it be implemented?  No one knows at this point.

Congress will be very active in January and February. It will be important for all of us to watch them closely and share our thoughts with our elected officials.  I don’t think that we will see any major changes in 2017, but that is my guess.  I will be in Washington in February, in part to discuss my clients’ needs and how the actions of Congress can help or hurt my people.

Until then, if you need a liver transplant like Mr. Mills of Whitley County, Kentucky, I strongly suggest that you get this scheduled soon. The press may paint you as a victim of your own folly for being in this mess, but if you put it off too long this really could be a tragedy of Shakespearean proportions.

DAVE

Wednesday was a terrible day in the office. I was a mess.  I had been awake most of the night, my worries as dark as the bedroom.  Clients called.  Clients texted.  Everyone, all through the day, wanted to know how this election would affect them.  I was too busy to write this update.  And I was too concerned about the possible impact to prepare a full report.  A friend came in around 5:30.  He asked me how I was doing.  I told him.  I probably did ten minutes on where we were and how worried I was about my clients.  He was very patient.   Then he asked me, again, how I am.  I had completely forgotten that my friend David is totally apolitical.  He was asking about my health!

We’ve had a couple of days to watch the president-elect articulate his vision and the current Congressional leaders voice theirs. They are not the same.  The future of health insurance will be determined by both the new president and Congress.  And the courts may also play a part in our future.

This blog is Health Insurance Issues With Dave. It is not my interest nor place to discuss any part of the election that does not deal with health insurance.  And health insurance is our method of compensating   medical providers for their products and services.  Health insurance is regulated on both the state and federal level, which means that decisions are influenced by finances and the public good.  Finances are in black and white.  The public good is open to discussion.

The president-elect campaigned on the promise to Repeal and Replace Obamacare (The Patient and Protection and Affordable Care Act).  The Republicans who control Congress have promised this for years.  On Tuesday the coyote caught the roadrunner.

First, Mr. Trump. As discussed in March, there wasn’t a detailed Trump alternative.  We had no idea, prior to the election, what his priorities were or how he would accomplish them.  Our closest peek into his thinking came at his Gettysburg speech in late October when he spoke of selling insurance across state lines and of increasing access to Health Savings Accounts, both Republican ideas.  This week he expressed his view that the Repeal and Replace would take place simultaneously and that two key provisions of Obamacare – coverage for pre-existing conditions and the ability of children to retain their parents coverage till age 26 – would be continued.

Congress has a different view. Some in Congress have PRIVATELY admitted that Obamacare couldn’t be repealed.  Amended?  Sure.  Changed?  You bet.  But the idea of repealing the law and blowing up our system, and 20% of our economy, and then eventually replacing the law would be a disaster.  Passing repeal bills was safe and easy.  There was no danger as long as a Democrat was in the White House to veto the law.

We have had a chance to review the various alternatives. Over the las few years I have covered plans from Governor Scott Walker, Speaker of the House Paul Ryan, and Senator Orrin Hatch.  Some have been exercises in ideology and others are closer to marketing projects, the rebranding of Obamacare to a Republican name.  You will hear a lot more about this in the coming months.

Let’s quickly hit a couple of the major talking points.

Selling Insurance Across State Lines – I have tackled this a number of times.  This is a link to the Kaiser Foundation’s explanation.

Covering Pre-existing Conditions – Everybody loves this, but it doesn’t work unless we have everyone participating.  Given the opportunity, lots of healthy people would choose to save their money until they needed coverage.  Health insurance is really expensive if only the unhealthy buy it.  That means that any law, Obamacare or its replacement, needs to have some form of mandated participation.

Subsidies – The current Tax Credit Subsidy is complicated.  There is a lot of room for improvement.  Some of the Republican plans will give you a tax credit in 2018 for what you paid in 2017 on insurance.  That only works if you can afford the premium in 2017.  That eliminates millions of Americans.

Health Savings Accounts – Another great idea if you’ve got disposable income and could us a tax break.  Otherwise, no big deal.

Preventive Care – This is really important, especially for children.  There is an upfront cost, but long term savings.  How preventive care is defined may be changed under the new administration.  This has been very contentious.

This has been a very long post and I truly appreciate your patience. There are no simple answers for complex questions.  I am very concerned about what the next year holds for us.

I leave you with a thought about a Ferris Wheel. The ride stops when you get to the top.  The view is incredible.  You are filled with joy.  The ride begins to move again and eventually you are at the bottom and forced to leave.  The world, even our little world of health insurance, is never as euphoric or bleak as it might seem.  We will get through this together.

DAVE