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.

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.

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.

A basic principle of politics is that the rules don’t matter if they inhibit your progress or agenda, but the rules are sacrosanct if they inhibit your opponents’ agenda or progress.

The Republicans have installed a Debt Clock at their convention in Tampa as a way to visually highlight their disdain for fiscal irresponsibility. The Republicans, with a Democrat in the White House and Harry Reid leading the Senate, are now deficit hawks. Even Condoleezza Rice, in her speech last night to the delegates, stressed the importance of getting our financial house in order. But it has only been a few years since Paul Ryan was voting for Medicare Part D and bailouts and Vice-President Dick Cheney famously declared that “Deficits don’t matter”.

Hypocrisy and the total absence of intellectual honesty are just as common on the other side. Up is down and down is up when it is politically expedient. The current Medicare debate is a perfect example.

Let’s take a two second detour to the “Bush Tax Cuts”. Congress, especially Republicans, like to pretend that revenues will increase if the tax rates decrease. But knowing that that is all BS, the cuts of 2001 and 2003 were made temporary and designed to end within ten years. This allowed Congress to ignore the fact that the legislation was not revenue neutral. They didn’t have to acknowledge the debt they were creating. Congress has been fighting about retaining those cuts for the last few years.

The Patient Protection and Affordable Care Act (PPACA) was billed as revenue neutral, too. It never was. Part of the funding for the PPACA came from the CLASS program, the ill-fated long term care policy that has already been eliminated. Part of the funding was to come from the new 1099 rules, which have also been repealed. There are still numerous fees and taxes sprinkled like fairy dust throughout the law. And 716 million dollars comes from future Medicare spending.

Ah Ha! The Republicans are right. He is gutting Medicare.

No, not really. As David Wessel notes in today’s Wall Street Journal, both Obama and Ryan remove a similar amount of future funding from Medicare. Mr. Romney has now backed himself into a corner and pledged to restore the money. That too will change.

The problem is that none of these men are at all credible when discussing this issue. The numbers never add up. The details never include the HOW something will work.

Where are we now?
1. Medicare was designed to pay about 75% of a senior’s health care expense
2. Our current system incentivizes care
3. Our current system creates an environment where fraud and abuse are almost inevitable
4. We have no way to cap expenses currently
5. About 30% of Medicare dollars are spent on a person’s last year of life

How do you control costs? The obvious answer is to reverse as much of the above as possible. How do you lose an election? The obvious answer is to attempt to reverse any of the above.

The President has proposed the creation of the Independent Payment Advisory Board (IPAB). By setting standards in both care and pricing, the government would begin to get a handle on unnecessary procedures and costs. The IPAB will classify certain questionable treatments as elective or self-pay. If you want it and can pay for it – go ahead.

Mr. Ryan would have you buy a private insurance policy. He would give you just enough to purchase a basic policy, the second worst in the marketplace. If you want more coverage, a plan that might pay for certain physicians or medications, you will make up the difference. The insurer will classify certain questionable treatments as elective or self-pay. If you want it and can pay for it – go ahead.

The results are about the same. The wealthy will always have access to care. The rest of us should be OK. If all of this looks vaguely familiar, think about the number of prescription medications that are now available over the counter. OTC doesn’t require a prescription, so the government (Medicare, Medicaid, and government employee coverage) and the insurers save money. No doctors’ visits. No coverage for the cost of the drug. If you want Prilosec, pay for it.

Albert Brooks, in his dystopian novel 2030, offered a vision of the U.S. where the Right To Life movement shifts its focus from abortion to preserving, at any cost, the lives of the elderly. Is it that far fetched to envision warehouses of comatose elderly connected to expensive hardware, alive in name only? Would a Republican Party ready to extend the protections of the 14th Amendment to the unborn require unlimited care for the brain dead? And if that care is mandated by the government, will it also be unfunded?

The answer – Perhaps. See all of those rules about small government vs. large government; regulations vs. the free market are only as strong as the special interests pushing our politicians. The good news is that our politicians occasionally surprise us.

So, which is better? Would you prefer a politician who tells you whatever he thinks you want to hear, whose only core commitment is to his own election? Or would you rather have someone who is clear-voiced and unashamedly direct in his pursuit of an agenda that even his followers consider unyielding?

My friend Bill (name changed) has a problem. Four years of President Obama are more than enough for Bill. Health Care. Foreign Policy. The Economy. There have been few bright spots for Bill, a moderate Republican. And moderation is the issue. He could vote for Mitt Romney, he told me and anyone else that would listen, because once in office Romney was the candidate most likely to rein in the whack jobs in the House.

In other words, he was hoping that the guy running for President was a pendulum. He has been left of Kennedy and right of Gingrich. Once elected, he should just flop into the middle.

This past Saturday morning, Mitt Romney chose Paul Ryan to be his running mate. On Saturday afternoon, Bill threw up his hands in disgust.

Since this is Health Insurance Issues With Dave, we should take a look at what will be the key issue of the campaign and the subject of millions of dollars of TV ads – Medicare.

Does Paul Ryan want to end Medicare as we know it?

Yes and No. The 2011 budget Mr. Ryan prepared and packaged as The Path to Prosperity: A Blueprint for American Renewal originally replaced the current Medicare program for all seniors in the year 2022. The Democrats beat that proposal like it was a piñata at a ten year old’s birthday party. The 2012 version, crafted in part with Ron Wyden (D-Ore), retains traditional Medicare as an option, thus killing it more slowly over time.

This blog has covered Medicare numerous times. It is important to note that Medicare was never designed to cover 100% of a senior citizen’s hospital or doctors’ bills. The first anniversary post of this blog included a complete breakdown of what Medicare does and doesn’t cover.

We should also note that the only time Either Side is telling the truth is when they are deriding the other guy’s plans for Medicare. The President does cut (mostly in future growth) over 700 billion from Medicare. But Mr. Ryan’s plan does not restore the cuts. Mr. Romney initially endorsed the Ryan budget while offering a vague statement of ideals designed to give the impression that he has a different plan.

The current Medicare spending for a typical 66 year old is currently around $5,700 per year. Both the President’s plan and Mr. Ryan’s assume a significant rise in cost to the government over the next 18 years.

The cuts aren’t the only detail the two plans share. Insurance Exchanges, the expensive new marketplace to purchase insurance, may be a sore spot for Republican governors, but Mr. Ryan is a big fan. The Patient Protection and Affordable Care Act (PPACA) utilizes exchanges for all ages. Mr. Ryan wants to set up exchanges, too, but only for senior citizens.

So what are the differences between the President’s plan and Mr. Ryan’s? According to The Path to Prosperity website, the most important element is that the PPACA creates the Independent Payment Advisory Board (IPAB) to orchestrate Medicare cuts. Mr. Ryan’s site raises the possibility of faceless bureaucrats rationing access and randomly denying needed health care. It is very scary.

The Ryan solution? Premium Supports / Vouchers. Starting in 2023, new Medicare beneficiaries will be guaranteed a ticket to the next to the cheapest (not the cheapest, the next one up!) insurance option in the marketplace. There will be more comprehensive plans available to those willing and able to pay the difference. Mr. Ryan envisions doctors, hospitals and insurers fighting for your partial payment.

You won’t be denied the opportunity to have access to any cure, any doctor, any hospital – which you can pay for.

But the 2012 plan keeps Traditional Medicare as an option.

“If you like your current insurance, you will keep it”, President Obama said during the health care debate. Those of us in the business knew that that was impossible. The grandfather rules were confusing and contradictory. The insurers could only maintain policies operating under separate regulations for so long. Medicare Part D, the underfunded Republican Rx program introduced in 2003, eliminated Medicare Supplement Plan F which was saving my clients a lot of money. It is hard to pretend that traditional Medicare, Medicare as we know it, would survive the Ryan plan.

Under the Ryan program, people who turn 65 prior to 2023 (such as Dave Cunix, class of 2020) will be allowed to stay on the current system. New beneficiaries will be offered the new system or an updated version of what we now have. How will funding for these different options be maintained? What will actually be the mandated minimum coverages? How much more will it cost for the government to regulate two systems? With no new healthy retirees coming into traditional (pre-2023) Medicare, how long will it be before we have a death spiral?

The possibility of capping our current Medicare system with no access to new, healthier members is why this debate is not limited to Americans under the age of 54. We, anyone who has the hope of seeing 2030, would be impacted by the Ryan plan.

Where does that leave us? We have out-of-control costs, no idea what we should and shouldn’t cover, and little willingness to pay what it would really take to get the job done. It doesn’t solve any problems, but sometimes, I guess, it does feel better when they just lie to me.

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

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

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

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

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

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

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

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

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

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

So one side has a large segment of the population frothing at the mouth in anticipation of more free stuff, while the other side is desperately trying to convince Americans that the current system is a stone’s throw away from perfection. Of course, the only perfection is the cynicism that both sides have mastered.

Medical costs are rising as doctors and hospitals adjust pricing in anticipation of more government involvement. New fees, like facility charges, are appearing on our bills. Medical buildings are now hospitals, and that increases all charges. Your insurance premiums reflect those increases. There isn’t anything complicated in this. Every time the cost of care increases, every time you are given a new ‘free” benefit, every time the definition of what constitutes preventive care is expanded, your premium has to increase.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

You can’t beat something with nothing.

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

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

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

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

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

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

Which ads are you going to miss?

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

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

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

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

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

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

And now, a word from our sponsor.

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

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

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

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

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

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

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

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

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

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

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

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

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

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