The new president of the Ohio Jaycees, back in the early 1980’s, was a good old boy from the southern part of our state. We’ll call him Bubba. I was a state level officer and had been very involved in the other guy’s campaign.

Bubba was a nice enough guy who was incapable of stringing four words together without saying the word “great”. No other superlative, just “great”.

The Ohio Jaycees were holding a state-wide meeting and Bubba was going to give a fifteen minute presentation. I created the Great Great Contest. I divided an oversized sheet of cardboard into a thousand numbered squares and allowed the guys to predict how many times Bubba would say “Great”. Each block cost $1. Half would go to the winner. Half to charity. You could hear the crowd counting throughout Bubba’s speech.

Bubba isn’t running for President, but I think about him every time I watch the Republican hopefuls debate. Which candidate will be the first to say that he will “Repeal Obamacare”? It is a race. I half expect Mitt Romney to be mouthing the words as the cameras focus on him during the introduction.

There are two more debates this week. Get out a sheet a paper and keep score. Who gets to be the first to promise to “Repeal Obamacare”? Who says it the most? How many times are Obamacare, and its orphaned cousin, Romneycare, decried in each debate? You may need a large piece of paper.

Now grab a post-it note to score how many times any of these candidates propose an alternative. My prediction – ZERO.

This blog has been clear. The Patient Protection and Affordable Care Act (PPACA) is a terrible overreach and a badly written bill. The numbers don’t add up. The stated goal, the motivation for this whole endeavor, was to cover the uninsured. The PPACA has not solved that problem. But, what does repealing it accomplish?

The PPACA is almost two years old. Businesses and insurance companies have spent millions of dollars to comply with the ever-changing regulations. President Obama was clear, prior to the bill’s passage, that “if you like your current health insurance plan, you can keep it”. That didn’t happen. The cost to maintain a separate series of “grandfathered” contracts compliant with the contradictory regulations emanating from Katherine Sebelius’s Health and Human Services was beyond reason. One by one, the insurers eliminated all of their old contracts. If you repeal the PPACA, do you have to go through the expense of changing the majority of the group and individual health policies in our country?

The PPACA made preventive care a mandatory benefit. Does that stay or go?

The PPACA allows children to stay on their parents’ insurance until age 26. How many pregnant 24 year olds would lose coverage if you suddenly repealed the PPACA?

Would the repeal of the Patient Protection and Affordable Care Act eliminate the health policies that were created for the chronically uninsured?

You get the idea. The PPACA may be a mess, but it, just like the problems it purported to fix, exists. Repealing the Presidents’ health care plan without having a well-crafted replacement might be worse than retaining it.

This blog has consistently doubted the Republican’s sincerity about repealing the PPACA. I view it as a safe fundraising ploy. It would take way too much effort to create a viable alternative. There is no risk to denigrating legislation disliked by over half of our populace. Creating an alternative would expose them to the same type of scrutiny and probably the same results. Even modifying the law was more effort than the Republican House could muster.

Bubba said “Great” 123 times. The winner received $140. Bubba isn’t running for President, but I am convinced that he was one of Michele Bachmann’s speechwriters.

When is selling not selling? Where is the line between helping your customer and primarily helping yourself? Determining that becomes harder each day.

One of my clients needed to talk. She had received a disturbing phone call at her home and wanted to know if she had handled it correctly and if I knew the back story. Mary (not her real name) was contacted by a national pharmacy. We’ll call the pharmacy chain Mega Rx. Mary was advised that her insurer would no longer cover medications for her and her family from their local Mega Rx. Since they knew that Mary would hate to loose access to Mega Rx, they would be happy to connect her to someone who could help her find an insurance policy that would allow her to retain them. All she had to do was stay on the line. Mary thanked them but said that she already had an agent and hung up.

Think about this for a second. The national drug store chain had fought and lost a battle with a national insurer. They were mining their records for anyone who had that insurer and had had a prescription filled in the last year or so. And if Mary was gullible and not paying attention, she might have somehow been talked into different insurance that would have definitely covered Mega Rx, but might not have covered her doctor, or given her and her family the same level of coverage.

The appointment to change individual health insurance policies usually takes an hour in my office and involves a lot more than whether or not Mega Rx is in the network. This silliness is taking place under our current set of rules. The states and the federal government are still writing the new rules. Some people don’t think we really need licensed agents. Why not let anyone sell insurance?

I just spent twenty minutes completing my application to renew my license to sell life and health insurance. I had to prove that I had completed 21 hours of continuing education and 3 additional hours of ethics training in the last two years. I actually had a total of 42. That does not include the 7 to 9 hours per year for Medicare products or the mandatory additional training for long term care coverage. I then attested that I haven’t been convicted of any crimes, haven’t had my insurance license suspended or revoked, and that I don’t owe back child support. This is true. You can not sell insurance in the State of Ohio if you owe back child support. I paid my $5 and I should get an approval notice some time next week.

All states have seen a value in licensing insurance agents. It is obvious that one value of the requirements is to weed out the part-timers. The public is better served by committed professionals who are willing to take the time and effort to stay current. And though insurance agents (me included) will never be confused with rocket scientist, we do serve an important function in the market as we help the insured public acquire coverage and navigate the process to get the most from their contracts. The insurers long ago (begrudgingly) accepted our value.

This brings us to the Patient Protection and Affordable Care Act (PPACA). The authors of this legislation did not believe that the public is capable of calling an insurance agent or company or shopping online to purchase health insurance. Since finding health insurance was so difficult, insurance exchanges, a marketplace, would be created in each state. As you can see from the Obama administration’s website, the exchanges, an additional layer of bureaucracy, is going to save you money. And how will you get to the exchange and who is going to help you choose the right type of policy for you? That would be the Navigators.

The PPACA is pretty sure that almost anyone that can fog a mirror is capable of doing my job. Any employee of trade association or union can walk you through the process. In fact, the PPACA spends more time on the notion that the Navigators can not be compensated by the insurers than it does on training or qualifications.

A well publicized letter from David M. Casey, Senior Vice President of MAXIMUS, a company that specializes in Medicaid enrollment, details the Patient Protection and Affordable Care Act’s aversion to professional insurance agents.

John Doak, the Oklahoma Insurance Commissioner, is succinct in his judgment. He has consistently challenged the federal government’s intrusion into insurance regulation and health insurance. He has asked what kind of training the Navigators will have in insurance products, health information privacy regulations (HIPAA), or ethics. And of course we already knew the answer, none.

The other question is “Who will be paying the Navigators”? You have two choices. Either the Navigators eventually become employees of an endlessly growing government program, or they are employees of organizations who have something to gain by you and I being steered into one policy versus another. And that brings us back to Mega Rx. The major pharmacy chains are currently exploring ways to have employees become Navigators under the future exchange program. Will they be impartial? Will they be looking out for your best interest? Will the sun rise from the west tomorrow morning?

This is too easy and way too transparent a case of conflict of interest. What if a major insurer is donating money to your local trade group? The employee of that trade group would work to navigate people to that company’s policy. There is a lot of money involved. This won’t be subtle. And it won’t be easily traced.

So when you get that phone call from the drug store, or the doctor’s office, or the Chamber of Commerce, and you will one day, ask yourself why. Slow the process down and try to determine who is getting paid and for what.

In the interest of creating transparency and simplicity, we have failed at both.

This is a post about someone with cancer. I have not met Ms. Ward, nor do I think that I ever will, but I wish her a successful recovery. This post may take issue with some of her choices and many of her conclusions. These differences should not be interpreted as personal. They are not. Too many of our discussions have devolved into the personal as they abandon fact and reason. This blog champions a polite discussion of the facts.

Spike Dolomite Ward has cancer. Ms. Ward is a forty-nine year old married mother of two. She lives in California. This past Sunday’s Plain Dealer included an article she wrote that initially appeared in the Los Angeles Times. Ms. Ward explained why she hasn’t had health insurance for over two years. Trust her, it is not her fault.

The key element, the point that requires ten paragraphs to justify, is that she has been saved by President Obama and the Patient Protection and Affordable Care Act (PPACA). How you ask? Will the President be administering the Chemo? No, but close. As we have discussed before, the PPACA included the creation of guaranteed issue policies that cover pre-existing conditions for people who have been uninsured for over six months.

• Significant medical condition like cancer? Check.
• About to have lots of expensive treatments? Check.
• Uninsured for over six months? Check.
• Insurance now seems like a really, really good idea? CHECK.

I completely understand the need to purchase homeowners insurance now that my house has burned to the ground.

Please read Ms. Ward’s article. It is entirely possible that the laws in California are very different from those here in Ohio. It is also possible that there is a touch of exaggeration and hyperbole in those first ten paragraphs. Don’t get lost in the details. They aren’t relevant. This post is about the uninsured and the individual mandate.

We are, or at least should be, responsible for our choices. Ms. Ward is not alone. There are millions of uninsured Americans. The poor have Medicaid, a program that should have received a lot more attention in the last two years. It is the working poor that are falling through our system’s cracks. There is also a large segment of the population who simply choose to spend the money on other stuff. I refuse to speculate as to Ms. Ward and her family’s status.

Ms. Ward is correct. Her life choices, her insurance choices, her and her husband’s job choices could have had devastating consequences. Instead, someone else, you, will pay the bills. Any solution that includes guaranteed issue and the complete coverage of preexisting conditions must include a mandate that requires everyone to have insurance.

The individual mandate has been both championed and disparaged by everyone from Newt Gingrich to Barack Obama. One day they embrace it. The next day they flee from the concept. As an agent, as someone in the system for thirty-three years, I am convinced that requiring people to participate is the only way a guaranteed issue plan would work. This is not limited to private insurance programs. A government plan is just as dependent on universal participation. That is why Medicare Part B and Part D penalize late enrollees.

All of the candidates expressed their hatred of the individual mandate at last week’s Republican debate. I understand. They are running for president. But the time has come to stop telling us that you hate “Obamacare” and to instead offer a realistic alternative. Better yet, there are lots of serious people waiting to hear any viable option that doesn’t include an individual mandate.

Whether or not an alternative is ever proposed and passed, we wish a full and speedy recovery to Ms. Ward. And we wonder how in the world we can afford all of the other Spike Dolomite Wards we are going to be supporting.

We all know people who have invested in $2,500 clothing racks. OK, the store called the equipment an exercise bike or a treadmill. But sitting idly in the bedroom with clothing draped over it, the apparatus is obviously a clothing rack. What a waste of money! If only these people had the discipline to take full advantage of their investment.

Recent studies performed by researchers at Duke University have proven that the above problem may not be shared by physicians. If a doctor purchases equipment, such as expensive heart-testing or imaging equipment, they use it. In fact, it appears that these doctors may be using their equipment regardless of whether the patient needs the testing or not.

That’s what I call discipline.

USA Today reported this past week about a Duke University study of 500 MRI scans that had been performed on patients with lower back pain. The researchers were trying to determine whether doctors who own the equipment order more tests than those who don’t. You bet they did. Almost twice as many normal results (106 vs. 57) were found on scans ordered by doctors with an economic incentive than by those who didn’t.

The article notes that MRI scanning equipment carries a price tag of over $1,000,000 and that the patient or insurer is charged about $2,000 per test. Once you’ve got the equipment, you might as well use it, just to be safe.

Consumer Reports carried a similar story in early November. Duke University researchers reviewed the health insurance records of 18,000 health patients. The original study was published in the Journal of the American Medical Association.

“…the researchers found that patients of doctors who billed for both technical and professional fees – an indication that the doctors owned the medical equipment themselves – were more than twice as likely to undergo a nuclear stress test and more than seven times as likely to undergo stress echocardiography than patients of doctors who did not bill for those fees.”

A July 25th article in Washington Post notes that unnecessary tests don’t just waste money. There are also the risks of false positives that lead to further unneeded procedures including surgery.

Whether we are discussing lower back pain or heart problems, the patient is always his/her best advocate. But when you are in pain or when you have been diagnosed with a heart problem and coming to terms with your own mortality, are you going to ask the doctor if a test is really necessary? Or, are you going to do what you are told, especially if the test is being paid by your insurance?

This is part of cost containment. It doesn’t matter whether insurers or the government is paying the bill. An aging population is going to have more conditions, not less. And doctors, unchecked, are going to order more tests, not less.

There are doctors that will point to the risk of lawsuits as for their motivation to order so many tests. Yes, tort reform is also an important part of cost containment.

As of today, December 5, 2011, there has been precious little done to control costs. The authors of the Patient Protection and Affordable Care Act may not understand why the price of health care continues to rise. But then again, there are lots of suburbanites who don’t understand why they haven’t lost any weight. They bought the StairMaster. It is in their bedroom. Under the towels.

It is November in Northeast Ohio. Homeowners are faced with an annual decision – buy a new snow shovel, buy/tune up the snow plow, or hire a plowing service. I was lucky enough to have always had a snow service when I had my house in Shaker Heights. For $250 a guy in a pick-up truck would magically appear every time there was as little as 2” of snow on my drive. He would clear the drive and make it safe for me and my family. Sometimes he would even sweep the snow off the walkway. $250 for six months. If it snowed only three times – $250. If it snowed thirty times – $250. I wasn’t purchasing the number of times he visited. I was buying peace of mind and security. And if it never snowed in Shaker Heights? Let’s not be silly. One year’s easy winter would surely be followed by a snow belt classic.

If you believe, as I do, that the Patient Protection and Affordable Care Act (PPACA) is designed to change who pays for health care in our country, then you had been waiting anxiously for yesterday’s decision from the Obama administration. Florida has aggressively fought the President’s legislation from day one. The latest salvo was a special request for a waiver of the 80% Minimum Loss Ratio (MLR) regulation. This special waiver has required a mound of paperwork and nearly a year of preparation.

And the verdict from the Centers for Medicare and Medicaid Services (CMS) was (drum roll please) – – – Come back in 30 days.

First, what is an 80% Minimum Loss Ratio? In the simplest of terms it means that for ever dollar of premium an insurance company receives, it must spend 80 cents on health care claims. That leaves 20 cents for taxes, administration, reserves, marketing, advertising, and profits. If the consumer has a good year and has fewer claims, the law requires the insurer to issue a rebate of the excess premiums. If the consumer has a really bad year, oh well.

I think you can see where this is going. Most of my clients are small businesses with fewer than ten employees. Some have only one or two employees. Many of my groups have little to no claims per year, while several of them more than make up the difference.

If a small business consists of three families, each paying $1,000 per month, we have an annual premium of $36,000. What happens if one of the spouses has a quadruple by-pass at $180,000? Where does the insurer get that money if it is returning excess premiums each year to the healthy clients?

The goal is to have a loss ratio between 65% – 80%. This goal is for the entire book of business, not on a client by client basis. We are pooling the risk, sharing the possibility of major accidents and illnesses among a large group of people. The MLR regulation effectively ends that. And in the end, it effectively ends private major medical insurance.

Insurers are threatening to pull out of the states that don’t get the federal waiver. At the very least, they will be forced to significantly restructure their product offerings. It is not an idle threat. This is all part of the process that began in March of 2010.

The Supreme Court will soon hear arguments about the individual mandate, a concept championed by Newt Gingrich and Bob Dole in the early 1990’s and pilloried by the Republicans today. This is a side-show. The Minimum Loss Ratio rulings will have far more impact on who pays for your healthcare in 2015.

I could have purchased a “pay as I go” snow service when I was a homeowner. What I couldn’t afford back then and can’t afford now is “pay as I go” healthcare.

The National Journal, a non-partisan Washington based news magazine, published the story as if it was news. Poll: Majority of Voters Want Medicare Funding Left Untouched  The first paragraph noted that 83 percent of the respondents oppose cuts to Medicare and higher beneficiary copayments. 70 percent believe that the government should be more active in fighting waste, fraud, and abuse in both Medicare and Medicaid. It wasn’t until the second paragraph that we got the rest of the story.

The poll was commissioned by Fight Fraud First. One of the members of the collection of groups that created Fight Fraud First just happens to be AARP, the same organization that sponsors an endless series of television spots scaring and/or rallying senior citizens.

So we have three questions.

1. Is it at all surprising that 83% of the population (assuming that the poll wasn’t weighted with seniors!) want as much money and benefits as they can get with little or no charges?
2. Would you expect a poll conducted by an organization named Fight Fraud First to release the results of a poll that didn’t strongly endorse the concept of fighting fraud first?
3. Was this news?

Since the first two questions are obvious, allow me to answer the third. NO!

We want painless solutions to all of our problems and we are at least 83% convinced that someone else should pay for the debts we have all created. I’m not sure if this mindset can be traced to the concept of paying for two wars by shopping or if it is simply more prevalent in today’s society, but it is everywhere we look.

I was in New York City a few weeks ago and had a chance to visit the Occupy Wall Street. Yes, it did remind me of the anti-war protests of the late sixties and early seventies. But at the risk of ticking off most of my readers, I have to tell you that there is little difference between the Occupy Wall Street crowd, a Tea Party rally, and a group of Libyan soldiers firing their rifles straight up into the air with little regard to where the bullets will land. Within each group is a small core that understands and can discuss the issues. There is also a larger faction that has a propagandist’s view of the group’s concerns, but is totally committed for the moment. The rest, the vast majority, have nothing better to do and no place better to be.

The links in the above paragraph will provide you with plenty of laughs whether you are on the Right or the Left.

In a perfect world, in the ideal democracy, those masses gathering at Tea Party rallies and camping out at Occupy sites around the country would be engaged in intellectual policy debates. These citizens would be working hard to find solutions to our country’s economic woes.

That is not happening.

What we have, instead, are people desperately attempting to assert their relevance. It appears to be very easy to confuse one’s self-interest with what is allegedly in the U.S.’s best interest. And this leads us to the current health care debate.

The Patient Protection and Affordable Care Act (PPACA) attempts to change who pays for health care, but does nothing to control the cost of care. Changing the payer doesn’t solve our problem of spiraling health care costs.

The current financial debacle has forced some in Congress to start thinking about reigning in costs. This has resulted in the special interest groups to snap into action. 

• The American Hospital Association has a woman staring into the camera, and our souls, decrying any cuts that could endanger her father’s health.
• AARP’s commercial supposedly speaks for 50 million seniors who are united to oppose any cuts and will vote, as one, against anyone who dares oppose them.
• The A.M.A. (American Medical Association) is spending big bucks to remind you that doctors are on your side.

Luckily, as Ohio residents we have been spared the finger pointing and shouting of the Republican presidential primary ads. Better Iowa than us.

The next year is very important. Will the PPACA survive? My guess is still Yes. The rules and regulations are being written and imposed now. It will be very difficult to simply reverse all of this, even if anyone wanted to, in January 2013. What you need to watch, what you need to ask are what cost containment measures, if any, are being implemented?

There is a lot of noise out there. People are marching to retain the life they think they have. Or they might be marching to claim their share of the American largesse that has eluded them. Many of these same people will soon be whipped into action to save their local hospitals or to protest a cut in nurses’ wages. The one constant throughout all of this will be the absence of personal sacrifice.

Ask people to pay more? That might create an angry mob.

This blog has campaigned for transparency, honesty, and basic accounting principles. This isn’t a Democrat or a Republican issue. This isn’t Left or Right. Asking for our elected officials to perform at a higher level may, at times, appear child-like and naïve, but why would we work so hard, investing our time and money, if we didn’t believe that we were trying to help our country find our best leaders?

Flying to New York this past weekend gave me extra time to read. I need to share an opinion piece from The New York Times and a memo from Health and Human Services. This will take a few minutes. It will be time well spent.

Jane Gross, author of A Bittersweet Season: Caring for Our Aging Parents and Ourselves, discussed the last years of her mother’s life in The New York Times. The article, How Medicare Fails the Elderly, detailed the medical care Medicare paid and the hundreds of thousands of dollars of services that depleted the family’s savings. It was brutal. Ms. Gross lays bare the inefficiencies of a system that rewards unwarranted expensive procedures that may more successfully enhance the medical provider’s life than the patient’s. Please read the article. It is a difficult read and there wasn’t a happy ending.

The memo is also about an ending. Kathy Greenlee, CLASS Administrator, sent a memo to the Secretary of Health and Human Services, Kathleen Sebelius, recommending that the program be suspended. CLASS is the acronym for the Community Living Assistance Services and Support Act. Ms. Greenlee was forced to report that there was no logal way to make this program work.

This was not a shock.

The CLASS Act was an important part of the Patient Protection and Affordable Care Act (PPACA). It was important to consumers because it promised to help pay for long term care. It was even more important to the President because, through a bit of accounting sleight of hand, the CLASS Act generated a $70 billion dollar surplus during the first ten years. That money would cover $70 billion dollars of deficit from the PPACA. See, revenue neutral!

Ms. Greenlee was forced to admit that the numbers did not add up. A voluntary program that didn’t have any underwriting couldn’t be actuarially sound the way the law was written. With no public funding available and healthy people not forced to participate, the independent actuaries predicted disaster. Thankfully, the program will be pulled now before any more money is wasted.

The need for long term care planning and the cost of that care are the themes that tie these two readings together. My fixation on transparency is why I have brought them to your attention.

Prohibition was about human perfectibility, that humans can be perfected. You could have the perfect marriage if you could eliminate alcohol. from Ken Burns’ Prohibition

I watched Ken Burns’ Prohibition on PBS last night. A group of people decided what would be best for everyone else. Armed with moralistic fervor inspired in equal parts by their G-d and their fear of others (immigrants and non-whites), they campaigned to eliminate someone else’s vice. And they succeeded in part until they failed entirely.

There is a shocking parallel between the Prohibition movement of one hundred years ago and today’s health care debate.

Part of what drives the current discussion is this concept of perfectibility. If only the profit motive was removed from the delivery of health care, if access was unlimited, then no one would die before his/her time.

• Can you really remove profit from health care?
• How unlimited is unlimited?
• When is it our time?

The simple answers are – NO!, Who knows?, and Gosh, what a silly question.

Doctors need to be paid.  Medical equipment suppliers need profits to build their businesses.  Pharmaceutical companies risk millions to develop new compounds that may cure illnesses and alleviate pain and suffering. The insurers play a role in all of this, too.  Eliminate them, the market organizers, and their function will have to be performed by the government. You may debate whether that would be more efficient that the businesses, but to deny that money is a key element in the delivery of health care is to deny reality.

Heart transplants? Liver transplants?  Any age?  Any health status?  Should a 75 year old overweight diabetic with bad lungs from years of smoking stand in the front of the line waiting for a new heart?  There have always been, and always will be, some limits to access.  What we have not had, as a country, is an open, honest discussion about limits. We are not talking about death panels.  We are talking about realistic expectations.  What is society’s responsibility to the sick and injured?

The last part of this is the most difficult.  Who amongst us wants to address our own mortality?  No amount of health care would keep us alive forever.  We are not machines.  Yet there are people who claim that changing our health care delivery system will magically enhance our life expectancy.

Which returns us to this concept of human perfectibility. Can we improve the payment and delivery of health care in the United States? Absolutely! The first steps will be transparency and an honest discussion about achievable goals.

Now would be a good time to start.

It is important to remember that everything works in theory. Communism, in its purest form, is just as effective as Capitalism, in theory. Reality is a much different story. The Russians and Chinese are now embracing many of the benefits of Capitalism just as the U.S. faced-down the Robber Barons and put an end to such practices as child labor a hundred years ago.

Reality has a habit of rudely poking holes in theories. My favorite piece of Swiss cheese is the Patient Protection and Affordable Care Act (PPACA). Today we are going to revisit the Preexisting Condition Insurance Plan, the stop-gap measure to provide access to coverage to the long-time uninsured.

Eighteen months and millions of dollars later, it might be difficult to recall that the main justification for completely remaking our health care system was to provide coverage for the uninsured. Remember the uninsured? They were of real concern two years ago. The PPACA was supposed to cure this problem.

Last June, in a post entitled The Shell Game, I discussed the five billion dollars the federal government had allocated to the Preexisting Condition Insurance Plan. Of more local relevance, $152,000,000 was given to Ohio for the four year interim program. Even though Ohio had about 17,000 chronically uninsured, state officials were thrilled that $152,000,000 would help 5,000 people get insurance. I felt that they were a touch optimistic.

Theory, meet Reality.

How’s the program working? Initial projections from the Office of the Actuary of the Centers for Medicare and Medicaid had as many as 375,000 uninsured Americans rushing the states and jumping at the opportunity to acquire heavily discounted coverage. As of April that crush was only 21,454. Ohio, with almost 1800 enrollees, is one of the most successful programs. Don’t worry. We may not insure that many people, certainly no where near the governments rosy projections, but all of the money will be spent.

Sunday’s Cleveland Plain Dealer detailed the difficulties Ohio and Medical Mutual of Ohio, the state’s contractor, are having raising prices and limiting access. The biggest problem was that no one was prepared for the shocking reality that really sick people rack up big claims.

Now we’re paying actual claims and those claims have come in much higher – the loss ratio is much higher – then had been projected, said Carrie Haughawout, assistant director for health policy for the Ohio Department of Insurance.

The claims for 1800 people were more than what they thought 5,000 unhealthy people would incur? That is hard to imagine. The simple math in last year’s blog post showed that premiums for a 60 year old male would need to be around $800, with the subsidy, to have a chance of covering the cost of care. The Ohio High Risk Pool is charging between $416 and $458 for a 60 year old non-smoker! That isn’t even close.

The PPACA does not include any meaningful cost containment. There is also no underwriting and no exclusions for preexisting conditions in the PPACA’s planned future which begins in 2014. So, as theory invades reality, one day all of these incredibly unhealthy individuals will be moved into the common risk pool. How will this impact the premiums you or your employer pays for health insurance?

The theory is that the unhealthy will disappear in the sea of doctor avoiding, health obsessed, average Americans who will hardly notice the difference of adding a couple hundred thousand chronically ill individuals into the mix. And besides, now they will be paying premium instead of just invading the E/R and counting on the kindness of strangers to pay their bills. Yeah, right.

The High Risk Pools, the Preexisting Condition Insurance Plan, was a dry run for the future of the PPACA. No real planning. Not nearly enough honest, transparent public discussion. An idea that meant well, but was underfunded and was neither properly explained nor promoted. The Preexisting Condition Insurance Plans were projected to do so much at what may have almost seemed like a reasonable amount of money. Instead, we have another program that has fallen tragically short.

Reality, meet Theory.

I’m sitting outside of Club Isabella waiting for a friend. There are six medical students at a near by table enjoying food, friendship, and a moment away from their daily stress. What do they talk about? They joke and laugh about doctors and classes, routines and procedures, and their daily grind. They are an interesting group. Two are women. Four appear to be of Asian descent. One, a tall thin white guy with his baseball cap on backwards, appears to have been delivered to us from Central Casting. They wave and shout to their friends walking by. They are incredibly normal.

I find this terribly reassuring. At 56, I am looking at the people who will be caring for me 20 years from now. They are bright, engaged, and sound like they are actually enjoying their work. This is important. If all of this work, time, and effort is just to get a title, a job, and a paycheck, they will never be fulfilled. And they probably won’t be very good at the practice of medicine. One can only hope that their discussions of cadavers (over dinner!) is a precursor of great careers.

This concerns me, the general happiness of physicians, because so much is changing in the practice of medicine. Many previously independent doctors are now, in 2011, employees of the major hospitals. Some have adjusted to this change. Some doctors embraced this. Many, however, have not. Being an employee, even a highly compensated one, is not the same as being your own boss. There is a certain freedom in being an independent business owner. And other doctors, like radiologists, have seen specialty treated like a commodity.

I’m not ready to have my health dependent upon the lowest bidder.

Our young doc-to-be’s at the next table have not experienced any of this. There is no transition for them. Medicine will be a corporate enterprise for them, complete with signing bonuses and holiday pay.

How will this impact the way they practice medicine? For one, they will have been initiated, from day one, into a system that allocates a specific number of minutes per patient. They will be instructed in profitability. They will always know the origins of their income. And once you are in this system, how hard is it to change employers? If, or when, the government becomes the major or single payer of health care, would these doctors even notice?

Hard to say.

We face a looming shortage of primary care physicians and gerontologists. I didn’t ask any of the future docs what they wanted to practice. I only wonder if their future employers will bother to ask.