Frank O. had been an agent for over twenty years the day I started with Prudential in October of 1979. My desk was next to his. Fifteen months later I was his manager and my desk was in a private office. I asked to spend a day in the field with Frank, not because he needed me, not even because he wanted me. At best, Frank tolerated me. No, I needed to learn what he was doing and how he had survived for so long as an agent.

The first stop was a longtime client of Frank’s. Climbing up the front steps, I noticed that my employee was walking to the side door. The side door? Frank reminded me that we were not related to the client. We weren’t family. We weren’t their friends. We were service providers and service providers enter via the side door.

It was at that moment that I realized how little I knew about the insurance business.

I was reminded of that humbling experience as I watched President Obama and Health and Human Services Secretary Kathleen Sebelius stumble, again, as they attempted to control the delivery and payment of health care. The biggest difference was that I, at age 26, realized how much I had to learn. Our President and his staff seem surprised that their frequent missteps are so apparent and so unacceptable.

My last post, The Ongoing Religious Battle, addressed the Obama administration’s decision to classify Birth Control Pills, IUD’s, the Morning After Pill, and some forms of Sterilization as preventive Care. The Patient Protection and Affordable Care Act (PPACA) includes a provision that preventive care is FREE. That is the government’s definition of affordable, FREE.

The predicted firestorm erupted. The Vice-President and other committed Catholics in the administration had warned of problems. The White House Chief of Staff resigned. Last Friday the President announced his solution. As long as you don’t care about the moral implications, the money, how insurance works, or intellectual honesty – it was the perfect compromise.

Everything is still free. The insurance company will pay for it.

(Before we go any further, let me assert that I am totally in favor of most forms of birth control and voluntary sterilization. Let me also remind you that this has nothing to do with me, personally. This is about us, all of us.)

It only took a few hours for the double talk of the compromise to become apparent. Senator Roy Blount (R-MO) quickly released a statement via email. It stated, in part:

It’s clear that President Obama does not understand that it isn’t about the cost – it’s about who controls the religious views of faith-based institutions. President Obama believes that he should have that control. Our Constitution states otherwise.
Just because you can come up with an accounting gimmick and pretend like religious institutions do not have to pay for the mandate, does not mean that you’ve satisfied the fundamental constitutional freedoms all Americans are guaranteed.

A little dramatic? Perhaps. I suspect that the Supreme Court will be the final arbiter as to whether this crosses the line. But, Senator Blount was absolutely right when he called out the President for his sleight of hand.

The insurance companies are just going to pay for Birth Control Pills, IUD’s, the Morning After Pill, and certain forms of sterilization? Really? How do they show that on their books? These are claims that are eventually paid by the employer. And of course, large employers, such as hospitals and universities, are often self-insured. The insurance company simply processes the claims and organizes the market.

President Obama decided that insulting observant Catholics and other people of faith wasn’t enough. He decided to insult our intelligence, too. The President declared that insurance companies should pay for Birth Control Pills, IUD’s, the Morning After Pill, and even sterilizations from company coffers because it will save them money. By eating these costs, the insurers won’t be paying for unwanted, unplanned pregnancies. Ignoring the fact that it isn’t the insurer’s money or responsibility, perhaps we should take this to its illogical extreme. If we want to save money and eliminate unwanted and unplanned pregnancies, why don’t we have the insurers hand out chastity belts? Of course that’s silly, but it is no less honest nor illogical as the President’s suggestion.

It is time to remind you that none of this is about contraception, women’s rights, or even preventive care. It is about creating an environment where private insurance becomes unaffordable and only a government solution will work. Whether that is by accident or on purpose is for you to decide. But if you have someone restructuring the delivery and payment of health care in this country who doesn’t understand the basics of the market and insurance, you might as well have your attorney remove your appendix.

Can you force your employees to live YOUR creed? More importantly, can you make it unpleasant and expensive for your employees to break your personal religion’s rules? The answer, as it is so often, is Yes and No.

Preventive Care is a key benefit of the Patient Protection and Affordable Care Act (PPACA). Katherine Sebelius, Secretary of Health and Human Services, recently decided that Birth Control Pills, IUD’s, and the Morning After Pill are all FDA approved forms of contraception and as valid a part of preventive care for women as mammograms and Pap tests.

The PPACA therefore forces employers to not only cover Birth Control Pills, IUD’s, and the Morning After Pill, but it also eliminates the copays for these items. They are free to the insured employee. This shifts the cost for these items to the insurance which in turn shifts the cost to the employer.

So, if you own a factory and you are opposed to these forms of birth control, you will soon be paying for your employees’ pills. Fair? Most of us will say Yes. We don’t want our employers to dictate moral positions to us.

But what if we aren’t talking about a factory? What if we are discussing a church or a church funded organization? Is there a difference? According to the Obama administration, the answer is No. Every employee has a right to preventive care and preventive care includes birth control. The Supreme Court may disagree.

We are constantly trying to define property rights in this country. Ron Paul takes the Libertarian position that the government doesn’t have the right to force you to conform to other people’s wishes. If you don’t want to serve African-Americans in your restaurant, the market should push you to reconsider, not the law. That is one extreme. The other extreme has the government involved in many of the day to day decisions of businesses. This involvement manifests itself in smoking bans in bars, the elimination of trans fats in restaurants, and forcing businesses to not only provide health insurance, but to determine the very nature of the coverage. This is where we are again.

Where is the line? Can the Catholic Church, which is adamantly opposed to most contraceptives, limit access to its priests, nuns, and church employees? Can the Church limit access to the employees, Catholic and non-Catholic, of its schools? What about Catholic hospitals that may employ hundreds of non-Catholics? How much influence is the employer granted?

The Supreme Court, in a 9 – 0 decision, recently ruled that the First Amendment “gives special solicitude to the rights of religious organizations” in how they treat their employees. This decision was reached in response to a lawsuit brought by a teacher who had been terminated by her employer, a Lutheran school. Chief Justice Roberts challenged “government interference with an internal church decision that affects faith and the mission of the church itself”.

Will the Patient Protection and Affordable Care Act allow you to provide access to birth control for all of your full-time employees? Yes. Will you as an employer pay for it? Yes. Will you be forced to provide access if you don’t want to? If you are a business the answer is still Yes. If you are a church or a religious based institution, the jury is still out.

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.