The Fifth Risk

Posted on April 5, 2019 by dave@cunixinsurance.com

One way to describe The Fifth Risk is “as the danger a society runs when it falls into the habit of responding to long-term risks with short term solutions.”*

I am sitting on a beach in Riviera Maya, a lovely area a half an hour or so south of Cancun, Mexico.  On CNN President Trump is threatening to close the southern border.   Here his name is seldom mentioned, even by his supporters.  My beach book is The Fifth Risk by Michael Lewis.  I read his last book, The Undoing Project, on the beach shortly after it was published.  The Undoing Project was about thinking and how decisions are made.  The Fifth Risk is, in large part, about the failure and consequences of not thinking.  The book is two hundred well-researched pages detailing the failures of the Trump administration’s transition team.

Mr. Lewis focused on two key areas of the government, the Department of Energy and the Department of Commerce.  Though it is clear that he could have chosen any of the cabinet level departments, he chose two of the more apolitical areas of our government.  And arguably two of the most important.

The Department of Energy gained notoriety in 2011 when presidential candidate Rick Perry, the Governor of Texas, tried and failed to remember its name.  He was attempting to list three cabinet level departments that could be eliminated.  Of course, he didn’t know that the D.O.E. is actually in charge of our nuclear arsenal, the security of all nuclear sites (past and present), and that the Chief Science Officer of the D.O.E is the de facto Chief Science Officer of our country.  Rick Perry is now the head of the Department of Energy!  He has yet to learn the full scope of the department he leads.  By the way, the D.O.E. has an annual budget of $30,000,000,000.

Here is where the Trump administration’s willful ignorance plays a role.  If your ambition is to maximize short-term gain without regard to the long-term cost.  If you want to preserve your personal immunity to the hard problems, it’s better never to really understand those problems.  There is an upside to ignorance, and a downside to knowledge.  Knowledge makes life messier.  It makes it a bit more difficult for the person who wishes to shrink the world to a worldview.*

White House Chief of Staff / Budget Director Mick Mulvaney made the rounds on last Sunday’s talk shows.  He brushed aside his attempt to defund the Special Olympics as simply an internal discussion.  He was on TV to defend the President Trump’s decision to join the lawsuit AGAINST the Patient Protection and Affordable Care Act (Obamacare).  He unequivocally declared that people with pre-existing conditions would not lose their health insurance.  He was mute about the other benefits of the law such as the expansion of Medicaid and the elimination of policy caps that were once as low as $50,000 on some policies.  Most importantly, Mick Mulvaney, Donald Trump, and the entire Republican Party have yet to provide a path forward.  If you eliminate the law, all of the protections and all of the funding ends right there.  The guy who doesn’t give a damn about disabled children is unlikely to worry about your access to insulin.  The short-term goal is to feed the base and eliminate the “Obama” of Obamacare.  The long-term problem is beyond their focus.

The woman at the next table is vociferously complaining about paying $500 per month to be on her employer’s group health policy.  She offers to trade plans with a Canadian couple.  They laugh and politely decline.

The Texas lawsuit is winding its way through the courts.  Will Chief Justice Roberts save the day, as he did in 2015, again?  More importantly, does anyone still believe that there will be a Republican plan, at the state of federal level, if the PPACA is declared unconstitutional?

A horrific tornado plowed through the city of Elk Grove the morning of May 16, 2017.  A man from the Federal Emergency Management Agency (FEMA) toured the area with Lonnie Risenhoover, the local emergency manager.

While driving the man around Elk City, Lonnie spotted Miss Finley.  Her house was a ruin and her barn was gone: surely she was eligible for relief.  Lonnie stopped so the FEMA guy might speak with her.  “You know,” said Miss Finley, “for the last ten years I prayed for a tornado to come and take that barn.  I didn’t think it would take the house, too.”  She seemed to think her reasoning self-evident.  The FEMA guy said that he didn’t understand: Why had she been praying for a tornado to take her barn? “Every time I pull out of the driveway I’m looking at that red barn,” she said. “And every time I pull into the driveway I’m looking at the red barn.”  At which point Lonnie asked the FEMA guy if he was ready to leave.  He wasn’t.  He was still puzzled: Why did it bother the woman to look at her red barn? “That barn,” said Miss Finley, “is where my husband committed suicide ten years ago.”

And so you might have good reason to pray for a tornado, whether it comes in the shape of swirling winds, or a politician.  You imagine the thing doing the damage that you would like to see done, and no more.  It’s what you fail to imagine that kills you.*

 

DAVE

www.cunixinsurance.com

Picture – The Fun Side Of The Border – David L Cunix

* Quotes are from The Fifth Risk by Michael Lewis.

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One Step Forward

Posted on March 19, 2019 by dave@cunixinsurance.com

 

My last blog post, Just Another Boring Week In Washington DC, reviewed my annual trip to Washington to discuss health insurance issues with our elected representatives and their staffs.  Health insurance agents have both a real understanding of how our private/public health care payment system works as well as the ability to express the positives and negatives in understandable language.  We are also in the position to champion our clients’ needs and concerns, issues that all too often are set aside or ignored.  One of those issues, one that has festered for several years, is how hospitals can classify a Medicare patient’s hospital stay as “for observation” which may impact subsequent coverage in a skilled nursing facility.  Under title XVIII if the Social Security Act:

The term “post-hospital extended care services” means extended care services furnished an individual after transfer from a hospital in which he was an inpatient for not less than 3 consecutive days before his discharge from the hospital in connection with such transfer.

 

Our group, the National Association of Health Underwriters, has been working to eliminate this problem.  I am pleased to announce that bi-partisan legislation has been introduced in both the House and the Senate.  H.R. 1682 is sponsored by Joe Courtney (R-CT).  The bill currently has 13 co-sponsors including Glenn Thompson (R-PA).  Senator Sherrod Brown (D-OH) introduced S-753 on March 12, 2019.  His 19 co-sponsors are a cross-section of the United States Senate and include Susan Collins (R-ME), Amy Klobuchar (D-MN), and James Lankford (R-OK).  Click here for a more detailed explanation of the legislation from Senator Brown’s website.


We have always presented this as a non-partisan issue, an issue of fairness.  It is gratifying to see Members of Congress from across the political spectrum step up to co-sponsor this legislation.   In the end, it is just one step forward.

DAVE


www.cunixinsurance.com


Picture – Observation Ain’t Enough – David L Cunix

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Just Another Boring Week In Washington DC

Posted on March 7, 2019 by dave@cunixinsurance.com

It was just another boring week in Washington DC.  Nothing going on.  True, the president’s former attorney and fixer, Michael Cohen, was staying at the same hotel as we were.  We happened upon the hearings while we were walking through the halls of Congress.   The president was in Vietnam to meet with the leader of North Korea.  Congress was debating a bill of disapproval over Trump’s emergency order.  And we were there, about 800 of us, to talk to our representatives about health insurance, the way most Americans access and pay for health care.  We may have been the least controversial people in the entire city.

I don’t wish to minimize our efforts or effectiveness, but we seemed to have been the Fords next to the Lamborghini display at the auto show. Some members of Congress and their staffs took extra time with us, savoring the half hour or so of normalcy.  Other offices were just so overwhelmed that we found ourselves meeting in stairwells and hallways.  No matter what, our elected representatives and their staffs were professional, prepared, and serious.  They are aware that they have been entrusted with a great deal of responsibility.  My annual trips to Washington restore my faith in our system of government.

These trips tend to be broken into two parts. The first involves speakers, usually thought leaders, members of Congress and the administration, promoting their vision for improving the health care system.  The rest of the week is spent on Capitol Hill meeting with our elected officials.  Somewhere in between all of this I try to squeeze in conversations with agents and company reps from around the country and a cigar at Shelley’s Back Room, a cigar lounge frequented by foreign diplomats, lobbyists, and politicians.

One has to admit that the current administration has tested my faith. We were pleased to have Alex M. Azar II, the Secretary of Health and Human Services (HHS), speak to our group on Wednesday.  This is a big deal.  We had already heard from John O’Brien who specializes in drug pricing for the administration and Brian Blase, a special assistant to the president for economic policy.  The Secretary, as the others before him, felt compelled to highlight the economy and the jobs’ numbers.  And of course, we were told that President Trump cared deeply about protecting coverage for preexisting conditions.  We were all too polite to note that this administration chose not to defend this provision in the Texas lawsuit.  We were also told that President Trump was concerned about Surprise Billing, a real issue for many of our clients.  The message was familiar.  It was the way it was delivered, the constant name-checking of their boss, that made it so odd.  At one point I closed my eyes and substituted “Dear Leader” in each sentence for Trump.  It worked surprisingly well.

It has been eight years since the passage of the Patient Protection and Affordable Care Act (Obamacare).  Some Democrats want to scrap the legislation and move to some form of single payer coverage.  More, possibly most, Dems would like to change and improve the law.  And the Republicans?  It depends.  After eight years of empty promises and weak options (Do you remember the American Health Care Act?) bomb throwers like Jim Jordon (R-OH) now have comments like this on their government websites: “First and foremost, we need to get health care reform done right, not done fast. Passing another thousand-page bill without amendments or debate will do nothing to help the economy, create jobs, or reform health care.” That may be translated to “Other topics are more fun.  I’ve moved on”.  But Senator Lamar Alexander and other Republicans are working, mostly around the edges, to improve the PPACA.  Our time was best spent with those representatives concerned about stabilizing the markets and making the system work.

I met with Tina Chhabra, a former pharmacist, in Senator Sherrod Brown’s (D-OH) office. I also talked with Catherine Wilson who works for Congressman David Joyce (R-OH) and Joe Herrbach from Congresswoman Marcia Fudge’s (D-OH) staff.  Congressman Joyce was in a hearing.  This is the first time he was unable to meet with us.

Much like last year and the year before last, our focus was on stabilizing the market. In a world dominated by sound bites and tweets, someone has to remind our elected officials of the real world implications of their legislation.  Here are a few of the areas we discussed with our members of Congress:

  • COBRA as Medicare Credible Coverage – This is one of those down in the weeds issues that had no champions, only victims.  COBRA doesn’t count as credible coverage.  Senior who retain their COBRA coverage instead of enrolling in Medicare when they become eligible, are considered to be “late enrollees”, subject to a waiting period, and will pay a penalty for the rest of their lives!  It is normally just a mistake.  Retirees over 65 may not have access to good, free information.  We can correct this.  H.R. 5104 died in committee last year. We hope to see it reintroduced soon.  This is the link to the previous bill – Medicare Enrollment Protection Act.
  • Transitional Relief – It seems to fall upon us to remind our friends in Washington about the importance of Transitional Relief / Grandmothered health policies.  These policies were written and issued in 2010 after the PPACA was passed until the end of 2013 when the law was fully implemented.  Many of us are dependent on our ability to retain these policies and wait nervously for the annual announcement.  There aren’t any policies sold in Ohio that can match the network access of the Anthem, Medical Mutual, and Golden Rule Grandmothered contracts.  Every Congressman and legislative aide quickly grasped the importance of granting transitional relief for these policies.  Some even thought that this should be simply granted permanent status.  As with so many other issues, this would disappear without our constant vigilance.
  • Retain the employer tax exclusion – More than 178 million Americans get their health insurance at work.  There were some proposals being floated to either cap the maximum amount of premium the employer could deduct or eliminate the deduction completely.  Talk about destabilizing the market!  There seemed to be little interest in overturning our markets in the offices I visited.

We had more time in some offices than others. Some of our representatives are more interested in how consumers could use the Tax Credit Subsidy outside of the Marketplace if there were fewer than two choices available in a particular county.  Others are more focused on delaying or repealing the so-called Cadillac Tax.  I would be happy to have a more in depth discussion of the issues over coffee (or cigars!) at your leisure.  It isn’t nearly as boring as it might seem.

DAVE

www.cunixinsurance.com

Picture – A Quiet Spot – David L Cunix

 

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Health Care Down Under

Posted on February 18, 2019 by dave@cunixinsurance.com

“Here’s an example of the mindset we have here that is second to none: It’s called the TAC – the Transport Accident Commission. Put simply, each of us pays a very small tax each pay check on a sliding scale that the TAC puts into a pool. If you get into a car/motorbike accident and if it is not your fault, the TAC pays every single cent of your costs. I know, I experienced it. I was in a motorbike accident 10 years ago. At the time I was unaware of the TAC’s benefits and honestly, as I lay on the ground in pain with cops around me yelling at cars to slow down, I actually worried that I would be bankrupted by the accident even though it wasn’t my fault and even though I had private insurance but not much of a policy at the time. Lo and behold, I filed my claim and the TAC could not have been more efficient and compassionate. Paid everything right down to my aspirin.” 

Insurance is a promise, an intangible, a hated monthly expense until the moment it is needed. And if/when the insurance fulfills its promise, there is nothing else that matches its level of value.  The above quote is from my friend Wendy who I have known since high school.  Wendy grew up in Ohio, but has lived in Australia for decades.  I recently asked her about their health insurance system.  She provided some personal info, some links, and the TAC story.

Your personal experiences will determine your impression of our system, just as Wendy’s impacts hers. Our ongoing debate about health insurance in the USA, our way to access and pay for health care, is a 50/50 mix of fact and emotion.  We are often told that America is the only western country without universal health coverage.  The speakers too often present universal care as being the same throughout the world.  It is not.  Each country has tinkered with the concept, utilized or prohibited private coverage, and struggled with the challenges of expensive medications and therapies.  The Australian Medicare system appears to be closer to our hodgepodge of coverages than it is to Canada’s.  That doesn’t make it better or worse, just different.  And if you are sick or injured and the insurance fulfills its promise, it is perfect.

The Australian Medicare system is funded by a 2% levy (tax) on taxable income. This provides access to the public system.  The public system covers the cost of visits to a general practitioner during normal business hours most of the cost of a semi-private room at a public hospital.  Your choice of physician, operating rooms and out-patient prescriptions are not included in the Medicare system. The patient is often expected to pay the cost of care and is then reimbursed by Medicare.  Australians also have access to a variety of private health insurance programs.

Just to be clear, bureaucratic writing is universally dense.  The following is from the official Australian Medicare site:

  Need for private coverage:

  • If you have an appropriate level of private patient hospital cover, you won’t have to pay the MLS, and depending on your income, you may be eligible for the private health insurance rebate. This rebate is an amount the government contributes towards the cost of your private hospital insurance premiums.

 

You may be entitled to an exemption from MLS for part or full year. This will be determined from the information that you provide in your tax return.

Depending on your circumstances, the Medicare levy, the MLS or variations to your private health insurance rebate may impact the refund you receive or the tax you owe.

If the MLS has resulted in you owing tax, you can take steps to avoid a liability in the future by:

  • reviewing your rebate

 

varying your PAYG withholding

For those who are interested, I am happy to include relevant links to the official site for further research.

 

The Australian public system offers access.  Their private system offers choice.  It is a two tier system that would be easier to implement in the United States than many of the other ideas currently being tossed about in Congress and on TV.  As with any system, Australia’s Medicare has its champions and detractors.  President Trump has been quoted as being a fan.  A more detailed and thoughtful analysis can be found in this 2016 Guardian article from Doctor Ranjana Srivastava, a doctor who works in the public system.

Back to Wendy:

“We also carry private insurance to cover things not provided by Medicare but also because we don’t always want to depend on the public system. For instance, my GP just referred me to a surgeon in the public hospital system. Since it is not urgent I will likely wait 2-3 months for an appointment but it will be fully covered. I could chose to go private based on my policy and get faster service and I have done that in the past. It just depends on what I need.

If you don’t have private health insurance you get a tax penalty anyway. I think I pay about $1400 annually for health insurance. I think that’s fantastic.”

Different countries, different systems. It is important to remember that there are almost as many ways to access and pay for health care as there are countries.  As we begin a new, and hopefully serious, discussion on how to improve ours, let’s take the time to learn about other systems so that we can avoid their problems and build upon their successes.

DAVE

www.cunixinsurance.com

Picture – Australia – David L Cunix

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The Tenth Blogiversary of Health Insurance Issues With Dave

Posted on February 2, 2019 by dave@cunixinsurance.com

Point of Personal Privilege – This post, the 266th, marks the tenth anniversary of Health Insurance Issues With Dave.  I could not have achieved this milestone without you, the readers.  My one year anniversary post thanked Brad Kleinman and David Toth, the two guys who taught a class on eMarketing and social networking at a Chamber of Commerce meeting in January 2009.  This blog has had a lot of other helpers along the way.  I would be remiss if I didn’t take this opportunity to thank a few of my best proofreaders/supporters, the people who push me to improve this blog – Susie Sharp, Ellen Jacob, and Annie Cohen.  There are the long-suffering team of Jeff Bogart and Lianesha Mays who are often exposed to working drafts of these posts.  It takes a lot to start any major project.  I can still remember my daughter, Jennifer Kuznicki, pushing me back to writing in the fall of 2008.  And I need to thank my number 1 cheerleader, the first to read all of these posts, and the only person who actually laughs at all of my jokes – Sally Mandel.  Health Insurance Issues With Dave appears on the original BlogSpot page, my website, on LinkedIn, and the AOL Patch system.  It has readers throughout the country.  My proudest moments are when I hear about attorneys, CPA’s, and other insurance agents providing this blog to their clients as a way to illuminate the issues.  I hope to continue to earn your time and attention.  Reminder – the links in this blog are normally footnotes, a chance to connect you to more information.  The rest of the links are just me having fun!

Though it might appear that much has changed over the last ten years, the key questions remain unanswered – What are our priorities and are we willing to pay for them?  What we know is that Americans really don’t care who pays for our health care whether it is the government, the insurance companies, or our next door neighbor as long as it isn’t us.  We want access to any doctor, any hospital, and we don’t want anyone asking WHY or IF the procedure is necessary or warranted.  “Deductibles? Copays?  Isn’t it enough that I have to pay the premium?”  The first post discussed a terminally ill man, covered by Medicare, who was on the list to get a new kidney.   Did that make sense?   Are we, as a society, willing to even have this discussion?

There is going to be a lot of talk during the upcoming presidential campaigns about different ways to fund health care. Do we retain our current system, with or without tweaks, or do we choose to move to some form of universal / single payer health care?  Lots of numbers, big numbers, will be tossed around like monopoly money.  $32 trillion here.  $50 trillion there.  Please remember that our current system of health insurance is simply a process to compensate medical providers, an organized process to pay for and access care.  Before your eyes glaze over, stop and ask a couple of questions:

  • What, specifically, will be covered?
  • What is the funding mechanism?
  • How will costs be controlled?
  • How will the system increase revenues when the initial cost estimates prove to be too optimistic?
  • What place will employers, currently major participants in our system, play in any future system?
  • Will participation of either the consumer or the provider be mandatory?
  • Do the insurers have a place in this?

My last post included a lot of information about Medicare.  It may seem odd, in 2019, to point out that words have meanings, but the blog was to serve as a reminder that the word, Medicare, actually means something.  Thus saying that you want everyone to have Medicare doesn’t mean that you want everyone to have free insurance that covers 100% of all health care.  That’s not Medicare.  We can’t have a useful conversation unless we speak clearly and honestly about the issues involved.

These four thoughts appear above the title of each blog post:

  • PURPOSE Short Articles designed to illuminate different aspects of the health care discussion.
  • CORE PREMISE If you think you know all the answers, you probably don’t understand all of the questions.
  • CENTRAL BELIEF Absolute Power Corrupts Absolutely
  • AUDIENCE Our current health care system impacts all Americans.

Thank you for ten great years.

DAVE

www.cunixinsurance.com

Picture – Have A Cigar – David L Cunix

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We Need Water

Posted on February 2, 2019 by dave@cunixinsurance.com

Ten days in the desert. Dry. Dirty. Thirsty. Very, very thirsty. And there, on a make-shift table, is a pitcher containing a liquid. Some people would simply drink the liquid, no questions asked. Some people might first try to make sure that the liquid was OK, perhaps not great but better than nothing. And some of us would hold out for a clear assurance that the contents of the pitcher was perfectly safe. There is a liquid in the pitcher. What we need is water.

UnitedHealth Care lost again. The recent decision from the California Supreme Court reaffirms the finding from the California Insurance Commissioner that UHC had failed its customers and should pay fines totaling $91.000.000. When Americans complain about our current health care system in general, and the insurance companies in particular, it is instances like this that trigger these feelings. There are times when our system must feel like a desert and any liquid would do.

The 2020 election season has opened with health care as a main focus. Several candidates have been quoted as supporting Bernie Sanders’ Medicare for All plan. Though it is early and Senator Kamala Harris might eventually offer a refined, personal version that differs from Senator Cory Booker’s plan, the basics may be the same. Our Senator, Sherrod Brown, co-sponsored the Medicare at 55 Act in 2017 and is still a big proponent of the concept. Since there may be as many as 30 Democrats running, we are likely to see a number of variations on this theme.

The one thing Democrats, whether there are 20, 25, or even 30 candidates, won’t do – run on the status quo. The Democrats have defended the Patient Protection and Affordable Care Act (Obamacare), basically a Republican plan, for ten years. Their base was always focused on something more grandiose, universal coverage. Even my parody of their planning, a post I wrote in October 2009, reflected the results of a Medicare for All type program not Obamacare. The Dems will expand the conversation in 2020. Some of the programs may not be realistic or achievable, but they will have goals beyond a mere fix for Obamacare.

First, Medicare is not a generic term. The word actually means something. There are four distinct Medicare Parts:

  • Part A – Principally inpatient hospital charges and skilled nursing facilities
  • Part B – Doctors and surgeons, in or out of the hospital, testing, durable medical equipment
  • Part C – Medicare Advantage policies
  • Part D – Outpatient prescription

Click here for a more complete description of Medicare coverages. Medicare is not free and it is not 100% coverage.

  • Part A – There is no charge if you have paid Medicare taxes over a 40 quarter period. The standard Part A premium is $437 per month if you paid less than 30 quarters and $240 if you paid Medicare taxes for 30-39 quarters.
  • Part B – The premium for most Americans is $135.50 per month.

 

The 2019 Medicare Part A deductible is $1,364. Part B is $185. Medicare is designed to pay approximately 75% of someone’s medical bills. Medicare beneficiaries have the opportunity to purchase Medicare Supplement policies, Medicare Part D (Rx) coverage, or Medicare Advantage policies to improve the affordability of health care.

Some plans build on the current Medicare foundation. Some just like the sound of the word “Medicare”.

Senate Bill 1742, Senator Brown’s Medicare at 55 Act, was incredibly straightforward. There is no attempt to change the basic structure of Medicare. There are even provisions for the purchase of Medigap (the federal term for Medicare Supplement policies), Part D and Medicare Advantage policies. We don’t know how much someone would need to pay to access Medicare Part A and Part B, the premiums for a Medicare Supplement and a Part D (Rx), and if after all of that it would be any better than a regular individual policy. It would depend, in part, on where you lived and the cost of care in your area.

Jacob Hacker is the Director of the Institution for Social and Policy Studies at Yale University. His program is Medicare for America. Professor Hacker builds on the Medicare model to create a plan that is both ambitious and aware of the costs associated with its implementation. The plan assumes both premiums as well as out-of-pocket expenses for care. This plan may be harder to sell but easier to enact. I think that we will see some versions of Medicare for America on the campaign trail this summer.

Senator Bernie Sanders has stated, “Health care must be recognized as a right, not a privilege for every man, woman and child in our country regardless of their income. The only long-term solution to America’s health care crisis is a single-payer national health care program”. According to his Medicare for All website, “As a patient, all you need to do is go to the doctor and show your insurance card. Bernie’s plan means no more copays, no more deductibles and no more fighting with insurance companies when they fail to pay for charges.” That is not Medicare. No deductible. No copays. No networks. No cost for utilization. And, no chance for success.

Senator Sanders and his team estimate that his plan will only cost @11 percent of GDP. Most other estimates are significantly higher. The Senator envisions an increase of the federal tax rate to as high as 52% on some Americans as well as changing the way capital gains and dividends are taxed as a way to defray the cost of his plan. While some focus on the funding mechanism, others are looking at the impact on hospitals and other medical providers. The Sanders plan may pay as much as 40% less than private insurers. Proponents point to the reduced paperwork and processing charges as if new forms and procedures won’t replace the ones we already know.

Bernie Sanders may have been a mirage in 2016, but Senators Harris, Booker, Brown, and a cast of others are running to be the real thing, the president of the United States. It is time for them to give us some water.

DAVE

www.cunixinsurance.com

Picture – Perfectly Safe – David L Cunix

Bonus – Water

 

 

 

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Baby Steps

Posted on January 11, 2019 by dave@cunixinsurance.com

Health Care Reality – You don’t have any privacy and there really isn’t any such thing as transparency.

Your mail boxes are littered with privacy notices from your doctor, your insurance agent, and every enterprise that you have ever done business with, such as the banks and credit card companies. And you are eventually alerted, about six months after the fact, when they get hacked.  Heck, they even throw in some free credit monitoring.  The federal government is worried about the manila folders in my file room while Home Depot gives up information from 53 million Americans.  And that is still less than the hacked Anthem database that included 78.8 million people.

Transparency would appear to be an easier problem to solve. After all, how hard is it to answer a simple question like, “How much does this test cost?”  In truth, damn near impossible!

A recent article in the Kaiser Health News detailed, the new Trump administration mandated hospital pricing lists are hardly useful.  The article discusses the difficulty someone would encounter in trying to determine how much an anticipated hospital stay would cost.  There is no point in trying to price out an emergency.  But, there are plenty of planned visits to the hospital.  Wouldn’t it be nice to choose the most cost effective place to receive care?

So let’s start with the most important fact – None of these posted prices are real. These are the chargemaster rates, the rack rate, the price that the self-insured and uninsured would be charged.  You are normally billed the negotiated fee, the price your insurer and the provided have negotiated.  This contractual amount will often be a percent of the chargemaster rate and vary by insurer and/or institution.  So, the number on the chart isn’t the number you will be charged.  Worse, the pricing is per service, supply, and facility.  An operation may include a charge for a number of rooms – operating, recovery, semi-private or private hospital room, plus, in certain hospitals, a facility fee just to walk into the building a breath the air. Doctors, sutures, and saline are all extra.

In honor of the administration attempting to do something positive, even if it is at best baby steps, I thought that we could look at one procedure, from one group of hospitals, just to get some idea of how this all works. I went to the Cleveland Clinic website and spent ten minutes trying to find anything.   I will save you some time.  The key word is “price”.  Not “prices”.  That will take you somewhere else.  Below is the listed price, per facility, for a labor and delivery charge for one baby.  There are different charges for twins, etc…  “The following list does not include charges for anesthesia, drugs, or supplies required for a particular delivery room procedure. Fees for physician services or anesthesia administration are also not reflected, and will be billed separately by your physician.” 

Remember, these are all hospitals within the same system:

  • Akron General – $4,585
  • Avon Hospital – N/A*
  • Cleveland Clinic – N/A*
  • Euclid Hospital – N/A*
  • Fairview Hospital – $2,828
  • Hillcrest Hospital – $2,370
  • Lodi Hospital – No mention
  • Lutheran Hospital – N/A*
  • Marymount Hospital – N/A
  • Medina Hospital – No mention
  • South Pointe Hospital – N/A*
  • Union Hospital – $95.25 per hour

* N/A is really what they have posted as if there are no labor and delivery services available in these hospitals!

What do we learn from the price lists? Well, regardless of other services, if you can run in, give birth, and leave in 7 hours, Kate Middleton style, you should visit Union Hospital.  Otherwise, not much.  As their disclaimer states, this doesn’t include doctors, anesthesia, or even a chair for the father.  We have to start somewhere.  And this is what baby steps looks like.

DAVE

www.cunixinsurance.com

Picture – Baby Steps – David L Cunix

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He Doesn’t Give A Damn

Posted on December 16, 2018 by dave@cunixinsurance.com

I was lamenting Friday night’s court decision in Texas.  Across from me was a doctor, a really smart guy, who was not displeased.  Upon prodding he finally agreed that many people, perhaps millions of Americans, might have reason to be concerned, but not him.  After all, his side, the politicians whom he has aligned himself with due to both financial and philosophical reasons, had won.  He could intellectualize the entire health care debate, but he didn’t see statistics much less people.  Like most doctors in Greater Cleveland, he works for a system.  The system handles all the dirty tasks of billing and collection and organizing the access to care.  He just provides health care to whoever ends up in front of him.  He just does his job.  I don’t know if the system beat the empathy out of him or if he ever had any.  I’m guessing he can turn his empathy on and off and thinks of people like us as leaky faucets.  The struggle to preserve the access and payment for health care continues.  My conversation with this doctor convinced me that he isn’t on our team, and that’s a shame.  Like I said, he’s a really smart guy and we’re going to need all of the help we can get.

Healthcare.gov, the access point for millions of Americans to purchase individual health insurance coverage, was forced to send out announcements that the Marketplace was still open today, the last day of Open Enrollment. Forced.  After two years of sabotage by  President Trump and his administration, there was real fear that the portal would be closed immediately.  Their site has a banner stating “Court’s decision does not affect this season’s open enrollment.”  I received my first client email moments after the decision hit the news.  Clients called the office to inquire about their status.   They needed to be reassured that nothing has changed, yet.  Welcome to America 2018 where governing by cynicism has given way to governing by fear.

This blog chronicled the run-up to the passage of Obamacare, the Patient Protection and Affordable Care Act.  There were more than enough disappointments, pork-barrel politics, and short cuts to fill these posts and tick off my Democratic friends.  And we have now had eight cynical years of the politics of repeal. (No links.  Most of the last eight years have dealt specifically with this BS.)  As long as we’ve had divided government the Republicans have had the luxury of whipping up their base, collecting large campaign donations, and the safety of impotence.  It was a game that they thought, like Risk, would go on forever.  But they won in 2016 and now have to govern and their actions have consequences.

What is at stake? What are some of the key consumer elements of Obamacare?

  • Guaranteed Issue
  • Preexisting Conditions are covered
  • No Health Screening – no penalty for previous illnesses or injuries
  • MEDICAID EXPANSION – coverage extended to the working poor
  • Tax Credit Subsidies – ongoing premium assistance that facilitates the purchase of coverage
  • Cost Sharing Reduction – a reduction in the deductibles and out-of-pocket expenses
  • Essential Health Benefits – compliant policies are comprehensive
  • No Maximum Benefit – elimination of the annual and lifetime limits

If you repeal the law without an alternative you eliminate all of the above and more. And what Republican alternative is waiting in the wings.  It took seven years for Mitch McConnell and crew to give us the American Health Care Act (AHCA), last year’s half-hearted attempt at a replacement.  There have been no public hearings.  There has never been an attempt to craft serious legislation.  There has never even been a serious attempt to improve and adjust the current law.

There was a decision last night in Texas. Americans are nervous.  The president of the Federation of American Hospitals is clearly ticked off. The American Medical Association had filed a brief in defense of the law.  President Trump has declared this court ruling a great victory.  Of course he has.

DAVE

www.cunixinsurance.com

Picture – The Empty Field – David L Cunix

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Beating The System

Posted on December 10, 2018 by dave@cunixinsurance.com

Open Enrollment season is coming to a close. The big challenge in Ohio is to pick the health insurance plan that will give you access to the doctors and hospitals you would want to utilize if you get sick or injured in 2019. If you are under age 65 in Greater Cleveland and paying for your own coverage, you only have one option to access the Cleveland Clinic, the Cleveland Clinic + Oscar plan. If you would like to get into the University Hospital system or Lake Health, you will choose Medical Mutual of Ohio. These policies are HMO contracts. Unless it is an emergency, you must use the doctors and hospitals in the system. Many of us have doctors in both systems. That doesn’t work. You must choose one system or the other.

This has put more than a few of us in a bind. Do you retain your cardiologist and find a new pediatrician for your kids? Which relationship is more important, the long held one with your psychiatrist or your comfort with your gynecologist? My advice to my clients is to choose the system, not the doctor. You can’t chase doctors. Not in Ohio.

As I’ve mentioned previously, I had a little health adventure in 2016. I took control of my care in early 2017 and put together a new team. A key member of this team is my oncologist. Great guy. He’s the one who orders the twice a year tests, including CT Scans, and then reviews them with me a week later. He always answers all of my questions. The last time we met I had one last question for him, a personal one. I wanted to know how he was doing since he seemed to be more focused on research than billable patient appointments. He assured me that he looked forward to our next visit in May 2019. I got a letter in the mail today from University Hospital that my oncologist had moved on and that the system would help me find a new doctor!

You can’t make a health insurance decision based on doctors. If you base your choice on doctors, you lose. You choose the system and find a doctor within it.

&    &    &    &    &

I had a pain my chest. It had bothered me for about a week. It might have been just indigestion, but I wasn’t sure. I could go to the doctor. I didn’t want to blow $50 or $100. I found out that my friend, Frank, had the same pain. I talked him into going to having it checked out. If it was nothing I beat the system and saved some money. The next day I heard that Frank had died. I rushed over to the Cleveland Clinic and got an executive physical. $2,000! They poked and prodded me and then told me that I was suffering from indigestion. I went to Frank’s house and asked his wife if he had suffered. She said, “No. He died the moment the bus hit him.”  A Woody Allen classic updated slightly.

DAVE

www.cunixinsurance.com

Picture – David L Cunix – A Different Bus

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Today’s Question

Posted on November 19, 2018 by dave@cunixinsurance.com

It is Open Enrollment here at Cunix Insurance Services. In eight short weeks I will email or talk with close to 500 people.  I have six to eight appointments in my office every day.  And it really doesn’t matter if the visitors are twenty-two or seventy-two, married or single, self-employed or working for someone else, everyone has the same question – WHY IS THIS STUFF SO EXPENSIVE?

That is a good question. I wish the answer was as clear as the question.

It is important to remember that health insurance is a payment system. It is our way to organize the access and payment for care.  If the insurance covers more care such as a colonoscopy as part of routine preventive care, maternity and mental health care the same as any other medical condition, and preexisting conditions, the price will be higher than if those costs were excluded. We appear, as a society, to have decided that these enhanced coverages are a good thing.  We may not want to pay for them, but we aren’t prepared to go back to a time of more limited benefits.

Are the insurers jacking up the rates just because they can? The short answer is probably not.  The Patient Protection and Affordable Care Act (Obamacare) includes the Minimum Loss Ratio.  The MLR forces the insurance companies to spend 80 cents of every dollar on claims.  The other 20% pays for all of their administration, marketing (including the agents), reserves and, if there is anything left over, profits.  I’d like to push this onto the Anthems, Medical Mutuals, and UnitedHealth Cares of this world, but they may not be the biggest villains of this story.

The rising cost of care is the biggest driver in the rising cost of health insurance. That free colonoscopy isn’t getting any cheaper.  Lifesaving treatments come at a price.  And it is all too much until that is for you or a loved one.  How much does that shot or pill cost?  Medications seem to be a huge and growing factor in the cost of care.

Prostate cancer is a common condition for men of a certain age. A client and I were sharing treatment stories the other day.  He was shocked that he was given an $18,000 shot.  Been there.  Done that.  The medication in that shot has been around for thirty years, but they still get $18,000!  Leslie Stahl’s report on 60 Minutes this week was on the price increases for medication to treat opioid overdoses.  Major news organizations have been documenting the escalating prescription drug pricing for years.  With little to no real action taken in Washington to curtail the price of medication, state legislatures are trying to fill the void, but it is an uphill fight.

This is November 2018 and the only thing I know for sure is that the price of your health insurance will go up for 2019. Most of my clients are seeing increases around 10%.  My Grandmothered Anthem policy went up 26% and there is nothing I can do about it.  It is a monthly reminder that we are all in this together.

DAVE

www.cunixinsurance.com

Picture – David L Cunix – Why?

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