In Other Breaking News

The President was bragging.  The car radio, tuned to CNN, was playing President Trump’s press conference.  Among his other claims of success, real or imagined, was his victory, yesterday, in the Supreme Court.  He quickly corrected himself and changed it to the Appeals Court.  He was talking about the Court of Appeals for the Fifth Circuit declaring the Individual Mandate provision of the Patient Protection and Affordable Care Act (Obamacare) unconstitutional.  Mr. Trump was elated.  He claimed that it was the Individual Mandate that made health insurance expensive.

Read the decision.

Most of the people I know in this industry, from across the political spectrum, realize that the Individual Mandate could lower premiums by expanding the available pool of clients to include the youngest and healthiest amongst us.  Since its origin from within the Heritage Foundation through the introduction of Clintoncare, Romneycare, and the creation of Medicare Part D (Rx) it has been widely accepted that plans that accept everyone (guaranteed issue) and that cover the most unhealthy (preexisting conditions) must be structured to incentivize participation by the entire eligible population.  The Individual Mandate only became a Republican strawman when the PPACA neared passage in 2010.

This blog has discussed the Texas lawsuit, the effort by 18 states and the Trump administration to declare the PPACA unconstitutional, in numerous posts.  We continue to cover it because the lawsuit’s success could eliminate coverage for nearly 54 million Americans with preexisting conditions and disrupt the way every one of us accesses and pays for health care.  Yes, all of us.  The elimination of Obamacare, its rules, its regulations, its heart, will impact individuals, employees covered by group health insurance, Medicare beneficiaries, and entire industries.   Over and above health, and that should be enough, we are also discussing about 20% of our economy.  But, I digress.  Mr. Trump is elated.

The Department of Health and Human Services (HHS), the part of this administration in charge of implementing our system had nothing to say about this latest court decision.  Here is the link to the department’s press releases of the last week.  If the Texas lawsuit succeeded, the nation would turn to HHS for a solution.  How would we cover preexisting conditions?  How would our system react?   As is so often in this administration, creating havoc is everyone’s job.  Solving problems is no one’s.

One of the parties in the lawsuit is the Association of American Physicians and Surgeons.  They aren’t just upset with Obamacare.  The AAPS is still fighting the creation of Medicare!   OY.

Though many legal scholars have derided the underlying legal argument at the heart of the Texas lawsuit, one would be foolish to rely on logic at a time like this.  Senator Lamar Alexander (R-TN), was quoted in a Kaiser Health News article as saying, “I am not aware of a single senator who said they were voting to repeal Obamacare when they voted to eliminate the individual mandate penalty”.  Yes, he was only trying to irreversibly damage the law.  He didn’t mean to kill it!  There are members of this administration that believe that dismantling the law would only impact residents in the 18 states pushing the lawsuit.  As noted recently, H B 390 was just introduced in the Ohio House to address these issues.  It is, at best, a start.

We just completed our annual Open Enrollment Period for individuals under age 65 and the Annual Enrollment Period for Medicare beneficiaries.  In truth, I’m exhausted.  But even more tiring is this struggle to make sure that Americans, at least the ones I impact, have health insurance, the way most of us access and pay for health care.  Yesterday’s breaking news was that the federal government and a group of states are working hard to destroy our health care system without any idea what would happen if, G-d forbid, they succeeded.

Oh yeah, there was another major news story yesterday, but this is an insurance blog!


Picture – Broken! – David L Cunix

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Still Waiting For A Real Solution

You are in the hospital preparing yourself, mentally, for surgery when a doctor enters pre-op.  He introduces himself as Doctor Jones, the anesthesiologist.  He has been asked to participate in today’s procedure.  He is NOT in your network.  This is no time to spring a surprise on you.  You are prepped and ready.  Dr. Jones is prepared.  He has a form for you to sign and he reads the first paragraph that includes these key points:

  1. The individual provider informs the covered person that the individual provider is not in the person’s health benefit plan provider network.
  2. The individual provider provides the covered person a good faith estimate of the cost of the health care services. This estimate shall contain a disclaimer that the covered person is not required to obtain the services at that location or from that individual provider.
  3. The covered person affirmatively consents to receive the health care services.

Here’s the question – Do you sign his form or do you put on your clothes and go home?                                                                                             

Those three points are directly taken from the current Surprise Billing legislation Ohio S B 198.  Until this loophole is removed, Ohioans will still be victimized by Surprise Billing.


Picture – You Had A Choice – David L Cunix

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First Aid

How big a Band-Aid do you need if you are attacked with a machete?  Today’s volunteer paramedics are Ohio House of Representatives Randi Clites (D-75) and Jeffrey Crossman (D-15).  Their bandage is the recently introduced 89 page House Bill 390.  The machete is Texas v. U.S., the lawsuit targeting the Patient Protection and Affordable Care Act (Obamacare).  They may need a bigger Band-Aid.

In an effort to save you time, here is the link to the Detailed Analysis provided by the Ohio Legislative Service Commission.  This is the Summary from the same site:

  • Repeals outright suspended provisions that allowed health insurers to pass on the cost of reinsurance to certain high risk individuals.
  • Codifies in state law the federal Patient Protection and Affordable Care Act’s (ACA’s) limitations on premium charges.
  • Codifies in state law the ACA’s ban of annual and lifetime limits.
  • Codifies in state law the ACA’s ban on preexisting condition exclusions.
  • Codifies in state law the ACA’s provisions requiring health plans to offer certain essential health benefits.
  • Codifies in state law the ACA’s cost sharing limitations.
  • Codifies in state law the ACA’s requirement that a health plan provide benefits that are actuarially equivalent to 60% of the full actuarial value of the benefits provided.

Legislation like this can be a tough slog to read.  It is a step by step process of affirming and / or amending sections of the Revised Code.  There are plenty of opportunities for both missteps and mischief in this type of bill.  Barb Gerken, the Chairperson of the Ohio Association of Health Underwriters’ Legislative Committee, immediately noticed that full-time employment had accidentally reverted to 25 hours per week.  That and other questions about Rx copayments were the first issues she noticed.  A careful reading will find other problems large and small.  Though there are lots of cosponsors, Democrats and Republicans, the final bill, if passed, will undergo significant changes before it might ever land on the governor’s desk.

House Bill 390 is an important first step.  The TV talk shows have featured numerous legal scholars who have derided the merits of the Texas lawsuit.  But the elected leaders of the State of Texas seemed determined to drag the rest of our country down to their level of health care insecurity.  Even if this lawsuit fails, there will be another.  A poker player only needs a “chip and a chair”.  Texas only needs an attorney and a lack of conscience.  We must applaud the efforts of Representatives Crossman and Clites.  In her testimony before the Ohio House Insurance Committee, Representative Clites cited her personal experience as the mother of a child who has endured major medical conditions.  It is estimated that nearly two million Ohioans suffer from a pre-existing condition that would threaten our ability to purchase health insurance.  We share her concern.  The question is whether the Insurance Committee’s Chairman, Representative Thomas E. Brinkman, Jr. (R-27), also shares our concern.

Eighteen states and the Trump White House are swinging a machete at our health care system.  It will take legislation, not Band-Aids, to protect us.  HB 390 is the first legislative step to help Ohioans retain access to health insurance, the way most of us access and pay for health care.  I’m looking forward to other serious proposals.  I just hope to see some soon.  That machete is too close for comfort.


Picture – It’s A Start – David L Cunix 

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I Got My Card!

It is no secret that I will turn 65 in February. My daily mail, the phone calls, and the pop-ups on Facebook are proof that my 65th birthday is eagerly anticipated by a whole host of marketers. And yet, we are all celebrating the same thing, my transition to Medicare.

Countless clients have nervously approached their enrollment into Medicare as if they were buying a house or, worse, unboxing a new cellphone. They thought that it would be confusing and difficult. I have been suggesting the same two options for years. One option is to simply go online to The other option was to go to the local Social Security office. Our local Social Security office (Beachwood, Ohio) has a great reputation for both efficient and respectful service. It was recently my turn to enroll in Medicare Part A and Part B.

Though it was tempting to just go to the Social Security office, I decided that I should try to enroll in Medicare online. The process begins up to three months before your birth month. On Friday, November 1st, I took the first step. The entire process, including registering on the Social Security website, took 20 minutes. It was easy, so easy I was actually worried that perhaps I had screwed up.

I received confirmation that the process had begun within days by both email and snail mail. On November 16th I received an oversized envelope in the mail. My card? I tore open the envelope to find the Extra Help forms. This program is designed to help financially challenged senior citizens pay the monthly premiums, annual deductibles, and co-payments for their Medicare prescription drug program. Thankfully, I don’t need Extra Help. But if I did, this form would have been a breeze to complete.

My Medicare Card came in yesterday’s mail! It took less than three weeks. There is no reason to be nervous. The process is not hard. Sometime in the next month I will apply for my Medicare Supplement and Medicare Part D (Rx). This couldn’t have been easier.

I started to pay in to Social Security and Medicare in 1970 at the age of 15. I never doubted that Medicare would be waiting for me to turn 65. Never. All of that faith has paid off.


Picture – The Newest Medicare Beneficiary – David L Cunix

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The Important News Was On Page 22


The front page of today’s Plain Dealer featured stories about algae, UAW workers second guessing their recent strike, and lead safety rules for child care centers.  Other stories were teased at the very top and bottom of the page.  But the news that will impact millions of Americans and a significant number of Greater Clevelanders was buried on Page 22.  Did you find it?  We now know the important Medicare changes for 2020.

  • Medicare Part B Premium – $144.60, an increase of $9.10 per month
  • Medicare Part A Deductible – $1,408
  • Medicare Part B Deductible – $198, an increase of $13

The Associated Press article by Ricardo Alonso-Zaldivar cited a statement from the Centers for Medicare and Medicaid Services (CMS) blaming these premium and deductible increases on “drugs administered in doctors’ offices.  Those medications are covered under the Part B outpatient benefit and include many cancer drugs”.

There was no mention of government funding, or that Medicare is unable to negotiate drug pricing, or any of the other issues contributing to the rising costs of health care.  Perhaps those are being held in reserve for the 2021 increases.

And when those increases are announced this time next year, don’t be surprised if they won’t be found in a Sunday paper on Page 22.


Picture – Ready For The Birdcage – David L Cunix

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Open Enrollment 2019

The leaves are changing.  It’s Open Enrollment Season, or as the Trump Administration calls it, “Weekend at Bernie’s”.

Medicare Open Enrollment is from October 15th to December 7th.  The compressed under age 65 Open Enrollment is now November 1st to December 15th.  Yes they overlap.  Plus, most of our group policies renew on January 1st.  Your local insurance office is very busy.

Please allow me to share a couple of thoughts.

Medicare Beneficiaries are always early for their appointments.  On October 15th, the first day of Open Enrollment, I had two clients waiting to talk with me at 1:50 for their 2 PM appointments.  One was 10 minutes early.  The other was 24 hours early.  She was scheduled for the 16th.  That might have been shocking had we not had an unexpected visit from our friend Bob (name changed) that morning at 11 AM.  His appointment?  December 2nd.  Six weeks early!  A new record.

*     *     *     *     *     *     *

It is almost election season.  Sometime over the next few months you will hear a friend say, “If (fill in the blank) wins, I’m booking the first plane to Canada!”  People from both sides say that, but we all know that they aren’t going anywhere.  We have an insurance version of that.  Every agent has heard, “If I get sick, I’m just going to get on a plane and go back to (insert country of origin here) where it won’t cost me anything!”  Seriously, they aren’t going to go back to England, Italy, or Russia the moment they feel chest pains.  These people are in the USA by choice, and they really have no interest in being anyplace else.  The insurance agent nods knowingly and then gets back to finding the client the right policy.

*     *     *     *     *     *     *

Open Enrollment can be very stressful for both the agents and the clients.  The Patient Protection and Affordable Care Act (Obamacare) policies change every year.  The prices usually go up.  The networks expand and contract. The deductibles and copayments are tweaked annually to comply with the ever-changing regulations.  We are in this together.  We need your focus and attention, if only for 45 minutes to an hour.  Some of our clients need to go through the Exchange to qualify for a Tax Credit Subsidy before they can pick the right policy.

This is blog has a national following and according to Google Analytics, most of you reading this are outside of my service area.  So this isn’t about me, it is about You and Your agent, whether she is in Portland, Maine or Portland, Oregon.  You and your agent are on the same team.  Your agent, very often a small business person purchasing his/her own coverage, is there to help you get health insurance, the way most Americans access and pay for health care.

We celebrate Open Enrollment.  There may not be cake.  There definitely will be coffee.


Picture – Knoxville In The Fall – David L Cunix

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They Suffer Least Who Suffer What They Choose

The song is American Gothic.  The artist, David Ackles.  I remember where I was when I first heard an odd song about an unsuccessful farmer and his less-than-faithful spouse.  The payoff was the last line, “They suffer least who suffer what they choose”.  I was only eighteen, but surely I had heard something like this before though I could not recall when.  We must accept some responsibility for what we have and what we lack.  This should not be confused with blaming the victim for circumstances beyond his/her control.  It simply means that we may be part of both the problem and the solution.  Or, we may actually be OK with the status quo.

And that brings us to Texas.  WalletHub, a personal finance website, accessed health insurance data from the U.S. Census Bureau to compare the rates of uninsured in our country.  There is a lot of information here and worth a couple minutes of your time.  The graphs show the percent of uninsured by race and income, children vs. adults, and the change since the passage of the Patient Protection and Affordable Care Act (Obamacare). This is the link to the comparison by state.  This is the link to the comparison by city.  To the surprise of no one, Texas came in last.  It wasn’t even close.

The adult uninsured rate for Texas in 2018 was 20.23%, 1 in 5 of every adult in the state.  The next closest was Oklahoma at 16.31%.  The rate for children was a shocking 11.15%.  These rates are an improvement over pre-Obamacare rates.  For comparison sake, Ohio ranks 18th with adults at 6.97% and children at 4.82%.  Not great, but not Texas.

In case you were wondering, Cleveland came in at 258th with an adult uninsured rate of 8.99%.  Dallas is 539th with an uninsured rate of 27.03% for adults and 16.96% for children!  There are Texas cities, like Laredo and Brownsville, with even higher numbers.

The Texas / Trump lawsuit is working its way through the courts.  Invalidating the PPACA without any replacement, transition, or clue would disrupt our system and eliminate the protections afforded so many of us by the law.  It is estimated that 27% of Americans under age 65, 53.8 million, have preexisting conditions that would impact whether or not they could purchase health insurance if we went back to asking health questions and underwriting.

Health insurance is the way most of us access and pay for health care.  It is one thing for the residents of Texas to accept a 20% uninsured rate.  It is quite another if we let them impose that on the rest of us.  It is incumbent upon us to act.  They suffer least who suffer what they choose.


Picture –My Team, My Pain, My Choice – David L Cunix

Quick Update:  This is from NPR.

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Hedge Fund Maneuvers In The Dark

There always has to be someone at the bottom.  There really is a group that is less trusted than insurance companies, less popular than Congress.   The winners of the “who is our least favorite / least trusted” are the owners and operators of Hedge Funds.   With the exception of Mitt Romney extolling the virtues of Bain Capital, many Americans only contact with a hedge fund or private equity company was when their local factory jobs were eliminated.  Disliking hedge funds isn’t limited to just Democrats or just Republicans.  There are very few truly bipartisan issues in Washington and our local statehouses.   Surprise Medical Billing may be just such an issue and we have some hedge funds to thank for this.

My last post, Step Away From The Wallet, discussed the misleading ads from a group called “Physicians for Fair Coverage”.  The ads, part of a $17 million dollar ad buy, have peaked the interest of the Chairman, Frank Pallone Jr. (D-N.J.) and Ranking Member, Greg Walden (R-OR) of the House Energy and Commerce Committee.  They are initiating an investigation into the three private equity companies that own major physician staffing agencies.

According to The Hill, the two Congressmen are pleased that this issue is totally bipartisan and even has the support of the White House.  Together they have focused their efforts to get more information from KKR, the Blackstone Group, and Welsh, Carson, Anderson & Stowe who own the staffing companies.  Surprise medical billing, especially problematic when the patient has carefully accessed non-emergency care in a network facility only to be seen by a non-network doctor, can result in thousands of dollars of unexpected costs.  It is a gaping hole in our system, the kind that seems perfect for a hedge fund to exploit.

The state legislatures are also looking at this issue.  Some states, like California, are more focused on consumer protection.  Other states may be more interested in maintaining the Status Quo.  Ohio is beginning to look at Surprise Billing.  Ohio SB 198, also bipartisan, had its first hearing this week.  It needs a lot of work and will look a whole lot different (hopefully) if it ever becomes law.  I will link a revised version when it becomes available.

The key today is that transparency in medical billing is an ongoing struggle.  Health insurance is the way most Americans access and pay for health care.  Health insurance companies help to organize the market.  They prove their value every time a patient is balance billed by a doctor employee of a hedge fund.   


Bonus – Orchestral Manoeuvres In The Dark – If You Leave

Picture – Not Another Hedge – David L Cunix

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Step Away From The Wallet

The commercial was scary.  There were children, CHILDREN, and old people, OLD PEOPLE, facing the possibility of being deprived access to needed health care!  Why?  Insurance companies and Congress are trying to solve the Surprise Medical Billing problem by denying fair payment to doctors.  The safety net could be “Shredded”.  The commercial was sponsored by Physicians for Fair Coverage.

The first time I saw this on Morning Joe I turned to Sally and said, “BS”.  Neither H.R. 3630, the No Surprises Act, moving through the US House nor the Senate Bill 1895, Lower Health Care Costs Act, address Surprise Billing for Medicaid or Medicare.  A recently released study revealed that in 2016 approximately 40% of privately insured patients received a bill from a medical provider that was not in their insurance network.  Privately insured.  That is the definition of Surprise Billing.  The commercial didn’t come close to the real problem.

This sleight of hand did not go unnoticed. Rachel Bluth, a reporter for Kaiser Health News, also had her doubts.  Here is a link to her well researched article.

It would appear that Forbes Tate Partners, the public relations firm that produced the ad, believes that we can solve this problem by forcing the consumer into arbitration.  With the deck stacked against the patients, their clients, the free-agent E/R doctors and anesthesiologists, will then get paid whatever they’d like.  Well I have a surprise for them – that ain’t gonna happen.  


Picture – Arbitrate This – David L Cunix

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The Rest Of The Country

According to the US Census Bureau, 97% of our country’s land mass is considered rural.  80% of us occupy only 3% of our land.  Neither the national news nor the national political candidates spend a lot of time talking about rural America.  Sure, we hear about a random farm bill or how the tariffs are destroying our agriculture and the need to bail out the farmers, but that is about it.  There is one other thing that makes the national news – the horrific health and health care of rural America.

Rural America has been disproportionately impacted by the opioid epidemicRural hospitals have suffered from underfunding.  Many Red States chose to not accept federal money and expand Medicaid.  Not enough doctors, facilities, or money.

A possible solution has been offered by presidential candidate Mayor Pete Buttigieg.  This is surprising because rural America is seldom the focus of any of the candidates and because the health care plans from the people running for president are more often the objects of derision.  I’m sure you’ve forgotten Scott Walker’s or Donald Trump’s.  This blog recently reviewed Bernie 2.0, a plan designed for shouting and arm waving but not to be implemented.  So I didn’t expect much from Mayor Pete.  Here is the link:

Securing a Healthy Future for Rural America

The first thing you notice is that this is a real proposal. Agree or disagree with his policy prescriptions, you can see the thought and effort.  Instead of empty platitudes and generalizations, there are 54 footnotes.

His goals:

  • Guarantee that people in rural areas have affordable health insurance options
  • Ensure that people in rural areas have access to critical health services by increasing the availability of health providers
  • Expand access to preventive efforts and effective treatment for mental illness and addiction
  • End the rural maternal health care crisis by making it easier for women to access critical services before, during, and after pregnancy
  • Make it easier for patients to receive treatment at or near their home by expanding telehealth services
  • Strengthen rural health facilities to better address new models of health and community wellness
  • Support rural communities in meaningfully reducing local health inequities
  • Reduce obesity and combat food insecurity
  • Improve access to transportation services

Importantly, his solutions are built upon existing programs.  He works to alleviate the shortage of physicians in rural areas by expanding programs that encourage and/or incentivize doctors to work in rural areas. Some of these programs could even be used to address the shortage in primary care doctors.  He addresses the maternal mortality rates and the underfunding of rural facilities. And the expansion of telehealth, with the connected expansion of high-speed broadband across the country, will provide immediate access to transportation-challenges patients.

There is no budget for any of this in Mayor Pete’s whitepaper.  Also, no funding mechanism. I have requested details from the Buttigieg campaign.  I will post them once received.  The problems are real.  The solutions make a lot of sense.  The question is whether a future President Pete or the US Congress would allocate the funds.

Look for many of these issues and Mayor Pete’s recommendations to be incorporated in next year’s Democratic Party platform.  A few of them, like the expansion of high-speed broadband across the country might appear in the Republican Party platform, too.


Picture – A Quiet Place – David L Cunix


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