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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A Reasonable Concern

It happened again this week.  A couple came in to ask an important question. “Is it safe for us to retire?”  My answer, as always, was a resounding “Maybe”.  This shouldn’t be so difficult.  The Patient Protection and Affordable Care Act (Obamacare) was supposed to put that issue to rest.

John and Mary (names changed) would like to retire and travel.  They had worked hard throughout their adult lives, saved responsibly, and prepared for their retirement.  John, 67, is employed by a major local company.  Mary, 58, is a self-employed consultant.  They are financially prepared for retirement.  The issue is health insurance.  Mary isn’t in perfect health and it is a long way to age 65 and Medicare.   These are professionals.  They read the papers.  They watch the news.  They want to know what is going to happen with the Texas lawsuit and whether or not Mary is going to be able to secure coverage.

These are reasonable concerns.

Health insurance is the way most Americans access and pay for health care.  Obamacare is the law of the land and is interwoven into our entire system.  And our health care system, medical industry, is approximately 20% of our economy.  Eliminating Obamacare, by Congressional action or by having the Supreme Court declaring the law unconstitutional, without a viable alternative could be devastating. 

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

AND, the underlying guarantee that doctors, hospitals, laboratories, and drug stores will be paid for their goods and services.

If you eliminate Obamacare without an immediate alternative, you put most Americans and our entire system at risk.

Is that too hyperbolic for your taste?  Ok. Let’s keep this simple.  An emergency appendectomy with a week in the hospital could be between $50,000 and $100,000. If you’ve got an extra $50K, you’ve got nothing to worry about.  The rest of us are concerned.

We have been here before.  The Supreme Court rendered a judgement on King vs. Burwell in June 2015.  There was real fear that with the help of the Supreme Court the coyote would finally catch the roadrunner and the Obamacare would be ruled unconstitutional.  Senator Orrin Hatch (R-UT), now retired, drafted an alternative plan.  Much of it was, by necessity, rebranded Obamacare.  The key was that Hatch’s plan would have passed and could have   been implemented, if the Supreme Court decision forced the Republicans’ hands.  The decision was 6-3 in favor of retaining the Patient Protection and Affordable Care Act.  The hastily created Republican plans from Hatch and others were quickly discarded.

There isn’t an Orrin Hatch in the Senate in 2019.  That is a shame.  With President Trump and Attorney General William Barr joining the fight on the side of eliminating coverage for preexisting conditions and guaranteed issue, we are assured that the Texas lawsuit will make it to the Supreme Court.  We may even have a decision by June 2020.  And yet, I have hope.  There is too much at stake and when real action, not BS politics, will be needed to save the country, I think that we can count on two pairs of Senators to rise to the moment.  The Chair of the Senate Finance Committee is Charles Grassley (R-IA).  I can see him working with Senator Debbie Stabenow (D-MI) to draft meaningful legislation.  The most serious health care legislation would come from the Alexander/Murray partnership.  Senator Lamar Alexander (R-TN) is the Chair of the Health, Education, Labor and Pensions Committee.  Senator Patty Murray (D-WA) is the ranking member.  Their legislative efforts reflect mutual respect and a desire to solve problems.

It is reasonable to believe that Congress would turn to these four Senators in the event of a national emergency.  The sudden termination of our system would be such an emergency.

The question remains whether it is safe for John, or YOU, to retire if you or a loved one is under age 65 and will have a need to purchase health insurance.  Gosh I hope so.  Because if the answer is NO, then we are doomed as a country.  We must be able to believe that our elected leaders can be trusted to push politics aside for the good of the country. 

I am excited to share with you that John will retire by the end of this year.

We are in this together…


Picture – Nothin’ But Blue Skies – David L Cunix


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Two Wrongs Don’t Make A Right

The answer to the cynical exploitation of a large segment of the American population isn’t to cynically exploit the same people and others by weaponizing fear and undeliverable promises to assure a different electoral outcome.  Sure it is tempting.  For eight years the Mitch McConnell led Republican Party demonized the Patient Protection and Affordable Care Act (Obamacare), promised to repeal it, and pledged to replace the law with better / cheaper access to health care.  It was a lie.  There was never any viable alternative plan and most of the votes to repeal were strictly for show.  The question is whether the Democrats should stoop to Mitch’s level.

Some of these posts are easier to write (and read) than others.  Ten years ago we were discussing the run-up to the PPACA.  Our focus was primarily on the Democrats leading the debate.  After the passage of the law, the Republicans fighting the smooth implementation of the law became the story.  Some of my Republican readers objected, not to the indisputable facts of these posts, but to the tone.  The first casualty of Obamacare was intellectual honesty.  Whatever innocence we may still have possessed expired the next day.

The Cynicism of Medicare For All

Medicare is Medicare / Medicare For All is not Medicare, as least not what we all understand the term to mean.   And this is where the cynicism begins.  Certain politicians, led by Bernie Sanders, want to trade off the reputation of Medicare, a well-regarded program designed to help senior citizens and the disabled access health care.  They want to usurp the good name, the perceived cost-effectiveness, and high level of acceptance with a program that would be significantly different, unlikely to ever be passed into law, and financially disastrous.  And we are left with one question, “Do the proponents of Medicare For All realize that their program has little in common with Medicare and even less of a chance for enactment and are simply exploiting their base, or do they really have no working knowledge of either of these programs?”

Medicare (real Medicare) is designed to pay approximately 75% to 80% of a beneficiary’s medical bills.  Our first detailed explanation of what was and wasn’t paid by Medicare can be found in this post from February 2010.  The Part A Deductible in 2010 was $1,068.  In 2019 it is $1,364, an increase of 28%.  The Medicare Part B Deductible in 2010 was $135.  Today it is $185, an increase of 37%.  After the deductible, Medicare Part B pays 20% of office visits while Medicare Part A pays a portion of the daily hospital room charges. Even the Medicare Part B premium, what most of us pay to participate in the program, has increased 22% from $110.50 in 2010 to the current $135.50 per month.  The deductible and premium changes are one way to insure the long-term viability of the program. As the cost of care increases, even with the controls Medicare imposes, the beneficiaries’ exposure also goes up.  Medicare Supplement policies are available to help cover the deductibles and other expenses not paid by the program.

Senator Sanders’ Medicare For All does not have a deductible, does not have copayments, and manages to add a number of new benefits including dental, vision, and long term care.  Here is the link to the actual legislation.  Where Medicare has from its inception kept an eye on cost sharing, Medicare For All is focused entirely on the word FREE:

IN GENERAL.—The Secretary shall ensure that no cost-sharing, including deductibles, coinsurance, copayments, or similar charges, be imposed on an individual for any benefits provided under this Act, except as described 6 in subsection (b).  (b) EXCEPTIONS.—The Secretary may set a cost sharing schedule for prescription drugs and biological products—(1) provided that— (A) such schedule is evidence-based and encourages the use of generic drugs; (B) such cost-sharing does not apply to preventive drugs; (C) such cost-sharing does not exceed $200 annually per individual, adjusted annually for inflation; and (D) such cost-sharing is not imposed on individuals with a household income equal to or below 200 percent of the poverty line for a family of the size involved.

How does Senator Sanders propose to pay for this?  Medicare For All is dependent on a major shift in tax policy coupled with a significant change in the payments to doctors and hospitals.  This grid from the American Hospital Association illustrates the substantial difference in fees paid by Medicare, Medicaid, and private insurance.  Medicare currently pays approximately 87% of the cost of care.  Private insurance pays 145%.  This cost shifting is what keeps our hospital doors open.  Could the hospitals and doctors absorb a 40% reduction in income?  Rural hospitals are already at risk under the current system.  The loss of the private insurance buffer could be devastating.

Before we address Senator Sanders’ tax proposal, we must first look at the last 20 years.  The Obama Administration was unable to sunset the Bush tax cuts.  The current administration passed another tax cut in 2017.  It is into this environment that the Senator is proposing a massive change in our concept of taxation.  These details are relevant because there are more than a few challenges to the math of Medicare For All with this funding.  Without…

  • 7.5% income-based premium paid by employers.  The first $2 million in payroll would be exempt.  This is not a business deduction.
  •  4% income-based premium paid by households (this is not capped)
  •  Eliminate employer deductions for health care benefits (see above)
  •   Increase the marginal tax rates to as high as 52%
  • Tax capital gains and dividends as ordinary income
  • Limit tax deduction for those households earning over $250,000 per year
  • Increase the Estate Tax and eliminate certain methods of wealth transfer
  • Create a Wealth Tax of 1% on households with assets of at least $21.5 million
  • Impose a one-time tax on currently held offshore profits
  • Charge a fee to large financial institutions
  • We’re not done yet
  • Close a loop-hole exploited by certain wealthy business owners
  • Eliminate the “last-in, first-out” accounting method

Please look at the above list.  How many of those tax increases could be signed into law?  The relatively modest changes of Obamacare caused a major uproar in this country.  How many of the proponents of this legislation, the elimination of private insurance in favor of a government run system fueled by ever increasing taxes, honestly think that this is a viable option?

This is not the public option.  That is something different and another day.  This isn’t buying in to Medicare at age 55, a bill that Sherrod Brown co-sponsored in 2017.  The Kaiser Family Foundation has created a side-by-side comparison of some of the most discussed plans.  This is the link.  These and other ideas are very different from Medicare For All.  Just like Medicare For All is very different than Medicare.  And Senators Sanders, Harris, and Warren know that.  And two wrongs don’t make a right.


Picture – The Taj Mahal, Or Not – David L Cunix

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The Word For Today Is SURPRISE

Surprise, Americans really do care about health care.  Surprise, repealing the Patient Protection and Affordable Care Act (Obamacare) is no longer good enough, especially when you don’t have a replacement plan.  And Surprise, there are a whole lot of Republican Senators (22) up for reelection in 2020.  There is a way, a bipartisan way, to address all of these issues.  Today we are going to discuss Surprise Billings.

According to the Kaiser Family Foundation:

“Surprise medical bill” is a term commonly used to describe charges arising when an insured individual inadvertently receives care from an out-of-network provider. This situation could arise in an emergency when the patient has no ability to select the emergency room, treating physicians, or ambulance providers. Surprise medical bills might also arise when a patient receives planned care from an in-network provider (often, a hospital or ambulatory care facility), but other treating providers brought in to participate in the patient’s care are not in the same network.  These can include anesthesiologists, radiologists, pathologists, surgical assistants, and others.  In some cases, entire departments within an in-network facility may be operated by subcontractors who don’t participate in the same network.1    In these non-emergency situations, too, the in-network provider or facility generally arranges for the other treating providers, not the patient.

This is actually a real issue.  Back in 2016, before my little health adventure, I spent several hours trying to verify that every doctor I was about to encounter was in my health insurance network.  I couldn’t do it.  I called both the insurer (Anthem) and the hospital (University Hospital).  I was completely at their mercy.  Luckily, everyone involved was in network.

Emergency care is even more of a crap shoot.  The patient normally has no choice where care is provided nor which doctors are seen.  20% of hospital admissions in 2014 that originated in the emergency room resulted in surprise billings. (Source – Health Affairs).  You may have the ambulance take you to a hospital in your network only to learn, after the fact, that the Emergency Room physician isn’t in your or any network.

There are several bills under consideration in Congress.  Most are bipartisan.  The Trump administration has been supportive.  With this opening, the stakeholders are starting to get more vocal and present possible solutions.   One coalition includes the National Association of Health Underwriters, the National Retail Federation, American’s Physician Groups, America’s Health Insurance Plans, American Benefits Council, Blue Cross Blue Shield Association, ERISA Industry Committee, and the HR Policy Association.  This group understands the nuts and bolts of medical billing and how Surprise Billing directly impacts clients, employees, and average Americans.  It is reasonable to expect that more consumer, business, and labor groups will sign on as action becomes more likely.

The group is organizing around the following principals:

  • Banning balance billing in situations where patients are involuntarily treated by an out-of-network provider. This includes: (a) emergency health care services provided at any hospital; (b) ambulatory transportation to any health care facility in an emergency; and (c) any health care services or treatment performed at an in-network facility by an out-of-network provider not selected by the patient.
  • Requiring health insurance providers to reimburse non-participating doctors or clinicians based on a federal standard in the above scenarios. All health plans should be required to reimburse a non-contracted hospital or health care provider in the above scenarios an amount equal to the negotiated rate for the same service under the patient’s health plan contract. If no such rate is ascertainable, then the plan should be obligated to pay the amount required for Medicare Parts A or B or a median contracted rate. These requirements should be applied to all ERISA self-funded health plans, and non-ERISA and insured plans, with the option for states to establish similar standards, so long as the state methodology would not increase patient cost-sharing or premiums.
  • Mandating hospitals and providers disclose the network status for attending physicians and clinicians prior to patients receiving care. For non-emergency situations, hospitals should be required to notify patients at their first point of contact, including by a provider on a patient’s behalf (e.g., scheduling surgeon), that some providers assigned to them may be out-of-network and inform them of their right to select in-network providers or decline care. This notice should be for informational purposes only and not constitute a waiver of patient rights, nor should it act as a statement of consent by the patient to pay for services provided.

This is a great first step.  There is a real possibility that Congress will pass legislation this term and that the president will sign it.  Good news out of Washington – Surprise.


Picture – Dr Thunder Monk Courtesy of Joan Naro – David L Cunix

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Practicing What I Preach

It was a Monday morning, a few weeks ago, and I was interviewing a new oncologist. Yes, interviewing because he was applying for a job, a really important job. My clients have heard me say this before. You are in charge of your health care. It is up to you to assemble a team of professionals and experts. They work for YOU. Do these doctors answer all of your questions? Do they answer the questions you don’t know enough to ask? Do you have confidence in them? If not, find another. It is only at this initial meeting that you are truly in control, because when you really need them, when you really need to rely on their expertise, you better be sure that you are prepared to cede to them an awful lot of control. I had an excellent meeting with the doctor and he has been welcomed to my team.

It has now been three years since my little health adventure and August will mark the three year anniversary of the end of my radiation therapy. Though I am not taking any medication or treatment I still incur tens of thousands of dollars of testing every year. Blood tests. CT Scans. Doctors’ visits. It costs a lot of money to prove I’m still here. My new oncologist had the pleasure of reviewing my latest semi-annual CT Scan. Each of these costs me $3,000. If I need this, I need it. My question was whether I still did. The answer, maybe not. We discussed this and decided that my next CT Scan could wait till May 2020, three months after I go onto Medicare. It doesn’t hurt to ask.

It was a few days later and it was time for my annual eye exam. The doctor saw something that got his attention. He called it a macular abnormality. He didn’t think that it was the beginnings of macular degeneration, but he wasn’t positive. He wanted me to see a specialist. So I asked, “Is this something that we’re going to monitor and I should check-in with a specialist after Medicare kicks in next February or should I stop at their offices on my way home?” The doctor said that it wasn’t an emergency but that it shouldn’t be put off till next year. Again, no unnecessary tests or procedures, but we don’t skip that what needs to be done. I contacted an ophthalmologist friend and was in his office the next Monday. The results – no problem. The first doctor did not overreact. He was right to express concern. The specialist, armed with the most up-to-date technology, was able to offer a more comprehensive diagnosis.

We talk about this often. Is every blood test necessary? Can the results be shared with everyone on the team? It is up to us to take charge.

*          *          *          *          *          *          *

There is an advantage to being billed for your insurance, for knowing that your policy has been paid. Most health policies don’t charge extra for paper bills. I believe in online banking. I authorize my bank to pay my policy, usually the first week of the month for the payment due on the first of the next month. The payment comes out of my account around the 28th and I know that I am safe. I try to get all of my clients to do this. Sadly, not everyone listens. Two of my Medicare clients lost their Part D (Rx) policies because their auto-drafts failed. This happens. They will not be able to purchase prescription coverage again till this year’s Open Enrollment in October.

Even worse are the people who insist on having their Medicare Advantage premiums or their Medicare Part D (Rx) premiums come directly from their Social Security checks. Think about this. You are asking the government to write a check to the insurance company for an amount that changes every year. What could go wrong? Lots! According to Kaiser Health News, Social Security screwed up the coverage of over 250,000 people. It wasn’t until a few weeks ago that it was discovered that these people hadn’t paid any premiums this year. Over 43,000 Aetna clients were affected. Humana, over 33,000. Some of these people were cancelled and will hopefully be reinstated. All of them owe back premiums that will have to be repaid. This is a preventable problem. All it takes is a bill in the mail.

You are in charge of your health care. Whether we are talking about assembling your health care team, making sure that you only get the tests that you need, or just verifying that your monthly premium is paid, it is your responsibility to take care of you. What could be more important?


Picture – LOW CARB Cherry Pie – David L Cunix

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What Happens If You Destroy Plan B?

There is a great freedom to taking a “risk-free” risk.  One example that comes to mind is the high school student that creates a business.  His parents are his main support.  Everyone wins if the new business takes off.  And if the business fails he simply gets another part-time job while attending school.  The student in this example always has a Plan B.  The only real risk would be if the student did something that endangered the family assets or the way the parents earned their incomes.  We all understand the value of having and protecting a Plan B, a backup plan.

A decision was made in 2010 to guarantee health insurance coverage, the way most Americans access and pay for health care, to people with preexisting conditions.  This was, for many Americans, the most important feature of the Patient Protection and Affordable Care Act (Obamacare).   The thinking wasn’t all that complicated – If you herd everyone into one large insurance pool, the sick and the healthy, we would spread the risk evenly making it possible to cover even the most unhealthy amongst us and at a reasonable premium.  Part two was that even if you are healthy today, there is no guarantee that you won’t be unhealthy tomorrow.  Pooling our risk made it more likely that insurance would be available when you eventually need it.

Did it work as planned?  NO!  The law may have been crafted with the best of intentions, but it fell short.  And, just as importantly, the PPACA had any number of opponents working against its success from day 1.

The law was dependent upon participation.  It was a given that the sick and injured would sign up for coverage.  I remember the initial Obamacare enrollment in the fall of 2013 for coverage beginning January 1, 2014.  I had families save over $1,000 per month with their new policies.  The new maternity benefits were very popular.  Young women and the unhealthy under age 65 all left my office smiling.  

Somebody has to pay.

Newton’s Third Law is that for every action there is an equal and opposite reaction.  If Doctor Herman’s (name changed) coverage decreased $1,200 per month, the healthiest amongst us are going to pay more.  There was a reason the insurance company was charging the higher premiums for those with preexisting conditions.  Worse, those higher premiums were often capped by law and didn’t begin to cover the claims incurred.  If the insurance pool is properly stocked with healthy people, we can withstand the claims of the unhealthy.  But, every time a healthy person leaves the insurance pool, the risk, the claims, are spread over a smaller group of premium payers.

I don’t believe that this is particularly hard to understand.  This concept of insurance is based on RISK, the possibility that you will need access to care.  We cannot build a system based on CERTAINTY, the knowledge that you will need care and that the cost of care is more than the cost of insurance.

The original law included the Individual Mandate, which penalized those who chose to not participate.  That has been eliminated.  There have been many attempts to weaken of sabotage the PPACA.  Last October the Trump administration published new guidance for Section 1332 waivers, the Obamacare provision that allowed states to improve the law.  Here is the link to the federal registry.  Reaction was swift and almost universally negative.

Most observers saw the new rules as a direct attack on people with preexisting conditions and the coverage that they so desperately needed.  The change allowed a state to note the existence of a Plan B (access to a policy compliant with the Patient Protection and Affordable Care Act) while actively promoting non-compliant policies that may not protect people with preexisting conditions.  It is no longer a “risk-free” risk if you destroy Plan B! 

Evaluations were quickly published by Deloitte, HealthTech Solutions, and Health Management Associates.  Within two months the Federation of American Hospitals, the American Academy of Family Physicians, and even AARP had weighed in and expressed concern.  These and others note the administration’s promotion of short term limited duration policies is designed to attract the healthier people from the comprehensive insurance market which will inevitably cause the prices to rise substantially.

The Democratically controlled House of Representatives passed H.R. 986 – Protecting Americans with Preexisting Conditions Act of 2019 last week.  This is the link to the text.  The goals of the legislation are:

  1. Prevent the destruction of the comprehensive insurance market (Plan B) by over-inflating the value and desirability of short term and other non-compliant policies.  
  2. To retain the value of the 1332 waivers in lowering prices by the creation of reinsurance pools and other innovations.  
  3. To enrage President Trump and draw a distinction between the political parties.

It is hard to guess whether or not this legislation will ever be addressed by the Senate, so goal 3 is the only certainty.  The White House issued a Statement of Administration Policy on May 7th, two days in advance of the final vote.  The final vote was primarily along party lines.  Republican Leader Kevin McCarthy published the amendments his members offered while the legislation was under debate.  My favorite was from George Holding (R-NC).  He proposed to change “the title of H.R. 986 to Insert Politically Punchy Title That Doesn’t Reflect The Bill Substance Act”.  That constructive effort garnered 184 votes on the House floor.  There isn’t any record on the Republican Cloakroom site of any productive amendments or any effort to improve the legislation.

I certainly hope that Mr. McCarthy and his buddy Mr. Holding never have to rely on Plan B.   Because if they have their way, it won’t be available when they need it.


Picture – No Outlet – David L Cunix

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Cynicism Taken To Its Illogical Extreme

Befuddled In Iowa

Senator Charles Grassley (R-IA) was confused.  As this video shows, he was conducting a town hall meeting when one of his constituents noted that her life was dependent upon the Patient Protection and Affordable Care Act (Obamacare).  He couldn’t understand why she was worried.  Preexisting conditions are covered under Obamacare and Obamacare isn’t’ going anywhere.  It is the law of the land.  Sure the courts could rule it unconstitutional, but that probably won’t happen.  She asked him about his votes to repeal the law.  He didn’t understand the question.  That was ancient history, over a year ago.  This constituent actually thought that his votes to repeal Obamacare were serious.

We are currently living in the age of cynicism.   From the moment that the last Republican Senator abandoned the negotiations that created the PPACA and forced the eventual party-line vote, we have had a consistent political pitch to repeal the law.  Through the first eight years the Republican controlled House of Representatives could pass as many bills as they wished without any fear of the consequences.  And even when the Republicans took over the Senate they had the safety of an adult in the White House.  There wasn’t any risk to their votes.  They could keep the base riled up, keep the campaign funds rolling in, and never worry that anything was going to happen.  And even when the Republicans controlled the House, the Senate, and the White House, there was always someone (McCain?) to save them from themselves.

The problem is that not everyone was in on the scam.  A significant portion of the American public benefited from the law.  They took every assault on the law personally.  The Medicaid Expansion provided access to health care to the working poor.  Guaranteed issue with coverage for preexisting conditions eliminated the fears of millions of Americans.  Young women were now guaranteed maternity coverage.  And children could stay on their parents’ policies to age 26.  Would they lose their coverage?  Worse, many of the Congressmen who cynically initiated the fight were eventually replace by people who weren’t in on the joke (see Eric Cantor).   And state legislators in red states picked up the fight and took to the courts.

This blog has discussed the Texas lawsuit.   The big news is that the Trump administration, once oddly neutral in the fight to retain coverage for preexisting conditions, is now committed to declaring the law unconstitutional and recommending that the entire law be overturned.  This has resulted in a new round of panic amongst diabetics, heart patients, and those of us who have battled cancer.  During Congressional testimony Attorney General Barr brushed off concerns, mostly because he doesn’t give a damn.  Senator Grassley told his constituent that the lawsuit will probably fail.  And if it doesn’t? 

Senator Grassley, in a separate interview, noted that his constituents have nothing to worry about.  After all, he and a group of his fellow Senators just introduced the Protect Act, S 1125.  There are three tells, three ways to know that this isn’t serious legislation. 

  1. 1.       If you look at the Senators’ press releases and websites (Grassley, Portman, etc.), there isn’t a link to the legislation, just glowing terms of what it supposedly would do.  There are also no details about how it would protect preexisting conditions in these press releases.
  2.       The legislation is cosponsored by 18 Republican Senators.
  3. 3.     Like most legislation that is for show, the text of the legislation begins with the usual preamble detailing the ills of Obamacare.  You can always spot BS legislation when the author doesn’t even bother to use the official name, The Patient Protection and Affordable Care Act, in the actual text.

I would review the legislation, but I see no reason to take it more seriously than the Senators who stuck their names on it.

Having failed to repeal The Patient Protection and Affordable Care Act without a viable replacement, the full force of the federal government is now trying to get the law overturned in the courts.  This has left more than a few people concerned about their health insurance, the way most Americans access and pay for health care.  And it has left at least one Senator, that guy in Iowa, totally befuddled.


Picture – Room 1200 – David L Cunix

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What If You, G-d Forbid, Use Your G-d Forbid Insurance?


The guy on the phone (a CPA!) wanted my opinion about a health insurance policy.  I’m not his agent and I wasn’t the first agent he called after buying this policy Friday from an out-of-state salesperson.  Steve (name changed) was looking for someone to congratulate him.  He had just beat the system!  Steve cut his family’s monthly premium in half to $700 and change.  So what if his new policy didn’t cover maternity?  He and his wife are long past that issue.  Steve insisted that I look over the benefits and quickly emailed the four pages.  Here are a few of the highlights:

All Benefits are Per Covered Person
Plan 4
In Hospital Indemnity – Pays a daily benefit for each day a Covered Person is Confined to a Hospital due to a Sickness or Accident. The first day of a Hospital stay must occur within 30 days of the Accident causing the injury.
Max Days per Confinement
Max Benefit Amount per Plan Year
ICU – Pays a daily benefit for each day of Confinement if an Accident or Sickness causes a Covered Person to be Confined to an Intensive Care Unit (ICU). The first day of Confinement in the Intensive Care Unit must occur within thirty (30) days of the Accident. This benefit is paid in addition to the In-Hospital Indemnity Benefit Amount.
Max Days per Confinement
Max Benefit Amount per Plan Year
ER Visit – Benefit pays if an Accident or Sickness causes the Covered Person to require and receive Emergency Medical Care in an emergency room of a Hospital. Treatment must be received within 24 hours of the Accident.
Max Visits per Plan Year
Physician Office Visit – Benefits pays for a Physician Office Visit as a result of an Accident or Sickness. The visit must be made to the Physician’s Office or Clinic. The visit to a Physician’s Office must occur within 30 days of the Accident causing the injury.
Max Visits per Plan Year
Ground Ambulance
Max Trips per Plan Year
Air Ambulance
Max Trips per Plan Year
Surgical Indemnity -Pays a Surgical Indemnity Benefit if a Covered Person has a Major or Minor Surgical Procedure performed while In-Hospital or an Outpatient basis in an Outpatient Unit.
Inpatient Major
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The Fifth Risk

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.*



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


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.


Picture – Observation Ain’t Enough – David L Cunix

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