The old definition of Chutzpah – A man kills his parents. He is tried and convicted.  As the court is about to announce his sentence, he stops the judge and begs for mercy because he is an orphan.  That’s Chutzpah.

The new definition of Chutzpah – After the Trump Administration has spent the last eighteen months intentionally destabilizing the health insurance marketplace, Alex Azar, the Secretary of Health and Human Services, publishes an article in the Washington Post with the headline “Obamacare forgot about you. But Trump didn’t.”  That’s Chutzpah.

Mr. Azar uses about a thousand words to trash the Patient Protection and Affordable Care Act (Obamacare), decry the rising premium costs that only some people have to pay, and tout the expansion of short term health insurance options.  He unfortunately ran out of space before he had an opportunity to mention any of the consumer benefits of the PPACA (guaranteed issue, coverage for preexisting conditions, etc…) or how President Trump and his administration have played a significant part in the premium increases for 2018 and 2019.

One of the points that Secretary Azar hammers is that people who get subsidies through the marketplace aren’t as negatively impacted by premium increases as those of us who pay the full premium. Yes, and the sun rises in the east daily.  This blog detailed how Mr. Trump’s Executive Orders and Trumpcare would balloon the deficit and raise premiums.  This was all explained last October.   Eliminating the funding for the Cost Sharing Reduction and the penalty for healthy people choosing to forego coverage (Individual Mandate) have had the predictable results.  The creation of an alternate health insurance marketplace for the young and healthy (Short terms on steroids) will only escalate the pricing crises.  It is hard to believe that someone with Mr. Azar’s resume wouldn’t know all of this, wouldn’t be able to explain this better than me, were he not a member of this Cabinet.

Mr. Azar wants us to know that President Trump didn’t forget us. This may a good time to pray for amnesia.  That and that Chutzpah is only fun to watch when you aren’t involved.


Picture – David L Cunix – He Had 4 Of A Kind


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Meet The New Boss

I felt like a time traveler. I was in a Mayfield Heights home, standing in a packed living room, listening to a political candidate dismantle the current administration’s (mis)handling of our country’s health care system.  Point by point the candidate highlighted the president’s statements and actions.  It was like shooting fish in a barrel.   The audience agreed with every point. Many of those in attendance volunteered to take yard signs and campaign.

I would have had a difficult time disagreeing with the generalities. I even found some of the details and potential solutions realistic.  But I still felt that I had been here before.

The advantage/disadvantage of a blog is the existence of a paper trail. OK. Now What? was published on November 3, 2010, the day after the Republicans regained control of the U.S. House of Representatives.

The Patient Protection and Affordable Care Act succeeded in energizing the opposition. Even centrist Democrats and Republicans were outraged by this combination of government overreach and intellectual dishonesty. Democrats representing swing districts, like John Boccieri, were pressured into supporting a bill that almost single-handedly caused their defeat.

Republicans have campaigned against the PPACA. Some have implied, some have even promised, to repeal this legislation. Can this legislation, passed only seven and a half months ago, be reversed? And, more importantly, do the Republicans want to?

NO and NO.

The Patient Protection and Affordable Care Act is not going to be repealed or reversed anytime soon. Oh, I’m sure Speaker-designate John Boehner will run a bill through the House. It will be great political theater. And, it will be risk free. The legislation won’t get through the Senate, and even if it did, it would be vetoed by the President.

I sincerely doubt that the Republicans would want to repeal this legislation. This is a fundraising bonanza. Campaigning against PPACA is far more profitable than solving the problems that necessitated the law.

So, we have a bad bill and the real possibility that cynicism may rule the day. Plus, we have yet to mention the insurers who have already spent millions to comply with the new rules and regulations. I firmly believe that the insurers have devised a path to real success under a government run health plan where they provide supplementary coverages. The major insurance companies would then have no desire to repeal the law.

We are quickly approaching the next calendar triggers of the health care legislation. It is possible that the Republican lead House of Representatives, far more interested in extending the Bush era tax cuts than anything else, might tackle meaningful reform in early spring. In a yet to be exhibited act of political maturity, the House could even draft a bill to limit and refine the PPACA. Such legislation could be passed by the Senate and signed by the President. It is possible. I leave the question of probability to you.

That was eight years ago. We are on the verge of a Blue Wave.  Some of the people swept into office will be as prepared as the candidate I heard Sunday afternoon.  Some will just be talented at pointing out President Trump’s obvious shortcomings.  Now, before the election, is the time to talk to the candidates.  Help them understand that health care is more than just a fundraising vehicle and that talking points don’t pay for medical bills.

Pray that we don’t get fooled again.


Pictures – David L Cunix – New Boss and Old Boss


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Make Insurance Cheap Again

The Wall Street Journal has never been a big fan of the Patient Protection and Affordable Care Act (Obamacare).  The paper has added gravitas to even the flimsiest of the alternate plans offered by the Republicans over the last few years.  But, the WSJ has also featured some of the deepest thinkers of the Conservative Movement.  One of these brighter stars is John C. Goodman, president of the Goodman Institute for Public Policy Research.

The Goodman Institute has been the intellectual force behind such policies as the recent Paul Ryan “Better Way” tax reform and other tax and health initiatives promoted by Republicans over the last twenty plus years. I confess that I have not been a big fan of their work.  A recent Opinion/Commentary piece from Mr. Goodman appearing in the WSJ did nothing to change my opinion.  Here is the link to the article.

My initial impression was that Mr. Goodman had strung together an interesting collection of non-sequiturs. Texas, the state that had the nation’s highest rate of uninsured, 27%, prior to the inception of Obamacare, appears to be a hot mess where the insurers and providers are still trying to get onto the same page.  We in Ohio are happy to not be Texans!   In Greater Cleveland we have watched the Cleveland Clinic partner with New York based Oscar to form a new partnership and Medical Mutual of Ohio cement a new relationship with University Hospitals.  It is a process and it is not without flaws.  2019 could be better.

I would have dismissed Mr. Goodman’s musing had it not been for this:

What’s driving this race to the bottom? The problem starts with the community rating system, which requires insurers to charge the same premiums to all comers regardless of health status.

Do you want cheap insurance? Do you want great coverage with access to the world’s best doctors?  According to Mr. Goodman and the politicians promoting his agenda, all we need to do is to return to medical underwriting.  We can save you a lot of money, if we are allowed to price our policies based on your health.    Of course, that only works, you only save money, IF YOU ARE HEALTHY AND STAY HEALTHY.  If you aren’t?  Oh well.

This blog started discussed the pitfalls of Community Rating in October 2009.  We, the insurance industry, can base our rates on you and the risk you present.  We have the statistics.  Age, gender, location, health status, hobbies, occupation, and even driving habits can impact your likelihood of having a claim.  One hundred years ago the insurance companies even charged premiums based on race.  The numbers, the math, determines the premium.  If we, as a society, choose to ignore or minimize these factors, the premiums are deemed to be fairer, especially if you are getting a lower rate.  The PPACA has insurers ignoring gender, health conditions, occupations, and hobbies.  The premium ratio between a 62 year old and a 22 year old was about 5 to 1 in 2013.  The PPACA limits that ration to 3 to 1.  All of these changes impact premiums.  Some people pay more.  Some people pay less.  And some now qualify for coverage when they would have been turned down a few short years ago.

Do we want to return to medical underwriting?

The Kaiser Family Foundation estimated that 52 million Americans would be declined for insurance if forced to submit to medical underwriting.  G-d knows I would be declined if my insurer was given a chance to ask me health questions.  And I remember what it was like to tell my clients that they were not eligible for regular health insurance coverage.  Is that the solution?

Maybe it is just different in Ohio. Maybe the concept of 27% uninsured seems like a bigger deal here, a place where a Republican governor fought to expand Medicaid to provide coverage for the working poor.  Taking insurance away from other people doesn’t make your insurance cheaper, not in the long run, not if we are going to treat the sick and injured.  Insurance is simply the way most Americans access and pay for care.  There can’t be cheap insurance paying expensive health care.  The two go hand in hand.  Managing health care costs, whether that is through provider networks or other limitations, will have to be part of the discussion.

Make Insurance Cheap Again? It was never cheap for some of us.


Picture – David L Cunix – Turning Back The Clock


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Attacked With A Dull Knife

The Patient Protection and Affordable Care Act (Obamacare) is under siege.  There is no need for a link here to back that up.  You already know this if you haven’t been asleep for the last eight years.  The law has withstood the faint-hearted assaults of the Congressional Republicans and a variety of presidential candidates.  And now health insurance, the way most Americans pay for and access care, is being attacked by a guy wielding nothing but bluster and a dull knife.  Obamacare vs. Trumpcare.  In the eternal battle between something and nothing, something always wins.

It has been a little over two weeks since the Trump administration, specifically the Centers for Medicare and Medicaid Services (CMS) announced that it would stop collecting and distributing money from the Permanent Risk Adjustment Program.  The government decided to retain $10,400,000,000 of the insurance companies’ money.  There are no taxpayer subsidies involved.

That has now been reversed.

In an email release Tuesday (because Tweets are reserved for the really important stuff!) CMS announced that it would release the money and reaffirm one of the basic pillars of Obamacare. Here is a link to the final rule. 

In CMS Administrator Seema Verma’s press release she notes, “Issuers (sic) that had expressed concerns about having to withdraw from markets or becoming insolvent should be assured by our actions today”.

The Cliff Notes Version: Nothing has changed!  Sure there were a couple of weeks of unneeded aggravation and another attempt to undermine the stability of the insurance markets, but in the end…  It is as if there really are adults, somewhere in Washington, who step in and stop Donald Trump before he can do too much damage.

We are a little over 90 days from the next Open Enrollment Period, the first without a penalty for failing to carry compliant coverage (Individual Mandate).  We are bracing ourselves for the last acts of sabotage, the last attacks on our system prior to facing our clients.  Thankfully, all he’s got is a dull knife.


Picture – David L Cunix – The Weapon


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Naked Aggression

Vladimir Putin was embarrassed on the world’s stage. Thousands of journalists, from print, TV, and online, were in Sochi for the 2014 Winter Olympics.  The pictures and stories of inept plumbing and shoddy construction made Putin look foolish and unprepared.  He changed the narrative and the world’s focus.  He invaded Crimea.  His attack of Crimea eliminated all discussion of the Sochi debacle.

Donald Trump appears to hold dictators and strongmen in high esteem.  He has noted that Xi Jinping of China has a lifetime gig.  He is outspoken in his appreciation of Rodrigo Duterte of the Philippines.  And he appears to have learned a lot from Putin.  Where Putin attacked Crimea, Donald Trump attacks our access to health care.  Last week was a particularly challenging week for the administration and the President again attacked our health care system.

CMS Stiffs the Insurance Companies

On Saturday, July 7, 2018, the Centers for Medicare and Medicaid Services (CMS) announced that it on would stop collecting and distributing money from the Patient Protection and Affordable Care Act’s (Obamacare’s) Permanent Risk Adjustment Program.  The Permanent Risk Adjustment Program had the insurers collect fees from everyone covered by insurance that would be distributed to the insurers proportionately to mitigate the costs associated with higher risk/claim clients.  From The Center for Consumer Information & Insurance Oversite on the CMS website:

“Reducing the incentives for health insurance issuers to avoid enrolling people with pre-existing conditions: The permanent risk adjustment program will assist health plans that provide coverage to individuals with higher health care costs and will help ensure that those who are sick have access to the coverage they need.”

This is an integral part of the market stabilization built into the PPACA.

In an act of naked aggression, the Trump administration is holding $10,400,000,000 of the insurance companies’ money.

Are you distracted? Will you forget about Scott Pruitt or the future of the Supreme Court or the needless fights with our allies when your health insurance premiums spike again?  The PPACA is surprisingly resilient.  The attempts to repeal it, though often just for show, have not been successful.  The sabotage from this Congress and President Trump have resulted in fewer choices and higher prices. Their goal has been to destabilize the insurance markets.  Here is a record of their achievements:

  • Remove the penalties of the Individual Mandate as of 2019
  • Shorten the Open Enrollment Period
  • Remove almost all funding for promotion and community outreach
  • Threaten to eliminate the funding for the Cost Sharing Reduction and when that failed to do enough damage, follow through with the threat
  • Attempted to eliminate or limit guarantees built into the PPACA
  • Encourage the creation of association policies and other options designed to cherry-pick the healthy from the general insurance pool.
  • Withhold money due the insurers and eliminate the future benefits of the Permanent Risk Adjustment Program.

Insurers, agents, and a variety of industry groups were surprised by the Saturday announcement.  The 2019 rates need to be filed now.  How should the industry respond to naked aggression?

There may not be a tank rolling into my parking lot, but I know when my clients and I are under attack.


Picture – Aggression – David L Cunix

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Having It Both Ways

The most cynical man in Washington was, once again, counting on the American public to believe his words and to ignore his actions. “Everybody I know in the Senate, everybody is in favor of maintaining coverage for preexisting conditions…There is no difference in opinion whatsoever”, said Senate Majority Leader Mitch McConnell last week.  Senator McConnell feverishly tried to block the passage and implementation of the Patient Protection and Affordable Care Act (Obamacare), and he has spent the last eight years trying to repeal it without a workable alternative, but please believe him when he says that he is concerned about your access to health care.  Worse, a certain percentage of the American public are prepared to dry Mitch’s crocodile tears.

This blog has discussed the political strategy of Republican-led states to sue the federal government over Obamacare. The Justice Department recently decided that it will no longer defend such provisions as the Individual Mandate and preexisting conditions in a district court case brought by Texas and a group of nineteen states.

Actions speak louder than words.  We have eight years sabotage and poison pills (see the abortion provision placed in last year’s Alexander / Murray negotiations).  Senator McConnell tells us that he is 100% in favor of protecting access to health insurance for the 52 million Americans under age 65 who have preexisting conditions, while simultaneously touting the Trump Administration’s new moves towards Association Health Plans and the destruction of the guarantees of the PPACA.  Mitch thinks that he can have it both ways.

There are, of course, responsible American leaders fighting Senator McConnell and Donald Trump. It is easy to point to Senator Sherrod Brown (D-OH) who recently said, “Families in Ohio will likely face higher premiums next year because of the actions taken by President Trump and Republicans in Congress.  Instead of working in a bipartisan way with Democrats to lower costs and expand access to care, we’ve seen this administration create instability in our health care system and it is hurting millions of hardworking families.” Easy, but the truth is that Senator Brown is running for reelection and too many will dismiss his comments, even though factual, as purely partisan.  We also need to hear from members of both parties who have shown as much interest in solving problems as scoring political points.

We need to hear from the governors.

A statement was released on Monday, June 18, 2018, from a bipartisan group of governors.  And yes two of them, John W. Hickenlooper (D-CO) and John R. Kasich (R-OH), seem to relish the opportunity to appear on the top of any bipartisan press release, but the other governors are new to this club of problem solvers.  The following statement was also signed by Bill Walker (I-AK), Tom Wolf (D-PA), Brian Sandoval (R-NV), Roy Cooper (D-NC), Steve Bullock (D-MY), Jay Inslee (D-WA), and Larry Hogan (R-MD).

Everyone in this country deserves access to affordable, quality health insurance. The Administration’s disappointing decision to no longer defend this provision of federal law threatens health care coverage for many in our states with preexisting conditions and adds uncertainty and higher costs for Americans who purchase their own health insurance.

Helping our neighbors get health insurance even though they have a preexisting condition is something Americans support and the Administration’s actions will hurt families in our states. This is not right.  We’re asking the Administration to reverse their decision and instead work with Congress and Governors on bipartisan solutions to protect coverage and lower health care costs for all Americans, all while protecting those with preexisting conditions.

Governors Kasich and Hickenlooper have been consistent in their efforts to make health insurance, our system of accessing and paying for health care, work for all Americans. They were fighting for sensible reforms last summer while Congress was attempting to dismantle the PPACA.  Where was Mitch McConnell last August while Kasich and Hickenlooper were discussing solutions?  By all accounts he was in his office licking his wounds after the defeat of his fictitiously named Better Care Reconciliation Act of 2017.

Joining the governors in this fight are business leaders, insurance executives, and any number of representatives of the doctors and hospital associations from around the country. Andrew Dreyfus, CEO of the non-profit Blue Cross Blue Shield of Massachusetts, is in Washington this week to discuss the importance of the consumer protections built into the PPACA.  According to the Boston Globe, Mr. Dreyfus will be pressing his case with a variety of congressional leaders.  I’m willing to bet money that he won’t get a chance to talk to Mitch.

And that is the question. Are Kasich, Hickenlooper, and Dreyfus simply spitting into the wind?  Is there a serious interest in Washington to help Americans to better afford and access health care?  That is an honest question in 2018.  And we won’t get any solutions as long as Congress and this President try to have it both ways.


Picture – Clip Art


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Sunset Of The American Dream

The United States is often called a nation of immigrants. Many of our families made the choice to leave their homes and make the arduous journey to a land that promised a better life, if not for them then at least for future generations.  A better life for some meant the right to practice their religion without government interference.  The American Dream included food for the hungry, prosperity for the impoverished, and freedom, a concept so alien that most could not define it, for all.

The American Dream is under attack.

Security. The American Dream is dependent on us feeling secure.  Secure in our faith in the rule of law.  Secure financially with a stable economy. Secure with access to quality health care paid, for the most part, by someone else.  Yes, someone else.  Most Americans have private self-paid health insurance, employer sponsored group coverage, Medicaid for the poor and working poor, Medicare for the disabled and elderly, or some combination of a couple of those.  This is hardly a perfect system, but it is ours.  Tampering with our process of compensating medical providers should only be done with the goal of improving the system.  Someone needs to explain that to the Trump administration.

The Trump Justice Department is actively trying to sabotage the Patient Protection and Affordable Care Act (Obamacare).  A main feature of the PPACA is the protection the law provides for those of us (about 52 million Americans under age 65 according to the Kaiser Family Foundation) who have preexisting conditions.  Unsatisfied with the destabilizing impact of removing the penalty associated with the Individual Mandate, the Justice Department has upped the ante and asked a district court to open the door to medical underwriting.   Donald Trump believes that we should return to the days when unhealthy people were charged more for their health insurance.  Denying coverage can’t be far behind.

This blog predates the PPACA by over a year. The Patient Protection and Affordable Care Act was a compromise bill created by Republican and Democratic lawmakers.  It both suffers and benefits from those compromises. But it was still being drafted right up to the vote and this blog has been clear that the PPACA was poorly written and much, too much, was left in the hands of the regulators.  This blog is neither defending the law nor the process.  But, our system was working to adjust to the changes initiated by the law.

There have been two types of Republicans since the passage of the PPACA, those who understand the nature of the law and cynically campaign and fundraise against it, and those who really don’t understand our health care system.  There was never been a comprehensive Republican alternative to Obamacare.  But the Republican tax bill that eliminated the penalty, as of next year, for failing to carry insurance, Trump’s decision to eliminate funding for the Cost Sharing Reduction, and this new effort to reduce access for Americans with ongoing health issues, usher in the era of Trumpcare.


Trumpcare                                                                              Obamacare

Erase a legacy                         Goal                                        Access to care

Destabilize                              Markets                                  Adjusted in time

Price based on health             Underwriting                         Community pooling

Short term politics                  Vision                                      Focused, if flawed

Guaranteed to fail                  Success                                   Needed to evolve


Some states are trying to stave off the disaster of Trumpcare.  Governor Phil Murphy (D-NJ) and Governor Phil Scott (R-VT) have recently signed legislation that will codify the Individual Mandate in their states.   New Jersey has also passed legislation that will take the money raised by the penalty to form a reinsurance fund to further help stabilize the market.  Several other states are reviewing similar actions.  Ohio, this being an election year, is marching in the opposite direction.

I cannot sit silently and watch the American Dream being attacked. How much worse it is when that attack is from within?


Picture – David L Cunix – Sunset Of The American Dream

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Out Of Sight. Out Of Mind. Out Of Money.

You may be forgiven if you haven’t been focused on the looming health insurance crises. Most of us are on information overload.  With the daily revelations of inappropriate business deals and the on again / off again nature of the summit with North Korea, who has time to contemplate the administration’s ongoing war with Obamacare (Patient Protection and Affordable Care Act)?  That’s our job.

Over 150 million Americans get their health insurance at work. The premiums are paid by their employers.  The employees’ portion, if any, is deducted from their paychecks.  Most of our clients on individual coverage (non-group) have the premiums deducted automatically from their credit cards or checking accounts.  The premiums are a huge issue in November, when the clients see next year’s price, and January, when that first higher amount comes out of the account.  Otherwise, the cost of insurance is just another part of that great American mystery, “I work hard, but I can’t seem to save any money!”

There are, of course, lots of Americans challenged by the recent changes in health insurance, our method of accessing and paying for health care.

It is fair to say that President Trump and the Republican-controlled Congress, having failed at repealing Obamacare, have quietly settled on sabotage.  The strategy might work.

The first salvo was President Trump threatening last spring to eliminate the funding for the Cost Sharing Reduction. The risk of losing millions of dollars chased insurers like Anthem Blue Cross out of the market.  He can play politics with the health care of millions of Americans, but the insurers who must answer to shareholders cannot.  Those insurers that remained in the market were forced to substantially increase their premiums.   Anthem’s decision to leave as well as the pricing moves by those that stayed were confirmed when Trump eliminated the funding in October.

Premiums are about to take another unnecessary jump. The Congressional Budget Office is projecting a 10% annual increase due to the most recent tax bill that eliminated the penalty for failing to carry compliant health insurance beginning 2019.   Killing the Individual Mandate will cost us 10% per year!  Without the (negative) incentive to retain coverage, many healthy Americans will drop their major medical policies and either go bare or purchase short term policies.  You can’t fund a health care system with just the sick and the responsible.  Premiums will rise exponentially. The CBO estimates that this alone will cause 4 million more Americans under age 65 to join the ranks of the uninsured in 2019.

The increase in premiums has been forcing more Americans to choose less comprehensive policies. Our top selling contracts may cover preventive care at 100% without copays or deductibles, but your child’s strep throat, with office visits, testing, and Rx, may cost you $100 or more.  It is not unusual for someone to have a $5,000 or $6,500 deductible.  That amount seems incidental if you have a major claim over $100,000.  But lots of people have smaller claims, under $10,000, and find that they are paying the entire bill.

The average American has about $1,000 in savings.  Where will that person find $4,000 or $5,000 the next time he/she slips on the ice or trips on an uneven sidewalk?

The limitations, restrictions, and network reductions of our new health plans are ignored or forgotten until you get sick or injured. And then it is too late.  And then no amount of stories about Korean missiles will get your mind off your bills.


Picture – Surprise! – David L Cunix

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There Is A Doctor In The House

Health Insurance Issues With Dave has interviewed doctors, hospital executives and other members of the health care industry.  Today is the first time I’ve handed the keys to a guest columnist.  

I am proud to introduce my high school friend Gregg M. Gaylord MD.  Dr. Gaylord is a Fellow in the Society of Interventional Radiology and is in the independent practice of medicine in Milwaukee, WI. He graduated U. of Cincinnati College of Medicine in 1981, and is Board Certified in Diagnostic/Interventional Radiology.

“I’m mad as hell…”

This famous line from the movie “Network” pretty much sums up how I feel about the now ubiquitous health care “network”.  Nearly every health insurance plan comes with some form of network that either pays only for services provided by physicians, hospitals, and other providers in-network (IN), or has a higher copay and deductible if you choose to go out-of-network (OON).

Networks of providers are formed by payers such as Medicare Advantage and health insurance plans who solicit special pricing from major medical centers and professional medical groups as well as medical labs, surgery centers, hospitals and other entities. In exchange for accepting what are usually lower fees, the IN providers gain exclusivity under the insurance plan. If you aren’t accepted into the network or won’t accept their contract, you can’t treat patients and expect to get paid by the insurance plan.  Independent individual providers are often excluded from networks, particularly on the individual “Obamacare” exchange plans. Some plans will pay for OON benefits, but at a much higher cost to the patient.  Deductibles are often doubled and depending on the type of plan, coverage can also be reduced by a significant percentage.  In many cases, a plan pays ZERO for out-of-network care except for emergencies.  And many of these plans have no network providers – therefore no coverage – outside of the state where you purchase the plan (again, unless there is an emergency, though once the emergency subsides you once have to use an IN provider).

Not every plan has a narrow network. Some plans still offer a broad choice, but these are often group policies provided at your job or through Medicare and Medicaid programs that offer a variety of options though at vastly different premium pricing.  If you are fortunate enough to have a broad choice of providers, you can usually keep your doctor.  But this is not always the case, and many employers are also limiting their plans to those with a narrow network in order to stave off – at least temporarily – large premium increases.

So what’s the beef? Purchasing a plan in the individual market usually comes with a narrow network plan with a narrow list of IN providers that has no OON benefits.  If your doctor is not in the network, too bad.  Pay for your own care out of pocket.  Don’t like the hospitals in your plans network?  Again, too bad.  Pay for it yourself.  The sales pitch is that your plan will reduce costs and therefore reduce premiums, and that by narrowing the network, health care providers will work together to provide higher quality of care.

But is it working? No one is sure at this point. Some plans are showing a relative premium reduction of 6-7% compared to plans with broader networks.  But premium prices are still headed up.  Predictably, by narrowing networks there is an incentive for hospitals and health providers to merge and consolidate services – a trend that started during the early Clinton years but is now accelerating.  This has led to upward price pressure in many markets.  And perhaps even worse, these consolidated models have yet to prove long-term quality improvement on a broad scale. Unfortunately, we know that failure to prove better quality has not prevented this model from moving forward. One example of failure to prove benefits prior to implementation of policy is the requirement for nearly all physicians and hospitals to utilize Electronic Health Records.  The benefits of EHR’s have yet to fully materialize, but the unintended consequences have included physician burnout, less time for nurses and doctors to interact with patients, and more and more reporting requirements that seem to add nothing to quality health care at this point.

Will narrow networks also lead to unintended consequences? In 2017 for the first time in the United States, independent physician-owned practices are no longer the majority. Employed physicians and independent physicians each constitute about 47% of physician practices.  In many cases, employed physicians are seeing drastic income reductions – something that may or may not prove beneficial to the system as a whole.  But a disturbing trend is the loss of autonomy in decision making which is being replaced by decision-making algorithms, management economic decisions, and incentives to increase referrals and therefore income “within the network”.  Worse yet, in some cases physicians are being punished for not generating sufficient income to the system.  Perhaps this will end with newer models of health care that shift responsibility and risk to the providers and the incentives will be to provide less care at lower cost.  Will higher quality result?  No one knows.

Bottom line? As networks narrow there is an incentive for providers to merge, and there will be fewer and fewer networks and hence physicians and hospitals to choose from. The doctor-patient relationship is being fractured ever more by third party payers and managers.  Patient choice might become a thing of the past, and in some case already has.

What will the response be by the very human providers? There seems to be a reversal brewing from the employed physicians who are seeking to go back to the independent physician or independent physician group model as they feel less and less valued in a system that places remote management in charge of decision making.  Some call this the “corporatization” of medicine – something that is already highly developed in the United States.

Until then, many providers are “Mad as hell”. And at some point – I wonder – will they “Not take it anymore”?

Gregg M. Gaylord MD

Special thanks again to Dr. Gregg M. Gaylord for providing us with his insight to the changing landscape of the health care industry.

Picture provided by Dr. Gaylord




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The Truth, And Getting Fired, Will Set You Free

Here is the key question: Did Dr. Tom Price, a longtime Republican Congressman from Georgia and, most recently, the Secretary of Health and Human Services (HHS), know that dismantling the Patient Protection and Affordable Care Act (Obamacare) was a terrible idea for all of the last eight years or did he just now realize the negative impact of his actions and advocacy?

Dr. Price recently spoke at the World Health Care Congress, an important meeting of the major stakeholders of the health care industry.  In a moment of clarity, the former champion of the repealing of all that is Obamacare said this about eliminating the Individual Mandate:

There are many, and I’m one of them, who believes that that will harm the pool in the exchange market. Because you’ll likely have individuals that are younger and healthier not participating in that market, and consequently that drives up the costs for other folks within that market.

Don’t worry. Within in a day he was walking back his statements, claiming that he was being quoted out of context.  As this blog has long contented, the first casualty of the creation of the PPACA was intellectual honesty.  Dr. Price is now hoping that nonpoliticians, such as his current employer, a health care staffing company, will focus on his new understanding of insurance basics.  Dr. Price is also hoping that his old buddies in the Republican controlled Congress will ignore his moment of candor and welcome him back in the club when he comes calling.

There are any number of Republicans who, now that they have chosen to not run for reelection, have suddenly been gifted with clarity and/or honor. Exhibit one for most people was John McCain’s July 2017 thumbs down, the final vote to defeat the Republican’s attempt to repeal Obamacare.  Most Americans forget that two other Republican Senators, Susan Collins of Maine and Lisa Murkowski of Alaska, had already voted against the poorly crafted measure.  Were they the only three members of the majority who knew how disastrous repealing the PPACA without a real replacement would be for American, or did a number of cowards and hacks breathe a sigh of relief when McCain stood up in their place?

Now the airwaves are filled with the brave and honorable. Charlie Dent (R-PA), Jeff Flake (R-AZ), and Bob Corker (R-TN) are just a few of the guys who suddenly feel compelled to share their thoughts on a variety of issues.  And, one by one, as members of Congress and this administration become ex-Congressmen and ex-federal employees, we will get more honesty about both domestic and foreign policy.  The input from insiders, no longer shackled by partisan talking points may help us to create better health care regulation.

First, we will have to forget so much of what these politicians said in the past. We need to say that it is all right now.  Because the truth, no matter when it is delivered, should be welcomed.  And it will set you free.


Picture – The Adult in the Room – David L Cunix

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