When Failure Is Not An Option

I completed both the Sudoku and the crossword puzzle from today’s newspaper.  I tackle these puzzles each day at breakfast and finish them, if I have a chance, later in the day.  The puzzles become more successfully challenging as the week progresses.  Solving Monday’s puzzles is really no big deal.  Friday and Saturday require more skill.  But be it Monday’s or Saturday’s, I hate to fail and give these games my best effort.

Insurance agents, especially those of us who have been practicing for decades, are used to a good challenge.  And, we hate to fail.  You might think that this is about selling.  It is not.  I am talking about the challenge of finding good, affordable health insurance for our clients.    This is not a game.  People’s lives depended on our success.  And that success was not guaranteed.

“Dave, you’ve got to find coverage for Jane or she’s gonna die.”

The name has been changed, but those words still ring in my ears nearly twenty years after a panicked husband called my office right after the association covering him, his wife, and hundreds of others lost their group insurance.  Her advanced cancer and other conditions made her virtually uninsurable.  Ohio and other states had a backstop at the time, a patchwork of HMO insurers that were forced to have periodic open enrollments.  The policies were limited, incredibly expensive, and difficult to access.  There were other failsafe options, like the association I had found for them two years earlier, but they were quickly disappearing in the early 2000’s as preexisting conditions overwhelmed our system.  And yes, I was able to find Jane and her husband coverage for her last couple of years of life.  It was one of my greatest professional successes.

There are those who would like to return to the way is used to be.  Let’s talk about what if was like to purchase a health insurance policy for you and your family in 2009.  You called my office and I asked you about your family’s health history.  I needed to know the entire health history of you, your spouse, and your children.  Sure you were prepared to answer questions about cancer and heart conditions, but I also needed to know about your kids’ ear infections and diagnoses of ADHD and asthma.  Our next questions dealt with accidents.  We then moved on to your driving records and whether or not you rode a motorcycle or traveled out of the country, and where.  You might be able to provide the answers we wanted to hear.  Lots of people couldn’t.

The insurance companies then had up to four options:

  1. Issue the policy at the standard rate
  2. Offer you a policy at a higher rate reflecting your higher risk
  3. Offer you a policy that excluded your preexisting conditions and/or hobbies (riders)
  4. Decline to issue a policy for one or more members of your family

Different companies accepted different risks.  Our job as independent agents was to find the company that would do the best job to insure each client (risk).

The Patient Protection and Affordable Care Act put an end to the underwriting of individual (non-employer sponsored) health policies.  This opened the door to millions of Americans with preexisting conditions.  There are now three questions:

  1. What is your date of birth?
  2. What is your home zip code?
  3. Do you smoke?

Here is my question – Do you really want to go back to 2009?

There are those in congress, in certain state capitals, and currently in the White House who would like to eliminate Obamacare.  And since there is no alternative, no other plan, no other fully-formed option waiting to immediately kick-in the minute the PPACA is repealed or declared unconstitutional by the Supreme Court, if you eliminate Obamacare you would return to 2009.

In 2016 the Kaiser Family Foundation found that 52 million Americans have preexisting conditions that would have precluded coverage under pre-Obamacare underwriting.  That is a little less than 20% of our under age 65 population.  One of them might be you or your family.

I love a good challenge, but I prefer my daily Sudoku and crossword puzzles, where there are no consequences to failure, to finding live-saving health insurance for less than perfectly healthy families.



Picture – Today’s Challenge – David L Cunix

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Assessing The Risk

The Merriam-Webster definition of insurance is:

…coverage by contract whereby one party undertakes to indemnify or guarantee another against loss by a specified contingency or peril

The steps are always the same whether we are talking about life or car insurance, health or fire insurance, or even if we are insuring whether a ship can load in Viet Nam and successfully deliver its cargo in San Diego.

  • Assess the risk
  • Pool it with like risks
  • Determine the cost to insure the risk based on the known factors plus the administrative costs and potential profit
  • Tender an offer to the potential client to insure the risk

Everything begins with Assessing the Risk.  And to assess a risk you must have good information.  The insurance industry can trace its success to its mastery of asking the right questions, from the right people, to fully understand the risks it has been asked to cover.  Anyone who has ever purchased a meaningful amount of life insurance remembers the health questions, the physical, and the insurer’s request for medical records.  The industry is constantly searching for better ways to develop a more complete picture of its clients.

Information is the key.

The health insurance industry, even in an era where we don’t do health screening questions of most of our clients due to the Patient Protection and Affordable Care Act (Obamacare), still depends on good, complete information to properly assess the risks we hope to insure.  And in the year 2020, information appears to be in short supply.

COVID 19 – How will the Coronavirus impact our health insurance premiums?  Honest answer – Who knows?  Really!  I’ve seen reports that we will eventually have Hell to pay for the outrageous cost of care, the sudden expansion of the ranks of the uninsureds, and the general upheaval in the hospital and business communities.  Others point note that COVID didn’t impact all parts of the country equally, that many non-emergency procedures such as hip and knee replacements were put on hold (which saves money), and the general resilience of the industry as reasons to shrug off the possible impact of the pandemic on our rates.  Both viewpoints are valid.  We don’t have nearly enough information to know how COVID 19 will impact rates for the years to come.  But we’ve never really had enough information on this disease.

President Trump is quoted in Bob Woodward’s new book, Rage, on February 7, 2020:

It goes through air, Bob. That’s always tougher than the touch. You know, the touch, you don’t have to touch things. Right? But the air, you just breathe the air and that’s how it’s passed.

And so, that’s a very tricky one. That’s a very delicate one. It’s also more deadly than your – you know, your, even your strenuous flus. You know, people don’t realize, we lose 25,000, 30,000 people a year here. Who would ever think that, right?

This is more deadly. This is five per- you know, this is five percent versus one percent and less than one percent. You know? So, this is deadly stuff.

This was/is important information.  Millions of Americans, not just insurance companies, could have done a better job assessing the risk COVID 19 posed to our families had we had good, complete information in January or February.  We as a country could have done a better job fighting this pandemic had there been one message, honestly delivered, from the White House on down.  To this day we have people mocked for wearing masks in public, often by people who really should know better.   The insurance industry, like the rest of the country, has been trying to sift through competing narratives in search of the truth, the hardest possible way to assess a risk.

The Texas Lawsuit – The Supreme Court will hear the Texas Lawsuit, the Trump / Republican request to declare Obamacare unconstitutional, on November 10, 2020.  Anyone following the current Senate knows that not only is there no Republican alternative should the case win, but it is unlikely Mitch McConnell could get his caucus to agree on much of anything.  The Texas Lawsuit is the equivalent of driving our entire health insurance system, the way most Americans access and pay for health care, over the cliff and Mr. McConnell has spent most of the last 3 years removing the guard rails.  How do we, as an industry, assess this risk?  What do we do if we are forced to start over?

We are about to enter the 4th quarter of 2020 with more questions than answers and more risk than we’ve known in quite some time.



Picture – Old School – David L Cunix

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Trump Draws A Lucky Ten

The Supreme Court gave the Trump administration a gift this week.  The Court ordered oral arguments for the Trump-backed Texas Lawsuit to begin on November 10, 2020, one week AFTER the election.  This allows Donald Trump to claim to be in favor of protecting Americans’ access to health insurance, even if they have preexisting conditions, while actively working to overturn the Patient Protection and Affordable Care Act, the law that currently makes this possible.  20 million Americans losing their health insurance during a pandemic would also appear to be of no concern to this administration.  That, too, may get missed by the lack of TV coverage prior to the Supreme Court hearing.

We would like to think that the Supreme Court will once again rule in favor of Obamacare.  Health care accounts for approximately 20% of our economy.  And health insurance is the way that most Americans access and pay for their health care.  But the Texas lawsuit could throw our entire system into disarray.  There are no guarantees that this Supreme Court will protect us this time.

So your assignment for today is to call, write, or email your Congressional representatives, House and Senate, and ask each of them what they are going to do if the Trump administration is successful and the Texas lawsuit wins.  Demand an answer.  Remember, your Republican representatives have voted dozens of times to repeal the law.  What would they do if the PPACA were to be declared unconstitutional?  It is what they allegedly wanted.  I’ve asked that question. I’ve never received an answer.  And for your Democratic representatives, ask them what they would do differently this time.

There will be no place to hide if millions of Americans suddenly lose their coverage.  Our country will need real leadership.  We will need the men and women of Congress to draft real legislation to solve this problem.  It can’t be done by edict.

The Supreme Court won’t hear this case until November 10th.  The court of public opinion may rule a week earlier.



Picture – The Ten Of Trumps – David L Cunix


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Special Delivery

A recent study led by Stacie Dusetzina, PhD, published in Health Affairs, found that Medicare Part D (Rx) plans encouraged the use of generic medications over the name brand drug.  The senior citizen pays significantly less for the generic equivalent.  And the best deals are available on the most commonly prescribed generics, often referred to as Tier 1 or Preferred Generics.  Medicare Part D policies incentivize, damn near beg, seniors to use the mail delivery option.  Many policies not only forego the deductible on Tier 1 medications, they will even send a 90 day supply directly to your home at no cost.  It is hard to turn down free.  A lot of my clients take advantage of this benefit.

The U.S. Department of Veterans Affairs is very proud of their ability to serve our veterans’ pharmaceutical needs.  The link to their site notes that in 2016 the V.A. processed 470,000 prescriptions daily.  It is impressive that 330,000 veterans received a package of prescriptions in the mail EVERY SINGLE WORK DAY.  That was four years ago.  Mailing medications saves the V.A. money, saves our veterans money, and it is convenient.

The elderly and disabled may not have easy access to a drugstore or V.A. facility.  The mailbox is only steps away.

We depend on our mail system for the delivery of medications, letters, packages, and yes, for ballots.  Anything or anyone who slows the delivery of the mail will negatively impact all of these needed services.



Picture – A Different Medical Device – David L Cunix

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Just Politics?

Otto von Bismarck is credited with “Politics is the art of the possible, the attainable — the art of the next best”.  The goal is not to posture and make noise.  The goal is to govern and get things done.  As in any art, there are greats, near greats, and others.  The US government is a huge stage.  The greats shine.  The near greats and others are exposed.

I spent a good part of today slogging through the 393 pages of H.R. 6800, the HEROES Act.  The US House of Representatives passed this bill on May 15, 2020.  There is a talent to drafting legislation, to knowing your goals and working through the various previously passed laws to get to your desired results.  The bill, like all Congressional bills, has any number of items which any of us could disagree.  Legislation produced by either the House or Senate are starting points.  The final legislation is produced in the conference committees that work out the final details.  The House got their work done on May 15th, over two and a half months ago.  The Senate couldn’t generate its bill by its own deadline of last Thursday.  There is way too much disagreement within the Republican ranks and President Trump and his team seem to have different goals.  A Republican compromise was released this week.  It was DOA.   Senator Lindsey Graham (R-S.C.) is prepared to immediately jettison one the White House’s priorities, a billion dollar plus new FBI building and has guessed that over 50% of the Republican Senators would vote against their own opening gambit.  There is no Senate bill.  The basis of all future negotiations will be the HEROES ACT.  So let’s take a look.

H.R. 6800 impacts almost all Americans.  Since this in Health Insurance Issues With Dave, we should take a look at a few of the provisions specifically relevant to health insurance.

  • Provide significant funds to the Center of Medicare and Medicaid Services for Program Management dealing with coronavirus on the state level
  • Create a Special Enrollment Period for individuals over and under age 65
  • Allow the government to pay for COBRA for those impacted by COVID 19
  • Modify and expand the Paycheck Protection Program
  • Increase the flexibility and carry-over provision of the Flexible Spending Accounts (FSA)
  • Relax the employer filing requirements of certain employer/insurance forms
  • Eliminate cost-sharing for COVID 19 treatment
  • Provide funding and establish requirements for COVID-19 testing and contact tracing
  • Require employers to develop and implement infectious disease exposure control plans

Details?  It is probably best to look at this as just part of a starting point.  Negotiations will begin in earnest in the next day or so.  Millions of Americans are dependent on state based unemployment insurance and the extra money provided by the federal government.  That is currently $600 and set to end this week.  The Heroes ACT extends the $600.  The current Senate offer is $200.  Again, this extra money ends in a few days.  That may be the main focus of this week’s talks.  The rest, such as FSA flexibility and COBRA funding, will fall into place.  This blog will report the results as available.

But if you are unemployed, if you are trying to determine how to pay for your COBRA health insurance, this isn’t politics and the art of the possible.  This is money and the key to survival.



Picture – Grand Masters – David L Cunix

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Picking Your Battles

Senator Claire McCaskill (D-MO) knew that she was going to have a tough reelection race.  It was 2012 and Missouri had taken a turn to the right.  Mitt Romney was going to beat President Obama.  The key would be to choose her opponent.  Knowing his weaknesses, Senator McCaskill chose Representative Todd Akin and helped his campaign.  It has been eight years and many of you still recognize his name and his statements about “legitimate rape”.   McCaskill picked her battles and won the war.

This blog has detailed the Obama administration’s decision to include birth control pills, IUD’s, and the Morning After Pill as part of the Preventive Care Benefit of the Patient Protection and Affordable Care Act (Obamacare).  The first of close to a dozen posts about this issue was More Free Stuff which was posted on July 24, 2011, almost nine years ago.  To be clear, I was not then nor am I now personally opposed to these forms of birth control.  This is not about my personally held beliefs.  Nor do the inclusion of or opposition to these birth control methods have much to do with medicine, insurance, or health care.   This is a battle over control and religion.  Kathleen Sebelius, then the Secretary of Health and Human Services (HHS), picked this battle.  And she won the war, until this week when the war was lost.

The Supreme Court decided in a 7 – 2 vote this week that businesses could limit or exclude coverage for birth control under religious or moral grounds.  The case, Little Sisters of the Poor Saints of Peter and Paul vs. Pennsylvania, was nine years in the making.  Chief Justice Roberts has expressed his frustration in having the birth control issue making its way to his court again.  He couldn’t understand why the two sides couldn’t find a way to accommodate each other’s beliefs and needs.  I am personally shocked that the Chief Justice would actually expect either side to want to accommodate the other, much less make an honest effort at accommodation.

The Obama administration proposed a compromise in February 2012.  The impacted employers wouldn’t have to pay for birth control.  The employers could opt out and the insurance companies would front the cost.  As noted in my post of February 13, 2012:

Senator Roy Blount (R-MO) quickly released a statement via email.  It stated, in part:

“It’s clear that President Obama does not understand that it isn’t about cost – it’s about who controls the religious views of faith-based institutions.  President Obama believes that he should have that control.  Our Constitution states otherwise.

Just because you can come up with an accounting gimmick and pretend like religious institutions do not have to pay for the mandate, does not mean that you’ve satisfied the fundamental constitutional freedoms all Americans are guaranteed.”

A year later in the post The Great Imposition, February 11, 2013, we learned that there were people who weren’t just offended that their businesses might be providing birth control to their employees.  We then discovered that the inclusion of birth control in individual policies meant that other people will be able to make their own decisions.  There appeared to be a large number of Americans who felt compelled to impose their religion/morality/choices on others.  You may not have realized that you were accepting someone’s definition of religion when you were accepting a job in their machine shop or dental office.  Now they were upset that they couldn’t extend their reach to complete strangers.

According to the Jesuit Review, in a survey of American Catholics including many who go to Church regularly, “just 8 percent said contraception is morally wrong, with 89 percent saying it was either morally acceptable or not a moral issue at all.”  This, again, is a reminder that this entire issue is about control and religion.

As we have previously discussed, our health insurance policies covered birth control pills even when they didn’t.  Under the old rules, teenage girls would complain about difficult menstrual issues and the family doctor would prescribe birth control pills to help regulate their cycles.  Two problems solved!  The pills weren’t free, but the parents who could afford the cost didn’t mind.  Those who could not afford the cost of the monthly prescription were sent to Planned Parenthood (yes, that Planned Parenthood) for a reduced cost or even free.  This was a workaround, neither efficient nor 100% honest.  The PPACA ended all of that.  Birth control was now available to everyone, not just to those who could afford it.  Universal access was not universally appreciated.

We learned in 2010 that corporations are people.  People may not be people.  Certainly people aren’t always treated as people.  But corporations are not only people, but it turns out, as I noted in a post from July 3, 2014, these entities can even have sincere convictions.  The Supreme Court (Burwell vs. Hobby Lobby), days earlier in a 5-4 decision, continued the trend of dehumanizing individuals while we anthropomorphize corporations.

This week’s Supreme Court decision was in response to a Trump administration action taken in October 2017.  At the time this action seemed as much about Trump scoring A Small Victory as it did about birth control.   The key was that it opened up the possibility of eliminating the benefit under either religious or moral grounds.  In my opinion the most important issue was that since the Obama administration had the power to define these forms of birth control as part of Preventive Care, the Trump administration could just as easily change the definition.  Two of the more liberal justices, Elena Kagan and Stephen Breyer, agreed that that each administration had the right to create exemptions.

So what does it mean? When it comes to the Supreme Court, I always turn to Amy Howe a reporter at ScotusBlog.  Here is her summation:

“As both Alito’s and Kagan’s opinions suggest, the battle over the exemptions from the birth-control mandate may not be over yet. Instead, the dispute will go back to the lower courts for them to weigh in on whether the expansion of the exemptions was the product of reasoned decision-making, virtually guaranteeing that the litigation surrounding the exemptions will continue until well after the 2020 election. And depending on the results of the election in November, a change in administration could lead to efforts to narrow or eliminate the exemptions. But at the very least, today’s decision cleared the way for employers to claim the exemptions going forward.”

We can’t always pick the battles we wish to fight, nor is there ever a guarantee of victory.  Former Senator McCaskill easily won in 2012, but she lost by 6% in 2018.  The battle over the access and payment of birth control will continue.  Each side will celebrate some victories and each side will suffer some defeats.  It is a battle both sides want.



Picture – Armed With A Pen, Hardly Dangerous – David L Cunix


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Construction vs. Destruction

Ronald Reagan famously said that the most terrifying words in the English language are, “I’m from the government and I’m here to help”.  The line garnered laughs and applause whenever he delivered it.  We’ll never know who wrote the quip or whether he really believed it.  But he had been an actor and he delivered the line with style and it was well received.  People in the southeast, an area ravaged almost annually by hurricanes from the Atlantic or the Gulf of Mexico, failed to see the irony.  The people living in the tornado alley states of Oklahoma, Kansas, Iowa, and others also cheered the line.  And so it became apparent that federal help (money) is good help as long as it is for you and wasted if it is for someone else.

Some of us are looking for a bigger picture, a way to describe the value of federal help, money, and regulation that can potentially help large segments of the American public.   The expansion of Medicaid, a federal-state partnership to provide health insurance to the poor and working poor, is one of those programs.  The Medicaid expansion was a key component of the Patient Protection and Affordable Care Act (Obamacare).

I had the great pleasure of hearing freshman Congresswoman Lauren Underwood (D-IL) speak while I was in Washington a few months ago.  Prior to her election she had been a nurse.  She drafted H.R. 4996, Helping Medicaid Offer Maternity Services (MOMS) Act of 2019.  Her legislation was designed to expand Medicaid services a full year postpartum.  The logic was clear.  “The majority of pregnancy-related deaths happen after the day of delivery, and nearly one quarter of deaths happen more than six weeks postpartum.”  It took a nurse to bring this to Congress’s attention.  I was so impressed with her presentation that I went to her office and got more information from her legislative aide.  Who benefits from this expansion of Medicaid?  Obviously the families of the women who have just given birth.  These are families in urban, suburban, and, importantly, in rural areas.  This also helps to make sure that medical providers, doctors and hospitals, are compensated in these settings.  Rural hospitals suffer from uncompensated care.  This is a solution.

H.R. 1425 – The Patient Protection and Affordable Care Enhancement Act includes Congresswoman Underwood’s Medicaid expansion.

The House of Representatives passed H.R. 1425 earlier this week.  The goal is to make the PPACA more effective.  Like the bill it is tweaking, this enhancement is neither perfect nor likely to garner a lot of support from the Republicans in the Senate.  The point is to put forth constructive, useful rules to make it easier for Americans to access and pay for health care.

My blog post from eight years ago today scoffed at the intellectual dishonesty of repeal and replace and asked instead for revise.  H.R. 1425 is a good starting point for an honest debate about revising the PPACA.  Sadly, you can only have a serious policy debate if you have participants from both political parties and the attention of the president.

H.R. 1425 has its detractors.  Some are just the usual suspects who appear to believe that they were elected to Congress simply to disagree with whatever the other side does.  We won’t waste time on them.  Nor will we mention some of our Congressional delegation more intent to have their pictures taken than to ever do anything.  There is a good chance that these Congressmen have not bothered to read the bill.  They have legislative aides for that.

The American Action Forum “is a center-right policy institute providing actionable research and analysis to solve America’s most pressing challenges.”  Christopher Holt, the Director of Health Care Policy, published an executive summary of H.R. 1425 on June 25, 2020.  This is the link.  It is only 7 pages and worth the read.  Spoiler Alert – he is not a fan.

Mr. Holt’s analysis is instructive.  You may like what he dislikes.  Or, your thoughts find a home in his words.  What is clear is his honesty about how his perspective impacts his view of the law.

Here are some of the key goals and provisions of the Enhancement:

  • Reduce premiums by bringing healthy people into the insurance pool. This is done by limiting and/or eliminating short term policies
  • Expand the Tax Credit Subsidy to make insurance more affordable
  • Fix the “Family Glitch”, the problem when the employee has coverage from work, but the coverage for dependents is too expensive. This was determined to be a huge issue since 2014.
  • Provide funding for reinsurance on the state level. The states that have done this have shown real savings on insurance premiums.  We keep hoping Ohio would do this.  The funding would help.
  • Incentivize the states that haven’t expanded Medicaid to finally do this. This might be what it takes to get states like Kansas and Missouri across the finish line.
  • Money for outreach and advertising for the annual open enrollment
  • The Medicaid postpartum expansion
  • The government would be allowed to negotiate with the pharmaceutical companies over pricing. This was H.R. 3 passed earlier in the term.

Those are some of the highlights.  Mr. Holt has his thoughts.  For a different perspective, you might also want to look at Katie Keith’s article in Health Affairs.  She is a touch more positive.  But whether you are in one camp or the other, an honest reading of H.R. 1425 is to see the beginning of a conversation, a path forward.  It is construction not destruction.  After 10 wasted years where little has been accomplished, wouldn’t it be great if the people we elected to help make our lives better focused on that job?  Health insurance, the way most Americans access and pay for care, is an issue for all of us.  I’d love to hear our Congressmen tell us that they are from the government and that they are here to help and mean it.



Picture – Clearing A Path – David L Cunix

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It Was All A Game

The Washington Post, CNN, and other news organizations published long, in-depth articles about the 2017 Republican tax bill.  The most cynical man in Washington, Mitch McConnell, needed to find extra money for his tax cut.  And, of course, neither Mitch nor President Trump ever passed up a chance to attack the Patient Protection and Affordable Care Act (Obamacare).  Eliminating the penalty for those people who failed to purchase insurance, the Individual Mandate, could free up as much as $300 billion.  (By the way, this is the very definition of cynicism.  Without the mandate, young and healthy people would skip insurance, prices would skyrocket, fewer people would purchase coverage, and the government would eventually save money since fewer people would get the tax credit subsidy help to pay their premiums!)  If you read the articles or anything else from that time, you will not find any mention of the tax bill making the PPACA unconstitutional.  Senators like Susan Collins (R-ME) and Lamar Alexander (R-TN) were still in discussions with their Democratic counterparts to strengthen other provisions of the law.

Senator McConnell was very aware of the dangerous game he was playing.  When asked in June of 2018 about the potential damage of the Texas lawsuit and the Trump administration’s position, Mr. McConnell said, “Everybody I know in the Senate, everybody is in favor of maintaining coverage for preexisting conditions…There is no difference in opinion whatsoever”.   But Mitch had years and years of actions that directly contradicted his words.  There were dozens of votes to repeal Obamacare.  There was the fictitiously named Better Care Reconciliation Act of 2017.  And that brings us to today.

The Trump administration filed its brief last night for the Supreme Court’s review of the Texas lawsuit.  Trump’s attorneys argue that the entire Patient Protection and Affordable Care Act should be eliminated.  ALL OF IT.  The administration’s position is clear.  Guaranteed coverage for preexisting conditions? Ditch it.  Preventive Care? Nope. Coverage for children to age 26? NO!  The law is irredeemable.  And they say it is all Mitch’s fault.

From Page 13 of the brief:

Nothing the 2017 Congress did demonstrates it would have intended the rest of the ACA to continue to operate in the absence of these three integral provisions. The entire ACA thus must fall with the individual mandate…

Our Republican friends have voted countless times to repeal Obamacare.  The Trump administration just called their bluff.  And yes, it is a bluff.  Always was.  There is no replacement waiting in the wings.  We are talking about nearly 20% of our economy.  We are talking about the way most Americans access and pay for health care.  And by the way, we are in the middle of a pandemic.

The Supreme Court will hear this case in October and won’t render a decision until after the election.  How convenient.  This may be all a game for some of our elected representatives in Washington. But it is not a game that anyone with preexisting conditions wants to play.



Picture – Right Game, Wrong Venue – David L Cunix



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Paper Mache Armor

Our Governor, Mike DeWine, is on TV with Dr. Amy Acton, the Director of Health, almost every day.  The Ohio House and Senate are in session and working.  Having our government working for us could be a good thing.  There certainly is no shortage of issues for them to address.

One of those issues is Surprise Billing.  On May 20th the Ohio House unanimously passed H.B. 388, the legislation specifically designed to address out-of-network care. The legislation was introduced in the Ohio Senate on May 26th.  It should get passed and be signed by the governor next week.  The Bill is only 14 pages and if you promise to take a quick look I won’t feel compelled to review all of it here.

The vast majority of H.B. 388 is devoted to the way out-of-network charges are defined and, more importantly, how the providers (doctors, facilities, ground ambulances, and clinical laboratories) will be paid.  There is a definition of the Benchmark or the fair market value for payment.  There is extensive verbiage related to negotiation and, if necessary, baseball style arbitration.  And as was reported in the newspapers, the consumer cannot be billed for the difference between his/her insurance plan’s reimbursement and the providers’ charges.

It looks great, but it is only paper mache armor.

H.B. 388 has the same gaping loophole as some of the other bills introduced in the Ohio legislature.  If you care to read along, turn to Page 6, Line 143 of the bill.  Let me summarize:

  • For services covered by the health plan, but are provided by an individual out-of-network provider, an individual cannot be balance billed unless all of the following are met:
  1. The provider informs the individual that the provider is not in the covered person’s health benefit plan.
  2. They provide the consumer with a good faith estimate, including a disclaimer that they are not required to get the services at that location for from the provider.
  3. The covered person consents to the services.

There was no budge on this provision.  A requirement that the disclosure be made 24 or 48 hours prior to the procedure would have been useful.  A requirement that the fees be clearly stated with an explanation of how or why the final price could change with a limit to that change would have been useful.  A prohibition of sticking a form in front of a patient mere minutes before a procedure and “asking” for consent, would have been useful.  My guess is that we will be revisiting this in a year or so once the abuses add up to a point where this has to be taken seriously.  I am sure that the hedge funds that own some of the biggest offenders, the ones whose actions created the need for this whole discussion, will have their consent forms printed before Governor DeWine can affix his signature to the final bill.

Or not.  Those are my concerns.

But our representatives, our senators, and our governor are working to protect us.  I just wish they would take the time to make our armor of stronger stuff.



Picture – Ready To Make My Shield – David L Cunix



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Sounding The Alarm

The focus of this blog, Health Insurance Issues With Dave, is, first and foremost, insurance, the way most Americans access and pay for health care.  There are three key players in this process: the medical providers, the insurance companies, and the government.  The medical provider section includes doctors, hospitals, pharmaceutical companies and everyone/everything else involved in the delivery of care.  The insurance companies serve both to organize the market and as a useful buffer between the providers and the patients.  And the government writes the rules, pays a huge portion of the bills through Medicare and Medicaid, and significantly impacts the pricing.  There is a natural push and pull in this process.  The American public benefits when all three sectors work towards a common good (Enlightened Self-Interest).  That isn’t easy and it depends on a determined focus and an honest effort.  To be clear, determined focus and honest efforts don’t guarantee success.  A lack of either determined focus or honest effort guarantee failure.

Deep In The Heart(less) Of Texas was posted on September 9, 2018.  This was the first blog dedicated to the Texas lawsuit, the attempt to have the courts declare the Patient Protection and Affordable Care Act (Obamacare) unconstitutional.  Today’s post will be the 14th warning of the havoc this could cause.  Yes, I keep sounding the alarm.  There isn’t any good will, focus, or honest effort involved in the promotion of this lawsuit.  And it only got worse when Donald Trump decided to champion its cause.

The sudden elimination of Obamacare without a replacement would terminate health insurance for millions of Americans.  This is so important that I was happy to see an article in Sunday’s (5/24/2020) Plain Dealer on the issue.  “If Obamacare was overturned, what would it mean here?” was written by Sabrina Eaton.  Welcome to the conversation!

Please read her article.  There is nothing, absolutely nothing, that contradicts my 13 previous posts.  I will note that Ms. Eaton bothered to contact Senator Portman’s office for the story.  He predictably declined to comment on the court case, but his spokesman did note that premiums have gone up.  I would never contact Senator Portman’s office about a solution or improvement to our health care system for the same reason you wouldn’t bother to call my Rabbi for a ham recipe.  But she tried.

As previously noted, I was both surprised and pleased to see this coverage in the Plain Dealer.  Considering the potential impact on our area, I expected them to sound the alarm regularly.  Imagine my shock when I went to their website to link this article.  It took some effort to find it.  Ms. Eaton’s article was posted on Cleveland.com on May 8, 2020, over two weeks earlier!  I guess Greater Clevelanders are lucky that there was so little going on this Memorial Day weekend that her article finally made it to print.  And though I have readers across the country, I would never compare the reach of my little blog to the readership of the once formidable Plain Dealer or its disorganized website.  An issue that impacts nearly 20% of our nation’s economy, the lives of millions of Ohioans, and the financial stability of our hospitals deserves our attention.  In the old days we could count on our newspapers to bring us the information we needed.

Will the Texas lawsuit succeed?  Stranger things have happened.  I promise to keep you informed.  And to keep sounding the alarm.



Picture – Thankfully Loud – David L Cunix


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