The Speech

Where were you when he delivered The Speech? Yes, it was just days after his inauguration when President Donald Trump addressed a joint session of Congress.  The topic, of course, was healthcare.  His victory could be traced, in part, to his rally cry to Repeal and Replace Obamacare.  This has been a Republican mantra since 2010, but it sounded new from Donald Trump.  His opponents, both Democrats and Republicans, had been taken aback by the aggressiveness of his assertions.  He had promised a great new health plan.  This blog was underwhelmed by the plan information he released during the campaign.  But there he was, delivering a prime-time address, unveiling his proposal.  Trumpcare was a comprehensive proposal that worked hard to provide protection for every American family. Leadership.

There was no speech.  There was no plan.  And, there is no leadership.

2017 has been a terrible year for serious people and a difficult time for those of us who once revered “The world’s Greatest Deliberative Body”.  Washington’s most cynical politician, Majority Leader Mitch McConnell, decided that he would push a bill through the Senate with as little scrutiny as possible.  Utilizing the Reconciliation rules, McConnell worked hard to keep the legislation under wraps.  No hearings!  No input from any of the stakeholders.  And absolutely, positively, no Democrats.  McConnell’s strategy was to get 50 of the 52 Senate Republicans to vote Yes and then have Vice-president Mike Pence break the tie.  The details were irrelevant.

It may seem crazy to you or me to upend nearly 20% of the economy, not to mention the method that we access and pay for healthcare, with a legislative sleight-of-hand. But it almost happened this past July.  And they are about to try again this week.

The current proposal is called Graham-Cassidy.  The authors are Senators Lindsey Graham (R-SC), Bill Cassidy (R-LA), Dean Heller (R-NV), Ron Johnson (R-WI).  Their television interviews have revealed the plan to be a last ditch effort to erase Barack Obama’s legacy, repeal parts of the Patient Protection and Affordable Care Act (Obamacare), and to transfer billions of dollars to states that have shown little interest in health insurance protection for their citizens,  Healthcare?  That hardly enters into their thinking.

Here are the basics of Graham-Cassidy


  • The federal exchange –
  • The tax credit subsidies
  • The Cost Sharing Reduction
  • The Individual Mandate
  • The Essential Health Benefits
  • The Medicaid Expansion
  • All funding for one year for Planned Parenthood (Surprise!)


  • With greater flexibility, the current protections for people with preexisting conditions would be at risk.
  • The majority of taxes used to pay for the PPACA would still be collected. The money would be dispensed to the states in the form of block grants. (Think the tobacco settlement)
  • Money that went to states that had expanded Medicaid will be redistributed to states that didn’t. Ohio would lose between $4 billion to $9 billion!

Who is strongly supporting this legislation?

  • Donald Trump

Who is opposed?

And where is our guy, Senator Rob Portman? He has been a solid Yes for every other lame-brained proposal.  He has maintained his usual silence on this one.  Perhaps he is waiting for Senators Lisa Murkowski (R-AK) and Susan Collins (R-ME) to save us again.

What we know for sure is that there will never be a comprehensive health care proposal from this White House. There will never be “The Speech”.

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You’re Invited

John Doak, Oklahoma’s Insurance Commissioner, is an outspoken critic of the Patient Protection and Affordable Care Act (Obamacare).  Mr. Doak and four other insurance commissioners were in Washington this past week to testify before a Senate panel.  Their goal was simple – What do we need to do NOW to strengthen the law for the benefit of the American consumer?

The five insurance commissioners, even ones like Doak who are opposed to the PPACA, all agreed on the importance of stabilizing the health insurance markets. The first step would be to lock in both the premium tax credit subsidy and the Cost Sharing Reduction, an important consumer benefit that has become a political football.  There appears to be bipartisan support to do this.  The big question is whether a bill can emerge from both the House and the Senate.

Another key area of agreement centers on the Section 1332 Waiver. Can Congress streamline the process of securing a waiver?

Ohio is preparing its Section 1332 Waiver application.  And we, agents and consumers, have an opportunity to participate.  Now is the time to provide your input into what rules should be changed or relaxed to improve health insurance pricing and availability. We have until October 15th to provide our ideas.

There are four areas of concern:

  • The delivery system
  • Benefit Package
  • Cost Containment and/or medical management options
  • Funding or the delivery of a reinsurance pool

Here are some questions to get you thinking:

  1. Should there be annual or lifetime maximums?
  2. Should pediatric dental and vision be optional?
  3. Would mandating a second opinion save money?
  4. Would a state exchange be more effective than
  5. If we develop a high risk pool, can we incentivize carriers from ceding business to the pool?
  6. Can certain benefits such as Mental Health or Maternity become optional?
  7. Should there be a baseline standard plan with the option to buy up?

I think you get the idea. The process is just beginning.  Our job is to stop complaining and to start working. You may post your suggestions in the Comment section or send me a private email at

We are all in this together. Let’s make health insurance, our way to access and pay for healthcare, more affordable and effective.



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Back To Work

Congress is off on recess. Some of our elected representatives are in their home districts, meeting with constituents, and discussing the issues of the day.  Judging from the news, most are locked in their homes, hiding from the public, and avoiding the press.  Even the usual stand-bys, Chamber of Commerce luncheons and district picnics are likely to lead to embarrassing questions about the recent craziness in Washington.  Neither you, my readers, nor I have the luxury of a month away from reality.

We are in the last week of August. Senior Open Enrollment begins October 15th.  The Open enrollment for individuals and families under age 65 begins November 1st, a little over two months from now.  Rates have not been finalized, due in part to President Trump’s indifference to market stability.  And for those who believe that change is inevitable, you ain’t seen nothing yet.

The Deck Is About To Be Reshuffled

Change is no longer on the horizon. Change is here and now.  New companies are entering into our market.  Old companies are either leaving or making significant changes.  And through it all only one question truly matters – “Will more Americans have access to high quality, affordable health care?”  The answer, at this point, can only be, “I hope so.”

This is a moment for adults. This is a moment for leadership.  Seven years’ of meaningless votes to repeal the Patient Protection and Affordable Care Act (Obamacare) have given way to bipartisan initiatives to stabilize the insurance markets.  Will these Congressmen and Senators overcome the objections of Paul Ryan and Mitch McConnell and craft a law that can garner enough votes?  Would Trump veto the bill?

Our elected representatives will be forced to deal with a number of significant issues when they return from recess. Health Insurance is but one area of concern.  There is a debt ceiling vote, the budget, Korea, Afghanistan, and a host of other major issues that were put on the back burner while Congress debated a variety of politically driven, incredibly illogical, Repeal and Replace bills.

Take a look at who is representing you in Congress. Take a look at the White House.  Are they up to the job?


Photo – The Halls of Congress by David L Cunix 2017

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We’re Off To Get A Waiver!

We’re off to get a waiver!  A wonderful waiver from Washington.

In an exciting new development, the State of Ohio is putting together a team of stakeholders to create a Section 1332 State Innovation Waiver. What will we ask for?  Will this stabilize and improve our health insurance market?

Per The Centers for Medicare & Medicaid Services (CMS), the Section 1332 Waiver is where each state has the opportunity to tweak the Patient Protection and Affordable Care Act (Obamacare).

Section 1332 of the Affordable Care Act (ACA) permits a state to apply for a State Innovation Waiver to pursue innovative strategies for providing their residents with access to high quality, affordable health insurance while retaining the basic protections of the ACA.

State Innovation Waivers allow states to implement innovative ways to provide access to quality health care that is at least as comprehensive and affordable as would be provided absent the waiver, provides coverage to a comparable number of residents of the state as would be provided coverage absent a waiver, and does not increase the federal deficit.

State Innovation Waivers are available beginning January 1, 2017. State Innovation Waivers are approved for five-year periods, and can be renewed.  Waivers must not increase the Federal deficit.

Simply said, an Innovation Waiver would allow the state to modify the existing law or create something entirely new to meet the healthcare needs unique to Ohio.

As the Legislative Chairman of our local chapter of the National Association of Health Underwriters (NEOHUA), I will be closely monitoring our state’s progress.  I will share information as it becomes available.

The first two states to file were California and Alaska.  Their needs and plans are totally different.  Hawaii, Vermont, and Minnesota have also filed applications.  What they all have in common are the goal to provide health insurance coverage to at least as many people, retain insurance that is both comprehensive and affordable, and to not increase the federal deficit.

We know the rules. We understand the goals.  Now, let the creativity begin.





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Dave Cunix – Career Counselor

Oliver really wanted to talk with me. I hadn’t heard from him since he took a job at a major law firm about ten years ago.  But NOW he wanted to talk.  I checked my email late Wednesday evening.  There were two emails, a Linked In message, a friend request on Facebook, and a message left on the office phone.  I scheduled a phone appointment for 9 o’clock Thursday morning.

Oliver (name changed) wants to open his own office. We discussed where he would set up shop and the areas of law he would practice.  I guessed that he was targeting the first of the year and wondered about the urgency to connect.  And that is when he asked to purchase coverage for August 1st.

Now? Oliver had decided to quit his job right now while he could still purchase a health insurance policy under the Patient Protection and Affordable Care Act (Obamacare).  The Senate was debating repeal and seemed unconcerned about people like him, people with preexisting conditions.  We had a heck of a time getting him insurance last time.  Oliver didn’t want to take a chance.

The Better Care Reconciliation Act of 2017 (BCRA) was released on June 22nd.  I printed it, read it, and had an analysis posted by the next day.  I’ve also printed and read Senator McConnell’s subsequent attempts.  There is a good chance that I have dedicated more time and paper to these half-baked plans than most of his fellow senators.  The question was never whether any of this could become law, but which senators would be forced to stop this charade.  In the end it was Senators Lisa Murkowski (R-AK), John McCain (R-AZ), and Susan Collins (R-ME).  One has to wonder if our Republican senator would have voted NO if the bill was actually going to pass.

But Oliver and millions of Americans just like him didn’t know what the Senate was going to do. Will this game of chicken continue until someone forgets to blink?  Will President Trump goad the Senate into another vote, and another, until someone screws up?  Will Trump further destabilize the health insurance market?  Will there be health insurance coverage available?

It is way too early for Oliver to quit his job. He’s not ready.  We reviewed the steps necessary to successfully create a business.  I assured him that we will find him health insurance coverage the day he actually needs it.

We focus so much on the big picture. We know that this debate is about nearly 20% of our economy.  We know that we are talking about the way Americans access health care.  But we too often forget that there are real people impacted by these political decisions.  Oliver.  Your friends.  Your parents.  Maybe even you.  It is time for Washington to see us.



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Wrong Way

Today’s Health Insurance Issues With Dave is a short quiz. Grading is Pass/Fail.

You find that you are going the wrong way on Gates Mills Boulevard. Do you

A.  Turn around in the first available driveway

B.  Turn at the first intersection or median cut-through

C.  Push the Detonate button and blow-up your car

D.  A or B whichever comes first

If you chose A, B, or D, please forward your copy of this quiz to your Congressional representative. The subject line should be Healthcare. If you chose C, you may already work in Washington.



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Begging The Arsonists To Put Out The Fire

Need a surgeon? Would you consult Dr. Jack the Ripper?  Would you hire Godzilla for your next construction project?  And yet, we have entrusted our healthcare system to Paul Ryan, Mitch McConnell, and Donald Trump.  What could go wrong?

The U.S. Senate is about to return from their latest vacation. The push is on.  Senate Majority Leader Mitch McConnell is determined to get his legislation, the Better Care Reconciliation Act of 2017 (BCRA), passed before their next vacation, the August recess.  Faster legislation, but not necessarily good legislation.

Health insurance is regulated on both the federal and state level. Our elected officials in Washington and Columbus have been very busy.  Some of their focus has been on tax cuts, election nullification, and sabotage.  And every once in a while, when they have nothing better to do, they put some effort towards solving problems.

A key element of the Patient Protection and Affordable Care Act (Obamacare) is the Individual Mandate, the requirement to purchase insurance.  This blog and numerous other published articles have noted that the Individual Mandate traces its roots to the conservative Heritage Foundation over twenty-five years ago.  The logic is simple – If we are going to offer health insurance to all Americans and cover preexisting conditions, we must have everyone participate.

You can’t fund a healthcare system if only the sick and the responsible are participating.

President Trump and Congress are actively sabotaging the system.  As previously discussed, Mr. Trump’s first Executive Order directed federal agencies to “waive, defer, grant exemptions from or delay the implementation of the Act…”  And with that the IRS stopped holding tax returns that didn’t include proof of insurance coverage.  Enforcement became optional.  But that isn’t enough for Congress.

The New York Times recently reported that a bill is moving through Congress that would prevent the IRS from enforcing the Individual Mandate.  Why leave anything to chance?  With the replacement bill floundering and Obamacare, by default, looking better every day, it is important to the Republicans to harm PPACA any way they can.  Every healthy person that chooses to not purchase coverage is a future rate increase for everyone else.

*    *     *     *     *

He left the message on our system. Every comment on this blog is appreciated.  He had given his response a lot of time and thought, so much that he wasn’t able to call my office until 10:30 on a Saturday night.  He was careful to mask his number to evade the caller ID but, oddly enough, forgot to leave his name.  My reader wanted me to know how much he respected President Trump and that my opinion wasn’t appreciated, though he didn’t use those exact words.



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What Road Is Paved With Bad Intentions?

At some point we have to ask, “Where the Hell are we going?” Seriously, we have a couple hundred Congressmen and 50-60 Senators gambling with 20% of our economy and people’s lives in an effort to negate the 2008 and 2012 elections.  And leading the charge is a guy so obsessed with his predecessor that he would sign a bill mandating daily doses of arsenic if he was told that it would reverse an Obama achievement.

The Patient Protection and Affordable Care Act (Obamacare) was passed in 2010 after months of Congressional hearings, public meetings, and debate.  The final law borrowed heavily from Republican plans pushed by The Heritage Foundation, Newt Gingrich, and Mitt Romney.  It was not the traditional Democratic plan focused on either a Single Payer or Public Option.  Like all compromises, there was plenty to love and lots to hate in the PPACA.  But the legislation’s intention was to give every American access to affordable healthcare.

Obamacare fell short of its goal.

What is the goal of the American Health Care Act (AHCA)?  What is the goal of the Better Care Reconciliation Act (BCRA)?

Both the House and the Senate bills are focused on tax cuts, Medicaid reduction, and defunding Planned Parenthood. Neither has a single provision to lower the cost of healthcare.  Neither provides access for a single American. Both bill would eliminate health insurance coverage for over 20 million Americans over the next ten years.

The AHCA and the BCRA are both championed and denigrated by President Trump.  It just depends on the hour.  The reason is simply.  He doesn’t care.  He just wants a win.

On Friday Senator Ben Sasse (R-NE) revisited a different Republican option, Repeal Now – Replace Later.  His website features his newly found relevance since President Trump has reversed himself and is now embracing this idea.  This simplistic concept features a triumphant Republican controlled Congress repealing OBAMAcare and then, now with a clean slate, the Republicans invite the Democrats to join them to create a similar system.  Yes, this is exactly like an arsonist burning down his own home and then demanding that you help him rebuild it.

There are, of course, other options. Steven Brill, author of America’s Bitter Pill, published an article last week in the Washington Post.   Nine ways to really fix Obamacare is a short list of common sense solutions that advance the goals of access and affordability.  There are Republican and Democratic ideas incorporated into these nine changes.  It is a short article.  Click here to read it.

I don’t know that there is a road to an insurance nirvana. But if there is, it certainly isn’t paved with bad intentions.



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Passover is my favorite holiday. And my favorite part of the Passover Seder is the singing of Dayenu.  As we list each miracle and wonder that was done for us, such as freeing us from slavery or saving us at the Red Sea, we say Dayenu.  Dayenu is loosely translated to “That would have been enough for us”.

The Patient Protection and Affordable Care Act (Obamacare) was a poorly written bill.  It was compromise legislation that didn’t fully satisfy anyone on the left or the right.  But when asked over the last seven years what Obamacare did well, I have always cited the expansion of Medicaid.  If the Patient Protection and Affordable Care Act had done nothing but expand Medicaid – Dayenu!

Destigmatizing Medicaid was the first positive step we could take as a society to help the poor and working poor. And Medicaid helps more than just the poor.  It also helps the disabled and the elderly.  Medicaid is our insurer of last resort, which means that an awful lot of our friends and neighbors rely on this government provided insurance.

In Greater Cleveland Medicaid coverage allows those in need access to our world-class medical facilities, highly trained doctors, and needed prescriptions. Medicaid even covers office visits which are much cheaper and more convenient than the inefficient emergency room.

The Kaiser Family Foundation has done extensive research on Medicaid.  Their Medicaid utilization graph has appeared on numerous TV shows as well as in newspapers such as the New York Times and the Plain Dealer.  On a national level Medicaid covers:

  • 49% of all births
  • 76% of all poor children
  • 60% of all children with disabilities
  • 64% of all nursing home residents
  • 30% of all adults with disabilities

Medicaid is helping our most vulnerable. Do we have some people who could/should be paying for their own insurance?  Of course.  Can we do a better job policing utilization and reimbursement (fraud and waste)?  Of course.  Can we significantly reduce funding without impacting access to care?  NO WAY.

There has been excellent reporting on Mitch McConnell’s Senate “working draft”, the Better Care Reconciliation Act of 2017 (Trumpcare).  Steven Koff of the Plain Dealer has delivered some of his best work.  The New York Times has again proven why it is the paper of record.  The “working draft” is only 142 pages.  It is a quick read.  Follow this link.  We’re talking about the way we, all Americans, access and pay for healthcare.  We are talking about nearly 20% of our economy.  It is your responsibility to at least read McConnell’s plan.  You have the time.

We can discuss the merits of a huge tax cut for the wealthy. We can wonder how eliminating the individual and employer mandates while retaining guaranteed issue won’t destroy the insurance market.  We can go page by page through the BCRA and ask “Why?”  But for today, I just want you to read the bill.  And if you do that, it will be enough for me.



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Trojan Horse

President Lyndon Johnson declared the War on Poverty in 1964.  It was a sincere effort, but poverty persists to this very day.  Senate Majority Leader Mitch McConnell, President Trump, and Speaker of the House Paul Ryan have decided that a War on the Poor is a better idea.  They are weaponizing healthcare.  The opening salvo was the American Health Care Act (AHCA).  And yesterday, June 22, 2017, we got the working draft of the Better Care Reconciliation Act of 2017 (BCRA).  The names might imply that these efforts are designed to enhance our access and payment of healthcare.  A more honest name might have been Bang Bang You’re Dead.

The Senate released a “working draft”. This could be the actual bill.  It could be a Trojan Horse.  Since McConnell is trying to ram this through under the Senate’s rules for reconciliation, we may not know until the last possible moment.

I apologize for focusing so much on process, but that is where we must start. Leader McConnell is an incredibly cynical politician.  He is a master of the game.  We need to at least know some of the rules.

Under reconciliation, McConnell only needs 50 votes for a tie. Vice-president Pence would then cast the deciding vote.  This “working draft” could be introduced as legislation.  Debate will be limited to TEN HOURS.  The Democrats would be able to introduce amendments, but debate is limited to TWO MINUTES per amendment.  The Republican majority could quickly defeat all of Dem’s motions.  Then, at the nine hour fifty minute mark, McConnell could introduce the actual legislation as a replacement amendment.  The real bill is then passed before anyone can read or debate it.

Farfetched? Really?  Have you been paying attention?

This blog will analyze the “working draft” over the next few days, but we must first focus on the process. Certain key Republican Senators and lobbyists have had advance copies of the BCRA.  The first to complain weren’t Senators Portman or Collins.  The first to the TV cameras to voice their disapproval were Senators Cruz, Lee, Paul, and Johnson who represent the extreme right wing of their party.  They voiced opposition to the concessions made to the moderates.  It feels like the fix is in.

I may see a Trojan Horse. The poor and working poor are staring at a tank.


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