The presentation by the two attorney/consultants was only 45 minutes long.  It just felt like four hours.  They were on firm ground when they stayed in the tax and law side of the Patient Protection and Affordable Care Act (PPACA).   Sure they got lost in the details and seemed compelled to flash every detail at their audience, but what they lacked in presentation skills was more than made up with the depth of their knowledge.  That was as long as they didn’t venture into my area.  They were lost when it came to the insurance part of the new law.  Couple their confusion with their power-point skills and you have the perfect recipe for an agitated audience. 

The young business owner seated next to me opined that none of this might matter much if the next administration reverses the law.  I laughed and reminded her of the Republican’s love for the PPACA.   We both just shook our heads.  She isn’t old enough to remember when Democrats and Republicans actually worked together in Washington.  She would never believe that Otto von Bismarck once remarked that “Politics is the art of the possible”.    

There appears to be plenty of politics in Washington, but nothing seems possible. 

This blog has discussed the numerous shortcomings of the PPACA for over four years, a full year before the law was even passed.  But pretending that last year’s Supreme Court decision or the November 2012 election didn’t happen is not productive.  We can’t all be as unproductive as the Republicans of the House of Representatives: 

House Speaker John Boehner said Thursday that next week’s vote to repeal the health reform law is being held to provide new lawmakers a chance to vote on it.“We’ve got 70 new members who have not had an opportunity to vote on the president’s health care law,” Boehner said. ‘Frankly they’ve been asking for an opportunity to vote on it.”

                      Politico 

That doesn’t mean that nothing is getting done and that no one has reached across the aisle in an attempt to make the PPACA work.  It simply means that you have to look a lot closer to home if you are hoping to find anything positive. 

The Ohio chapters of the National Association of Health Underwriters (NAHU) held their annual Day at the Statehouse last week.  This is the trade group that represents health insurance agents.  We were in Columbus to hear from some of the legislators that are the most involved in our area and from Lieutenant Governor Mary Taylor who also serves as the director of the Ohio Department of Insurance.  Our afternoon was taken with appointments with various legislators.  I was scheduled to meet with State Senator Scott Oelslager and the effervescent Minority Whip of the Senate, Nina Turner who represents me in Columbus.  

Some of the states that have both Republican governors and Republican led legislatures have chosen to fight the PPACA.  Still!  We in Ohio are fortunate to have realists in Columbus.  And though these leaders have taken a lot of heat from members of their own party, they continue to work through the process even though they disagree with the PPACA.  Our first speaker was Representative Barbara Sears the sponsor of the recently signed H.B. 3.  As Majority Floor Leader of the Ohio House Representative Sears shepherded the rules that would establish the training and responsibilities of both agents and navigators in the new exchange system.  This is legislation that had bi-partisan support.  While some states are satisfied with turmoil and the possibility of the PPACA dying under its own weight, Ohio is taking some of the steps necessary to make it work.  

Lieutenant Governor Taylor’s presentation also gave me hope.  Regardless of what she personally thinks about the PPACA, Ms. Taylor is committed to doing her job as director of the department of insurance.  A big part of that job is reviewing every policy that will be allowed to participate in the Ohio exchange.  That exchange is supposed to be available October 1^st.  As of last week ZERO policies have been presented for review and approval.  No insurer wants to go first.  She is already making plans for the onslaught she is anticipating in mid-June.  If there is going to be a problem with the exchanges, it won’t be because of Mary Taylor. 

Regular readers of this blog know that I don’t spend a lot of time complementing our elected representatives as a whole and even less on Republicans.  I certainly did not vote for Governor Kasich and disagree with most of his positions on major issues.  But you have to admire any leader, Democrat or Republican, who puts his state’s needs first. 

My first appointment was with Senator Oelslager from Stark County.  I was there to talk about other ways to help our clients get through the coming transition.  None of my issues had anything to do with me, personally.  We needed to talk to the legislators about S.B. 9 which cleans up the old, but soon to be unneeded, Ohio Open Enrollment Program.  We also wanted to alert the legislators that Ohio still defines full-time as 25 hours per week while the PPACA uses 30.  You get the idea.  Cleaning up these and other seemingly small conflicts will save our clients big headaches in the future.  So that was the purpose of my meeting with Senator Oelslager. 

We spent the first ten minutes talking about the Kennedys.  Republican Oelslager was inspired to go into public service by John and Robert Kennedy the way countless young men were inspired to pick up a guitar after seeing the Beatles on the Ed Sullivan Show.  I found him to be engaging and well-informed. 

My only disappointment of the day was that Senator Turner was called into a meeting.  I instead met with her bright and energetic Legislative Aide, Adam Warren.  Mr. Warren was an excellent substitute.  I hope to have more conversations with him in the future. 

So what I have learned is that politics is still the art of the possible.  We just have to limit our discussion to the actions of our state legislators.  It’s a start.

George Orwell – Animal Farm

Congress never fails to disappoint.  Whether you are discussing financial disclosure and insider trading or just the day to day struggles with the Sequester, our elected officials from both parties seem find the retention of their jobs as their number one priority.  And unless you are a total whack job running for the Senate from Connecticut, a major determinant of election success is the campaign war chest.  Money gets you to Washington and once you’re there, you sure want to stay.  

Like the previously mentioned insider trading issue, Congress has crafted laws that appear to apply to everyone but them.  And that brings us to the Patient Protection and Affordable Care Act (PPACA).  There was a poison pill buried deep within the PPACA by Charles Grassley (R-IA).  While negotiating with the Democrats in the summer of 2009, Grassley pushed for Congress and its staffers to be required to participate in the future health care process.  If the PPACA was good enough for the average American citizen, it was good enough for Congress.  

Theory meet reality. 

Today’s POLITICO reveals the backroom negotiations that have been going on for months to resolve this problem.  Congress and their staffers are currently covered by the federal government, their employer.  Approximately 75% of the cost of their coverage is paid by the government.  The insurance is good.  The 75 / 25 split is fair.  But an exchange doesn’t work that way. 

The health care exchanges will be offering plans that conform to the new plan designs created by Health and Human Services.  As this blog has detailed in the past, the new metal plans (platinum, gold, silver, and bronze) will have a lot of benefits that you may, or may not, want.  These new benefits and the elimination of medical underwriting will have a significant impact on premiums.  The new taxes on health insurance will also add to the escalating prices of individual and small group health insurance. 

The first health care exchanges will be designed to sell individual policies and small group health insurance.  An employee of the federal government, covered by group health insurance, wouldn’t be shopping at an exchange unless he/she was losing the group policy.  BINGO!  To comply with the law and reality, Congress and the staffers have to buy their own policies, at their own expense.  They may qualify for a tax subsidy if any of them earn less than 400% of the federal poverty rate. But they lose the 75% now paid by their employer. 

Senator Richard Burr (R-N.C) is quoted in the POLITICO article as noting the impact.  “…put yourself in the position of a lot of entry-level staff people who make $25,000 a year, and all of a sudden, they have a $7,000 a year health care tab?  That would be devastating.” 

Congress fears a brain drain as young, under-paid employees, untainted by the cynicism years in Washington breeds, leave the Capital for a more affordable start to their careers.  And who in Congress wants to pay for his/her own coverage?  So Democrats and Republicans are working behind the scenes to exempt themselves and their staffs from the effects of the PPACA. 

There is no one working to exempt you. 

Businesses, especially those with fewer than 100 employees, are assessing their need to offer group health insurance to their employees.  Many will follow the government’s lead and eliminate coverage.  Dropping coverage eliminates compliance questions, paperwork and expense.  The employees will be left to fend for themselves. 

In other words, the PPACA will perform as designed.  Less and less Americans will rely on their employers for health insurance benefits.  And as we are herded into the exchanges with their ever escalating prices, a great hue and cry will rise from our fellow citizens for rate relief.  The transition to a Single Payer System will then appear to be the only solution.  Damn near welcome. 

Except for those who have been exempted.  There is really only one rule: All animals are equal. But some animals are more equal than others.

DAVE

Today’s news gave me the opportunity to view two competing views of reality.  The headline at the top of Page B1 of today’s Plain Dealer was “Hospitals keep leaning on lawmakers over balking at Medicaid expansion”.  It took two reporters and over 30 paragraphs to clearly explain why hospitals around the state were pushing to have the Republicans in the Ohio House reconsider their decision to kill Ohio’s participation in the program to deliver health care to the poor.  Dr. David Bronson of the Cleveland Clinic’s executive board and Robin Bachman, assistant vice president for government affairs and public policy at Sisters of Charity the nonprofit Catholic system that operates St. Vincent Charity Medical Center, seemed to completely understand how the Medicaid expansion would work and benefit their hospitals.  The Speaker of the Ohio House, William G. Batchelder (R-Medina), wasn’t as clear. “I have never seen anything as confusing as this situation,” said Batchelder. 

It was easy to understand Batchelder’s confusion.  His governor, John Kasich, had crossed the big red line and agreed to expand Medicaid, a key part of the Patient Protection and Affordable Care Act (PPACA).  Republicans are supposed to block Obamacare, not implement it.  Worse, the Hospital Association and the Ohio Chamber of Commerce are also OK with the expansion. 

There was one guy, two pages away on Page A7, who was not confused, who is never hampered by either indecision or second thoughts, and who was totally prepared to stay the course.  Kevin O’Brien, the Plain Dealer’s representative from the Right and resident scold, KNOWS the answer.  Unconcerned about budgets or deficits during the first six years of the Bush presidency, Mr. O’Brien now appears to spend a great deal of his waking hours tinkering with his own, personal, federal debt register.  Accepting the expansion of Medicaid “would do nothing more than move some of Ohio’s hospitals a few places farther back in the line of institutions and practitioners destined to starve to death under the federal bureaucratic yoke if Obamacare remains the law of the land and produces the single-payer, government-run health care by utterly destroying the insurance market, as it is designed to do.”   

Even when we agree, we disagree. 

This blog has contended for three years that we are marching towards a single-payer type system.  I am not a fan.  Never have been.  But, that doesn’t mean that we will have bodies on the streets, abandoned hospitals, and shuttered clinics.  I’m not even positive that any BMW dealerships will be forced to close. 

We can’t have a conversation if we don’t lower the volume. 

The online Crain’s Cleveland Business released an article this afternoon about MetroHealth’s position in this fight.  We are paying for the care Metro delivers.  We pay in higher insurance rates and higher taxes.  In an effort to take a stand against the President, Speaker Batchelder may have, accidently, destroyed a program that was funded entirely by Cuyahoga County and the federal government.  The article explained why Metro is so concerned.  “Expanding Medicaid to cover more of the county’s poorest residents –who typically are the most expensive to treat because they often use the emergency room for routine care or have neglected medical needs – is expected to help buoy MetroHealth’s finances.” 

So will Medicaid be expanded in Ohio?  I think so.  It will be a bit of a slog and the horse-trading may be unpleasant, but I think it will get done.  And once again we are all reminded that the national health care debate is not about health care.  Never was.  

The issue is money.  Who is going to pay our medical providers?  And once that is settled, we might tackle How Much?

Alarm bells.  Warning lights.  Bespectacled insurance agents jumping up and down and waving our arms.  The last three years have had no shortage of dire predictions.  Most have been ignored.  The warnings were coming primarily from Republican leadership and insurance agents.  Our motives were suspect.  Though many in my industry offered possible modifications to the Patient Protection and Affordable Care Act (PPACA) to make the law more workable, the Republicans only offered to repeal the legislation, a totally impossible political grandstanding ploy.  With the choice appearing to be all or nothing, the American public chose all.  

The canary died last Tuesday. 

The Society of Actuaries released their study on March 26^th.  Their prediction is an average increase of 32% in 2014 in the individual health insurance market.  That is the average.  New York policies may decrease an average of 13.9%.  Ohio?  You don’t want to know.  The Society of Actuaries is looking at an 80.9% increase for Ohio individual policies. 

Does this mean that your policy is going up 80%?  Yes and no.  If you are really, really unhealthy, your premium may be decreasing.  If you are young, healthy, and have a good job – this could get ugly.  If you are young, healthy, have a good job, and male – this could get very ugly. 

How much of this increase will you see?  The answer depends, in part, on your income.  The Obama administration is counting on federal subsidies to hide the full impact.  With assistance available to consumers earning up to 400% of the national poverty level, lots and lots of Americans will be getting help. 

Where will all of that money come from?  Individual policies will have two new fees (taxes) assessed on them as of January 1, 2014.  The Reinsurance Fee adds $5.25 per insured member per month.  That means that a family of four pays an additional $21 per month.  The second fee is the new Market Share Fee which is projected to be an additional 2 – 3% of premium.  The rest of the money will come from federal taxpayers. 

The Obama administration has responded predictably to the actuaries’ report.  Health and Human Services (HHS) Secretary Kathleen Sebelius admitted that “there may be a higher cost associated with getting into that market where folks will be moving into a really fully insured product for the first time.” 

That moment of clarity was quickly followed by questions about the canary.  The Christian Science Monitor reported that Secretary Sebelius said that “it’s too soon to talk specifics about premiums until the insurance companies submit their bids this summer”.  She again predicted that the online exchanges will encourage competition which would bring down prices.  And of course, the White House has questioned the motives and validity of the study. 

I am particularly amused by the competition argument.  Large corporations, many of them publicly traded, are going to lose millions, not by accident, but because they will be blindly caught up in a bidding war to insure our sickest Americans.  A little real world capitalism is going to be a real shock to some of our Washington bureaucrats. 

My own policy, a high deductible H.S.A. qualified health plan, renewed recently.  My rate increased over 30% and yet, the premium is still competitive.  Claims, taxes, new charges like the facility fees that are now appearing on our bills, and the incredible cost to comply with the new legislation are all contributing to this year’s increases.  Next year?  I suspect that 30% will be a fond memory. 

Damn.  Our canary died.

DAVE

Robert Anderson grimaced.  The next to the last thing in the world Bob (name changed) wanted to do was to defend The Path To Prosperity, Paul Ryan’s new budget.  The very last thing would be to defend or even to agree with the Democrats and the President.  This was going to be a difficult meeting for Bob. 

I would describe Bob as a Conservative, right-wing Republican.  He prefers Constitutionalist.  He voted for Mitt Romney because he is a realist.  A vote for anyone else last November was really a vote for Obama, but it was not a vote cast with pride.  Paul Ryan was a welcome addition to the ticket.  Bob had touted Ryan as the country’s future for years and he felt validated when the Congressman was chosen for the number two slot.  That was last year.  Now, March 2013, Bob was going to take crap from his friends in the middle and the left. 

Paul Ryan’s budgets have always been more about politics than numbers.  These are budgets designed for the campaign trail.  No Ryan budget has ever had a chance of passage in the Senate.  No Ryan budget could be signed by a president, especially this President.  All of that is understood in advance.  But this time Ryan went too far. 

How far?  When FOX calls out a Republican, he has officially jumped the shark. 

Mr. Ryan’s new budget assumes the repeal of the Patient Protection and Affordable Care Act (PPACA).  Oh sure, he retains much of the savings and revenues from ‘Obamacare” and the tax changes of the last year.  He just dumps the benefits.  It is as if the last election and the two long years of campaigning never happened. 

Robert Anderson – business owner, Constitutionalist, American – was totally frustrated.  He has taken the time to meet with our elected officials.  He has explained the significant flaws in the legislation to members of both parties.  But Robert, unlike Congressman Ryan, understands how doing nothing, how letting this law be enacted without needed modifications, will hurt his business.  Republicans voting for the repeal of the PPACA are Republicans voting for the legislation’s enactment in its current form. 

So Bob Anderson is now forced to agree with Dave Cunix, centrist Democrat.  Neither the Democrats nor the Republicans want the PPACA to succeed.  The Republicans won’t help to modify it because they want to be completely uninvolved.  The PPACA is the key to unlimited campaign financing.  The Democrats will use the failure of the PPACA to welcome a Single-Payer system. 

The insurance companies who will be selling supplemental policies and taking care of the administration of this future Medicare-like program are cheering from the sidelines.  Bob Anderson may be disappointed in Paul Ryan’s budget, but the politicians, left and right, are quite content.

DAVE

One of the key points of this blog is that the health care debate has never been about health care.  Never.  Money isn’t the prime driver.  Money is the only driver.  How do the hospitals, doctors and other medical providers get paid, and how much, are the real issues.

Except for a couple of purists, no one really cares who pays the doctor or hospital as long as it isn’t you, the patient.  Do you really care if your $300,000 bill from the Cleveland Clinic or University Hospital is paid by Anthem Blue Cross or the federal government?  Honestly?  No.  All you really want to know is how much, if anything, you will owe once the dust settles.  And the providers?  The insurers pay more, but have a lot of paperwork.  Medicare pays less, but quickly.  Based on the number of medical providers that accept Medicare (darn near everyone), I’m guessing that there are no serious complaints.  The hospitals may even like having two major funding sources to play against each other.

I have tried to teach my clients what I know of the game.  My senior clients learn about the origins of Medicare Parts A and B, the backroom deals that gave us Part D (Rx), and why costs are out of control.  Countless clients have been clued in that those obscene charges are negotiable before and after services have been rendered.

Your perception of our system changes today thanks to Time magazine.  Blessed with budget, time, and amazing persistence, Steven Brill has given us Bitter Pill, Why Medical Bills Are Killing Us.  Mr. Brill tracked claims and laid bare the abomination that is our system of billing for services – real or imagined.  Straightforward in his prose, laborious in his detail, Mr. Brill presents a system of overpaid executives and hyper profitable not-for-profits.

The real issue isn’t whether we have a single payer or multiple payers. It’s whether whoever pays has a fair chance in a fair market. Congress has given Medicare that power when it comes to dealing with hospitals and doctors, and we have seen how that works to drive down the prices Medicare pays, just as we’ve seen what happens when Congress handcuffs Medicare when it comes to evaluating and buying drugs, medical devices and equipment. Stripping away what is now the sellers’ overwhelming leverage in dealing with Medicare in those areas and with private payers in all aspects of the market would inject fairness into the market. We don’t have to scrap our system and aren’t likely to. But we can reduce the $750 billion that we overspend on health care in the U.S. in part by acknowledging what other countries have: because the health care market deals in a life-or-death product, it cannot be left to its own devices.                                Steven Brill – Bitter Pill, Why Medical Bills Are Killing Us

You won’t agree with all of Brill’s conclusions.  I certainly don’t.  But read his work.  This should be the new starting point of our national conversation.

Cause and effect.  Stand in the rain and you will get wet.  We get that.  We aren’t surprised, normally, when 1 plus 1 gets us 2.  But human nature will, at times, have us rooting for a different result.  There are times when we desperately want to be able to walk between the rain drops or somehow add 1 plus 1 and get 5.  Or even 6!  And we are surprised, shocked, when we get wet. 

The Cleveland Plain Dealer carried a wire story yesterday by Noam N. Levey.  The P.D. headline was Health care premiums to rise?  In the Los Angeles Times it was States worry about rate shock during shift to new health law.  You’ll want to read the Times’ version.  It is fifteen paragraphs longer. 

Some of the biggest proponents of the Patient Protection and Affordable Care Act  (PPACA) have suddenly realized that health insurance premiums are about to increase.  A lot.  How much?  No one really knows for certain.  The plan’s advocates are openly nervous even though they appear to be soft-peddling the full extent of the problem. 

Affordable care is in the eye, or wallet, of the beholder. 

Oregon’s insurance commissioner, another supporter of the law, said new regulations could push up premiums for young customers by as much as 30% next year.  He urged administration officials to slow enactment of the new rules.  

Noam N. Levey

State insurance commissioners across the country have focused on the increased benefits built into all of the policies, the elimination of underwriting, and the new age/rate ration as particularly troublesome.  Young, healthy males in their early 20’s now pay about 1/5 the price of healthy males in their early 60’s.  The new law reduces the ratio to 1:3.  Will the rates decrease for the 60+ year olds?  Maybe a little.  So to hit the ratio, the rates for the young must increase. 

The ratio change impacts the young disproportionately.  Ending underwriting and adding maternity, and lots of other new benefits described in previous posts, will also escalate premiums.  Still, fans of the PPACA maintain that young people will gain enough in benefits to offset the cost. 

How does a 25 year old afford a $250 to $300 monthly premium?  Subsidy!  Americans who don’t receive their health insurance from their employers may qualify for a federal subsidy.  The subsidy is available to people earning up to four times the federal poverty level which is about $92,000 for a family of four.  Curious about how much subsidy you might get?  Check out the online calculator created by the Kaiser Family Foundation.  It is really easy to use. 

So the government passed a law, makes a lot of rules and regulations, pushes up insurance premiums, and then lots of us get a subsidy.  It would appear that everything is in balance.  For once, a happy ending! 

Not so fast.  The money for the subsidy has to come from someplace. 

$101,700,000,000 over ten years is a good down payment for the PPACA.  $101.7 billion doesn’t cover the actual cost of the President’s plan, but the Health Insurance Tax (HIT) is a key element.  The HIT is a tax charged to insurance companies on fully insured health policies.  These are the policies covering individuals, the self-employed, and small businesses.  Medicare Advantage and Medicare Part D (Rx) contracts are also affected.  This tax will be passed directly to the consumer. 

The 2011 Oliver Wyman projection was ugly.  The ten year total cost projections:

•   $2,150 – Single coverage
•   $5,080 – Family coverage
•   $2,760 – Small group single employee
•   $6,830 – Small group family
•   $3,590 – Medicare Advantage beneficiary
•      $161 – Medicare Part D (Rx) participant 

Adding $15 to $20 per month for a single or $40 to $45 per month for a family won’t help to make insurance more affordable.  But at least we know where the government is getting all that money for those subsidies.  For now. 

Representative Charles Boustany (R-LA) and Representative Jim Matheson (D-UT) have introduced bi-partisan legislation to repeal the Health Insurance Tax.  

The President’s health care law is full of hidden tax increases. Beginning in 2014, millions of American small businesses will be subjected to a new health insurance tax (HIT) coming at a cost over $100 billion. This tax will close many small businesses and kill jobs once implemented. The HIT will cost each affected family an average of $5,000 in higher premiums over the next decade. The Jobs and Premium Protection Act prevents premium increases for small businesses and protects jobs by repealing this unfair tax. It keeps more money in the hands of small business owners and employees instead of levying higher taxes on job creators and American workers. I encourage my colleagues to join in honoring our commitment to protect small businesses and the millions of workers and families depending on them.

Congressman Charles W. Boustany, Jr., M.D., (R-South Louisiana) after introducing “The Jobs and Premium Protection Act” 

Will the tax close small businesses?  Probably not.  Will Boustany/Matheson pass the House?  Probably.  Would a similar bill pass the Senate?  NO!  If the cost of insurance is your biggest concern, this tax and the legislation to repeal it are relevant.   If the government spending money it doesn’t have is your major concern, then you will want to see the tax enacted. 

New benefits, the elimination of underwriting, the age/rate ratio, and the new Health Insurance Tax all add significantly to the cost of health insurance as of January 1, 2014.

Surprised?  Really?  Let me get you an umbrella.

DAVE

www.bcandb.com

Galileo before the Holy Office

 Women are imprisoned in their homes, and are denied access to basic health care and education. Food sent to help starving people is stolen by their leaders. The religious monuments of other faiths are destroyed. Children are forbidden to fly kites, or sing songs… A girl of seven is beaten for wearing white shoes.
– President George W. Bush, Remarks to the Warsaw Conference on Combating Terrorism, November 6, 2001 

Regular readers of this blog are all too aware that the health care debate has very little to do with the delivery of health care, the prevention of illness, or even curing the sick.  The majority of the legislation and the debate is about money – How do we pay the doctors, hospitals and other medical providers?  And how much?  So this is really a political and financial discussion.  But not today.  Today, religion invades Health Insurance Issues With Dave.  And religion never takes any prisoners. 

Warning – If you are easily offended, stop now.  Come back and visit next week. 

Next month marks the third anniversary of the Patient Protection and Affordable Care Act (PPACA). The hundreds of pages linked above are the framework, the goals, that serve as the outline that will be fleshed out in thousands of rules and regulations in the years to come.  Heavily promoted, from day 1, was that Preventive Care was going to be covered with no copays or fees under all health insurance plans. 

Why cover Preventive Care?  I don’t call State Farm when I need to get the oil changed on my car.  But suddenly we are all going to get our annual physicals for FREE.  We love free stuff.  Now, if I get my annual exam and you don’t, then this works for me.  You are helping to pay for my exam.  If, however, we all get annual exams, then we are all paying for our own exams and it’s not really free.  But let’s not mix facts into this feel good moment.  Three years ago we learned that we were going to get something out of this – FREE Preventive Care. 

What we didn’t know, in March of 2010, was that Preventive Care included Birth Control Pills, IUD’s, and the Morning After Pill.  Who knew that the something for nothing section of the PPACA would become the most controversial portion of the legislation?  

Allow me to summarize this issue by citing one of its most intemperate spokesmen, Kevin O’Brien of the Cleveland Plain Dealer. 

This isn’t just about big, church-affiliated institutions like schools and hospitals, although they’re an important part of the argument.  It’s not even about contraception.  That’s just the issue that sparked the argument.

It’s about an individual right to live according to one’s faith.

What Barack Obama thinks about contraception is of no consequence whatsoever.

What each business owner who would be absorbed into a federal scheme to make contraception more widely and more cheaply available – factors that will encourage its increased use – thinks is the only thing that matters.  

Those who believe that the government’s plan offends G-d should not have to participate in it.  The free-exercise clause in the First Amendment – is in effect everyday, not just Sundays – says so. 

And there you have it.  My religion, or how I happen to interpret my religion, or the Truth as revealed to me be my spiritual leader will now determine which taxes I pay and what I give or withhold from my employees. 

Start with Mr. O’Brien’s fixation on Sundays.  For millions and millions of Americans, Sunday is no different than Tuesday.  The USA is home to Jews (Saturday), and Muslims (Friday), and, Atheists (no Sabbath at all).  And of course, he assumes that all Christian denominations choose to follow, this time, the teachings of the Catholic Church.  Do 100% of all Catholics abstain from Birth Control, IUD’s, and the Morning After Pill?  50%?  According to Gallup, the number of Catholics who accept the use of Birth Control is 82%. 

We would laugh at the idea of Orthodox Rabbis trying to outlaw shellfish. 

Can we tailor each law to bend to the religious prerogatives of each citizen without devolving into total chaos?  Ten years ago we chose to invade a defenseless country that supposedly had weapons of mass destruction.  IT DIDN’T.  Many a religious leader fought this second war and claimed that it was immoral.  Did millions of Americans get to opt out and stop paying their taxes?  Of course not.  

The paragraph that opens this post deals with our reaction to the Taliban. 

Even by Muslim standards, the Taliban is considered extreme in the way they interpret the Koran and how they apply the rules to day to day living.  But our friends the Saudis still don’t let women drive.  

Would a Saudi, living in the USA, be forced to hire a woman for a driving position?  Pay property tax for a school district that had a coed driver’s education program?  Pay women the same as men?  

Where is the line?  Catholicism can make rules, but not Methodists?  Shall we poll the Hindus amongst us about our beef price supports?  Once you open this door, it will be very hard to close it. 

The Patient Protection and Affordable Care Act has more than a few problems.  We need to determine how we are going to pay for all of the changes that were once thought to be covered.  We need to decide whether Birth Control Pills, IUD’s, and the Morning After Pill should be considered Preventive Care and covered without cost to the user.  Each person’s personal morality may inform his/her opinion and play a part in the discussion, but religion won’t rule the day. 

Not in 2013.  Not in the United States of America.

A Kind-hearted Physician sitting at the bedside of a patient afflicted with an incurable and painful disease, heard a noise behind him, and turning saw a cat laughing at the feeble efforts of a wounded mouse to drag itself out of the room.

“You cruel beast!” cried he.  “Why don’t you kill it at once, like a lady?”

Rising, he kicked the cat out of the door, and picking up the mouse compassionately put it out of its misery by pulling off its head.  Recalled to the bedside by the moans of his patient, the Kind-hearted Physician administered a stimulant, a tonic, and a nutrient, and went away.

The above is from Fantastic Fables, a book written by Ambrose Bierce and first published in 1898 over one hundred years before Sarah Palin stumbled into the end-of-life conversation.  Mrs. Palin’s contribution was to fan the fears of those worried about death panels.  Mr. Bierce calmly asked us to define humane.

This post marks the four year anniversary of Health Insurance Issues With Dave.  The very first edition dealt with a very, very unhealthy gentleman in his late 70’s who was in line to get a new kidney.

• Did it make sense to place a healthy kidney into the body of someone that old and that unhealthy?
• Should the kidney go to someone younger or in better overall health?
• Should society, in this case Medicare, pay for this quixotic procedure? 

I didn’t pretend to have the answers in 2009.  I’m no closer today.  Worse, this is a conversation that we as a country have managed to avoid.  But as we change our system of health care financing through the implementation of the Patient Protection and Affordable Care Act (PPACA), we are going to have to discuss this whether we want to or not.

It isn’t always life and death.  An eighty-eight year old woman visited the Cleveland Clinic last week.  After examinations and tests by several doctors, nurses, and technicians, it was determined that yes, she did have a cataract, but no, she did not require immediate surgery.  Still, if she wanted to have the procedure, they were prepared.  Money was not a consideration.  Medicare and her Medicare supplement would have covered the entire cost.  She elected to wait until she had no choice.

Is it great that our elderly have such wonderful, comprehensive health coverage?  I don’t know.  It FEELS great.  But is there a line and where is it?  If we agree that all Americans have a right to unlimited care, then we must begin the process to collect the funds (taxes) necessary to pay the bill.  If we want to set limits, then now is the time to start that conversation.

The subject of that first post never received the new kidney and died from one of his many ailments.  I learned a lot about death this year as I watched a friend struggle with cancer.  He lost that battle.  I don’t know if he ever fully grasped the value of Hospice and palliative care or how much help and comfort he received in his final days.  I, however, now have a much greater appreciation for Hospice and the doctors, nurses, and technicians who staff these units and facilities. 

And we are left with the questions – How much medical care is needed and how much is too much?  And of equal importance – Who gets to decide?

Are we ready to define compassion?

DAVE

www.bcandb.com

Jim Renacci (R-OH) got caught.  Last Thursday’s Plain Dealer called out the congressman in the PolitiFact column. 

Obamacare includes “a $63 charge every American will begin paying (in 2013) as a way to cover some of the increased costs associated with providing health insurance to those with pre-existing conditions.”

And this was deemed Mostly False. 

So what did Congressman Renacci get wrong and why is this important?

• The $63 fee is part of a Health and Human Services (HHS) rule.  And though this fee is as good as done, it is not done so this isn’t good.
• The $63 fee is slated for 2014 not 2013.
• The $63 fee is a charge each employer would pay per person covered under a group health insurance policy.  The money would help defray the cost of insuring all of the unhealthy Americans who will soon be flooding our health care system.
• The $63 fee is supposed to decrease over three years and then disappear. 

The last point is the most amusing.  How many governmental fees, otherwise known as taxes, have you seen disappear? 

So, PolitiFact is technically correct.  Mr. Renacci oversold his point.  What he could have said is the HHS is about to impose another charge to employers to help cover the cost of the Patient Protection and Affordable Care Act (PPACA).  He might have noted that HHS is making up the rules as it goes, is actively looking for funding sources, and has yet to facilitate an honest, open discussion about priorities. 

Renacci was wrong and PolitiFact was irrelevant. 

* * *

The health care debate is replete with faux experts and near truths.  Here is what I know: Premiums are increasing, now and in the foreseeable future. 

My small group clients are getting hit hard.  The March small group renewals from Anthem are well over 20%.  My Medical Mutual groups are seeing rate increases in the high teens.  The clients aren’t interested in theories or promises.  They are only concerned with the size of their monthly bills. 

What is contributing to the rate jump?  Some of this is the ramp-up to 2014, but the insurers will tell you that the rates reflect the reality of higher health care costs and increased benefits.

Carrie Haughawout, assistant director for health policy of the Ohio Department of Insurance, recently told the Dayton Daily News, “Ultimately health insurance rates are just reflecting the cost of health care and the cost of health care has been going up for years, so the cost of health insurance has correspondingly been going up.” 

In that same article, Aetna spokesman, Scot Roskelley, blamed premium increases on “the increasing prices of hospital care, prescription drugs, doctor’s visits, and other health care services.  Other underlying cost pressures – from the underpayment for government insurance to the rising rates of obesity – also drive up premiums.”  

The only cost drivers Mr. Roskelley skips are all of the new free benefits that have been added to individual and small group health policies.  Some people seem to believe that $3,500 colonoscopies are just gifts from the insurance fairies. 

ThinkProgress found a law professor from Washington and Lee, Timothy Jost, who opined that “The cost of new benefits should not be a big deal.  Most of the costs of health insurance are for inpatient, outpatient, physician, lab, radiology, and pharmaceuticals, which virtually all insurers now cover.” 

At Washington and Lee, cheerleading is nine tenths of the law! 

* * * 

Dave Jones, California’s insurance commissioner, is really unhappy.  He is allowed to jump up and down and stamp his feet, but he cannot block insurers from raising their rates.  He’d like to change that.  He would like California to give him more authority. 

The regulatory gold standard may be New York.  A recent New York Times article noted that insurers may have requested an average increase of 9.5% on individual policies, but the actual state approved increase was only 4.5%.  Small group rates had an even bigger spread.  The insurers proposed an average increase of 15.8% but saw that number knocked down to 9.6%. 

We are left with two options.  Is insurance priced the same way as trinkets at some third world tourist trap?  Do the insurance companies price their products high enough so that the regulators can score well-publicized victories while the companies still receive sufficient funds to perform their primary function – insure the public?  Or, did reducing the insurers’ renewal rate increases by 40% possibly jeopardize the companies’ future ability to pay claims?  Are the regulators making insurance no more secure than a government program?

.

So which is more important to you, Renacci and others on the right overselling the new fees or the future stability of how we fund the payment of medical services?  It all affects us, those of us living in the real world.

DAVE

www.bcandb.com