A Promise To My Dad, A Successful Crusade, And What Happens When The Greedy People Win

This entry is for my Dad.

I haven't actually seen him for quite awhile. Our 26-year-old son was three months old when we learned my Dad's doctors found cancer in one of his kidneys.

As with most families, first we panicked, then we cried, then we went to work, helped by the assurance that Dad would do everything in his power to fight his disease.

This was in my COSE days. We ran a pretty big health plan even then, so I was on good terms with the CEO of Dad's insurance company, and also knew the head of the Cleveland Clinic. We got him the best of care. And after his surgery, he enrolled in an early clinical trial focused on immunotherapy as a weapon against cancer. The researchers injected a vaccine made from his tumor into his body, in hopes that the procedure would kick his immune system into overdrive and fight the spread of his disease.

He had a couple pretty good years. But then he began to have trouble remembering things, and once experienced a terrifying August afternoon at a family reunion, when for a few hours, he had no idea where he was or who his family members were.

An exam a couple days later confirmed that the cancer had spread to his brain. He was scheduled for radiation therapy the next week. It was Labor Day weekend, and he was to receive his first treatment the Tuesday after Labor Day.

Our entire family...Mom and Dad, their seven kids (a couple of whom were still teenagers) plus spouses and grandchildren...got together as we always did, at my sister's country cabin, for a Labor Day clambake. Spirits were high, if a little forced. And that day, I had my last conversation with my Dad.

We found ourselves sitting quietly on the front porch. I wanted to make sure he was okay; we knew his prognosis wasn't good. But that wasn't what he wanted to talk about. He wanted to talk about me. It was brief, but it was the single most powerful conversation I've had in my life.

My Dad said, "I've been thinking I've been pretty lucky with my medical treatment. The Clinic certainly bought me more time than somebody with my kind of cancer has any right to expect.

"But in the last couple weeks I've been thinking about what happens to those poor S.O.B's who get sick and DON'T have a son in the health care business, the people who don't have special knowledge, special connections, or a special family. Who fights for THEM?

"Either I'll get better or I won't. That's not in my hands. And I know my kids will take care of their mother, and vice versa. What I hope is that you'll keep those folks in mind. Somebody has to stand up for the people who need the kind of help you've given to me. Remember, Jesus said, 'Whatever you do for these, the least of my brethren, you do for me'."

What was I supposed to say, except what I always said to my Dad?

"Yes, sir. I'll do my best."

Three days later, during his radiation treatment, the cancer exploded in his brain. When he came home to hospice, he was conscious but found it very hard to communicate. Six weeks later, he was gone.

My mission at COSE had always been to provide our members with a good deal on health insurance coverage. But after that conversation, I had a broader mission: to fight for access to affordable health coverage for people who need it.

We fought with insurance companies, to make them work more efficiently, hold them accountable, and qualify sole proprietors for group coverage through COSE. We fought with hospitals to force them to be more transparent and keep their costs under control. We fought in the marketplace. We fought in the state legislature for the right to bring managed care plans to small businesses, and to keep special interests from enacting benefits mandates which would raise the cost of our members' health coverage. And we fought in Washington, to keep Congress and regulatory agencies from messing with small businesses' health coverage.

I figured we couldn't help everybody. But small business owners, and the people who work for them, were among those to whom health coverage was generally not available at affordable prices, and many of those who work but don't have health coverage work in small businesses which couldn't buy coverage.

We experienced some pretty good results. For seven years straight, we were able to keep our members' rate increases below ten percent per year; in a couple years, rates increased by less than five percent.

Because we offered an unbelievably good deal, COSE enjoyed phenomenal membership growth. Year after year, COSE membership and participation in our health plans grew by 1000 companies and 6000 employees per year, net of losses.

And in the early '90's, a regional research organization conducted a study of the working uninsured in Ohio. They concluded that, despite having the highest health care costs in the state, the percentage per capita of working people in Cleveland who lacked health coverage was half that of other metropolitan areas. The reason? Empirical researchers couldn't say conclusively, but the existence of the COSE health plan was certainly a factor.

So I felt that I was doing my best to keep the promise I made to my Dad.

When a few COSE representatives were invited to The White House to brief the first President Bush on how Cleveland was succeeding where other communities were not, I knew my Dad was there with us. And when the President came to Cleveland to tell the country about COSE's success (my Mom was in the audience), I knew my Dad would have been proud.

And when we were invited to the Clinton White House to talk with Hillary and Ira Magaziner about health care reform, and they blithely accused us about not caring about helping people get insurance, we had the data to suggest otherwise, and told them our objections to HillaryCare weren't based on politics, but on our knowledge that their approach couldn't possibly work. My Dad, who loved a good fact-based argument, was patting me on the back.

Of course, a story this good couldn't possibly end happily. COSE's parent organization got a new CEO, who thought our aggressive advocacy on behalf of small businesses was "disruptive" to the corporate agenda. COSE's lead insurer got a new CEO, a CPA, who decided that, despite the fact that COSE was their most profitable customer in real dollars, the insurer's profit margin per group wasn't high enough. Some of the community's larger employers got all huffy because COSE, with its 12,000 companies and 80,000 employees in the health plan, was getting a better deal on health coverage for small businesses than they could get for their employees. And some area hospitals (including our friends at the Cleveland Clinic) began to be concerned that COSE was getting big enough that we could begin to have an effect on their pricing.

So I was shown the door, in favor of a new staff leadership who looked at the health plan not as a responsibility we owed our members, but as an opportunity to generate a lot of revenue without doing a lot of work. They made a new deal, which traded the organization's role as an aggressive negotiator on behalf of its members for the best possible prices for an agency role, selling plans on behalf of its insurer in exchange for a piece of the action...about 2 percent of collective premium (1.8 percent actually, in case the COSE folks decide to call me a liar). COSE no longer says how big the health plan is, but it was closing in on $500 million in 2004, and premiums have reportedly doubled since then. So by making the transition from members' advocate to marketing channel, COSE's picking up quite a chunk of its members' money.

Membership has declined. Participation in the health plans has stagnated, but COSE's doing just fine...and the Executive Director is making about $400,000 a year and driving a new Jaguar.

I was reminded of all this yesterday, when I had a business meeting with a friend and long-time COSE member, who has a small law practice. He showed me his COSE renewal letter. His rates are scheduled to increase 26%...to over $1500 per month per employee, despite very little utilization. He told me that his premiums have more than doubled in the past five years, and he's not sure how he can afford to continue to cover the cost. COSE tried to sell him a HDHP, but he thinks they're a scam (I tend to agree), and a HSA plan, but, he said "If I could afford the HSA contribution, I'd just pay the frickin' premium for my current health plan."

The guy wants to continue to do right by his family and his employees, and he asked me, "What should I do?"

I didn't have a good answer. Because I'm still working on an alternative. I owe it to all those small companies out there who need somebody to stand up for them.

And I owe it to my Dad...

Anybody out there feel like helping?...