Archive for the ‘Healthcare’ category

The French Message

April 24, 2017

Yesterday France held the first step in electing its next President. In the French system all candidates run in round 1 and if one candidate receives more that 50% of the votes, that person becomes President. If not there is a round 2 between the two top finishers. The results were: the top finisher Emmanuel Macron, about 24% and Marine Le Pen, about 21%. Said differently, a centrist, not aligned with either of the two major parties and a far right (formerly fringe) candidate will meet in the run-off.

Macron, is a new comer who has never held a major elected position, garnered more votes than all the other 10 candidates. Early pundit predictions say Macron should win the run-off and become France’s next President. Le Pen, however, has been attempting to steer her far right party back towards the middle and may take advantage of unexpected events over the next month.

So what should Americans take as the message from this election?

For France, jobs and border security were key concerns of the electorate. As in America, jobs are a spotty issue. For those unemployed, it is a big deal while those with jobs don’t see the urgency.

Le Pen cites globalism (France First) as the unemployment problem’s root. For Le Pen the answer is leaving the EU and enacting protectionist measures. Macron, on the other hand, sees the world as global and that France must become more competitive in order to lower unemployment.

Border security is another matter. Le Pen used this term to explicitly call for restriction on Muslims including deportation of French Muslim citizens (two passport holders) under certain situations. Le Pen also paints these mainly North African Muslim immigrants as job takers and social services sponges. Macron is relatively silent on this issue reflecting the majority of French citizens (live and let live) attitudes.

France, population-wise is a bi-modal country with one large, densely populated city (Paris) and all the rest. Paris which most tourist flock to is also the center of banking and business. The rest of France is mainly agrarian and in certain cities home for large factories (like auto and air industries).

France has a strong socialist history featuring today the 35 hour work week and a highly developed set of regulations around work rules (pay, benefits, transfer, lay-offs, and firing). In short, it is easier (and often less costly) for a French company to not hire when demand increases. Consequently, even when times are good, one should expect less hiring in France.  The French social contract is well appreciated by French citizens and proposals to change it present a large challenge.

Blaming the EU misses entirely the point and returning France to the French franc will only acerbate the economic situation (where will investment come from?) and open the door for economic policies convenient to the ruling party but ruinous to the country.

So what are the messages relevant to the US?

  • Muslim baiting is not a sure winner. North Africans and other Muslims have had a difficult time fitting into French society.  They look and act differently than the traditional French population. It is true that unemployment and economic distress are higher amongst these Muslim groups but connecting these residents to the overall French malaise is not self evident. (Hmmm, do you think undocumented US residents from Mexico have anything to do with the employment rate in the coal industry?)
  • Jobs is a complicated subject. The idea that closing borders will increase employment is a tough sell (what about exports or reprisals from other countries?). Proposals to increase specific sectors present risk to other sectors. French citizens realize this. (Hmmm, do you think rhetoric will return jobs to the coal mining industry, or tax cuts for the wealthy will translate into lower unemployment?)
  • Voters lack confidence in their legislators. The rejection of the left and right traditional national parties confirms the lack of confidence that traditional leaders can improve the overall French life. (What do Americans think of a Congress which has voted almost 50 times to repeal Obamacare and cannot agree now on what to replace Obamacare with, even though Republicans have control of both houses of Congress and the Presidency?)

One must be careful to not read too much into the French first round election results. French voters have traditionally been volatile people living amongst general apathy. At this point, the French seem to have acted prudently.

Vive La France.

Public Option?

April 21, 2017

The GOP and the Trump White House are beating the healthcare drum again. The President promises a really good plan for replacing Obamacare. According to a report in the Washington Post, Trump said, “We’re doing very well on health care.” “The plan gets better and better and better, and it’s gotten really good, and a lot of people are liking it a lot.”  “We have a good chance of getting it soon. I’d like to say next week, but we will get it.” Hmmm.

I suspect those Americans who loose their coverage or those who subsequently find out their coverage covers a lot less will not think their health plan got “better and better”.

Republicans are now debating behind closed doors a plan which seeks to bring together conservatives (Freedom Caucus who do not want any hint of entitlements in healthcare and would prefer for the government to not be involved at all), and moderates (The Tuesday Group who fear sharp political retribution if the benefits of Obamacare are rescinded). The Tuesday crowd are offering weasel words that would allow States to opt out of certain Obamacare services. Hmmm.

The overall facts appear unchanged. The American Health Care Act, even as amended, will provide less coverages to fewer Americans than Obamacare and will provide huge tax savings for the wealthiest Americans. The GOP’s embrace of “the best healthcare money can buy” is a sad replacement for the Affordable Care Act (Obamacare). Is that the best we can hope for?

Here’s a dream.  “Medicare for all” could be a next step in healthcare. Compared to the “oh so many” for-profit insurance companies today (which stand between you and your doctor), Medicare, which insures post 65 year old Americans, and fits seamlessly into existing doctors, hospitals, and pharmacies, could offer “a ready to go” alternative.

Of course Medicare is not without some problems, namely how it is funded. Republicans will decry the expansion of government and seek ways to defund Medicare. Cooler minds, however, might see Medicare as the ideal vehicle to determine what is basic healthcare and how to pay for it, especially if Medicare became the standard package for employer provided healthcare.

No sane discussion of healthcare reform should avoid the obvious elephant in the room. Americans spend more on healthcare than any other country in the world and receive mediocre healthcare outcomes in return. The difference in cost is significant (greater than two times).

An additional revelation is that balancing the Federal Budget can not be achieved unless there is a fix for Medicare and Medicaid, both of which collect less in tax revenues than they spend on healthcare benefits. With “Medicare for All” there is one program providing basic coverage with significant negotiating power with healthcare providers. Existing insurance companies could continue to “administer” Medicare benefits but would be unable to set different conditions around services.

Most likely efficiencies associated with a single payer would be insufficient to assure Medicare would be solvent. Consequently tax reform coupled with healthcare reform could be seen as reforms aimed at serving all Americans and not as ploys to pass on huge tax breaks to the already very wealthy.

Despite wrong headed GOP motivation on both tax reform and healthcare, Democrats, unfortunately, appear willing to simply play for a tie (defined as thwarting the American Health Care Act thereby keeping Obamacare) and rejecting tax reform unless the proposal is revenue neutral or positive.  Hmmm.

The can is poise for another kick down the road.

Metamorphous?

April 12, 2017

When the US sent Tomahawk missiles streaking towards a Syrian airbase, the impact on the American media was startling. “OMG, President Trump had reversed himself, maybe he was not an isolationist after all”. Like one rose does not make a summer, the same can be said of the Trump presidency.

There appears to be several seismic forces at work (behind the scenes) in the White House. Unlike the irresponsible (eg Bannon, Miller, and Flynn) early influencers, a much more seasoned and predictable group has been gaining control and access to President Trump’s ear. Appointments such as Secretary of State Tillerson, Defense Secretary Mattis, and Director of National Security McMaster along with Vice President Pense have brought a certain amount of deliberateness to policy.

Of course, one bombing raid does not make a sustainable foreign policy either.

It would be easy to ascribe the early White House disarray to what is euphemistically called a “populist” perspective and the feeding of those views to the President. It is just as likely, however, to consider President Trump as a person without any specific world strategy and flying by the seat of his pants, so to speak.  In other words, President Trump can be swayed in any direction if the public reaction is favorable. With the President’s current advisors, the White House is on an asymptotic path toward George W Bush’s world view.  Hmmm.

Many might think this change is a huge slap down for President Trump. Unlikely.

President Trump wants to be a two term President and in doing so validate his narrow 2018 election. Mrs Trump may have had some dumb children but Donald J was not one of them. He sees the more conventional foreign policy as conducive to enacting more of his domestic priorities. Hmmm, President Trump has a domestic agenda?

As with foreign policy, there is a perennial conservative strategy for domestic policy too. Lower tax (for the wealthy), smaller government/less regulations (for wealthy businesses), and all sorts of perks for the evangelicals (to gain the votes needed to reward the wealthy with less government and lower taxes).  Gutting the EPA, FDA, and the Justice Department are distractions.  Why the lack of clarity on a plan for the perennial favorites in favor of the slash and burn items?

President Trump will be 100% in favor of any domestic policy unless the public opinion runs strongly against him (like with Obamacare). Remember President Trump wants two terms and if the votes aren’t there, neither will be Trump.

IMO, the change the media has highlighted with the Syrian raids is not a metamorphous at all. Rather it is a group of competent statesman shouldering out populous agitators. In time, the infamous rules specifically designed to block Muslims from America will go silently into the night. These rules are impractical and represent a lot of effort and unfavorable blow back with no measurable gains to be seen. A similar fate most likely awaits the Mexican border fence too.

Sooner or later, the Trump Administration will get to domestic policies.  The enormity of the task of tax cuts coupled with large infrastructure spending can not be overstated.  Tax cuts (or as it will be pitched) are about the greedy taking more and the average American paying the bill.  Infrastructure spending could be very positive for employment and overall productivity but it will be expensive.  Republicans will almost assuredly be unable to agree upon how to finance the tax cut and infrastructure policies. Hmmm.

So, one last question. Does the apparent resoluteness exhibited in the Syrian strike capture the Trump we should expect next week, or next month, or next year? Unlikely, because Donald Trump is a on-off, transactional person who won the election on an unachievable platform.  President Trump will not take predictable set backs lightly and will try with other domestic policy subordinates.

But at least with the foreign policy team, he should make far fewer bozo policy moves.

Republican Healthcare Secret

April 6, 2017

Today there were reports that the unofficial  second effort to repeal and replace Obamacare had collapsed. It appears that potential changes to the initial failed repeal and replace (American Health Care Act), while encouraging to the Freedom Caucus was unacceptable to moderate Republicans. In other words original no votes that were willing to change to yes votes were offset by original yes votes who would now vote no. Hmmm.

These healthcare deliberations speak volumes about the Republican Party. For the better part of seven years the standard Republican Obamacare line has been “job killer”, “a disaster”, and “we will fix healthcare”. Through the buzz of political speak, one can see that there never was a Republican Plan. Many different Republicans may have had plans but as a Party there was never agreement on anything other than the value of insinuating that the Affordable Care Act was in someways defective and by association, Democrats were also defective. Hmmm.

Republicans are now revealing (1) they are not a party of one mind, and (2) the Freedom Caucus hold views which are mean spirited, ill informed about basic healthcare, and really represent a third party, not a faction of the larger Republican Party.

Around the world, other modern countries have settled on healthcare models which provide basic healthcare to their residents. These countries have found that preventive care and reasonable controls on healthcare provider’s profit incentives produce superior health outcomes for their residents and much much lower costs to boot.

The Freedom Caucus is claiming they won’t agree to any Obamacare changes unless there is a reason to believe healthcare premiums will decrease. On the surface this sounds reasonable. But when one considers the Freedom Caucus approach (eliminate Federal mandates over what services healthcare policies must cover), one suddenly realizes that the Freedom Caucus is comfortable with insurance companies reestablishing pre-existing condition limits and embracing stripped down policies (like catastrophic care only) which provide no access to basic preventative healthcare. The Freedom Caucus has written the book on “the best healthcare money can buy”.

The Republican Healthcare Secret is much more about the party itself than healthcare. The Freedom Caucus would also seek to not just roll back (or moderate) recent gains in civil rights, human rights, and environmental protections, the Freedom Caucus would seek to deny there is any basis for these rights to exist or protections to be implemented.

One might think the right thing for Republicans to do would be to expel the FC from the Party. But the Freedom Caucus has been beneficial to the GOP also. Caucusing with the Republican Party, the combination has been able to “control” Congress, and thereby chair the major committees. While the GOP was the Party in opposition, there was always a greater danger than ideology, the other Party. Now the Republican Party has control of the executive and Congress and can no longer ignore the role of responsible governance.

Damn that Freedom Caucus.

A Week Of Eye Opening

March 26, 2017

This past week has been an eye opener for what a new Republican Congress stands for. How about “for everything” and “for nothing”? Or, maybe “for effective government” and “for ineffective” government? Or, maybe “for sincere government” and “for insincere government”? Hmmm.

This first revelation was striking. Republicans had passed legislation to repeal Obamacare about 80 times during the past 6 years and had campaigned in 2016 for the complete repeal and replacement of Obamacare. Yet when the opportunity was there, Republicans had no replacement plan.

The GOP had many plans, all disingenuous, but there was no one plan Republicans could agree upon. Hint: do you realize GOP candidates lied about their intentions?

The most popular refrain the GOP used was lowering the premium costs which “Americans” are experiencing. To some degree, in some places, this claim seems justified but Republicans were happy to leave this claim unclear. Americans receiving healthcare coverage from their employer, Medicare, or Medicaid, received no staggering premium price increases. These Americans were shielded from the increases some individuals in certain areas experienced.

So why would Republicans make such a claim? Could it be that most all Americans experience some form of uncontrolled healthcare cost increases (as they did yearly before Obamacare) and don’t understand why hospitals, doctors, and drugs cost so much?

Few, if any of our politicians called out for a universal, single payer system to replace Obamacare. Shamefully, Republicans instead called for changes to Obamacare which were designed to reduce cost increases pressure by insuring less people! How do those politicians sleep at night?

But simply reducing coverage was not good enough for some Republicans. The “Freedom Caucus” members sought to change Medicaid from an entitlement for the most needy to a capped block grant which would become the sole responsibility of States in a few years.

The “Freedom Caucus” wants to deconstruct the Federal Government and healthcare seemed an opportune way to begin the process. “Freedom Caucus” members represent a clear and present danger to modernity.

Most Americans have little skin directly in the healthcare game. Next up on Congress’ docket is likely to be “tax reform” where almost all Americans have an opinion.

While there is much good that can be achieved (like eliminating or vastly reducing the number of tax loopholes, exemptions, and deductions), changes which will lower the overall tax revenue or the progressive nature of the tax code, are sinisterly designed to reward the wealthy and to starve the Federal Government and its ability to function.

With tax reform, even more than with healthcare, it will be critical to study what any proposed changes might accomplish before voting upon any bills. The devil will almost certainly be in the details.

This past week revealed a White House and a Congress whose intentions are hidden.   On one hand, the Republicans seem unfit to govern and on the other hand, seem not a friend to the average American.

I wonder whether this GOP leadership will have learned anything that might restore faith in their intentions? I really wonder whether the White House or the Freedom Caucus care?

Utah Shoots… At Wrong Target

March 24, 2017

Utah Governor, Gary Herbert hailed the Utah Legislature’s passing of a law which would lower the drunk driving blood alcohol level threshold from .08 to .05, making Utah the lowest limit State. The Governor reassured Utah residents that the new limit would save lives. Hmmm.

Deaths due to drunk driving have risen in recent years to 45 in 2014 and then receded to 38 in 2015. In total there were 275 automobile accident deaths in Utah in 2015. Hmmm.

I wonder what Utah is doing about opioid overdose deaths which are running one per day.

There certainly are no good reasons for any traffic deaths but if .05 is better, wouldn’t .04 be even better? Utah appears to be shooting for an ever smaller diminishing marginal return.

Utah, of course, has the right to put its efforts where it thinks best. But why would going from .08 to .05, or from 38 drunk driving deaths to say 25 or 30 (if the lower limits were to work) justify any effort when they have opioid induced deaths piling up at one per day, and no apparent plan to reduce?  Hmmm.

Distraction any one?

Free Market Health Care

March 23, 2017

The Republican sponsored “American Health Care Act” is floundering in Congress. The replace portion (as in repeal and replace Obamacare) is in trouble for curious reasons given that Congress and the Presidency are both in Republican hands. The political farce which is unfolding casts a sharp light on the undeniable fact that there is no Republican Party united around a core set of principles. Rather today’s Republican Party is a party of convenience which unite around not being Democrat or progressive.

The shallowness of this union shows through in the Republican argument over repealing Obamacare and trying to agree upon a replacement. Maintaining “no pre-existing condition” or “no life time benefit limits” exclusions along with keeping children on parent’s policies until age 26 showed the world Republicans were caring and compassionate (or so they said).

But doing away with the individual mandate and dropping certain taxes has brought into focus the difficult task of how to pay for these benefits and keep the same number of Americans on the insured roles. The inescapable GOP conclusion is that insurance costs will not come down unless, Republicans say, the free market kicks in. If this mysterious free market does not bring down the cost of insurance, then individuals and Medicaid will see large increases in cost.

The most conservative Republicans, true believers in everyone should have access to the best healthcare they can afford, are now proposing to eliminate the 10 healthcare benefits mandated in Obamacare. Hmmm.

  1.  Outpatient care—the kind you get without being admitted to a hospital
  2. Trips to the emergency room
  3.  Treatment in the hospital for inpatient care
  4.  Care before and after your baby is born
  5.  Mental health and substance use disorder services: This includes behavioral health treatment, counseling, and psychotherapy
  6.  Your prescription drugs
  7.  Services and devices to help you recover if you are injured, or have a disability or chronic condition. This includes physical and occupational therapy, speech-language pathology, psychiatric rehabilitation, and more.
  8.  Your lab tests
  9.  Preventive services including counseling, screenings, and vaccines to keep you healthy and care for managing a chronic disease.
  10.  Pediatric services: This includes dental care and vision care for kids

It shouldn’t take a genius to realize that without some requirement like these 10, insurance companies can price policies high and steer customers to stripped down version such as  catastrophic coverage. Moderate Republicans, especially those representing poor or inner city districts, see a huge backlash coming in the next election if the ultra conservatives prevail.

Conservatives are quick to counter, “doesn’t everyone have the right to buy only as much insurance as they want? Why would a single young man want to pay for pre and post natal coverage if he is not married?”

That strikes right to the heart of the matter. Healthcare costs, are generated by hospitals, doctors, and drug companies and don’t change simply because of insurance changes. The number of pre- and post natal visits will be the same regardless of whether a young man chooses to carry broad coverage or just a stripped down policy. The implication, however, should not be lost, everyone else will pay more if the young man is allowed to buy stripped down policies. That is the definition of insurance.

Republicans are ringing their hands over this dilemma. Conservatives say they will vote against the American Health Care Act if the bill looks too similar to Obamacare and Moderates say without certain coverage and federal assistance (like tax credits and Medicaid) they will vote against it.

Congress members appear to be living in a make believe world. If somehow Congressional leaders along with President Trump can work out a compromise and pass the American Health Care Act, then just looking at the reduce insured numbers and the fewer services many Americans want (and need), Republicans will lose in 2018.