Archive for the ‘Healthcare’ category

The Other Side Of The Coin

November 3, 2017

House Republicans have just released their proposed tax code rewrite. Experts are rushing to digest the proposal and perform the difficult task of assessing how this Republican bill will impact Americans. Wait, wait… if you are wealthy, you do not need to worry. This Republican plan will treat you well and provide opportunities for clever tax advisors to find new ways to save you tax payments.

The bill provides most (but not all) the gifts the rich have been expecting. The top bracket of 39.5% remains although the income threshold has been raised to $1,000,000 allegedly in deference to the “gift to the wealthy” optics.  Carried interest, estate tax elimination, and reduction of corporate taxes (35% to 20%) for private owner businesses will provide the wealthy with plenty of tax relief opportunities while the tax burden is shifted to lower income Americans.  And, for those unfortunate Americans earning $500,000 to $999,999, you will just have to pay in a lower bracket.

The deal is not set yet. Republicans from high tax States will argue for sweeteners in the restoration of State and local tax deductions and full credit for mortgage interest. Lobbyists representing all sorts of industries will go into full court press to preserve other deductions and credits. It is entirely possible that this attempt at tax code changes will stall or fail outright.

But it is entirely possible that this proposal or something substantially the same will pass. What then?

For sure it is maddening that very wealthy people like the Koch Brothers and Robert Mercer will pay less taxes.  It is maddening that as a consequence, the tax burden will shift to less wealthy people (like the Middle Class), or the cost of this tax cut will flow to the national debt, or both.

But that is not the real damage that this tax code change will bring.

A coin has two sides. On one side, heads, is the smiling faces of Americans paying less in taxes. The other side, tails, however, means there will be less government revenue to cover already approved government spending. Let there be no mistake, with lower tax revenues there must be less government spending sooner or later.

Republicans will be quick to assert that there are all sorts of waste and corruption in government spending. Why, Republicans will point out that there are able bodied Americans drawing social security disability benefits who could be working. And look at Medicaid excesses associated with the Affordable Care Act. And, with their faces now reddened, Republicans will bluster about spending in all sorts of other areas. Surely, cutting wasted money can be made.

Maybe. The problem usually boils down to which programs are viewed as wasted spending and what justification makes those expenditures “wasted”.

For example, Republicans have attacked the Affordable Care Act (train wreck, a jobs disaster) even though there were some 20 million more Americans insured with Obamacare than before. And, what have Republicans offered? Their best proposals offer less coverage and insure 10-15 million fewer Americans.

So, when it comes time to submit “post tax cut” Federal Budgets, what makes anyone think Republicans won’t feel that reducing programs which benefit all but the rich will be perfect targets?

The theme which comes up time and again is that there are no free lunches. Republicans are breathlessly trying to sell this tax code change as great for the middle class and the key to unlocking our economy, and best of all, there will be no cost to average Americans.

Really?

Advertisements

Governing Part II

November 2, 2017

The Republican Party now holds the reigns of government with control of the Presidency and both houses of Congress. Despite this apparent political control, Republicans have been relatively impotent. Governing Part I offers the thought that the Republican Party is a collection of disparate factions whose inherent policy goals are in conflict externally with a majority of voters’ interests, or conflict internally with other Republican factions’ policy demands, or both.

Implementing the Republican majorities has become surprisingly difficult and fraught with potential unwelcome blow back at the next elections.

Does this imply that Democrats would govern better?

Maybe… but at the very least, the Republican dysfunction speaks to the outsized influence mean spirited conservative big money (“dark money” per Jane Mayer) plays.

Democrat governance would speak to different financial interests. IMO, progressive views, characterized as “center, slightly left”, would be far more pragmatic and directionally sensitive than the current regressive Republican policies.

Contrary to Republicans’s notion that America’s future is destined to look like its past, “Make America Great Again” is on the wrong side of history.

  • Globalization is a fact from which retreat is not possible… and still have America grow in economic terms. Low cost manufacture will chase low cost, high quality labor. High cost manufacturing will reduce Americans’ standard of living. Free and fair trade are a must.
  • Growing income inequality is not a sign of globalization, but rather a greedy, thoughtless, and selfish product of wealthy Americans. Labor regulations and a creative tax code are needed to share the fruits of capitalism more productively.
  • Global warming is real and will drive dislocations in energy supplies. Attempts to favor oil and coal over natural gas or renewable energies denies the science behind global warming, increases the atmospheric carbon, and brings on the destruction associated with rising seas.
  • Digitalization (computers, internet, wifi, artifice intelligence and automation) has changed labor’s definition of “good jobs”, basic skill requirements, and the training and education needed.
  • Population growth rates in developed countries has slowed to below replacement rates and has placed a new value on immigration. Comprehensive US immigration reforms is a far wiser approach than building a wall.
  • Most of the developed world see basic healthcare as a citizen’s right and a necessary government/private sector service. Often over looked is that basic healthcare as a right helps center a person’s thinking around the value of government.
  • Retirement protection is an emerging need. With most companies no longer offering defined benefit retirement plans, and 401k savings plans subject to changes in the tax code, a national retirement pension fund would seem wise. The general notion is that retirement with dignity should be a right for everyone but how to fund such a program must be identified.

So, how does the Democrat Party stack up against these realities of our changing world?

  • Dark Money – Democrats have accepted campaign donations from a wide range of sources, dark money conservative sources excepted.  Reasonable limits and full transparency has been a Democrat position.
  • Globalization – Democrats have reluctantly embraced free trade including NAFTA and the TTP despite the objections from organized labor.
  • Global Warming – Democrats have openly embraced the science behind global warming theory and have endorsed policies which restrict carbon dioxide emissions. Democrats have given only lip service to dislocated labor (like coal miners).
  • Digitalization – Democrats have proposed a wide range of training and education programs but as in many other programs, have not told Americans what it will cost to implement their ideas nor what it will cost the Country if these ideas are not implemented.
  • Immigration and a diverse work force are solid Democrat principles, again if these positions can be sold to the Unions.
  • Basic healthcare – Democrats supported the Affordable Care Act but only a few Democrats strongly spoke out for single payer, universal healthcare for all (like that found in Europe).
  • Retirement Support – Democrats support the government’s role in assuring workers the dignity of a social security-like payment which makes retirement “livable”.

Are you ready to sign up for the Democrat Party?

Remember how Democrats acted after the majority Democrat Party passed the Affordable Care Act.   When election time rolled around, however, many Democrat candidates were silent and tried to change the subject when their Republican opponents criticized Obamacare. Democrats did not campaign on the idea of repealing Obamacare, as did Republican candidates, nor did Democrats vigorously defend Obamacare.

Lukewarm, would you call it?

Great leaders come along every so often. FDR, JFK, LBJ, and to a lesser extent, Bill Clinton were effective in passing important legislation. Barack Obama, when Democrats controlled Congress did get through healthcare reform but not much else (except by Executive Order). Obama will be more remembered for what he urged Congress to do as well thwarting what a mean spirited Republican Congress tried to do.

In this age of sound bites and tweets, will Democrats portray themselves in proactive terms? If Republicans are the Party of small government, low taxes, and individual initiative, what are Democrats?

Party of Opportunity, Security, and Leadership (for all Americans) in the 21st Century might be a place to start.

Hmmm.

Beautiful Healthcare

October 8, 2017

The Tweet-meister has once again promised Americans “beautiful” healthcare, without the “high premiums” some individual insurance seekers are experiencing. What magic does President Trump have in mind? Do you think he will embrace Medicare for all? Do you think he will recommend the US adopt a single payer system like Australia, Canada, or most of Europe?

Unlikely.

To date, the GOP has been serious about controlling cost exposure for those in the single payer market. Shamefully, the Republicans have chosen various forms of “less coverage”, “fewer insured”, and outright mistruths to portray their proposal as providing “beautiful” healthcare coverage. Why?

Opposition towards the Affordable Care Act (Obamacare) has been mainly a partisan political event. Republicans have never been serious about maintaining (or increasing) the basic healthcare insured rolls. Republicans have eyed the single payer (largely individual owner proprietorships) who could be counted upon to vote Republican.  The rest of Americans were far less important.

The GOP has lamented rising rates and declining insurance company participation in certain markets. Behind these crocodile tears, however, has been (you select which one), either (1) a basic ignorance of how any insurance market works, or (2) a cruel belief that those added by Obamacare were mostly lazy Americans unwilling to do what it takes to work hard.

Why would insurance companies keep raising rates in many markets? Does anyone connect that people who were sick and now have insurance might just be using it?

Does anyone think that many who otherwise reneged on paying doctors and hospitals previously (and by the way, those costs were written off by everyone else paying through insurance), and were now enrolled in Obamacare, were not going to use healthcare?

There have been some commonsense proposals, short of single payer, such as putting all single individuals seeking insurance into a group composed of all other single individual Americans (forming groups like employers do). The idea is that insurance companies could then set rates based upon this much large pool.

This approach might stabilize insurance markets but over all there is no way this proposal will lower healthcare spending. People who are sick or have experienced healthcare coverage for the first time with Obamacare will still get sick and will still want to use healthcare services.

The tweet-meistre might do well if he asked questions about how to lower healthcare costs without reducing coverage or those covered.

Such a line of questioning will invariably lead to where costs are generated, namely doctors, hospitals, and drug companies. This healthcare industry is like no other in the modern world and represents 1/6th of the US economy. If in some magical way, President Trump decreed that the US should adopt a healthcare model like Germany or France, where healthcare spending is about 1/2 that of the US (with equal or superior healthcare outcomes), it would require years to transition to that model without bankrupting many doctors, hospitals, and drug companies, not to mention healthcare insurance companies.

All I can say is that after such a transition, healthcare would be “beautiful” for the average American.

Obamacare’s 9 Lives

September 26, 2017

With Senator Susan Collins’ thumb down, it appears the Affordable Care Act (Obamacare) will live to die another day. This is a victory for decency to be sure, but fiscally US healthcare remains a uncertainty. What does this say about those who govern?

Senator Rand Paul said the GOP bill (Graham-Cassidy) was too much like the Affordable Care Act (too much entitlement), and he said he would not vote for it. Senator John McCain told Senate Republicans to use a bi-partisan approach when Congress deals with 1/6th of the economy. Republicans did not, and McCain said no thanks.  And, Susan Collins announced her “no” following the release of the CBO score indicating millions of Americans would lose coverage with Graham-Cassidy. Others such as Senators Cruz and Murkowski were rumored as “no” but have not spoken out.

The general theme of Republican opposition has been exploding cost. Republicans seem concerned that the Federal Government will pump billions into healthcare and that amount will not be enough as healthcare cost will increase each year. A subset of these fiscal worriers sees Medicaid expansion as the culprit and have selected block grants to States as a way to cap the Federal Government’s financial obligation.  Both of these concerns are reasonable but is it reasonable to take healthcare away from some in order to keep the Federal cost down? Hmmm.

Senator Bernie Sanders has seized this opportunity to hype “Medicare for all”, a single payer system, as the best way to fix Obamacare. OMG, here comes socialism Republicans are crying out.

What an opportunity for someone to articulate in a calm voice that the rest of the modern world provides basic healthcare to all their residents at 1/2 or less what it costs America and these other countries have excellent (better than the US) health outcomes.

If Republicans were really serious about the fiscal aspects of Obamacare, one would think that adopting a healthcare system similar to France, Germany, or Switzerland’s would make sense. Unfortunately, these universal, single payer systems cut out insurance company profits and in turn campaign donations to politicians.
Hmmm.

There might be a tendency to take a deep breath that Obamacare has survived again.  Obamacare’s nine lives are not a forever thing.

Republican’s disregard about pre-existing conditions and even whether everyone, regardless of means, should have access to basis healthcare pose a menace to most Americans.

One might think that faced with a ground swell for Universal, single payer, Republicans might see Obamacare as a preferred alternative.

McCain’s Repeal and Replace

September 23, 2017

Senator John McCain informed Senate Republican leadership that he could not support the latest “repeal and replace” bill (Graham-Cassidy). This placed the proposed legislation one vote away from defeat and would then end a Republican only healthcare action. Was this McCain’s finest hour?

Senator McCain rejected partisanship saying healthcare was too important a matter to not have bi-partisan support. Life could have been much simpler for McCain if he had just chosen to wait and in the end go along. But for the 80 year old Senator afflicted with brain cancer, the future might not seem so endless. For whatever his reasons, Senator McCain made a principled decision without regard to special interest pressure and money.

Hip, hip, hurrah for John McCain.

Repeal And Replace II

September 21, 2017

Republican Senators are marching, somewhat like lemmings, towards a cliff over which they are likely to plunge. The Graham-Cassidy proposal is craftily constructed healthcare (not) bill. As previous GOP attempts, this repeal and replace version eliminates the individual mandate, frees employers from the requirement to provide their workers healthcare insurance, and frees businesses and the wealthy from certain Obamacare related taxes.

Graham-Cassidy also shamelessly bribes the 50 States with a promise of a block grant which can be spent as the States see fit thanks to large cuts to Medicaid.

For some States, Medicaid cuts are unwelcome since when they do the math, these States realize they will receive less money than with Obamacare. For other States, especially those who did not expand Medicaid under Obamacare, Graham-Cassidy looks like new found money.

The vote scheduled for next week represents a wholesale capitulation by Republican Senators to big money interests. The vote is expected to be held without the daylight of any public hearings and without knowledge of the CBO review, both steps Senate Republicans had vowed to provide just months ago.

There is, however, no reason to expect the CBO score to indicate less Americans will lose coverage than in previous GOP attempts.  One must wonder why the GOP insist upon retracing its already discredited path.

At risk once again are the most vulnerable, the poor, those with pre-existing conditions, and the suddenly unemployed. Most Americans gain healthcare coverage through employer provided insurance and will not feel the impact of any “repeal and replace’ legislation (until such time as it becomes fashionable for employers to decline to offer coverage at all). The wealthy, if required, could pay for healthcare personally, and while no one likes paying for anything, healthcare insurance cost for the wealthy represents a tiny percent of their disposable income.

One is tempted to blame President Trump and assign this shameful legislation to him. Wrong.

From all reports the President has tissue paper thick knowledge of healthcare and has applied his learnings to Graham-Cassidy.

There is no doubt the President will praise the bill if the Senate finds the 50 votes necessary for passage (President knows about winning). There is also no doubt that were Graham-Cassidy to become law and the public become disenchanted with GOP governance, President Trump will then disown the legislation and blame the Senate.

When People Think Differently

August 8, 2017

The idea of “universal, single payer” healthcare seems so obvious as both the most efficient and least costly method of delivering a nation’s basic healthcare, it seems incredible that there are so many Americans who do not embrace this notion. Why would that be?

Fewer and fewer Americans remember the time before the wide spread availability of insurance company provided healthcare. Yet the US system of “for profit” healthcare insurers is a relatively recent happening. Following WWII, employers began offering health insurance as an employee benefit designed to retain employees in a period of relatively full employment. Health insurance as a benefit caught on and employers have found it difficult to retain workers without offering health insurance. Hmmm.

Also escaping most Americans knowledge is the cottage industry which is necessary to support the multitudes of healthcare insurers. Healthcare service providers (doctors, hospitals and drug companies for example) must carefully keep track of each patient and how much service that patient has consumers, report those services using each insurers different set of codes on each insurers specific form, and then argue with each of these insurers to insure they receive reimbursement for the services already provided. This entails millions of more healthcare workers who do not themselves provide healthcare. Hmmm.

More than two dozen other modern countries (like Germany, France, England, Japan, and Canada) utilize a single payer, universal healthcare service delivery system. These countries all offer “best in class” healthcare services at about one half the total cost experienced in the US. These countries also report excellent healthcare outcomes and boast longer life expectancies than the US. Oh, and these countries provide this healthcare to all residents. Hmmm.

So, why would anyone not be in favor of universal healthcare?

In the US there are many who decry the idea of universal healthcare. They predict unacceptably long wait times to see a doctor or receive treatments. They ask the question “if healthcare is so good in other countries, why do people from Canada travel to the US for medical care?”, and “Why should we put the government between you and your doctor?”, the ask.

The politics of healthcare is even more fascinating and not easy to understand. Progressives are for a universal system and conservatives are not. Conservatives point to Progressive’s record of entitlements and using taxes to fund the cost. Conservatives see creeping socialism behind the call for universal healthcare and the resulting dependency of Americans to look for government to solve all their problems. And worse, universal healthcare will bloat the government making what is already (in their opinion) too big, even bigger. And even worse, conservatives don’t want their tax dollars going to pay for healthcare for someone else. Hmmm.

Hmmm. What could be simpler. Big government, less choice, poorer quality, and offering out of control cost increases, conservatives claim.

Why do conservatives think that way when there are so many examples around the world that prove otherwise? Why don’t conservatives recognize that some Americans already have “universal healthcare”. These Americans, of course, are over 65 and are enrolled in Medicare.

Is this a subject of “the glass is half empty, or half full”? Do progressives and conservatives see the same problem (basic healthcare available to all Americans) or do they see different solutions to different problems (basic right versus small government with low taxes)?

If Americans see the same problem, conservatives may still view the delivery of basic healthcare too difficult a task for “American thinking” and from their perspective, a universal healthcare system must inevitably end up with poorer healthcare and higher costs. Progressives could, alternatively, see no problem too great for Government to solve and therefore discount totally conservatives’ warnings.

The recent Congressional fight over repeal and replace for Obamacare should make conservatives take notice. The conservative sponsored alternatives largely failed because they offered less coverage for the poor, those with pre-existing conditions, and the elderly.   Voters representing those groups made their views known. Progressives and conservatives would be wise to heed this warning.

Healthcare is not free and does require funding. Most other countries employ a “prevention” oriented healthcare philosophy, inhibitions towards uncontrolled price increases, and utilize a consumption tax (value added tax) to fund healthcare along with modest co-pay requirements.

Obamacare could be a starting point were Republicans to acknowledge that Obamacare was based upon Romneycare (Massachusetts) and that was based on a proposal from the conservative Heritage Foundation think tank.

If conservatives can’t agree with progressives on what the problem really is, voters make make the choice for them. The 2016 Presidential elections was a clear sign that the electorate was dissatisfied with both parties and threw its support to a total outsider.

What will voters do next time?