Archive for the ‘medicare’ category

Healthcare, A New Take?

June 5, 2017

Former Oklahoma US Senator, Tom Coburn, gave a genuinely heartfelt argument on how to fix healthcare. Coburn’s solution  –  total free enterprise. Use the free market, Coburn said, where millions of Americans could seek “great quality” healthcare at the lowest prices. The former Senator used the Amish as an example of price shopping with the outcome – great coverage at low cost. Hmmm.

Tom Coburn is a doctor (MD) by education and should know something about healthcare. Senator Coburn is a conservative and has a history of concern over healthcare cost.  Senator Coburn, needless to say, was not a fan of the Affordable Care Act (Obamacare).

And to be sure, there are situations with our current healthcare delivery model ripe for abuse.  Fee for service, Medicare payment for unneeded services, and non-negotiated drug costs in Medicare Part D are a few examples.

Most Americans are largely divorced from healthcare’s actual cost. Most Americans are covered by group health plans (paid for by employers) or for those over 65, Medicare. While there are deductibles and co-pays, these costs are nominally small compared to the overal healthcare cost. Consequently most Americans are content with and expect their employer and their insurance provider to fight with doctors, hospitals, and drug companies and manage these healthcare services prices.

Do you think insurance companies, who have built into their policy prices their earning would welcome a lower premium cost which would in turn lower profits for their shareholders? Hmmm.

In addition to employer provided and Medicare, there are Medicaid (for those who qualify) and the single payer market to make up the rest. (I am excluding the VA system for reasons of simplicity.) It seems ridiculous to believe that Americans on Medicaid roles, who can not afford to buy their own healthcare policies now because they are too poor would suddenly be able to find their way through the medical and insurance maze and buy adequate healthcare insurance.

The individual market could be different however, since the members might have the financial means. But, does anyone think that suddenly insurance companies will welcome Americans with pre-existing conditions and charge them the same low rates as healthy young Americans? One might wonder what Senator Coburn has been smoking?

The free enterprise system, instead of being healthcare’s savior, is actually its devil. Our free enterprise, capitalist system honors the concept of maximizing profit. American healthcare costs have risen at two times the rate of inflation for years.  No better recent example is the American drug industry where prices have escalated at unprecedented rates. Disgracefully, one can buy in Canada the same US produced drug for substantially less. Hmmm.

Americans are regularly reminded about innovation and increased productivity from competition in a capitalist system. We are asked, “do you want to give that up”?

Americans, instead, need to ask a simpler question, “are there other healthcare delivery models around the world that cost less (say one half what the US spends) and are associated with better health outcomes”?

Senator Coburn’s proposition might work if all Americans had the same health prospectus and the same capabilities to make a deal. Buying an automobile or an airplane ticket are examples of where the free market is working. Americans pay widely different prices for essentially the same goods or services. Americans can, however, chose not own a car or use an airline to travel with no life or death consequences. Healthcare is different.

Over two dozen countries around the world have adopted healthcare delivery systems which cost half that which Americans spend and achieve better outcomes for all their citizens. Broadly speaking these healthcare delivery systems emphasize “prevention” and “ease of use”. These plans insure everyone (universal coverage) and employ a “single payer” administrative model. There are no “negotiations” between citizens and healthcare providers.  The role of doctors, hospitals, and drug companies are to serve the customer while earning a fair but modest profit.

Insurance companies may, if they wish, participate as a “plan administrator” facilitating payments for healthcare providers. Their profit is negotiated with the national healthcare agency (a government organization) so there is no temptation for insurance companies charge “what the market will bear”.

So in countries like Germany, basic healthcare is available to all residents at the same low co-pay cost (a national value added tax pays for most of a German’s healthcare cost). Socialism?

There is no effort or thought, however, that all Germans should be driving a BMW instead of a Volkswagen or  having no car at all.  What type of car a German buys and how much he/she pays for it is a free market event.   Germany has a capitalist economy but treats healthcare as an individual right.

Why is this such a foreign idea in Washington?  Why are Republicans so dead set about reducing healthcare in a land where healthcare costs are two or more times the level of other modern countries?

Are Republicans seeking the best healthcare delivery system money can buy?

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.

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?

Is The Free Market The Answer?

March 20, 2017

The “repeal and replace” gang have been telling Americans for a long time that healthcare needs to be about choice, that the high cost of healthcare is because the free market is not working, and things will get better when Government no longer comes between the patient and the doctor.

Admittedly, supporters of Obamacare have been handicapped because healthcare spending is still high and rising annually. How can one speak against what Republicans are saying when what Republicans are criticizing is not working well either?

Whoa. Let’s slow this down and review some inconvenient facts.

The Affordable Care Act (Obamacare) is about insuring more Americans, not directly dealing with how much healthcare costs. So right away if voters don’t want to pay (via subsidies and expanded Medicaid) for more insured, than it is entirely unnecessary to put forth misinformation about more choice and better healthcare, just admit that as an American one feels no need for universal healthcare coverage. Full stop.

Now if one wishes to invest energy and tinker with the Affordable Care Act, let’s consider a few popular Republican myths.

  • Get the Government out from between you and the doctor. Is the implication that I should accept (for profit) insurance companies making better decisions on what treatments are covered or what drugs are acceptable? At the very best of possibilities, how are these two options different? And, with insurance companies public corporations with a requirement to make a profit, how can insurance companies not be more costly?
  • Competition is the answer to lowering healthcare costs. The suggestion is that with more policies available (selling insurance across State lines) natural free market principles will drive down costs. Insurance prices are related to real healthcare costs which are generated by hospitals, doctors, and drug companies, not insurance companies. Insurance companies simply hitch a ride on basic costs.  Insurance premiums assumes usage and underlying costs PLUS insurance company profit. If insurance companies guess wrong, they just raise the price of their policies.
  • Patient centered Healthcare puts the individual in charge. This “wordsmith” slogan “Patient Centered” has no connection with underlying costs. “Patient Centered” is about providing the patient with information about their health status and suggested medical treatments and services tailored to improve health outcomes. Is this not what we have today?
  • American Healthcare is the best in the world. This myth is put forth whenever there is a suggestion that other countries have better healthcare delivery systems and surprisingly achieve that superiority at substantially lower costs. There is little to be gained from disputing how good the Mayo Clinic, the Cleveland Clinic, or Johns Hopkins might be, or for that matter many other large teaching hospitals across the country. Most Americans, however, only read about these institutions and do not receive medical treatments from them. Life expectancies, percent of residents receiving basic healthcare, and treatments for serious illnesses rank American healthcare well down the list of modern, developed countries.

The number one problem with America’s healthcare delivery system is cost. Americans spend twice as much as most other modern countries (with healthcare outcomes equal to or superior to America’s). The number two problem is that America’s healthcare delivery system does not include all Americans since cost puts it out of range for poorer, sicker, and older Americans.

These are not myths, these are facts. So all the smoke and fiery words about repeal and replace the Affordable Care Act miss the primary targets as did Obamacare.

Given all this, is the free market even remotely likely to improve a fundamentally flawed healthcare delivery system?

The Healthcare Maze

March 16, 2017

The Affordable Care Act “repeal and replace” discussion, has displaying the worst in our two main political parties, and just as importantly, has also pointed to a deaf spot in both the parties’ hearing. I wonder whether there will be a waking up or whether ideological beliefs will continue to drown out the roar of the crowd.

Republicans say many things but basically it is a combination of “healthcare is about choice”, “healthcare is about being patient centered”, or “healthcare cannot be about more entitlements”. Democrats say that the Republican plan will cover fewer people and cost those covered more. Democrats object to the Republican plans but offer no alternatives other than status quo. Why?

Most of those covered by the Affordable Care Act have gotten healthcare insurance for the first time in their lives. The 20 million or so Obamacare people include individual mandate enrollees, pre-existing condition refugees, and the poor who now quality for expanded Medicaid. Think about that, 20 million out of 340 million Americans can’t be the source of all this Congressional hassle. Hmmm.

Could it be that the national cry to “repeal” Obamacare and the objection to the American Health Care Act (the replace part) is because neither address effectively the current high cost of healthcare?

The US spends twice as much each year on healthcare per capita than any other country in the world.

Why are politicians more concerned with cutting Medicaid rolls than asking why healthcare costs so much? Why would anyone call a healthcare delivery system “patient centered” when most Americans find the premiums unsatisfactorily high? Why would anyone be satisfied with a national healthcare system which costs more than equally effective systems in other countries and still not cover all Americans?

The Healthcare Maze and the current debate is totally irrational without a full debate about what makes up yearly healthcare spending and why it is so much higher than two dozen other modern countries around the world.

Where Is The Center In Troubled Times?

January 18, 2017

When George W Bush was elected in 2000, Bush campaigned as a “compassionate conservative”. What could be better, a mix of pragmatism and concern for others? The wealthy smiled as the Bush Administration made a case for two tax cuts. The evangelical community smiled when government policy turned upon science severely limiting stem cell research and linking foreign aid to impoverished countries’ family planning methods.

And the gates were opened for the neoconservative movement, blindly supporting Israel and simultaneously destabilizing the Arab world. Along came the Patriot Act, secret subpoenas, and Justice Department sanctioned torture.  Hmmm. That America’s part of the world tilted strongly to the right and away from the center would be an understatement.

Barack Obama brought into power countervailing tendencies. Science was again respected as evidenced by renewed concerns about global warming, use of data in forming public policy, and research into solar and wind technology. The Obama Administration pointedly worked to end the Iraq and Afghanistan wars and to close the dark spot on America’s image, the Guantanamo Detention Facility. And, most remarkably, the Obama Administration attempted to bring US healthcare into the realm of other world class, modern industrial countries by passing the Affordable Care Act.

The Republican Party, lead by the Tea Party/Freedom Coalition howled in horror about the reckless race to the left. It was not, however, clear that President Obama was guiding America towards the “center” until Bernie Sanders’s campaign revealed much more progressive goals. For many conservatives, however, President Obama’s policies represented socialism, if not outright communism.  To highlight this, the Republican Party’s complete rejection of Merritt Garland’s Supreme Court nomination underscores GOP rejection of centrist governance.

As the Trump Administration readies itself to take office, the Republican controlled Congress appears like the cat ready to eat the canary. The Republican Congress can’t wait to take the country back and “back” will be well to the right of center.

The unknown, strangely is President-elect Trump. Will he focus upon the ideological right or what ever is needed to stimulate economic growth? Will President Trump trade support for right wing ideas in return for support of his growth initiatives? Or, even worse as some conservatives worry, would a President Trump simply be a Democrat in Republican clothing?

“Regaining The Center” may appear a desirable goal, especially in comparison to the conservative hinterlands Republicans boast as the fruits of taking America back. The GOP possesses enough votes in Congress that Republican initiatives can carry the day. “Regaining the Center” may serve the reader well by putting GOP policies in context as a public reminder that Republicans seek benefits for their wealthiest members, at the expense of the average person.  If there are benefits, these pluses flow incidental to their main purpose.

For now, the GOP and the Trump Administration can do pretty much what they wish. In two years and again in four, voters get to assess Republican stewardship.  As with George W Bush’s Administration whose results were mixed but on the big issues, failures, “Regaining the Center” may sound prophetic.  The center may soon appear much less unsettling for independents to shift left of the Trump Administration without doing a full Bernie Sanders.

 

Ready, Set, Fire, Aim

January 16, 2017

With only a few days left before President-elect Trump becomes President Trump, the feeling is like the calm before the storm. On Friday, January 20th, 2017, the Republican Party gets a full house and a friendly President to boot. The GOP wish is to undo the last 8 years and make the future like the past, the distant past. The public has been advised “to fasten their seat belts” and watch our elected leaders make things happen beginning on the very first day.

Hmmm.

We can remove some mystery about any consequences from GOP actions. There will be massive reductions in taxes paid by the top 1%. Even the irresponsible repeal of Obamacare is at its core a tax cut for the wealthy.

Corporate tax rate reduction unless accompanied with elimination of business tax deductions, exemptions, and loopholes will accrue more money for the wealthy. And eliminating the myriad of regulations which we are told are hamstringing our economy, will put even more money in the wealthiest’s pockets.

So for at least some Americans, January 20th should be a red letter day.

Every action has a reaction too. Repeal of Obamacare will immediately beg the question what happens to those insured by the Affordable Care Act? The GOP will attempt to keep enough of current Obamacare recipients covered that they can look the camera in the eye and say, “see we replace Obamacare with patient centered, not Washington centered healthcare”.

But two facts will emerge. (1) The GOP will have to find money to cover whatever parts of the ACA it puts forward as “patient centered care” and will most likely hide their healthcare subsidies. With no new taxes, the healthcare costs will go straight to the national debt.  The GOP will adamantly deny this with a look of sincerity.

And, (2) The number of people covered will shrink as will the quality of their coverage.  The “free” market will offer reduced coverage to those unable to pay the going price for standard coverage. Those impacted the most will be the most vulnerable and, not surprisingly, those least able to garner public sympathy.

This is a pretty sad commentary on the Grand Old Party.

But there’s more.    IMO, Trump will support juicing the economy with tax cuts and government spending so that his prediction of greater economic growth can materialize. Trump, however, will run into opposition from fiscal conservatives who want to see the debt decreased, not increased. Trump, the deal maker, will step forward offering to trade his support for much of the GOP agenda, despite his own preferences, in return for support of new spending.  You scratch my back, I will scratch yours. Hmmm.

With “Ready, Set, Fire, Aim”, Republicans will run unnecessary risks. Unintended consequences and collateral damage are almost assured with current GOP plans. As the first 100 days domestic casualties begin to mount up, voters view of President Trump will become tarnished.  At that point, President Trump will make sure everyone knows he favored this or that, and instead those in Congress, much over rated, all talk and no action did not follow his advise and are to blame. Hmmm.

Most of the Republican game plan will hurt small groups… initially. For example, the 20 million ACA subscribers pale in comparison to the greater 340 million US population. Increasing the Federal Debt won’t impact anyone at first. The subsequent risk, however, is the building pressure to reduce other Government spending… like Medicare, Medicaid, Social Security, and a myriad of social safety network programs. And as these messy regulations are revoked, freeing up America’s great capitalist engine and creating jobs on every corner, conditions for another financial meltdown, run away inflation, and renewed disillusionment with Washington will gratuitously appear.

President Trump has an initial White House lease for 1461 days. It would be a shame for the Trump Administration to let hubris in the first 100 days help destroy the next 1361.