Archive for the ‘obamacare’ 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?

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?

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?