Posted tagged ‘health care’

Life Is Not That Complicated

January 28, 2014

Retiring Oklahoma GOP Senator Tom Coburn said in an interview that fixing the Affordable Care Act is necessary, and not so difficult.  He alluded to a GOP proposal which enshrines the elimination of “pre-existing conditions” exclusions and provides a path for all Americans to purchase their own coverage.  He justified his proposal on the basis that some two hundred thousand have signed up for ACA while over two million have had their coverage discontinued.  Under the GOP proposal, no one would be forced to do anything, and everyone would have the opportunity to buy coverage.  Hmmm

There is no evidence to date that defending ACA at all costs is worth the effort.  The ACA is only one of many ways to reduce the injustices and the potential to cap the out of control costs that our US health care delivery system is built around.  Without a doubt there are other good alternatives available short of adopting far superior systems found in most all other developed countries.  But taking Coburn’s comments lying down only sets Americans up to buy a bridge he might have for sale next.

So what must we recognize.

The 50 million or so Americans who were uninsured prior to ACA were composed broadly of those who chose not to buy any insurance, those who could not buy adequate insurance and those would buy insurance but lacked the financial capability.  The two million Americans that Coburn estimates have lost coverage result from a wide range of generally low wage paying companies who reduced employee hours to a level where these employers were not required to provide coverage.  These companies claim they could not afford to increase their benefit costs and stay in business.  Hmmm.

Now back to the GOP plan.  Allowing the young and healthy to opt out of insurance, by simple math, means that everyone else pays more.  It also leaves open the gravy train where the uninsured still use hospital Emergency Rooms driving up the hospitals’ costs and when many uninsured fail to pay, these costs find their way to everyone else through inflated billings.

The pre-existing cohort apparently under the GOP plan can buy insurance if they can afford the premium.  The GOP seems adamant that insurance companies must offer coverage even if the customer cannot afford it.   Hmmm.

The US spends around $2.9 trillion per year for health care services.  This equates to about $9,000 per person per year, man, woman, and child.  This is roughly twice as much as any other country in the world.  Hmmm.

It is simply a shame that our politicians spend so much time arguing about the Affordable Care Act when the entire health care delivery system is built upon an unsustainable financial model.

Who Are These People?

January 3, 2014

On New Year’s eve, Supreme Court Justice Sonia Sotomayer granted a stay to the Sisters of the Poor allowing them to escape certain benefits contained in the Affordable Care Act.  The Sisters argued that even though they would not physically have to pay for these women’s health provisions, just having to assign the right to someone else violated their religious beliefs.  In the good Sisters’ collective minds, it was ok for their employees to receive substandard health care (compared to everyone else) just because the Catholic Church does not teach sensible family planning.  This matter will be decided eventually in the Courts but I am not sure how these otherwise holy people can sleep at night.

The Sisters are not the only ones who take exception to the ACA.  The talk shows are constantly declaring that Americans are overwhelmingly against the ACA.  Who are these people and why?

Let’s begin with those over 65.  They are part of Medicare and covered even with pre-existing conditions.  They have no basis to be against ACA.

Next, lets look at those employed by major employers both private and public.  These Americans continue receiving the same benefits as before, and although costs are rising, there is no indication that ACA is driving up costs yet.

How about those who could afford insurance and are under 26?  Why, they are included now on their parents plans if they are still dependents.

How about those with pre-existing conditions?  Guess what, they can now purchase insurance at rates far lower than before.  Its not them.

Well, what about those living in reach of the poverty level?  Here it does get murky.  In States that have expanded Medicaid, the path is clear.  Adding in Government subsidies, these poorer Americans can get insurance at very low rates.  Those living in States which refused to be part of the Medicaid expansion, the story is not so pretty.  These Americans, however, are far short of any majority.  Hmmm.

Arguably ACA is far from perfect.  A straight forward, single payer, universal health care delivery system would have been far superior.  It would also have been a nightmare to implement given the irrational stand many take when the single payer system is suggested.

If we assume the news media has not made up the numbers and that a majority of Americans are indeed against ACA, we must ask why?  Is it they feel they personally have no responsibility for those with pre-existing conditions, or are too poor to purchase health insurance?  Do these Americans subscribe to the notion that all Americans are entitle to as much health insurance as they can afford?

Undoubtably, this is the position of some Americans.  Even the Sisters of the Poor are for everyone being insured.  The Sisters just have this one aspect they do not want anyone to obtain, but otherwise they want health care for those who cannot afford it.  So does this give us insight on “who those people are”?

I think so.  Those opposing ACA are people who cannot see beyond their own personal circumstances.  If they already have insurance and have the ability to purchase the full range of women’s health care procedures, then ACA brings nothing special.  It is those who lie at the margins who might not be able to get preventive care that needs and wants the full ACA package.

Strangely, many of those groups opposing ACA also oppose women’s rights (abortion).  ACA offers one path to minimizing abortion while dignifying a women’s right to choose.  Avoiding unwanted pregnancies is the most straight forward way to satisfy both sides of the abortion debate.  I wonder whether the Sisters in their heart of hearts support the position?


When No Deal Is The Deal

December 10, 2013

Representative Paul Ryan and Senator Patty Murray have been leading an effort to find a “deal”.  The scope of the deal would include some relief for the sequester and also set spending limits for the next two years.  The objective is to avoid another government shutdown or default on the debt.  Sounds sensible if not heroic, but the substance falls quite short.

Prima facia, the country’s tax code is so convoluted it should be against the law.  Entitlement, especially Medicare and Medicaid are woefully underfunded and should constitute fiscal mismanagement to be allowed to continue as is.    A pinch here or a pinch there on the over all budget without dealing with these two big problems won’t have much impact upon the growth of the debt.

These two elements (tax reform and entitlements) constitute the heart of a political impasse.  Without tax reforms (leading to more tax revenue) Democrats will not support any other changes, especially to entitlements.  Without cuts in entitlements, Republicans won’t budge on any changes in the budget, and as an article of faith, no new taxes will be considered.

The Obama-Boehner “grand bargain” which included tax reform and entitlement cuts, seemed so obvious.  Washington, today, is deafly silent about that possibility.  While it remains an option, it certainly is not one for an election year.

The Murray-Ryan deal is the equivalent of “no deal” even if it can be struck.  Nothing happens versus the systemic problems facing a slow growing nation.  At a time when decisive handling of the nation’s infrastructure could prepare the US for global competition in the 21st century, there is no budget room and sadly, no will to deal with the future.  Just as disturbing is the blind eye both parties are showing towards healthcare.  While the Affordable Care Act promises to reduce the inequality of healthcare delivery and may slow the growth of future healthcare costs, it still leaves the US far short of more than two dozen other modern countries in cost and quality of care.  Not dealing with healthcare also leaves in place the festering sores called Medicare and Medicaid.

If Representative Ryan and Senator Murray cannot lead us to a tiny deal, how can we expect our elected representatives to deal with real game changers?


Eyes Up?

December 3, 2013

In the olden days, when coaches were trying to teach youngsters how to play basketball, they would devise various drills where the players were required to dribble the basketball without looking at the ball.  The intention was an early example of “multi-tasking”.  Coaches wanted players to gain proficiency in bouncing the basketball using their fingertips while at the same time they surveyed the court finding ways to implement the game strategy.   Doing two things well was the goal.

In an analogy, the problems with “” can be traced to the White House’s inability to undertake two things at once.

Dribbling the ball is analogous to designing, developing, and launching software for the web site.    (This was not some trail blazing event.  Similar web sites and others as complicated have been developed in the past and are being developed everyday now.  Doing it well simply requires practice and discipline.

Keeping the eyes up while dribbling is analogous to the White House political management role.  Too much White House attention is spent, unfortunately, just trying to outwit political opponents.  While this is necessary (although not ideal), in the Obama White House the consequence was too little management of the site design and development.

To be fair, the White House business is not web site development any more than it is to fight a war.  Both are tools to achieve some policy.  But doing two things well at once is a requirement of the office.

The Affordable Care Act is an important reform of what was the existing US healthcare delivery system.  By introducing a customer friendly web site, the White House could take an important step in bringing ACA value to Americans.  This should have been obvious to Administration officials.  There is little excuse for a second class web site introduction.

What is, however, even more important is that the White House ensure that Americans understand the difference between the benefits and requires of ACA, and the web site purposes.  A less than perfect web site in no way lessens the importance or value of ACA reform benefits.

It is late to be learning how to keep “eyes up while dribbling”, but the selling of ACA over Republican opposition is not finished.  Coach Obama better get his game face on and get back on the court.  ACA is too important a reform to lose over something not related to healthcare.

Bring Back Ear Marks

October 21, 2013

Ear Marks, the time honored procedure where a Congress member writes into legislation some provision that normally brings money to his/her district or often to a specific benefactor.  It makes any reasonable person gag to think that laws can have provisions which hide in the bills verbiage that have nothing to do with bill’s title or intent.  But the ways of Congress are sometimes mysterious.

With the rise of the Tea Party, “ear marks” became a bad word.  For sure many ear marks were ridiculous when isolated and highlighted.  But they served a purpose.

Congress members seek to be reelected.  Reelection usually requires a well off campaign fund as well as local discouragement to other potential challengers.  Bringing home the “pork” was the most proven method.

Ear Marks while sounding awful (and truly were shameful) did not cost a lot when compared to the size of yearly government expenditures or even when considering the annual deficit.  Ear Marks, however, did foster a spirit of “compromise” as well as a focus on must do legislation.  As long as there was an expectation that each Congress member would get their turn to dip into the public trough, Congress members could be kept in line.  Hmmm.  Oh, for the good old days.

Today it is less important to bring pork to the home district (although Defense appropriation still do this).  Today there are PACs which dump huge amounts of special interest money on Congress members desks… providing they are aligned with the ideological bent of their special interest supporters.

There has been much criticism of President Obama.  “He won’t engage with the GOP”, it is said.  These critics predict that there will not be any progress in Washington until the President engages.  Hmmm.

What should the President say?  Should he point out that the US is the only modern country that does not provide health care for all its residents and the health care it does provide is twice as expensive as other countries?  Should the President point out that illegal immigration is in fact a “Mexican” problem and that there are straight forward ways to gain control of new immigrants?  Should he say that undocumented immigrants already living here, say for more than five years and who have no criminal record, ought be allowed to become citizens on both humanitarian and pragmatic grounds (cost to send back and children who are citizens)?  Should the President say (again) the deficit could (and should) be closed with a balanced/shared approach involving government spending cuts (including entitlements) as well as new taxes?  Or, should the President emphasize that those bridges and roads which are crumbling are essential to a healthy economy and we need to find ways to maintain and improve them?

Just saying this again, I agree, is not “engaging”.  There can be no engagement unless others say something back.  In the olden days, the something was “I need this ear mark or that one”.  Today the dialog is written in some special interest’s back room.

The sad part of this is that ear marks are not the answer to the mess President Obama finds himself in.  The President is simply frustrated with the low intellectual level of Congressional discourse.  To his fault, President Obama prefers to say nothing rather than engage in clear demagoguery.  To say, President Obama does not suffer fools well might be an understatement.

I wonder whether Hillary will do better?


Shut It Down, Shut It Up

August 2, 2013

Senator Ted Cruz wants to “shut the government down” and Senator Rand Paul wants Governor Chris Christie to “shut up”.  What a classy group of new conservative Senators Congress can now boast.  Hmmm.

Most likely Cruz does not really want to shut the government down.  For reasons that aren’t quite clear, he says he really wants instead to shut down “Obamacare”, the Affordable Care Act.  Paul probably really didn’t think Governor Christie was hoarding Federal funds that could instead have gone to national security.  Instead both Cruz and Paul are saying controversial things they hope will identify them as future leaders of a Republican Party.

Christie and other more moderate Republicans are saying “not so fast”.  These Republicans are pointing out that Cruz and Paul have not thought through the consequences of their proposals.  And in the opinion of these moderates, the consequences will be bad for the GOP.  (What about the country?)

Pause…  Let’s catch our collective breath.

The national economy is slowly but steadily recovering.  Most everyone wishes it was recovering faster and unemployment was lower.  The national debt is shrinking but not very quickly and with a balanced budget not in sight.  Most everyone intuitively believes the US should balance its budget.  While there is argument over the roll of tax increases, no one foresees balancing the budget with taxes increases alone or with 100% budget cuts.  Most economists, however, worry that a sharp increase in taxes and a proportionate reduction in government spending will bring our economic expansion to a halt.  Hmmm.

So what should our politicians be telling us we should do?

A slow but steady recovery has the advantage of lessening the chances for creating dangerous “bubbles” like we saw in 2007 with the housing industry and the derivative trades.  Small to moderate tax increases (like income tax code reform) and small to moderate reductions in government spending (like the size of the sequester) every one to two years might actual make progress.  But balancing the budget?  Not in the cards.


Medicare, Medicaid, and Defense Spending.

These three Federal expenditures are huge and growing.  Progress made with small to moderate increases in taxes and/or reductions in spending will be eroded with sucking sound of increased Medicare, Medicaid, and Defense spending.

Obamacare is a red herring.  It has nothing to do with the deficit by itself.  Shutting down the Government has nothing to do with the deficit (the money is already spent, the bills are already owed).

Healthcare and what is defined as “our national interests” has everything to do with the cost of Medicare, Medicaid, and Defense spending.  Any politician who cries out to repeal, roll back, or defund Obamacare (ACA) is disingenuous unless he/she offers a detailed alternative which offers the same coverage and does it at a lower cost.

Our national interest is a harder question to answer.  Since George W Bush (read Dick Cheney) lead America off its course and into endless wars in the Middle East, we have seen a world community only too happy to see America act as the world’s policeman.  Where is our national interest?

By the same token, an isolationist US would most likely produce a world where regional conflicts were numerous and international trade was severely restricted.  One can imagine a very dysfunctional world.  Hmmm.

I am getting the feeling that small to moderate change is actually a very prudent approach.  Whether some politicians like it or not, the current (and likely future) demographics, call for the US to work hard and cleverly towards an “inclusive” society.  What we might have thought was an inclusive society in the past, may not fill the bill in the future.  Senators Cruz and Paul (and all the others shouting to be heard) ought think about where the US is really headed and what internal changes will be necessary to meet the needs of that population.

Once the country pragmatically focuses on the future, then these spokesmen can more clearly see whre our national interests really are and what policies best serve them.

It won’t be “Shut Down” or “Shut Up”.

How Long Will The Grand Bargain Take?

July 31, 2013

I can understand some of the critical reviews of President Obama’s time in office.   The more serious reviewers find him as only an average chief executive.  His opponents find him an utter failure, worst ever.  Hmmm.

The expectations for this “post racial” President were very high indeed.  Living up to the hype would be very difficult for anyone.    President Obama’s shortcomings, however, lay not so much in his goals (what he wanted to do), but in how he has tried accomplished his agenda.  As chief executive, he has proposed legislation and Congress has said “no thanks”.

The President identified (correctly in my opinion), healthcare, as the most important strategic objective.  He wanted to correct health care injustice and get control of its spiraling cost.  For example, Obama pointed to upwards of 50 million Americans who had no coverage, to Americans who were denied coverage on the basis of a “pre-existing condition”, and to millions who were one illness away from complete financial failure.

His goals were worthy but his actual achievement, the Affordable Care Act, is a pigmy compared to what is actually needed (and what is found in the rest of the modern world), and ACA is still a fight he must wage every day.

Compounding his problems, the President has been pushing on a rope trying to get anything through Congress.  The GOP has lapsed into a “just say no” approach.   In their zeal to blacken (get the pun) President Obama’s record, Congress has turned its back on the needs of the greater USA.  The President has tried to stand above the “food fight-like” Congressional behavior but instead has too often appeared aloof.  (It took former President Bill Clinton to adequately explain President Obama’s first term because Obama either couldn’t or wouldn’t try.)  The end result, no action.

Today the New York Times published an article comparing the US performance on global inequality measures.  Simply stated, the US appears to be “exceptional”, unfortunately in a disappointing way.

Comparing other countries, the US rated on (1) Income inequality (5th worst), (2) literacy inequality (5th worst), (3) Infant mortality (4th worst), (4) child poverty (4th worst), and (5) single parent families (worst).  Hmmm.

The President has said often “we can do better”.  And for sure doing better is not lower taxes for corporations or the top 2%.  Rather “doing better” is far more likely linked to increasing the economic strength of the middle class which should raise all boats (even those of the top 2%).

Improving the middle class’ economic strength will require a greater share of corporate returns being shared with ordinary workers.  It must also involve bringing under control the staggering cost of health care, particularly the annual increases.   A revamped health care system such as a universal system like Germany’s would replace Medicare and Medicaid and allow the US to focus on the costs of a single health care delivery.  If the US could find the resolve to move to a system like Germany, health care costs would drop by as much as 50% while health outcomes would increase.  Businesses would no longer be saddled with contributing to health care through employee contributions, and the Federal Budget could more easily be studied with Medicare and Medicaid eliminated.

Regrettably, there is no interest in Congress.  To improve the US position in these “inequality” measures will require an interested and dedicated set of public servants.  And to turn the current crop of Congress Members into public servants seems just as remote a possibility.

So maybe all that is left for President Obama is to lay out just how exceptional the US really is (pretty nice place for the top 2%), and what strategic changes need to be made (much less income inequality, tax reform (including new taxes), sharply lower health care spending, and corresponding reduction in government spending (Medicare, Medicaid replaced by universal health care).

The chances for any serious action seems not timely at this moment.  I wonder how long it will take?


What Can We Learn From The Federal Budget Impass?

April 9, 2013

President Obama will soon make known his proposed 2014 budget.  Aides are busily leaking key provisions as if they were passing out candy.  We are being told the President will speak to the need of balancing the budget but not to its urgency.  He will speak to changes in “entitlements” and the need for increased taxes (on the wealthiest).  And we can count on “government investments” in areas the President feels worthy.

Americans can count upon the loyal opposition to rebuke the President’s proposals.  It cuts too much here and does not go far enough there.  Taxes are off the table.   He’s weak on defense and wasteful on social programs. The President is not the leader we need!

Progressives will find the President’s cuts to entitlements cruel and unnecessary.  They will point to more taxes and deeper cuts to defense.  They will see a different man as commander in chief than the one who ran for office in 2008.

When one boils all this down, the prospect of a long term deficit cutting budget seems remote.  Prospects around positioning the economy to grow faster seem just as remote.  Hmmm.

Historians tell us that nations, even wealthy ones like the US, cannot run deficits indefinitely.  Economists tell us that sooner or later lenders will jam up the interest rate on the borrowed money and grind our economy to a halt just trying to cover interest expense.

Some political leaders have taken these views to heart.  These leaders propose deep spending cuts normally to programs their constituents do not support.  Other leaders do just the opposite.  Let’s even increase spending in order to get the economy humming again.

Spend or cut, what should it be?

If the US were a business, most every business person knows there should be large opportunities for efficiency improvements.  All organizations, given time, become full of redundant positions and often with workers who have become less productive due to age, illnesses, or simply complacency.  The Federal Government is no different in this respect.

Oh, and remember that the Government is often “the employer of last resort”.  A good politicians almost always takes advantage of government spending when it brings jobs and revenue to his/her district.   So, we can pretty much forget about deficit reduction programs built around trimming the government work force.

Just as disingenuous is the political rhetoric calling for more jobs.  While higher employment would seem in the right direction, the world is no longer a place where “blue collar” jobs are good jobs.  Globalization has changed everything and manufacturing jobs which were once prized pay the wage of the lowest wage country anyplace in the world.  So how is a family to survive on less that the minimum wage (say $15,000 or less)?

There are still decent jobs in America.  More and more these jobs are going to graduates from colleges and universities who have themselves amassed six figures in debt just to pay for their education.

And those at the top of the income pyramid, earning millions each year, their prize is a tax rate below the middle class.

So what can we really learn from the Federal Budget?

  • First, the budget process is broken.  Congress cannot decide rationally how much to spend and how much to tax.
  • Second, there is no national consensus on how to create “good paying jobs”, how to provide skilled and motivated workers for these jobs, and how to manage quality of life services such as education and healthcare so that they are effective and affordable.  These are critical building blocks.
  • Third, there is no ownership of the current situation.  Americans lacking skills are not owning up and doing something for themselves.  Health care costs are obscenely high and continue to rise.  Most Americans, however, are insulated by employer provided insurance or Medicare so they just look the other way.  And, Americans seem content to reelect Congress members who have proven ineffective and silently watch these public officials increase their own personal wealth while letting America drift.

There is a school of thought that says the best Government action is no Government action.  While there are countless examples where that adage has been shown wise, is that enough now?

Like it or not, government sets the broad rules with which we play.  The current rules are not working and worse are trending even more negative.  What ever the next set of rules might be, these new rules must call for shared sacrifice.  The argument over extending the Bush Tax Cuts was always the wrong argument.  Tax rates should have gone up for everyone.  How else will enough people realize that they are in a pot of water where the fire is surely going to bring it to a boil.


Knock-Knock, Anyone Home?

March 28, 2013

Today’s newspaper carried an Associated Press article which makes you wonder.  The article covered a just released report by an “actuary group”.  The bottom line, the Affordable Care Act would result in increase of over 30% for certain health insurance policies.  Whoa.

The AP reported that this increase was do largely to the inclusion of previously uninsured “pre-existing condition” Americans.  Hmmm.

A 30+% increase is quite large.  But what a quandary that presents.  Repeal Obamacare, save the 30% and dump several million Americans back in the land of no health insurance.  Hmmm.

One might also remember the huge fight that took place over the individual mandate.  Government officials told us that everyone needed to be insured so that the new revenue from previously uninsured Americans could cover the cost that this mostly healthy cohort would cause.  In essence, the individual mandate was supposed to be a sop for insurance companies.

Consider the following.  Most everyone of us will go through a cycle of being healthy and low cost (to insurance companies) when we are young to varying degrees of “unhealthiness” and much higher cost when we are older.  Everyone.

So why do insurance companies not use “average” health cost by placing all of us in the same pool?  Why should someone working for a large employer pay less for insurance than an individual who is self employed?

There are many reasons given.  One of the most popular is that Americans who take care of themselves (healthy lifestyle) deserve to pay the lowest possible rate.  Hmmm.  For sure there is some truth about lifestyle choices, but most medical opinion is that “genes” are the real game changers.

If this AP report’s prediction turns out to be correct, it may hasten the necessary questions to be asked.

How can this “exceptional” country, USA, be satisfied with health care that is the most expensive in the world (twice as much or more), receive mediocre outcomes, and still not include all Americans?

The Big Gulp

March 12, 2013

It is difficult to see the New York Appeals Court decision to strike down Mayor Bloomberg’s sugar drink size limit as much more than a victory for the Sugar lobbying group.  As a point of law, maybe the fact that the City’s health department had no authority to regulate 7/11’s played a role.   As a result, the ban applied only to restaurants (beverage  servings greater than 16 ounces).  The Court said the law was “arbitrary and capricious”.

The law’s intent was to make it more difficult for New Yorkers to consume large quantities of sugar containing drinks.  This was an indirect attack on obesity and a direct effort to decrease health care costs.  Hmmm.

Restricting these “big gulp” beverages was a symbolic gesture.  It did nothing to put common sense into the caloric content of many other foods and drinks widely available in New York City.  It did nothing to control what consenting adults (and children) do within their own homes.  And, of course, it did nothing to save New Yorkers from obesity when they traveled outside the city.

So with all those limitations, who cares that the Court said “no”.

Most nutritionists tell us that weight control is a balance of energy expended with food ingested.  If one eats more, then one must exercise more.  Very simple.

In the real world, however, this message seems to be drowned out with other messages.  Just walk down any street in New York City, or in any Walmart, or any public gathering across the country.  Weight control and obesity are not characteristics Americans manage well.

So this is not a New York City problem?

Obesity is an American health problem.  If simply being fat was a fact and not a health problem this entire discussion would be unnecessary.  What people eat or drink is their own business.  Government intrusion is unwanted and a very dangerous precedent.

There is, however, wide evidence that high sugar and high calorie drinks and foods are correlated with increased body weight and obesity.  High body weight and obesity are associated with health issues.  US health care costs are the highest in the world and getting higher each year.  In part, all Americans are paying more for their health care insurance coverage because so many fellow Americans have weight related diseases.


The Big Gulp may in the end be nothing more than a shot across the bow.  It is, however, powerful statement about what citizens ought to do themselves, without any government requirement.  Mayor Bloomberg has demonstrated the guts and intelligence rarely found in public officials.  Three cheers for the Mayor.