​The Graham-Cassidy reform-and-perhaps-replace-but-not-really-repeal plan has earned praise from a fair amount of analysts on rightish side of center, and it does indeed use a vigorous federalism as it’s guiding principle, kicking the debate down to the individual state level.

This is really chasing the emerging reality. Texas already delivers health care in ways that are different from New York or California. Graham-Cassidy would give states more room to work out their own solutions by block-granting money that would have gone to Medicaid expansion or premium tax credits under the Affordable Care Act. You want single-payer and high taxes? Move to California. You want affordable premiums and higher-deductible plans that mean you pay more for day to day health care but you’re covered for the larger expenses you may face? But lower taxes and more jobs? Move to Texas.

Their plan is a reasonable solution to what is becoming an unbridgeable gap between Democrats who now increasingly pledge their allegiance to single-payer systems (until they find out what rationing is like when it comes to healhcare) and Republicans who want real choice and real competition in the health insurance market.

Ah, the health INSURANCE market. Yes, insurance industry lobbyists have been a constraint on innovation you might say. But, health CARE is so much more than just insurance premiums. That is not a clarion call for big spending, by the way. It’s merely to point out that a major factor in increasing premiums is often lost in the current debate:

Hospitals in America are producing very high-cost products and services and are a supported by powerful lobbyists that do their share of whispering and bending ears to ensure that innovative competitive solutions do not threaten their cozy, coast-to-coast oligopoly.

One reason for this is the employer-based plans where customers don’t see the true cost and thus the true price of the health services they select. So the big and fat and getting fatter hospital networks can keep raising prices far beyond what almost any other industry is able to get away with. And if money from employer-based plans is not enough to cover the increases, why there’s always the federal government.

So let’s hope that if Graham-Cassidy can get passed into law – and it perhaps just might – then the next step would be to look at freeing up healthcare in America from the welter of self-serving regulations that keep competitors at bay. And maybe the state level is indeed the best place to attempt those types of innovations

​It won’t be single-payer! It won’t be single-payer!

Sorry for shouting at Senator Sanders out here on the sidewalk. Here’s what I mean.

Like in the case of gay marriage or de facto open borders, the Democratic Party is shifting hard to the left on health care, and dragging some moderate or RINO Republicans with them.

Yes, this has to do with Bernie Sander’s surprisingly successful campaign, which ignited millennial interest and brought Scandinavian-style socialism to the doorstep of American politics in a way that previous hard left groups were unable to do. And attitudes are shifting. Whether attitudes are following or leading Sanders’ efforts to introduce single-payer health care in America is something that perhaps the wonks at 538.com can figure out.

But today we hear about Sanders’ plan. And here’s why it will never be truly single-payer.

To achieve single-payer it’s not Trump supporters whose corpses you will have to bulldoze out of the way. They tend to be open to entitlement goodies including government healthcare which in America mostly means Medicare.

It’s the wealthy and solidly upper middle class blue voters in places like NYC and San Francisco that will never, ever, ever give up their employer-based health insurance. To let go of a system that allows them a wealth of choices with regards to their daily health care needs and that their employer mostly foots the bill for, is asking far too much of righteous, well-paid lawyers, accountants, techies, and managerial level workers. They won’t do it, and people like Pelosi and Schumer know this perfectly well because they feel exactly the same way, because that’s also who they are.

So, if over the next few years single-payer becomes a real possibility, how do you preserve employer-based insurance and how the heck do you pay for single-payer? Goodbye corporate tax-cuts? Goodbye tax cuts period, is more like it.

And what model does America look to to consider ideas for Medicare-for-all-except-us-wealthy-liberals?

Here’s a suggestion that President Trump can use in his bargaining with Canada over the northern neighbor’s terms for a revamped NAFTA:

You want to preserve some form of NAFTA up in Canada, on which your wealth greatly depends? You get to send us a committee describing how your single-payer system works. Wait. Wait. Don’t smile. AND. We get to set up employer-based insurance policies for all of you (fairly) wealthy, liberal Canadians. Think of it this way:

Ivanka gets photo ops with their Prime Minister. Smiliing about her universal daycare policy with a rainbow of adorable little kids scattered around them on the White House lawn.

Jared gets photo ops with the CEO’s of Unitedhealth, Wellpoint Inc., Kaiser Foundation Group, Humana, and Aetna. In Ottawa. Smiling next to whoever is in charge of leading Canada’s brave new revamping of it’s creaking government healthcare system.

So Medicare for all can smooth Canadian feathers by asking for their wisdom on how to let government run health care. And American enterprise can uproot Canada’s government monopoly on healthcare and give Canadians something magical … choice of healthcare plans. All in exchange for preserving some form of NAFTA.

And Senator Sanders? He gets to work away in committees on the Hill, arguing over how much to raise taxes on wealthy liberals to pay for his scheme. Unfortunately those raised taxes won’t just be on wealthy liberals, will they?

The BCRA is a modest reform of Obamacare that curtails the growth in Medicare spending over the next decade (assuming a future Democrat administration and Congress don’t cancel these modest attempts at slowing the rate of growth) and loosens the mandates, although it does keep a sort of penalty for going without insurance for several months. This is now painted as practically murder by progressives. And the CBO with their crystal ball predictions of 22 million losing their health insurance have also been a key factor influencing voters.

It’s working. For Democrats.

Look at how quiet GOP Senators are. They aren’t saying a thing, or they’re casting doubt, or they’re outright dismissing the bill. The latest polls showing the unpopularity of the proposed legislation have clearly influenced the GOP. And no amount of skillful process-managing can bridge the enormous ideological differences between GOP Senators. One “common-sense” euphemism after another about doing things right and getting it down and makings sure we nail it down, can’t change that fact.

Maybe Charles Krauthammer is right. Maybe we are witnessing the slow death of the ideal of healthcare as a private insurance proposition and not as a social right that voters are entitled to. There is no real insurance in Obamacare, but rather the use of the existing insurance industry as a tottering scaffolding to drape subsidies, taxes, penalties, and mandates over the top of it’s creaking framework.

Until it starts collapsing, in state after state because insurance companies are going broke following the ACA’s rules.

Perhaps an idea like Universal Catastrophic Insurance, where voters have a guaranteed protection against major medical expenses but have to pay most of their monthly or weekly or daily medical expenses, could be a way out. Given how voters have reacted to current GOP efforts at merely reforming Obamacare, that’s unlikely however.

What happens next? Can McConnell pull off a miracle? It’s looking very doubtful at this point. His final attempt at compromise between a Senator Lee and a Senator Collins, for example, might involve front-loading money to help lower-income workers with their health insurance and back-loading cutbacks (which are really just reductions in the rate of growth of Medicare).

If this fails, then what? Does this mean that Obamacare is an established entitlement, and as such, will continue to expand and involve more and more government rules, regulations, taxes, fees, penalties, and on and on? And will this even be cheered on by a majority of voters? If so, then Elizabeth Warren is right. Voters really just want universal health coverage and it’s up to Democrats to sell them on the idea without all the half-truths and complex mechanisms inherent in the ACA.

Imagine. President Warren meeting with the Canadian Prime Minister and the two of them heading up to Camp David to relax and have a long chat about government-owned-run-and-operated healthcare and how to finish the job. And finish off private health care in America.

Yes that’s an over-the-top scenario. One that will hopefully never come close to happening. But healthcare in America is at a historical crossroads one feels, and it is not clear that private healthcare will predominate in America in the future. Senators should keep that in mind over the next few weeks. Especially GOP Senators.

Oh joy oh joy! We get to talk about health care again.

So. We now have the Senate’s Better Care Reconciliation Act – that’s BCRA – and it’s a watering down or subsidizing up of the American Health Care Act – that’s AHCA – which itself was a clear start, but nothing more than a start, at partially dismantling the Affordable Care Act – or the ACA – which we all know is Obamacare.

Do you really want to go through all the changes in rather overwhelming detail? Read Christopher Jacobs’ review in The Federalist. If there ever was a healthcare policy wonk, he’s it.

Do you want to know what the “family glitch” is? Chris Jacobs helpfully explains it’s when members of a worker’s family do not qualify for subsidies if said worker qualifies for employer-based health insurance. Even if said worker’s employer-based health insurance does not cover his family members. Thus the glitch. Apparently the BCRA solves the AHCA’s family glitch problem. Did you know that the word glitch probably comes from German or Yiddish? And was first used to refer to engineering problems at Cape Kennedy around 1965? And yes, apparently the BCRA solves the family glitch problem.

Ah but it’s not just the family glitch that was solved. We also have Avik Roy cheering GOP Senators for diving into the details of the AHCA and like navy seals triumphantly emerging on the surface with the AHCA’s section 202 in hand. Section 202 of the AHCA you ask? It involves a transitional schedule of tax credits rather than the flat tax credit that kicks in regardless of income under Ryan’s AHCA, and that was meant only as a bridge between Obamacare and Ryancare. What did the Senators do? They made it permanent so that the tax credits in the BCRA now depend on income, rather than being flat. That means lower income workers get more subsidies for their health insurance compared to the House’s AHCA plan.

That means, according to Avik Roy, that low-income workers and near-elderly working poor will now be able to afford health insurance that they might not have been able to under the AHCA. That’s surely what President Trump meant when he said we need a plan that is less “mean” didn’t he? He knew all about section 202 of the AHCA, didn’t he? Didn’t we all?

Then again maybe we didn’t. Health care policy in America is fiendishly complex with conflicts between hospitals, patients, doctors, healthcare workers, insurance companies, employers, employees, independent workers, small business owners, local government, state government, and the federal government. And taxpayers of course, which is a term that covers several of the already mentioned groups. And all the other groups I surely forgot to mention.

No single plan can satisfy perhaps even a clear majority of these constituencies. But most of us don’t have the time, passion, or focus to clearly think through the countless trade offs that any health policy in America necessarily involves. But that doesn’t mean we shouldn’t try. Health care is fundamental, and Obamacare is unsustainable without serious reform/replacing, or without way more taxes and subsidies. Those two truths mean everyone has to do a little research and decide what they think about healthcare policy. For their own and the country’s good. And yes, it’s a pain.

It’s still here. The Affordable Care Act has been taken off the operating table; Doctor Price and Doctor Ryan (yes only one of them is a real doctor) have taken off their scrubs and headed home after a presser or two. And The President did not look nearly as disappointed as the Speaker of the House, after the vote was called off this Friday afternoon. By the President on advice of the Speaker. Or by the Speaker on advice of the President. Or something like that.

So as the patient with ACA on its hospital wrist band is suddenly given leave to head out the sliding doors pf the hospital and wander through the cities and towns of America, the question becomes: is it a zombie just waiting until its head explodes? And until it scatter its broken pieces around every state of the union? Or is it really kinda healthy and therefore there are many people glad that Obamacare is … still alive!!

President Trump did indeed state at various points during the electoral campaign that he thought perhaps the best thing would have been to let Obamacare collapse until there was no option left but to have a bipartisan bill that was able to clean up the mess of exiting insurance companies, skyrocketing premiums, and high deductibles. Now the president has had his wish come true.

Did President Trump invest political capital in Ryan’s AHCA? Of course he did. Quite a lot. We’ll see exactly how much as the weeks and months pass and Congress and the White House move on to attempt tax reform and infrastructure spending. But the tax savings that would have, theoretically at least, been achieved with the AHCA will now not be there to fund a program of tax cuts.

Plus the wounds and scars of a failed attempt at passing a major piece of legistlation – how about just getting it out of one of the houses of Congress, never mind actually passing it – will also make cooperation between GOP members of Congress a lot more prickly as they try to pivot and “roll forward” in the optimistically steely words of Texas’ Kevin Brady.

But the really noteworthy aspect of this first major failure for the Trump Administration and the GOP Congress is that the president seems more than willing to work with Democrats. Once Obamacare becomes manifestly unsustainable, that is. He said as much in his brief press conference in the Oval Office, shortly after Speaker Ryan had given his.

Would Senator Schumer, or Nancy Pelosi, be interested in sitting down with President Trump? Right now, one doubts that very much. But it could happen. It depends on how much salt they decide to rub into the wounds. And how any attempt at a bipartisan reform of healthcare in America gets framed. Would it be fixing the flaws in Obamacare? A little nip and tuck here and there so the zombie looks nicer?

Or would it be a case of digging in that scalpel and going for the bone? Maybe some amputations. Artificial limbs. A new head. For example. Or how about burying the zombie once and for all? Sorry, Chuck and Nancy can’t do that. Can they? Neither can Colins and Murkowski. And it may be that a clear majority of voters want some sort of a healthcare entitlement zombie alive and walking the streets of America. As of now, they have their wish.

If the GOP used to be divided between conservatives and moderates, but is now divided between libertarians and populists, then any legislation as important as the AHCA is next to impossible to achieve. Or at least very, very difficult. Democrats don’t even need to be part of this tower of babel. Although they can’t resist joining in, naturally.

Speaker Ryan’s AHCA will have to modified to have a reasonable chance of passing both Houses of Congress. But in which direction? President Trump – in other words – has to decide what philosophy he wants to support as he uses his executive weight to convince, persuade, and threaten enough House members and every single GOP senator to sign off on the bill.

A GOP conservative perspective, make that a libertarian perspective, admits that more people will be uninsured as a result of repeal. But with taxes, mandates, penalties, regulations, and subsidies eliminated or drastically reduced, private market solutions will drive down premiums and force providers and insurers to create innovative solutions across state lines. And in the end, there may not be anywhere near the number of newly uninsured patients that CBO estimates predict there will be as result of repeal.

A true populist – on the other hand – wants adequate, or better, coverage for just about everyone who is a legal resident of America. That is one tiny step from single-payer universal coverage. The means might differ, but the goals are the same as Bernie Sander’s vision of a socialized American healthcare system.

How the heck do you bridge those two views? When they are essentially inside of the same party? Yes, that’s pushing the populist perspective of Trump Democrats, for example, who basically want Obamacare to be fixed and do not trust its top-heavy centralized system of mandates and penalties. But their views are a long, long way from Senators Paul, Cruz, and Lee.

Who does President Trump listen to, as he decides how to push the as-yet-to-be amended version of Speaker Ryan’s AHCA through Congress? So far, he seems to be more concerned with getting Paul’s, Cruz’s, and Lee’s votes. Repeal as completely as possible now. And then replace with something as conservative, or libertarian, as possible in a month or two. Maybe. Perhaps.

Could the president pivot towards a more populist healthcare proposal? Throughout his campaign, he was clear that he was no conservative when it comes to healthcare. His newfound sympathy for conservative/libertarian concerns is something fairly recent, and definitely post-election. Of course, being a businessman who worries about costs, it would have been fairly straightforward for members of his administration – once they moved into the White House – to lay out some of the unfunded liabilities associated with the ACA. as well as Medicaid and Medicare. That might have helped turn the president.

With healthcare, especially this bill, once you get down in the policy weeds, it’s hard to ever come back up for air and a little perspective. The amount of commentary and policy ideas clash and conflict over differing perspectives on what healthcare insurance actually means. And then what to do, given your view of what health insurance is.

In the end, President Trump will have to expend precious political capital – which he clearly has right now in greater amounts than many critics realize – on legislation which Democrats will try to hang around his presidency. Some want him to walk away from it. Some are willing to listen to him. Some will fight him on this to the end, from both the left and the right.

If the president is able to shepherd some/any version of the AHCA through Congress and survive the mid-term elections as well as do some sort of tax and regulations slashing, he won’t earn a place next to FDR, but he will definitely nudge LBJ out of the way on the presidential stage. Whatever you may think of the big-government policies of either FDR or LBJ. Or the emerging policies of President Trump.

The American Health Care Act – or ACHA; or TrumpCare if you must say it that way – takes a modest middle-of-the-road approach to reforming some aspects of Obamacare. It is therefore reviled by the left for cutting back subsidies slightly by replacing them with refundable tax credits. It is therefore reviled by the right for replacing subsidies with refundable tax credits rather than standard tax deductions.

TrumpCare makes modest attempts to reign in some of the Medicaid expansion that has been a key driver of Obamacare’s expanded coverage. The freeze is delayed to 2020, and incentives are therefore given for people to sign up now before the freeze goes into effect. This angers conservatives. But it also angers progressives because the health care security (an oxymoron by most standards, and one which really means health care entitlements paid for by the government) of Obamacare has been replaced by something just slightly more market-oriented.

And the toughest conundrum of them all: risk pooling. In other words, how in goodness name do you incentivize younger healthier people who are unwilling to take on Obamacare with all it’s conditions and mandates? Because if you don’t, you’re left with the older, sicker patients who drive up costs exponentially and push premiums skyward.

In the Washington Post, Paul Waldman penned an attack article on TrumpCare where he focused on the 30% penalty the current GOP plan imposes if you go without health insurance for 2 months (as opposed to Obamacare’s mandate that penalized people without insurance in a slightly more severe fashion). He writes this about Trumpcare:

If young people make that calculation en masse, the risk pool winds up confined to people who are older and sicker, premiums skyrocket, insurers flee and the whole thing collapses.

Does this sound slightly familiar? As in exactly what has been happening with Obamacare? As in the key weakness of the ACA, a weakness which has been driving up premiums and causing the exchanges to collapse in state after state? This is partisan grenade throwing over relatively minor adjustments to health care policy. Vox, a progressive/radical beacon of activist muck racking journalism – for crying out loud – said this:

A curious thing has happened to the Republican replacement plan as it evolved through multiple drafts; it has begun to look more and more like Obamacare itself. The bill keeps some key features of Obamacare, like giving more help to lower-income Americans, and the Medicaid expansion, in a scaled-back form.

Is TrumpCare true repeal? No it is not. Senator Cruz has outlined in Politico a cohesive plan to use reconciliation to repeal most of Obamacare’s features and replace them with expanded HSA’s (which TrumpCare does do to an extent) and a nation-wide insurance market where lower income people can buy cheaper disaster insurance (high deductibles) and use their HSA money to pay for regular medical expenses. It is truly conservative and runs straight in the face of the progressive view that health care is an entitlement, not a service.

TrumpCare tries to bridge the enormous gap between conservative plans like Senator Cruz’s, and progressive views that would really like a single-payer healthcare plan – like Canada has. And who view Obamacare as a minimum acceptable standard on the road to Canadian style socialized medicine.

That means that TrumpCare is neither Obamacare (although it is very close) nor CruzCare. And it will be attacked from both ends of the spectrum. Trump will indeed own it and it will be interesting to see what further changes are made as the president pushes his plan through Congress. The president will need all the art he is able to muster to get this deal to fly.

By Tuesday, January 3, Senate Budget Committee Chairman Mike Enzi had already introduced a budget resolution aimed at resurrecting Congress’ previous attempt at repealing Obamacare. An attempt vetoed by Obama, of course, last year. A repeal bill is scheduled to be presented by January 27. That’s in a little over 3 weeks, which is at the speed of light, as far as Congressional bill-making is concerned.

On January 15, right in the middle of those two dates, Congressional Democrats are planning rallies against the repeal, to take place around the country apparently. And Wednesday, January 4th, Obama and Pence held dueling meetings in Congress to rally their respective teams around what will be the first big showdown of the 115th Congress, and President Trump’s new administration.

Wedged in between these key dates, is a dusty little ceremony that will take place at the Western Side of the U.S. Capitol. One wonders whether angry protesters dressed as zombie patients will try to disrupt the proceedings along with all the other angry identity-politics groups that feel so offended that America did not vote as they saw fit.

In other words, things are moving very fast with this new Congress and new administration. At least as far as repeal is concerned. Replacing Obamacare, however, is something that will likely be delayed by at least two years, if the rumblings coming from various legislators are any indication. Trump has made this issue his, but the GOP Congress has pushed repeal and replace for much longer.

At the American Enterprise Institute, two healthcare policy wonks, Joseph Antros and James Capretta, have suggested slowing down. Both have been part of the federal healthcare bureaucracy, and their complaint seems to center around how ACA enrollees could be harmed by destabilizing Obamacare, through repeal and a delayed replacement of the ACA. They want to keep the exchanges viable by ensuring funding keeps flowing, and worry that absent the tax penalties meant to enforce compliance, the downward spiral of insurance companies withdrawing from the unprofitable plans, and healthy people staying away in greater numbers with no penalty for doing so, will mean less coverage, more expensive coverage, all for less people.

So, this is different from what is already happening to Obamacare because … ? They make no mention of allowing competition across state lines for example. The view of Antos and Capretta is firmly from within the federally administered world of regulated healthcare. This is hardly out-of-the-box thinking.

But they do make an interesting point. Because repeal will be done through the reconciliation process, it can only affect those parts of Obamacare that have to do with taxes and subsidies or credits. Not the regulations – the detailed requirements that will still be part of what remains of the ACA after repeal. So we will be left with rules that presume – as they put it – the subsidies and mandates (that the tax penalty enforces) without the money to back it up. That means insurance companies will find it even more expensive to remain within the ACA exchanges and will drop out at a faster rate.

And what did Obama have to say to Congress on Wednesday? Avoid talking too much about policy. Talk about the impact on people’s lives. Healthcare is a minefield, it’s true. To score political points, you have to hide the true cost of any subsidized healthcare system – like ACA – and focus on the individual stories of those who gained coverage. Unfortunately, Obamacare is collapsing – whether the GOP repeals it or not – and the costs of Obama’s grand scheme can not be reduced to scare stories. Whatever plan replaces it, that new plan will have to justify its costs to a public that has seen the Affordable Care Act become far less affordable and offer less care than it promised 6 years ago.

You avoid policy, explaining it and showing how it will be paid for, in terms of healthcare at your own peril as Obama is finally realizing. The voting public will have to realize it as well.

Obamacare – ok the Affordable Care Act, is that better? – is collapsing, state by state. Younger healthier potential enrollees are not enrolling. The incentives – how much premiums you pay and what kind of deductible you face and what kind of coverage you get – are making them choose to stay away and defer their choices. Perhaps you can construct a longer term economic model based on the expected costs of a health crisis with the likely percentages and the expected cost. And decide that they should enroll, just in case. But by many metrics, younger and healthier people are making a reasonably rational choice.

As are sicker, older people who have rationally decided that Obamacare is a good deal for them. Those two subsets of health care consumers means that Obamacare is currently unsustainable without several things:

  • Higher premiums
  • Higher deductibles
  • More bailouts/subsidies courtesy of you the taxpayer

And even with all three of these responses factored in, many insurance companies are finding Obamacare unprofitable to say the least. That means that the next president will have to clean up the mess and either reform Obamacare or create a new health care plan. Hillary Clinton likely has plans all set up to effectively dump Obamacare through a vigorous reform program that preserves it only in name and broad outlines, all the while praising her former boss’s flawed plan.

Of course Hillary’s reforms will certainly involve lots more regulations. But different regulations. By new agencies or renamed agencies, or re-configured government departments working for you, the health care consumer. Regardless of what state or county you live in. That will work out wonderfully won’t it?

Thank goodness we have an alternative with Paul Ryan’s Patient Choice Act. Right??

Uhm. Have you actually looked into the PCA? Have you scanned the long-form summary, for example? Found at Ryan’s house.gov site? Here’s a few gems:

If you are on SNAP (what used to be called Food Stamps) then forget about buying junk food with your SNAP card. That means you might have to fork over hard cash for that bag of Nachos that gets you through the weekend. You will be told what to buy with your SNAP card. Or the clerk will be told what you CAN’T buy. How? Who knows? Will there be brawls at convenience stores between clerks and SNAP card people?

Seniors who adopt “healthier behaviors” will be rewarded with lower Medicare premiums. Makes sense, in terms of improving health outcomes. But it also adds another layer of paperwork for retired people and means the government is even more involved in your daily life, telling you in minute detail how to live. Of course you could live free … without Medicare. Not an option for many.

The CDC would create a web-base prevention tool based on your private data: your health records, how fat you are (sorry! body mass index), your sordid family details (sorry! your family history) which will all go into an Orwellian little app-thingy that will tell you exactly how to eat, drink, sleep, have sex, exercise, and any other part of your personal life the CDC feels is relevant.

There are some less invasive ideas in the PCA to be fair. Like reworking the tax code to incentivize health outcomes instead of health insurance outcomes. Like the HDHP (High Deductible Health Plan) combined with HSA, the Health Savings Account. This bundled option offers affordable catastrophe insurance with a tax-free way to save towards your health care costs.

But the point is that there is no perfect optimal solution. There are only tough trade-offs. The best you can do with health care is to offer smarter trade offs. And Ryan’s PCA does do that. But it also promises care for everyone AND affordable premiums. Sorry, but somebody somewhere is going to have to pay for that. The bills always come due. Just like with Obamacare.

As if the state of California isn’t struggling bad enough with it’s fires and water shortages, there’s a new dilemma that affects all parents and children in the state. With the passing of SB277, children will be required to be vaccinated in order to attend schools. Passing this bill was a split reaction to stop anti-vaxers in their tracks and to increase vaccination. However, this just isn’t the correct way of achieving that goal.

Currently the population is protected from infectious diseases because of the high percentage of people already vaccinated, but there now vaccinated children who didn’t have a specific vaccine like “Chicken Pox” that will be kicked out of school until updated. One outcome of this is forcing children into homeschooling.

I’m not defending anti-vaxers by any means, but this about measles it falls into the government having control that it shouldn’t. This bill is open ended, therefore vaccines can be added into it without any voting or approval from anyone but the CDC. The group that also approves the food on the shelves feeding an obesity epidemic. Nothing but shady business. The government should not have the authority to dictate a medical procedure of any kind.

It’s also entirely comical that Governor Brown, a Democrat, supports pro-choice for women to have the right to choose, yet signed a bill mandating the medical decisions for a child a women chooses to have or not have. This bill isn’t protecting individual rights, and violates “inalienable rights” of life, liberty and property. If you’re more comfortable with collective rights over individual rights, catch a place to a communist nation.

The strategy of pursuing the Independent Payment Advisory Board, named the ‘Death Panel’, was not the most ideal method for dismantling Obamacare. The Supreme Court declined to hear the case, recorded by the Goldwater Institute in Arizona, who described the bureaucratic DC advisory group as prompting seniors’ passings. It was a pointless bit of theater. While the Independent Panel Advisory Board, or IPAB, obliges a supermajority vote in Congress to override its choices and that implies less balanced governance, its choices are truly about adjusting a legislature program – Medicare – with all its standards and regulations, and the passing board moniker appeared a pointless bit of dramatization. Medicare is without a doubt a tremendous piece of human services spending; in 2011 it represented around 47% of inpatient clinic expenses while speaking to around 15% of the populace. What’s more, that is the way it was intended to be; giving state backing of the matured. Who gets it, how they get it and how they pay for it has been a long-standing level headed discussion. Should Medicare be improved? The answer is evident however discovering a harmony between giving human services to seniors, and permitting decision and rivalry to apportion social insurance spending is demonstrating practically outlandish.

The claim will be refiled obviously. The lower courts decided that until the IPAB begins settling on choices any suit is untimely. One trusts that the Goldwater Institute, by hopping the firearm, has not hurt their essential case (the suit was part into two sections: one over the IPAB and the other over a patients right to ‘therapeutic independence’ or the privilege to pick not to have Medicare and to not be fined for taking that choice). On the off chance that the aim was to attract thoughtfulness regarding the IPAB, the case has succeeded. On the off chance that the purpose was to diminish the force of a board that is not sufficiently responsible to Congress, the jury, actually, is out until the IPAB begins settling on a few choices. At that point we can hold up until SCOTUS administers on the new claim which will be recorded sooner or later, and we can include another layer of guidelines and regulations to the brush of those as of now in presence.

There is one nefarious consequence of the Affordable Care Act, Obamacare to most, that is not mentioned as much as it should be: the damage to eyesight to anyone actually trying to read even a small portion of the act. For example, consider one relatively modest item under the act; reforms to the Medicare payment system. This entails moving from a fee-for-service reimbursement scheme to a bundled-payments reimbursement scheme. While fee-for-service is reasonably self-explanatory, try wrapping your head around the tantalizing concept of a bundled payment reimbursement scheme: the reimbursement of health-care providers on the basis of expected costs for clinically-defined episodes of care. Essentially, it is a middle ground between fee-for-service and lump-sum payments per patient treated. And those clinically defined episodes of care are usually complex and expensive procedures like heart surgery, obviously important in age-based schemes like Medicare.

The concept started in Texas apparently back in the mid 80’s and various projects since that time claim to have saved HMO’s money, did not cost hospitals money, and paid the surgeon and his or her crew, if you will, additional money. The question is, where did the savings come from? Or more precisely, who lost out on some of that cash? Into whose pocket were those systematic inefficiencies going that bundled payments miraculously moved to all the good guys? Did the insurance companies lose out? Between private insurance, HMO’s, PPO’s, specialists and staff, and patients themselves, not to forget attorneys and their litigation, the collection of players – each with their own strategies and often conflicting goals around literally life and death situations – means healthcare’s complexity is overwhelming and continually increasing. Oh, and that additional player not listed just now, the government. Imposing regulations, handing out subsidies to level a playing field that’s really a dense thicket of data, policy and regulations, and opinions.

Behind all this lurks the economic concept of pooling: Based on your predisposition to certain illnesses as well as your age and other health factors, an insurance company may price your risk and associated payments beyond any reasonable capability for you to pay. The opposing concept is moral hazard and the risk that people will take advantage of any subsidies and demand unnecessary treatments. And any trade-off between these two is essentially a political choice, aside from any real inefficiencies that are actually weeded out by, in this case, a bundled payments system. However, there is a third factor and that’s the ever-expanding technologies, including prescription drugs, that are coming on the market. On the market, meaning the billions, or trillions, spent on R&D have to be recouped. Does this factor get gamed as well? Undoubtedly, but making sure all have fair, (not even Obama’s policy advisers are quite going as far as suggesting equal, as of yet at least), access to healthcare still hits the wall of having to pay for the subsidies both to patients and sometimes to providers and others.

And that means asking how much bang for the buck is Obamacare producing? The CBO projects that over the next decade, Obamacare will increase insurance coverage by a net of around 27 million patients. The cost is projected to be around $ 2 trillion in total for the same time period. That’s slightly more than $74,000 per added patient over a decade. That’s a 2015 Ford F series truck plus a slightly used Toyota Corolla. Or a very nice downpayment on most homes between California and New York City. A not insubstantial amount. Is it worth it? For some, clearly yes. For others, it’s a further invasion of big government in their lives, whether they actually are forced to enter the scheme or merely have to pay for it through their taxes. And remember, we’re talking about a government office estimate. It could be better, or it could be a whole lot worse in 2025.

Will Florida matter as much in 2016 as it did in 2000? We seem to be getting a preview in the bare-knuckles, too-close-to-call race for governor. Incumbent Rick Scott and Democratic challenger Charlie Crist are at it, and it will only get nastier between now and November. That won’t be such a bad thing in fact because one of the central focal points in the mud slinging is Obamacare. Rick Scott built one of the largest healthcare companies in the world, Columbia HCA, and was then forced to resign after a payments scandal with respect to medicare and medicaid that resulted in charges being laid and a $600 million fine being paid. This will be dragged across the stage by Crist’s campaign, but the fact remains that Scott was not personally implicated and no charges were laid against him.

Governor Scott, on the other side, is launching attacks on Obamacare and the flexible – from Republican to Independent to Democrat to staunch Obama ally – Crist’s support for the Affordable Care Act. His attack is based on the fact that Crist’s support for Obamacare is not about liberal principles on the part of the former governor, but rather convenience. He gets the full support of the White House in return for being an unqualified supporter of Obamacare. Whatever party, whatever policy it takes, Charlie Crist wants back in the governor’s office. And Crist seems to be aiming for South Florida’s undecided voters rather than just focus on Central Florida.

That means working on turnout among Democratic voters in South Florida. Does that sound familiar? The primaries that both contenders easily won indicate that voter turnout among Republicans was higher. Not a good sign for Crist’s campaign and hence his focus on South Florida. That means not only talking about Obamacare but also railing about immigration – Rick Scott’s stance on immigration that is. In fact, after winning four years ago with a hard-line stance, Scott has softened on the issue, supporting reduced college tuition for younger illegal immigrants, the so-called dreamers. Crist is also focusing on South Florida because Obama has managed to win there – barely, but win he did – for two consecutive elections, And those staffers that plotted those victories are now available for Crist’s campaign. Tampa, as always, is still key and if Crist can do well there then his chances against Scott improve. Scot will keep hammering with negative ads to ensure Democratic or Independents do not turnout in increased numbers. With Libertarian Adrian Wyllie as a wild card, the election for governor in the sunshine state will be very hard to call. If Crist wins, it will not be what he stands for, but because Democrats are scared that Florida will go the other way in 2016. So they are willing to suspend judgement on who Charlie Crist really is, and vote for the former Republican.

Rates are going up for Obamacare. What a surprise. The Affordable Care Act has as its goals, increasing coverage, reducing costs, improving affordability, and increasing the quality of healthcare. This is an absurd mixture of conflicting goals; but you can’t say that because it’s health care. Even under the – somewhat – more efficient system of private insurance, these goals imply trade-offs. There is no way around this fact in the real world. No amount of intelligent organization – leaving aside the fact that the ACA is less of an improvement and more of an added layer of bureaucratic complexity – can erase this trade-off. How can you possibly increase the quality of healthcare for millions of Americans and not pay for it? How can you increase coverage for patients who either couldn’t afford or were seen as high risk by insurers and not have rate increases to cover at least some of the added cost?

Well you do it by a delicate balancing act that inevitably ends up landing on its backside. The two forces at work here, in economic terms, are pooling and moral hazard. At one end of the spectrum, with a free market solution, insurers are drawn to pooling as the more profitable strategy: lower-risk, healthier patients are accepted while higher risk patients are either not accepted or must pay much higher rates. Moral hazard in this case is very low; patients will not over consume health care services and clog the system. At the other end you have a single payer system that funtions with rationing; you need a hip replacement? We´ll wait a few years and see if you die first to save on costs. There is little pooling, everyone is in the same state-run boat and have to wait their turn to one day hopefully get the treatment they need. Except government officials of course, who seem to get prompt attention under any system. Moral hazard, the wasteful use of resources because there are no disincentives against wasteful or risky behavior, is very high in this case.

Most health care systems in the developed world are some mixture of these two. That means trade-offs, and managing those trade-offs to produce the result aimed for is no easy matter. In the case of Obamacare, patients are passive recipients. In free market solutions, like those proposed by Dr. Ben Carson, patients can take charge of their health the same way people have learned to do with their retirement savings. It still leaves the problem of catastrophe insurance – a bad accident, a fatal disease – and that is where state subsidies should really focus. But when you launch a boat as big as Obamacare, added decks inevitably get built. The result is titanic, but rather than an iceberg that will sink you in the blink of an eye, what you get is a slowly sinking ship that has to bailed out – both by taxpayers and Obamacare users themselves. Rates are going up? No kidding.

 

As House Republicans have carefully explained to the press, voters in Virginia are to blame for the lack of a comprehensive alternative plan to Obamacare. With Cantor gone and Kevin McCarthy getting up to speed as the new house majority leader, the best that can be hoped for is some policy principles cobbled together that candidates can campaign around in November. There is a lack of “bandwidth” as David Drucker puts it in the Washington Examiner, meaning, one supposes, that no one McCarthy is hiring as staff will want to touch the issue until some time much later.

I wonder if someone forgot to tell Ben Carson that he lacks bandwidth? There he is touring on his bus without the benefit of a well funded House Majority Leader team of staffers to do all the right polling and tell their boss not to touch the issue. Yes, he is a doctor, but more than that, he has a very clear idea of what health care should look like and is not at all reluctant to articulate it. Turning the question around, would someone like Ben Carson ever make it to House Majority Leader? It is likely the good doctor is not interested in taking that route, and would probably admit that someone like Kevin McCarthy or even Eric Cantor is more suited to the job. It makes you wonder if policy ideas – real ideas on what government should or should not do, and how they should do it – are just not possible late in a mid term election year in the House of Representatives. And mid-summer is late by any election year standard. Unfortunately for that theory, Newt Gingrich and Richard Armey wrote the Contract With America and then introduced it 6 weeks before the 1994 elections, dealing the Clinton Administration it’s first serious electoral defeat. The catalyzing issue? Clinton’s failed 1993 Health Care Reform. Maybe someone on Kevin McCarthy’s staff has a copy of both plans. It would make for useful reading.

Indiana Gov. Mike Pence spent over 10 years in the House and had established conservative credentials with many of his policy stances on immigration and family values. The former Tea Party Caucus member now has some conservatives mad over his health care plan for his state that could bring health care to over 450,000 low income uninsured residents. He plans to expand the state’s Healthy Indiana Plan which now covers about 50,000 low income residents. The plan would rely on health care savings plans and patient input according to the governor’s office but what gets conservatives mad is the fact that it will rely on over $16 billion of federal money to pay for its $18 billion cost. Indiana will shell out $1.5 billion. So the question becomes – aside from the balancing act Pence has to play between calling for an end to Obamacare and expanding health care coverage in his own state – do subsidized health savings account promote more efficient use of health care services?

The answer would depend on how Indiana plans to use these so-called health care savings accounts. The essence of a true health savings account is you control how much you save and how much you plan to use now or to set aside for future costs. What strings would be attached in Pence’s plan? When the federal government is contributing about 90& of the costs you can be sure that conditions will be rapidly attached and a whole slew of rules for the benefit of the low income earner will be put into place. Would the governor consider using the health care plans as a way to fund the costs over time – perhaps giving an increasing amount of room for the plans after a certain amount of time – rather than use them as a way to control costs? Or could both approaches work side by side? The answers will tell if Indiana’s plan is an alternative to, or just an extension of, Obamacare.

You can’t help but come away energized after listening to Ben Carson. Energized, not necessarily empowered. His clear and convincing proposal to provide an alternative to Obama’s healthcare plan starts with Health Care Savings Accounts, HSA’s, and makes us realize that the viewer can control his or her medical care to a much greater extent than many think possible. By providing that crucial supplement to a High-Deductible Health Plan, or HDHP, an HSA gives the taxpayer control. Not big government, not big insurance. How much to set side, how and where to spend it: you decide that. You take it from job to job and you roll over any unused amounts at year end. Yes, health is unpredictable and serious illness can be very costly. That’s why HDHP plans exist to essentially provide catastrophic insurance and there are still government and other options to cover any expenses left over. We have accepted the change from defined benefit to defined contributions when it comes to pension plans. And despite a financial crisis and a long recession, that process continues. The problem of making an informed choice applies both in pension plans and HSA’s and likely overwhelms many. But ask yourself; do you want an insurance bureaucrat or government employee limiting your choices or do you want to educate yourself about the options and make a reasonably informed choice? That is taking charge, and that is energizing.

But not necessarily empowering. Where does the term empowering come from? It seems to have its birth in social activism of a century ago, and that means the hard left in most cases. The term was coined in a book by Barbara H (not Barbara Probst Solomon) Solomon, Black Empowerment, published in 1976. In other words, the term empowerment comes from various applications of marxist liberation theory and how it was applied to gender and race and sexual orientation and other groups by left wing radicals trying to find their place in the 70’s. The term appears here to stay as it is adopted in a wider variety of settings, among corporate stakeholders, to use one example. Dr. Ben Carson does not need reminding of any of this; he will surely use the term empowerment. When he does, it means something very different from radical sociologists trying to gain converts. Few of us can match the talents of a brilliant mind like his. But we can share his faith that each of us can work towards solving the challenges in our lives. Reading up a little on his site, SaveOurHealthcare.org is one good one way to start. Dr. Ben Carson, take back empowerment! For all of us.

The Man With MERS

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Filed Under Healthcare, Latest News on May 8 

The first case of MERS, or Middle East Respiratory Syndrome, has arrived in the U.S.;more specifically, a clinic in the Chicago Area where a health care worker has been hospitalized after a trip to Saudi Arabia. Officials won’t release too many details about the man, but an invited expert on FOX described him as a doctor who had travelled to the peninsula with the express purpose of treating MERS patients. Dr. Ian Lipkiin, a Columbia University MERS expert, stated that it was impossible to isolate the virus over in Saudi Arabia “given the interconnectedness of our world.” So far the virus, which may come from camels or bats, has killed over 100 of the 400 or so patients who have become infected. That’s a very high rate of fatalities, around 30%. The good news is that it appears not to be easily transmitted from patient to patient, requiring close contact, although it does seem to be airborne.

Does Dr. Lipkin know the Indiana man who is in isolation in a clinic in that state? The community of doctors who are experts in the disease and/or have treated MERS patients cannot be a very large one; not yet at least. Is the spread of a new virus always inevitable as Dr. Lipkin suggests? Or is something else at play? Do experts in a pathology have a right to go to the source of a new disease to study it asap despite the fact that they may become transmitters themselves? How does society, or more precisely any given nation, respond to such new viruses? On the one hand, we want to gather as much information as possible on the disease, and who better than a health care professional, usually a doctor, to undertake such a tricky task? The data they may gather and relay to places like the CDC can and usually does save lives, sometimes many lives. But do we have to passively assume that any new disease that emerges anywhere on the planet will end up in the U.S. and there is little one can do? It seems that on occasion scientific curiosity, both noble and useful, conflicts with public health. In the case of our anonymous health care worker, it may have been wise to have required him to undergo a period of isolation before allowing him back in order to ensure that he hadn’t picked up the virus. Better to have such a requirement in the early stages before it becomes logistically impossible and a constraint on people’s freedoms.

In Maryland, the rollout of Obamacare has people rolling up their sleeves and swinging, verbally, at each other. Both people in this case happen to be Democrats, contenders for Governor in the state’s Democratic primary at the end of June. Apparently the rollout was way less than smooth in Maryland where they decided to replace the technology with that used in Connecticut. Douglas Ganser, the state’s Attorney General, derided his opponent, the state’s Lt. Gov. Anthony Brown, as not having had a “real job” and presumably not being up to the task of running Maryland and its troubled rollout of Obamacare. The fact that the Lt. Gov. is an attorney wasn’t what got Ganser all fussy and in a fingerpointing mood; Anthony Brown is also an Iraq veteran who, despite serving his country in a war zone, has never had an honest job according to the Attorney General who attacked Brown’s ads where his service is mentioned.

Veteran’s groups are not impressed; Jon Soltz of VoteVets.org called on Ganser to “stop smearing those of us who served in Iraq as not having had a ‘real job'”. Behind the indefensible attack by Ganser is a desperation to prove that he can successfully manage the botched rollout, which the Lt. Gov. was in part responsable for, and prove to his state that Douglas Ganser is the one to bring them Obamacare. Rather than think about changing the act itself, we have ugly smear tactics by the Attorney General. Doing so, he can then win the primary, win the vote, and tinker with Obamacare once safely in office. Having served the country in a warzone, often performing highly complex tasks in an environment that goes way beyond stress, however, is not an asset apparently. Not when wrestling with botched rollouts in Maryland.

Friday morning, embattled Health and Human Services Secretary Kathleen Sebelius announced she would step down from her post. In response President Obama lauded her accomplishments and claimed due to her work with the ACA, she’s earned the right to retire. Hmm, in the private sector she would’ve been canned months ago.

True Sebelius has done some beneficial things in the healthcare field but her tenure as HHS Secretary will be remembered for one thing, the botched rollout of the ACA. Now she did lead up the roll out of the ACA and oversaw it so one can say the blame for its numerous problems can be placed squarely on her shoulders. I for one disagree to a point on that. The blame should be shared by those subordinates who failed to fulfill their duties, her for failing to run a tighter ship, and the President for failing to further reign in what is the hallmark of his administration.

Sebelius is credited with helping to rectify the problems initially encountered with Healthcare.gov but the problems initially faced should never have been of the magnitude they were. It is unfathomable how the ACA, a sweeping government program that is costing so much and effects so many can be so poorly implemented. I’m not even talking about the actual substance of the ACA which is another story, instead the actual public unveiling. If the government can’t even effectively unveil a series of websites and state exchanges for a program of such great importance and set to cost trillions, imagine how haphazard lesser programs are handled.

And then to hear the President go on about how he will miss her advice and friendship. Oh really. From summer 2010 to two months after the rollout of the ACA, November 2013, the two failed to meet even once for a one-on-one discussion according to the White House calendar. Now I understand when leaders place faith in people and leave them to their own devices. The problem though is this is not just some government program, it’s the Presidents hallmark law. Where was the interest? Furthermore, the President waits until two months after its initial roll out to have a personal meeting. Yes communication was had through different mediums but in all honesty, this required the down to earth discussions that can only be had, through one-on-one meetings.

Rightfully so, much blame has been and will continue to be placed on Sibelius for the disastrous roll out of the ACA. But remember one thing, just as much blame should be placed on her superior, the President for allowing this to happen. Instead of doing the right thing and listening to his advisors, he chose to keep her on so as to not have the Administration appear to be in the midst of a civil war. My memory of this debacle will not be of the mistakes of Sibelius but of the lack of leadership.