Saturday, February 23, 2019

Revisiting the public option Obamacare debate of 2009

From a blog posting and column written during the debate of including the public option in the proposals for what became Obamacare.  

October 12, 2009

My August  2019 updated comments in support of a public option:

What the private health care system needs is more competition from government options and non-profits who are not profit and stockholder driven. In addition, all purveyors of public options, including Medicare and Medicaid as constituted now, should be able to negotiate formularies with drug companies. Consumers need to have affordable choices of both public, private and union and employer-provided plans that are not junk and covering pre-existing conditions. How we get there are several ways. Competition is the basic driver of prices. Unaffordable comprehensive policies are no choice. If you can't afford them, a choice of 0 is meaningless.
If you are given no choice but only able to have of a government program, that, too, is depriving consumers of choice. On that basis, I support the public option instead of the Canadian system. Price, taxes, and government costs v benefits are important, but politically "choice" is the more sellable approach. That one plan or another would deprive consumers of choice or insurance they like now that may be better than a public option may be effective lines for those who support the Sanders type plan, but in the long run, consumer choice is a more positive sales point for a public option approach, though it might not be the cheapest in terms of government spending or consumer out of pocket expenses.

October 12, 2009 comments continued:
Last week the Congressional Budget Office gave the Democrats' health care reform legislation an early Christmas present. They put a price tag on the Baucus plan that makes Democrats look like fiscal conservatives and Republicans as penny wise pound foolish. It also gives room to add the public option that polls show 60-65 percent of the electorate want and leaves the congressional Republicans with egg on their faces.

The CBO calculated the Baucus plan would cost $829 billion over the next ten years, $71 billion under the maximum amount of $900 billion the President had set. Furthermore, it reduces the federal debt by $81 billion. The Congressional Republicans, advocating for the continuation of the status quo, are still supporting the “do nothing” option which would be $81 billion more expensive than the Baucus plan.

Of course, what you pay for is what you get. The Baucus plan would leave at least 18 million uncovered, relying on the emergency room for health care, with a 41 percent greater risk of dying prematurely, and leaving the uninsured in danger of adding to the staggering bankruptcy figures.

Baucus also left out the public option. His is the economy model with gas fuel efficiencies when a significant majority of voters still want a hybrid with a choice of a public option.

However, there is wiggle room for both the public option and for more extensive coverage to be added in later on the Senate floor and or in conference committee. There is even a financial incentive to do so. The beauty of the CBO estimate is that there is enough cost slack to allow more of the uninsured to get access to affordable health insurance, to include a public option, and still make the case that the Democrats are more fiscally responsible than the Republicans.

The CBO had “scored” the cost of the public option in the House version as being $10 billion cheaper over 10 years than a version without a public option, because the competition would force down the high private insurer's administrative costs.

Aside from stonewalling, one Republican strategy has been to offer sound-good “alternatives” that look more like the cardboard substitute for a shiny toy the chubby-faced kid in the Ally Bank commercial called “a piece of junk.” Adding insult to injury, there is not even a CBO price tag attached, so an apples to apples comparison of plans cannot be made. Republicans have offered tweaks worthy of adopting, but they ignore their limits as panceas. The oligopoly of private insurers, protected from anti-trust action, makes a farce of the “alternative” to promote competition by allowing cross state insurance purchases. Thirty-five states have already adopted tort reform that caps jury awards with no evidence of impact on health care costs. The other panacea: Let's change human behavior — if you go on a diet and stop smoking, you will get a break on your insurance costs.

This year, 71 percent of doctors, the most adamant group opposing socialized medicine over the past 100 years, are supporting either the Obama plan or the Canadian system. That is the ultimate credible attestation that the summer fear campaign Republicans launched to scare us has no merit. Overwhelmingly, most docs do not believe that reform would be a socialistic government takeover of the medical system, or would get between you and your physician.

The Republicans are still fear-mongering that seniors would lose $500 billion in Medicare benefits. Full disclosure: I am one of the 20 percent of Medicare recipients on the useless Advantage program, targeted for cuts. My Medicare benefits will not be cut. There is a difference between administrative costs and benefit cuts. Wise up, seniors.

The result: Congressional Republicans look like they are stonewalling, heartless grinches, not caring if people die without insurance. They have postured themselves as protectors of the insurance industry and as anti-consumer. They want to deny consumers a choice of a public option. They want consumers and taxpayers to keep on paying private insurers for their premiums that are rising four times faster than care delivery cost and to continue paying for excessive charges for their high salaries and commissions.

Unlike Democrats, they have not even bothered to put consumer protections from insurer abuse into any legislation whatsoever, giving only lip service to some vague future legislation that would outlaw insurer's coverage denial for pre existing conditions or dropping coverage for the sick, and arbitrarily denying claims.

No wonder moderate Republicans outside Congress — New York Mayor Bloomberg, former Republican standard bearer Bob Dole, former Sen. Bill Frist, California Gov. Arnold Schwarzenegger and others — have looked at the polls and are urging moderates to get on board with reform. They must have realized that their party's tactics may not be the best political face they could put forward in the 2010 midterms.

Sunday, February 17, 2019

The Russian connection: why care?

A version of this was published in the on line edition of the Sky Hi News, 2/20/19

While we are waiting for the Mueller
Special Counsel report on Russian interference in the 2016 elections to see if the Trump campaign or Donald Trump himself conspired with the Russians, ask ourselves, why should we care?  The Russian connection did not register in the top three issues motivating voters to cast ballots as they did in the 2018 midterms. In NBC exit polls about 50 percent of the voters thought it was important but only 60% of Democrats and 20% of Republicans approved of Mueller’s handling of his probe.  Here is why we should care. Russia is at minimum an adversary whose national interests are at odds with US security concerns.  The cold war may be over, but Vladimir Putin’s agenda has roots in long-standing Russian history, if not in the old Communist vs Capitalist terminology.

Thanks to Mueller’s frequently court filed indictments and sentencing documents, it is accepted by most that indeed the Russians did conduct a propaganda campaign to convince US voters to pull the lever for Trump. There are some recent developments deduced from Mueller’s filings charging Trump’s campaign Chair Paul Manafort lied about a meeting he and his sidekick Rick Gates had with Ukrainian suspected Russian intelligence operative   Konstantin Kilimnik in a New York cigar bar August 2, 2016. Trump campaign’s internal polling data, useful for targeting social media messages, was handed over to Kilimnik and a peace plan for Ukraine was discussed that would have resulted in lifting sanctions imposed by the West for Russia’s grab of the Crimea and eastern Ukraine. The evidence Mueller’s team presented convinced the judge to agree to revoke Manafort’s plea agreement, subjecting him to more jail time.  If this were the Cold War, Manafort’s actions could have been considered treason. 

Much of the Mueller findings presented in court filings involve Ukraine, Crimea and sanctions levied on Russians for their territorial incursions. Manafort was a political consultant to the former president of the Ukraine who was ousted for his pro-Russian policies. Other elements at play are Russia’s  historical expansionist imperatives:: Crimea, the Baltics, and Balkans are centuries old  keystones to Russian national desires for  access to warm water ports for their otherwise ice locked military and trade vessels, keeping former Satellites as buffers against Western invasions (they were invaded by both the Nazis and Napoleon), and their objections of  placing NATO troops and intercontinental ballistic missiles at their skirts. Putin publicly believes that the breakup of the Soviet Union was a Russian tragedy with the loss of the USSR satellites that provided ports and buffers. None of this is in the US or our allies’ national security and military interests defending against such expansionism.

Manafort’s joining the Trump campaign in early 2016 was simultaneous with Trump’s fleshing out the details of Trump’s pro-Russia foreign policy., lifting sanctions against Russia, reducing and weakening NATO to cripple it as a deterrent to Russian desires to control the Baltics and the Balkans, including Montenegro.
 Trump has uttered so many words of praise for Vladimir Putin, observers had termed it a “bromance” and attributed it to Trump’s long-time interest in building Trump Tower Moscow.  Trump Inc. was in negotiations for the Tower well into 2016.  Even since his election, Donald Trump has held secret meetings with Putin, and sometimes echoes Putin’s public talking points word for word, preferring reports from Russian intelligence over his own agencies. Trump recently lifted sanctions against a powerful Russian oligarch, Oleg Deripaska, a friend of Putin, and he pulled the US out of the IMF (intercontinental ballistic arms control treaty), instead of strengthening it, permitting Russia without oversight or penalty to continue to develop their mid-range ballistic missiles.  He has made public efforts to pull out or defang NATO, but so far, he has made little headway

Friday, February 15, 2019

Let me choose: An American trait

A version of this was published on line by the Sky Hi News February 27, 2019

Two very hot controversial public policy issues, one appealing to the right and the other to the left, share something in common. Americans prefer to be free to choose among alternatives, especially when their personal lives and health are directly affected.   What first comes to mind is the issue of abortion.  However, for Democrats choice is a value that cannot be ignored when they shape health insurance legislation, either   Democrats will have a winning hand if they support keeping choice in health care insurance and women’s control over their own bodies.

A Wall Street Journal/NBC 2018 poll showed 71% (and 52% Republicans) do not want Roe v Wade overturned.  They want to make their own decisions about their bodies. An overwhelming majority does not want someone else’s moral and religious views or government to tell them what they cannot do in these most personal gut-wrenching decisions. 

The issue of a woman’s right to choose is a cultural, religious, health,  and moral matter, but health insurance is a quality of life, health, and pocketbook issues.   Permitting consumers a choice between private and public insurance providers, and the ability to keep their current insurance and doctor are the keys to strong public support of proposals for health insurance reform.

Over 60% polled in mid-2018 liked Medicare for All (half of Republicans and majorities of independents and Democrats), but when asked if they want to end their choice of private insurers, only 10% approved, as the Kaiser Family Foundation discovered. KFF also found, “nearly half of Republicans and majority of independents and Democrats favor an optional Medicare-for-All play. Public support for Medicare-for-All shifts significantly when people hear arguments about potential tax increases or delays in medical tests and treatment and recent polling also shows many people falsely assume they would be able to keep their current health insurance under a single-payer plan...
Another survey, reported by the Hill in early 2019 found 70% support for Medicare for All, but if a plan would eliminate private insurers ( called single payer), support dropped to 13%. 

The two issues that almost scuttled Obamacare were opposition to the mandate that required everyone to have health insurance and subscribers finding they did not get to keep their doctor as they were promised.  

There is also an ideological pushback to any national health plan.  It is a tradition ingrained in the GOP psyche. The Grand Old Party is following a Grand Old Tradition, a historically long held ideology, opposing Social Security, Medicare, and Medicaid tooth and nail and they are beginning to invoke an ideologically based opposition argument again. 
 Any public program that distributes resources from those better off to those who cannot afford basic living expenses is one definition of socialism.  In some quarters, any publicly funded program that supplants private business is also considered socialist. Republicans are already beating the drum that anything proposed by any Democratic candidate is that awfully feared word “socialism.”  It will fail as it has in the past as a political slogan when the needs for quality of life and life itself are unmet to such an extent that it is more important to individuals and families than adhering to some ideological ideal. Those current polls are evidence we have reached that point. FYI. Not all kinds of public health insurance plans eliminate private insurers as the fear mongers on the right want you to believe.

Price and costs are still a very large part of the conversation. Here is the rub. The counter-argument against allowing consumers to have a choice of whether to participate or not is expensive.    The larger the subscriber pool mix of high users and low users, the cheaper the system is for the average patient. Providing every choice consumers desire comes with it a higher price tag. There are so many variations of degrees of government involvement in health care, that the tradeoff becomes which one can we as taxpayers afford vs. what we feel we need and want.

Obamacare was based on a conservative think tank plan to save the private insurance industry. They feared the adoption of single-payer national health would eliminate private insurance. Obamacare was structured to use private insurers. and it also provided the mechanism to provide a subsidy only to those who could not afford private health insurance.  Medicare also allows the use of private insurers and a great deal of choice of providers. Obamacare also provides consumers a choice of nonprofit and for-profit insurance plans providing various levels of coverage and out of pocket expenses.  It saw some impact with the removal of the mandate Trump engineered through executive order, but it has managed to keep its head above water in spite of it.

The objection by consumers of Obamacare was they did not get to keep the doctor if their choice because the choices did not include the network or provider they once had.  This was likely based on experience with employer-provided insurance.  Employers frequently changed the choice of insurance providers as they got better deals for their employees and their company’s bottom line, causing employees to find a new doctor or network. Job changes also often require a choice of different providers in employer-provided plans. 

More thoughts in a discussion from a reader who thinks national health will not work like it does in Europe because the US population is so much larger.  He would rather reform the old, pre-Obamacare system and keep the government out. Here is my answer: "Government out of medicine worked so badly and so many could not afford treatment or insurance, that is why Obamacare happened and the midterms went the way they went. . However, I am not sure how you deduced that just because a system scales up to size it de facto will not work. Medicare works so well and it is applied to the entire US that to touch it is the third rail of US politics.. Why can't it work if more subscribe to it. In fact, it should work better because the pool would include younger, healthier members, not just old people near the end of life. Ps Tort reform would have little impact..since much of it has already been done state by state. That is a fantasy and the CBO already scored it as having little impact. Agree on the lower drug costs; Obamacare permits cross state lines compacts but no one has done it because there are problems with private provider networks and the state by state control of insurance commissioners. Good luck in rocking that turf boat that has grown up with private insurance.. I am in favor of a system that preserves consumers right to choose between a private insurance plan and a Medicare based buy in.... that leaves no one out without ability to get the health care they can afford. It is not the cheapest way to go, but it fits the American psyche. that likes choice.."

Monday, February 11, 2019

Recent polls are flashing warnings for both parties

A version of this was published in the on line version of the Sky Hi News:

 I have been following public opinion polls closely it seems forever. It is a habit I picked up during years of being active in politics, doing polling myself, and hiring pollsters. The value of nationwide polls is not predicting who or what will win on election day; we have seen too many misfires when elections are close. The voting registered through the Electoral College often distorts the nationwide popular vote outcome. State by state polls have more meaning then.  The highest value of national polls is helping political strategists keep a grip on reality even in a closely divided nation where there still can be lopsided results on public policy issues. Democrats and Republicans should consider them flashing caution lights and ignore them at their own peril.

 Analyzing polls can be tricky. How many, when, who were asked, and how important were ranked issues to voters, are critical elements in interpreting polls. Ask yourself if 80% of Republicans support Donald Trump, why is it he had been polling around 40%-43% nationally per multi polls reported by conservative leaning Real Clear Politics, February 6.  It is math. There are more Democrats than Republicans. In 2018, Gallup found 40% identified as Democrats, 29% as Republicans and 28% as independents. For example, Donald Trump’s State of the Union address polled 76% approval, but CNN found only those who watched it were polled and they were 17% more Republican, warping the results a bit. Nonetheless, Trump nearly a week later showed a significant bump in job approval over prior national polls. How permanent that bump will be may be short lived if he shuts down the government again or calls for a national emergency.  Right now, the country is more closely divided on the president than it was just before his State of the Union address.

Per Gallup, in the 2018 midterms, healthcare, the economy and immigration topped the list of public policy issues.” Other issues that at least seven in 10 voters rate as ‘extremely’ or ‘very’ important include the treatment of women in U.S. society, gun policy and taxes. The investigation into Russian involvement in the 2016 U.S. election and climate change rank at the bottom, although roughly half still considered them important”.

 For every public policy issue that has widespread support it seems there will always be at least 30% of the voters who disagree.   It is rare if approval of anything exceeds 65 to 70% but polls registering 65% or higher are as near to a national consensus as we can get. To reach that figure, parts of more than one demographic, party affiliation, or geographic location must agree.  

 I set out to find any publicly released polls that registered approval/disapproval of opinions on issues and politicians in at least the 65- 70% range I did.  Caution lights for the GOP:  90% favor background checks on guns (Politifact) and taxing the ultra-rich scored 76% approval. (reported Fortune and News Max).  Nonpartisan, nonprofit Pew Research found 70% against overturning Roe v Wade. Building the wall was not as decisive, but mid fifty percent polled opposed it.   reported by The Hill, and over 69% did not think it was a priority, per a Fortune magazine report. Whether the president should declare a national emergency to build it, a CBS poll found 66% disapproval.

 There is clearly a flashing yellow caution light for Democrats trying to craft their platform on health care insurance.  While polls show Medicare for All has had 70% approval, (The Hill) a Kaiser Foundation poll found if it means eliminating private insurance (single payer), approval crashed to 10%. However, only 14% want the current system and they found degrees of support for Medicare with private supplements, and choice between public and private plans.



Monday, February 4, 2019

Trump gives "intelligence" a bad name.

A version of this was published on line at the Sky Hi News, February 5, 2019

Aside from reports Donald Trump has a short attention span and poor reading comprehension skills, there is another disturbing meaning to Trump's definition of   "intelligence".  Those who have tried to brief him, including his former secretary of state, reportedly called him a “***moron “. There are recent reports by other intelligence briefers who said he was "willfully ignorant" and he exploded in anger when he was given information that contradicted his public statements and agenda.   Not only is he ignoring and dismissing his own intelligence agencies' conclusions, he is forging US foreign policy based on something other than rational use of any objective real-world facts supplied by his own agency appointees. If our country survives the next two years without a major foreign policy blunder, we can count ourselves lucky.

 He has recently dismissed the conclusion presented in their annual report on threats to national security to Congress by US intelligence heads that contradicted his own assertions. No, Mr. President, ISIS is not dead; no, Iran is abiding by their disarmament agreement, and, no, North Korea will not give up nuclear capability because it is too basic to their regime's survival. The "crisis" at the Southern border did not even register in their list of top ten security threats.  Trump called the intelligence chiefs “naive”, he sent them "back to school”, and now he termed in press remarks their findings are just opinions with which he can disagree, as if these professionals were writing an op ed piece with an ideological agenda.  Thousands of agents risk their lives to gather such facts and awesome technology provides even more information. That gulf between Trump's words and the intelligence agencies' conclusions is enough to make us wonder where he ever got some of his ideas.  Could he be   listening to foreign intelligence service findings whispered in his ear by even Russian President Vladimir Putin himself? He has had several one on one secret meetings with him. After all, he has taken Putin's word over our own services in public before.   Last July in Helsinki, Trump dissed US intelligence agency reports that Russia interfered in the 2016 elections, and instead accepted Putin’s words of denial as the truth.

There are good reasons to suspect Trump has been listening to Putin because the foreign policy he is conducting supports Russia’s goals. Trump and Russia do not support US security policies that have created peace and prosperity in Europe post-Soviet era. Trump's foreign policy initiatives aid Russian actions to expand their influence and control to former Soviet spheres of interest.  Putin's stealth invasion of Ukraine and his Crimea annexation resulted in the West imposing punishing sanctions on Putin’s oligarch friends. Trump just lifted sanctions on one oligarch, and would like to remove all sanctions, period. While repeating Putin’s very words, Trump called NATO “obsolete” and he threatens to pull out from NATO, a mutual defense treaty, which would clear the way for Russia to try Ukraine /Crimea - like takeovers in the Baltics and Balkans without triggering an automatic military response. US pulling out of Syria would leave Russia with greater influence the Middle East.  Trump’s recent pulling out of the IMF treaty will allow Russia to develop their mid-range nuclear capability out in the open. No IMF treaty? No sweating compliance or fearing punishment when or if they have been outed and making this a much more dangerous world.

Trump's disdain for US intelligence services has a history in the Iraq war and   faulty US intelligence verification that there were indeed weapons of mass destruction in Iraq.  There were at that time no international inspectors on the ground in Iraq. Saddam cleverly created the fiction he had the capability in order to deter future attackers. The situation is very different in Iran. Thanks to the multinational Iran nuclear deal, that country has been constantly monitored by inspectors on site and shipments of nuclear material into Iran have been subject to inspection and control.  Trump pulled out of the deal.  Some fear Trump may be cooking up a reason to invade Iran, egged on by hawkish advisers.  Destroying the Iran nuclear deal would end those inspections, but fortunately other signators continue the program without us.