Category Archives: medicaid

All Posts, American Foreign Policy, budget, Congress, deficit, donald trump, medicaid, taxes

THE PRESIDENT OF CHAOS

The picture on my computer screen should be better so I tried adjusting it.  That made it worse so I’ll hit it with a sledgehammer and see if that helps.  Unfortunately, that foolish approach is being applied by President Trump to vital national interests like health care,  defense,  immigration, and budgets.

One of Trump’s competitors, Jeb Bush predicted the problem back in 2015 saying,  “Donald, you know, is great at the one-liners.  But he’s a chaos candidate.  And he’d be a chaos president.  He would not be the commander-in-chief we need to keep our country safe.”

Never a dull moment...
Never a dull moment…

President Trump promised to repeal and replace Obamacare with something better: “We’re going to have insurance for everybody…There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.”…“I was the first & only potential GOP candidate to state there will be no cuts to Social Security, Medicare & Medicaid”.

As President, Trump never proposed a way to provide health care regardless of Americans’ ability to pay for it and he did support cutting Medicaid.  Obamacare has insured about 20 million Americans who had no benefits before the law passed; and at the same time it has slowed the growth of the nation’s healthcare spending.  It’s a success but it needs improvement.  When nothing that he or other Republicans proposed passed, Trump swung his sledgehammer at Obamacare’s most vulnerable spot, the individual markets.  He announced termination of the federal  subsidy to insurance companies for low-income subscribers.  That will damage the already fragile individual insurance markets in some communities – breaking our healthcare system without a plan to replace it.

Trump threatens to withdraw from our agreement with Iran, under which they shut down their nuclear weapons program and gave up 98 percent of their nuclear materials.  The agreement was designed with one goal in mind – don’t let Iran develop  nuclear weapons.  We managed to get Russia, all of Europe and China on the same page because they all agreed with that goal; and it was our combined power that made the deal possible.  Trump can’t persuade Iran to do other things that he wants so out comes the sledgehammer to break the Iran agreement.  If the deal falls apart and if China, Russia and Europe go their own ways, there will be nothing to restrain Iran’s nuclear ambitions.  By destroying the Iran deal without a plan to replace it Trump also tells other nations  that any President can ignore commitments made by his predecessors.  The USA will be seen as untrustworthy.

The DACA program for children brought to the US illegally is an imperfect solution to a problem that congress has been unwilling to address.  Trump promises to hit it with his sledgehammer – forcing law enforcement to round-up and deport children and young adults who have lived most of their lives as Americans.  Again, he has no plan for replacing what he will destroy.  Many young adults will be driven to hide in an underground economy where they have little opportunity for success.  That’s a breeding ground for dissension, hopelessness and crime.

Trump plans to hit your wallet with a sledgehammer too – by cutting taxes, mostly for the wealthy, while increasing military spending and  our national debt at even faster rates than his predecessors.  Americans will have to repay that debt at some future date.  Our ability to borrow money for a true catastrophe or war is already impaired because so much of our debt capacity has been used.  We currently owe $20 trillion.  That is about $62,000 for every American or $161,600 for every American who works at a full or part-time job.

Donald Trump again proposes the sledgehammer approach saying,  “I am the king of debt,”…”I love debt. I love playing with it.”  and “I would borrow, knowing that if the economy crashed, you could make a deal”…”And if the economy was good, it was good. So therefore, you can’t lose.”  When he says “make a deal”, that means refusing to pay our debt, most of which is owed to Americans.  It’s not the same as letting one of his casinos go bankrupt.

If the Republican congress allows President Trump to deliver more sledgehammer blows to our nation, the resulting chaos will belong personally to Donald Trump and each legislator who supported him.  The GOP will own the chaos but the American people (including DACA kids) will pay a heavy price for it.

All Posts, Congress, economy, health, medicaid, north carolina

Congressional Legislative Malpractice

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The 13 Senators who drafted a bill to replace Obamacare are all Republican, male, white, over age 40, and prosperous.  California, Florida and New York, which together account for one-fourth of our population, were not in the room but there were two Senators from number fifty Wyoming.

Discussing diverse opinions is one way to identify and avoid unintended consequences of new legislation. Do Republicans think that women, middle class, minorities, young, poor, and other Americans left out of the process have no ideas worthy of consideration?

They did their work in secret meetings without input by experts in health policy or economics, out of the sight of the public and the press.  The result is a political bill to satisfy Republican ideology with little regard for facts or alternatives.

Previously, Republicans in the House of Representatives passed a similar bill that was designed behind closed doors without serious public hearings, expert testimony or debate.  They proceeded despite a Congressional Budget Office projection that it would cause 23 million Americans to become uninsured.  The CBO’s estimate of spending reductions from the bill  amount to $43 per month saved for each person who loses health benefits – not a good deal!

There’s no doubt that Obamacare has serious problems in the individual and small employer exchanges.  Republicans try to mislead us into believing that those troubles mean that the law is failing.  It isn’t.   Because of Obamacare 20 million more Americans are now insured and the rate of growth in total health care spending is lower than it was before Obamacare.  It is a successful law that needs improvements.

Bluntly, Republican lawmakers don’t believe that all Americans should receive basic health care regardless of their ability to pay and they’re willing to let other Americans die for that ideology.  Republican leadership intends to pass their bill before Americans understand that it will cause more people to lose health benefits,  more healthcare related family bankruptcies and more individuals suffering death or disability.

Rushing ill-considered bills through a legislature to satisfy an ideology is not limited to the congress.  North Carolina Republicans imagined an “emergency” when Charlotte passed a civil rights ordinance allowing transgender citizens to use restroom facilities consistent with their gender identity (and, in most cases, consistent with their physical appearance).  Rather than holding hearings and carefully considering what (if any) legislation was needed, they packed the infamous HB-2 with unrelated and controversial provisions then passed it as “emergency” legislation.  If standard legislative processes had been followed, a more appropriate response (or no response) to Charlotte’s ordinance might have been made.  HB-2 has been mostly repealed, but the damage to the state’s reputation remains and some economic losses will never be recovered.

Similarly, North Carolina Republicans gerrymandered the state’s congressional and legislative districts through secret processes.  They hired attorneys who hired consultants to design legislative districts that would give massive election advantages to Republicans.  Because the work was done through attorneys, they were able to claim attorney-client privilege as justification for refusing to let the public and the press see exactly how they instructed the consultants.  The US Supreme Court ruled that the result of their work was racial discrimination.  It again seems obvious that an open process with public hearings could have produced a better outcome.

If Republicans were practicing medicine rather than legislating, their negligence would be called malpractice.  They circumvented the rules and procedures  that  assure thoughtful deliberation before laws are passed. That violates American values, undermines trust in government and exposes us all to the negative consequences of ill-considered laws.

Senate Republicans plan to debate, amend and pass a healthcare bill back to the House of Representatives in 10 days, with no public hearings and no expert testimony.  As an example of the unanticipated consequences of doing that, unemployed Republican rural voters in the coal mining areas of the Kentucky mountains will probably lose their Medicaid benefits and see closure of clinics opened to serve them under Obamacare.  Health care has added more jobs than mining lost in the Kentucky mountains.  Similar outcomes are inevitable in other places.  The damage to the credibility of our legislative processes is severe.  Worst of all, Americans will die as a result of Republican legislative malpractice.

All Posts, donald trump, health, medicaid

DO YOU HAVE A RIGHT TO HEALTH CARE?

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The legendary American philosopher Yogi Berra supposedly said, “If you don’t know where you want to go, you’ll end up someplace else.”  That is the story of American health care.  We have not decided whether health care is a “right” for all Americans or a “privilege” for those who can pay.  It seems that health care is a right for some of the people all of the time and for all of the people some of the time but not for all of the people all of the time.  If you find that confusing, then you’re on the right track.  We haven’t chosen our destination and we have arrived at a place that confuses and frustrates us.

Health care with little or no out-of-pocket expense is a lifetime right for veterans and for prisoners serving life sentences.  I can’t think of any other large groups who have that benefit.  Medicare eligibility bestows a permanent right to most health care for those who pay their out-of-pocket share.  The rest of us have temporary and partial rights that depend on our employment, wealth, personal choices and luck.

Our national debate should be about who has a right to health care, which elements of health care are included, who will pay for it, and how the cost will be paid.  Arguments about whether or how to replace or repeal ObamaCare (the Affordable Care Act) are pointless and counterproductive until we make a firm national decision about whether health care is a right.  Where do we want to go?

Critics of ObamaCare point to extremely high insurance premiums in some of the exchanges where insurance is sold to individuals and small groups.  Some areas of the country have only one insurance company participating in exchanges.  Those problems are real but correctable.  They occur in local segments of the healthcare marketplace and are worst in states that resisted ObamaCare by refusing the Medicaid expansion.

Here’s a snapshot of what ObamaCare has accomplished.  The annual rate of increase in health care spending (both government and private) was 3.3 percent before ObamaCare.  It dropped to 2.7 percent after ObamaCare was implemented.  Simultaneously, the number of uninsured Americans decreased by 20 million.  That is a picture of success.

President Trump’s promises sound amazingly like President Obama’s.  For example, on January 15, 2017 Mr. Trump said, “There was a philosophy in some circles that if you can’t pay for it, you don’t get it. That’s not going to happen with us.” …People covered under the law “can expect to have great health care. It will be in a much simplified form. Much less expensive and much better.”  In the same interview, he claimed that the people covered by Medicaid expansion would continue to have coverage.

A credible replacement for ObamaCare should improve on its performance.  But according to the Congressional Budget Office (non-partisan and under Republican supervision) the bill that Republicans tried to rush through congress would have led to 52 million uninsured (4 million more than before ObamaCare).   Less thorough analysis from the highly respected Commonwealth Fund agrees.   The President and Congressional Republicans dispute the CBO estimates but they have produced no research to support their conclusions.  It’s all based on their opinions.

Two principles of ObamaCare are that basic health care is a right for all Americans and that everyone should be required to participate in the cost.  Those principles are implemented through the individual mandate to purchase approved coverage along with Medicaid expansion for the very poor.  Approved coverage includes  services for prevention and early diagnosis of health problems that often lead to premature death, disability and extreme expenses.  The Republican plan lacked similar features and would produce more late stage diagnoses of illnesses that were preventable but not curable once they occur.

Because there was no individual mandate in the Republican bill, there would be two options for care of those who don’t pay.  Either provide the care and build the cost into the bills of those who do pay or let those who can’t pay suffer or die without care.   The individual mandate is better than either of those alternatives.

What should we do?  I have asked for a meeting with my (Republican) Congressman.  I want to show him the evidence that I’ve found and I want him to show me any evidence that the Republican replacement would produce better results. What will you do?  Your answer will come to you after you decisively answer this question, “If the person that I love most in this world is sick and broke, does she /he have a right to health care?” ___________________________________________________________________________

Evaluate performance data from the US and other developed nations HERE using tools developed by the Organization for Economic Cooperation and Development.

This prior column  contains links to references and more evidence.

 

 

All Posts, deficit, health, medicaid

Replacing Obamacare

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President Trump and our Republican controlled congress have promised to quickly repeal and replace ObamaCare.  President Trump says that coverage will be better, cost will be lower, and everyone will be covered.

We should consider where we were before ObamaCare and where we are today as a basis for judging proposed replacements.  Using the years 2004 – 2009 as a baseline for how we were doing before ObamaCare and 2010 – 2015 as a measure of its effectiveness, here are some facts.

Each of the following statistics is for five years of change before and after ObamaCare.   All spending is inflation adjusted to 2010 dollars.

Below is similar cost data from a different source and a link that will allow you to browse a wealth of relevant information.

The cost of employer sponsored health plans has been growing slower since ObamaCare.
The cost of employer sponsored health plans has been growing slower since ObamaCare.

Evaluate performance data from the US and other developed nations HERE using tools developed by the Organization for Economic Cooperation and Development.

 

 

Some other changes brought about by ObamaCare are:

  • Before ObamaCare, important screenings like colonoscopies and mammograms were unaffordable for many people.  Now they are covered without deductibles.
  • Insurance companies and employers can no longer deny coverage or charge more for pre-existing conditions.  Previously, cancer survivors, diabetics and others likely to need expensive care were uninsurable on most family budgets.
  • Lifetime limits on coverage were banned.
  • Mental health services are covered on the same basis as other medical and surgical services
  • Dependents can stay on parents’ coverage up to age 26.

ObamaCare is a success compared to what we had before it passed.  But health care costs are still rising faster than our economy is growing and we still have over 28 million uninsured Americans so more improvement is needed.

The ObamaCare insurance exchanges where individuals and small employers should be able to purchase affordable coverage are not consistently working well .  Millions of young, healthy Americans are not buying coverage as required by the law.  That leaves a disproportionate number of unhealthy and older people in these insurance pools.  In markets where that has happened, premiums have risen at double-digit rates and several insurance companies dropped out, leaving meager choices for consumers.

That problem leads directly to critical questions about replacing ObamaCare.  Will congress decide that it’s acceptable for some Americans to have no health benefits?  If everyone is going to have benefits, is there a less expensive alternative than Medicaid expansion?  If so, will it be included in the Republican replacement for ObamaCare?  If not, will it then be acceptable for doctors, hospitals and other health care providers to deny services to those who can’t pay?  To be very clear to free market friends, “There ain’t no such thing as a free lunch.”  If the ObamaCare replacement does not include a way to pay for care of the uninsured then either they will die without care or the cost will be built into your bills and insurance premiums.

There are proven ways to provide more care for less money while covering the entire population.  Every other developed nation has adopted one of them and they are all more cost-effective than ObamaCare.  They range from price controls to “medicare for all” or government operated health care similar to the British model.  All of them require a larger role for government and that seems to be the antithesis of Republican thinking.  President Trump said that no one should be required to buy health insurance.  At present it appears that he intends to provide something (health care) for everyone without requiring anyone to pay for it – a miracle of biblical proportion.

We can hope that the post-election hostility will wane in favor of intelligent consideration of how to replace or improve ObamaCare. It can be done if legislators and the President are willing to forego political rhetoric for what is practical.  If they are not, then both human and economic catastrophes are likely.

All Posts, ethics, justice, medicaid, north carolina, public education, race

WHY DON’T PEOPLE TRUST GOVERNMENT?

Did you ever play a game with a child who wanted to change the rules after something didn’t go his way?  As a child matures, parents and others teach him fair play and we expect him to accept fairness, honesty and basic decency as guiding principles by about the age of 10.

The few who don’t learn those lessons generally become known as whiners, bullies or both.  They typically get their next lessons in places lacking adult supervision.  The bullies get put in their place by somebody who stands up to them and the whiners are ignored until they figure out how to socialize. Most eventually learn to succeed without getting their own way every time.

A few folks never learn the lesson, and as big people (I’m reluctant to characterize them as adults) they are still bullies or whiners.  Their behavior puts the leaders of North Carolina’s Legislature in these categories.  (Please excuse the all-male characterizations in this column.  I don’t know what else to do when all of the Republican leaders are boys.)

Phil Berger, Tim Moore and his predecessor Thom Tillis, as leaders of the House and Senate, changed the rules to enable Republican Governor Pat McCrory to politicize state employment.  Specifically, they passed a law allowing him to hire up to 1500 political appointees into various positions in state government.

When Roy Cooper defeated McCrory for Governor, the bullies decided to change the rules again.  The easiest way to do that was to revise state laws before the inauguration so that Cooper could not veto changes.  They arranged a sneak attack at the end of a special session for flood relief by announcing plans to adjourn and re-assemble on the same day for another special session.  It became obvious that they had been gathering signatures to authorize the session for some time.  They allowed about five hours for introduction of legislation.  In that brief time, carefully crafted legislation increasing the power of Republican leadership and drastically reducing the Governor’s authority was introduced.  The plan was conceived well in advance.

Republicans have the votes to pass these bills.  Given their history with HB-2, they may do it before this column is published.  They can do it without serious debate and without time for consideration by the public.  That’s how they passed HB-2, and North Carolina has paid a heavy price for it.

Here is some of what they want to do.

  • Reduce the number of political appointments by the new governor from 1500 to 300. This would also make about 1200 McCrory political appointees into permanent state employees.
  • Eliminate the Governor’s two appointment slots to the boards of state universities.
  • Remove the state’s Chief Information Officer (responsible for information technology across all state offices) from appointment by the governor and have that position appointed and supervised by the Lieutenant Governor (a Republican).
  • Re-organize and merge the State Boards of Elections and Ethics in ways that reduce the Governor’s appointments and guarantee Republican chairmanship during election years.
  • Make the Superintendent of Public Instruction (Republican) independent of supervision by the Board of Education
  • Require that all of the Governor’s cabinet appointments be confirmed by the Senate.

There is a lot more in these bills and there is no way that anyone can adequately understand their implications without time for consideration and debate.  Much like HB-2, there will be unforeseen consequences in addition to the apparent self-serving intent.

There are two ways to prevent this impending train wreck.  One is for enough Republican legislators to stand up to the bullies leading their party by refusing to pass the bills in a special session.  They can insist on adequate consideration by the public and the legislature.  If they fail, Governor McCrory could grow a spine and veto the bills.  Taking such firm action might even create the possibility of resurrecting a political future for him.

Are there enough Republican legislators who value fairness, honesty and decency and who have the courage to stand up to bullies?  Is Governor McCrory, who no longer needs the support of the bullies, willing to stand up and be counted?  If these bills pass, is there any form of cheating that should be off limits to whoever has power?

I’ll close with a quote from one legislator.  “This is why people hate us.”  He’s right.

For those who are interested, here are links to the as-filed versions of some of the bills submitted for the special session as posted on the website of the North Carolina General Assembly

SB 4 :   http://www.ncleg.net/Sessions/2015E4/Bills/Senate/PDF/S4v0.pdf  Ethics, elections and court reform bill creates Republican advantage and control of elections Board

HB 17:  http://www.ncleg.net/Sessions/2015E4/Bills/House/PDF/H17v0.pdf changes public instruction, UNC and department head appointments and authority of Superintendent of Public Instruction

HB 6:  http://www.ncleg.net/gascripts/BillLookUp/BillLookUp.pl?Session=2015E4&BillID=H6 creates independent CIO nominated by Lt Gov

Link to all 21 house bills submitted for the special session:  http://www.ncleg.net/gascripts/lastaction/todaysaction.pl?Biennium=2015E4&ActionChamber=H&DateReport=12%2F14%2F2016

Link to all 7 senate bills for special session:  http://www.ncleg.net/gascripts/lastaction/todaysaction.pl?Biennium=2015E4&ActionChamber=H&DateReport=12%2F14%2F2016

 

 

All Posts, budget, economy, health, justice, lgbtq, medicaid, north carolina, taxes

We can do well while doing good

The ongoing debate about the economic impact of HB2, North Carolina’s “bathroom law” seems both sad and laughable because its effect is so small when compared to another foolish decision made by the state’s Republican legislature. The economic and human damage done by the decision to reject expansion of the Medicaid program is greater by far.

Republican friends, before you disagree, do your homework and discover the facts for yourselves. Bring truth to the debate and then see how your legislature’s decisions look under that bright light. Before considering human impact, let’s examine some raw financial facts.

The Robert Wood Johnson Foundation and the Urban Institute have collaborated on research to understand the economic impact on states that rejected Medicaid Expansion. They found that health care funding in North Carolina would be increased by $41 billion in the decade from 2017-2026 if the state accepts Medicaid expansion. That would require $4.9 billion of state funding and would bring $36.1 billion in federal funding. Do the math. $36.1 minus $4.9 equals $31.2 in net gain. Another way to look at it, suppose someone offered you $36.10 in exchange for $4.90. Would you accept it? That is one billionth of the deal that Republicans rejected.  The legislature knew this information when it rejected the Medicaid expansion.

Some will argue that our state budget is too large and we shouldn’t increase it further by expanding Medicaid. That is a reasonable concern, so let’s look at Medicaid expansion in the context of other government spending.

Most federal highway grants require a 20 percent state match. State funding of $4.9 billion would produce a federal highway match of $19.6 billion. That is $16.5 billion less than we would get if we spent the money on Medicaid expansion. Therefore, if one accepts purely financial justification for not expanding Medicaid, the state would be better off by $16.5 billion to reject the highway match and use the money to fund Medicaid.

In addition to providing health care to uninsured North Carolinians, the Medicaid expansion would create thousands of new jobs in health care to replace those lost in other industries.

The argument that “we can’t afford it” doesn’t hold water when made by legislators who spend money on items that yield a far smaller return on investment. It’s a matter of priorities, and this legislature obviously sees other spending as more important than keeping poor people alive and creating jobs.

What about the human effect of the decision? The Medicaid expansion was designed to provide coverage for the working poor, many of whom have jobs (sometimes more than one job) but who are paid so little that they can’t afford insurance even with the help of the Affordable Care Act.  Whatever became of that right wing mantra “take a bath and get a job”? As cynical as it sounds, the Medicaid expansion is designed to support exactly that behavior. It provides health care for people at the bottom of the economic ladder so that they can stay healthy enough to work and support themselves.

Instead of supporting a program that fits with their own traditional philosophies, Republicans rejected the expansion. That leaves us with a law that requires hospitals participating in Medicare and doctors with privileges to practice there to provide emergency and obstetrical care without regard to a patient’s ability or willingness to pay. The cost of that is invisibly built into the prices paid by everyone else. As a result, North Carolinians will pay for surgery to add a few months of life for an emergency patient diagnosed with advanced colon cancer. But we won’t expand Medicaid to pay for the colonoscopy that could have prevented the cancer from forming in the first place. The result of Republican policy is higher cost and a dead patient.

Yes, HB2 is a foolish law that should be repealed. Yes, the cancellation of concerts and sports events has an economic impact on hotels, restaurants and tourism. Yes, the law unfairly discriminates against a largely defenseless class of citizens. Yes, it should be repealed. But so far no one has died as a result of HB2 and the economic impact is microscopic compared to the rejection of Medicaid expansion.

It’s a fabulous opportunity when the right thing to do is also the profitable thing to do.  We have two such opportunities at the moment.  Accept the Medicaid expansion.  Repeal HB2.  Everybody will win.

Republican friends, the facts don’t support your policies.  It’s time to change your minds.

All Posts, budget, Christianity, Congress, deficit, economy, justice, medicaid, poverty, public education, taxes

STICKS STONES AND STEREOTYPES

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Election campaigns are under way and the name-calling season is open.  Names, labels and stereotypes can influence our opinions and our elections so it’s important to be aware them. Continue reading STICKS STONES AND STEREOTYPES →

All Posts, health, medicaid, taxes

DOING THAT COULD MAKE YOU BLIND

A South Carolina man is learning that there are some things that feel good at the time but, yes, they can make you go blind.  Here’s a recap of his story, much of it from the Charlotte Observer.  Luis Lang was self-employed with a good income and a 3300 square foot house worth more than $300,000.  He knew that the law (Obama Care) required him to buy health insurance, but it felt good to spend the money  on other things. Continue reading DOING THAT COULD MAKE YOU BLIND →

All Posts, economy, health, medicaid, north carolina

How To Fix Obamacare

If your loved one  is seriously ill or injured and can’t pay for health care, should America provide what she/he needs? If health care costs are beyond the reach of many Americans,  should government take action? If you answer “yes”, the next steps are about how to achieve the goals; and it’s time for fact based solutions to the problems of American health care. Continue reading How To Fix Obamacare →

All Posts, budget, deficit, economy, health, medicaid, north carolina, poverty, taxes

JUST SAY YES TO MEDICAID

The decision by North Carolina’s governing Republicans (every single one of them) to reject Medicaid expansion will cost the state’s residents $37 billion by 2022. That is roughly enough money to run the entire state government for 21 months. They looked at the money and just said “no”. They looked at uninsured people living in poverty and just said “no”. They looked at hospitals and doctors who care for uninsured people, and they just said “no”. And they just said “no” to unemployed workers who would have found jobs in the Medicaid expansion. Continue reading JUST SAY YES TO MEDICAID →