Okay, But Not Now
We are right to mock the hypocrisy of elected Republican officials that criticize the Affordable Care Act (aka Obamacare) for leaving millions of individuals uninsured and doing little to address the high cost of health insurance. Instead of creating policies to address these two Obamacare shortcomings, Republicans decided to exacerbate them by withholding funding to insurance companies that all but ensure that premiums will rise even higher and fewer individuals will have health insurance. We are also right to sneer when conservative intellectuals and Libertarians extol the virtues of a so-called free-market health care system where people are free to buy or not to buy any level of health insurance, and from any location they want. When the reality is that health insurers aren't in the habit of offering a la carte health plans. There's also the issue of opaque pricing with “free market health care.” Another issue with conservative and Libertarian views on health care is that half of the purchasers can buy insurance at a significant discount because of the workplace health insurance premium tax exclusion and the other half have no such benefit.
But at some point, and I think the time is now, Obamacare supporters and proponents of single payer or universal health care will have to realistically and publicly address how their proposed policies will deal with the problems of health care costs and affordability. Unlimited health care at any cost paid for by the government is not a realistic option, and no such system exists anywhere in the world. There are and should be limits on the amount of medical care an individual receives if they are not paying for it or if doctors and hospitals determine additional care would have no meaningful impact.
Our current U.S. health care system already places limits on the amount and form of medical care individuals receive. Sometimes these decisions are based on ability to pay the cost of care, and at other times they are based on medical science. However, this approach of rationing medical care won't be sufficient in a Medicare For All style system. Rationing of medical care will have to be front, and center of any government paid health care system. But that is not to say that people will not have access to care the government won't pay for; they are free to purchase health insurance or health care individually.
Some people may believe that a government codified system of medical care rationing harms the poor and favors the rich. Not necessarily. First, the poor won't likely pay anything for their medical care, and they will have access to preventative and continuous care that should improve their health status. Second, the poor won't have to pay for costly medical innovations, one of the real drivers of outrageous U.S. health care costs, but they will benefit from them. And third, the stigma applied to government-provided health care is diminished and so is the incentive for doctors and hospitals to treat the poor differently.
Right now proponents of government-paid health care for all our engaged in a battle to keep the poor from losing access to medical care. They may feel that they have to accomplish this goal first before they can start the conversation about their ideal health care system. Meanwhile, opposers of government-based health care use the socialists, communists, and hippie-dippy, out-of-control spending argument to make universal coverage look less attractive than the status quo. And I fear they are winning this argument because of a weak counter-argument of a greedy, evil opposition. Continue Reading...
America has always been a nation divided. The country fought over its divisions in a gruesome war, one side lost, and the nation stitched itself together again. But the stitches never healed and America never adopted a unified identity. This lack of identity led to smaller wars, culture wars, including conservative values versus liberal values, and the role of government versus the responsibility of the individual.
And with the election of Donald Trump, America's culture wars has reached fever pitch. So much so that some people believe America is headed for a second Civil War; but if not war, towards defining a new national identity. But don't underestimate America's ability to make minor adjustments and put off making tough decisions. A second American civil war is unlikely, but so is adopting a national identity acceptable to all. More than likely, America will move in the direction of greater universality in some areas because political and social forces at the time pushed us there.
We are currently experiencing a grudging push by some toward universal health care because, despite Trump supporters' hatred of their cultural opposites, many of them need assistance paying for health care. Even conservative columnist, George Will,
I recently read a comment on social media from a doctor equating accepting Medicare and Medicaid to (a doctor) signing her slavery agreement. And as insulting and inaccurate (slaves didn't sign agreements!) as this statement is, the sentiment is not too far off from what many doctors in America share. Doctors often refer to Medicaid as charity work.
The claim that Medicaid reimbursements do not cover the cost of care is near universal. Some specialists claim they make about $8/hr. treating Medicaid enrollees. Others publish a sampling of their Medicaid reimbursement payments online to show Medicaid paying less than $5 for care billed at $400. Of course, they never share all of the information about a claim, just enough to "prove" their narrative of poverty inducing Medicaid rates.
Meanwhile, physician complaints about Medicaid are the same as the ones they have about private insurance; they just hate Medicaid (and Medicare) more because of the lower reimbursement rates. For all payers, doctors complain about jumping through hoops to get paid, late payments, paperwork, and regulations. Some doctors have also complained about the behavior of Medicaid patients (don't exactly know what they mean by that).
Unfortunately, doctors and hospitals can get away with their Medicaid-rates-are-too-low claims because they are the ones setting the rates. And, as we know, they charge different rates for different groups of patients—Medicare, Medicaid, patients with private health insurance, patients without private health insurance, etc. But these rates aren't related to actual costs because a doctor's time and effort are never measured. So doctors cannot prove Medicaid rates don't cover the cost of their services. Still, that doesn't stop them from demonizing Medicaid, but the reality is that doctors don't like any program or law that controls the fees they can charge or requires them to meet certain standards.
Brief Primer On Medicaid Reimbursement Rates Continue Reading...
Decades ago Dr. Martin Luther King, Jr., spoke about the triple evils in society—poverty, racism and militarism. These three things still exist and continue to feed off of one another, but this week three more evils emerged. Speaker of the House of Representatives, Paul Ryan; Secretary of Health And Human Services (HHS), Tom Price; and Director of the Office of Management And Budget (OMB), Mick Mulvaney recently embarked on a tour to spread Step One of their evil health care plan. Shameless lying about an Obamacare death spiral is to be expected from these three, but the callous response to their health care bill's impact on the elderly and poor is shocking.
With a little preparation, Ryan, Price and Mulvaney hit the media circuit and boy did their true colors shine through. Ryan continued in his persona of the cocky politician staying true to his conservative principles. Price adopted the role of the all-knowing physician giving the uniformed a hard dose of medicine on the evils of government "interference" in health care. And Mulvaney, serving as Trump's representative, is just hard to watch.
The one and only good thing about the introduction of the American Health Care Act (AHCA), is that it totally destroyed Paul Ryan's (fabricated) reputation as a brilliant policy wonk. Ryan's contribution to the AHCA is ideological and administrative. Ideologically, Ryan does not believe in taxing rich people and does not like entitlement programs. Consequently, questions about the tax cut for the wealthy and the gutting of Medicaid elicit smirks and God-awful responses from Ryan, including these gems from his interviews with radio host, Hugh Hewitt and Fox News' Tucker Carlson, respectively:
“But we always know, you’re never going to win a coverage beauty contest when it’s free market versus government mandates.” Ryan's response is reminiscent of remarks made by former Louisiana Governor, Bobby Jindal, when he rolled out his Obamacare repeal plan:
"whatever amounts of money conservatives were willing to allocate to address a problem, Democrats would always be willing to spend more, so conservatives cannot get into a bidding war." And, “I think it's a mistake if we measure health care reform in terms of how many people we give cards to.”
But Ryan wasn't done being a jerk, this is what he said when called out by Carlson for eliminating an investment income tax on the richest Americans as part of his reform reconciliation bill, "I'm not that concerned about it because we said we were going to repeal all of the Obamacare taxes and this was one of the Obamacare taxes."
And concerning millions of people potentially losing Medicaid coverage, Ryan has expressed absolute giddiness about the billions of dollars in federal savings and the prospect of de-federalizing Medicaid once and for all.
With Paul Ryan, you get an ideology without a soul.
Tom Price, Preserver of the Doctor-Patient Relationship And Access Proponent Continue Reading...
The upper middle class is finally receiving the attention it deserves but probably doesn't want. The income inequality standoff between the 99% and the 1% that exploded after the 2008-09 Great Recession is moving downstream. About five years after the start of the recession, economists, social and public policy experts and intellectuals began to notice where the real growth in income was happening. Articles in the Wall Street Journal and Fortune both reference a study by Stephen Rose of the Urban Institute that claims that in 2014 the “upper middle class controls 52.1% of America’s income.”
But it’s not just rising income inequality between the upper middle class and the lower income classes that is getting attention, it’s their increasing political clout that is receiving bad reviews. Some public policy writers believe that the upper middle class is destroying America. Check out some of these headlines:
"The Upper Middle Class Is Ruining America And I want it to stop." written by Reihan Salam, 2015, slate.com.
"The Dangerous Separation of the American Upper Middle Class," written by Richard V. Reeves, 2015, brookings.edu.
"Check Your Privilege, Upper Middle Class," written by Richard Reeves, 2016, washingtonpost.com.
Personally, I never really thought about the status of the upper middle class until last month when I spent two weeks with about 100 of them on a cruise from Moscow to St. Petersburg, Russia. Now, I can't confirm that all of the people I met on the cruise were legitimately upper middle class, but I'm guessing many were.
Let me explain. In his article in slate.com, Reihan Salam, said that “upper-middle-class is a state of mind. We’re talking about families that earn well into the six-figure range yet don’t feel rich, either because of their student loan debt or the enormous cost of the amenities they consider nonnegotiable: living in well-above-average school districts for those with children or living in “cool” neighborhoods for those without.”
So, if Reihan is correct that upper middle class is a state of mind, my cruise mates who casually compared the number of countries they visited, fit the bill. They also, according to every article I read about this group, and I’ve read a few dozen, possess all or most of the characteristics of the upper middle class: mostly white, educated, current or former professionals (doctors, lawyers, financial advisors, public-sector administrators, etc.) lifestyle-focused, with the ability to spend thousands of dollars on, experiences, and segregated from the lower income classes.
Should We Care About The Upper Middle Class?
Why does a blogger dedicated to writing about health insurance and retirement saving public policy issues care about the upper middle class? Well, as a former workplace employee benefit professional, I know that workplace health insurance and retirement plans favor highly compensated workers. You know, those employees who make above the FICA tax limit and the ones who can afford to contribute the maximum amount to their 401(k) and whine that they are not able to contribute more, tax-free. Continue Reading...
This week health care policy watchers are focusing their attention on the Affordable Care Act (aka Obamacare) alternatives put forth by Senator Marco Rubio and Wisconsin Governor Scott Walker. I can’t say that I was eager to read another Republican health care reform proposal. But as someone who makes a point of reading all publicly available health care reform proposals, I took the time to read them. And although short in length, reading them was exhausting.
All the major conservative health care reform boxes are checked…
I didn’t see anything in the Rubio and Walker proposals that I haven’t seen in other conservative health care reform proposals. Tax credits. Check. HSAs. Check. Employer tax-preference reform. Check. Medicaid block grants (state-controlled). Check. Allowance of bare bones medical plans. Check. State high-risk pools. Check. Interstate insurance plans. Check. Return to the pre-Obamacare status quo. Check.
Bottom line with these two proposals is that they contain very little detail but are clearly making the point that they are okay with the pre-Obamacare health care environment of crappy health plans but want major changes in health insurance plan tax treatment.
But as these two proposals are being dissected, another health care reform conversation is taking place among Republican presidential candidates that is more interesting and worrisome. At least three candidates have discussed raising the Medicare eligibility age beyond age 65 and/or privatizing the program. Republican presidential candidates Jeb Bush, Chris Christie and Marco Rubio have all proposed these types of changes to Medicare. But to be fair many Republican lawmakers in the House and Senate support these types of changes to Medicare and it was on the table when the Democrats drafted Obamacare. Continue Reading...
- Black Lives Matter is a protest and advocacy movement founded in 2012 to address the dehumanization of black people.
- Occupy Wall Street is a protest and advocacy movement started in 2011 to address social and economic inequality.
- The Tea Party is a political movement established in 2004 promoting a fiscally responsible and limited government.
The individuals these movements represent want to change the status quo. And what they are finding out is that it is not easy. The Occupy Wall Street protestors know well how harsh the opposition can be. Politicians and many in the mainstream media often treat them with disdain. The Black Lives Matter protestors have to constantly defend their existence to critics and supporters. Even the Tea Party, the most organized and well funded of the three modern social movements has its haters among the elite.
As these movements struggle to develop their platform, their powerful critics, including many in the media and elected politicians, label them subversives and their leaders, hustlers. They say they are unorganized, naive and unable to articulate their purpose. As was the case for all new social, economic and political movements in the U.S., the odds are against them. Much as it has been for those looking to reform the American health care system. Continue Reading...