Wednesday, July 19, 2017

Taming Healthcare Costs

In my last post, I mentioned that the most contentious aspect of the health care debate is costs.  For instance, media groups leaning right as well as the architects of the Republican proposal known as the Better Care Reconciliation Act (BCRA) will tell you in response to the statement that it cuts Medicaid payments, that it in fact increases them, which is true.  Unfortunately, it is also true that this increase is much less than those under the Affordable Care Act (ACA) which is why media groups which lean left are emphasizing this reduction, and why many Governors from both parties are nervous about their ability to make up the difference.

My own Senator, Pat Toomey from Pennsylvania, from whom I receive a weekly update, makes the former case by emphasizing that it "puts Medicaid on a sustainable path, averting a future fiscal crisis".  In other words, less payments from the federal level, so that we can still afford the program at all.  How Toomey expects states like Pennsylvania to make up the difference is not part of his defense.

And, that is the rub.  Regardless of which side you lean to, costs have been rising, and will continue to rise if we don't examine the facts behind the problem.

America is aging, its population increasing on average by two years every decade, and will continue to do so as a result of the plethora of baby boomers (those born from 1946 to 1964).  For those 19 years, just about 4 million live births occurred in America every year; that is over 75 million people! In addition to this burst of births, we are living longer as life expectancy for Americans has increased on the average by 9 years (from just under 70 to just under 79) since 1960.

In other words, more people are living longer which produces higher health care costs. But that is just the beginning of the story.  It is not just that there are and will continue to be more older people, but our expectations of the quality of our health have also increased dramatically.  New knees, new hips, new faces, new organs, all extend our lives, but cost much more money. And the incredible boom in the pharmaceutical industry which now provides easy relief for so many real and imagined ailments, adds even more to the rising costs.

We experience pain, no one's favorite feeling, and rush to the local health care provider or upstairs medicine cabinet to ease our suffering.  Not necessarily a bad thing, but not cheap in comparison to understanding and accepting that a little pain is a signal from our body that we are doing something wrong.  Indigestion?  Take a purple pill and eat whatever you like.

It is a bit ironic that we turn to pharmaceuticals for what ails us in record numbers, yet we bemoan the outrageous profits and salaries in the pharma industry, and are aghast at the spreading opioid epidemic.  When the common answer to life's ups and downs is a little yellow pill, then we must expect to pay for all that medication, one way or the other.  But, solving the increasing federal funding morass for health care costs by passing along the responsibility to the next level is less an answer, more a case of passing the buck.

So, what is the answer?

First, we need to admit that we have a spending problem.  The United States spends significantly more money per capita than any other country.  In one of the tables I found, in 2015 we spent two times as much per person, or more, than all but 9 other countries in the world, including Canada, Australia, France, Japan, and the United Kingdom, among others, while attaining only limited benefits from these extra expenditures.  Most rankings of healthcare outcomes by country lists the United States in the middle of the pack  (or lower) in life expectancy, infant mortality, cancer survival rates ,etc.  All which means that we are not getting good value for the money we are spending. Or put another way, too much of the money is being diverted from addressing health problems to maintaining profits, excessive executive salaries, political campaign donations, advertising which convinces consumers that they are sicker than they are, and, most of all, to maintain the medical/pharmaceutical complex at the cost of actually improving wellness.  

https://en.wikipedia.org/wiki/List_of_countries_by_total_health_expenditure_per_capita,

Second, if we are going to continue to be apoplectic in thinking that a single payer/universal health care system is "socialized medicine", then we need to come up with another method of creating the biggest pools possible so as to spread out the higher costs for the elderly and sick among the young and healthy, while maintaining reasonable premiums.  There is not doubt that costs are lower in countries with single payer systems, but perhaps those models don't automatically apply to a country with a higher population and more diverse economic and cultural demographics.

One aspect of the recent GOP proposal isolates the sick into pools outside the mainstream, thereby lowering costs for the majority but forcing those with chronic or fatal diseases to choose between life and money.  Yikes!

Perhaps a better answer lies somewhere in between.  I have often proposed a single payer system run by the states.  The federal requirement of a minimum level of insurance coverage for all would still be law, but each state would be charged with establishing exchanges which feature a variety of health insurance plan options, but still offered by the current health insurance industry.  Remove employers from the equation to eliminate the disadvantage that the self employed currently faces, and include all elected officials who serve that state, regardless if they work in a state capital or Washington thereby making them consumers of the same system they help develop.  (Removing the employer participation may also free up some money, perhaps to invest in more livable wages, and, of course, capital improvements for the business itself).

Certainly, the federal government would still need to provide some funds for this system but the states would be tasked with negotiating the costs and details of the various insurance plans to be offered to its citizens.  Those that qualify for assistance, based on that state's particular demographics, would be eligible, as opposed to making it a federal demographic.

The goals would be to redirect responsibility for health care insurance back to the individual family or person, provide affordable options that balance low premiums with high deductibles for those with few health issues, higher premiums but lower deductibles for those with chronic health issues, caps on yearly and lifetime expenditures regardless of health, and no preexisting conditions clauses. Health care insurance becomes a right but a right that requires individual responsibility to manage.

The good news in all this is that the baby boomer peak will occur and we will reach a point where costs may somewhat flatten on their own.  But that is still 20 years away, if we assume the majority of people born in the baby boomer generation, will be dead by 2037.  

In the meantime, we might also want to remind our elected officials and those we see in the mirror each day, that there is plenty of money in these great United States to pay for better outcomes and provide health insurance for all American citizens.  Considering the $200 million contracts being signed by various athletes, the eight figure salaries being paid to CEO's, the billions of dollars being spent by the American public on entertainment, and the literally, trillions of dollars that are safely tucked offshore by the 1% who value their wealth more than their country's future, it is hard to fathom why we agonize over the costs of providing health insurance and improving health outcomes.

Perhaps a reevaluation of our priorities is the true path to finding a solution.

 

Tuesday, July 18, 2017

GOP Healthcare Plan

It appears that the long awaited repeal and replace Obamacare health care bill that was promised will not come to fruition in the near future.  It is truly a sad indicator of how partisan the politics of America has become that we find ourselves in the unenviable position of having a flawed national healthcare program in place as acknowledged by both parties, most Americans, and the majority of health care providers and insurance companies, but do not have the stomach, guts, leadership or whatever other word you might want to use, to fix it.

As far back as I can remember, our collective approach to the problem of providing a reasonable cost for the majority of Americans to pay for their moderate health care costs, while addressing the needs of the minority of Americans who cannot afford to pay for their above average health care costs, has ranged from assuming the heath insurance industry would humanely balance their profit with the well being of their customers, to creating arbitrary affinity groups (through employment, union or other trade or age related membership) to increase the pool thereby spreading out the costs, to the truly horrific idea that sick people deserve to be sick due to their poor lifestyle choices or equally poor luck from the birth lottery.

Mixed in with these inadequate approaches, the specter of America's love affair with individualism and capitalism pretends that health care is a commodity just like a car or a house, so that those with the most money will naturally be able to purchase the best health care, and those with the least will have to make do with the economy version.

And, we eschew the national health care model of most of the rest of the "civilized" world which creates a national pool of customers to lessen the costs of individual sickness or group trends of disease, by asking everyone to pay a little more in taxes.  The fact that this bigger pool is really just an extension of the affinity groups we are using today, is lost in the angst created by those who use the S word (socialism) to belittle the universal health care model that addresses the real issue behind our debate: costs.

The good news is that we should recognize that in their lack of unity, the GOP has done a valuable service to America in their inability to create a better plan.  It is imperative that the liberal media and pundits try to avoid gloating over the fact that they had 8 years to come up with a new plan and failed miserably, and focus on the fact that for whatever reason, concerns over the reduction of insured Americans, concerns over the sky rocketing costs which would have been passed along to the states, or even concerns that the GOP repeal bill did not go far enough to remove government from the heath care morass, whatever the reason, we must praise our GOP controlled legislature for not following through on their repeal and replace mantra by voting for just any new piece of legislation.  I applaud them for finally realizing that it is easy to criticize, but much harder to govern.

Will they merely repeal?  I would like to think that the answer is no, even if only because they are afraid of losing their job when they next run for office.

And who knows, perhaps the loss of the last 8 years, which might have afforded the chance to amend the ACA so that the needs of the truly sick, and those with limited access to health care insurance could have been addressed while balancing the costs to the aforementioned chronically ill along with the majority of Americans who face average and less than average health care needs, will spur us to find common ground across the water cooler, and common ground across the political aisle.

 

      

Thursday, July 6, 2017

Discovery

Slow month in June; less than 20 hits a day on my blog.  It is months like that which make me question why I continue to share my thoughts.  Am I kidding myself to think that anyone cares to read my opinions?  Am I fooling myself to think that my writing is cogent, thoughtful, relevant, or any other term one might consider a compliment?

I rationalize the time I spend in this endeavor with the possibility that someday my posts will be read by someone of influence who will find them important enough to share within their circle of followers.  Or perhaps a particular opinion or thought might inspire someone to act in such a way that the world is better for it.  Or even that in continuing to record my thoughts, small ripples of change might begin their long journey towards an unknown shore, effecting behavior or a future philosophy in a positive way.

Or, perhaps, that those in my small circle of influence might feel better for having read them.

A resurgence of interest from Russia has me wondering.  In the past I have received some very nasty comments from a few Russian readers, making me think they might be the source of activity in that country.  Is negative interest better than no interest at all?  Is our president's fascination with Putin generating interest in that country for the opinions of Americans, even someone as obscure as myself?

Just finishing the Spring edition of Lapham's Quarterly, called Discovery.  As usual, many fascinating articles, essays, thoughts on the subject from the depths of history.  A few that I took note of.

In the opening essay by Lewis Lapham, founder and continued inspiration behind the quarterly, he laments the rise of the machine, and our burgeoning dependence on technology for our information. This is not to say that being able to access Laphams digitally is a problem, but that in our growing dependence on our phones and tablets for information, we too often eschew the knowledge of the past, alluded to in Goethe's observation, that he who cannot draw on three thousand years is living hand to mouth.  Lahpam's further comment that the failure to connect the past to the present, the present to the past, "breeds delusions of omniscience and omnipotence, which lead in turn to factories at Auschwitz and the emptiness of President Donald Trump."

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A snippet from Vera Rubin's Women's Work, recounts how, as an astronomy student at Vassar College in 1947, she wrote a postcard to Princeton University asking for a catalog of the graduate school.  She received a nice little note in response from the dean of the graduate school that Princeton did not accept women in its graduate physics and astronomy programs, so he would not be sending along a catalog.  It wasn't until the 1970's that such a thing would happen.

Rubin also recounts how in 1976 when the Smithsonian Air and Space Museum presented as its first planetarium show a history of American astronomy, only male astronomers, all but one white males, were included.  To Rubin, the thousands of little girls who streamed into the show, in addition to learning about space, learned the limitations of their futures as a result of being born female. Repeated efforts by Rubin to request the addition of female astronomers and their contributions were met with a shrug, presumably by white males.

Stories like this make me laugh at the recent rise in white male angst over the perceived slights that the attempts to even the playing field for women and minorities has generated.  I guess practically forever in recorded history is not long enough for them to be given all the advantages!

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From the House of Representatives' report on the Energy Tax Prevention Act of 2011, a bill was voted on in the House which would prohibit the administrator of the EPA (that is Environmental Protection Agency, lest you forget, an agency created during Nixon's Administration) from "promulgating any regulation concerning, taking any action relating to, or taking into consideration the emission of greenhouse gas to address climate change".  During the vote, three amendments were offered by the Democratic minority, one which would accept the scientific evidence that climate change is unequivocal, one that would accept scientific evidence that greenhouse gases are the root cause of the observed climate changes, and the third that the public health of current generations ins endangered, and that the threat to public health will continue to increase as greenhouse gases continue to accumulate in the atmosphere.

Laphams recounts this episode under the heading "Tyranny of the Majority", reflecting that fact that the GOP majority defeated all amendments, and passed the bill as a way of protecting the fossil fuel industry to the detriment of public health.  Fortunately, the bill did not pass in the Senate. Unfortunately, it is not far-fetched to imagine a similar bill passing both houses, and then be certainly signed by President Trump.

It is understandable why so many voters chose to turn over control of both the executive and legislative branches to the GOP, after the stagnation of the political process the last 6 years of the Obama Administration, but there seems to be a precedent which indicates that when a split government is in place, and the voters hold both parties accountable to the concept that common ground must be found to create a government that considers both majority and minority perspectives, then the majority does not operate in a tyrannical fashion, nor does the minority embrace the role of obstructionism to detriment of all.

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In a 1953 talk General Electric physicist Irving Langmuir, who received the Nobel Prize in Chemistry in 1932, identified several symptoms of what he called pathological science - that is, "the science of things that aren't so".  A few of his 6 symptoms of Fake News include:

Claims are of great accuracy.

Fantastic theories are contrary to experience

Criticisms are met by ad hoc excuses thought up on the spur of the moment

Finally, in reference again to the recollections of Vera Rubin and the open discrimination she fought as a career scientist, one can only wonder how many achievements were delayed or missed throughout history due to the premise that only white males should be given the opportunity to think, to research, to discover.  The good news is that the genie is out of the bottle.  When given the same opportunity and resources as their white male counterparts, similar levels of achievement, success, and innovation are attained by men and women, regardless of race, ethnicity, or any other means by which humans limit those who are different from themselves.  Especially in the case of women, one might say despite the obstacles placed in their path.

The bad news is that we seem to be in the midst of a cycle that finds the pendulum swinging in the wrong direction in this matter.  Let's hope that we can recover from our misdirection, and discover (again) that the nature of inspiration lands equally in the minds of all and every type of human, and that to fully take advantage of that muse we must reject the notion that She prefers one gender, one race, one country over the rest.