tag:blogger.com,1999:blog-35039576861582742882024-03-13T21:05:43.124-05:00On Health Care Tech & PolicyMargalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.comBlogger281125tag:blogger.com,1999:blog-3503957686158274288.post-56568934831712736942019-06-05T10:05:00.000-05:002019-06-05T10:05:39.531-05:00Health Care is a Risky Business<div class="separator" style="clear: both; text-align: center;">
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For over a decade Washington DC has been busy with fixing health care. For over a decade, the same government bureaucracy, the same advocacy (read lobbying) organizations, the same expert think tanks, the same academic centers, the same business associations, with the same people hopping around from one entity to the next, have been generating and applying the same “innovative solutions” differentiated solely by their aggrandizing names. The result? Health care is more expensive than ever. More people than ever can’t afford to seek medical care. More doctors are disheartened, to the point of committing suicide. All this while the illustrious transformers of health care are accumulating fame and riches, probably exceeding their own expectations, with no end in sight.<br />
<br />It is no secret that back in 2016 many of us voted for Donald Trump hoping that he will “drain the swamp” or at the very least blow it all up into a spectacular artesian fountain of filth. He didn’t and he won’t. The swamp won. Our special health care swamp is deeper and wider than most, and the Trump administration is making it deeper and wider than ever before. The single payer lobby is simply proposing to move the existing health care swamp to a bigger and more noxious location, so it has plenty of room to expand in the future. The swampy strategy for fixing health care has always been, and by the looks of it will always be, a game of hot potato. The potatoes are us.<br />
<br />At the core of the guileful verbosity of health care transformation there is nothing more than an elaborate effort to shield corporations, and the governments that serve them, from financial risk. It’s really that simple. We pay our premiums and our payroll taxes, month after month, year after year, and when the time comes, if it comes, they’d much rather not pay the medical bills they are contractually or statutorily obligated to pay. Blame sick people for being sick. Blame the sick for not shopping the clearance aisle. Blame doctors for treating the sick. Blame hospitals for admitting too many sick people, too often and for too long. Punish them for the errors of their ways. Teach them a lesson or two. And most importantly, make them pay until it hurts.<br />
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Managing the Health Care Consumer</h4>
The most blatant attempt to throw people under the bus is the insanely brazen effort to remake medicine into a consumer industry. Patients, according to the narrative, are empowered when they spend their own money on health care. Increasing deductibles for health insurance, while also increasing premiums and limitting choice of service providers, is how we weaponize sick people in the war against rising health care prices. If enough diabetics choose to die rather than overpay for insulin, prices for the drug will surely go down eventually, because Southwest Airlines will come up with a disruptively innovative version of insulin that will not be as fancy, but it will be cheap enough to spur increased market participation and push Eli Lilly into bankruptcy. Any day now.<br />
<br />The return to pre-1965 days of consumerism in health care for the first $6,000 of medical expenditures was a good step forward, but the road to fully optimized profitability is long and full of terrors. Consumers are like goats. If left to their own devices, they will destroy your landscape in five short minutes. However, with proper guidance and supervision, they will clean and protect your property from the dangers of random wild fires. Managed Care insurance plans, coupled with high deductibles, ensure that consumers do not eat into your nice profits, while consuming enough garbage to keep your bottom line from going up in smoke.<br />
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From Volume to Value</h4>
Offloading risk to sick consumers is working relatively well by all accounts, but it is not working well enough, and it is not working for beneficiaries of public insurance where the consumer lever is rather short and limp. And so, we push the “provider” lever next. Once patients became consumers, their doctors, naturally, became providers. And just like empowered consumers, empowered providers should have some financial skin in this game. In the current system, you see, providers are just sitting there, placidly watching the register go cha-ching every ten, fifteen minutes like clockwork. If the consumer gets better, fine. If not, also fine. As long as there are no malpractice lawsuits, and the cash keeps flowing, providers are surely satisfied. How do policy makers and garden variety health care experts know this? Simple. It’s called projection.<br />
<br />Moving “from volume to value” does not mean moving from indiscriminate overconsumption to eclectic consumption of excellence. It means moving from lots of variably priced stuff to small amounts of cheap stuff. It means moving from assumed abundance to assumed scarcity. If you can find excellence at the Dollar Store, good for you. If you can’t, well, whatever. Saks Fifth Avenue is out of bounds. And your provider is supposed to enforce those boundaries, at his or her own risk. If you manage to sneak into Saks, your provider will be punished. If you stay where you belong, your provider will be rewarded. Simple. It’s called stewardship.<br />
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Global Budgets</h4>
This is not fair. Obviously. These very clever risk levers are based on wealth, and since we have massive wealth inequality, the levers are largely discriminatory. Wealthy providers couldn’t care less about adding or removing a dollar from each patient visit. Poorer providers can be driven out of business by a fifty cents difference in “reimbursement”. Wealthy patients don’t have to become consumers at all. For patients who are not wealthy enough (or poor enough), even the Dollar Store is cost prohibitive. There is too much privilege at the top. The only fair solution is to shut down Saks Fifth Avenue completely. If everybody is forced into the Dollar Store, eventually the Dollar Store will get better. It will become as good as Saks, but at $1 prices, because the wealthy will demand it. Right. <br />
<br />Shuttering the Saks Fifth Avenue of health care is hard. You can’t just show up at Bayonne Medical Center one morning with a wrecking ball and have at it. Fortunately, the Medicare For All aficionados have a solution: Global Budgets. Once the Federal government controls all health care dollars, they give Saks Fifth Avenue a fixed amount of money to service all their customers for the year. The amount of money is calculated based on Dollar Store costs, with a little markup perhaps, so we don’t appear overly vindictive. Within a few months, you won’t be able to tell the difference between a Saks store and a Dollar Store, except maybe the crumbling façade from a bygone era. That’s how we rid ourselves of inequality and excess privilege, of course.<br />
<br />Remember when Paul Ryan and his evil acolytes proposed replacing the open-ended Medicaid financing model with block grants to States (i.e. fixed amount of Federal money to service all their Medicaid beneficiaries)? There is a one hundred percent overlap between the people who screamed about millions dying in the streets if Medicaid moves to block grants, and the people now climbing the Medicare For All barricades in support of global budgets. Rationing medical care for the poor, or “by ability to pay”, is immoral. Rationing medical care for everybody, regardless of ability to pay, is righteous. Simple. It’s called justice.<br />
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A Permanent Solution</h4>
It is not surprising that health insurance companies would look out for their bottom line at customers’ expense. After all, these are insurance companies, like home insurance or car insurance, which are notorious for continuously devising innovative ways to minimize current and future payouts. Perhaps it is also not too much of a shocker to see that government is at its best when working to eschew commitments made to its citizens. What should however give you pause is that both government and health insurers seem to have finally found a good way to coopt physicians into doing their bidding. Not all physicians, of course, but more than enough to make a permanent difference in the practice of medicine. Either due to misplaced fear or newfound conviction, your doctor’s prime directive now is to do no harm to the United States Treasury and the corporations for which it shills. <br /><br />Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com3tag:blogger.com,1999:blog-3503957686158274288.post-70845053234702309332019-04-27T08:26:00.000-05:002019-04-27T08:26:34.736-05:00The Medicare For All Heptagon<div class="separator" style="clear: both; text-align: center;">
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I am going to make a prediction here. No matter who we elect in 2020, Bernie or Trump or anything in between, Medicare For All is not going to happen in America. One can run an electrifying campaign on the promise of Medicare For All, or indignantly against it, but this is pure theater on both sides. I don’t know if God can make a rock so big and heavy that even He can’t lift it, but I do know that government can make corporations so big and powerful that even government itself can’t break them. <br />
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For decades our government encouraged the health care industry to consolidate vertically, horizontally and obliquely so it can achieve “economies of scale” and therefore lower consumer prices. In the last couple of decades, the government also compelled the industry to computerize its operations, because technology makes everything better and cheaper. Once the resulting monopolistic behemoths were summoned into existence, it was time to nationalize the whole lot, into one super monopoly, with super technology and super economies of scale. The only other example of such government monopoly in America is the Military.<br />
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Obviously, our standing armies must be, by definition, a national monopoly, but note that the Navy is not building its own ships and the Air Force is not building its own planes and the Army is not manufacturing tanks. The government is contracting with private suppliers for pretty much everything, from butter to bullets. The Military Industrial Complex is a network of very large and utterly corrupt contractors for the government, yielding more power over foreign and fiscal policy than Congress, the President, and all citizens put together, while delivering practically nothing either on budget or on time. A powerful Military is essential to America’s safety and global success, so we grind our teeth and keep paying. And medical care for hundreds of millions of people is at least as important.<br />
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I am not entirely sure how people think Medicare For All is going to work. Are you folks envisioning an angry President Bernie dragging Samuel Hazen into the Oval, wagging his finger at him and making an offer Mr. Hazen cannot refuse? Something like, “I will pay $50 per head and not a penny more, because health care is a human right, and if you want to be a disgusting millionaire or billionaire, go write a bestselling book, like I did…”, at which point Mr. Hazen will be hanging his head down in shame and gratefully take the $50 deal. Upon his return to Nashville, Mr. Hazen will immediately schedule book writing workshops for all HCA department chiefs to compensate for cutting all salaries in half. Yeah… no, that’s not how this works.<br />
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Go ask Northrup Grumman or Lockheed Martin or General Dynamics or even Boeing or Booz Allen or any other “beltway bandit” how getting money from the Feds really works. There are well-greased revolving doors between the Pentagon and its contractors. There are stock options and executive positions for high ranking Federal employees. There are 535 people in Congress responsible for allocating budgets, and all 535 are for sale. Most of this infrastructure is already in place for health care too and building the HHS Heptagon shouldn’t take very long. The American President has little to no power over Federal spending, and even less so when it comes to large procurement contracts, as the current occupant of the White House discovered the hard way, during the Lockheed F-35 kerfuffle.<br />
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Clearly large health systems will survive and thrive under a Medicare For All law, but how about private health insurance? Future President Bernie says they will all be banned. Is that so? Currently a full third of Medicare beneficiaries are insured and “managed” by a handful of large private health insurers. Medicare is paying those private contractors fixed amounts of money per head for their services. Medicaid is doing the same for most of its beneficiaries, and all military health insurance (TRICARE) is contracted out to the usual suspects. Basically, the vast majority of people covered by public insurance, are really insured by gigantic insurance corporations. Fact: under the hood, taxpayer funded health care is the bread and butter of private health insurance companies.<br />
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When future President Bernie and the hordes of uninformed supporting characters in the 2020 elections festival say that private health insurance will be banned, they are lying to you. What will be banned under a Medicare For All law, is your ability or your employer’s ability, to purchase health insurance directly from a private company. Instead, the government will procure contracts in bulk as it sees fit, assign people to them as it sees fit, and pay for these contracts with tax revenue as it sees fit. Just like they pay for battleships, fighter planes, bombs, tanks and such. The United States Military is known for lots of great things. Value-based purchasing, and cost-effectiveness in general, are not among those things.<br />
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Depending on who you ask and what is included in the definition of health care, Medicare For All is projected to cost between three and four trillion dollars per year, which is five times the amount we spend on the Military. This number is calculated based on costs under current law, minus the waste generated by the cacophony of hundreds and thousands of different insurance plans, different health care facilities and their too many to count service and product vendors. The projections do not include the effects of the inevitable massive consolidation of everything health care into a dozen or so Federal contractors, able and willing to demand multi-billion dollars contracts for services worth a few million dollars at most on the open market. Remember the Obamacare marketplace website? Multiply that by orders of magnitude and you have Medicare For All.<br />
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Medicare For All is as egregious a misnomer for this plan as the Affordable Care Act was. When they say Medicare For All, they mean Federal government procured health insurance for all. When they say everything soup to nuts will be covered, they mean everything the heavily indebted Federal government thinks should be covered, and can afford to cover, will be covered. When they say health care will be better, more plentiful and much more affordable, they mean please vote for me in 2020. Medicare For All will be built on the largely immovable foundation our government chartered and nurtured for half a century. If you want a glimpse into a Medicare For All future, go look at any Medicaid Managed Care plan in any impoverished southern State, and look at the balance sheets of the associated contractors and sub-contractors.<br />
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It doesn’t have to be this way. We don’t need to bulldozer everything we have, and we certainly don’t need to pretend that we can, or that we must. And we need to remember that the proper role of government in a free country is not to manage the health or the care of all its citizens. Free people are not the wards of a State responsible for keeping them healthy, productive and happy. The role of a democratic government is to keep predators, foreign and domestic, including corporate ones, at bay, while providing a sturdy safety net for the few who cannot care for themselves. Let’s do that instead. It will be better, faster and cheaper than the fictional construct called Medicare For All.Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com3tag:blogger.com,1999:blog-3503957686158274288.post-80256558828693254122019-04-02T17:34:00.000-05:002020-02-24T16:26:41.796-06:00What the hell do we have to lose?<div class="separator" style="clear: both; text-align: center;">
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If you live or work in Washington DC, your number one health care question is how do I (or my meal ticket people) win the next election. If you live or work in Caruthersville MO, chances are that your most pressing health care question is how do I (or my immediate family members) get a hold of some insulin this month. Theoretically speaking, in a healthy democracy, the answer to both questions would be one and the same. In America, in the year 2019, this is no longer the case.<br />
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The Washington jetsetters most aligned with the Caruthersville culture (whatever that means), will pop up on your TV screen promising at least fifty insulin shops on Main Street, all competing for your insulin business, until insulin prices plummet to gas station coffee levels. Not to be outdone, the opposing Washington faction, will promise you free insulin for life, and to sweeten the deal, they will throw in free college for your semi-literate children who couldn’t pass a college entrance exam with a gun to their head. They will also promise free childcare for your grandkids, so just in case your daughter does not make it into that free college and does not become an astrophysicist as planned, she can still pursue her Walmart career.<br />
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We are being hoodwinked. We are being robbed. We are being disrespected and infantilized. Stealing our votes has become easier than stealing candy from babies. There are more of us by orders of magnitude than there are of them. They certainly have better and bigger weapons. They are better trained and better organized and have better discipline. We also have collaborators in our midst, who are difficult to spot. Let’s face it, in every conceivable way, Washington DC and its sprawling appurtenances have become what the Court of St. James was to our forefathers.<br />
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Health care is complicated because it has so many degrees of freedom, few of which we can reliably identify. Some degrees of freedom are yet to be discovered, others look independent, but are not, and vice versa. Furthermore, the boundaries of what we call the health care system are ill-defined and in a perpetual state of flux. At our current state of knowledge, deterministic theories of health care systems are not possible, i.e. you cannot infer past states or future developments of the health care system based on its current state, which is why both health care historians and “futurists” consistently fail to produce any valuable insights, let alone solutions.<br />
<h4>
Option One</h4>
The first and most common strategy for changing complex systems is to essentially ignore the complexity, zero in on one’s pet peeve, kick it hard in the shins, and hope for the best. That’s what LBJ did in 1965 and that’s what President Obama did in 2010. One was wildly successful, the other less so. Why? Both LBJ and Obama identified a segment of the population driven into misery and poverty for lack of affordable medical care and passed legislation to have the government assume financial responsibility for their medical care, to various degrees. Both LBJ and Obama faced militant opposition to their proposals. Both had to compromise and twist arms to make it happen.<br />
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However, the health care system wasn’t nearly as complex when LBJ acted on it. As luck would have it, LBJ was able to separate a piece of the system from the whole in a relatively clean way and move on that piece and that piece alone. It would take half a century for the ripple effects of LBJ’s kick in the shins to reach all other parts of health care, for better or for worse. By the time Obama got his shot, the health care system became almost impossible to detangle. Almost. Instead of working hard to carve out his pet peeve from the bigger mess, expose its shins, and deliver a blow, President Obama chose to kick the whole system softly in multiple spots, hoping the change will materialize only where intended. It did not.<br />
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Obamacare’s main thrust was to provide health insurance to the 45 million Americans who were then uninsured, mostly because they couldn’t afford to buy insurance. If that’s all Obamacare endeavored to do, it would have probably been a resounding success. Instead, Obamacare chose to partially address the uninsured problem directly, while simultaneously attempting to lower the overall costs of health care, so the unaddressed portions of the problem will address themselves. It was too much intervention for the system to absorb at once, particularly since the underlying philosophy was old, unimaginative and empirically proven to be morally and operationally bankrupt.<br />
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At the very core of Obamacare is Richard Nixon’s (or rather Edgar Kaiser’s) notion that health care is best when throngs of people, devoid of agency, submit themselves to medical decisions of expert organizations whose job is to minimize the costs of health care. This idea is why we are told that the job of doctors is to “keep” people healthy and be “stewards” of scarce resources, why we need a health system instead of a “sickness” system, and why Obamacare mandated preventive care to be “free” across all health care. This idea is why most Medicaid, large chunks of Medicare and the Obamacare exchanges were surrendered to “managed care” and “accountable” organizations, why fee-for-service is incessantly vilified, and why massive medical surveillance by computers has been instituted. And this idea is why independently minded private practices had to be demolished.<br />
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Remember those vaguely defined degrees of freedom? It turns out some of them had to do with pricing. You want free preventive care? Sure, no problem, just pay a higher deductible. You don’t want to pay a fee for each service? Oh well, then pay a hell of a lot more for each “bundle”. You want a “health” system? Perfect, just pay more for “sickness”. You want billion-dollar precision surveillance of the herd? Easy peasy, just pay more for everything. You don’t like how things turned out? Too bad, because while you were busy pontificating, we all merged ourselves into too-big-to-push-around “health” entities, so take it or leave it, see if we care.<br />
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Option Two</h4>
The health system we have today is very different than the one we had when Obamacare became law. It has bigger teeth, sharper claws and spectacularly buff muscles, and its grip on our lives has tightened significantly. You can’t close your eyes and click your heels to go back to pre-Obamacare times. You may be able to strip twenty million people of the lousy health insurance they now have, but you can't “repeal” the mergers and acquisitions of the last nine years, you can’t resurrect thousands upon thousands of small practices and pharmacies, and you can’t rip out trillion dollars of computerized surveillance. You can certainly indulge in fantasies of shooting it dead with your Medicare for All silver bullet, but the post-Obamacare health system is no fictional werewolf. It’s a very real animal. You can certainly wound it, but nothing is more dangerous than a wounded beast.<br />
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The only way forward is to do what Obamacare should have done, albeit under much more difficult circumstances. You still have around 30 million people with no health insurance, and over 100 million who are underinsured because they can’t afford the new deductibles. You also have small limited opportunities to lower expenditures on certain health related items such as prescription drugs and extra payments to hospitals. You also have a slew of Federal regulations and administrative programs that make everything a bit more expensive, with no added benefits to either buyers or sellers of medical services. Before you do anything though, you must overcome a very painful mental hurdle. Medical care is and will remain very expensive for the foreseeable future, and that’s okay.<br />
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We don’t know how to cure Alzheimer’s. We don’t know how to cure diabetes, kidney disease, heart disease and most cancers. These things make medical care expensive. Five percent of Americans use fifty percent of health care funds every year. Fifteen million people use around one million dollars each, in any given year. If these very sick people didn’t exist, or if medicine had nothing to offer them, health care would be affordable for everybody else. Alternatively, if medicine had a fully restorative cure for these and other afflictions, health care would be dirt cheap and life would be much better for everybody. Science will do its thing eventually, and nudging it won’t hurt either, but for now, we need to bite the bullet and pay up.<br />
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First, we spend lavishly:<br />
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<li>Expand Medicaid to 200% Federal Poverty Level (FPL). The Obamacare Medicaid expansion was up to 138% FPL. Where did they come up with that number? The FPL is a joke. No person can live on $6.245 an hour when working full time, which is equivalent to the FPL. Expand Medicaid a little bit more (yes, I just said expand Medicaid).</li>
<li>Get rid of the individual market for health insurance. Create locally managed group plans for counties or whatever geographical measures make sense in a given area. Let those groups shop for health insurance just like employers do. This will put to rest all the “preexisting conditions” sound and fury. </li>
<li>Subsidize these group plans so nobody pays more than a certain percent of their income and establish parity with current employer sponsored insurance. Yes, it is going to cost money, probably more than Obamacare, but it won’t break the bank.</li>
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Now let’s save a few pennies:<br />
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<li>Do the prescription drugs thing. Don’t reimport from Canada, thus taking advantage of “Socialized” medicine, while badmouthing it with gusto. Grow a pair and take on the drug cartels. If the President can threaten China with tariffs, Mexico with shutting down all trade moving through the border, the EU with dismantling NATO, and North Korea with nuclear annihilation, he can certainly negotiate a better deal for America with a bunch of pharmaceutical sleaze balls, no?</li>
<li>Get rid of the “free” preventive care and allow direct primary care, and any cash services that are priced lower than plan negotiated fees, to count against deductibles.</li>
<li>Speaking of deductibles, cap those nationally at ten percent of premiums.</li>
<li>Incentivize competition in physician services, and discourage shady referral schemes, by paying independent small practices, more than hospitals for the same service. Look at this as a form of reparations for past discrimination. </li>
<li>Get rid of all Medicare and Medicaid funded “initiatives” that have no clear purpose or return on investment and disallow anything that is not a direct payment to a medical professional, facility or supplier, from being included in health insurers’ medical loss ratios.</li>
<li>Require all sellers of health insurance to submit to yearly value-based performance evaluations and publish the results. This is not about clinical quality. It’s about quality of service, and value-based is the proper term here (for a change).</li>
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There is obviously more, a lot more, that we could do, but these are my pet peeves. Other people will have their own. If we keep it simple, and if we are careful when detaching little pieces from the tangled mess that is our health care system, we should be fine. The folks in Caruthersville MO will be getting plenty of insulin, and the wise men and women brave enough to take this or a similar route to solving the health care conundrum, will get reelected in a landslide. The alternative is that in a pointless battle against Obamacare, those who defend the Obamacare status-quo will win in a landslide (regardless of Medicare for All empty promises), because starving people will not trade the piece of stale bread in their hand, for promises of champagne and caviar due to arrive in two years or so, if all goes well.<br />
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The President’s political instinct was correct. Health care must be addressed in a positive and generous manner at this exact moment in time, or the party will be over sooner than anticipated (pun intended). Those who advise the President to postpone the discussion are not serving him or the nation well. These are the same people who pushed the stingy and cruel Paul Ryan agenda that brought the house down last year (pun fully intended).<br />
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The truth is that right now, nobody in Washington DC has a realistic solution for health care, so why not try something different? What do you have to lose? I mean, seriously... What the hell do you have to lose?Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com4tag:blogger.com,1999:blog-3503957686158274288.post-4151536950019185462019-03-12T08:30:00.000-05:002019-03-12T08:30:07.748-05:00Disquisition on Medicare for All<div class="separator" style="clear: both; text-align: center;">
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Medicare for all Americans is on the table now. Think about it. The not-in-our-lifetime utopian vision of every progressive liberal, complete with dancing rainbows and unicorns, is now within reach. Alternatively, the socialized medicine Trojan Horse that will turn these United States into a toilet-paper free Venezuela is now before Congress. There are over half a dozen <a href="https://www.kff.org/interactive/compare-medicare-for-all-public-plan-proposals/" target="_blank">bills</a> in Congress, introduced by serious people with serious intentions, proposing some version of government administered universal health insurance in America.<br />
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Whichever ideological camp you’re in, it is a profound disgrace that in America today many people cannot afford basic medical care, as profound a disgrace as having veterans sleeping on sidewalks, as profound a disgrace as having one in five children living in poverty, as profound a disgrace as having Americans going to bed hungry. This was not supposed to happen in our “shining city upon a hill whose beacon light guides freedom-loving people everywhere”. It just wasn’t supposed to be this way in a country founded on the inalienable right to pursue happiness. Regardless of why it happened, whose fault it is, or how to “fix” it, America was not supposed to be this way. It just wasn’t.<br />
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<i>"We the People of the United States, in Order to form a more perfect Union, establish Justice, insure domestic Tranquility, provide for the common defence, promote the general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity, do ordain and establish this Constitution for the United States of America."</i></blockquote>
Our union is as far removed from perfection as it was in the years leading to the events of April 12, 1861. Whether you obsess over political affairs or social issues, our justice system seems to be established on very shaky and uneven ground. Domestic tranquility must have been some sort of eighteenth century inside joke. Our welfare is anything but general, the much-admired blessings of liberty seem to accrue to the few who do very little to secure them, and things don’t look any better for our children and grandchildren. We can debate the fine legal points, the Articles and the Amendments, but there is no question in my mind that we are failing miserably in at least five out of the six stated goals of our Constitution.<br />
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What do all these polemics have to do with “fixing” health care, you may ask. Health care is not a standalone issue. It cannot be debated, let alone “fixed”, in a political, historical and moral vacuum. Our health care woes are one manifestation of a much larger systemic failure of American society. The “concentration of power” in fewer and fewer hands is a calamity that was foreseen by a bitter, desperate man as he lay dying, and promptly ignored by many generations since, including our own. <a href="https://www.constitution.org/jcc/disq_gov.htm" target="_blank">John C. Calhoun</a> stared into his self-inflicted perdition and we stared back at him from the flames.<br />
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<i>“At this stage, principles and policy would lose all influence in the elections; and cunning, falsehood, deception, slander, fraud, and gross appeals to the appetites of the lowest and most worthless portions of the community, would take the place of sound reason and wise debate. After these have thoroughly debased and corrupted the community, and all the arts and devices of party have been exhausted, the government would vibrate between the two factions (for such will parties have become) at each successive election … These vibrations would continue until confusion, corruption, disorder, and anarchy, would lead to an appeal to force”.</i></blockquote>
The tragedy at this point is that we, as an “E Pluribus Unum”, cannot rationally analyze, let alone agree on, either the nature or the cause for our failure to thrive, and as long as that remains the case, we will not be able to “fix” health care, or anything else for that matter. But perhaps there is still some room for discussion at the edges of Armageddon…<br />
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One glaring commonality between all Medicare for All proposals is that they are neither Medicare nor for all. Nobody is proposing to make Medicare available to all Americans, which is rather strange if you think about it. The battle cries of Medicare for All, the ubiquitous #Medicare4All hashtags, are pure propaganda. The proposed plans range from letting a few more poor people buy into Medicaid (not Medicare) to the Cadillac plans of <a href="https://www.congress.gov/115/bills/s1804/BILLS-115s1804is.pdf" target="_blank">Bernie Sanders</a>, <a href="https://www.congress.gov/115/bills/hr676/BILLS-115hr676ih.pdf" target="_blank">John Conyers</a> and the brand new bill introduced by <a href="https://jayapal.house.gov/medicare-for-all/medicare-for-all-act-of-2019/" target="_blank">Pramila Jayapal</a>, including prescription drugs, dental, vision and long-term care, with no premiums, no deductibles and no copays, given free to all citizens, regardless of financial status. In addition to the official bills introduced in Congress, there are lengthy <a href="https://www.peri.umass.edu/publication/item/1127-economic-analysis-of-medicare-for-all" target="_blank">proposals</a> from policy groups touting their superiority and/or soundness compared to all other Medicare for All arrangements. The opposing faction is peculiarly devoid of grand ideas.<br />
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The problem with grand ideas though is that, by definition, they must rest on a multitude of assumptions and some assumptions are better than others. You can assume for example, that breaking an egg on a hot surface will get you breakfast. It’s been done trillions of times and therefore one can say that this is a pretty safe assumption, maybe even a fact. You can then be tempted to assume that putting a hot rod through an egg will yield the same results, since the egg is broken and in contact with a hot surface. Now obviously, the hot rod is just a first step, and after extensive tinkering you have a brand-new type of frying pan with an electronic egg breaker embedded in the middle. It costs ten times as much as the frying pan you trashed and it’s only good for eggs, but it does break the eggs, something you never knew was a problem. Oh, and it only makes scrambled eggs, so you save time on complex cognitive tasks.<br />
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Obamacare sounded pretty good before it morphed into a pugilistic contest between bureaucracies. Berniecare, sounds pretty good too. I mean what’s there not to like? All health care is free, and we don’t have to pay more than we are paying now for health care. We may even need to pay less, in aggregate. And the payments will be more justly distributed across the population. And every single person, no matter how privileged, will have the same exact glorious health care. Heck I’ve been arguing for a system like that myself. For those interested, I am also arguing for peace on Earth, prosperity, health and happiness to you and your loved ones. <br />
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Despite what hot-headed reformers are trying to tell you, American health care is not worse or scarcer than it is in other developed nations. It is better and more plentiful. The sole problem with health care in this country is that it is not affordable for most Americans. What does “not affordable” mean though? Does it mean that health care prices are too high? Does it mean that we don’t choose our care wisely? Or does it mean that people are too poor? The answer is of course yes and no on all counts. Furthermore, “fixing” any one of the above problems will likely exacerbate the others. Nobody knew health care could be so complicated, obviously, but it is.<br />
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Real GDP per household (2.2 persons) stands around $120,000. Median income per household is half as much. We currently spend on average $24,000 per household per year on health care. If every household got a fairer share of GDP, perhaps health care would be less “not affordable”, but even in the most egalitarian scenario, health care would still be a huge financial burden. Medicare for All seeks to shift the health care burden from individual households to the nation. When the nation is faced with burdens of this type, it either goes into debt or cuts budgets. Debt of this magnitude spells bankruptcy down the road, and budget cutting translates into Rationing. Pick your poison.<br />
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But maybe we can ration wisely. Maybe we can replace volume with value. Maybe. Either way, when volumes for one service line go down, another service line seems to miraculously become more popular. If we force all service lines to cut down on volume, prices per unit will inexplicably start soaring to keep the topline steady. Then how about combining nationalized health care financing with price controls, as all Medicare for All bills are suggesting? After all, this is working well for Medicare, no? Yes, it is working for Medicare, because hospitals and doctors can charge the difference to private insurers. If there are no private insurers, hospitals and doctors will need to cut their costs. How do most firms cut costs? By letting employees go and/or reducing their salaries.<br />
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Over <a href="https://www.theatlantic.com/business/archive/2018/01/health-care-america-jobs/550079/?utm_source=atltw" target="_blank">16 million</a> Americans are currently working in the health care industry. If you want to cut that mythical 30% that is presumably waste, I can guarantee in writing that before one wasted piece of paper is eliminated, 6 million people will be out of work. In all fairness, a couple of the more radical Medicare for All proposals include income replacement and “retraining” for a few hundred thousand health insurance industry workers envisioned to be displaced, which amounts to a few drops in the disaster bucket. Such massive unemployment will wipe out entire communities, not to mention the stock market, pensions, retirement savings, tax revenues, and safety net budgets. It may also deal the long overdue coup de grâce to the struggling American middle class.<br />
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In a service economy, which is what all progressive minds are glorifying now, if you cut spending on services, you shrink the economy, with all attendant consequences. And no, having more money in your pocket to buy more crap from China does not improve the situation one bit. The supreme irony is that when we add the resultant financial aid for those who will lose their health care jobs, and the many more affected by the ripples of our trimmer health care expenses, we will end up precisely where we started, if we’re lucky, which is not very likely. The point here is not to bash Medicare for All plans. The point is to highlight the magnitude of what is discussed. By comparison to Medicare for All bills, Obamacare was just minor tinkering, and look where it got us.<br />
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There are only four countries in the world, including our own, that have a GDP greater than our annual health care expenditure. Restructuring health care in America is like restructuring the entire economy of, say, France or the United Kingdom, and then some. The United States is the third most populous country after China and India and has the greatest influx of new immigrants each year. Pointing to how great the Singapore model is working, or how quickly Taiwan transformed its health care system is, forgive me, laughable. If we learn one thing from the Obamacare escapade, it should be that in health care, nothing, absolutely nothing, scales as predicted on paper.<br />
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Finally, as hard as it may be for you these days, please remember that smart people, with yards of skin in this game, may disagree with your preferred solution, not because they are greedy, not because they hate poor people, not because they can’t do the math, not because they are evil, and not because they are deplorable or crazed Marxists. So, please, get off your soapbox (I certainly did), look reality in the face without fear or prejudice, start listening to ideas that make you uncomfortable, and understand that pontificating about Medicare for All is as useful as bloviating about free-markets.Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com8tag:blogger.com,1999:blog-3503957686158274288.post-44402170351465526482019-02-20T09:41:00.000-06:002019-02-20T09:41:38.235-06:00The Bonfires of Health Care<div class="separator" style="clear: both; text-align: center;">
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Let’s burn health insurance down. Greedy corporate bastards should burn. Big Pharma and big hospitals should probably burn too. You know who else is really, really, bad? Wall Street. Let’s burn the banks. And let’s burn Big Tech and the entire Silicon Valley cartel. Let’s also burn Big Agribusiness that’s making us fat and sick. And let’s burn the Oil companies that are destroying the planet, and let’s burn the automakers too. Heck, let’s burn all the globalist billionaires and while at it, let’s burn the White House. Let’s have a cathartic bonfire of all things we passionately hate.<br />
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The “scorched earth” military strategy was tried and found true time after time throughout recorded history. Unfortunately, the Geneva Convention banned this useful practice a few decades ago. Not to worry though, the aficionados of all burning things discovered a modern version of the same: the “scorched economy”. Like General Sherman marching resolutely to the sea, the warriors against all things evil are marching from election to election on what will hopefully soon be the ashes of the Great American Economy, and from those ashes the brotherly, egalitarian and perfect in every way, Phoenix shall rise. We simply cannot allow democracy to die in darkness. Hence, we will light the most magnificent bonfire the world has ever seen, and democracy will die in a glorious blaze second only to the Sun itself.<br />
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Health care is one fifth of the American Economy, and it is a highly combustible mixture of money, disease, pain, suffering, death, greed, lust, inequality, exploitation, theft, and even murder, along with every other sin known to mankind. It is a good place to start our illuminating destruction of evil. Health insurance companies cannot be allowed to exist. Pharmaceutical corporations must all die, and yes, hospitals should all be shuttered down. Heck, even doctors should be wiped off the face of the earth.<br />
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Our government, where we all come together to do good, should provide care to the sick, and preferably health to the healthy. Our government, by the people for the people, should invent new ways to prevent and cure disease. Health care should be given in the comfort of one’s home by artificially intelligent machines. Doctors and hospitals, like walls, are immoral 14th century implements, that can be easily replaced by moral technology, such as drones, sensors and other electronic “things”. Once nobody gets paid to do health care, because government, and because, you know, “technology”, health care will obviously be free. Problem solved. Move on.<br />
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To paraphrase Susan Sontag (mostly because one cannot write anything today without some reference to the Third Reich), 10 percent of any population is irrational, no matter what, and 10 percent is rational, no matter what, and the remaining 80 percent can be moved in either direction. In our case, the irrational 10 percent is alternately running for some elected office or serving on expert TV panels on everything, from fighting ISIS to fighting cancer, largely based on ability to quickly skim through Wikipedia articles. And when Medicare for All is deemed necessary to avert climate change, according to a recently introduced House resolution, one is forced to wonder if a Dodo Bird in Every Pot will be the winning electioneering slogan of our times.<br />
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Health care according to many well-intentioned people should be a “Right”. Americans have many such Rights enshrined in our Constitution, and the Right to health care seems to fit the bill. We have the Right to free speech for example. Is my Right to free speech exercised the same as, say, Jeff Bezos’s Right to free speech? We all have the Right to Assistance of Counsel if accused of a crime. Is an assignment to a public defender, the same as being able to hire Alan Dershovitz? We have a Right to not be assessed excessive bail. Do you have any idea how many people languish in jails for lack of $50 to post bail? Declaring health care to be a Right is a cheap and very cruel form of demagoguery.<br />
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What if health care is not a Constitutional Right, but just a right to a free public service, like say K-12 education? American public education has the largest cost per capita, middling outcomes, rampant systemic inequality, underqualified and underpaid teachers, and a constant stream of flailing Federal initiatives to have no child left behind. Lots of “tech” though, in every failing, illiterate classroom, and more added every day, except in the posh schools of the rich. That’s what a free public service looks like when the foundation is broken. There is little reason to believe that free public health care will be different, once the evil private sector goes up in flames.<br />
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Here’s an interesting thought. Would you be surprised to learn that employer sponsored commercial health insurance is the most egalitarian health insurance system around? Do you know why? Because the “decision makers” are required to live within the decisions they make. Unlike salaries and taxation, when it comes to health insurance, the big powerful CEO gets the same exact plan that his secretary gets. Their interests are perfectly aligned in this case. Compare that to free public services, like health care and education, where decision makers are in no way obligated to live inside the “comprehensive” solutions inflicted on everybody else. Think about that. There may be a clue here on how to go about fixing many things in this country.<br />
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Once you are safely in orbit around the Washington DC swamp, you will never again have to send you children and grandchildren to a public school, never again have to shop for health insurance, never have to use public transportation, never have to worry about rent, utilities or anything else the “American people” worry about day and night. All the problems you pretend to solve are theoretical. Other people’s problems. Sure, you may be a very good person, genuinely wanting to bestow medical care on all Americans, but it’s not like your little kid is at risk of dying because you can’t afford an asthma inhaler. Theoretical problems tend to generate theoretical solutions. Theoretical solutions seldom work in practice.<br />
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Setting everything and everyone on fire and watching it all burn in a semi-religious exorcism of all that is and has been evil in America, is not the same as having your own plump derrière baptized by the flames.<br />
We who are about to be sacrificed in your <span class="vmod">self-aggrandizing</span> arsonist rituals, categorically refuse to fuel the bonfires of your fake revolution. Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com2tag:blogger.com,1999:blog-3503957686158274288.post-17614906935696915922018-02-03T15:12:00.000-06:002018-02-03T15:12:38.993-06:00Ambergan Prime<div class="separator" style="clear: both; text-align: center;">
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Dear primary care doctor, Jeff Bezos is about to devour your lunch. All of it. And then he’ll eat the table, the plates, the napkins and the utensils too, so you’ll never have lunch ever again. Oh yeah, and they’ll also finally disrupt and fix health care once and for all, because enough is enough already. Mr. Bezos, it seems, got together with two of his innovator buddies, Warren Buffet from Berkshire Hathaway and Jamie Dimon from J.P. Morgan, and they are fixing up to serve us some freshly yummy and healthy concoction.<br />
Let’s call it <a href="https://www.reuters.com/article/us-amazon-healthcare/amazon-berkshire-jpmorgan-partner-to-cut-u-s-healthcare-costs-idUSKBN1FJ1NF" target="_blank">Ambergan</a> for now.<br />
<br />This is big. This is huge. It comes from outside the sclerotic “industry”. And it’s all about technology. The founders are no doubt well versed in the latest disruption theories and Ambergan will be a classic Christensen stealth destroyer of existing markets. When the greatest investor that ever-lived combines forces with the greatest banker in recent memory and the premier markets slayer of all times, who happens to be the richest man on earth, all to bring good things to life (sorry GE), nothing but goodness will certainly ensue.<br />
<br />Everybody inside and outside the legacy health care industry is going to write volumes about this magnificent new venture in the coming days and months, so I will leave the big picture to my betters. But since our soon to be dead industry has been busy lately bloviating about the importance of good old fashioned, relationship based primary care, perhaps it would be useful to understand that Ambergan is likely to take the entire primary care thing off the table and stash it safely in the bottomless cash vaults of its founders. It’s not personal, dear doctor. It’s business. Ambergan will be your primary care platform and you may even like it.<br />
<br />I am not sure what Mr. Buffet is contributing to this venture, other than cash and the warm bodies of his employees to pilot the venture. As to Mr. Dimon, he could probably run a modern analytics-based, risk-assuming health management entity, a.k.a. insurance company, while blindfolded and with both hands tied behind his back, so he may be useful in the short term. Let’s face it though, the most interesting actor here is Mr. Bezos and his Amazon platform of everything. Whatever else happens, it is probably safe to assume that within the next ten to twenty years, most people will be getting much expanded primary care services directly, and almost exclusively, from Amazon.<br />
<br />Amazon is a transactional platform, where people buy and sell things that Amazon does not make, and often does not even stock. With its more recent forays into TV, movies and music, Amazon also has some experience selling, mostly subscription based, services to consumers. As strange as it may sound though, most <a href="https://www.forbes.com/sites/greatspeculations/2017/10/27/amazon-posts-solid-quarter-as-aws-drives-top-line-growth-profits/#297321f74745" target="_blank">Amazon profits</a> come from a very different source. Amazon Web Services (AWS), a computing platform (cloud) service, mostly for businesses and governments is a modest part of Amazon revenues, but a huge contributor to its profits. This lay of the Amazon land practically begs for a little cross pollination, and health care may very well be the ideal vehicle for that.<br />
<br />Cloud services like AWS are essentially eliminating inhouse professionals and expertise in maintaining the basic infrastructure of computing, outsourcing it all to Amazon. Rings a bell? You can almost see the Amazon ads for its primary care services, telling hospitals that they should concentrate on their core business, which is cutting people open and stitching them back together, and leave routine care to Amazon’s primary care platform, expanding or shrinking just in time to match organization demands, with guaranteed uptimes of 99.99999%, and so forth. And you can almost see the direct to consumer ads too, can’t you? Sure you can. You know you can.<br />
<br />A few days ago, before the Ambergan announcement sent the health care markets into a tailspin, Amazon hired a <a href="https://www.cnbc.com/2018/01/19/amazon-hired-seattles-martin-levine-from-iora-to-add-to-health-group.html" target="_blank">top doctor</a> from one of those trendy primary care corporations that like to misrepresent themselves as Direct Primary Care (DPC). People speculated that Mr. Bezos, who previously invested in another failed DPC organization, may be ready to try his own hand at fake DPC for his own employees. Meh… It didn’t sound right to me, because with or without Ambergan, the Amazon stars were already aligning towards a massive thrust into health care, from the bottom up, as any good disruptor usually does.<br />
<br />A few weeks ago, Amazon offered us an opportunity to invite Jeff Bezos into our bedroom. No, he won’t interfere with anything. You won’t even know he’s there. He’ll just sit quietly beside your bed and watch you sleep, until you ask for something, if you do, and if you don’t, that’s fine too. It’s called <a href="https://www.theverge.com/2017/9/28/16378472/amazons-echo-spot-camera-in-your-bedroom" target="_blank">Echo Spot</a> and other than being unusually cute, the camera/microphone device that looks a little like an old-fashioned alarm clock, is just another extension of the Alexa line of surveillance/service products that run your home and your life, which is precisely what an ideal primary care doctor is supposed to do, i.e. keep you healthy, where health is <a href="http://www.who.int/governance/eb/who_constitution_en.pdf" target="_blank">defined</a> as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”. <br />
<br />You will subscribe to Ambergan Health. You will be monitored by Alexa in your home and maybe a future tiny Echo will let Alexa go outside with you. Perhaps they’ll throw Apple a crumb here to keep an eye on you when you leave your home, although it’s becoming increasingly unclear why you should. When you feel sick, you will summon a doctor on your Echo screen, and eventually he will appear preemptively before you get inconvenienced by any symptoms. You will be examined, diagnosed, treated and monitored in your home. And this should take care of most needs of most people most of the time. Not only is this a good start, but it’s a foundational step, and a perfect place to practice, because you can’t cater to complex needs if you have no idea how to care for simple needs.<br />
<br />Will there be room for marginal plays in drug pricing and maybe devices or exclusive contracting with delivery systems, as most experts (who drove health care into the ground) seem to think? Maybe, but negotiating lower prices for bulk purchasing is neither unique nor disruptive. It does sound like Ambergan will begin by deploying its services to its own employees, but make no mistake, this cannot be about creating yet another middling scheme for self-insured employers. If that’s all Ambergan is, there will be no innovation and no disruption. This must be about the entire health care market. This must be about doing to health care what Amazon did to retail. Amazon didn’t kill retail by restricting consumer choice to idiotic narrow networks of starving suppliers. That’s the Walmart model. Amazon decimated retail in precisely the opposite way. This is a business venture gunning for large market shares, and yes, I know it’s not seeking profits right now, but the entire Amazon retail bonanza started without profit and it remains mostly so to this day.<br />
<br />If you’re a primary care doctor, soon you will be able to have your own little storefront on Amazon, instead of or in addition to some strip mall or non-descript medical building. You will have to provide specifications for your services and cash will be king. Remember those new interstate licensing compacts? That will help here and so are the ever more relaxed telehealth rules and regulations. How about the recent rise in burned out doctors and cash practices? It’s almost like this was meant to be.<br />
<br />For the initial enterprise offering, substitute doctor farm for server farm and you get the AWS of medicine. For the end result, add another layer to the AWS, and substitute each doctor in the farm for say, detergent or movie, and you get the grand idea. Since everybody is shopping for substitutable services, this is the perfect insertion of the high-volume retail model into the high-profit AWS model.<br />
<br />Ambergan need not buy clinics, employ doctors or contract with systems, although it might start out that way. It just needs to get as many doctors as possible on the Amazon Health platform and have them compete, while people review and rate them into oblivion or success. The Amazon platform IS the network, and there will be terms, conditions, stars and promotions. There certainly are many legacy obstacles to overcome, and perhaps that is why Amazon couldn’t or wouldn’t go it alone. Throwing highly regulated markets wide open requires two strong lobbying arms, and a federal government willing to play fast and loose. The stars are indeed perfectly aligned for the first true disruption of our health care since 1965.Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com2tag:blogger.com,1999:blog-3503957686158274288.post-60235762655331851722018-01-16T13:16:00.000-06:002018-01-19T00:31:04.639-06:00The Kentucky Apocalypse <div class="separator" style="clear: both; text-align: center;">
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The Commonwealth of Kentucky, best known for its weirdly colored grass, fine bourbon and equestrian pageantry, is about to be destroyed by the Trump administration. Many will suffer and perhaps die because Kentucky obtained a Medicaid waiver to impose additional and often insurmountable hardships on poor people receiving their free health care from the State. Since all I need to know, I learned on Twitter, allow me to share with you some illuminating insights from the Twitterati.<br />
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The evil Republican Governor of Kentucky, Matt Bevin, is <a href="https://kentuckyhealth.ky.gov/SiteCollectionDocuments/Kentucky%20HEALTH%20Press%20Release.pdf" target="_blank">salivating</a> at the prospect of changing Medicaid as we know it, which obviously means that poor people and especially people of color will be suffering greatly under this plan. You really don’t need to know more, since this should be reason enough to mobilize the worried wealthy, who are tossing and turning in their featherbeds night after night, searching for ways to save the poor. For those who are neither worried nor wealthy enough to really care, here are the ominous provisions of the Kentucky racist, homophobic and xenophobic plan to change Medicaid (it is all these things because it was not only approved, but encouraged by the Trump administration, and we all know what that means).<br />
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The most egregious transgression in the <a href="https://kentuckyhealth.ky.gov/SiteCollectionDocuments/Kentucky%20HEALTH%20Demonstration%20Approval.pdf" target="_blank">Kentucky HEALTH</a> plan is the imposition of work requirements on Medicaid beneficiaries. The first thing that comes to my mind when they say “work requirements” is that sign at the entrance to Auschwitz saying that work makes you free. In Kentucky, the Republicans argue that work makes you healthy. Same thing. So, what are those monstrous work requirements? Medicaid recipients who are not children, who are not below the poverty line, who are not elderly, who are not pregnant, who are not disabled, who are not medically or mentally frail, who are not providing care to children or other disabled individuals, who are not experiencing hardships such as domestic abuse or homelessness or other disruptions in their lives, must spend approximately 4 hours a day in school (any school), training (any training), apprenticing, acquiring useful skills, volunteering in the community, searching for a job or actually working somewhere.<br />
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Wait, wait…. Don’t raise your eyebrows and don’t think or say anything. If you are reading this, you are most likely rich, likely white, well-educated and perhaps even male. Medicaid beneficiaries are none of these things. We all know that any of those endeavors could be truly insurmountable hardships for people who are poor, black or Hispanic, uneducated and female. We know that, because we are not racists, misogynists or just plain bigoted SOBs, like the Republicans running Kentucky and that insufferable man running the country (or so he thinks).<br />
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Besides, most Medicaid beneficiaries who don’t fall in the exempt categories are already working. The ones who don’t work, or study, or do anything beneficial for themselves or others, are experiencing circumstances beyond their control. Helping them gain control over their lives is not Medicaid’s job because health and wellbeing have nothing to do with socioeconomic circumstances. And even if Kentucky wanted to “nudge” people into, say, getting their GED by funding a special rewards account, the bureaucracy involved in tracking all sanctioned activities, all exemptions and special circumstances is just too daunting for “these people” to navigate. Trust me on this one, I read it straight from the keyboards of Hollywood celebrities and several current and former big health care executives.<br />
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The second affront to humanity in the Kentucky plan is to charge poor people premiums for health insurance. Not only that, but those who can’t pay the premiums may be kicked off Medicaid. Granted, the premiums range from $1 to $15 (in lieu of regular copays), and all the exemptions for ill health, frailty and poverty do apply here as well, but that still leaves a sizeable number of poor people who could be denied medical care just because they forgot to pay the monthly dollar twice in a row, or couldn’t afford the higher premium. These highly discriminatory practices targeting the poor are unheard of in other industries or even in the commercial segment of health care itself, where insurance premiums are largely voluntary.<br />
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To be fair to Kentucky, there is a mechanism by which people who did not pay their premiums on time can regain their Medicaid coverage, which brings us to provisions reminiscent of the Jim Crow days in the South. The Kentucky plan, you see, has a literacy provision for regaining access to care. This is obviously targeted at people of color and immigrants from what the GOP Leader calls “shithole” countries, which as every wealthy person in Bel Air knows, cannot read or write, as evidenced by the thumbprint (or large X, depending on the State) appearing on most Medicaid applications. I have zero doubt that the Attorney General of the State of California will be taking the depraved Governor of Kentucky, and the Trump administration that enabled him, to court, and I have no doubt that the 9th Circuit Court of Appeals will find in favor of justice and equality, as it always does.<br />
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Until then, it seems that some Medicaid beneficiaries in Kentucky may have to sit through torturous health literacy or financial literacy classes, where they teach boring stuff about how to deal with debt, how health insurance works and how one can navigate these treacherous waters. There is no mention of a test or anything at the end, but this still seems like an unwarranted and blatantly racist imposition on “these people”. Even more outrageous though is that Kentucky is providing incentives, which can be used to purchase gym memberships, for Medicaid beneficiaries to take other classes, such as chronic care management or nutrition or drug addiction coping skills. What do illiterate people, drug addicts and all “these people” need gym memberships for? It’s like telling them to “eat cake” ….<br />
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And on and on goes the Kentucky HEALTH plan, listing one offensive section after another. The problem with this plan, which will live in infamy until the Sun goes supernova, is the cold, heartless and blatantly racist assumption that people who need Medicaid are as capable of functioning in modern society as anybody else. It ignores decades of teachings. It ignores hundreds of years of slavery and Anglo Saxon colonialist supremacy. And it ignores basic Christian values, because Jesus didn’t just sit there giving classes on how to fish. He gave people fish, and it worked great for Him and for His followers, eventually. If you see yourself as the Lord and Savior of huddled masses, you will want to do what Jesus did. If you feel equal to people who need Medicaid, but perhaps a bit luckier at this moment, you will dismiss everything I wrote here as total bullshit.<br />
<br />Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com5tag:blogger.com,1999:blog-3503957686158274288.post-44356645291110574822017-12-26T09:29:00.001-06:002017-12-26T09:29:50.972-06:00The Power of Silicon Valley<div class="separator" style="clear: both; text-align: center;">
<a href="https://2.bp.blogspot.com/-mYJJWcuSeYo/WiggjjFO3pI/AAAAAAAABaY/OSIvZcJKvtUGiHDu2NxrH7-snLmmtmWVwCLcBGAs/s1600/Pied_Piper2.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 0em; margin-left: 0em;"><img border="0" data-original-height="1105" data-original-width="1365" height="161" src="https://2.bp.blogspot.com/-mYJJWcuSeYo/WiggjjFO3pI/AAAAAAAABaY/OSIvZcJKvtUGiHDu2NxrH7-snLmmtmWVwCLcBGAs/s200/Pied_Piper2.jpg" width="200" /></a></div>
A few weeks ago one man, named @jack, decided that millions of people will be allowed to use up to 280 characters when expressing themselves on Jack’s public square platform. One man decides how many letters each and every one of us, including the “leader of the free world”, can use when we talk to each other. Just like that. Nobody seemed the least bit perturbed by this notion. Another dude, named Mark, decided to ask people for <a href="https://www.theverge.com/2017/11/9/16630900/facebook-revenge-porn-defense-details" target="_blank">nude pictures</a> of themselves, so he can better protect them from the bad guys. We shrugged that off too. Then, in a most embarrassing exercise in public humiliation, our democratically elected representatives <a href="https://www.c-span.org/video/?436360-1/facebook-google-twitter-executives-testify-russias-influence-2016-election" target="_blank">begged</a> three slick lawyers representing these platforms to effectively regulate what people can say or see on “their” platforms. <br />
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So here we are, in the land of the free and the home of the brave, where Jack and Mark decide what you can or cannot say, and what you can or cannot hear or see. This, my friend, is the power of “platforms”. In the old days, it used to be that he who pays the piper calls the tune. In the artificially intelligent technology age there are no pipers. He who owns the pipe makes it play whatever the hell he wants it to play. And as <a href="https://www.axios.com/sean-parker-unloads-on-facebook-2508036343.html" target="_blank">Sean Parker</a>, a Facebook founder, elegantly put it, “God only knows what it's doing to our children's brains”. Perhaps God knows, but he is certainly not the only one who <a href="https://www.statnews.com/2017/11/14/smartphones-decline-teen-mental-health/" target="_blank">knows</a>, because these platforms are built with the explicit intent to get people <a href="https://www.prnewswire.com/news-releases/smartphone-addiction-creates-imbalance-in-brain-300558945.html" target="_blank">addicted</a> to and dependent on the platform.<br />
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Funded with cash from sexist pigs and harassers, <a href="https://techcrunch.com/2017/09/08/meet-the-tech-company-that-wants-to-make-you-even-more-addicted-to-your-phone/" target="_blank">a startup</a>, whose business model is to help other startups “hook” people on trashy little apps, is calling itself <a href="https://usedopamine.com/" target="_blank">Dopamine Labs</a>. “Dopamine makes your app addictive” is their promise. According to the website, they use AI and neuroscience to deliver jolts of dopamine that “don’t just feel good: they rewire the brain’s habit centers” of users to “boost usage, loyalty, and revenue”. “Your users will crave it. And they'll crave you”. At its rotten core, Silicon Valley is a drug cartel, a very clever and savvy cartel who managed to convince the world that its brand of drug addiction is actually good for you and either way, it’s inevitable.<br />
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But just getting billions of people on techno-drugs is obviously not the end game here. After extracting trillions of dollars from addicts who would rather go without food and medicine, than go without an iPhone X that costs more than a full blown top of the line computer, the Capos of Silicon Valley Inc. are now realizing that there is plenty more left to extract from the armies of zombies they are creating. "Because I'm a billionaire, I'm going to have access to better health care so ... I'm going to be like 160 and I'm going to be part of this, like, class of immortal overlords. [Laughter] Because, you know the [Warren Buffett] expression about compound interest. ... [G]ive us billionaires an extra hundred years and you'll know what ... wealth disparity looks like."<br />
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Ah, yes, health care, the final frontier. When <a href="https://www.reuters.com/article/us-usa-healthcare-cancer-costs/the-cost-of-cancer-new-drugs-show-success-at-a-steep-price-idUSKBN1750FU" target="_blank">Keytruda</a> (the Jimmy Carter drug) became available, it was considered too expensive at around $150,000, but times are changing. The FDA recently approved the immunotherapy drug <a href="https://www.healthline.com/health-news/concern-rises-over-price-tag-for-breakthrough-cancer-treatment" target="_blank">Kymriah</a> from Novartis with a price tag of $475,000, although Novartis says it could have charged more, presumably because this drug is a life saver of last resort for small children with cancer. Next, another CAR-T cell therapy cancer drug, <a href="https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm581216.htm" target="_blank">Yescarta</a> was approved by the FDA for adult cancer and Gilead Sciences priced it at only $373,000 a pop (that’s how value-based health care works). At this rate of innovation, it should not be too difficult to project a precise date for the emergence of that immortal class of overlords.<br />
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Developing personalized drugs, like immunotherapy, requires mountains of data from millions of people, and this is where the app-addicted public has a crucial role to play. Before the overlords can become immortal, we all need to “donate” our medical data, submit to experimentation, get sick and die, and yes, here and there a few lucky bastards will benefit from therapies their children will never be able to afford. Not surprisingly, Mr. Parker, the aspiring overlord, is now invested in an <a href="https://www.parkerici.org/about/#core-team" target="_blank">immunotherapy platform</a> to coordinate research, or something like that. But Mr. Parker is a diversified investor. He has a couple more platforms. One is there to save the world from the AIDS epidemic by providing support to the Clinton Foundation.<br />
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The other platform is designed to help us vote. Yes, vote. The guy who promises to show us what wealth disparity really looks like is building platforms, complete with little dopamine jolts and colored pictures of bananas, to teach us all about “civic engagement”, because according to <a href="https://www.recode.net/2017/2/1/14476462/civic-tech-organize-march-change-citizen-engagement-democracy-brigade" target="_blank">Mr. Parker’s venture buddy</a> “the tools we build in Silicon Valley represent the best hope for fixing our democracy”. Everything was just fine with “our democracy” until all investments in the Clinton Foundation came crashing down like a house of cards in one fateful night in November 2016, when the overlords were positively robbed by a dopamine-deficient populist mob. In a wholesome democracy, when you pay for a President, you’re supposed to get a President.<br />
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Of course “our democracy” has been “broken” in one way or another for upwards of two hundred and forty years, but I think we can all agree that “our democracy” today is less broken than “our democracy” in 1789. There is great utility though, in declaring something to be broken, especially something big and nebulous like “our democracy”, because such declarations are almost always followed by assertions that the diagnosticians of brokenness are uniquely positioned to become the fixers of all broken things. Our health care is broken. Our education is broken. Our justice system is broken. Our economy is broken. Our tax system is broken. Our infrastructure is broken. Our entire goddamn country is broken. Oh, what the hell, the entire freaking world is broken. And Silicon Valley is our only hope.<br />
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Silicon Valley has essentially only one product, a very versatile product indeed, but a single product nevertheless. Silicon Valley doesn’t actually make this product. They harvest it by casting gigantic computerized platforms and collecting everything caught in their digital nets, very much like <a href="http://www.imdb.com/character/ch0002106/quotes" target="_blank">Bubba’s shrimp</a>: “… shrimp is the fruit of the sea. You can barbecue it, boil it, broil it, bake it, sauté it. Dey's uh, shrimp-kabobs, shrimp creole, shrimp gumbo. Pan fried, deep fried, stir-fried. There's pineapple shrimp, lemon shrimp, coconut shrimp, pepper shrimp, shrimp soup, shrimp stew, shrimp salad, shrimp and potatoes, shrimp burger, shrimp sandwich. That- that's about it.”<br />
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Information is the fruit of humanity. You can boil it and broil it to intimidate doctors and manipulate people, to extract immortality (and cash) for you and yours, thus fixing health care. You can sauté it and puree it to terrorize teachers and crush the minds of small children, to generate armies of drones (and cash), thus fixing education. You can sift it, scramble it, steam it, and serve it to nullify judges and juries, to protect property rights (and cash), thus fixing justice for all. You can slice it, dice it, can it and ban it as needed to keep all that cash flowing, thus fixing “our democracy”.<br />
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Remember Jack and Mark? Unlike Mark, Jack is allowing users to remain anonymous on his platform. On Jack’s platform, if you see a blue checkmark next to the name of someone, you can reasonably conclude that you are talking, or rather listening, to a “real” person, instead of, say, a Russian bot. Over time, it became clear that according to Jack, real people are those who are rich, powerful, or have enough “followers” to influence public opinion. Everybody else on Jack’s platform is shrimp. But Jack is an honorable man.<br />
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Jack is fixing “our democracy” by revoking the coveted blue checkmarks from <a href="http://time.com/5026886/twitter-verification-policy-richard-spencer-jason-kessler/" target="_blank">some white supremacists</a>. Presumably Messrs. Spencer and Kessler are no longer real. On the other hand, the multitude of rich and powerful rapists, pedophiles and garden variety perverts, are still very real according to Jack’s superior morality framework. Mark is fighting the good fight on behalf of “our democracy” in a different way. His platform is pursuing the enemy from without, by tracking enemy advertising paid for with rubbles, not yuans or ryials or euros or dinars or wons or yens, only rubbles, because the legendary KGB masterminds always pay in rubbles (with a return address of <span lang="RU" style="font-family: "calibri" , "sans-serif"; font-size: 11.0pt;">Моско́вский Кремль</span><span lang="RU" style="font-family: "calibri" , "sans-serif"; font-size: 11.0pt;"> </span><span style="font-family: "calibri" , "sans-serif"; font-size: 11.0pt;">103073</span>) for all their international spying needs. <br />
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Now that “our democracy” is all nice and fixed, the Cartel can apply lessons learned to “democratize” medicine and fix “our health care” too. Health care is rife with old people, old fashioned ideas, and it is scattered all over the place. Nothing a big platform, dripping with dopamine jolts, can’t fix though. Uber for health care. Facebook for health care. Health care is like the iPhone. Information “blockers” will be prosecuted (this one is for real). Structured data. Metadata. e-Visits. Remote monitoring. Predictive analytics. Population management. This stuff is just begging for a medical platform with hundreds of millions of patients “sharing” their health, their illness and their medical experience with each other, with doctors, researchers and of course the platform overlord and his customers.<br />
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You will share your symptoms, your concerns, your treatments, your outcomes. You will “like” CT scans, “star” lab results, and rate doctors, heath insurers, drugs or devices. Perhaps they’ll have a “dislike” button too. You will post videos of your colonoscopy and maybe live stream your telehealth session. You will ask for advice from patients like you and “clap” for the ones you like best. Your cancer remission could go viral. The platform will ensure you see things you care about and shield you from unsettling content. Before you know it, you will feel compelled to check your “health” every 5 minutes, and certainly when your iPhone vibrates with new images from Bertha’s mammogram, or when your Apple “watch” beeps with updates from your <a href="https://www.cnbc.com/2017/11/30/apple-coo-jeff-williams-heart-study-interview.html" target="_blank">fantasy clinical trials league</a> or with an urgent reminder to record your pre-hypertension medication intake so you can receive the coveted 20% discount on Christmas fruit cakes at <a href="https://www.statnews.com/2017/12/03/cvs-acquires-aetna/" target="_blank">CVS</a> just in time.<br />
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Platformized health care will be cheap, convenient and readily available. And just like communications, shopping, porn, and news, it will be fake, manipulative, addictive and designed to “protect consumers” instead of benefiting citizens, or patients in this case. Jack doesn’t converse with his buddies on Twitter. Mark doesn’t get his news from Facebook. Jeff doesn’t shop for deals on Amazon. And none of them will be getting medical care from a phone or a watch. You will. Your children will too.<br />
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Facebook <a href="http://thehill.com/policy/technology/363089-facebook-introduces-messenger-kids" target="_blank">just introduced</a> a “safe” messenger for children under 13. Parents are supposed to set this up for their babies. Many will do just that. And experts will be exalting the thoughtfulness of the Cartel for creating a less toxic version, suitable for hooking children on the product. Why would a six year old need to message his “friends” online, instead of chasing them in the backyard? Why would a three year old need to watch sickly <a href="https://medium.com/@jamesbridle/something-is-wrong-on-the-internet-c39c471271d2" target="_blank">YouTube videos</a> prepared exclusively for toddlers, instead of playing with alphabet blocks on the carpet? Why would the most powerful 71 year old man in the world self-destruct on Twitter instead of running said world? Why can’t you read an entire book anymore? Such is the power of the Silicon Valley Cartel.Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com0tag:blogger.com,1999:blog-3503957686158274288.post-4390662687104004202017-08-12T08:45:00.000-05:002017-08-12T08:45:10.292-05:00Only Trump Can Go To Single-Payer<div class="separator" style="clear: both; text-align: center;">
<a href="https://3.bp.blogspot.com/-IjMgFwPX3WU/WY8Fe6hH92I/AAAAAAAABZM/gFvg35ubDEs3tk1qHg8gSr3-J-dCDdxjQCLcBGAs/s1600/Nixon_Mao_1972-02-29.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="457" data-original-width="590" height="154" src="https://3.bp.blogspot.com/-IjMgFwPX3WU/WY8Fe6hH92I/AAAAAAAABZM/gFvg35ubDEs3tk1qHg8gSr3-J-dCDdxjQCLcBGAs/s200/Nixon_Mao_1972-02-29.png" width="200" /></a></div>
There is an old Vulcan proverb saying that only Nixon could go to China. Only a man who used to work for Joseph McCarthy could set America on a path to better relations with a virulently Communist country. A few years after Nixon went to China, Menachem Begin, the Israeli Prime Minister who represented people believing that the state of Israel should stretch from the Nile to the Euphrates, gave Egypt back all the lands conquered in a recent war and made a lasting peace with Israel’s largest enemy. They said back then that only Begin could make peace with the Arabs.<br />
<br />Today, I want to submit to you that only Trump can make single-payer health care happen in this country. Only a billionaire, surrounded by a cabinet of billionaires, representing a party partial to billionaires, can make that hazardous 180 degrees political turn and better the lives of the American people, and perhaps the entire world as a result. Oh, I know it’s too soon to make this observation, but note that both Mr. Nixon and Mr. Begin were deeply resented (to put it mildly) in their times, by the same type of people who find Mr. Trump distasteful today. The liberal intelligentsia back then did not have the bona fides required to cross the political chasm between one nation and its ideological enemies, or as real as death immediate foes. The liberal intelligentsia today lost all credibility in this country when it comes to providing a universal solution to our health care woes.<br />
<br />Free health care (and free college) are not solutions. These are rabble rousing slogans to gin up the vote, slogans that end up in overflowing trashcans left in ballrooms littered with red white and blue balloons after everybody goes home to get some sleep before the next round of calls to solicit funds from wealthy donors for the next campaign. Providing proper medical care to the American people is a monumental enterprise that engages tens of millions of workers from all walks of life, every second of every day, in every square mile of habitable land, littered with the hopes and fears of hundreds of millions of invisible men, women and children who call this great country their home. This is not something that can be made free. Nothing is free in our times, not even sunshine and fresh air.<br />
<br />For the jaded, the cynically inclined, and those who are simply too afraid to jump off this cliff, and therefore argue that single-payer is not politically feasible, I have a simple question. Did you all think a couple of years ago, that a President Trump is politically feasible? Okay then. Here is what I believe could be a relatively plausible scenario enabling this one-of-a-kind administration to use its unconventional political capital (if you can even call it that) to get us on the road to making health care great again, greater than ever before.<br />
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Step 1: Disaster</h4>
The current system, held together with string and duct tape must undergo a seismic shock, preferably a moderate shock and one that does not involve war and famine. The way things look now, the most likely implosion will be the Obamacare individual market. If the Trump administration holds back ransom money from insurance companies (a.k.a. CSRs), or engages in other mischievous behavior, and the individual mandate is not enforced, we may very well have a minor disaster on our hands. In addition, the President's Commission on Combating Drug Addiction and the Opioid Crisis is requesting that the President declare the opioid epidemic a national public health emergency. Put these two together and you see how lots of people are, or will shortly be, in dire need of medical services not currently available to them via existing “insurance” channels.<br />
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Step 2: Relief</h4>
The opioid crisis will need much more than providing care for its current victims, but we will need a coordinated effort to provide all necessary medical services to people addicted to opioids who are uninsured, or whose insurer is refusing to pay for the extensive programs needed for recovery. People who were able to afford insurance under Obamacare without, or with minimal, subsidies and are now left hanging to dry will also need a solution, and if they are sick, they will need immediate relief. This would be the perfect time to cut through the red tape and institute the Disaster Relief and Emergency Access to Medicare (DREAM) program. The DREAM will open Medicare to the victims of Obamacare and the victims of the opioid epidemic. This will be put in place as a temporary disaster response program, subject to extension of course, until a more permanent solution can be found. I doubt too many people in Congress could vote against such measure.<br />
<h4>
Step 3: The DREAM</h4>
No matter how short lived, all government programs including temporary ones need rules and regulations to execute now, and to be replicated in future emergencies as needed. Besides, any respectable bill needs more than just a title. How do we define opioid addiction? How do we define Obamacare victim? How do they sign up? What do they get? How much will it cost?<br />
<br /><b><u>Opioid Crisis</u></b><br />
<ul>
<li>Congress will appropriate $45 billion for this program for a period of five years to cover administrative costs, medical costs and program analysis costs. </li>
<li>Emergency funding will be provided to Federally Qualified Community Centers (FQHCs) to set up a process for opioid addiction screening. FQHCs are non-profit clinics, funded by the Federal government to serve low income populations regardless of ability to pay. All physicians and staff are salaried. The funding will be administered by the Health Resources and Services Administration (HRSA) and defined by the Secretary of Health and Human Services (HHS).</li>
<li>Any American citizen or lawful permanent resident will be eligible to access any FQHC and undergo opioid screening as specified by the Secretary at no cost. Individuals eligible for relief, based solely on clinical criteria, will need to provide information about their insurance status. Upon receipt of consent from the individual or legal guardian if the screened individual is a minor, eligibility results and insurance information will be sent from the FQHC to CMS for enrollment in the DREAM program. </li>
<li>If the eligible person (EP) is currently covered by commercial insurance, CMS will contact the EP’s insurance plan and require that the plan contacts the EP or legal guardian and obtains proper consent to transfer the EP’s coverage to the DREAM program. Following EP consent, Medicare will become the primary payer for the EP. Medicare at its sole discretion may discontinue eligibility for the EP and the commercial plan must reinstate coverage for the EP at that time. All subsidies paid by the Federal government to the insurance plan, if any, will be paid into the Medicare trust fund for the duration of DREAM participation.</li>
<li>The EP will pay to Medicare premiums equal to the last monthly amount the EP paid to the commercial plan. Medicare will cover all opioid related services with zero deductible and zero copay. For other services the EP deductible and copays will be equal to those of traditional Medicare beneficiaries (parts A, B and D). Medicare will end DREAM eligibility for an EP who missed 3 consecutive monthly payments.</li>
<li>If the EP is insured, or eligible to be insured, through Medicaid or any other public program, Medicaid or any other public program, will transfer into the Medicare trust fund estimated monthly premiums as calculated by the Secretary for the duration of DREAM participation. Medicaid will become the secondary payer for EPs previously enrolled, or eligible to be enrolled, in Medicaid.</li>
<li>If the EP is uninsured and not eligible for public insurance, the EP will be enrolled in Medicare (parts A, B and D), under the same terms as beneficiaries 65 years or older for the duration of DREAM eligibility, except that all opioid related services will be covered with zero deductible and zero copay.</li>
</ul>
<b><u>Obamacare Crisis</u></b><br />
<ul>
<li>Congress will appropriate $45 million for this program for a period of five years to cover program administration, evaluation and analysis. All other program costs, if any, will be absorbed by CMS budgets.</li>
<li>Any American citizen or lawful permanent resident who is not offered employer sponsored insurance, and is not eligible for Medicaid or another public insurance plan, and is not eligible for Federal subsidies on the Obamacare exchanges equal to at least 50% of total costs of the current benchmark plan, or resides in a county where no Obamacare plans are available on the exchange on the first day of the open enrollment period, will be eligible to enroll in Medicare parts A, B and D, at an annual rate of average Medicare spending per beneficiary (MSPB), adjusted for EP age.</li>
<li>The Secretary shall publish a list of DREAM premiums for three age bands, 0-21, 22-45, 46-64, no later than one month before the first day of open enrollment for the Obamacare exchanges. All DREAM rates will be assessed and billed for each individual EP. No family rates will be available and no Federal subsidies will be given to DREAM enrollees.</li>
<li>The EP, or a legal guardian if the EP is a minor, is responsible for premium payments to Medicare. EP deductible and copays will be equal to those of traditional Medicare beneficiaries (parts A, B and D). Medicare will end DREAM eligibility for an EP who missed 3 consecutive monthly payments.</li>
<li>For each program year the Secretary shall conduct and publish comparative analyses of Federal spending on Obamacare exchange enrollees and DREAM program enrollees to inform Congress and the public on the merits of each program.</li>
</ul>
<h4>
Step 4: Consequences</h4>
See? Wasn’t that bad now, was it? Defining the program is relatively easy and the above is just an abbreviated example. Other details will need to be added, removed or changed, but the main idea here is to open Medicare in the short term to people who are hurting and are underserved by the commercial health insurance markets. There will of course be consequences. First, the Obamacare exchanges will most likely go bust, and we will have to expand the DREAM to allow enrollment of people who will bring their subsidies with them. Second, employers may decide to fund Medicare premiums instead of dealing with health insurance in house. Third, the folks who don’t qualify for the DREAM program may start chomping at the bit, seeing how DREAMers get to choose pretty much everything without breaking the bank. <br />
<br />Yes, yes, I know. I’m being too clever by half, but surely someone who professes to be the voice of the forgotten men and women, could see his way clear to make this happen. It will, after all, lead to a complete repeal and replace of Obamacare. And for all timid liberals enamored with the poetry inscribed at the feet of Lady Liberty, let’s help the President erect a statue of liberty at the gates to Medicare. Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com0tag:blogger.com,1999:blog-3503957686158274288.post-4693472755599151622017-08-03T14:03:00.000-05:002017-08-03T14:03:11.833-05:00Is Single-Payer the Right Payer?<div class="separator" style="clear: both; text-align: center;">
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As is customary for every administration in recent history, the Trump administration chose to impale itself on the national spear known as health care in America. The consequences so far are precisely as I expected, but one intriguing phenomenon is surprisingly beginning to emerge. People are starting to talk about single-payer. People who are not avowed socialists, people who benefit handsomely from the health care status quo seem to feel a need to address this four hundred pound gorilla, sitting patiently in a corner of our health care situation room. Why?<br />
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The all too public spectacle of a Republican party at war with itself over repealing and replacing Obamacare is teaching us one certain thing. There are no good solutions to health care within the acceptable realm of incremental, compromise driven, modern American solutions to everything, solutions that have been crippling the country and its people since the mid-seventies, which is when America lost its mojo. To fix health care, we have to go back to times when America was truly great, times when the wealthy Roosevelts of New York lived in the White House, times when graduating from Harvard or Yale were not cookie cutter prerequisites to becoming President, times when the President of the United States conducted meetings while sitting on the toilet with the door open and nobody cared. Rings a bell?<br />
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Single-payer health care is one such bold solution. Listening to the back and forth banter on social media, one may be tempted to disagree. We don’t have enough money for single-payer. Both Vermont and California tried and quit because of astronomic costs. Hundreds of thousands of people working for insurance companies will become unemployed. Hospitals will close. Entire towns will be wiped out. Doctors will become lazy inefficient government employees and you’ll have to wait months before seeing a doctor. And of course, there will be formal and informal death panels. Did I miss anything? I’m pretty sure I did, so let’s enumerate.<br />
<h4>
Single-payer is going to bankrupt the nation</h4>
We have $3 Trillion in our health care pot right now. We have 325 million Americans, men women and children of all ages. First grade arithmetic says we have almost $10,000 per year to spend on each American, the vast majority of whom is either young or healthy or both. For comparison, Medicare spends on average around $12,000 per year for the oldest and sickest population. Last year a platinum plan for a 21 year old cost less than $5,000 per year and this includes the built in waste of private health insurance. So please, tell me again how we can’t afford to pay for everybody’s health care needs at a Medicare actuarial level, which is slightly less than commercial platinum.<br />
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And no, we need not increase taxes either. You keep paying what you’re paying. Your employer keeps paying what it is paying. The government keeps paying what it’s paying. But instead of dispersing all that cash to all sorts of corporate entities standing in line with their golden little soup bowls ready to catch the last drop, we put it all together in one big beautiful barrel, and pay for care directly to those who provide care - one pool, one budget, and one accounting system for all. This is a national endeavor. It is irrelevant that Vermont failed and California bungled the whole thing. Do you think California and Vermont could afford to provide for their own armies, air force and navies? I didn’t think so.<br />
<h4>
Single-payer will cause millions to lose their jobs</h4>
Hundreds of thousands of people work for commercial insurers. Claims need to be processed, money needs to be collected and paid out, books need to be kept, customers and service providers need to be supported, computers have to be maintained, audits need to be performed, contracts need t be managed, lots and lots of labor and lots and lots of decently paying jobs. Do you have any idea how Medicare administration works? Or are you under the impression that Medicare runs itself with no human labor? Have you ever heard of Noridian or Cahaba? No? Then I respectfully suggest that you should refrain from opining about the horrors of single-payer.<br />
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Medicare is run by private administrative contractors called <a href="https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/What-is-a-MAC.html" target="_blank">MACs</a>, each assigned to specific geographical regions and specific portions of Medicare services. In addition to the MACs there are slews of functional contractors that specialize in one or more types of supporting services to the MACs. These are private entities no different from Boeing, Lockheed Martin, Hewlett-Packard, Booz Allen Hamilton, GE and many more. They employ thousands of people and if Medicare becomes our single-payer, there will be more MACs, more functional contractors, and hundreds of thousands more private employees.<br />
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That said, it stands to reason that consolidation from many payers to one, will introduce some efficiencies and the total number of available jobs will be reduced, so here is a solution to this potential problem. Currently all insurers including Medicare and Medicaid are offshoring claim processing and in the case of private insurers other functions, including clinical, as well. Change the regulations and bring those jobs back home where they belong in the first place, and offer them to those who will lose their commercial insurance jobs. This administration is especially well positioned to effect such changes to CMS regulations.<br />
<h4>
Single-payer will take away our freedom</h4>
What if Sam’s Club only carried General Mills cereal and Costco only carried Kellogg’s? What if you had a Costco membership but stopped by another store to pick up some Cheerios and were charged ten times as much as Sam’s Cub sells it for? No it’s not exactly the same, but you get the idea. Would you consider this to be freedom of choice? Or would you rather have one big huge market where all brands sell their products directly to you competing against each other? The latter is how single-payer could work. Freedom to shop for an insurance plan is freedom to shop for your preferred rationing scheme and ultimately your own flavor of death panel.<br />
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Traditional Medicare allows you to choose your doctor and your hospital and it pays for all medically necessary services. No commercial plan can say the same unless it’s one of those platinum things nobody can afford. Traditional Medicare can do that because it sets the prices for all health care providers, instead of negotiating with a few preferred vendors. Medicare can take these liberties because it’s big enough and because it’s a Federal program. But Medicare doesn’t pay for everything. That’s why most seniors purchase supplemental plans if they can afford them, and if they are poor enough, Medicaid kicks in as the secondary payer. Being the safety net for the fixed price single-payer should be the sole function of a new and federally administered Medicaid. <br />
<h4>
Single-payer will destroy our health care</h4>
I think American medicine is the best in the whole world. Not because it’s expensive and not due to the corrupt ways in which it’s being financed, but in spite of these things. Finding a better way to pay our medical bills has nothing to do with the quality of American medicine. The concern here is that once Medicare becomes the only game in town, it will unilaterally cut its fee schedules and all hospitals will go bankrupt, all doctors will be driven into homelessness, no new drugs will be developed and we’re all going to die. On the other hand, the Federal government is the sole purchaser of aircraft carriers, stealth bombers, and weaponry of all types. How cheap are those items? How powerless and decrepit is that industry?<br />
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Precisely because of the lessons learned from the mighty military industrial complex, single-payer reform will have to change three things in the structure of our current so-called health care system. First, all hospital consolidation and acquisition of physician practices will need to be rolled back. Second, petty regulations, vindictive carrots and sticks strategies and crude attempts at social engineering by clueless bureaucrats, will have to be dismantled brick by brick. Third, physicians will need to form a union of independent small contractors to negotiate fees and terms alongside the already powerful hospital associations. I have been a longtime proponent of a <a href="http://onhealthtech.blogspot.com/2015/01/why-physicians-must-unionize.html" target="_blank">physicians’ union</a>, even in our current system, to serve as check and balance to corporate greed and government arrogance. A single-payer system cannot and will not succeed without unionized independent physicians. <br />
<h4>
Single-payer is not the American way</h4>
We have been conditioned by large corporations to think that what they do to us is the nature of free-markets, and thus the only way to achieve prosperity for all. I would submit (for the millionth time) that what <a href="https://techcrunch.com/2017/07/29/apple-removes-vpn-apps-from-the-app-store-in-china/" target="_blank">Apple</a> is doing to the world has nothing to do with Adam Smith’s free markets. The actors in classic free markets must be approximately equal. When sellers are so big that they need artificially intelligent tools to even notice the existence of buyers, there is no free market. When the price of products sold exceeds the lifetime incomes of most buyers, there is no free market. When no one can muster enough moral turpitude to publicly say that if you’re poor, your babies should die, there is no free market. There is no free market and there can be no free market in health care.<br />
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There can however be competition. Perhaps not in sparsely populated areas, and perhaps not for highly complex procedures, but there can be competition for most health care services in most places. The uniform single-payer price should be set so that innovative hospitals and entrepreneurial physicians can thrive by charging less and those holding themselves in higher than usual esteem, or those who choose to provide luxury, are free to charge more. If all sellers are small enough, and if the standard single-payer price is fairly negotiated, we will have a real market, because people will shop to save money (in a rewards system like credit cards have) and some will shop for status and vanity.<br />
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Will there be a role for private insurance? There could be, but private insurance should not be allowed to cover any services covered by the single-payer because that would take us back to where we are today. Let private insurance cover stuff nobody needs, but wealthy people like to flaunt, like fresh baked brioche for breakfast after having a baby, or executive physicals in palatial settings, and let those things become frightfully expensive, as these types of things usually are in a free market.<br />
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Single-payer will create a new set of losers. Health care executives making tens of millions of dollars every year for no particular reason will be losers. Perhaps they can find new careers at Boeing or Lockheed Martin seeing how their expertise is easily transferable. Health insurance stocks will tank and improperly managed pension funds will also lose bigly. People running for elections will see a major cash cow go dry after the initial struggle is over and done with. There will be powerful losers and it won’t be easy.<br />
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But Obamacare has its losers too. Hard working, taxpaying middle class citizens were the designated losers of Obamacare. Some by commission and most by omission, because Obamacare made no attempt to solve the health care problems facing the vast majority of workers with employer sponsored health insurance. That bomb keeps ticking away at a steady pace. The newly empowered Republican Party has nothing to offer either, and I can’t blame them. There is nothing more we can do here. We tried everything else, and now it’s time to do the right thing. It’s the American way.Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com0tag:blogger.com,1999:blog-3503957686158274288.post-12994937022902749082017-07-03T09:00:00.000-05:002017-07-03T09:00:24.938-05:00The Legend of Health Care<div class="separator" style="clear: both; text-align: center;">
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Once upon a time, in a kingdom by the sea, broad consensus has been reached, which seems rather weird nowadays. America, you see, was spending too much money on health care for too little in return. We spent almost twenty percent of our GDP on health care, which was much more than any other developed country in the world, but our health outcomes were middling at best. And the costs just kept rising. Something had to be done before health care terminally crowded out every other public need. The Affordable Care Act, Obamacare, was that something. It was supposed to “bend the cost curve” and everybody was supposed to learn that “less is more”.<br />
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And so the nation rolled up its sleeves and got to work. Insurance companies were supposed to limit their administrative waste and tightly mange care. Hospitals were supposed to bundle and warrant episodes of care. Doctors were burning out trying hard to cut the volumes of their expensive services, while exercising stewardship of scarce resources (i.e. dollars). Pharmaceutical companies were to be taken to the shed for regular beatings. Patients were educated to choose wisely and seek value for every insurance penny. And in a bizarre remake of Fantasia, the government was cheerfully orchestrating the entire effort with rules, regulations, computerizations and spontaneously generated armies of consultants. <br />
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It didn’t work. Not even a little bit. Yes, across the board industry profits and stocks were soaring, as were the loudly lamented loses from sky-scrapping premiums paired with ballooning deductibles (don’t ask, health care is complicated). And yes, Obamacare put a big dent in the “free loader” problem (as the uninsured issue was described to the Supreme Court by the Obama administration), but other than that, everything else was in the “showing potential” or “more research is needed” stage. It wasn’t for lack of trying either. The levels of “disruptive innovation” were positively dizzying. Ever increasing heaps of monies were getting shuffled relentlessly from here to there and back again, amidst vigorous debates on the merits of this or that “initiative”, but for some peculiar reason, not one dollar was ever taken off the health care table.<br />
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And then the warm and cozy incubator, where health care expenditures were being raised and nurtured for ages, experienced the mother of all disruptions. Donald Trump got himself elected President. Bluster and bravado notwithstanding, Mr. Trump is a weak President, with no political machine and no support inside the criminal beltway, or the moneyed power-centers that rule this country. The raging crowds that propelled Mr. Trump’s unusual ascent turned back into pumpkins at midnight on November 8th, 2016. He is virtually alone in Washington DC and it seems that slowly but surely the President is realizing that you gotta dance with the one that brung ya.<br />
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The Republican Party is now aiming in earnest to take a good portion of government money off the health care table. After seven years of planning, plotting, squirming and howling, the conservative wing of the GOP finally got its hands on the chips’ rake, and they intend to use it. This should not come as a surprise to anybody, but the Obamacare repeal and replace theater can be very instructive in ways that have little to do with a succession of wacky bills that will never become law. For starters, it’s worth noting how beautifully the current commotion validates that Paul Ryan and his fiscally responsible buddies are, and always have been, less than concerned with the infamous 47% of Americans who would never vote for Mitt Romney (but somehow voted in droves for Donald Trump). <br />
<h4>
Heath Care Hopscotch</h4>
Most importantly though, the responses to Mr. Ryan’s slash and burn reform proposals, from both sides of the fake ideological aisle, teach us that we will never be able to “bend the curve” of health care costs through a regular parliamentary process. Never. And here are some vignettes that might explain why.<br />
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When President Obama signed his landmark health care reform legislation, an individual mandate to purchase insurance was included. The mandate was originally proposed by a premier conservative think tank, and copiously derided by the President himself during his 2008 primaries. Once Obamacare became law, the Republican Party took its objection to the individual mandate all the way to the Supreme Court, and when it lost its case there, embarked on a seven years (and counting) quest to repeal and replace Obamacare. Somewhere in the middle of that journey, the GOP fielded presidential candidate Mitt Romney, the first implementer of the individual mandate in Massachusetts (with Paul Ryan, the greatest Obamacare warrior, as his running mate). How much of the Republican opposition to forcing people to buy insurance had to do with conservative ideology and how much it had to do with political opportunism, and how much it had to do with Mr. Obama himself, is up to you to decide.<br />
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Back during the 1995 budget wars President Clinton <a href="https://www.washingtonpost.com/archive/politics/1995/12/07/clinton-vetoes-gops-7-year-balanced-budget-plan/e7a56467-ea2d-467e-a818-790640a4f5d8/?tid=a_inl&utm_term=.913cad0d502b" target="_blank">proposed</a> a “"per capita cap" on federal spending for Medicaid, in which federal payments would be made for each eligible person but with the amount rising each year only according to adjusted inflation increases”. Although the Medicaid cap never came to be, according to then Senate Minority Leader Thomas A. Daschle (D-S.D.) "Virtually every Democrat indicated today that they could support it. In fact no Democrat indicated that he could not support it”. Fast forward twenty years or so, and the GOP proposal to impose inflation adjusted per capita caps on Medicaid is equivalent to the murder of millions of Americans in the eyes of current Congress Democrats, many of whom were also there in 1995.<br />
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Heath Care is just a political bludgeon. There are two ideological bookends for the theoretical idea of health care: equality vs. free markets. But when it comes to gory details, and heath care is a cornucopia of goriness, there are no principled positions to be taken. Everything can be twisted and fit into all but the most extreme ideologies (i.e. either everybody has a right to all the care they want or you get what you can pay for) and there are few, if any, people firmly entrenched at each end of the spectrum. Once you acknowledge that there is a morally valid spectrum, you can hop, skip and jump all over the place to serve your immediate political needs, which easily explains the vignettes above and many more acts of intellectual and linguistic chicanery commonly employed in health care policy propaganda.<br />
<h4>
The Unbending Curve</h4>
When the Democratic Party had its chance to bend the curve, they chose to spend more upfront and hope that harassing doctors and managing patients will bend the curve in mysterious ways. Republicans seem more inclined to use brute force to push the curve down at its weakest point, while hoping that the same doctor and patient harassment tactics will counteract the damage caused by any shortages in health care funding. Whereas Obamacare brought us a flurry of innovations designed to move the system to value-based payments so we can save a few bucks, GOPcare will be bringing us a flurry of equally impotent innovations designed to move the system to value-based care so we can squeeze more quality from fewer bucks. In other words, the more things change, the more they stay the same.<br />
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If we want to spend less money on health care, then we need to spend less money on health care. That pesky curve is not going to bend itself. All industry innovations claiming to save money are simply moving coins from one profit center to another, usually where the profit margins are higher and efficacy is lower or practically nonexistent. Curbing patients’ utilization of proper medical services, which is already lower compared to other developed countries, is a virtuous endeavor. Curbing the wanton rise in prices of said services is either evil Communism, or heartless Capitalism, depending on how the winds blow in Washington DC. The simple truth is that bending the curve means paying less than the industry feels entitled to, and the medical industrial complex shall not be denied. But there is new hope now…<br />
<h4>
Dollar Store Care</h4>
The progressive half of our ruling class seems to have had an epiphany of sorts. Medicaid, you see, is now an array of no frills, managed care, commercial health plans with atrociously narrow and underpaid networks. Medicaid is the Dollar Store of health care and as such it is the ultimate value-based solution. Wouldn’t it be nice if we could put the entire former middle-class on Medicaid and call it universal health care or even single payer? Besides, Medicaid accessorizes very nicely with that new and so very hip universal basic income pushed by progressive billionaires who are sucking up every bit of wealth from every living thing. The conservative half of the ruling class would much rather see a free market of Dollar Stores for health care. The GOP value-based solution is to reduce public funding for health insurance and let the market for Medicaid style commercial plans do its thing unencumbered by the heavy hand of government and the excessive burden of Federal dollars.<br />
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The existential question now before us is whether the government will be charitable enough to subsidize our Dollar Store purchases or not so much. There is no longer any debate about the race to a Dollar Store standard of care in America. The goal posts have been moved. Expectations have been reset. Mission accomplished. A win for progressives is Medicaid for all. A win for conservatives is Medicaid for some. The final score: Billionaires 1, America 0. What’s next?Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com1tag:blogger.com,1999:blog-3503957686158274288.post-34217284036985631832017-03-28T08:09:00.000-05:002017-03-28T08:09:24.774-05:00Trump Lemonade for Dr. Price<div class="separator" style="clear: both; text-align: center;">
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President Trump campaigned on making health care better, cheaper and available to all Americans, regardless of ability to pay. Once Mr. Trump was safely in the White House, the Republican “thought leaders” in Congress were quick to supply him with their stale and superficial “plans” to repeal and replace Obamacare, which were written in protest to President Obama’s policies and were never meant to be implemented. When scrutinized by the rank and file of the Republican Party, it turned out that the Ryan/Price American Health Care Act was neither repealing enough for some, nor replacing enough for others. Nevertheless, Mr. Ryan felt a sense of urgency to ram his pet bill down the throats of not only the opposition party and the public at large, but also the throats of his own party and its rookie President.<br />
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The Democratic Party lost no time in whipping up public frenzy against the Ryan/Price bill, and Speaker Ryan lost no time in generating a sense of false urgency to pass his bill now, now, now, because for Paul Ryan this was a once in a lifetime opportunity to begin dismantling the welfare state. From the left, it looked like the bill will be withdrawing billions of dollars in health care benefits from the most vulnerable citizens who also happen to be Trump supporters. From the right, the bill looked like Obamacare Lite because it didn’t throw all the poor people under the bus fast enough.<br />
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These were the cards President Trump was dealt. If he signs the bill, he breaks his campaign promises and loses his base. If he comes out against the bill, he confirms the worst fears of all Conservatives and loses Republican support in Congress. There is zero chance for this President to appeal to another set of voters anytime soon, and currently, there is zero chance that even one Democrat in Congress will support anything President Trump proposes, no matter how liberal and beneficial that proposal might be. It was a difficult hand to play, but he played it brilliantly, in my view. Or maybe it was just beginner’s luck.<br />
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Right now the Democratic Party and its echo-chamber media are celebrating the defeat of the would-be destroyers of Obamacare. The Republicans are in disarray again. Paul Ryan has been humiliated. Trump, the closer, the grand deal maker, lost big league. Nancy Pelosi declares victory without having to fire one parliamentarian shot. The President in the meantime calls <a href="https://www.nytimes.com/2017/03/24/us/politics/donald-trump-health-care.html" target="_blank">The New York Times</a> and <a href="https://www.washingtonpost.com/powerpost/president-trump-called-my-cellphone-to-say-that-the-health-care-bill-was-dead/2017/03/24/8282c3f6-10ce-11e7-9b0d-d27c98455440_story.html?utm_term=.6e94d2e8dc8a" target="_blank">Washington Post</a> reporters and doesn’t sound angry at all. No irate tweets. No below-the-belt punches. No fighting back. No nothing. How weird is that? Think about it. Is this how a beaten Donald Trump sounds like? Nope. That’s how a winning Donald Trump sounds like - calm, collected, magnanimous and low-keyed. President Trump passed his first test.<br />
<h4>
What’s not next?</h4>
According to my Twitter list of health care policy experts, the Big Bad President Trump will now “sabotage” Obamacare so it fails spectacularly, right before the mid-term elections, dragging millions of poor people down with it. Sabotage, espionage, life is good when you are kibitzing from the sidelines. Now why would a Trump administration want to create huge hardships for millions of people right before the mid-term elections? The thought process here is that if Obamacare collapses, the people will blame the Democratic Party, because as long as Republicans do not repeal and replace anything, Democrats continue to “own” health care. Therefore, the GOP will finally have a mandate to get rid of Obamacare any way they see fit, and will likely increase their majorities in both houses in 2018. There is only one little problem with this logic: when things go wrong, most people blame the currently governing administration, not the previous ones, and rightfully so.<br />
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Deliberately blowing up the health care system is a criminal endeavor that must be executed in the public eye, because Secretary Price cannot promulgate secret regulations. No administration can afford to do something like this, and expect to survive. Every new President in recent memory insisted that he “inherited a mess”, and every President then gives a State of the Union Address taking credit for fixing said mess. President Trump will be no different. Obamacare may not be in a “death spiral”, as detractors love to decry, but for millions of people, including those who receive generous subsidies, Obamacare is already a monumental mess. No sabotage needed.<br />
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Here is a tiny example. Remember that poor 64 year old, making $26,500 per year who, according to the <a href="https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/americanhealthcareact.pdf" target="_blank">CBO</a>, ended up paying $1,700 under Obamacare and would have had to pay $14,600 under the Ryan plan? Well, that’s only part of the story, because those dollar amounts are just for premiums. Thus a fully subsidized healthy 64 year old is indeed paying “only” $1,700 for the cheapest Silver plan currently available on the Obamacare marketplace (in my zip code). A sicker 64 year old, making $26, 500, with high medical expenses is projected to have over $7,500 in total yearly costs, which is almost 30% of his gross income. I would like to humbly suggest to the Washington DC jet-setters that for this gentleman, there is no difference whether he needs to pay $7,500 or $14,600, or $140,000 or $14,000,000. He can’t come up with any of this. He is uninsured for all practical purposes. The only difference is that under Obamacare, they may have talked him into donating $1,700 to some insurance company. <br />
<h4>
What is next?</h4>
I know conservatives and libertarians abhor the sheer existence of Medicare and Medicaid, but a savvy Secretary of Health and Human Services (HHS) could use the girth and might of these government programs to nurture the reemergence of a relatively free market in medical services, and minor bi-partisan legislation could create a relatively less predatory market in medical products. These two efforts will do more to reduce the price (and costs) of health care than any Obamacare folly or any Obamacare repealing and replacing idiocy. Furthermore, the effects could be framed in terms of freedom, choice, access and even deficit reduction, in addition to quality and affordability for those less fortunate, pleasing people on both sides of the ideological aisle.<br />
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Here is my very modest wish list for Secretary Price. All I’m asking for is that from this point onward, we start practicing evidence-based health care reform. <br />
<ul>
<li><b>Independent Evaluation</b> – Between CMS itself, CMMI, HRSA and other agencies, HHS has billions of discretionary dollars in its budget to try new things, and even more billions to implement statutory experimentations. Traditionally, large sums of money have been spent on health system “transformation” to patient-centered, team-based, coordinated, value-based, managed care (feel free to insert your favorite buzzword if I left something out). Many, but not all, of these “demonstration programs”, pilots, innovation models, etc. include evaluation studies to assess performance and so far the results have been tepid at best, but artfully spun as inconclusive. I want independent evaluations of all CMS funded “initiatives”, and I want programs that do not deliver on promised fantasies to be wound down immediately and the money reallocated to better thought out projects.</li>
<li><b>Practice Research</b> – For the last decade or more, it has been the unequivocal position of HHS that better health care at lower costs necessitates large integrated delivery systems. There is not one iota of bona fide research to support this assertion. And yet, the Federal government has engaged in massive direct and indirect efforts to dismantle the so called “cottage industry” of small independent physician practices. I want CMS to fund several serious comparative-effectiveness studies across various medical practice models before it’s too late and we have nothing left but monopolistic chains for medicine. And I want CMS to follow through and undertake the deconstruction of all infernal medical factories where nobody knows your name, but everybody knows your risk score.</li>
<li><b>Hospital Research</b> – I remember reading something a couple of years ago about someone trying to study the effectiveness of hospitalist care compared to community doctors who are allowed to admit and care for their own hospitalized patients. Hospitalists are another pre-Obamacare “innovation” based solely on hospital profitability arguments. As such, it caught on like wild fire and we have very few community physicians left who follow their patients inside the hospital walls. I want to see that study performed immediately, before the last dinosaurs die off and we forget that continuity and coordination were once built into health care, by default.</li>
</ul>
That’s it. That’s all I want for Christmas. Disappointed? Don’t be. A comprehensive, well researched report on our health care delivery models (shall we call it The Price Report?) could change the trajectory of health care in America and the entire world. I did not forget about Medicaid, the ludicrous deductibles, the device taxes, the pharma bidding and all those big huge things every pundit is reciting on cable news channels. These are important things of course, but they are temporary solutions at best. Single payer, if implemented tomorrow, is going to implode just as quickly as Obamacare did, and end up rationing care worse than the British system does. The various free market solutions are even more vulnerable to the ominous crescendo of unchecked profit extraction and incompetence engulfing our health care system.<br />
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Health care cannot be sustainably fixed in broad political strokes. If we want a real and lasting solution, we will need to step away from the political theater and engage in painstakingly detailed work on fundamentals. Health care is about medicine, and medicine is about applying science to the bodies and souls of people. We know how to do it. We do have the best health care in the world. We just forgot where it is, so now we have to systematically look around until we find it again. Hopefully Dr. Tom Price understands the historic moment he finds himself in.Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com5tag:blogger.com,1999:blog-3503957686158274288.post-31785182891804512932017-03-23T09:00:00.000-05:002017-03-24T12:53:01.739-05:00A Citizen's Amendment to RyanCare<div class="separator" style="clear: both; text-align: center;">
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There are <a href="http://acasignups.net/sites/default/files/2016_total_coverage_pie_chart.jpg" target="_blank">approximately</a> 18 million Americans who purchase health insurance on the so called individual market, on and off the Obamacare exchanges. There are another 14 million or so who could be buying insurance on the individual market, but choose not to buy anything. This puts the total individual market at about 10% of Americans. Half of those are, or are eligible to be, heavily subsided through Obamacare (including those huge deductibles). The other 5% are facing the full brunt of health insurance price increases under Obamacare. Of those, 3% are paying for Obamacare health insurance and getting garbage in return for their money, while the remaining 2% are uninsured. This is the magnitude of the primary problem we are supposedly trying to solve.<br />
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The 17% of Americans on Medicare are not upset at Obamacare. The approximately 23% of Americans on, or eligible to be on, Medicaid are not angry at Obamacare either (although the 1% eligible for the Medicaid expansion in states that chose not to expand it, might be angry with their Governors). Some of the 50% or so, who are getting health insurance through their employer, and used to get rather flimsy insurance in the past, may be somewhat disgruntled because the Obamacare imposition of “essential benefits” caused their share of premiums and deductibles to rise, and their ability to choose their doctors to plummet. This is the secondary problem we are supposedly trying to solve.<br />
<br />
The <a href="https://housegop.leadpages.co/healthcare/" target="_blank">American Health Care Act</a> (AHCA) addresses neither problem and exacerbates both.<br />
<h4>
Three Pronged Care</h4>
The proposed GOP solution is “<a href="https://www.whitehouse.gov/repeal-and-replace" target="_blank">three pronged</a>”. Prong One repeals Obamacare (whatever that means) and replaces it with more widespread, but less generous, subsidies for the individual market and reduces funding for Medicaid, while also reducing Obamacare taxes on corporations and wealthy individuals, including taxes slated to increase the longevity of the Medicare trust fund. Prong Two is a flurry of yet to be determined regulatory relief that the Secretary of Health and Human Services will be supposedly providing at his discretion. Prong Three consists of new legislation, which will require the support of at least some Democrats in the Senate, to relax both the definition of Obamacare “essential benefits” and the regulations on health insurance corporations, so cheaper insurance plans can proliferate across the land (as they did before Obamacare).<br />
<br />
The most important thing to understand about the Three Pronged Care proposal is that although the CBO can, <a href="https://www.cbo.gov/publication/52486" target="_blank">and did</a>, estimate the effects of the first Prong, nobody can estimate the cumulative results of all three Prongs, because nobody knows what the second Prong is and because it will take an act of God to make the third Prong materialize. Since we are talking about health care, think of this as some sort of orthopedic, cardiac or transplant surgery. First you cut the patient open, then you remove or adjust the offending parts, and then you put in something new and hopefully better. Coming in after a previous surgeon messed things up is obviously harder, but cutting the patient open and walking away until you figure out if you want to or are able to do more, is hardly a viable option for the patient, and will likely result in a huge malpractice suit (plus a copious prison sentence) for you. <br />
<h4>
What if Prong One is as good as it gets?</h4>
Unfortunately, this is precisely what Paul Ryan and his ragtag coalition are proposing to do with Prong One, whose sole effect will be to add insult to the Obamacare injury. Once we accept the premise that the Federal government has an <b>obligation</b> to help people get health care, the remaining disagreements are just haggling over price. And once we dismiss highfalutin principled rhetoric, the problem with Prong One is that for most people, in absence of Prongs Two and Three, this is just a stingier version of Obamacare. The GOP argument that two imaginary birds in the bush are better than a real bird in hand flies in the face of millennia of human wisdom. On top of that, there is absolutely nothing in Prong One that even begins to address the fundamental problem in our health care system, which is the unit price of health care services. Therefore, premiums and deductibles will likely continue to rise unabated.<br />
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In all fairness though, there is a twisted argument to be made that if you cut subsidies and there is less money available, insurers will work hard to lower the price of their products to match what the “market” can bear. That may be true if the reduction in funds affected the entire market, instead of at most 10% (likely 5%) of it, and the least profitable 10% to boot. In “normal” markets, a non-participation rate of 10% percent is certainly sustainable and actually pretty good for the sellers. That said, smaller health insurance vendors currently specializing in Medicaid managed care could step into this niche and offer a commercial product through their existing underpaid networks. If you’re a physician, this prospect should set your hair on fire.<br />
<h4>
The Free Market Delusion</h4>
At some point we will need to collectively disabuse ourselves of the notion that a market in health care insurance could be created without abolishing the provision of health insurance benefits through employment. I know everybody is talking about Flo and the little lizard selling health insurance on TV as the ultimate solution to health care affordability, but that is nothing short of demagoguery. Note that practically all auto insurance is business to consumer (B2C), while health insurance is overwhelmingly business to business (B2B). I suggest you try buying a cow from a feedlot and see for yourself how much negotiating power your consumer status bestows on you in a B2B market. If you want to try a free market solution for health insurance, you would need to do more than just kick a few poor people off their subsidies. You would need to kick 150 million people off their employer health insurance plans. Good luck with that.<br />
<br />
I have to admit that there is something compelling about the conservative vision of a portable health insurance product that people buy and carry with them wherever they go. Obviously health insurance that is intended to serve people from cradle to grave cannot be a game of Russian roulette with covered benefits, or as Mr. Ryan refers to it, “patient-centered” insurance. Equally obvious is the fact that State and Federal governments will still have to honor their obligation to help those who can’t afford to purchase insurance for a predefined set of “essential benefits” on their own. Will such semi-free health insurance market deliver the health care affordability we seek? Not likely. The deceptively simple truth is that you cannot successfully tackle the pricing failure in the health insurance market without first taking an axe to our dysfunctional health care delivery system.<br />
<h4>
The Three Prong Shuffle</h4>
Obamacare not only failed to put a dent in health care delivery prices, but arguably made things worse by actively encouraging system consolidation. Under the best case scenario, a heavily modified GOP Prong One plan (e.g. higher tax credits, lower tax cuts for the rich, more money for Medicaid), will not change the Obamacare trajectory one bit and will not provide meaningful relief to people hurt by Obamacare. All this tinkering and re-tinkering with an insignificant portion of the health insurance market is like obsessively unclogging the kitchen sink on the Titanic. The sketchy descriptions of Prong Three, the free market prong, are just too ridiculous to consider at this point, but Prong Two, the regulatory prong, has great potential. After reading the <a href="https://rules.house.gov/sites/republicans.rules.house.gov/files/115/PDF/115-AHCA-SxS-MNGR-Policy.pdf" target="_blank">manager’s amendment</a> to the Ryan Make America Poor Again plan, I would like to offer my own citizen’s amendment.<br />
<ul>
<li><b>New Prong One:</b> Swallow hard and let the AHCA die a merciful death. Extend some temporary relief to the 5% hurt by Obamacare. Give Secretary Price a chance to affect regulatory changes first. Medicare is the de-facto price setter for health care services. The Secretary can affect changes to Medicare fee schedules and payment models that will quickly ripple through the commercial sector. I would start with the <a href="https://www.ama-assn.org/about-us/ruc" target="_blank">RUC</a> and hike the relative value of comprehensive primary care. I would create a monthly CPT code that can accommodate subscription based primary care (not quite what the Direct Primary Care lobby wants, but darn close). And I would engage in a long string of multi-payer initiatives to accelerate dissemination of measures to control unit prices, while leaving behind the naïve and failed attempts to cut utilization.</li>
<li><b>New Prong Two:</b> This is not a purely health care prong, but it is necessary because this is the only way to fix health care in America. Get those tax cuts done, renegotiate trade agreements, fix the education system, get infrastructure projects going, get manufacturing back, drain the swamp, and create lots of opportunities. Introduce specific pieces of legislation along the way to negotiate drug prices, break health system monopolies or at least encourage independent, small and more cost-effective practices to thrive. Keep up a brisk regulatory and deregulatory program to curtail the flow of billions of health care dollars to opportunistic corporations that do not provide care or any other benefits for patients. Think creatively about connecting health insurers’ participation in State/Federal programs to affordability in the individual market (at the very least make it count in Medicaid RFPs).</li>
<li><b>New Prong Three:</b> If all goes well, we can finally do away with Obamacare, which should become automatically obsolete if Prongs One and Two are executed successfully (otherwise Obamacare will be the least of our problems). If the economy catches fire and more people have good paying jobs, and health care unit prices are at the very least contained, fewer people will need subsidies or Medicaid welfare. Make a note to schedule a symbolic full repeal and replace on January 21st 2021. I am certain it will pass with strong bi-partisan support. </li>
</ul>
Will Washington DC put the horses in front of the cart for a change? Not by choice. However, the good news is that all of a sudden Prong One seems to be on life-support in the House and dead on arrival in the Senate. The excellent news is that President Trump made another <a href="http://insider.foxnews.com/2017/03/15/president-donald-trump-tucker-carlson-tax-returns-obamacare-disaster-wiretap" target="_blank">promise</a>: "We will take care of our people or I’m not signing it" (it being Prong One, whatever it ends up being, if it ends up being). The disastrous news is that no self-respecting Democrat will engage in any effort to help the President help the American people. That would be too much to ask of our elected representatives. Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com2tag:blogger.com,1999:blog-3503957686158274288.post-11541751029297107792017-03-11T09:56:00.000-06:002017-03-11T09:56:42.349-06:00RSVP to an Invitation from Steve Bannon<div class="separator" style="clear: both; text-align: center;">
<a href="https://3.bp.blogspot.com/-DXX8ZNTE_ak/WL47WzSDbxI/AAAAAAAABV8/MI1SkLp3A68p7I5GfwodorD8v8a2LrGXACLcB/s1600/Bannon.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="240" src="https://3.bp.blogspot.com/-DXX8ZNTE_ak/WL47WzSDbxI/AAAAAAAABV8/MI1SkLp3A68p7I5GfwodorD8v8a2LrGXACLcB/s200/Bannon.png" width="170" /></a></div>
Steve Bannon, the White House Chief Strategist and nationalist lightening-rod extraordinaire, has made his <a href="https://www.youtube.com/watch?v=lT59InhawBg&feature=youtu.be" target="_blank">public speaking debut</a> at the Conservative Political Action Conference (CPAC) a couple of weeks ago. I’ll leave the dissection of his remarks to people who get paid millions of dollars to spin things, but at the very end of the interview, Mr. Bannon invited the audience, and by extension the American people, to help the Trump administration in a very peculiar way: “We want you to have our back... but also and more importantly, hold us accountable. Hold us accountable to what we promised. Hold us accountable for delivering on what we promised”. Well, Mr. Bannon, here is my RSVP to your most gracious invitation.<br />
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I would like to hold you accountable for the way you are handling, or rather mishandling, the debate around Obamacare, and health care in general. As far as I can tell, and by your own admission, your job Mr. Bannon is to implement the President’s agenda as presented to the American people for consideration during his campaign. I have watched approximately 90% of candidate Trump’s rallies, all the debates and all the interviews, because as a bleeding heart liberal, I had to be sure I knew exactly what I was voting for. What he promised, what you all promised, was to protect Medicare, Medicaid and Social Security and you made it crystal clear that Mr. Trump was the only candidate (excluding the defeated Bernie Sanders) to commit to this trifecta of righteousness. I would like to hold you accountable for delivering on this promise in its entirety.<br />
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Yes, Mr. Trump promised to “repeal and replace the disaster known as Obamacare” multiple times to standing ovations, and yes, he spoke loosely about selling insurance across state lines and health saving accounts and having all sorts of choices. In rally after rally, the President explained over and over again what he thought was wrong with Obamacare: the premiums going through the roof, especially that blessed 116% in Arizona, the high deductibles that make it impossible for people to see a doctor unless they are hit by a truck or are near death (whichever comes first, I guess). But most of all he spoke about “something terrific” that will replace the “failing Obamacare” and more recently President Trump promised health insurance for all Americans including those who cannot pay for it. I would like to hold you accountable for this terificness in all its promised glory.<br />
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My inclination is to say that so far your team has not delved into the intricacies of health care reform. If you would have, one or another incendiary piece of paper would have leaked to The New York Times by now. I get that dealing with insurance is not as philosophically elevating as dealing with culture wars and other grand historical trends, but back in the trailers of the Appalachian Mountains, and in the modest homes of rust belt workers who lost their jobs to the globalized economy, and at every kitchen table in the America where decisions are still made at kitchen tables, health insurance is a life and death problem. President Trump promised to be the voice of these <a href="https://www.commentarymagazine.com/articles/our-miserable-21st-century/" target="_blank">forgotten people</a>. He promised to speak for them, fight for them and win for them. Of all the promises you made, this is the one promise I will hold you most accountable for.<br />
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The other day the new GOP “secret plan” to repeal and replace Obamacare has been finally unveiled in <a href="https://waysandmeans.house.gov/american-health-care-act/" target="_blank">two</a> separate <a href="https://energycommerce.house.gov/news-center/press-releases/energy-and-commerce-republicans-release-legislation-repeal-and-replace" target="_blank">pieces</a>. We have seen Obamacare replacement plans from the party of Ayn Rand long before this election, so I will not hold you accountable for the childishly vindictive Ryan “plan”, or the more comprehensive cruelty of Dr. Price’s “bill”, and I know that this “new” abomination, which is a clumsy cross between the two, is not your plan, Mr. Bannon. For all I know this may be a brilliant strategy to eschew the responsibility of fixing Obamacare, because this new plan is not likely to clear the House and it certainly won’t get through the Senate, but in the unlikely event that it does, I will hold you accountable if this exercise in boldfaced deceit ever becomes law.<br />
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The “experts” will be delving into all the gory details, but please allow me to cut through the chase. The GOP plan is a perfidious conservative concoction. The GOP plan is killing Medicaid and Medicare. The GOP plan is reducing premium support for most people without employer or government supplied health insurance. The GOP plan is increasing exposure to those awful high deductibles for millions of additional people, poorer older and sicker than before. And finally, the GOP plan is cutting taxes for wealthy people and corporations. Is this your idea of how we put America First, Mr. Bannon? Is this President Trump’s idea of how we Make America Great Again? It never occurred to me to ask, sir, but what do you guys mean when you say “America”? I cannot obviously hold you accountable for the answer, but history and whichever God you pray to, eventually will.<br />
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I do agree with you Mr. Bannon on the nefarious effects of a globalized economy and the feckless role played by a “globalist, corporatist media” machine, and I have your back in this fight for the soul of America and the dignity of the American worker. I am sure you can appreciate how difficult it is for a liberal to make such statements amidst the frothing and frenzied neo-McCarthyism upon us now. The only remaining question, Mr. Bannon, is whether you have our backs. I have not seen President Trump shrink from a fight before, and whether you like it or not, health care, not Russia, will be the defining issue of his presidency. As conservative corporatism is fusing with progressive globalism, combining the worst of both worlds into a formidable force against the people, I will hold you accountable for failing to side with the irredeemably deplorable masses that put you in the White House in the first place.<br />
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President Trump needs to stand up and clearly state that he will not sign a bill that takes away whatever little health care poor, sick and low income people still have. These people are us, Mr. Bannon. They are the #TrumpTrain, the Movement, the Bikers for Trump, the Latinas for Trump, the “build that wall” and “lock her up” chanters, and the ones who took you up on your offer, because “what the hell do they have to lose”. They didn’t come “pouring in” to demand less health care for themselves so there’s more cash available for the “administrative government”. These people may not know much about the abject art of politicking, but they have vast expertise in getting screwed. They know it when they see it. And they are seeing it now, Mr. Bannon. They are seeing it now.<br />
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It would be most unfortunate, and the end of the road for me, if the first legislation enacted by this administration is one where once again men in fancy suits forget those who have always been forgotten, in stark contradiction to explicit promises made repeatedly, both before and after the elections. A government of, by and for the people, another frequently made promise, does not enact immoral legislation, and the GOP plan to repeal and replace Obamacare is beyond immoral. Your boss, Mr. Bannon, is the President of the United States of America. He is the President of the American people, even the poor ones, especially the poor ones. He has the power and the duty to veto immoral legislation, and we the people will hold President Trump accountable for that.Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com3tag:blogger.com,1999:blog-3503957686158274288.post-36428991998923454562017-02-24T08:00:00.000-06:002017-02-24T08:00:32.310-06:00A Scientific Method to Repeal & Replace (wink) Obamacare <blockquote class="tr_bq">
<i>“So how about it, Nash? You scared?” <br />“Terrified... mortified... petrified... stupefied... by you.” </i>(--A Beautiful Mind)</blockquote>
Fear is now a sign that you are an intelligent, educated, open-minded and caring person. Being scared is incontestable proof that you have a beautiful heart. When it comes to your health, there is palpable terror that soon, very soon, the bad guys will take away Obamacare, which was the source of health care and life itself for many. And make no mistake the enemy is coming for us all, now that we lost the war to “the Republicans”. It is therefore incumbent upon brave souls everywhere to join La Résistance Américain. Since I am not now and never have been a brave souled Maquisard, I’ll just sit here and daydream about a kinder and gentler occupation, until the Vichy comes for me.<br />
<h3>
Obamacare is the Status Quo</h3>
Obamacare went into effect only three years ago, but in the age of information technology, years are like decades. Obamacare with its many tentacles and offshoots is deeply and solidly entrenched in the health care landscape. There is zero chance that anybody will be able to dig up its rhizomic growth into the actual practice of medicine, so let’s play along and see what can be done about the large shiny part, visible to the naked eye, namely health insurance.<br />
<br />
Traditionally, health insurance coverage is segmented into public insurance, employer group insurance and individual markets. However, considering the changes introduced by Obamacare, a different classification, may be in order: People who have all or most of their health care paid for, people who have some of their health care paid for, and people who must pay for all their health care on their own. <br />
Health insurance for all classes now includes a fixed set of “essential benefits”, no limits on lifetime spending and prohibition from factoring preexisting conditions into coverage decisions has been expanded to include non-group policies. This is the post Obamacare status quo. This is what the Republican Party is currently endeavoring to repeal and replace. It is important to note that while approximately 95% of Americans are eligible for either fully or partially subsidized health insurance, there is a 5% “donut” hole of mostly middle class, mostly precariously employed people, left to fend for themselves.<br />
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Democrats are poking fun at Republicans for lacking an Obamacare replacement plan after six years of complaining and symbolically voting to repeal the law multiple times. The irony here is that the GOP has plenty of plans that could have been put in place in 2008 and even in 2012, but not today. Why? Because none of the old plans are equal, let alone better, than the new status quo. The simple fact is that on its face, and for the short term, Obamacare helps far more people than it hurts. The other simple fact is that the one overriding fiduciary responsibility of members of Congress is to get themselves reelected.<br />
<h3>
The Basic Laws of Repeal and Replace</h3>
With that in mind and considering that for some peculiar reason getting rid of Obamacare was a major campaign promise for both the GOP and the new President, I would like to humbly suggest an entirely scientific set of basic laws for repealing and replacing Obamacare.<br />
<h4>
<b>Zeroth Law of R & R: Drain the swamp</b></h4>
If two systems (insurance and hospitals) are in profitable relationship with a third system (government), they are in profitable relationship with each other. This law helps define the notion of corruption.<br />
<h4>
First Law of R & R: Do no harm</h4>
No harm now and no harm in the future. No harm while you’re healthy and no harm if you get sick. <b>Every American covered by some type of health insurance should be no worse than he or she currently is. </b>Premiums should not be higher. Out of pocket spending should not be higher. Benefits included should not be fewer. Access to and choice of doctors and hospitals should not be reduced. And finally, government spending should not increase by too much either. If this law sounds to you like some sort of ridiculous wizardry, it isn’t. There are plenty of places to look for, and find money, other than working people’s pockets. Additionally, failure to comply with this basic law will guarantee loss of elected office for anybody remotely associated with such folly. Equivalently, perpetual election machines of the first kind (hurting people) are impossible.<br />
<h4>
Second Law of R & R: Fix what’s broken</h4>
Fix what the people say is broken, not what dead economists might have said is broken. <b>Premiums</b>, especially for unsubsidized people, are too high. <b>Deductibles</b> are way too high not just for those who have to pay full price for insurance, but increasingly so also for employer sponsored workers. <b>Choice of doctors and hospitals</b> is being narrowed for everybody, except the very rich and the very well connected. Those are the three things that voters need Congress to fix. Blabbering about death spirals and actuarial risk pools will get you zero (0) votes in your next election. Reducing Federal government spending on health care by a few billion dollars means nothing (0) to voters who have to cover the shortfall from their own individual pockets or go without. Equivalently, perpetual election machines of the second kind (ignoring people) are impossible.<br />
<h4>
Third Law of R & R: Watch your language</h4>
Do not lie to the American people and do not use words you don’t fully understand just because self-described experts use those words often in casual conversation. Don’t tell people that their health care will be affordable if they open another empty savings account. Don’t insult the intelligence of sick people by telling them that if they band together with other very sick people they’ll be able to buy more affordable health insurance. Do not tell States that cutting Federal support for Medicaid will finally free the States to innovate. First, the “dishonest” press will roast you alive, and second, your “base” of forgotten men and women will be forgetting all about you. Equivalently, perpetual election machines of the third kind (deceiving people) are impossible.<br />
<h3>
Repeal & Replace for Dummies</h3>
Based on the four simple laws above, I would like to submit one possible sequence of broad steps to “repeal and replace” Obamacare.<br />
<ul>
<li><b>Step 0:</b> Get rid of the individual mandate. It is irksome to many, it accomplishes nothing, and it’s already gone anyway. This, in and of itself, satisfies the minimum requirement for stating that Obamacare has been repealed.</li>
<li><b>Step 1:</b> Take a baseline of who has what in the way of health insurance, and this includes covered benefits, because reducing health insurance prices by cutting benefits violates the First and Third Laws.</li>
<li><b>Step 2:</b> Exclude programs where Obamacare changed little to nothing. Ignore the small changes and per the First Law, leave expansions in place.</li>
<ul>
<li>Medicare, VA and other military related – Leave those out. Fix the VA separately.</li>
<li>Medicaid – Leave it alone, except make sure the remaining Republican governors expand it in their (your) states (threats, waivers and whatever it takes to help them save face).</li>
<li>Employer insurance – Leave the 26 years old children and the removal of lifetime limits in place because neither one makes much difference to affordability (preexisting conditions were never an issue for this group).</li>
</ul>
</ul>
Now we’re down to <a href="http://acasignups.net/sites/default/files/2016_total_coverage_pie_chart.jpg" target="_blank">about 18 million insureds</a> in dramatically different situations. Half are subsidized to various degrees based on their <a href="https://www.healthcare.gov/glossary/federal-poverty-level-FPL/" target="_blank">Federal Poverty Level</a> (FPL). People with less than 400% FPL (a bit south of $50,000 per year) get some form of <a href="https://www.healthcare.gov/lower-costs/save-on-monthly-premiums/" target="_blank">subsidy for the premiums</a>, but many are struggling with outrageous deductibles. Those who make less than 250% FPL get <a href="https://www.healthcare.gov/lower-costs/save-on-out-of-pocket-costs/" target="_blank">help with their high deductibles</a> as well. The 9 million who pay full price, along with 7 million of the uninsured, are in desperate need of relief from Obamacare. Add to that an increasingly large portion of employees whose employers “offer” exceedingly high deductible plans, and you have your Obamacare resentment in a nutshell.<br />
<ul>
<li><b>Step 3: </b>The easiest and cheapest solution to the problem would be to allow people on the individual market to purchase Medicare coverage and direct all Federal subsidies (which will need to be spread out more broadly to include the 10% "donut" hole) back into Medicare. There should be no objection from the health insurance industry since they all seem eager to leave those tiny markets anyway. But of course, nobody is going to do that, because this would appear to be “government run health care” of the “socialized medicine” variety.</li>
<li><b>Step 3 (alternate A):</b> Allow all subsidized people on the Obamacare exchanges to “buy” into local Medicaid plans, which should reduce cost significantly, and use the savings to broaden the subsidies to include the hurting half, with an option to get more “coverage” if they use those new subsidies to buy into Medicaid as well. Personally, I don’t find this alternative very appealing, certainly not as appealing as the Medicare option, but again, seeing how all Medicaid is privatized now and how health insurers are making fortunes from Medicaid, there should be no serious objections. This alternative violates the Second Law when it comes to choice of doctors.</li>
<li><b>Step 3 (alternate B):</b> If increasing membership in Medicare or Medicaid (or both) is too much of a political hot potato (and it is), let’s use some of those buzzwords y’all enjoy throwing around to create a market-based solution. We have around 18 million people who participate in the individual market and perhaps another 13 million who fit the profile, but choose not to participate. We are talking about at most 10% of Americans. I am pretty sure that some “brave” health insurance companies (preferably non-profits) would be willing to bid for contracts to insure these people. You can do this by state or by region “across state lines”. Here’s the deal: people don’t need choices of health insurance plans. They need choices of doctors and hospitals. </li>
<ul>
<li>One generously subsidized HMO plan with an adequate but narrower network, which is essentially a Medicaid style option, but more expensive (go figure).</li>
<li>One less generously subsidized PPO plan with a comprehensive network, which is similar to a Medicare Advantage PPO.</li>
<li>You can add in your “health savings accounts” here, but only if they are fully or partially funded by the Federal government in lieu of direct payment to insurers. This is also a good place to experiment with subscription based comprehensive care, a.k.a. direct primary care (DPC), which introduces a small element of free-market competition into the health care delivery system.</li>
</ul>
<li><b>Step 4: </b>Limit employer high deductible plan offerings, because what is a reasonable deductible for the CEO, is most definitely not reasonable for the assembly line worker. If you think Obamacare is a huge problem now, wait until the employer health insurance sector collapses, and it will if left to its own devices. Yes, fully funded health savings accounts (and DPC) could be used here as well.</li>
<li><b>Step 5:</b> If you are serious about providing relief to all the people, the government cost for replacement will be higher than the current Obamacare costs. To reduce health care insurance prices, you will need to consider the Zeroth Law of R & R and intervene in the pricing of health care products and services, such as drugs, devices, technology, regulations, the predatory environment created by consolidation of health systems, and the deprofessionalization of physicians.</li>
</ul>
Since all sides in this debate have strong ideological convictions or equally powerful financial interests, preventing them from civil collaboration, the most likely result of this R & R effort is that the people will end up getting hurt, again. But if the 2016 election wasn’t a clear enough message for you, here is another Nobel Prize worthy message attributed to John Nash (or rather the writers of A Beautiful Mind):<br />
<blockquote class="tr_bq">
<i>“If we all go for the blonde and block each other, not a single one of us is going to get her. So then we go for her friends, but they will all give us the cold shoulder because no one likes to be second choice. But what if none of us goes for the blonde? We won't get in each other's way and we won't insult the other girls. It's the only way to win. It's the only way we all get laid.”</i></blockquote>
<br />Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com0tag:blogger.com,1999:blog-3503957686158274288.post-32191771138058215462017-01-24T08:00:00.000-06:002017-01-24T08:00:34.109-06:00Resist the Fiction of Health InsuranceIt has come to pass. President Donald J. Trump. Are you scared? Are you planning to “resist” the policies you imagine President Trump will pursue by tweeting furiously with clever hashtags galore? Would you prefer to move my fastidious quotation marks from “resist” to “President”? This is after all, the first President in a very long time to take office without the blessings and financial support of established “world order” leaders. It must be rather disconcerting to proceed without clear guidance from our betters, especially seeing how well they served us over the last decades, and particularly when it comes to affordability of health care in America.<br />
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Are you binge-watching the Obamacare drama playing on America’s center stage these days? Are you tweeting and retweeting every shred of information that proves Obamacare is a huge success, and its repeal will mean certain death for millions? Or are you busy proclaiming your faith in free markets, the (undemocratic) government of Singapore, or the charitable nature of Americans in general and doctors in particular? Is President Obama your tragic hero, or your shifty villain? Is President Trump your great liberator (although he promised not to do anything you really want), or the Grinch who will steal health care (although he promised to preserve everything you really like)? Are you not entertained? Pass the bread, please.<br />
<h4>
Health Insurance</h4>
In the latest plot twist of the greatest political show on earth, which according to all expert comedians managed to put Ringling Bros. and Barnum & Bailey Circus out of business, our newest Republican President <a href="https://www.washingtonpost.com/politics/trump-vows-insurance-for-everybody-in-obamacare-replacement-plan/2017/01/15/5f2b1e18-db5d-11e6-ad42-f3375f271c9c_story.html" target="_blank">announced</a> that “we’re going to have insurance for everybody”, even people who “can’t pay for it”. Sounds like some sort of universal health care to me, no? Ah, the sweet irony… Amidst my deep joy with the ensuing gasps, grunts and groans, I have to assume that President Trump is really talking about health care for everybody, including those who can’t pay for said care, because “health insurance” is a fictional construct designed to extract profit from misfortune.<br />
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Would it surprise you if I said that most people in this country, or any country, don’t actually have “health insurance”? Medicare is not insurance. Medicaid is not insurance. TRICARE and CHAMPVA (Civilian Health and Medical Program of the Department of Veterans Affairs), as well as care provided by the Department of Veterans Affairs and the military, are certainly not health insurance. Even the health insurance you get from your employer is not insurance in the strict sense of the word. These are benefits, defined benefits. Obamacare extended these benefits to more people, and by essentially eliminating individual underwriting and monetary caps, it practically did away with the notion of health insurance. Good riddance.<br />
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Nevertheless, practically all our Obamacare conversations are about health insurance (or coverage), because those who sell products called “health insurance” want us to discuss health care on their terms. It’s more profitable that way. When we talk about insurance, we can talk about pools, actuarial risk, death spirals, corridors, and all sorts of obscure and complicated things that seemingly justify the need to pay health insurance companies for something. And what is that mysterious something we pay so much for? It’s certainly not “insurance”, seeing how at least half the <a href="http://www.unitedhealthgroup.com/~/media/4F32B92CA7D74B509F37B32D0B649845.ashx" target="_blank">revenues of for-profit insurers</a> come from federal and state governments. It’s complexity. We pay insurance companies to paint a thick layer of complexity over the health care delivery system.<br />
<h4>
Price of Care</h4>
How much is a jar of pickles? Well, it depends on the brand, the size of the jar and yes, the grocery store where you shop, but one thing is certain: every person in your store pays the same amount of money for the same jar of pickles. Not so with your doctor visit. If you have traditional Medicare, your doctor gets $75 for a regular visit. If you have traditional Medicaid, he gets $40 for the same visit. If you have BCBS Super HMO, he gets $70.51. If you have BCBS Super HMO+, he gets $72.37. If you have BCBS Freedom PPO, he gets $82.86. If you have Cigna Gold Choice, he gets $90.03. If you have Cigna Liberty Sucks, he gets $65.99. If you have…. and on and on it goes, for the same exact 15 minutes, from the same exact doctor, in the same exact room. The doctor one floor up may have a completely different set of fees from the same exact complement of insurance plans. Add to that the avalanche of <a href="http://onhealthtech.blogspot.com/2016/05/the-heart-and-soul-of-macra.html" target="_blank">“value-based” payment “initiatives”</a> triggered by the massive underbelly of Obamacare and the picture gets murkier than ever.<br />
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So what’s the real “value” of that doctor visit? Irrelevant, my dear Watson. Irrelevant. The true value is in not having a value at all. Why? Because then your doctor will need expensive software and an army of “expert billers”. The insurer will need different mega software to manage accounting across “product lines” and “initiatives”, and an army of analysts of its own. Of course contracted fees and quality initiatives change all the time, so the change process needs to be managed on both sides of the transaction. Extrapolate this to hospitalizations, diagnostic testing, procedures, a variety of specialists, and before you know it nobody has a clue what the price of anything is, except of course the number crunching data aggregators, usually owned and operated by, you guessed it, insurance companies.<br />
<h4>
Choices Galore</h4>
There is nothing America hates more than one-size-fits-all health insurance, you know, like Medicare. There are two health insurers and 23 individual “plans” on the Obamacare exchange in my county. Two are Gold, twelve are Silver and eight are Bronze. The same insurers offer additional “choices” off the exchange, and other choices for the employer market. There must be well over 50 “plans” from my health insurer alone floating out there. They vary by type and metal, and within each metal they vary by a few dollars here, a few dollars there and a few percentage points here and there. They all offer all the required Obamacare benefits. Why do I need two PPO Silver plans, from the same insurer, one with a $336.20 premium and one with a $336.91 premium, and similar earth shattering differences in deductibles, out of pocket maximum, copays and co-insurance?<br />
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I don’t, and neither does anybody else, other than the insurance company, of course. That layer of complexity must be nurtured and maintained. The more plan choices we have, the more we can agonize over each miserable and completely irrelevant detail. Furthermore, if the government pays for everything, including your deductible, the “actuarial value” of the plan means very little. If you’re not poor enough to qualify, and not wealthy enough to buy a top shelf plan, or pay your own way, you’re screwed no matter what you choose. The Ryan/Price “solution” to this quandary is to allow insurers to create many more plans that differ not only in price, but also in the benefits they cover, thus making insurance great again.<br />
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You can have plans that don’t cover pregnancy for example, or maybe they don’t cover physical therapy or expensive cancer drugs, because customers know best and government shouldn’t tell them what to buy. Well, that’s awfully nice, but what if your diaphragm malfunctions, or you shatter your tibia playing hoops, or God forbid those headaches were not due to stress, can you then switch to another plan just in time, or are you barred because preexisting conditions? This is a serious question, because if you can switch, every healthy person could maintain coverage for ten bucks a month, and if you can’t switch, then what’s the point having all those threadbare “plans” to “choose” from? <br />
<h4>
Let’s just get real</h4>
As gloriously delicious as the health insurance spectacle is promising to be, dwelling on it won’t solve anything. Whether you call it health insurance, health benefits, medical services or just plain health care, the darn thing is just too expensive. It’s too expensive for us to buy with our own money and it’s too expensive for us to buy with tax money. It was too expensive before Obamacare, it’s too expensive now, and the massive complexity introduced by the health insurance industry and its perpetually revolving door in and out of government, is making sure it will remain too expensive forever. Why? Because the more money we spend on health care, the better health insurance companies do, and they are doing <a href="http://www.nasdaq.com/symbol/unh/stock-chart?intraday=off&timeframe=9y&charttype=line&splits=off&earnings=off&movingaverage=None&lowerstudy=volume&comparison=on&index=djia&drilldown=off&sDefault=true&symbol=WCG&symbol=HUM&symbol=CI&symbol=ANTM&symbol=AET" target="_blank">swimmingly well lately</a>.<br />
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And nothing, absolutely nothing, the GOP put forward up to this point is poised to change that. President Trump argued convincingly enough that we cannot solve major problems unless we are willing to correctly identify the problem by its proper name. I agree. If we are going to identify and refer to the main threat to our security as radical Islamist terror, then we should be brave enough to call the health care problem by its proper name. It’s not insurance. It’s funding. The question is not how we provide “access” to some fuzzy notion of health insurance to everybody. The question is how we fund the actual delivery of medical care to all Americans at a federal level or even state by great state.<br />
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This does not necessarily mean tax funding of free health care for all. It does not mean single-payer or Socialized medicine. It also does not necessarily imply free-market fantasies, supplemented by our legendary charity. It does not mean that employers are either off or on the hook, or that pooling money to pay for fluctuating medical needs is forbidden. It doesn’t mean that insurers should all go out of business either. It just means that the American people have no obligation to guarantee empires, executive salaries, profits, earnings, and return on equity for any industry, and certainly not at the expense of their own health. Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com6tag:blogger.com,1999:blog-3503957686158274288.post-20379466466453147982016-12-08T08:00:00.000-06:002016-12-08T15:45:15.063-06:00As Obamacare Lay Dying<div class="separator" style="clear: both; text-align: center;">
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The brand new President Barack Obama, whether wittingly or not, invested his entire political capital in reforming health care in America. He gambled and he lost, not because he had nefarious intentions, but because he left the gory details to a corrupt Congress and a shady cadre of lying and conniving technocrats, ending up with something vastly different from what he campaigned on. From everything I’m reading now, Mr. Trump is about to walk in Mr. Obama’s footsteps, and if he does, the results will be unsurprisingly identical.<br />
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On the campaign trail, Mr. Trump repeatedly stated that Bernie Sanders forfeited his place in history when he “made a deal with the devil” and embraced the corrupt Democratic Party establishment that fought his candidacy in most abject fashion. Guess what? Mr. Trump seems to be making the same deal with the red version of the same devil. Mr. Trump’s cabinet choices indicate that he is now embracing the ultra-conservative factions of the Republican Party, the same people who actively or passive-aggressively opposed his candidacy. Nowhere is this peculiar and completely unnecessary capitulation more evident than in the beleaguered health care sector.<br />
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Mr. Trump campaigned on repealing and replacing Obamacare with something “terrific”, because Obamacare premiums are “going through the roof”, and because deductibles are so high that you can't actually use your Obamacare plan “unless you get hit by a truck”, and because people can’t keep doctors and plans they like. Mr. Trump also recognized that some Obamacare provisions are good and should be retained. One would therefore assume that whatever Mr. Trump proposes to replace Obamacare with, will lower premiums, lower deductibles and increase choice of plans and doctors. Although the details were rather fuzzy, two things were consistently mentioned during the campaign: selling insurance across state lines and utilization of health savings accounts. Both “ideas” can be summed up as essentially deregulation of the health insurance industry and the unleashing of free-markets. We’ve seen this movie before.<br />
<h4>
Déjà Vu </h4>
<a href="http://www.cepr.net/documents/publications/dereg-timeline-2009-07.pdf" target="_blank">As late as 1978</a>, interest rates on loans were governed by local state usury laws. Based on biblical moral and ethical considerations, these local regulations placed modest limits on interest rates charged by banks in a particular state. Just like our own advocates for selling health insurance across state lines, the national banks lobbied back then for the ability to lend across state lines, which means that the bank home state governs the interest rates in all other states. In 1978 the Supreme Court ruled in favor of the banks, and in 1980 Congress passed formal legislation to that effect. The result, as surprising as that may be, was not fierce competition between banks offering the lowest possible interest rates in all states. Instead, some states immediately removed all caps on usury in order to attract big banks, and high interest rates spread like wildfire, rendering state protections against usury irrelevant.<br />
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With a little more help from the Court, the same deregulation was applied to credit card late fees in 1996, with the same typical free-market results for citizens who watched their late fees quadruple. To create the appearance of efforts to counteract the disastrous effects of deregulation on interest rates, the Federal government created the Consumer Financial Protection Bureau, an agency with no power to do anything of consequence, and which is currently busy spending taxpayer money on a <a href="http://www.huffingtonpost.com/adam-levin/this-government-database_b_5447686.html" target="_blank">mega database</a> containing “more information than most people can remember about themselves”, financial, personal and social. The parallels to health care should be self-evident.<br />
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And then of course there is the saga of the Glass-Steagall Act of 1933, which enforced the separation between banking, insurance and dealing in securities, because mixing these activities was seen as a conflict of interest and an increased risk to bank failures. Glass-Steagall was repealed in pieces, with the death blow delivered by the Financial Modernization Act of 1999. Financial institutions merged and integrated vertically and horizontally into gigantic experiment labs for innovative financial instruments with no oversight and no accountability. The results came home to roost in 2008, with millions of people kicked out of their homes while their taxes were diverted to feed the gargantuan players of free financial markets. We never had a Glass-Steagall in health care, but watching hospitals merging, gobbling physician practices and morphing into underwriters, while insurers are expanding in the opposite direction, is more than enough to trigger that spooky déjà vu feeling.<br />
<h4>
Savings</h4>
Health Savings Accounts (HSA) are another financial instrument beloved by free-market advocacy groups. The idea is to allow people to spend their own money as they see fit, instead of forcing them to buy government defined insurance benefits. To sweeten the deal, HSA moneys are not taxable. HSAs are usually paired with so called catastrophic health insurance to cover life’s major disasters. The theoretical logic favoring HSAs is impeccable. Why should you buy insurance for things you don’t need? Why should you buy insurance for routine services you know you will need and are able to budget for, just like you budget for oil changes for your car, haircuts, gutter cleaning and such? Just imagine how expensive all these things would become and how little choice you would have, if you paid for them with insurance. Fair enough.<br />
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There is one small problem though. According to a recent <a href="https://www.federalreserve.gov/2015-report-economic-well-being-us-households-201605.pdf" target="_blank">Fed report</a>, “forty-six percent of adults say they either could not cover an emergency expense costing $400, or would cover it by selling something or borrowing money”. Another survey from <a href="https://www.gobankingrates.com/personal-finance/data-americans-savings/" target="_blank">GoBankingRates</a> found that “nearly seven in 10 Americans (69%) had less than $1,000 in their savings account”. A <a href="http://gothamist.com/2016/11/26/more_than_half_of_all.php" target="_blank">new study</a> from the Association for Neighborhood & Housing Development finds that “more than half of New Yorkers are one paycheck away from homelessness”. These are not “just” the traditionally poor people in inner cities, rural boonies, Appalachian trailer parks, or however your pampered mind imagines poverty in America. This is the middle class. <a href="http://www.theatlantic.com/magazine/archive/2016/05/my-secret-shame/476415/" target="_blank">These</a> are the “nice” people you see every day all around you. So how much funding do you think will be going into those spiffy HSA accounts? Not much. <br />
<h4>
Catastrophic Care</h4>
This week, President-elect Trump picked Rep. Tom Price, a former orthopedic surgeon, to be the next Secretary of Health and Human Services, and Dr. Price is a man with a <a href="https://tomprice.house.gov/HR2300" target="_blank">plan</a>. The plan is to replace Obamacare with age adjusted, tax credits and HSAs, while making the same model available to employers, Medicare and Medicaid too. People would use the tax credits to buy catastrophic health plans across state lines, and deposit the difference in their HSAs to cover routine health care. Sounds good until you realize that the tax credits proposed by Dr. Price are ridiculously low and would cover less than half the cost of a catastrophic insurance plan. Now, it is possible, that once all Obamacare protections are removed, trashy little health plans, priced exactly the same as the tax credits, will return to the marketplace, but I seriously doubt that anything will be left over for HSA deposits. I’m willing to bet that the majority of employers will jump at the chance to extend the same parsimonious offer to their employees.<br />
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Once the Medicare modernization features of Dr. Price’s plan are also implemented and Medicaid gets cut and tossed into the lap of perpetually bankrupt states, America will finally achieve universal catastrophic health care. Let me dispel the bleakness for a brief moment though. Dr. Price’s plan has all sorts of great features for doctors. Malpractice insurance reform, freedom to provide cash services to Medicare beneficiaries, freedom to balance bill, some relief from regulatory burdens and a seat at the table for medical associations, are all included in the plan. It is also quite possible that physicians in non-catastrophic specialties will get to enjoy some well-deserved leisure time. I can’t imagine too many non-catastrophic customers, flush with non-existent HSA cash, banging on their doors. <br />
<h4>
Augment and Replace</h4>
Mr. Trump has a mandate to replace Obamacare with something “terrific”. He has a mandate to defend Medicare, Medicaid and Social Security. Those are the things he campaigned on and this is the mandate that comes with his election, nothing more and nothing less either. The conservative apparatus that rode into power on his surprisingly long coattails has no independent mandate. Donald Trump was elected President of the United States by the people of these United States in spite of the Republican Party not because of it. We did not send Mr. Trump to the White House to help Speaker Ryan and his conservative posse of faux intellectuals to dismantle the big bad “welfare state”. I can only hope that the President-elect understands that the manufactured urgency of repealing Obamacare, while blowing up Medicare, is nothing but a shrewdly laid trap for him personally, for his presidency, and for the American people.<br />
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It may be helpful to remember that for each Obamacare frustrated person, there is at least one fairly content person, and many if not most of those content people are less affluent, mostly white, working families who either receive large subsidies or have become eligible for Medicaid. These are the forgotten workers Mr. Trump promised to speak for, fight for and win for. Yes, Obamacare needs to be replaced, and the best and safest way to replace it is not to repeal it, but to augment it. Try selling insurance across state lines if you must. Add options to pair catastrophic plans with HSAs. Heck, while you’re at it, might as well try an experimental public option. And sure, get all your anti-abortion stuff in there to keep the faux intellectuals happy. Let people choose what works best for them, because free people trump free-markets every single time, and that is truly terrific.Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com1tag:blogger.com,1999:blog-3503957686158274288.post-41130503500556718672016-11-21T08:54:00.000-06:002018-12-01T09:24:51.948-06:00Call to Action: Organizing for Patient Care<h4>
<i>By</i> NIRAN S. AL-AGBA, MD and MARGALIT GUR-ARIE <span class="post_author"></span> </h4>
On November 8th America elected a President who ran on a promise to restore government of the people, by the people, for the people (among other things). However, we cannot expect such government to be given to us on a silver platter, no matter who resides in the White House. We must build it ourselves, by definition. Government of, by, and for the people requires the people to stand up and do more than just vote every four years, do more than author clever blogs, do more than compose brilliant tweets, post cynical quips or write constructive comments on the websites of power. Self-government requires informed citizens with a vision to organize, mobilize, and take purposeful action.<br />
For the last eight years we engaged in all of the former and none of the latter. We know many of you are in the same predicament. We are the everyday people and frontline doctors everybody in government is supposedly trying to help. We don’t entirely doubt the intent, but the end results have been so much less than we want, so much less than the American people deserve, so much less than we know is possible. We come from vastly different backgrounds. We have diametrically opposed political ideologies. We have a broad and dynamic spectrum of prescriptions for how health care in America should work. This is our strength.<br />
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You may be elated by the 2016 election outcome; you may be on the fence, indifferent, worried, depressed or positively enraged. Whether you love it or hate it, you cannot deny that something extraordinary happened on November 8th. Whether you think disaster breeds opportunity or victory itself is the opportunity, let’s “seize the present; trust tomorrow even as little as you may” and try to gain some control over our personal and professional fates. <br />
<h4>
Call to Action</h4>
We would like to propose that we organize a workgroup of physicians and people with interest in health care to create evidence and consensus based guidance and recommendations for the new administration as it undertakes major changes in health care policy, legislation and regulation. Our initial thoughts are that we create an objective position paper to address the impeding changes to current health care legislation, free of political and partisan shenanigans. Our dreams are that this grows into a perpetual grassroots advisory group which brings real-world experiences, varied points of view and wisdom from the frontlines of medicine and from everyday life into the hallowed halls of government to inform the work of public servants.<br />
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If you think the American people and their doctors should have a voice in governance, if you believe the welfare of your patients stands above politicking, if you want to amplify your voice and the voice of others, please join us. If you think you can contribute a small amount of time to such effort, we invite you to kick start this endeavor. You can remain anonymous if you so choose. You can contribute as much time as you have available. You can choose how, when and what. Let’s leave the actual details open and brainstorm together how best to move forward quickly.<br />
<h4>
Let’s Roll</h4>
Are you all in? Would you prefer to dip your toes in the water first?<br />
Email us today: mga111026 at gmail.com<br />
We will communicate via email to set up a conference call and take it from there. We will do the housekeeping, bottle washing and ashtray emptying to get us started. For those who already expressed enthusiasm (or guarded interest) on Twitter and elsewhere, retweet, spread the word and let’s make this happen. It’s time.<br />
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<br />Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com0tag:blogger.com,1999:blog-3503957686158274288.post-75257298558803198372016-11-12T00:57:00.000-06:002016-11-28T02:11:26.964-06:00Is the Better Way Really Better?<h4>
<i>Dear President-elect Trump,</i></h4>
The American people, myself proudly included, chose to send you to Washington DC to do their bidding. That’s what happened on November 8th 2016. Everything you hear now from the elite punditry is aimed at obfuscating this simple truth. Forget about dainty glass ceilings, we the people were able to break through the fortified ramparts erected by entrenched money and power and exercise our right to govern ourselves. I would caution the smug intelligentsia against underestimating the wisdom of the people once again, and I would caution you against forgetting who sent you there and why we did so. We now know we have the power, and what the people giveth, the people can taketh away.<br />
<h4>
RyanCare</h4>
The ecstatic welcome you received from Paul Ryan and Mitch McConnell the other day looks more like an act of violence than one of true reconciliation. Fair weather friends are usually there because they want something, and in this case they want to hijack the people’s agenda and replace it with their own conservative garbage. Mr. Ryan in particular has been proposing bogus alternatives to Obamacare with alarming regularity. Similar to Obamacare, Mr. Ryan’s health reform plan is based on belief in his own superior intelligence and devoid of any evidence that it can indeed work. Unlike Obamacare, the Ryan plan is also based on the assumption that helping the poor get poorer and the rich get richer is the ultimate role of government.<br />
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A few days before this historic election, I used your Old Post Office renovation project to highlight the <a href="http://thehealthcareblog.com/blog/2016/11/03/dear-quite-possibly-president-trump/" target="_blank">big picture</a> facets of health care in America in ways you can easily relate to. It will be very helpful if you read that first, believe me. From reading your latest Obamacare repeal and replace literature, I am starting to think that you are about to swallow Mr. Ryan’s fantasy hook, line and sinker. I would like to remind you that on the campaign trail you promised to replace Obamacare with “something terrific”. In keeping with tradition, the GOP <a href="http://abetterway.speaker.gov/?page=health-care" target="_blank">Better Way</a> may be great for GOP corporate donors, but for us, it is anything but terrific.<br />
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Have you read Mr. Ryan’s plan, Mr. President-elect? I suggest you do, and I suggest you ask your old friend Chuck Schumer to bridge an introduction to Bernie Sanders, who is perhaps the only other elected public servant not beholden to lobbyists and special interests. If I had to summarize the difference between RyanCare and Obamacare I would say that whereas Obamacare is providing people with a government defined set of health care benefits, RyanCare is proposing to make a government defined financial contribution towards purchase of health insurance. This difference extends to all insurance including Medicaid and Medicare, with RyanCare essentially dismantling Lyndon Johnson’s 1965 landmark legislation. I know you’re now in the “take the lumps out, son” phase, but some lumps were just meant to be taken as is. <br />
<h4>
Industrial Care</h4>
While Obamacare and RyanCare differ on how they finance health care services, they are unsurprisingly similar when it comes to controlling health care delivery costs, because this portion of both nightmares was dictated by corporate lobbyists and special interests. When you leave medical decisions in the hands of millions of people interacting with hundreds of thousands of doctors in unique ways, the result is utter chaos, or what we call freedom. The Obamacare lieutenants decided early on that the best way to exert control over costs is to industrialize health care. You have to admit that this sounds pretty tempting. Industrialization has made lots of things cheaper and often better and more reliable. The conservative Ryan plan, which is by definition dismissive of workers and non-wealthy people in general, went all in with this aspect of Obamacare.<br />
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But here we are attempting to industrialize people. Not only is this impossible without enslaving humanity as a whole, but these futile attempts at industrialization are costing us a fortune. This is the fundamental round-hole-square-peg paradigm plaguing both Obamacare and RyanCare, because insurance prices are driven by the prices of goods that are being insured and you cannot have affordable insurance prices for unaffordable products. During the 2008 election season, President Obama made fun of Mrs. Clinton’s proposal to mandate that everybody buys health insurance, because it would be like trying to solve homelessness by mandating that all homeless people buy a house. A couple of years later he did precisely that. RyanCare on the other hand is turning health care into a food stamps program.<br />
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<b>Here is the most important piece of health care information you’ll ever need: </b>When you go to a doctor who runs his or her own small business, you pay half as much as when you go to a doctor that is employed by a large health conglomerate, and you get better care to boot.<br />
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To be fair, consolidation of health care started decades before Obamacare, but the Obama administration trifecta (the 2009 Stimulus, the 2010 Obamacare and the 2015 MACRA) made consolidation of health care providers pretty much mandatory. In a perverse and illogical way, this set of laws ensures that excessive health care prices are baked into this cake in perpetuity. In particular, the bi-partisan and fairly new MACRA legislation represents a complete regulatory capture of medicine, its transition to indentured servitude to moneyed interests, and hundreds of billions of health care dollars wasted. Get rid of MACRA Mr. President-elect. Replace it with what Sen. Tom Cotton suggested on the floor right before the Senate voted on it. You do that and you are 90% where we need you to be.<br />
<br />
The other day I listened to your favorite negotiator, Mr. Carl Icahn, and his description of how excessive regulations are killing our industries by discouraging capital investment in new machines, which in turn suppresses productivity growth, leaving stock buybacks the only venue for CEO enrichment. Health care is different. In health care, regulatory capture mandates the purchase and expensive operation of machinery that is designed to kill productivity, which leaves consolidation to gain market power, the only revenue enhancing alternative. MACRA is the final, and still removable, nail in this coffin. Whatever you do with Obamacare, if you leave MACRA in place and allow the passage of the 100% lobbyist crafted 21st Century Cures Act, it will all be for naught. To put it in construction terms, if your remodeled Obamacare is the building, MACRA and the Cures Act, are the termites and black mold devouring it from within.<br />
<h4>
Words that Go Bump in the Swamp</h4>
I know the President of the United States sets the tone, but cannot possibly be delving into policy details. Unfortunately, Mr. President-elect, policy details is where corruption lives. You may not be bound by allegiances to money and power, but your political appointees will be. Big league. They will come to you with executive summaries, both written and verbal, so here are three of the most common, most potent and most dishonest health care buzzwords. You should never use them, and you should never use advice from any swamp dweller that is using them, because these are code words for defrauding the public and we, the public, know that, and we are watching carefully. As simple as that.<br />
<br />
<b>Patient-Centered</b> – Every calamity in health care is patient-centered. Every time you hear or read patient-centered, repeal and replace it with “circular firing squad”. The most common usage is to demand “transformation to a patient-centered model of care”. Now, you’re a smart man, think. What the hell does that mean? Try these: guest-centered resort, golfer-centered club, gambler-centered casino. See what I mean? People who pitch patient-centered ideas are known as “thought leaders” or “industry experts” and are invariably looking to fleece either doctors or taxpayers or both.<br />
<br />
Patient-centered means big health systems using big computers to collect and analyze personal information of patients and target them for certain services that optimize payments and revenues for the system. Very much like the RNC campaign software worked to target voters for you. You think that system was voter-centered? With that answer in mind, perhaps it would be a good idea to remove that patient-centered reference from your website and fire whoever put it there. You are supposed to be the authentic one, remember?<br />
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<b>Value-Based</b> – This is a very simple one to understand, because as a businessman, you should know what value-based pricing means, and you should know that it is not something that has the buyer’s welfare in mind. You should also be cognizant of the fact that value-based schemes are intended to enable wealthy patrons to purchase better stuff, while the masses are kept content with generic, cheap stuff. This may work well for socks, but this is not how health care can or should operate. There is no such thing as generic versions of coronary bypass surgery, or buy-one-get-one-free dollar-store stents.<br />
<br />
Value-based care is the key to the regulatory capture of medicine. Its sole purpose is to herd doctors and the working class into cheap, substandard systems of health care, and use the leftover money to enrich a vast array of special interests, ranging from insurance companies, think tanks, Silicon Valley vultures, and all the way to software developers in India and computer manufacturers in China. Like all fraudulent schemes to steal hundreds of billions of dollars, this is a huge and very complex subject, but for now you just need to beware people carrying value-based health care solutions. Treat them like they were carrying the plague.<br />
<br />
<b>Transparency</b> – I heard you read this term from the teleprompter in a speech about health care. I know you didn’t put it there. Please, stop. President Obama promised the nation that his will be the most transparent administration in history. It ended up being the exact opposite. You said many times during your rallies that you are struck by how smart the American people really are. You were correct in that assessment. We may not look smart, or sound smart, but we are smart and you, of all people, should sympathize with our predicament. We know that a promise of transparency is only necessary if the enterprise is a secretive sham. When you promise transparency in health care prices, we know that we are about to be brutally beaten, raped and robbed. Transparently.<br />
<h4>
Bottom Line</h4>
We did not vote for you because we fell in love with the Republican Party elitist agenda. If that were the case we would have elected Mitt Romney in 2012 or Jeb! in 2016. We picked you precisely because we recognized that the conservative agenda, much like the progressive agenda, is an anti-working people agenda. We know what “defined contributions” are. We know what “vouchers” imply. We know what “skin in the game” means for us. And we know what the synonyms for “modernizing” Medicare and “block granting” Medicaid are. Thanks, but no thanks. We didn’t take much of your campaign-trail bluster literally, but we took your promise to be our voice seriously. Consider this a friendly reminder from the deplorable gallery.<br />
Godspeed Mr. President-elect!Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com0tag:blogger.com,1999:blog-3503957686158274288.post-16994399478138063622016-11-04T12:23:00.000-05:002017-12-26T23:22:39.167-06:00Our Deplorable Health Care<div class="separator" style="clear: both; text-align: center;">
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Even the most ardent Obamacare supporters are now forced to admit that the law has hit a rough patch this year. The opposition to Obamacare is positively gloating with self-congratulatory “I told you so” assessments of the supposedly dire situation. Defenders of the cause are counteracting with the customary deluge of charts and graphs to prove unequivocally that Obamacare is actually turning out better than they expected. Integrity and honesty being in short supply on both sides of this quandary, chances are excellent that no matter what happens next, the American people will lose big league, unless….<br />
<br />
If Mrs. Clinton becomes the next President of the United States, Obamacare will survive largely unharmed with a few minor tweaks to address a few minor initial oversights, best summed up by <a href="http://www.nytimes.com/2016/10/03/us/politics/obama-health-care-act.html?_r=0" target="_blank">Sara Rosenbaum</a>, a professor of health law and policy at George Washington University: “The subsidies were not generous enough. The penalties for not getting insurance were not stiff enough. And we don’t have enough young healthy people in the exchanges.” To complete the solution, Mrs. Clinton may very well throw in an option to buy into a Medicaid managed care plan for rural hillbillies (similar to the Arkansas “innovation”), and call it “the public option” to make the lefty wing of her party happy.<br />
<br />
If Mr. Trump becomes the next President of the United States, Obamacare will come under vicious attacks. Mr. Trump, who is running as a Republican, adopted the GOP “repeal and replace” Obamacare battle cry pretty much verbatim. On Tuesday, one week before the election, at Valley Forge of all places, the Trump team unveiled its alternative to Obamacare. There was not much under that veil: selling insurance across state lines, health savings accounts, price transparency and Medicaid block grants to states, along with a commitment to retain the preexisting conditions clause and to have a transition period so nobody gets hurt. Team Trump didn’t even try to come up with a serious solution and I’m glad they didn’t, because it would have been incredibly dumb if they did, and because this gives me an opportunity to make my case.<br />
<br />
~~~~~~~~~~~~~~~~~<br />
<br />
<b><i>Dear (perchance) President Trump,</i></b><br />
<br />
I know you don’t know much about health care, and that’s okay, why should you? You probably know that health care isn’t working well in America. Very few things seem to be working as well as they should or as well as they used to work. This, after all, is why you say you ran for President. There is unanimous agreement that health care needs to be made great again. The disagreement is on how to go about it. On the campaign trail, you had to come up with something to throw against Obamacare, which is fine, but now you have to actually fix it and those are two very different things, as all Presidents before you discovered to their chagrin, so here are a few Obamacare points to keep in mind.<br />
<ul>
<li>Obamacare cannot be repealed and replaced in one stroke. It’s a lovely catchy phrase, but Obamacare is massive legislation that begot more legislations, such as MACRA (look it up), and thousands of regulations, many already fully implemented, others in various phases of implementation. Money has been spent, mergers and acquisitions have occurred, companies have been funded, contracts have been awarded, people have been hired, and this sea of change is engulfing private and public sectors inside and outside health care to the tune of $3 trillion dollars annually. You cannot change 20% of the economy the first day in office. Not even if you know precisely how you want to change it. And you don’t. My advice here is to settle down for the long haul.</li>
<li>Obamacare doesn’t need to be repealed at all. It just needs to be gradually replaced. It’s like renovating the Old Post Office with the tenants living in the building through the entire project. It’s very tricky because the end results are paramount, but the process itself is as important. The tenants, you see, are the American people, and you work for us now, and I assume you don’t want to get fired mid project. We expect you to come in under budget and ahead of schedule, of course, but we also expect no dust or debris in the lobby, no beams crashing on our heads, no interruption in utilities, and very little noise, and you promised not to disappoint us. It’s going to be wicked hard, but we know you can do it, hence our vote.</li>
<li>Obamacare is not health care. Obamacare is the two bit façade they slapped on our health care. Fixing health care is precisely like renovating a building. Sure, you have to rip off the cheap paint and plaster, but you don’t start demolishing things like a bat out of hell, do you? First you get engineers to assess the building, its structural integrity, its surroundings and its potential or lack thereof. You get architects to look at blueprints, floor plans, shafts, beams, columns, electric, gas, water, HVAC, etc. You do some market research to see what people want and can afford. Then and only then, you make new plans, you make schedules, you price and choose materials, you bargain and fight, you hire workers, and the fun begins. I’m pretty sure you know what happens if, at any point, you skimp on prep work.</li>
<li>Obamacare was put together by political hacks who serve special interests and their lobbyists, and by ideologues who think the American people are too stupid to care for themselves. Obamacare in its totality is a corrupt entitlement system for large health care corporations and for Silicon Valley. If you assemble the conservative version of the Obamacare team of scavengers, your will fail. If you accept the perfidious, back-stabbing, premises of the Ryan plan to gut health care for the people who voted for you, you will fail. If you want to fulfill your promise to the American people, you’ll have to bypass the punditry swamp, put on a hardhat and go down to where health care happens and get your information first hand and free of charge.</li>
</ul>
Obamacare is irrelevant. Obamacare is at a minimum a distraction and at a maximum an impediment to affordable, high quality health care, because Obamacare misses the point entirely. I am sure you know from personal experience that in America one can get the best health care in the whole world, if one belongs to the privileged elite. What needs to be fixed is the distribution of health care across the nation. Not to disparage your “policy” speech at Valley Forge, but perhaps you should consider that the health care Inferno is nine circles deep, and what you see at first blush is just a hint of the horrors that lay beneath. <br />
<ul>
<li>Health care is too expensive in America because America has become too poor. Health care is too expensive because American workers didn’t get a meaningful pay raise in decades. Health care is too expensive because poor people tend to be sicker and so are their children. Health care is too expensive because there are too many middlemen and regulators between doctors and patients taking profits for busywork that adds no value. And most of all, health care is too expensive because politicians must pay back for their last campaign, and raise money for the next. </li>
<li>Health care is not a “consumer” product or service, and as Bill Clinton said, health insurance is not like auto insurance or home insurance. People don’t want to “shop” for medical care like they shop for hotels or shoes. It is frightening and humiliating to shop for your life or the life of your child. Imagine if you had to do that in a dire situation and understand that all people feel the same way (even the deplorable ones). Price transparency is just a load of crap. It’s one of those empty phrases politicians use to hoodwink voters. You are not a politician, so don’t do it. Just say no. </li>
<li>Free market for health care will work as well as free trade is working for the economy as whole. There is no such thing as free trade or free markets. There never has been and never will be. Trade and markets are manipulated and defined by the shrewdest and strongest participants. Sick people of limited means are no match for global corporations that managed to bring our entire government to its knees. Free market health care will leave most Americans with no doctors, no medicine and no care, just like free trade left us with no factories, no jobs and no income. You offered to be our voice, to fight for us and drain that swamp. There is no bigger swamp than health care in America.</li>
<li>Just take a look at the disgrace called Medicaid. No, seriously, look at it. Tossing block grants over the wall to states that are even more corrupt than the federal government, and washing your hands of the whole mess, will just make things worse. Remember that the vast majority of people on Medicaid are employed. They are employed in those new and improved crappy jobs that replaced manufacturing. Medicaid is now a penny-vacuuming machine that treats both doctors and patients like trash (with all due respect to your VP). Here is a litmus test for health care plans: would anyone you know be okay with getting care through Medicaid? Are any doctors you know okay with working for Medicaid? No? Neither is anybody else. You can’t fix health care without fixing Medicaid. </li>
</ul>
I don’t know how to fix health care. No matter how loudly they scream, how certain they are that theirs is the absolute truth, and how vigorously they waive their illustrious credentials, nobody knows how to fix health care. Nobody. My suspicion is that we are trying too hard. Health care is overmedicated with solutions that have toxic side effects, for which we apply other solutions with even higher toxicity, and before you know it a mild case of the flu starts to look like metastatic cancer. So what should you do on your first day in office? Anything you want, anything at all, anything but health care.<br />
<br />
Take your time. Find the real health care still flickering underneath the suffocating layers of Obamacare and its bloated legislative and regulatory progeny. Find real doctors who still care for the health of real patients as they did before health care became a national trough for consultants, lobbyists and other fancy thieves. Beware the experts carrying charts and graphs and big data. Ask <a href="http://www.inc.com/jeff-bercovici/peter-thiel-startup-red-flags.html" target="_blank">Peter Thiel</a> about “big data” and “machine learning” and do trust him on this one. The daunting complexity of health care is largely due to greed, fraud and treachery. If you want to make health care great again, work hard to make health care simple again.Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com4tag:blogger.com,1999:blog-3503957686158274288.post-47015305377527637992016-09-01T09:17:00.000-05:002016-09-01T09:17:14.816-05:00The Dog Whistles of Health Care<div class="separator" style="clear: both; text-align: center;">
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Discrimination in health care was institutionalized in Independence, Missouri on July 30, 1965 when President Johnson signed the Social Security Amendments of 1965 into law, <a href="https://www.princeton.edu/~starr/articles/articles14/Starr_LBJ_HC_Legacy_1-2014.pdf" target="_blank">creating</a> “two moral frameworks for public financing of healthcare”. Medicare was supposedly an “earned” right for the elderly, while Medicaid was framed as a “welfare” program for the poor. It was a necessary political compromise. It was just a first step and bigger and better things would certainly be accomplished in due course. It was better than nothing. But fifty years later, and after taking yet another “first step” with Obamacare, the wasteful, divisive, discriminatory, and ultimately self-defeating direction we chose back in 1965, and again in 2010, has not changed one bit.<br />
<br />
After 45 years of tinkering with Medicare and Medicaid, Obamacare in a bold stroke expanded the welfare model of medical care upwards into the heart of what used to be known as the American middle class, the former engine of progress and prosperity. First, Obamacare expanded the Medicaid program itself to include people who are less poor than current Medicaid recipients. When Medicaid opened its doors in 1966, it provided charity health care to <a href="http://www.statista.com/statistics/245347/total-medicaid-enrollment-since-1966" target="_blank">approximately</a> 2% of Americans. <a href="https://www.medicaid.gov/medicaid-chip-program-information/program-information/downloads/june-2016-enrollment-report.pdf" target="_blank">Today</a>, over 22% of Americans (72.6 million) and almost half of our children (35.3 million) are receiving their medical care via this welfare program and the numbers are trending sharply upwards. <br />
<h4>
Gift Horses</h4>
But the greatest innovation of Obamacare is undoubtedly the Health Insurance Marketplace, which is a brand new welfare program for the middle class. People who are not deemed poor enough to receive Medicaid charity can obtain Federal medical assistance on a means-tested sliding-scale. Largely unbeknownst to them, another <a href="https://aspe.hhs.gov/sites/default/files/pdf/187866/Finalenrollment2016.pdf" target="_blank">10.5 million</a> working Americans were placed on welfare while “shopping” for health insurance in 2016. <i>These people</i> are reportedly rejoicing their good fortune, because Obamacare is better than anything <i>these people</i> ever had, or could ever hope for.<br />
<br />
In recent days, <a href="http://www.huffingtonpost.com/entry/aetna-obamacare-pullout-humana-merger_us_57b3d747e4b04ff883996a13" target="_blank">Aetna</a> announced that it will drastically reduce its participation in the Obamacare marketplaces, joining a long string of other health insurers, including giants like United Healthcare and Humana, and small local outfits like <a href="http://healthcare.dmagazine.com/2016/08/24/first-united-then-aetna-scott-white-and-now-oscar-analyzing-the-2017-marketplace-after-big-name-exits/" target="_blank">Scott & White in Texas</a>, all of which cited massive financial losses in this market. It looks like next year the many “choices” available to <i>these people</i> in the Obamacare marketplace will be <a href="http://www.nytimes.com/2016/08/20/upshot/obamacare-options-in-many-parts-of-country-only-one-insurer-will-remain.html" target="_blank">severely curtailed</a>, particularly in <a href="http://thehill.com/policy/healthcare/292019-how-obamacare-is-splitting-in-two" target="_blank">areas</a> where poor, uneducated, low-information voters reside. The “choices” were not great to start with, seeing how most Obamacare plans rely on managed care provided by narrow networks of doctors and hospitals, and the level of charitable support is fixed, regardless of your “choice”. The optics of many choices was there to create an illusion of consumers “shopping”, as opposed to just having people apply for welfare.<br />
<br />
The price for sparing <i>these people</i> the social stigma of being on welfare turned out to be not only too high, but also too low (think Escher paintings here). People who qualify for Medicaid are <a href="https://www.healthcare.gov/medicaid-chip/getting-medicaid-chip/" target="_blank">prohibited</a> from “shopping” on the Obamacare marketplace, unless they are willing to forgo handouts and pay full price, because a “Marketplace insurance plan would cost more than Medicaid and usually wouldn’t offer more coverage or benefits”, and a government website proudly <a href="https://www.medicaid.gov/medicaid-50th-anniversary/overall-medicaid/overview-medicaid-anniversary.html" target="_blank">declares</a> that Medicaid “generally provides a more comprehensive benefit package than private insurance”. If this is true, the Obamacare architects decided to pay private insurers on the marketplace more for less, which is not preventing insurers from bleeding cash. On the other hand, some of the same insurers, and many others, seem to be making money hand over fist in the Medicaid market which pays less for more.<br />
<br />
How is that for a brain twister? Yes, yes, I know, if you are a physician and you accept Medicaid, you know precisely how to untwist this nasty little knot, but this narrative was not created for you. The first thing, or person (loosely speaking) to remember here is Jonathan Gruber. A while back Mr. Gruber shared with us that the <a href="http://thehill.com/policy/healthcare/223578-obamacare-architect-lack-of-transparency-helped-law-pass" target="_blank">guiding principles</a> in the rooms where Obamacare was designed were that American voters are stupid and that lack of transparency is a good thing. It should be obvious by now that the introduction of Obamacare to the public was false and its initial incarnation, chockfull of choices, “subsidies”, marketplace “shopping” and all, was (designed to be?) temporary. But hey, it was just a first step and it was better than nothing. So what’s next?<br />
<h4>
The Morning After</h4>
As is the custom in our great nation, now that Obamacare marketplaces have been exposed as the hoax they really are, the cheerleading section is transitioning to its Monday morning role of funeral criers. Every ‘splaining media outlet is diving into lengthy treatises about risk pools, moral hazard, actuarial values, complete with charts and “I told you so” interviews on how to salvage the situation. The government, as usual, is doubling down on the “everything is (still) awesome” anthem of planned stagnation. Insurers leaving the marketplace are a sign of normal competitive business. Sky rocketing premiums are a result of initial underpricing of products. Things will eventually even out. And besides, why worry your little head about premiums going up or down, if <a href="https://aspe.hhs.gov/sites/default/files/pdf/206741/APTCMarketplace.pdf" target="_blank">the government is paying for the ride</a>?<br />
<br />
See, the more the premiums go up in 2017, the more people would be able to pay less for marketplace plans. This is because very poor people are <a href="http://cahc.net/wp-content/uploads/2016/07/CAHC-IssueBrief_ExchangeEnrollment_061616.pdf" target="_blank">disproportionately</a> more likely to use the Obamacare marketplace, and <i>these people</i> seem to have a predilection for cheap health insurance plans. Theoretically, all Americans except the 20% or so at the top (the <a href="http://familiesusa.org/product/federal-poverty-guidelines" target="_blank">fifth highest income quintile</a>), are eligible for welfare in the marketplace if their stars fall slightly out of alignment. Right now, the self-appointed elites are piloting this marketplace solution for people who have few if any choices in life in general, but make no mistake, the forthcoming rollout to the rest of us will be fast and furious.<br />
<br />
After you read a dozen or so articles on the subject, several options surface as the popular wisdom of the unpopular elite minority who won’t be caught dead anywhere near an Obamacare marketplace:<br />
<ul>
<li>On autoplay since 2012 – Repeal and replace the whole darn thing with something really good.</li>
<li>Whistling past the graveyard – Stay on target. Ignore the noise. Keep pushing the happy narrative. Nothing to see here. Next year will be better.</li>
<li>Pedal to the metal – Add some serious fangs to the individual mandate. Force insurers to eat their marketplace veggies if they want public cash desserts. </li>
<li>Resurrection – Remind me, why did we drop that “public option”? What was it again?</li>
</ul>
Plebeian logic says that at least for the immediate future we will be whistling past the graveyard of health care in America. After that, as strange as it may sound (go ahead and bookmark this), they will be rolling all four option into one grand solution.<br />
<h4>
The Pauper Option</h4>
If you are eligible for Medicaid in the state of Louisiana for example, you have five choices, which is more than some Obamacare marketplace “shoppers” have. On the <a href="https://www.myplan.healthy.la.gov/LASelfService/en_US/choose.html" target="_blank">Healthy Louisiana</a> website, you can enroll, select a plan, compare plans, compare networks of providers, and compare plan benefits, including co-pays, cash rewards for healthy behavior, free cell phones and even free diapers and school supplies. Is this a marketplace? I think Healthy Louisiana is as much a marketplace as the Obamacare Venezuelan shopping mall. It provides infinitely more information. It includes plans from Obamacare quitters, such as Aetna and United Healthcare. The state pays less, beneficiaries get more, and insurers make very nice profits.<br />
<br />
In Baton Rouge, there is one (1) oncologist in the United Healthcare network and zero (0) plastic surgeons in the Aetna network. Sometimes, you just have to travel to New Orleans, Shreveport or Lafayette. It’s only a few hours by car. Most people don’t need oncologists and plastic surgeons. Most people are perfectly fine just having 100 family practitioners, almost half of which are doctors. In Louisiana, Medicaid pays <a href="https://www.lamedicaid.com/provweb1/fee_schedules/FEESCHED.pdf" target="_blank">$41.53 for a typical office visit (99213)</a>, which is a bit more than half the Medicare rate, and usually less than half of what private insurers pay. With a full time schedule, and average overhead, a primary care doctor seeing nothing but Medicaid patients in Louisiana, will end up with $100,000 to $130,000 a year before tax.<br />
<br />
This is the secret sauce. This is what’s missing from the Obamacare marketplaces. There may be room for additional tinkering with networks, but it won’t be enough. The only way to bring costs down is to attack the supply chain. Like Walmart. Like Medicaid. But you can’t do it if you have to compete in earnest, because you will lose all your suppliers. Everybody has to do it together, and that would be collusion. So you either merge & acquire until you are the sole insurance provider in a market, or you make the government do it for you. Either way, we end up with a marketplace of Medicaid plans. Like Healthy Louisiana.<br />
<br />
Before you argue that physicians will just stop accepting Obamacare marketplace plans, remember that many, many doctors do take Medicaid and adding 12.5 million people from the marketplace to the 72.6 million already on Medicaid is not a big deal at all. This is why insurers that specialize in Medicaid do better on the Obamacare exchanges. It’s not that they know how to <a href="http://www.washingtonexaminer.com/insurers-secret-to-winning-at-ocare/article/2600240" target="_blank">manage</a> <i>these people</i>. They know where to find and how to manage <i>these doctors</i>.<br />
<br />
They probably won’t call it Medicaid. Maybe Medimart will be acceptable. It will most likely cost a little more to maintain the appearance of respectability, at least for a while, but this is a generous program for <i>these people</i>. The line is drawn at 400% Federal Poverty Level (FPL), and as the global sharing economy grows, and as employers begin to see the light, those who can’t quite reach six figures incomes, eighty percent of people in America, will be “shopping” at Medimart, because that’s what <i>these people</i> do.Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com1tag:blogger.com,1999:blog-3503957686158274288.post-28913192225185767922016-08-08T09:00:00.000-05:002016-08-08T09:00:05.347-05:00Open Letter to Senator Bernie Sanders<div class="separator" style="clear: both; text-align: center;">
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Dear Bernie,<br />
<br />I was one of the gullible liberals who thought and vehemently argued for months on end that you could win the Democratic Primaries fair and square. After all if a rookie billionaire with zero political credibility and a spotted past could win the Republican nomination, why wouldn’t an unimpeachable United States Senator be able to do the same in my party? We both know the answer(s) to that, don’t we, Senator? You chose the high road when all was said and done, but was that the right road? I have no doubt that your entire career and this ill-fated campaign in particular were driven by a desire to lift the exploited, the downtrodden, the poor and the excluded to their rightful place in a government of the people, by the people, for the people. In which case, Senator, you are now squandering the opportunity of a lifetime to change history in a way no one else can, or ever could, or will ever be able to even try.<br />
<br />You may be telling yourself that once you failed to win from the outside, the smart choice was to fight from the inside. You may be taking great pride from that lefty progressive platform you managed to negotiate. When was the last time any President felt hamstrung or guided in any way by the party platform? Ninety-nine percent of the public doesn’t know what the party platform looks like. It’s an empty achievement, and you probably know that. There will be no fight for fifteen. There will be no free college. There will be no extended family leave, no pay equity and certainly no single payer health care. And there will be no end in sight to the steady hemorrhage of middle class jobs to slave labor countries. But I’m sure you know this too, Senator.<br />
<br />Nobody is going to bother the venerable Wall Street institutions hanging around our collective neck like a rock. Nobody is going to lose sleep over the Silicon Valley technology cartel, which is quickly acquiring more power than the biggest bank ever had. And there will be war, Senator Sanders, as sure as I am sitting here and you are sitting there, there will be war. With a little bit of luck, it will be an old fashioned cold war that will further impoverish the nation and strip citizens of even more civil rights. If luck runs out, and it will, Americans will again die in some God forsaken desert with an unpronounceable name, to “protect our freedom”.<br />
<br />How do you feel, Senator, when you watch the swarm of millionaires and billionaires coalescing around the candidate you endorsed? Michael Bloomberg, Warren Buffet, Mark Cuban and now Meg Whitman, are all praising your former opponent and promising to fund her campaign. Heck, even the Koch Brothers seem sympathetic to her cause, not to mention the deluge of conservative purists crossing party lines spontaneously or after being actively wooed by the Democratic candidate running on the most progressive platform ever. Your preferred candidate said that our cause is her cause, and this must be why hedge-fund managers rewarded her with something like $50 million in campaign “donations” (so far). Do you think any of these powerful interests gives a rat’s ass about our political revolution?<br />
<br />Have you noticed, Senator, how the only places where your name is still spoken are Trump rallies? The much touted shift to the left in the Democratic Party ended abruptly when the television cameras were powered off in the Wells Fargo arena in Philadelphia. The impressive array of professional exploiters of humanity, and the planet we live in, who are stepping all over each other to swear allegiance to the Democratic candidate is matched only by the unbridled enthusiasm of the hired guns of the corporate media. There will be no campaign finance reform, no end to fossil fuel indecency, no end to fracking and drilling and pillaging and slashing and burning, but it will all take place with the utmost respect for stately decorum. Was this your vision for our future back in April of 2015, Senator? It wasn’t ours.<br />
<br />Our $27 voices have been silenced when you decided to suspend yours, and frankly Senator Sanders, I don’t think that decision was entirely up to you. This was not a regular primary season where one can barely tell the difference between campaigns before they all merge into one bland compromise. As you said many times, this was indeed a revolution. Yes, you sparked the flame, Senator, but we build the fire. It wasn’t yours to do as you please with, and you were certainly not empowered to deliver “your supporters” to the subjugation of the status-quo. To put it in terms everybody understands these days, we funded this revolutionary venture with our hard earned money and our feet, and you, Senator, had a fiduciary responsibility to your shareholders.<br />
<br />We lost one battle and you conceded the war. We can’t undo the loss, but you can undo the concession to some extent. You can at least try to make things right for people whose $27 investment represents a week’s worth of food. On a personal level, you have much to lose if you do this, but when you fan the flames of revolution (even a political one), personal sacrifice is baked into the cake. You should have known that, Senator, and you should have made peace with that from the start. I have to confess here that I am not entirely surprised by your decision. Your acquiescing response to subtle and not so subtle efforts to coopt this political revolution, by what I consider unsavory actors, was in my mind a harbinger of things to come. And things came.<br />
<br />I’m not asking you, Senator, to get out there and campaign for “the other” movement propped up by millions of small donations from people who can’t afford to donate either. I am asking you to recognize in your heart of hearts that the road of our political revolution does not go through another Clinton administration. I am asking you to recognize that eight more years of keeping people down, while fraudulently posing as their champion, are far more devastating for our revolution, this nation, and the world at large, than a Trump administration could ever be. These are desperate times for most of us, so I am asking you Senator Sanders, to remember that you have a responsibility, nay, a duty, to stand up one more time and help us keep hope alive, Sir.Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com6tag:blogger.com,1999:blog-3503957686158274288.post-57804877409718014952016-08-01T09:02:00.001-05:002016-08-01T09:42:37.181-05:00Cyberwar, what is it good for?<div class="separator" style="clear: both; text-align: center;">
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Some wars are supposed to last forever. Lyndon B. Johnson started a war on poverty. Richard Nixon kicked off a war on drugs. Ronald Reagan initiated a war on terror. Poverty, drug use and terror are booming. It’s time to launch another good ol’ war. Let’s make it relevant, cool, hip and infinite. So how about a 21st century war on Cybertheft? This may sound trifle by comparison to those other wars, but wars are rarely about the actual title we bestow upon them. The war on terror evolved into a war on people living under secular dictators, the war on poverty ended up being a war on poor people, and the war on drugs became a war on black people. The war on Cybertheft will be the war on all people everywhere.<br />
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The war on Cybertheft has been simmering since the banks decided to do business online. The threat of “identity theft” should have been a monumentally mobilizing battle cry. But it wasn’t. Oh sure, it spawned a bunch of fear inducing <span class="me" data-syllable="ex·po·sé">exposé</span>s and some mildly successful businesses, but all in all, it failed to generate the zombie apocalypse panic it was supposed to trigger. Luckily, our wise leaders decided to put all our medical information on the Internet. It’s one thing for a Romanian hacker to gain access to your checking account balance, and quite another if Marcel is suddenly able to peruse your history of vaginal yeast infections. It makes no sense really, but the latter seems like an unbearable and humiliating violation of who you are. Wars have been launched for much less than that.<br />
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Let me give you an example that is splashed all over the news lately. A nondescript bunch of hackers broke into Democratic Party servers, stole all sorts of documents and emails and provided them to WikiLeaks for publication. This incident proved to be an embarrassment for the global money cartel behind our democratic curtain, and at the same time a great opportunity to score some cheap points in this weird election while stoking the fires of war. Within 24 hours, and with ample assist from corporate media tools, the conversation moved from corrupt, political machinations to an alternate universe where the Kremlin is colluding with insurgents to overthrow the rightful rulers of America. Terrifying stuff.<br />
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Back to medical records. There is a major, and very public, wringing of hands in policy and technology circles on how to safeguard the privacy and security of computerized medical records. Huge health care databases seem to get hacked almost on a <a href="https://threatpost.com/iot-medical-devices-a-prescription-for-disaster/119155/" target="_blank">daily basis</a>. Shady hackers are <a href="https://www.databreaches.net/damn-anyone-know-what-facilities-these-are/" target="_blank">advertising</a> stolen medical records for sale on the “dark” web. The term “ransomware” is entering the health care vernacular (i.e. hackers asking health related entities to pay for keeping security breaches secret). Some experts say that thieves engage in <a href="http://kernelmag.dailydot.com/issue-sections/features-issue-sections/12688/identity-theft-medical-records-healthcare/" target="_blank">fraudulent billing</a> (it is a bit unclear to me how a fraudster makes money when the hospital charges you for a fake surgery, unless the hospital is stealing its own data). Other experts are hypothesizing that medical data could be used for <a href="https://www.fastcompany.com/3056013/why-health-care-is-the-absolute-worst-at-security-qa" target="_blank">personal blackmail</a> (with not one shred of evidence). Hackers are posting <a href="http://www.dailydot.com/layer8/655000-patient-records-dark-net/" target="_blank">screenshots</a> of EMRs saying that this is the data they “stole” (although gaining access to an EMR is not equivalent to having its data). Pretty scary stuff here too, no?<br />
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But here is what is not happening. You don’t see curated lists of famous people treated for cooties. You don’t see lists of women who had abortions or of politicians suffering from palmar hyperhidrosis. You don’t really see anything that could be due to theft of strictly medical information and the “samples” posted by hackers are about Social Security numbers, dates of birth, addresses, phone numbers, emails and all the stuff you can steal from a bank. Is this a big deal? Maybe, but judging by the number and magnitude of <a href="http://www.informationisbeautiful.net/visualizations/worlds-biggest-data-breaches-hacks/" target="_blank">security breaches</a> in the last few years, there must be dozens upon dozens of copies of our financial data floating out there and frankly, people seem rather oblivious to the whole thing. We can’t have that. We need some pizzas, some fireworks, like they have in politics.<br />
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As I’m writing this, more Democratic Party servers are being hacked, prompting increasingly unhinged conspiracy theories to justify a reboot of the Cold War with Russia, and if we’re lucky a real war. You see, in this election we unfortunately have one candidate who didn’t get the memo outlining the benefits of a nuclear war with Russia. Blabbering about NATO’s lack of purpose and how nice it would be to get along with Putin is not moving us forward. Watching CNN or reading The New York Times or the neo-conservative rags, is like watching a train wreck in slow motion. The Cybertheft attacks on Democratic Party servers are worse than Watergate, maybe worse than Pearl Harbor or 9/11, it’s an attack on our Nation, and there should be stern consequences (did you notice the unusual patriotic rah-rah at this year’s Democratic convention?).<br />
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America, we’re under attack. We are being Cyber-attacked on our own soil. A foreign power is attempting regime change in our country by exposing the dirty electioneering of the party currently in power. The question is not how come we have banana republic electioneering. The question is how come Putin dares to point that out. We don’t know if Putin did any such thing, but the theoretical possibility that he might have, or may do so in the future, is reason enough to perhaps slap some more sanctions somewhere, or move a few tanks or submarines closer to the <a href="http://www.defensenews.com/story/defense/international/europe/2016/05/12/us-missile-shield-begins-operations-romania-russian-anger/84275982/" target="_blank">missile shield</a> we just deployed in Romania (?) to protect it from Iran (?). So Annie, get your guns, because Cyberwar is just the prelude.<br />
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In health care the war on Cybertheft of essentially financial data is a front for facilitating massive trafficking in actual medical information. The government agencies in charge of health information technology are accelerating the good fight to “protect” security and privacy with its quintessential tools of building awareness, promulgating regulations and <a href="https://www.healthit.gov/buzz-blog/privacy-and-security-of-ehrs/opportunity-sharing-information-cyber-attacks/" target="_blank">funding</a> the creation and enforcement of more regulations. But the war on who gets to be the king cyber thief is getting a bit more interesting, and perhaps more important to humanity, than the Russia-bad-America-good games played on the global theater stage, because while the public is being distracted by the legends of “TheDarkOverlord” who is stealing and selling disconnected phone numbers, the data cartel is emptying the vaults of our collective human dignity.<br />
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It was Google that invented the idea of data “liberation” to put a progressive face on its efforts to amass and sell access to personal information. It was the disruptive innovation lobby in health care that ported the data liberation movement to health care in the hopes of lowering the barriers to entry in an exceedingly complex and saturated market. The government bought the idea lock, stock and barrel because governments love surveillance of citizens and because our government is in bed with, or in the pocket of, giant technology companies aspiring to liberate a piece of the $3 Trillion health care market. But something strange happened on the way to data without borders. The government decided to fund Precision Medicine and it <a href="http://www.sandiegouniontribune.com/news/2016/jul/06/NIH-scripps-topol/" target="_blank">awarded</a> the biggest chunk of money to the most vocal advocates for the creative destruction of imprecise medicine.<br />
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It didn’t take long to figure out that an academic medical center, as flush with cash as it may be, is no match for Google or Apple when it comes to stealing personal information from millions of people. And it didn’t take long to figure out that data liberation is set up to work in one direction and one direction only – from everywhere, into Google, Apple and other mega-rich Silicon Valley companies. So after years of pushing the free-market miracles of iPhone medicine and genomic tests, it’s time to <a href="http://www.nature.com/news/stop-the-privatization-of-health-data-1.20268" target="_blank">demand</a> that government declares personal information to be a “public good” confiscated at will and freely available to tech giants and researchers, because anything else would be, wait for it, racist. Yes, racist, like in discriminatory against non-white minorities. The only thing left to ponder is whether we will be destroyed quickly by external weaponry, or extinguished slowly from the inside out.<br />
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On January 17, 1961 President Dwight Eisenhower delivered his <a href="http://mcadams.posc.mu.edu/ike.htm" target="_blank">farewell address</a>, warning the nation of what he called the military-industrial complex: <i>“In the councils of government, we must guard against the acquisition of unwarranted influence, whether sought or unsought, by the military-industrial complex. The potential for the disastrous rise of misplaced power exists and will persist.”</i> Note the wonderful nuance when he says “sought or unsought”. Whatever arguments, apologies, explanations, justification you may be inclined to offer, that “unwarranted influence” is undeniably here. We chose not to heed Ike’s warning and have been paying in blood and treasure ever since. The balloon payment is right around the corner.<br />
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And Ike had one more lesser known warning: <i>“For every old blackboard there are now hundreds of new electronic computers. The prospect of domination of the nation's scholars by Federal employment, project allocations, and the power of money is ever present – and is gravely to be regarded. Yet, in holding scientific research and discovery in respect, as we should, we must also be alert to the equal and opposite danger that public policy could itself become the captive of a scientific-technological elite.”</i> He saw it clearly. He saw it coming more clearly than we, who are living in it, are seeing it today. From half a century away, Dwight Eisenhower saw the forest in which we wander, lost amongst the trees.Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com3tag:blogger.com,1999:blog-3503957686158274288.post-1573829088168038252016-07-06T09:09:00.000-05:002016-07-06T09:09:03.052-05:00Brexit, MACRA and the Price of Tea in China<div class="separator" style="clear: both; text-align: center;">
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MACRA seems to be the talk of the town right now. MACRA and MIPS and APM and the dozens of sub-acronyms flying around like so many arrows in this Game of Thrones, Battle of the Bastards. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law over a year ago. That’s right, MACRA is the “law of the land” now, and it became law of the land with overwhelming bipartisan support in Congress and with much lobbying and cheerleading from medical associations. MACRA is not a proposal. It’s not some random regulation. It’s not something that can be stopped or changed without an act of Congress.<br />
<br />And MACRA is very lengthy and very detailed legislation. There is nothing surprising or unexpected in the recent publication of proposed implementation details that was not spelled out in the original MACRA text. It is possible that the degree of specificity in the CMS proposed rules for MACRA implementation finally hit home with the clarity absent from typical legislative language. It is also possible that an actual implementation date a few months down the road is more threatening than one that is a few years out. Either way, we are now witnessing a flurry of social media chatter lamenting MACRA, asking for changes in MACRA and demanding to stop MACRA altogether. I hate to say it, but all this huffing and puffing is a day late and a dollar short, folks.<br />
<br />Amongst the avalanche of angry articles, militant tweets, desperate conversations, calls for action (commenting on the proposed rules), apologies and condescending propaganda, perhaps the most touching post I’ve seen came from David Introcaso at <a href="http://thehealthcareblog.com/blog/2016/06/23/wheres-the-value-in-macra/" target="_blank">The Health Care Blog</a>, which shows in great detail how the MACRA is not really measuring “value”. Dear David, MACRA wasn’t meant to measure anything. It wasn’t meant to improve anything. It was meant solely to aid and abet the <a href="https://books.google.com/books/about/The_McDonaldization_of_Society.html?id=GWmuSztNeCsC&printsec=frontcover&source=kp_read_button&hl=en#v=onepage&q&f=false" target="_blank">McDonaldization</a> of health care. Submitting MACRA comments to the CMS is like bickering over the choice of rope after being sentenced to hang by the neck until you are dead.<br />
<br />Efficient, quantifiable, homogenized, controlled and dehumanized, that’s what health care must become, and when it does, health care will be plentiful, easily accessible and affordable for all poor people everywhere. Like Happy Meals. So how do we fight this? If you’re a physician in a leadership position, you don’t. Why should you? The more money we can save by cutting down “inappropriate utilization”, and the more money we can save by penalizing working doctors, the more cash will become available for executive bonuses. If you are a physician entrepreneur, you have bigger fish to fry. This is your once in a lifetime opportunity to invent a Zuckerberg platform for health care or a Bezos venue for online health care. If you just see patients from dawn to dusk, well, why are you doing that? There are leadership programs and entrepreneurial classes for doctors sprouting everywhere.<br />
<br />If you’re old fashioned or driven by idealistic notions, get over it. We live in a globalized economy. We don’t live on Planet Earth. We don’t live in a global village, or even a globalized society. We don’t even live in the Matrix. We live in the economy. It’s the economy, stupid. It’s like the Serengeti, dumbass. Migratory herds of wildebeests, zebras, antelopes, whose sole purpose in life is to be eaten by big cats. Is there a way out? Can the wildebeests, stop as one, turn around as one, and vanquish the predators? They tried that in Great Britain the other day. They called it Brexit. The globalized economy is still reeling from that blow, and every fat cat, every hyena, every vulture and every maggot, mobilized to define the Brexiters as a bunch of racist, bigoted, uneducated, mentally challenged, Luddite, toothless old farts, too stupid to appreciate the majestic beauty of the Serengeti.<br />
<br />On my Twitter stream some of the more frustrated physicians suggest that perhaps doctors should take a page from the Brits and stage a Drexit. True, revolution is contagious, but what does the doctor plight have to do with Brexit and globalization?<br />
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Post Brexitum Ante Drexitum</h4>
On June 23rd the people of Great Britain <a href="http://www.theguardian.com/politics/ng-interactive/2016/jun/23/eu-referendum-live-results-and-analysis" target="_blank">decided</a> by referendum that European Union technocrats, congregating in Brussels Belgium, shall no longer be empowered to dictate which <a href="https://t.co/IX0z6WtbuQ" target="_blank">tea kettle</a> an Englishman can or cannot use. The Brexit was essentially a vote against globalization, against a common regulatory framework and against the free movement of labor to support a common market where the rich get richer, the middle classes gets poorer, and the poor get to work for a bowl of thin gruel. Globalization has been excellent for the elites and not too shabby for a slice of society immediately under the elites, while gutting the vast majority below. And the gutted majority was supposed to meekly accept the inevitability of this new world order. Is this starting to ring your liberty bell?<br />
<br />There are approximately one million medical school graduates in the U.S. Of those, a small number are considered elites. These are the CEOs of big companies, the CMOs and CMIOs, the board members of every kooky startup, those who give keynote addresses at industry shindigs, those who write books, give interviews and do podcasts, those who shape and promote government agendas. Then come the thousands of highly specialized physicians who make money by the boatloads and are shielded from reality (for now). At the lower end are all other working doctors, with primary care bringing up the massive rear. The distribution of riches and pain seems similar to the UK, the US, and frankly, to a host of other third world countries.<br />
<br />Whereas working people are told that they suffer from “anxiety” and various “phobias” (and stupidity), doctors are labeled “burned out” or “suicidal” (or disruptive) when failing to live up to the McDonaldization of life in the global economy. The elites of course are immune to these afflictions due to their superior visionary intellect. The rest of us need to be gently “nudged” to alter our “behavior”. Physicians need to have their “culture” and “readiness to change” evaluated. We all seem to need remedial education for how to “communicate”, how to “transform” or “adopt change”, how to be “sensitive”, and how to be grateful for all the unearned “privileges” we enjoy while billions of others are worse off. My grandma used to make similar arguments for why we should eat her revolting creamed spinach, but let’s go back to globalization.<br />
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Globalized Health Care</h4>
Remember when we used to say that all health care is local? We don’t say that anymore. Now we have centers of excellence far away from home and small rural hospitals that are all but doomed. <a href="http://www.doctorondemand.com/team" target="_blank">Dr. Phil and Sir Richard Branson</a> want me to get medical advice from strangers in other states. My TV frequently advertises state of the art hospitals in Dubai. Transcription services, claims processing, utilization reviews, and even radiology services have been globalized already. As technology pushes itself into medicine, with apps and artificial intelligence and even those pedestrian EHRs, remember that computers, tablets, phones and such, are all made in China’s slave labor camps, software is largely made in India or Pakistan or by imported slave laborers, maintenance and help desks are mostly overseas and some are in private American jails.<br />
<br />The lethal combo of HITECH/ACA/MACRA is essentially a redistribution of payments from local doctors (and the local people they employ) to cheaper semi-skilled and unskilled labor across state lines and across the globe. The benefits accrue to global corporations directly and indirectly, because profits in globalized business models are much larger, and the locus of power is shifted from geographically anchored professional expertise to global technocrats. This is not a disruptive innovation. From the days of Nebuchadnezzar to the East India Company and beyond, those who wished to rule the world understood that commandeering and destroying local infrastructure and uprooting people are the best ways to foster compliance with centralized governments far away.<br />
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Hard Drexit vs Soft Drexit</h4>
Unlike the Brexiters, physicians have no country of their own, and the <a href="http://gomerblog.com/2016/06/rns-mds-hold-nurexit-drexit-votes/" target="_blank">Gomer Blog</a> notwithstanding, there is no mechanism for a referendum. There is no Union or Guild or national body that could allow doctors to organize a serious Drexit that will pull all doctors, or at least a critical mass of practitioners, out of the acronym games. But even if a Physician Union existed, it is not clear what doctors would want to exit. Do they <a href="http://www.medscape.com/viewarticle/865288?src=wnl_mdplsnews_160701_mscpedit_wir&uac=38450FX&impID=1144672&faf=1?src=soc_tw_share" target="_blank">opt out</a> of Medicare and Medicaid en masse? Do they opt out of all insurance contracts, because they are essentially the same? Not likely. Perhaps a small number of physicians who provide the least expensive services could survive in cash only practices, but the vast majority could not. And the producers of HITECH/ACA/MACRA know too well that this kind of Drexit is not an option.<br />
<br />But there is a softer type of Drexit. One choice is to pay for protection. This is a time honored method for keeping bad guys from raiding your small business. There are companies, health systems and even insurers that will bundle physicians of all specialties into large organizations to better cope with large regulatory climates designed for the global economy. Theoretically, you can remain independent in such arrangements. Theoretically. The other choice is an equally time honored method for standing your ground. Civil disobedience.<br />
<br />You don’t have to comply. Nobody is going to take your medical license away, and considering the meager ratio of physicians to population, nobody is going to prevent you from seeing patients. They will however pay you a bit less than if you complied with HITECH/ACA/MACRA. Think of it as an independence tax (low single digit percentages) over the next decade or so. If you sit down and calculate the price you’d have to pay for compliance with regulations, including opportunity costs, you will find that civil disobedience puts you slightly ahead or, at the very least, it breaks even with compliance.<br />
<br />Bottom line here is that you need to do your own math. Ignore the rhetoric. Ignore the doomsayers and the saviors of mankind. Every single person who opens their mouth on this subject has a vested interest that may or may not align with your interests, and the interests of your patients. Remember that the technocrats at the CMS are forecasting that you will be taxed no matter what you do, so why spend money and effort on a rigged game?<br />
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Instead, turn it around. Refuse to serve in the army of globalization on moral and ethical grounds. Wear it like a badge of honor. Advertise your Drexit. Make a poster for your clinic. Put it on your website. Stand with your patients. Let them know that you put patients first and money a distant second. Be a conscientious objector to a world order where we the people don’t matter anymore. Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com4tag:blogger.com,1999:blog-3503957686158274288.post-88303825756966141792016-06-15T08:00:00.000-05:002018-03-26T11:18:23.398-05:00Confession of a LiberalTRIGGER WARNING: Long read, Trump<br />
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<tr><td style="text-align: center;"><a href="https://4.bp.blogspot.com/-k0X-68WQQh0/V2CRaje9S4I/AAAAAAAABRE/i8AzartEttwjdDnzelzAI4S4p5PbzqArACLcB/s1600/SD%2BBottoms.png" imageanchor="1" style="clear: right; margin-bottom: 0em; margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://4.bp.blogspot.com/-k0X-68WQQh0/V2CRaje9S4I/AAAAAAAABRE/i8AzartEttwjdDnzelzAI4S4p5PbzqArACLcB/s200/SD%2BBottoms.png" width="147" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-size: xx-small;"><i>Source: <a href="http://bit.ly/25WxUKo" target="_blank">http://bit.ly/25WxUKo</a></i></span></td></tr>
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I am a woman and I am an immigrant to this country. I am Jewish by birth and atheist by faith. I am fairly well educated, borderline socialist and straight Democratic ticket voter. I have no use for guns, I despise hunting, and I believe the death penalty is state sponsored murder. I think abortions are perfectly fine and I think everybody should be free to choose how they use their own body for their own happiness and joy. I have no respect for authority, strength, power or large wads of cash. Come to think of it, I have no respect for anything or anyone in particular.<br />
On November eighth, barring any natural disasters, I will be voting for Donald Trump and according to my liberal bible, I will be doing so for all the wrong reasons.<br />
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Reason #1: Feeling the Bust</h4>
There was a brief moment there when I thought Bernie Sanders may just pull it off. He didn’t, and I should have known he wouldn’t. The first time I heard Bernie speak, it felt like he was reading my mind. The billionaire class, big corporations, a rigged economy, tax funded college and health care, and the list goes on and on. It was too good to be true. Bernie did not speak about foreign policy that day, and when he finally did, I found some things I could disagree with. I have a feeling Bernie himself may disagree with some of his own foreign policy positions.<br />
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I was fairly sure that a President Sanders would have been able to cross off very few, if any, items on his to-do list, but that was not the point. A political revolution (unlike the real one coming down the pike) takes time, and I was willing to be patient, because I thought I would sleep better at night knowing that the person in the White House is on my side, and sleep is very important. In addition to nuclear codes and veto power, the President of the United States has that nifty tool invented by Theodore Roosevelt and named after his own self: the bully pulpit. Can you imagine a President Sanders State of the Union address, blasting the billionaire class and the greed of Wall Street? No? Try it. It’s very therapeutic. Well, that’s all over now, so what’s next?<br />
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Reason #2: I’m not with HER</h4>
This may be one of those divisive cultural issues, but in the place where I come from, an American woman became Commander in Chief almost half a century ago, and all across the globe many other women have served or are currently serving in similar positions. I must beg forgiveness for my lack of appreciation for this historic moment when America came one step closer to catching up with Bangladesh. If you believed in Bernie Sanders’ words long before you heard Bernie speak, and I mean really and truly believed, with both your heart and your brain, there is absolutely no way you can wake up one morning and be with HER, because she is the embodiment of everything you want to blow to smithereens.<br />
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Yes, President Obama <a href="https://www.youtube.com/watch?v=S9W0F2mz1jc" target="_blank">endorsed</a> HER because he doesn’t “think there’s ever been someone so qualified to hold this office”, and yes, I wholeheartedly agree, because the last few decades have transformed the United States Presidency into “this office”, which fits HER like a glove. Obviously, HER unique, and truly historic, qualification is that, according to President Obama’s own spokesman, she is currently under “<a href="http://www.reuters.com/article/us-usa-election-clinton-emails-idUSKCN0YV2P3" target="_blank">criminal investigation</a>” by the FBI. Neither Bernie Sanders nor Donald Trump has anything remotely as qualifying as that little jewel. Unfortunately, I am not looking for someone to “hold this office”, but for someone to refurbish and restore “this office” to its Teddy Roosevelt condition. <br />
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Reason #3: I’m a Racist</h4>
I didn’t think I was a racist, but it seems that I am. If I say that black lives matter, I’m a racist because how about white lives and Asian lives and Native American lives? Don’t they matter? Of course they do. All lives matter. Oops. Now I’m a racist because all lives matter is code words for black lives don’t matter. If I say “radical Islam” instead of “radical Islamism”, I’m a racist, because without the “ism” I’m offending our friends and allies in the fight against terror (i.e. the <a href="http://www.ibtimes.com/clinton-foundation-donors-got-weapons-deals-hillary-clintons-state-department-1934187" target="_blank">largest clients</a> of our military industrial complex). If I support school vouchers, I’m a racist, because I propose to defund inner city schools where children are mostly black. If I oppose school vouchers, I am also a racist because I am trying to deny black children the same opportunities that privileged white children have. So I must be a racist. I don’t think I know what racist means anymore, but I hear that <a href="http://www.dailykos.com/story/2015/8/5/1408937/-Bernie-Voted-to-Protect-the-Racist-Border-Militia-Thugs" target="_blank">Bernie Sander</a>s is a racist and Mr. Trump is also a racist, so as a racist, I should probably stick with my own kind. <br />
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Reason #4: The Copperheads</h4>
Let me tell you a little story, folks. Back when Abe Lincoln was leading the nation through its most painful fight for survival as a truly free nation, a group of conservative Democrats, called the <a href="http://quod.lib.umich.edu/j/jala/2629860.0032.105/--lincoln-s-critics-the-copperheads?rgn=main;view=fulltext" target="_blank">Copperheads</a>, came within inches of destroying everything Lincoln and his Republican party ultimately achieved. The Copperheads were strict constitutional constructionists espousing a philosophy practically identical to that of sanctimonious conservative ideologues who are viciously fighting the Trump candidacy today. The party of Lincoln, and the party of Teddy, has been slowly and stealthily hijacked by the Copperheads. To my immense delight, Donald Trump, who during a recent rally blurted out that “this is called the Republican Party, it's not called the Conservative Party”, is prying the party of Lincoln out of the cold grip of the Copperheads, and they loathe him for it.<br />
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Reason #5: FDR said so</h4>
The other President Roosevelt asked the country to judge him, not by his deeds, but by the enemies he has made, and that was good advice. Donald Trump has accumulated the most excellent team of enemies I have ever seen in modern politics (by my liberal standards, of course). Here is just the latest <a href="http://www.bloomberg.com/politics/articles/2016-06-10/david-koch-won-t-fund-trump-coronation-in-cleveland" target="_blank">statement</a> from Mr. Trump, after being snubbed by the Grand Copperhead and his brother: “I think the American public will be happy to know that the Koch brothers will not have influence over a Trump administration or the lives of the American people”, and this is just the cherry on top.<br />
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From the corporate raider who used 47 percent of our nation as his personal spittoon, to the avid Ayn Rand disciple who proposed to give old people two dollars for health care and let them go figure it out, to the Silicon Valley artificially intelligent extraction machine, and all the way through the calcified remains of the Copperheads themselves, the righteous indignation coalition for the preservation of global capital rights is raining fire and brimstone on Donald Trump and anyone who won’t publicly disavow him. Without knowing anything else about Mr. Trump, this would be sufficient information for me, but there is more. When the stars of corruption align so perfectly, there is always more.<br />
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Reason #6: The Media</h4>
Throughout history, the press was never impartial. It was never just about reporting the news. In fact the First Amendment reference to the press is precisely about protecting the freedom of journalists to attack politicians as they see fit. From the dawn of the Republic, there has never been a President or a candidate for political office that has not been chewed up, or promoted and endorsed, by this or that media outlet. This was all fine and dandy when each newspaper was a small business, and when public TV stations maintained a modicum of decorum in return for being granted free use of public airwaves. But the framers of the constitution did not and could not foresee a day when all media is owned by a handful of global corporations, and that’s where we are today.<br />
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The problem is not that the media is too liberal. Just ask Bernie Sanders how well the liberal media served his liberal campaign. The media looks and sounds liberal because it is targeting liberals. People who consider themselves conservative are already indoctrinated into corporate servitude. Liberals need to be cajoled by other liberals pointing to imaginary streams of racism, bigotry, misogyny and xenophobia, punctuated by indignant exhortations of “this is not who we are”, until they internalize the egalitarian benefits of free trade and open borders (i.e. an endless just-in-time supply of cheap slave labor for global corporations). I don’t know about other liberals, but I oppose slave labor, which leaves me very little wiggle room here.<br />
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Reason #7: I Love our Conmen</h4>
Thomas Jefferson was elected President based on his very public opposition to strong Federal government. Then he went and bought half a continent without asking anybody’s permission. I guess he was a conman. Teddy Roosevelt was put in the White House by his wealthy buddies, and then he turned around and chose to throw them under the bus in favor of the “working man”. He must have been a conman too. Abraham Lincoln was most certainly not elected President based on his promise to launch a civil war that will kill half a million Americans, but he did that anyway. He was the ultimate conman. I voted for Bill and I got NAFTA and “the era of big government is over”. I voted for Barack Obama twice, and I got no hope and barely any change. I think I have a peculiar predilection for conmen, and my liberal friends say that Mr. Trump is a conman.<br />
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I’m a little worried about this conman thing though. I made it my business to watch dozens of Trump rallies, interviews and press conferences. Daniel Webster would be rolling on the floor laughing at Mr. Trump’s oratory skills, because he has this plebeian way of talking to his audience, instead of directing soaring sophistry down at them. His body language is concerning too, because he seems way too relaxed and comfortable chatting away (gaffes and foot-in-mouth and all that) in front of thousands of regular people, but tenses up like crazy during media interviews or when they bring out those godawful teleprompters for more upscale audiences. I fear that he may not be a genuine conman after all, but at this point I’m running out of options.<br />
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Reason #8: Teddy made me do it</h4>
So come November I will be voting for a xenophobe who is married to an immigrant, a racist bigot whose grandchildren are little Jews, an old fashioned misogynist who calls strange women “darling” and puts his daughter in charge of his own company, a dangerous man who wants to build schools and hospitals and bridges instead of financing foreign wars, a rabid Republican who wants to preserve and strengthen Medicare and Social Security, an authoritarian who wants to negotiate good deals, a sleek conman who couldn’t finesse his message if his life depended on it. And I will be voting for a bully, because whereas being a bully in third grade is a bad thing, bullying from the pulpit is in the President of the United States job description. Teddy put it there, and I adore Teddy. I want a Bull Moose for President this year.Margalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.com4