Sunday, March 19, 2017

Does politics make us idiots

From: Rob Shattuck <rdshattuck@gmail.com>
Date: Sun, Mar 19, 2017 at 7:41 PM
Subject: Does politics make us idiots re health care?
To: mkilgore@uab.edu

Meredith Kilgore PhD
Chairman
Department of Health Care Organization and Policy
UAB School of Public Health

Dear Dr. Kilgore:

I am endeavoring to absorb (mainly via the early morning and Sunday political talk shows) the debate about the American Health Care Act. I am trying to get a sense of what will result if it is enacted into law.

The bill has not been finalized, and significant changes are being negotiated. Also, the bill is only the first part of a multi-step legislative and regulatory plan, which could take many months to implement.

For various reasons, it seems preposterous to be able to have much sense of what will result if the American Health Care Act, and its follow ons, are put into effect.

While the proponents of the American Health Care Act will have control over the regulatory component, the additional legislative components will be subject to the uncertainties of future Congressional action.

The CBO report makes projections that are adverse to the proponents of the American Health Care Act.

The proponents try to deflect the CBO report by using speculative contentions that, I think, are dubious and not likely to play out the way the proponents say. Frankly, I don't know how the proponents actually believe what they say will happen.

Given that, it is understandable if I say our Alabama legislative delegation in Washington will not provide help to Alabamians who want a good sense of what will result with their health care under the American Health Care Act.

I have endeavored to say what I think in a blog, which you can find at Alabama expertise re health care.

I am sending this email to you because of your Department's orientation, which is described on the Department's website to be about the following,
"The collected laws, regulations, and approaches taken to making decisions and implementing policy to protect the health of communities and populations. Public health policy issues include a wide range of topics including health care reform, insurance reform, prevention of communicable diseases, food safety, and stem cell research."
That is exactly the academic expertise which I seek for my purpose.

We have no choice but to live with our politics. I believe our politics limits us in solving our problems. I believe the American Health Care Act is a good example.

I will post this email at Does politics make us idiots?

If you think our politics can do better than how I say it is doing regarding the American Health Care Act, that would be very significant. Please email me if that is the case. Otherwise I will understand if you do not reply.

Thank you.

Statements re health care

Here are statements from responders and other information related to Alabama expertise re health care.

Rep. Palmer issued below statement on March 16th.
“We have one opportunity to answer the healthcare crisis the American people are facing. In my opinion, the current bill does not answer this crisis. I voted against the American Health Care Act in the Budget Committee because the promises of changes in the future are insufficient. Now that the bill has been reported out of committee, I will continue to work for the changes that are necessary to ensure Medicaid is a viable and affordable program to provide healthcare to the people who need it most. In that regard, I believe block granting Medicaid to the states and requiring work for able-bodied working age adults are essential to achieving this objective. I look forward to working with my colleagues to make these and other improvements to this bill.”

Rep. Aderholt issued below statement on March 17th.
“President Trump called me to the Oval Office this morning to discuss the American Healthcare Act, because of his understanding that I could not support the current language of the bill.

Thursday, March 16, 2017

Alabama expertise re health care

I am not aware of any reply from the Alabama legislative delegation to my solicitation of their views related to the American Health Care Act, particularly concerning coverage and affordability (and other matters I inquired about in Health care and Letter to Rep. Sewell).

In the clash of advocacy in Washington DC, the sides mainly argue in favor of what they want, and they prevaricate and avoid that which does not support what they want. This methodology is not optimal for helping voters get an accurate picture of what the American Health Care Act  will or will not achieve.

The Alabama legislative delegation, to the extent they say anything, are likely to echo what their side says in Washington DC. That, as stated, is not optimally helpful to voters.

Maybe, in the face of what the politicians serve up to the voters, it is a pointless exercise for Alabamians to strive to get an accurate picture related to the American Health Care Act.

Be that as it may, there is expertise and knowledge in Alabama which could helpful in a voter quest to get a more accurate picture than they can get from the politicians.

I will try to solicit views and information from these resources in Alabama.

One good resource are academics. For example, UAB has a Department of Health Care Organization and Policy, which has more than 20 professors. Professors in that department, as well as other professors and departments have relevant expertise which may be drawn upon..

Health insurance companies, hospitals and doctors should be well informed about how Obamacare is working and its attendant problems, and how it can be expected that  the American Health Care Act would perform. 

Personnel who work in the Alabama Medicaid program should be able to shed useful light on how it can be expected that  the American Health Care Act will affect Medicaid in Alabama. 

Alabama newspapers, TV stations, and radio programs should have an interest in obtaining and purveying relevant information, and they may be of help for voters to get  an accurate picture related to the American Health Care Act

Business chambers of commerce have an interest in the health care bill from the perspective of business.

I will endeavor to solicit views from the above parties.

There is likely going to be a variety of opinions that may be proffered, and there also may be significant bias in the views expressed. 

Short statements from responders that would lend themselves to comparison would seem best for the purpose of trying to get an accurate picture of what the American Health Care Act will do. If responders provide statements, the responders should try to set aside their own biases and agenda and think only from the perspective of Alabamians generally.

I will endeavor to post responses I receive.

For what it is worth I set forth below my own layman's statement about the American Health Care Act.

[Edit: After My statement below, I will append the contacts I am making to solicit statements. I am posting statements I receive and relevant information at Statements re health care.]

My statement
The provision of health care in the United States is a monstrously difficult problem.

The existing system is badly fragmented, and that contributes greatly to difficulty in solving the country's health care problem. Obamacare has done little for lessening the fragmentation. The American Health Care Act is not going to do much either.

The United States system is hugely expensive compared to what other countries pay for their health care. In the United States, health care is in the range of 20% of the total economy, whereas other countries do with much less, in the range of 9% to 14%. This disparity in national health care costs is in dire need of attention and is a large component of the difficult problem the United States faces regarding its health care.

Cost is not the sole consideration, but getting health care for less cost should be in the fore of what Congress is doing. In reducing cost, attention should still be paid to what is needed to provide adequate health care. With that in mind, consider the following:

A. Things that can reduce cost

1. If medical malpractice is reformed, and defensive medicine is reduced, that will help reduce the country's health care costs. An estimate of the amount of reduction is something that responders can usefully inform Alabama voters about.

2. The government can play a role in reducing health care costs by exerting control over prices. The biggest impact could be regarding drug prices, which might start with Medicare negotiating drug prices with the pharmaceutical companies. This is  a controversial step, which may be part of steps 2 or 3 of the Republican plan. Any such control will have ramifications, including reducing availability of some drugs and lessening the development of new drugs.

3. If there is a reduction in total demand for health care, prices will fall and premiums and deductibles should fall. The American Health Care Act will reduce government funds for health care by means Medicaid cutbacks and replacing higher subsidies with lower tax credits, and this will translate to a reduction of demand. Under principles of supply and demand, the reduced demand should result a reduction of prices but the amount of such reduction is very problematic and may be negligible. It is probably the wildest of imagining by the Trump team that this reduction in demand by cutting back Medicaid and people dropping coverage will result in more than a small fraction of what is in their minds for reduced premiums and deductibles. Further the reduction in prices, premiums and deductible is not due to increased plan choice, but due reduced spending and reduced health services, drugs and medical equipment being obtained.

B. Increasing plan choice is chimera for reducing cost

If there is more choice in insurance plans, people may plan they don't want certain services, drugs and equipment to be covered under their plan. and that can allow the insurance company to charge them less in premiums and deductibles.

That creates a problem, however, that, if those people are allowed to do that, the people who need the services, drugs and equipment that the first set of people forego will have to pay higher premiums and deductibles to have the services, drugs and equipment covered by their plan. In other words, plan choice can reduce premiums and deductibles for some people but increase them for other people.

The same applies as regards the Obamacare mandate and what happens if it is eliminated.The elimination of the mandate will reduce premiums for those who choose not to have insurance coverage. As is well known, under Obamacare, the mandate results in healthier people having to buy insurance and pay premiums. If healthier people do not buy insurance, that will result in higher premiums and deductibles for the unhealthier people who buy insurance.

It should also be pointed out that consumers are unaware of the substance of their plan choice and and ostensible competition in premiums and deductibles. Under Obamacare, where there are standard benefits, insurance companies have competed on premiums and deductibles by reducing their "networks." Consumers cannot make a meaningful comparison of slightly higher or lower premiums compared to the "value" of a larger or smaller network. If there is more plan choice, comparison of premiums and deductibles will prevent genuine competition from happening.

C. My picture for Alabama voters to think about

The picture I would offer to Alabamians is that the country has spent six wrenching and expensive years endeavoring to implement Obamacare, and the result has been very inadequate in addressing the country's immense difficulties in providing health care.

The American Health Care Act is going to wrench the country for more years to come. It is not going to do much to solve the long term problem of providing health care in the United States. The country is going to be beset by great problems for many years to come.

The American Health Care Act will achieve a reduction of health care spending and a reduction of health care received by millions of Americans, but that is not a viable long term solution to the problem.

Medical malpractice reform and government control of health care prices offer meaningful ways to reduce health care costs and need to be pursued. The are steps in the right direction, but more is needed to tackle total health care costs in the United States (to bring them in line with what other countries are able to do). This includes reforming the countries fragmented health care system, which should help significantly in reducing cost.




Tuesday, March 14, 2017

Letter to Rep. Sewell

[Letter sent by email to Rep. Terri Sewell (D), AL 7th Congressional district]

From: Rob Shattuck <rdshattuck@gmail.com>
Date: Tue, Mar 14, 2017 at 12:38 PM
Subject: Re: I want to hear from you
To: Representative Terri Sewell <AL07TSIMA@mail.house.gov>

Dear Representative Sewell,
With the CBO report out, it is increasingly clear that the Republican bill mainly effectuates reduced health care spending (and comcomitant reduced health care) by means of Medicaid cutbacks and replacing the subsidies with lower tax credits resulting in less insurance coverage.
The Republicans and the Trump team are endeavoring mightily to avoid the stark reality of the bill.
They are rejecting the CBO report's conclusions, but the Republicans and the Trump team offer no substantive counter-report that sets forth different conclusions to rebut the CBO's conclusions.
They seek to change the subject from "coverage" (by asserting coverage does not result in care being received), to focusing on actual receipt of care.
No doubt high deductibles and other factors are currently resulting in patients choosing not to receive care or otherwise not receiving desired care.
Whatever the amount of desired care that is not currently being received, the Republicans and the Trump team don't provide a credible basis for how their bill will result in actual care being received that is not being received currently.
The main thing the Republicans and the Trump team assert is that increased plan choice and "competition" will result in lower premiums and lower deductibles, and that will result in more insurance coverage and more health care being received.
This is a chimera.
Whatever lower premiums and deductibles result for people who choose not to have coverage or who choose reduced coverage under more plan choices, that will result in higher premiums and higher deductibles for other people. The CBO report fairly well lays this out, reporting that premiums will increase by 15% to 20% through 2020 and then decrease by 10% in 2026.
Further, a 10% decrease by 2026 is hardly increasing the affordability of health care anywhere close to what the Republicans and the Trump team are trying to lead Americans to believe will happen under the Republican plan.
To repeat, the Republicans and the Trump team have no credible counter-report to rebut the CBO's conclusions, and they are only making assertions that are not supported by anything meaningful.
The CBO's full report can be read by download by clicking here.
I believe that Alabamians need to be informed of the foregoing stark realities about the health bill. I am endeavoring to do that in the limited ways that are available to me. I am sure you want to inform Alabamians of such stark realities, and I hope you and your supporters can contribute to that being done.
Thank you.



Saturday, March 11, 2017

Health care

To Rep. Gary Palmer, AL 6th Congressional district
The country is once again confronting overhauling its health care system.

Health, and how health care is obtained, are of huge concern to just about everyone.

The implementation of Obamacare during the past seven years has been wrenching and expensive for patients, providers and insurance companies. There have been defects and failures in the country's health care system for 25 years. One can well be dubious of Congress acting again on this subject, and whether our country's tortured experience in health care will continue for many more years to come regardless of what Congress does.

Under the circumstances, I think you owe it to your 6th district constituents to make a comprehensive exposition of your views about the following:

1. What do you think would be the best thing for Congress to do from the point of view of Alabamians (which hopefully would be applicable for all Americans)?

2. Assuming it is not realistic that Congress will do what you think best, and Congress is considering various things, what are the particular aspects, in order of their priority in your mind for Alabamians, that you will advocate for as the legislative process proceeds? (Possibly, you consider yourself as having little or no influence regarding the legislation, in which case just respond to the question by informing Alabamians of what you think Alabamians should consider important in the legislation and what Alabamians should try to find ways to push for in the legislation.)

Update 3/12
On this morning's Sunday talk shows, Trump spokespersons on behalf of the Medicaid spending cutbacks in the health care bill made the contention that allowing States more control over how Medicaid funds are spent would result in more and better health care being provided with fewer funds. It is requested of Rep. Palmer whether he believes Alabama would be able to provide more and better health care to those being served by Medicaid with fewer funds, provided the state had more control over the funds. If Rep. Palmer's answer is yes, particular information is requested about particular expenditures that are currently being wasted or spent inefficiently in the Medicaid program, which information would show how Alabama would do better with lesser funds if the state has control of the funds. Also, it would be appreciated if Rep. Palmer could give names of Alabama personnel in the Alabama Medicaid program who could vouch for what Rep. Palmer says.


A chimera of expanded plan choice reducing premiums and deductibles
The Trump team is touting that their plan will make health care more affordable by reducing premiums and decreasing deductibles, which will come about by increasing plan choice and increasing competition among plans, including across state lines.
In insurance, all premiums and deductibles go to pay for health care services, drugs and medical equipment plus insurance company overhead and profit.
Ultimately premiums and deductibles can be reduced only if prices for the health care services, drugs and medical equipment are reduced and/or less health care services, drugs and medical equipment are obtained.

1. Reductions not due to increased plan choice
a. If prices are controlled by the government, the government can reduce prices by fiat. The controlling of prices will result in less services, drugs or equipment being provided. The reduction of prices cannot be considered a result of competition.
b. If there is medical malpractice reform, and premiums for medical malpractice and amount of "defensive medicine" are reduced, that should result in reduced premiums and deductibles. This reduction is not a result, however, of more plan choice and more competition in plans.
c. If there is a reduction in demand, prices will fall and premiums and deductibles should fall. The health bill will result in a large reduction in demand by reason of Medicaid cutbacks and people dropping insurance because higher subsidies are replaced with lower tax credits.  Under principles of supply and demand, the reduced demand should result a reduction of prices but the amount of such reduction is highly unquantifiable and may be negligible. It is probably the wildest of imagining by the Trump team that this reduction by cutting back Medicaid and people dropping coverage will result in more than a small fraction of what is in their minds for reduced premiums and deductibles. Further the reduction in prices, premiums and deductible is not due to increased plan choice, but due reduced spending and reduced health services, drugs and medical equipment being obtained.

2. Reductions due to increased plan choice are highly dubious
If there is more choice in insurance plans, people may plan they don't want certain services, drugs and equipment to be covered under their plan. and that can allow the insurance company to charge them less in premiums and deductibles.
That creates a problem, however, that, if those people are allowed to do that, the people who need the services, drugs and equipment that the first set of people forego will have to pay higher premiums and deductibles to have the services, drugs and equipment covered by their plan. In other words, plan choice can reduce premiums and deductibles for some people but increase them for other people.
The same applies as regards the Obamacare mandate and what happens if it is eliminated.The elimination of the mandate will reduce premiums for those who choose not to have insurance coverage. As is well known, under Obamacare, the mandate results in healthier people having to buy insurance and pay premiums. If healthier people do not buy insurance, that will result in higher premiums and deductibles for the unhealthier people who buy insurance.
It should also be pointed out that consumers are unaware of the substance of their plan choice and and ostensible competition in premiums and deductibles. Under Obamacare, where there are standard benefits, insurance companies have competed on premiums and deductibles by reducing their "networks." Consumers cannot make a meaningful comparison of slightly higher or lower premiums compared to the "value" of a larger or smaller network. If there is more plan choice, comparison of premiums and deductibles will prevent genuine competition from happening.
Alabamians at mercy of chimeras on high
Rep. Palmer is asked above to speak about health care to his constituents. The extent to which he will oblige remains to be seen.
The extent to which Senators Shelby and Strange and Representatives Byrne, Roby, Rogers, Aderholt, Brooks, and Sewell will or can articulate for the benefit of Alabamians what has been asked of Rep. Palmer is dubious. It is also dubious the extent to which any of them will have meaningful input in the shaping of whatever legislation results.
Alabamians can watch daily the forces clashing high above. Not only can Alabamians do little to affect the out come high, they are being served up chimearas.
The Trump team is ready to reject whatever the Congressional Budget Office projects about reduced coverage, increased or decreased premiums and deductibles, particularly for those less able to afford greater financial burden or having greater needs.In rejecting CBO scoring, the Trump team does not appear of have substitute projections for Alabamians to have a sense of what is going to happen to their health care. The Trump team is making chimerical assertions about large reductions in premiums and deductibles that is going to save the country from the Obamacare "disaster."

Monday, March 6, 2017

Reducing taxpayer cost of maintaining Trump family

To Senators Shelby and Strange and Representatives Byrne, Roby, Rogers, Aderholt, Brooks, Palmer and Sewell

Can Congress do anything to reduce the taxpayer cost of maintaining President Trump and his family?

Just how much is too much for the taxpayers to be called on to pay?

Is the situation that of President Trump practicing his "art of the deal" prowess on the American people, in which Congress needs to negotiate on behalf of the American people against President Trump?

Costs of President Trump's family living arrangements
One current estimate is that Melania and Barron's living in New York is costing New York about $150,000 a day, and New York is seeking reimbursement from the Federal government and the American taxpayers of these costs..

The Hill estimates that the cost of a President Trump weekend  at Mar-a-Lago (now up to four weekends) is $3,000,000 per weekend

This is while the membership fee at Mar-a-Lago (owned by the Trump organization) was recently doubled from $100,000 to $200,000.

Many people want access to President Trump, and profits will accrue to Mar-a-Lago from people who want to "pay to play" or augment their social profile by hobknobbing with President Trump.

Besides the costs to taxpayers, these opulent living arrangements for President Trump and his family are imposing significant business costs on other people. This is being reported currently in the Mar-a-Lago area. Businesses in the Trump Tower area suffered significant costs before January 20th. The situation currently is not clear.

Taxpayers paying for Trump business
President Trump is giving every indication that he seeks to increase his wealth as much as possible while he is President, and he will exploit the Presidency to benefit the Trump family business. Moreover, taxpayers are going to pay costs in support of the Trump profit making enterprise.

In January, Eric Trump made a Trump organization promotional trip to Uruguay, and the United States taxpayers will foot a bill of about $100,000.

. As the news article reporting on the Uruguayan trip says:
The Uruguayan trip shows how the government is unavoidably entangled with the Trump company as a result of the president's refusal to divest his ownership stake. In this case, government agencies are forced to pay to support business operations that ultimately help to enrich the president himself. Though the Trumps have pledged a division of business and government, they will nevertheless depend on the publicly funded protection granted to the first family as they travel the globe promoting their brand.
Only time will tell how much money the Trump organization will make off the Trump Presidency, and how much taxpayers will pay in support of the Trump family business.

Trump's "art of the deal" with the American people
One can only marvel at President Trump's deal making prowess in the above deal he is (unilaterally) sticking the American people with, including taxpayer support of the lavish living style of President Trump and his family, exploiting the Presidency to increase his family wealth and making the Trump businesses more profitable, and getting taxpayers to pay costs in support of the Trump business enterprise.

Many people were dubious about President Trump's character and motivations in running for President and thought he ultimately would be seeking his own glorification and did not care very much about helping the American people. The "art of the deal" President Trump is practicing on the American people will only be validation for the skepticism of these people about President Trump.

Those who are ardent Trump supporters may begin to have doubts about President Trump's character and motivations in considering the above deal President Trump is trying to stick the American people with.

Those supporters may start to find some hollowness in the President words in his inauguration address. As President Trump lives his opulent life style at taxpayer expense and as he exploits the Presidency to increase the Trump family wealth, supporters may wonder how genuine President Trust was in saying things such as
The forgotten men and women of our country will be forgotten no longer.
and 
But for too many of our citizens, a different reality exists: Mothers and children trapped in poverty in our inner cities; rusted-out factories scattered like tombstones across the landscape of our nation; an education system, flush with cash, but which leaves our young and beautiful students deprived of knowledge; and the crime and gangs and drugs that have stolen too many lives and robbed our country of so much unrealized potential.
Congress needed to represent American people in the deal
In this unilateral deal that President Trump is trying to stick the American people with, Congress needs to step forward and represent the American people.

The below Feb. 22nd op/ed piece in The Wall Street Journal makes a good suggestion that Congress ought to put forth on behalf of the American people for their deal with President Trump. The idea is basically to put the Trump business in a public trust while President Trump is in office, with profits to flow to the Federal government while President Trump is in office and those profits can be used to pay for both the lavish lifestyle of President Trump and his family and also to support the conduct of the Trump business.

Congress may come up with other ideas in negotiating for the American people against President Trump.


A Real Fix for Trump’s Conflicts of Interest

Congress should establish a public trust to oversee his company.


Shortly before becoming president, Donald Trump announced that his business empire would be placed into a trust overseen by his two eldest sons. All profits generated by foreign governments at his hotels will be transferred to the U.S. Treasury. The plan represents a step in the right direction, but it isn’t enough to settle doubts about conflicts of interest in the Trump administration.
Congress and the president should instead work together to establish a public trust that oversees the Trump Organization throughout Mr. Trump’s presidency. All profits from the business would be paid directly to the U.S. government. His family could still be involved in the business, but ultimate authority would go to a congressionally appointed independent government trustee or board.
The profits could be used, among other things, to offset the cost of Mr. Trump’s weekend trips to Mar-a-Lago or the extra security required for his family at Trump Tower in New York. Since the government would have ultimate control over the business, it would have an incentive to align the interests of the business with those of the country. If a particular deal is good for the Trump Organization but bad for the U.S., the company would side with what’s best for America.
The president in West Palm Beach, Fla., Feb. 17.
The president in West Palm Beach, Fla., Feb. 17.PHOTO: GETTY IMAGES
This solution is not without difficulties. As head of the executive branch of government, Mr. Trump could define the “national interest” in ways that unduly favor his business interests. The Trump children and other employees of the Trump Organization, who know better than any government overseer, could manipulate “profits” and investments to postpone revenues and reduce the amounts to be paid to the government.
Nevertheless, government ownership and control may be the best of many imperfect options. It would provide greater transparency about exactly what the Trump Organization’s interests, assets and liabilities are. This could facilitate more-open debate on how conflicts of interest should be resolved. Ambiguity only encourages unfounded speculation and conspiracy theories.
Congress could try to go it alone and pass such a plan with veto-proof majorities, though it would be standing on shaky legal ground because of the Fifth Amendment’s prohibition on the taking of private property for public use without just compensation. But Mr. Trump should realize that such a proposal is in his best interest. This setup would severely undercut any argument that he is working in his company’s interest, not the country’s. As soon as he leaves office, his family will likely inherit a strong and untainted business.
If Mr. Trump continues his current strategy, he can expect an endless stream of lawsuits, boycotts, political criticism and second-guessing of his motivations. Handing off the company would stop much of that immediately. And if he does well as president, his business will prosper. Joining these public and private interests would be exactly the kind of innovative solution that Mr. Trump applauded as a businessman.
Mr. Cohen is a professor of law at the University of Virginia.

Saturday, March 4, 2017

Crisis

To Senators Shelby and Strange and Representatives Byrne, Roby, Rogers, Aderholt, Brooks, Palmer and Sewell

President Trump's new charges that President Obama wiretapped the candidate's Trump Tower offices during the campaign is potentially plunging the country into crisis.

I think Congress needs to go into its own crisis mode. I don't know exactly what the form of such a crisis mode should be.

Please speak to your Alabama constituents about this.

Thank you.