Posts Tagged ‘health care’


November 11, 2016

No more gridlock! With Republicans controlling all three branches of government, we will see action on all kinds of fronts.

I realize that making predictions is a fool’s game, but I’m writing down what I expect to see in order to test myself. Nothing would delight me more than to be wrong on many of these prognostications… but we’ll see.

Health care. Obamacare is toast. Mostly we will revert to the status quo ante, which was not good. The one piece I can’t quite foresee is whether Republicans will repeal the law requiring insurance companies to insure everybody, regardless of pre-existing conditions. The one piece I am sure of is that they will repeal the mandate that everybody buy insurance. Without that mandate the economics of the insurance-based system don’t work, especially if the insurance companies have to insure everybody. Obamacare tried to patch up the existing system; it was questionable whether it could succeed even if encouraged. We’ll never know! I predict that health care will be in crisis within Trump’s first term. Eventually (in the next decade) we will end up with single-payer insurance, which we should have had in the first place.

Trade. Not much will change. There will probably be a show of saber-rattling, maybe with China, but Republicans are the party of big business and business interests are strongly for maintaining the status quo. .

Immigration. Not much will change. There will be an early show of building a wall—a Potemkin wall about 10 miles long somewhere in Texas. Immigrants, legal and illegal, will continue to come, but there will be a great reduction in the number of refugees accepted through legal processes. The millions of immigrants living without papers will continue doing as they have done; they will not be deported—business and farming interests will make sure of that–nor will they be given a path to citizenship.

Tax reform. Taxes will be cut, especially for the rich along the lines of Paul Ryan’s proposals. This will result in huge deficits, which will result in legislation cutting programs for the poor. The deficits will continue to mount until we reach a financial crisis.

Infrastructure. We will finally get money for roads and bridges. This will last until huge deficits catch our attention, probably in 2-3 years.

Regulation. The regulatory apparatus of the federal government will be reduced in every area, but especially regarding banks and financial institutions, consumer protection, and the environment. The impacts of these changes will be diffuse and hard to measure, except regarding banks and financial institutions, where they will inevitably create a crisis that will require a bailout. How long before this happens is hard to predict, but that it will happen is as close to a sure thing as we know. Banks and financial institutions have not learned how to regulate themselves; and Republicans both hate regulations and love banks and financial institutions.

Climate, coal, solar. Attempts by the federal government to slow climate change will end. Problems with climate change will continue to grow (as they probably would even if we did our best). I can’t foresee how cataclysmic the problems will be, nor how soon they will become cataclysmic. The coal business in America will continue its death spiral, as fracking spreads (with less regulation!) and keeps the price of energy low. Solar and wind energy will grow due to their efficiencies and also because some large states (California) will subsidize their use.

Social issues. Abortion will continue unabated, though perhaps the Supreme Court will allow more restrictions in Southern states. Gay marriage will be universally accepted. There will probably be more latitude for people and institutions to discriminate by, say, refusing to bake a wedding cake or make facilities available for gay marriages, but people will care less and the issue will all but disappear. Marijuana legalization will continue to spread; problems with illegal drugs like heroin will also continue to grow. Over all, America will continue to move toward more liberal and hedonistic values, as seen on TV.

Social Security and Medicare. There will be benefit cuts. Social security’s finances will be stabilized, probably by raising the age of retirement; and Medicare will continue to grow hugely more expensive, prompting even more cuts. See Health Care, above.

Foreign relations. Not much will change. There is no appetite for “boots on the ground” nor for a policy that enables Iran to build a nuclear bomb. The world will be slightly friendlier for dictators, but they weren’t doing badly before. Terrorism will continue unabated for the foreseeable future; the problems of the Middle East will continue and the refugee crisis will grow.

The unknown. By definition, the unknown cannot be predicted, except for this: we will be confronted by problems that we do not anticipate. Some possible areas: financial meltdowns, events of nature (storms, earthquakes), cyber disasters, terrorism, war. But there may well be categories that we don’t even know exist. How will the new Republican/Trump administration respond? That is hard to foresee, but recent history does not encourage a rosy view of Republicans’ ability to cope with reality. For the last eight years Republicans running Congress have majored in outrage, not in governance. And President Trump has no experience in governance at all. He does not seem to be a calm and measured person. The category of “unknown” is by far the most frightening of all—as it always is.




Bitter Pills and American Medicine

February 28, 2013

My brother-in-law Hank Herrod, former dean of the University of Tennessee medical school, encouraged me to read Time Magazine‘s cover story on the cost of medical care. I always pay attention to my brother-in-law, especially when he tells me something about medicine, so I read the article online. It took a long time–it’s a long, long article–and it made me sick. The guts of the article follow patients through their hospital care and the back-breaking charges they incur. It explains in detail what those charges are and how they are decided. If you think American medicine is based on market economics, think again.

Cutting the Deficit

April 11, 2011

I’m never going to be a policy wonk, but I find that if I squint and tilt my head a little to the side, I blur a lot of distracting appendages and can make out the main shape of the budget problem. The distractions are things like NPR and Planned Parenthood. The main shape is the bloated form of health care—Medicare and Medicaid—that promises to keep growing forever. If you can’t get health care costs under control, you have no hope of balancing the budget.

If you have ever had the slightest involvement with health care, you know there is money to be saved. For example, a resident working in a major county hospital tells me that because the authorization process for certain tests takes so long that the patient would be dead before they got the okay, residents sometimes admit patients to the hospital who don’t need to be there. It’s horribly expensive (and comes out of your pocket) but it’s the only way to get the tests. Anybody working in the guts of the health care system can tell similar stories. There’s tons of waste and abuse. But the system has a lot of built-in resistance to change. And it’s easy to demagogue proposals for change. (Death panels, anyone? Rationing health care?)

Obamacare took a shot at some cost control measures—not many, but some. In the Obamacare approach, the diet is in the details—a million and one policy-wonk changes to the system.

Paul Ryan’s approach is just the opposite. Don’t bother with the details. Just say: here is how much money we have—figure it out. People (and states) will be given vouchers to pay for health care. The rest is up to them and the health care system (including insurance companies).

It’s a Gordian-knot solution. You don’t untangle the knot. You cut it. There’s a lot of appeal in its simplicity. But the devil will still be in the details.

If the Obama approach puts a lot of faith in policy wonk prescriptions, Ryan places a lot of faith in the “free market” health care system.  If you give it a certain set amount of money, it will figure out how to spend it wisely.  I’m not optimistic. As far as I can see, the system isn’t a system, just a collection of interest groups whose workings are greased with a lot of money.

Suppose we adopt Ryan’s approach. What happens when a middle-class somebody with inadequate insurance gets very, very sick, requiring a million dollars worth of treatment that his insurance won’t pay for? Does that somebody just die? If ten thousand middle-class somebodies die, how long does Ryan’s approach last?

What do you think? Can the policy wonks figure out how to make the system work efficiently? Or will putting the system on a strict allowance make it stop overeating?  When I consider these two options, I’m pushed toward the much-reviled Canadian option, which combines elements of both: a strict allowance, with policy wonks in charge of figuring out how to spend it. And yes, we ration health care. Just like we do now.

The Cost of Health Care

September 15, 2010

After a year of non-stop mind-numbing partisan rhetoric on health care, it’s been a relief to hear the sweet sounds of silence since the Big Bill passed. However, I got a reminder recently that the issue is still with us.

I turned 60 this year, and as a birthday present my health care insurance company increased my rates.

As a self-employed person, I buy catastrophic insurance from Blue Shield. I’ve had the policy for years. Kaiser would be cheaper, but in terms of pay-for-service, I believe this is the cheapest insurance I can get for two adults. The deductible is $5,000, so most years we pay for all our doctor bills, prescriptions, etc. on top of our insurance premiums.

The annual insurance bill now is $21,168.

Is this sustainable? I don’t think so. According the Census Bureau, the median family income in 2007 was $50,000. Who can afford to pay 40% of their income for health insurance?

I don’t know what the answer is, but I’m pretty sure we don’t have it yet. So brace yourself for more mind-numbing partisan rhetoric.

Obama’s Persistence and the Republicans’ Discipline

March 25, 2010

I’m happy health care reform passed, but don’t worry, I’m not going to go into my reasons. I believe that baby has already been thoroughly thrashed about, pro and con.

What interests me now is: what next?

Republicans made an electoral bet that the nation hated reform so much that the elephants could ride “no” to victory. And indeed, all the polling data suggested so.

America remains a 50/50 nation, with the two sides more polarized than ever, but independent voters came down solidly against the health care reform bill.

However, between now and the November elections is a political lifetime. It could be that the Republican furor peaked too soon. I thought Obama came off pretty well in the last month before passage—reasonable, clear, and strong. And I’m pretty sure the sky won’t fall, as the Republicans repeatedly predicted it would—at least, it won’t fall before November.

So we’ll see. If independent voters are really convinced that Obama is CEO of Big Government Takeovers, there will be a big swing toward Republicans, the kind of movement we saw in the Massachusetts Senate race.

But if they’re not solidly convinced of that, and health care doesn’t deteriorate dramatically, and the economy picks up a little, and nothing else goes wrong, it’s likely that the Democrats will see only a modest slide, such as the majority party nearly always experiences.

If the Democrats don’t collapse, we’ll see whether Republican leaders can keep their troops 100% unified in opposition to all things Obama. It’s not a natural state for politicians to refuse to negotiate. Republicans have the forty Senate votes to stop anything. But it’s just as hard for them to keep everybody on the reservation as it was for Obama to keep all his 60 votes in line when he had them.

In the health care battle two character qualities stood out: Obama’s persistence, and the Republicans’ discipline. I think we know now that Obama is not a quitter. He’s going to keep on trying to get things done. Will the Republicans maintain absolute unanimity in the face of it? Persistence vs. discipline. We’ll see.

The Psychology of Indecision (I Feel Cranky)

November 13, 2009

It’s hazardous to psychoanalyze your family members, obnoxious to psychoanalyze your friends, and downright dubious to psychoanalyze a nation. Nevertheless:

I’ve been thinking about the national mood, which is cranky. In four critical areas we are teetering on the verge of decision: health care, Afghanistan, financial regulation and climate change. All four are extraordinarily complex, all four appear urgent, and as a nation we are finding it very difficult to make up our minds about all four.  For each of these concerns I give at least even odds that we will not reach any decision of consequence in the coming year.  (Of course, not to decide is to decide, but in most of these cases the same issues would then be back with us next year.)

This indecision feels bad. I find myself looking back longingly on our election just slightly more than a year ago, when it seemed that we had made up our mind to something fresh and new. That felt good. Elections, however they turn out, give the sense of decision in a way that Congressional deliberation very rarely does. (It was the Republicans’ turn to feel good in last week’s gubernatorial elections—their turn to feel as though they had accomplished something.)

I relate our current crankiness to the dis-ease I myself feel when I am trying to make up my mind about a personal matter. Whether the decision is big or small, I am restless, crabby, and unproductive. I can’t sit still. I look for distractions. (Bless the internet for providing them, better than TV ever did!) All the alternatives seem bad. I need to spend more time analyzing their flaws. So many unknown aspects could go wrong.

Some people get so overwhelmed that they literally cannot make a decision. But healthier minds usually manage to move ahead. We decide on the Grand Tetons as our vacation destination, we plunk down money to reserve a cabin (lots of unknowns there), we put the dates on our calendar, we begin to get dog sitters and house sitters and all the rest.

And then we feel better. The unknowns remain. So do the imperfections of our choice. But we are in motion. We will work out the problems as we go. We will live with the imperfections.

In all four areas of national choice, we’re stuck in the crabby land of indecision. Added to that, we have a constitution that was deliberately crafted to make decisions difficult. (Thank God it’s not California’s constitution, which was crafted to make us crazy.) Added to that, there’s a partisan spirit in the land that sidetracks deliberation.

Beware of governments making decisions that aren’t thought through. (Remember Iraq?) I’m glad for the deliberative process. I realize that making a decision, any decision, feels better in the short run, but it doesn’t necessarily feel better in the long run.

At some point, though, you know all you are going to know, and it’s time to decide. Will we? Will we decide on a direction for any of these four matters within the next year? I hope so. I want to move on. I want to feel better.

Health Care with Fins

July 20, 2009

I have nothing original to add to the current search for health care solutions. Here’s my contribution: a metaphor.
Our current health care system is a 1961 Cadillac.
It is comfortable, big and expensive.
We love the fins, because they make us feel as though we are flying. (In truth, they do nothing at all.)
We adore the chrome, which makes us feel like kings and queens.
It guzzles gas, it doesn’t hold the road, it frequently breaks down, and the bench seats make our rear ends ache. But we can’t give it up, because it is so large and shiny and American.
We hate to sacrifice this gilded carriage for some tinny, tiny Japanese model. Why should we fret about gas mileage when we have a 1961 Cadillac?
Here’s a picture, in case you have forgotten:

Are We Serious?

June 26, 2009

A few days ago all the news was about Iran. Today all the news is about Michael Jackson. “Shock and Grief Over Jackson’s Death,” says the New York Times. Thank God we can move on from all that foreign news, and slip into something more comfortable.
Even while Iran held the headlines, half the discussion revolved around whether Obama’s soundbites sounded tough enough. Tom Friedman had an interesting column in the Times ( He pointed out that if we really wanted to pressure the Iranian government we would quit our addiction to imported oil.  But that would cost us something. It’s easier to make huffing and puffing noises.
It’s always been easier to treat politics as entertainment than to grapple with serious issues and to make hard choices. But right now, our national ability to avoid confronting unpleasant realities seems to have reached a new high. Health care, anyone?