Posts Tagged ‘Medicare’


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.




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.