Thursday, 30 March 2017

Take Two of These, and Call Me in the Morning. They're Great. Really. Terrific.



The Doctor Will See Your Pay Stubs Now

The Trump administration swung and missed again last week with its failed attempt to shepherd its key Bill to "repeal and replace" the Affordable Care Act through a somewhat dubious House. The failure is being seen as a serious whiff for the new administration as it seeks, desperately, to find its footing two months in.

It was, despite the bluster of the new president, always a long-shot. The ACA is quite honestly terrible legislation that is on the express tracks to collapse; if I were even more cynical than I am, I would call it a piece of Machiavellian art in its cleverness, so poorly conceived and so obviously headed to failure that the only rational explanation is that its authors, sensing that our current system of providing health care coverage was teetering, decided to give it a shove to hasten the day that the whole house of cards collapses, creating the final crisis that will allow the implementation of a single-payer scheme similar to one of the current systems in Europe. 

I'm guessing, something along the lines of the way medical care is funded in Germany.

To be clear, the problem in the US is not about health care. It's never been about health care. The problem is how to pay for medical care, who will pay, and what services will be delivered and to whom. 

I've been asked what issues I have with the ACA; why, specifically, do I think it is the tire fire of the nation. Why does it need to be replaced?

It is actually not one thing, but a series of rather obvious ones. 

The first is that the Affordable Healthcare Act in general is that it is a bold face lie.

Think back to 2008 (or earlier, if you prefer). What did the American public actually ask for? They asked for affordable healthcare. 

Health care itself, as available in the US, is pretty damned good. We have among the best hospitals in the world; we have the top doctors. We have greater access to cutting edge medicines and lead the world in research.

So, we asked for affordable care - hence the name. Did the ACA deliver?

No. 

The most important is this: the whole point of health care “reform” was ostensibly to make health care more affordable and thus, increase the access of poor/lower-middle class to basic health care.

Simply expanding the pool of coverage by raising taxes on a chunk of people (which is what happened - taxes on employer-funded policies were raised, as were taxes on higher incomes, plus the “penalty” for those who did not want to participate, which is also a very regressive tax) while putting nothing in place to curb costs in my opinion combines the very worst parts of our previous, “private” (sic) system with the worst elements of the public-payer options in Europe.

Namely, there is no attempt to enhance negotiation of drug prices or fees.

Here is a key point - you've been and you continue to be lied to. Despite the bullshit you hear from the likes of Bernie Sanders, “big pharma greed’ is not what is driving health care costs - medicines account for less than 10 per cent of health care spend - so while allowing Medicare to negotiate drug prices would of course help, doctor and hospital fees simply have to be reduced. There is no mechanism to assess long-term comparative effectiveness (early attempts to include, e.g, approches like Dartmouth-Hitchcock were quickly shot down). EVERY European system does some sort of health technology appraisal before medicines and procedures are considered for re-imbursement. These were quickly eliminated due to arguments about “death panels”.

For costs to be contained, Americans are simply going to have to accept that you will not get every new, cutting edge treatment. This is already the case in Europe.

Next, special-interest giveaways, such as exempting certain union contracts was just naked political payback. Why should one person get a special perk because he belongs to, say, the UAW, and that union gives money to the Democrats? The arguments about exempting union “Cadillac plans,” and other theivery like the “Cornhusker Kickback” make the result unpalatable.

Combining all of this, the ACA is just a mess. At some point, it is going to collapse.

For the ban on “pre existing condition” piece (very popular) to hold, young people need to accept that yes; you are going to have to pay.. “Insurance” is risk sharing. It needs a huge number of healthy people to pay for (and not use) medical care. Sorry; that is just a fact.

The biggest problem both in the US and in Europe is not about delivery. It is about money. We all want top quality health care. Well, that costs money.

For the system to be sustainable, it needs to be funded. This should not be controversial. And sorry; while I accept that “the rich” need to pay a bit more, the system will not work unless taxes are raised, significantly, on the middle-class.

Bernie Sanders argues (quite convincingly) about how well systems like the Nordic social democracies work well. I have lived in France, and there is a lot to be said about “socialism” (sic), once we abandon dismissing ideas because we do not like the labels. Frankly, there are things in Europe done well, and Americans should consider them objectively. But the flip side is that taxes on lower-middle and middle class Europeans are far higher than similar taxes on Americans. Middle and top marginal rates in Europe kick in at levels that you would probably find surprising.

If we want a good system, every one of us is going to pay more. Period. Paragraph.

Finally, I think that in the long run, the only real solution if we want real “affordable” health coverage with access for all is a single-payer scheme, funded equitably by all (including, especially, those who will benefit), with the power to decide which procedures, medicines, and hospitals will be covered and which will not.

The ACA does not address any of these in a realistic way.

As I said, I think it was almost designed to fail.

Now, the Republicans have been talking about getting rid of the mess for years. Donald Trump was elected, partly promising first to repeal, then to repeal and replace the ACA. Once he got the keys, he discovered, driving a rickety, 70 year old stick-shift with a cracked head gasket, failing clutch, and a near empty-gas tank is difficult.

He and Paul Ryan failed. Utterly.

So, how big a black eye is this? What does it all mean?


It is a very big deal, but I think not for the reason many will say.

As I see it, the biggest impact of the failure of the Republicans to pass the AHCA is this: 

It reveals that Donald Trump is not a king. 

There are many, many people (friends of mine, included) who argue that Trump is going to ‘destroy America,’ and that he is some dangerous, criminal master mind along the lines of Lex Luthor who is going to dismantle first the US government, then civil society, and then ultimately, the world itself.

Well, with the colossal failure to secure votes to pass the AHCA, it should now be obvious (if it was not before) that, despite the claims to the contrary, Donald Trump is not a king.

For those of us who paid attention in civics class, we understand that, with a few exceptions, the executive branch has extremely limited legislative powers. I know that President Bush and President Obama used executive orders to basically write legislation, and I know that the congress essentially abrogated its responsibility to push back on the increasingly imperial presidencies. I understand that the press, whose job it is to hold our elected officials accountable, basically ignored the power grabs and cheered it on.

But the fact is, if the press hold the president accountable, and the congress does its job, then the president is not going to be able to get very much done.

FINALLY, the free press are asking questions rather than cheering in the stands. FINALLY legislators in the president’s party have discovered that they do not have to go along with the guy in the White House.

This failure of Trump and Ryan to even bring to a vote a bill that many agree was a mistake should put an end to the nihilistic fantasies that have captured the fevered minds of too many.

Trump lost this round; but in the end, the discussion is slowly turning from "Trump is Hitler" to "Trump is incompetent."

Trump, of course, was never Hitler, but he is likely to be inept at managing the presidency. The fact that he cannot rule by fiat should disarm some of his critics, and I a suspect, may force the president to trim his billowing sails just a bit.

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