Public Policy and Governance – Page 149

A Doctor’s Prescription

As the primary battles heat up, “Medicare for All” (or in Mayor Pete’s more “do-able” formulation “Medicare for All Who Want It”) has become perhaps the hot-button issue.

The Trump Administration continues to wage war on the Affordable Care Act, a/k/a Obamacare–part of Trump’s determination to erase anything and everything Obama accomplished– and thanks to Mitch McConnell’s success in placing partisans on the federal bench, that attack may succeed.

Anyone who follows the news, or has a Facebook feed, knows what we “consumers” think, and polling confirms that large majorities of Americans would welcome some form of national, universal healthcare. But what about doctors? What do medical professionals who have to work within today’s uneven patchwork of a system have to say?

I asked my cousin, the cardiologist whose insights I periodically share.

I encourage you to click through and read his post in its entirety, but I want to share several observations that I found particularly telling. The first is his reminder that we don’t go “shopping” for healthcare the same way we shop for a new pair of shoes.

Although comparison shopping makes sense when we buy a product like an automobile, such market forces do not apply to health care. Negotiation of prices of various treatments is seldom available, especially not for the complex needs of the desperately ill who consume a large share of resources. Multiple private insurance plans obscure this issue even further.

He then cites a recent study that found a significant part of the variation in medical spending–and more than half of all Medicare spending– to be determined by capacity rather than by medical need.

And speaking of cost…

In contrast to the ACA’s requiring private insurers to spend at least 80-85 percent of their revenue on delivery of health care, more than 98 percent of Medicare’s expenditures are so devoted. Estimates vary, but one-quarter to one-third of our current costs are driven by insurance company overhead, profits, and the administrative costs. Roughly half of these costs would be recovered under single-payer and could instead be devoted to the delivery of meaningful health care.

And then there are drug prices.

Drug prices must be controlled: Acceptable drug lists vary widely among health plans. Negotiated prices depend strongly upon the buyers’ purchasing volume. Only a single-payer system enables the kind of unified bulk purchasing of drugs and medical devices that would give the buyer adequate power. A model for this structure exists today here in the Department of Veterans Affairs (VA). Due to governmental authority to negotiate drug prices for the VA, it pays roughly half the retail price of drugs.

I italicized that last sentence, because it astonished me. No wonder other countries allow government to negotiate drug prices–and we can all guess why Congress expressly forbids our government to do the same.

But what about doctors’ pay? Shouldn’t doctors’ incomes compensate them for those years of medical training and residencies? Wouldn’t we lose medical personnel under a national system?

A recent analysis found that a single-payer model does not lead to a loss in physician income, allowing for care-givers to receive adequate reimbursement of expenses plus fair profits, while ensuring value for taxpayers. Streamlined billing under single payer would also save physicians vast overhead costs, enhanced by reducing the need for the many employees to fulfill the varied requirements and forms of the private insurance companies. Moreover, physicians might best be compensated with regular salary-type payments rather than the current “fee for service” model, which encourages excess medical tests and procedures that drive up costs without providing better outcomes.

And finally, what about private insurance? Opponents of a single-payer system warn that people who love their current coverage (these are people I’ve yet to encounter, but I’ll assume for the sake of argument that someone, somewhere, actually likes Anthem, et al) would lose it. My cousin seems to be recommending Mayor Pete’s “Medicare for All Who Want It” approach. He also makes a point that Kamala Harris made in a recent interview:

The population of the U.S. would likely require additional tiers of care provided by private insurers, which might add extra services to basic care such as private room selections, lower waiting periods for non-urgent problems, elimination of co-pays, long-term care, dental care, etc.

The bottom line: the doctor has diagnosed America’s current approach to healthcare as deathly ill and probably terminal. You can read his prescription in its entirety at the link.

Comments

Follow The Money

Want to know what America’s real priorities are? Easy; just follow the money.

Some of what we find when we examine federal spending isn’t a surprise. We’ve all watched as the Trump Administration has eviscerated the EPA, for example, so cuts and rollbacks there may infuriate but not surprise us. After all, Trump has dismissed climate change as a “Chinese hoax,” eliminated subsidies for clean energy, and slapped tariffs on solar panels.

Given this administration’s well-known bias against science, evidence and clean energy–not to mention Trump’s fondness for the dying coal industry–I shouldn’t have been surprised by the general thrust of a recent study of America’s federal subsidies for fossil fuels by the International Monetary Fund.

But I was.

Because the amount of the subsidy was staggering.

The United States has spent more subsidizing fossil fuelsin recent years than it has on defense spending, according to a new report from the International Monetary Fund.

The IMF found that direct and indirect subsidies for coal, oil and gas in the U.S. reached $649 billion in 2015. Pentagon spending that same year was $599 billion.

The study defines “subsidy” very broadly, as many economists do. It accounts for the “differences between actual consumer fuel prices and how much consumers would pay if prices fully reflected supply costs plus the taxes needed to reflect environmental costs” and other damage, including premature deaths from air pollution.

Since most observers consider the U.S. defense budget to be hopelessly bloated, the fact that fossil fuel subsidies exceed that budget is absolutely mind-blowing.

The study concluded that if fossil fuels had been fairly priced in 2015–i.e., priced without those direct and indirect subsidies by the federal government– global carbon emissions would have been reduced by 28 percent, and deaths from fossil fuel-linked air pollution would have been cut in half.

People (like me) concerned about the environment may not have recognized the enormity of the fossil fuel subsidies, but most of us were pretty sure that a lot more federal dollars go to support fossil fuels than are directed to programs incentivizing the development of clean, alternative energy. The IMF study confirmed that suspicion.

And then there’s the extent to which our financial support of fossil fuels exceeds our investment in education. Seeing those numbers was another gut punch. After all, Americans give lots of lip service to education; we’ve had “education Presidents,” and it is the rare politician who doesn’t make education a prominent part of his or her platform.

Nevertheless, according to Forbes Magazine, that same IMF study determined that the U.S. spends ten times more money propping up the fossil fuels that drive climate change than we spend on education.

Globally, fossil fuels receive 85% of all government subsidies. What if we diverted just a portion of the U.S. subsidies and used that money to improve public education?

Virtually every candidate for the Democratic Presidential nomination has expressed concern about climate change, and an intention to combat it. Voters can determine just how committed they are to the environment by asking whether the candidate plans to continue the obscene subsidies that waste our tax dollars, pad the bottom lines of immensely profitable oil and gas interests, and prevent us from effectively addressing an existential threat to the planet.

Just think what we could do if we redirected a substantial portion of the defense budget (as, interestingly, the Department of Defense itself has advocated) and entirely terminated the unnecessary, wasteful and arguably immoral subsidies for fossil fuels.

Comments

Adventures In Privatization

For a considerable period of time in the late 1900s, privatization of government functions was all the rage. (Not that it was true privatization; as I’ve noted before, actual privatization requires that government completely withdraw from whatever activity was involved, leaving its provision entirely to the private sector.)

What public entities call privatization is almost always contracting-out or outsourcing–providing a service through a third-party surrogate rather than through government employees.

Enthusiasm for the practice has abated considerably, as research has steadily deflated the claims made by proponents. Contracting out doesn’t usually save money, for one thing, and the ability of government to monitor those with whom it contracts has proved to be less than ideal, to put it mildly.

Also, in far too many situations, contracting has become the new patronage.

There are certainly public functions that lend themselves to outsourcing, but thanks to the American penchant to go “all in” on the latest management fad, contracting has often proved disastrous. From poor outcomes, to cost overruns, to outright corruption, analyses have been increasingly negative. A recent research project adds one: government outsourcing decreases employee diversity.

A new study by researchers at the University of Georgia revealed that when governments contract work out to private companies, fewer African-American, Hispanic, and female employees are hired.

Over the past twenty years, private contracting has become a popular way to improve efficiency in the public sector.

“Increasingly, services that were once performed by public employees, are provided under contract by private firms,” explained study author J. Edward Kellough, a UGA professor of public administration and policy in the School of International and Public Affairs. “The question,” he added, “is whether this growth in contracting has been detrimental to minority and female employment.”

That’s not nearly the worst of it.

The Trump Administration has been contracting with private prison companies to house refugees at our southern border. Private prisons are arguably the most striking misuse of government outsourcing, and their operation of border facilities has raised understandable outrage.

I’ll let Paul Krugman take it from here.

Is it cruelty, or is it corruption? That’s a question that comes up whenever we learn about some new, extraordinary abuse by the Trump administration — something that seems to happen just about every week. And the answer, usually, is “both.”

What about the detention centers at the border?

And the same goes for the atrocities the U.S. is committing against migrants from Central America. Oh, and save the fake outrage. Yes, they are atrocities, and yes, the detention centers meet the historical definition of concentration camps.

One reason for these atrocities is that the Trump administration sees cruelty both as a policy tool and as a political strategy: Vicious treatment of refugees might deter future asylum-seekers, and in any case it helps rev up the racist base. But there’s also money to be made, because a majority of detained migrants are being held in camps run by corporations with close ties to the Republican Party.

Krugman then sums up the whole sorry experiment with “privatization.”

Privatization of public services — having them delivered by contractors rather than government employees — took off during the 1980s. It has often been justified using the rhetoric of free markets, the supposed superiority of private enterprise to government bureaucracy.

This was always, however, a case of bait-and-switch. Free markets, in which private businesses compete for customers, can accomplish great things, and are indeed the best way to organize most of the economy. But the case for free markets isn’t a case for private business where there is no market: There’s no reason to presume that private firms will do a better job when there isn’t any competition, because the government itself is the sole customer. In fact, studies of privatization often find that it ends up costing more than having government employees do the work.

Nor is that an accident. Between campaign contributions and the revolving door, plus more outright bribery than we’d like to think, private contractors can engineer overpayment on a scale beyond the wildest dreams of public-sector unions.

Krugman makes an even more important point about accountability.

As he says, if you outsource garbage collection, it’s pretty easy to determine whether the garbage has been collected (although I’d note it’s not so easy to tell where it’s been dumped…). But if you hire a private company to do something the public can’t see–like prisons or migrant camps– it’s easy to hide poor performance and generous overpayments to political cronies.

And running a prison, which is literally walled off from public view, is almost a perfect example of the kind of government function that should not be privatized. After all, if a private prison operator bulks up its bottom line by underpaying personnel and failing to train them adequately, if it stints on food and medical care, who in the outside world will notice?

And of course, the administration and its cronies profit from these facilities. It’s hard to disagree with Krugman’s final observation:

Every betrayal of American principles also seems, somehow, to produce financial benefits for Trump and his friends.

Comments

Uncommon Common Ground

The unrelenting assault on American democracy and norms of governance has led many of us to focus pretty single-mindedly on the insanities coming from Trump’s Washington. As a result, we miss events that might otherwise be more widely reported.

Had a Facebook friend not posted this article, I’d have missed it. As it was, it was so counter-intuitive, I immediately looked for confirmation. But it’s true: George Soros and Charles Koch have teamed up to support a new think-tank that will work toward what would be a dramatic change in American foreign policy– an end to this country’s “forever” wars.

An article in Slate explains this rather startling partnership,

Any initiative that boasts funding from both George Soros and Charles Koch—boogeymen of the right and left, respectively—is going to garner some attention. But the Quincy Institute for Responsible Statecraft, a newly planned anti-war foreign policy think tank, aims to get noticed for more than just the money behind it. Its founders hope that, as operations ramp up in the coming months, the institute will provide a critique not only of the Trump administration’s foreign policy, but of the hawkish bipartisan consensus in Washington.

The group’s inception is driven by a shared concern over the United States’ long-standing reliance on military force over diplomacy, as well as the belief that “the foreign policy establishment is ill-equipped to interpret what was happening, particularly the foreign policy of Donald Trump, let alone to combat it and steer it in a better direction,” says co-founder Stephen Wertheim, a historian at Columbia University and writer on U.S. foreign policy.

The new Institute will advocate for withdrawal of U.S. troops from combat missions in Syria and Afghanistan; perhaps more importantly, it is expected to support substantial reductions of the defense budget, and foreign policies relying more on diplomacy and less on confrontation.

While much of the foreign policy establishment supports diplomatic initiatives like the 2015 Iran nuclear deal, Wertheim believes that there’s not enough of an apparatus to support them. “Worthy initiatives like the Iran nuclear deal—it was way too hard to fight for them, and then it proved too difficult to maintain them,” he says.

The Quincy Institute takes its name from President John Quincy Adams, who famously warned Americans against going abroad “in search of monsters to destroy.”

They plan to set up offices in D.C. and begin hiring fellows in the coming months as well as release several reports before the end of this year. In addition to Wertheim, the group’s founders include Trita Parsi, the former president of the National Iranian American Council and a leading proponent of the Iran nuclear deal; Suzanne DiMaggio, an expert on negotiations with Iran and North Korea currently with the Carnegie Endowment for International Peace; journalist Eli Clifton of the Nation; and the historian and retired Army Col. Andrew Bacevich.

Koch has long been a favorite bogeyman for anyone who isn’t a right-winger or doctrinaire libertarian; he and his brother have spent millions promoting deregulation, opposing universal health care and fighting efforts to address climate change. But Charles is also known for what the article calls “iconoclastic views on foreign policy” and for supporting a less interventionist foreign policy.

Soros is a longtime supporter of civil society and democratic movements, and for championing civil liberties and liberalization of autocratic countries. But that support doesn’t necessarily translate into military interventions to accomplish those ends.

“We are all for democracy and human rights,” Wertheim says. “But what is the best way to promote those things? If we rhetorically promote human rights and democracy in ways that lead to war or the kind of starvation sanctions we currently see with Iran, that does not advance human rights.”

In my more optimistic moments (few and far between as those have become) I wonder whether the Trump Presidency’s awfulness may be sparking a positive blowback. I’ve seen a genuine resurgence of interest in civic knowledge, and it is impossible not to notice–and applaud–the enormous increase in civic activism and engagement.

As the Slate article notes, Trump’s foreign policy approach (which the article labels “idiosyncratic” and I would define as incompetent-fascist) has appalled everyone: “neoconservatives, liberal internationalists, anti-war leftists, libertarians, and conservative realists.” As this uncommon example of common ground illustrates, Trump has been a wake-up call in all sorts of ways.

Let’s just hope enough Americans actually wake up, and once Trump is gone, don’t just hit the snooze button.

Comments

Stop The World…Your GOP In Action

Evidently, when Ivanka wasn’t being inappropriately intrusive at the recent G20 meeting in Tokyo, her father was trying to talk other heads of state into abandoning their commitments under the Paris accords.

If you harbor any doubt that what remains of the Republican Party is an uninformed and anti-intellectual Trump cult, the party’s assault on efforts to ward off the worst effects of climate change is the most obvious evidence.

What happened just recently in Oregon is an example.

A major climate-change bill, which [activists] had worked on for the last several years, was on the verge of passing the state legislature, which, since last year’s midterm elections, has been controlled by a supermajority of Democrats. Governor Kate Brown, a Democrat, had campaigned on its policies, and planned to sign it. On climate policy, Brown had said, “Oregon can be the log that breaks the jam nationally.” Then, last week, eleven Republican state senators walked out of the statehouse, fled the capitol, and apparently hid out of state, in order to deny the rest of the Senate the necessary twenty-person quorum required to move the bill to a vote. Representatives of fringe right-wing militia groups said that they would protect the state senators “at any cost,” and that protesters supporting the bill at the capitol should be warned of their presence.

The proposal had gone through lengthy negotiations and public meetings. Lawmakers had taken citizens’ comments. The bill was supported by all nine of the state’s federally recognized Native American tribes, and even by the state’s electric utilities. Major corporations in the state supported it.

In order to defy both the majority of the legislature and public opinion, the Republican lawmakers simply fled.

On Friday, members of right-wing militia groups including the Three Percenters of Oregon, who took part in the 2016 takeoverof Oregon’s Malheur National Wildlife Refuge, posted a different form of encouragement on social media, saying that they were willing to provide the hiding senators “security” and “refuge.” They also appeared to be organizing a weekend protest at the capitol, scheduled for when lawmakers gathered on Saturday. A commenter on Facebook offeredto bring “a few pickup loads of manure” to drop on the capitol’s steps. An unnamed source told Will Sommer, of the Daily Beast, that “dozens of armed militia members have ‘mobilized’ to protect the state senators, and said there was potential for violence if law enforcement officials try to bring the senators back to Oregon.” In response, Oregon state troopers recommended that the capitol be closed on Saturday “due to a possible militia threat,” according to a spokeswoman from the Senate president’s office.

Poll after poll confirms that a substantial majority of Americans is concerned about climate change, and believes government should forcefully address it.

I’m old enough to remember when politicians would reflect popular opinion–even when they didn’t agree with it– in order to be re-elected. Thanks to the demise of genuine democracy–courtesy of Citizens United and gerrymandering, among other assaults–today’s Republican lawmakers are responsive only to one constituency: their donors, who prioritize today’s bottom line over tomorrow’s planetary survival.

In an administration notable for lack of consistency (not to mention competence), there has been one area of single-mindedness: attacks on science accompanied by persistent rollbacks of environmental protections.

Self-destruction is by definition insane.

What if I had been told by trustworthy experts that my furnace had a 95% chance of blowing up at any moment, but I refused to replace it because I wanted to augment my already fat bank account and there was a 5% chance it wouldn’t blow? That would be nuts. What good would my bank account do me if my furnace blew up and killed me?

Yet that is the position of today’s GOP. There is no rational defense for that position, because it is indefensible. It is, quite literally, insane.

Unfortunately, in the immortal words of Tom Lehrer, “We’ll all go together when we go.”

Comments