Health Care One More Time

Republicans love to accuse government of waste and fraud while pointedly ignoring waste and fraud in the private sector. (I always think of that biblical phrase about ignoring the beam in one’s own eye...if you want to talk about fraud, Senator Scott….).

That disconnect is particularly obvious when it comes to America’s incredibly wasteful insistence on private sector health care. Several years ago, I was on a university research team looking at certain aspects of Indiana’s health care environment. I no longer recall the outlines of our investigation, but I do still remember my shock at learning that–at that time–seventy percent of all American health care costs were being paid by some level of government.

It wasn’t just Medicare and Medicaid, or the CDC, or the numerous federal programs aimed at specific diseases. State and city governments support local hospitals for the indigent, and other local programs; more significantly, the millions of people in the U.S. who work for a government entity–universities, police and firefighters, schoolteachers, etc. etc.–have health insurance paid for by tax dollars.

What really blew my mind was the realization that the money government was already spending would be enough to cover almost all of the costs of a national health care system if we simply reduced the enormous amounts spent–wasted– on duplicative paperwork and insurance company marketing and overhead.

What made me think about that long-ago epiphany was an article from The Fulcrum sharing “shocking statistics” about American healthcare.

The first was the number of people on Medicaid. (Not Medicare–Medicaid.) Most of us think of publicly funded healthcare as something offered by Canada and countries in Europe, not the adamantly “private” U.S.

The shocking truth is that most of the U.S. population will soon be on some form of government-sponsored health insurance. Right now, 158 million Americans (nearly half of the nation’s 330 million population) are covered by a combination of Medicare, Medicaid and subsidized enrollment in the state and federal exchanges. Experts predict that percentage will climb.

Within that population is an even-more shocking statistic: According to the Centers for Medicare & Medicaid Services (CMS), enrollment in Medicaid surpassed 90 million in 2022.

This program, traditionally linked to a small population of Americans in poverty, will serve more than 100 million people in fiscal year 2023 (or 1 in 3 insured Americans). Since 2020, Medicaid enrollment has jumped 30% thanks to expansion programs in several more states under the Affordable Care Act and Covid-19 public health emergency funding.

The article highlighted several problematic consequences of that staggering figure, especially the difficulty experienced by enrollees in finding primary care doctors.

The second statistic concerned individuals who aren’t on either Medicare or Medicaid.

Since 2000, medical costs have risen each year by 4.85%, significantly outpacing the 2.85% annual increase in GDP.

With healthcare premiums rising at a faster rate than revenue, businesses have made up the difference by transferring the financial burden to employees in the form of high-deductible health plans.

In 2022, despite below average healthcare inflation, U.S. employees paid a shocking 10.4% more in out-of-pocket healthcare expenses than the year before.

Already, medical costs are the No. 1 cause of bankruptcies in the United States. If a recession ensues as many economists predict, millions more workers and families will suffer economic hardships.

Number three? Forty-eight percent of those eligible for Medicare choose Medicare Advantage.

“Traditional” Medicare, enacted by Congress in 1965, continues to use a fee-for-service reimbursement model—one that pays doctors and hospitals based on the quantity (rather than quality) of medical services they provide.

In 1997, Congress created an alternative program called Medicare Advantage (MA). Unlike traditional Medicare, this option is “capitated.” That means the federal government pays healthcare providers an annual, up-front fee based on the age and health status of the enrollees.

Supporters of MA say that capitation incentivizes doctors to keep patients healthy without over-treating and over-testing them.

However, there are some downsides. Although seniors enrolled in MA enjoy more predictable annual costs and added benefits such as eyeglass coverage, they have fewer choices when selecting doctors and hospitals.

I found that last observation interesting, since most people who oppose national healthcare insist that Americans value choice more highly than cost. Apparently, we don’t.

The article concludes by reminding readers that healthcare inflation has exceeded GDP growth for half a century. The U.S. spends more than twice as much as the next most expensive nation for health care, and the last time I looked, American healthcare was ranked 37th. Meanwhile, employers and families are increasingly finding the costs out of reach.

These statistics just confirm that ideology can kill. (If you doubt that, look at the disproportionate number of Republicans who died of COVID because they refused to be vaccinated.)

Clinging to the belief that we aren’t already “socialized”–and very inefficiently– costs all of us a lot of money.

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Homophobes’ New Focus

A  2022 Grinnell College Poll found that 74% of Americans believe same-sex marriage should be a guaranteed right .Only 13% disagreed (the remaining13% were uncertain.) Also last year, Gallup announced that approval of same-sex marriage had hit a new high.

Faced with numbers like that, what are Republican homophobes to do?

Not that they aren’t trying. Daily Kos recently reported that

Conservatives are working hard to ostracize and delegitimize marginalized folks and are attacking the LGBTQ+ community wherever they can, ranging from sports bans to health care barriers to criminalizing drag shows. 

Given current American attitudes toward more “run-of-the-mill” gay folks, trans children have been taking the brunt of the  GOP’s attacks. 

As the ACLU has recently reminded us, even before this year’s start of state legislative sessions, the organization had pinpointed  over 25 pre-filed bills that “would strip away young transgender people’s ability to access necessary and life-saving health care.” Over 100 anti-LGBTQ bills have been introduced so far, and the majority target trans rights.

As the ACLU noted, the same politicians that don’t want women to control their own bodies also oppose allowing trans people to make decisions around their own gender identity and medical care.

I realize that Americans have had less time to become accustomed to–or even familiar with– the issues raised by transitioning. I can even understand the concerns around athletic performance and the possibility that trans women might have an unfair advantage, although medical science tells us those concerns are unwarranted.

It is much harder to understand the animus that leads GOP lawmakers to propose bills punishing supportive parents and doctors who provide medical care to transgender minors. It’s especially hard for me to understand why those legislators think they have a right to interfere in such profoundly personal matters.

South Dakota lawmakers have introduced a bill they call “Help Not Harm;” it would ban physicians from prescribing hormonal therapy and from performing gender-affirming surgeries on minors (something I’m told doesn’t occur). Physicians who provide such care would be subject to review by a medical board, and potential loss of their licenses.

Utah lawmakers have introduced several anti-trans bills. One would prevent trans youth from updating their birth certificates until they turn 18. A far more harmful bill would–in addition to banning that non-occurring surgery for minors — would also bar the puberty blockers and hormonal therapies that are prescribed.

Nebraska Republicans have introduced “Sports and Spaces”– banning youth from participating in sports teams that don’t align with their sex as assigned at birth. The bill would also bar trans youth from using locker rooms that align with their gender identity.

More than a dozen states have introduced anti-trans health care legislation. Dailly Kos lists Virginia, Utah, Texas, Tennessee, North Dakota, Oklahoma, South Carolina, Missouri, Montana, Nebraska, New Hampshire, Kansas, and Kentucky–and a friend of mine who lobbies Indiana’s General Assembly on behalf of several medical associations tells me they expect a similar attempt in Indiana.

Evidently, it isn’t enough to pick on women and trans children. The GOP knows how terribly dangerous librarians are. As the linked article reports,

Over in North Dakota, Republicans are racing to ban even more books. As reported by the Associated Press, Mike Lefor, who serves as House Majority Leader, introduced HB 1205 seeking to ban books with “sexually explicit” content from all public libraries in the state. Not just keep them out of young adult sections. Not just exclude them from certain programming. Not just from school libraries. Ban them from public libraries, period.

And yes, that “sexually explicit” includes depictions of gender identity and sexual orientation. The measure proposes up to 30 days imprisonment for librarians who don’t remove such books from libraries if the bill becomes law. Folks could also face a $1,500 fine and a Class B misdemeanor. 

When the Supreme Court overruled Roe v. Wade in Dobbs, it called into question an important principle of constitutional jurisprudence called substantive due process. That doctrine means that there are certain issues that government doesn’t get to decide. For over fifty years, the Court has recognized that “intimate personal decisions” not specifically enumerated in the Bill of Rights also must be protected against overreaching government– that the Bill of Rights requires respect for individual autonomy– that liberty means there are places in the lives of individuals where government doesn’t belong.

Only the individual involved can know who he or she or they really is. We can only hope that conflicted individuals are able to access the help of supportive parents and caring doctors–and even a librarian or two. 

Certainly not a state legislature.

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My Obligatory Rant About the Debt Ceiling

Okay–I’m sure that readers of this blog are well aware of the current threat by the usual suspects to hold the debt limit hostage in order to get concessions on spending from the administration and the Democrats in Congress.

I’m also sure that most of those readers understand what the debt limit actually is–unlike the intended targets of the crazies’ messaging.  America’s debt ceiling does not authorize spending–it authorizes government to borrow funds as necessary to pay for spending that Congress has already authorized. (That’s why the GOP obediently voted to raise it during the Trump administration–even though the Trump tax cuts significantly increased the deficit and thus the amount to be borrowed.)

Here’s an analogy: you went shopping and maxed out your credit card. The bill from the credit card company comes due, and your spouse says “We aren’t paying it until you agree to [whatever].” You either accede to the whatever, or destroy your credit rating, find yourself unwelcome in the places you shop, and incur higher interest rates in the few places that still accept your business.

In 2011, when Republicans last played this game, the delay in raising the limit caused a  downgrade of U.S. Treasury debt, raising government borrowing costs by $18.9 billion over ten years.

If the GOP’s  current game of chicken succeeds–if America fails to pay the bills Congress has previously racked up–the country (and globe) would descend into recession, Social Security and Medicare payments would stop, federal workers, soldiers and defense contractors wouldn’t be paid… And you could kiss your tax refund goodby.

The U.S. is one of only two countries requiring a separate vote to raise the debt limit–most countries understand that a vote to spend X on program Y implicitly authorizes payment even if funds need to be borrowed. For many years, rational lawmakers in both parties routinely raised the limit.

Since “rational” no longer describes most GOP lawmakers, what should the administration do? I’ll let Paul Krugman answer that question.

Krugman  warns that “it’s not even clear that the Biden administration could surrender if it wanted to.”

The current crop of House Republicans makes the Tea Party, which (alas) used the debt limit to blackmail President Barack Obama, look reasonable. Today’s G.O.P. doesn’t even seem to have a coherent set of demands; a significant number of caucus members may well want a crisis, preferring to “watch the world burn” under a Democratic administration.

If surrender isn’t an option, what is?

Democrats could seek a “discharge petition” to force a vote on raising the debt limit despite opposition from G.O.P. leaders. This would both take time and require support from a handful of sane Republican House members. But it’s surely worth trying.

Second, it’s probably possible to use financial engineering to bypass the debt limit. The most famous proposal calls for minting a platinum coin with a face value of, say, $1 trillion, depositing that coin with the Federal Reserve and spending out of the bank account thus created. Believe it or not, this would almost certainly be legal.

Another option would involve raising money by issuing “premium bonds” when existing debts come due — bonds whose face value is the same as that of the bonds they replace, so that they don’t officially increase the debt, but offer high interest rates, so they sell for much more than their notional value.

Krugman also points to language in the 14th Amendment providing that “the validity of public debt shall not be questioned,” and suggests that language might be construed as authorizing the government to ignore the debt ceiling rather than defaulting on payments.

Which option should Democrats pursue? I’d say all of them. Above all, this is no time for officials to worry about seeming silly or undignified. The Biden administration is facing the threat of economic terrorism — that sounds extreme, but it’s basically what creating an artificial debt crisis amounts to. And it should do whatever it takes to face down that threat.

So–what now? The Treasury department is ramping up what it calls “extraordinary measures” to avoid default, but without a resolution, the country will stop being able to pay its bills sometime around June 5th.

Even if the administration was willing to “negotiate,”  Republicans cannot seem to agree on what it is they want. In yet another demonstration of their lack of discipline (and in many cases, sanity), several on the far Right are insisting on cuts to Social Security and Medicare, while others are focused on cutting the Defense budget. 

And what, you might ask, about the “moderate” members of the GOP? That’s easy: there aren’t any. Bret Stephens was right-– today’s GOP consists only of reptiles and invertebrates.

Stay tuned….

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Universal “Scholarships”

Both the IBJ and the Capital Chronicle have reported on the legislature’s current effort to totally privatize education in Indiana. If passed, Senate Bill 305 would allow any and all parents to get taxpayer money to enroll their children in a private school or home school them. 

The legislation would dramatically expand Educational Scholarship Accounts (ESAs)–a more neutral term for the vouchers that–for very good reason– are no longer as popular as they once were.

In 2021, Indiana’s General Assembly approved ESA’s for special education students by burying the proposal in the budget, where it escaped much in the way of sustained scrutiny. SB305 would expand the program to all students, via a universal Education Scholarship Account.

The existing ESAs are limited to students who qualify for special education, and whose families meet income limits. (Not that those limits aren’t generous–a family of four can make up to $154,000 annually. That’s three times the amount required for a student to qualify for the federal free or reduced price lunch program.)

SB 305 would extend the ESA program to all students, regardless of a student’s educational needs or their family’s income level.

So what’s wrong with ESA’s? 
 
As numerous observers point out, there’s a lot wrong. For one thing, the bill lacks any public oversight or measures ensuring accountability. The state would simply give tax dollars to parents who would be trusted to spend it on their children’s education (there doesn’t seem to be any mechanism to ensure that the dollars would actually be used for education) at any school of their choice, or for home schooling and/or educational materials.
 
Apparently, all a parent needs to do to get some $7500 per student is fill out an online application promising to spend “part of the money” for the study of “reading, grammar, mathematics, social studies or science.” No standards. No requirements for art, music, foreign language or–perish the thought–civics. Not even those pesky criminal background checks required of public school teachers and volunteers.

Interestingly, the program would be managed by the state’s treasurer–not the Department of Education. 

Clearly, education isn’t the goal.

Researchers have exhaustively documented the results of current voucher programs, and repeatedly demonstrated that these programs have failed to improve educational outcomes. Over 90% of voucher recipients take them to religious schools that frequently substitute dogma for science and history. My own research confirms that–in Indiana at least– few, if any, include civics instruction. (My personal favorite among the history textbooks most widely used in these religious schools describes slave trade as “sometimes unwilling black immigration.” Ya think?)

As the Capital Chronicle reported,

Indiana has about 87,000 private school students, according to the Indiana Department of Education (IDOE). About 44,000 of those use the state’s Choice Scholarship program — which allows families to receive vouchers to attend private schools. But the remaining 43,000 would be eligible for the grant, which would average around $7,500 statewide.

That would add more than $300 million a year to what the state is already sending to private, mostly religious schools.

The voucher program started similarly with a cap of 7,500 students at a cost of $15 million. The cap doubled the next year and now there is no limit and a current annual cost of $240 million.

As I reminded readers a few days ago, Indiana’s current voucher program classifies families that earn up to $145,000 per year as “poor” enough to have the state pay for their kids to attend private schools. Qualification for state-funded childcare and/or pre-kindergarden is a different matter: families bringing home a mere $27,500 are “too rich” to qualify.

None of this makes sense unless the legislature’s actual goal is to encourage an exodus from the state’s public schools, a goal that furthers other longtime efforts: destroying the teacher’s union, and finding a “work-around” of the First Amendment’s prohibition against funneling tax dollars to religious organizations.

SB 305’s proposed expansion would cost a fortune and fail to deliver educational benefits. Worse, those dollars would come from our already under-resourced public schools. That would especially harm rural Hoosiers who live in areas too sparsely populated to support private alternatives.

Since it is no longer possible to defend vouchers on educational grounds, this misbegotten effort is being sold under the current MAGA banner of “parental choice.” 

Whenever I hear these culture warriors utter the word “choice,” I expect a bolt of lightning to strike. They want the “choice” to avoid vaccinations, the “choice” not to have their children learn accurate history, the “choice” to keep “Heather Has Two Mommies” out of the library…

But other people’s choices? (The choice to support sound, secular public education, or terminate a pregnancy, for example?) Not so fast!

If SB 305 passes, it will certainly affect the choices of people who might otherwise be thinking of relocating to Indiana. 
 



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Pool Tables And Gas Stoves

Sometimes, we need to remind ourselves that drumming up fear to achieve less-than-admirable ends is nothing new.

I was on the treadmill the other day, listening to old show tunes on my iPods. ( My very unsophisticated musical tastes run to Dean Martin and the Rat Pack, although I make exceptions, especially for show tunes.) I was speed-walking to the Music Man. 

“Ya Got Trouble” was the song sung by Professor Harold Hill when he is using the fact that a pool hall has opened in River City to stoke fear in the city’s residents.

You probably remember:

Friends, let me tell you what I mean. You got one, two, three, four, five, six pockets in a table. Pockets that mark the diff’rence Between a gentlemen and a bum, With a capital “B,” And that rhymes with “P” and that stands for pool! And all week long your River City Youth’ll be frittering away, I say your young men’ll be frittering! Frittering away their noontime, suppertime, chore time too! Get the ball in the pocket, Never mind gettin’ Dandelions pulled Or the screen door patched or the beefsteak pounded. Never mind pumpin’ any water ‘Til your parents are caught with the Cistern empty On a Saturday night and that’s trouble, Oh, yes we got lots and lots a’ trouble. I’m thinkin’ of the kids in the knickerbockers, Shirt-tail young ones, peekin’ in the pool Hall window after school, ya got trouble, folks.

Hill ramps up his warning, telling the “fine folks” of River City what’s in store:

One fine night, they leave the pool hall, Headin’ for the dance at the Armory! Libertine men and Scarlet women! And Rag-time, shameless music That’ll grab your son and your daughter With the arms of a jungle animal instinct.

Scary! Hill warns that, “the idle brain is the devil’s playground!” But then he offers the antidote to all this evil: a boy’s band. For which he will sell them the instruments and band uniforms.

Contemporary Harold Hills are selling medicines for imaginary diseases  all around us.

Did the Consumer Product Safety Commission issue a finding that gas stoves can cause asthma in small children? OMG! “They” are coming for our gas ranges! Those “woke” bureaucrats in Washington are going to ban the use of gas cookstoves, and they probably won’t even pay compensation! That’s what you get when you let Democrats run the administrative branch of government!

The fear and frenzy stirred up by GOP culture warriors prompted the head of the agency to issue a statement confirming the research results and the fact that the CPSC is looking for ways to reduce indoor air quality hazards, but does not intend to ban gas stoves. 

CPSC also is actively engaged in strengthening voluntary safety standards for gas stoves.  And later this spring, we will be asking the public to provide us with information about gas stove emissions and potential solutions for reducing any associated risks.  This is part of our product safety mission – learning about hazards and working to make products safer. 

There’s a lesson here for Americans who laughed at the comedic effectiveness of Harold Hill, or are currently marveling at the ability of Republican culture warriors to convince lots of people that “the government” is coming for their gas stoves. Stoking fear about– and then directing anger against– otherwise innocuous matters, works. In the Music Man, the tactic sold band instruments; in the great gas stove eruption, it allows angry citizens to confirm their anti-“wokeness” and determination to vote against “the libs.”

We see the tactic all around us. 

Are LGBTQ people more visible? Those Drag Queen story hours and library books about Heather’s Two Mommies are turning toddlers gay!

Are the kids learning about events we older folks didn’t encounter in school? Things like the Trail of Tears or the Tulsa massacre? Allowing teachers to include the seamier side of American history is a “woke” attack on American Exceptionalism and the firmly-held belief that we are–and have always been–the good guys.

Did epidemiologists tell us to  protect our friends and families from disease by wearing masks during a pandemic? They are obviously part of that “woke” elite that is constantly attacking American freedom!

Etcetera, etcetera.

Ya got trouble, my friend–right here in  America! You need to fight back. Threaten the library. Scream at school board members and have the smug culture warriors who dominate your legislature tell teachers what they can and cannot say. Insist that the President fire Dr. Fauci! (Whoops–too late. He retired.)

And tell your friends on Facebook that the government will have to pry your gas stove out of your cold, dead, oven-mitted hands.

Harold Hill clones are everywhere.

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