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.

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Denial Sends A Different Message Than Trump Thinks It Does

In yesterday’s post, I described Donald Trump’s obsession with Barack Obama, and the way his resentment over Obama’s clear superiority drives so much of Trump’s embarrassing behavior. I attributed that obsession to Trump’s racism–a racism displayed once again in his appalling tweets telling four Congressional women of color (three of whom were born in the U.S.) to go “back” to “their” countries .

His racism explains a lot, but Trump’s personal deficits and appalling immaturity also contribute to his disastrous Presidency.

Charles Blow recently focused on that immaturity in a column titled “Trump Detests Apologetic Men.” He began by describing Alexander Acosta’s public “explanation” of his recently revealed sweetheart deal with pedophile Jeffrey Epstein.

It remains to be seen whether Acosta’s news conference performance will save his job. As The New York Times reported, “Mr. Acosta’s appearance before cameras was seen as a crucial test of whether he will keep his job, with an audience of one as President Trump watched and weighed a decision.”

But that’s the thing that stops you: For Trump, this isn’t about the charges or the children. For him, this is about how men perform denial. In the mind of the misogynist, a man’s word is the weightiest thing in society, even when he’s lying. One’s test of survival and prosperity isn’t what you say, but how you say it. It isn’t what you do, but how you defend or deny it.

As Blow notes, it isn’t the facts of this or any other case, that matter to Trump.

It doesn’t matter if you attack the country Trump is sworn to defend, as Russia’s Vladimir Putin did, if you are “extremely strong and powerful” in your denial.

It doesn’t matter if you are accused of giving the order to hack up a Washington Post columnist’s body with a bone saw, as the Saudi Crown Prince is.

It doesn’t matter if you are accused of sexual impropriety, assault or rape — Brett Kavanaugh, Rob Porter, Bill O’Reilly, Roger Ailes. Just deny, deny, deny. Admit nothing.

If a man strongly, passionately denies something, then he has performed his function, he has risen to — or descended to — the moment.

The column included a quotation from Trump that reveals his utter inability to understand the way in which his behaviors are seen by normal, adult persons:

According to Bob Woodward last year, Trump talked about a “friend who had acknowledged some bad behavior toward women.” When counseling that friend on how to respond, Trump said, “You’ve got to deny, deny, deny and push back on these women.” Trump continued: “If you admit to anything and any culpability, then you’re dead. That was a big mistake you made.”

In Trump’s world, apologies and punishments are for the weak. They are for losers.

Of course, that’s the exact opposite of reality in grown-up land. People who refuse to admit their mistakes, who refuse to own their own errors–who refuse to apologize when they’ve misbehaved or even inadvertently offended someone–are actually seen (accurately, I would argue) as immature and insecure.

That’s because defensiveness is childish. It is children who react to accusations by denying they did whatever it was, or by insisting that whatever was said or done was right and the accuser is wrong, no matter the evidence to the contrary. Children must be taught to recognize that everyone makes mistakes, and that people will think better of them, not worse, if they own their behaviors.

People who’ve actually grown up know that it is evidence of maturity to say “I was wrong. I’m sorry” when an apology is indicated.

Of course, some people never do grow up. There’s a reason people so often compare Donald Trump to a third-grader, and it isn’t just his vocabulary.

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It’s Never His Fault

If there is one area of consistency in the chaos of Trump World, it’s this: no matter what the problem is, it isn’t his fault.

The black guy did it.

Juanita Jean has one of the latest manifestations: As she writes, “I knew Fox News would find a way to blame Barack Obama for Epstein’s plea deal with Acosta.”

Apparently, a Fox commentator insisted that “Bob Mueller knew about this.” (The relevance of that assertion escapes me, but whatever…) He then went on to say that Acosta’s plea deal was “from 2008, under a Democratic administration.”

As Juanita Jean points out (and a television pundit–even one on Fox– should know) Obama wasn’t elected until six months AFTER the plea deal. “But, as we know, Obama has magical powers to make things happen even before he was born in Kenya.”

This is part of a pattern among Trump supporters–a pattern set by Trump himself. It isn’t enough to reverse every policy Obama’s administration put in place, irrespective of its merits. It’s necessary to respond to any problem, any challenge, by blaming Obama for it and insisting that he, faultless Trump, has improved the situation.

For example, Trump continues to insist that the horrific family separation policies put in place by his administration were really attributable to Obama, multiple fact checkers to the contrary:

According to FactCheck.org, “previous administrations did not have a blanket policy to prosecute parents and separate them from their children.” It was after the Trump administration announced its “zero-tolerance” immigration policy in April 2018, in which everyone who illegally entered the U.S. was referred for criminal prosecution, that thousands of migrant children were separated from their parents.

After he ordered and then aborted an air strike on Iran, Trump went on a Twitter rant blaming Obama for the tensions with Iran–tensions that escalated following Trump’s abrogation of the pact Obama had negotiated, a pact that had cooled those tensions.

He has behaved this way from the beginning: When millions of women took to the streets to protest him, shortly after he took office, Trump blamed Obama:

President Trump said Tuesday morning he believes former President Obama “is behind” nationwide protests against the new administration’s policies, taking an unusual swipe at his predecessor.

More recently, despite the fact that he has been President (okay, he’s occupied the Oval Office) for two and a half years, he blamed Obama for Turkey’s recent purchase of Russian weapons.

My favorite example of “the black guy did it” was an interview I saw (if someone has a link to the original, please post it) in which a relatively young MAGA hat wearer was talking about 9/11, and demanding to know where Obama was. “I’d really like to know why we didn’t see him responding when the planes hit.” Of course, few people had even heard of Barack Obama in 2001, when George W. Bush was in his first full year as President.

The only thing Trump and his base don’t blame on Obama is the one thing for which Obama is undeniably responsible: the economy Trump inherited.

These examples–and plenty of others (just google Trump blames Obama)–vividly demonstrate two things: Trump’s childish inability to take responsibility for his own actions and mistakes; and his racist obsession with his predecessor.

You can almost hear him brooding: How dare that black man be so much smarter, classier and (most egregious of all) more admired than I am?

Sane Americans are also brooding–about the incalculable damage this sorry excuse for a human is doing to our country and our planet, and especially about the racist reactions to the election of his predecessor that motivated his base and propelled him to the Oval Office.

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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.

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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.

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