Let’s fix the larger gun death problems

Mass shootings are very tragic and heart wrenching. Homicides are also tragic. Yet, the biggest gun problem and another tangible and avoidable problem make up between 60% and 70% of annual gun deaths in America. The lion’s share of gun deaths in America are suicides. Last year, over 23,000 of the 38,000 plus gun deaths were suicides. This ratio is not unusual and tracks pretty well year in and year out.

The other much smaller, but more avoidable gun death problem is accidental shootings. And, tragically the ones doing the shooting or getting killed are children who come across a weapon. To lose a child is the worst nightmare I could possibly imagine. But, to lose one because you did not put away your gun, is even more traumatic. The gun owner has to live with the guilt. While accidental shootings are about 2% of gun deaths, they seem to be ones we should be able to avoid irrespective of one’s fervor for the 2nd Amendment.

After each mass shooting, there is concern registered by kids and parents about not letting this happen again. The people for and against more gun control go into camps with some saying now is not the time, while the others asking when is the time. I must give a huge amount of credit to the Parkland kids and others around the country who are forcing action. But, outside of a little lip service in Washington, nothing tangible happens. They may regret inaction come November.

These past few months, the barest of minimum change was done, but there was the President of the United States speaking before the NRA convention last week. He was the one who taunted Congress representatives for not standing up to the NRA. These were obviously just words, which we should be used to by now. With this said, I do give kudos to Florida who acted a little more demonstrably than DC.

To prevent more suicides, background checks on all sales with elongated waiting periods are needed. Doctors must be permitted to ask patients if there is a gun in the house as the propensity for suicide is much higher than one without. All it takes is an impulse and it is over. We must add more psychologists and counselors to schools. The greater gun risk is a depressed student taking his or her life. And, we should expand Medicaid in the remaining 18 states along with its mental health benefits.

As for the accidental shootings, the majority of states require guns to be locked up at home, but why do not all states have such a requirement? I have shared this before, but I asked my father-in-law to lock up his weapon, as I did not want his grandkids around a loaded weapon. He did so. One idea that has merit is requiring a finger printed trigger, where only the owner can use the weapon.

Please note that none of the above speaks of taking weapons away. These steps would help reduce the number of suicides and accidental shootings. Even if the number is only 100, 500 or 1,000, those are lives saved. Isn’t this what it’s all about?

 

 

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That healthcare thing

In more than a few surveys, the majority of Americans have noted that healthcare is a key dinner table issue. In several surveys, shoring up and stabilizing the Affordable Care Act (ACA) is preferred by a smaller, but still majority of Americans, than its repeal.

With a background of being a former benefits actuary, consultant and manager of benefits, here are a few facts and observations that I encourage you to research and verify.

– The ACA borrows from a Republican idea implemented by Governor Mitt Romney in Massachusetts which was advocated by de facto Tea Party leader Senator Jim DeMint for the whole country. Some elements can be found in a healthcare idea of Senator Bob Dole when he ran for President in 1996. These are reasons Republicans had a hard time with other ideas to repeal and replace it.

– The ACA is designed to require employer and public plans to offer certain minimum level benefits. The non-employer benefits are delivered through healthcare exchanges of policies and the expansion of Medicaid for people near or in poverty (32 states and the District of Columbia elected to do this).

– The biggest benefits of the ACA are guaranteed issue and renewability of coverage and the premium subsidy for people with incomes up to 4 x poverty limit. If you or a child has a preexisting condition, guaranteed issue and renewability are huge benefits.

– The botched roll out of the online exchanges sits at the feet of President Obama. For this to be such an important issue, it deserved better planning. The online exchanges are doing much better now, but you don’t get a second chance for a first impression. And, this poor roll out was used as fodder to nay-say the program, even though the problems were fixed.

– The ACA has experienced higher premiums due to adverse selection (pent-up demand and more high risk than better risk customers), but it is frustrating that the Republican Senators and President have masked their role in making premiums even higher. Senator Marco Rubio led an effort to strip 89% of the funding to insurers for initial adverse selection a couple of years ago and President Trump stripped out funding for co-pays and deductibles for lower paid people last year. Both of these changes cause premiums to increase even more than they otherwise would have.

– The lack of expansion of Medicaid in 18 states means the ACA is still not fully implemented. Per The Commonwealth Fund, this implementation would help people, rural hospitals and state economies. GOP Presidential candidate John Kasich called Medicaid expansion a no-brainer when he did it in Ohio as Governor.

The ACA is not perfect, but it is working OK. It could work even better if it were stabilized and improved. Taking away the mandate will be harmful and cause premiums to go up even more. What troubles me in our zero-sum game of politics is we are foregoing improving an imperfect law, which we have done countless times before on major changes. The way I see it, Congress and the President own this law now. If it fails, people should look to them asking why did they let it happen. This impacts people.

I have mentioned before several changes to consider. National healthcare is not going to happen in our country as it is too political and the healthcare industrial complex is strong. Yet, I advocate expanding Medicare in a targeted way down to age 62 (or maybe 55). Unlike the more complex Medicaid, Medicare actually works pretty well and strips out the profit load embedded in insurance premiums. This will reduce exchange premiums and Medicare premiums, as it makes both audiences younger on average.

I think we need to reconstitute the adverse selection and co-pay subsidies to insurers. The federal government needs to repay insurers they stiffed and invite insurers who left back into the exchanges. I would also recommend the remaining states expand Medicaid and I would add back the mandate for coverage, even though this feature is unpopular. If there are areas where competition is not significant, select use of Medicare (or Medicaid) could be deployed in those counties.

There are other changes that should be considered, but we need to shore this thing up. Congress and Mr. President, the ball is in your court as well as the legislatures for those eighteen states.

 

A few straightforward suggestions to fight poverty

“If incarceration had come to define the lives of men from impoverished black neighborhoods, eviction was shaping the lives of women. Poor black men were locked up. Poor black women were locked out.”

The above quote comes from the Pulitzer Prize winning book “Evicted” by Matthew Desmond. Its subtitle is also telling – “Poverty and Profit in the American City.” The dilemma is we have a poverty problem that stretches from urban to rural America. Yet, it manifests itself daily in the eviction courts of American cities and towns, whether it is from apartments, houses or mobile homes.

The book speaks of how fragile the rental community is regardless of race, yet the black community tends to have a higher rate of exposure to evictions in urban areas. Unexpected expenses, transportation problems, and tragedies can push people paying a very high portion of their rent over the edge and out the door. Ideally, 30% of family income should be toward housing and utilities. Too many of these folks are paying well above that percentage.

It should be noted that there are other drivers of fragility. Some have opioid and other dependencies. Some are fragile due to too many children that stretch the budgets of even the best planners. Some are in downward spirals with unsupportive landlords. And, many of those unexpected expenses that arise are healthcare related.

What are some suggestions to remedy these issues? Based on my experience as a volunteer Board member helping working homeless families and my reading, I would like to throw out some ideas for consideration.

First, we need to talk more about it. America has a huge disparity in distribution of wealth which is not talked about enough by leaders. Where and to whom one is born are greater predictors of success as the American Dream  has waned for too many.

Second, we need to fund more family planning efforts not less. There is a high correlation between poverty and large families. When family planning is funded and birth control access and education are increased, poverty declines, system health care costs decline and abortions decline.

Third, more mechanisms to reduce evictions need to be in place and funded. Crisis assistance funds show success in helping keeping the electricity on and, when funded, reducing the number of evictions. Stopping homelessness (or fragility) before it starts can make a huge difference and will have a positive echo effect.

Fourth, we must invest in impoverished  areas making them more suitable for families both with opportunity and resources. In their absence, crime and other poor influences fill the void.

Fifth, while I have concerns about the new Tax law with its impact on debt and heavy emphasis on the wealthy and corporations, a huge opportunity was missed when we could have added an increase in the minimum wage tying it to automatic increases due to wage inflation. I worry that less money than expected by the law’s drafters will end up in the hands of workers.

Sixth, we must address our opioid crisis in America. To be frank, cutting access to healthcare and mental care insurance benefits are not the answer. We must stabilize access and cost of healthcare, yet opposite measures have been taken in the past few years under the guise of political gain.

There are many more ideas, but these will help. On the investing front, many locations have seen success with using historical tax credits leveraging private money. There is a concept called ABCD (Asser Based Community Development) which shores up or repurposes an deteriorated asset creating jobs.

But, first we need to talk about this real and pervasive problem.

 

 

 

The President almost did something good, then…

People need to know that our President is not big into details, nor does he care to be. He is not very conversant on healthcare or the Affordable Care Act, for example. Yet, he almost slipped up and accomplished something good. Alas, he changed his position within 24 hours.

Just last week, he signed two executive orders to help healthcare in the US. Neither order would be very helpful and both will cause premiums to go up under the ACA. In fact, he said if we eliminate the subsidies for deductibles, co-pays and co-insurance on people making less than 2 1/2 the poverty level it would just hurt the insurer’s profits. That simply is not true, as our deficit would go up by $20 Billion per annum and people without subsidies would see premium increases.

But, while this was going on, Senator Chuck Schumer kept telling him about the bipartisan effort of Senators Lamar Alexander and Patty Murray that would stabilize and improve the ACA. Their efforts would restore the subsidies that Trump wanted to do away with. Insurers were pricing 2018 premiums higher sans these subsidies,

Trump encouraged Alexander while Schumer did the same with Murray. The President actually did the right thing, as Alexander and Murray were going about their business in the right way with hearings and committe meetings. This is how legislation should be done, which has been lost on our two Congress chamber leaders.

When Alexander/ Murray announced they reached agreement, the President was supportive. Alexander actually thanked the President for his role in making it happen. Yet, just after Alexander called to thank him, Trump changed his mind and now does not support it. Less than 24 hours had elapsed.

Of course, his support may change and Alexander/ Murray are not done yet, but Trump had a chance to take credit for helping Americans. This could have been a helpful major piece of legislation, which is missing from his tenure. Alas, he realized he would be helping the ACA and he had to destroy it. That is what he promised to his base. While imperfect, the ACA is not broken, but it does need improvements. If it eventually fails, it is on this President and Congress’ shoulders.

Any more questions?

For over two years, I have been amazed at how a man, who is so consumed with himself and has given so little regard to the plight of others, can become the President of the United States. He convinced far too many people, whose voice has not been heard, that he was on their side. Unfortunately, they did not pay attention to his history which reveals he has only one cause – himself.

Yesterday, this man decided to kick poor people one more time, stripping subsidies under the ACA for deductibles, co-pays and coinsurance for those who qualify because of low wages. This man owns the imperfect, but working ACA. He has sabotaged it from the get go picking up the baton the GOP Congress gave him, so if the ACA fails as a result, it is on his and GOP leadership’s shoulders.

A few weeks ago, he rolled out the outline of his tax plan that uses sleight of hand with a small tax break for the middle class, while eliminating the Alternative Minimum Tax, Estate Tax above $5 million in value, and the ACA tax on wealthy people, while cutting the individual and corporate tax rates. This is a clear windfall for the “haves” with a little gain for the “have-nots.”

Next, we should consider his proposed defunding of programs to retrain displaced coal miners. At the same time, he was enabling coal owners to invest in digging more coal with fewer workers. An energy expert said, “Trump is not for coal miners, he is for coal owners.” The dilemma is the current and former coal workers don’t know this.

The focus on fossil fuel and attack on environmental regulations is another slap at the disenfranchised. They tend to be the ones who feel the brunt of environmental rollbacks. A rancher in Montana, who has successively fought against the oil companies, notes that he cannot name one western town that has benefited long term after the oil rush abates. He said “all of the money goes back to Houston and Calgary.” The ranchers and farmers are left holding the bag to fix all the environment problems.

Speaking of environmental calamities, after much better responses to hurricanes in Texas and Florida, the response to the hurricanes which devastated Puerto Rico has been slow and fraught with problems. Yet, after pronouncing what a great job he was doing, Trump has continually harangued people in need, actually verbally and physically insulting them when he visited and afterwards.

Finally, the President’s attack on civil liberties, protest and free speech is the coldest dagger of all. He is basically telling everyone to “believe no one else but me.” His actions and words say he will squelch these unpatriotic troublemakers. To me, he is saying how dare they question what is going on in this country or what I am doing?

Well, I dare ask one question to everyone. Do you have any more questions about whose bread is being buttered by this President?

My former party does not know much about healthcare

The Graham-Cassidy Bill seems to be on its last legs, but these bills are like Jason – just when you think you kill the serial killer, he remains alive. This latest effort may be the worst bill by my former party, which I left in 2006. It is apparent to me that Republican leaders don’t know much about healthcare and don’t care to know or take the time to know. That includes the man in the White House who just wants to sign something that negates something Obama did. “Who knew healthcare could be so complicated?” he asked earlier in the year. The answer “Everyone, but you.”

Every bill either put forth by the Senate this year or passed by the House has been scored poorly by the Congressional Budget Office (CBO), has been not appreciated in polls and has been denigrated by medical and hospital associations. Not involving women, Democrats, experts and due process in the planning revealed a haphazard approach to legislation.The Graham-Cassidy Bill is the worst of the bunch as it places the burden, and eventually all of the financing, on the states. In a nutshell, the bill says we cannot figure this out, so we are punting it to you.

In addition to the tens of millions of Americans negatively affected by these bills, if passed, the authors make a concerted effort to kick people in poverty and near-poverty in the teeth. Since we have a poverty problem in America, these bills are especially cold-hearted. And, Graham-Cassidy gives states the right to do away with pre-existing conditions, which was incorrectly refuted by Cassidy after being called on the carpet by Jimmy Kimmel. Seeing protestors in wheel chairs at the Senate was telling.

Further, I have shared with Senators, Congressional Representatives and the White House, these bills would be dilutive to the economy. Standard & Poor said yesterday in their global report the Graham-Cassidy would harm the American economy by $240 Billion through 2027 and cause 580,000 job losses. In a nutshell, when people in need no longer have insurance, the trade-off becomes between food/ rent and medicine. So, less is spent in the market place which dilutes the economy.

Yet, let me emphasize one thing that has been raised by more than a few state Medicaid Directors and Governors. Building a new healthcare delivery system will take longer than the time given. In my view, it will take longer than even these folks are thinking about. In business and government, leaders tend to vastly underestimate the complexity to set-up administration of things. As President Obama found out, setting up healthcare exchanges was hard and initially failed to deliver.

This is an important observation about the Affordable Care Act. It is in place. It is not in a death spiral and it is not broken. From the lens of fewer uninsured, it has been successful. Yet, it needs improvements, but first it needs to be stabilized. Part of the reason for the latter is the GOP’s efforts to hamstring its success by defunding subsidies for adverse selection to insurers. Coupled with slow funding of other subsidies, nineteen states who did not expand Medicaid and general naysaying, the law has not been given full opportunity to be successful.

So, this retired benefits actuary, consultant and manager recommends the ACA be stabilized under some version of the bipartisan Alexander/ Murray Bill. Then all members of Congress can spend more detailed and thoughtful time in deciding how healthcare can be delivered going forward. My recommendation is they improve the ACA.

Monday, Monday

With a shout out to the Mamas and the Papas, I borrow their song title to share a few miscellaneous thoughts this Monday.

Kim and Trump scare me as they see who has the longest private part. I hope cooler and more rational heads prevail. I keep thinking neither man is that stupid to launch a nuclear warhead, but the probability is higher than it was a year ago.

Just to make sure the White House incumbent does not understand the risk climate change poses, even after Hurricane Harvey was made worse as a result, he appoints another climate change denier to head NASA. It is one thing to not having scientists in positions that should likely have them – Departments of Energy, EPA and NASA- but they should at least not pretend they know more than scientists do. Their arguments ring shallow.

The White House incumbent will be telling us this week what he plans to do with kids of undocumented parents who were brought here. These over 800,000 kids and young people have the backing of business leaders and Congressional leaders. Speaker Paul Ryan says leave this to Congress, but he fails to recall Obama acted because Congress would not, even after a bipartisan Senate bill was passed. The business leaders see this as an intellectual capital issue as well as a fairness issue. Trump has been all over the place on this issue, so who knows.

Thank goodness the waters are subsiding in Texas and Louisiana. It will be a long, arduous struggle to repair and rebuild. Someone mentioned earlier said it would be quick, which are just words. I hope our Congress can help in funding. And, I wish FEMA, HUD and the EPA well in helping these people.

Have a safe week. If you are religious, say a little prayer for wise actions by incumbent heads of state and helpful public servants for those in need.