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.

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Let’s speak plainly

After watching a few newscasts with politicians using words that sound nice, but lack substance, I am in the need of some plain spoken comments. Here are a few to start the conversation. Please let me hear some of yours.

The US President and Congress are speaking of Tax Reform, but what I am hearing are tax cuts. We have a debt of $20 Trillion and an annual budget deficit. There is no way in hell to reduce either with lower tax revenue. We need spending cuts and tax increases, but no politician has the stomach to do what is needed.

Steve Bannon is the latest White House departure to say the President likes for his direct reports to compete for his attention and favor. People say this is how he likes to run his businesses. Two comments. First, I have witnessed this model as an employee, manager and consultant and it is a highly unproductive model. Second, biographers and financial reporters have all said Trump’s business record is spotty. He is a great salesman, but the word great is rarely used to describe his management style. It shows in the level of chaos and incompetence in the White House. General Kelly has helped, but it is a tall hill to climb.

While I understand the reasons for Brexit, I have been very concerned by the consideration and vote to exit the EU. From the outset, financial experts forewarned of the British leaving the EU. They spoke of EU headquarter movement, less investment, and less collaboration. This is already occurring in plans of the exit. I understand Former PM Tony Blair has an idea to govern immigration better without leaving – my strong suggestion is to hear him out.

Along these lines, those who want to retrench from global markets need to know a truism – it is very hard to shrink to greatness. I understand middle income workers in flourishing economies feel the brunt of globalization, but a large part of that is due to and will continue to result from technology gains. Retraining is a must. Shoring up wages is a must. But, we need to be careful about retrenching from global markets, that also add jobs here.

What are your thoughts? Do you agree with these comments? If you do not, let me know why?

 

The President and Congress own Obamacare

I have written often about the imperfect Affordable Care Act and ways to improve it. I have written often about the Republicans role in sabatoging the ACA making premiums even higher by not funding promised payments to insurers for adverse selection as well as naysaying the law and not expanding Medicaid in 19 states.

This sabatoge continues under this President who says the ACA is in a death spiral. It is hurting in many areas, but stabilizing in others. He said he wants to let it implode and then fix it.

Mr. President, that is not good enough. You are threatening to cease further promised payments to insurance companies which will harm people. You see, what you and Congress fail to realize is you own Obamacare. If it fails, it is on your watch. And, to be frank the significant majority of Americans and the press do not recognize the role you played in hamstringing the imperfect law.

My strong advice is to do what is necessary thinking of its patients and users. Those Americans out there deserve your best efforts to help them. Watching the ACA fail after you greased the skids is extremely poor form and uncaring. It is that simple. Fix the ACA. That is what is done to laws that need it to help people.

Gone to seed

We have a poverty problem in the United States. Too many of our declining middle class did not rise to the next strata, falling instead, to near poverty and into poverty. Yet, we do not talk about this problem enough. We have let their ladders out of poverty, go to seed along with their environment.

Poverty should be succinctly defined, as it is often misdefined along with simplistic diagnoses. Quite simply, poverty is the lack of money. The causes are many and complex, so the solutions must be holistic.

Some like to say it is due to lack of virtue. Some like to say it is due to lack of work ethic, while others may claim it is due to drug use or alcoholism. When I work with people in poverty, I witness hard working, often pious people. I see people with a lesser propensity to do drugs than general society.

If we recognize the simple definition of poverty as lack of money, we can focus our attention on providing ladders out of poverty. We can invest in the communities that have gone to seed, both with economic and social capital. We can start with redeveloping depleted assets. The term coined with a successful program in Atlanta is ABCD – Asset Based Comminuty Development.

ABCD could focus on repairing and not closing a community school, recognizing the during and after school value it offers. Or, it could be redeveloping a gone to seed golf course or empty textile or tobacco mill. Or, it could be repurposing a mall to be a school, church, charity or governmental building. Replacing or refurbishing blighted assets makes a huge difference.

Coupled with these investments must be education and career development, or social investments. Jobs and careers are scarce in too many areas. Opportunities must be introduced and nurtured to make them sustainable. STEM education, apprenticeships, trades skills are part of an all of the above tactical strategy,

But, we must be mindful of four negative trends in areas that have gone to seed – crime, opioids, food deserts  and single families. Community policing by people living in the community is key. Targeted help with the opiod epidemic is important. Better food choices must be available as they may not have a grocery market. And, we must have holistic sex education and access to planned parenthood tools and birth control.

What we cannot have is kicking tens of millions off health care insurance. We cannot reduce an already minuscule food stamps program. We need to think about improving the minimum wage.

These are just a few ideas. But, first we need to address what people in poverty lack – money.

 

 

 

Thursday needs a song and a few other thoughts

Off the top of my head, I am having a hard time thinking of a song with Thursday in the title or chorus. As I write this, I can remember a few songs for the other days of the week, with Wednesday being the hardest one to recall. So, with a special shout out to Thursday, here are a few odds and ends.

I mentioned in a comment earlier this week that Tesla is on target for rolling out 250,000 of its new affordable electric car. The car sells for US$35,000, is fun to drive and can go 215 miles on a charge. It should be noted that Elon Musk’s Tesla is one of the leading edge innovators on advanced battery storage.

I read yesterday in Reuters that Geely Volvo will only produce electric and hybrid cars after 2019. Let that statement sink in a little. Volvo will not produce combustible engine cars after 2019. I want you to think about that as the President wants to increase fossil fuel production. Apparently, Geely Volvo sees a different future.

At the same time these articles appeared, Scott Pruitt, who heads the EPA decided to spend our tax money in delving further into the climate change is a hoax theory. This is after the EPA removed various research links to papers and work on climate science from its website at Pruitt’s order. This alternative research flies in the face of peer reviewed science that questions the veracity of findings. Apparently “making America great again” means to throw away our advantage and let the world pass us by.

Finally, just to further this point, ice floes off of Antarctica are melting at a faster pace than expected. Now, we should note that when floating ice melts, it does not by itself contribute to sea level rise. But, these ice floes protect the land ice and, once gone, the land ice will melt at a faster pace and that will impact sea level rise.

So, Messers. Trump and Pruitt, are you quite sure we want to leave the Paris Climate Change Accord, focus on climate change denial and invest more heavily in fossil fuels? Yes, this is about the environment, but is also about jobs. The jobs are growing much faster in renewable energy and related industries.

Undoing how we make decisions

Best-selling author Michael Lewis’ latest book is called “The Undoing Project – A Friendship that Changed our Minds” which focuses on how we make decisions. Two transplanted Israeli psychologists named Daniel Kahneman and Amos Tversky partnered together for years and were acclaimed for their work in showing we are less rational decision-makers than we think we are, especially where risk is involved.

In short, we include our biases in how we interpret data and probabilities, so we do not all see the issue the same way. But, even more telling is we can be influenced by how the question is posed to us. Their analysis eventually led to a Nobel Prize in Economics, which was awarded to Kahneman after Tversky had passed away. The reason is their work created a new breed of economics called “Behavioral Economics.” But, their work had converts using it in the practice of medicine, setting public policy and even in making NBA draft picks. They ask that people step back and question things. Your bias may lead you to pick the most improbable cause or choice, so if you question yourself and others you may find the best probable path forward.

The other key takeaway is the tremendous partnership these two had over the years. They were very different personalities, yet it was difficult for them to know who had more input into their work. They often flipped a coin to decide whose name should go first in a paper. Their partnership was so constructive, it was difficult on people in the US who tend to believe one of the partners was a greater contributor. Tversky, being more outgoing and confident, was more easily and incorrectly thought of as the lead. Kahneman questioned everything even when he was far more right than wrong, so he came across as less confident. Ironically, it was his questioning things that challenged Tversky to reconsider strong positions. They yin and yanged like an old married couple.

It would be difficult for me to define their work in such a short piece, so let me share some of their examples which may be illustrative. Their most famous piece is called “Prospect Theory: An Analysis of Decision under Risk.” If you were given two options where (1) gave you a 50% chance to win $1,000 and (2) provided a gift of $500, most people would pick (2) as a sure thing. Yet, if the question is reframed and the two options were (3) which gave you 50% chance to lose $1,000 and (4) which provided a sure loss of $500, most everyone would pick (3) the gamble.

As they dived further into questions like this, they discovered that people would regret losing the sure thing as they did not have the money, yet were more risky with money they did not have. When they altered the probability of winning or losing, the same result would occur, even when the odds were much more in your favor to win (or not lose). But, they also learned how the questions were framed made a huge difference.

If an Asian disease was expected to kill 600 people and you could take one of the following actions, which one would you choose where Option (1) would save 200 people and (2) had a 1/3 chance of saving all 600 and a 2/3 chance of saving none? Most people chose Option (1) to save 200 people. Yet, if the question is framed as Option (3) where 400 people would die and (4) where there is a 1/3 chance none would die and 2/3 chance all would die, most people chose Option (4). Yet, it is the same question.

Another key concept they introduced through study is “representativeness.” If you added information to a question, people would believe the greater accuracy meant they should choose that option. This would even be true if the information added was irrelevant or unimportant. In other words, if something is described in more detail than other options, it creates an information bias. They illustrated this to be true with experts in a field, as well as with laypersons.

Lewis uses the example of medical doctor who embraced Kahneman and Tversky’s work named Don Redelmeier. Redelmeier would question quick conclusions by doctors made under stress, where they would use information bias. A good example came when a car accident left a woman with an irregular heartbeat after they treated her. The doctors hung their hat on the fact she had a medical history of excess thyroid hormones and just assumed that was causing the irregularity.

Yet, this was a remote probability. They were led down this path because of the extra piece of information. Redelmeier had them question this remote idea and look further. It turned out the more likely cause was indeed the reason for the irregular heartbeat – a collapsed lung from the accident. Because they had more information on a condition, they stopped looking for other causes that did not obviously surface.

I encourage you to read the book for the two reasons Lewis wrote it. It is more than just the work of Kahneman and Tversky on making decisions. It is also about how two different people can collaborate so successfully and be far more together than they were separately. They valued this partnership and made it work well for them and us.

Note: Lewis also wrote “The Blind Side,” “Moneyball,” “Liar’s Poker” and “The Big Short,” to name a few.

 

A few suggestions on ACA Reform

Since the House and 13 Senate Republicans have decided not to listen to the American majority or review actual data, here are a few suggestions on reforming the ACA. The ACA is imperfect and seeing higher premiums than expected in some places, but critics overlook three key things. It has dramatically reduced the number of uninsured, it has introduced positive benefit requirements to all plans including employer sponsored ones and its premiums are even higher due to Republican Senators stiffing insurers.

What should we do about improving the ACA? First, do not pass any variation of the ill-conceived AHCA bill passed by the House. It is obvious the gang of thirteen GOP male Senators are not listening to the American majority. For what it is worth, here is what this retired benefit consultant, actuary and manager suggests for consideration.

– Pay insurers for the amounts promised them under the ACA to take on initial adverse risk (as was done when Medicare Part D was rolled out) and invite them to stay or return to the exchanges. Part and parcel with this change is to restore the risk corridor funding for adverse selection going forward. This will bring premiums down.

– Fully expand Medicaid in the remaining 19 states. The National Governors Association advocates the positives of Medicaid expansion with Ohio Governor and former Presidential candidate John Kasich calling it a “no brainer.” This will help rural hospitals, economies and residents as well as others in more urban settings.

– Reduce eligibility to Medicare to age 62. This will reduce the overall risk profile under the exchanges and Medicare since the added Medicare population is older than the average exchange population it would leave and younger than the Medicare population it would be joining.

– Where competition in the exchanges is nonexistent with only one provider, offer a public option through Medicare or a variation therefrom. The pricing needs to be fair when contrasted to the lone offering as you want provide viable choice, but not drive the lone insurer away

– Finally, I would suggest we evaluate the efficacy of all fee arrangements under the ACA. Which ones make sense to continue, which ones make sense to alter, and which ones should be shelved or replaced?

It would also be helpful for naysaying for the sake of a party position to cease. Some impressionable people have refused to consider the ACA because a politician told them not to saying it was horrible or in a death spiral. People need to be mindful that health care and insurance are complex and politicians are offering advice in areas for which they are not licensed or knowledgeable to do so.

To be frank, I would rather see us go down the path of a national health insurance model. Yet, that is s tough sell in this country. So, improving the ACA is the better course versus what is being discussed. Plus, the strategic expansion of Medicare noted above will permit us to study this option and expand or contract it based on its measured veracity.