tag:blogger.com,1999:blog-34499723850286944632024-03-08T11:59:08.286-08:00Pending HorizonJon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.comBlogger114125tag:blogger.com,1999:blog-3449972385028694463.post-83693280885642812982020-09-14T13:52:00.001-07:002020-09-14T13:52:17.615-07:00Why we need Universal SNAP<p>No American should ever go hungry. It is a simple and powerful message with a clear, simple solution: Universal SNAP. </p><p> The Supplemental Nutrition Assistance Program, formerly known as food stamps, provides qualified low-income people with an average of $127 a month to help purchase food. The problem is, of course -- as with any means-tested program -- that many people fall through the qualification cracks, fail to apply, or are actively kicked off by Republicans' efforts to restrict access with work requirements. The solution is to increase SNAP and make it universal. Have the government send everyone a card that every month is automatically loaded with more funds. Everyone gets the card regardless of age or income. Such a program would only cost about $600 billion a year. That is less than the military budget ($705 billion) and a fraction of the cost of universal basic income or Medicare for All. </p><p>
I think politically, as a policy to improve society in the near term, and as part of a long term plan to build support for more progressive reform, it is a great idea with almost no institutional support. It's a relatively cheap way to prove the value of universal programs over means-tested ones. I suspect it has not gained traction because it has fallen in the uncanny valley of being both radical and not radical enough. </p><p>
On one level, I suspect most people believe the current means-tested SNAP program is good enough, but it simply isn't. There are currently 26 million adults who report their households sometimes or often don’t have enough to eat. This is a devastating tragedy it is well within our power to address. </p><p>
On another level, much of the nation's political energy comes from middle class people and is directed toward big ticket universal programs which also address big concerns for middle class people. This includes plans like universal free college, universal pre-K, and Medicare for All. While universal SNAP would be a modest financial help to middle class people, hunger is not a real pressing concern.</p><p>
Finally, the other big focus of political activism is big, transformative ideas like Universal Basic Income. Compared to that, Universal SNAP definitely seems small and would in theory be made redundant if UBI were ever adopted. </p><p>
I think it is unlikely, though, that the United States would in a single step go from a stingy, heavily-tested social safety net to a full, high-price tag UBI in a single step. This is where the genius of Universal SNAP comes in. There is a clear moral case for it, it is very easy to message, and it would provide real help to address a clear, distinct problem. “No one should go hungry in America” is an easy message to get behind, and this would accomplish that. It is also easy to administer, relatively low cost, and a way to prove the value of universal social programs. It's a first step to a better society.</p><p>
</p>Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com1tag:blogger.com,1999:blog-3449972385028694463.post-27469016936859202022020-08-03T07:30:00.001-07:002020-08-03T09:23:18.850-07:00Community Involvement Jury Duty: A better way to reflect the actual publicCurrently, there are two predominant ways of gauging public sentiment around government policy, and they are both deeply flawed. We need a better system to decide how the public feels about complex policy options: I propose community involvement jury duty.<br />
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One way we typically assess public sentiment is through polling. While this can be highly effective in getting the general public's position on issues, it only really works if the issue is well known and/or easy to explain in a single poll question. Its biggest drawback is that it's ineffective for complex matters like comprehensive plans to rezone neighborhoods. Any issue that is too complex, too obscure, or that most people don’t pay attention to, is not well suited for polling.<br />
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The other way we measure public sentiment is listening to active public input - things like informational meetings, public testimony, community events, neighborhood associations, etc… While valuable, these processes are inherently biased in two ways. The first is an intensity bias. This tends to favor the status quo. Many policy decisions often result in large, diffuse groups who marginally benefit -- as well as a very small group of people who lose in a specific way. The winners are rarely going to show up at meetings, but the losers will. For example, a plan to cut down a tree to make a stoplight more visible will benefit the entire community, but only in a small way few are going to go to a public meeting about. But the person whose house is benefiting from the shade of this one tree might very well complain.<br />
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The other inherent bias is one that strongly favors people with the time, knowledge, and financial wherewithal to take part in these things. Rich people, retired people, people with flexible schedules, people without kids, and those already actively engaged in politics are all more likely to be able to take part in these processes. Efforts can of course be made to make these processes more open (widely publish meeting schedules, community outreach, having meetings at unusual times), but they can at best only slightly improve the situation. The simple fact is most working parents have limited ability and desire to weigh in on every issue.<br />
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<b>Community Involvement Jury Duty</b><br />
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Think of community involvement jury duty like a mandatory, government-run focus group. It would operate much like jury duty does (or at least how jury duty should). For major issues, two different panels of roughly 13-21 people with a stake in the matter would be selected in a process very similar to jury duty. The individuals would be selected at random but in a way that ensured the whole group formed a representative sample closely matching the racial/ethnic economic mixture of the specific area.<br />
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Attendance would be mandatory in the same way jury duty is. All participants would be paid for their time, provided daycare and a legally binding excuse from work. The process would run for several hours over the course of a day. The relevant agency behind the proposal would give a presentation about the issue explaining the background and goals. Organizations opposed to and in support of the idea would also be given time to make their cases to the group. The participants would have plenty of time to ask questions, look over any materials, offer their group and later individual feedback.<br />
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The results of these sessions would not be legally binding but should be given significant weight in all planning and decision making processes. It is likely the best way to understand the opinions of the vast majority of the public who don't have the time or inclination to actively weigh in. Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com0tag:blogger.com,1999:blog-3449972385028694463.post-66457571768560504762018-11-19T10:16:00.000-08:002018-11-19T10:21:57.700-08:00Every part of health care industry is accusing the rest of ripping you off<div class="c2" style="-webkit-text-stroke-width: 0px; background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; letter-spacing: normal; line-height: 16.85px; margin: 0px; padding-bottom: 0px; padding-top: 0px; text-align: left; text-decoration: none; text-indent: 0px; text-transform: none; white-space: normal; word-spacing: 0px;">
<span style="font-family: inherit;"><span style="font-size: small;"><span class="c0" style="color: black; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">To understand why American spends such a shocking amount of health care you don’t need a degree in economics or even a strong understanding of the numerous laws which govern our system. All you need to do is listen to what every part of the health care industry is saying about every other part. On twitter the industry is pointing out how basically every part of the system use their market/legal/political power to rip you off.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span class="c5" style="color: black; font-style: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">Insurers blame drug makers, hospitals, physicians groups, and individual doctors</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="color: black; line-height: 16.85px; margin: 0px; padding-bottom: 0px; padding-top: 0px; text-align: left;">For example the health insurers are </span><span class="c3" style="color: #1155cc; text-decoration: underline;"><a class="c1" href="https://www.google.com/url?q=https://mobile.twitter.com/AHIPCoverage/status/1050744291931410432&sa=D&ust=1542655190201000" style="color: #1155cc; text-decoration: underline;">repeatedly blaming</a></span><span style="color: black; line-height: 16.85px; margin: 0px; padding-bottom: 0px; padding-top: 0px; text-align: left;"> the drug companies for </span><span class="c3" style="color: #1155cc; text-decoration: underline;"><a class="c1" href="https://www.google.com/url?q=https://mobile.twitter.com/AHIPCoverage/status/1050744291931410432&sa=D&ust=1542655190203000" style="color: #1155cc; text-decoration: underline;">exploiting</a></span><span style="color: black; line-height: 16.85px; margin: 0px; padding-bottom: 0px; padding-top: 0px; text-align: left;"> their government granted monopolies to </span><span class="c3" style="color: #1155cc; text-decoration: underline;"><a class="c1" href="https://www.google.com/url?q=https://twitter.com/AHIPCoverage/status/1039151379145793536&sa=D&ust=1542655190204000" style="color: #1155cc; text-decoration: underline;">“price gouge”</a></span><span style="color: black; line-height: 16.85px; margin: 0px; padding-bottom: 0px; padding-top: 0px; text-align: left;"> sick children and their desperate parents. Price gouging the insurers claim is because the drug makers known people </span><span class="c3" style="color: #1155cc; text-decoration: underline;"><a class="c1" href="https://www.google.com/url?q=https://twitter.com/AHIPCoverage/status/1037743414203297793&sa=D&ust=1542655190205000" style="color: #1155cc; text-decoration: underline;">have no alternatives</a></span><span class="c0" style="color: black; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="color: black; line-height: 16.85px; margin: 0px; padding-bottom: 0px; padding-top: 0px; text-align: left;">The insurers also </span><span class="c3" style="color: #1155cc; text-decoration: underline;"><a class="c1" href="https://www.google.com/url?q=https://twitter.com/AHIPCoverage/status/1037822751321542656&sa=D&ust=1542655190207000" style="color: #1155cc; text-decoration: underline;">blaming the hospitals</a></span><span style="color: black; line-height: 16.85px; margin: 0px; padding-bottom: 0px; padding-top: 0px; text-align: left;">, </span><span class="c3" style="color: #1155cc; text-decoration: underline;"><a class="c1" href="https://www.google.com/url?q=https://twitter.com/UHC/status/1052469262168674304?s%3D17&sa=D&ust=1542655190209000" style="color: #1155cc; text-decoration: underline;"> physician groups</a></span><span style="color: black; line-height: 16.85px; margin: 0px; padding-bottom: 0px; padding-top: 0px; text-align: left;">, and </span><span class="c3" style="color: #1155cc; text-decoration: underline;"><a class="c1" href="https://www.google.com/url?q=https://twitter.com/UHC/status/1044531481803141123&sa=D&ust=1542655190211000" style="color: #1155cc; text-decoration: underline;">doctors</a></span><span class="c0" style="color: black; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> for taking advantage of people in the emergency room. When people are at their their most vulnerable, can’t shop around, or even say no; insurers are pointing out hospitals and doctors take advantage of people by charging ridiculous prices. </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span class="c5" style="color: black; font-style: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">Drug makers blame hospitals, doctors and insurers</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="color: black; line-height: 16.85px; margin: 0px; padding-bottom: 0px; padding-top: 0px; text-align: left;">Of course the finger pointing goes both ways. The drug makers blame the Pharmaceutical Benefit Managers (often own by insurers) for </span><span class="c3" style="color: #1155cc; text-decoration: underline;"><a class="c1" href="https://www.google.com/url?q=https://twitter.com/steveubl/status/1039527649356521473&sa=D&ust=1542655190214000" style="color: #1155cc; text-decoration: underline;">high cost</a></span><span style="color: black; line-height: 16.85px; margin: 0px; padding-bottom: 0px; padding-top: 0px; text-align: left;">. They blame the hospitals for </span><span class="c3" style="color: #1155cc; text-decoration: underline;"><a class="c1" href="https://www.google.com/url?q=https://twitter.com/PhRMA/status/1037310538664095746&sa=D&ust=1542655190215000" style="color: #1155cc; text-decoration: underline;">marking up</a></span><span style="color: black; line-height: 16.85px; margin: 0px; padding-bottom: 0px; padding-top: 0px; text-align: left;"> medication by as much as 700%. They also point out that most of rapid growth and health care spending is really been drive by the </span><span class="c3" style="color: #1155cc; text-decoration: underline;"><a class="c1" href="https://www.google.com/url?q=https://twitter.com/steveubl/status/1022164960397459456&sa=D&ust=1542655190217000" style="color: #1155cc; text-decoration: underline;">high prices for hospitals and doctors</a></span><span class="c0" style="color: black; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">. </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span class="c5" style="color: black; font-style: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">The hospitals blame the drug markers and Pharmaceutical Benefit Managers</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="color: black; line-height: 16.85px; margin: 0px; padding-bottom: 0px; padding-top: 0px; text-align: left;">In turn the hospitals are blaming the drug makers and </span><span class="c3" style="color: #1155cc; text-decoration: underline;"><a class="c1" href="https://www.google.com/url?q=https://twitter.com/MgVantrieste/status/1051880770565001216&sa=D&ust=1542655190219000" style="color: #1155cc; text-decoration: underline;">PHB for charging too much</a></span><span style="color: black; line-height: 16.85px; margin: 0px; padding-bottom: 0px; padding-top: 0px; text-align: left;">. Pointing out </span><span class="c3" style="color: #1155cc; text-decoration: underline;"><a class="c1" href="https://www.google.com/url?q=https://twitter.com/MgVantrieste/status/1042804553681461259&sa=D&ust=1542655190220000" style="color: #1155cc; text-decoration: underline;">insane price increases</a></span><span style="color: black; line-height: 16.85px; margin: 0px; padding-bottom: 0px; padding-top: 0px; text-align: left;"> that is currently take place. In fact the hospitals are so convinced that “</span><span class="c3" style="color: #1155cc; text-decoration: underline;"><a class="c1" href="https://www.google.com/url?q=https://twitter.com/MgVantrieste/status/1043184907663695872&sa=D&ust=1542655190222000" style="color: #1155cc; text-decoration: underline;">Big Pharma</a></span><span style="color: black; line-height: 16.85px; margin: 0px; padding-bottom: 0px; padding-top: 0px; text-align: left;">” and PHB are a ripping people off they created their own non-profit drug company, Civica Rx. An organization that comes very close to accusing drug makers of </span><span class="c3" style="color: #1155cc; text-decoration: underline;"><a class="c1" href="https://www.google.com/url?q=https://twitter.com/CivicaRx/status/1042828438082646016&sa=D&ust=1542655190222000" style="color: #1155cc; text-decoration: underline;">putting people lives at risk for profit</a></span><span class="c0" style="color: black; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span class="c5" style="color: black; font-style: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">Physician groups blame insurers</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="color: black; line-height: 16.85px; margin: 0px; padding-bottom: 0px; padding-top: 0px; text-align: left;">Physician groups are </span><span class="c3" style="color: #1155cc; text-decoration: underline;"><a class="c1" href="https://www.google.com/url?q=https://twitter.com/EnvisionLeads/status/1050824471144255488?s%3D17&sa=D&ust=1542655190224000" style="color: #1155cc; text-decoration: underline;">blaming people’s financial difficulties</a></span><span class="c0" style="color: black; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> on insurers refusing to pay the high prices they demand. Leaving people with crushing surprise bills.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span class="c5" style="color: black; font-style: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">Conclusion</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span class="c0" style="color: black; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"></span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span class="c0" style="color: black; font-style: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The simple fact is that they are all right to a large degree. When the health care industry itself keeps telling us the system if full of price gouging, monopoly exploitation, and abusive practices we should believe them.</span></span></span></div>
Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com99tag:blogger.com,1999:blog-3449972385028694463.post-20103991551264914952018-09-04T07:54:00.002-07:002018-09-04T07:54:43.790-07:00Can Democracy survive space?<div dir="ltr" id="docs-internal-guid-c5663288-7fff-ba66-df13-df01abae18e4" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The recent political “debate” over climate change and the lack of action has got me thinking about how something similar would play out in space. It has left me wondering if democracy is even possible in space. A question I would love to see more explored in literature.</span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The big benefit of a democracy is that eventually it tends to make decent decisions. However, it tends to move slowly. It is great at muddling through an issue while importantly avoiding horrible decisions. On Earth this is fine because most of the very important stuff will keep happening no matter how gridlocked or misguided the politics becomes. The rains will keep falling. The trees will keep turning carbon dioxide into oxygen. The rivers will keep flowing, etc.</span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Even with an issue like climate change, where there is significant talk about whether we have reached a “tipping point,” that tipping point is really bad but not the-end-of-all-life bad. Even with big temperature increases, life will still exist. The suffering will be significant, but we would still have a chance to take dramatic action to adjust and correct.</span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">In space it is different. On a colony on Titan or a generation ship to Alpha Centauri there is little margin for error. If people don’t believe the experts' predictions about how many more years the air scrubbers can run without a major overall, there is no second chance and the consequence is everyone dies. In space, if a democracy handled a similar issue the way we have climate change, it would be the end of all life in the colony.</span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">It is possible that these environments are as a result going to naturally gravitate to highly authoritarian systems. Or if there are democracies, they might form with the creation of a parallel power structure controlled by engineers or an unquestionable AI. This power structure could have an almost mystical role, much like the Church in medieval Europe, with its own rules and laws. </span></span></span></div>
Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com1tag:blogger.com,1999:blog-3449972385028694463.post-82818985985237295832018-08-06T07:24:00.001-07:002018-08-06T07:24:21.561-07:00Is the Medicare For All we want Australian?<div dir="ltr" id="docs-internal-guid-8f78eaf9-0f9c-3d04-ef73-e4080181ed3e" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">While the American left debates what the term “Medicare for All” really means, it would be worthwhile to look at Australia’s program also known as Medicare. After studying the issue for years, I’ve come to think the unique features of Australian Medicare might just be the version of Medicare for All that American voters might actually most support.</span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">In some ways, Australian Medicare is well to the left of Sen. Bernie Sanders’ (I-VT)</span><a href="https://www.congress.gov/bill/115th-congress/senate-bill/1804/text" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;"> Medicare for All Act of 2017, </span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">and in other ways it is to its right. Australia's system has a much higher degree of government ownership of hospitals but leaves a somewhat larger role for private insurance.</span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">How it works</span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Under Australian Medicare everyone is covered, and health care is free at point of service as long as you go to a doctor who accepts the Medicare rate as full payment (most do) and only use the public hospitals. The public hospitals provide quality, no-frills health care (such as shared rooms instead of private rooms) with modest waits. An individual would be perfectly fine if they got all their care under this free system, and many do. </span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Australia also has many private hospitals that you can buy private insurance to pay for. These facilities provide short waits, greater provider choice, and perks like fancy private rooms. </span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The most interesting part of the Australian Medicare system to me, though, is how rates are set. The government sets a reimbursement rate it is willing to pay for a given service. Doctors at private offices can choose to accept the Medicare rate as full payment when they see a patient and are encouraged to do so with a bulk billing incentive. If they do, the patient pays nothing. Alternatively, the doctor can choose to add an additional fee that the patient needs to pay, only if the patient is clearly made aware of the additional fee in advance (so no surprise ER bills or similar nonsense). People can buy insurance to cover these additional fees. </span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The bulk billing incentive combined with the administrative hassle that is inherently created for any doctor's office if they choose to charge co-pays means the </span><a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2017-hunt046.htm" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">vast majority of provider visits are free</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">.</span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Australian Medicare: three advantages</span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Fee negotiations strategy - </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">One perennial issue with any government insurance program is choosing provider rates, and there is no one clear best answer. No matter how high the fees are, providers are always going to claim they aren’t high enough. For example, hospitals in America constantly claim to be losing money on Medicaid and Medicare patients despite all the economic evidence against cost shifting. Providers will try to scare the public with claims that low fees will result in a lack of appropriate care or rationing. These are actual potential concerns if rates are truly too low, but providers will claim they exist regardless, making it difficult to separate the noise from reality. </span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Letting doctors charge more than the set rate while financially encouraging them not to is one tool to help with this fee-setting issue. It serves both as a relief valve and a warning system, as well as a bullshit detector. </span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">As long as a majority of doctors accept the fee as full payment, it is a strong indication the fee is sufficient and that providers' attempts to get more money should be ignored. If for any procedure a majority of providers start charging a co-pay, it is an indication the fee might be too low and should be raised. It also means that if any fee is too low, the response would be more new co-pays instead of blunt, across-the-board reductions in the procedure.</span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Low cost </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">- The Australian Medicare system doesn’t place a high value on giving people a choice of hospital or making sure every single provider is in the public system. Instead it focuses on making sure everyone can get access to necessary care somewhere. This lets Australia provide everyone with free care really cheaply. Australia spends a lower share of GDP on health care than Canada. There is strong evidence that most people would happily choose a system with less provider choice in exchange for lower costs. For example, among people who qualify for TRICARE, consumers overwhelmingly pick the less choice/lower cost option. In polling </span><a href="https://www.naic.org/meetings1808/cmte_b_2018_summer_nm_materials.pdf?729" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">twice as many</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> said their top priority for health care was reducing cost instead of increasing consumer choice. </span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Channeling the rich people’s need to be special instead of fighting it -</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> One thing that does not get talked about enough by single-payer supporters is that rich people are remarkably determined to get the "better," more expensive version of everything, even if it is in fact not better at all. People with money are also remarkably clever about finding ways to use their money to get the "better" option. A system can either actively try to fight this dynamic, or it can try to channel it in a less disruptive way. Many single-payer advocates in the United States want to try to fight this dynamic.</span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Fighting it can be very hard. Even in Canada, which has likely tried the hardest of any country to make their health care egalitarian, there are </span><a href="https://www.thestar.com/news/canada/2017/03/18/should-the-wealthy-be-allowed-to-buy-their-way-to-faster-care-at-private-clinics.html" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">membership-based private clinics which function very much like private insurance</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">. These raise a real problem. Rich people in Canada use their access to private clinics and private lab work to effectively cut the line for hospital services. As a result, the choice countries really face tends to be either letting the rich using their money to cut the line or creating a system so the rich at least fully pay for their own private line. Most single-payer countries around the world tend to have some form of private system that around 10% of the population uses. </span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">While Australia promotes private insurance more than I think is optimal, I think channeling this rich-people impulse rather than fighting it is the better policy decision. If rich people want to waste their money on going to hospitals with fancy marble lobbies or paying for the privilege to serve as guinea pigs to test out new experimental treatments, I don’t think it is worth spending political capital to try to stop them.</span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Conclusion</span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">If Medicare for All comes to America, it very well might be the Australian version. By focusing on its main goal, Australian Medicare can provide everyone with free at-point-of-service care at an incredibly affordable price. It also has a fee system which does a good job of dealing with the most difficult problems of any single payer proposal in America: choosing the right reimbursement rate and dealing with people who insist they get the better option. </span></span></span></div>
Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com19tag:blogger.com,1999:blog-3449972385028694463.post-1421339875381429112018-07-16T10:11:00.002-07:002018-07-16T10:11:13.823-07:00Business shorts and why I'm very pessimistic about climate change<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Climate change is a very real and serious problem. Fully addressing it is going to take powerful leadership and quite frankly sacrifice. Most major plans to true deal with the issue will require the general public to pay more for energy, transportation, and/or change their lifestyle in ways they do not want. Ways that on net will make people somewhat worse off since they will need to pay for the pollution they created which up till now has been mostly free. Yet despite the challenge what makes me most pessimistic is not the political rhetoric or the need for collective sacrifice but fashion.</span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span>
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">There is one amazing truly win-win-win thing we could do the help with climate change, business shorts. </span></span></span></div>
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<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><a href="https://www.energy.gov/energysaver/home-cooling-systems/air-conditioning" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">Six percent of all electricity produced in</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> the United States is used on air conditioning. If men were encourage to wear business shorts during the summer instead of long pants or comically impractical wool suits, we could reduce that number. It would be a win for businesses and organization who get to spend less on AC. It would be a win for the planet. Finally, It would be a win for the people in the shorts. Having lived in both the DC and NYC region having to go to work in full pants when it is over 95 degree with 80% humidity is torturous.</span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span>
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Yet for some reason business shorts aren’t widely adopted. Most importantly the top business leaders, non-profit organization leaders, and politicians who claim climate change is a massive threat are still walking around DC in business suits in the middle of summer. They think we need bold action and shared sacrifice, but they aren’t even willing to risk looking unfashionable even it if could save the planet while making the so much more comfortable. Our leaders would rather let the planet burn and live with swamp ass than having people see their calves.</span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span>
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">If our leaders aren’t going to make this most minor of personal sacrifice for the goal and first try to push society to adopt these win-win-win solutions, I have no optimism we can ever do the hard stuff. When I finally see a senator in shorts this summer I will believe we are taking climate change seriously. </span></span></span></div>
Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com1tag:blogger.com,1999:blog-3449972385028694463.post-54028986179596127012018-04-26T08:06:00.000-07:002018-04-26T08:06:11.468-07:00Medicare for all Madlibs: Nomenclature for Democrats' new health plans<div dir="ltr" id="docs-internal-guid-718135ac-0279-de60-a037-2f601480e8a1" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The good news is that Democrats are trying to expand public health insurance to more Americans. The bad news is they have almost a dozen plans to expand coverage with the word “Medicare” in the title, creating a rhetorical nightmare. So I created this helpful nomenclature to simply describe what the different plans do.</span></span></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7zbMhNJxBrllJ_EJjtPIFFJBtOXg6Uw_q29w24evGSVNv6noxBwy4jfUpuMuUuXprCCUKQreMDiO4wkuKW0wutCcElq_zvFkWqaY3JwqYo7dEHW5GLbPCifMinwJkPLcDBNNZ8dhPv0U/s1600/MadlibsMedicareforall.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="319" data-original-width="1117" height="180" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7zbMhNJxBrllJ_EJjtPIFFJBtOXg6Uw_q29w24evGSVNv6noxBwy4jfUpuMuUuXprCCUKQreMDiO4wkuKW0wutCcElq_zvFkWqaY3JwqYo7dEHW5GLbPCifMinwJkPLcDBNNZ8dhPv0U/s640/MadlibsMedicareforall.JPG" width="640" /></a></div>
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<div dir="ltr" id="docs-internal-guid-718135ac-027a-12a0-813c-43201f0dc561" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">These three areas are not the only places plans differ, but they represent the most important policy disagreements over which much of the political debate will likely take place: Whether or not everyone will have access to the new program, whether or not private insurance will be allowed to continue to exist, and how cost sharing will be involved are the big differences among Democrats right now. Names aside, these are the details that matter. </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Universal</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> - Everyone can access it if they want </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Limited</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> - Only certain people due to age, income, location or employment arrangement are allowed to take part</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Buy in</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> - An individual or company would need to actively choose to use the program</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Opt-out</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> - If an individual did nothing they would be automatically enrolled in a new public insurance program, but they could do something to choose private insurance instead.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Only </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">- The new Medicare program will be the only basic health insurance for people; private insurers would be forbidden from offering duplicate coverage. </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Free at point of service care - </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">No copays, coinsurance or deductibles for coverage benefits</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Nominal cost sharing - </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Nominal co-pays for some services</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Traditional cost sharing - </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Co-pays, deductibles, and/or coinsurance similar to current Medicare and many employer-based plans.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">For example:</span></span></span></div>
<ul>
<li><span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">HR 676, the Improved and Expanded Medicare for All, is </span><span style="background-color: transparent; color: #980000; font-style: italic; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Universal</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> Medicare </span><span style="background-color: transparent; color: #38761d; font-style: italic; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Only</span><span style="background-color: transparent; color: #38761d; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">with </span><span style="background-color: transparent; color: blue; font-style: italic; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Free at point of service care</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> </span></span></span></li>
<li><span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The Center for American Progress’s Medicare Extra for All is </span><span style="background-color: transparent; color: #980000; font-style: italic; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Universal</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> Medicare </span><span style="background-color: transparent; color: #38761d; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Opt-out </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">with </span><span style="background-color: transparent; color: blue; font-style: italic; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">traditional cost sharing</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> </span></span></span></li>
<li><span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Rep. Brian Higgins’ </span><a href="https://www.congress.gov/bill/115th-congress/house-bill/3748?q=%7B%22search%22%3A%5B%22Medicare+buy+in%22%5D%7D&r=1" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">Medicare Buy-in Option</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> Act is an </span><span style="background-color: transparent; color: #980000; font-style: italic; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">age limited</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> Medicare </span><span style="background-color: transparent; color: #38761d; font-style: italic; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Buy-in </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">with </span><span style="background-color: transparent; color: blue; font-style: italic; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">traditional cost sharing</span></span></span></li>
</ul>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Here are most of the current plans to expand public insurance, and almost all have a title of Medicare. By 2020 there are likely to be at least a half dozen more:</span></span></span></div>
<ul>
<li><span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The House “</span><a href="https://www.congress.gov/bill/115th-congress/house-bill/676?q=%7B%22search%22%3A%5B%22medicare+for+all%22%5D%7D&r=1" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">Improved and Expanded Medicare for All</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">” bill</span></span></span></li>
<li><span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Sen. Sanders' slightly different “</span><a href="https://www.sanders.senate.gov/download/medicare-for-all-act" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">Medicare for All</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">” bill in the Senate</span></span></span></li>
<li><span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Sen. Bennet and Sen. Tim Kaine’s “</span><a href="https://www.congress.gov/bill/115th-congress/senate-bill/1970/text" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">Medicare-X Choice</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">”</span></span></span><span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> </span></span></span></li>
<li><span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Rep. Brian Higgins’ </span><a href="https://www.congress.gov/bill/115th-congress/house-bill/3748?q=%7B%22search%22%3A%5B%22Medicare+buy+in%22%5D%7D&r=1" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">Medicare Buy-in Option</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> for people over 50</span></span></span></li>
<li><span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Sen. Debbie Stabenow’s </span><a href="https://www.congress.gov/bill/115th-congress/senate-bill/1742?q=%7B%22search%22%3A%5B%22Medicare+buy+in%22%5D%7D&r=2" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">Medicare at 55</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> </span></span></span></li>
<li><span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Rep. Carol Shea-Porter’s </span><a href="https://www.congress.gov/bill/115th-congress/house-bill/2065/text?q=%7B%22search%22%3A%5B%22Medicare+buy+in%22%5D%7D&r=3" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">Medicare You Can Opt Into</span></a></span></span></li>
<li><span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">The Center for American Progress’s “</span><a href="https://www.americanprogress.org/issues/healthcare/reports/2018/02/22/447095/medicare-extra-for-all/" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">Medicare Extra for All</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">”</span></span></span></li>
<li><span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Sen. Jeff Merkley and Sen. Chris Murphy’s “</span><a href="https://www.murphy.senate.gov/download/medicare-bill" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">Medicare Choice Act</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">” which would create Medicare Part E.</span></span></span></li>
<li><span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Jacob Hacker's slightly different </span><a href="http://prospect.org/article/road-medicare-everyone" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">Medicare Part E</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> plan</span></span></span></li>
<li><span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">Gerard F. Anderson's and Hugh R. Waters' original, slightly different </span><a href="https://www.brookings.edu/research/achieving-universal-coverage-through-medicare-part-everyone/" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">Medicare Part E(veryone)</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> </span></span></span></li>
<li><span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;">I was apparently the only one trying to prevent this linguistic madness when I gave my plan </span><a href="https://shadowproof.com/2017/07/24/medical-insurance-care-national-single-payer-bill-mica/" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline; white-space: pre-wrap;">Medical Insurance and Care for All (MICA)</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline; white-space: pre-wrap;"> a distinctive and easy acronym. </span></span></span></li>
</ul>
Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com3tag:blogger.com,1999:blog-3449972385028694463.post-86517711504795270292018-02-01T09:32:00.000-08:002018-02-01T09:32:08.700-08:00Predicting the news cycle in every state post marijuana legalizationNow that several states have legalized marijuana, it has become almost comically easy to predict how the news cycle will develop in each new state. It always follows this basic pattern:<br />
<ul>
<li><b>Day one -</b> Marijuana is legally on sale! <a href="http://www.businessinsider.com/us-marine-makes-first-legal-pot-purchase-in-colorado-2014-1">Look at these happy people being the first to buy!</a></li>
<li><b>Week one </b>-Legal marijuana stores are <a href="https://www.huffingtonpost.com/2014/01/06/colorado-marijuana-shortage_n_4550866.html">running out of pot!</a></li>
<li><b>Week two </b>- Marijuana is too expensive with marijuana taxes! <a href="https://www.cbsnews.com/news/california-pot-advocates-say-tax-rates-too-high-legal-recreational-marijuana/">Maybe we need to cut marijuana taxes</a>!</li>
<li><b>Month two</b> - Marijuana is legal but people in the state are <a href="https://www.huffingtonpost.com/2014/01/06/weed-colorado-black-market_n_4548338.html">still buying from the black market</a>!</li>
<li><b>Every Halloween after legalization</b> - <a href="http://abc7.com/health/watch-out-for-marijuana-edibles-at-halloween/2572312/">Be careful of people handing out pot candy!</a> (No one does this, but this story appears every year)</li>
<li><b>Year one</b> - Actually, <a href="http://www.westword.com/news/marijuana-prices-are-falling-in-colorado-and-heres-why-6834217">prices at legal dispensaries have come down below pre-legalization</a> levels and are putting pressure on the black market after all.</li>
<li><b>Year two or three</b> - <a href="https://www.bizjournals.com/portland/news/2018/01/10/exclusive-a-reckoning-has-arrived-for-oregons.html">Oh no, legal marijuana is getting too cheap!</a> </li>
</ul>
We are now getting to see the pattern start all over again in California. Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com3tag:blogger.com,1999:blog-3449972385028694463.post-73837501435868620182018-01-23T07:25:00.000-08:002018-01-23T07:25:00.274-08:00My four year-old marijuana prediction was off by just three weeks<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiGbd2Jhexyu0MnXtJrwNyt8cFHitWh8E7zWvkZvXgjE1UEuFf6Jvheco3TptOMzMXp3OmRzIC8NQdk0DTHrY2lOLmRqSfF2VeA1VJLddso_LqlTUjkEnRv8UrRylsltAyWL16sIhoSESs/s1600/Capture.PNG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="576" data-original-width="419" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiGbd2Jhexyu0MnXtJrwNyt8cFHitWh8E7zWvkZvXgjE1UEuFf6Jvheco3TptOMzMXp3OmRzIC8NQdk0DTHrY2lOLmRqSfF2VeA1VJLddso_LqlTUjkEnRv8UrRylsltAyWL16sIhoSESs/s320/Capture.PNG" width="232" /></a>Vermont has <a href="https://www.huffingtonpost.com/entry/vermont-legalizes-marijuana_us_5a566401e4b03bc4d03d8492">become the ninth state to legalize marijuana and the first state to do so via the legislature </a>instead of a ballot measure. So I'm going to take a moment to toot my own horn.<br />
<br />
Back in January 2014, I published <a href="https://www.amazon.com/dp/B00HU6ZI18">After Legalization: Understanding the future of marijuana policy. </a>In it, I predicted that by 2018 roughly nine states would have legalized marijuana and that Vermont was likely to be the first to legalize marijuana via the state legislature. I also predicted Canada was likely to be the first major country to move forward with legalization in 2017.<br />
<blockquote class="tr_bq">
<div style="line-height: 100%; margin-bottom: 0in; text-indent: 0.5in;">
<span style="font-family: Times New Roman, serif;"><span style="font-size: small;"><b>2017</b></span></span><span style="font-family: Times New Roman, serif;"><span style="font-size: small;">
–This is when the fight is likely to move from the ballot to the
state legislature. After voters in multiple states approve
legalization, politicians in other states will feel comfortable
backing the idea—or political pressure will force them to approve
it. <b>It's very likely that Vermont, Hawaii, and Rhode Island will move
forward with marijuana legalization in early 2017 or 2018.</b> They are
three of the most liberal states in the country and have a history of
being progressive on marijuana reform: Hawaii was the first state
legislature to adopt medical marijuana, Vermont was the second, and
Rhode Island was the third. I also expect the changing political
environment created by a wave of victories in 2016 to push many state
legislatures to adopt smaller reforms, such as reducing their
penalties for simple possession. </span></span>
</div>
<div style="line-height: 100%; margin-bottom: 0in; text-indent: 0.5in;">
<span style="font-family: Times New Roman, serif;"><span style="font-size: small;">At
the same time, several foreign countries will probably adopt
legalization. The political situation in Canada regarding this issue
is worth watching, because it could put some real pressure on the
United States to finally act. In 2013, the leader of the Liberal
party of Canada endorsed marijuana legalization,</span></span><a class="sdendnoteanc" href="https://www.blogger.com/blogger.g?blogID=3449972385028694463#sdendnote1sym" name="sdendnote1anc"><sup>i</sup></a><span style="font-family: Times New Roman, serif;"><span style="font-size: small;">
and there is a very good chance his party could win back control
after the next federal election likely to take place at the end of
2015. If the Liberals are serious about moving forward with marijuana
reform, a smart time to do it would be right after the United States’
2016 election, when several American states on or near the Canadian
border are likely to legalize marijuana.</span></span></div>
</blockquote>
<div id="sdendnote1">
While not every one of my predictions has been perfect, I'm very happy with how well I have done so far. One my biggest mistakes was that I thought the District of Columbia wouldn't legalize until 2020 because people in the District would be too afraid of Congress interfering. The people of the District did approve marijuana legalization in 2014, but Congress stepped in to block the city from adopting a regulatory model -- so I got it half right.<br /><div class="sdendnote">
<br />
</div>
</div>
Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com21tag:blogger.com,1999:blog-3449972385028694463.post-49784926037076107362017-12-29T13:56:00.003-08:002017-12-29T13:56:55.359-08:00Making new state payroll taxes better with health insurance<span style="font-size: small;">Several <a href="http://cepr.net/blogs/beat-the-press/in-honor-of-donald-trump-s-big-tax-victory-let-s-hear-it-for-state-level-employer-side-payroll-taxes">progressive economists</a> and <a href="https://www.vox.com/policy-and-politics/2017/12/28/16818680/state-local-tax-deduction-income-payroll-trump-tax-reform-republican">thinkers</a> are promoting the idea of a new state payroll tax to get around the fact that the Republican tax plan has limited the deduction on state and local income taxes. I think this is a good idea, but if we are changing blue states' tax structures we can also improve health insurance coverage at the same time. </span><br />
<br />
<span style="font-size: small;">The Republican tax also repealed the individual mandate. While there is a serious debate about how much impact the loss of the mandate will have on enrollment and premiums, it is likely it will reduce the number of people with health insurance. This has given Democrats an opportunity to come up with a new, better, and more popular way of expanding coverage. </span><br />
<br />
<span style="font-size: small;">My suggestion is to make the new state payroll tax roughly $2 per hour more than what is needed to replace the state income tax but to give employers a $2 per hour deduction for providing health insurance. For the vast majority of employers/employees who already have coverage via work, this would have zero impact, but it would work as a soft employer mandate for companies that don’t offer coverage. This is similar to the <a href="https://en.wikipedia.org/wiki/Healthy_San_Francisco#Funding">Healthy San Francisco program</a> adopted in 2007, which successfully expanding coverage/access in the city. </span><br />
<br />
<span style="font-size: small;">This employer mandate would directly increase the number of people with health insurance since some companies would likely offer coverage as a result. It would also provide a pool of money to improve affordability and/or access. It could be used to do a reinsurance program, provide coverage for immigrants not eligible for Medicaid, provide wrap around tax credits on the state exchanges, or provide funding for public health insurance efforts.</span><br />
<br />
<span style="font-size: small;">My preferred policy would be for states to also create a public option/Medicaid buy in and use the money from the employer mandate to provide subsidies to make it affordable for everyone. Between the cost savings from the public plan being able to negotiate lower prices and the extra money from the employer mandate, the state should be able to actually make coverage truly affordable for everyone.
</span>Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com3tag:blogger.com,1999:blog-3449972385028694463.post-64794333114435571982017-11-27T09:17:00.000-08:002017-11-27T09:17:21.642-08:00Los Angeles’ marijuana plan: the illusion of social equity<div dir="ltr" id="docs-internal-guid-5715aa1c-fe79-fcdc-4738-afad5603ba1f" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Los Angeles is deciding to </span><a href="http://www.latimes.com/local/lanow/la-me-ln-marijuana-equity-20171020-story.html" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">focus on racial equity</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> in their recreational marijuana licensing system, but I think the way </span><a href="http://clkrep.lacity.org/onlinedocs/2017/17-0653_pc_9-13-17.pdf" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">they are going about</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> it suffers from a serious problem in framing. Their concept of equity relies too heavily ensuring that the small number of people who get marijuana licenses includes some local low-income minorities. Instead of making sure a few minorities are among the small number getting rich off of the recreational marijuana business, true equity would be the not letting any individuals get rich off of it. All the potential profits should go to help people across the city.</span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span>
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Portland, Oregon has </span><a href="http://www.oregon.gov/olcc/marijuana/Documents/Approved_Retail_Licenses.pdf" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">155 recreational marijuana stores</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> and a population of 639,863. Assuming Los Angeles ends up with a similar ratio of stores to people, that would be 963 marijuana stores. This estimate is close to projections of the number of medical marijuana dispensaries operating legally or illegally in LA: </span><a href="http://www.laweekly.com/news/heres-an-official-los-angeles-map-of-marijuana-shops-8306497" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">1500</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">. </span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span>
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Let's assume LA actually manages to create a system that is even capable of giving out licenses in a way that corrects for the city's history of racist arrests, so the vast majority go to low-income minorities. Let’s also assume everyone who gets a license is capable of running a successful small business -- something that is also not guaranteed given high failure rate for small businesses -- and manages to create a business worth a million dollars. </span></span></span></div>
<ul style="margin-bottom: 0pt; margin-top: 0pt;">
<li dir="ltr" style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: disc; text-decoration: none; vertical-align: baseline;"><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">The best possible scenario</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> is that these efforts effectively serve as a lottery with just a few hundred winners in a city of 4 million people. Big rewards delivered to a tiny group is a strange way to correct for broad social discrimination. </span></span></span></div>
</li>
<li dir="ltr" style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: disc; text-decoration: none; vertical-align: baseline;"><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">The worst case scenario</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> is the city spends a significant amount of money and effort helping a few low-income individuals trying to start marijuana businesses, but due to a federal crackdown or normal business problems, many end up worse off.</span></span></span></div>
</li>
</ul>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span>
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">If Los Angeles wants to focus on true social equity, the better strategy would be not to worry who gets the licenses but who gets all the profits. The profits should go to the public, not to individuals or companies. The Los Angeles government could directly run all the marijuana stores, like </span><a href="http://www.mensjournal.com/travel/articles/weedtown-usa-home-to-americas-first-city-owned-pot-shop-w444235" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">North Bonneville, Washington has</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">. Or the city could give licenses only to existing community non-profits with a proven track record and an explicit commitment to use all proceeds for certain activities like free health clinics. Or the city could focus on maximizing taxes and licensing fees to allow the city to extract almost all the value. </span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span>
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The recommended approach of giving special loans or waiving licensing fees for a few ‘deserving’ individuals is not how to create true equity. That is the illusion of equity. The fact that the Los Angeles Cannabis Task Force: Social Equity Committee was made up of “ both inside and outside the cannabis industry in Los Angeles” including “existing business owners, entrepreneurs, [and] investors” is likely why it used this limited problematic framing. Their idea that give the licensing system the veneer of social justice and equity, but still assure a few well placed people will make the profits.</span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span>
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Currently, LA is planning to set aside some of its marijuana tax revenue to help communities hurt by the drug war. The city could amplify this plan to make sure </span><span style="background-color: transparent; color: black; font-style: italic; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">all </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">of the profits from the marijuana industry go towards programs like free pre-k for all low-income residents.</span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span>
<div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Finding ways to make sure almost every dollar of profit goes to the city government would do way more to help communities hurt by the drug war than effectively handing out a handful of lottery tickets.</span></span></span></div>
Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com1tag:blogger.com,1999:blog-3449972385028694463.post-31756954305543587382017-10-30T09:29:00.000-07:002017-10-30T09:29:47.820-07:00Trump's accidental health care experimentThe Trump administration's ham-fisted attempts to sabotage Obamacare are going to make this open enrollment one of the biggest natural experiments in health care, and we should learn from it.<br />
<br />
Trump has done two big things to try to hamstring the Affordable Care Act exchanges.<br />
<ul>
<li>One was to <a href="http://money.cnn.com/2017/08/31/news/economy/obamacare-trump-advertising/index.html">dramatically cut funding for Healthcare.gov outreach ads</a> and navigators to help people select insurance plans, but many blue states that run their own exchanges will continue to spend as much on outreach as they did in the past. </li>
<li>The other was to end cost sharing reduction payments to insurers, which is <a href="https://theintercept.com/2017/10/24/how-to-shop-for-health-insurance-on-november-1-and-why-you-shouldnt-have-to/">having a very weird impact</a>. In some states it has resulted in big increases of affordable tax credits, making insurance much more affordable for those making between 200-400% FPL. How big the impact is varies significantly across states.</li>
</ul>
What this has created is a massive natural experiment on two metrics. Some states will see a large increase in premium tax credits for this group but very little outreach spending. Some will see large increases in premium tax credits and strong outreach spending. Some will see only small increases tax credits and little outreach spending, and others will see small tax credit increases and strong outreach spending.<br />
<br />
It will be a real chance to see what impact the tax credit level and outreach spending have on enrollment, as well as to test just how rational individuals are when it comes to buying health insurance. We will get to see how much impact outreach efforts really have and how big a difference more subsidies make. <br />
<br />
Trump has created needless chaos, but it would be stupid not to learn from it. I would hope experts in health care would make predictions now that can compared against the real world data.<br />
<br />
(I personally think the impact of outreach spending is being overstated and the impact of providing more tax credits will be far more significant. The <a href="https://www.cbo.gov/publication/53009">CBO predicted</a> the short term impact of ending the cost sharing reduction payments would be a modest drop in the number of insured, but I suspect the number could easily increase.) Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com1tag:blogger.com,1999:blog-3449972385028694463.post-16099042398931305032017-10-13T15:25:00.000-07:002017-10-13T15:25:45.288-07:00Democrats should only accept permanent cost sharing reduction payment<div dir="ltr" id="docs-internal-guid-fe6fc0a0-17d6-2884-5987-f1736769618d" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Now that President Trump has stopped payments for the cost sharing reduction for low income individuals on the Affordable Care Act exchanges, he is talking about using this as </span><a href="http://www.washingtonexaminer.com/trump-invites-democrats-to-deal-on-healthcare/article/2637458" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">leverage for negotiations with Democrats</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">. Democrats should make it clear they will vote for nothing short of a full and permanent appropriation of the cost sharing reduction. They should reject any short term, one-year or two-year appropriation or any attempt by Trump to trade it for something he wants.</span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">This move by Trump was a spiteful act of policy nihilism. It is going to cause real chaos for insurers and individuals. Some people will be financially hurt, but the damage is fairly manageable. Thanks to the design of the ACA, not paying the cost sharing reduction just causes the premium tax credit to go up even </span><a href="https://www.cbo.gov/publication/53009" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">more, making insurance cheaper for some people</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">. Ironically, this move might even have, on net, a positive impact on the number of people who can afford care. Even if it doesn’t, Trump will very likely lose the coming lawsuits about it anyway.</span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">So while this is a vengeful and dramatic act of sabotage, Democrats should make it clear it is one they are willing to live with. </span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Trump has proven himself to be a bully, which is why it is critical Democrats stand up and say they will not be bullied. Make it clear they will not negotiate to undo Trump's inflicted chaos. </span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">This is a great issue for Democrats to take a stand on and not give an inch for because even if they lose, the policy fallout is manageable. But if Democrats reward Trump's bullying tactics by voting for anything short of permanent appropriation with no strings attached, it will only encourage him to do it again and again.</span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">This fight is already bad enough, but I shudder think about how, if successful, Trump might use this tactic when the stakes are much higher, like over the debt ceiling or starting another war.</span></span></span></div>
Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com1tag:blogger.com,1999:blog-3449972385028694463.post-45429900831423619402017-09-05T09:04:00.001-07:002017-09-05T09:04:13.324-07:00Private insurance is about making things dieMany people don't realize one of the main social benefits of any private insurance system is to let things die. Insurance is often viewed as primarily about spreading risk, and that is part of it, but pricing risk is often an arguably more important function of insurers.<span style="background-color: yellow;"></span><br />
<br />
This is often a good thing. You want an insurance system that effectively kills a project to build houses on a dangerous slope prone to mudslides by refusing to offer insurance or setting premiums way too high. It is good when a company with unsafe equipment/practices is shut down because they can no longer afford liability insurance.<br />
<br />
A system that effectively kills dangerous real estate developments or businesses due to pre-existing conditions is good because people can live or work elsewhere. A system that effectively kills people by pricing them out of care because they were born with a genetic disorder is profoundly immoral. People can't choose another body.<br />
<br />
<br />
Pre-ACA, the health insurance system didn't do a bad job; private health insurance did a very good job at something most people think is deeply unfair.<br />
<br />
Once you remove what is normally the main social benefit of private insurance --pricing risk to make things die-- you are left with health insurance companies with only three other functions: spreading risk, negotiating with providers, and customer service. The problem is, the industry is terrible at two of these.<br />
<br />
Private health insurance companies openly admit they can't effectively spread risk on their own since some individuals have very high cost health care problems, and these individuals can no longer be priced out. The private health insurance lobby (AHIP) has <a href="https://www.ahip.org/wp-content/uploads/2017/06/RiskPool_IssueBrief_6.30.17.pdf">actively been calling</a> for the government to recreate a government reinsurance program -- government insurance for the insurers that spreads the risk for them.<br />
<br />
The private health insurance lobby also admits they are <a href="https://www.ahip.org/wp-content/uploads/2016/02/HospitalPriceComparison_2.10.16.pdf">terrible at negotiating</a> with hospital and drug makers. For most procedures, they have negotiated rates much higher than what the government did for Medicare.<br />
<br />
We now have a weird health insurance system where the private insurance companies can't do their main job because we consider it immoral, they are asking the government to step in to perform their second most important function for them, and they admit they are really bad at their third most important job.Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com3tag:blogger.com,1999:blog-3449972385028694463.post-52290142525932825302017-09-03T09:35:00.002-07:002017-09-03T09:35:44.650-07:00Let's stop using accounting gimmicks - Obamacare Ad edition<div dir="ltr" id="docs-internal-guid-9492c2eb-4892-ef76-655e-a7f9895fa8ba" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The decision by the Trump administration to </span><a href="http://thehill.com/policy/healthcare/348763-trump-administration-to-slash-obamacare-outreach-funding" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">slash the Affordable Care Act exchange advertising </span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">from $100 million to just $10 million is bad policy. There are many legitimate reasons why it is bad policy, so I implore people on the left to stick to these real arguments instead of using arguments based on accounting gimmicks. </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Many people have pointed out that cutting this government ad spending produces “no direct taxpayer savings,” since the money comes from a 3 percent fee added to all insurers' premiums on the exchange to cover the cost of operating the exchanges and running government outreach. The idea <a href="https://twitter.com/ASlavitt/status/903366361841324032">taxpayers</a> aren’t <a href="https://twitter.com/benwikler/status/903485236985470976">paying</a> for these ads is *technically* correct, only if we take the most extremely narrow view of government spending.</span></span></span></div>
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<span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7o6-KUoPx0Eri5sIM5MUp_-KJHA3-RfU4UO0SJik9jiAuCWXN5E7J8KC_5R47CbvH8oFuQSTmSEOCbS347L2UI2KWN7hY4xtA1-qhAo54opOCumtdeiWdXw1rJ70oZsjGuWtq0aV0Mac/s1600/userfee.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="339" data-original-width="747" height="181" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7o6-KUoPx0Eri5sIM5MUp_-KJHA3-RfU4UO0SJik9jiAuCWXN5E7J8KC_5R47CbvH8oFuQSTmSEOCbS347L2UI2KWN7hY4xtA1-qhAo54opOCumtdeiWdXw1rJ70oZsjGuWtq0aV0Mac/s400/userfee.JPG" width="400" /></a></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The fact is the vast majority of people who buy insurance on the exchanges qualify for affordablity tax credits. Due to the way the tax credits are designed, anything that increases average insurance premiums on the exchange causes a near identical increase in the amount the government spends on tax credits for each low income individual.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">What this means is that when the HHS imposes a “user fee” on insurers using the exchange, the insurers end up just increasing premiums for people by the exact cost of the user fee. This forces the Treasury to increase spending on tax credits by basically that same amount. The design means the Treasury is effectively paying for almost all of the user fees that have been funding these outreach ads -- it just does it in a needlessly complicated, indirect, and wasteful way. </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">It works out that for every extra dollar HHS charges in user fees, it is effectively making Treasury give the HHS roughly 90 cents via higher tax credits.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">If you think the government spending significantly less on advertising for the health insurance exchanges is bad policy, just argue that. It is easy to make that policy argument, because it is bad policy. But please stop making stupid accounting gimmick arguments that we're not really talking about taxpayer spending. We have just hidden the spending in a complicated system of fees/subsidies that really just inefficiently moves money from one part of the government to another.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">This desire to pretend government spending isn’t really spending or taxes aren't really taxes has been incredibly destructive to our government and terrible for long term progressive politics. It is why we end up trying to make so much policy via inefficient tax deductions to hide the true cost, or with public/private partnerships that let us pretend mandated fees imposed on government-selected private monopolies are technically not “taxes.”</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">If you think the government should spend money on something, please just argue why. </span></span></span></div>
Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com1tag:blogger.com,1999:blog-3449972385028694463.post-37287807350033627972017-08-25T10:48:00.000-07:002017-08-25T10:48:26.404-07:00Democrats still aren't treating health care as a right<div dir="ltr" id="docs-internal-guid-6b7edc41-1a6f-c764-8b33-33b6da65e0ad" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Republican efforts to undermine, alter and/or repeal the Affordable Care Act expose one of the greatest logical failings of the law. Despite what supporters of the ACA claim, Obamacare did not make health insurance universal or treat health care as a right. The ACA still treats health care insurance as a welfare program that people either “deserve” or don't.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Forget what proponents of the ACA claim, the only thing that matters is the actual law -- and in cold legislative terms, the ACA makes it clear health insurance is simply not a right for Americans. </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The ACA’s provisions clear define certain people unworthy of health insurance because of the choices they make. It allows companies to charge people who use tobacco <a href="http://www.commonwealthfund.org/publications/blog/2015/jan/insurance-premium-surcharges-for-tobacco-use">50 percent more</a> than non-tobacco users. This surcharge could increase the cost of premiums by thousands of dollars making health insurance unaffordable. That is the point, to force people to choice between insurance or smoking. Not an easy choice given that tobacco is highly addictive.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Democrats left the door open, and now Republicans are driving a truck right through it. According to the </span><a href="http://www.washingtonexaminer.com/mulvaney-agrees-with-jimmy-kimmel-test/article/2622843" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">Washington Examiner</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">, Mick Mulvaney, Trump’s budget chief, believes that a “person who sits at home, eats poorly and gets diabetes” isn't worthy of receiving health care assistance. Similarly, Republican governors around the country are </span><a href="http://www.huffingtonpost.com/entry/medicaid-work-requirement_us_590b5b33e4b0e7021e955c21" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">trying to add work requirements to Medicaid</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> to deny poor people deemed unworthy of receiving this welfare. </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Democrats claim to be outraged by these moves, but sadly the difference between Democrats and Republicans on this is only a matter of degrees, not principle. Republicans declaring people unworthy of affording health insurance because they drank too much soda or don't have a job is, in principle, no different than Democrats declaring that someone is unworthy of health insurance because they smoke. </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"><span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"></span></span></span><span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"><span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Either
affordable health care is a right that everyone should have access to
with no exceptions, or it is a welfare program that the government can
decide who is or is not deserving of. </span></span></span></span></span></span>You don't lose your right to free speech or your right to freedom of religion, because you use tobacco or make other legal bad choices. That is the point of a right, it is meant to apply to everyone. </span></span></span><span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"><span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"></span></span></span> </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">If Democrats believe health care is a right, then they need to treat it. Obamacare didn't and it is time for Democrats to admit that and promise to change. </span></span></span></div>
Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com5tag:blogger.com,1999:blog-3449972385028694463.post-63655409208504323472017-08-23T08:24:00.000-07:002017-08-23T08:24:05.919-07:00Democrats, please stop offering bad public option plansSince the failure of the Republicans' efforts to repeal the Affordable Care Act, Democrats have started new pushes for letting people buy public insurance. While I'm glad to see movement in this direction, the three most prominent plans offered so far are just worse, limited versions of a public option. There appears to be no obvious political or policy reason for offering a worse version.<br />
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<li><b><a href="https://www.stabenow.senate.gov/news/senator-stabenow-announces-medicare-at-55-act">Medicare at 55 Act</a></b> - This bill would let people buy into Medicare if they are 55 or older. It is from Sens. Debbie Stabenow (D-MI), Sherrod Brown (D-OH), Tammy Baldwin (D-WI), Sheldon
Whitehouse (D-RI), Patrick Leahy (D-VT), Jeff Merkley (D-OR), Jack Reed
(D-RI), and Al Franken (D-MN).</li>
<li><b><a href="http://healthaffairs.org/blog/2017/08/09/making-the-exchanges-more-competitive-by-bringing-medicare-into-the-fold/">Medicare buy-in, but only for Affordable Care Act exchanges with three or fewer insurers</a> </b>- This plan is from famous health care policy analysts Gerard Anderson, Jacob S. Hacker, and Paul Starr.</li>
<li><b><a href="https://www.vox.com/policy-and-politics/2017/8/22/16171160/schatz-health-care-medicaid">"Medicaid Buy-in," which is just an option to buy into a new state public insurance option called "Medicaid"</a></b> from Sen. Brian Schatz(D-HI). While the details are vague, the plan seems to let states have the option to allow people to buy into a new public health insurance that would be called "Medicaid" even though it would not have Medicaid's benefits or super low costs.</li>
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Depending on the details, I think all of these proposals would make our system marginally better, but I fail to see the political or messaging logic behind any of them compared to pushing for a universal public option/Medicare buy-in. <br />
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Politically, the health care industry is likely to fight each of these proposals as strongly as they would a universal public option. First, all of these plans would cut the industry's profits by billions, so it's a given they will oppose any of them. Second, the industry isn't stupid. They would see any of the plans as a path toward a universal public option so they would fight it with as much force as they would a fully universal proposal.<br />
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While limiting public insurance proposals will likely do nothing to reduce industry opposition, it does reduce popular support. All of these plans would potentially benefit fewer people than a universal public insurance plan, which means fewer regular people will have a reason to fight hard for them. <br />
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In addition, the message for a public option/universal Medicare buy-in is simple: <b>private insurers suck, so we will let you buy public insurance instead.</b> The messaging and logic behind these plans make little sense.<br />
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If private insurance doesn't work well for people at age 55, why isn't it a problem at age 54 or 53? Why shouldn't everyone else get also get to buy into Medicare?<br />
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Similarly, if we think people would benefit from a "Medicaid buy-in," why are we leaving it up to the states? This is an especially important question after we saw so many red states reject the Medicaid expansion.<br />
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Limiting the proposals isn't going to generate Republican approval either. As we just saw with Obamacare, Republicans will attack any proposal as a "big government takeover" regardless of what it does.<br />
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I understand making tough compromises to achieve goals and broaden the coalition, but there seems to be zero logic behind these compromise proposals. These plans are needlessly limited but gain nothing.<br />
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These limits won't fool the industry. They won't fool Republicans. They will only excite less of the base. And they will make it harder to sell, since the plans now lack simple, cohesive logic.<br />
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Can someone point to one reason why any of these plans would be politically easier? Can someone name one powerful industry lobbying group or bloc of voters that you gain by imposing needless limits on a Medicare buy-in? An universal Medicare buy-in already has <a href="https://s3.amazonaws.com/s3.boldprogressives.org/images/Big_Ideas-Polling_PDF-1.pdf">overwhelming support</a>. <br />
<br />Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com0tag:blogger.com,1999:blog-3449972385028694463.post-68664822914131998362017-08-16T09:43:00.000-07:002017-08-16T09:43:26.644-07:00Where is the Progressive push for an ERISA Waiver?<div dir="ltr" id="docs-internal-guid-4a280a4f-ebeb-617f-9907-461b5c33eed6" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Progressives in Congress seem to have dropped the ball on what could be one of the most important health care deals of the year. The best hope for future progressive state health care reform might slip away without anyone on the left even noticing.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Currently, there is talk around a small bipartisan health care reform package. The</span><a href="https://www.axios.com/what-could-be-in-a-bipartisan-health-care-package-2468027741.html" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;"> potential proposal</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> mainly contains Republican promises to actually continue to implement the ACA’s cost sharing reductions in exchange for a modification of the law’s Section 1332 State Innovation Waivers. That would let red states relax some of the law’s regulations. Overall, this is a terrible deal for progressives, but there is a chance to make it fair.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">If progressive Democrats insisted any deal that changes ACA state innovation waivers also include the ability to waive parts of the Employee Retirement Income Security Act of 1974 (ERISA), it would be a true ideological compromise and one that could be deeply important long-term. It would achieve the conservative goal of returning more power to the states and make progressive state reform possible.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">ERISA effectively prevents states from doing anything to regulate large employer health insurance. It has been a major hindrance to state health care reform efforts large and small over the decades.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">For example, back in 2007 a </span><a href="http://www.nytimes.com/2007/01/18/business/18walmart.html" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">Maryland</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> law to make large box stores provide health insurance was overturned because it violated ERISA. Similarly, last year the Supreme Court threw out a Vermont law that would </span><a href="http://healthaffairs.org/blog/2016/03/10/the-consequences-of-gobeille-v-liberty-mutual-for-health-care-cost-control/" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">create an all-payer claims database</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">. Without states even being able to gather basic data, it is almost impossible for states to seriously consider any reforms based on liberal or conservative principles.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">ERISA would likely be a </span><a href="https://www.rand.org/content/dam/rand/pubs/research_reports/RR1600/RR1662/RAND_RR1662.pdf" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">massive legal and financial hindrance</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> to any state single payer effort, but it also prevents more modest reforms that move in that direction. </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">For example, Hawaii’s employer mandate is the only state law exempt from ERISA because it was approved before the federal law. The Hawaii law is </span><a href="http://www.gallup.com/poll/202814/hawaii-leads-states-record-sixth-time.aspx" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">highly</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span><a href="http://www.kff.org/other/state-indicator/adults-19-64/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Uninsured%22,%22sort%22:%22asc%22%7D" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">effective,</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span><a href="http://www.kff.org/other/state-indicator/single-coverage/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Total%22,%22sort%22:%22asc%22%7D" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">keeps costs low</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">, and it is popular; but for four decades no other state has been allowed to copy it. Similarly, states’ attempts to make American health care more like the Swiss health care system with its all-payer system would likely face ERISA issues.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">If any group or politician claims to really want state single payer but isn’t actively fighting to get an ERISA waiver included in any deal, they are simply not serious about the politics or the policy.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Achieving state single payer would be a major undertaking that will require winning numerous fights, but this is one of the most important and easiest. If the progressive grassroots isn’t even trying to fight for it right now, they might as well just give up entirely.</span></span></span></div>
Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com1tag:blogger.com,1999:blog-3449972385028694463.post-71501350823852988252017-08-14T08:33:00.000-07:002017-08-14T08:33:55.728-07:00Three charts show why we can't move on from health care<div dir="ltr" id="docs-internal-guid-4e84eddc-dec4-05f6-a0d3-eba8cca00caa" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Now that the Republicans' repeal and replace efforts have failed, you are seeing some on the left </span><a href="https://www.realclearpolitics.com/articles/2017/07/03/democrats_beware_the_single-payer_siren_134331.html" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">suggest</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> that progressives move on from health care. The general idea is that the ACA is good enough, health care is hard, and Democrats should focus on other progressive policies like universal pre-K or paid parental leave.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The most prominent example of this thinking comes from </span><a href="https://www.nytimes.com/2017/08/07/opinion/healthcare-single-payer-children.html" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">Paul Krugman</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">, who calls for Democrats making only small tweaks to the ACA: </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Meanwhile, progressives should move beyond health care and focus on other holes in the U.S. safety net.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">When you compare the U.S. social welfare system with those of other wealthy countries, what really stands out now is our neglect of children. Other countries provide new parents with extensive paid leave, provide high-quality, subsidized day care for children with working parents and make pre-K available to everyone or almost everyone;</span><a href="https://www.americanprogress.org/issues/education/reports/2013/05/02/62054/the-united-states-is-far-behind-other-countries-on-pre-k/" style="text-decoration: none;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">we do none of these things</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">. Our</span><a href="https://data.oecd.org/socialexp/family-benefits-public-spending.htm" style="text-decoration: none;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">spending on families</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> is a third of the advanced-country average, putting us down there with Mexico and Turkey.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The reason progressives can’t move on from health care, even if they wanted to, is that our out of control health care industry will eventually eat everything. </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The money that should be going to social programs for education, transportation, and children is effectively <a href="http://www.commonwealthfund.org/~/media/images/publications/issue-brief/2015/oct/squires_oecd_exhibit_08.png?la=en">being stolen</a> by the health care industry. </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">We could have Norway-level social programs without new taxes if we had Norwegian health care.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">This is a problem which is only getting worse, not better. Large employers say insurance costs will grow by </span><a href="https://www.washingtonpost.com/news/wonk/wp/2017/08/08/large-employers-say-health-plans-will-cost-more-than-14000-for-an-employee-in-2018/?utm_term=.2c804d3d1af5" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">5 percent next year, </span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">faster than the rest of the economy. The <u><span style="font-family: inherit;"><a href="http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS?locations=CA-DK-JP-DE-NL-NO-CH-GB-US">cost curve is unbent</a>.</span></u></span></span></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtL-9KDLaaPmn4WW8WIvvJVlly7i2ZMDOloXaRuHXxrmmdC9D7U_6iBxPefqO287SGnkyVHFeuZGAg0nKKBLuGeZc7HjweUDRlCeiMMM_Ibw-gig1b1C9B3zOOvFeQy6paR-zECZ3Yedg/s1600/chart%25281%2529.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="573" data-original-width="927" height="394" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhtL-9KDLaaPmn4WW8WIvvJVlly7i2ZMDOloXaRuHXxrmmdC9D7U_6iBxPefqO287SGnkyVHFeuZGAg0nKKBLuGeZc7HjweUDRlCeiMMM_Ibw-gig1b1C9B3zOOvFeQy6paR-zECZ3Yedg/s640/chart%25281%2529.png" width="640" /></a></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Even if we did create social programs like universal pre-K or paid parental leave, it is likely the ever-growing cost of health care would eventually force them to face cuts.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">No social service is safe as long as health care demands a larger and larger share of the budget. Democrats current rally around free college, but that is something we effectively already had in places like California a few decades ago with the University of California system. The problem is health care kept starving the public system of money. Bring down health care costs, and California could reverse this trend. The <a href="https://www.gao.gov/products/GAO-17-213SP">Government Accountability Office</a> makes this problem clear trend</span></span></span><span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"><span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">.</span></span></span></span></span></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgkQph9_VfdviIIK1z_oQSIqYuNkaLiVvrmUpRlBS08rJvBSYNuFvFsgialeeE9efHBzf8_zaT0W2hDTKjO2XmkB5x3yYpx8Dfq2Mx-tplfsHWUPoRuVck1O0pnuFqYbY4sdJ7CneT92j0/s1600/GAO+chart.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="593" data-original-width="1136" height="334" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgkQph9_VfdviIIK1z_oQSIqYuNkaLiVvrmUpRlBS08rJvBSYNuFvFsgialeeE9efHBzf8_zaT0W2hDTKjO2XmkB5x3yYpx8Dfq2Mx-tplfsHWUPoRuVck1O0pnuFqYbY4sdJ7CneT92j0/s640/GAO+chart.JPG" width="640" /></a></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Contrary to what Krugman says, we need more than “incremental improvements in the A.C.A.” His comparison of Obamacare to the Netherlands is deeply misguided. While the ACA superficially resembles the Dutch system, it lacks the </span><a href="http://www.nejm.org/doi/full/10.1056/NEJMp1410422#t=article" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">significant government cost control measures</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> on providers and </span><a href="https://www.government.nl/topics/medicines/keeping-medicines-affordable" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">drug makers</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> that the Dutch use to keep their spending only barely in line.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">These are policies doctors, hospitals, and drug makers in America would heavily oppose. Pushing America towards Dutch-style health care would be a monumental reform effort that would face the same opposition from the health care industry that single payer would.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">At some point progressives are going to need to make the health care industry stop ripping off the American people. If we don’t, all other social programs that cost money will be swallowed by this ever-growing blob. Every progressive social program is in danger until we really deal with health care. </span></span></span></div>
Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com6tag:blogger.com,1999:blog-3449972385028694463.post-35655721635198712902017-07-29T18:03:00.000-07:002017-07-29T18:03:08.229-07:00Why Trump’s Threat to Congress is so Bonkers<blockquote class="twitter-tweet" data-lang="en">
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If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!</div>
— Donald J. Trump (@realDonaldTrump) <a href="https://twitter.com/realDonaldTrump/status/891334415347060736">July 29, 2017</a></blockquote>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Saturday on <a href="https://twitter.com/realDonaldTrump/status/891334415347060736">Twitter</a> President Trump seemed to threaten to take away Congress’s health care benefits. Let me explain why this would create one of the most amazing and bizarre acts of political irony in American politics. It would expose a dozen layers of hypocrisy, possibly end up as one of Trump’s most popular acts, and it could ultimately be what takes him down.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">The hypocritical history</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">You may wonder why Trump has the power to mess with congressmen’s and their staff’s health care benefits. It all goes back to 2010 when Democrats were writing the Affordable Care Act. In an attempt to make Democrats look like hypocrites, Republicans offered an amendment which would force Congress to get health insurance via the new ACA exchanges. This move backfired once the Democrats decided to vote for it and even used it as a selling point for their law.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The problem is the amendment, like basically everything the GOP did during the debate over the ACA, was designed only as political theater with no concern for policy. As a result, if you actually implemented the amendment as written, it would force Congress to buy insurance on the DC exchange at full price, just as millions of Americans who make over $50,000 a year but don’t have employer coverage are doing right now.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The possibility of actually having to pay the full out of pocket cost for expensive premiums, like millions of Americans currently do, caused a bipartisan freakout. Passing a special bill to fix it, though, would open any member up to attack ads, so instead Republicans and Democrats begged the Obama administration to bend regulation in a legally questionable way to fix it. Note that hypocritical Republicans endlessly attacked Obama when he used similarly legally questionable regulatory fixes to help other groups.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The solution was to stretch the</span><a href="https://www.wsj.com/articles/force-congresss-hand-on-health-care-1500845251" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;"> interpretation of the law</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> to effectively treat every congressional office as its own small business. That allowed the offices to use the money that previously went to their former federal employee insurance as a special subsidy to buy insurance on the exchange. One can argue this is fair, but it is not really what a technical reading of the law says, and Congress could easily change it anytime.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">More importantly, not only was this hypocritical on a process level for the GOP, but also on a policy level for both parties. After all, most Republicans just voted to repeal the employer mandate, yet they freaked out at the idea of not having their own employer provide insurance . </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Similarly, Democrats promised that even the unsubsidized insurance on the </span><span style="background-color: transparent; color: black; font-style: italic; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">Affordable</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> Care Act exchanges would be affordable for the middle class, but they balked at actually having to pay anywhere near that much for insurance.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">In addition, members of Congress from both sides have advocated for moving away from employer-provided insurance and toward people buying their own coverage. It was John McCain’s </span><a href="http://www.heritage.org/health-care-reform/report/the-mccain-health-care-plan-more-power-families" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">plan in 2008</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> and the core of the bipartisan </span><a href="https://en.wikipedia.org/wiki/Healthy_Americans_Act" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">Wyden-Bennett</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> plan. Yet when they were almost forced to become the test bed for this move away from employers paying for insurance, they did everything to avoid the fate they wanted for everyone else.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">There is no way this works</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The
most bonkers part is Trump is threatening to do this to get Senate
Republicans to agree on an Obamacare repeal, and there is no way that
would work. The GOP just proved they can’t agree to even a skinny bill.
Also, given what everyone knows about John McCain, Susan Collins, and
Lisa Murkowski, there is no way they would become more willing to
compromise after being publicly threatened and extorted. </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">The insanity of what is happening next</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">If Trump actually follows through on this threat, it could be very popular and one executive action he takes that is well within his legal purview. He could probably even spin it as one of his only “drain the swamp” moves. </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">After all, people don’t like it when Congress gets treated differently. They also dislike political stunts. The fact that Congress never fixed the problem via legislation shows they know it is a political loser.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Ironically, though, Trump’s most popular executive action could also be what brings him down. Congressional Republicans have been putting up with a lot of questionable behavior from Trump, but if he literally takes money out of their pockets, that could change. If Congressional Republicans stop defending him, the investigation flood gates would open. </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">The irony of the long term impact</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The final ironic twist is if Trump actually does it, the long term effect might be to make American health care more progressive, not less. Paying full price health insurance in the United States is crazy expensive -- way more expensive than it is in any other industrialized country. Maybe if everyone in Congress is forced to feel just how out of control American health insurance premiums are for a few years, they might take serious the idea of cost control.</span></span></span></div>
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Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com0tag:blogger.com,1999:blog-3449972385028694463.post-42095846412451741602017-07-18T09:23:00.001-07:002017-07-18T09:23:09.678-07:00Private health insurers admit they will always behave terribly<div dir="ltr" id="docs-internal-guid-69040545-5682-663f-430b-34ab32445d35" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The group America’s Health Insurance Plans came out strongly against against the Cruz amendment in the Senate Republican health care bill, but the Cruz amendment is terrible only because America’s private health insurers are collectively promising to act terribly every chance they get.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The Cruz amendment would allow insurers to sell policies that don’t cover everything and exclude people who actually need health care. AHIP </span><a href="https://www.ahip.org/letter-to-u-s-senate-regarding-consumer-freedom-option/" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">rightly notes</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">: </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">As the U.S. Senate considers the Better Care Reconciliation Act, we are writing to urge you to strike the "Consumer Freedom Option" from the bill. </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">It is simply unworkable in any from and would undermine protections for those with pre-existing medical conditions, increase premiums and lead to widespread terminations of coverage for people currently enrolled in the individual market.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">What is important to note, however, is that this scenario only happens if the private insurers make it happen. The Cruz amendment merely </span><span style="background-color: transparent; color: black; font-style: italic; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">allows</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> insurers to offer deceiptive or exclusionary non-compliant plans -- the insurers don’t have to. </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">If the insurers really care about people with pre-existing conditions and a stable market, the insurers could reach a collective agreement that none of them would offers these plans -- problem solved. Just because the Cruz amendment would allow them to behave badly doesn’t mean they have to. The market only destabilizes if private insurers choose to destabilize it in the pursuit of short term profits. </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The fact that no one inside or outside the industry thinks such collective action is even in the realm of possibility means that while condemning the Cruz amendment, the private insurers revealed something telling about their true nature. </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">AHIP is promising that as an industry, insurers will eventually exploit any legal leeway they are provided to make money, even if it costs people their lives. They are promising to do things they publicly admit are morally wrong if the government doesn’t hold them back at every turn. </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">They are indirectly admitting they can’t stop themselves from hurting people, like a werewolf begging to be chained up in the basement before the full moon. This who is in control of the country's health care.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Yet Democrats are still wondering why an individual mandate forcing people to be customers of an industry which admits they can’t be trusted was deeply unpopular.</span></span></span></div>
Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com3tag:blogger.com,1999:blog-3449972385028694463.post-698331827561449652017-07-07T07:57:00.003-07:002017-07-07T07:57:18.101-07:00An easy way to solve the Medicare For All tax problem<div dir="ltr" id="docs-internal-guid-a0501775-1d8c-fa43-3e64-cf6124066de1" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<a href="https://kaiserfamilyfoundation.files.wordpress.com/2017/07/9064-figure-4.png" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="" class="size-kaiser-slide wp-image-223890" data-attachment-id="223890" data-comments-opened="1" data-image-description="" data-image-meta="{"aperture":"0","credit":"","camera":"","caption":"","created_timestamp":"0","copyright":"","focal_length":"0","iso":"0","shutter_speed":"0","title":"","orientation":"0"}" data-image-title="9064 – Figure 4" data-large-file="https://kaiserfamilyfoundation.files.wordpress.com/2017/07/9064-figure-4.png?w=960" data-medium-file="https://kaiserfamilyfoundation.files.wordpress.com/2017/07/9064-figure-4.png?w=300" data-orig-file="https://kaiserfamilyfoundation.files.wordpress.com/2017/07/9064-figure-4.png" data-orig-size="960,720" data-permalink="http://www.kff.org/9064-figure-4/" height="298" src="https://kaiserfamilyfoundation.files.wordpress.com/2017/07/9064-figure-4.png?w=735&h=551&crop=1" width="400" /></a><span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Polling has consistently shown broad public support for Medicare For All, or single payer health care, but every policy position is vulnerable to attacks. The most common attacks used against Medicare For All revolve the around overall cost and the need to raise new taxes. These issues can be a problem, but one that is easy to solve if supporters are willing to be creative.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Traditionally, single payer plans suffer from the issue of "big, scary numbers." Take, for example, the recent bill in California where </span><a href="http://www.latimes.com/politics/essential/la-pol-ca-essential-politics-updates-first-fiscal-analysis-of-single-payer-1495475434-htmlstory.html" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">headlines about it</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> often focused on its overall cost to the government of $400 billion instead of the net change. Much of that $400 billion sticker price simply added up to the state consolidating the billions it spends on several health programs (Medicaid, state employe benefits) into one program. </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">It is also easy to scare people over the </span><a href="http://www.kff.org/health-reform/poll-finding/data-note-modestly-strong-but-malleable-support-for-single-payer-health-care/?utm_content=57075448&utm_medium=social&utm_source=twitter" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">tax increases</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> needed to pay for a pure single payer system, even though it would mean individuals would pay less in taxes for healthcare than they currently pay in premiums.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Supporters of Medicare For All should engage in a multi-faceted educational effort to inform people about the value of these trade-offs, but they should </span><span style="background-color: white;"><span style="color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">also realize there is an easy way to avoid some of these political problems</span></span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">First, allow companies and individuals under 65 to buy into Medicare. </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Second, require all companies buy their employees Medicare or private coverage at least as good Medicare from insurers that must pay into a risk adjustment program. This is already how Medicare basically works with Medicare Advantage, except companies would be making the choice.</span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Most of the cost of our healthcare system is already hidden from individuals by the tax-exempt status of employer-provided insurance; so instead of trying to teach everyone about this, just modify it. This plan would hurt companies that don’t already provide coverage but cause significantly less disruption than eliminating employer-provided insurance and replacing it with a new tax.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">This plan mostly eliminates the need for very large new taxes or the "big, scary number" problem. Everyone with a job will technically get coverage via their work and those without jobs could mostly be covered by moving around money already spent on Medicaid, ACA, etc… </span></span></span></div>
<span style="font-family: inherit;"><span style="font-size: small;"><br /><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The strong employer mandate is not a perfect funding source, but it is good enough. In practical terms it would function much like a payroll tax with a ceiling. It is basically how </span><a href="http://www.commonwealthfund.org/~/media/files/publications/fund-report/2016/jan/1857_mossialos_intl_profiles_2015_v7.pdf" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">Germany funds its health care system</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">, and it would effectively get us to where the country needs to be.</span></span></span>Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com8tag:blogger.com,1999:blog-3449972385028694463.post-23987677619812128282017-06-14T09:22:00.000-07:002017-06-14T09:22:28.188-07:00Maybe health care CEOs are just greedy and don't care about peopleAlmost every segment of the health care industry technically opposes the new Republican health care bill, but overall the industry's opposition has been rather tepid. <a href="https://www.nytimes.com/2017/06/13/opinion/halfhearted-opposition-republican-health-care-misery.html">David Leonhardt at the New York Times</a> offers this explanation:<br />
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<blockquote class="tr_bq">
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Why
haven’t the big lobbying groups done more? I think there are two main
answers. First, in past campaigns, groups were largely defending their
own financial interests. People fight hard when their own money is at
stake. Today’s opposition is at least as much about principle as profit,
and lobbying groups haven’t been willing to go all-out for principle. </div>
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Second,
the groups are wary of attacking the Republican Party, given its
current power. “We’re living in a world in which it’s just Republican
votes,” one lobbyist told me. Speaking loudly against the bill risks
alienating powerful politicians — and risks making the health care
groups look partisan.</div>
</blockquote>
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I think there is a much simpler solution. Health care CEOs are just greedy and really don't care about regular people who might need care. </div>
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The American Health Care Act would cut government spending on health care by cutting poor people off from insurance. This would marginally cut health care companies' profits, so you would think health care companies would strongly oppose it. But the law would also be a <a href="http://www.npr.org/2017/05/04/526923181/gop-health-care-bill-would-cut-about-765-billion-in-taxes-over-10-years">big tax cut for the rich</a>. </div>
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Leonhardt acknowledges as much in his column: "Virtually every big health care group views the Republican plan as a
disaster, one that would harm many Americans largely in the service of
cutting taxes <a href="http://time.com/money/4710863/trumpcare-gop-health-tax-cut-rich/">for the wealthy</a>."</div>
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The simple fact is, lobbying by large health care companies is directed by industry CEOs and other top corporate officers. All of these people will see their taxes cut by the law. Even if the law makes their companies slightly less profitable on net, most will likely be personally better off. The fact that the law would hurt a lot of poor people simply doesn't bother them that much.</div>
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There is plenty of evidence to suggest health care industry leaders are willing to put personal and corporate gain above the public good. During the negotiation with President Obama over the Affordable Care Act, the industry's top demand wasn't "make sure everyone has coverage." Instead, <a href="http://www.huffingtonpost.com/2009/08/13/internal-memo-confirms-bi_n_258285.html">PhRMA pressed Obama to oppose</a> drug re-importation and to keep Medicare from negotiating drug prices; this kept drug profits high. Similarly, hospitals wanted the <a href="http://www.nytimes.com/2009/08/13/health/policy/13health.html?utm_source=huffingtonpost.com&utm_medium=referral&utm_campaign=pubexchange_article">ACA to omit a public option</a> that would reduce their profits. The hospitals made this demand knowing full well that the absence of a public option would increase costs, resulting in the law covering fewer people. </div>
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For many rich people, greed is more motivating than principle. In many cases, greed is what drove them to become rich in the first place. Leonhardt writes, "I feel a pang of discomfort every time I describe the <a href="https://www.nytimes.com/2016/12/20/opinion/democrats-had-a-knife-and-the-gop-had-a-gun.html">radicalism</a> of today’s Republican Party." It can also be uncomfortable to acknowledge that many people are simply greedy.</div>
Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com3tag:blogger.com,1999:blog-3449972385028694463.post-38057420560896887212017-06-02T10:02:00.000-07:002017-06-02T10:02:06.757-07:00A party's platform is about succeeding after the election<div dir="ltr" id="docs-internal-guid-e881a0ad-6506-4062-fca1-caaa26619bf5" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Since the national Republican and Democratic parties divide themselves along ideological lines, American politics has followed a very predictable pattern. It is defined by a punctuated equilibrium.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">One party wins total control of Washington and has a brief moment to make a big impact. Inevitably, the party in power messes up and loses control of Congress. This is followed by a period where little happens until the opposition also wins the White House. The other party now has their tiny moment to make their mark-- until they mess up.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The Republicans didn’t win in 1994 -- the Democrats lost. The same is true for the Democrats' 2006 victory and the GOP's 2010 victory. </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Each time, the party in power screwed up badly and could have been beaten by a group of monkeys in clown suits. Bill Clinton's job approval rating was terrible heading into the 1994 election, due to failed health care and energy tax plans. In 2006, George W. Bush owned the failed Iraq war and the aftermath of Hurricane Katrina. By 2010, Barack Obama had failed to respond to the massive housing crisis or go after anyone who caused it. People spend a lot of time studying winners to divine the secret to their success, but often the answer is they were just facing super easy opponents.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">This is why an opposition party shouldn’t focus on simply winning again at all costs: that is mostly determined by the party in power stumbling. They should focus on what they want to do once they do win. These brief moments when a party has total control are the rare times anything big happens, but it only happens if the party is united behind a set of ideas.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Taking advantage of these moments of total control is also critical because of one other major characteristic of American politics: we almost never reverse legislation. Once a policy is enacted, it tends to stick. No matter how much the opposition rallies against it and promises to repeal, they almost never do. </span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Democrats in 2008 rallied against the corrupt Medicare Part D law, the Bush tax cuts, and Guantanamo Bay. Yet after they gained power, Obama pushed to keep the corrupt Medicare Part D deals intact, backed a law to save almost all the Bush tax cuts, and never closed Guantanamo. Similarly, the Republican party ran on the promise to “repeal and replace” Obamacare for years, and now their effort is bogged down in the Senate.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Trump has become the poster child for why a party shouldn't do anything to win, just for the sake of winning. With a lack of cohesion and discipline, the GOP is possibly squandering their moment for the next decade.</span></span></span></div>
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<span style="font-family: inherit;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Democrats have become very focused on beating Trump, but Trump is going to do most of the work defeating Trump. The real focus should be on what they will do in that moment after.</span></span></span></div>
Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com1tag:blogger.com,1999:blog-3449972385028694463.post-83338225958216295682017-05-22T09:42:00.002-07:002017-05-22T09:44:13.788-07:00How I would design a state single payer law<div dir="ltr" id="docs-internal-guid-f0110640-30fd-bd08-5ef3-301bd9a880a8" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">After providing an analysis of all the issues facing the pushing for single payer health care this country, I thought it was important to provide details for how I would personally design a state-based health care effort. Several states are talking about moving towards a single payer system but for any plan to work it needs to deal with the <a href="https://shadowproof.com/2017/05/02/road-to-single-payer-healthcare-overcoming-hurdles-at-the-state-level/">unique legal and financial hurdles a state would face</a>. I don’t feel the need to do this at the federal level, since a federal single payer system would legally be much easier to implement.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">My state plan for affordable universal health care is not what I think would be the absolute “best” policy possible, but the best I’ve been able to piece together that would have a reasonable chance of success given the political and legal hurdles. This strategy is based on four criteria that should be used to judge any proposal:</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">It needs to, on net, make most people better off.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">Any step forward should weaken or at least not strengthen those institutions opposed to real reform. </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">This is what I consider to be a major failing of the Affordable Care Act. Forcing people to buy subsidized insurance from poorly regulated private insurance companies only increases their power.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">It should still create a clear path for better improvements even if part of it is struck down by the courts or denied by the federal government. </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">You don’t want a plan that would completely fall apart if one federal waiver is denied or if a court ruling goes the wrong way. If there is a single weak point, that is where it will be attacked. </span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">It should keep direct disruption to a minimum.</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> Any real reform is going to need to take on the health care industry, and given the industry’s size there is no way to make this omelette without breaking eggs. That said, there is a big political reason to try to minimize the negative disruption it would cause to regular people.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The plan should be insulated as much as possible from potential political, financial, legal and federal attacks. I think it is important to start with the assumption that any state health care plan for real reform will face a hostile federal government and federal courts. First, history shows it likely will. Second, it is easier to add to a plan that's designed to be built on than it is to take away from a plan where all the pieces were crafted to fit together.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">If facing a hostile president and federal courts: A state run public insurer that directly covers many and is open to most everyone</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Even if the state can’t get any waiver from federal law or new federal funds, it should be able to build a Medicare-like public insurer, according to a </span><a href="http://www.rand.org/pubs/research_reports/RR1662.html" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">Rand analysis</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">. In addition, the state could automatically sign up most people or give them the option to join this new public insurer. </span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The state would first set up some type of insurance company. It could be a direct government program, like Medicare, or a corporation owned by the government, like the North Dakota Mill and Elevator. </span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">This public insurer would operate as much like Medicare as possible, to reduce administrative work for providers. This state-based public insurer would offer three plan tiers. Tier one would have benefits, co-pays and out-of-pocket costs equal to roughly what the state currently provides state employees. Tier two would have benefits roughly equivalent to the average plan provided by middle-size private employers. Finally, tier three would be an ACA silver plan for legal reasons.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">Auto-enroll state and local employees in tier one</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">To make this public insurance plan work well, the state would then leverage the health care dollars it does control. The public insurer would handle the state’s Medicaid program. It would also start by gradually transferring basically all state and local employees to the public insurer's tier one plans. This would minimize disruption in coverage for public employees. This large pool would give the public insurer the significant market power necessary to negotiate rates with providers. I would peg provider reimbursement rates to the Medicare rate plus 5-10%. This would allow it to offer insurance at a very good price.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">Open it to all employers and add a modest employer mandate</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">That state would allow all companies regardless of size to buy tier one or tier two coverage from the public insurer. The public insurer should be able to offer a price that would be very attractive to companies, possibly costing more than 10% less than private insurers. It is likely within a few years a significant share of companies would switch. By making the policies similar to what people already have and putting the decision to switch on employers, this also minimizes disruption.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">This would be combined with as large of an employer mandate or “pay-to-play” requirement as would likely serve as an ERISA challenge. What exact amount that would be is difficult to guess.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The public insurer would have the tier three plan for one simple reason: To get all the federal ACA subsidies low-income individuals without employer coverage need to sign up for a silver plan on the exchanges. </span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The state would take action to ensure that the public insurer was basically the only option on the exchange and to make sure everyone qualified signed up. I would create an automatic enrollment and premium collection system for all individuals not covered by their employer.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Since an ACA silver plan is pretty terrible coverage and the subsidies are insufficient, the state would need to provide some extra money to make care truly affordable. The state could create its own cost-sharing subsidies to make tier three coverage the equivalent of tier two. </span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The money needed for these subsidies would be relatively modest. Some could come from savings in state employee health care spending. Some would come from the employer mandate fine. Some could come from the public insurer adding a small surcharge to the premiums it charges private companies. Some could come from general revenue.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">The result</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">This would not create a true single payer system, but it would get us a lot closer within the constraints we face. Medicare would technically still be separate. Some companies would still give their employers private insurance, but within a few years it is easy to see how 80% of people are directly covered by Medicare or the new state Medicare-like public insurer. It should provide affordable care to almost everyone.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Compared to the other alternatives, it would need minimal new taxes and minimal direct disruption to people’s current coverage. For people with employer provided coverage, the government won’t “make you lose your current coverage.” If your coverage changes, it will be because employers realize it is so much better.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Most importantly, this foundation is easy to build off of if/when the federal government and federal courts are less hostile. The following elements can be added from the beginning if the federal government is willing to provide the waivers or later when a new president is elected.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">If the state can get an Obamacare 1332 waiver</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The Affordable Care Act does allow the HHS to grant </span><a href="https://www.cms.gov/cciio/programs-and-initiatives/state-innovation-waivers/section_1332_state_innovation_waivers-.html" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">State Innovation Waivers</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">. States can use all of the money that would have been spent on ACA provisions for their own plan if their program will “provide access to quality health care that is at least as comprehensive and affordable as would be provided absent the waiver.”</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">If a state gets a waiver, this plan could be amended to eliminate the ACA exchange work around mentioned above. Instead, the state could automatically enroll anyone without qualified employer provided coverage in the tier two plan. This would be paid for with the waiver money, the other revenues discussed above and charging these people a “mandatory premium” or new income tax.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">If the state can get a Medicare waiver</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">It is theoretically possible that HHS could grant a waiver to let a state administer Medicare, but it is untested. If the state could eventually get such a waiver, it could just have the new public insurer also operate Medicare in the state. This should streamline administration and reduce health care overhead costs in the state. It would also allow the state to take a more holistic approach when it comes to deciding reimbursement rates.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">If the state can get ERISA amended</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Dealing with ERISA issues would take an act of Congress, but if Congress does change the law the next step would be fairly simple. This would make reform much easier and more efficient. </span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Instead of encouraging employers to use the new public insurer, the state would simply require all companies to give their employees the equivalent of tier two coverage or pay a tax equal to the cost. This technically hides the cost while getting the desired outcome. This is not the “best” way to finance health care policy, but it is by far the least disruptive and most politically tenable option. These steps would move my plan from quasi-single payer to true single-payer.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">First lay the groundwork</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Of course, before we can get to that point, a lot of groundwork needs to be laid. States need to be made ready. On the one hand, that means pushing for legislative changes that weaken the relative lobbying power of the heath care industry. This includes health care regulations like a higher minimum loss ratio for health insurers, a mandate that only non-profit plans can be sold on the individual market, </span><a href="http://www.modernhealthcare.com/article/20160901/NEWS/160909980" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">banning surprise billing</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">, etc… It also includes political reforms like campaign finance rule changes, lobbying restrictions, etc…</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">At the same time, efforts should be underway to build popular support and elect candidates willing to be cosponsors for a specific legislative plan, not a vague idea. Politicians claiming support for vague principles is not as good as public support for a bill. It is easy for cynical politicians to find an excuse for why a specific bill doesn’t apply to their promise or why a bad bill does. This happened a lot in 2009 with Democrats and is especially evident right now as Republicans scramble to figure out what “repeal and replace” means.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: inherit;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">That is why I'm putting forward this plan outline. I’m not claiming it is the best possible plan or even the one progressives need to rally around. But it demonstrates what such a plan needs: a realistic way to deal with the legal and political hurdles to any state-based reform. </span></span></span></div>
Jon Walkerhttp://www.blogger.com/profile/08572685384863064332noreply@blogger.com0