Everything I learned about health care

I have been following and writing about health care policy for almost a decade, and I feel this new series I've produced for Shadowproof is the summation of everything I learned. It at least touches on everything I have learned about how to make universal policy work.

Most importantly, it addresses the political dynamics that are killing, bankrupting, or creating financial strain for countless Americans. The major problem with health care policy is not figuring out what works. We know what works, by looking around the world. The problem is convincing politicians to do the right thing when the industry is spending millions to convince them to keep our system broken but profitable.  

You can find part one here: Road To Single-Payer: How The US Can Achieve Universal Health Care

You can find part two here: Road To Single-Payer: Understanding Different Universal Health Care Systems

It should be around five parts in all, with one part published each week here.

Trump is too ignorant to do health care

During a Wall Street Journal interview, President Trump talked about what could theoretically be a highly risky but successful strategy to get a “win” on health care. He admitted he has broad powers to sabotage the Affordable Care Act exchanges and may threaten to cut off subsidies for millions, so “the Democrats will start calling me and negotiating.”

The real takeaway from this bold admission is not that Trump is considering this strategy, but that he is so ignorant about health care he doesn’t even understand his own strategy.

Theoretically scaring Democrats into accepting a health care compromise might have worked at some point, but it required two things.

First, Democrats need to fear that if the exchanges continue to have problems, voters will blame them at least as much or more than Trump.

This was already tough because polling from before this interview shows voters are more inclined to blame Trump for any problems with the ACA going forward. Of course, polling about how people think they might react two years from now to future hypotheticals is a weak predictor. Obamacare was the Democrats' law, and conservatives are good at spin. Trump’s team could quietly undermine the exchanges with a slew of small regulatory changes that he claims are meant to to help, but actually hurt by increasing uncertainty. The key part, however, is doing it "quietly." People don’t really understand insurance regulation, so as long as the changes subtle, it would create a dicey blame game. Democrats would say Trump ruined the exchange, Trump could say he tried to save them but they were too flawed.

Instead, Trump told a major national publication that he may actively sabotage the law in a big and public way. Now I doubt Democrats are too worried they will get blamed.

Second, to work the offered compromise needs to be better than just letting the ACA exchanges fail.

Using executive authority, Trump could do real damage to the exchanges, making insurance more expensive and unobtainable for millions. So if Trump offered Democrats a compromise that would produce results worse than what we currently have yet better than how it would be if Trump undermined the exchanges, Democrats might feel compelled to think about it.

Instead, Trump has thrown his weight behind the American Health Care Act. If approved it would produce a system even worse than one where Trump sabotages exchanges. Even if some of the exchanges struggle, the ACA’s Medicaid expansion would remain. Democrats are slowly coming to accept that the Medicaid expansion was the best part of the ACA and did the most good. The AHCA would make the individual market terrible and slash Medicaid.

This is not a complicated analysis. This is deal-making 101. If you want to try to coerce someone into making a deal, the deal needs to be better than the threat. You don’t threaten to scratch someone’s car unless they set it on fire, especially while on camera.

Trump's statement suggests he is totally ignorant about what his health care bill would do, what Democrats want, how Congress works, and what he is actually threatening. This is not merely a risk strategy; Trump doesn’t even know enough to understand his own strategy. It is tough to see how he succeeds with any legislation.

As I predicted, Canada is likely to legalize marijuana this year

Another one of my marijuana predictions appears about to come true.

From the CBC:

The Liberal government will announce legislation next month that will legalize marijuana in Canada by July 1, 2018.

CBC News has learned that the legislation will be announced during the week of April 10 and will broadly follow the recommendation of a federally appointed task force that was chaired by former liberal Justice Minister Anne McLellan.

Back in 2014 in my book After Legalization: Understanding the future of marijuana policy, I wrote that this was likely to happen in 2017:

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, 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.

Despite the fact that marijuana opponent Jeff Sessions has been named US Attorney General, marijuana policy reform continues to move forward. Additionally, marijuana legalization is more popular than ever. I have long suspected that as more Americans see marijuana legalized by neighboring states and Canadian provinces, support will only grow.

The House GOP has literally given up on legislating health care

This headline is not poetic embellishment, it is a disturbing statement of fact: The House Republicans are planning to vote on a major health care bill they effectively admitted they haven’t finished writing. This is what the House Energy and Commerce Committee said about their changes to their now "finished" version of American Health Care Act:

To further ensure older Americans have the help they need to access the care that’s right for them, the amendment to AHCA would provide the financing for additional support for those with high health care costs before the bill goes to the Senate. Under current law, Americans can deduct from their taxes the cost of medical expenses that exceed 10 percent of their income. Our proposed amendment reduces this threshold to 5.8 percent of income.

This change provides the Senate flexibility to potentially enhance the tax credit for those ages 50 to 64 who may need additional assistance.

People who don’t often pay attention to the legislative process may not appreciate what a big deal this is. Effectively, what House Republicans are saying is that they think they should provide an extra $75-$85 billion on tax credits to help older Americans buy insurance, but they don’t want to figure out how.

So instead of writing an amendment to increase tax credits, they wrote an amendment to alter tax deductions -- a change no one wants. The House GOP included this change because it would cost roughly $85 billion, giving the Senate "flexibility" to write their own laws.

To recap, House Republicans are planning to vote for something they don’t support in the hopes that the Senate will remove this wasteful provision and replace it with some tax credit change that costs the same amount.

Whether you agree with a law or not, it should be universally accepted that it is the job of Congress to actually write laws. Regardless of ideology or party affiliation, I would hope everyone can realize what an absurd dereliction of duty this is. Basically, the only job of our elected legislators is to turn their desired policy changes into actual legislation so it can be implemented. We need the actual legislative language to study and understand what our government plans to do.

$85 billion is a lot of money. Deciding exactly how this $85 billion is going to be spent will have massive implications for millions of people and countless businesses. For instance, simply increasing the tax credit for this age group to $7,000 would help the relatively well off, but it would leave the poor without coverage. Using it to improve credits in more expensive regions would help Alaska but do nothing for Ohio. Helping only lower-income adults would require some bureaucratic management. The examples go on.  

Each of the designs would impact other parts of the bill in major ways. That is why these legislative details are so important, and choosing them is basically the sole job of members of Congress. Yet instead of spending a few more days working out these important details, House Republicans have declared they just don’t want to do their job anymore. They may have a vote on a major bill impacting millions of people tomorrow, which they admit they haven’t actually finished writing.

No, really: Democrats should offer an AHCA alternative

Some people on the left are rightly mocking Sen. John Cornyn (R-Texas) for saying Democrats who don't like the Republican Obamacare repeal-and-replace plan should put forward their proposal. After all, the Democrats' already did: it is the current law.

But this is a good chance to highlight differences and drive home the problems with Trumpcare. While the ACA has gotten marginally more popular during this repeal fight, polling shows almost no one thinks the law is perfect, and most want to see it significantly improved.

Democrats could quickly and easily put out a package based on already-scored ideas that would reduce premiums, increase coverage, and lower the deficit. It would do all the things Trump promised to do during the campaign but is now planning do the opposite of with his current repeal-and-replace plan.

It could simply contain a public option, a drug manufacturer rebate provision, and an improvement in exchange subsidies.

Public Option: Back in 2013, the CBO determined adding a public option would save $158 billion over 10 years and offer premiums 7 percent to 8 percent lower than private plans. It would also ensure there would be a reliable option in the huge segment of the country where the exchanges have only one or two insurers.

Require Manufacturers to Pay a Minimum Rebate on Drugs Covered Under Part D of Medicare for Low-Income Beneficiaries: In 2016 the CBO estimated this would reduce the deficit by $145 billion.

Improve Exchange Subsidies: Democrats can set aside $3 billion to make this plan nominally deficit reducing. They could use the remaining $300 billion in savings to significantly improve exchange subsidies. There are many ways to do that, but I would recommend capping what anyone on the exchange pays for a silver plan at 8 percent of their income -- the same limit used in Switzerland. This would fix the very real and deeply problematic Obamacare subsidy cliff. This should also increase the number of people insured.

Since this is a political proposal with no chance of passing, it makes sense to keep it simple, but it would be a smart move. Even if the Republican bill fails, that is not the end of the fight over health care. Paying for their own health care is the top concern for American families. People want to see change. Putting forward this package would show Republicans want to cover fewer people and provide less help to struggling families while Democrats want to lower premiums and provide more help to middle class families. All Democrats need to do is actually care more about helping people than corporate donors, and they can win the debate.

The Dustin Plan: a very easy and very stupid way to reduce average premiums

There is a very easy and very stupid way to dramatically reduce premiums in the non-group market. I call it the Dustin Plan. If you make it illegal for anyone to buy individual insurance except for people named Dustin who are under the age of 30, average premiums in the non-group market would be cut by roughly 70%. Young people named Dustin are very healthy, so very cheap to insure. Of course, this is terrible for millions of people not named Dustin.

While not as dramatic, the House Republican health care plan basically includes a version of the Dustin Plan. The Republicans are trying to highlight this one piece of "good news" in their otherwise terrible CBO score, but it is not good news.

First, the mix of people enrolled in coverage obtained in the nongroup market is anticipated to be younger, on average, than the mix under current law. Second, premiums, on average, are estimated to fall because of the elimination of actuarial value requirements, which would result in plans that cover a lower share of health care costs, on average. Third, reinsurance programs supported by the Patient and State Stability Fund are estimated to reduce premiums. If those funds were devoted to other purposes, then premium reductions would be smaller. By 2026, average premiums for single policyholders in the nongroup market under the legislation would be roughly 10 percent lower than the estimates under current law.

The Republican plan will bring average premiums down by making insurance so expensive for many older Americans in the individual market that they would be forced to go uninsured, leaving behind only young people in the risk pool. It would, in fact, improve life for thousands of young Dustins, but by making insurance out of reach for millions of people who really need care.

It is a reminder that the focus placed on many metrics in the health care debate, such as average premiums or even total number of people with "insurance," is often misguided or misleading. The real question is how many people are able to get care when they need it and be able to afford it.

The tech world is spending like it expects robots to take your jobs

There seems to be a rather big split between some leaders in the tech world who think mass automation driving unemployment is just around the corner and many economists who think the relatively slow growth in productivity means these fears are misguided. Both these worlds have been wrong over the years in big ways, but this is not just idle chatter from the tech world.

The biggest tech companies are betting a lot of money on technology that would result in millions of jobs becoming obsolete. Just this week, Intel spent more than $15 billion on a self-driving car technology company. From Business Insider:

Intel, in its second-largest acquisition in its 50-year history, is spending a whopping $15.3 billion to buy the self-driving-car-tech company Mobileye.

If self-driving vehicles are the future — as Uber, Alphabet, and others believe — Intel wants to sell the bits that make them happen.

Just as PCs were once adorned with the reassuring "Intel Inside" stickers, the chipmaker is betting that it can gain a similar foothold inside another product that could sell tens of millions of units ever year.

Tech leaders could be wrong, but they are certainly spending money as if they are convinced the robots are coming -- at least for our driving jobs, which employ around 5 million Americans.