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The Wrongologist

Geopolitics, Power and Political Economy

Last Night’s Debate and Medicare For All

The Daily Escape:

Dix Pond from the Dix Mountain trail, Adirondacks, NY – July 2019 photo by Shelley VK

A few thoughts about last night’s Democratic debate. Tom Sullivan captured Wrongo’s thinking:

“Watching Part One of the second Democratic debate was an endurance contest. CNN’s 30-second response format was a disaster, barely giving candidates time to formulate a sentence before being cut off. Questions from CNN moderators seemed designed not to probe policy issues, but to get candidates to snipe at each other.”

And snipe they did. The fringe and vanity candidates tried very hard to tell us which policies wouldn’t work. They were enabled by CNN’s question-askers, who mostly asked gotcha questions designed to provide sound bites for Republican attack ads down the road.

Elizabeth Warren won the night by responding to a poor-mouthed critique from Republican-lite John Delaney about health care:

“I genuinely do not understand why anyone would go to all the trouble of running for president just to get up on this stage and talk about what’s not possible. #DemDebate pic.twitter.com/cOCz5TS3AF”

— Elizabeth Warren (@ewarren) July 31, 2019

But, let’s take a moment to talk about the topic that took about most of the first hour of the debate: Medicare for All (M4A). Wrongo wants to remind everyone about an Upshot article on Monday in the NYT by Austin Frakt and Elsa Pearson. It asks, “What Would Medicare for All Cover? From the article:

You can divide current Medicare coverage into two layers.

The first is relatively transparent. Traditional Medicare does not cover certain classes of care, including eyeglasses, hearing aids, dental or long-term care. When the classes of things it covers changes, or is under debate, there’s a big, bruising fight with a lot of public comment. The most recent battle added prescription drug coverage through legislation that passed in 2003.

So the authors say that a Medicare for all program that excluded all private insurance coverage, and that resembled today’s traditional Medicare would leave Americans with significant coverage gaps. And therefore, we should have a debate about what M4A would cover.

The writers go on:

…there is a second layer of coverage that receives less attention. Which specific treatments does Medicare pay for within its classes of coverage? For instance, Medicare covers hospital and doctor visits associated with cancer care — but which specific cancer treatments?

The devil is always in the details.

Although Medicare is a national program, most coverage determinations are local. Private contractors that are authorized to process Medicare claims decide what treatments to reimburse in each of 16 regions of the country:

What people are covered for in, say, Miami can be different from what people are covered for in Seattle. Many treatments and services are covered automatically because they already have standard billing codes that Medicare recognizes and accepts. For treatments lacking such codes, Medicare makes coverage determinations in one of two ways: nationally or locally…..There are more than 2,000 local coverage determinations….National coverage decisions, which apply to the entire country, are rarer, with only about 300 on the books.

Wrongo wasn’t aware of these differences in coverage, and that is something to talk about if/when M4A is seriously discussed in Congress.

It seems that what should be covered by any health insurance program is an evolving target, informed by changes in treatments and their reported efficacy.  The issue isn’t unique to Medicare. Wrongo prefers the decision to include or exclude a treatment not be made by an insurance company that can make more profit based on what forms of healthcare are offered.

For example, in many private plans, cataract surgery isn’t covered, while Medicare does provide coverage for a basic lens replacement.

And we shouldn’t allow the perfect to be the enemy of the good. In this country, tens of millions of people have no coverage, and tens of millions more are either under-insured, or face very high deductible plans. By contrast, throughout all other developed countries, every person is covered for all medical needs.

A few things to think about between here and the 2020 election.

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Who The Dems Should Nominate for President

(There will be no Thursday column this week. Wrongo is in NYC.)

The Daily Escape:

The Passion Facade, La Familia Sagrada by Gaudi, Barcelona, Spain

Wrongo has been highlighting several people who have big ideas that could move our country toward reform of capitalism. One issue that impacts that reform is health insurance, and many Congressional candidates who won in the 2018 mid-terms ran either on preserving the ACA, or on implementing Medicare for All.

Talk has started on the 2020 presidential election, and the almost 30 potential candidates that seem set to try for the White House. Now that a Texas judge has declared the ACA unconstitutional, and should that decision be upheld, health insurance should be a big issue in 2020.

For Democrats, politics is a game of good policies badly presented. For Republicans, politics is a game of bad policies skillfully presented. With that in mind, let’s turn to Sen. Chuck Schumer (D-NY), who on Sunday with Chuck Todd, refused to endorse Medicare for All. Instead, he said: “there are lots of different routes” to a universal healthcare system.

Though Schumer says he will support a “healthcare plan that can pass,” there is no evidence that any of the alternatives to Medicare for All have a better chance of passing than Sanders’ single-payer plan that was introduced last year. In the House, a majority of the Democratic caucus supports single-payer.

This is what we have to look forward to in 2019 and 2020. The Dems old guard will try and triangulate on policy in an attempt to corral a few Republican Senators. Nancy Pelosi is not a fan of Medicare for All.

A few of the old guard are running for president, including Bernie and Joe Biden. On the progressive side of the Democratic Party, there is a big age gap to a few relatively young politicians who are clearly progressive-purists.

Benjamin Studebaker has a provocative column, “Why We Cannot Nominate a Young Person in 2020”. His argument is that Democrats who are between 40 and 60 may have the right level of experience and political gravitas, but they all grew up in the Party of the Clintons:

…the overwhelming majority of Democratic politicians in their 40s and 50s are centrists who came of age politically in the ‘90s and ‘00s. These are people who got into Democratic Party politics because they grew up admiring the Clintons….They have spent their political lives working with Gore and Kerry and Obama and that’s the discourse they swim in. Corey Booker is 49. Kamala Harris is 54. Beto O’Rourke is 46. Kirsten Gillibrand is 52. Amy Klobuchar is 58. This group has…been tutored in triangulation from the time they were political toddlers.

Studebaker says that we can’t count on any of these candidates if we want Medicare for All, or a host of other policy improvements. He thinks we need someone who was too left-wing for the Democratic Party in the 1970s, and there is only one such person left alive: Bernie Sanders.

Wrongo isn’t sure. The NYT’s David Leonhardt, in his “Secret to Winning” column, says that the Democrats need a candidate who can, and will run as an economic populist:

They need a candidate who will organize the 2020 campaign around fighting for the little guy and gal….It would be a campaign about Republican politicians and corporate lobbyists who are rigging the game, a campaign that promised good jobs, rising wages, decent health care, affordable education and an end to Trumpian corruption.

Leonhardt thinks that several of those younger Democrats can do the job. He says that the formula is: Return to an updated New Deal. Put the public interest first, not the interests of the over-privileged elites. Force corporations and the rich to pay increased taxes.

Norm Ornstein notes that by 2040, 70% of Americans will live in 15 states, which means that the other 30% of the country will choose 70 of our 100 senators. And the 30% that are in charge of the Senate will be older, whiter, more rural, and more male than the 70%.

Whomever the Dems nominate must have a plan to successfully strip away a few red states. Economic populism can help do that, since it helps the working classes and unemployed. Higher taxes on corporations and the wealthy, a higher minimum wage, and universal health care coverage are the cornerstones of the winning strategy.

The nominee must be someone who is authentic, not someone who is simply an ideologically pure lefty.

Being authentic means someone who doesn’t poll test every idea, and doesn’t base their messaging on what the editorial board of the NYT or WaPo thinks are the right ideas.

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Send Establishment Democrats to the Bench

The Daily Escape:

City Hall Subway Station, NYC – via @themindcircle

We live in disorienting times. Disorienting in that our society, and our values, are in motion. We are no longer anchored by social mores, beliefs, or any shared vision of the future. Our politics are evolving as well. We can’t simply blame Trump, or those who elected him for taking us to this scary place. The bipartisan consensus that’s ruled this country since the 1940s — neoliberal domestic policy, and neoconservative foreign policy ─ no longer produces the same results for our citizens that it has produced since the Eisenhower era.

Establishment Democrats bear some of the blame. And looking forward to the mid-terms and beyond, they have failed to do the simplest work — forming a worldview, then persuading others about their vision, and the steps to achieve it.

We can also blame establishment Republicans, but they have collapsed. The new right is much farther right, more authoritarian, and whiter. And who would have thought they would be the pro-Russia, anti-FBI, anti-DOJ, and (maybe not a complete surprise), the pro-police state party?

History shows that when society turns like this, the establishment parties can disappear, as did the Federalists and the Whig parties. And when one party changes, the other must as well. After Lincoln, neither the Republicans, nor the Democrats, were the same parties.

Perhaps it’s time to take these words in the Constitution to heart:

…to secure these rights, Governments are instituted among Men, deriving their just Powers from the Consent of the Governed…

Therefore, if the Dems are to win back the hearts and minds of the people, regardless of what the banks and corporations want to do, Government must be the advocate for the People.

That requires that our political parties confront the banks, corporations, military contractors, and the other oversized creatures that feed at the government trough.

Is that something that the establishment Democrats (Wrongo likes calling them the “Caviar Dems”) are willing to do? They used to champion social and economic justice, but not so much today. Today, they follow the same neo-liberal economic policies that Republicans champion.

And with few exceptions, they are as neo-conservative on foreign policy as any Republican.

Republicans have undergone a different mutation. They celebrate the globalized economy, and support the domestic gig economy as a means of growing corporate profits. They still celebrate Christian values, so controlling Supreme Court appointments is their great achievement, along with ruinous tax cuts.

America’s corporate tax revenues are going down, while social and infrastructure costs keep rising. So far, under both parties, government has continued to spend money it doesn’t have. It borrows, and pretends that everything is under control.

Now, after 10 years of economic expansion, we continue to pile up deficits. What’s going to happen in the next recession? The truth is, we are poorer, and weaker, as a country than we think. But few politicians are willing to help us face reality.

We see both Bernie Sanders and Alexandria Ocasio-Cortez, the Democratic nominee for Congress in NY, describe themselves as socialists. But, in fact, that’s not what they are. Merriam-Webster defines socialism as:

Any of various economic and political theories advocating collective, or governmental ownership and administration of the means of production and distribution of goods.

Obviously, they hope to take over the corporate-friendly establishment Democratic Party, but if you call yourself a socialist, then, at a minimum, you need to advocate for government ownership of the means of production, i.e., industry. You’re only a socialist to the extent that you advocate that.

Will Bernie or Alexandria nationalize General Motors, Apple, or ExxonMobil? No.

Even advocating for “Medicare for all,” isn’t socialism. Neither Medicare, nor other single-payer programs like Medicaid, are really socialized medicine. No one is advocating for an actual government takeover of hospitals, or turning doctors into government employees. If they really wanted socialized medicine, their cry would be “VA for all,” not “Medicare for all.”

Sanders and Ocasio-Cortez are social democrats. In a social democracy, individuals and corporations continue to own the capital and the means of production. Wealth remains produced privately.

But taxation, government spending, and regulation of the private sector are much more muscular under social democracy than is the case under today’s neo-liberal economic system.

Joel Pett has a great illustration of the difference between Sanders/Ocasio-Cortez and Republicans:

It’s time for the Dems to change direction. Carry the “Medicare for all” banner proudly. Work to end income inequality. Work to add jobs for the middle class.

Send the establishment Democrats to the bench.

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Buffett: Focus on Lower Health Care Costs, Not Corporate Taxes

The Daily Escape:

Ribbon Chapel, Onomichi Japan – photo by Koji Fujii

Andrew Ross Sorkin wrote about Warren Buffet and the Berkshire Hathaway annual meeting in Omaha. Thousands of people attend these meetings, which are known as “Woodstock for capitalists.” Sorkin reports that Buffet made this comment:

The tax system is not crippling our business around the world.

Sorkin said that Mr. Buffett, was blunt and pointed, implicitly rebuking his fellow chief executives, who have been lobbying the Trump administration and Washington lawmakers to lower corporate taxes. Buffett said that those who have been single-focused on seeking relief from their tax bills would be smart to shift their attention to health care costs, which are growing and swallowing evermore corporate profits. The Kaiser Family Foundation reports that 49% of Americans, about 156 million, are insured by their employer. More from Sorkin:

The need for corporate tax relief has become the lodestar of the corner office, with CEOs rhapsodizing  over President Trump’s plan to try to stimulate growth by cutting tax rates for businesses.

But as Mr. Buffett pointed out, these chief executives are missing the bigger issue: As a percentage of our GDP, the cost of maintaining our American health care system is rising at an alarming rate. And Corporate America pays a big (and growing) chunk of that bill.

Buffett wasn’t talking about the cost of health insurance, which is a fraction of the total cost of health care. He suggests that today’s corporate tax rates are a distraction, not a true impediment to growth:

If you go back to 1960 or thereabouts, corporate taxes were about 4% of GDP…And now, they’re about 2 % of GDP.

While tax rates have fallen as a share of gross domestic product, health care costs ballooned:

About 50 years ago, health care was 5% of GDP, and now it’s about 17%.

Buffett is a smart guy. He raises an argument for focusing on the underlying costs of our health care system, something that goes far beyond the debate around the Affordable Care Act, or what will replace it. Buffett says that our global competitiveness has fallen largely because our businesses were paying far more for health care — a tax by another name — than those in other countries.

As Buffett said: (brackets by the Wrongologist)

When American business talks about [corporate taxes] strangling our competitiveness, or that sort of thing, they’re talking about something that as a percentage of GDP has gone down…While medical costs, which are borne to a great extent by business, have swelled.

Here are the facts:

  • In 1960, corporate taxes in the US were about 4% of GDP. The percentage fell steadily, reaching a bottom in 1983 before rising slightly over the last few decades. Today, it is 1.9%.
  • In the meantime, health care costs as a percent of GDP have skyrocketed. Today our health care costs are 17.1% of GDP, up from 13.1% in 1995.
  • Germany’s cost is 11.3%, up from 9.4% during the same period. Japan’s is 10.2%, up from 6.6%. Britain’s health care costs are 9.1% of GDP, up from 6.7% percent in 1995.

That makes our health care cost disadvantage far greater than our tax differential. It harms American companies in particular, since they bear such a large share of those costs, which firms in our competitor countries do not. US Corporations spend $12,591 on average for coverage of a family of four, up 54% since 2005, according to a study by the Kaiser Family Foundation.

But Congress avoids the issue, and CEOs don’t talk about it. A final quote from Warren:

It’s very tough for political parties to attack it…it’s basically a political subject…

In fact, Buffett’s partner, Charlie Munger, is the rare Republican (Buffett is a Democrat) who has advocated for a single-payer health care system. Under his plan, the US would enact a sort of universal type of coverage for all citizens — perhaps along the lines of the Medicaid system.

Which brings Wrongo to his final point: Medicaid expansion is the one part of Obamacare that can be said unequivocally to work. It’s a single payer program funded by the Federal government. So it’s bitterly ironic that the Republican’s reaction to Obamacare is to assault and roll back an existing Federal program, from LBJ days.

Of course, kicking poor people who benefit from Medicaid will always be popular with Republicans. So, Republicans, by making Medicaid worse, will try to restore their natural order of things.

Lazy, uninformed voters = Lazy, uninformed legislators = Lazy, uninformed policy.

It’s that simple.

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American Exceptionalism Doesn’t Include Your Healthcare

The Republican’s effort to repeal and (maybe) replace the Affordable Care Act (ACA) began today. From NPR:

Opening punches were thrown in what one top Democrat today called “the first big fight” of the new congressional year — the promise by President-elect Donald Trump and GOP lawmakers to repeal and replace the Affordable Care Act.

The Obamacare debate is political and ideological, and it obscures a hard truth about healthcare in America. Historically, we spend more money than any other country on healthcare.

In the late 1990s, the US spent roughly 13% of its GDP on healthcare, compared to about a 9.5% average for all high income countries. However, the difference has steadily increased. Last year, as the ACA continued to roll out, healthcare costs hit 17.5% of GDP, the highest ever. That’s $9,695 per person.

We spend over $3 trillion on healthcare annually, and that rate of spending is expected to accelerate over the next decade. With all the debate about Obamacare, and what should replace it if it is repealed, we are ignoring what healthcare costs in the US, relative to other high income countries. It may surprise you that America doesn’t have better care than other high income countries, if we compare life expectancy to per capita health expenditures:

Source: Visual Capitalist

Americans spend more money, but do not receive similar results to other countries using the basic metric of life expectancy. The chart shows that the divergence started before 1980, and it widens all the way to 2014. While the 2015 statistics are not plotted on this chart, but we know that the healthcare expense in 2015 was 17.5% of GDP, so the divergence is likely to continue to widen.

The conclusion is that while our healthcare spending is considerably higher than in other high income countries, it’s also relatively less effective. If America spent more money and got the same results, we might say that our system is unique, but it produces similar outcomes, so let’s keep it the way it is.

But in fact, Americans on average live shorter lives than people in other high income countries. In fact, life expectancy went down in 2015:

The overall death rate for Americans increased because mortality from heart disease and stroke increased after declining for years. Deaths were also up from Alzheimer’s disease, respiratory disease, kidney disease and diabetes. More Americans also died from unintentional injuries and suicide.

We have a broken political system, one that cannot deal with the root cause of our expensive healthcare, or the fact that our healthcare system simply doesn’t produce the results that others can.

Despite the talk by Republicans about Obamacare being socialized medicine, our system is private, with the exception of the health insurance provided by Medicare and Medicaid. Our insurance companies are private, our physicians and providers are private.

By some estimates, the private multi-payer system in the US adds $0.38 for every dollar spent to cover the profits and the discreet management organizations that exist in our multi-payer system. The problem is that there is so much money (over $1 trillion) going to the private players, that they will fight like hell to keep the system as it is.

And they have the lobbying funds available to fight to keep the status quo. Thus, we will continue to deal with excessive costs regardless of no Obamacare, or some jury-rigged GOP Obamacare replacement.

In our Exceptional system, the fact is that even though you pay for health insurance, you are not the actual customer. When you go to the doctor or to the hospital, you are not the actual customer. The Insurance companies are the true customers of the doctors and the hospitals, and for the insurance companies, their shareholders are the true customers.

And before you question the statistics, saying for example, that the US counts infant deaths differently than they do in other countries, the infant death rate in the US is about 0.5% of births, and with about 4 million births in the US that translates into about 20,000 infant deaths. If you remove 20,000 people assigning them a life span of zero, in a country of 320 million people, the overall average life expectancy rises by only 1.81 days (43.4 hours). That is the statistical life span increase assuming we had zero infant deaths. (Please check Wrongo’s math).

Higher infant death rates have virtually no effect on the results shown on the chart.

Remember: Whomever is getting that extra $1 Trillion dollars every year has a trillion reasons why they should keep getting it.

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