Whither Healthcare?

“Now, I have to tell you, it’s an unbelievably complex subject. Nobody knew health care could be so complicated.”  — President Donald Trump 27 February 2017

And you know what?  He is correct.

As the Senate debates and votes on Trumpcare to repeal and replace Obamacare over the coming days, much will be written and talked about regarding its impact and efficacy.  Some will think it is great and others will think it a travesty.  It all depends on what the goal for the program might be and how one thinks that goal should be attained.  Is Trumpcare, or the American Health Care Act (AHCA) (as it is called in the House of Representatives while the Senate Bill is called the Better Care Reconciliation Act of 2017) designed to help Americans and keep them healthy or is it an attempt to do the bare minimum while saving the government, and ultimately tax payers, money?  One’s view of Trumpcare also depends on whether or not Obamacare, or the Affordable Care Act (ACA), is working for you.

Put more succinctly, is healthcare in the greatest country on earth a right or a privilege?  Should it be open to a free market — those that can afford to pay do, those that can’t need to earn more money — or something that every citizen deserves?  If you happen to think that healthcare is a privilege, you get what you pay for, then you may as well stop reading here because you basically think that the government should have nothing to do with healthcare.  If you think that access to healthcare should be a right, then read on. Be forewarned however, that this is, as the president says, complex. Politicians of every stripe also parse and obfuscate elements of healthcare to their own advantage. It can be difficult to determine where the truth lies — especially since many times two people can both be technically correct while interpreting the meaning in totally different ways.  As I like to say, it is the difference between what things are and what things mean.

Here is the crux of the problem.  The United States does not suffer from poor medical care.  People come from all over the world to have their health problems resolved here in the U.S. — if they can afford it. That is the problem.  It is not the quality of care, but rather having access to good care and being able to afford it. Access and affordability are the reason we need insurance plans which is what both Trumpcare and Obamacare are really about.

The U.S. does not really have a health system.  It has a series of health systems depending on whether the individual is on Medicaid or Medicare (the dreaded by conservatives single payer system), or on the VA or Tricare (military) system (basically socialized medicine), or gets insurance through an employer (where most people get their insurance), or buys it on the open market (usually very expensive).

A pervasive goal in the U.S. should be that no one goes bankrupt due to an unexpected illness or injury. Likewise no one should have to forgo medical treatment because they cannot afford it.  Both happen in the U.S., although by most accounts, Obamacare went a long way in reducing the numbers of people in either situation.

So let’s design a system that helps people get care without using their every last dollar.  Let’s assume we want a system where no one can be turned down — or charged unattainable amounts of money — for a pre-existing condition.  This seems to be one area that most politicians can agree upon and one of the most popular aspects of Obamacare.  How to do that?  It does not take a genius to see that maybe I won’t buy any insurance until I get sick or injured and I will save a lot of money in the meantime.  That leaves only those with pre-existing conditions on the insurance rolls — a situation which will either leave the premiums so high as to be unaffordable, or leave the insurance companies holding the bag and going bankrupt.  To even out the costs and make them more affordable to all, we would then require everyone to have insurance — the dreaded mandate. However, it may not be fair or even affordable for everyone to buy insurance, especially for people that do not receive insurance through their employer, so if we are going to require it, then we should come up with a system to help people pay for it — the other debated aspect, subsidies. Those three elements are the basis for every proposed health care plan concocted by politicians.  If you play around with one of the three, it impacts the other two.  It becomes a very complicated game.  How one plays the game depends on my opening statement — what is the goal for the plan?

On top of that throw in hot button issues such as who can do what (Planned Parenthood anyone?), whether in our proposed system we “punish” young healthy citizens by making them subsidize the old “sick” citizens, should the government have the power to tell people that they “have” to have insurance, and who pays for all this, the wealthy or the poor who are most likely to benefit from a plan like this.  It does indeed get complicated in a hurry, and also very emotional for a lot of people.

In evaluating a planned system, lots of politicians focus on premiums and deductibles — and not always together.  It is possible to devise a plan with very low premiums, lower than Obamacare, but does it cover everything?  Does it have a high deductible?  Does it have annual or lifetime caps? What pre-existing conditions are covered?  Those and other details mute any discussion about premiums.  To coin a phrase, we cannot compare apples with oranges.  Premiums are certainly relevant when discussing the cost of a particular plan, but it is not sufficient to get a true picture of the impact or value of that plan.

To muddy the issue, the president makes unfounded claims about Obamacare.  He says “it is dead.” Except it isn’t.  But the president and the Republican leadership are trying hard to kill it, partly to force through Trumpcare.  Insurance exchanges are drying up and companies are pulling out because of the biggest fear they have — uncertainty.  The Congress has yet to decide if they will provide the money for the aforementioned subsidies to help people afford the mandated insurance.  And they have announced that they will not enforce the mandate.  Two of the legs of our three-legged plan are being distorted, that means the third leg is terribly out of balance which makes it appear the system is not working.  If insurance companies don’t think they are going to get paid — or that they will be left holding the bag for high cost pre-existing conditions which they are required to cover — then there are two choices.  They can raise premiums or leave the market.  Most experts assert that without the uncertainty coming from the White House and Capital Hill, the health insurance system in the U.S. would be stable and hold down costs for most (most — not all) Americans seeking health care.  Many people now have insurance that would not otherwise have it.  The result is “wellness checks” and other preventive health measures now sought out by people that did not seek it before.  Therefore they are healthier and the over all expenditures for larger, more catastrophic care comes down because they are less necessary.  Like it or not, the states that expanded Medicare under Obamacare generally have more small hospitals and clinics serving the poor or rural areas of their states because those hospitals have a known source of income for the care they provide.  Many of those small hospitals and clinics closed in states that did not expand Medicare and there is significant concern over the reduction of those Medicare funds under Trumpcare.  In mostly rural states such as Alaska and Maine, even their Republican Senators are concerned and may vote against the proposed Senate bill.  Senators Murkowski and Collins both realize what the proposed reductions in Medicare mean to their states and are worried, as are others.

Whatever your own views on healthcare in the U.S. take a good hard look at any plan floated to solve the problem.  I am no expert on this subject.  Not at all.  I recognize that we do not have a bottomless purse to pay increasing costs for social programs.  I get it.  Personally, I think we leave a lot of possible solutions (such as a single payer system which prevails in many modern nations, such as Canada) on the table because of emotional political arguments rather than a factual airing of the pros and cons to different solutions.

It boils down to one’s personal views.  Do you get what you pay for and if you can’t pay you don’t get it? Or should the greatest nation on earth also provide the best healthcare available to its citizens?  If so, how is it paid for?  There are no easy answers, but I think we are making it harder on ourselves than needed.  Democrats and Republicans state that they both have the same goal — to make healthcare available to our citizens and at a cost that is sustainable.  If that is the case, then everything else is politics.

To me, we have a system for providing affordable care through an insurance program called the ACA — Obamacare.  No one thinks that system is perfect.  Democrats affirm that they are willing to work with Republicans to fix what needs to be fixed.  Republicans shout that Democrats are obstructionists while jamming through a bill that even most Republicans did not get a chance to look at.

You can look it up, you don’t have to take my word for it, but in putting together Obamacare the Democrats took nearly a year, held countless hearings, folded Republican amendments into the final bill, and tried to put together a bipartisan bill.  Politics interfered at the end of that process and one could argue that Democrats jammed it through at the end.  But contrary to what you now hear, it was not a secret process and it wasn’t a slap dash final product.  I am not sure what the rush is in the Republican held Congress at this point.  This is major legislation that will impact many Americans and a large chunk of our economy. There is no need to play hurry up ball at this point.  Every piece of legislation has some perverse and unintended consequences.  Obamacare has some.  Trumpcare certainly will if it has not been properly vetted and reviewed.  It is too important to just slam through, whether or not you support the fundamental political and social theories behind it.

This process is not in the best interests of our country.  I hope that cooler heads prevail and that everyone takes a step back.  Take a deep breath.  Let’s regroup and come forward with a bipartisan approach to helping every citizen find effective and affordable healthcare.

I’m not holding my breath.


A Burning Fuse

As you probably heard, on Sunday a U.S. Navy F/A-18E Super Hornet shot down a Syrian SU-22 Fitter ground attack bomber.  This was the first air-to-air destruction of a piloted aircraft by the U.S. since 1999 and the second by a NATO aircraft in the region following the November 2015 shoot down of a Syrian SU-24 by a Turkish Air Force F-16.  Both Syria and their ally Russia immediately protested the action.  In addition, the Russians declared that any U.S. or coalition aircraft flying “west of the Euphrates River” while Russian or Syrian aircraft are in the area “will be considered air targets” and subject to attack. Today, a U.S. F-15 shot down an armed Iranian drone, the second one this month.

While none of the participants in the many-sided Syrian conflict desire to go to war with each other, and certainly the Russians and the U.S. do not war, the conditions are very volatile in a confined geographic area.  This is a dangerous situation that is very susceptible to a mistake or miscalculation by one of the parties leading to a hot war, or at least a serious shooting incident.  In short, it is a burning fuse that needs to be snuffed out before reaching the explosives.  Given the conflicting goals of those involved, that may be difficult.  The situation is exacerbated by the Russian withdrawal from a de-confliction protocol whereby U.S. and coalition aircraft communicate with Russian aircraft to warn and alert each other of their locations and missions.  Negotiations are underway to restore that protocol. This is the second time that the Russians withdrew from it, the first coming after the U.S. Navy cruise missile strikes against a Syrian airfield last April.  The relationship then was shortly restored.

The shoot downs occurred following Syrian and Iranian attacks on U.S. backed anti-Syrian forces fighting the dictatorship of Bashar al-Assad.  Some coalition advisers were near the forces attacked from the air.  Following several warnings, the U.S. says it acted in self-defense.

It is difficult to tell the players without a score card.  In short, the major players in Syria are Russia, the United States, Turkey, Iran, the United Kingdom, and France.  Supplying arms and money to the anti-Assad regime are Saudi Arabia and Qatar.  (Remember also that Saudi Arabia and Qatar are involved in their own dispute which resulted in the isolation of Qatar from the outside world.  Both are allies of the U.S. but the dispute is serious and involves Qatari relations with Iran, which is engaged in a major struggle with Saudi Arabia for dominance in the region.  And, oh by the way, one of the major airfields used by the U.S. in the fight against the Islamic State (ISIS) is in Qatar as is the air control headquarters and the Forward Headquarters for the U.S. Central Command.  It’s complicated.)

U.S. and coalition forces are mainly fighting from the air, with some U.S. Special Forces on the ground training and advising various militias fighting against ISIS and covertly supporting those aligned against the Syrian regime. Russia supports the Bashar regime and both Russia and Syria consider any group inside of Syria fighting against Bashar’s forces as “terrorists.”  This includes those supported by the U.S. coalition.  The Russians claim to be fighting ISIS but in actuality they are going after the “terrorists” that oppose Bashar’s regime, which was the case with the recent aircraft and drone attacks leading to the shoot downs. Turkey also opposes the Bashar regime but also opposes the Kurdish PKK (The Kurdistan Workers Party), a group fighting for a Kurdish state carved from Turkey, Syria and Iran.  The PKK is considered a terrorist group in Turkey, but many of the forces that have liberated parts of Iraq and Syria from ISIS are other Kurdish forces trained by the U.S.  Iran supports the Bashar regime, but also opposes ISIS.  Iranian forces and militias are fighting in Syria in support of the regime and in Iraq, in conjunction with Iraqi troops, to root out ISIS.  Iran also supports Lebanon’s Hezbollah which is fighting in Syria to support Bashar.  In something of a proxy war, Saudi Arabia and Qatar are aiding anti-Bashar forces with money and arms, even as they have their own dispute and Qatar is friendly to Iran.

Got all that?  And the country is about as big as the Middle Atlantic states — roughly Richmond to New York City and Pittsburgh to the west.

U.S. policy in Syria has been and is muddled.  Since taking over in January, the Trump Administration has not articulated a clear policy or strategy towards Syria.  Our focus is primarily on defeating ISIS, an effort that is slowly but steadily eliminating their caliphate in Iraq and Syria.

The lack of a clear strategy in Syria is reflected in the April cruise missile attacks.  At the time, I applauded President Trump’s decision to express our dissatisfaction over the Syrian use of chemical weapons.  But it was only a one time strike to “send a message” and had no real long-term ramifications or follow-up.  There was no strategy behind the strikes.  (One way to tell the seriousness of such a military attack is the longevity of the action and the targets chosen.  If we really wanted to punish Bashar’s regime the attack would have been centered on Damascus and gone after the Interior Ministry or Ministry of Defense in order to make the decision makers pay a price.  Instead we destroyed some aircraft at a remote air base.  To truly take on a larger military operation — which I am not advocating — it would have been a much more serious decision that could lead to direct military conflict with Syrian forces, and conceivably Russian forces. While we are concerned with the humanitarian conditions in Syria, it is not currently our policy to resolve the Syrian conflict through combat.)

The take-away from all this is that the Middle East continues to be a tinder box that could go from a smoldering problem to a conflagration without much effort.  Despite bluster and name calling, neither the U.S. or Russia want to see the situation escalate — especially against each other.  But both nations need to be very careful as other players in the region could relish such a situation in order for them to meet their own priorities and interests, not the least of which is to diminish the stature of the United States in the region and in the world.

These are dangerous times that must be taken seriously.  While we are focused on our own internal daily struggles and tweets, we also must keep our heads up and our eyes on the ball.  The rest of the world is busy pursuing their own agenda.  If we want to be part of events that shape our future, then we must pay attention and clearly state our own goals.

 


The Battle of Midway Island

Yesterday, 4 June, marked the 75th anniversary of the Battle of Midway Island in 1942 where the U.S. Navy defeated the Imperial Japanese Navy and reversed Allied fortunes in the Pacific campaign. Prior to the battle, the Japanese were on the offensive throughout the Pacific area.  Following the battle, they fought a series of defensive operations and steadily retreated back to the home islands.

In a nutshell, the battle entailed an all-in strategy by the U.S. commanders, Commander-in-Chief Pacific Admiral Chester Nimitz and the tactical commanders Rear Admirals Raymond Spruance and Frank Jack Fletcher.  Thanks to cryptologists that broke the Japanese code, the U.S. was aware of the Japanese plan to attack Midway Island and presumably, remove the U.S. from any further ability to thwart Japanese expansion.  The attack on Midway was accompanied by a nearly simultaneous (due to circumstances the attacks were actually a day apart) on the Aleutian Islands in Alaska — an attempt to remove U.S. Army Air Corps aircraft from being in range of the Japanese home islands.

In the battle four Japanese aircraft carriers went up against three from the U.S. Navy.  In short, all four Japanese carriers — Akagi, Kaga, Hiryu, and Soryu — sank, along with the resulting loss of airplanes, pilots and crews.  They also lost a heavy cruiser, a destroyer, and other ships were badly damaged.  The Japanese Navy was never able to recover from those losses as their industrial capacity simply could not replace what was lost, along with the lack of seasoned pilots.  The U.S. Navy lost one carrier, the USS Yorktown and one destroyer.  Military historians such as John Keegan call the victory “the most stunning and decisive blow in the history of naval warfare.”

Without going into all the details of the battle, it is apparent that there many instances of heroic actions. In our present days of troubled times and divisive political arguments, I find it worthy to focus on a small, but significant portion of the battle.  I trust that today, we can find men (and now women) that hold the same high level of selflessness, courage and devotion as those of the torpedo squadrons of the Douglas TBD Devastators from VT-3 on Yorktown, VT-6 on Enterprise, and VT-8 from the Hornet. These airplanes flew low and slow in order to attack surface ships with torpedoes.  In order to get the torpedo on target, it meant a long, slow, straight approach into the teeth of the Japanese air defenses.

The Devastators were on their own due to inexperience on the part of the American commanders coupled with the desire to strike the Japanese first.  Therefore they launched their aircraft piecemeal which resulted in an uncoordinated attack by the torpedo bombers without fighter escorts.  They were doomed.  Of the forty-one aircraft launched, thirty-five were lost attacking the targets, with no hits against the enemy.  On each of those airplanes, a three-man crew piloted and fought the aircraft.  A heavy loss of life.  The aircraft was never used again in battle in the Pacific.

Their sacrifice secured the victory because while the Japanese were preoccupied with the torpedo bombers, they became confused as to the big picture.  This allowed the Navy’s dive bombers and remaining fighter escorts to arrive over their targets virtually undetected and caught the bulk of the Japanese aircraft on the deck of the carriers while refueling and rearming.  Three Japanese carriers were destroyed in about five minutes and the fourth sank from its damage later in the day.

The pilots and crews of the Devastators did not think that they were on a suicide mission.  No one expects anything bad to happen to them, individually, when on a mission.  Yet, they understood the odds and that they weren’t good.  By the time of the battle, the U.S Navy knew that the aircraft was obsolete and vulnerable, but no replacement aircraft had yet made it to the fleet.  Additionally, once over the Japanese fleet they knew that they were alone, without fighter escort, and had no idea where the dive bombers might be.  They knew that the plan, a coordinated attack with all forms of aircraft striking the Japanese simultaneously was out the window. They were on their own.  And yet, they went forward, alone.

As we argue over less important issues today, it serves us well to remember the sacrifices made by those that went before us.  They knew that they were involved in a cause bigger than their individual lives, and they knew that only true sacrifice would carry the day.  Along with our thoughts as a grateful nation, we should also step back and think of our own lives and ability to follow in their foot steps.

We can all benefit from their selfless example.


We’ll Always Have Pittsburgh

I was elected to represent the citizens of Pittsburgh, not Paris.

— President Donald J. Trump on 1 June 2017

As most of you know, President Trump announced his intention to withdraw from the Paris Climate Accord during a speech in the Rose Garden at the White House.  This announcement fulfills a campaign promise that he continually made in the run-up to the November election.  His base, and several close advisers clearly think that putting the United States in the same company as Syria and Nicaragua (the only other nations not in the agreement), instead of in the company of the other 195 nations that agreed to the Accord in December 2015, is a positive development.  Other advisers, including Secretary of State (and former Exxon-Mobil CEO) Rex Tillerson reportedly did not and advised the president to stay within the boundaries of the agreement. As a consequence, many misstatements were made about what was or was not in the Accord.  Somehow, it got caught up in an argument over whether or not climate change is a hoax, as the president continually claimed on the campaign trail, or is it backed up by a preponderance of evidence that human beings are contributing to the changing climate on Earth.

The main effort of the Accord was to reduce green house gas emissions.  These emissions are the root cause of rising global temperatures, which in turn are melting the polar ice cap, shrinking the ice shelves in Antarctica, and eliminating glaciers around the world.  As the world’s ice melts, sea levels increase putting coastal land, and many island nations, in danger of being covered by water. Will this happen tomorrow or even next year?  No.  However, 196 nations (until the U.S. announced its withdrawal) agreed that it was a real and present danger to life as we know it on this planet. Long-term problems need long-term solutions, and that was the aim of the Accord.

In my view we can restate it another way.  Forget about arguments for or against climate change. Put it in terms of being pro or anti pollution.  Who is for more pollution?  Apparently, the president and his key advisers such as the Administrator of the Environmental Protection Agency (EPA) Edward Scott Pruitt and White House Chief Strategist Steve Bannon who reportedly convinced President Trump to leave the Accord.

Rather than looking at the Accord as a positive thing for the citizens of the United States and all living things around the world, the president put his opposition to the agreement in economic terms.  To me, this is a short-sighted vision that provides misleading hope for the future for those struggling in the economy with mining and manufacturing jobs that are disappearing whether or not the U.S. remains in the Paris Accord.  The president also claims his decision is a matter of sovereignty and a chance to keep “others” from telling us what to do in our own country.  Or as the president said, “As of today, the United States will cease all implementation of the non-binding Paris Accord and the draconian financial and economic burdens the agreement imposes on our country.”  Apparently no one told him what “non-binding” means and also forgot to inform him that the agreement does not set any burdens on any country outside those that the individual countries voluntarily agree to for themselves.

This is what makes the president’s announcement extremely puzzling.  Under the Accord, each country sets its own commitments with the common goal of “holding the increase in global average temperature to well below 2 degrees C above pre-industrial levels” which is intended to begin to reduce the long-term warming trend rather than stop it, but more on that in a minute.  The point is that if President Trump did not agree with the goals laid out by the Obama administration, under the terms of the Accord, he could change them.  He did not have to leave the agreement.  This makes his statement that “we’re getting out, but we will start to negotiate, and we will see if we can make a deal that’s fair” even more preposterous.  He is not going to get 195 nations to renegotiate.  And it isn’t necessary, just adjust the commitment under the terms of the existing agreement.  I cannot decide if he is being purposely misleading or if he does not understand what he is talking about.

This is a central point for understanding why it is bad policy for the United States to withdraw and makes me believe that the move was intended as an “in your face” insult to the Europeans (thus the reference to the citizens of Paris) and a purely political decision to appeal to the hard-core base that voted for him in 2016, rather than truly thinking about the long-term needs and welfare of our citizens.

This is also reflected in his claim that the United States could not build new coal plants but China and India can, and will, thus somehow depriving the U.S. of the coal-burning market.  Wrong again.  As has been repeated,  the agreement is non-binding, and also has nothing in it that prohibits the United States from building coal-burning plants and it has nothing in it that “allows” China and India to do so. To so state is purely political demagoguery, or ignorance.  In the United States, coal plants are being replaced not because of EPA regulations or because of the Paris Accord, but because of market forces — mainly, because of the abundance of natural gas at cheaper prices.

Coal jobs currently number about 50,000 according to the Bureau of Labor Statistics.  Nearly universally, economic analysts say that the combination of natural gas and technological advances in mining mean that number will not grow, and is likely to decrease.  As pointed out in an article by Christopher Ingraham that number of coal miners compares to about 80,000 employees at Arby’s restaurants or the approximately 150,00 employed in the car wash industry. 50,000 is a drop in the bucket for our entire economy and not at all near the catastrophic impact that the president implies.

Clearly coal mining jobs are important to the 50,000 so employed, but dropping out of the Paris Accord is not going to help them in the future.  When the Pony Express went out of business because of the telegraph and railroads, those people found new jobs.  And so it goes throughout history — innovation and technological progress cause people to lose jobs, but new jobs are created.  For example, the energy efficiency industry had about 2,700,000 jobs in 2016 of which about 677,000 jobs were in the renewable energy sector (solar, wind, hydro, etc.).  President Trump should be putting effort into retraining and educating miners and others in dying industries to allow them to help themselves and the economy in the future rather than promising them a past in which they cannot long survive.

At the same time, those that find environmental issues important, and a threat to our survival, need to do a much better job at making the case.  When asked to choose between the environment and jobs as our president states it, many Americans will choose jobs every time.  It is important to educate voters and all our citizens about the importance of working towards improving our environment.  It is also important to explain and educate voters that a clean environment and jobs are not mutually exclusive. Indeed, environmentally related jobs are a growth industry and go a long way in reducing unemployment.  Railing and ranting will not convince others.  Education and reasoned arguments as to why we are better off under an agreement such as this one, including how it creates jobs (and not in the government bureaucracy), is important to our long-term goals and well-being.  Use this as a wake up call.

Without going through every portion of President Trump’s speech on departing from the agreement and comparing it with the actual Accord, there is one thing he got right — sort of — although it did not appear that he understood what he was saying.  He said, “Even if the Paris Agreement were implemented in full, with total compliance from all nations, it is estimated it would only produce a 2/10 of one degree – think of that. This much [held his fingers nearly close together] Celsius reduction in global temperature by the year 2100. Tiny tiny amount.”  The size of the reduction is unknown and several experts contend that it will be more significant than the president intimated.  But here’s the point, the signatories of the Accord acknowledge that the limits pledged thus far will not meet the 2 degrees Celsius goal, but the efforts to reach that goal will be better than just letting the pollution continue and allow temperatures to continue to rise unabated.  In other words, the signatories were working on the premise that something is better than nothing and that as technology and developments continue evolving in the coming years, new ways of reaching those goals will become apparent. Time will not stand still and the world and its technology will not always be the same as it was in 2015 or now.  The president seems to miss that point.  He seems to think that the world won’t reach the goal anyway so screw it.

Since the president’s speech really did not discuss the issue of global climate change, how to deal with it best, or point out misguided practices, it can only be seen in this light.  It was instead one more example of his belief that some kind of conspiracy — primarily by our closest and most important allies — is holding the United States back and dictating what we do or cannot do.  His belief appears to be that by putting “America First” that he can do, or not do, whatever he feels like, the rest of the world be damned. This is extremely dangerous to the future of the United States and its place on the world stage.