It Just Will Not Stop

Just when one thinks that just about everything that could happen under the Trump Administration has already occurred — it can’t possibly get any crazier, but it does.  Last week was chock full of newsworthy items, any one of which would have been worthy of discussion but they just kept coming and coming. Over the last week or so, we’ve seen proof that President Trump still does not understand the dignity and impact of the presidency.

To quickly cover a few of the highlights before getting to the main event — health care bills — let’s do a tour d’ horizon.  Two venerable institutions, the Boy Scouts of America and Police Departments across the country, had to issue apologies and “clarifications” following President Trump’s speeches to the annual Boy Scout Jamboree in West Virginia and to a Long Island New York police department.

In the former he gave a political speech that was short on inspiration to America’s youth and long on past grievances, politics, and a reminder of how personally great everything Trump is and will be. Some parents threatened to pull their kids from the Scouts.  President Trump supporters opined that the “kids loved it” forgetting that they are boys and teens and that when you get 40,000 kids together in one place, especially mostly boys, they will laugh and cheer at just about anything, especially if flatulence is involved. On Long Island the president seemed to say that police brutality when arresting suspects was okay.  As usual, whenever called out on similar pronouncements, it was proposed that it was a “joke.” Police departments around the country could only cringe and issue statements that such statements were no joking matter and that their (fill in the city) police department does not condone such action.

Within days of President Trump announcing the new White House Communications Director Anthony Scaramucci, aka “The Mooch”, aka “Mini-me” Mr. Scaramucci went on a rant to a New Yorker Magazine reporter that disparaged key senior members of the White House staff and included numerous references, in full graphic detail, to acts of biology that to my knowledge are impossible.  No comment from the president at the time.  Others in the Administration opined that he’s just a “New Yorker” and apparently that’s how New Yorkers talk about co-workers.  Having lived for a number of years in New York state I don’t recall anyone talking that way and certainly not in the name of the President of the United States.

In Tweets (Tweets!) the president continues to disparage his own Attorney General and his first and for a very long time, only official supporter for president.  According to some accounts this is a prelude to cleaning out the senior levels of the Department of Justice including the Attorney General, his deputy, the Acting FBI Director, and Special Counsel Robert Mueller.  No problem there.  In another Tweet the president arbitrarily told all active duty transgender military personnel that their services were no longer required “in any capacity” because they are a burden and “disruptive.”  Suddenly somewhere around 7,000 soldiers, Marines, Sailors and airmen are in limbo and told that somehow their patriotism and willingness to defend the nation does not count.

In yet another Tweet, the president fired his chief of staff Reince Priebus.  The Tweet announced that retired Marine general and serving Secretary of Homeland Security John Kelly would be the new chief.

Whew!  A full week.

On the upside for those of us rooting for a successful and appropriate presidency there were several positive developments.  As I write this, reports are that Anthony Scaramucci was removed from his job of ten days as the Communications Director.  I have no inside information but I suspect that the new chief of staff had something to do with that as Mr. Scaramucci bragged last week that he only reported directly to the president and did not have to answer to anyone else on the staff.  My knowledge of General Kelly, although limited, would indicate that he would absolutely not tolerate antics such as those of Mr. Scaramucci.  Perhaps the General can bring order to the White House staff.  We’ll see, but a good first step.

Also positive, the Chairman of the Joint Chiefs of Staff General Joseph Dunford, USMC let it be known that the military does not act on Tweets or any other form of informal communications when a policy decision is to be made, even a Tweet by the president concerning transgender policy.  Hurrah. It remains to be seen what actual policy evolves, but it is good to know that spontaneous utterances by the president will not precipitate military action.

Further good news came out of the Congress that overwhelmingly passed a bipartisan bill strengthening sanctions primarily against Russia, but with some additional provisions against Iran and North Korea. The Congress felt it necessary after listening to, and observing the actions of, President Trump with regards to Russian President Putin and our president’s apparent fascination with him.  The White House staff had worked hard behind the scenes to stop the passage of the bill but both houses of the Congress got up on their hind legs and said “no” to the president on this issue. A positive sign that they may increasingly exercise their role in governing as an equal branch of the government.

Many Republican Senators and Representatives also went on the record along with their Democrat colleagues to oppose President Trump’s Tweet policy on transgender individuals in the military and the treatment of Attorney General Sessions.  Clear signs that the president will not get blanket support from them.  As an aside, the president now taunts Republicans as well as Democrats via Twitter seeming to make it clear that he does not consider himself a Republican.  But to most of us, that is no surprise.

And of course let’s not forget that North Korea tested new Intercontinental Ballistic Missiles (ICBMs) that experts think can reach targets on the U.S. mainland as far as Chicago.

Arguably the biggest news of the week was the failure to repeal or repeal and replace or otherwise get rid of the Affordable Care Act (ACA) lovingly known as Obamacare.  Most of us followed the news and at least heard of the ins and outs of the entire suspense filled week of “will they or won’t they?”  They did not.  One could ask why after seven years of clamoring for (and voting over 50 times for) the repeal of Obamacare the Republicans were not ready to put forward their own coherent health plan. One could also ask why the only argument put forward by most Republicans, and especially by the president, had nothing to do with the merits of the proposed replacement plan(s) but rather the only argument was that Obamacare was “bad” — nothing about why the new plan would be better.  SAD!

But be careful.

I do not think the health care battle is finished, only in a strategic pause.  There will be further efforts to repeal or repeal and replace.  For supporters of Obamacare, or supporters of a bipartisan effort to repair Obamacare and to make it better, do not relax.  The fat lady has yet to sing.

Over the weekend President Trump tweeted out (how else?) that Obamacare was going to implode and implicitly that he would make it happen.  On Sunday the Director of the Office of Management and Budget (OMB) Mick Mulvaney went on television to be explicit about the president’s threats/promises. As I have written in this space before, the president can do grave harm to the current Obamacare system, primarily through non-enforcement of the mandate and by withholding funds to subsidize premiums. He also made news by threatening the Congress and Congressional staffers with actions to increase their premiums.  I am no expert in this area, but this is what I understand is the issue.

Is it possible for the president to make Obamacare “implode” as he promises?  As with most things, the answer is “it depends” on what part of Obamacare one refers to during the discussion.  Since Obamacare remains the law of the land, the president cannot make it go away at once.  He can, however, create enough chaos in the system that it can degrade over time.  Remember that most Americans get their health insurance through their employers or through the government (military, VA, military retirees, Medicare, etc.).  For middle to low-income working adults and for children that do not have employer or government health insurance they mostly get their insurance through Medicaid or in a market place created by the ACA.  Although a major factor in the latest debates, Medicaid is provided by law and cannot be legally changed without a change to the law. What is really under discussion are the ACA market places.  Since the ACA was fully implemented, about 10 million Americans get their coverage via the government market place.  These are the people you most hear about on the news and in political rallies, be it how bad the system is or how wonderful the system is.

The administration has a number of ways to degrade the ACA.  In a slow motion effort, they could stop advertising and marketing the exchanges so that people either don’t know that the markets still exist (a lot of Americans are unsure as to what is available after all the latest hubbub) or miss deadlines to sign up because there was no public advertising as to how or when to get on board.  Additionally, if the administration follows through by not enforcing the mandate (either get insurance or pay a fine) healthy people will get out of the market which causes costs to rise for the insurers which is then passed on to those still in the market — their premiums rise — or the insurer gets out of the market because it isn’t profitable for them if they have to eat the added costs.  (Remember the three legs from my 23 June post. To work, if we want to cover pre-existing conditions, the system needs a mandate to keep the pool costs low by balancing healthy folks with those that we already know have problems, but then to be fair, we subsidize those that have to have insurance but cannot afford it.  Get anything out of whack, and the system starts to wobble — the promised “death spiral.”)

President Trump is threatening/promising to speed up the process by withholding cost sharing payments. As I write, they are only released through the end of July — today. (The next deadline is in late August.)  The ACA requires insurance companies to hold down the deductibles, co-pays and premiums for those in the individual market place. However, the insurance companies are not charitable organizations and they are in business to make money.  To make up the loss of revenue to those companies every month the government makes up the difference on the costs — currently about $600 million a month.  Should the Trump administration stop paying those subsidies, premiums for those on the market place would sky-rocket or the insurers would just pull out of the market.  This is a lot of what you hear about when those that oppose the ACA say it is “collapsing.”  Health care and health insurance is not “collapsing” for most Americans, but it could for those middle to low-income Americans that are on the individual markets should the president follow through and try to cause the ACA to “implode”.

He claims the Democrats will “own it” and he will take no blame.  I think he is fooling himself if he takes deliberate action to make it tough on the citizens he swore to protect.

There is one more esoteric wrinkle in the president’s threats that you may hear more about this week. Mr. Mulvaney explained the issue and says that the president is serious about implementing it.  This involves the health insurance for members of Congress and their staffs.  Despite rumors to the contrary, by law the entire Congress and their staffs are on the ACA — they get their insurance from Obamacare. But with a wrinkle.  President Obama’s administration put out a policy that allowed them to treat each individual office of each Senator and Representative each as a small business.  This means that they are eligible for the subsidies just talked about above, saving them lots of money out of their own pockets. Before setting our hair on fire, take a minute to think about it.  Certainly the individual Senators and Representatives could afford to pay full price in an employer plan, but most staffers, interns, administrative personnel, etc. working in their offices are young folks not making much money.  It would have a huge impact on them should President Trump change the policy to exclude them from the subsidy program.

Today is the start of a new week.  Let’s hope it is a dull one.  We need to take a collective deep breath and take a few minutes to enjoy the summer.  And summers in official Washington D.C. are supposed to be dull.  Nothing going on.  If so, hold on to your hats come September.


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 Medicaid 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 Medicaid and there is significant concern over the reduction of those Medicaid 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 Medicaid 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.