Friday, November 02, 2007

SM / SP / MA

“Any government-run program proposed by a Democratic presidential candidate might be quickly tarred by conservatives as ‘socialized medicine.’” That’s from the New York Times, October 20, 2007.

End of story, right? Not so fast.

Socialized medicine (“SM”), sometimes described, perhaps more palatably, as single-payer (“SP”), and, still more palatably perhaps, as Medicare-for-all (“MA”), may be a third rail for presidential candidates, but what about ordinary, everyday state legislators?

After all, if the Portland School Board can approve, as it did on October 16th and by a seven-to-two margin, a measure (having to do in a general way with public health) that absolutely horrifies the bulk of the public, even including many of those who consider themselves liberals, then mightn’t there be just a possibility that our state legislators will get it into their heads that we’re going to have SM/SP/MA never mind the widespread shock and outrage?

In fact, our legislators would be able to point to no less a personage than Mitt Romney as their inspiration. Romney, whenever he gets pinned down as to why, as a presidential candidate, he opposes the very same measures to extend coverage that he ushered into law in Massachusetts as governor, says that he “…prefers to let the states experiment with different ways of expanding coverage.”

Suppose the unthinkable came to pass. What would happen next?

Of course, what would happen next would be a referendum on the statewide ballot at the earliest possible date and presumably that would be that. (Such a referendum would in fact be the polar opposite of the petition to hold a vote in favor of SM/SP/MA that was to have begun circulating come Election Day in November.)

But, what would happen from the point of view of public health? And what about the economic impact?

What most people would notice first would be that they no longer had health insurance premiums to pay or to be deducted from their pay. They would also cease to be burdened by direct payments to doctors, hospitals and other health care providers for procedures and services not covered by their policies.

This would certainly be a nice break for all those who struggle each month with their household budgets, but would there be a piper to pay for this windfall?

Perhaps not, but before exploring that question, let us consider the next development that would surely attract widespread notice in Mainers’ daily lives.

Suddenly, all of the thousands of doctors’ visits that we make each day would be free of the insurance process. No more insurance cards (except perhaps the MaineCare card), no more forms, no more explanations of benefits, just a manageable copayment (perhaps waived for the indigent). And there would be no reason to restrict patients’ choice of doctors, since all health care would be covered by the new SM/SP/MA program.

Would this new regime cause people to descend on doctors and hospitals for every minor complaint, overwhelming the system, or would it free people to seek out early, preventive care and so not end up in hospital emergency rooms?

This is another point for further debate. I will return to it later, but the reader is invited to begin pondering his/her own response to an open care environment, perhaps drawing conclusions about the likely public response.

The third of the immediately noticeable changes concerns our state’s thousands of employers, both large and small. Suddenly, they too would be freed of health insurance costs and the associated administrative burden. If you are an employer reading this column, please stop and give some consideration to what this change would mean for your business. Even if you do not subsidize a dime of your employees’ group health insurance coverage, consider how the administration of health insurance complicates payroll accounting and tax filings.

Please also note that health care providers – doctors, hospitals, labs, clinics – in addition to reaping the employer administrative benefits will realize a far more important savings in terms of the resources they now devote to filing claims.

Each of these three changes in everyday life – the household budget windfall, the end of insurance gatekeepers, and the simplification of employers’ administrative burden – would take effect before the repeal referendum and, more important, before any of the other much talked-about fiscal consequences.

Before voting to repeal the SM/SP/MA measure, the public would have a good opportunity to experience what life would be like were the measure to stand.

And now, what of those fiscal consequences?

True, there’ll be a piper to pay in return for the beneficial changes that households, employers, and health care providers will experience. If patients no longer remit anything more than modest copayments, employers no longer remit a hefty portion of their cash flow to private insurers, and private insurers no longer remit for claims, then the health care providers have to recover their costs (but not profits – bear in mind that almost all of Maine’s hospitals are not-for-profit) from – yes, that’s right, the state government.

And the money for the state government’s remittances to health care providers can only come from one place. Yes, that’s right, from taxpayers.

But wait a minute. Didn’t we conclude that, to begin with, right up front, households would see savings on insurance premiums as well as direct payments to health care providers because of high-deductible policies, policy exclusions, and other coverage gaps? Didn’t we reach the same conclusion about employers, that their health insurance subsidies would no longer be necessary nor would the associated administrative work? Wouldn’t every health care provider see an even more substantial reduction in administrative time and expense?

So, on the one hand, the state government would have to step in as payor, and the state government gets its money from taxpayers (households and businesses), but, on the other hand, all of the households and businesses have seen money freed up as the first consequence of instituting the SM/SP/MA system.

Where does this come out on balance?

“Therein lies the rub,” some would say, making much of the fear of change that so often deters us from a course of action, be it action for our own personal account or for our collective account as Maine citizens.

The actual dollar amounts of the savings to households and businesses and of the costs to the state government have been the subject of a multitude of studies, estimates, and debates, but, of course, the net balance of savings versus SM/SP/MA costs is simply not possible to determine in advance.

Because it is indeterminate, should we refrain from ever taking a chance on it?

Most would probably agree that we should “never say never” but how then to make a decision?

I would invite you to take a closer look at the consequences of adopting an SM/SP/MA system. Compare the system that we would have to the one that we already have.

For example, we have established that a great deal of administrative work would no longer be necessary. This is an indication of cost efficiencies, is it not?

Administrative cost efficiencies ought to swing the balance in favor of SM/SP/MA.

I have alluded to increases in doctor visits once SM/SP/MA removes the barriers, and I have also made the suggestion that ease of access to health care providers ought to promote preventive care, which in turn ought to help head off the number of acute cases that end up being treated in emergency rooms.

If more health care is happening on a preventive basis and less is happening in emergency rooms, would this not mean that care will cost less to render?

If care costs less to render, ought that not also swing the balance in favor of SM/SP/MA?

I hope you will agree that, even without making sophisticated cost estimates, it’s possible, simply by comparing the way things would work under an SM/SP/MA system to the way they work today, to reach some conclusions about which kind of a system costs more.

Is there any consequence of adopting an SM/SP/MA system that would push costs higher?

The answer is “yes” because an SM/SP/MA system would give access to care where it is now denied entirely. More people would have access to doctors and hospitals, and that’s surely going to have to be paid for, by the state government.

Should we reject an SM/SP/MA system because it means the state government will have to come up with the money to care for people who have no access to health care under the present system?

Now we are at the heart of the matter. We have pared the issue down to the core question of deciding to stick with a system in which some people do not get care.

Is that what we want? I don’t think so.

So tell your state legislator: pass an SM/SP/MA bill, pronto. There is no reason to fear such a system. It will save money because it is more efficient. It will get care to people who do not now have it.

Saturday, September 09, 2006

YWCA closes, newspapers temporize, community loses

The following is offered from the perspective of my service as a Pro-Bono (worked without salary) United Way Loaned Executive in 1999.

YWCA’s failure is our own


Thank you to Ed Beem for having the courage to identify the real meaning of the closure of the YWCA. I have yet to find local newspaper coverage that addresses the matter in anything other than what one might find in a business section: armchair quarterbacking the organization's decision making. The YWCA board included one of the highest officers of our most prominent local financial institutions, as well as several others well-placed among the Greater Portland leadership set. The YWCA was a United Way member organization, but each year the Greater Portland United Way struggles to equal a campaign fundraising goal that is no higher than what it raised eight years ago. No one can dispute that costs for United Way member organizations have risen substantially over the course of those same years. Health insurance rate increases by themselves are enough to put the typical non-profit under. As Mr. Beem concluded, “Shame on us.”

Olympia, Susan and their billionaires

On June 8, 2006, Senators Snowe and Collins voted in favor of complete, permanent repeal of the estate tax. (Just so there's no confusion, the estate tax is the legal name for what President Bush never fails to call the "death" tax.) Our senators think that even a billionaire’s estate should pay no tax. If you asked them, they would tell you that this will lead to a healthier economy. The Treasury will go without hundreds of millions of dollars every year, but Mainers will be better off. Programs funded by those dollars will either go without or the enormous budget deficit will yawn wider, the debt and interest payments spiraling commensurately higher. But Mainers will be better off. I wonder if they really believe that, or if somewhere inside themselves, they fear those billionaires and what they might do to their chances of reelection if displeased by their votes on this measure. Perhaps the Administration, ever on the lookout for the welfare of its billionaire backers, has Snowe and Collins convinced that the Iron Works and the Navy Yard will be shuttered if the senators oppose tax repeal. Then I guess, in that sense, we are indeed better off, or at least those workers and their families are. And they say that Snowe's seat is secure in the coming election, so I guess we can look forward to six more years of support for billionaires.

Saturday, April 15, 2006

Manifesto-- March 2005

"Why?” That's what I sometimes read with respect to the Bush Administration. Why are they doing these destructive things? Why are they running up that deficit? Why are they letting the dollar's value dwindle? Why are they starving their own Leave No Child Behind program? Why hasn't the Homeland Security Department secured our chemical plants? Why drill in ANWR when China is the logical destination for that oil?

"This is crazy!” I've read over and over, sometimes in just those words, sometimes in language to the same effect. To be sure, what I read is through the lens of The New York Times, but its reporters are doing their job: passing along what people are saying around the country. That's why I read the paper. I don't have all day for chat groups; I don't know where the blog writers get the time for the long lists of "Blogs I Read" that decorate their sidebars.

Well, I hate to say it, but history instructs that those who fail to divine their opponent's motivations, especially those who conclude that their opponents must be insane, certainly those who throw up their hands and declare their opponents inexplicable, are themselves on the verge of extinction.

There are a few who have shown a glimmer of understanding. A leading columnist has cited the neocons' plan to "starve the beast," a reference to the strategy of dangling tax cuts as a carrot that is in turn used to destabilize ("defunding") the entire system of entitlements erected since FDR (target du jour: Social Security). And yet, that is at best only a partial understanding, and no sooner is it put forth than another columnist piously warns of putting more and more power into Chinese hands (via Treasury debt issuance to fund the twin deficits), and still another columnist waves the red flag with regard to the abrogation of the venerable Rules of the United States Senate.

The Senate rules debate is particularly instructive. The reportage cites, on the one hand, Democratic senators' warnings that doing away with one rule (open debate) could lead to doing away with other rules (unanimous consent), and, on the other hand, moderate Republican senators' concerns that the future could bring a time when the tables are turned and it is the Republicans who are subjected to a succession of simple-majority votes. But no one makes the next logical leap of reasoning: those behind the movement to exercise the nuclear option have no intention of ever being out of power.

"Well, that's all very well and good," you say, "but willy-nilly, the electorate is fickle, and they will find themselves on the sidelines, by and by." Oh, really? Well, perhaps you should focus a little bit more on that other sequence of events, the one that the Democratic senators are warning about. In that scenario, the Senate just grinds to a halt. If I remember my American Government course, the whole body would have to vote on everything, including the appointment of each cadet at West Point.

But the Democratic senators are just as clueless; they think that would be the end of the matter. Things would go back to normal, the status quo restored, cloture again subject to a 60-vote majority. In fact, and here I begin to reveal my hand, the Rovians (including POTUS as a devoted follower), want the Senate to grind to a halt. Once that happens, they can point out that it needs to be fixed. Right away! Crisis!

And then, with the Senate "fixed" (not necessarily done away with, but emasculated, probably by some sort of emergency action of the Chief Executive, justified in the name of national security, from internal terrorist threats), suddenly being out of power isn't so much of a concern.

The nuclear option proponents are willing to destabilize the Senate by doing away with one, time-honored rule. They are hoping that the other side will react by "working to rule." They would welcome the paralysis that would result. Theirs is a plan of fomenting popular resentment against inconvenient institutions. Paralysis would provoke the underlying resentment against "do-nothing Congresses" and "Beltway Insiders."

But that plan, though it qualifies as outside-the-box thinking, far enough outside that most columnists and Congress members cannot see it coming, is still not enough. Come 2008, the Constitution is going to force these people to get themselves elected again. Something has to be done to assure that election goes the way the last one did -- or else never takes place at all.

And so the narrow idea of defunding government and then starving the beast had to be expanded into a program of creating crisis everywhere: foreign policy, trade policy, you name it. Given enough crises, you can maybe even get the Twenty-Second Amendment rolled back.

What if the central banks of the world conclude it's unwise to hold dollars? Wonderful! A crisis! What if OPEC concludes the Euro is more appropriate for buying and selling oil? Wonderful! A crisis! What if a lightly guarded chorine plant is compromised, killing 17,000 people? Wonderful! A crisis! What if 99% of US high schools cannot show adequate yearly progress and must have their funding cut? You get the picture.

The beauty of the plan is, it strokes the intelligentsia. They rub their hands together with anticipation of how silly they can make the White House look. "Look what damage these Administration policies are doing, how counterproductive they are!" Surely, think the columnists and the Democratic senators, now the public will see that we were right all along. Isn't that what we all thought when it turned out there were no WMDs, and when the Abu Ghraib photos came out?

But instead, it became apparent that a large swath of the public was willing to believe the Swift Boat Veterans for Truth. In February 2000, in New Hampshire, Bush was asked an open-ended question about Compassionate Conservatism, inviting him to issue a defining sound bite. "Well, I think that taxpayers deserve our compassion," was what he came up with. And then he went on to defeat McCain and get almost as many votes as Al Gore; the monster was given life. In the 2004 campaign, concurrent revelations about lying its way into a full-scale military invasion of a nation not then at war and erecting a worldwide torture empire did not prevent a majority from returning the Administration to power. The monster had matured, grown strong.

The stakes just keep getting higher. Power is at issue, absolute power. Whatever it takes to stay in power, get more power. That is the game that's being played. Or at least that's the game being played by one side; the other side doesn't yet grasp that it's all on the table. It's o.k. to tank the economy, the dollar, the US Treasury (probably even o.k. to default on US government debt for the first time). A few lives lost in a chemical leak or a detonation in one of our seaports? O.k., if it gets us where "the country" needs to be. Ripping apart kids' schools? O.k. if it gets us where "the country" needs to be (by getting rid of public schools and their teachers' unions).

Sometimes I have read others' worries that the nation was approaching a chasm. And then, that's all; it's just their expression of angst. Presumably, having unburdened themselves, they then go back to what they were doing. They go driving out of their neighborhood in their SUV, intent on getting to work. I recall one famous documentary maker unburdening himself about the rise of a "state religion." He even acknowledged that some might think he'd gone off the deep end even to speak of it as a serious concern. I read on, waiting for him to draw the logical conclusion, to say what a citizen should do under such circumstances. I read on right to the end; it wasn't there. He didn't say. I guess he didn't know. I think he can't imagine what to do. If the press is impotent. If a deceit is discovered and its perpetrator is elected anyway. If gross violations of human rights on the part of democracy's bastion are exposed, and the perpetrator is elected anyway. There doesn't seem to be anything we can do.

But that's because we cannot imagine the kind of things that have to be done to resist an implacable foe. And it's also because we are really very comfortable on the whole, aren't we? Or at least we are so long as we keep driving that SUV to the office every day. When the ballot box doesn't work anymore, there is only one other place you can go, and it's not compatible with SUVs and six-figure salaries. You have to go out in the street. And stay there. Like King. Like Gandhi. The Germans in the 1930s weren't willing to do that. They cast their votes and hoped it would pass. But it's mathematical. Once enough of the populace reaches a destructive, obtuse, vengeful frame of mind, a nation starts down a course that goes in only one direction and doesn't swing back. A tipping point, if you will.

Some might object that street protests have themselves been neutralized. What good is a protest if it's inside of a cage on the far side of town from the protest's object? Well, my take on that is we have gotten used to instant coverage, easy publicity for symbolic street actions. We are all, both sides, "blue" and "red" well aware that the sound bite makes all the difference. And now our photo opportunities have been taken away, in the name of security.

But I am not talking about questing for publicity. I am talking about taking our lives into the streets.  I am talking about changing our lives, laying down the tools of our trades for the sake of a higher calling. To stop this sort of thing, when sounds of protest have been muted and even the "bites" and "ops" that manage to emerge haven't slowed the monster in the least, you have to be willing to put yourself on the line. You have to be willing to forsake your livelihood for the sake of holding onto your civilization. You are putting your economic existence on the line so that life in these United States doesn't become an issue of preserving your physical existence. You leave the SUV in the garage. You won't be needing it until this struggle is concluded. You live hundreds of miles from Washington? Doesn't matter. If you drive, there won't be any place to put your car. What do you think this is, anyway? A sporting event? Something you do and then drive home from? A day of protest marching?

You don't have to be in the streets of Washington, anyway. You and everyone else who will fight this fight can do so, in numbers, right in your home community. Perhaps outside your Congress member's local office, perhaps at the local federal building. Probably right out in the town square.

You do this with the full awareness that you'll likely spend a few nights in jail. Probably incur a fine. Be placed in handcuffs. Maybe even hit with a nightstick.

You may even be stoned, especially at first when you may be fighting for our civilization alone, or in a small group, reviled as a splinter faction.

You need not be concerned about being ignored. Why? You always have it in your power not to be ignored. Gandhi showed us. It's so simple. Many others have shown us the way. All you do is stop eating. There's a right way to do it, too. Slowly, with plenty of liquids, including juices, perhaps a crust of bread.

You scoff? "Oh, is that all?" you say. "Just don't eat? Are you off your rocker?"

Well then, picture a man, myself for example (assuming I can muster the courage to set aside my busybody pecuniary ways), in a city square, or perhaps even on the sidewalk outside the White House (but only one at a time there, or else standing at least one hundred feet apart). He (or she) arrives, with a sign ("Stop the torture" for example), and is promptly ignored, even by the press. Then the first day goes by, and the second day. Juice and a crust of bread only. On the third day, s/he's moving noticeably slower, but still being ignored. After a week, you're still there, possibly even still have your sign, but you don't move much. You try to stand as much as you can, but more and more of the time, you're on the ground. Do they cart you off? For loitering, perhaps? Or for "your own safety?" And what if you persist even then, like Gandhi, lying in bed with his family around him, begging him to eat. (Do they insert a tube?)

Can you do this? Surely, not many of us have done it, in history. But the ballot box isn't going to help us, and, like Gandhi and King, we do this to reduce violence not to contribute to it. We do not go the route of Lenin or Robespierre or John Brown. In that case, what other course is there? What other tool do we have?

I will try. To get myself to do this. Maybe I will see you there.

Tuesday, April 04, 2006

Insurers accused of not reporting lobbying

Insurers accused of not reporting lobbying

TO:     Alessandro A. Iuppa, Maine Insurance Commissioner

Mr. Iuppa:

A complaint has been filed with your office regarding the behavior described in this article, and I wish to put you on notice that calling the insurers' non-compliance an "oversight" is simply UNACCEPTABLE. I demand that a penalty be imposed. More important, the Insurance Bureau must take specific steps to confirm the non-compliance, issue a reprimand and disseminate these actions in newspapers and other public forums. In reviewing Anthem's Dirigo testimony, I noticed that they are using a lawyer (and, no doubt, his supporting staff of paralegals, etc.) from the most expensive law firm in the state. They seem to have unlimited resources, coming from policyholders' premiums (such as the premiums that my wife and I pay to them each month, even while our son is on Medicaid), and they do not hesitate to use those resources in defense of their own selfish interests. And now we have the executive director of their lobbying group professing innocence. THEY WILL DO WHAT THEY CAN GET AWAY WITH. The question is, are you going to let them? Maine is a small state, sir. If you again avoid taking action, think about that. The next time you see a friendly community activity on your weekend time, think about how, the rest of the week, some of those people are putting it to the others (and raking in salaries, benefits and bonuses).

Richard Wolfe
Cumberland Center

Wednesday, March 22, 2006

Friedman: Dubai and Dunces

Thomas Friedman, writing of “Dubai and Dunces” says, “Dubai is where we should want the Arab world to go. Unfortunately, we just told Dubai to go to hell.” Excuse me? I thought that where Bush wants the Arab world to go (or so he says) is in the direction of democracy. Economic transparency may be a desirable landmark in that direction, but it is not the final destination. Dubai refers to its head of state as “the ruler” and maintains the world’s largest secret police presence per capita. Or is it the economic success of Dubai and, on a far larger scale, China, that we want, never mind noisy democracy? Indeed, is that now what we want for ourselves? I’m sure it's not what Friedman wants, but when he advances his “flat world” thesis he needs to be more careful of the implications for democracy.