The Affordable Care Act and health care costs

Published in the St. Louis Post-Dispatch

A recent study by the Society of Actuaries suggests that under the Affordable Care Act, premiums for health insurance are likely to increase by 32 percent for individual and small group policies. While the study does not fully capture some of the act’s cost-control mechanisms, it does highlight a significant challenge for the U.S. health care system: deciding how much to spend to keep any one person alive.

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The Ohio Rape and Civil Discourse

This is about the conviction of the two boys in Ohio on the charge of raping the young girl. It will make some people mad, and for that I’m sorry. However in some ways, peoples’ reaction to the case illustrate what has gone wrong with our society. We have lost our sense of perspective, our moderation, and with that we are debasing both our civil society and our language.

I’m not defending what the boys did. They put their fingers where they didn’t belong and generally treated a human being in a very callous way. But I have read the boys being described as inhuman, even as monsters. Take a moment to think about how bad it could have been. Not too long ago, a woman in India was gang-raped in broad daylight while being beaten so severely that she eventually died. The girl in Ohio could have been found dead with every part of her body horrendously damaged and violated. But she wasn’t.

Again, I am not defending what the boys did. However if we use our most extreme language to describe these two boys and their actions, what words do we use to describe the men that actually do kidnap and violently rape young girls? If the two boys in Ohio are monsters, what is the appropriate term to describe the men in India? Are commentators actually suggesting there is a moral equivalence between the rape in India and what happened in Ohio?

It’s easy to view the Ohio case as proof of whatever one finds wrong with our society. The rampant sports culture. The male dominated world. The systematic sexualization and debasement of women. It’s easy to make the boys examples of all that is bad and hateful in the world. Except they aren’t. They aren’t archetypes, they aren’t examples, they are just two teenagers, two children, that did something very bad at a high school party. It is not fair to them to make them the personification of evil.

This, surely, is one of the things that has made our society more harsh and much less civil – the willingness of each side to immediately paint an event or person with the most horrific language possible. Accusing the two boys in Ohio of being monsters. Comparing Obama to Hitler. They aren’t that different, and both are distortions of fact and language.

If we keep abusing language, words, then over time the words themselves lose their meaning – they become less precise, and less impactful. And over time it gets harder and harder to have a real conversation about the challenges facing our society, our country. The word “political correctness” doesn’t get used much anymore, but this is surely an example. Any commentator that suggested even a hint of moderation, a hint of forgiveness, was summarily trashed in the media and the social networks.

Again, I’m not defending what the boys did, I am defending moderation and civil discourse. Extremism of language chokes off real conversation. It makes people on both sides of the spectrum afraid to offer their opinions, because of the firestorm of hateful words that will be unleashed against them. I’ve read enough history to know that civil society has never been completely civil. But it used to be more civil. It used to be possible for two people to discuss an event, a part of society, without feeling the need to label each other as monsters.

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White Paper – SELF-MANAGED GROUPS AND HEALTHCARE REFORM

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SELF-MANAGED GROUPS AND HEALTHCARE REFORM

For all of our talk of healthcare as an individual resource, “my healthcare”, it is actually a group resource, a shared risk pool like any other kind of insurance. And like any other kind of insurance there has to be a limit to the group’s liability – no group health plan can afford to pay an unlimited amount of money for any person’s care. This question, “How much can we afford to pay to keep any one person alive?” as harsh as it is, has to be answered. If we don’t trust insurers and employers to strike the balance, then we need to let the group members themselves decide – we need to let the members of the tens of thousands of group health plans take control of the annual plan decisions and decide the proper balance between cost and coverage.

This paper makes the case for allowing self-managed healthcare groups within our existing healthcare system, for allowing the members of group health plans to take control of the annual plan decisions that are currently made by their employer or insurer. With that control they can make the same broad decisions employers make annually on the boundaries of coverage and also on the appropriate limits on liability for the group.

This paper also suggests that self-managed healthcare groups in conjunction with an approach to funding referred to as a Fixed Tax Credit offer a realistic path to transforming our healthcare system to insure equitable, universal coverage for all. The Fixed Tax Credit approach would change the funding mechanism but not the structure itself, fitting into our existing healthcare system with minimal upheaval or disruption. It won’t solve every healthcare issue facing our country, but would be a significant step towards meaningful healthcare reform.

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Risk and Healthcare Reform

Self-managed groups offer perhaps the only meaningful opportunity for healthcare reform in the United States.

For all of our talk of healthcare as an individual resource, “my healthcare”, it is actually a group resource, a shared risk pool like any other kind of insurance. How we draw the boundaries around the care that the pool will pay for, and how much the pool will pay for the care of any one individual, are the most basic questions in healthcare.

These questions are also the primary points of contention in the debate over healthcare. Many Democrats favor a national health plan, with the Federal Government deciding the covered care and how much will be paid to keep any one person alive. Many Republicans don’t trust the government with this kind of power over individuals’ lives and would prefer to have those decisions made by insurance providers.

But the Patient Protection and Affordable Care Act (PPACA) has for all practical purposes ended the debate – PPACA effectively forbids insurance companies from drawing financial boundaries around acceptable care. Among its provisions are prohibitions against insurers setting annual and lifetime caps on the cost of care, the two most effective tools insurers had to limit costs. An estimated 8,000 people in the U.S. had reached their lifetime caps of $2 million to $5 million. By some estimates as many as 200,000 people will exceed $2 million in healthcare spending in the next twenty years.

Health insurance is now perhaps the only type of insurance in the U.S. that is forbidden from setting limits on liability. If the choice is only between a government-run national plan and private insurers, the government plan will eventually win; PPACA comes close to guaranteeing that costs for private insurers will keep on rising and eventually they will be priced out of the market. The federal government, not bound by the rules it applies to private insurers, will be the low cost option, and eventually the only option.

Our only opportunity to save private insurance in the U.S. is to change who answers the questions. If the federal government refuses to allow private insurers to draw financial boundaries around the group, and many people don’t trust the federal government, then the only answer is to let the risk pool itself draw the boundaries – to let the group of people actually receiving the care decide which financial limits they are willing to live with.

This is a radical notion – letting the group of people receiving the care decide where to draw the boundaries. It would mean accepting that different groups might draw the boundaries differently. It would mean accepting that some people would be allowed to die because the cost of saving them is too high, because spending a million dollars on one person’s treatment would bankrupt the risk pool.

The challenges to self-managed groups aren’t technical – they would be easy to implement in our existing healthcare care system and further offer a path to meaningful healthcare reform. Instead, the challenges are ideological. Conservatives have spent decades trying to shoe horn healthcare into the framework of the free market and have somehow convinced themselves that care should be bought by individuals, not the risk pool they are part of. Accepting self-managed groups would mean accepting that yes, healthcare is a group activity. Liberals don’t like the idea that everybody would not have exactly the same coverage, and that some self-managed groups could in theory introduce personal responsibility and even morality into their definitions of covered care. And perhaps some Liberals don’t actually think our citizens are smart enough to draw their own boundaries around acceptable care.

Most importantly, of course, the Liberals are winning – if PPACA continues unchanged we will eventually have a national health insurance plan. Conservatives, for all they dislike the idea of a national plan, seem to dislike reality even more. They continue to promote solutions that play well on Fox News but have only a passing connection to how healthcare actually works; its hard to imagine them winning the battle of ideas, let alone actually changing the legislation. Self-managed groups can win the battle of ideas, and provide a real alternative. Giving the group the ability to make its own decisions on how much to spend to save a life is our only real chance of keeping that decision out of the hands of the our government.

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Healthcare Reality

What Level Of Respect Does Society Owe An Individual? The answer is “The level of respect an individual affords himself or herself.” This, truly, is one of those core questions that is a starting point for so many policy decisions. We as a society are too compassionate to let people die – we pick up the pieces of the self-destructive and help them get on with their lives. But picking up the pieces costs money, and sometimes a lot of money. How many times do we owe it to a person to help them? There is no easy answer, but this is a question we have to address.

We Need to Recognize That We Cannot Afford to Save Every Person. We need to put an acceptable cost on saving a person, if the cost is too high let that person die. There, I said it. Yes, this is harsh, but this is what society, government, has to do – assign a cost and decide whether or not we can afford to pay that cost. We do not have unlimited resources. This doesn’t meant that people can’t use their own money to extend their lives. Yes, that means that rich people will get better care than poor people, but they have better cars and homes – why wouldn’t they have better healthcare?

The government does have a right to require people have some form of healthcare coverage. Compassion places a floor on possible outcomes – we do not let people without insurance die if something bad happens to them, but instead society bears the cost of paying to get them well. It is not unreasonable for government to mandate that individuals be responsible for themselves and buy health insurance.

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The Tragedy of the Modern Republican Party

With the House Republicans’ extension of the debt ceiling it could be that the Republican Party is finally moving back towards fiscal reality. But it’s hard not to be just a little melancholy about the state of the Party. The Fiscal Conservatives had won, and the ideologues in their own party threw it all away.

The Republican faction that talks of “starving the beast”, that actively wants to force our government into default, aren’t fiscal conservatives – there is nothing fiscally conservative about attempting to bankrupt our government as a way of shrinking it. They are more accurately described as Ideological Conservatives, Republicans that never accepted the compromise that our country reached in the 1930s to create our current role for government. They never accepted Social Security, or that government should redistribute some of the benefits of capitalism to insure that every American had an opportunity to participate in our economy.

The mainstream Republican Party did accept the compromise forged under President Roosevelt. Eisenhower didn’t try to overturn the New Deal and even expanded the federal government’s role. Nixon was a strong supporter of unions. The compromise was accepted for a range of reasons. It fit Republican’s ideas of compassion and moral obligation. Republicans have favored a constrained government but still saw a need for a strong national government as a key to a strong national economy.

And most of all Republicans accepted the compromise because it worked. Because making sure the elderly didn’t starve and that workers could secure increasing wages helped build a vibrant consumer economy. Because using the federal government to extend equality of opportunity made our nation stronger.

Certainly Republicans were concerned about the growth of government, recognizing that if voters got in the habit of looking to government to solve their problems its size and responsibility would tend to keep growing. Fiscal Conservative’s answer was to push for a balanced budget. Deficit spending – decoupling government spending from taxes – almost guarantees that the amount of money government spends will grow. People just tend to spend more if they can put it on a credit card.

A balanced budget, forcing voters to pay for government as they used it, protected against the growth of government. If voters actually had to pay for the services being provided they would be much more cautious about extending government.

A balanced budget was a core belief of the Party’s fiscal conservatism for decades, part of a larger message of economic prudence and competence. Republicans didn’t question the need for a strong government but instead told voters that they were the party to make government more efficient, to make sure we got the most for our tax dollars. The Republican Party’s campaign message was that it could run government better.

After decades of pushing, through many twists and turns, the fiscal conservatives finally achieved their goal during Clinton’s presidency – Democrats finally acknowledged the importance of a balanced budget. Congress and the President agreed to a budgeting process referred to as “Pay as you go”. Any proposal for a new program or initiative had to be deficit neutral – the proposer also had to specify which existing program would be cut or which taxes would be raised. Fiscal conservatives in the Republican Party had finally engineered the last piece necessary to control the size of government, to insure that the role for government that grew out of the Depression would work.

Except of course, Ideological Conservatives didn’t want it to work – they wanted it to fail. When George W. Bush was elected president, they knew voters wouldn’t support changing the role of government. Instead Ideological Conservatives chose a different path – they pushed for tax cuts that essentially de-funded the role of government. They replaced a balanced budget with massive deficits with the expectation that eventually this would cause our current role of government to collapse under its own weight.

The Bush years validated every nightmare fiscal conservatives had about deficit spending. The size of the government jumped. Deficit spending created a financial bubble that destabilized our economy. And when the bubble collapsed into a financial crisis and severe recession, people became even more dependent on government.

This, really, is the tragedy of the modern Republican Party. The fiscal conservatives had won. But everything they worked for was destroyed, not by the Democrats, but by Ideological Conservatives in their own party.

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Welfare

Welfare Needs to be a Tool To Extend Freedom. In a democracy, government should work to extend equality of opportunity, to ensure that each individual has the ability to take control of his or her own life. Our welfare system should be one of the tools government uses to extend freedom (and yes, most Republicans do believe in welfare for this purpose).

The Standard of Success Has to be Economic: I agree that we want our welfare system to produce happy, well-balanced citizens. But the only standard government can really use to evaluate the welfare system is economic – do the children that are supported through the welfare system grow up to be economically self-sufficient, tax paying citizens? The government can’t evaluate happiness, and shouldn’t be in the business of trying. But we can measure economic self-determination – we can know if kids who come through the welfare are able to support themselves. At some point we need to quantify the government’s successes and failures in extending freedom.

The Right Wind Pretends Social Engineering is Optional. Sometimes people on the right speak as if Social Engineering is something government can choose not to do. It is not a choice, it is a description of reality – every act of government, at some level, engineers society in a given direction, from where to put a highway to which crimes should be federal. Pretending that government doesn’t engineer society doesn’t make it so – it just means the consequences of the engineering are unanticipated.

The Left Doesn’t Seem to Like the “Engineering” Part. Sometimes people on the left seem to have forgotten the engineering part of social engineering. Part of the process is to define expected outcomes and compare the results against the expectations. If expectations aren’t met, then the engineering is changed – we try something different. Arguably many parts of our welfare systems aren’t meeting expectations – we aren’t giving the people who come through the system the ability to take economic control of their lives.

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Guns and America

Back in the day I was part owner of a bar with a sometimes rough clientele. We had off-duty police officers as patrons and on the busy nights we hired an off-duty officer, in uniform, for security. We had a drunk off-duty cop start to pull a gun on a patron he found annoying; our working cop tackled him before anything bad happened.

Most law abiding people never come face to face with a mugger or murderer. But they come in contact with hundreds of other law-abiding citizens every day. Sometimes two law-abiding citizens get into a dispute, over a parking space, a traffic maneuver, even a misinterpreted stare in a bar late at night. Sane people sometimes do crazy things when they get angry. More guns in circulation means more guns get drawn, more accidents happen and more people get shot. It’s foolish to think that having more guns has made our society safer.

Back in the day I lived in the top floor of a duplex in a rough neighborhood. The owners, an elderly couple, had lived on the first floor for several decades as the neighborhood changed around them. Every night he took the dog for a walk with a gun in his pocket. Every once in a great while he felt the need to display the gun to people that seemed to be walking his way with a purpose. Nothing bad ever happened, and nothing made the news. But having the gun allowed he and his wife to live their lives less in fear and with more freedom.

It would be great if every American felt safe in their neighborhood and trusted the police to protect them. It would be great if people like my landlord didn’t feel the need to keep a handgun to protect he and his wife. When we talk about gun deaths in the United States, these are the guns we are talking about – handguns. When we talk about handgun control, it’s people like my landlord that we are talking about. It’s hard to imagine our country will ever take handguns away from the tens of millions of Americans that feel safer with a handgun in their homes.

It’s the mass killings with assault rifles that usually lead to calls for more gun control. I know some people that have assault rifles, and some of those people keep them in secret gun closets. They don’t have the assault rifles because they are afraid of crime, they have them because they are afraid of the government and the society our government might lead us to.

It would be great if every American trusted our government enough to not feel the need to keep a private arsenal. But that’s not the case. “National Character” is a nebulous term, but if it exists then surely a part of the national character of the U.S. is that we are distrustful of authority. For a portion of our population that means being distrustful of government, our government.

So there you have it. The guns that that are responsible for the vast majority of gun deaths are the guns people use to feel safe in their homes and on their streets, handguns. The guns that are responsible for the mass killings, assault rifles, are the guns that people buy to feel less afraid of our government. It would be great if we had fewer handguns floating around and did a better job of keeping them out of the hands of criminals. And it would be great if we could make assault rifles a little less lethal and did a better job of keeping them out of the hands of the mentally ill. But it’s hard to imagine that the U.S. will ever be a gun-free country. Guns, and gun violence, will continue to be part of what makes the United States different than the rest of the world.

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The AIG Bailout and the Tea Party, Part 2

The bailout of American International Group (AIG) during the financial crisis illustrates the conflicts between philosophy and reality that the Tea Party will have to address if it wants to actually change anything.

During the financial crisis the Federal Government injected $182 billion into American International Group (AIG), a very old insurance company that had sold tens of billions of dollars of unregulated insurance on mortgage backed securities. The government worried that if AIG was allowed to fail it would take down several leading investment banks and this in turn could take down our whole economy, turning the recession into a depression.

It was undoubtedly the right thing for the government to do, but this was also perhaps the most galling of all of the government’s bailout efforts. AIG and the large investment banks had generated billions in profits during the mortgage bubble by creating, buying, selling and insuring mortgage backed bonds. Now taxpayers had to protect AIG and the banks from the collapse in value of mortgage backed bonds even as taxpayers were seeing their own home values fall.

For Tea Party members and for many voters, AIG highlighted everything that was wrong with the various government bailouts. It was a massive extension of the government’s responsibility for the economy and it was inherently unfair – giant companies got government assistance they didn’t deserve while thousands of smaller businesses were allowed to fail.

There is a part of the Tea Party movement that feels the answer to avoiding a repeat of the bailout is to end the federal government’s role as the guarantor of our financial system. But while this has a nice ring to it philosophically, it’s not realistic. When Adam Smith wrote about the glory of the free market, he used sheep markets as an example. The key to the functioning of the market was that each buyer could decide for themselves the value of a sheep – the buyer could feel its coat and muscle tone, check its eyes and mouth.

This level of personal knowledge and inspection isn’t possible in a national economy. Instead, the federal government assumes the role of guarantor of claims, providing assurances that banks aren’t using your deposits for their own purposes and that companies on the New York stock exchange accurately report their financial results. It’s not too much of a stretch to say that a national economy isn’t possible without a strong national government – federal financial regulation is a critical element of our capitalist system.

And the financial crisis didn’t happen because we had too much government financial regulation. It happened because the government rolled back regulation. With pushing from Wall Street and both Republicans and Democrats, the federal government backed away from two key regulatory principals – you can only buy insurance on something you own, and if you sell insurance you have to maintain financial reserves to cover possible losses. The mortgage bond insurance that AIG sold was bought by companies that didn’t actually own the bonds, but instead were speculating that the bond’s value would fall. And AIG didn’t maintain reserves to cover potential losses.

One of the ways the government protects our economy from financial swings that could become recessions and depressions is by keeping individuals and companies from doing things that are speculative and frankly, stupid. By limiting the stupidity up front, the government insures that it won’t be forced to step in and clean up a mess that could bring down the whole economy. When we rolled back regulation and started allowing very large financial institutions to do stupid things, it was inevitable that eventually the government would have to step in to clean up the mess.

Thus the quandary for the Tea Party movement. It is rightly angry at the bailout and the extension of government responsibility that it represented. But the best way to insure the government isn’t again put into a position where it is forced to bail out giant financial institutions is to again increase regulation of the financial sector. This is the paradox – it will take a stronger government to insure we have a smaller government.

AIG Bailout and the Tea Party, Part 1

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Unwed Mothers and Cheating History

I named this blog “Cheating History” because I think this is the one overriding question our country needs to answer – how do we avoid the inevitable decline that has overtaken every other great nation throughout history? How does the United States cheat history?

I think the U.S. does have a chance to cheat history because of our unique combination of democracy and capitalism. It’s calcification that kills great nations, the tendency of any society to lose its dynamism and settle into a rigid class structure. Those people who were successful when a society was young and dynamic start to change the rules to insure that they and their children get to keep what they got. This makes the class structure less fluid and allows fewer opportunities for the poor to get ahead, to make their own pile of money. Eventually the society stops tapping into the potential within the class structure as a whole and at that point the decline begins.

In theory democracy, with its constant churning of political power, and capitalism, with its constant churning of economic opportunity, can work together to create a permanently fluid class structure. A society where rich people go broke on their own merits and where poor people can get rich, again on their own merits. In theory, democratic capitalism should allow a country to avoid the historical decline.

The United States, of all countries, should have a chance to create a permanently fluid society. But instead we are going in the opposite direction – our country is calcifying. The rich have gotten significantly richer over the past several decades and the poor have stayed poor to the point where we talk about having a permanent underclass. It’s easy to point to changes in tax laws and other factors to explain the calcification at the top. But more worrisome are the changes at the bottom, the many different factors that are creating a society where the poor can’t get ahead.

Sometimes I think there is a tendency to blame all of the poor’s problems on the Republicans. Part of the lack of opportunity for the poor is certainly related to the calcification at the top, and this is driven by policies that the Republicans champion. But it extends beyond that – the poor increasingly lack the skills and character necessary to pursue the opportunities that are available. Unfortunately I think this is attributable more to the people that are trying to help the poor.

The changing of the social norms against unwed mothers offers an example. The single strongest predictor of economic success for children is the presence of two parents. Yet in part out of compassion we have changed our social norms to be more accepting of out of wedlock births. This has made us a kinder and gentler country but has also helped lead to a significant jump in the number of children born to single, poor mothers. By any measure these children will have a much harder time learning the skills they need to succeed.

This is the tragedy of many of our efforts to help the poor – we wind up undermining their ability to develop the skills they need to participate in our democratic, capitalist system. Compassion has led to many changes that have benefitted the lives of the less fortunate. But it is also helping to shape our society in a direction that making our class structure less fluid and making it harder for the United States to cheat history.

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