April 26, 2019

Horse 2536 - The Trouble With "The Trouble With BernieCare"

The thing about Facebook and my general reluctance to engage with the site, is that I know that the platform itself has been optimised to keep people's eyeballs on it for as long as possible. One of the ways that it does this is by co-opting us into becoming both receivers and generators of outrage. The old adage of the newspaper business of "if it bleeds, it leads" has not only become a central engine of how Facebook works but the principle of the algorithm which is designed to pour light pollution into our eyes for as long as possible.
I generally find inspirational posts vapid, pictures of smiling people on holiday sadness inducing (as clearly everyone else in the world is having a funner time than I am), and pictures of babies boring. I am the owner of a nineteenth century brain which demands walls of text and a thousand words in place of a picture.
The scary thing is that Facebook knows that I like following politics and I suspect that the people who know me and follow me also know this. Consequently, I occasionally get tagged in posts on Facebook which people think that I might be interested in but in actual fact, they turn out to be partisan waffle pieces which are of lower quality than I could have written. This week I was tagged in a post on Facebook from Joe Grogan; who I already knew was director of the White House's Domestic Policy Council.
This piece in particular, made my hackles, feckles and schmeckles stand up; thus, fulfilling Facebook's main objective of making me both a receiver and generator of outrage.

To set the scene. United States Senator from Vermont, Bernie Sanders presented a Medicare-for-all bill to the US House of Representatives, on Wednesday 17th April. To call the legislation ambitious is an understatement. If we ignore politics for a second, the passage of the bill which would abolish the private health insurance industry and establish the equivalent of Britain's National Health Service, would be the single most disruptive piece of social policy passed in America in the twenty-first century. If we don't ignore politics and instead play out here in the real world, the legislation is impossible to pass.
Getting a simple majority in the Senate is hard. Getting a veto proof majority of 67 votes is impossible. Getting Republicans to agree with a piece of legislation which has been proposed by an independent running further to the economic left than their sworn enemies, would be as likely as President Trump submitting himself for impeachment and then running the case for the prosecution. It ain't never gonna happen, no way, no how.

Nevertheless, Joe Grogan, the director of the White House's Domestic Policy Council, wrote a piece for RealClearPolitics which is an "ideologically diverse" political news aggregator, which is amazingly paranoid in every paragraph. Dubbed BernieCare, the legislation is never going to ever reach committee stage and exists as a signal of intent. A lot would fundamentally need to change before the United States started doing anything even approaching a single payer, let alone establishing anything like the National Health Service of the UK.

Last week, Sen. Bernie Sanders introduced a bill that would end health care as we know it, and Americans should thank him for letting us see where the Democrats want to take the country. Its central premise appears to be that Washington bureaucrats know better than patients and doctors.

Let me just start here by stating the obvious that neither patients nor doctors actually run or manage the health system. Patients are clients who use the services of the system. Doctors are employees of the system, whose job it is to give treatment to heal the sick. Private hospitals, insurance companies, health management organisations, all have their own internal bureaucracies. The only place where you get doctors running their own internal bureaucracies is where you have private practices where you have sole proprietors or small partnerships of less than about 50 members.

But as if taking health care choices from patients isn't bad enough, this bill also hurts seniors, eliminates private health insurance for nearly 180 million Americans, wipes out Medicare Advantage for over 22 million, and harms our economy for generations to come. It doesn't stop there: For good measure, the bill removes critical support for children and service members' families while providing free care to illegal immigrants.

YES! Oh, happy day. Eliminating private health insurance is possibly the single best thing that could possibly happen to the health care system. Insurance works best when you have the pool of risk inside the pool most closely matching the insurance risk of the general population of insurable items. Any position less than 100% of the population buying into the system means that because the people who are likely to want insurance are also likely to want to be paid out of that same system, then by definition private health insurance covers a higher proportion of bad risks than it otherwise would have done.

I do not understand this argument in principle. I am forty years old and although my eyeballs have decided to call time on short distances, I am otherwise fit and healthy. I am the classic midpoint in life which splits expected health care outcomes in twain. In general, everyone who is younger than me only presents themselves to a doctor because of the usual sorts of minor complaints that people expect and the biggest reason that people who are younger than me die is because of catastrophic physical injury. In general, everyone who is older than me, presents themselves to doctors because they have more chronic and ongoingly slow diseases and complaints. Ever since the invention of basic public health care measures like the supply of potable clean water, the removal of sewerage, and pathogen control, the classic childhood diseases like measles, typhoid, cholera and influenza were mostly controlled by the 1920s. Taken as a whole of life study, the people who are most likely to use health care services, are old people.
Again, it appears as though the whoever wrote this has never been to either a GP's office, a specialist, or a hospital in their life. Health care hierarchies for treatment are worked out on a sliding scale of immediacy and urgency. There isn't exactly a preference to necessarily treat old people and so the idea that younger people are going to create some sort of demand pushed distortions is complete hogwash.

According to estimates from nonpartisan experts, BernieCare could cost taxpayers more than $32 trillion over the next 10 years. Sanders decided a health care bill is a good place to direct our taxpayer dollars toward illegal immigrants rather than put America First. BernieCare allows the government to define who counts as a resident of the United States and makes all residents eligible for "free" health care. It's always good to see wealthy foreigners from socialist health systems like Mick Jagger come to the U.S. to pay for the best care in the world, but the senator from Vermont wants to give it away to any foreigner for free, courtesy of American taxpayers.

$32 trillion sounds like an awful lot of money but when you consider that US health care system already cost $3.5 trillion in 2017, then if you use the estimates from nonpartisan experts, then that would be $35 trillion over 10 years. BernieCare even according to this shabby hit piece from the current White House would save $5 trillion. That's 14% saved right there. If you can save 14% on anything and especially on a scale this big, you would be either stark raving insane not to accept it.

As for the argument that the American will be overrun by people from overseas, I
do not understand this argument at all. It is almost as if whoever wrote this piece is willfully facetious.
Let's assume that illegal immigrants pour across international borders for the sole purpose of obtaining health care. It is of course a stupid assumption but since we're playing in the backyard of idiocy, we may as well make pies from their mud puddle. Health care is not like a buffet. You do not load up on health care as though it were a succulent Chinese meal.
People either present themselves to a general practitioner in the first instance because they have an ongoing problem with their health, or they present themselves to a triage unit because of accident or emergency. In the case of the former, that will involve a measured and lengthy process to establish a course of treatment and ongoing management and in the case of the latter, the immediate and present danger (in some cases that someone will die) will be evaluated by the A&E Department of the receiving clinic (which is often a hospital).
The truth is that people who have chronic health problems generally do not cross international borders unless the conditions in their own countries are so terrible that the risk is worth it. Also, if your country denies basic treatment to someone who is clearly in so much distress that they have presented themselves to the A&E Department of a hospital and your country chooses to deny basic immediate treatment to them, then your country is scum. Health Care isn't a right in the United States, which says more about what business people who actually control the country think about 'We the people' than anything else. Health Care should be provided without fear or favour.
Also, why mention Mick Jagger? That's a bizarre cultural reference which belongs in a past which generations younger than I would find completely irrelevant.

Lest anyone think that there would be no room for private insurance in Sanders' new system, he has clarified that wealthy people would be able to pay for hair transplants and nose jobs. And to keep the pesky citizenry from complaining about essential treatments that could save their lives or the lives of their loved ones, his plan would ban all advertising for health care products and services. You see, if the government can keep Americans totally ignorant of what's out there, then it's easier for them to tell us we are out of options and make us suffer in silence.

I hate to say it (because it's so mind-numbingly obvious that it warrants banging one's head on the table) but drug advertising is stupid in principle.
The reason why firms think that it is a good idea to pay to put their messages and propaganda in front of people's eyeballs is that they have the expectation that people will be persuaded to buy their product (and the rather idiotic fact that US law compels drug companies to produce public information about their product). I don't have a problem with that necessarily but drugs are one of those goods where all the advertisements in the world aren't going to make a lick of difference. The idea behind advertising is to create a desire in people to buy the product and this pushes the demand curve upwards.
The only problem with it (and it is a fundamental problem) is that desire is not the driver for drug purchases. If you have a disease of the kidneys which is helped by a specific chemical which is delivered by a drug, then advertising to you is pointless because it is your doctor who is authorised to sign off on the prescription. If you don't have that disease of the kidneys, then no amount of advertising is going to make you buy it because not only are you barred from its purchase but unless you are out of your freaking mind, what the cheese and biscuits are you buying that medicine for in the first place?

The second reason why drug advertising is clinically stupid (I performed the double-blind test) is that advertising is an input cost which makes the product more expensive. It is impossible to make a thing cheaper and more accessible by making it more expensive. What good reason is there for putting advertising on television to tell people about a drug if they cannot use it, or alternatively if they need it? The general public aren't pharmacologists, so telling them about a drug is mostly pointless because they cannot possibly know what the effects of any drug is going to be in concert with their existing medication. Unless to say that Mr Grogan just really likes those adverts because he secretly gets to laugh every time, they mention death and/or anal leakage.
The only entities which benefit from higher drug prices is the drug companies; which have motives running almost exactly counter to the general public.

To be fair, Sanders did identify a few areas for cost savings in his bill. In what appears to be an effort to make sure military families do not receive the special support they deserve; he proposes to abolish Tricare. The military is not the only group targeted by this plan. The Children's Health Insurance Program (CHIP) would also be eliminated under Sander's vision. And of course, seniors would lose their specialized support as everyone else floods into Medicare and claims scarce resources.

Good. Those programs only need to exist because the current system needs to be pushed to provide a basic standard of health care to vulnerable people. If literally everyone was included, then specific legislation to curb the bad behaviour of private companies does not need to exist. And as for the suggestion that children and seniors would lose their specialised support, that's only because that support is extended.
This whole argument is like claiming that racists have their vote diluted because of the expansion of the franchise.

Sanders' legislation allows for the secretary of Health and Human Services to consult a broad array of institutions when deciding how to implement his Utopian vision of health care. Organized labor, Indian tribes, various medical associations, and unspecified "business groups" make the cut, as do other federal agencies. Noticeably absent are Jewish and Catholic hospitals, which play a critical role in American health care delivery. BernieCare may not have room for religious providers in its America.

You've just laid out one of the fundamental principles of why this is good legislation. The Department of Health and Human Services should consult with all of the relevant stakeholders. That is how you get governance with a greater degree of consensus.
The line about Jewish and Catholic hospitals being absent from consultation, is clearly dogwhistling and if scrutinised properly, is a call to violate the First Amendment. Granted that religious based institutions should retain the right to practice their beliefs in action but what exactly does a government agency have to say about and to a religious institution other than regulatory oversight?

The Trump administration agrees that there are real problems in U.S. health care, but the solutions do not include fewer choices and more power handed to bureaucrats to make health care decisions for American patients. Medical care has gotten too expensive, but we should be working together to get costs down; not using health care costs as a backdoor to reshape the economy of this great country. We should build on what works and fix what's broken. That is why President Trump is working to protect people with pre-existing conditions, end surprise medical bills, increase the transparency of medical costs, lower drug prices, expand access to affordable coverage options, increase patient choice, stop the spread of HIV, end the opioid epidemic, transform kidney care, and accelerate therapies for paediatric cancer.

The Trump Administration and the Republicans in Congress while they had control of both houses, made it a headline policy to "repeal and replace Obamacare'. Having successfully done the first, there has never been legislation put forward to achieve the second part of that ambition. How exactly do you achieve lower costs for medical care when the interested parties who provide said services, have the profit motive baked into their very being?

As I've said in the past, if Bernie Sanders or his colleagues want to get serious about addressing any of these issues, they should know that the White House doors will always be open. Let's work together to confront the problems of health care affordability and access, and do it together, in a bipartisan fashion.

As we've seen in the past, while the White House doors might be open, there has been very little if any attempt to find solutions in a bipartisan fashion. Notwithstanding the fact that the current administration lacks the necessary skill to make deals with its own side of politics, much less the other side of the aisle.

Joe Grogan is director of the White House's Domestic Policy Council.

Joe Grogan is a former lobbyist for drug giant Gilead Sciences before joining OMB in 2017, and had repeatedly put forward plans for rolling back parts of the Affordable Care Act through regulation.

Of course, he is allowed to make criticism of legislation put forward by his political opponents but both he and I and Bernie Sanders know that this legislation will never be passed. This is one of those things that would die before it ever got to committee stage. Why does it exist? Because this is about course setting. Quite frankly, the United States should have done everything in the bill by about the end of 1948. Bernie's bill is a practical enactment of some of the clauses by FDR.
The fact that this discussion about what health care looks like is being had in 2019 instead of 70 years ago means that people like Joe Grogan have been winning for a very long time and they have no intention to dismantle the economic advantage that they personally sit on.

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