Trump: Time to Resist. Provoke. Change.

At Federalist 2.0 we are in the positive change business. This may seem like a challenging task in light of the new Trump administration and the Republican Congress. But we have been handed a gift, the gift of Donald, Minority Donald, the gift that may just keep on giving. 

We are too small and immature to even think about making substantive change for now. We will need to help rally large numbers of concerned citizens to make that happen. But perhaps we should start by being strong advocates for resistance in the near-term.   

RESIST

What do we do with the Donald?  We should resist him. Aggressively and at every opportunity.

Resistance may only slow him down; it almost never points the way to change.  But the Donald is a natural magnet for resistance, and the energy of resistance can then be channeled to more productive ends. 

We should promote resistance in any way people feel moved to commit and act—rallies, yelling at town hall meetings (they are content free anyway, so making a lot of noise is just making visible what lies underneath), picketing, buttons, demonstrations, sitting in at Trump Towers—anything that makes noise and can get noticed in the media.

In doing this, we should rationalize resistance: Yes it does not directly affect change, but we have to slow the train down before turning it around. Resistance is also fun and relationship forming / community building. What is crucial in Resistance is persistence; as soon as it goes quiet, it goes away, it has no life beyond the moment.  Resistance is the energy we need to get to the next step.

 PROVOKE

The next stage of civic engagement is taking on something specific, but not with a plan for remediation.  This can be mixed with Resistance, but is generally more effective separated, as provocation usually needs some kind of logical argument. 

Think in terms of massive letter or e-mail campaigns, and active discussion in social media about not repealed but rather repairing Obamacare is Provocation.  We may think of any interaction with the political establishment that is issue based as provocation. 

We can promote provocation by offering sound arguments about why to be against something, and organizing efficient ways of reaching your congressman.  But letters to others and social media posts will help as well, or organizing a letter or e-mail campaign, or creating a sustained force of provocation, something that goes on and on and on.   

A sequence of compelling anecdotes work well in this area of civic engagement.

People get mad and focused about things that are specific.

CHANGE 

This is what we hope to do, which is make specific recommendations to our elected officials about what they should do and organize sufficient quantities of people behind the ideas that our officials have to pay attention.   This is what we mean by effective civic engagement.

SATIRE

Satire in the political world is probably necessary, is fun, and can be engaging.  We suggest considering the Trump as an object of ridicule, of satire.  Two thoughts come to mind immediately:

(1) Always call him Minority Trump.  He has a very thin skin.  He was not elected by a majority.  He does not speak for us, he speaks for the other America, the minority of Americans rooted somewhere in our racist past, before the Civil War.  We can abbreviate this to MT at times, an abbreviate with an interesting pun built in as you sound it out.  He is MT!!! 

We should consistently portray him as diminished, below the people, underneath the power curve, not of the people, for the people, and certainly not by the people; he looks up at the Lincoln Memorial with envious eyes but a look in his face that knows he will never be there, swaddle in his own flag, his rattle leaking pellets. 

If we can get some traction and we are successful at this imaging, he will tweet us out, and we will be made, an audience guaranteed for a long enough period to turn them into real political creatures. 

(2) A part our Federalist 2.0 web site will be a continuing lampoon of MT.  We are working on the “Lie of the Week section”.  There will features of the best editorial cartoons and cartoon contests.  There will be the persistence image of a sandbox and a drawing of Trump in diapers, ranting with the scepter and grain.  There could be Swiftian short pieces of direct satire which could try to be fresh.  

Why not just kill off all those who cannot afford health care (modeled after “A Modest Proposal”) If we insist on limiting health care to those who can afford it, we should do the same with education.  Draining the swamp just creates a desert.  America is First in Weapons of Mass Destruction and infantile movies; we are way down the list around the world in education performance, health care, health itself (obesity rate), infrastructure, train speed, national debt, income gap, carbon abatement: Trump is amplifying every area in which we are behind to make us further behind (this could be a moving set of bar charts with MT pushing down the bars where we are below others).

Wonder what President Lincoln might be thinking as Trump discussed healthcare reform recently: “I have to tell you, it’s an unbelievably complex subject. Nobody knew that health care could be so complicated.” Duh.

It could be argued, and is being argued, that the best treatment of Trump is to ignore him, the one thing he really cannot stand.  That might have been effective before the election (but probably not); now it is simply opting out. 

Trump will dominate the headlines and social media for as long as he is in office.  Some think he is manipulating the press intentionally; I think he is just being Trump, the C actor wishing he was on reality TV still and could go home afterward with no consequences, “Your Fired” his only contribution to the world.  

 Trump cannot and should not be ignored.  So best to exploit his huge gravitational force.

The Problems with Obamacare and Finding a Better Way Forward.

There is a blinding glimpse of the obvious when looking at the Affordable Care Act (Obamacare) that was enacted back in 2010: It is a mind-numbing 2409 pages in length, and as a result it is just way too complex for most elected officials and the general public to understand, much less determine an intelligent and straightforward way to amend it.

It Starts with Name Confusion

A recent NY Times article reported that “A sizable minority of Americans don’t understand that Obamacare is just another name for the Affordable Care Act.” In the survey conducted by Morning Consult -  they reported that nearly one in three of the respondents said either they thought Obamacare and the ACA were different policies (17%) or didn’t know if they were the same or different (18%). 

NPR interviewed the Chief Research Officer Kyle Dropp of Morning Consult recently about the survey. He observed "Something like 35% of Americans did not realize they were the same policy. And that number spiked among Millennials and among adults with lower incomes. And these these are specific populations that might most be affected by some of the policy proposals."

It's really hard to debate an issue when some people are not even sure they are talking about the same thing. Establishing a baseline knowledge for a majority of Americans on the ACA might be a good place to start.

Attempts at Explaining ACA

We found several admirable attempts at explaining ACA - what it is and some the problems it is facing.

First the Obama White House You Tube channel offered up a white-board treatment of "What Obamacare Means for You." It does a decent job of identifying the major moving parts of the ACA in under three minutes.

The Kaiser Family Foundation "The You Tunes Get Ready for Obamacare" video is an entertaining way of explaining how most Americans get their health insurance under ACA, and how it works for various segments of the population. 

 Back to the Future

At this point it might make sense to take stock of where America is on the healthcare discussion, and what should be done with either revamping the ACA or simply starting over with a completely new legislative initiative on health care.

Looking back to the Federalist Papers (#62) written by James Madison we admire the passage that reads:

"It will be of little avail to the people, that the laws are made by men of their own choice, if the laws be so voluminous that they cannot be read, or so incoherent that they cannot be understood..."

 This aptly describes the ACA at present.

More on The Affordable Care Act

Is it worth trying to salvage ACA or repeal it all together as Trump and many Congressional Republican have been advocating? Consider the following:

Back in 2013 the Washington DC based think tank Brookings Institute detailed why the implementation of the ACA has been so difficult, this also gives insights into why it may well be impossible to reform. Shortly after this report was released, The Week summarized key takeaways from the report:

1.     Government complexity comes with the territory.

2.     This “pro-market mindset” has also prevented the US from adopting a national system to provide or pay for universal healthcare (as many other countries did years ago)

3.     Instead of government-run healthcare, the U.S. has relied primarily on employers to purchase health coverage for their employees in the private market, with government policy filling in the gaps. The very fact the current system has so-called "gaps" makes it complex.

4.     Because the goal of ACA was to fill this last gap, which involved both expanding Medicaid and subsidizing purchases of private insurance, the legislation was inherently complex, noted Brookings: "There is no simple way to patch a patchwork."

5.     The law complicated things with the creation of the online insurance marketplaces. It would have been simpler to put the federal government in charge of creating exchanges, as the Brookings' analysis noted, and that was actually an early plan. But, because insurance is regulated at the state level and varies greatly across the country, the 50 states had to be involved.

A Better Way Forward?

The BBC published a great look at “Why is Obamacare so controversial?” late last year. It gives an overview of what the law does, some major data point highlights, and polling-based insights on consumer satisfaction with law. 

It also addresses why conservatives oppose the law, and lists some of the bigger problems.

The BBC identify the following ACA flaws that may be a good place to start fixing in the short term:

1.     Address the impact of the 2012 Supreme Court ruling that struck down the ACA provision saying states had to change how they administer Medicaid – which were supposed to be expanded to cover more poor people, while being funded by the Federal Government. Poor and working class families who don’t qualify for Medicare find themselves having to pay for private insurance or often-times going without coverage.

2.     Insurance companies are backing out of participating in Obamacare because fewer Americans than anticipated are signing up; that in turn raises insurances costs for everyone, which then further drives down participation. For some middle-income Americans, the subsidies available for buying Obamacare policies are not generous enough and the fines for not having coverage are too small to encourage them to enroll in plans.

3.     Premiums are to rise by an average of 25% in 2017. This increase was predicted at the start of the law, and the government subsides to help pay for insurance will also increase. But those who should be covered by the Medicaid expansion aren't eligible for those subsidies.

Instead of repealing ACA in its entirety, it might make sense to address some of the component part issues in the short-term, while stepping back and concurrently seeking a simpler and more holistic solution for the US healthcare quandary in the long-term, perhaps by 2020.

Will Free Markets Work for US Health Care Reform (Post ACA)?

The Emperor’s New Clothes 

On the eve of being sworn in as the 45^th President of the United States – Donald Trump has promised a replacement plan for ACA that will provide “insurance for everybody” that is “much less expensive.” This pledge contradicts Republican proposals which prioritize consumer choice over universal insurance. GOP lawmakers said the President had meant to promise “access” to insurance for everyone. 

Harkening back to Hans Christian Andersen’s original tale about the Emperor from 1837 – are people who question this highly ambiguous position “unfit for their positions, stupid or incompetent?” 

Maybe Trump will help clarify all this with a few tweets sometime soon.

  

The Republicans are now focusing on market-friendly mechanisms to reform health care. But what exactly are free markets in the context of health care?

Back in 1973 the US Supreme Court defined "fair market value" as "the price at which the property would change hands between a willing buyer and a willing seller, neither being under any compulsion to buy or to sell and both having reasonable knowledge of relevant fact." How many of us have "reasonable knowledge" of medical procedures or costs? 

This begs several obvious questions: Are there any parts of the current health care market that actually operate this way?

As the NY Times reported recently “As you know, the American health care system is not like a normal market. When you make most health care decisions you don’t get much information on comparative cost and quality; the personal bill you get is only vaguely related to the services; the expense is often determined by how many procedures are done, not whether the problem is fixed…The Republicans are going to try to introduce more normal market incentives into the process. They are probably going to rely on refundable tax credits and health savings accounts so everybody can afford to shop for their own insurance and care.”

Will Market Incentives Work in Health Care?

This question actually begs several questions: From an economic standpoint - will market mechanisms improve quality and reduce costs? And a behavioral one – will most people be willing and able to shop effectively (if at all) for health care insurance,? Or do they want someone else (like their employer or a government agency) to make the decision for them?

Free markets don’t work in Health Care for several reasons:

In a completely unregulated market – healthy people will not buy health insurance plans as often as sick people will. Insurance companies exist because some people get sick, but they make money because more people (in theory) don’t. As the Congressional Budget office observed in their recent report -  the repeal of ACA will drive the cost of health insurance up as insurers try to pay for the costs of the sick people they cover, further pricing out healthy people whom the insurers need to keep the costs down. 

This can lead to an untenable downward spiral: The whole market falls apart because they are too few healthy, less expensive people paying insurance premiums to cover the costs of the sick, more expensive ones.

Second there is the issue of incomplete information, especially compared with how most people go about buying just about anything else. When people get sick and go to a doctor, do they know that the doctor has their best interests in mind? Do most people have any idea of what the “right price” for a given problem / procedure is? Are they give a choice of treatments with clear cost / benefit comparisons? Under current policies prices for medical services are generally confidential. 

One can call hospitals or health insurers to ask for the cost of a stand medical procedure say knee replacement or cataract surgery, but they’re likely to be told that price information is proprietary – until they get the bill.

Most of us take our doctors at their word, undergo the prescribed treatment or procedure, hope for the best outcome and pray that most or all of the medical bills will be covered by insurance.

Next there is the problem that access to care in a free market system for many is completely contingent on one’s ability to pay for it, or be lucky enough to have employer-sponsored health insurance or qualify for Medicare or Medicaid. If we collectively believe health care insurance is a right, and that it is immoral to allow sick people to suffer, a free market system that leaves 50 million+ Americans without insurance is complicity in that immorality. Add this dilemma that medical studies show that the poorest people are also the sickest, and this “new and improved” approach will deny health care to the people who need it the most.

Consider a prototypical family of four living in Illinois. Both parents work for small companies that don’t offer health care insurance. They work hard, but without advanced degrees they pull in $55,000 in annual household income. Too much to qualify for Medicaid, yet after taxes, housing, transportation, food and other basic living expense they can hardly afford the $16,500 per year health care insurance bill, even with ACA tax credits and CHIP (Children’s Health Insurance Program).  

Finally, American health care costs are completely out of line with the rest of the developed world, and free-markets will not fix this problem. In France the average daily cost of a hospital stay is $853, in the US it is $4287. An MRI costs on average $335 in the UK, $363 in France but $1121 in the US. These and other price variations are detailed in the 2012 Comparative Pricing Report of the International Federation of Health Plans – a trade association for health insurance companies.

Our universal single-payer health-care plan for older Americans, Medicare, has lower costs and lower overhead than the system serving those under age 65. We should take this “blinding glimpse of the obvious” at face value and consider a similar single-payer health-care plan for all Americans?

 

Healthcare Insurance: It’s Really Complicated!

President Trump, meeting with the nation's governors at the end of February conceded that he had not been aware of the complexities of health care policy making: "I have to tell you, it;s an unbelievably complex subject. Nobody knew that health care could be so complicated." This may qualify as Trump's most profound observation to date. 

As we have advocated previously - Why not take the elements of Obamacare that work and then take the time to properly study appropriate alternative approaches over the next four years rather than undertake a knee-jerk partisan effort to kill off the entirety of ACA?

Why not aim for a genuine re-tool of US health care by 2020 and work towards the goal of providing universal health care for all Americans versus providing it only to those who can get it from their employer or the government, or afford to pay for it themselves – leaving an estimated 60 million people in the lurch of being uninsured?

                                                                                                                

What Will Happen if the Affordable Care Act is Repealed?

The Affordable Care Act (Obamacare) was designed to help more Americans have health insurance. It mandated that people have coverage. It made health care insurance easier to obtain. It also expanded Medicaid to cover lower-income people, established state marketplaces for purchasing insurance and provided subsidies to help cover the cost of premiums. 

It also prohibited insurance companies from denying coverage based on pre-existing conditions. The policy goal was clear: Provide health insurance to as many Americans as possible to help pay for medical procedures. 

It is important to remember that as the new Republican Congress and Executive branch move aggressively to repeal ACA - it was the Republicans that first put forth the basic tenants of the ACA back 1993. This was based on ideas the conservative Heritage Foundation put forth the their 1989 lecture entitled “Assuring Affordable Health Care for All Americans” written by Stuart M. Butler which included the idea of universal health care for all Americans. 

We would add to the notion of universal health care the overwhelming need to promote good health among Americans. Think of this as a “wellness dividend,” as a public good - one that could benefit the entire spectrum of Americans. It would deliver the dual-benefit of improved productivity and reduced health care costs if people simply don’t get sick as often as they do now due to poor health (from being over-weight, smoking, eating poorly, substance addiction, etc)

The Repeal of the Affordable Care Act

Now here comes the new Republican majority US congress and the Trump Administration and their efforts to repeal the ACA. A non-partisan Congressional Budget Office study just reported that 18 million people could lose their insurance within a year when this happens, and insurance premiums are likely to shoot upward if Congress repeals the ACA. Later, after the elimination of ACA’s expansion of Medicaid eligibility and subsidies for insurance purchased through ACA marketplaces, the number would increase to 54 million and then to 59 million in 2026.

Repealing the penalties that enforce the “individual mandate” would “both reduce the number of people purchasing health insurance and change the mix of people with insurance,” as younger and healthier people with low health costs would be more likely to go without insurance, the budget office said.

How many are at risk due to pre-existing conditions?

Before the Affordable Care Act was passed, many Americans faced being denied coverage from a new health insurer if they had a pre-existing medical condition. The ACA provision requiring insurers to cover everyone, regardless of pre-existing conditions, is a very popular component of the law.

The Kaiser Family Foundation projects that if the pre-existing conditions provision is repealed, 52 million Americans could be at risk of being denied coverage in the future.

The foundation concluded that in 11 states at least three in every 10 non-elderly adults would have this type of pre-existing conditions: WV, MS, KY, AL, AK, TN, OK, LA, MO, IN, KS – ironically all states that voted from Trump. Guess those voters missed the fine print on this issue.

What about the impact for people on Medicare?

A full ACA repeal will definitely impact a vast majority of Americans who are over 65 years of age and on Medicare.

A repeal will restore higher payments for the services performed under the managed care part of Medicare known as Medicare Advantage (which delivers extra coverage, like vision, hearing, dental, prescription drugs and health / wellness programs) per Kaiser. This will in turn lead to higher premiums for the people signed up with these programs.

The big ACA repeal whammy will be the reversal of efforts to close the “donut hole” for prescription drugs. One part of ACA dramatically cut the amount Seniors pay for prescription drugs. The “donut hole” existed before ACA when beneficiaries got some coverage up to a certain dollar amount, and then got none until a higher dollar catastrophic coverage provision kicked in. 

How much more will Americans have to pay out of pocket?

According to a Commonwealth Fund - Rand study released last fall, the current policyholder who purchased coverage on one of the marketplaces spends on average $3,200 in out of pocket costs annually for the premium and other costs, such as co-payments. 

The study found that repealing ACA alone without a replacement plan would increase out-of-pocket costs to $4,700 per year.      

Some replacement scenarios could produce a larger increase while some could result in smaller increases the study said.