• Using Smart Tech to Solve the Impass in US Health Care

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    The American health care payment system is stuck in the mud–mired down by traditional ways of delivering medical services.

    We can do better. Major, cost-effective technologies are available to be utilized.

    It is unlikely that the Senate Republican factions will resolve their health care related legislative differences, although last-minute compromise is possible. Also, it is unlikely that Congressional Republicans and Democrats will bridge their ideological and political differences. The American public demands lower cost, effective, appropriate health care coverage.

    Pragmatic economics, coupled with technology, is key because money to be saved by reducing Medicaid expenses can be used to provide increased health care coverage to the really Medicaid eligible, working Americans, and retired senior citizens.

    This reality concept will be regarded as mean-spirited by the 45 percent of American adults who do not have full-time employment, and the 94 million people who have decided to remove themselves the job market, and their political supporters. Requiring work as the consideration for receiving Medicaid social benefits is not necessarily mean-spirited.

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    Why Obamacare Failed

     The Obamacare (ACA) health care law concept and implementation has failed because it has substantially increased health care premia and reduced coverage.

    The Republican House alternative may be better than ACA, but it will be changed because the Republican Senate has three or more competing groups with conflicting approaches to health care legislation, none of which conform to the House version.  A two-party compromise Senate health care bill is unlikely to be reached because Democratic senators will not vote for Republican health care legislation, and the likelihood of a good faith compromise is nil.

    There is an impasse: a predicament affording no obvious escape. Meanwhile, the future health care of Americans is in limbo.

    The solution is apparent, but unperceived: patient data collection by smartphone, and the acquisition of an available personal health care profile and its adaptation.

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    Nobody’s happy with the Republican proposals, either

     The most recent health care public polling suggests dissatisfaction with both parties’ plans.

    For example, the Republican House bill, repeal and replace ACA, has only 16 percent approval.

    The public approval of ACA and whether efforts should continue to repeal and replace this law are almost evenly split among the public.

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    Self-interested players in Health Care . . . with different goals

     The health care discussion arena is composed of numerous self-interested players. Their interests are often different.

    Following are differing perspectives:

    • Provide what the public needs, rather than what they want
    • Older people use more than one-half of the health care money in the last few months before they die
    • The younger generation believes that they are health infallible, and they do not want to pay for older generation and senior health care expenses
    • What can the federal and state governments afford to pay for health care that competes with other national priorities such as road building and maintenance, education, national security, and military defense?
    • Compassion for the health care underclass has financial limits: single-parent families, the disabled, many of whom could be employed part-time, and alcohol and drug addicts
    • Many private health care insurance companies have and are canceling their participation in government sponsored health care plan coverage because of contemporary major losses and future financial uncertainty
    • The fallback solution that may emerge may be a federal government single payer, rather than the private sector insurance
    • Personal health responsibility:  stay healthy and save money for oneself and for the government is not part of American culture
    • High volume Medicaid provider hospitals provide high technology services that are duplicative and are expensive, although these devices are not fully utilized in many urban areas
    • Primary care physicians correctly believe that they are under-reimbursed for the essential Medicaid services that they provide. As a consequence, many primary care physicians are leaving the practice of medicine, or they decline Medicaid patients because of the high volume of paperwork documentation that is required

    Economics encompasses all of these issues: what can taxpaying citizens and their government afford, and what is the priority allocation among competing government services?

    Although there are no easy solutions, we need to use the best technology currently available and some emerging ones, and supplement them by training a new generation of medical-technology providers.

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    Medicaid’s Explosive Growth, Explosive Costs

     President Obama’s ACA increased Medicaid eligibility to 133 percent above the poverty line. However this Medicaid increase was challenged in NFIB v. Sibelius, finding that it was state coercive, and that the federal government could not compel states to increase Medicaid eligibility.

    The federal government pays states for a defined percentage of their Medicaid program expenditures. The Federal Medicaid Assistance Percentage (FMAP) varies by state based on criteria such as per capita income. The average federal payment made to states is 57 percent; 50 percent for wealthy states, and 75 percent for lower per capita income states.

    The 1965 Medicare amendment to the Social Security Act established the Medicare and Medicaid programs. The concept of Medicaid is that it is a social health care program for families and individuals with limited resources and special needs that is funded by federal and state governments. States manage the program and they have broad discretion to determine eligibility and benefits. Medicaid eligibility is an ideological and political battleground. Reduction of people who receive Medicaid benefits is regarded as mean-spirited – an estimated decrease of 20 million Medicaid recipients by the year 2027.  In contrast, there may be as many as 20 million Medicaid recipients who are not eligible.

    An estimated 1/3 of people who receive Medicaid payment are able-bodied who can work in the public or private sector. This concept – “get off the couch and go to work” – is now enforced by some states which have passed “Workfare” legislation wherein able-bodied persons must work to qualify for social program benefits.

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    Back to the States to Cope with Costs

     Consider another proposition that places health care responsibility with states, rather than the federal government.  States would receive a federal government payment, varying from 50 to 75 percent based on poverty eligibility levels. The states would have responsibility and flexibility to determine eligibility and the amount that they would pay for Medicaid expenses. The federal government responsibility would be to audit state health care payments to be certain that health care money provided by the federal government would not be diverted to other state programs. The advantage of total state responsibility would be administrative control, program efficiency, adherence to strict eligibility enforcement, and the political choices to be made by state citizens, that would vary by state.

    Economics drives political and social policy decisions because funding for Medicaid health care is finite. The FDA has provided an exception to the spiraling cost of Medicaid by reducing the cost of prescription medicine for patients. Many drugs do not face competition from cheaper generic alternatives even though their intellectual property protection rights have expired. When there are two or more generic competitors the drug cost to consumers drops by about 50 percent, saving consumers an estimated $250 billion dollars. Economic competition in medicine can result in major cost savings. The issue is whether economic cost saving and program efficiency can compete and overcome political differences.

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    Conclusion: Looking Forward

     Look to the future of medicine and health care. Hardware and software permeates all sectors of health care, but it has not been applied in medical practice. Sensors, imaging, patient genetic history, artificial intelligence, and home health monitoring, if used nationally, can retard or reduce the $3 trillion annual health care expense.

    US health care is the primary responsibility of doctors and hospitals that have made marvelous contemporary advances in patient diagnoses and care. The future improvement will be to exponentially advance contemporary health care by focusing on available, cost-effective technology.

    This is an opportunity to create a new, innovative profession: data-based health care consulting, with or without traditional M.D. degrees; and for medical schools to adopt emerging technology in their curricula.

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    Richard Friedman worked on Medicaid and Medicare cost containment for the US Department of Health, Education and Welfare 1974-76 when these programs were 9 percent of GDP – now at 18 percent. He has provided legal representation to hospitals and physician groups while in the private practice of law.

     

     

  • ZipDialog Roundup for Monday, May 1. . . May Day! May Day!

    Topics and articles chosen with care. Linked articles in bold purple

     Government to stay open through September, thanks to bipartisan agreement over a Continuing Resolution (Washington Post)

    The bipartisan agreement includes policy victories for Democrats, whose votes will be necessary to pass the measure in the Senate, as well as $12.5 billion in new military spending and $1.5 billion more for border security requested by Republican leaders in Congress. –Washington Post

    Comment: Rare agreement–on anything.

     Bret Stephens’s first NYT column just ran. It said some climate science findings are clear-cut, others less so. HERETIC ALERT!!! NYT readers immediately began cancelling their subscriptions.

    You can agree or disagree with Bret’s views, which are balanced and presented with supporting data. But heads exploded all over Cambridge, Berkeley, Ann Arbor, and the Upper West Side.

    Anyone who has read the 2014 report of the Intergovernmental Panel on Climate Change knows that, while the modest (0.85 degrees Celsius, or about 1.5 degrees Fahrenheit) warming of the Northern Hemisphere since 1880 is indisputable, as is the human influence on that warming, much else that passes as accepted fact is really a matter of probabilities. That’s especially true of the sophisticated but fallible models and simulations by which scientists attempt to peer into the climate future. To say this isn’t to deny science. It’s to acknowledge it honestly.

    By now I can almost hear the heads exploding. . . .

    Let me put it another way. Claiming total certainty about the science traduces the spirit of science and creates openings for doubt whenever a climate claim proves wrong. Demanding abrupt and expensive changes in public policy raises fair questions about ideological intentions. Censoriously asserting one’s moral superiority and treating skeptics as imbeciles and deplorables wins few converts.

    None of this is to deny climate change or the possible severity of its consequences. But ordinary citizens also have a right to be skeptical of an overweening scientism. –Bret Stephens in the NYT

    For this kind of wild-and-crazy talk, CNN reports “NYT subscribers dropping paper over climate column” Here’s just one example:

    Comment: Who says religion is dead? The Times’ readers reaction is roughly the same as citizens in Calvin’s Geneva if you had said, “Let’s discuss whether to keep one or two Saints’ Days.” 

     The impact of ISIS terror attacks on Europe’s “state of mind”  (Dr. Tsilla Hersco at Begin-Sadat Center, Bar-Ilan Univ., Israel)

    EU now favors discreet cooperation with Israel to combat terror, while still opposing Israel’s own measures to combat Islamic terrorism

    The appalling terrorist assaults perpetrated by ISIS in Europe have led to significant changes in the European state of mind. By exposing the vulnerability of EU state borders, they have prompted rudimentary initiatives to secure those borders and increase counter-terror cooperation among EU member states, while also boosting the popularity of far-right parties.

    The attacks have given rise to a discreet cooperation between EU member states and Israel in dealing with the terrorist threat, but have not prompted the EU to change its critical position regarding Israel’s defensive measures against Palestinian terror. The moral double standard of the EU on this issue might undermine its own fight against Islamist terrorism. –Dr. Tsilla Hersco at BESA Center

     Nancy Pelosi to face primary opponent associated with Bernie Sanders  (The Observers) Her adversary, Stephen Jaffe, is a prominent SF lawyer, specializing in discrimination, sexual harassment, and whistleblowers.

    Comment: Pelosi will be wading in campaign cash, but she won’t be able to run on a record of recent achievements. There aren’t any.

    Larger issue: The prospect of being “primaried” from the left could become a major obstacle for any Democrats who want to work with Trump, and vice versa. My guess is that it already affected Missouri Sen. Claire McCaskill, who voted to filibuster Neil Gorsuch even though Trump easily won Missouri.

     Here are two words I’ve never seen before in one sentence: “accordion heartthrob” But that is the NYT headline for Dick Contino’s obituary. His career in B-Movies also inspired novel by James Ellroy (who also wrote L.A. Confidential).

     Sure hope he likes irony: Chicago Police Chief’s SUV broken into during a ‘crime of opportunity’  (Chicago Tribune)

    Comment: Imagine, if you will, breaking into Al Capone’s car by accident. What’s the over/under on how long you live? One day?

    In today’s Chicago, what’s the likelihood they’ll even find the perps?

     Macron (leading Le Pen in the French election runoff) is right about this. It’s not just France that will want out if the EU if it doesn’t reform. BBC article here.

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    Hat tip to Ed Vidal for the CNN story about NYT cancellations.

     

  • Meals on Wheels: Does the Trump Budget Cut It? Separating Facts from Political Spin

    One of the most devastating attacks on Pres. Trump’s proposed budget is that it cuts funding to Meals on Wheels. The program provides meals to the elderly poor.

    It is understandable that people would be upset about this prospect, which has received headlines but little real scrutiny.

    There are two main questions here:

    1. What tasks should government undertake?
    2. Does the Trump budget abandon a basic responsibility and seriously cut Meals on Wheels?

    The Government’s Core Responsibilities: Ensure aid to the poor and hungry

    No one should go hungry.

    Basic principle: If a country is wealthy enough to afford it, the state should ensure that everyone has access to healthy nutrition.

    It should compel taxes to ensure that and direct some of the funds to feeding the poor. It is a very good thing we have Food Stamps, Meals on Wheels, and other programs that do that.

    Some money is inevitably misspent, either by the government or recipients. But, in aiding the poor, we should remember the principle on which our criminal justice system is built:

    It is better that ten guilty persons escape than that one innocent suffer.

    -Blackstone, Commentaries on the Laws of England (1760s)

    It is better to see some money misspent than to see one hungry person suffer.

    Meanwhile, we should work hard to eliminate the misspending so taxpayers are treated fairly and the money can go where it is needed.

    If a person is healthy and of working age, then it is reasonable to impose some work requirements in return for such aid, if voters wish.

    In a country with a vibrant civil society, then private assistance should be encouraged, as it is in the US, with wonderful effects for both givers and receivers.

    Did Trump’s Budget Cut Funds to Meal on Wheels?

    No, not really.

    The main federal funding for the program comes, appropriately, through the “Older Americans Act Nutrition Program.”

    There are no proposed cuts to that program, and Meals on Wheels says so.

    So what was the New York Times talking about when it reported the cuts and everyone else parroted their report?

    The Trump budget proposes:

    the complete elimination of the $3 billion Community Development Block Grant program, which funds popular programs like Meals on Wheels, housing assistance and other community assistance efforts. –New York Times

    So, you have one specific program cut. It is a controversial block grant program, which many consider corrupt, in which local officials have wide discretion in allocating the money. A small portion of that discretionary local allocation goes to Meals on Wheels.

    Comment: What the NYT said was technically accurate but fundamentally misleading because it did not indicate that such a small percentage of Meals on Wheels funding came from this source or that the source itself was controversial and considered corrupt by many. What makes the NYT report troubling is that it is, in effect, editorial commentary wedged into a hard news story.

    You can think the whole program should stay. Or you can think it should go. Or you can think, as I do, that it is fine to cut the block grant program but, if you do, then add resources to other programs that help the very poor.

    But whatever you think is the best policy, you should recognize that saying the budget wipes out Meals on Wheels is not only a vast exaggeration, it is political spin.

    Best Quick Summary

    This from Investors Business Daily:

    Contrary to news reports last week, President Trump is not eliminating funding for Meals on Wheels. He’s not even cutting it.

    How do we know this? Meals on Wheels says so. A statement issued by Meals on Wheels America on Thursday notes that 35% of the revenues at the 5,000 or so local Meals on Wheels programs come via the Older Americans Act Nutrition Program.

    Trump’s budget outline says nothing about this program whatsoever.

    What Trump’s budget does propose is cutting is the corruption-prone Community Development Block Grant program, run out of Housing and Urban Development. Some, but not all, state and local governments use a tiny portion of that grant money, at their own discretion, to “augment funding for Meals on Wheels,” according to the statement. –Investors Business Daily

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