Up With Extremism
by Thomas L. Friedman - NYT - January 16, 2016
From its very inception, Donald Trump’s campaign for president has been life imitating Twitter. His candidacy is built on Twitter bursts and insults that touch hot buttons, momentarily salve anxieties and put a fist through the face of political correctness, but without any credible programs for implementation.
Where Trump has been a true innovator is in his willingness to rhetorically combine positions from the isolationist right, the far right, the center right and the center left. If I were running for president, I’d approach politics in the same way: not as a liberal, a conservative, a libertarian or a centrist.
I’d run as an extremist.
The agenda that could actually make America great again would combine the best ideas of the extreme left and the extreme right. This year is probably too soon for such a radical platform, but by 2020 — after more extreme weather, after machines replace more middle-class jobs, after more mass shootings and after much more global disorder — voters will realize that our stale left-right parties can’t produce the needed answers for our postindustrial era. Accelerations in Moore’s law, the market and climate change are transforming the workplace, the environment and nation-states, leaving people feeling insecure and unmoored.
It’s time for a true nonpartisan extremist, one whose platform combines the following:
■ A single-payer universal health care system. If it can work for Canada, Australia and Sweden and provide generally better health outcomes at lower prices, it can work for us, and get U.S. companies out of the health care business.
■ Expansion of the earned-income tax credit to top-up wages for low-income workers and introduction of a negative income tax to ensure a government-guaranteed income floor for every American. In an age when machines are gobbling low-skilled jobs, we’ll need both.
■ Common Core education standards as the law of the land, to raise education benchmarks across the country, so high school graduates meet the higher skill levels that good jobs will increasingly demand. But those higher standards should be phased in with funding to enable every teacher to have the professional development time to learn the new curriculum those standards require and to buy the materials needed to teach it.
■ Controlling low-skilled immigration while removing all limits on H-1B visas for foreign high-skilled knowledge workers and doubling the research funding for our national labs and institutes of health to drive basic research. Nothing would spin off more new good jobs and industries than that combination.
■ New accelerated tax incentives and elimination of all regulatory barriers to rapidly scale up deployment of superfast bandwidth for both wire line and wireless networks to ensure that next-generation Internet services are developed in America. And borrowing $100 billion at today’s super-low government interest rates to upgrade our ports, airports and grids and to create jobs.
■ Bans on the manufacture and sale of all semiautomatic and other military-style guns and government offers to buy back any rifle or pistol in circulation. It won’t solve the problem, but Australia proved that such programs can help reduce gun deaths.
■ To pay for all this, a phased-in innovation and tax agenda that incentivizes start-ups and hiring. That means: Slash all corporate taxes, income taxes, personal deductions and corporate subsidies and replace them with a carbon tax, a value-added consumption tax (except on groceries and other necessities), a tax on bullets and a tax on all sugary drinks — with offsets for the lowest-income earners.
We need a tax system that shrinks what we don’t want — carbon, sugar and bullets — and incentivizes what we need. If we slash corporate taxes, many more companies will want to locate here, and the ones domiciled here will have the incentive to bring home foreign profits and plow them into research and new business lines.
■ An independent commission appointed to review Dodd-Frank and Sarbanes-Oxley to determine which, if any, of their provisions are needlessly making it harder for entrepreneurs to raise capital or start businesses. We need to be sure we’re preventing recklessness — not risk-taking.
■ Copy Britain: Strictly limit national political campaign spending and the length of the campaign to a period of a few months. It makes it much harder for billionaires to buy candidates.
■ Increased military spending and ensuring that our intelligence services have all the legally monitored latitude they need to confront today’s cyberenabled terrorists — because if there’s one more 9/11, many voters will be ready to throw out all civil liberties. And with the world cleaving into zones of “order” and “disorder,” we’ll need to project more power to protect the former and stabilize the latter.
In sum, our slow growth, inequality and national security challenges require radical solutions: strengthening safety nets, curbing the bad environmental and health behaviors that are bankrupting us and paying for it all by sharply incentivizing risk-taking, innovation, investment and hiring.
That calls for a nonpartisan extremist for president who’s ready to go far left and far right — simultaneously. That’s my 2020 vision, and in four years the country just might be ready for it.
Lost Jobs, Houses, Savings: Even Insured Often Face Crushing Medical Debt
by Margot Sanger-Katz - NYT
Here is the surest way to enjoy the peace of mind that comes with having health insurance: Don’t get sick.
The number of uninsured Americans has fallen by an estimated 15 million since 2013, thanks largely to the Affordable Care Act. But a new survey, the first detailed study of Americans struggling with medical bills, shows that insurance often fails as a safety net. Health plans often require hundreds or thousands of dollars in out-of-pocket payments — sums that can create a cascade of financial troubles for the many households living paycheck to paycheck.
Carrie Cota learned the hard way that health insurance does not guarantee financial security. Ms. Cota, a 56-year-old travel agent from Rosamond, Calif., learned she had the autoimmune disease lupus in 2007. She ran up thousands of dollars in medical and dental bills and ended up losing her job, and eventually her house.
“I had to move in temporarily with my ex-husband,” she said in a recent interview. “I’m staying with him until I can figure out what to do.”
In the new poll, conducted by The New York Times and the Kaiser Family Foundation, roughly 20 percent of people under age 65 with health insurance nonetheless reported having problems paying their medical bills over the last year. By comparison, 53 percent of people without insurance said the same.
These financial vulnerabilities reflect the high costs of health care in the United States, the most expensive place in the world to get sick. They also highlight a substantial shift in the nature of health insurance. Since the late 1990s, insurance plans have begun asking their customers to pay an increasingly greater share of their bills out of pocket though rising deductibles and co-payments. The Affordable Care Act, signed by President Obama in 2010, protected many Americans from very high health costs by requiring insurance plans to be more comprehensive, but at the same time it allowed or even encouraged increases in deductibles.
“We’re at a point where there’s been slow growth in health care costs and huge improvements in the numbers of people who have health insurance,” said Sara Collins, a vice president at the Commonwealth Fund, a health research group. “But there is this underlying trend towards higher cost sharing that could put increasing numbers of people at risk for being underinsured.”
Among those who reported having problems paying their bills despite having insurance, 63 percent said they used up all or most of their savings; 42 percent took on an extra job or more work hours; 14 percent moved or took in roommates; and 11 percent turned to charity.
Randy Farris, 58, a factory worker from Conger, Minn., needed a knee replacementthree years ago. His insurance covered 80 percent of the bill, but he needed to cash in an I.R.A. to pay his $4,000 share. “I haven’t been to the doctor since because I don’t want any more doctor bills,” he said. His wife’s retirement savings had been wiped out years before, he said, when he used them to pay her hospital bills after she died of cancer.
The health law has led to a decline in the number of Americans suffering financial stress from health problems, thanks to the new options for receiving coverage, especially for the poor. But the problem is still widespread, touching roughly a quarter of Americans under 65, when the insured and uninsured are looked at together. Americans older than 65 are covered by Medicare, which more frequently protects people from major financial trouble.
Unlike other polls, which have focused on the ways that insurance affects health care, the new Times-Kaiser survey explored the effects of medical bills on people’s daily lives well beyond the medical system. We found that medical bills don’t just keep people from filling prescriptions and scheduling doctors’ visits. They can also prompt deep financial and personal sacrifices, affecting their housing, employment, credit and daily lives. Kaiser has released a report today, detailing the survey’s main findings about this population.
“The major impact is actually a pocketbook or economic impact: their ability to pay the rent or the mortgage or buy food,” said Drew Altman, president of the Kaiser Family Foundation.
Yes, Obamacare is in dire need of fixing. Here's a guide to the best options.
by Michael Hiltzik - LA Times
ou can set your watch by it, or at least your calendar. If it's a day of the week ending in "Y," the House congressional majority is preparing to vote to repeal the Affordable Care Act. These days are no exception: A repeal vote in the House is scheduled for this week, linked to a provision to cut funding for Planned Parenthood. Both will be DOA at the president's desk.
What's lost in this openly partisan waltzing around is that many aspects of the ACA are in dire need of fixing. Some are the result of hasty or poor drafting; others reflect practical problems that emerged once Obamacare went into operation.
These are inevitable occurrences with any major legislation, though they don't have much to do with the real issue conservatives have with the ACA. In the view of John E. McDonough of Harvard's School of Public Health, it's that Obamacare raises taxes on the wealthy while giving them "bupkis" in direct benefits.
A lot can be done to correct the real flaws in the ACA, and Timothy S. Jost, emeritus professor at Washington and Lee law school, and Harold Pollack of the University of Chicago have provided an extensive guide, published a couple of weeks ago by the Century Foundation.
Jost and Pollack approach their task as admirers of the ACA, which they note has brought the percentage of Americans under 65 without health insurance to its lowest point in five decades. Yet they acknowledge that "some of its approaches have turned out to be ineffective, poorly targeted, or not ambitious enough to address deeply rooted problems.”
Here are a few of their main recommendations.
--Fix the "family glitch." Jost and Pollack properly call this "the most glaring defect" in the ACA's subsidy structure. Under the ACA, a worker is ineligible for ACA subsidies if he or she is offered affordable health coverage by an employer. Whether because of a drafting error or inattentive rulemaking by the IRS, that ineligibility extends to all members of the worker's family even if affordable family coverage isn't obtainable from the employer.
The Rand Corp. has estimated that the change would add as many as 4.7 million Americans to the rolls of the subsidized insured at a cost of up to $8.9 billion, or about two-tenths of one percent of the federal budget.
--Improve subsidies and otherwise reduce the burden of cost-sharing. Sticker shock in the individual health insurance market has shifted from premiums to deductibles, co-pays and out-of-pocket limit. These still leave too many working-class families with heavy medical bills, and discourage some from signing up for insurance at all, even given the existing subsidies. That's especially true of families earning over the eligibility ceiling for tax subsidies, which is 400% of the federal poverty line ($97,000 for a family of four).
deduct
Health insurance deductibles have been rising for more than a decade, even in employer-paid plans, though the rate of increase has slowed since enactment of the ACA. (The Century Foundation)
Jost and Pollack endorse increasing subsidies for families below 400% of the FPL, and providing those over that line with subsidies that would bring down coverage costs to a given percentage of household income -- say 8.5%. One option is to give those families the option of fixed-dollar tax credits that would improve insurance affordability while still leaving them responsible for most of the costs.
--On Medicaid, give states an option they can't refuse. The Supreme Court in 2012 saved Obamacare generally but threw a monkey wrench into a key provision mandating that states expand Medicaid to cover the poorest households. The court made Medicaid expansion voluntary, and 20 states, all with GOP control of the legislature or governorship or both, are still holding out.
One common rationale of the holdouts is that the federal share of the expansion, which is 100% through this year, will gradually ratchet down to a permanent 90% through 2020. Jost and Pollack call this "one of the most generous federal-state financing arrangements in the history of health policy," and observe that expansion has been a boon to state governments and economies that have accepted the change.
But in some states it remains at least an ostensible argument against expansion, which has left more than 3 million Americans uncovered in the holdout states. So they propose making permanent a federal share at 100%. This will cost about $5.2 billion in 2020, when 11.9 million adults would be covered.
--Eliminate estate recoveries from the new Medicaid patients. The ACA drafters overlooked that traditional Medicaid rules allow states to recover the cost of care from the estates of patients who received expensive care on the public's dime despite owning homes or other assets that could be sold to repay the program.
That provision remained in place for patients gaining coverage from Medicaid expansion, even though they're a discrete population and uniquely charged for coverage among ACA beneficiaries. (The tax subsidies enjoyed by wealthier insurance enrollees don't have to be paid back.) Several states say they may try to recover Medicaid expenditures from enrollees over 55; others such as California say they won't do so, but have the right to change their minds.
The provision is unfair at best and counterproductive at worst, since it may discourage some households eligible for Medicaid from signing up, fearing that their meager assets eventually will be seized. The rule is a record keeping nightmare and the return is insignificant. Jost and Pollack rightly say that Congress should kill it.
--Restore the "public option" by offering Medicare to the 60+ population. The original public option, which resembled Medicare for all, was killed during the ACA's legislative phase by opposition from the drug industry, hospitals and physician groups, and medical device makers who feared having to negotiate prices with Medicare.
Jost and Pollack propose a demonstration program offering Medicare to Americans in the near-retirement cohort -- say ages 60 to 65, after which they're eligible for Medicare anyway. This group tends to have high medical needs, pay the highest insurance rates under the ACA's limited age-based cost ratings and often earn too much to be eligible for subsidies. But they might benefit the most from early admission to Medicare.
These are, on the whole, responsible, well-targeted fixes to flaws that become manifest. Some, including a fix to the family glitch, can be managed by administrative order. Others require action by Congress. Obamacare's critics in Washington have continually claimed that they're in favor of better health and healthcare for all Americans, but don't like the way the ACA delivered it. Here's their chance to take a few steps showing a genuine commitment.
Despite a host of political and practical challenges, Obamacare keeps chugging along
LA Times Editorial
he House of Representatives is expected to give final approval Wednesday to a bill that would repeal much of the 2010 Affordable Care Act — a measure that President Obama will surely veto, and that Republicans will not be able to override. A more serious threat to the program has been rising premiums and insurance-company losses in the state marketplaces for Obamacare policies, two factors that some analysts feared would trigger a death spiral of mounting premiums and declining enrollment. The results so far, however, suggest that Obamacare is surmounting these challenges as well.
2015 was a tough year for Obama's signature domestic program. A dozen nonprofit insurance co-ops created by the law have failed, unable to survive despite hefty government aid. Meanwhile, many insurers sought double-digit increases in premiums for 2016 to compensate for higher-than-expected healthcare claims. UnitedHealthcare, a large national insurer, went further, shutting down its marketing of Obamacare plans and suggesting that it wouldn't sell them at all in 2017.
But these incidents don't tell of a program crumbling under its own weight — they're signs of an industry adapting to the enormous changes wrought by the law. Eager to grab a large chunk of the new Obamacare market, some insurers priced their policies too low in the first years of the exchanges, when they had little experience to guide them. Their adjustments this year pushed up premiums for the benchmark plan — the one on which subsidies are based — by 11% on average across the exchanges.
According to the Kaiser Family Foundation, the increase was significantly lower in large cities across the country, where there was more competition among insurers and larger pools of customers. Many consumers also were able to save money by switching insurers. Besides, about 80% of Obamacare enrollees receive subsidies that limit premiums to a percentage of their income, blunting the effect of any rate hikes.
With about a month left in the open enrollment period, the 37 federally operated state exchanges are on track to meet or exceed the (admittedly conservative) projections for sign-ups, with larger numbers of new customers and young enrollees than at the same point last year. And as more states open their Medicaid programs to a larger share of their poor residents, the number of uninsured Americans continues to shrink. The rising cost of healthcare remains a problem, and the Affordable Care Act's efforts on that front haven't yielded dramatic improvements. Nevertheless, covering more people with insurance is crucial to making the systemic changes needed to bring healthcare costs under control. And on that front, at least, the law is still working.
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