A few thoughts on the prospects to “repeal and replace” Andy Harris (and Obamacare, too)

The other day I noticed on social media that our Congressman, Andy Harris, had put up a post explaining his vote for Trumpcare 2.0, the “repeal and replace” bill for Obamacare. (Most people refer to it as the American Health Care Act, or AHCA.) At the time I saw this there were 1,043 comments on his post and probably 80 to 90 percent of them were negative. I can guarantee you that 80 to 90 percent of his district doesn’t oppose his vote, but thanks to this so-called “Indivisible” movement we are seeing some of the most seriously squeaky wheels get the grease that comes from taking 30 seconds to write the linguistic equivalent of “you suck!” on his wall. So I took about five to ten minutes to write my response, because there was a little research involved.

1,043 comments, mostly from people who probably didn’t vote for Andy in the first place, vowing he’s going to lose in 2018. Y’all need about 139,000 more folks.

In terms of repealing the disaster known as Obamacare, this was the correct vote, We have a long way to go in the process and it’s way too early to say what will happen in the Senate (except that regardless of what it is, Maryland’s Senators will vote no.)

Oh, and by the way, I just checked out that Allison whats-her-name and if she’s praising NARAL she’s not getting too far in this district. Most of us stand for life.

Also, since you are on the subject of town halls up and down the thread, could you get those aforementioned Senators down here to have one? Interesting how I never hear anyone clamoring for that.

I have to admit I was only being semi-flippant when it came to “Allison whats-her-name” because I had closed my window and honestly didn’t feel like looking it up. Her name is actually Allison Galbraith and she makes her living from, of all things, steering companies to government contracts. I kid you not.

But to begin this piece I want to address the two people who replied directly to my comment, whose names are Gail Jankowski and Bill Schwartz. I’m going to quote their opening sentences here, ladies first.

Gail: We will get MORE than enough votes to replace him because more and more constituents are learning just how negatively this AHCA will affect them!

Bill: Maryland is a Blue State and we need to ensure that the first district is fairly represented.

I’m sure Gail and Bill are nice enough people, and in her case she gets bonus points for (at least presumably, judging by the surname) marrying into a Polish family. (By the same token, I won’t take any points from Bill just because his ancestors insisted on unnecessary consonants.) But they seem to have a slim knowledge of political reality.

What the vast majority of people “know” about the AHCA comes from the talking points being fed to them from the media, which isn’t exactly a set of unbiased observers. But the 2018 campaign won’t begin in earnest for another 15 to 16 months, and what I’ve found out over the years, Gail, is that the issue you may think will drive the electorate this far out isn’t always the one that is front and center by the time people really begin to pay attention, let alone when votes are cast. The big difference between the era of the TEA Party eight years ago in the Obama administration and the Indivisible movement now is, while both are having a discussion about health care as a topic in the off-year before the election – although Obamacare was more dominant in the fall and winter of 2009 – the economy was much, much worse back then. If the economy is in good shape come the fall of 2018, the AHCA will be a minor issue by comparison. People generally vote with their pocketbooks, and the reason the 2010 election was such a wave was the pent-up outrage at an administration that addressed health care before job creation and the economy. (The sticker shock effects of Obamacare were the reason for the 2014 wave election, since it took effect in earnest that year.)

So if the economy remains in decent shape, the AHCA will be so minor of a concern by then that Andy Harris will once again get his 60-65% of the vote and cruise to victory. You see, Bill, Maryland is indeed (and unfortunately) such a blue state that our previous governor and the Democrats got greedy – or at least as greedy as their incumbent Democrat Congressmen would allow them to be. I’ve made this point before, but if the composition of the First Congressional District were the same in 2008 as it became in 2012, Andy Harris would be on his fifth term. By erasing the northern half of Carroll County from the previous configuration of the Sixth Congressional District and adding it to the First, it assured whoever the GOP puts up in the First District will win because the plurality of the state’s Republican voters now reside in the First, and it’s by a factor of almost 50% more than any other district. So based on the electorate of the district the First is fairly represented. (The rest of the state? Well, they are just poorly represented, but I’m working on that.)

So now let me turn to another aspect of social media. My friend Sarah Meyers, who describes herself as a proud moderate Democrat (and is a member of our county’s central committee) was distraught about the passage of the American Health Care Act, claiming, “The Republican House just voted to allow insurance companies to deny me healthcare.”

Now I’ll set aside the false conflation of actually having health care provided and paying for it, since there are other methods of doing so out there, but my response essentially noted that she is in the minority of people who are net beneficiaries of the ACA in terms of paying less. Those who get their insurance through their employer are paying far more, a fact that she chalked up to the “greed” of the insurance companies. But the “greed” is tempered by the fact that group insurers have to pay out 80 to 85 percent of their premium income on medical care, leaving the remainder for “administration, marketing, and profit.” Since neither administration nor marketing are free, one can presume these insurers are not rolling in profit. This “medical loss ratio” is part of the ACA and may be one reason why insurers are dropping out of the business.

One of the next arguments I got was that the ACA “saves lives,” presumably because those who could not afford insurance or were no longer being tossed off for the various reasons of pre-existing conditions, lifetime limits, and so forth were being covered. But the evidence of this is anecdotal at best, and rather dubious in the amount of inference that has to be made. It truly depends on the source, but the best scholarly guess is a net wash. Even some of the partisans concede it’s a bogus argument. And while there’s always the emotional appeal of someone who can come out and claim they are a survivor because they had health insurance through Obamacare, it’s pretty difficult to speak with someone who didn’t because Obamacare made their deductible too expensive.

The most radical solution offered up was the old single-payer bromide, from local leftist Chuck Cook:

Single payer is the only solution, and it has been proven to work in every single industrialized first world nation on the planet… except ours. We are the outlier due to conservative ideology that honors the wealth of billionaires over the health of children.

Uh…..no. Honestly, we’re very close to having a single-payer system in place here given the lack of competition in many places and tight regulations on the health insurance industry in terms of how much they can make, what they must cover, and how they conduct their business. Basically it would be a Medicare/Medicaid for All system and you can just ask a doctor (whose Medicare reimbursement increased a whopping 0.24% this year, with Medicaid reimbursement being a fraction thereof) how they like it or check out study outcomes, as the left-leaning Kaiser Family Foundation did recently, noting…

Multiple studies, though not all, have documented improvements in beneficiaries’ self-reported health, reduced stress and anxiety, and improved quality of life following Medicaid expansions. The Oregon Health Insurance Experiment, which used a research design that is considered the gold standard, compared the experience of adults who gained and adults who did not gain Medicaid coverage through a lottery that allocated a limited number of new Medicaid “slots” for low-income uninsured adults in the state. The study found that Medicaid improved self-reported mental health and reduced clinically observed rates of depression by 30% relative to the uninsured group. The findings related to impacts on physical health were mixed. Medicaid increased the detection of diabetes and use of diabetes medication, but did not have a statistically significant effect on control of diabetes, high blood pressure, or high cholesterol. The researchers note that the study did not have sufficient statistical power to detect changes in these measures, and also that factors including missed diagnosis and inappropriate or ineffective treatments, among others, could mitigate the impact of coverage on clinical outcomes.

…to see if this meets your definition of “proven to work.” For me it’s lacking.

I think both sides agree, though, that the problems with the system are defined simply: access and cost. The government’s solution was twofold: one side was to force everyone into the insurance market whether they wanted to be or not (hence, the “shared responsibility payment”) so that the healthy people would balance out the sick and the other side was to try and make preventative care cost nothing out of pocket, but the problem with that is doctors aren’t going to work for free because they have families to feed, too. And thanks to all of the billing and coding concerns we have with modern government medicine, a good percentage of the staff in any doctor’s office is the overhead required to deal with billing and not there for patient care. (It’s akin to the number of administrators in a school system who don’t educate children.) In other words, “free” is the extra $2,000 on your deductible or $40 a week out of your paycheck.

One analogy often used as a comparison to health insurance is auto insurance, which is also mandatory in most states (New Hampshire is the lone holdout.) However, when you buy auto insurance it does not cover oil changes, new tires, and other mechanical issues. Similarly, the original intent of health insurance was to cover the medical bills in case you were hospitalized, as opposed to supplemental insurance like AFLAC which covers other expenses.

The idea of insurance is that of calculating and sharing risk among as many participants as possible. Let’s say you have a group of 1,000 40-year-olds whose lives are all insured for $100,000 and you know four of them will die on the average in a given year. You then know your premium pool will have to be set to $400,000 plus an amount set aside for the off-chance of a year where more than 4 die, plus administrative expenses, plus a little for shareholders. If you assume those other expenses total $300,000, then each participant would pay $700 a year to be insured for $100,000 if they die, which they may find is a prudent and affordable hedge against that risk as they have families to support. It would be impossible for a group of 2 or 10 to be able to do this, but over a thousand people it’s very attainable.

However, what we now have with health insurance isn’t truly insurance because there is so much mandated coverage and the risks are highly unpredictable. Nor are they being shared among all the participants equally because some are paying themselves through their employer, some are being subsidized for their coverage by the government, and others are completely on the government dime. Because a large amount of the money comes from funds never seen by the buyers (deducted from their checks, or just plain subsidized) they don’t much care what treatment costs, just their premiums and deductibles.

So let me return to the car insurance analogy. You have to have car insurance, and it has to be minimum coverage, but after that the market is relatively free and there are a whole lot of competitors. If you get tired of Allstate because they raised your rates 50% for no good reason, there’s always Progressive. When Flo gets too annoying, Jake from State Farm will be happy to help. If you don’t like them, we have local independent agents. They compete on price, coverage, and service – so why can’t that be the case with true health insurance, too? And what I mean by “true health insurance” is that you select what you want to cover from the options provided by the companies, or you can skip it altogether. (Or, the option for employers to provide group coverage can be left in place as well, as I’ll get to in a moment.)

I can already hear the Sarah Meyerses of the world screaming “but pre-existing conditions!” Yes, there can be high-risk pools created for those at the state level, or even groups of states can create a compact to make the pool even larger and share the cost among more people. If states want to create incentives for employers to provide insurance, that’s fair game as well. I happen to think the Tenth Amendment is the part of the Constitution that’s supposed to be most flexible, allowing states to do a large number of things that should be off-limits to the federal government. I may or may not agree with them, but that is their right to do so. There’s very little need for federal involvement in health care at all – certainly nowhere near the amount we have now.

I’m sorry to break this to Chuck Cook, but the United States isn’t like the rest of the “industrialized first world.” We are a constitutional republic where the federal government is intended to be limited, not maximized and in control of everything. (It’s also worth mentioning that the wealth of our billionaires – and the talent of a lot of other, less well-to-do American people – is quite often freely given to assist in promoting the health of people both here in America and around the world. Here’s a great local example.) So the idea that we don’t have single-payer health care is one of those rare things that’s still a feature of ours and not a bug. That’s not to say it can’t stand some serious improvement, though.

Let’s just see if we can’t make it more in conformance with what our great American experiment in liberty is supposed to be all about, mmmmkay?

Some thoughts I have on Trumpcare

I don’t quite think I have to reintroduce myself to all of you, but it truly has been a long time since I sat down and wrote a piece for the consumption of my readers. (Editing Cathy’s last piece and writing two articles for the Patriot Post doesn’t really count for that purpose, nor does updating my Shorebird of the Week Hall of Fame page to add a couple player moves.) Unfortunately, things won’t improve on that front for some time, but the opportunity which presented itself to take my writing time was one I could not pass up.

But in this interregnum, we were given the bill to “repeal and replace” Obamacare, and since we are told President Trump has threatened to find primary opponents for any Republican who opposes it, I think I’m safe in calling this package Trumpcare. It’s still a government entitlement because there was a replace added with the repeal, and that already put a strike against it in my book.

The document I am going to base my initial impressions on will be the “talking point” document put out by the House GOP. To be honest, I really don’t have time at this point to read the original 123-page bill in depth, although I downloaded it for future reference and glanced through it to help with this piece. I look at this website as what the House Republicans are using as their chief selling points to the bill, so presumably this is their vision for federally-sponsored health care going forward. We have lived under Obamacare for about three years (as I recall, the major provisions did not all take effect before 2014, although some were in place shortly after the bill passed in 2010) so we know its effects: sizable increases in insurance premiums, a massive expansion of Medicaid (paid for in large part by Uncle Sam) to ratchet up the number of people with health insurance, subsidies for those who have less than a certain income yet are forced onto or choose to partake in the individual insurance market, the reduction in the number of competing insurance companies in many areas of the nation (some have just one insurer available to them), and the virtual elimination of catastrophic health insurance plans as insufficient for the needs of those insured. There were also a number of regulations and restrictions on insurers put in place, key among them the requirement of children being covered under a parent’s policy through the age of 26 and the elimination of discrimination based on pre-existing conditions.

With this massive incursion into private industry, for the first time the federal government required purchase of a product under penalty of law – those who chose not to buy health insurance were subject to a “shared responsibility payment” collected by the Internal Revenue Service. Imagine if you had to buy a car every four years whether you were happy with the one you had or not, and you may have the idea of how people felt about this. Obviously the economics of it were to make everyone pay a little something, but that’s not the way a free country is supposed to work for something that’s not essential to core functions of government.

Here are some of the provisions within the American Health Care Act (AHCA):

  • It “dismantles” the Obamacare taxes on prescription drugs, over-the-counter medications, health insurance premiums, and medical devices.

Okay, so far so good, although I suppose the definition of “dismantle” is in the eye of the beholder. I glanced through that section of the bill and it looks like this would not take effect immediately but at the end of this year. As a whole, individuals may see a little bit of savings but it won’t be something they will notice.

  • It eliminates the individual and employer mandate penalties.

This is perhaps the best news of all, but there is one huge catch to this: instead of paying this as a tax provision, you would have to pay a penalty to the insurance company in the form of a surcharge on premiums if you start up insurance again after not having it for a period of time. And that catch basically negates the whole benefit of removing the IRS from the equation, although I suppose an insurer could use the waiver of this surcharge as an incentive to bring people in.

  • It maintains the prohibition on charging more or denying insurance based on pre-existing conditions.

I have a big problem with this – not that it wouldn’t necessarily benefit me because I have asthma but because the idea for an insurance company is to make a profit by balancing the risks shared by the vast pool of policyholders with the expenses incurred by reimbursing those insured for loss. If someone is very likely to be a net loss to the insurer because they have a pre-existing condition, it should be the right of the insurer to refuse service. After all, banks don’t lend money at the prime interest rate to people who have poor credit records or no verifiable means of income because that would put their capital at too much risk for the return, so they either refuse the customer outright or charge an interest rate commensurate with the risk. That should be the right of a private insurer, too.

I was reading on social media that Maryland once had a high-risk pool for such patients, which was bankrolled by the state. While it’s not the use of taxpayer money that would be my most favorite, it is a state’s right to do so if they chose and there was nothing wrong with that system because it wasn’t directly competing with the private sector.

  • It keeps the provision of dependents being on their parents’ plan until they are 26.

This is another bad feature of Obamacare that should be buried with the rest of it. If you are 26 you should be able to stand on your own two feet and either be working for someone who offers insurance or be able to afford a plan on your own. (Or choose not to have insurance, which would be your right - although not necessarily recommended.)

  • AHCA also establishes what it calls a Patient and State Stability Fund.

Over the next nine years, the federal government will give out $100 billion to the states to assist them with their goals of insuring every citizen. I read quickly through this section and there are some provisions that give me heartburn: there are strings attached to the expenditure of the money and the states are required to come up with a larger and larger portion of matching funds for whatever they use the money for, up to 50 percent by the end of the program in 2026 – assuming, of course, this doesn’t become a more perpetual giveaway (which I’m convinced it will.) There is $15 billion allocated to this over the next two years and $10 billion per year after that, and I’m sure states will say this isn’t enough because they like that financial crack of Uncle Sugar’s money.

  • Modernize and strengthen Medicare by transitioning to a “per-capita allotment.”

The legalese on this one is beyond my scope of comprehension, but to me the idea of modernizing Medicare would be that of sunsetting it, not strengthening it.

  • Enhance and expand Health Savings Accounts.

One of the better features, although it would be even better with the free transfer of money between HSAs and other entities such as an IRA or 401 (k). If you needed more money in a particular year you should be able to move it without penalty.

  • A monthly tax credit for those who can’t afford insurance, up to $14,000 per year.

A subsidy under a different name. Basically they are replacing one tax scheme with another, still targeted to particular people.

All in all, I think the repeal should take place without the replace. It seems to me that we had a whole political movement and a bumper crop of angst spring up over the last eight years because people did not want any part of the government interference in their health care that Obamacare brought to us. Over that time, we lived with the disappointment of Republican excuses: “we’re only one half of one third of government,” “we have the House and Senate but the President won’t sign this,” “we can’t defund because there would be a government shutdown,” and so forth. After 2016, there was a Congress and President who campaigned on repeal, and yet you give us this?!?

A better alternative may be the plan presented by Senator Rand Paul, although it’s not perfect either. But it’s better than the GOP alternative, which is a great letdown for those of us who waited for the moment to eliminate the (not so) Affordable Care Act.

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