Why are we "reforming" healthcare? Pt. 2

This is an honest question for most right-wing supporters of repealing Obamacare: What are the substantive, objective, measurable goals you hope to achieve?

When  Obamacare was being debated (for more than a year), any supporter thereof was able to say what the goal was: universal coverage and slowing the growth in the cost.

What is the goal now? What end does Sen. Todd Young, Rep. Susan Brooks, Rep. Todd Rokita (he with the wife earning $20,000/month from the Town of Fishers), or Rep. Trey Hollingsworth (R-TN IN) hope to achieve?

If we get a substantive answer to that question, we can then determine whether Rs and Ds actually share a common goal. I suspect they don't.

On Elephants and Incomes

Yesterday, I watched the PBS Nightly News Hour and there was a very interesting discussion on the so-called "elephant" chart. For those unfamiliar, here it is:

This is the so-called "elephant" chart. The name makes sense if you imagine the uptick on the right representing the trunk, and the large hump in the middle and left representing the elephant's back.

Anyway, it is important to note what this chart shows. The horizontal axis represents where people are in the global ranking from rich to poor. The vertical axis represents income growth from 1988-2008.

Clearly, someone at 50 on the horizontal chart has half the world making more than him and half the world making less. For comparison purposes, a family of 4 making $40,000/year is currently in the riches 11.3% of the global population. That family of 4 making $20,000/year is in the top 20% of the global population. That family of four making $200,000/year is in the global top 0.4%.

As the chart shows, there has been enormous income growth for those between approximately the 10th percentile and the 70th percentile. To give some perspective, this chart shows the following:

• If you made $1,000/year in 1988, you would likely make $1,500/year in 2008
• If you made $200,000/year in 1988, you would be making roughly $320,000/year now.
• If you made $20,000/year in 1988, you probably make about $19,000 now.

This pretty clearly shows the hollowing out of American middle class and that of the remaining developed world. In 1988, you will recall, globalization really kicked off. By 1993, the U.S. had ratified NAFTA.

I think that if you ask most Americans, they are quite happy that the developing world, particularly in India and China, has done so well. However, it is difficult to conclude anything but that this global income growth has come at the expense of the middle class in the developed world.

The saying used to be that it is better to be a C- student in America than an honors student in China, because America provides so much more opportunity. I think that is no longer the case, and the days of getting a factory job and working 8-5 for 40 years so you can retire and afford to move to Florida are over.

This may also explain much of the rise of right-wing nationalism throughout the developed world, from Trump to Brexit to the near-miss in France with Marine LePen.

DISCLAIMER: I am not an economist, but I do find this chart to be very revealing and interesting.

Healthcare Comments & Response - Part 1

As a rule, I try not to respond directly to comments, as I feel that I have an unfair advantage - this is my blog and hence my "microphone" is the loudest. Nonetheless, as the plight of American access to healthcare is clearly a big concern of mine, I would like to respond directly to some commentary I received recently from an anonymous source. Here goes my annotated response:

The healthcare system is broken. 

This is something upon which the commenter and I agree.

 I have pretty good coverage because I am college educated and work for a large hospital .

No, you have good coverage because you work for a large hospital. There are plenty of college educated people who have terrible or no coverage. It has very little to do with your educational input and instead has a lot to do with the size and nature of your employer.

I cannot complain too much about my coverage. Our deductible is $1300 per person not to exceed $2600 per family . After that , if I am treated at the hospital where I work, I am covered at 100% . I have an HSA which my husband ( who works at said hospital ) contributes $75 per paycheck for office visits , and drugs . We pay $109 per paycheck ( twice a month ) for our coverage .

I am glad, Anonymous commenter, that you have good health insurance coverage. If I could get your "deal," I would gladly take it. I would gladly take a 1300/2600 deductible and pay $218/month for insurance plus $150/month for a HSA to cover out-of-pocket. Regrettably, I don't have that choice. If you, dear commenter, would like to propose a public policy whereby that deal is available to people who don't work for large hospitals, count me as a supporter. In addition, I note that your comment later demonizes the CEO of IU Health for how much he makes. Sauce being equally delicious on the goose as the gander, perhaps next time you start thinking about the overhead of American healthcare, you will recall that your own insurance is part of that overhead.

 I think it all depends where you work and what you do for a living . 

I suppose it does. It also depends on your age. I note that many Baby Boomers and Gen Xers are able to get on as permanent, full-time employees at large incumbent employers, whereas so many Millennials  are relegated to "temp" status, working for a set hourly wage (sub $15/hour) with no benefits and no job security. These sentiments as to where one works and what one does for a living are nice, but when it comes to healthcare, the janitor at the City-County building has better health insurance than does an entrepreneur. How's that for incentivizing behavior?

People who do not have insurance are not turned away from where I work , a hospital or my husband's . 

I'm not sure what the point of this is. Is this supposed to be some sort of absolution of the healthcare industrial complex? They won't leave you to die in the streets. They'll give you the service, and then they'll bankrupt you with the bills. Hurray!

The hospital may give you ER care, but if you need any sort of follow up care, you're on your own. No medication. No physical therapy. No follow up.

Also, they will seek to recover for their bills. I see the back end of this "policy," and hospital corporations do not simply "forgive" these bills. They will drive you to ruin to collect on them. This is not charity. They will file suit against you and you will have a judgment hanging over you for the rest of your life unless you (a) pay it or (b) file bankruptcy. Freedom!

Finally, that care isn't just given away for free. The hospital is not in the business of losing money, and someone, somewhere, has to pay for the care that your hospital provides "for free." That someone, unfortunately, is both those who have insurance and those who actually have the cash to pay their medical bills. The costs get shifted. It's not free, and it's not a solution.

People who do not have insurance are not turned away from where I work , a hospital or my husband's . Indiana has HIP which is a very good Medicaid type program for Indiana residents . But it dies require one to take the initiative and research and sign up .

Let me be very clear about this. HIP is Obamacare with a few bells and whistles to make conservatives feel warm and fuzzy about "personal responsibility" or something. When (not if) the federal government succeeds in destroying Obamacare, it will destroy HIP with it. Full stop.

Further, my wife and son went on HIP 1.0 when my son was born, as I was in law school at the time. The insurance was indeed better than any private sector insurance I've bought before or since. Someone, anyone, remind me again why the free market is preferable to the public sector as regards healthcare.

All I know is we take good care of our patients whether they have insurance or not and St V I know accepts interest free patents for three years !

This is, again, a standard-bog reaction I tend to hear from people who work in healthcare any time it's pointed out that the American system sucks. Nobody doubts that American healthcare providers, generally, do their best to take care of patients. Specifically, I believe that nurses, orderlies, lab techs, doctors, etc., are genuinely concerned, on a personal level, about the well-being of their patients.

I don't think that my comments regarding a better system for the financing and delivery of healthcare is the equivalent of saying that America's healthcare providers suck. Rest assured, if that was my point, I would be quite explicit about it.

With that said, I note that the commenter twice refers to how hospitals don't turn people away and, generally, have a large heart. Any system that depends on charity and a wholesale disregard of material human interest is not a system upon which I would rely.

Depending on the charitable inclinations of hospitals is not a sound policy to ensure that an increasing percentage of Americans can afford healthcare any more than depending on the benevolence of Budweiser to ensure that we can all afford beer at the race. The interests of the parties simply don't line up.

All the hub bub about getting rid of Obama Care is about the republicans trying to insure that the hospitals can remain profitable, and very profitable they are , Dan Evans at IU Health made 3.9 million being CEO , is that REALLY necessary! NOT !

There is a bunch to unpack here. First of all, I don't even know what to say about Republicans. I suspect that if any of them had toddlers who were diagnosed with lifelong conditions and didn't already get that sweet sweet government insurance (that they, by the way, decry as evil-socialist-takeover-end-of-freedom-road-to-serfdom when anyone else gets it), then perhaps they would be more concerned about the effects of their policies. As it sits, I think they view this as a game that is unattached to anything they actually care about other than the possibility of cutting more taxes.

As far as hospitals being profitable, I don't really have any problem with that either. However, it does seem that providing an essential service should be lucrative but not the source of multi-generational wealth. It seems that if 40-year-old doctors (who finished med school at 30, roughly) can threaten to retire if they dislike health policy in this country, then perhaps they're overpaid. But I digress.

The other big thing I thought about when seeing this is that the commenter simultaneously brags about her own hospital compensation and then faults Dan Evans for his. As noted above, dear commenter, your amazing health insurance that you speak of is part of your compensation package. It drives up the cost of healthcare for everyone else because your employer is providing this healthcare to you as part of your compensation package. While Dan Evans' salary is an easy thing to look at and say it is excessive, that is only one person. How many people who work at your hospital get your health insurance? What do you think that would cost per month on the open market?

If we want to ensure that healthcare in America is delivered in a free market, we need to ensure that the free market is capable of same. There is a reason why we don't leave police work, national security, road construction, primary education, or so many other things to the free market: the free market can't deliver those things.

Why are we reforming healthcare?

I have posted a number of times about what I want in a healthcare reform. My wish list is rather simple:

1. I want premiums to go down to a level of affordability that does not render them a veritable mortgage payment, as they presently are.
2. I want my health insurance to be there for me when I need it.

It's a rather simple wish list.

One of my preferred publications, Vox, did a story today about what a variety of our senators in D.C. believe the purpose of their healthcare reform is. Some excerpts:

We can start with the Maverick John McCain, the GOP's 2008 standard bearer (who was stuck in the unenviable position of having to be the successor to George W. Bush's clusterf**k tenure).

Tara Golshan

Policy-wise. What are the problems [in the American health care system] this is trying to solve — and is the bill doing that right now?

John McCain

Well, it's whether you have full repeal, whether you have partial repeal, whether you have the basis of it. It's spread all over.

Tara Golshan

But based on the specifics of the bill you have heard so far, is it solving the problems [in the health care system]?

John McCain

What I hear is that we have not reached consensus. That’s what everybody knows.

Tara Golshan

Right, but outside of getting the votes. From what you hear of the actual legislation being written, is it solving the problems you see —

John McCain

It's not being written. Because there's no consensus.

Tara Golshan

But generally speaking, what are the big problems it is trying to solve?

John McCain

You name it. Everything from the repeal caucus, which as you know, they have made their views very clear — Rand Paul, etc. And then there are the others on the other side of the spectrum that just want to make minor changes to the present system. There’s not consensus.

So, according to John McCain, the goal of the GOP health policy is to make sure that we change the current policy? do we have actual, substantive goals other than sticking it to Obama?

Let's move along to another senator, that conservative stalwart of thoughtfulness and son of JFK conspirator Ted Cruz.

Dylan Scott
Stepping back, what is the most important thing for this bill to achieve? How is it going to make things better? 

Ted Cruz
The most important objective in repealing Obamacare is to lower health insurance premiums.
The biggest reason so many millions of people are frustrated and angry with Obamacare is that it’s caused premiums to skyrocket, making health insurance unaffordable. That is a problem the federal government caused, and we need to fix that. 

Dylan Scott
Do you think you can lower premiums for everyone, though? Because obviously there are some policies that could lower premiums for some people but might not for others.

Ted Cruz
Under Obamacare, the average family’s premiums have increased over $5,000 a year. Every week, when I go back to Texas, I hear from Texans who say, “I can’t afford health insurance for my family.” That is an enormous problem, and it is the direct legacy of the failed policy of Obamacare. 

Dylan Scott
So the idea is that it needs to average out to a premium decrease, even if some people might see higher premiums? 

Ted Cruz
We should work toward giving consumers more choices, more options, more competition, and as a result lower prices that are more affordable.

Now, this is a master class in dissembling. For all of those who yearn for the repeal of Obamacare, my question remains: What is the goal, and how do you expect the bill being debated to achieve that goal?

As I've pointed out before, we spend a whole lot of money on healthcare in this country and get very little in return, relative to the rest of the world. Imagine, for a moment if you will, if we were getting hit like this for gasoline in America? American gas costs 69% of the global average price of gas, whereas American healthcare costs roughly 200% of the global average. 

How would you react if someone said that we were going to create policy that would result in gasoline costing nearly $6/gallon, whereas it presently costs roughly $2/gallon? Would that be a triumph of freedom and repeal of job-killing regulations, or would that feel more like you're getting taken for a ride?

I will be the first to admit that Obamacare was sub-optimal. I will also say that as soon as the GOP can show me a proposal that will (1) lower my premiums to something closer to the global average cost of healthcare; and (2) ensures that my healthcare coverage (be it through private insurance or the government) is there for me and my family when I need it, I will be a full-throated supporter of whatever proposal they roll out.

I, for one, am tired of this ride and would like our policy makers to do something to make it stop hurting. Who's with me?

Meadowood Dog Park

How many times have I seen an urgent NextDoor post about how someone lost a dog? More than I can  count. While I'm at it, how many times have I heard people lament that Meadowood Park seems to offer very little to the residents who live near it? Regrettably, more than once. (Personal Note: I love Meadowood Park and take my kids there at least once/week . . . my wife probably takes them there 4-5 times/week).

Nonetheless, I think that most would agree that Meadowood Park is a valuable gem for the neighborhood and a monument to the foresight of the developers of this neighborhood. After all, they could have just sold more lots there and possibly made more money. For reasons that I can't enumerat (whether it was the Town of Speedway or a developer's decision), Meadowood Park was set aside and now we get to (a) enjoy it to the max, and (b) make sure that it remains a thriving place for our descendants and "progeny."

It is in light of all of this that I propose a dog park for Meadowood. For starters, a dog park is a wonderful place for dog owners to take their dogs to exercise. There are plenty of elderly dog owners in Speedway, and I believe that this would be a wonderful thing for them to exercise their dogs as opposed to taking them for long and regular walks.

Additionally, there is the social aspect of a dog park. Whether it is elderly dog owners socializing during the afternoon or millennial dog owners socializing during happy hour, a dog park would have a nice spin-off effect of building community social bonds.

Also, people are generally willing to support and pay for things they use, understandably. As it stands, Meadowood Park is a wonderful resource that appears to be rather underused. While the playground is great for people (like me) who have small children, it provides very little value to those who don't. Similarly, the ball diamonds are great for kids who play little league and adults who want to play in a rec league, they provide little value to the retiree who has no interest in playing baseball or softball.

There are a number of other assets to Meadowood Park, and I don't want to be seen as saying that it is devoid thereof. However, a dog park would be a minimal investment with a maximal result.

This is, of course, an overhead view of Meadowood Park that also includes Wheeler Elementary and a good chunk of the neighborhood. Here is a closer view:

Again, this is an aerial view of the park. It is oriented with North at the top, and I envision a dog park in the southwest "corner" of the park. Here is a closer view:

Of course, this rectangle does not account for the "angle" of the view, nor is it precisely placed. It is put in to suggest an approximate location for a dog park. The location is ideal, in that it is nestled among the trees and would provide a shaded area for people to take their dogs, socialize, etc. As an added bonus, because it is among the trees, it would interfere minimally with the activities that people already do in the park.

As far as cost goes, the area I've outlined is roughly 200' X 80'. I am not a fencing professional, but I did a rough price estimate on Google, and I was informed that chain link fence generally costs $7/linear foot in materials and $10/linear foot in labor. I remain agnostic as to whether Speedway already has the staff to perform the labor. However, based on the Google estimates of $17/linear foot and my estimate of 560 linear feet, I believe that this can be done for less than $10,000. Mind you, $10,000 is not just spare change that shows up in the couch, but given that each house in Speedway pays roughly $1500-$2000/year in property taxes, $10,000 does not seem like an inordinate amount of money, particularly given the possible upside to this.

As far as additional costs, I do not know whether this would increase Speedway's annual insurance rates, law-enforcement costs, etc. I do think that it would increase community cohesiveness, which generally increases property values.

Just a thought.

Commercial Property on Main St.

I keep hearing about how the incumbent business owners on Main St. are being harmed by the redevelopment thereof. I keep getting confused about what their problem is.

This is two distinct parcels on Main Street. Clearly, the picture is dated, as the building that used to house the Town Press now houses Tacos & Tequila (I can't wait . . . sounds so delicious), and the vacant lot to the right now houses O'Reilly's (here again . . . ) and Wilcox Engineering (unaffiliated with "Wilshaw," by the way).

Anyway, I choose these two properties because they are two of the original properties on Main, in their more-or-less original state. These properties were assessed, for taxation purposes, at $69,900 (on the left) and $37,800 (on the right). Links to the publicly-available property tax assessments can be found here and here.

Based on that property assessment, one could own both of these buildings for $107,700. Call me skeptical on that, and my skepticism was born out.

Just today, I was perusing the internet and came upon this listing. For those who prefer not to click through, the listing is for Ted's Beauty Shop, located at 1344 Main St..

This property is presently assessed, for tax purposes, at $99,100, as of 2016. The asking price for the property is currently $489,000.

By my calculations, that is an increase of approximately 493%. Someone, PLEASE, explain to me what it is that the property owners along Main St. have to complain about. I can think of approximately 389,900 reasons why the owner of Ted's Beauty Shop (Stella Szatkowski) should be supportive of Main Street's redevelopment.

Similarly, I can think of plenty of reasons why the incumbent property owners along Main Street should be, give or take, 493% supportive of the redevelopment efforts.

Finally, please note that the property just to the south of Ted's Beauty Shop is owned by the Speedway Redevelopment Commission. It was bought in June, 2015, for $65,000, according to tax records. I will be interested to see the final sale price for Ted's Beauty Shop, but based on the asking price, it appears that the efforts of the Redevelopment Commission are bearing fruit. Keep up the good work!

Fiduciary Duty

As I have mentioned before, I am an attorney. One of the things that goes along with representing clients is that I have a "fiduciary duty" to them. Stated in simple terms, it means that I have to put their interests ahead of mine. If there is a situation where our interests diverge (for example, imagine I'm helping a client sell real estate and know that the buyer intends to sell it to me so that I can profit handsomely), I have to inform the client of the conflict and, often, get a waiver of the conflict in writing. This is the essence of a fiduciary duty.

My father, a manager for a corporation, had a fiduciary duty to the corporation.

It is in light of that definition of fiduciary duty that I question why it is that my doctor does not have a fiduciary duty to me. While I, the lawyer, control (to some extent) the outcome of my client's litigation, the doctor controls the outcome or very existence of his patients' lives. You, dear reader, tell me which one requires more trust.

If my doctor owns the MRI machine, he doesn't have to tell me that when he orders an MRI. Huh.

If my doctor owns a piece of the surgical center, he doesn't have to tell me that when he orders a surgery. Huh.

Huh.

Is it just me, or should my doctor have a fiduciary duty to me, not only to give me his best advice as to medical treatment, but also to tell me which procedures or drugs are financially frivolous and whether he is receiving something of value as s direct result of his medical directives (whether or not there is a quid pro quo)?

Some thoughts on health care. . . something clearly lacking in controversy (sic).

With Friends Like These . . .

Ladies and Gentlemen, I give you Mr. George Will:

Today, conservatism is soiled by scowling primitives whose irritable gestures lack mental ingredients. 

Can't help but imagine who he's talking about. . . You can read the entire thing at the National Review.

My Understanding of History and its Lessons - Part I

I am not a historian, nor do I play one on TV. In fact, I didn't even stay at a Holiday Inn Express last night. I did, however, major in the humanities in college and pay at least passing attention in high school. In light of that extensive scant historical training, I'd like to offer a lesson I gleaned from it.

In roughly 1908, Henry Ford perfected a fairly revolutionary idea for his day: assembly line manufacturing. Contrary to popular belief, Henry Ford did not invent the assembly line, but he did perfect it.

To say the least, manufacturing made the fabrication of fairly complex things, like say an automobile, considerably easier and less expensive to do, when done on a large scale and supported by well-capitalized industrialists. While the manufacture of the automobile put many previous artisan car builders out of business (if not immediately, then eventually), it put the automobile within the financial reach of considerably more customers than previously. I don't have the exact figures, but a car made in roughly 1900 cost about $1,000 in 1900 dollars. By 1924, Ford was selling the Model T for about $265 in 1924 dollars . . . a price cut of about 75% in real dollars, not adjusted for inflation.

That is one hell of an innovation, and the ripple effects were clearly far and wide. An automobile suddenly became affordable for the "masses," and was no longer a plaything for the wealthy. As a result, the American auto industry became one of the industrial powerhouses of mankind, and a thing for the country to admire and celebrate. Additionally, the nation responded by constructing an interstate highway system and built out its cities, towns, and counties with car-passable roads. A small town in central Indiana even started an endurance race to see who could make a car go 500 miles the fastest.

Unfortunately, it also had the effect of replacing high-skilled jobs with relatively low-skilled jobs. Previously, building a transmission, for example, was a very difficult thing for one person to know how and be able to do. After Henry Ford, it was still a difficult task, but when you're building 100,000 of them with 500 workers, they get considerably cheaper to build per unit and each person only has to know how to put one portion of it together. The world can have transmissions for much cheaper. Cheaper transmissions mean cheaper cars. More people can afford cars. The trucking industry becomes a thing (to name but a single example). All well and good, except for the guy who used to make a good living hand-building transmissions and now works putting one portion of it together on an assembly line for a fraction of the pay.

Bummer. It is a good thing that, eventually, people came to realize that when every member of the workforce makes so little he can't afford much "stuff," then the builders of that "stuff" can't sell any "stuff." America relied on the benevolence of employers to pay well for awhile until it became untenable, and we started making laws about unions, labor practices, etc. (Mind you, there is a lot of history that I am omitting when discussing working conditions, pay, unionization, worker's rights, etc.) However, we ultimately figured out a way to make it work and have the government and industry working symbiotically in such a manner as afforded the citizens of this country to be balanced in their contentment with their present station in life and able to consume on the one hand, and not becoming idle but instead striving to better themselves and their families through hard work on the other hand.

It sure is a good thing that President William Howard Taft, by no means Mt. Rushmore material, decided that embracing the innovations of Henry Ford, and allowing local governments to work in their own immediate interests to develop roadways, was a better course of action than trying to protect the livelihoods of the hand-made transmission guild or the buggy whip makers.

Because President Taft and his successors understood that innovation is good and allowed Henry Ford to profit from it without seeking to protect the handsome profits of the Pullman Railroad Car Company, to give one example, or the jobs of the buggy whip makers, to give another, the American auto industry was allowed to flourish. Because the American auto industry thrived, we were able to develop the American trucking industry. With affordable coast-to-coast shipping, California vineyards could sell their overpriced Pinot Noir to rich financiers in New York (one example illustrating the point and utility of national shipping).

Lets not forget that things could have gone the other way. We were not destined to be a superpower but became one because we made good decisions along the way. Making good decisions in the future also seems like a good idea. Draw your own conclusions as to what my lesson was. Answer tomorrow.