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Medicare does “NOT PAY FOR ITSELF”

In the comments section of an earlier post (1/3 of Medicare is Wasted), Maggie Mahar had stated to everyone; “Medicare Does Not Pay for Itself.” This is what I meant by that comment:

“For more than a decade the the federal government has borrowed to pay for the rising cost of Medicare. Debt-financing of Medicare will increase sharply as the population over 65 doubles from 2010 to 2030 and the number of beneficiaries over 85—with the greatest medical needs—triple.”

Note, using borrowed money to finance Medicare is not something happening in the future as it began more than a decade ago. Yet, as the article notes: “Members of Congress are reluctant to argue with constituents who sincerely believe that they have ‘paid for’ Medicare with payroll taxes and premiums. Most find it more convenient to tiptoe around the minefield of Medicare financings.” So the charade continues even today.

People who believe that they have paid for their Medicare with payroll taxes and premiums are terribly naïve and do not realize how much Medicare actually costs or how much “Medicare for all” would cost.

The article goes on to explain the history of how we arrived where we are today and why I make the comment on Medicare:

“In the mid-1990s, Democrats proposed to balance the Medicare budget by limiting fees paid to physicians for services, while Republicans sought to contain the costs by transferring the program to managed care insurers and capping the annual per capita rise in premium subsidies.

In 1997 the leadership in both parties agreed to a plan that would eliminate borrowing for Medicare, principally by limiting the growth in the level of fees paid to physicians. That Medicare reform, along with increasing general revenues paid by taxpayers in the highest bracket, led to a federal budget that balanced in fiscal year 2000.

The balance turned out to be short-lived. In 2001 and 2003 Congress passed debt-financed reductions in income tax rates. And in 2003 it also suspended the application of ceilings on fees set in 1997. Later that year Congress used debt to finance a new Medicare prescription drug benefit and higher payments to Medicare managed care plans.

As a result, the portion of Medicare paid for with dedicated taxes dropped from 73 percent in 2000 to 53 percent in 2010, the year that the first of the Baby Boom generation became eligible for Medicare.”

“After the 2008 election of President Obama, Democrats sought Medicare ‘savings’ for the purpose of expanding other medical services rather than balancing the budget for Medicare. In order to offset the cost of expanded PPACA medical services for families with low incomes; they placed restrictions on reimbursement rates, provided incentives for more efficient delivery of medical care, raised the Medicare tax paid by taxpayers with high-earned incomes, and applied Medicare taxation to gains from investment.”

On the other side of the political spectrum, “Republican House Budget Chairman Paul Ryan exemplifies his party’s ambivalence toward Medicare reform. He ran as the vice presidential candidate on a ticket in 2012 that attacked the Affordable Care Act’s limits on Medicare reimbursements. Yet before and after that election, he incorporated those very cost-saving measures into his own budget plans.”

Incumbents from “both parties find it awkward to even talk about the practice of borrowing to pay for Medicare. Obviously, an extra layer of interest on debt simply increases the program’s long-term cost. Any attempt to highlight that issue naturally invites the question of whether to cut Medicare costs or raise tax revenue dedicated to the program. No mainstream politician seeks to cut benefits by almost half and down to the level payable by revenues from premiums and payroll taxes. Democrats condemn any increase in payroll taxation as ‘regressive,’ while most congressional Republicans have signed a pledge to oppose any tax increase.”

Both sides of the aisle feint a reluctance to either cut Medicare benefits or increase Medicare withholding taxes and an honest discussion with their constituents regarding Medicare financing knowing full well something must be done. Indeed, it is politically expedient to kick the can or the bucket into the next decade avoiding the third rail of Medicare.

What can we do? I will answer that question in my next post.

Notes and References:
1. “Pay As You Go Medicare” Washington Monthly, Bill White, June 23, 2014

2. Maggie Mahar writes the Health Beat Blog Maggie is also the author of Money-Driven Medicine: The Real Reason Health Care Costs So Much (Harper/Collins 2006). Mahar also served as the co-writer of the documentary, Money-Driven Medicine (2009), directed by Andrew Fredericks and produced by Alex Gibney. Before she began writing about health care, Mahar was a financial journalist and wrote for Barron’s, Time Inc., The New York Times, and other publications. Her first book, Bull: A History of the Boom and Bust 1982-2003 (Harper Collins, 2003) was recommended by Warren Buffet in Berkshire Hathaway’s annual report.

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1/3 of Medicare Spending is Wasted

This was initially posted at Angry Bear September 14, 2014 by Maggie Mahar of Health Beat A little history: Dan and I invited Maggie Mahar to write at Angry Bear Blog as I was covering much of the Healthcare debate and Maggie could add much more in-depth knowledge and analysis of healthcare than I could. This is an important post as it gets down to the nitty-gritty of Medicare-For-All, things we need to know, and why it may not work.

Maggie Mahar in answer to a commenter:

You write: “That claim that one-third of Medicare spending is wasted sounds pretty questionable to me.”

This is your opinion. If you had spent the last 20 years working as a medical researcher investigating unnecessary treatment, your opinion would be of great interest to all of us; but, I’m assuming you have not done so.

Thus, you might be interested in some facts . . .

Dr. Donald Berwick, who headed up Medicare and Medicaid during the 1st half of the Obama administration has said, repeatedly, that at least 1/3 of Medicare dollars were wasted on unnecessary tests, procedures and drugs that provide no benefit for the patient. He is only one of dozens of health policy experts who have made the same statement. (Google “Health Affairs” the leading medical journal that focuses on health policy and “unnecessary treatments” Over the past 30 years, researchers at Dartmouth have provided stacks of evidence documenting unnecessary care in the U.S.

You also write: “I doubt that treatment protocols in the U.S. are all that different from other countries.”

Again, this is your opinion. Unfortunately, you are wrong.

In other countries, doctors and hospitals tend to follow evidence-based guidelines. In the U.S. a great many doctors object to the idea of someone telling them how to practice medicine even though that “someone is “science”. They value their autonomy and prefer to do things the way they have always done them. Of course this is not true of all doctors; but even when you look at protocols at our academic medical centers, you find that the way they treat similar patients varies widely.

Here, I’m not talking about how much they charge for a procedure (which also varies widely) but how many tests they order, how often they prescribe spine surgery for someone suffering from low-back pain, how often they tell a woman she needs a C-Section . . .

One big problem is that our doctors and hospitals are paid on a “fee – for service basis;” in other words, the more they do, the more they are paid.

As Dartmouth’s Dr. Eliot Fisher points out: “U.S. patients are not hospitalized more often than patients in other countries; but in the U.S., a lot more happens to you while you’re there.”

In addition, traditionally our medical schools have trained doctors to practice very aggressive medicine. The resident who orders a battery of tests is praised. Students are told “Don’t just sit there (and think). Do Something!” Traditionally, our medical culture has been a very macho culture and it is just beginning to change.

Finally, Americans tend to think that “more is always better.” Larger servings in a restaurant, bigger cars, bigger homes, etc. And when it comes to healthcare, patients in the U.S. tend to think that “more care is better care.” They are wrong. Every medical product and service carries some risk. If it provides no or little benefit, the patient is exposed to risk without benefit.

When medical protocols in the U.S. are compared to how medicine is practiced in other countries, researchers have found: —- Much unnecessary spine surgery. The rate of back surgery in the U.S. is five times higher than in the UK. Studies have shown little difference in long-term outcomes for patients who undergo back surgery compared to those who select non-surgical treatment.

The U.S. does more testing than other countries. For instance, the number of MRI and CT tests for every 1,000 people in 2010 was double the average in other OECD countries. Comparatively, there were also more tonsillectomies, caesarean sections and knee replacements. Regardless of how much more, nearly every procedure, scan and drug costs; it’s nothing compared to how out-of-whack the medical heroics thrown at Americans in the last stages of life The Cost of Health Care: A Country-by-Country Comparison

Colonoscopies are prescribed and performed more frequently than medical guidelines recommend and are given preference over less invasive tests that screen for colon cancer. Those less invasive tests are not only routinely performed in other countries, they’ve also been proven to be just as effective by the U.S. Preventative Services Task Force.

“We’ve defaulted to by far the most expensive option, without much if any data to support it,” said Dr. H. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice.

In the U.S. many more patients die in ICU’s getting futile care. This is a painful, lonely way to die. In other countries, more patients are treated in hospices or allowed to go home where nurses and even doctors visit them.

Half of all heart surgeries (using stents) do no good. We know which half! But stent-makers and other providers have turned this into a big business.

- Our drug companies enjoy 20% profit margins.

- Our device-makers boast 16% profit margins.

We are over-medicated (particularly older people), and undergo too many surgeries that involve very expensive devices. Medicare covers virtually everything (even drugs that have been shown to be dangerous–until they are taken off the market). If it does not cover all of the newest treatments and products lobbyists would howl– and Congress makes sure that heads roll.

This is one reason why we don’t want to give everyone 40 to 65 a chance to enroll in Medicare. No one could afford it. (This idea was considered in the late 1990s. Do you have any idea how much 40-65 year olds would have to pay for our extraordinarily inefficient and wasteful Medicare system? On top of that and like people over 65, they would have to pay hefty sums for MediGap to Medicare advantage — private insurance plans that cover all of the things that Medicare doesn’t.

Medicare is now beginning to cut back, and over time it will refuse to pays for unnecessary surgeries (heart surgeries, unproven prostate cancer surgeries, and some hip and knee replacements, unless the patient has tried physical therapy first–and losing weight, if possible. (Some people just can’t lose weight, even under a doctor’s supervision.)

Medicare will also stop covering every new drug that comes on market, setting up a formulary and only paying for drugs that are effective — and cost-effective. The same will be true of devices.

Then — and only then — we might talk about letting people 40-65 sign up for Medicare, though in many cases, research on quality of care suggests that they would be better off with the best of our non-profit insurers: Kaiser, Geisinger, etc.

Medicare is a highly politicized bureaucracy and inevitably, Congress dictates what it can and can’t do. Medical guidelines should be set by medical researchers and doctors who have no financial interest in the outcome.

Maggie Mahar is the originator and author of the Health Beat Blog. Maggie wrote “Money-Driven Medicine: The Real Reason Health Care Costs So Much (Harper/Collins 2006),” and was the co-writer of the documentary, Money-Driven Medicine (2009), directed by Andrew Fredericks and produced by Alex Gibney.

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Where the ACA Should Go Next?

run75441: This is the first in a series of 3 posts written by Maggie Mahar discussing Medicare, what it covers, and what it lacks in coverage. Maggie touches on the Public Option and Medicare. I start to get edgy when people talk about the Public Option, Universal Coverage, Single Payor, Medicare-For-All, etc. as they do not really define it and who will control its funding. We have a Congress which is intent on cutting the PPACA/ACA/Obamacare, which many take offense to today, and leave us with far less. I am not so sure we can trust Congress and politics to insure our healthcare.

On Tue, Sep 9, 2014 at 1:47 PM, Dan <cdansplace2@aol.com> emailed:

Rortybomb, New Piece on Where the ACA Should Go Next Rorty touts the 2009 House Bill which calls for a Public Option and described here To improve ‘Obamacare,’ reconsider the original House bill

Maggie Mahar replies:

Originally I favored a public option, but in fact, at the time, no one really spelled out who would run the public option–or how it would be run.

One of the best things about the ACA is that lets both HHS and CMS make end-runs around Congress. I would never want a public option that was run by Congress.

Here is the comment I just posted in reply to the post “Where the ACA Should Go Next”

I would need to know far more about the public option—and how it would be different from Medicare– before voting for it.

Medicare is extraordinarily wasteful– 1/3 of Medicare dollars are squandered on unnecessary treatments that provide no benefit to the patient. Why? Because Congress is Medicare’s board of directors, and lobbyists representing various specialist’ groups, hospitals, device-makers and drug-makers control Congress.

Meanwhile, Medicare does not cover much needed care, ie. vision checks are just one example. This is why the vast majority of Medicare beneficiaries must buy separate private insurance (MediGap or Medicare Advantage) to supplement what medicare doesn’t cover.

Finally, I favor narrow networks. They keep costs down. The doctors and hospitals that are not included in the networks are those that refuse to negotiate  prices.  By excluding them we remind doctors and hospitals that we can no longer afford letting providers charge whatever they wish. No other developed nation allows doctors and hospitals to simply set prices.

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The Individual Mandate: Has the Obama Administration Silently Repealed the Rule that Virtually Everyone Must Have Health Insurance?

Maggie Mahar has been featured at Angry Bear Blog and has written for Angry Bear Blog from time to time. This article has been taken from her blog, Health Beat.

Obamacare’s critics continue to argue that the Affordable Care Act (ACA) will self-destruct. Now, some claim the mandate that uninsured Americans must purchase coverage– or pay a stiff fine— is so “riddled with new loopholes and exemptions” it ceased to exist.

14 New Waivers

When the ACA passed Congress in 2010, it offered a handful of basic exemptions to the mandate of everyone must be insured. For example, if the only comprehensive coverage available would cost more than 8% of a household’s income, the fine would be waived. Individuals who were in jail, or belonged to a recognized religious group that objects to all insurance, including Medicare and Social Security, they to could be excused.

But then, late in 2013, the administration quietly added some 14 new ways the uninsured could dodge the fine.. “’This latest reconstruction’ of the ACA received zero media coverage,’ a Wall Street Journal editorial declared, ‘and the Health and Human Services Department (HHS) didn’t think the details were worth discussing in a conference call, press materials or fact sheet.’”

Yet if the new waivers went largely unnoticed, reform’s opponents claim that the swelling list of escape clauses will have a huge impact. By 2016, they say, almost 90% of the nation’s 30 million uninsured will be able to ignore the mandateof buying insurance – without paying the piper. So much for universal coverage.

Just last week Bloomberg reported of; some Republicans referring to the new list of loopholes as a “stealth repeal” of the individual mandate. To her credit, Bloomberg’s Caroline Chen points out the contradiction in the GOP’s arguments. The same critics who, in the past, argued that the mandate represented “unwarranted government coercion” now criticize it for being too “wimpy.” Can they really have it both ways?

“Hardship Exemptions”

The new waivers were designed to help those who are facing hard times. Some exemptions will suspend penalties for 3 months – others for a year.

Perhaps the most important waiver bails out low-income Americans who have the bad luck to live in a state refusing to expand Medicaid. Originally, the ACA stipulated states must extend Medicaid to adults earning less than 138% of FPL ($27,310 for a family of three), with the Federal government paying the lion’s share of the extra cost. At the same time, the ACA set out to help low and middle-income families earning more than 138% of the FPL by providing government subsidies designed to help them purchase insurance in their state exchanges.

But then, two years after the PPACA passed Congress, the Supreme Court blind-sided the reform’s architecture by ruling states could opt out of expanding the federal/state. program. No surprise, politicians in Red states saw this as an opportunity to undermine Obamacare.

Today, twenty-two states still are refusing to open the Medicaid umbrella to cover some of their poorest citizens. As a result and in many cases, only parents earning less than 50% of the FPL ($9,893 for a family of three) qualify for Medicaid for Medicaid and childless adults remain uninsured in almost all of these states. (When Medicaid passed Congress in 1965 legislators decided that only “the worthy poor” should be covered. People who did not have children were not considered “worthy”.)

Now, roughly4 million low income adults who earn too much to be eligible for Medicaid in their states and too little to qualify for government subsidies in the Exchanges have been left out in the cold. As a result, the administration has waved the penalty for this group for at least a year.

By 2016, the situation is likely to change. Politicians who have refused to take the federal aid letting them expand Medicaid are facing tremendous political pressure. Hospitals, in particular, cannot afford to continue to care for uninsured patients without being reimbursed. States like Texas and Florida are leaving millions of federal dollars on the table. They may be the very last to cover their poorest citizens; but over the next year or two, Red States will no doubt cave to the pressure.

Bankruptcy, Domestic Violence, Fires and Floods

Other hardship exemptions cover a wide range of financial catastrophes. For example, you may be excused from the fine if:

- You were evicted in the past 6 months or are facing eviction or foreclosure;
- You received a shut-off notice from a utility company;
- You recently experienced domestic violence;
- You recently experienced the death of a close family member;
- You are homeless;
- You experienced a fire, flood, or other natural or human-caused disaster that caused substantial damage to your property;
- You filed for bankruptcy in the last 6 months;
- You had medical expenses you couldn’t pay in the last 24 months that resulted in substantial debt;
- You experienced unexpected increases in necessary expenses due to caring for an ill, disabled, or aging family member;
- You expect to claim a child as a tax dependent who’s been denied coverage in Medicaid and CHIP, and another person is required by court order to
give medical support to the child. In this case, you don’t have the pay the penalty for the child;
- As a result of an eligibility appeals decision, you’re eligible for enrollment in a qualified health plan (QHP) through the Marketplace, lower
costs on your monthly premiums, or cost-sharing reductions for a time period when you weren’t enrolled in a QHP through the Marketplace; Your individual insurance was cancelled because it did not meet the ACA’s standards, and you believe other Marketplace plans are unaffordable;
- You experienced another hardship in obtaining health insurance.

The last and very broad escape clause prompted Robert Laszewski, a master spinner of Obamacare myths, to ask:“Is there really an individual mandate?”

Laszewski is not alone in this belief. When the administration announced the new exemptions, The Wall Street Journal’s editors joined the chorus of critics, complaining that originally the ACA reserved waivers for “the truly down and out.” But now, the WSJ argued, Washington was tacking on exemptions that would excuse virtually anyone. The Journal quoted Douglas Holtz-Eakin, president of the conservative American Action Forum. A long-time foe of reform, Douglas quipped; “the rules have become so lax, it seems if your pajamas do not fit well, you do not need health insurance.”

But in fact, the mandate still has teeth. Indeed the CBO estimates that the IRS will collect some $4 billion from those who choose to go it alone in 2016, subtracting the fines from taxpayer refunds. (If you are not due a refund in a particular year, the tax collectors will deduct the penalty from your refund in future years.)

Who Will Be Paying Billions in Fines?

Does this meant that the IRS will be dunning poor and middle-class families who just haven’t heard about the bill—or don’t understand it? By and large, no. The CBO reports two-thirds of those fines will be paidby upper middle class and upper class Americans who object to the PPACA for political reasons.

Most could afford insurance, but bring home too much to qualify for subsides, and as a matter of principle, are rejecting Obamacare. The notion of “shared responsibility” does not move them. They would rather pay a fine than jump into an insurance pool with their fellow citizens. They believe that they are responsible only for themselves and their families.

What Reform’s Opponents Do Understand – the ACA Cannot Survive Without the Individual Mandate

The mandate is as the WSJ has acknowledged; out “at the core of reform.” Without the mandate, its deadlines and penalties, many Americans would simply wait until they became sick and then sign up for coverage. When they recover, they might well stop paying their premiums, and drop the insurance.

If that happened, people who need surgery, chemotherapy, or expensive medications soon would outnumber the healthier and younger folks in the insurance pool. Premiums would spiral for everyone. The system simply cannot afford “free riders” — defined as “people who receive the benefits of “a public good” (like universal coverage) “without contributing to paying the costs.”

In 2014, most people had not yet heard of the 14 new hardship exemptions that were added in December of 2013. This might explain why, last year, the penalties were without a question . . . effective, especially for young people,” Erin Hemlin, health care campaign director for “Young Invincibles,” a group that reaches out to young adults, recently told Politico/Pro.

Hemlin reports on a survey published last May showing that 40 percent of respondents indicated they would not have gotten insurance without the individual mandate. For adults ages 18 to 29, it was even more important, with 42 percent saying they signed up to avoid the fine.

What no one knows is what will happen over the next two years. By 2016, many more Americans will have heard about the waivers. But given the size of the subsidies and the growing number of Americans who have tried Obamcare and like it; I doubt that many will ask for a free pass.

How Many of the Uninsured Will Even Try To Get A Waiver?

What Laszewsi, Holtz-Eakin, the WSJ, and a gang of other Obamcare critics ignore is applying for a waiver is not as simple as it might sound. First, almost all hardship exemptions require documentation to prove that you qualify.

Secondly, while in some cases, you can apply for exemptions when filing your taxes, most require you to fill out a separate three – page form providing extensive information about everyone in your household.

Meanwhile, just applying, providing the documents, and filling out the applications is no guarantee that your fine will be cancelled. Decisions are made on a case-by-case basis. Finally, if you do succeed in being approved, you will receive a certification number in the mail—and then must fill out and file a newly drafted tax form.

Taking all of this into account, how many people will take the time and trouble to apply for a reprieve that, in most cases, will let them skirt the penalty for just three months?

The critics also forget that hard times are likely to make people more risk-adverse, not less. Imagine that you are a battered single mother. Recently, you divorce and your husband’s employer no longer covers you. Would this seem like a good time to drop coverage? What if your home was hit by a hurricane — would you be inclined to ditch your family’s health insurance?

This helps to explain why, as of October 2014, TurboTax estimated that less than 5 percent of those who would qualify for exemptions had applied.

Keep in mind that those who have lost their jobs, or have fallen victim to some other form of financial disaster, may well discover that they now are eligible for Medicaid. Others are likely to qualify for generous government subsidies that will help cover their premiums. Last year, nearly 9 out of 10 people who purchased insurance in state marketplaces qualified for tax credits that cut the average premium by 76 percent—to just $82 per month. Almost half of those who received subsidies wound up paying $50 or less.)

My point is that the majority of the uninsured would be better off if they didn’t try to escape the mandate, and instead applied for government help that would make insurance either free, or very cheap.

Waivers Don’t Just Cancel Fines, They Open the Door to New Coverage

The best hardship exemptions do more than erase the fine. Some let the uninsured apply for coverage in their state exchange after the open enrollment period ends on February 15, while others let those who are down on their luck purchase insurance that doesn’t meet Obamacare’s strict rules for “minimum essential coverage.”

For example, if a natural disaster kept you from enrolling on time, you can sign up after the February deadline. If you received a letter from your insurer telling you that your old coverage was cancelled because of the ACA, this year you can meet the mandate by buying a low premium catastrophic insurance which will offer free preventive care as well as coverage for worst-case scenarios.

In the end, what many Americans don’t understand is that ACA penalties are not aimed at punishing those who opt out of Obamacare. As Healthcare.gov CEO Kevin Counihan recently told The Hill: “Our goal is not to get income [from penalties] or to make this difficult for folks. Our goal, fundamentally is to get people insured.”

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Medicare does “NOT PAY FOR ITSELF”

In the comments section of an earlier post 1/3 of Medicare Spending is Wasted, I had stated to everyone, “Medicare does NOT PAY FOR ITSELF.” This is what I meant by that comment:

“For more than a decade the the federal government has borrowed to pay for the rising cost of Medicare. Debt-financing of Medicare will increase sharply as the population over 65 doubles from 2010 to 2030 and the number of beneficiaries over 85—with the greatest medical needs—triple.”

Note, using borrowed money to finance Medicare is not something that will happen in the future. It began more than a decade ago. Yet, as the article notes: “Members of Congress are reluctant to argue with constituents who sincerely believe that they have ‘paid for’ Medicare with payroll taxes and premiums. Most find it more convenient to tiptoe around the minefield of Medicare financings.” So the charade continues even today.

People who believe that they have paid for their Medicare with payroll taxes and premiums are terribly naïve and do not realize how much Medicare actually costs or how much “Medicare for all” would cost.

The article goes on to explain the history of how we arrived where we are today and why I make the comment on Medicare:

“In the mid-1990s, Democrats proposed to balance the Medicare budget by limiting fees paid to physicians for services, while Republicans sought to contain the costs by transferring the program to managed care insurers and capping the annual per capita rise in premium subsidies.

In 1997 the leadership in both parties agreed to a plan that would eliminate borrowing for Medicare, principally by limiting the growth in the level of fees paid to physicians. That Medicare reform, along with increasing general revenues paid by taxpayers in the highest bracket, led to a federal budget that balanced in fiscal year 2000.

The balance turned out to be short-lived. In 2001 and 2003 Congress passed debt-financed reductions in income tax rates. And in 2003 it also suspended the application of ceilings on fees set in 1997. Later that year Congress used debt to finance a new Medicare prescription drug benefit and higher payments to Medicare managed care plans.

As a result, the portion of Medicare paid for with dedicated taxes dropped from 73 percent in 2000 to 53 percent in 2010, the year that the first of the Baby Boom generation became eligible for Medicare.”

“After the 2008 election of President Obama, Democrats sought Medicare ‘savings’ for the purpose of expanding other medical services rather than balancing the budget for Medicare. In order to offset the cost of expanded PPACA medical services for families with low incomes; they placed restrictions on reimbursement rates, provided incentives for more efficient delivery of medical care, raised the Medicare tax paid by taxpayers with high-earned incomes, and applied Medicare taxation to gains from investment.”

On the other side of the political spectrum, “Republican House Budget Chairman Paul Ryan exemplifies his party’s ambivalence toward Medicare reform. He ran as the vice presidential candidate on a ticket in 2012 that attacked the Affordable Care Act’s limits on Medicare reimbursements. Yet before and after that election, he incorporated those very cost-saving measures into his own budget plans.”

Incumbents from “both parties find it awkward to even talk about the practice of borrowing to pay for Medicare. Obviously, an extra layer of interest on debt simply increases the program’s long-term cost. Any attempt to highlight that issue naturally invites the question of whether to cut Medicare costs or raise tax revenue dedicated to the program. No mainstream politician seeks to cut benefits by almost half and down to the level payable by revenues from premiums and payroll taxes. Democrats condemn any increase in payroll taxation as ‘regressive,’ while most congressional Republicans have signed a pledge to oppose any tax increase.”

Both sides of the aisle feint a reluctance to either cut Medicare benefits or increase Medicare withholding taxes and an honest discussion with their constituents regarding Medicare financing knowing full well something must be done. Indeed, it is politically expedient to kick the can or the bucket into the next decade avoiding the third rail of Medicare.

What can we do? I will answer that question in my next post.

Notes and References:
1. “Pay As You Go” Medicare Washington Monthly, Bill White, June 23, 2014

2. Maggie Mahar writes the Health Beat Blog Maggie is also the author of Money-Driven Medicine: The Real Reason Health Care Costs So Much (Harper/Collins 2006). Mahar also served as the co-writer of the documentary, Money-Driven Medicine (2009), directed by Andrew Fredericks and produced by Alex Gibney. Before she began writing about health care, Mahar was a financial journalist and wrote for Barron’s, Time Inc., The New York Times, and other publications. Her first book, Bull: A History of the Boom and Bust 1982-2003 (Harper Collins, 2003) was recommended by Warren Buffet in Berkshire Hathaway’s annual report.

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1/3 of Medicare Spending is Wasted

Urban Legend—

You write: That claim that one-third of Medicare spending is wasted sounds pretty questionable to me.”

This is your opinion. If you had spent the last 20 years working as a medical researcher investigating unnecessary treatment, your opinion would be of great interest to all of us; but, I’m assuming you have not done so.

Thus, you might be interested in some facts . . .

Dr. Donald Berwick, who headed up Medicare and Medicaid during the 1st half of the Obama administration has said, repeatedly, that at least 1/3 of Medicare dollars ware wasted on unnecessary tests, procedures and drugs that provide no benefit for the patient. He is only one of dozens of health policy experts who have made the same statement. (Google “Health Affairs” the leading medical journal that focuses on health policy and “unnecessary treatments” Over the past 30 years, researchers at Dartmouth have provided stacks of evidence documenting unnecessary care in the U.S.

You also write: “I doubt that treatment protocols in the U.S. are all that different from other countries.”

Again, this is your opinion. Unfortunately, you are wrong.

In other countries, doctors and hospitals tend to follow evidence-based guidelines. In the U.S. a great many doctors object to the idea of someone telling them how to practice medicine (Even though “someone” is “science”). They value their autonomy and prefer to do things the way they have always done them. Of course, this is not true of all doctors. But even when you look at protocols at our academic medical centers, you find that the way they treat similar patients varies widely.

Here , I’m not talking about how much they charge for a procedure (which also varies widely) but how many tests they order, how often they prescribe spine surgery for someone suffering from low-back pain, how often they tell a woman she needs a C-Section . . .

One big problem is that our doctors and hospitals are paid “fee – for service;” in other words, the more they do, the more they are paid.

As Dartmouth’s Dr. Eliot Fisher points out: “U.S. patients are not hospitalized more often than patients in other countries; but in the U.S., a lot more happens to you while you’re there.”

In addition, traditionally our medical schools have trained doctors to practice very aggressive medicine. The resident who orders a battery of tests is praised. Students are told “Don’t just sit there (and think). Do Something!”. Traditionally, our medical culture has been a very macho culture and it is just beginning to change.

Finally, Americans tend to think that “more is always better”. Larger servings in a restaurant, bigger cars, bigger homes, etc. And when it comes to healthcare, patients in the U.S. tend to think that “more care is better care.” They are wrong. Every medical product and service carries some risk. If it provides no or little benefit, the patient is exposed to risk without benefit.

When medical protocols in the U.S. are compared to how medicine is practiced in other countries, researchers have found: —- Much unnecessary spine surgery. The rate of back surgery in the U.S. is five times higher than in the UK. Studies have shown little difference in long-term outcomes for patients who undergo back surgery compared to those who select non-surgical treatment.

The U.S. does more testing than other countries. For instance, the number of MRI and CT tests for every 1,000 people in 2010 was double the average in other OECD countries. Comparatively, there were also more tonsillectomies, caesarean sections and knee replacements. Regardless of how much more nearly every procedure, scan and drug costs; it’s nothing compared to how out-of-whack the medical heroics thrown at Americans in the last stages of life The Cost of Health Care: A Country-by-Country Comparison

Colonoscopies are prescribed and performed more frequently than medical guidelines recommend and are given preference over less invasive tests that screen for colon cancer. Those less invasive tests are not only routinely performed in other countries, they’ve also been proven to be just as effective by the U.S. Preventative Services Task Force.

“We’ve defaulted to by far the most expensive option, without much if any data to support it,” said Dr. H. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice.

In the U.S. many more patients die in ICU’s getting futile care. This is a painful, lonely way to die. In other countries, more patients are treated in hospices or allowed to go home where nurses and even doctors visit them.

Half of all heart surgeries (using stents) do no good. We know which half! But stent-makers and other providers have turned this into a big business.

- Our drug companies enjoy 20% profit margins.

- Our device-makers boast 16% profit margins.

We are over-medicated (particularly older people), and undergo too many surgeries that involve very expensive devices. Medicare covers virtually everything (even drugs that have been shown to be dangerous–until they are taken off the market). If it does not cover all of the newest treatments and products lobbyists would howl– and Congress makes sure that heads roll.

This is one reason why we don’t want to give everyone 40 to 65 a chance to enroll in Medicare. No one could afford it. (This idea was considered in the late 1990s. Do you have any idea how much 40-65 year olds would have to pay for our extraordinarily inefficient and wasteful Medicare system? On top of that and like people over 65, they would have to pay hefty sums for MediGap to Medicare advantage — private insurance plans that cover all of the things that Medicare doesn’t.

Medicare is now beginning to cut back, and over time it will refuse to pays for unnecessary surgeries (heart surgeries, unproven prostate cancer surgeries, and some hip and knee replacements, unless the patient has tried physical therapy first–and losing weight, if possible. (Some people just can’t lose weight, even under a doctor’s supervision.)

Medicare will also stop covering every new drug that comes on market, setting up a formulary and only paying for drugs that are effective — and cost-effective. The same will be true of devices.

Then — and only then — we might talk about letting people 40-65 sign up for Medicare, though in many cases, research on quality of care suggests that they would be better off with the best of our non-profit insurers: Kaiser, Geisinger, etc.

Medicare is a highly politicized bureaucracy and inevitably, Congress dictates what it can and can’t do. Medical guidelines should be set by medical researchers and doctors who have no financial interest in the outcome.

Maggie Mahar is the originator and author of the Health Beat Blog. Maggie wrote “Money-Driven Medicine: The Real Reason Health Care Costs So Much (Harper/Collins 2006),” and was the co-writer of the documentary, Money-Driven Medicine (2009), directed by Andrew Fredericks and produced by Alex Gibney.

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Where the ACA Should Go Next?

On Tue, Sep 9, 2014 at 1:47 PM, Dan <cdansplace2@aol.com> emailed:

Rortybomb, New Piece on Where the ACA Should Go Next Rorty touts the 2009 House Bill which calls for a Public Option and described here To improve ‘Obamacare,’ reconsider the original House bill

Maggie Mahar replies:

Originally I favored a public option, but in fact, at the time, no one really spelled out who would run the public option–or how it would be run.

One of the best things about the ACA is that lets both HHS and CMS make end-runs around Congress. I would never want a public option that was run by Congress.

Here is the comment I just posted in reply to the post “Where the ACA Should Go Next”

I would need to know far more about the public option—and how it would be different from Medicare– before voting for it.

Medicare is extraordinarily wasteful– 1/3 of Medicare dollars are squandered on unnecessary treatments that provide no benefit to the patient. Why? Because Congress is Medicare’s board of directors, and lobbyists representing various specialist’ groups, hospitals, device-makers and drug-makers control Congress.

Meanwhile, Medicare does not cover much needed care, ie. vision checks are just one example. This is why the vast majority of Medicare beneficiaries must buy separate private insurance (MediGap or Medicare Advantage) to supplement what medicare doesn’t cover.

Finally, I favor narrow networks. They keep costs down. The doctors and hospitals that are not included in the networks are those that refuse to negotiate  prices.  By excluding them we remind doctors and hospitals that we can no longer afford letting providers charge whatever they wish. No other developed nation allows doctors and hospitals to simply set prices.

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Obamacare Enrollment 2015: How Many People Will Sign Up Next Year? (Public Support for Obamacare Is About to Turn a Corner) Part 1

Thanks to the Affordable Care Act, some 10 million previously uninsured adults gained coverage during the open enrollment period that began on October 1, 2013. Last month, the New England Journal of Medicine reported that the share of Americans who are “going naked” has plummeted from 21 percent in September of 2013 to 16.3 percent in April of this year.

Even though open enrollment officially ended on March 31, 2014, people are continuing to sign up. Anyone who experiences a major life change (getting divorced, losing a job, having a baby) can still purchase insurance on the Exchanges this summer. Others are dropping out because they landed a job, married someone with insurance, or turned 65.

Earlier this month, Aetna told Investor’s Business Daily “the degree of attrition was “scary” and “unexpected,” and as a result, enrollment is “shrinking.” But enrollment expert Charles Gaba soon put that rumor to rest. Perhaps Aetna is losing customers, but overall, enrollment is holding up. Indeed, ultimately, the Congressional Budget Office (CBO) projects that by the end of 2014, 12 million formerly uninsured Americans will be covered either by the Obamacare insurance they purchased on the Exchanges or by newly expanded Medicaid programs.

On November 15, a new open enrollment period begins. Now the big question is this:

Will the ACA Be As Popular In 2015 As It Was In 2014?

Over at the Huffington Post, Jeffrey Young is pessimistic. In a post headlined “Why Obamacare May Have Trouble Signing Up As Many Uninsured Next Year,” he quotes Richard Onizuka, the CEO of the Washington Health Benefit Exchange saying “we got the low-hanging fruit” last year. The people who most needed healthcare signed up right away. These include folks with pre-existing conditions, who had been shut out of the market under pre-Obamacare rules.

By contrast, in this second round of enrollment, Young points out that reformers will be trying to sign up people who are not desperate for insurance, and who may be harder to reach, including: “Hispanics . . . people who have less education, live in remote rural areas . . . don’t have Internet access or don’t consume news.”

Moreover, Young notes: “public opinion about the law itself is negative.” Indeed, nationwide polls show that approval ratings for Obamcare have been sinking in recent months. Reform appears less popular than it was when enrollment began in October of 2013. As a result, Young believes that enrollments will tumble: The CBO now predicts that just 7 million Americans will gain insurance in 2015.

But as I will point out in my next post, there are indications that in states where Obamacare enrollments have been most successful–including Red states – the Affordable Care Act (ACA) may be about to turn a corner, even among Republicans.

This explains why Republican Party leaders who decide how to spend campaign dollars have begun backing away from ads attacking Obamacare. The GOP senses that, going forward, bashing Obamacare will no longer be the best way to bash Obama. Too many people are finding out why reform is a good deal.

Ten Reasons Why Obamacare Will Cover Another 10 Million in 2015

Usually, I agree with Young—his analysis of health care reform is both fact-based and shrewd. But in this case, I’m not persuaded. I can think of at least ten good reasons to expect that another 10 million will either purchase Exchange insurance or join Medicaid’s rolls next year.

- The millions who have already signed up are now telling friends and neighbors about the benefits of Obamacare — including the fact that 87% of them received government subsidies that helped cover premiums. Polls show that while many Americans don’t trust the media’s conflicting reports about Obamacare, they do believe the information they receive from friends and relatives.

- Word-of-mouth will dispel rumors that continue to confuse potential customers. For example, In July a Kaiser Foundation poll revealed that 37% of those polled thought that under the Affordable Care Act, people had no choice of policies. They believed that anyone who bought coverage in an Exchange was shoved into one government-run plan.

- Amazing, when Enroll America conducted a survey in April, just after the first enrollment period ended, it discovered that 26% of those who had not signed up still had not heard that the government was offering financial assistance to low-income and middle-income people who bought coverage in the Exchanges. Those who did enroll were twice as likely to know about the subsidies (56% vs. 26%). In the months ahead, millions will learn more about true cost Obamacare as friends talk about what they are paying for their policies.

- Many will find that premiums are lower than they were in 2013, in part because more insurers will be selling policies on the Exchange, increasing competition. I recently received a letter from my insurer telling me that, next year the premium on my zero-deductible Exchange plan will be falling by 10%. As state regulators make final decisions about which increases they will and won’t approve, I will be writing more about how many insurers are dropping rates.

- In 2015, the Refuseniks will have to pay a fine that rises from 1 percent of yearly household income or $95 per person (whichever is greater) to 2 percent of household income or $325 per person. A family of four earning $70,000 would have to fork over $1,400—and receive nothing in return.Or that same family can sign up for a subsidy, pay part of the premium and wind up with comprehensive insurance that includes free preventive care, and caps out-of-pocket costs.

- This fall, it will be far easier to use the online websites than it was in the fall of 2013. By the end of the first enrollment period, most sites were working smoothly (though by then many would-be customers had given up). This year, there should be many fewer glitches because the administration has persuaded Mikey Dickerson, the Google engineer credited with fixing bottlenecks on the Healthcare.gov website last spring, to become the government’s full-time IT czar.

- The “navigators” charged with helping customers find plans that meet their needs, either in person, or on the phone, will be that much more experienced, and many will have received more training. There will also be more bi-lingual navigators available.

- Over the next year, more states will expand Medicaid. Political pressure is mounting: states that refuse to take the federal dollars that Washington is offering are leaving too much money on the table, and voters are hearing about it. In North Carolina, for instance, local newspapers are reporting that, over the next decade the state risks missing $51 billion in federal payments. Hospitals would get $11.3 billion of that amount. At present, North Carolina hospitals are threatening to lay off workers. If North Carolina expands Medicaid, another 400,000 Americans would be insured under the ACA. And that’s just one state.

- As low-income people who have joined Medicaid talk to their neighbors, more will become aware that the rules for eligibility are changing. We’re likely to see a major impact in the Latino community where language barriers have blocked government efforts to spread the word.

- More young adults will find out that they can sign up for a parent’s employer-based insurance and stay on it until they turn 27. A Deloitte survey of young adults reveals that in April, 45% still had not heard about this Obamacare benefit.

- The Kaiser Foundation’s July poll reveals that most people who actually signed up for Obamacare rate their policies as “excellent” or “good.” This, along with what I know about how the ACA is helping millions, is the major reason why I am convinced that as the newly insured share their experience with others, public support for health care reform will climb—especially among those who most need it.

- As I will explain in part 2 of this post, some affluent Americans who don’t need the ACA or its subsidies (because they already are covered by employers) may be inclined to remain nervous about Obamacare. But Americans who are wealthy enough to feel that they and their adult children are economically secure are a shrinking minority. This is the one good thing that can be said about growing economic inequality.

Originated at Health Beat Blog

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Children from Central America Surge Across Our Border: Congress Must Now Decide Whether to Change the Immigration Law that George W. Bush Signed in 2008

by Maggie Mahar

If you think fertilized eggs are people but refugee kids aren’t, you’re going to have to stop pretending your concerns are religious– Syd’s SoapBox

News reports have been filled with conflicting theories explaining why tens of thousands of unaccompanied children from Honduras, El Salvador and Guatemala, have been streaming into the U.S.  Some observers say that their parents are sending them here, so that they can take advantage of the social services and free education available in the U.S. Others argue that they are not coming here willingly, but that they have been forced to flee gang violence in their home countries that ranges from murder to rape. Still others charge that President Obama’s lax immigration policy has drawn these migrants to the U.S.

Unfortunately many of the reports circulating in the media and the blogosphere are not backed up by evidence. Even worse, the American Immigration Council  (AIC) says, “some are intentionally aimed at derailing the eventual overhaul of our broken immigration system.”

I have been fact-checking those reports for more than two weeks.  Below, a summary of you need to know as we debate this tangled story.

The AIC recently released a report, based on documented interviews with more than 350 children from El Salvador which states that  “crime, gang threats, or violence appear to be the strongest determinants for childrens’ decisions to emigrate.”

Typically, the gangs try to recruit children. If they refuse, they and/or family members are shot.

The United Nations High Commissioner for Refugees (UNHCR) offers charts showing how that in 2012, the murder rate in Honduras in was a whopping 30 percent higher than UN estimates of the civilian casualty rate at the height of the Iraq war. The charts  also reveal that, statistically speaking, Honduras, Guatemala and El Salvador are twice as dangerous for civilians as was Iraq.

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Polarized Politics Led To Cantor’s Defeat– and Cochran’s Victory. Why the “Uncommitted Center” Is So Important (Cantor part 2)

Part 1; Cantor’s Defeat and What It Does Not Mean

When House Majority leader Eric Cantor lost his seat to ultra-conservative David Brat, the Washington Post’s Ruth Marcus summed up the majority view among political pundits: “The episode offers a disturbing commentary about the poisonous, polarized state of American politics.” 

I cannot agree. I don’t think “polarization” is toxic.  To the contrary, as the poet William Blake once wrote “Without Contraries, No Progress.”  Conflict can clarify issues, and help us move forward.  Indeed, the clash of opinions is a time-honored way of testing their validity.

Do you remember the 1990s, a decade when it became difficult to tell the difference between Democrats and Republicans? While Republicans headed toward the far right, Democrats moved right of center. During his second term, Bill Clinton started to sound all too much like Ronald Reagan, as he set out to “reform welfare,” forcing single mothers to go to work, even though we weren’t offering them affordable day care. After leaving the White House, Clinton reclaimed his position as a stand-up liberal, but at the time, the distinction between Democrats and Republicans was badly blurred.

Today, the difference between the two parties is clear.  I wouldn’t say that Democrats are ultra-liberal, but conservatives have moved so far to the right that Democrats had no choice but to take a stand on critical issues including: global warming, gun control, the need to raise the minimum wage, and universal access to health care.

By contrast, in the 1990s, Congressional Democrats were “lukewarm” on health care reform. As Paul Starr reports in his newest book, Remedy and Reaction, Senate Finance Committee chairman, Daniel Patrick Moynihan, Democrat of New York, actually stood up to say, “We don’t have a health care crisis.”

But by  2010,  the crisis was obvious, and Democrats came together. Pelosi and Harry Reid marshaled the votes, and Congress passed legislation which, while far from perfect, is solidly progressive: Low-income and middle-income Americans receive the subsidies they need; insurers can no longer discriminate against people suffering from pre-existing conditions, and preventive care–including contraception–is free.There is much more work to be done, but at last, we have begun.

Since then, Congressional Democrats have not had the votes to pass much-needed legislation in other areas.

But at least President Obama is no longer the compulsive compromiser that he appeared to be during his first term in office. I see this as progress. As I have argued in the past, on some issues compromise is not an option.  Too much is at stake.

On the ground,voters are as divided as their elected representatives.  Politically active Democrats have begun to move  left of center while Republican voters have become more conservative. The Pew Research report that I discussed in the first part of this post reveals that a decade ago, only 10% of politically engaged Republicans took a conservative stance on almost all issues. Today, 33% express consistently conservative views. At the other end of the political spectrum, almost forty  percent of committed Democrats are consistent liberals, up from just 8% in 1994. The overall share of Americans who express consistently conservative or constantly liberal opinions has doubled over the past two decades from 10% to 21%. .

“As a result,” Pew reports, “ideological overlap between the two parties has diminished. “Today, 92% of Republicans are to the right of the median Democrat, and 94% of Democrats are to the left of the median Republican.”.

“Republicans and Democrats are more divided along ideological lines – and partisan antipathy is deeper and more extensive – than at any point in the last two decades. And a new survey of 10,000 adults nationwide finds that these divisions are greatest among those who are the most engaged and active in the political process.”

Is Polarization A Threat to the Nation?

Most pundits are appalled.
“It’s a poisonous potion,” writes Bloomberg’s Mark Silva:

“Increasing Ideological Uniformity.

“Partisan Animosity.

“Stir it up:  and what you have is ‘Political Polarization.’

“The antipathy cuts both ways” Silva adds.

On that last point he is right.  As Pew points out, the share of Republicans who have very unfavorable opinions of the Democratic Party has more than doubled over the past 20 years – from 17 percent to 43 percent. Similarly, the share of Democrats with very negative opinions of the GOP also has more than doubled – from 16 percent to 38 percent. . .

“There are actually people who view the other political party as a ‘threat to the nation’s well-being’” Pew notes, “with 27 percent of Democrats saying this of the Republican Party, and 36 percent of Republicans saying this of the Democrats. Those numbers, too, have essentially doubled during the past two decades.”

“Pew calls it ‘a rising tide of mutual antipathy,’” Silva observes.

Let me be clear: l Like Silva, I too, abhor the extremes where sheer anger replaces reason.. (I cringe whenever I hear a good friend say that Dick Cheney should be “put up against a wall and shot.” He says this quite often.)

But I would point out that arch-conservatives seem much angrier than liberal Democrats. This is why Republicans come out to vote, particularly in mid-term elections, in much larger numbers. Rage sends them to the polls.

What I find most disturbing is that these conservatives seem to loathe, not just liberals, but anyone who they view as “Other”:  People who are dark-skinned, poor, foreign, gay, or a feminist who stands up for a women’s rights is  deemed “Not Us.”  This mixture of xenophobia, racism, homophobia and misogyny is what I find truly frightening.

The Disengaged Center – Nearly 40% Of All Americans

Most importantly, what  Silva ignores is that while committed Republicans have headed further right, and committed Democrats have shifted to the left, only 61% of Americans are committed to either party.

The Pew poll reveals that fully 39% belong to an uncommitted center: “Many of those in the center remain on the edges of the political playing field, relatively distant and disengaged, while the most ideologically oriented and politically rancorous Americans make their voices heard.

Those in the center are quieter, less likely to vote, and less likely to make political contributions. These are the people who say “I just don’t pay much attention to politics.” Or, “I’ve given up on politics and politicians.”

But according to Pew, while many in the center do not vote, they do have opinions. “These centrists are not moderates. Those in the center hold strong views on various issues,” the Pew report explains. “The difference is that they are not consistently liberal or conservative.” An over-riding ideology does not determine all of their decisions.

For example, some favor gun control, but are opposed to health care reform. On immigration, their views are mixed. Pew’s research reveals that “all told, 37% of non-ideological Americans support drastic changes in America’s immigration policies.”  Some favor deportation of all unauthorized immigrants while others support immediate citizenship if certain conditions are met.”

Because they are not blinded by a single ideology, their minds are open to listening to rational arguments on various issues. This is why we need them at the polls.

On this point, I am hopeful. As conservatives move further and further to the extreme right, more and more Americans are becoming alarmed. As a result, we may well see more disengaged, disaffected, and discouraged citizens beginning to pay attention to politics.

Mississippi

This is exactly what happened Tuesday, in Mississippi, where veteran Republican Senator Thad Cochran beat back a challenge by State Senator Chris McDaniel, a Tea Party favorite.

On June 3, Cochran, an establishment Republican who has served in the Senate for 24 years, lost the Republican Senate primary to Chris McDaniel, a former talk radio host and Tea Party–backed state senator,

Because neither won 50 percent of the vote. the race went into a runoff. At that point, most observers assumed that Cochran would lose.  With his intense support from passionate Republicans, combined with wide backing from national Tea Party groups, McDaniel was the favorite.

But in the last three weeks of the race, Cochran began to reach out to black voters. He was betting that African-American Democrats might well come out to vote against McDaniel, who is  well known for his New Confederate views. (A Southern reactionary, McDaniel laments how the country has changed, since the days before civil rights legislation passed. He misses the “Old South”.) On his radio talk show, he also had made     racist and sexist remarks that I find too offensive to repeat.

Cochran’s strategy proved shrewd. In the run-off, African-American turnout in the 24 counties with a black population of 50 percent or more was up almost 40 percent from the primary.

Make no mistake: Cochran is a conservative Mississippi Republican. Black Democrats know this. But as one voter said: “One of the other white men is going to get in there. We need to choose.”  By turning out for Cochran these liberals made sure that a rabid, racist conservative would not have a vote in Congress.

You might wonder: How could Democrats vote in a Republican runoff? In Mississippi, which does not register by party affiliation, any registered voter can vote in the Republican runoff election as long they did not vote in the Democratic primary during the first round of balloting on June 3.

Most African-Americans didn’t bother to vote for Travis Childers, the winner of the Democratic primary.  They didn’t think he stood a chance. Thus, they were free to cast a ballot for Cochran.

At Cochran’s satellite office in Hattiesburg, Stacy Ahua, 25, a black field organizer, managing a get-out-the-vote operation explained Cochran’s strategy to the Washington Post: “Some of our people forgot to come out for that first vote and we’ve really tried to get things moving. I think everybody now understands the stakes, whether you’re Democrat or Republican, Catholic or Baptist.”

Exactly. This is what right-wing extremists are now doing nationwide: defining what is at  stake. I thank them.

No surprise, McDaniel’s supporters are livid that African Americans sealed their candidate’s defeat. Already, they are talking about a write-in campaign on his behalf. This  could split the Republican vote.

At the same time, success may persuade African Americans and other Mississippi liberals  to turn out for the mid-term elections. And,  if there is no write-in campaign,  right wingers who are furious at Cochran may refuse to vote. In other words,  Travis Childers might stand a chance. He  is a conservative Democrat, but still the GOP would have one less seat in the Senate.

Convincing Americans That It’s Worth Taking the Time to Vote: The Argument for Partisanship

Writing in the American Prospect, Paul Starr recently made the argument that “if Democrats are going to convince their supporters it is worth the trouble to vote . . . . they need to advocate policies that make as loud and stark a contrast as possible with those of the Republicans. Obama’s belated emphasis on raising the minimum wage and increasing overtime pay are good examples of the approach. Taxing the 1 percent to finance broadly distributed benefits also fits this description. . .

“Such policies will predictably be described as class warfare,” Starr acknowledges. “But . . . the objective is actually to get back to an income distribution more like the level that prevailed in the Eisenhower administration. The entire political and legal spectrum has been moved so far to the right that what used to be centrist only seems populist.”

But in recent years, the zeitgeist has turned. .Both the issues and the candidates are more sharply defined than in the past. As a result, Starr notes, “voter turnout in the 2004 and 2008 elections returned to levels America hadn’t seen in 40 years. Fox News and MSNBC stir up the emotions not just of their devoted viewers, but of those who abhor them; liberals and conservatives alike may be more inclined to vote.

In an earlier piece Star argued: “Democracy needs passion and partisanship provides passion.” Yes.

In Some Cases Compromise Is Not Possible

But do we really want “passionate” partisan representatives in Congress? Don’t’ we want to elect politicians who will compromise with each other?

Not necessarily.

On the face of it “compromise” sounds eminently reasonable, and very often, it is appropriate. When it comes to negotiating tax rates, we may be able to “split the difference’—at least in some cases.

For example: until very recently, the Federal government taxed estates over $1 million. Now the IRS collects a tax only if the estate exceeds $5 million. (In 2013 this change cost us roughly $13 billion in government revenues.) Some conservatives would like to abolish the tax altogether; liberals would be inclined to go back to taxing amounts over $1 million. I could see both sides reaching middle ground by agreeing to tax estates over, say, $2.5 million.

But sometimes we can’t meet in the middle. Some values just are not negotiable.

Below, a short list of issues where Republicans and Democrats disagree, and I would argue, compromise is not possible.

Gun control:  When as are talking about the slaughter of innocents, we cannot “split the difference” with the NRA. There is no reason for civilians to own automatic and semi-automatic weapons. And no one should be able to buy a firearm of any kind without a thorough background check.

Medicaid Expansion: The right to healthcare is a universal right, not a matter of states’ rights. The notion that poor adults should have access to medical care in some states, but not in others, is untenable. Once again, what is at issue here is not money, but blood.

Immigration reform: Do we really want to send Honduran 15-year-olds back to a homeland where they are likely to be maimed, killed, or enslaved by a gang?  (See part 2 of this post)  We must offer asylum to those who are at risk, just as, over the years, we offered protection to at least some European Jews (far too few), as well as some Russian dissidents. Skin color or ethnicity should not affect that decision.

As for children who were brought here by undocumented parents years ago, the idea of sending them back to a country that they don’t know is impossibly cruel. Finally children who grew up here should not be barred from attending college because they are labeled “illegals.” We need more educated workers.

Raising the Minimum Wage:  We know that children in the U.S. go to bed hungry because a parent cannot earn enough to feed them. Food stamps run out before the end of the month. And, if we  lift the minimum wage, we can assuage union fears that more immigrants will depress the average American’s paycheck.

Global warming: On this topic right-wingers are not only a threat to the nation, they’re a threat to the globe. Two-thirds of Americans (67%) say there is solid evidence that the earth has been getting warmer over the last few decades, a figure that has changed little in the past few years. Yet conservatives have managed to block action.

Nevertheless we should thank right-wingers for highlighting the issues. Voters are no longer simply talking about candidates’ personalities. We are facing basic differences in what we think is “right” and “wrong.”

A Pew Research Center survey of “American Values” reveals that when it comes to rock-bottom moral questions, liberals and conservatives simply don’t agree. In particular, Pew reports, when Republicans are asked about government regulation and involvement in our lives, they are more adamant than ever before: Individual rights should be paramount; the government should not interfere.

By contrast, progressives tend to believe that government has a responsibility to regulate with an eye to the “common good”–and to tax and spend with the goal of creating a fairer, more egalitarian society.

Ultimately, their positions illustrate the tension between two political goals: freedom and equality. Conservatives favor freedom; liberals are more concerned about equality.  The reason we have two parties is so that voters can choose.

Can’t we have both freedom and equality? Of course–but in some cases there is a conflict between individual rights and what is best for society as a whole. Then, voters must decide.

On such critical questions, I would argue that we are not looking for a mid-point between “right” and “wrong.”  Either we expand Medicaid for everyone—including childless adults–or we don’t.

In a democracy, our elected representatives should reflect what the majority of Americans think is truly just—including the 40% who are not card-carrying conservatives or liberals.

And in fact, recent polls suggest that most U.S. citizens do have clear views on these issues. The majority favor stricter gun control laws;  think that illegal immigrants should be allowed to stay in this country and eventually apply for citizenship; support a proposal requiring companies to cut greenhouse gas emissions that cause global warming even if it means higher utility bills; believe that we should raise the minimum wage  from $7.25 to $10.10–or higher and support Medicaid expansion

Why then is Congress gridlocked on these questions? Because only a minority of Americans vote , particularly in midterm elections that decide the fate of so many Senators and Representatives.  Thus Congress reflects the beliefs of some Democrats and Republicans at each end of the political spectrum, but not the will of the majority.

Originated at Health Beat Blog

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