Relevant and even prescient commentary on news, politics and the economy.

The Mutt Speech

One Mutt’s Speech for You to think about after celebrating the long Weekend from the nationalistic holiday called the Forth of July while others are fleeing terror and violence.

John Winger: “Cut it out! Cut it out! Cut it out! The hell’s the matter with you? Stupid! We’re all very different people. We’re not Watusi. We’re not Spartans. We’re Americans, with a capital ‘A’, huh? You know what that means? Do ya? That means that our forefathers were kicked out of every decent country in the world. We are the wretched refuse. We’re the underdog. We’re mutts! Here’s proof: his nose is cold! But there’s no animal that’s more faithful, that’s more loyal, more loveable than the mutt. Who saw ‘Old Yeller?’ Who cried when Old Yeller got shot at the end?

Nobody cried when Old Yeller got shot? I’m sure.

I cried my eyes out. So we’re all dogfaces, we’re all very, very different, but there is one thing that we all have in common: we were all stupid enough to enlist in the Army. We’re mutants. There’s something wrong with us, something very, very wrong with us. Something seriously wrong with us – we’re soldiers. But we’re American soldiers! We’ve been kicking ass for 200 years! We’re ten and one!”

“Stripes” Bill Murray the Mutt Speech

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United States Women beats the Netherlands 2-0, wins its fourth World Cup

This clip is of Rose Lavelle scoring the second goal in the 69th minute of the game. The clip has been disabled and must be seen on YouTube. Click on the arrowhead first and then the “Watch this video at YouTube” and it will take you there. United States’ Rose Lavelle doubles lead vs. Netherlands | 2019 FIFA Women’s World Cup™ Highlights, Fox Sports, Fox News, July 2, 2019.

Nothing like going in for the winning insurance goal coming after Team Captain Megan Rapinoe converted a penalty kick. Megan Rapione went on to win the Golden Ball as the most valuable player during the Women’s World Cup and the Golden Boot for being the top scorer.

A Huge Well Done!

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Destroying Social Security to Save It

Connecticut Representative John Larson Proposes Plan To Destroy Social Security In Order To Save It, by Dale Coberly

Connecticut Congressman John Larson introduces H. R. 860, Social Security 2100 Act which will cuts taxes, strengthen benefits, prevents anyone from retiring into poverty, and ensure Social Security remains strong for generations. larson.house.gov

It sounds good, but of course he wants it to sound good. In the past we have had to be worried mostly about plans from the “Right,” the crazy people who want to Save Social Security in order to destroy it. Their plans sounded good, too.

To make it easier on myself, I am going to just list Larson’s points and offer a few words about them in the hope you will think twice.

Larson: The Social Security 2100 Act Expands Benefits

There is a benefit bump for current and new beneficiaries — Provides an increase of 2%.

Me: A 2% increase in benefits would mean nothing to beneficiaries. Unlike the reduced inflation indexing the bad guys were proposing, this increase will not accumulate over time.

What Social Security faces is a potential 20% cut in benefits if the payroll tax is not increased to keep up with increases in life expectancy. The increase needed would be about 2% of payroll. 2% of payroll becomes 20% of benefits because the 2% you pay is matched by 2% your employer pays for. That extra 4% over 40 years of working becomes 8% over 20 years of life expectancy, and that 8% becomes roughly 20% due to the effective interest that arises automatically from pay as you go financing.

Larson: Protection against inflation. Increases the COLA formula to better reflect costs incurred by seniors.

Me: Probably a good idea. But the “normal” inflation adjustment, if paid for by that 2% increase in the payroll tax, will provide increased benefits that may be adequate. The question is how are we going to pay for a higher COLA? My suggestion is that a tiny bit larger increase in the payroll tax would not be felt, and would avoid the politically suicidal “make the rich pay” part of Larson’s plan unnecessary.

Larson: Protect low income workers. A new minimum benefit will be set at 25% above the poverty line.

Me: Again, probably a good idea. But not if it changes the “worker paid” feature which is so important to Social Security’s political future.

If the workers want to pay more for a higher benefit dedicated to those who paid for the insurance against ending among the poorest, then that’s fine. It’s not so fine if the increase is paid for by “the rich,” because the rich will not pay for it. And it’s not so fine if it becomes subject to increased hiding of income to free-ride on others paying the tax. Not to mention the costs of managing the means testing that this implies.

Larson: Cut taxes for beneficiaries.

Me: Social Security is supposed to be insurance against ending up poor. Currently no one pays taxes on their Social Security income unless they have other income over $25.000 per year. Combined with their SS income this would suggest an income in retirement of about $45,000. This is not poverty.

There are other ways to jiggle around the SS ‘break points” or taxing of benefits. The tax on part of SS income for those with enough other income to stay out of poverty turns out to be the simplest and fairest. Might be important to remember that SS is not only “what you paid in,” but is about double what you paid in because of the effective interest of pay as you go.

You pay taxes on gains from every other investment. So there is nothing immoral or counterproductive about taxing part of SS benefits for those who otherwise have sufficient income. This tax is returned to the Social Security trust fund and is part of what helps pay those increased benefits for the poor.

Larson: Strengthens the Trust Fund

Have millionaires pay the same rate as everyone else.

Me: This is the bit that destroys Social Security. Currently millionaires pay the same rate as everyone else: 12.4% of the first $130 thousand per year. This is enough for them to pay for what they get from Social Security… an effective real interest of around 1 or 2 percent, plus the insurance value in case their millions of dollars disappear before they retire, or when they become disabled or die leaving dependents.

They only get that 1 or 2% compared to your 2 or 3% and the poorest up to 10% or more because the money they would get if everyone got paid the same interest is what enables SS to pay the bigger “interest” needed to pay for basic needs of the poorest.

“Making” them pay 12% on ALL of their income would be a huge tax increase they would get nothing out of. They would fight it forever.

It would be like having a cop watch the check-out line at the grocery and demanding every customer show their tax returns and “making” anyone with “too much” income pay for the groceries of the next ten people in line.

This sounds fair to some people who think that the “rich” stole their money from the “poor.”
Maybe some did, but this is not the way to fix that problem. If you want to tax the rich more, fine. If you want more welfare, fine. But don’t do it to Social Security, which works, and has worked for eighty years exactly because it is NOT welfare. NOT “soak the rich.”

Larson: 50 cent per week to keep the system solvent. Gradually phase in an increase in the tax by an average of 50 cents per week.

Me: Sounds familiar. Question is why stop at 50 cents when a dollar will keep the system solvent forever without the political dangers of “make the rich pay”?

Do we think an extra 50 cents per week out of an income of 50k per year is going to be felt? Note that for the poorest people making 20K per year, the “dollar per week” turns out to be 20 cents per week (The increase needed to keep SS solvent forever is one tenth of one percent of income per year.)

This is mindless greed. Greed so stupid it defeats itself.

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Democratic Presidential Candidates Addressing Maternal Healthcare

Back in April, I finished up an article for ConsumerSafety.Org called A Woman’s Right to Safe Healthcare Outcomes. The topics covered in this as given to me by ConsumerSafety.Org were Clinical Trials, Essure, and Maternal Mortality. All of the topics dealt with women’s healthcare. Of the three issues addressed, I found Maternal Mortality to be the most compelling.

I told the story of a white upper middle class couple, Lauren Bloomstein a nurse and her husband Larry a surgeon. They went to the hospital to have their first baby. Lauren was a healthy young woman who did everything right. Unfortunately Lauren’s OB before and during her delivery missed many of the signs she was suffering from preeclampsia or high blood pressure. Lauren died after giving birth to a healthy baby girl. It is not unusual for doctors failing to heed the warning signs a women or her symptoms are alerting them too.

The warning signs of life-endangering problems were there, were missed (pain in the kidney area), or ignored (abnormal high blood pressure for Lauren). Excuses for other causes of the pain (reflux) were made, and pain killers administered to dull the pain and other symptoms (blood pressure) not explored while she deteriorated in front of her husband who suspected preeclampsia. The missing part of this was the protocol to diagnose early on and prevent Lauren from slipping into late stages of preeclampsia. This is not an isolated incidence as the deaths of women giving birth keep increasing as evidenced in the chart.

Even with the PPACA, expanded Medicaid in place; and when compared to their Canadian sisters, American women are three times more likely to die from the start of a pregnancy up till one year after the birth of a child (defined by the Centers for Disease Control). The death rate for American women is 26.4 deaths per 100,000 as opposed to 7.3 deaths per 100,000 in Canada (Chart). The ratio worsens when compared to Scandinavia countries as American women are six times as likely to die as Scandinavian women.

There are two stories, one for economically secure women and another for minority, native American, rural, and lower income women.

The statistics worsens for women of color with their being more likely to die in pregnancy or childbirth and are nearly four times more likely to die from pregnancy-related causes than white women. In high-risk pregnancies, African-American women are 5.6 times more likely to die than white women. Amongst women diagnosed with pregnancy-induced hypertension (eclampsia and pre-eclampsia), African-American and Latina women were 9.9 and 7.9 times in danger of dying than white women with the same complications. Native American and Alaskan Native women experience similar discriminatory care. Half of all U.S. births are covered by Medicaid and covers women up to two months past delivery leaving a substantial gap after child birth when other issues can arise.

Barbara Levy, vice president for health policy/advocacy at the American Congress of Obstetricians and Gynecologists; “We worry a lot about vulnerable little babies and we don’t pay enough attention to those things catastrophic for women.”

The emphasis has been on safe baby care and safe birthing which lead to a significant decline in baby mortality. As reported in a Propublica, NPR report, the difference in “maternal mortality numbers contrast sharply with the impressive progress in saving babies’ lives.” Maternal death rates while giving birth and up to one year later has increased by an approximate 10 deaths per 100,000 since 2000 till 2015 or greater than the 9.2 deaths per 100,000 in the U.K, (Chart).

In my email account, I found my usual Health Affairs article with a lead off title “The Maternal Health Crisis: Policies of 2020 Candidates

“Many of the Democratic presidential candidates met in Columbia, SC at the Planned Parenthood Women’s Health Forum to share their reproductive health proposals, including plans for maternity care. On Thursday, June 26th, they will engage in their first debate. Donald Trump launched his re-election bid on June 18th, 2019. While his campaign website does not include any specific reference to maternal mortality, members of his administration have recently brought attention to rural maternal health challenges.

This renewed focus on maternity care is desperately needed: U.S. rates of maternal mortality are the highest in the developed world and have been rising since the 1990s, with women giving birth today more likely to die in childbirth than their mothers. These adverse outcomes are also marked by significant racial disparities, with non-Hispanic black and American Indian/Alaska Native women at least 3 times as likely as non-Hispanic white women to die around the time of childbirth.”

About time.

run75441 (Bill H)

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Supreme Court to hear cases over ACA risk-corridor funds

Supreme Court to hear cases over ACA risk-corridor funds

“The U.S. Supreme Court said Monday it will take up cases over whether the federal government must pay billions of dollars to health insurers that sold coverage on the Affordable Care Act exchanges.

Letter to The Editor – Modern Healthcare Alert

If you are going to report on this particular incident with the Cromnibus Act which passed December 11, 2014, why not give the complete history of how the Risk Corridor Program was stymied?

Initially, then Budget Committee Republican Ranking Member Senator Sessions wrote a letter to the GAO asking whether the Risk Corridor payments were being appropriated correctly. In a letter back to Sessions the GAO said Agencies can only appropriate funds at the discretion of Congress. Funding had not been properly secured for the Risk Corridor Program. This effectively stopped any new funding from being used for the Risk Corridor Program; however, funding could be transferred from other healthcare programs.

With the aid of House Energy and Commerce Chair Fred Upton and House Appropriations Chair Jack Kingston, Section 227 was inserted into the Cromnibus Act.

“None of the funds made available by this act from the Federal Hospital Insurance Trust Fund or the Federal Supplemental Medical Insurance Trust Fund, or transferred from other accounts funded by this act to the “Centers for Medicare and Medicaid Services – Program Management “ account may be used for payments under section 1342(b)(1) of Public Law 111-148 (relating to risk corridors).”

This was far more nefarious than Congress as a whole making this budget neutral and its hides what Republican Senator Sessions, and House Representatives Upton, and Kingston did to sabotage the ACA, drive up premiums, bankrupt Coops, cause companies to leave the healthcare exchanges, and cause constituents to lose coverage.

Yes indeed, Congress did vote for the Cromnibus Act in the waning day(s) left before a government shut down. Section 227 was inserted during those last few days and more than likely overlooked in the process of passing a budget bill so the government would not shut down.

run75441 (Bill H)

Should these companies win at SCOTUS review, the costs and blame should be assigned to these three as their motives were “solely” party politics over country thereby penalizing citizens.

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Does President Trump Read “JAMA Network Open?”

It is doubtful Trump reads much beyond his own signature on Executive Orders and Twitter commentary. Someone is attempting to align him with current thinking creating a persona of his being a thoughtful and reasoning president as opposed to . . . ?

In “Again, Healthcare Cost Drivers Pharma, Doctors, and Hospitals ,” I had posted stats from a 2016 JAMA paper covering the period from 1996 to 2013. Healthcare costs had increased $1 trillion of which 50% was due solely to pricing. One significant factor in the JAMA report was the $66 billion increase in costs for diabetes treatment of which $44 billion was due to pharmaceuticals pricing. One impact to diabetes treatment was Eli Lilly’s increases for Humalog which was $21 per vial in 1996. By 2017, the price increased to $275 (700%) for a vial, a one-month supply. Humalog is a decades old drug and the manufacturing has not changed significantly.

“JAMA Network Open” has issued an end of May 2018 paper on pharmaceutical pricing trends covering the years from the period 2012 – 2017, “Trends in Prices of Popular Brand-Name Prescription Drugs in the United States.” The question it asks:

• What are the prices of top-selling brand-name prescription drugs in the United States and how have these prices changed in recent years?

answer:

• In this evaluation of 49 common top-selling brand-name drugs; 78% of the drugs have been available since 2012, have seen an increase in insurer and out-of-pocket costs by more than 50%, and 44% have more than doubled in price.

and concludes:

• Brand-name drug pricing associated with government-protected market exclusivity is likely to continue to increase and warrants greater price transparency.

Similar to what President Trump has proposed which “still” does not empower constituents to seek alternatives and typically the alternatives are just as costly.

Study Methodology

Data was obtained of 35 million individuals from the Blue Cross Shield Axis (data base) for the time period of January 2012 through December 2017. The researchers reviewed prescribed drugs exceeding $500 million in US sales or $1 billion in worldwide sales.

Within the identified parameters of 2012-2017 sales, 132 brand-name prescription drugs were identified. 49 of the 132 top-selling drugs exceeded 100 000 pharmacy claims, substantial cost increases among these drugs was experienced within the inclusion parameters with a 76% median cost increase, and 48 of the drugs had regular annual or biannual price increases.

Thirty-six of the 49 drugs were available since 2012. Twenty-eight had experienced an increase in insurer and out-of-pocket costs exceeding 50% and 16 more than doubled in price. Insulins such as Novolog, Humalog, and Lantus and tumor necrosis factor inhibitors such as Humira and Enbrel experienced highly correlated price increases coinciding with some of the largest growth in drug costs.

The results of the study revealed the median sum of out-of-pocket and insurance costs paid by patients or insurers for common prescriptions and presented both annually and monthly.
Pricing increases for 13 new drugs from January 2015 through December 2017) and entering the market in the last 3 to 6 years was not different than those (36) having been on the market longer, a 29% increase [median] from January 2015 through December 2017.

Nor did the study differentiate between drugs with or without a FDA approved therapeutic equivalent (number of drugs, 17 vs 32; median, 79% vs 73% price change).

Changes in prices paid were highly correlated with third-party estimates of changes in drug net prices (ρ = 0.55; P = 3.8 × 10−5), suggesting that the current rebate system incentivizes high list prices and greater reliance on rebates resulting in increased overall costs.

“The study concludes the growth of drug spending in the United States associated with government-protected market exclusivity is likely to continue. Greater price transparency is warranted.”

Interpretation? Pharmaceutical companies (and I will include companies such as Mylan [EpiPens]) are using the patent drug laws and resulting exclusivity time period to maximize profit margins ($14.50 for every $1 invested [WHO]) protecting their products from competition. A similar exclusivity holds true for generic products also (time periods for the introduction for a similar generic product). “Can You Patent The Sun (Jonas Salk)?

I sat over dinner with one Exec. VP from a major pharmaceutical company who confirmed what I had said in an earlier post (Can You Patent The Sun?) and here. A new pricing strategy is being used by pharmaceutical companies which maximizes return based upon benefits achieved in treatment, life, healthcare system, and in society. It is a well thought out reasoning being delivered by intelligent purveyors of healthcare supplies portraying a modicum of caring or concern for societal welfare while pursuing the profit motive. Novartis CEO Vas Narasimhan (not the one I talked to);

“Cell and gene therapies are bringing about a new era of cancer medicines going beyond ‘just improving lives and are saving them.’ The new therapies are challenging the traditional model for paying for medical treatment and the industry is divided on this approach. Pricing for these one-time usage therapies are to be based on four key measures of value – the improvements they offer to patients both clinically and in terms of their quality of life, and the resulting benefits to the health-care system and society.”

The pricing application is not limited to new drugs, cancer meds and gene/cell therapies; it is also being applied to older drugs and also generic replacements.

Findings:

Between 2012 – 2017, the study reveals an industry wide increase in costs for top-selling brand-name prescription drugs and less costly generic replacements. The increase in costs, biannual, and annually for 36 pharmaceuticals since 2012 can also be seen in newer drugs coming on the market after 2012. A pattern or practice of pricing determination based upon 4 values in the pharmaceutical market which will continue into the foreseeable future.

This particular chart depicts annual net price and annual paid price increases showing the percentage increases. This becomes more interesting where I cover “rebates” and whether the reduce costs.

Given median cost increases of 9.5% annually, the yearly increases will result in a doubling of costs for brand name drugs in this study every 7 to 8 years.

New and old brand-name competition does little to control rising costs of products which can be used interchangeably (hence this shoots transparency in the foot for constituents talking to pharmacists) such as Humira and Enbrel or diabetes drugs such as Humalog, Humulin, and Novolog. “Relative cost changes are highly synchronized” resulting in large increases over the last 6 years. As mentioned there appears to be a pattern or practice of pharmaceutical companies acting in concert.

There is little evidence of price changes associated with the existence of therapeutic equivalents such as generics, biosimilar drugs, or drugs entering the market later.

Legislated pricing transparency may lead patients to seek alternative drugs if available which may result in different pricing trends than what was observed over the six years of when the study was done. The impact of such is unknown as is the likelihood of those trends as they may already be in progress due to volume changes or speculation of volume changes due to expiration of exclusivity.

Neither was there evidence of products entering the market 3 to 6 years ago having different trends compared with other drugs in the first years of availability.

Transparency is need in the costing of drugs and the setting of prices by manufacturers. Only in the US, does the manufacturers of the product set the pricing. In Europe, pricing is influenced by governments.

Research and Development

There is a balancing act between reasonable pricing for consumers and the costs for bringing innovative drugs to market. The United States does provides strong patent laws globally. However, legal strategies by the pharmaceutical industry such as patenting the peripheral aspects of a drug (think EpiPen and its cap) extend protections beyond the original patent and delay generic and biosimilar versions. Furthermore, if a generic version brought to market by one company can not be used in the same manner by following the instructions of the brand name version; the company of the patented version can ask the FDA to block the generic version (again think Mylan’s Brand EpiPens and the TEVA generic [See; “Can You Patent The Sun?“]).

Healthcare and pharmaceutical companies can maintain exclusivity and pricing as set by the manufacturer much longer and well beyond the original patent limits with a range of new innovations. In similar countries as the US as found in western Europe, governments set pricing. The end result is a large discrepancy in pricing between the US and European countries for the same drug.

It is near impossible for private insurers to negotiate pharma pricing and Medicare is forbidden to do so. The Institute for Clinical and Economic Review’s value-based price benchmark is one approach to establish appropriate pricing. Using the four key measures the ICER assigned a cost effectiveness value of up to $1,688,000 for Kymriah for its use in children. This analysis takes into account all of the R&D cost in developing a drug, bringing it to market, and the cost save as measured against other therapies. Using the same ICER 4-point value-based analysis and understanding the range effectiveness determined by the ICER, Novartis set Kymriah list price for pediatric use at $475,000, well below the ICER’ cost effectiveness value, and $373,000 for adult cancers.

So, how is this drug paid for by the less financially endowed patients? Coupons by the manufacturer and rebates to the insurance payor set a net price for the patient which is price and profit neutral.

Rebates

Several points; Transparency of how rebates occur and affect net pricing is limited as to the impact of them on the pharmaceutical industry and healthcare insurance, rebates on list prices set by manufacturers are given by the manufacturers to commercial healthcare insurance and some government programs not including Medicare, and the rebates will vary by drug, by payer, and constitute “16% of all private insurer-branded drug spending returned as rebates in 2016.”

Whether rebates lower or increase costs is debated due to the lack of transparency of their application.

Due to the lack of data, this particular JAMA study used third party information or estimates of net price data on each drug. The observations did reveal a high correlation between increases in the rates of insurer and out-of-pocket costs paid for each drug and the net prices (ρ=0.55). The association suggests the offered industry supposition of higher list prices and greater reliance on rebates reducing costs may not be true.

Instead and a bit redundant by me, the paper offers an opposing supposition of increases in list prices, and the resulting increases in insurer and out-of-pocket costs paid, may coincide with increases in net prices, which in turn make these drugs more expensive overall. Seemingly biannual price increases should not be considered benign pricing strategies to offset paid against net price discrepancies in the current rebate system.

If true, this would be a façade making it appear rebates have an impact on final costs to the healthcare system and pricing to the patient. Rebates may only be a shuffling $dollars around.

Greater transparency of the process is needed to determine what is and what is not a cost save. The transparency is not for the purpose of patients deciding what to buy or pharmacists to recommend alternatives; although, it could be used by constituents to support healthcare proposals to bring prices down.

A healthcare system and its coverage without a foundation or mechanisms to control or account for costs is simply a blanket to pricing and hides its impact.

Run75441 (Bill H)

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Women Strike in Switzerland for Equal Pay

Interesting there is not a peep on this in the US and literally hundreds of thousands of women gathered in the streets of the Swiss cities. 40,000 in front of parliament in Bern and the same was repeated in the cities of Lausanne, Geneva, and other places. It is said the turnout is greater in numbers than the protest in 1991. Much of the same inequalities are recognized in Switzerland as they are in the US. Women lose is salary if they take time off. This is not only in gross income, it is in hourly, weekly, or month income when compared to equivalent paid time period.

However in Switzerland, there is a movement afoot to again equalize the differences experienced between genders which has been written into the Swiss constitution. In Switzerland, equal rights for women and men were enshrined in the Federal Constitution by voters on June 14, 1991. 40 years after the popular vote to make it a part of the constitution, the goal of equality has yet to be achieved.

Five key indicators illustrate the day-to-day gender inequality in Switzerland:

– Lack of wage (median gross) equality with women making 12% less than men. The difference was even greater with women earning 14.6% less than their male colleagues which could not be explained by education, years of service, or role in the company.
– The majority of men work full time while only 41% of women do. Much of this is explained by the difference in out of home and at home workloads which men are impacted less in their careers.
– The division of housework in couple’s households remains the same. Women choose part-time work to care for children followed by other family responsibilities. Men working part time are pursuing an apprenticeship, a course of study, or are simply not interested in full-time work. This difference is reflected in the unequal distribution of domestic work of which women do the bulk.
– Due to working less paid hours, women get less from the Old-age and Survivors Insurance as well as the Occupational Pension fund. provision.
– Women in City, Canton, and Federal government are underrepresented.

In a country where even a labor strike action is rare, women have been concerned about neglecting their jobs and workplaces. To adjust for the time off, women demonstrators have decided they will finish their work day at 15.24 on Friday afternoon a time chosen to reflect the differences in pay for the same or a similar job done by men. The 15:24 reflects the almost 20% wage disparity with men. Many women and men in support of the movement are wearing fuchsia purple clothing on Friday the symbolic color chosen to reflect the event.

The strike has been covered in foreign media such as the Financial Times and on the BBC. There was also support from the United Nations.

Huge turnout for women’s strike in Switzerland, SwissInfo

Minding the gap between the sexes in Switzerland, Kai Reusser (graphics) and Sonia Fenazzi (text), Swiss Info.

Hundertausende Frauen fordern rasche Fortschritte bei Gleichstellung, Regula Bühlmann, SGB/USS

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Housing and Young People

We’ve lost the plot on the classic life arc of yesteryear. Places where real estate is cheap don’t have many good jobs. Places with lots of jobs, primarily coastal cities, have seen their real-estate markets go absolutely haywire. The most recent evidence of this remarkable change comes in a new report by the real-estate firm Unison. The company, which provides financing to homebuyers by “co-investing” with them, calculated how long it would take to save up a 20 percent down payment on the median home in a given city by squirreling away 5 percent of the city’s gross median income per year.

Nationally, the gap between income and home value has been rising. Using “Unison’s methodology“, it took nine years to save up a down payment in 1975. Now it takes 14.

• The typical Los Angeles resident will spend 43 years saving for a 20% down payment and can look forward to moving into a new home in 2061.
• In 2018, the monthly mortgage payment on a median home grew twice as fast as incomes.
• When adjusting for inflation, today’s average real wages have the same purchasing power as 40 years ago.
• Only half of today’s 30-year-olds earn more than their parents did.

Clearly, the old rules of buying a home don’t apply anymore.

This is the new rule: home co-investment.

Unison connects aspiring homebuyers and existing homeowners with institutional investors who offer debt-free access to cash for the chance to share in a home’s appreciation. Our HomeBuyer program provides cash to our partners – you – to supplement a down payment on a new home. Our HomeOwner program allows homeowners to unlock equity in their home to pay off debt, remodel or fund a major purchase.

This isn’t a loan, which means there are no monthly payments and no interest. If the home depreciates, then Unison shares in the loss.

The aggregate numbers make the decrease in access to the real-estate market seem gradual, albeit troubling, and underplay the spikiness of the country. In Los Angeles, it would take 43 years to save up for a down payment. In San Francisco, 40. In San Jose and San Diego, 31. In Seattle and Portland, 27 and 23, respectively. In the east, New York and Miami topped the list, requiring 36 years to save up that down payment. Only Detroit, at seven years, was under the national average from 1975.

Generationally, this has huge consequences. Imagine you’re a 30-year-old in Los Angeles with the median income. By Unison’s math, you can imagine buying a home at 73. For young people in high-opportunity metro areas, the route to home ownership is basically blocked without the help of a wealthy family member or some stock options. Meanwhile, older people who bought under much more favorable circumstances have seen their equity stakes grow and grow and grow.

Many of these policies served to restrict the number of affordable homes. So, now, decades later, in many cities with good economies that have drawn new residents, increased demand has not been met with commensurate supply. Young people of all races are experiencing the consequences of these policies, but given the compounding nature of wealth, the relative inaccessibility of home prices is an ongoing disaster for the racial wealth gap.

This is a well written C&P which can be found at The Atlantic, Technology “Why Housing Policy Feels Like Generational Warfare (To Millennials, at least), ” Alexis C. Madrigal

The excuse I have heard as a township planner for not building affordable housing is: “it is only cheap once!” In 2009 many of us saw our housing drop by up to 50% in value.

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Covering the Sahara Desert with Solar Panels to Fight Climate Disaster?

Juan Cole at Informed Comment has a post up by Will de Freitas Should we cover the Sahara Desert with Solar Panels to Fight Climate Disaster?

A map of North Africa is shown, with a surprisingly small box somewhere in Libya or Algeria shaded in. An area of the Sahara this size, the caption will say, could power the entire world through solar energy.

Over the years various different schemes have been proposed for making this idea a reality. Though a company called Desertec caused a splash with some bold ideas a decade ago, it collapsed in 2014 and none of the other proposals to export serious amounts of electricity from the Sahara to Europe and beyond are anywhere close to being realized.

An engineer at Nottingham Trent University has researched various options for Saharan solar, Amin Al-Habaibeh and discusses the sheer size of the Sahara desert and amount of sunshine it receives:

– It’s larger than Brazil, and slightly smaller than the US.

– If every ray of sunshine hitting s the Sahara was converted into energy, the desert would produce enough electricity over any given period to power Europe 7,000 times over.

So even a small chunk of the desert could indeed power much of the world, in theory. But how would this be achieved?

According to Amin Al-Habaibeh, there are two main technologies which can be applied to this project and each has their pros and cons:

– Concentrated solar power using lenses or mirrors to focus the sun’s energy in one spot, which becomes incredibly hot. This heat then generates electricity through a steam turbine.

– A tower in the middle of the mirror or lens is the “receiver” which then feeds heat to a generator.

– Some systems store the heat in the form of molten salt. This means they can release energy overnight, when the sun isn’t shining, providing a 24 hour per day supply of electricity.

– Concentrated solar power is very efficient in hot, dry environments, but the steam generators use large amounts of water.

– There are also the regular photovoltaic solar panels which are much more flexible and easier to set up, but less efficient in the very hottest weather.

Amin Al-Habaibeh: “Just a small portion of the Sahara could produce as much energy as the entire continent of Africa does at present. As solar technology improves, things will only get cheaper and more efficient. The Sahara may be inhospitable for most plants and animals, but it could bring sustainable energy to life across North Africa – and beyond.”

The issue may be in how to transmit the energy to other areas? Is it still transmission via immense cables?

The longer we delay, wait, deny, and ignore the issues we produced for climate; the more drastic the action to be taken. There is more to the discussion on producing power from the sun in the desert and worth exploring. In Juan Cole’s post: Should we cover the Sahara Desert with Solar Panels to Fight Climate Disaster? there are other sites identified in which to do similar installations.

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Interesting Healthcare Outcomes . . .

Opioid Overdose Now Provides 1 in 6 Donor Hearts,” Ashley Lyles, MedPage Today

Overdose-death donors have accounted for a rapidly growing proportion of cardiac allografts, with a 14-fold increase from about 1% in 2000 to now 16.9%, “consistent with the rising opioid epidemic,” reported Nader Moazami, MD, of New York University Langone Health in New York City, and colleagues in The Annals of Thoracic Surgery. Earlier findings:

A total of 1,710 of 15,904 (10.8%) cardiac transplantations were from ODDs, approximately a 10-fold increase from 2000 (1.2%). ODDs were more frequently older than 40 years of age (87.2% vs 70.1%; p < 0.001), had higher rates of substance abuse, were more likely hepatitis C positive (1.3% vs 0.2%; p < 0.001), and less frequently required inotropic support at the time of procurement (38.4% vs 44.8%; p < 0.001). Overall survival was not different between the groups (p = 0.066). Discarded ODD allografts were more likely to be hepatitis C positive (30.8% vs 5.3%; p < 0.001) and to be identified as conveying increased risk by the Public Health Services (63.3% vs 13.2%; p < 0.001), but they were less likely to be discarded because of a diseased organ state (28.2% vs 36.1%; p < 0.001).

In many states, overdose-death donors comprised greater than 25% of cardiac allograft donors in 2018, with a high of 50% in Delaware.

While there have been concerns regarding allograft function and infectious risk, the researchers noted overall survival was the same between recipients of overdose-death and non-overdose-death donor organs (P= 0.066).

The discard analysis of donors who had at least one organ transplanted but not the cardiac allograft showed overdose-death donor hearts (7.4% of all discards) were: less likely to be discarded due to being in a diseased organ condition than those donors who died of other causes (28.2% vs 36.1%; P less 0.001), more likely deemed higher risk by Public Health Services (63.3% vs 13.2%; P less 0.001), and more likely to be hepatitis C positive (30.8% vs 5.3%; P less 0.001).

Even with the hazards of using a heart from an opioid abuse donor, survival outcomes of recipients of hearts that come from donors that have died from opioid overdose are equivalent to ones that we have traditionally been using, and because of this we believe that there are more donors out there that can be utilized.

STIs: ‘Hidden, Silent, Dangerous’ Global Epidemic, Molly Walker, MedPage Today

World Health Organization (WHO): “no substantial decline in global STI prevalence since 2012”

An approximate one in 25 people worldwide had at least one curable, sexually transmitted nonviral infection in 2016.

The incidence of gonorrhea, chlamydia, trichomoniasis and syphilis amounts to about one million new infections each day, and more than 376 million new cases annually. Additionally as Melanie Taylor MD and medical epidemiologist at the WHO Department of Reproductive Health and Research (and colleagues noted), “there has been no substantial decline in the number of new infections since the data was last updated in 2012.”

Also of the WHO Department of Reproductive Health and Research Teodora Wi MD; “We cannot sweep [sexually transmitted infections] under the carpet and pretend they don’t exist while we continue to stigmatize people living with STIs, neglect their care. and fail in prevention.”

STIs are a “hidden, silent, dangerous” epidemic, and are still “persistent” globally, despite an increase in education about the dangers of sexually transmitted infections. Dr. Taylor added that it’s not just stigma and shame that keep people from treatment — many patients do not realize they are infected.

In my first week of 4, the Grey’s Anatomy bunch swarmed my half of a hospital room and gayly announced, you do not have HIV, Hepatitis C, or any STD/STIs. Puzzled look on my face, “when am I getting out of here?”

Dropped From Health Insurance Without Warning: Was It Legal? , Julie Appleby, KHN

Those who qualify for a subsidy due to income being less than 400% of the federal poverty level (roughly $50,000 for an individual) have a 90-day grace period to make payment after missing a payment. The law requires insurers to notify those policyholders they have fallen behind and face cancellation. If a payment is made in full before the end of the 90-day grace period, they are reinstated. If not they are canceled and medical costs incurred in the second and third months of the grace period fall on the consumer.

This policy keeps federal subsidy dollars flowing to insurers during the grace period, even if a consumer has a financial wobble.

It’s different for people who are a part of the ACA; but, their income is above 400% and do not qualify for a subsidy. They are subject to state laws and they can be dropped much more abruptly. Most states have a 30 day Grace Period for payment; however, Prior Notification law differs state to state.

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