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

Other Immigration Issues Here and Elsewhere

From SWI, Swiss news: Switzerland’s House of Representatives has rejected an initiative by the right-wing Swiss “People’s Party” to limit immigration and cancel a deal with the European Union on the free movement of people.

Albert Rösti, head of the Swiss People’s Party warns that “uncontrolled” immigration could increase the current 8.5 million Swiss population to ten million and place additional pressure on infrastructure and the environment. It also says free movement of people encourages employers to recruit foreigners at cheap rates rather than Swiss people.

Sound familiar?

Per SwissInfo.ch , Switzerland faces a “shortage of workers 10 years out according to the Swiss Employers’ Association which warned Switzerland could face a shortage of 700,000 workers in ten years’ time.  Immigration is a key to plug the gap.”

To help close the potential gap, professionals possessing engineering backgrounds will be needed with a priority on civil and electronic engineering being the most important. Also technical skills in such fields as heating, ventilation, and air-conditioning have moved up from third to second place in needed skills followed by fiduciaries, auditors, and IT ability. These types of capabilities and skills are not possessed by present day migrants coming to Switzerland.

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US Firearm Related Mortality

New analysis of 1999-2017 firearm deaths looks at changes in each state and within age, gender and racial/ethnic groups

Nationally, firearm-related mortality rates increased in period 2015–2017 after remaining relatively stable in period 1999–2014. Firearm mortality increases can be seen in “most” states and the demographics to the mortality seen in varying degrees. The increases suggest a worsening epidemic of firearm mortality geographically and demographically abroad. In both time periods, the fractions of firearm deaths due to suicide and homicide remained consistent.

In order of magnitude, the rates of homicides, suicides, and unintentional deaths incurred in the United States are 25.2, 8.0, and 6.2 times higher than rates occurring in other developed countries. While remaining relatively stable from 1999 to 2014, the age-adjusted firearm mortality rates in the US increased for three consecutive years starting in 2015 as shown in Exhibit 1. One has to wonder why this could be.

Click on the image to enlarge.

The increases are also apparent across the nations demographics (race, sex, age), mechanisms of death (suicide, homicide, etc.), and are broken down by states across the nation which I will not be showing today. Well beyond a majority, the states saw increases and a few have experienced decreases. The Health Affairs study “US Firearm-Related Mortality: National, State, And Population Trends, 1999–2017,” is the first to define the mortality of deaths by state. The Health Affairs state detail is too massive to display here and the study is only open to subscribers. I believe the more important part of this study is the upturn in the death rate starting in 2015. One can only speculate what has brought on the increase.

After the leap, Methodology, Limitations, and Conclusions

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Is Progressive Idealism Self-Defeating?

Like many liberals, I am encouraged by the new energy of progressives and the growing political support for progressive causes.  But I also share the common worry that the idealism of progressives is in danger of becoming self-defeating (see, e.g., Judis and Edsall for two recent discussions).  That’s a problem, because the stakes are high and we don’t have much room for error.

As I see it, progressive idealism today has two manifestations, one political, one economic.  Political idealism manifests itself in a reluctance to acknowledge the scale of the political challenges progressives face, the scorched-earth opposition that awaits us, and the need to find potential allies among the not-so-progressive and to design policies and arguments that can win them over.

On the economic side, idealism makes progressives reluctant to take policy design seriously.  For example, there is a big gap between progressives and economists (including progressive economists) on carbon pricing and other aspects of climate policy.  There is also a gap on fiscal and budgetary policy, and on many other issues.  To some extent, this simply reflects the unavoidable fact that non-economists always find economics counter-intuitive – if they didn’t, we wouldn’t need economists.  But the problem today goes beyond this.  There is a strong tendency to rely on moralistic thinking, to assume that every wrong has an easy remedy and that good intentions can solve any problem.  This goes along with a resistance to thinking about tradeoffs, costs, and market-oriented solutions like carbon pricing, and a tendency to favor command-and-control policies and to ignore fiscal constraints.  I suspect that we have right-wing economists and politicians to thank for this state of affairs, but whatever its cause the rejection of careful economic thinking on the left is real.

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Rep Jayapal and Sen Sanders Have Introduced Medicare For All Bills: Part 2

Part 2 discusses why we must have the government issue payments to hospitals, clinics, etc. and also set the budgets for hospitals and this is how they are paid rather than billing multiple insurers and also patients. There is also only one payer. The later part is what I have been pounding on repeatedly. Forget prices and work with cost data. It is then we have a much clearer picture of the costs of healthcare and we can begin to control prices.

Rep Jayapal and Sen Sanders Have Introduced Medicare For All Bills: One Is a Lot Better Than the Other, Healthcare for All Minnesota, Kip Sullivan, May 8, 2019

What is an ACO and why is it a defect?

Congress included in the Affordable Care Act of 2010 (aka Obamacare) a section (Section 3022) requiring CMS to establish an ACO program within the traditional FFS Medicare program. It is not clear why Congress chose to use ACOs. Congress was warned in 2008 by the Congressional Budget Office (CBO) that ACOs would not save money for Medicare. The simplest way to describe ACOs is to say they are HMOs in training. Like HMOs, they are corporations that own or contract with chains of hospitals and clinics; they have the equivalent of enrollees; they attempt to keep their “enrollees” from seeking care outside their networks; they bear insurance risk (that is, they are paid on a per-enrollee basis and in exchange are obligated to provide medically necessary services to their enrollees); and because they are risk-bearing organizations, they generate overhead costs similar to those created by traditional insurance companies.

More on ACOs and the absence of Single Payer budgets past the leap

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News and Words that Caught My Eye this Week

Teacher of the Year‘ kneels during college football championship attended by Trump,”ABC News, January 16, 2020

During a ceremony honoring the 2019 “Teachers of the Year,” one in particular stood out.

The honoree from Minnesota, Kelly Holstine, chose to kneel during the national anthem at the NCAA football championship game on Monday, where the ceremony took place, “to stand up for marginalized and oppressed people,” according to a tweet she wrote, which included a photograph of her kneeling.

“Like many before, I respectfully kneeled during Nat’l Anthem because, ‘No one is free until we are all free,'” she wrote, referencing former San Francisco 49ers quarterback Colin Kaepernick and citing a quote from Dr. Martin Luther King, Jr.

Virginia school board refuses to ban Confederate flag” from the dress code, Today, Alyssa Newcomb, January 16, 2020

A Virginia school board is refusing a dress code ban on clothing showing the Confederate flag, despite the appeals of the board’s only black member.

The Franklin County School Board in Rocky Mount, Virginia, voted 7-1 on Monday against formally writing a ban on the Confederate flag into the dress code. The board cited Tinker vs. Des Moines, a 1969 case that ruled students were allowed to wear black armbands to protest the Vietnam War and did not lose their right to free expression, even while attending school.

“In Franklin County, we do not have any documented cases of a substantial disruption caused by the Confederate flag

The Miseducation of the American Boy,” The Atlantic, Peggy Orenstein, January 15, 2020

I knew nothing about Cole before meeting him; he was just a name on a list of boys at a private school outside Boston who had volunteered to talk with me (or perhaps had had their arm twisted a bit by a counselor). The afternoon of our first interview, I was running late. As I rushed down a hallway at the school, I noticed a boy sitting outside the library, waiting—it had to be him. He was staring impassively ahead, both feet planted on the floor, hands resting loosely on his thighs.

My first reaction was Oh no.

It was totally unfair, a scarlet letter of personal bias. Cole would later describe himself to me as a “typical tall white athlete” guy, and that is exactly what I saw. At 18, he stood more than 6 feet tall, with broad shoulders and short-clipped hair.

Additional after the Leap

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Coming for Your Coverage, Trump’s Plot Against Health Care Continues

Adapted from; “Trump’s Plot Against Health Care Continues, He is still coming for your coverage and lying about it.,NYT Opinion, Paul Krugman, January 13, 2019.

Trump in a tweet: “Mini Mike Bloomberg is spending a lot of money on False Advertising. I was the person who saved Pre-Existing Conditions in your Healthcare, you have it now, while at the same time winning the fight to rid you of the expensive, unfair and very unpopular Individual Mandate…..”

As one reporter noted, President Trump was not in office when the PPACA established a unpenalized right to healthcare even if you had pre-existing conditions. Much of Trump’s efforts since taking office has been to wipe away President Barack Obama’s legacy of which the PPACA was a major accomplishment in spite of the well known resistance to his even being in office coming from Republicans “even” before he took office. Due to President Trump’s efforts, key parts of the PPACA have been removed and legislation pushed through a majority Republican Congress attempting to repeal the PPACA. The DOJ is now attempting to have the PPACA repealed before . . . nope, now after the election so the blame can not impact it.

Prior to this latest lie by Trump, an earlier lie in 2019 had the Administration work through the CMS to take action against protections for people with pre-existing conditions by allowing states to let individual market insurers vary premiums and cost sharing based on “health outcomes.” A new CMS project allowed up to ten states to apply and then establish “health-continent wellness programs.” The state programs would let insurers vary premiums and cost sharing by as much as 30 percent based on upon an enrollee’s meeting designated health outcomes, a return to charging sick people more than healthy people.

So there has been an unending stream of efforts to repeal or stymie. (More Krugman after the leap)

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Sales Income for Drugs have Exceeded Risk Adjusted R & D Costs

I have been beating the drum for transparency of cost information before granting exclusivity for drugs via patents. With a patent, companies can charge what the market  will bear and have demonstrated they will do so on particular drugs such as insulin, Vimovo, EpiPens, etc. as well as other drugs identified in recent papers on Drug Pricing also. The following chart depicts cancer drug Sales Income as it relates to R & D Costs. It is an example of how quickly R & D costs can be recouped for Cancer drugs with the median being 2 to 5 years.

To get to the point quickly,  of the 156 US FDA-approved cancer medicines identified, 99 had data for more than half of the years since approval and were included in the WHO (Page 23) analysis. Total sales from this set of medicines (US$ 106.9 billion) represent 80.4% of the estimated global revenue of cancer medicines in 2017 (US$ 133 billion). At the end of 2017, forty-nine (49.5%) of the cancer drugs had cumulative sales of over US$ 5.0 billion and at the end of 2017, five drugs had accrued sales incomes of greater than US$ 50 billion for the originator companies: rituximab (US$93.7 billion), trastuzumab (US$ 88.2 billion), bevacizumab (US$ 83.4 billion), pegfilgrastim (US$ 64.0 billion), imatinib (US$ 63.8 billion) (Fig. 3.5, p.26). Pricing of Cancer Medicines and Its Impacts Technical Report.

The median time to generate revenue to fully cover risk-adjusted R&D cost of US $794 million was 3 years (range: 2 years; 5 years, n=73). For the maximum estimated risk-adjusted cost of R&D (US$ 2.827 Bn), the time to cost recovery was 5 years (range: 2 years; 10 years, n=56).  A threshold analysis found that 99% of the 45 cancer medicines with sales data for 10 years from their first year of launch had generated incomes sufficient to at least offset the risk-adjusted R&D costs irrespective of the assumed threshold values for R&D costs (Fig. 3.4). (page 24 25)

 

Past the Leap, Trends in Prices of Popular Brand-Name Prescription Drugs and why You can not Negotiate Blind Folded

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Preventing Surprise Medical Bills

The idea I have is not to be surprised. I am a careful patient who asks a lot of questions and also advocate for myself. I have refused treatment when they use drugs which may threaten my health further (Heparin). I am also not well liked by the bloodsuckers who come in to draw blood and stab me through the vein for two weeks and destroyed my left arm in the process. Ask them questions and do not be so willing to accept treatment (if cognizant) until they answer your questions and then get their name. Take names and dates. It is ok to be a forceful advocate for yourself. When all is said and done, the bill will come to you alone.

If you are on Medicare, do not stay for observation unless you have a Plan G or Plan F. If you are on Plan N Supplemental to Medicare or lower, the plan will NOT pay 100% for Observation. You have to be admitted. You can go anywhere with Medicare for treatment.

Medicare Advantage? You had better be in network or have some type of alternative program within your plan.

There are good points to this article which is why I “C and P-ed” it here per their request.

As taken from Preventing Debt from Surprise Medical Bills, Bankrate, Madison Blancaflor. July 19, 2019

The cost of healthcare has become a hot topic in American politics in recent years, and with good reason. A recent survey found that 22 percent of Americans are losing sleep over healthcare or insurance costs, up from 13 percent just one year ago.

One aspect in particular has even gained attention from both Congress and the President within the past two months: surprise medical bills.

Congress has proposed bi-partisan legislation that sets up consumer protections against surprise billing in certain situations. President Trump also issued an executive order in June that calls for hospitals to be more transparent upfront about prices for common tests and procedures, a measure that should go into effect later this year. (While the House took out the 10 year exclusivities for Biologic drugs in the NAFTA Bill, similar  ended up in the Budget bill giving exclusivity for 12 years on new biologics. As I have pointed out repeatedly, risk adjusted R & D costs are recouped in a median period of 3- 5 years. It is another give-away to  pharma which adds to costs.)

Past the leap, causes and prevention of Surprise Billing.

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Pharma Price Increases 2020

As reported by Market Watch and Axios, drug prices are on the rise the beginning of 2020. The increases exceed the 2% inflation the nation has been incurring and the 3.4% growth in wages recently incurred by nonsupervisory labor. According to Market Watch, overall drug pricing will rise 5.8% at the start of 2020 due to price increases. This is about the same as Medical CPI.

Fortune Magazine; “The price hikes are almost all below 10%, with the median price increase hovering around 5%, though more price increases could come in the following weeks.

The increases are lower than the 2019 average price increase at 6.3% and it is within the 10% annual limit many Big Pharma companies have pledged to honor while politicians zero in on drug pricing as a key talking point in the 2020 election.”

What is an issue is what the end consumer pays in price and how those prices play back into the cost of the drug, the cost of healthcare, and the rising cost of healthcare insurance. Bob Herman at Axios points out; brand name drugs start out with high sticker prices such as Humira’s $58,000 per year (Elsevier’s Gold Standard Drug Database). Healthcare insurance plans negotiate discounts off of the list price which are kept secret and the negotiators (PBMs) keep some of the savings for themselves which is also kept secret. The drug is awarded a Tier status within each insurance company plan at a price preserving the discounts as profit for the healthcare plan and the PBM. The balance goes back to the manufacturer.

The pricing system for brand name drugs administered by a doctor and yet another system for certain hospitals are different from the one for healthcare insurance companies.

For a generic drug which costs $3 to make and sells for $15; the resulting split of the remaining $12 could be a manufacturer receiving an approximate $3, the pharmacy $1.50, a wholesaler $2 and the largest share going to the healthcare insurance company managing your insurance plan’s drug benefits of approximately $5.50.

Past the leap, why is it difficult to negotiate prices.

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Republics and the war-making power

Republics and the war-making power

In view of the militry carrying out Trump’s order to kill an Iranian general, I thought I would weigh in on the issue of the war-making power historically by republics.

I don’t have much to add to the substance of the immediate debate. Killing an Iranian general was certainly an act of war. It was also a big escalation on the US side. At the same time, the US’s economic blockade of Iran, which it has been attempting to enforce against third parties as well, has been if not an act of war itself, at least tiptoeing up to the very line. Similarly, Iran’s conducting of low-grade hostilities by proxies against the US has also really been an act of war. So I’m not sure that the line-crossing is as bright as it may appear at first blush.

That being said, it seems obvious that the consequences of the strike were not well-thought out, and there almost certainly is no strategic follow-up plan.

Additionally – and what I want to focus on here – is that also almost certainly, there was no imminent emergency requiring immediate action by the President rather than consultation with an approval by the Congress, as mandated by, you know, the Constitution. This event has been at least equal to the most blatant usurpation of Congress’s power in decades (Reagan’s reprisals against Libya and George HW Bush’s capture of Noriega in Panama were probably in the same league).

This got me to thinking: how historically have republics vested their war making power? Since recently I’ve read two books on the Roman Republic, histories of medieval Venice and Genoa, and am now reading about the Dutch Republic, that’s something I can contribute — because their systems had a common theme.

 

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