Tuesday, December 31, 2013

Closing Thoughts on 2013, Opening Thoughts on 2014...

Closing Thoughts on 2013, Opening Thoughts on 2014...

2013 was a year of frustration for just about everybody. President Obama's year was especially so on a variety of issues from the botched Healthcare.gov rollout to the handful of "mini-scandals" involving the IRS, the Justice Department tapping various reporters phone lines, the Edward Snowden revelations regarding the NSA activities, the remnants of the FBI's operation called "fast and furious," to large question marks surrounding our foreign policy in no less than three countries (Afghanistan, Israel, and Syria.) Make no mistake, we also haven't heard the end of the Benghazi tragedy, as you can count on it being kept alive at least through the 2016 General Election.

As we pivot to 2014, it appears the issues with the Healthcare.gov website have been mostly corrected and signups through the month of December have been robust. While that's good news for the Obama Administration, it doesn't mean there's calmer waters ahead. Its a fairly safe bet when those first patients start walking into emergency rooms early on the morning of January 1st, there's going to be many questions on who has insurance, who thinks they have insurance but who doesn't. What physicians and hospitals are no longer "in network?" Are the cyber connections needed for a smooth transition from the old days to the new days under Obamacare up and running correctly? Glitches can be expected and their presence won't mean the entire program is a failure. Nor will the stories that we're bound to hear about people and families telling their stories of anger and frustration because something didn't work the way it was supposed to. Other large social programs such as Social Security, Medicare and Medicaid all experienced growing pains when they were rolled out. All figured those problems out and are wildly popular and in no real danger of being eliminated any time soon. The fact that social programs need tweaked from time to time is to be expected.

When the White House wasn't defending itself against this or that story, there were a few successes. The defeat of the Defense of Marriage Act was a landmark ruling for same sex couples and it seems every month another state votes in same sex marriage rights. Eighteen States or 36% of the country has passed such legislation onto its books with more to follow in 2014.

With the defeat of gun legislation in the Senate back in April, it was understood that 2013 would not be a year for much progress on that front. Despite the ongoing efforts of the Sandy Hook parents and other gun control advocates, the votes just aren't there, despite what polling tells us in terms of most Americans supporting enhanced background checks in the purchase of a gun. Which is too bad. I don't and I suspect President Obama doesn't want to take away the average gun-owners pistols or hunting rifles. We just want to make sure only the people who should get a gun, are able to. I think that gun reform will only happen in a time when some large event like the Sandy Hook shooting hasn't happened. In the aftermath of such an event, emotions on both sides are running too high and compromise is almost impossible. To be clear, there is no gun reform conceivable that would've stopped Adam Lanza. We also shouldn't craft gun reform policy on the emotions of a tragedy such as that. Cooler heads and calmer times will make for better policy outcomes.

The outrage that Mr. Snowden kicked up with his revelations on the NSA surveillance programs certainly hasn't gone away nor will it any time soon. Questions abound from is the FISA Court really a serious entity and not a rubber stamp for requests (I say it is a serious body) to the following: Since our communications data from cell phones, emails and other internet activity is compiled on some level, whom do we trust most to oversee it? A publicly funded government agency or a profit seeking private enterprise? As unseemly as it seems, I'd rather have the Government browsing through this type info than I would Verizon, AT&T or Sprint. Truth is, they're all doing it. By the way, I say Snowden is a criminal, a traitor and should be prosecuted to the fullest extent of the law. He is no patriot. He endangered a great many of our citizens and put this country at large at risk.

A few words about Syria. Chemical weapons are clearly taboo around the world and the vast, vast majority of countries have signed treaties rejecting their use. As well they should. On the other hand, a death is a death and it eludes me how anywhere from several hundred to 1400 death from chemical weapons is a stop the press, prepare for war type event but a death toll in excess of 100 thousand Syrians not to mention upwards of 9 million who have been uprooted from their homes and are now refugees seems to barely register on Mr. Obama's foreign policy radar. With virtually all the moderate Syrians gone, the country has become hell on earth for those who have remained.

2013 wasn't exactly a banner year for Congress, to be sure. Approval ratings in the single-digits make President Obama's mid 40's look positively wonderful. Second terms are always rough on Presidential approval ratings, so don't get too excited if Obama's numbers don't bounce back. He's not far from lame duck status. Speaker of the House John Boehner finished stronger than he started as the efforts of Paul Ryan and Patty Murray found some common ground (but no compromises) on a new budget bill. Next year will see the start-up of the mid-term election campaigns so I suspect we'll see some additional bi-partisan legislation so both sides can claim "...a willingness to reach across party lines and do what's right for the American people, blah, blah, blah..."

You know who had a great 2013? Pope Francis. Big time...

2014 will be a somewhat similar year to 2013 in terns of Washington DC. With the passing of each month on the calendar, President Obama will only become weaker and weaker. Given Congress' obstruction toward the White House when Obama was at his most powerful, I can only imagine how bad it will get once we hit the 2014 mid-terms. Look for the President to come out of the gate strong and ambitious in the new year. He's got until November to accomplish his next set of goals. After the midterms, he'll be at his weakest.

Speaking of mid terms, I think the Democrats will lose a few seats in the Senate but hold onto majority status, the Republicans will gain a few seats in the House. More interesting in my mind will be the coming fights between the Republican establishment and the Tea Party members. Look for the House to welcome a few more Tea Party legislators to its ranks in January 2015. (Get the popcorn...)

On a positive note for the administration, if Obamacare continues to see good enrollment numbers and can minimize the early snafus and ensuing negative media coverage, the GOP will find itself in a bad place of still wanting to get rid of the Affordable Care Act. The optics of such a strategy will be of one party trying to take away something that is helping a great number of people with no clear replacement solution in place. (GOP ideas such as selling across state lines, HSA's and tort reform are not solutions, they just sound like good ideas until you understand the problems with all of them. Selling across state lines leads to adverse selection which leaves the people who need insurance the most in the worst position to get it, HSA's are great if you can afford them, but too many Americans simply can't and Tort reform addresses about 1.5% of all health care spending. It just doesn't do much for that many.)

I think there's a less than 50% chance that President Obama succeeds in raising the minimum wage. If he surprises me, he wins....if Congress blocks him, they've just handed the Democratic candidate for President in 2016 a major talking point.

Sunday, December 29, 2013

The Latest From Health care Triage

Despite what you hear these days about the good old days, things really aren't all that bad today. Lots of things are better today than they were 10-20-30 years or more ago...

Dr. Carroll explains...

Looking back at the First World War, Could it Happen Again?

Worthwhile read from The Economist on the idea that past can be prologue. Specifically, are their parallels between the First World War and current times?

An except:

Yet the parallels remain troubling. The United States is Britain, the superpower on the wane, unable to guarantee global security. Its main trading partner, China, plays the part of Germany, a new economic power bristling with nationalist indignation and building up its armed forces rapidly. Modern Japan is France, an ally of the retreating hegemon and a declining regional power. The parallels are not exact—China lacks the Kaiser’s territorial ambitions and America’s defence budget is far more impressive than imperial Britain’s—but they are close enough for the world to be on its guard.
Which, by and large, it is not. 
Read the entire article here... 


Wednesday, December 25, 2013

A Message From Reasonable Conversation...

From the editorial staff of Reasonable Conversation, we wish everyone a...


Bill & Tim

Sunday, December 22, 2013

Holiday Medical Myths Debunked...

By who else?

Dr. Aaron Carroll, with this week's Healthcare Triage:

Was 2013 A Good or a Bad Year for the Affordable Care Act?

Roughly a week left in 2013, and the year end reviews are popping up everywhere. Was it a good year? A bad year? Who knows?

To the more specific question was 2013 a good or bad year for the Affordable Care Act or "Obamacare" as its often referred to, I say it was a very good year.

Some of you may ask how on earth could anyone consider 2013, with its bungled rollout of the exchanges, with its poorly-worded "if you like your plan, you can keep your plan..." not to mention its last second changes exempting certain slices of the population from the individual mandate while forcing most to still carry health insurance, etc. a "very good year?"

I say it was a very good year because, for the most part, the ACA is moving forward toward its goal of decreasing the number of uninsured Americans. Yes, it stumbles at times, looks down-right awful at times, makes no sense at times, but it lives on. Remember the 48 or 49 attempts by Congress (let's give credit where credit's due, the House)? Virtually none of them stood a chance against the majority controlled Senate or Mr. Obama's White House of really getting rid of it. Those votes were symbolic, and played to the base and almost no one else. I'm not sure how big of a bang the last 15 generated compared to the first 15, but hey, Speaker Boehner gets to run the show in the House (wait, did I just type that?) and if he wants to spend the House's time and our money holding these "for show only" votes, who am I to object?

The ACA has problems. Some pretty big ones, in fact. The private insurance market is in chaos, the rollout of the Healthcare.gov website has been well chronicled and fairly assessed as a rank amateur disaster by many and people seem to dislike Obamacare more than they like it. Far too many states, mostly in the South have (so far) rejected the Medicaid Expansion which leaves many poorer people and families on the outside looking in as far as accessing health insurance coverage.

As long as the ACA is moving, albeit imperfectly, towards full implementation and its goals, its been a pretty good year. Here's my reasoning. Every year that Obamacare continues to draw breath reduces the likelihood that it will be repealed anytime soon by the Republican Party. Had Mitt Romney defeated President Obama and at the same time, the Democrats lost control of the Senate, while the GOP maintained control of the House, the chances are very good the Affordable Care Act would've been shown the door. None of that happened, here we are, two years later and millions of young people are staying on their parents health insurance. Millions are benefiting from the increased access to preventative care services. Millions are benefiting from the expansion of Medicaid in many states, providing some with health insurance for the first time in their lives. Hospitals are well on their way toward re-engineering their operations with a nod toward quality of care and less so fee for service and quantity of care. Even the health insurance companies are mostly behind the ACA. Sure, they probably don't appreciate how President Obama stuck them with some headaches in the individual market over the last six weeks or so, but business models have been over-hauled. Changes in policies, procedures and products have all been planned for and are being implemented at a not insignificant cost to the insurance companies themselves. As Sam Cooke sang years ago, "a change is gonna come..." Is there a rational case anyone can really make to see all of the above done away with or reversed? Seriously?

I don't agree with those pundits who love to cite the website issues or the ensuing slow signup rate as an indication of  the official and permanent failure of Obamacare. We won't know how successful this change will wind up being for a few years. How many young people will sign up? How fast? What other problems that we don't know about yet will surface? What tweaks to the law, that once were routine for the Congress but now are most definitely not, will or won't be put into place? How many and how soon will states who have so far rejected the expansion of Medicaid change course and accept the Fed's offer? We can't know all of these things right now.

Most of the issues you've read about in the last few months will, in the end, get sorted out. Slowly but surely, things will get smoother with the occasional problem needing attention. Whether or not the GOP ever becomes part of the solutions is a question for another day. I suspect Conservatives in moderate or swing states will be the first to try and help out as a show to their constituents of their ability to legislate in a bi-partisan way. Mind you, the risk of these moderates being primaried by Tea Party candidates is real and will happen in many cases. How many elections these challengers from the right will actually win is unknown, but so far, their record is mixed.

While the doom and gloom reporting from some media sources and talk show programs will almost certainly continue. (I just can't conceive of Rush Limbaugh or Sean Hannity reversing their course on this and ever coming out in even a modified support of the ACA.) More and more people will sign up for coverage. More and more people will benefit from having health insurance. More and more people will avoid seeing coverage cancelled or treatments terminated mid-course because of plan limitations. Medical bankruptcy rates should begin to decline. A lot of good is going to be realized across the United States even while we shake our heads at website issues, unintended consequences and a host of other blunders we haven't even thought of yet.

If projections are accurate and the Republicans hold on to the House and walk away with a stronger Minority in the Senate, there's still President Obama and his veto pen just waiting in the West Wing. There is ZERO chance Obama would ever kill his own landmark health care reform.

That brings us to 2016 and another Presidential election. Odds are it will feature Hillary Clinton and somebody (Brian Schweitzer-D Gov. Montana, perhaps?) up against god knows who from the GOP. Regardless, by 2016 there will be another two full years of ACA signups in place. The healthcare cost curve will likely continue to bend in a favorable fashion and the screwups in the individual marketplace from 2013 will seem like ancient history. If the platform for the GOP is going to be a version of "let's take something away from millions of people we'd like to vote for us and still get them to vote for us" well, that'll be quite something to watch.

2013 was a very good year for the Affordable Care Act simply because it suffered no fatal blows. The patient continues to survive and get stronger every day. If the ACA was considered in "critical condition" prior to the Supreme Court vote back in early June of 2012, we might today classify it in "fair condition, but the prognosis is good as the patient is improving."





Tuesday, December 17, 2013

Healthcare Triage: Survival vs. Mortality Rates...(What's it really mean?)

The latest episode of Healthcare Triage.

As many of our readers are middle aged, we're (as a group) starting to get diagnosed with more and more conditions and diseases. If you've followed Reasonable Conversation, you know we devote a lot of our attention on healthcare reform and policy. We've all heard the terms "Survival Rates" and "Mortality Rates" tossed around, but what do they mean and what's the difference. As we get older, its going to be useful to understand how the terms are most often used, what they tell us and how politicians often mis-ise them to make their political points.

 The preview from Healthcare Triage:

 Almost every time someone wants to proclaim the US to be the "best in the world" in health care, they point to survival rates. Those refer to the percent of people who live a certain amount of time after they've been diagnosed with a disease. But there are real problems in using survival rates to compare the quality of care across systems. The metric people should be using is mortality rates. And when we compare mortality rates, we don't look nearly as good. Why is this important? Glad you asked. We answer in this week's episode.


 Subscribe to their You Tube channel to watch all Healthcare Triage episodes...

Friday, December 13, 2013

Conservatives speak up for Mandela

With the death of Nelson Mandela, some American conservatives haven't spoken highly of South African leader, particularly in reference to his background that included flirtations with violence and Communism. But there are other voices on the right taking the opposite view, recognizing his transcendent leadership and principled fight against oppression.

Try this from an article by longtime Mandela supporter Newt Gingrich:

Some of the people who are most opposed to oppression from Washington attack Mandela when he was opposed to oppression in his own country. After years of preaching non-violence, using the political system, making his case as a defendant in court, Mandela resorted to violence against a government that was ruthless and violent in its suppression of free speech.

As Americans we celebrate the farmers at Lexington and Concord who used force to oppose British tyranny. We praise George Washington for spending eight years in the field fighting the British Army’s dictatorial assault on our freedom.
Patrick Henry said, “Give me liberty or give me death.” ...
Doesn’t this apply to Nelson Mandela and his people?
Some conservatives say, ah, but he was a communist.
Actually Mandela was raised in a Methodist school, was a devout Christian, turned to communism in desperation only after South Africa was taken over by an extraordinarily racist government determined to eliminate all rights for blacks.
I would ask of his critics: where were some of these conservatives as allies against tyranny? Where were the masses of conservatives opposing Apartheid? In a desperate struggle against an overpowering government, you accept the allies you have just as Washington was grateful for a French monarchy helping him defeat the British.
Finally, if you had been imprisoned for 27 years, 18 of them in a cell eight foot by seven foot, how do you think you would have emerged? Would you have been angry? Would you have been bitter?
Nelson Mandela emerged from 27 years in prison as an astonishingly wise, patient, and compassionate perso …
 As much as any person in our lifetime he had earned our respect and our recognition.

Before you criticize him, ask yourself, what would you have done in his circumstances?


There is this from the Washington Times:

Communists were right to support both the African National Congress and the cause of ending apartheid. Conservatives were on the wrong side of history on the issue. The true conservative position on apartheid should have been to oppose it...

The oppression of blacks under apartheid was far more morally odious than the oppression that the Founding Fathers opposed — and fought the Revolutionary War to destroy. It is repulsively hypocritical to maintain that Nelson Mandela was a terrorist for fighting for the freedom of his people, while reverencing the Founding Fathers of America for doing the same thing — under an indisputably less oppressive regime.


Finally, conservative columnist Deroy Murdock admits he had been wrong about Mandela in the National Review:

Like many other anti-Communists and Cold Warriors, I feared that releasing Nelson Mandela from jail, especially amid the collapse of South Africa’s apartheid government, would create a Cuba on the Cape of Good Hope at best and an African Cambodia at worst...

Nelson Mandela was just another Fidel Castro or a Pol Pot, itching to slip from behind bars, savage his country, and surf atop the bones of his victims.


Far, far, far from any of that, Nelson Mandela turned out to be one of the 20th Century’s great moral leaders, right up there with Mahatma Gandhi and Dr. Martin Luther King Jr. He also was a statesman of considerable weight. If not as significant on the global stage as FDR, Winston Churchill, and Ronald Reagan, he approaches Margaret Thatcher as a national leader with major international reach.


RIP Madiba.

Links to the quoted articles:

Newt Gingrich

Washington Times

Deroy Murdock/National Review:

Monday, December 9, 2013

How is Obamacare Paid For? (The Details...)

Healthcare Triage devotes this week's issue to explaining, in less than 7 minutes, exactly how the Affordable Care Act is paid for. Dr. Carroll, take it away:

 (Reasonable Conversation dedicates this post to our friend and faithful reader, Mr. Keith Baklarz...)

Thursday, December 5, 2013

Nelson Mandela Dies...

Nelson Mandela
July 18, 1918 - December 5, 2013

The Associated Press has a detailed obituary:

Former South African President and anti-apartheid revolutionary hero Nelson Mandela has died at his Johannesburg home. He was 95.
He had returned home on September 1 in a critical condition after being in a Pretoria hospital for almost three months -  the fourth time he had been admitted to hospital since December. He had battled a series of lung infections and respiratory illnesses in the past few years.
Mandela, who spent 27 years in prison after being found guilty of being sabotage and conspiracy to overthrow his country's government before being released in 1990, became South Africa's first democratically elected president, holding office from 1994 to 1999.
One of the world's most famous people, he has long been a figurehead for racial unification, following his efforts to heal his own country after centuries of division.
News of his death has prompted an outpouring of grief from all corners of the world.
Mandela had a history of lung problems, after falling ill with tuberculosis in 1988 toward the tail-end of his prison term before his release and subsequent presidency.
While doctors said at the time the disease caused no permanent damage to his lungs, medical experts say tuberculosis can cause problems years later for those infected.
The Nobel laureate had an acute respiratory infection in January 2011.
Following the chaos that surrounded his stay at a public hospital then, the South African military took charge of his care and the government took over control of the information about his health. It released little, mostly saying early in his last hospital stay that he was in a "serious but stable condition'', but in late June it said he was "critical but stable''.  In July the government denied that he was in a vegetative after a lawyer for some of his family told a court his life support system should be shut off.
Mandela was one of the most revered leaders of the 20th century and his legacy will forever be the abolition of apartheid in South Africa.
The man endearingly known throughout South Africa as Madiba - his Xhosa clan name, which literally translates to grandfather - cemented his place in history when he became the first democratically elected president - black or white.
As a founder of Umkhonto we Sizwe (Spear of the Nation), which was the armed wing of the African National Congress (ANC), Mandela was a militant anti-apartheid activist from a young age.
He was sentenced to life in prison after being charged and convicted of sabotage in 1962.
Left to the mercy of the prison guards in a white supremacist South Africa, his release 27 years later in 1990 set in motion the cogs of an anti-apartheid movement that had the backing of much of the world.
His release was all the more astonishing for a total lack of animosity toward his captors. In a speech on the day of his release, Mandela quoted his own words, which he spoke at his trial in 1962:
"I have fought against white domination and I have fought against black domination. I have cherished the ideal of a democratic and free society in which all persons live together in harmony and with equal opportunities.
"It is an ideal which I hope to live for and to achieve. But if needs be, it is an ideal for which I am prepared to die."
Four years later apartheid in South Africa had ended and in 1995 Mandela became the first elected president - ending the irony behind the name the Republic of South Africa.
His presidency was spent building what his inaugural address called a "rainbow nation at peace with itself and the world".
As the ANC party under Mandela began to dismantle the racial divide, his attention turned to the issue of HIV/AIDS, which according to the World Health Organisation, affects about 6.5 million people in South Africa.
But the crusade was more personal for Mandela, who lost his eldest son in 2005 to the disease at the age of 54.
After his departure from politics, Mandela also sought to step away from the public eye with appearances in recent years becoming fewer and farther between.
His last public appearance was in 2010 when South Africa hosted the FIFA World Cup.


Blogging, as you've probably noticed has been fairly light the last few weeks. Mostly the reason for this is the annual increase in my performance schedule. From mid November through New Year's Day, my schedule essentially doubles. Which doesn't leave much time for writing...

I have been reading, however, lol...

Of late I've been very frustrated with:

*The Healthcare.gov rollout, which defies all logical understanding. Obama and his team did themselves no favors by not being more hands on and more open to the true feelings and concerns of their IT team. The "you can keep it if you like it" mispeak/lie will hang around Obama neck for a while. Yet another unforced error by our President.

*The GOP's bogus reaction to people losing their insurance. First of all, its a fairly thin slice, less than 10% of the entire health insurance market, who lost their coverage. Secondly, where exactly was the GOP's outrage the last ten years or so as the individual market routinely tossed people off their plans when they felt like it? If it didn't outrage you then, it shouldn't outrage you now.

*I've given a lot of thought to the question of raising the minimum wage and I agree with many voices on the left that it should be increased. Several states have raised their minimum wage levels (Oregon and New Jersey to name two.) I suspect in time more and more will follow suit.

*I'm still looking for the first conservative to make the connection between Iran being allowed to sell its oil on the world market and lower gas prices here in the United States. As so many right wing armchair economists have told me for years, increased supply means a dropping of prices, which was the basis for increasing domestic oil production. Well, Iran is now allowed to sell its oil on the world market, which increases supply and look what happened to our gas prices. Down significantly the last few weeks. How about that?

*My partner Tim Dickinson is away on assignment until after the first of the year.

*Blogging will be light through the first of the year...basically, I'll post when I can...

Happy Holidays!