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When I was a child I remember watching the Republican convention with my dad in 1968 (I believe) and hearing a speech that was rather incendiary (goes to show you what having 3 channels only will force you to watch). My dad dismissed the speaker with a “Oh, he’s one of those “John Birchers.” I had a chance to catch Paul Ryan’s speech last night and for some reason I thought back to that quality time I spent with my dad.

I was disappointed in Congressman Ryan’s characterization of “Obamacare” as an “new entitlement” rather than the health care system reorganization that it actually is. I was even more disappointed in the disingenuousness of his claims regarding the effect of the Affordable Care Act on Medicare as compared to the intent of the House of Representatives as announced in the “Path to Prosperity” budget that he is given credit for authoring. What mostly caught my ear, however, was his description of life in “Obama’s America”:

None of us have to settle for the best this administration offers—a dull, adventureless journey from one entitlement to the next, a government-planned life, a country where everything is free but us.

Healthcare access has been a poorly and erratically funded entitlement ever since the founding of this country, as has public education. I guess in a sense people have moved from the entitlement of a delivery in a controlled environment to the entitlement of public education for a long time so perhaps we are contemplating a move in another direction.

This prompted me to look into what Ayn Rand would consider to be appropriate for health care delivery, as she seems to be providing at least as much influence over Republican thinkers today as the John Birch Society had in the 1960s. I found the essay (famous, it turns out): Health Care is not a Right, penned in 1993 by Leonard Peikoff, and here is the gist:

[It’s as if there was a right to haircuts and] haircuts are free, like the air we breathe, so some people show up every day for an expensive new styling, the government pays out more and more, barbers revel in their huge new incomes, and the profession starts to grow ravenously, bald men start to come in droves for free hair implantations, a school of fancy, specialized eyebrow pluckers develops — it’s all free, the government pays.

So, how does that translate to healthcare?

Under the American system you have a right to health care if you can pay for it… Some people can’t afford medical care in the U.S. But they are necessarily a small minority in a free or even semi-free country. If they were the majority, the country would be an utter bankrupt and could not even think of a national medical program. As to this small minority, in a free country they have to rely solely on private, voluntary charity. Yes, charity, the kindness of the doctors or of the better off — charity, not right, i.e. not their right to the lives or work of others. And such charity, I may say, was always forthcoming in the past in America. The advocates of Medicaid and Medicare under LBJ did not claim that the poor or old in the ’60’s got bad care; they claimed that it was an affront for anyone to have to depend on charity. But the fact is: You don’t abolish charity by calling it something else. If a person is getting health care for nothing, simply because he is breathing, he is still getting charity, whether or not President Clinton calls it a “right.” To call it a Right when the recipient did not earn it is merely to compound the evil. It is charity still — though now extorted by criminal tactics of force, while hiding under a dishonest name.

Yes, I think I can see a line between President Obama’s vision regarding healthcare and those who follow Ms Rand.

A question came from a colleague about the Paul Ryan’s plan to balance the budget Medicare. Specifically, the question was whether someone on the Democratic side would ALSO be able to balance the budget and maintain the Medicare benefits to which Americans have become accustomed. In case you are also wondering, my answer is as follows:

If the question is whether or not there is the ability to maintain the provision of the services provided by CMS with a decreased cost, the answer is that the PPACA actually has provisions for this. Within the Affordable Care Act are provisions, which if enacted, will reduce Medicare liability (or revenue if you are a health care entity) both for the elderly (found here) and for the dual eligibles (found here) but at the price of taking some control away from the system and a reduction of dollars in the system. If ACOs work as intended, there will be less of a loss in primary care than there will be in specialty care (as evidenced here) but as of yet there are none in Alabama.
If the question is whether there is anyone who can provide services under the fee-for-service model and protect Medicare, the answer is no. Ryan’s 2011 plan doesn’t accomplish this. As outlined in 2011, it would cap “premium support” at $8,000 (roughly $2,000 less than 2009 US per capita spending though only $1,700 less than Alabama per capita spending (found here)). So, there would be less money in the system, no controls over product quality, and someone would still be liable for the additional costs once the beneficiary either was unable to get “insurance” because of cost or went beyond policy limits.

A primary contributor to Costa Rica’s success has been its focus on the well being of its people.  For Costa Rica, health and education are priorities for the success of their nation.

The attention to health has brought this middle-wealth country’s health indicators in line with those of OECD countries.[viii]  In 2001 the average life expectancy at birth in Costa Rica was 76.6 years.[ix]  In 2000, 97% of births were attended by skilled professionals, 89% of the pregnant women were given prenatal care, and 93% of children under 1 had health insurance.[x]  From 1990 to 2000 life expectancy increased by 0.8 years, the fertility rate dropped, and the population grew due to an influx of Nicaraguan immigrants.[xi]  In 2000 there were 16 physicians and 3.2 nurses per 10,000 population.[xii]  In 1999 there were 12,000 people living with HIV/AIDS, giving an adult prevalence rate of 0.54%.[xiii]  However, Costa is the only Central American country to provide antiretroviral treatment to all patients through its social security system.[xiv]  The leading causes of death were cardiovascular disease and neoplasms, which is comparable to many OECD countries.[xv]  Spending on health care has increased steadily over recent years, and in 2000 it composed 9% of the national GDP.[xvi]

(report to the Global Economic Council, 2002)

I received an e-mail today from Doctors for America. This group is a “national movement of physicians and medical students fighting for a system in which everyone has equal access to quality healthcare.” I signed up (membership is free) when the “Obamacare” debate was raging to express my core belief in access to quality healthcare publicly. Several other physicians in my group signed up as well. At one point there was a map and we accounted for a large majority of the Alabama membership.

Today’s e-mail (also found on their blog) pointed out that the Ryan health care plan was going to be voted on in the Senate and urged us to contact our elected representative to let out voices be heard. My voice often carries a message at odds with our congressional delegation and I tire of writing to them but I recommend that you read the blog post for yourself. To use their summary of the the high points, if passed (and signed by the president) the new law would:

  • Eliminate traditional Medicare and replace it with a voucher for seniors and disabled Americans to buy their own insurance. Each person would receive a fixed-amount voucher to choose a private insurance plan. The value of the voucher would increase with time, but would not rise at the same rate as insurance premium increases.
  • Cut Medicaid funding for states by turning it into a fixed-amount federal block grant program.  With the block grant program, states that are already struggling to cover Medicaid patients would have to make do with decreased federal help.  The Kaiser Family Foundation estimates that within 10 years, 44 million people who would have been on Medicaid in would not have coverage – that includes children, pregnant women, seniors in long-term care, and the disabled.

The proposed changes in the Ryan budget would:

  • Decrease access to health care.  Seniors, disabled, children, and low-income Americans would lose the safety net that currently protects the health and security of millions.
  • Decrease quality and ineffectively control costs. Vouchers and block grants will not reduce the underlying drivers of health care cost growth. Lasting cost control will come from a transformation of the ways we deliver and pay for health care. It will not come from simply shifting the responsibility for paying to America’s seniors and most vulnerable.  Many new delivery system reform projects, such as the Accountable Care Organizations and Patient Centered Medical Homes, will work to encourage quality of care (reduced waste, greater coordination, and improved efficiency), rather than the high quantity of care that is driving up health care costs and doing little to improve patient health.
  • Put patients at increased financial risk. Vouchers for insurance premium support and block grants will control federal health spending over time, but they will do so by shifting financial risk and administrative burdens onto state and local providers, families, communities and vulnerable beneficiaries.

President Obama will veto this if it passes. I remain disappointed in our elected legislators who have an opportunity provided by the Affordable Care Act to force health care providers, big pharma, and to a certain extent patients into producing and consuming more cost effective care. If this effort were undertaken, it should lead directly to better health outcomes and less spending on health care—money that could be spent on other goods and services. Instead they are participating in a thought exercise regarding whether or not health care is a commodity that will respond to market forces.

The American public is of one voice. They do not want a change in benefits, and they want someone else to pay for those benefits. If that ends up with me in a defined contribution plan for health care during the most expensive 30 years of my life, I’m moving.

I have to admit that as a relatively healthy late middle-aged male, I don’t think a lot about my own death. My own physical exercise is undertaken, I guess, to stave off death as long as possible but as I suffer from no chronic ailments at this time and come from a very long-lived gene pool, I would rather focus on  other things.  I am a little worried that “they” want to take away my Medicare but don’t dwell on my upcoming but distant 7th decade at this time. The discussion over the “sustainability” of Medicare has downplayed the provisions in the Affordable Care Act that should lead to reduced cost in Medicare, discussed here. Instead, the discussion has focused on the House proposal to give patients a sum of money (tied to the consumer price index so effectively being reduced every year)  under the assumption that “the market,” when unregulated, will lead to better, less expensive health.

I found myself reflecting on life, death, the human condition, and the health care market today while reading the paper. There was an article about “medical tourism,” but not the good kind. This author interviews the mother of a gentleman who died. He was paid for a kidney (perhaps why God gives us two, kind of a savings plan for poor people who in their time of desperate need can have $5,000 US “withdrawn” from their back) but unfortunately died post-operatively. The recipient, after returning to the US, also died of complications of the procedure.

Per this article:

For decades, wealthy Brazilians, Mexicans and Saudis have gone to U.S. and European hospitals for medical care they couldn’t get at home. In the past decade, that pattern has changed. Hospitals from Puerto Vallarta, Mexico, to Medellin, Colombia, now lure middle-class Americans with promises of high-quality care at a fraction of what it would cost them at home.

Medical tourism company MedToGo, based in Tempe, Ariz., says it will offer kidney transplants in Mexico and Costa Rica for about $50,000, a fifth of the cost in the U.S.

In the illegal organ trade, brokers scour the world’s slums, preying on the poor with promises of easy money in exchange for a kidney.

In Colombia, 321 foreigners got transplants from 2005 to 2010, according to the country’s National Health Institute. Juan Lopez, a doctor who oversees Colombia’s organ transplant system as director of the NHI, says many of these surgeries are driven by profit for hospitals, doctors and brokers.

Turns out that a poor person from the slums is willing to sell a paired organ (a kidney, for example) for what seems like a lot of money to them ($5,000) and a non-poor person is willing to pay what seems like a reasonable amount of money ($150,000) for that same organ. The market works, and not in a way that makes me feel good. I am afraid that the Title Pawn industry will have nothing on the organ procurement industry when it comes to market forces and unsavory behaviors. I am convinced that vouchers will not lead to a reduction in health care costs. On the contrary, it will lead to more folks seeking out more health care as they approach death and are made promises that will never be kept. It may result in  people entering into contracts which reduce human dignity and increase the suffering of others.  People in ill health who are desperate will not only supplement their vouchers with their personal fortune, but will potentially pay with their shortened  life as the burden of iatrogenic illness increases.
The Affordable Care Act includes strong market regulation. The market prior to the passage of the Affordable Care Act, although poorly regulated, at least had sufficient regulation to prevent trafficking in human organs. When our friends return from another country with their brand new kidney, will we congratulate them on getting quite the bargain? If vouchers were enacted for Medicare, would we allow those who can afford it to get the same bargain here?

The most recent 24 hour news cycle obsession, THE GOVERNMENT SHUTDOWN, came and went with the ultimate consequence still up in the air. The immediate consequence, the Cherry Blossom Parade completing the fully planned route, was a good outcome for those who were in DC. The long-term outcome may have far-reaching negative consequences to the most vulnerable of our society.

The American public, or at least a vocal subset, has spoken out against continued “unchecked” spending. That subset demanded reductions in spending which seem to have been granted as a result of the recently completed negotiations. The news cycle seems to have distorted the American public’s perception of the budget and the consequences of the “largest reduction in federal spending ever.” 40% of the public believe that NPR accounts for 5% of the federal budget, not the 0.00014% that it actually does, and as such no doubt believe that the crisis will be over following the closure of the stations. The news outlets continue to carry the “outcry” for more draconian actions that would seem counter to the interest of the population.

Congressman Paul Ryan seems to be the latest darling of the news cycle. He has declared that ACA will bankrupt the country and has a budget plan that (in the words of The Atlantic):

In a nutshell, Ryancare phases out Medicare to expose consumers to the true costs of health care. Under Ryancare, the government would send seniors a voucher equal to the amount that we’re projected to pay for the typical Medicare recipient in 2022. Every year after 2022, the voucher’s value would increase at the pace of the consumer price index — considerably slower than the typical growth of health care spending. As government pays for a smaller share of health care, families will bear greater exposure to health costs. Conservatives hope that if we expose patients to the true costs of health care expenses, they’ll be more frugal about treatments.

As the New Republic points out, we already have a plan that will slow the growth of health care without putting frail elderly at risk of premature, painful death:

The Affordable Care Act’s central hope is that Medicare can lead the health-care system to pay for value, cut down on overtreatment, and cut out treatments that simply don’t work. The law develops Accountable Care Organizations, in which Medicare pays one provider to coordinate all of your care successfully, rather than paying many doctors and providers to add to your care no matter the cost or outcome, as is the current practice. It also begins experimenting with bundled payments, in which Medicare pays one lump-sum for all care related to the successful treatment of a condition rather than paying for every piece of care separately. To help these reforms succeed, and to help all doctors make more cost-effective treatment decisions, the law accelerates research on which drugs and treatments are most effective, and creates and funds the Patient-Centered Outcomes Research Institute to disseminate the data.

And, as the New England Journal of Medicine points out, the Congressman’s plan would lead to health care haves and have-nots on a very large scale in 40 short years

Although the Ryan–Rivlin and House Budget Committee plans are called “premium support,” they actually jettison all or most of the consumer protections that distinguish premium support from bare vouchers. Both would shift costs to Medicare enrollees. The CBO estimates that by 2030 the House Budget Committee plan would increase the out-of-pocket share of health care spending for a typical Medicare beneficiary from the current 25-to-30% range to 68%. By 2050, the House plan would cut federal health care spending by approximately two thirds.

The American public may be willing to let the NPR stations go silent in exchange for assurances that the country will continue to exist for a couple of more years. Congressman Ryan, or so the news accounts suggests, believes that for us to continue to exist as a country we are not going to be able to do what every other western country does:  provide health care for our citizens without regard to their ability to personally pay. His budget suggests that folks should be able to personally fund large portion of their health care or else allow receive care only if a non-governmental organization deems them worthy. This is consistent with the FreedomWorks vision for American health care but interestingly enough not consistent with the latest Kaiser poll.

There used to be a disclaimer on “Dear Abby” that the column is for entertainment purposes and should not be used for decision-making purposes. I hope to see such a disclaimer appear on certain media more frequently. Me, I get my news from NPR.