Healthcare, Nullum Gratuitum Prandium

Nullum gratuitum prandium (there is no free lunch).  Health care in America is going to cost somebody something.  The question now seems to be, how much will it cost and where are we going to find that “somebody” willing to pay.  Is it really that hard to figure out what’s wrong with our current healthcare system and come up with solutions that offer something better than what we now have?

You can call it Obamacare, or Trumpcare, or Medicare, just don’t call it, “I Don’t Care.”  Eventually, everybody cares.  If you live long enough, you, or someone close to you, will need something more than a Band-Aid.

Well, the first problem we have is where to find the money.  I have a few ideas that will help us along.  They may not be the total solution, but I think most of these ideas are better than giving the wealthy deep tax cuts while shifting the healthcare burden to the remaining 99.9% of us.  Cutting taxes and cutting coverage seem to be simple solutions developed by lazy minds.  Good solutions are only difficult if you go in trying to cut how much we spend on healthcare while looking to find ways that private industry can make a greater profit.   If you try to pair a massive tax cut for the wealthy with an improved healthcare delivery system, you are doomed.  Such goals are not just unattainable they are unrealistic.

In Greed We Trust

What would be achievable?  You could identify additional revenue sources while lowering existing costs for healthcare.  You can outline the structure for the delivery system.  The one very important rule here is that everyone must participate.  Healthcare coverage can’t be voluntary.

Why don’t we?

1. Eliminate the cap on Social Security where people earning over $127,000 (in 2017) stop paying into the system.  Then take the added revenue from this “new tax” and put 20% into the Social Security System and the remaining 80% into a Medicare for All Fund.
2. Mandate that all employers who don’t fully provide an approved healthcare insurance plan, who have 25 or more employees and/or contractors, be required to pay $1.00 per hour into a compulsory savings plan (CSP) up to a maximum of $40 per week.  Where contractors, part-time, or salaried employees can be shown to work fewer than 40 hours per week, the $1.00 per hour rate will apply.  The CSP is set up for individuals and would be held in interest-bearing accounts.
3. Employers who do provide an approved healthcare plan will pay a lesser amount for each employee than the amount identified in number two above.  This will go a long way to make insurance “portable” in the event that employee becomes unemployed.  These payments will also go into an employee identified CSP.
4. Begin taxing those workers currently exempt from paying Social Security, like some federal and state employees, railroad workers, and certain religious groups.  You would only tax these individuals when their salaries exceeded the current Social Security cap.  For these individuals 100% of the amount collected would go to the Medicare for All Fund.
5. Impose new taxes on liquor and tobacco that will go directly to the Medicare for All Fund.  Charge $0.01 per ml of distilled spirits ($0.75 for a 750ml bottle), charge $0.01 per oz.) for beer (12 cents a bottle), and similar rates for other forms of alcohol.  Tobacco could be billed at $0.05 per gram of tobacco in your product, which would be about $0.75 for a pack of 20 cigarettes.  If marijuana is ever approved and taxed, it too would be included here.
6. Raise the top marginal tax rate and raise the capital gains tax.  Reagan lowered the marginal income tax rate from 70% to 28% and the capital gains tax went down to 20%.  Raise both by two percentage points to help pay the cost of Medicare for All.
7. Reinstate the luxury tax implemented in 1991 by George H.W. Bush but eliminated in 1993, and put it to paying for healthcare.  Individuals who can afford big-ticket items like luxury cars, private aircraft, yachts, furs, and expensive jewelry can afford to help out the nation that provides them with the opportunity to make the big bucks.
8. Tax corporations and wealthy individuals who elect to make political donations to PACs and similar organizations, in excess of previously established contribution limits.  They should have a portion of that donation taxed and funneled into our national healthcare coffers. 

I’m sure I missed some other logical sources of revenue like charging politicians every time they are caught in a lie, but we don’t want to raise too much revenue.  Our current president could end up funding the entire plan.  The figures used in the enumerated points above are all arbitrary and completely negotiable but serve as examples of reasonable sources of revenue for healthcare.

Now, what can we do to make healthcare more affordable?  Let’s reduce the cost of that care.  Why not allow the Federal Government to act as a central purchasing contractor for all medications, medical equipment, and medical supplies.  The government would negotiate the rate that they will pay/reimburse for those items.  They would be allowed to negotiate the prices for drugs, medical supplies, and medical equipment in the global marketplace, not just the US.  Buy America first, but not exclusively at the expense of our healthcare.  This one act could make a dramatic impact on current costs.

Negotiate Prices

All US citizens under age 65 would be provided basic Medicare type services.  The existing Medicare structure could work where everyone is covered by the federal plan for basic healthcare.  Insurance carriers could operate at the state, regional or national levels as they choose and could offer enhanced plans for those willing to pay.  They could use the federal negotiated rates for drugs, equipment and supplies, or they could negotiate their own rates.

Insurance carriers would be required to offer their plans to all residents of the states or regions where they elect to operate.  National carriers would have to be open to all citizens.  The federal government would charge a fee to all insurance carriers offering health insurance and accordingly underwrite those carriers against catastrophic losses in the event of pre-existing conditions or unforeseen chronic illnesses or injuries.  Fees and thresholds would need to be negotiated regularly.

No healthcare would be free.  Some form of copayment would be required for all services.  Where an individual has a CSP (compulsory savings plan), copayments would be made from that fund.  There would be an opportunity, after an individual goes on regular Medicare at age 65, to cash out any funds remaining in their CSP, tax-free.  This compulsory savings plan would provide some incentive for people to avoid unnecessary trips to the doctor and to try to maintain a healthy lifestyle.  Stay healthy and you have money in the bank at age 65.  At $40 per week and nominal interest, a little used CSP could have over $100,000 in it at retirement.  They could then use some of this money to buy a good supplemental health insurance plan or just take that long-postponed vacation to Singapore.

I mentioned Singapore only because they currently have a healthcare plan that provides better national health care coverage than the U.S.  They do this for a lower per-capita cost and provide better care.  According to a year 2000 study conducted by the World Health Organization, Singapore ranks 6^th overall in the world for the quality of care.  Bloomberg ranked them as the most efficient in the world in 2014.  America ranked 50^th out of 55 countries in the Bloomberg review.  Life expectancy in Singapore is 82.65 while Americans can expect to make it to 78.94.  While these reports, like any complex analysis, may be subject to criticism, the takeaway here is that there are many better programs in many other countries.  We can and should do much better.

I don’t have access to the resources of our congress.  I don't have the Congressional Budget Office to work the numbers offered here to discern their viability, but then I wasn’t elected and paid to do that job either.  Come on congress.  Earn your keep.  You know you can come up with a good plan.  You certainly came up with a better healthcare plan for yourselves*.

*  One theory about the urgent need to repeal the ACA, put out by by Jeffery Frank of the New Yorker in his January 17, 2017 article , was that access to the Federal Employees Health Benefits Program (FEHBP) was eliminated by Article 1312 of the Affordable Care Act.  The FEHBP was the wonderful plan that the Post Office, Congress, and congressional staffers had enjoyed since 1959.  With the repeal of the ACA, these same government employees could go back to their original plan with all its benefits.  Is Congress so devious that they would better themselves at the expense of their constituents?

I'll have what Congress is having. (scene from When Harry Met Sally)

The Plutocratic States of America

A man standing on the bank of a river watches a man in a canoe go by and exclaims, “Boy is he rich.”  The man in the canoe sees another man in a 16’ open-fisherman and proclaims that man to be wealthy.  The man in the open-fisherman heads out to sea and spies a 34’ cabin cruiser and dreams of the wealth of the owner of that magnificent craft.  The cabin cruiser owner is sitting at the stern of his boat (he has a captain of course) and sees that he is about to be overtaken by a 95’ mega-yacht and wonders if that owner is sitting in his air-conditioned salon being served cocktails and hors d'oeuvres by his steward.  He too dreams of being truly wealthy like that lucky mega-yacht owner.

Plutocracy is from the Greek ploutokratia or government by the rich, 
from ploutos wealth + -kratia rule, power.

You see, it’s all a matter of perception, or the size of your boat (or canoe or shoes) to keep the metaphor going.  Here, in the wonderful PSA, most people dream of more and more and, you get my drift.  The man in the mega-yacht can’t even see the man on the riverbank but he knows he exists and feels better about himself accordingly.  The wealthy are only wealthy if they feel wealthy by comparison with others who are less fortunate.

Median Household Income 2010-2014

The mega-rich need to not only maintain their status as very wealthy Americans but they need to increase the financial distance between themselves and those “poorer-than-me” folks behind them.  This “financial gap” needs to be ever widened for the truly wealthy to realize any progress in their status.  You see, it is not just about the dollars but also, perhaps more importantly, about the power and control that are needed to expand that gap.

The people in this rarified atmosphere of wealth and power have been referred to as the top 1/10^th of one percent.  How much money is that?  Well, that actual dollar figure is hard to ascertain because while you and I file an income tax return with rather easily traceable sources like wages, interest on savings, and dividends on investments, the very wealthy are a bit more difficult to track.  By one estimate the top one percent of Americans own almost 40% of everything.  That same analysis states that the top 0.1% is represented by about 16,000 families with around $6 trillion in assets.  This would mean that these families have assets equivalent to two thirds of the rest of America.  In 2011, PolitiFact indicated that the top 400 wealthiest Americans have over half of all the wealth in the US.

Not Since the Roaring 20's Has the Concentration of Wealth Been So Lopsided

US wage earners, who may have highly skilled jobs, could soon find that their skills are no longer needed because globalization and technology have put them in direct competition with lower paid workers in foreign economies.  These same individuals may find that not only have their jobs been lost but their life saving may be destroyed by these same economic changes.  Workers in the US that lack the education, training, or skills needed in the new technology driven economy, will see their wages decline or disappear entirely as mechanisation and developing world labor competition take their toll.  Political job creation promises will not be enough to undo the damage done by these global market forces.

This article is not about begrudging the very wealthy their ownership of a disproportionate share of assets.  That is, after all the American way of life, aka The American Dream.  I will however challenge this group when they try to widen the financial gap by taking even more from the rest of us by controlling our government.  I will resist when they try to degrade the quality of our health care (already in deplorable condition based on what we currently spend) and try to attack Social Security as an un-earned charity.  I will call them out when they improve their status by degrading the quality of our educational system.  I will again be upset when they get richer through tax breaks for their brethren while shifting the burden to the other 99.9% of us.  I will express outrage when they feign that our military needs even more money while our infrastructure deteriorates at an alarming rate.  I will sound the alarm when they literally blow smoke up our collective asses claiming that climate change is a hoax.  I will challenge them when they offer false promises of new jobs and other societal benefits if we will make concessions where they benefit.  Trickle down economics is just that, a TRICK-le.  The emphasis here is on the TRICK.

Citizens United Decision Tips the Scales

Education or lack thereof is used to control the financial gap.  Wealthy individuals make sure their children are afforded the benefits of a much better than average education.  Prestigious preschools, private middle and high schools, and private colleges all help ensure that wealthy children will be members of the wealthy elite when they graduate.  At the same time, they fight any attempt to better the education of the rest of our society.  Financially starve public education and then offer charter schools as an answer to the problem created by the now deteriorating public schools.  A win-win where education suffers and a few charter school owners can make a fast buck.

Ours is no longer a democracy.  Ours is now a plutocracy where our society is ruled by the small minority of our wealthiest citizens.  While the collapse of the Soviet Union in December of 1991 spawned the creation and expansion of the Russian oligarchy, it was perhaps Citizens United v. FEC on January 21, 2010, that provided the final nail in the coffin of our already failing democracy.  Prior to Citizens United, influential-level campaign donations by the wealthiest among us, was restricted to quasi-legal and illegal activities. 

[Note that you may click on any graphic to enlarge for detail.]

Election Spending Pre and Post Citizens United 2010 Decision

Jeffrey A. Winters, a political scientist at Northwestern University, wrote that, "oligarchy and democracy operate within a single system, and American politics is a daily display of their interplay."  Former president Jimmy Carter has stated that the United States is now “an oligarchy with unlimited political bribery,” as a result of the Citizens United decision, which removed most restrictions of political donations.

Does anyone of sound mind have any doubt that money can buy legislative access.  This is not a partisan issue.  Democrats, Republicans, and Independents alike, benefit financially from their time in office.  The net worth of our congress increases by an amount that far exceeds their salaries.  We are a nation governed by wealthy individuals who are in turn made richer by even wealthier individuals and corporations.  The chart below covers the top 20 congressional leaders who have seen their net worth skyrocket while in office.  The figures shown are annual averages.  You may want to know that the average salary of our congressional leaders is $174,000. plus benefits.  How several of these individuals have had increases in the millions is of some interest.  It must be the "benefits".

Top 20  Members of Congress with Annual  Average Increases in Wealth 2012
Note that Ms Pingree (top) was due to marriage

It should be clear here that the Citizens United decision needs to be overturned.  The inalienable rights of our Constitution belong to We the People and not to corporations and labor unions.  Money should never be equated or confused with the right to free speech.  The old joke about the Golden Rule where he who has the gold gets to make the rules is just that, a joke.

Whoever Has The Gold Makes The Rules

While we are led to believe in the democracy created by our Constitution, we are unduly influenced by the power of political spending.  Gerrymandering of voter districts and restrictive election laws are all designed to control the outcomes of elections.  Seemingly unlimited spending on outrageous attack ads during the days leading up to a vote are all paid for by deep-pocketed individuals and corporations who will benefit from the outcome.  It would be easy to blame the un/under-educated for their malleability when it comes to the political rhetoric that besieges us daily, but I have witnessed individuals with advanced degrees spouting easily discredited political bullshit.  Ignorance in such cases is voluntary.

The Wealthy in Control of Government 

The President, The FBI, A Bit of History

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President Donald Trump: “What Do You Think Of Me So Far?

Well, to be perfectly honest sir, some things could have gone better.  Your recent trip of foreign diplomacy has had mixed reviews.  Saudi Arabia and Israel seemed happy to see you, the rest of Europe, not so much.  The British, Germans, and French don’t seem to be your biggest fans.  Even the pope looked like he would rather be sitting on a prayer rug in a mosque in Kabul, than to be standing next to you.

Smiling Trump----------------------------The Pope       

On a brighter note, I can’t think of another time in history when almost half of all Americans could name the presidential line of succession down to its fifth layer.  Trump, Pence, Ryan, Hatch, and Tillerson are the current line-up.  Your guess is as good as mine as to why they would know this.

Line of Succession as of June 1, 2017, subject to change.

I’m sure this knowledge comes partly from television shows like Designated Survivor, House of Cards, The West Wing, Scandal, and Madam Secretary.  However, yours is the biggest reality show on TV and naturally gets only the highest of ratings.  This is perhaps because it is carried by CNN, Fox, and MSNBC 24/7 ad-nauseam.  That show is the Donald Trump Breaking News Show.  These three networks hang on your every tweet.  Everyone tunes in.  Half of the audience is hoping you have screwed up something that will get you impeached but without the world imploding.  The other half of the country is hoping you prove they were right in voting for you by actually bringing back their jobs without cutting their benefits.

Most of us now have Breaking News numbness.  It was rumored that for a short while the CNN Breaking News graphic had to be taken off line to cool down.  Wolf Blitzer was forced to temporarily use the old, “This Just In” phrase that doesn’t really have the same impact.

I’m sure most would agree that your firing of James Comey, while he was in the midst of investigating you and your associates, could have been handled better.  You will probably survive the independent counsel investigation, but some of your friends may not fare so well.  Just a point here, when they talk about Russian ties, they are not talking about the silk things you wear eight inches past your belt line.  Although, to be fair, your ties are not made in Russia.  They are made in China, Bangladesh, Honduras, and Vietnam, along with your Trump shirts and suits.

The Borscht Thickens  

Again, on a positive note, you have managed to confuse folks with your seemingly random position changes.  We hope that your “rope-a-dope” antics are really a tactic and not just general confusion.  We are all waiting for you to come off the ropes and say something eloquent and meaningful.  The rope-a-dope only works if you eventually stop the beating and go on to win the fight.  On a personal note, both you and Ali are from the same area of the world.  You are of German/Scottish ancestry (mother was a Scottish immigrant seeking a better life in America) and Ali was Irish.  Ali’s great-grandfather emigrated from Ennis, County Clare, Ireland in the 1860’s.

The Rope-A-Dope          

So far, your presidency has parallels with another of America’s great presidents.  Richard M. Nixon.  Both you and President Nixon were maligned by the press.  You both made inroads with China.  You both fired people who were investigating your offices.  (Nixon ordered the firing of Archibald Cox and you fired James Comey.)  Both of your White House press secretaries (Ron Ziegler and Sean Spicer) struggled to explain a White House with more positions than the Kamasutra. 

Kamasutra Positions

Nixon hired young political operatives to disrupt the campaigns of Democratic candidates.  You only encouraged the Russian government to hack Hillary Clinton’s emails.  I’m sure you had nothing to do with the hacking of the Democratic National Committee and the subsequent release of damaging information to WikiLeaks.

Another similarity, both of you know how to use your thumbs.

Thumb Use, Nixon's Looks Bigger

You won the presidential election by letting Hillary Clinton and the Democratic National Committee know that there are no rules in a knife fight.  Harvey Logan learned this bitter lesson from Butch Cassidy in the movie that bears his name.

Rules?  In a knife fight?

You seemed surprised when, after you promised to fix Obamacare in a matter of weeks, you found it to be “complicated.”  Who could have seen that coming?  It could be simple.  You might just copy the highly successful health care plan worked out for members of Congress.  They have unlimited coverage for life.  They all seem happy.  Why not just give that same plan to the rest of us?  Upon closer examination, by a local class of third graders, it would seem that plan would bankrupt the nation. 

Perhaps you should look internationally and pay a visit to Singapore.  According to Bloomberg Financial, the Singapore system is the world's most efficient.  By contrast, the US spends over 17% of its GDP on healthcare (2014 numbers).  This is higher than any other nation in the world.  Singapore comes in at 4.9% of GDP spent on healthcare.

We spend more of our GDP on healthcare than anyone else, and yet we rank 37^th in the world in quality.  This is according to World Health Organization statistics.  Singapore BTW, ranks 6^th.  You could also look to Physicians for a National Health Program which has done a good job evaluating the Single Payer system.  I will agree Obamacare looks like a thoroughbred designed by a committee.  That’s because it was designed by a committee.  We can certainly do better. You have the House, the Senate, the Supreme Court, and half a dozen family members supporting you.  What are you waiting for?

Thoroughbred Designed By A Committee

Well, between:

• that annoying little North Korean munchkin launching missiles every other day;
• repealing and replacing Obamacare;
• trying to build a gazillion peso wall on the southern border;
• several investigations into you, your staff, your family, and your advisors with regard to their ties to Russia;
• the persistent laughter of Vladimir Putin ringing in your ears;
• a war with the media;
• insomnia (assumed by your tweeting schedule);
• constipation (assumed because much of the time you seem full of ....);
• destroying our environment  *1
  
• deporting and blocking immigrants (what would your immigrant mother have said?)
• creating thousands of manufacturing and mining jobs in areas without factories or mines; and
• problems with ISIS, Afghanistan, Iraq, Iran, Syria, Russia, Germany, England, Canada, Australia, France and NATO;

you would seem to have your little hands full.

Nuke the Chinese

Remember, it’s not called paranoia if they really are out to get you.

Background Music Playing Fail To The Chief

*1   The destruction of our environment (you just pulled the US out of the Paris climate agreement) could just be a clever tactic on your part to solve all of the problems in the Middle East.  Just make the whole place too damned hot for anyone to live and, problem solved.  Are you that clever?   Hmmm! 

Wait, I just remembered.  You don't believe in climate change.  Just when I think you've done something clever I realize my mistake.  No one should assume you are clever.  Dumb luck at times perhaps, but never clever.

-------------------------------
FOOTNOTE

You claimed that you pulled out of the Paris climate agreement because you were elected by the people of Pittsburgh and not the people of Paris.  I'm sure you didn't realize it when you spoke but the city of Pittsburgh, Pennsylvania voted overwhelmingly for Hillary Clinton (by a margin of over 108,000).  When you go to spin this later on you can probably get Sean Spicer to say you were talking about Pittsburgh, Oklahoma (in corn country) and not the one in Pennsylvania's coal country.  The Oklahoma folks aren't too concerned about climate change.  But, if they ever figure out that their recent droughts and wildfires are connected to the weather, they might have a change of heart.