Monday, May 29, 2017

George Halvorson and Cenk Uygur on Health Care

This video is a rational discussion of health care systems in other countries and commentary about the American variety of systems. 
Remember there is no single system in America. As you listen to descriptions of health care in other countries, keep in mind the crazy patchwork of systems we call health care in America. This is what a few people still like to imagine is the world's best healthcare.
Here is the duke's mixture...
  • Group insurance -- individual or family
  • Medicare for old people -- pays 80% of controlled prices, and the beneficiary either pays the balance out of pocket or purchases a supplemental private insurance policy
  • Medicare Advantage -- This is NOT the same as original Medicare but a reborn HMO, also called "managed care." About a third of Medicare eligible beneficiaries have MA.
  • Active duty military and their families -- full medical support.
  • Veterans who qualify -- either by a service-connected injury or other medical condition (or not, but the system is means tested for those who apply later).
  • Tri-care -- formerly known as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) a health care program of the United States Department of Defense Military Health System for U.S Armed Forces military personnel, military retirees, and their dependents, including some members of the Reserve Component. 
  • Medicaid -- medical care for those who are officially destitute
  • SCHIP -- State Childrens Health Insurance Program. In Georgia we call it Peachcare
  • ER -- Emergency Medical Treatment & Labor Act (EMTALA) is a federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay, but since its enactment in 1986 has remained an unfunded mandate.
  • And finally, the exchanges and other features of the Affordable Care Act aka Obamacare (By now everybody claims to already know about ACA so I feel no need to describe that system here.)

Tuesday, May 23, 2017

Marsanne Golsby Comments on Confederate History

I'm blogging this post for quick reference. This is excellent. 
I have nothing to add other than my admiration for her courage to speak out at this time. She has my enduring respect and best wishes.  

About the removal of the Confederate monuments in NOLA:

This right here is where we've tripped ourselves in the South all these years. We've confused sentiment, familial loyalty and especially, a love of place, with a connection to a cause utterly unworthy of almost all of us.

There's nothing romantic about enslaving people. There's nothing romantic about rape. There's nothing romantic about lynchings. Enough!

I've been to a bunch of Civil War battlefields, most notably Vicksburg, where my great great grandfather, William Monroe Goldsby (Golsby) , was fatally wounded. He died a few days later in a hospital in Newton, MS. I never met him but I love him. My grandfather was named after him. I grew up with his legend around me. Honestly, with what he knew, I'd likely have done the same thing. Ima sit with this a moment. I'd likely have done the same thing. Be careful about judging people.

My GG grandfather sacrificed everything because he was duty bound. It's not his fault he lived in the wrong place for that time. But. I will not confuse my family love or my respect for his commitment with an endorsement for the cause for which he died. For 156 damn years we've had this backwards. It's twisted. It's messed up.

I love the South! I love my family, and the drawl, and my grandmother's butter churn and the recipes, connection to the land, sense of community, the flint and powder shotgun above the fireplace mantle when I was a kid and the GENUINE FRONTIER fearlessness from which I was just two generations removed! We lived in the country just outside Shreveport. My dad taught me to shoot when I was just seven and I'm a big proponent of responsible gun ownership.

I have my great grandmother's spinning wheel in my dining room. That's William's daughter in law he didn't live to meet. I'm PHYSICALLY connected to the 19th Century. I honor and cherish those family ties. I had loving parents and grandparents and I'm a sentimental gal.

But NONE of that translates into embracing bigotry.

It's time to color inside the lines of the history books. In Southern classrooms, they lied to us, out of institutional racism. Maybe not out of spite, but at the very least out of a need to avoid guilt and grief. My parents and teachers were children during the Great Depression. I've been tight on money but I've never been within 10,000 miles of forced hunger.

I've been to Gettysburg. On the way to fight that battle Lee's army kidnapped free blacks in the North and sent them back south into slavery. There is NOTHING to romanticize or justify. Lee's army kidnapped free blacks in northern states and sent them back to the south to be enslaved, raped, their children
stolen or sold off.

Monuments are for those we want to HONOR. My GG grandfather left a toddler and pregnant wife. I don't think he'd have wanted a damn monument. He'd probably preferred to not have his life wasted in a senseless and immoral fight.

Not all of my great great grandfather's blood rotted in a trench for rats to eat in 1863. Some of it is in my veins. And every bit of that implores me to implore us to create a different legacy, one he'd think was worth his sacrifice, one he could truly embrace, one in which his spirit can feel genuinely redeemed.

Put the statues in museums. Don't destroy them. Use them as teaching opportunities. But burn that nasty flag. To those of you who are upset at the removal of the monuments, I ask you, what do you tell your black friends about your support for honoring the defenders of slavery? What about how they feel? I'm not accusing anyone of racism and I don't mean that question as an accusation. For me, in considering my position on this issue that point was what made the difference.

I originally wrote this a month ago, when the first of the NOLA Confederate monuments came down. Now I just saw where they took down Lee's statue. I'm going outside to cheer. I'll betcha my great great grandfather, Private William M Goldsby (Golsby) First Louisiana, Heavy
Artillery, CSA, age TWENTY SEVEN, the age Adam is now, will be cheering with me. Grandpa, this is for YOU! You did not die in vain because I'm here, running my mouth on your behalf, more than 150 years after your death.

This is now a public post because folks asked. I don't usually make my posts public because I'm 62 and I don't give a crap if you agree or not. But if you disagree and cannot do so cordially, you can't imagine how much I will enjoy blocking you or how quickly it will happen. I'm fast, especially for my age.

Friday, May 5, 2017

"Medicare for all" or Public Option

Medicare for all has been a popular refrain, but there are a couple of points that need to be mentioned.

First, most other countries have a system that is a combination of "government" services plus private-pay providers, with the system knit together by some form of private insurance. I don't know the details, but the main difference between Canada and the UK, for example, is that Canadian Medicare is virtually all-encompassing (administered at the provincial level, not nationally) with no private insurance -- though I have read that some private insurance and providers do exist. Britain's NHS, on the other hand, is a universal provider for everyone, but the services (and wait times) are replicated privately, augmented by a robust private insurance alternative for those who can afford them. A series of reports at The Health Care Blog several years ago offered a first-person report by an American physician who went to Britain to see for himself. His reports were fascinating, and I was left with the impression that NHS is more comparable to our own Medicaid than Medicare -- and he specifically said many Brits never darken the door of a NHS facility. However he underscored the fact that in the case of any emergency or for some complicated cases NHS was preferable to any private providers.

That said, I decided some time ago that a public option is a better alternative -- using the exchanges already in place -- than displacing everything with Medicare for all. That would truly satisfy those cries about choices. And if you like your doctor (and insurance) and want to keep it -- and can afford to do so -- good for you.

A word about American Medicare

Most people don't realize that Original Medicare has been slowly losing beneficiaries for the last few years with the advent of the misleadingly named Medicare Advantage private alternatives. MA is basically the cleaned up version of PPO and/or HMO "health maintenance" systems -- all privately organized and knit together by a private insurance company. About a third of all Medicare eligible people are no longer beneficiaries of Medicare, having been kidnapped by the MA private sector alternative.

I am familiar with both Original Medicare and Medicare Advantage because my wife and I have been with both. When we first qualified for Medicare a MA plan was available in our area and we both decided for that -- not knowing all the details, but attracted by the bizarre fact that not only did we not need supplemental insurance, but that the "premium" for MA was ZERO!
I was mystified, but that was the case and the attraction was irresistible.

At the end of that year, that particular MA plan was discontinued for our county, and we then faced two options: either return to original Medicare (plus a supplement) or enroll in a different MA plan from a different insurance company. By then we had learned that original Medicare is a better option for someone with a complicated medical picture (read "expensive") but for someone in pretty good health, MA is less expensive.

MA vs original Medicare is the senior version of what the insurance people call "adverse selection" with MA being the senior analogue to young people who don't expect to have expensive health care, but who hit the wall should they get hit with a catastrophic medical problem (or combination of issues).

So here is the dirty little secret not widely known about PPACA: once someone has been enrolled in Medicare Advantage, the price of returning to original Medicare can be steep -- in the form of "medical underwriting" which is essentially the equivalent of having a preexisting condition. It's like life insurance. The older and/or sicker you are, the more the insurance will cost. (That "community rating" system the GOP wants to retroactively make optional for the states never left for the Medicare set. Think "preexisting conditions" writ large.)

Which brings us back to the "Medicare for all" discussion. Most people don't realize that Medicare does NOT cover 100% of medical costs. Thanks to a lifetime of payroll taxes only 80% of charges are covered. The other 20% of medical bills is the responsibility of the beneficiary. The beneficiary then faces two choices -- pay out of pocket, OR pay for supplemental insurance covering the other 20% -- and even then, there will be co-pays, deductibles and limitations that come with private insurance.

It becomes a damned if you do, damned if you don't choice. And in the end, American health care remains a rationing system -- rationed by affordability.
And anyone who wants to pay privately is welcome to do so -- hence a thriving field of cosmetic and other options, including medical tourism. But when the money runs out, and "spending down" depletes enough assets, the safety net finally becomes Medicaid.

And that is a completely different conversation...