The ACA Exchange Poster Child – Covered California: Works for some, not for others

CoveredCaCalifornia, has long had the reputation as being one of the most progressive, or liberal, states in the nation. Often in a neck and neck battle with New York over who gives more free-stuff to its people at any given time, California long ago adopted the philosophy that what is good for some should also be good for all. The concept of income redistribution though higher taxes is not a new one for California residents.  Yet this state, nicknamed “the Golden State,” and home to Hollywood, Biotech, Oil and Silicon Valley fortunes often confounds because there are also strong anti-tax forces that from time to time rise up and limits California’s spending power through measures like Proposition 13. Continue reading

Tax Code Driving ObamaCare Implementation: California’s ACA Odyssey Preview

Click to access the Original Article by John Gonzales

John M. Gonzales reporting for the California Healthcare Foundation Center for Health Reporting wrote a must read article called, How the U.S. tax code will drive Obamacare implementation, starting April 15. I strongly suggest all read it.

The negative effects of Obamacare on costs and care were immediate, and the ongoing negative effects are just starting to be disclosed and to build. Yesterday, I participated at a Health Care Summit put on by Continue reading

Yosemite now Santa Rita Jail: Green Energy here we go again

In July 2011, I wrote this short blurb about the solar project in Yosemite…

Just your average government project.

2800 Solar panels
Producing 12% of Yosemite’s electricity
Saving $50,000.00 per year
Cost $5.8 million in stimulus

And you wonder why the federal government is out of money and needs more debt! It will only take 116 years to recover the expense in savings. What is the life of a solar panel?
Could this kind of genius calculation explain the debt crisis?

What is the best, is our government, issue the EPA, are promoting this project on the local news!

And now today in the local paper is an article called, “Jail gets greener through own grid…” by Robert Jordan.
So the salient parts of this article are these…

The solar “grid” cost $11.7 million to build.  The funding came from a Department of Energy grant of $6.9 million, $2 million from the California Energy Commission, and $2.5 million in political extortion, oops I mean a grant from PG&E.

And, do you know what this phenomenal project will deliver in annual savings? At least $100,000 per year is the way they put it.  Now $11.7 million, divided by $100,000 equals — I better get out my calculator because this is obviously higher math — Oh yeah… it will take 117 years for the payback for this expense…

It is amazing how much you can spend for the good of the world when it is not your money!

Does anyone need to say any more about this foolishness?

Entitlement vs. Safety Net: It’s not a matter of degree!

Well, let me start with this disclaimer! I am not anti-social security, anti-Medicare or anti-Medicaid…  I am saying this in advance of the e-mails I know I will get from the people who will not read the article clearly and will stop thinking just as soon as they believe one of their special programs might be threatened.  I believe very strongly that we need a safety net—it’s just the current system we have is no longer a safety net.

The headline in my local paper says Brown seeking Medi-Cal cuts: Governor requests flexibility from the White House.  For those not in California, Brown is our Governor Jerry Brown and Medi-Cal is California’s implementation of Medicaid.

I am going to keep this short and sweet, if I can.  We should comment Governor Brown for taking the initiative to address the overwhelming costs of Medi-Cal (Medicaid) that is bankrupting our state.  California is in a much worse position than most of the other states because, as the Governor found out when he took office, California is in the top one or two of any state in any measure of the amount of entitlements we are providing to our population per capita. In his first budget, Gov. Brown took on this issue and began the effort of reducing these most generous programs, which may have made sense when we were one of the richest economies in the nation, to the median benefits offer of all the national state programs.  I think this is a very pragmatic, and still generous, approach considering we are now the top state in the national measure when you look at fiscal insolvency.

We need to address this issue now as the time has run out as our deficit build and we become one of the most cost ineffective places for business in a national economy that is one of the most cost ineffective locations to do business on the planet.  Kudos to Governor Brown for taking these very hard steps directly in the hard face of his own parties’ public ideology and attempting to get to a solution to this massive problem.

But overall the problem is not one of just Medi-Cal in California. It is a much larger problem, a systemic one. It is a problem that traverses all the programs including Medicare and Social Security. Beginning with the Social Security, conceived as a temporary safety net program to help the aged who had their savings and investments devastated by the one-two punch of the collapse of the stock market followed quickly by the depression as a result of the great drought induced dust bowl in the mid-west. In turn, Social Security and the myriad programs that have followed have evolved from that of a simple safety net. Originally, first seniors, and then others, could look to these safety nets as a small aid to what they could earn and save for themselves to tide them through a short difficult time that may occur beyond their real ability to plan. Now with the extension of Social Security to include Medicare and Medicaid, these programs are not viewed as a safety measure but as a replacement.

If we look to Medicare as an example, it can be argued that it is a vital insurance program to support the healthcare needs of our aging population and our disabled. And for some this is clearly the case. But it can also be argued that for many, even though the checks are being written to providers covering their health care needs in later years, if this is really supposed to be a safety net, the government is not paying for their health care; it is paying for the purchase of that flat panel TV when I was forty-five, or the vacations I took, or the new car I purchased every four years, or some other expense I would not have made if I had not had the expectation of the government picking up the tab for my potential catastrophic healthcare needs in my last five years of life.

I know the former discussion is not a pleasant one to have as it brings us back to the point that our actions today have ramifications for tomorrow. In the generation prior to mine, they had the belief that they needed to save much of their excess money for a rainy day. We have come to believe that the rain is now offset by our wonderful and blatantly generous Uncle Sam. So, we are empowered by the change from the safety net to that of an entitlement, to believe we are OK to purchase that vacation home, instead of saving the money because when, not if, we get sick, Medicare will take care of it. I remember my father preaching to me siblings and I in the 1960s that we should never count on these programs because a.) It was our responsibility to plan and pay for ourselves and family—not our neighbors responsibility, and b.) The government will probably not have the money when we need it as this system just won’t work.

Well thanks for the advice Dad, I took it to heart and have followed your example. But, despite my savings we, the citizens of the U.S. and of California are at the point you so correctly predicted and poor California’s Governor Jerry Brown now has to be the first state leader to start to take away all the things we have been trained to be dependent on. You see much of these expenses are no longer about emergencies and simply providing for a base existence, they are now becoming more about quality of life. It is not enough to provide basic services for the poor; we need to also give them cell phones.

I don’t want to see people suffer, and I don’t want to deprive people of some form of basic existence. But with the coffers bleeding cash at a pace that is now in excess of what we can produce on an annual basis we need to start to make distinctions between, emergency necessary for life services and those services that provide more for the quality of life! I commend Governor Brown, for taking these steps. I know they are not easy for him because of his strong humanitarian heart. I am glad he was not just imbued by our creator with that humanitarian heart but also received the gift of a great mind that recognizes we need to find pragmatic adjustment and exceptional courage to take the unpopular steps to find a solution. With this accolade also comes caution. We need to remember that even Governor Brown is human, and is in a system that will require him to make some decisions that he and the rest of us will not like, simply to get part of this done. We can expect all the purists to take shots at every single deficiency and change from all sides with no recognition as to the realty of a public and political governmental process.

Regardless, I will say I appreciate what he is trying to do, and will attempt, even when he make decisions, like High Speed Rail, that I fundamentally disagree with, that he is doing this based on his befief that it will contribute overall to the solution of this complicated equation for the viability of California and its citizens.

$25 billion in foreclosure relief: Will Americans really benefit?

(this article originally  ran in California Political Review it is re-posted here with permission.)

Median Housing Price compared to CinC 1960 to 2009

While the news today is full of various articles touting the $25 billion government settlement between the nation’s biggest banks and homeowners there is one big question for the nation’s citizens, and in my local case Californians—will this really be a benefit? While I am looking at this from a California perspective, this really is the same for the country as a whole.

In examining this question, there are at least three things to consider:

  1. Will the initial settlement amount become a meaningful amount for homeowners and truly affect their current financial situation?
  2. What are the long term implications of this settlement for mortgage holders?
  3. Will this settlement resolve the underlying problem in housing prices and declining values?

Before I get into this topic, first let us commend California’s Attorney General, Camilla Harris, for her efforts at getting a better deal for Californians.

Meaningful Amount

Question number 1 is perhaps the most current.  Clearly, this is the question on anyone’s mind who owns a home in California.  Will the $25 billion really have a material effect on my mortgage problems?  California has the most homes underwater of any state, according to Santa Ana-based data firm CoreLogic.  There were as of September 2011, more than two-million homeowners that owe more on their homes than they are worth.  By percentage, California ranks fifth with 30.2% of all homes upside down in value.  Compare this with the national average of 22.5% and you will see there is a big problem here.

If you take the national total of 10.9 million home owners spread across the $25 billion, and you apply a “historical fairness” standard where everyone gets treated equally, you get an average payment to each homeowner of $2,293.58—not very meaningful is it? Now, some believe that the “rich” do not need, or deserve, the extra money, so using a “revised fairness” standard, and the fact that some significant number of people will not apply for the funds, the settlement group estimates that the average amount granted to those participating will be more like $20,000.00.  This number sounds better but, there is a big but attached. The combined negative equity of all US homes is over $700 billion meaning that the average homeowner is underwater by at least $50,000.00.  And higher priced homes, like those owned by the rich, often are underwater by a significantly higher percentage.  Adding in the fees and other charges that will get levied by the banks for the processing of these claims and the effective gain drops even more.  So on a national basis, some could take the cynical view that this is not a meaningful amount—but, what about for Californians?

California, by the CoreLogic study has about 2.06 million homes underwater.  The state is targeted to get about $430 million. Using the same comparison above, the “historical fairness” allocation would be $208.74 cents per homeowner and the “revised fairness,” amount, where the rich don’t get any help, will equate to about $3,779.82.  Since California’s market has been hit harder than many other states and its average home price is much higher, the proportional amount negative equity is also likely higher.  So, one could argue that Californians may not only feel the amount is meaningless, they may also feel it is not fair overall!

Long Term Implications

Like most things revolving around government driven programs and settlements, we need to think about the long term consequences.  Where does the money come from that makes up the settlement?  Well it comes from the banks—right?  As the last stop before it gets paid into the settlement that is correct.  But, while this may be the end of the story, as usual, it is not the whole story.  The money comes from us via two primary routes; one visible and understandable and the other confusing and relatively insidious.  First, it comes from the bank’s profits, if any.  And of course their profits, if they have them, come from the fees they charge us, and if the bank’s costs go up they charge more fees to us and we pay them.  So in this route the money comes from us.  The second main route, the more insidious one, is from loans made to the bank by the Federal Reserve to help the banks maintain liquidity or inject more cash into circulation, sometimes called “quantitative easing.” In this case, the money is created out of thin air by the Federal Reserve increasing the total amount of money in circulation—with no increase in value of the underlying assets—passed down to the banks to pay out to us to reset our loans and it reduces the real value of our money.  The result is; goods increase in price, the money we earn goes less far, and we in effect are even poorer.

The cynics among us, who have concluded long ago that there is no free lunch, realize that no matter what the money we get is really coming from us. They may argue that the long term implications from this program are not very good.  The reality is, there really is no free lunch and we can expect that this particular settlement will not work out well for any of us in the long run.  Since many of the people who have the worst upside down mortgages would appear to many other to have been rich, it is not clear that this program would even be a model for the execution of “income redistribution” that some proffer as a solution to all of our ills.

The Underlying Problem

If you look at the graph at the top of this article you will see that the route of our underlying problem goes much deeper than it first appears.  While some argue the cause is the profiteering of the rich and corporations, and others charge it is the irresponsibility of people borrowing to buy houses they could not afford, the real root of the issue is the underlying basis of our economy.  Prior to 1972, the total amount of currency in circulation, referred to as the CinC, was about $500 billion dollars.  The amount of actual currency was restricted by a mandate that each dollar had to be backed up by a set amount of gold.  By 1972, this had become a huge problem as we could not increase the amount of currency and the government, therefore we,  did not have enough cash to pay for all the expenses the country was racking up like War, Social Security, Medicare, Medicaid and myriad other subsidy programs.  Also we were accumulating an increasingly large trade deficit.

But in 1972, then President Nixon, removed the country from this check and balance. By today we have increased the amount of money in circulation to about $16 trillion.  This is a thirty-five times increase in the total amount of the money supply.  No one will argue that the total value of the US assets has also increased thirty-five times—hence the problem.  If you look at the chart, you will see that the median home price in 1972 was about $24,224.  At the peak of the housing bubble in 2005-2006 the median price had risen almost point for point with the increase in the money supply to $298,500.  If you now look at what the median home price would have been if we had not done this, the median price projects to be more like $115,734. The point is that if it is true that the amount of money in circulation is not representative of the real value of American assets, then our total economy, is overvalued.  Even with the tech gains from our NASA investment in the 1960’s and 1970s, the economy would project to be about a $5 to 6 trillion economy not $16 trillion.  Housing, under this calculation, would have to decline another 46% in order for all to match up.

Even if these calculations are off and the relative value of our assets has increased at a rate higher than the pre 1972 rate, there is likely still a large correction coming to our economy in general and housing in particular.  California will be the eye of this perfect storm.  I submit that this mortgage fix neither addresses the underlying problem nor ameliorates Californian’s personal and current dilemmas.  I think it may really do the exact opposite and compound our problems with false hopes, false senses of security and increasing debt based on inflated values that are doomed to correct.

Regardless, this is an unbalanced fix in that it is trying to fix the debt side for a few and ignoring the unbalanced asset value side for everyone else.  Even if pumping more arbitrarily printed money into the economy buoys the market in the short term, the continued unrealistically inflated values will again decline and once again we will be faced with the same problem. This will promulgate more borrowing against what likely will continue to be declining values in an overvalued economy—potentially spelling disaster. The only fix that will work is to address both sides of the problem across the board resetting both the Debt and Equity Value side at the same time.  Perhaps it is time for either the Federal Government, or California, to consider a “Land Bank” system of mortgage financing.  We need to address the balance sheet of the bank and homeowners at the same time we address the asset value side of the equation. Only then can we truly, fairly, and equitably address the fundamental problem.

So in the end is this deal a good deal for Americans?  For Californians? And the more important question we all need to start asking is this!

Regardless of the impact to me personally, is this the right thing for America?

I keep wondering why this is so hard!

California AB171 & AB254: And we wonder why healthcare costs in CA continue to increase?

One of the largest drains on every states budget is healthcare cost.  California has historically been in the top of state healthcare expenditures due largely to its past of providing one of the most generous sets of program benefits in the country.  Both Governor Brown and Secretary Dooley deserve a tremendous amount of credit for acknowledging the mounting problem of healthcare costs and taking steps to begin the process of addressing it.

Healthcare costs in the U.S. are estimated to top $3 trillion this year.  That is a significant increase from the estimated $2.4 trillion in 2009.  The Affordable Care Act (ACA), aka Obamacare, is supposed to be lowering the costs and improving efficiencies for healthcare.  While it can be argued, and it has vociferously, that it is early in the process and the projected savings will begin in the next four to five years, there are some significant indicators from the administration in Washington DC that more and more of the promised savings will not happen.  This will spell further disaster for states like California that already shoulder a disproportionate share of the healthcare burden of our population.

Before we can discuss AB154 and AB171, let’s review some broader recent decisions and data that have a direct impact on California’s projected healthcare costs.

Part of the plan to afford the care under the Affordable Care Act was to appropriate revenue from the purchase of healthcare and penalties for non-purchase of policies.  The governing method to assess the fees and assure collection was the IRS.  Within months of its passage the government had to admit that the idea of the IRS administering this program’s revenue would not work and that segment of the legislation was repealed.  This now begs the question how will this revenue be assured?

As we are all painfully aware, there is some disagreement over whether or not the Affordable Care Act’s mandate to purchase insurance is constitutional.  Scholars, pundits, and constitutional lawyers on both sides are already at polar opposites over the issue with each side quoting chapter and verse as to why, or why not, it will be upheld or declared unconstitutional. The reason for the gulf in the interpretation of the underlying law is its base on a prime case called Wickard v. Filburn from 1942 that started the justification for the federal government’s expansion into what had prior been clearly state jurisdiction.  Any non-lawyer’s reading of the case simply defies common sense—this will be a very sticky wicket indeed. If the Supreme Court declares the mandate unconstitutional then much of the insurance reform inherent in the bill falls apart. Another large segment of projected saving will revert to increased expenses ultimately burdening the state both directly and indirectly.

The U.S. Secretary of Health and Human Services, Kathleen Sebelius, has recently ruled that the CLASS Act—a segment of the bill that was designed to expand options for people who become functionally disabled and required long-term services and support—is not affordable by the definition under the act and therefore it has been suspended.  Where will these costs fall if the federal government stimulates the expectation but fails to provide the funding?

A major part of the projected savings was though the requirements of Accountable Care Organizations (ACO’s).  In the bill they were projected to provide a savings of approximately $333 million per year, or just about $1 billion over three years. The CBO recently announced the results of a 20 year study focused on disease management and value based payment methods that fundamentally negate most, if not all, of the assumption on which these projected savings were based. In fact the study indicates they will potentially increase costs.

Another main point of the Affordable Care Act was to eliminate treatment disparity.  Who wants to argue for disparity? No one!  But even CA Secretary of Health and Human Services, Dianna Dooley, has said publically that “…we all need to get used to the idea that disparities will exist.”  I commend her for this statement because it is unequivocally true.  There is a basic law of diminishing returns that says that you will spend 80% of your money trying to arrest 20% of the problems.

Another key segment area of the ACA savings plan is Insurance Rebates. The act maintains that it has teeth to control the insurance industry profits because of its ability to mandate rebates for fees in excess of the medical loss ratio that the U.S. Secretary of HHS sets.  In the first place, the rebate amount is a mere trifle compared to the $3 trillion national expense.  More importantly, rebates have been mandated by the federal and state governments of Pharma for years.  Rebates do not lower costs at all.  Rebates in this bad play are methods to redirect money from the general consumers of the products, prescription drugs in this case, to other areas that the federal government, or the state, wants to spend them.  They do nothing but increase the cost in an arbitrary and specious way and obscure the real cost of care in America.  If monies flow in payments to the drug companies, and then flow back to the states, and the states, like California, can redirect these monies back to the programs or the general fund to fund more patients, it amounts to nothing more and a consumption tax.  A look at the California budget shows that about ½ of the drug spend for some programs comes through mandated rebates.  Sure this is a good thing for the participants in the programs, if like California the moneys flow back to services—not all states do this, some pay for other infrastructures—but it is not good for understanding the real impact of these programs economically as the myriad of convoluted funds flow become impossible to track or account effectively.  Frankly, the $3 trillion in health costs for the U.S. is not likely even close to $3 trillion because it is an unintelligible mix of both invoice pricing and actual reimbursement payments.  And for those who do not know, a healthcare provider typically is getting reimbursed from eleven cents on the dollar to twenty-two cents on the dollar for services they bill—and they seldom can predict the amount.

Yet another key segment of savings under ACA was the premise that hospital readmissions will reduce.  The plan is to select a series of specific disease states and for the government to begin to select measures that will allow for adjustment, read penalties, to hospitals that have higher than the selected measures for readmission.  Houston, we have a problem.  One of the biggest drivers of healthcare cost is age related illnesses.  Since 1964, when we created Medicare and Medicaid, the lifespan has increased from about 70 years old to almost 83 years old today.  The effect of this increased lifespan has been to significantly increase the cost of care in one’s life and shift the cost curve of lifetime health expenses to our last few years of existence. A recent Kaiser study now indicates that almost 85% of our lifetime expense for healthcare will be made in the last 5 years of life—and the trend is still increasing.  We are aging, our culture of how we manage our elderly relatives has shifted from family responsibility to outsourced solutions (nursing homes), and we now are more focused on quality of life than just life as the basis for our expectation of care.

Let’s stay on the topic of re-admissions for another moment because this is a big one.  One of the assumptions that drive the belief that we can reap savings by setting measures and penalties is that and assumption is that the reason for the readmission is that hospitals get more money for readmissions. As a result, they are not doing much, or enough, to improve the outcomes in the first place.  But this is a false assumption for many reasons.  To illustrate the issue, let’s discuss Hospital Acquired Infections.  The premise is that Hospitals are sloppy or slipping when it comes to hygiene and if they simply do a better job following antiseptic protocols to reduce infection, then these unnecessary costs will go down.  The people drawing this conclusion do so from the basis that healthcare is more of a cause and effect system, a static system, where we have fixed cures for most of what affects us.  This is one of the main cores of why we keep thinking we can make progress if we just keep doing X process more and better…. But the problem is, the practice of healthcare, after all, actually is largely a war with other species (bacteria, viruses, and other complex pathogens), a war with our environment, (accidents, violence, and pollution) and also a war with ourselves (diet, exercise, work habits, and sleep). From time to time, we can see gains for ourselves in these battles, but our mortality assures us that we will all eventually lose the war. Basic biology and the laws of nature have stacked the deck against us. Innovations in technology, science, and medication have helped many of us delay the day of our ultimate surrender, but these advances have also fostered the false belief that no price is too high to pay for an extra day or week of life. Related to infections, we are losing this war as our chemical and biological weapons have continued to become less and less effective. The protagonists, other species, have evolved resistance to our weapons and the remaining available chemistries’ at our disposal have become more toxic to us who take them. Hospital readmissions will likely continue to increase.

Lastly, ACA relies heavily on projected savings from the mandate of conversion to Electronic Health Records (EHR’s).  While EHRs are a good thing and will very likely improve patient outcomes, any projected savings, should they even materialize, will be negligible.  How can I predict this so definitively?  If you look at where the healthcare dollar is spent only about 12 cents is spent in administrative costs today as it is.  The percentage that may be gained in efficiency from conversion to electronic records will likely be 10% to 20% of that number which would yield about 1.2 cents, to 2.4 cents, for every healthcare dollar.  The current plan for EHRs does nothing to change the current HIPPA regulations and as such the sharing or coordination of care though the transportability of these records between providers and sponsors is very expensive and practically prohibitive.  The application of technology has always been made with the promise of increased productivity and lower costs but an honest assessment of the past 40 years shows that overall lower cost and significant gains in productivity are the exception not the rule.

The largest cost drivers, where EHRs could have a major influence, are in the areas of duplicated services, defensive medicine, fraud, and abuse.  By many estimates, on both sides of the political spectrum, only about 33 cents of the governmental healthcare dollar is realized in services—about 60 cents is lost in these areas.  There is little debate on this total number across the aisles.  There is large debate as to whether the costs are larger in the fraud and abuse area or in the duplicated services/defensive medicine areas.  This debate is moot as EHRs could have the potential to drastically reduce these aggregate costs if, and only if, they are coupled with mandated coordination of care and benefits across all available sources.  By the way, I don’t mean single payer.   Single payer is a great sound bite but the term likely does not really describe what people are seeking.  Do we really want all care to come from a governmental source—eliminating choice, volunteer treatment, faith based programs, non-profits, philanthropic sources, corporate sources, etc.?  When I have had this discussion with various legislators, both state and federal, the answer invariably has become; well no, of course not!  What most really seem to want, and what is necessary to make this all work, is a central point of administration with the ability to connect the providers around the patient as the center point in a kind of virtual care team.  This is relatively inexpensive, does not initially even require full HER implementation to achieve significant savings, and provides a great role for state government to play.

With this as a backdrop, we come to the last big issue facing why healthcare is continuously increasing in cost and the issues with AB154 and AB171 drastically put at risk California’s healthcare future.  AB154 is legislation recently approved by the Assembly that will require private insurers to cover diagnosis and treatment of mental illnesses (it appears all mental illnesses on the books).  AB171 requires coverage of developmental diseases such as autism.  The Assembly also approved legislation to cover oral chemotherapy and mammography regardless of age.  While I applaud the sentiment, these kinds of actions that constantly increase the overall coverage of anything, and everything, which can ever affect anyone as they perpetuate their long risky walk through life to older and older age, in conjunction with the items previously discussed, are setting California up for a perfect storm.  As the ACA projections continue to fall apart and as the federal cost for healthcare programs like Medicare and Medicaid continue to increase, states like California will be left in the crosshairs of larger expectations for treatment and less, perhaps no, federal money to pay for it. Already the president refers to Medicaid as a state program.  I guess he forgets that both Medicare and Medicaid are just parts of the federal Social Security Act of 1964.  Of course, the states consider this a federal program and due to the increasing drain on state budgets some are trying to figure out how they can again opt out of this federal program.

Our largest issues come down to the following things.  We no longer truly insure health care to preserve basic life.  More and more we are requiring insurance to cover “quality of life.”  We have extended though technological gains the amount of time we can spend on the planet to the point that we are now on average way beyond the period where our bodily systems effectively fight the healthcare war.  As we have gained the additional ten more years of life from the past forty years of technical and medical accomplishments, we have moved into a new reality that to preserve our quality of life during this extended period we are consuming consuming more and more of our resources.  Unfortunately, much of what programs like Medicare and Medicaid are now paying for are not the actual costs of care.  They are paying for the things we purchased during the former years to improve our quality of life way beyond the realm of healthcare.  These programs are really funding the earlier purchases of larger screen flat panel televisions, vacations, 2nd homes, new cars.  They fund the things that, prior to 1964, we typically did not purchase because we knew we needed the money for our elderly rainy day funds.  We were worried that we would need to pay for the catastrophic accidents and illnesses that fate dictated we would face as we aged. Today we are all free to make these lifestyle purchases because the threat of elder catastrophe is now covered by entitlement.

This is not an argument to go back to the way it was, not an argument to eliminate these programs, not an argument that we should die earlier.  I know of no one that wants to see people die younger, suffer more, or live in destitution.  The point of this article is to bring to the front the dilemma.  It is here we need to develop a better dialog and, as Ben Franklin said, “find compromise, through tolerance.”  It is here we also need to start to focus our hard decisions on where personal responsibility ends and our safety net begin.  Until we do this, California faces the coming perfect storm and like all other state will likely face it alone without federal help.  The decisions we make on items like AB154 & AB171 while laudable are significantly increasing expectations and hence our risk of future economic collapse.  Remember it was Albert Einstein who said, “Insanity is doing the same thing over and over again and expecting different results.”  Wait, is this why AB154 is being passed?

I commend the Governor and the Secretary for their effort to begin to address this dialog.  While there are many who want to lay blame for everything at their feet, I find in both inappropriate and counterproductive.  Both have had long records of public service.  Both began, perhaps, more on the side of idealism but they have each arrived at pragmatism based on hard one experience and dedication to effective solutions.  I can’t think of any I would rather have trying to help California move these issues forward.  That said it is time we all begin to recognize the depth and diversity of the problems, reset our expectations and all become responsible for the solutions!

State and Federal Budget Crisis Solved: Professional Political Class Finally Provide Value

OPresient Obama leaving Air Force One upon arrival in San Francisco on fundraising tour

"A picture is worth a thousand words." -Fred R. Barnard: Its about the money.

Please bear with me on this article.  in contrast to the best advice for writing, I have not put the conclusion at the start.  I am assuming you are all thinking Americans, and you are willing to make a short journey with me to find your own answers at the end!

Unequivocally, we have developed a professional political class.  We, the people, have created this new ruling class of professional legislators – or at least allowed them to evolve – over the past 72 years.  Like most of our entanglements in modern history, this consequence  was driven by little more than a series of short term decisions that were made to accomplish short term goals with no thought to the long term impacts of these actions.

Why not a national sales tax on all political sales(contributions)?

Up until the early 1900s, politicians were citizens first.  They were regular people, living and working alongside their neighbors.  They had local jobs, farms, or businesses and each and every piece of legislation they passed affected the citizen politician exactly the same way it did their neighbors.  Since the wages and expenses that they derived from their service in state or federal government was both part time and not meant to provide a living wage; their motivations were to be productive members of their localities, emphasis on production in whatever capacity, as it was the best path to wealth and prosperity.

Since these citizen politicians, could not make their livings relying on the payment from government, the various legislatures were part-time with the sessions restricted to just a few months each year. While in session, citizen politicians also made sure they got as much done as possible, and their supporting staffs and expenses were kept well in check because often the governmental stipends did not adequately support them, so the citizen politicians often came out of their own pockets for at least some of their staff. A great way to assure dedicated representation.

As we move through the early 1900s we see a gradual and steady increase in the salaries, perks, and reimbursable expenses that our legislatures received.  Like all of our historical short sited decisions, there was strong rationalization to such increases.  Some of the citizen politicians, living with the constant drain on their personal funds, were susceptible to graft and corruption by the men hanging out in the lobby of the Willard Hotel in Washington, DC (origin of the term lobbyist) – where most stayed during the legislative sessions. Of course, it was argued by the legislators that if they received better wages, more liberal expense budgets, and perquisites in office, they would be less susceptible to corruption.

Commerce (n)

(Business / Commerce) the activity embracing all forms of the purchase and sale of goods and services

[from Latin commercium trade, from commercārī, from mercārī to trade, from merx merchandise]

Collins English Dictionary – Complete and Unabridged

The next step, taken in the middle of the 1900s, was to extend the legislature.  Again, it was rationalized that the part-time legislatures, were critical to the growth and prosperity of the country, or the states, and there was so much work to be done that they needed to increase their time in session.  These arguments, like all of the rationalizations before them, were seen as reasonable and necessary.  As a result, buy the end of the century, we have, with few exception, full-time state and federal legislatures, and most importantly, a full-time, professional political class.  Their livelihoods significantly disconnected from the legislation passed and its effects on their local communities.

While in the past, our citizen politicians life and liberty was supported by their own personal productivity in their local communities as farmers, shop owners, business owners, manufacturers, and professionals like doctors and lawyers; for the most part today’s professional political class trades in votes and legislation for the specific benefit of those who can get them re-elected.

It is an easy statement to say that there is a direct relationship from big corporate money and the payments the professional political class receive, through various means both legitimate and illegitimate.  While corporate interests play a part, the aggregation of small money interests plays at least as significant a role through unions, political action committees, professional organizations, and the strength of the various parties, among others.  Regardless of the source, the money alone is not the focus of the trade – in the end it is about the votes!

Votes themselves are the stock and trade of professional politicians.  All the money paid into the various campaigns is exchanged for this tangible, valuable item – the vote.  Since we no longer have citizen politicians and most of our state and federal legislatures are the full time employers of this new professional political class – who employ by far much more than half of all the people in America, why don’t we recognize this for what it is?  This is nothing more than a commercial enterprise! No different than Google, Linkedin, Facebook, the AARP, or many other national organizations.  It can be argued that the parties themselves as simply franchisors.

“Obama visit nets millions: Next stop – LinkedIn for town hall meeting”
– Contra Costa Times, 9/26/2011

President Obama, arguably the top franchisee of the Democratic party, was in the San Francisco Bay area this weekend selling his wares.  He collected, somewhere between, $3.5 and $5.5 million in back to back fundraisers.  Think about all the money that is being paid for these goods and services sold by our professional political class.  It begins to boggle the mind; does it not?

When we had part-time citizen politicians it was appropriate to call these campaign contributions.  But I think today we can all agree that calling them political sales is more accurate in this day and age.

Perhaps we should have a national sales tax!  But it may not be necessary to assess this tax on all segments of commerce in our economy.  We only need to assess a “National Political Sales Tax” (NPST) on the one segment of the economy that is clearly generating most of the “commerce” in the nation.  We should implement a national sales tax on these political sales.

In the long run we may get some real benefit.  We could see a significant reduction in our state’s and national debts in the short run as the massive amounts of money flow into the various coffers. We may also begin to see the reduction is the constant din of political advertizing, direct marketing and evening phone call solicitations.  If for some reason this benefit does not rise, or rise fast enough, then we could extend the NPST to cover all political purchases as well.  At a 10% tax rate, the purchase of one of those $19.00 muffins would yield $1.90 in revenue to the federal and/or state coffers.  How many muffins do these guys consume in a year?  Looking at Jerrold Nadler, Barney Frank, Chris Christie, Haley Barbour, and many, many others this alone could wipe out lots of debt!

Of course many are just not going to like this idea! No one wants to see their livelihood threatened by taxes.  I would suggest that if they object to the tax then we should demand a return to the citizen politician, and the part time legislatures of the past.  In the long run I think it could be one of the most beneficial changes we could make for our country.

Hey, I’m just asking!

Of Volks-latures:Our future – Sold – to us, by us.

Volks-lature vs Maybach-lature

These early citizen statesmen, tended to relate the effects of everything they did to the impact on themselves, their family and the community.

The collective display that was put on last night by our elected officials shows that we have allowed political privilege to supersede the role of elected legislator. Historically, our elected officials were for the most part volunteers. Up until the mid-1930’s congress operate largely on an alternating 3 month then 6 month period in order to allow the legislators to go back home and tend to their farms, and businesses. As such, they stayed quite engaged in community and reality.

These early citizen statesmen, tended to relate the effects of everything they did to the impact on themselves, their family and the community. Their ideals appeared larger and more discrete. Likely to our mind they also had more character and commitment since they served, often and significant cost, not benefit, to family and business. Of course there was corruption, but that form of corruption was more visible, as the delta between those partaking in graft, stood out like beacons from those who did not.

A citizen statesman returning home to a significant increase in prosperity as a result of his short time in Washington tended to send tongues ‘a-waggin’ if you know what I mean. Today our professional class politician is tacitly expected to find his fortune in the words and ideals he may sell to the most or the richest. Like comparing a Maybach to a Volkswagen Beetle, we have politicians who are the ‘Volks-Vagon’ the people’s car; and those who are the Maybach Laundolet the car where “the customers’ wishes come first.”

In the case of the ‘Volks-lature’, they focus their message and sales pitch more towards the masses. They chose the low-cost high volume strategy and offer to convey as many as possible to the nirvana they seek. On the other hand, we have the ‘Maybach-lature’ who have selected to sell to a very few with much higher margins. Unlike the Volks-lature who feed in the troughs with the rest of the masses, the Maybach-lature have chosen to feed in the food chain of the rarefied air, at the table with the best linen and the finest wine. And in realty they are no different, just existing in a different part of the econ-system.

In the end it is we who are providing their existence and much of the things they do are in fact self-fulfilling activities, calculated to continue their reign and enhance their equity.

You see, for the most part, they both exist to do one thing. Sell us our dreams in return for their livelihood and existence. Sure, some still have ideals and the drive to make a difference, but it is more the sirens song of wealth and power that has captured most of their hearts minds and more importantly – practice. Even the most ideological fall rapidly under the spell of the professional political class in Washington, who control their moments, provide their thoughts and calculate their longevity with a keenness that would have made Mr. Gillette very proud.  The tools of each, are one as with the other, as their weapons are all class focused. For one it is envy – for the other – fear.  In either case, it is the other classes that are the fault, and only theirs can save those that matter!

Overall, it ends up the same for us all regardless of whether we eat at the trough or at the fine table. In the end, it is we who are providing their existence and much of the things they do are in fact self-fulfilling activities, calculated to continue their reign and enhance their equity. It is we who pay for it and it is we who are now suffering for it.

This is one reason I have declared: I am a Mugwump. Further frustrating is the fact that the overall debate continues to be focused on who should get what from whom as opposed to what we need to do for ourselves and our neighbors. There are those that argue anyone that has more should be forced to give it up to all of those that have less. Then there are those who also argue that there are some who need a safety net and that we should provide systems and some government intervention for those who can’t – not those that won’t. See Was Shakespeare Correct.

Looking sharply at the debate you see similar ideals in the grand area but in the graphite at the point of the pencil the line is obscure – not so fine. The real debate is in the definition of who should get the benefits of government intervention and at what point personal responsibility ends and public responsibility begins. Further debate centers on the dividing point between personal philanthropic charity and government mandate over personal property redistribution.

In the end, the biggest problem is that we have allowed our political system to degenerate to the point where the body politic, once a largely part-time and voluntary collection of average citizens – making laws and regulations for themselves as well as their neighbors – and in whom little direct benefit of the laws they passed held influence, has been replaced by a full-time professional class legislature with little influence from the laws they pass and maximum influence, in fact their livelihood, comes from the direct (in the form of compensation), and indirect (in the form of votes and campaign contributions).  It is this that is their lifeblood driving the legislation they make – specific to any and all vested interest.

So whether you are a conscript of the Volks-lature or an acolyte of the Maybach-lature, we have all ended here at the same point. We have been sold a significant bill of goods by those we trusted to protect us and it will, regardless of what they do or don’t do in the next few days, be on our shoulders to again pay the bills. All of our shoulders! Because never in the history of mankind has a political system been able to provide a way for everyone to get everything – with no one doing nothing.

It is a damnable shame!

A Zero Sum Game: When will you actually get it?

We have all become inundated with a daily dose of how unfair the world is to all of us. Thanks to the media in general, and the partisan public relations engines of both parties, it seems we have nothing to worry about regarding our future, other than getting what we want by taking what others have. Or for a select few – and you know who you are – having others take what we have worked so hard to earn.

Oh yeah, some of you didn’t really earn it did you? You got it from your parents, didn’t you? And of course your parents didn’t really earn it either, they took it from the masses. They had the audacity many years, or generations ago, to start a business and be successful. And of course they were successful because people, mostly middle-class people no doubt – the robber barons always sell their insidious goods to the middle class don’t they?

Yes they made their widgets and sold them to the people. And at first it all went well and everyone was happy. The businessmen (robber-barons) made the things we want in the U.S. and we paid them for them and then IT happened…

We found out just how much money you were making, even though each of us only paid a small amount – and at the time that small amount seemed ok. But you committed a heinous crime. You got successful. Not just successful – too successful. You made too much money and you moved up town… How could you?

Then as we complained to our congress people about how you were simply robbing us all, they stepped in and enacted, rules, and laws and taxes to make it fair. So we could get some of our money back in our pockets by redistribution.

And then you made it worse! As your profits went down you didn’t hire as much, in fact you laid off some of us. And then when we bought less because some were out of work you raised prices. Then we could not afford to buy your products as often and your sales dropped and you laid off some of us people.

The Chinese saw your success and your rising costs and they started to build the same product you did. We bought theirs because it was cheaper, and also to teach you a lesson. Soon, you on your own decided if you didn’t find cheaper workers you would be out of business. So you moved your factory to Mexico, or Singapore or China. How could you?

So, we asked our congress-people to fix this again, and they slapped on import duties. Yea, that will show them – and you… But, you both just raised the retail price and we ended up paying more for the same thing. Yea, our wages were not going up as fast as the prices but we had some tricks up our sleeves yet.

Since you and the other businessmen (robber barons) were now hiring cheaper and cheaper workers, we formed unions and made you pay us more and give us more stuff just to work for you. If you didn’t unionize, we got congress to increase the minimum wage and legislate some of the great free things you need to give us just cause we work for you – again we showed you. Now again, you had to pay us what we wanted if you hired any of us. Sure, you could no longer sell much of your product to the rest of the world cause it was too expensive and the quality was no longer any good because we don’t really have to meet any standards for you to pay us, but you were sharing your prosperity with us weren’t you? It’s only fair!

Of course, you again raised your prices to cover these new costs and you complained that you were no longer competitive and foreign products were taking the market and your company could not export anything either because of price and quality. Look, when we saw that what you said was true we stood up to help didn’t we? We are not uncaring after all! We came to your rescue and we asked congress to give you some tax breaks and subsidize our purchase of your products.

I know what you’re going to say! Sure, all of our taxes went up to pay for the cost of the programs to give the tax breaks and subsidies – but look even you understand the money has to come from somewhere. And rightly so, most of it came our of your share. That’s why you raised your prices again isn’t it? When will you learn, Mr. Robber Baron, that you can’t fool us! Yea, you say you’re not making any money, but we don’t believe you! You live uptown. You made a lot of money. We see your cars, your yachts, your corporate jets… So what if we are only paying a few cents profit for your product when we buy it, you sell a lot of it to us don’t you. Look you owe us! Without us you would not exist. What do you take us for, common workers? We don’t do common labor – don’t you get it! We are Americans, not some third-worlders. We don’t work cheap buddy. It’s about time you figured that out. And don’t try to hire those illegal immigrants either. We won’t let you exploit them like you used to exploit us!

So you better get a clue. It is not important if you can produce a product cheap enough so we can afford to buy it. We don’t need your product. We can buy the one from India, or Sulawesi. America is the import master of the world don’t you see? Why do you think we have such a huge trade deficit – we have bought over $11 trillion more in goods than we sold since 1972 – only American’s can do something like that bub!

You know we don’t need your kind in America – I mean you manufacturers, and oil producers, and steel companies, and commercial fishers, and lumber companies, farmers, and miners, and others like you. You are not nice to the environment, you harm animals, you exploit workers, you make noise, and you don’t create the kind of jobs we deserve. We went to college you know. We deserve high paying non-labor jobs anyway. We buy all that stuff from other countries anyway. Let their people not go to college and do that hard messy and dangerous work.

You know, it doesn’t matter anyway. When we want more, we will just increase regulations, increase taxes – on you, and get our legislators to increase what the government owes us, and what you have to pay for, or give to us – that is if If we debase ourselves enough to actually work for you. Yea sure, you can try to increase the prices but you know what we will do about that – now don’t you?

Was Shakespeare correct: is the fault within ourselves?

Cassius:
“Why, man, he doth bestride the narrow world.  Like a Colossus; and we petty men walk under his huge legs, and peep about to find ourselves dishonorable graves.  Men at some time are masters of their fates:  The fault, dear Brutus, is not in our stars, but in ourselves.”

Julius Caesar (I, ii, 140-141)

Historically, the interpretation of this dialog has been, Cassius, a nobleman, is speaking with his friend, Brutus, and trying to persuade him that, in the best interests of the public, Julius Caesar must be stopped from becoming monarch of Rome. Brutus is aware of Caesar’s intentions,  and is torn between his love of his friend Caesar and his duty to the republic.  Cassius continues by reminding Brutus that Caesar is just a man, not a god, and that they are equal men to Caesar. They were all born equally free, and so why would they suddenly have to bow to another man? On another level this phrase has been interpreted to mean that fate is not what drives men to their decisions and actions, but rather the human condition.

In this case, Cassius was arguing that the problems of Rome’s people were a result of the human condition.  And that if the avarice of Caesar, and his cohort, could be eliminated then the condition would itself improve.   This historical diatribe is truly the argument of the ages.  If frames the argument of many, if not all, of the issues of our time.

Whose responsibility is _________?
(fill in the blank with almost any word or phrase)

Is our health care – our responsibility or that of the collective society?  Is our survival in terms of food, housing, clothing, creature comforts of heat and air conditioning that of ourselves, or the responsibility of those that have more than we?  On whose shoulders does the success of our society reside – to each according to their need from each according to their ability/initiative – or – to each according to our ability/initiative and from each to those in need according to our humanity and generosity?

Looking across our political landscape, today, we clearly are a nation divided by our ideologies and views of how the world should work.  We seldom exercise compromise either, outside our ideological castle (see my article On Tolerance) or, it seems, even within it (see my recent article, Consider a Mugwump).  For quite a while, I have felt we were a nation of thirds:  one-third hard left, one-third hard right, and a third in the middle, the middle drifting either way based on the issues and ideologies at hand.  But is that really the case?

For those that confidently inhabit the edges of the bell curve, they have the utmost convictions that their ideological purity is what is important for solutions to be correct and just.  RINO and DINO labels tarnish anyone foolish enough to consider a position with even the slightest hint of grey.   To argue such a grey area can often lead to more than chastisement, but often to banishment. How have we arrived at this locus?  Is it that the middle is growing, and the tea-party despite the attempts at marginalization or reinforcement from both sides is representing a new and still defining set of values and frustrations?

Macbeth:
To-morrow, and to-morrow, and to-morrow,
creeps in this petty pace from day-to-day,
to the last syllable of recorded time; and all our yesterdays have lighted fools the way to dusty death.  Out, out, brief candle!  Life’s but a walking shadow, a poor player, that struts and frets his hour upon the stage,
and then is heard no more. It is a tale told by an idiot, full of sound and fury, signifying nothing.

Is it possible that the root cause of our problems is in fact ourselves?  That our economic and ideological problems are an extension of our innate nature?  Are we now so enamored with our own Colossus, that we believe we are due all?  That we should all have anything we want, whenever we want, and the consideration that achievement of these things rests firmly in the divine rights passed from the stars and our own demands and that all others who have should – no,  must – grant part of their ‘haves’ to the rest of us who don’t and remain wanting?  Clearly, for some, this is not the case – I do not intend to damn any segment of mankind in this discussion.

Is this who we are today?  If so, when did we change?  Did we ever change, or have we really been like this all along?  Interestingly, the discussion has been alive and in debate throughout recorded history.  From Socrates to Aristotle, from Shakespeare to Twain, all have debated the relative merits and shortcomings of man.  Are we improving, degrading or simply continuing our journey with lots of sound and fury – signifying nothing?

While for the most part, I do not know much – in the end, I do feel I know this!  With all the talk of the crushing federal debt, and for many states like California crushing state debt as well, and the debate over tax cuts for the rich, or the role of unions in our demise – or their role in our success, or entitlements vs. safety nets, or our trade deficit or competitiveness in the world – whatever the topic; we are doomed to the creeping and the sound and the fury if we don’t change our own dynamic.  If we continue to pay, as an example, $68 dollars per man hour to produce a widget in the U.S. that others in the world are willing to produce for $28.00 per man hour, we will remain an acquiring not supplying nation.  If we continue to demand ideological purity, then the best men, or women, for the jobs will never come into office.  If we abdicate our own responsibilities to ourselves and each other in favor of some small group, who will for the most part be corrupted like all who gain power and control are corrupted, we will end up as we are today and as it appears we have been for all time.

We can continue to allow our elected officials to flummox us with the same pandering, platitudinous, piffled phraseology like;

  • the deepest recession since the great depression; or
  • this will provide business the certainty they need to...; or
  • we will continue quantitative easing and strengthen the economy… (Fed-Res speak for inflating the currency)

Each of these phrases, and many, many more just like it, are geared to obscure, conflate and confound the public into continuing to creep in our petty pace from day-to-day and not upset the status quo.  But it is the status quo we must upset or we come once again to the sound and fury part.  Like a big circle, or perhaps a loop by Dr. Moebius, we always seem to be ending right back at the same point.

At the beginning I asked a question.  It is clear to me that I cannot answer the question for anyone other than myself.  I ask you to find your own answer to this question.  And if you find the same answer as I, then let us all change ourselves.  In doing so we may change others and perhaps cut through the creeping, the sounds and the fury and signify something after all!

Afforable Care Act and Disease State Programs: What is the future?

As the Patient Protection and Affordable Care Act (ACA) continues the trek down the long tortuous hallway to become implemented law, a misquoted line, from Hunter S. Thompson, comes to mind. (I am using one of the misquotes)

“Hollywood, a long tortured hallway where thieves and pimps run free and good men die like dogs, for no good reason. There is also a bad side” – mis-quote of Hunter Thompson

We have all become complacent as to the unintended consequence of government deeds.  In researching my book, “The History and Evolution of Health Care in America: The Untold Backstory of Where We’ve Been, Where We Are, And Why Health Care Needs More Reform,” In a small way, I have become some kind of dubious expert on the historical record of the unintended consequences of the actions taken by our government, and many others, related to healthcare in America.  For some time now, I have been concerned that there may be very significant unintended consequences of the Affordable Care Act, particularly relating to special disease state programs offered by both states, and the federal government like; HIV/AIDS, hepatitis, heart disease, COPD, diabetes, etc.

ADAP as an Example

(While mandated rebates sounds like a great thing for consumers – it is not.  Federally mandated rebates are one of the drivers increasing the cost of medications to all of us and a major cause of the lack of transparency in drug pricing. I discuss this extensively in my upcoming book.)

An example of the kind of program I am referring to in California, would be the AIDS Drug Assistance Program (ADAP).  The California AIDS Drugs Assistance Program is a prescription drug coverage program funded, in part, by Title II of the Ryan White CARE Act created in 1990 by the US Congress and reauthorized in 1996, 2000, 2006 and 2009.

The ADAP program, provides medication purchase assistance to people suffering with AIDS, based on specific eligibility criteria.  The program sets limits on income, viral load, CD4 count, etc.  Depending on the criteria, eligible participants receive assistance ranging from; payment of insurance co-pay – up to and including full coverage of the medications proscribed, as long as the drugs are covered under the state’s extensive ADAP medication formulary (the approved list of medications).

You may be eligible for California ADAP services if:

  • You are a resident of the State of California
  • You are at least 18 years of age
  • You have a HIV/AIDS diagnosis (Requires Physician’s Letter and recent CD4 Count and Viral Load)
  • ADAP will only process prescriptions written by a licensed California physician/prescriber
  • You have limited or no prescription drug benefit from another source
  • You have a Federal Adjusted Gross Income of not more than $50,000.

ADAP is not all that California provides under the Ryan White Care Act to Californians suffering from AIDS, but it makes up the largest of the Office of AIDS’ (OA) expenditures – roughly $434 million of $1.3 trillion in total budget.  Of the $434 million number about 30%, approximately $126 million, comes from the California State General Fund, approximately 23%, $100 million, comes from the Ryan White Care Act funds, and 48%, $210 million, comes from mandated rebates from drug manufacturers

The Ryan White Care Act ¹

The Ryan White Care Act is the United States largest federally funded program for people living with HIV/AIDS. The act sought funding to improve availability of care for low-income, uninsured and under-insured victims of AIDS and their families.

Unlike Medicare or Medicaid, Ryan White programs are “payer of last resort”, which fund treatment when no other resources are available. As AIDS has spread, the funding of the program has increased. In 1991, the first year funds were appropriated, around US$220 million were spent; by the early 2000s, this number had almost increased 10-fold. The Ryan White Care Act was reauthorized in 1996, 2000 and 2006. The program provides some level of care for around 500,000 people a year and, in 2004, provided funds to 2,567 organizations. The Ryan White programs also fund local and State primary medical care providers, support services, healthcare provider training programs, and provide technical assistance to such organizations.

In fiscal year 2005, federal funding for the Ryan White Care Act was $2.1 billion. As of 2005, roughly one-third of this money went to the AIDS Drug Assistance Programs (ADAP) which provides drugs for 30 percent of HIV-infected patients. The primary activity of ADAP is providing FDA approved prescription medication.

 So,  why should we be concerned?

One of the major reasons for the enactment of The Ryan White Care Act, and the subsequent creation of ADAP programs in the first place, was the inability of those with this tragic disease to get adequate coverage from their insurers.  A diagnosis of HIV/AIDS became a red flag to insurers that either precluded coverage, if it was a pre-existing condition, or HIV/AIDS patients found their policies dropped for a myriad of other reasons mostly due to lifetime limits and trumped-up problems.  As a result, people with a diagnosis of HIV/AIDS could not get insurance.  The Ryan White Care Act and the various ADAP programs offered under this federal program through the 58 states and territories have done a wonderful job of helping treat, help to arrest the spread, and improve the quality of life of those with this horrible disease.  I think, this is undisputed.  The Ryan White Care Act and ADAP have been unqualified successes.  One of those rare occurrences within governmental programs.

President Obama’s 2012 HIV/AIDS budget requests $21.4 billion in funding for  Domestic HIV/AIDS activities. – Kaiser Family Foundation Report on HIV/AIDS Policy 

Having spent a good deal of time, for the past few years, in Washington, DC traveling the same long tortured hallway Hunter was claimed to have spoken about, I have developed a pretty good understanding of what is making things work there now-a-days.  The main issue on everyone’s lips, not just Republicans, is reducing spending.  The last re-authorization of Ryan White, in 2009, was a heated, and anger riddled, argument.  There were those then (including many leading democrats like Senator Kennedy) that did not want to reauthorize the existing legislation.  They were advocating creating new legislation that better dealt with the realities of the disease as it stood today.  But like most entitlements, the constituents, and their very vocal advocates, did not trust the government to bring them the program that they wanted.  While, they all agreed that the Ryan White Care Act was not great, they felt it was better than what they might get.  In the end, the political pressure drove the legislation to be reauthorized and extended four more years.  Determined to not see this, in their view, unwieldy and ineffective Act reauthorized one more time, Kennedy’s staff made sure that the 2009 re-authorization legislative language included a sunset provision that prohibited another re-authorization down the road.

 Well Things Have Changed – Haven’t They?

The biggest problem with AIDS today is that people no longer feel guilty nor afraid of the disease!
– Britt Weinstock, Senior Health Policy Advisor – Congressional Black Caucus

Well they have and have not.  Illustrated in the statement made by Britt Weinstock (one of the brightest and dedicated individuals I have met in Washington DC) in a meeting with me in 2007, the overall nature of the nations focus and funding for HIV/AIDS had changed.  It was then getting increasingly difficult to get attention in congress and squeeze out the necessary funding.  When the Ryan White Care Act was originally conceived the nature and treatment of HIV/AIDS was that of a terminal illness on the rise to a national epidemic.  Today it can be a treatable, if chronic, condition.  Then people diagnosed with AIDS had an expected lifetime of a few months to 8 years.  Today, with treatment, they can live mostly full and productive lives.  Like most other chronic diseases we face today, as the prognosis for HIV/AIDS has improved the lifetime cost of treatment has increased many fold.

As far as the Affordable Care Act goes, if this legislation continues to be enacted, it will prohibit insurers from barring HIV/AIDS patients from getting insurance to cover their needs – a seemingly good thing.  In fact, many states have already set up special funds for patients with pre-existing conditions and temporary high-risk insurance pools as an interim solution till the ACA takes full effect.  In the May revision of California Governor Brown’s 2011-12 Budget, the Office of AIDS are projecting saving some money by changing ADAP eligibility so that some of the covered patients shift into the states Pre-Existing Condition Insurance Plan (PCIP).  This program is a federally funded program and does not, at this point, receive any funding from the California State General Fund.  With cuts to Medicare, Medicaid, and Social Security now in open discussion, will such programs be deemed as necessary?  With Ms. Weinstock’s statement in mind will American citizens agree with the priority of additional funding?

As a result of the historical empathy and generosity of Californians, HIV/AIDS patients in California currently receive some of the best program benefits in the US today, and as a result, the public health crisis from HIV/AIDS has been contained and almost all patients in California have access to quality care and the required medications.  The question is – for how long?

As was seen in the 2009 re-authorization of Ryan White, many politicians did not want to be on the wrong side of the HIV/AIDS or GLBT activist communities and as such even the lion of the senate yielded and agreed to their demands for re-authorization.  But the game has definitely changed!  Before the choice for politicians was either, I agree to fund these programs or, since there was no insurance or other option for HIV/AIDS patients – they would die.

Today, the question politicians have to answer from the general public is; “Why do we need these types of programs? We just passed ObamaCare and everyone now gets insurance, or subsidies to buy insurance!”  The question for HIV/AIDS and other special disease state patients is, will politicians, having many fiscal-crisis related issues now the focus before them – without the ability to just print money to pay for them as we have in the past – have the strength to stand up to the rest of the fiscally troubled middle-class and say…

“Well you see…  Ahhh…  Well…  the Affordable Care Act…  aaaa, really didn’t cover everyone they way we thought…  And you see…”

Or will they just not re-authorize Ryan White and other special disease state programs like it and push it all off to MediCare, Medicaid and the ACA or the states.

How long can politicians in Washington, DC and Sacramento, continue to fund these needed programs?  How long will the politicians have the courage to stand up and continue in light of the looming fiscal crisis and its impact on seniors, disabled, children and under-served middle class and lower class Americans?  The question to the politicians really will be,

“Why do we need these programs if we just passed ObamaCare and spent trillions on it?”

“Politicians could use the answer, “Well….  Ahhh…  You see – aaaaa…..  Well it’s like this, you see, the Affordable Care Act really didn’t protect everyone!”  Some politicians may see it as a safer action – a more re-electable action – to not reauthorize these programs because; unlike before, when the choice was either we authorize these programs or people die because they can’t get insurance; now, to the vast majority of Americans, it seems no longer necessary because we just spent trillions to ensure that everyone has health care –  didn’t we?  Can a politician stand there and tell Mr. and Mrs. Middle Class America that the health needs for this increasing but still minority population of Americans is greater than their own fiscal needs?  And more importantly will these middle class Americans have the willingness to accept it.  Do we truly think, that we can fund everything we want by just taxing the richest 1%, 5%, or 10% of Americans?  If you look at the numbers, despite the rhetoric, we probably can’t.

This is a tough one!  Regardless of how anyone feels about the ACA – and almost no one actually likes it on either side – just like most other government programs, it is designed for somewhat near the lower-middle of the bell curve.  The people on the extreme edges of the bell curve get either poor or no benefit from these programs.  This is a fiscal reality.  The cost of the benefits for the people in the covered range of the bell curve where the programs are offered, has to be born by all the rest of the population.  The fringes never really get completely covered, even though the center of the bell is not in the middle-point of these curves.  So, we will always likely need specialty programs if we are going to commit to have the government take care of the most fragile among us!

It remains to be seen if this will be the case.  As I said, I am very concerned at this point that the Givernment of the People, By the People, and For the People is still able to do this, unless we rethink what this commitment means and more importantly, how to accomplish it.  We need to fundamentally restructure healthcare and rework, from scratch, the supply chain.  Perhaps we need to look not just at the government, but beyond government as well, to our individual relationships with, and responsibilities to, each other if we hope to find some answers.

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¹ Wikipedia contributors. “Ryan White Care Act.” Wikipedia, The Free Encyclopedia. Wikipedia, The Free Encyclopedia, 19 May. 2011. Web. 8 Jul. 2011.