Why Ebola petrifies us: One reason is healthcare’s unobtainable expectations.

Ebolacare givers practice safe procedures

Ebola caregivers practice safe procedures

Petrified & Angry

We are petrified of Ebola. It is a deadly disease, but we are much more scared of this today than we were of Polio, and Tuberculosis years ago. Why?

In the 1940s and 50s, modern medicine was a bit less advanced than we are today.  We had many more diseases to be afraid of.  Polio was an epidemic. Outcomes from Polio were not particularly good. Tuberculosis (TB) was a significant issue as well.  People with TB were quarantined.

Travel in that period was not as easy and ubiquitous as it is today yet, we routinely restricted affected people’s movements. In some cases we incarcerated them in sanitariums to protect the public at large. Despite these actions and the lack of effective treatment for these, and many other, diseases, people were no where near as panicked then as we see them today with the current Ebola crisis.

People who grew up in this era will tell you that most Americans accepted the dangers these microbes presented as a regular part of life. Sure, they were afraid of the diseases but they recognized that they had little control over potential infection. If they became infected they understood that HealthCare did not have cures. While there may have been many things to help ease the symptoms, odds were usually not very good that they would see their symptoms eliminated. Continue reading

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Article 4 – The Plague of Myths – Myth 3: We Can, and We Should, Live Forever!

We don't really have a healthcare system and its killing any reform.

We don’t really have a healthcare system and its killing any reform.

This is the fourth of a series of articles that are being published over the coming days and weeks. The series of articles will define the problems, at a higher level, that we have in what we call our healthcare system, why they are important and how they have conspired to foil our various attempts to “fix” healthcare. Each article will encapsulate one, or more, related issues, describe the problem and its effect today, how it historically developed and describe the framework of the solution(s). The final article will summarize the solutions and describe their intrinsic benefits.
(If you would like a more detailed read you may go directly to the draft Whitepaper titled, HEALTHCARE REFORM 2.0: Beyond the Partisan Divide Lies Pragmatic Solutions currently version 1.1)”

List of Articles:

  1. Introduction to Healthcare reform: What’s next
  2. Article 1 – Introduction to the Real HealthCare System
  3. Article 2 – The Plague of Myths: Myth 1 Healthcare Costs Too Much
  4. Article 3 – The Plague of Myths: Myth 2 Healthcare, It’s Good for What Ails You!

We all want to live longer

It is clearly an historical ideal to live longer. We all, for the most part, desire not to die anytime soon. I am sure that for most of us it is a completely natural instinct to continue to live. We often find it morally abhorrent to want to die prematurely – like from suicide. It would be completely counter intuitive from what we know about the survival instinct, and the laws of natural selection to decide to become premature feedstock for the organisms that prey on us. Our individual desire to survive is primitive and persistent for most of our lives. And it is safe to say we have been built this way! Continue reading

Article 3 – The Plague of Myths – Myth 2: Healthcare, It’s Good for What Ails You!

We don't really have a healthcare system and its killing any reform.

We don’t really have a healthcare system and its killing any reform.

“This is the third of a series of articles that will be published over the coming days and weeks. The series of articles will define the problems, at a higher level, that we have in what we call our healthcare system, why they are important and how they have conspired to foil our various attempts to “fix” healthcare. Each article will encapsulate one, or more, related issues, describe the problem and its effect today, how it historically developed and describe the framework of the solution(s). The final article will summarize the solutions and describe their intrinsic benefits.
(If you would like a more detailed read you may go directly to the draft Whitepaper titled, HEALTHCARE REFORM 2.0: Beyond the Partisan Divide Lies Pragmatic Solutions currently version 1.1)”

List of Articles:

  1. Introduction to Healthcare reform: What’s next
  2. Article 1 – Introduction to the Real HealthCare System
  3. Article 2 – The Plague of Myths: Myth 1 Healthcare Costs Too Much
  4. Article 3 – The Plague of Myths: Myth 2 Healthcare, It’s Good for What Ails You!
  5. Article 4 – The Plague of Myths: Myth 3 We Can, and We Should, Live Forever!

Do our expectations of Healthcare match reality?

We have a large number of myths that govern our beliefs about our current Healthcare system – or non-system to be more accurate.  One of the larger set of myths that drive our perceptions of both the positives and negatives of our healthcare system are our beliefs and expectations as to what we should get from healthcare and the underlying medicine.  We believe, that modern medicine has cures for almost anything we face.  We believe that the continual research and discovery that has occupied much of the past 164 years has led to a firm and almost complete understanding of the science of disease, injury, and treatment.  We believe that there is little difference in cost between the things we need for survival and the things that we want to improve our lives.  We believe that the current methods of treatment and the discoveries we have made over the past 80 years are making us a stronger more robust species.  We believe that the doctor is typically the best and most qualified person to deliver the care we need. And we believe that in most cases going to the doctor is safe and leads to improvements in our health. These are just a few of the myths and misconceptions we have about the current state of medicine and what we should expect from our healthcare system. Continue reading

Article 2 – The Plague of Myths: Myth 1 Healthcare Costs Too Much

We don't really have a healthcare system and its killing any reform.

We don’t really have a healthcare system and its killing any reform.

“This is the second of a series of articles that will be published over the coming days and weeks. The series of articles will define the problems, at a higher level, that we have in what we call our healthcare system, why they are important and how they have conspired to foil our various attempts to “fix” healthcare. Each article will encapsulate one, or more, related issues, describe the problem and its effect today, how it historically developed and describe the framework of the solution(s). The final article will summarize the solutions and describe their intrinsic benefits.
(If you would like a more detailed read you may go directly to the draft Whitepaper titled, HEALTHCARE REFORM 2.0: Beyond the Partisan Divide Lies Pragmatic Solutions currently version 1.1)”

List of Articles:

  1. Introduction to Healthcare reform: What’s next
  2. Article 1 – Introduction to the Real HealthCare System
  3. Article 2 – The Plague of Myths: Myth 1 Healthcare Costs Too Much
  4. Article 3 – The Plague of Myths: Myth 2 Healthcare, It’s Good for What Ails You!
  5. Article 4 – The Plague of Myths: Myth 3 We Can, and We Should, Live Forever!

The Plague of Myths

There are many myths that pervade our beliefs and therefore underlying assumption about our so called healthcare system. We believe that;

  • We have a healthcare system,
  • We believe that we already have, or are very near to having, cures for almost everything,
  • We believe what is good for us as individuals is good for the human species,
  • When it comes to healthcare we think that what we want is the same as what we need,
  • We either believe only government should have the role of providing care or we believe that government should have no role at all,
  • We believe that America can afford it – whatever it is,
  • We believe that Employer Sponsored Insurance has been a good thing,
  • We believe Co-Pays and Deductibles have helped lower costs and reduce consumption, and
  • We believe many, many others myths as well.
  • We also believe that American Healthcare costs too much! Continue reading

Article 1: Introduction to the Real Healthcare System

We don't really have a healthcare system and its killing any reform.

We don’t really have a healthcare system and its killing any reform.

“This is the first of a series of articles that will be published over the coming days and weeks. The series articles will define the problems, at a higher level, that we have in what we call our healthcare system, why they are important and how they have conspired to foil our various attempts to “fix” healthcare. Each article will encapsulate one, or more, related issues, describe the problem and its effect today, how it historically developed and describe the framework of the solution(s). The final article will summarize the solutions and describe their intrinsic benefits.
(If you would like a more detailed read you may go directly to the draft Whitepaper titled, HEALTHCARE REFORM 2.0: Beyond the Partisan Divide Lies Pragmatic Solutions currently version 1.1)”

List of Published Articles

  1. Introduction to Healthcare reform: What’s next
  2. Article 1 – Introduction to the Real HealthCare System
  3. Article 2 – The Plague of Myths: Myth 1 Healthcare Costs Too Much
  4. Article 3 – The Plague of Myths: Myth 2 Healthcare, It’s Good for What Ails You!
  5. Article 4 – The Plague of Myths: Myth 3 We Can, and We Should, Live Forever!

 We don’t have a system

When it comes to America’s, so called, Healthcare System, one of the biggest reasons that most of the attempts to “fix” our healthcare system have consistently yielded more unintended consequences than benefits is that we treat the symptoms of the disease not the disease itself. We have a number of misconceptions about our healthcare system and the first and foremost is that we believe that it is, in fact, a system.  It’s not!  It never has been.  What we think of as our healthcare system is really nothing more than a disjointed, tangled collection of practices, methods, procedures, policies, laws and guidelines that have been developed over the past 200 plus years.  Most of this collection of things were developed for the furtherance of one failing group or another.  Most were promulgated to preserve the business of individual practitioners – doctors, physicians, pharmacists, hospitals, pharmaceutical manufacturers, insurers, nurses, therapists, program sponsors, etc. With rare exception, many of this collection of things were not focused on the needs of the patient. Continue reading

President Trumpets Obamacare Rebates as Deadline Approaches: Beware of Greeks Bearing Gifts!

President Trumpets Obamacare Rebates as Deadline Approaches - Time Swampland

President Trumpets Obamacare Rebates as Deadline Approaches – Time Swampland

Nought from the Greeks towards me hath sped well. So now I find that ancient proverb true, Foes’ gifts are no gifts: profit bring they none.” So observed the great philosopher and teacher Sophocles about 430 BCE.  Today we loosely translate this as, “Beware of Greeks bearing gifts!

No quote could be more apropos in regard to the supposed $500 million in insurance rebates being sent to 8 million Americans under #Obamacare. Like most ponzi schemes, at first blush this appears to be a great deal for America and Americans. 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

The Supreme Court Decision: It hurts to be wrong-but it hurts more to be right and still wrong!

Now that we have all heard the decision by the Supreme Court on the Patient Protection and Affordable Care Act (Obamacare), perhaps it is time for some reflection.  I know as I read the decision Thursday morning, while I was waiting in the queue preparing for a radio interview on the issue, I felt both vindicated in my initial analysis, but also left wanting and inadequate for not seeing the sideways tax justification for its declared constitutionality.

First a recap

There were four questions heard by the Supreme Court in this case. Continue reading

Obamacare Supreme Court Ruling Likely Tomorrow: What will it mean to me?

If the discussion around water-coolers across the nation, or if the intensity of the discussion I have been having at meetings, discussions, or speeches I have given lately is any indication; then regardless of the decision from the Supreme Court tomorrow on the Affordable Care Act, or Obamacare if you prefer, the nation will once again find itself in a vitriolic and unnecessary national argument.

If you want to find out about the background of the core issue, you can read my Health Care Mandate and the Commerce Clause Articles or you can read, Supreme Court to hear arguments on Obamacare: An enigma, based on a canard, wrapped in a conundrum and read how the decisions could come down.

Regardless of the decision, it is clear that we will again have a major upheaval over any decision.  Passions are still running extremely high, and everyone seems to think this is the “be all and end all” of our future life, liberty and pursuit of happiness.  And all of us are wrong!

The decision, regardless of how it comes down, will neither further harm our healthcare system, nor will it improve our healthcare system because we just do not have a system in the first place.  What we have is clearly not a system.  In my recent book, The History and Evolution of Healthcare in America: The untold backstory of where we’ve been, where we are, and why healthcare needs more reform!, available at Barnes and Noble and  Amazon, and other fine bookstores, I discuss how we got to what we have today, how the practice of healthcare has evolved over the years – sometimes not for the benefit of patients – how we arrived at the point where what we believe and expect from healthcare is more mythical than reality, and some ideas on what we need to do to make available both choice and effective care for all.  It is a result of our collective mythical vision of healthcare and inaccurate focus on the symptoms, not the problems of our healthcare system, in the current bill, that we find ourselves with a collective national angst that will in the end just yield political discord not fix the fundamental problems.

As I write this, I am listening to the debate on the Eric Holder contempt of congress issue, also pending determination tomorrow.  Again we are in the middle of a huge national division and if one is cynical enough, we may come to the conclusion that this is all part of some diabolical plan. Since we have come to the place where instead of citizen politicians, we now have a professional political class whose job is to sell us free stuff and fulfill our wants, more than our needs, in exchange for our votes, and thereby significant power and riches; perhaps this is why we seem to have become a nation of thirds who argue everything, and find our leaders unable, or more likely unwilling, to fix the problems.

We are now composed of about 1/3 hard left progressive, 1/3 hard right conservative, and about 1/3 of the nation seem caught in the middle.  You should wonder, what would politicians have to get reelected on if they stop giving us free stuff; and how, on earth, would they get us to give them money so they can afford campaigns, if we are not mostly extremely irritated over something?  I am starting to think it is not our integrity and character that gets us engaged in critical issues anymore, but more likely it is just our passions.

There are some who declare that “Fast and Furious,” was a planned effort to create a national outrage in order to continue to clamp down on gun rights and perhaps severely restrict the second amendment.  Some label this actual fact, and some call this nothing more than wild conspiracy theory.  We all participate in this to some extent because we now habitually believe there can only be one extreme or another, not some logical blend in the middle.  The problem for those of us who are not trying to find conspiracy at every corner, is that we are at a nexus of a number of events created by the actions of the current and prior administrations that all seem to have at least some conspiracy elements in the actions.

In addition to “Fast and Furious,” you have the the actions and events over immigration reform, and the President’s recent unilateral action to implement some form of a dream act. You have the Supreme Court’s ruling on the Arizona Law and the administrations action to shut down the rulings effect by suspending the cooperation between ICE and Arizona’s police departments, and if you look back at the Affordable Care Act debate in congress. You have on the record, statements from people like Barney Frank and Charlie Rangle, and some others, who stated that the health care bill would be the path to a National Single Payer Healthcare system.  While you can look at each item discretely, and argue there is no Machiavellian agenda, when you look across the entire spectrum one needs to wonder if there is some agenda at work after all. And of course, the answer becomes; Yes –  there is an agenda.

Of course there is an agenda, and hopefully it is because those pursuing it truly believe what they are doing is right for America and Americans.  But being right for America and right for Americans may not always yield the same decision.  If may seem right for Americans to have congress conflate the promise given by the Constitution to all for Life, Liberty and the Pursuit of Happiness into an extrapolated promise of free heath care for everybody paid for by the government.  Conversely, at the same time it may not be right economically for the viability of America, to assume what historically was a personal responsibility if the assumption of these costs would bankrupt the nation.  Both decisions, in the narrow view, are good and reasonable decisions.

One path to a decision, has the benefit of giving something to political constituents that will help endear politicians to their electorate and gain reelection.  The other, could change the last fifty years of building the expectation that it is the government, not the individual, that needs to be responsibility for their own heath.  Regardless, this is just not a good situation for any of us, and it is partly why the bill that passed to become the law that is Obamacare is not really liked by either side or the middle.

While the 1964 extension of Social Security Act to include Medicare and Medicaid, was sold as a safety net, the reason for the passage was political gain, clearly on display if you listen to the Johnson tapes available today on-line.  And, subsequent to passage, regardless of whether or not there really was a Machiavellian plan, we have continued to want, and/or allow, Congress to convert the “safety net” into a national entitlement.  The end point is the same.

This is the reason that as we await the decision from the Supreme Court tomorrow, I do not think it will matter one iota in actually addressing the problems that we need to solve or developing a real system to make available both choice and effective healthcare for everyone.

History and Evolution of Healthcare in America now released

Status

The History and Evolution of Healthcare in America is now released. Click here or on the image to order your advance copy today!

You can order your very own personalized copy here.

NEWS!!! Now available at great prices from Amazon.com

and Barnes and Noble.com

Here is what others are saying!

From the beginning of mankind, health and health issues have played a major role in life, but the issues and care have evolved enormously from the time when the first settlers set foot in America to the present. In The History and Evolution of Healthcare in America, author Thomas W. Loker provides a historical perspective on the state of healthcare and offers fresh views on changes to Obamacare.

Insightful and thorough, The History and Evolution of Healthcare in America offers a look at

  • what healthcare was like at the birth of the nation;
  • how the practice of providing healthcare has changed for both caregivers and receivers;
  • why the process has become so corrupt and expensive;
  • what needs to happen to provide both choice and effective and efficient care for all;
  • where we need to most focus efforts to get the biggest change;
  • what is needed to get control over this out-of-control situation.

Loker narrates a journey through the history of American healthcare—where we’ve been, how we arrived where we are today, and determine where we might need to go tomorrow. The history illustrates how parts of the problem have been solved in the past and helps us understand what might be necessary to solve our remaining problems in the future.

Opinion – Image – NYTimes.com: Understanding in Three Steps?

Opinion – Image – NYTimes.com.

Understanding Step 1

This chart from the New York Times, is very interesting.  The data presented is very telling but perhaps not in the way the author intended.

When you look at these charts what do you see?  After you look and answer the question for yourself go to the next step.

Understanding Step 2

See this article for more information: President Obama’s Speech: Critical Question Continued.

What I see when I look at the data is very different from what I think the author’s point is.  We are all tainted by our biases.  We look at data, compose charts and in the end we see what we want and often construct the defense of the reality we want to see.

What I see when I look given the discussion in my prior article is first that Productivity tracks point for point with the increases in currency from 1972 on.  This should not be any surprise.  The way we measure Productivity is directly related to currency.  The question is in this case the old one, “which came first the chicken of the egg?”  In this debate one side will say chicken and the other will say the egg.  One side will be firmly of the mind that the productivity drove the increase in currency according to economic theory,  the other side will say the increases in currency inflated the productivity numbers.  Either may be correct and both are at this point irrelevant.  Which drove what now pales in comparison to the question of is the current net value of the U.S. supportive of the amount of currency (value) we have applied to it.  This is 1/2 of the most important questions.  The other 1/2 is – if not, how do we fix it?

The next thing I see in the charts, is that Wages did not track to the rise in currency nor did the gains of the wealthy.  While you see some trending with the increases in either prosperity or currency, you should expect to see that.  Wealthy people have the ability to derive more of their worth from long-term gains and theoretically should capture more of the currency in the economy.  Again the argument of fair or not fair, while a fun and spirited debate does not change the fact that the trend-line of the data does not correlate to the Currency in circulation chart in the prior article anywhere nearly as closely as Health Care Costs or Housing Costs.  It is these subtle differences that suggest an alternate cause for the increases of prosperity.  Further it is the timing of the trends.

Finally, I see that the debt line that is shown in the chart is not indicative of the true debt but in fact the result of the application of the increased capital to pay off part of the debt that accumulated from 1972 due to the trade imbalances.  We have accumulated over $12 trillion in trade deficits to the world since 1972 when we dropped the gold standard.  If you plot that curve against the Currency in Circulation curve again they are almost a point for point match.  The debt curve reported is not a point for point match.  It is the result of result of the combination of the two.

Understanding Step 3

Remember Mark Twain said, “there are lies, damn lies and statistics!”  All of these numbers need to be suspect – mine included.  But in the end this is not a republican issue nor democrat issue – it is an American issue and it will take all of us to address it.

President Obama’s Speech: Critical Question Continued

In his speech last night president Obama asked a key question.

President Obama asked, “Where would America be if we had not passed Medicare and Medicaid?”

As I said in my post last night, “President Obama’s Critical Question,”  the president’s question should not have been be a feel-good throw-away line, as it is the underpinning of the base argument, that Medicare and Medicaid have been good for us as a people and for the country. Clearly, the president believes that the answer to these questions is in the affirmative. But, what if the answer is not?  These are areas that I think many need to analyze.

Those who have been reading my articles know that I have a strong concern that the underlying issues in our health care system and our economy are systemic and the areas we are focusing on are, in effect, addressing the symptoms of the problems – not the root causes.  In my upcoming book, “The History and Evolution of Health Care in America: The untold back-story of where we’ve been, where we are, and why health care needs more reform!” I look at the relationship between the rising costs of health care and trace in part one cause to the large expansion of government programs like Medicaid and Medicare.  I also found correlations between the rapid increase in the amount of currency we created, after we jettisoned the gold standard in 1972, and the disproportionate allocations of these new monies to health care and other government subsidized programs like housing.

The relationship of the Total Money Supply (M3) to our current economic issues I will cover in a later article, but for now look at the direct, almost point for point, correlation of the rise in the total health care spend in the U.S. and the increase in the money supply.  I think there is no doubt that the significant increase in the amount of currency in circulation and the rapid rise of health care costs run hand in hand.  It is very clear, as Sancho said to his master, Don Quixote de la Mancha,

“Whether the stone hit the pitcher or the pitcher hit the stone – it was going to be bad for the pitcher!”

In this case, we can argue later whether the increase in currency drove the increase in costs or the increase in costs drove the need to increase the currency, it was the expansion of Government programs like Medicaid and Medicare that drove the increase in costs.

Housing also rose in a point for point correlation as well.  Unlike with health care, you can see it was an advance indicator.  This make sense, according to economic theory and the basic premise of fractional reserve banking because our the engine of economic expansion (the creation of new money) is debt.  Most preferably mortgage debt.  If housing prices did not rise and new homes and the resultant mortgages did not happen then the banks would have become rapidly out of covenant if the new money existed before the new mortgages were there to leverage against.

Lastly in this article, I include a chart of a few other cost histories, lest we think that all parts of the economy had the same correlation to the increase in the money supply.  Clearly, wheat corn and eggs did not experience the same effect from the increase in the money supply – nor does it appear they led the need to increase the supply.  I believe that most peoples practical experience is that not all things have risen in value twenty times in the past forty years.  Herein is the potential rub!

I will continue the discussion related to the presidents key question in my next article.  In that I will focus on how the creation of Medicaid and Medicare changed our personal character related to our view of our personal responsibility for our health care and how this change has affected our fiscal habits and our purchasing patterns and trends.

Please feel free to comment on this article or send it to others.  As I have said many times this is not a republican nor democrat issue.  I think this is an American issue.  I am not an economist just someone trying to understand why these things are happening now.  We need pragmatic solutions not demagoguery so lets find out what is the truth and then how we can fix it!

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.

Health Care Mandate and the Commerce Clause (Part 4)

The patient protection and affordable care act purchase mandate –
A four-part series on the relation and effects of the Commerce
Clause to Health Care

By: Thomas W. Loker

The following is the last segment of a four-part series where author, Tom Loker, explores the impact of the Commerce Clause on Obama-Care.

Image by Author

PART FOUR: A Time for a Fresh Look

In the last article, Sliding Down the Slope, we discussed how continuing court decisions and additional legislations have continued to push us further and further down the slope of federal oversight and control of increasingly larger parts of our daily lives. We also looked at how our historical interpretation of the commerce clause has muddied the water as to where the responsibility of the states to regulate our actions ends and responsibility federal government begins. Now, let’s look at this, from an everyday person’s perspective, as to what this may mean related to the current debate over the constitutionality of the PPACA mandate for all to purchase insurance.

 Who’s Right?

However, going back to the issues the framers were attempting to protect against, is it consistent with the framers view that the expansion of liability, as it is promulgated under this act, should so far abrogate personal responsibility as to the outcome of bad choice and bad behavior? Merely arguing that there is some benefit to a consumer does not make the clause relevant. The original expansion argument under Filbern that any commerce can be derived to be interstate commerce no longer seems to be a reasonable inference. Intrastate commerce itself is not innately subject to federal jurisdiction. The principle motivation to protect the consumer is not, in-and-of-itself, sufficient justification to regulate intrastate commerce, nor does it immediately give rise to the notion that all commerce is interstate.

The issue of the application of the Commerce Clause related to PPACA is even more muddled in that one of the principled arguments against this legislation is that it does not open the state-centered administration of health insurance nor does it provide an open and competitive interstate market. Most, if not all states, specifically regulate insurance provided within their borders. The inability of consumers to purchase insurance plans across state lines itself should stave off the argument that this is in some way per se interstate commerce and subject to the clause. The historical Filbern argument is even more difficult to rationalize in the absence of a transportable open state policy mandate.

Intrastate Regulation and Fairness

A reach to enforce the mandate for purchase of insurance under the auspices of the Commerce Clause is a hard one, indeed, in that the benefits to consumers that could be argued in the justification to impinge individual freedoms and economic liberties for the greater good are lost when the purchase itself is confined within intrastate regulation. Effective argument can only be made based on interstate availability of insurance whereby the policies available across the state line are comparable in standard of fees and services provided and transportable from state to state after purchase. An item, good, or service that is purchased in, and only is consumable, within one state and is subject only to the regulations of the state where the service was purchased and consumed in no way logically rises to become interstate. Further, any argument that attempts to provide nexus for an interstate affect, as in the case of Filburn, should be deemed to interpretation in the same manner as was done in Lopez.

A Voice Speaks Out

Specifically in relation to the Commerce Clause; let us agree with Justice Kennedy and walk a slow and careful path. In every case possible, let us demur to the authority of the state and the preservation of individual rights and liberties.

Finally, most recently in hearings of the Judiciary Committee relating to the debate for the need of tort reform legislation pursuant to the PPACA debate, one congressman, who shall remain nameless, while arguing why Tort reform was not necessary for the federal government to consider, made the following argument: He stated that in his long history as a strong states’ rights advocate, he had never seen an instance where health care was provided in a clinical setting and where the clinic existed simultaneously in two states, or between the borders of two states. As such, the provision of care was always done within the border of one state and therefore could not be interstate. The congressman further stated that if the person received care in one state, while a resident of another state, and that the care was provided under the licensure, regulations and authority of the state where the service was provided, that this was still no more interstate commerce than any other commercial action as prosecuted within a state on a daily basis.

Clearly, the evolution of the argument of the Commerce Clause, as providing a basis for regulations governing protection to consumers, can from time to time provide a broad and expedient method to justify such federal powers; these powers are innately the proverbial slippery slope. The framers carefully crafted the Constitution to preserve individual liberties and freedoms above all others. To allow expansion of federal powers under the aegis of the Commerce Clause, which has happened over the past few hundred years, is one of the more dangerous areas of law we have today. As such, full and unfettered caution must ensue.

The Judge Steps Up

Justice Kennedy wrote,

“[T]he Court as an institution, and the legal system as a whole, have an immense stake in the stability of our Commerce Clause jurisprudence as it has evolved to this point. Stare decisis operates with great force in counseling us not to call into question the essential principles now in place respecting the congressional power to regulate transactions of a commercial nature. That fundamental restraint on our power forecloses us from reverting to an understanding of commerce that would serve only an 18th century economy, dependent then upon production and trading practices that had changed but little over the preceding centuries; it also mandates against returning to the time when congressional authority to regulate undoubted commercial activities was limited by a judicial determination that those matters had an insufficient connection to an interstate system.”

Let us agree with Justice Kennedy and walk a slow and careful path. In every case possible, let us demur to the authority of the state and the preservation of individual rights and liberties. I also suggest we only allow federal regulation when such regulation is meant to provide a mechanism by which it can normalize controls on behalf of consumers among states; where interstate commerce requires only federal control for solution or provision of benefit; or where it is necessary to regulate the actions among the states, not among or between the citizens of the states. Let us be mindful that the actions of the states themselves will not harm the public good or unfairly impost taxes, duties or levies between the states or with other nations or Indian tribes.

This treatise, outlied in these four articles, is just one lay person’s read of this issue. If we cannot explain it to every man and woman. Perhaps the reach is simply too far!

Please remember to post a comment below.  If you like the article please let others know about it!

Health Care Mandate and the Commerce Clause (Part 3)

The patient protection and affordable care act purchase mandate –
A four-part series on the relation and effects of the Commerce
Clause to Health Care

By: Thomas W. Loker

The following is the third segment of a four-part series where author, Tom Loker, explores the impact of the Commerce Clause on Obama-Care.

Part Three: Sliding Down the Slope

The Dreaded Slipery Slope

At the end of the last article, Simple Issues – Complicated Problems, we were discussing some of the earlier expansions of the federal reach under the commerce clause and one landmark case, Wickard vs. Filburn, which strains many ordinary people’s cognitive grasp.   There are some other significant legislations and court decisions that take this strain to a new level – perhaps venturing into lands, heretofore, exclusively explored by the venerable Rod Sterling of Twilight Zone fame.

Two Sides of the Same Coin

The Pure Food and Drug Act of 1906, made law that the liability for addiction and potential harm of a nostrum was in the hands of the person who purchased it not the manufacturer

In the late 1880’s, the rise in power of monopolies and cartels was having a deleterious effect on the population.  State laws provided effective controls intrastate, but the lack of solid legislative protections for the patent medicine manufacturers interstate was leaving them open to both economic and physical damage. The so called patent medicines were not protected by patent at all. Patents mandated disclosure of materials and methods so instead these manufacturers relied on trade secrets and brand protection.  Brand protection on an interstate level was the root of the problem for the patent medicine men.  In this mix grew one of the most dangerous cartels, the Proprietary Manufacturers Association, the makers of patent medicines.  While most states had forms of trademark protection, it was effective interstate protections that the Proprietary Association effectively lobbied for, and congress passed, with the Trademark Act of 1870.  Enacted under the authority of article 1, section 8, clause 8 alongside the Commerce Clause (clause 3), the Trademark Act allowed the members of the Proprietary Association to receive additional protections fostering their rapid growth and providing an instrument that allowed them to secure their brands interstate without having to disclose their formula or ingredients.  The effect on the population was devastating, not so much as to the economic impact, but to the addictive and deadly nature of the hidden ingredients in these nostrums. The effect on congress was even more troubling as the association’s power grew exponentially and soon they controlled 80% of all newspapers in the U.S., and with that and other contract-related devices, they had substantially gained effective legislative control.

Trademark Law Found Unconstitutional

As part of the political battle taking hold to reign in this emerging problem, the initial Trademark Act was challenged and found unconstitutional because it failed to make any reference to commerce with foreign nations, among several states, or with Indian tribes.  Moreover, the court found that the act made no mention of “the character of the trade to which it was to be applied or the residency of the owner.”   The battle continued with the Trademark Act of 1881, and then later the Trademark Act of 1905.

In addition to the Trademark laws that were effectively lobbied on behalf of the patent medicine men, the Sherman Antitrust Act of 1890 was another step in  the government’s battle to protect the citizenry.  Created to control the anticompetitive and harmful actions of cartels like the Proprietary Manufacturers Association, the Sherman Act provided a framework to protect consumers from anticompetitive behaviors of cartels, monopolies and trusts.  Reflecting the political climate of the day, and the power of the Proprietary Manufacturers Association, the Sherman Act politicians were virtually unwilling to use the law until Theodore Roosevelt’s presidency fifteen years later.  Specifically justified under the Commerce Clause, the Sherman Act and the extensions that followed like the Clayton Act, Robinson-Patman Act and other pieces of law began to leverage the Commerce Clause as a means to argue for and extend the reach of federal regulation in areas of interstate commerce, particularly when it was for the good of the consumer.

The Control of the Patent Medicine Industry

Dr. Miles Medical Co. v. John D. Park & Sons Co., 220 U.S. 373 (1911) established that Retail Price Maintenance (RPM) was per se illegal and helped to interrupt the significant control the patent medicine industry was exerting over retailers of the period.  The tenant of the per se illegality of Retail Price Maintenance remained black letter until recent years.  Recent rulings like GTE Sylvania (1977) and Leegin Creative Products, Inc. v. PSKS, Inc., 128 S. Ct 2705 (2007) have begun to reverse these long standing decisions as reconsideration by the courts are again questioning the underlying basis of authority under the Commerce Clause.

Like Wickard v. Filburn, the creation and enforcement of the Sherman Act was motivated by the desire to protect the public.  Unlike Filburn, the Sherman Act stays well within the logical confines of interstate commerce to provide its authority for the protection of the consumer. It also serves to establish a limited framework for its use.  This act provided an indirect method by which to limit harm to consumers being wrought from the Proprietary Manufacturers Association.  This indirect method also became necessary and appropriate because the courts at that time did not recognize an ability to assess the manufacturer of an items liability mainly because the consumer made a reasonable choice.

As seen codified in the enactment of the Pure Food and Drug Act of 1906, much of the liability for the addiction and the potential harm of a nostrum was not in the hands of the manufacturer, but in the hands of the person responsible for its purchase. So, as long as the manufacturer made the consumer aware of any of a list of specific potentially “harmful” ingredients it was thought to be held harmless.

Civil Rights Act—Interstate Normalization

The Commerce Clause has repeatedly been used to help legislate behaviors at the federal level.  After the passage of the Civil Rights Act of 1964, the Supreme Court issued several rulings supporting the use of the Commerce Clause in regulating enforcement of discriminatory behavior in businesses.  In the case of Heart of Atlanta  v. United States, 379 U.S. 241, the court ruled that Congress could regulate a business that served mostly interstate travelers.  More interestingly, in Daniel v. Paul, 395 U.S. 298 (1969), the court ruled that the regulation of recreational facilities was permitted because three out of four items sold at its snack bar were purchased outside of the state thereby subjecting the facility to the jurisdiction of the federal regulation under the Commerce Clause.

Again, it is clear that the intention of the act itself was to protect consumers against discrimination based on race, religion, or national origin.  The intention of this particular legislation is clear and understandable.  For the everyday person, the argument endorsed in Daniel v. Paul becomes problematic in that it smacks of interpretation driven by outcome.  For most readers, it is very hard to swallow that the Commerce Clause comes into play because some or even most of the items sold in a related activity may have been subject to interstate purchase.  This stretch makes it hard to find any tacit alignment that bolsters the rest of the arguments many of which appear weak and overly broad.

Gun Free School Zones

Gun-Free School Zones v. Lopez, the Supreme Court was faced with a challenging decision.  A 12th grade student had been convicted of carrying a concealed handgun into a school in violation of the Gun–Free School Zones Act of 1990.  The lower court found that in Wickard v. Filburn the Court had ruled that Congress was exercising its Commerce Clause power to police local economic activity because the individual states were powerless to regulate it themselves. More specifically, this was determined to be the case because in the opinion of the court only the federal government was able to manage the national wheat supply and control prices.  The lower court reasoned that if you extrapolated the same arguments to acts of gun violence because crime negatively affected education, congress could conclude that crime in schools clearly affected commerce; therefore it ought to be federally regulated.

Nationalizing Police Power

One can rapidly come to the conclusion that if this in fact were true, the entirety of all police power in all states could be nationalized because all crime therefore has some impact on interstate commerce. In this case, the Supreme Court overturned the lower courts verdict.  Justice Thomas, in his concurring opinion, argued that allowing Congress to regulate intrastate, noncommercial activity under the Commerce Clause would confer on Congress a general “police power” over the entire nation.

Clearly, once again, the intention was to find some way to allow the federal government to help protect the citizenry from harmful acts.  While the intention was and is noble, the argument that this is an applicable extension of federal power under the Commerce Clause simply does not hold.  In allowing these stretches to carry our normal imagination to such levels that old Rod would be proud.  Mr. Sterling started each show with the quote, “You’re traveling through another dimension — a dimension not only of sight and sound but of mind. A journey into a wondrous – land whose boundaries are that of imagination. That’s a signpost up ahead: your next stop: the Twilight Zone!”  The difference between Mr. Sterling’s excursions and the commerce clause debate, are that the ramifications of this mind trip have very significant  consequences on each of us, and ultimately the health care we will be able to
access.  In the last and final article we will discuss the Patient Protection and Affordable Care Act. (PPACA)

Health Care in America: Where We’ve Been, Where We Are, and Why Health Care Needs More Reform!

Tom Loker has written a book that takes the reader on an intriguing journey as he/she walks along with Loker from the inception of this country to learn about the behind-the-scenes goings on with health conditions, health maladies, health remedies, and evolving health care reform. Beginning with the state of health when the Pilgrims first hit that “rock” to the current day when Congress locked horns, Loker stuns the reader with knowledge never Continue reading