Dylan's Nobel

I know Dylan is The Seer to many.  Not just...guys.  I caught the early, nasal years.  Some things struck me: 20 years of school and they put you on the day shift; William Zanzinger.  But who was he imagining when he warned:

"Go away from my window.
Leave at you own chosen speed.
I'm not the one you want, babe.
I'm not the one you need.

"You say you're looking for someone
 Who's never weak, and always strong.
Someone to defend you and protect you
Whether you are right or wrong,
Someone to open each and every door...

"Well it ain't me babe!"

Geez, I hope not.  In any case, I didn't linger.

I marvel at Joni Mitchell lyrics, rhythms (dug up the records - yes, records!  after a recent move):

"Just before our love got lost
You said 'I am as constant as the Northern Star,'
I said
'Constant in the darkness, where's that at?
If you want me I'll be in the barn..."

Sippie Wallace via Bonnie Raitt ("Give It Up or Let Me Go"), Randy Newman ("Rednecks," "Sail Away...").  Plenty more.  Well, congrats to Bob and fans.

There's a class on Dylan at Harvard.  Where, in doubtless unrelated news, the food service workers are on strike.

Thank You For Patiently Waiting

“The TPP* will bring us into the 21at century… Global supply chains…Winners and losers…”  Pres. Obama

The Warriors, a Team Beyond Comparison

By Harvey Araton, NYT  5-31-16                 

“Golden State has drastically extended the standard scoring range, which makes comparing it with storied N.B.A. teams of yore like distinguishing between a smartphone and a land line.”

First try: 10 a.m. 

Me: Hello, AT&T?  I just moved, and there’s supposed to be a forwarding message at my old phone number to my new number.  But I just called my old number, and my old answering message is still playing.  Also, my password no longer works at my old number, so I can’t tell if anyone’s left me a message at the old number.  Can you help, please?

Agent:  Hello. Thank you for calling AT&T.  No worries, we will take care of your problem.  Will you please tell me your current phone number and the 3-digit code at the end of your bill?

Me: Sorry, I just moved and I don’t have by old bill handy.  I can tell you the amount of my last bill, though, for identification.

Agent: No worries. Can you please tell me your current phone number and the 3-digit code at the end of your bill?

Me: No, I don’t have my paper bill with me, I just moved, but I can tell you the amount I paid on my last bill, since it’s written here in my checkbook.

Agent: I’m so sorry, let me understand.  Do you need new service?

Second try:10:15 

Me: Hello, AT&T?  I just moved, and there’s supposed to be a forwarding message at my old phone number to my new number.  But I just called my old number, and my old answering message is still playing.  Also, my password no longer works at my old number, so I can’t tell if anyone’s left me a message.  Can you help? Please?

Agent: That is a different department.  No worries, we will take care of your account, Miss Ellen.  Can I put you on hold while I contact the other department?

10:25

Agent:  Thank you for patiently waiting.  Miss Ellen, can you tell me the 3-digit code at the end of your phone number on your bill?

Third try: 10:30

Me: [allow your imagination to run wild]

Agent: Let’s see, the problem is that your old number isn’t due to be discontinued until the first of the month, which is tomorrow.  I checked, and there’s no way to move the date up today.  But that disconnect will happen tomorrow.  Then your callers will get an automatic message, telling them to call your new phone number.

Me:  Thank you, that is very helpful.  But the other problem is that my password for the old number doesn’t work, so I can’t tell if anyone’s left me a message there.

Agent: I see.  Let me get our technical team on the line, to reinstate your password for the day.  I’m going to put you on hold, and we’ll get someone on the line who can help.

[I am on hold.  I go to iTunes to try to download some music.  iTunes tells me I am no longer subscribed to whatever part of their service I need to get a new song to play.  Would I like to download the new program?  I click on the icon to download the updated program.  Meanwhile I listen to the tunes I already recorded:  Judy Collins “We Want a Revolution” suite from Marat/Sade; “You Don’t Own Me,” Leslie Gore; “The Longest Time,” Billy Joel; and on to Katie Goodman, Kweskin Jug Band, Taj Mahal, and Tom Lehrer.]

10:45

[Recording]:  You’ve reached the repair department at AT&T.  Due to heavy volume, your call may not be answered for up to 4 minutes.

[The Comcast tech couldn’t find the connection to the internet in our new place, so we’re working off of borrowed wireless until we can get real Ethernet service, next week. 

[iTunes sends a message that there has been an error in downloading the updated program.  I can try again later.  Meanwhile, it would like to add or update service from Apple, Quicktime, and other programs.  I think about “The Golden Notebook,” and get up to unpack.]

*TPP = Trans Pacific Partnership

Escalating Drug Prices Likely from Secret “Fast Track” Trade Bill

Congress could vote this week on a “Fast-Track” trade bill that would dump a double whammy on the many Americans whose health and finances are already hit hard by the high price of prescription drugs.  Wikileaks and the NY Times today published a draft chapter on drugs, negotiated entirely in secret as part of the Trans-Pacific Partnership (TPP).  

If it approves proposed “Fast Track” rules, Congress would surrender its ability to amend this chapter, and whatever remaining secret text that the secret negotiations produced.

The leaked trade chapter, entitled Transparency and Procedural Fairness for Pharmaceutical Products and Medical Devices, was presented in December, 2014, to the 12 nations negotiating the Trans-Pacific Partnership (TPP).  It could derail present programs that offer access to affordable prescription drugs in the U.S. and abroad, including Medicare and Medicaid, and stymie future progress.   

How to create and produce affordable medicines, and assure wide access to the resulting products, is a critical, life-and-death concern for both the public and the drug industry.  A new treatment for Hepatitis C can transform lives, but the price tag of $80,000 a year will condemn too many to go without it.  Existing U.S. laws that rely on competition from copycat generic drugs to achieve affordability will be less effective in the case of new drugs classified as biologics, which are far harder and in some cases impossible to copy.  The TPP text reveals threats to existing and proposed systems that cover and finance access to medicines in the U.S., Australia, New Zealand, and elsewhere, and will increasingly have to address these emerging products, including policies on:

·       Direct-to-consumer advertising

·       Rules on the extent and timing of drug industry participation in government decisions about the selection and pricing of covered prescription drugs

·       The treatment of medical devices

·       The grounds for a drug company to initiate a trade charge against a country’s drug coverage and pricing systems

These threats and ambiguities are the inevitable result of misguided efforts to determine critical health, economic and social policy issues through the secret process of trade negotiations, dominated by commercial interests, while explicitly excluding and silencing other experts, consumer advocates, public officials, and the public at large from the debate. The few non-industry participants on trade advisory committees are prohibited from revealing or publicly discussing the contents of privileged negotiating text.  Such a process cannot succeed in a democratic system.

Open public debate reveals and helps to determine where agreement is possible, and which issues will remain contentious. It is the only basis for providing reliable assurance to our trading partners that the negotiations reflect what the U.S. will actually stick to.

Congress must vote No on Fast Track/Trade Promotion Authority.

- Ellen Shaffer, CPATH

Hobby Lobby's Religion: Boko Haram

House of Reps. all-male hearing on contraception, 2012

Hobby Lobby today announced that although it is a corporation, it does indeed have a religion: Boko Haram.  When its Christian owners argued before the Supreme Court to assert their right to deny insurance coverage for 4 types of birth control on the basis of the corporation's religious beliefs, Justice Sotomayor questioned "How does a corporation exercise religion?"  The Corporation itself has so far been silent on its actual religious affiliation.


"With so many of our successful practices under attack around the globe this month, we felt it was time to speak publicly in defense of our faith.  On May 6, a Boko Haram leader claimed responsibility for abducting hundreds of Nigerian school girls, planning to sell them. In the U.S., with legislation in Missouri and Louisiana aiming to strip abortion providers of their right to practice, and  proposals advancing in Congress to ban abortions after 20 weeks, when low-income women and women with medical abnormalities are most likely to need them, our staunch doctrine of assuring the long-term, structural subservience of women has been making enormous strides.


"The firing of Jill Abramson for her 'brusque' management style as NY Times editor, to be replaced by the man who had responded entirely appropriately by punching a hole in the wall at the Times, was simply more than we could have hoped for.


"This cascade of previously unimaginable successes has of course inflamed uncontrollably whiny, emotional, and humorless feminist apparatchiks around the globe, from groups like a Billion Rising, and the Trust Women/Silver Ribbon Campaign.  These modern women and their supporters would convince the US Supreme Court that it's time to set the record straight and dismiss Hobby Lobby's arguments, simply because they reflect the last gasp of the backwards, fringe mentality we represent. And frankly, the recent denunciation of Boko Haram by Al Quaeda contributed to prompting our declaration. By coming out publicly to claim our corporation's religious affiliation with Boko Haram, we intend to put all such diversions to rest."


(The corporation went  on to explain how this unique circumstance entitled it to claim its independent right to assert that Plan B should not be covered by Hobby Lobby because it is an abortifacient, which is otherwise labeled by mainstream scientific evidence as "absolutely without any foundation whatsoever.")

Tobacco: Symbol of Corrupt Trade Policy

The deadly tobacco industry increasingly deploys trade charges intended to bludgeon countries from Uruguay to Australia into abandoning policies that keep kids from getting addicted, and help smokers quit, as well documented in today's NY Times.

The U.S. Trade Representative should fix this problem during negotiations on the proposed 12-nation Trans Pacific Partnership (TPP).  But stalemates in U.S. trade policy are perpetuating this obvious injustice.

Trade ministers derive priority status within governments based largely in outdated beliefs that they will magically conjure prosperity by conspiring in secret, allegedly to eliminate trade barriers such as tariffs and quotas which in fact have long go been substantially reduced.  The predominant business of agreements like the TPP is actually reducing "technical barriers" to trade - that is, democratically adopted laws and regulations that protect the public's health, environment, labor standards, and financial transactions.

In the secretive, rarified world of trade negotiations, even when public health succeeds in getting a proposal to the negotiating table on an issue like tobacco, it is subject to be traded away at any moment by a trade minister who views it primarily as a bargaining chip for deals on more important concerns, like sugar, cars, or financial derivatives.

The Center for Policy Analysis on Trade and Health (CPATH) has systematically documented how tobacco industry trade challenges threaten public health's rights to implement tobacco control measures. Medical and public health leaders in the U.S. and worldwide have echoed the call to "carve out" tobacco from trade agreements.

Malaysia presented a carve-out proposal at TPP talks in August, The USTR has advanced two increasingly weak compromises. Legal analysis from Georgetown [R. Stumberg, Safeguards for Tobacco Control: Options for the TPPA.  America Journal of Law and Medicine, 39 (213); 382-441] has confirmed in irrefutable detail that compromises short of a "carve out" would be virtually ineffective.

Tobacco use is the leading preventable cause of death worldwide, claiming 6.3 million deaths a year, including 1,200 Americans daily, and draining almost $200 billion a year in U.S. health care costs and lost productivity. Tobacco is barely a blip in the U.S. economy, and less than a fraction of a percent of our exports.

But the tobacco industry has made it clear that it will oppose any restriction on its rights to continue to appropriate trade rules. They've bought a box seat to the hermetically sealed, secretive trade negotiations, and the solid complicity of the U.S. Chamber of Commerce.

Public health has no such advantages.  Interestingly, though, we have the truth.  And in this possibly unusual case, the truth is increasingly difficult to ignore.

Report Back: CPATH to USTR - U.S. Must Protect Public Health in the TPP

The U.S. Trade Representative gave new meaning to the phrase, "magical thinking" at a Nov. 18 talk in San Francisco. And new urgency to the demand for an honest debate on the economy and on the Trans Pacific Partnership (TPP).

 

Last week, Wikileaks released the most detailed report of the proposed trade agreement to date It reveals the full text of the controversial intellectual property chapter, that would govern fundamental rights including access to medicines, internet freedom, and cigarette package warning labels. In addition, it shows which countries support which versions of the proposals.

The U.S. does not look good. The leaked documents delineate that the U.S. would allow corporations including Big Tobacco and Big Pharma to rake in enormous profits while exposing the public's health to continued havoc by challenging tobacco control regulations, extending patent and trademark rights that would raise the prices of medicines, and raise the cost and availability of health care through patenting surgical techniques, for example. Disturbing enough.

Scores of members of Congress had already signed letters denouncing these proposals, and pledging to block them. Public health and medical organizations, and entire nations, have urged the U.S. to curb these abuses.

But on November 18, United States Trade Representative Michael Froman and Agriculture Secretary Tom Vilsack engaged in a discussion at the Commonwealth Club of San Francisco, moderated by the Club's Greg Dalton. When Dalton specifically asked U.S.T.R. Froman to address concerns regarding the trade pact's limits on internet freedom and access to medicines, he got back the same happy talk the Administration has been babbling all along.

In a breath-taking effort to imagine that the entire population had lost the capacity for literacy, Froman asserted, "What we're trying to do with the TransPacific Partnership is open up markets in some of the fastest growing regions in the world, raising standards on labor, the environment, access to medicines, intellectual property rights, and create new disciplines for the 21st century global economy."

He went on to claim both that the TPP was the most transparent trade agreement ever negotiated, in view of the USTR's many consultations with every sector of American society, and that the American people would only fully understand how beneficial the TPP is once the negotiations are concluded and the public sees the final product.

Just prior to the public event, San Francisco Supervisor Eric Mar and Co-Directors of the Center for Policy Analysis on Trade and Health (CPATH), met briefly with Ambassador Froman, and urged him to protect public health and rein in Big Tobacco in the TPP trade negotiations.

Supervisor Mar presented USTR Froman with a letter expressing his deep concerns that the provisions of the recently leaked Intellectual Property Chapter of the TPP "may undermine the right and ability of local, state, and national governments of participating countries from exercising their domestic sovereignty in order to adopt or maintain measures to reduce tobacco use and to prevent the harm it causes to public health." The letter posed key questions on U.S. proposals related to intellectual property rights and the tobacco industry, and requested a written response on how U.S. proposals will ensure that the United States and other TPP nations will be able to fully implement and enforce strong tobacco control legislation.

CPATH Co-Directors Ellen R. Shaffer and Joe Brenner articulated the concerns of major U.S. medical and public health groups, which are calling on the U.S. to take a leadership role to protect the public's health from tobacco-related disease and death, and to carve-out tobacco from the TPP negotiations. They presented a binder of letters and statements from CPATH, the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Congress of Obstetricians and Gynecologists, American Public Health Association, CA Health Officers Association, California Council of Local Health Officers, and the Public Health Institute, CA-Public Health Association-North, and Alameda County Public Health Commission.

During questions from the public, CPATH Co-Director Joe Brenner asked, "San Francisco and California have taken effective action to reduce tobacco-related disease and death. When California attempted to ban the carcinogen MTBE from gasoline to protect health for years ago, a Canadian company, which made a component, filed trade charges against the U.S. and sued for $970 million for lost profits under "investor-state" provisions in NAFTA. The U.S. is proposing to give corporations these same rights in the TPP, including to challenge local tobacco control regulations. Why?" USTR Froman responded that the U.S. has never lost a court challenge under these provisions, and that new TPP provisions are different. Wait 'til we see it.

"The ongoing efforts to usher through in secrecy a pact with nations representing 40% of the globe's gross domestic product is corroding our democracy," says Shaffer. "For example, an editorial in Bloomberg erroneously equated the secrecy of the TPP with the embattled but entirely transparent Obamacare health care reform program.

"To be clear: Trade negotiations have been a corporate-controlled subterranean process for decades. The Obama Administration didn't start this. But it has utterly abandoned the responsibility to change it. It is an anomaly in our democracy which we can no longer tolerate. The technical details matter, and we have a right to understand the fine print as well as the broad strokes. The United States must lead the way towards a 21st century trade agreement, that starts, proceeds and ends with a fully public debate."

Your support makes our work possible. Please contribute today:

http://www.cpath.org/id1.html

NYT: Why Some People Can’t Keep Their Insurance Plans

http://www.nytimes.com/interactive/2013/10/30/us/why-some-people-cant-keep-their-insurance-plans.html?ref=politics

Despite repeated assertions by President Obama that people who like their health insurance will be able to keep it under the new health care law, many people who bought insurance on their own — a small fraction of the insurance market — will have to buy new plans. Related Article »

Medicare, Medicaid,

military coverage

Share of people with

employer-sponsored

insurance

29%

49%

Uninsured

5%

16%

Individual market

10-15 million people

Policies must meet new standards ...

Beginning Jan. 1, new policies issued must cover a minimum share of health care expenses and offer 10 “essential health benefits”:

1.

Outpatient care

7.

Rehabilitative and habilitative

services and devices

2.

Emergency room visits

3.

Hospitalization

8.

Lab tests

4.

Maternity and newborn care

9.

Preventive services and

chronic disease care

5.

Mental health and

substance use treatments

10.

Pediatric services, including

dental and vision

6.

Prescription drugs

... unless a plan is grandfathered in ...

If a policy was in effect when the law passed in March 2010 and has not been changed significantly, people already on the plan could remain on it, and the plan would not have to meet the new requirements.

 

... but many people will need to purchase a new plan because:

• Many plans do not currently meet the law’s standards for coverage.

• Most people in the individual market do not keep their policies for more than a year, so most would not be eligible to be grandfathered.

• Insurance companies cannot change grandfathered plans or sell them to new customers, so they have incentive to cancel the policies.

Some people will also move to Medicaid coverage.

More than one million low-income adults currently in the individual market will be newly eligible for Medicaid in 2014 because they live in a state that has decided to expand the program.

 

Why Rates Are Increasing for Some People

The total cost of policies will be higher on average ...

Many plans offered on the individual market will have more benefits and more consumer protections than they did before. The pools will also cost more for insurance companies since they cannot deny people with pre-existing conditions.

In the individual market,

on average, rates for group will:

... but people will be affected differently ...

INCREASE

DECREASE

SEX The law bans insurers from charging women higher premiums than men of the same age.

MEN

WOMEN

AGE The law bans insurers from charging older adults more than three times the amount they charge younger adults.

YOUNG

OLD

HEALTH The law bans insurers from charging people with health problems more.

HEALTHY

UNHEALTHY

... and many people will be eligible for government subsidies.

An estimated 48 percent of people on the individual market will be eligible for tax credits to reduce their costs, based on their income level.

Obamacare: Making Lemonade

Responding to: PERSPECTIVE

The ACA and High-Deductible Insurance — Strategies for Sharpening a Blunt Instrument

J. F. Wharam and Others

N Engl J Med 369:1481, October 17, 2013

The authors point out the real and predictable failings of a market-based health care system: it costs too much (duh).  And they suggest more market-based reforms to fix the problems of unaffordably high deductibles and co-pays in the Obamacare health insurance exchanges (premiums could be lower too).  California is perfectly poised to leverage the situation by taking the obvious next step towards a single payer system (a goal for 2017): authorize the elected Insurance Commissioner to set the prices of the health insurance plans. The legislation's been introduced and almost passed several times.  The Exchanges have already whittled down the insurance plans to only a few left standing, and set compulsory enrollment, and standardized benefits. Chopping their rates and profits gets pretty close to the role health insurance plans already now play in Medicare, as third party administrators.  

Ellen Shaffer in the Media

Dr Ellen Shaffer reacts to the United States Government being shutdown

Cameron Green speaks to Co-Director of the Centre for Policy Analysis Dr Ellen Shaffer
ABC NewsRadio Afternoons - Last updated 16:07 Duration 7:12

ABC Australia 9-30-13

http://www.abc.net.au/newsradio/listen/

 

 

Impact of the Shutdown! Economic and Healthcare

The Point Is

Sue Hilderbrand, KZFR, Chico, CA

http://kzfr.org/broadcasts/view/328

6:00pm, 10-2-2013

comment

The government shutdown will be the topic of conversation from the economic impacts to how long it may last.  Christian Dorsey, of the Economic Policy Institute, will talk about how the shutdown effects the lives of real people (as opposed to politicians and the next election) and the politics behind it.  Dr. Ellen Shaffer, UCSF, will talk about how the Affordable Care Act (ACA) is being impacted, if at all, and how the ACA will impact the lives of millions of currently uninsured Americans. 

Shaffer in AJPH on the Affordable Care Act: The Value of Systemic Disruption

AJPH: The ACA; Value of Systemic Disruption – Ellen R Shaffer

It is important to recognize the political and policy accomplishments of the Patient Protection and Affordable Care Act (ACA), anticipate its limitations, and use the levers it provides strategically to address the problems it does not resolve.  Passage of the ACA broke the political logjam that long stymied national progress toward equitable, quality, universal, affordable health care. It extends coverage for the uninsured, who are disproportionately low income and people of color, curbs health insurance abuses, and initiates improvements in the quality of care.   However, challenges to affordability and cost control persist.
 
Public health advocates should mobilize for coverage for abortion care and for immigrants, encourage public-sector involvement in negotiating health care prices, and counter disinformation by opponents on the right.

Tables in the article summarize major changes in coverage, insurance company protections, and quality/affordability.

 (Am J Public Health. Published online ahead of print February 14, 2013: e1–e4. doi:10.2105/ AJPH.2012.301180

Best tweet of the night

MR summary: Mexican drug lords use Obamacare 2 buy guns frm Libyan terrorists 2 sell 2 single moms who dont have time to make dinner

Arrogant, racist Romney could not believe that the President actually remembered accurately his own statement in the Rose Garden labeling the Libyan incident an act of terrorism.  And still didn't believe it til Candy Crowley confirmed it.  (He didn't ask if she was married.)

Women, Choice and Power

Turns out, women are a key voting bloc in the upcoming election. It's up to us not only to get each other engaged, and voting. but to demand credible commitments that address our concerns.

Here are our choices heading into the political conventions:

A Republican Party fueled with unprecedented gushers of corporate cash that draws political life support from the medieval wing of several fundamentalist religions, whose fantastical beliefs about women's biology are rooted in their ironclad devotion to patriarchy.

A Democratic Party also overly dependent on the parasitic finance sector, that is now reaching back to the Lily Ledbetter Equal Pay Act of 2009 to symbolize its commitment to women's economic empowerment. It depends for political fuel in no small part on the indisputable fact that the Republicans are profoundly scary.

Polls show the 2 running neck in neck.

In fact, this election offers women a clear choice. The Republican platform would make criminals of the 30% of American women who've had an abortion (including me, once because of a fetal anomaly diagnosed in my second trimester). The Affordable Care Act, which Paul Ryan has voted repeatedly to repeal, assures more affordable birth control and extends Medicare's financial health, in contrast to Ryan's proposal to privatize it.

But it's not enough to debunk the opposition's lies, or to point out that they rely on stoking fear and anger. Some recent polls of women who are not politically active show that they do react viscerally to the demeaning insults slung by decision-makers they perceive as "mean, old, white men." But they are living difficult lives, bounded not only by state legislatures that snatch away their birth control and penalize them for their reproductive decisions, but by extensive financial hardship. One quote: "I'm happy this month that I haven't had to sell plasma to feed my children."

So here are some things to call for in Charlotte:

1. An iron clad commitment to preserving and protecting Social Security and Medicare. These two programs form the bedrock of women's financial security as we age. They are under attack explicitly by the Republicans. And too frequently for comfort, our side also periodically lip synchs the lies about the needs to reform these "entitlements." Let's hear Sen. Majority Leader Harry Reid and future House Speaker Nancy Pelosi confirm that the programs are solvent, and that they will not compromise on preserving and improving these programs.

2. It's great that Nancy Keenan of NARAL and Cecile Richards of Planned Parenthood will be speaking. Women's rights to make their own decisions about their reproductive health are fundamental to our economic and personal wellbeing, including access to legal, affordable birth control and abortion. We hope their introductions will include words of support from HHS and the Surgeon General.

3. Finally: Lots of women. On the podium, speaking, in charge, active, visible, and vocal. Women of all races, and for that matter, candidates for races. We know who the top ticket nominees are. Let's give a boost to the EMILY's List all-star roster of pro-choice Democratic women candidates, people like Maggie Hassan for governor of New Hampshire, Congressional candidates like Grace Meng, Christie Vilsack, Val Demings, and Tammy Duckworth, and Elizabeth Warren and Tammy Baldwin for Senate, and of course, incumbent Sen. Claire McCaskill. Since Canadian-born former governor Jennifer Granholm can't run for president, nominate her now for a Cabinet post, if she wants one, and give her air time.

We're going to write checks, emails and op eds, as well as getting out the vote. We have power. Let's recognize and exercise it.

Paul Ryan: Marching Backwards on Medicare

Let's get one thing perfectly straight:  Paul Ryan wants to end Medicare.

His 2012 proposal is less straightforward about it than his 2011 proposal.

It would, nevertheless, end Medicare. And the Affordable Care Act.

Single payer/Medicare for All?  Fuhggedaboudit.

Here's  quick back-of-the-envelope on how it shapes up:

Features	Medicare Now	Old Ryan Plan	"New" Ryan Plan
Age you are eligible	65	67, increase starting 2023	67, complete by 2034
Privatization initiatives	Drug plan, Medicare Advantage	Vouchers for everyone	Vouchers phased in
Extra costs to seniors	Baseline	$6,000 a year	?
Medicare as % of Federal expenditures	6.5%	?	4.5%
Savings mechanisms	ACA: IPAB, primary care,  EMRs, ACOs	Vouchers: Individual seniors control costs through purchases	Vouchers: Individual seniors control costs through purchases + Insurance industry competition

Do we need to do more to improve and expand Medicare? Indeed. But Ryan would double down on disaster.

On Medicare for All, he had this exchange with reporter Sam Husseini, published June 13, 2011:

Sam Husseini: If you’re a fiscal conservative and you want to provide a safety net, why wouldn’t you be for something like a single-payer health care system?

Paul Ryan: I think a single-payer health care system would be a disaster for people who need health-care the most. I think it would cause rationing, waiting lines. I think it would be a fiscal house of cards, I think it would help accelerate a national debt crisis and hurt the economy.

Husseini: Wouldn’t it save a lot of money and cover everybody?

Ryan: Absolutely not. I totally and fundamentally disagree with it. I believe that you can have affordable access to healthcare for all Americans, including people with pre-existing conditions, without a government takeover of the healthcare sector. If we actually have government-run healthcare, what I think you’ll have is government managing, government-rationing healthcare. I think that will be a fiscal disaster, I think that it would accelerate a debt crisis that would slow our economy and take jobs and economic growth from those people that need it the most, which are people who are out of work.

Husseini: Doesn’t Medicare have a much lower — 2 or 3 percent — overhead compared to the insurance companies? Which — insurance companies –

Ryan: — That’s an apples and oranges comparison. If you take a look at Medicare itself, Medicare is going bankrupt.

Husseini: That’s the healthcare system in general that’s going bankrupt.

Ryan: There are three facts about medicare that you simply can’t dispute: 10,000 seniors are retiring everyday with fewer workers going into the workforce to pay for them; healthcare costs are skyrocketing at about four times the rate of inflation, which threatens medicare’s ability to give affordable care; and number three, the non-partisan experts agree that Medicare is going bankrupt. So Medicare’s status quo is bankruptcy and that threatens healthcare not only for current seniors but obviously for future seniors, so I believe a patient-centered healthcare system — reforms that put the patient at the center of the healthcare system, not the government — are the best for people who need healthcare and they’re best for the economy, and they’re the best way to avert a debt crisis.

Husseini: But isn’t the problem with healthcare fundamentally the corporate structure? I mean your biggest funders are a who’s who — Northwestern Mutual –

Ryan: — Which is a big employer in Milwaukee by the way —

Husseini: — Aurora Health Care, Abbott Laboratories, Credit Suisse — the insurers — [see "Paul Ryan's Health Industry Ties..." Humana Inc., Blue Cross/Blue Shield and Aetna]

Ryan: — Government-run healthcare doesn’t work. Wherever we’ve seen government-run healthcare, it’s failed.
Husseini: You think that people are worse off in France and Canada?

Ryan: I think we’re worse off if we go with a government healthcare system that will cost us jobs, it will increase our deficit and our debt and I do believe, and I put ideas on the table that show, that we can get to a patient-centered healthcare system that helps create jobs, that helps get healthcare costs under control, and gives everybody affordable healthcare coverage for everyone regardless of income or pre-existing conditions.

Husseini: You think poor people in Europe are worse off than poor people here?

Ryan ends questioning here.

Mr. President: Campaign on Health Care Reform!

Dear Mr. President:  
You won on health care.  Campaign on it.

You won historic legislation in 2010. Your advisors told you to change the subject and campaign on the economy.  You lost the mid-term elections, big time.

 
You won a victory in the Supreme Court this week. The same advisors who counseled you then are at it again. I don't know what economic accomplishments they think you should run on.  I know a few things about what you've done in health care.

The Affordable Care Act instituted system reforms in how we pay doctors, and how they practice medicine, that are reducing the actual cost of health care. This is tremendous news.  It is not showing up yet in reduced insurance premiums.  But your law makes it possible to do so.

 
Health care spending growth has slowed from double digits to 4% or lower. Further, hospital admissions are down, even among insured people. Writing in Health Affairs in April Kenneth Kaufman states that "independent of the recession, other fundamental and structural changes are likely contributing to the flattening of the cost curve, and further, these changes have the potential to significantly alter the curve’s path into the future."
 
Kaufman quotes Jeff Goldsmith, Ph.D., President of Health Futures, Inc., who "suggests that the makeup and organization of the nation’s physicians is one source of the slowing cost growth. Physicians of the past 30 years typically practiced in solo or small group practices. Under the fee-for-service system, they were incentivized to work long hours, see as many patients as they possibly could, and buy into labs, ambulatory clinics, and specialty hospitals. As a result, they tended to be high users of inpatient and outpatient services. These more entrepreneurial physicians are now reaching retirement age and many tens of thousands are opting to exit the workforce. Replacing them are physicians of a new generation, which has different work and lifestyle expectations. For many younger physicians, owning a practice is not as important as having time to spend with the family and a steady, predictable income.

"One effect is that physicians have sought employment by hospitals...and in larger group practices, many of which now employ hundreds of doctors. They are practicing medicine in ways that remove utilization and cost from the system. Protocols to reduce variation in care delivery, chronic disease management, case management, and other approaches are increasingly being adopted by physicians nationwide. Larger practices owned by hospitals and other entities will have the capital and human resources required to successfully reduce care costs through such approaches, slowing health-spending growth going forward."

 
Other efforts include "moving from an activity-based business model that incentivizes utilization of services to a value-based model that incentivizes population health management across the continuum of care,"
 
Why aren't we seeing lower insurance premiums, then? 
 
First, the insurance industry isn't yet sufficiently regulated.  The Exchanges starting in 2014 will make regulation more likely.  States can use the ACA now to regulate on their own.  A progressive new Congress could create a competing public option, and allow states to create entirely public financing systems like Medicare.  Secondly, the system reforms are not yet universal.  In fact, some physicians are turning to "boutique" practices where they can take only wealthy patients who will continue to pay whatever high fees the docs require to maintain their incomes.

The political good news is that the opposition program will clearly hurl us right back into the days of double-digit health care cost inflation, while cutting seniors and others out of access to care. Surely impressive information for the American people.

The Ryan/Romney proposals would turn Medicare and Medicaid into voucher systems.  Every person would get a coupon worth a certain dollar amount, and go out and look for the best deal from doctors, hospitals, and drug companies.  This means bringing the kind negotiations from the car dealership to the hospital every time we and our families get sick.  For most rational Americans, not an appealing prospect.  It is certainly the end of Medicare.

 
The opposition hounded Dr. Don Berwick out of his position as administrator of the Medicare program, precisely because of his expertise in the kind of system reforms that are now working.
 
Mr. President, you need to stand with the many patients already benefiting from the improved coverage and consumer protections provided by the ACA, and fight for a second term that will propel us forward towards universal, affordable health care.

  

Single payer declared as Supremes nix mandate

On the heels of the Supreme Court decision on June 15, 2012, invalidating the individual mandate provisions of the health care reform law, the President and Congress took swift action to implement a Single Payer system. Asked to define a single payer system, the President said, "Well, you know, sort of like Medicare."

Long time health policy analyst and reform advocate Ellen Shaffer noted that the surprising transition had occurred subsequent to the following events:

Massive demonstrations now known as the Grrl/Geezer/PanEthnic Spring erupted throughout the country, responding to the failure of the U.S. political system to take effective action in the face of shifts in the global economy, devastating losses of jobs and income security, demographic changes, and the degradation of human and environmental health.

Shocked by racially motivated police actions, the laser-like focus of increasingly unhinged legislators on humiliating women in the name of ending "government tyranny," and the closure of community colleges, the cross-generational coalition used phone trees and social media to call on the Fed Up across the political spectrum to exercise personal responsibility by showing up and uniting.

The uprising derailed widespread expectations that a negative decision on the mandate would likely add momentum to the information-free right wing, relegating further effective health care reform to the back burner for decades.

The reform program demanded identifying and implementing the best practices from around the world for economic innovation and growth compatible with human health and environmental sustainability, including models in the U.S., Germany, Brazil, Argentina, China, and India, and an end to energy dependence on oil. The new health care system will draw from the effective Cuban model of primary care available in schools, communities and workplaces, using U.S. information technology to coordinate care, implemented by professionals in non-hierarchical categories, who reflect the populations of their communities. Health care and education - including for health professions - will be entirely publicly subsidized, and housing prices stabilized at 1990 levels.

Communications were transferred to the Stewart/Colbert/Maddow network, in partnership with Our Bodies Ourselves, radio KKCR /Kauai and radio KPOO/San Francisco. The Defense Department was eliminated, with the resulting financial windfall redirected to the lifetime care of military veterans.

The top .01% of the U.S. wealthy were given the option of life at sea with video simulation games stroking their egos, and periodic air-lifts of supplies; or 5 years of pro-bono work as classroom assistants in newly revitalized elementary schools.

Opposition to the health care program was promptly abandoned by the health insurance, hospital, medical, drug and information technology industries, as well as by the labor movement and its trust funds and by the Chamber of Commerce. Karen Ignani announced her retirement, and PNHP admitted that it wasn't really all Liz Fowler's fault, energizing an explosion of critical and strategic thinking.

Supreme Court Hears Challenges to Affordable Care Act - Your Comments?

The Supreme Court hears challenges to the Affordable Care Act this week. Below, the Court’s links to hearing the proceedings; and a summary of the questions at issue from the NY Times. Please use the Comments space below to post your own succinct, relevant and illuminating comments on this historic debate, and links to other resources.

http://www.supremecourt.gov/publicinfo/press/viewpressreleases.aspx?FileName=pr_03-16-12.html

The Court will hear argument in the Patient Protection and Affordable Care Act cases on March 26, 27, and 28. Because of the extraordinary public interest in those cases, the Court will provide the audio recordings and transcripts of the oral arguments on an expedited basis through the Court’s Website.

The Court will post the audio recordings and unofficial transcripts as soon as the digital files are available for uploading to the Website. The audio recordings and transcripts of the March 26-28 morning sessions should be available no later than 2 p.m. The recording and transcript of the March 28 afternoon session should be available no later than 4 p.m.

Anyone interested in the proceedings will be able to access the recordings and transcripts directly through links on the homepage of the Court’s Website. The homepage currently provides links to the orders, briefs, and other information about the cases. The Court’s Website address is http://www.supremecourt.gov/.
http://www.nytimes.com/interactive/2012/03/19/us/guide-to-supreme-court-challenges-to-obama-health-care-law.html?ref=background

A Guide to the Supreme Court Challenges to Obama’s Health Care Law

Over three days starting March 26, the Supreme Court will hear arguments in an appeal from a decision largely ruling for 26 states, a business group and several individuals who contend that the 2010 health care law, President Obama’s signature legislative achievement, is unconstitutional. Related Article »

The Question: Is it too early to consider this case since the health law’s penalties do not start until 2014?

The central provision of the health care law, often called the individual mandate, requires most Americans to obtain health insurance or, starting in 2014, face a penalty.

A 19th-century law, the Anti-Injunction Act, forbids challenges to tax assessments until they are due, barring suits “for the purpose of restraining the assessment or collection of any tax.” The Supreme Court had interpreted the term “tax” very broadly for purposes of the law, and it has suggested that the act is “jurisdictional,” meaning that courts are powerless to hear suits barred by it even if both sides agree to proceed.

If the Supreme Court considers the individual mandate a tax under the Anti-Injunction Act, it may conclude that it cannot hear a challenge until April 15, 2015, when the first penalties become due.
The United States Court of Appeals for the Fourth Circuit and a dissenting judge on the District of Columbia Circuit agreed that the act requires courts to defer consideration of the challenge to the individual mandate.

The federal government initially argued that the act applied to bar the challenges, but it has changed its mind and now asks that the suits be allowed to proceed, agreeing with its opponents on this point. The states challenging the law say the act does not apply to them, as opposed to individuals, in any event. Because all of the parties agree that the Supreme Court may hear the case, the justices appointed a lawyer to argue that the act applies.

Among the questions the Supreme Court is likely to consider in connection with the act are whether a challenge to the mandate is the same thing as a challenge to how it is enforced, whether the penalties imposed by the health care law are taxes and whether the act is an inviolable jurisdictional command to courts.

Congress remains free, now or later, to amend the act to allow challenges to the health care law.

Date of Hearing: March 26
Time Allotted: 90 minutes

40 min.: Robert A. Long, friend of the court, appointed to argue that the suit is barred.
30 min.: Solicitor General Donald B. Verrilli Jr. says the challenges may go forward.
20 min.: Gregory G. Katsas, representing the National Federal of Independent Business and other private parties, agrees with the government on this point.

The Question: Is the individual mandate constitutional?

This is the heart of the case. The lower courts issued conflicting decisions in the numerous challenges to the health care law, and the Supreme Court agreed to hear an appeal from only one of them, from the United States Court of Appeals for the 11th Circuit, in Atlanta. That decision struck down the mandate. In contrast, the Sixth Circuit, in Cincinnati, and the District of Columbia Circuit upheld the law, while the Fourth Circuit, in Richmond, Va., said the constitutionality of the law was not yet ripe for review.

The federal government argues that Congress was authorized to enact the individual mandate under two provisions of Article I, Section 8 of the Constitution — its power to regulate commerce and its power to tax. The leading Supreme Court precedents support the mandate, too, the government says, because the health care law addresses a pressing national problem that is economic in nature.

Opponents of the law say that the requirement to buy a product or service is unprecedented, regulates inactivity rather than activity and would allow Congress essentially unlimited power to intrude on individual freedom. They say the government cannot articulate a principle that would limit its power were the law upheld.

Date of Hearing: March 27
Time Allotted: 2 hours

60 min.: Solicitor General Donald B. Verrilli Jr. defends the law.
30 min.:Paul D. Clement, representing 26 states, challenges the law.
30 min.:Michael A. Carvin, representing the private parties, challenges the law.

The Question: If the individual mandate is ruled unconstitutional, must the rest of the health law fall as well?

Should the Supreme Court strike down the individual mandate, it must decide whether some or all of the balance of the law must fall as well.

Though the lower-court ruling issued by the 11th Circuit determined that Congress had exceeded its constitutional authority in enacting the individual mandate, it said the balance of the law survived. Neither side agrees. The government argues that two provisions requiring insurance companies to accept all applicants at fixed rates are intertwined with the mandate and must fall along with it.

Opponents of the law say the mandate is its keystone, meaning that no part of the law can survive without it. Here, too, the Supreme Court has appointed a lawyer to argue a position that neither party advances – that the mandate may be surgically removed if the court holds it unconstitutional.

Date of Hearing : March 28
Time Allotted: 90 minutes

30 min.: Paul D. Clement, representing 26 states, argues that the entire law must fall.
30 min.: Deputy Solicitor General Edwin S. Kneedler argues that most of the law should survive, even if the mandate is struck down.
30 min.: H. Bartow Farr III, friend of the court, appointed to defend the ruling that struck down only the mandate.

The Question: Was Congress entitled to impose conditions on the states in expanding the Medicaid program?

The sprawling 2010 law contains many provisions not directly in front of the court. But the justices did agree to hear a challenge to a provision relating to Medicaid, a challenge by the 26 states that argues that Congress exceeded its constitutional authority by expanding the eligibility and coverage thresholds that states must adopt to remain eligible to participate in the joint federal-state program that provides health care to poor and disabled people.

The problem, they say, is that Congress did not tie the law’s new conditions only to new federal money but rather made the new terms a condition of continued participation in Medicaid, threatening states with the loss of all federal Medicaid funds.

The federal government argues that such shifting conditions are routine in all sorts of federal programs and that the Medicaid program itself specified at the outset that the rules could change.

Date of Hearing: March 28
Time Allotted: 1 hour

30 min. Paul D. Clement, representing 26 states, challenges the law.
30 min. Solicitor General Donald B. Verrilli Jr. defends the law.

Links to Briefs:
http://www.americanbar.org/content/aba/publications/preview_home/11-398_Anti-InjunctionAct.html
http://www.americanbar.org/content/aba/publications/preview_home/11-398.html (minimum coverage)
http://www.americanbar.org/content/aba/publications/preview_home/11-5683.html Medicaid expansion; consolidated

The Court heard arguments today, Monday, March 26, 2012, on the Anti-Injunction Act issue of the Patient Protection and Affordable Care Act cases. (Dept. of H&HS v. Florida, 11-398) The audio recording and unofficial transcript of the oral argument on the Anti-Injunction Act issue are available at this link: http://www.supremecourt.gov/oral_arguments/argument_audio_detail.aspx?argument=11-398-Monday

For Trayvon Martin: Now Imagine

http://www.imdb.com/title/tt0117913/quotes

From "A Time to Kill," 1996.  Matt McConaughey as lawyer Jake Tyler Brigance, presents the summation defending his black client for attacking his daughter's rapists:

Jake Tyler Brigance: [in his summation, talking about Tonya Hailey] I want to tell you a story. I'm going to ask you all to close your eyes while I tell you the story. I want you to listen to me. I want you to listen to yourselves. Go ahead. Close your eyes, please. This is a story about a little girl walking home from the grocery store one sunny afternoon. I want you to picture this little girl. Suddenly a truck races up. Two men jump out and grab her. They drag her into a nearby field and they tie her up and they rip her clothes from her body. Now they climb on. First one, then the other, raping her, shattering everything innocent and pure with a vicious thrust in a fog of drunken breath and sweat. And when they're done, after they've killed her tiny womb, murdered any chance for her to have children, to have life beyond her own, they decide to use her for target practice. They start throwing full beer cans at her. They throw them so hard that it tears the flesh all the way to her bones. Then they urinate on her. Now comes the hanging. They have a rope. They tie a noose. Imagine the noose going tight around her neck and with a sudden blinding jerk she's pulled into the air and her feet and legs go kicking. They don't find the ground. The hanging branch isn't strong enough. It snaps and she falls back to the earth. So they pick her up, throw her in the back of the truck and drive out to Foggy Creek Bridge. Pitch her over the edge. And she drops some thirty feet down to the creek bottom below. Can you see her? Her raped, beaten, broken body soaked in their urine, soaked in their semen, soaked in her blood, left to die. Can you see her? I want you to picture that little girl.

Now imagine she's white.