Posts Tagged ‘Obama’

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More inexplicable behavior.

Monday, September 21st, 2009

The Obama administration continues its inexplicable campaign against Honduras. Today, the WSJ astute columnist, Mary Anastasia O’Grady, tries to make some sense of the policy.

The Congressional Research Service has analyzed Obama’s claims that the Honduran Supreme Court was part of a “coup d’etat” in removing lame duck president Zelaya.

“The Supreme Court of Honduras has constitutional and statutory authority to hear cases against the President of the Republic and many other high officers of the State, to adjudicate and enforce judgments, and to request the assistance of the public forces to enforce its rulings.”

—Congressional Research Service, August 2009

No help there for Obama.

Ever since Manuel Zelaya was removed from the Honduran presidency by that country’s Supreme Court and Congress on June 28 for violations of the constitution, the Obama administration has insisted, without any legal basis, that the incident amounts to a “coup d’état” and must be reversed. President Obama has dealt harshly with Honduras, and Americans have been asked to trust their president’s proclamations.

Now a report filed at the Library of Congress by the Congressional Research Service (CRS) provides what the administration has not offered, a serious legal review of the facts. “Available sources indicate that the judicial and legislative branches applied constitutional and statutory law in the case against President Zelaya in a manner that was judged by the Honduran authorities from both branches of the government to be in accordance with the Honduran legal system,” writes CRS senior foreign law specialist Norma C. Gutierrez in her report.

Do the facts matter? Fat chance. The administration is standing by its “coup” charge and 10 days ago, Secretary of State Hillary Clinton went so far as to sanction the country’s independent judiciary. The U.S. won’t say why, but its clear the court’s sin is rejecting a U.S.-backed proposal to restore Mr. Zelaya to power.

Why is Obama doing this? Is Hugo Chavez that close an ally ? The Hondurans know they do not want to live in another Venezuela.

But it may be that Americans should be even more concerned about the heavy-handedness, without legal justification, emanating from the executive branch in Washington. What does it say about Mr. Obama’s respect for the separation of powers that he would instruct Mrs. Clinton to punish an independent court because it did not issue the ruling he wanted?

Since June 28, the U.S. has been pressuring Honduras to put Mr. Zelaya back in the presidency. But neither Mrs. Clinton’s spurious “rule of law” claims or the tire iron handed her by Mr. Obama to use against this little country have been effective in convincing the Honduran judiciary that it ought to abandon its constitution.

It seems that Mrs. Clinton is peeved with the court because it ruled that restoring Mr. Zelaya to power under a proposal drafted by Costa Rican President Oscar Arias is unconstitutional. Thus, the State Department decided that in defense of the rule of law it would penalize the members of the Supreme Court for their interpretation of their constitution. Fourteen justices had their U.S. visas pulled.

Now, Obama’s own Congressional Research Service denies he legal basis for his action. There are ways to show Honduras that we support them and that our national government does not represent the opinion of the people. Zelaya is now claiming to be back in the country, perhaps hiding in the Brazilian embassy.

Mr. Zelaya, a close ally of Venezuela’s populist President Hugo Chávez, was ordered arrested by Honduras’s Supreme Court in June after he pushed an illegal constitutional rewrite that critics worried would have allowed him to stay beyond his term. But the soldiers sent to arrest him feared his detention would spur bloodshed and instead put him on a plane to exile, also violating the country’s constitution.

Mr. Chávez on Monday hailed Mr. Zelaya’s return and said his oil-rich country stood ready to help him return to power. “Now let’s do what we have to do,” Mr. Chávez told Venezuelan TV.

In Washington, the Organization of American States, which suspended Honduras shortly after Mr. Zelaya’s ouster, said it was holding an emergency session to deal with the ousted president’s surprise return.

In Tegucigalpa, people were nevous but calm, said Moises Starkman, an adviser to the interim government. Others said they didn’t believe Mr. Zelaya’s words about having come in peace. Now, we are siding with leftist dictators.

Here is a blog with links to organizations in Honduras.

Here is a list of organizations that will get help to the people of Honduras.

UPDATE: More pro-Honduras sites.

I don’t know what is the matter with Obama. He seems more comfortable with ACORN than democracy. He grants visas to Burma’s dictators but not to elected representatives of Honduras. It’s almost like he doesn’t like democracy.

There is more here about Zelaya and his media campaign.

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Implausible deniability

Monday, September 21st, 2009

The Obama administration seems to be well on the way to surpassing the record for ineptitude of the Carter administration. Its actions in the ballistic missile defense situation in eastern Europe are about as bad as it can get.

UPDATE: There is another theory about Obama’s actions. It is that his actions are deliberate gestures and indicate his contempt for the US allies he insults.

We must keep in mind the fact that Obama is not a yokel and that the State Department is there to prevent an ill-informed president from unnecessarily stepping on toes. What happened last Thursday was a deliberate gesture. It was aimed at our allies in eastern Europe and at Russia, and it was recognized as such in Poland, the Czech Republic, and Russia. Vladimir Putin spoke of Obama’s decision as a courageous act. Our friends in eastern Europe would not have used that adjective. A signal has been given, and they know the meaning.

We are living in a dangerous time. It seems highly unlikely that Barack Obama will get his way in domestic affairs. The Democrats may control Congress, but they now fear a rout in 2010, and they are likely to tread with caution from now on. In foreign affairs, however, presidents have a relatively free hand, and this president has ample time to do damage to a country that, there is reason to suspect, he deeply hates.

I don’t know if this is a credible explanation but nothing in American history so far explains these actions.

Last week the Obama administration announced that it was reconfiguring U.S. plans for ballistic missile defense (BMD) in Europe, beginning with halting plans for installations in Poland and the Czech Republic. The shift would include an increased emphasis on Aegis-equipped warships already being upgraded to BMD capability that would patrol the waters of the North Sea and Mediterranean. At a press conference last Thursday, U.S. Secretary of Defense Robert Gates emphasized the technical rationale for the decision: The assessment of Iran’s ability to develop an intercontinental ballistic missile had shifted, indicating that the development of such a missile is a long way off; this new scheme would protect Europe, which was still at risk and would continue to be vulnerable; and the new scheme would be in place sooner and ultimately would be more effective.

As it happened, technology aside, the decision met one of Russia’s ongoing demands — that the United States should not base BMD installations in Poland and the Czech Republic. However, Gates stated that “Russia’s attitude and possible reaction played no part in my recommendation to the president on this issue. Of course, considering Russia’s past hostility toward American missile defense in Europe, if Russia’s leaders embrace this plan, then that will be an unexpected — and welcome — change of policy on their part.”

This is unbelievable and is a cause for worry that the Russians will perceive this statement as worse than weakness.

U.S. President Barack Obama insisted that the decision had nothing to do with the Russians, saying it was merely a bonus if Russia’s leaders ended up “a little less paranoid” about the United States. Speaking to CBS’s “Face the Nation,” Obama said, “My task here was not to negotiate with the Russians. The Russians don’t make determinations about what our defense posture is.”

If Gates and Obama are to be believed, the decision to halt deployment in the Czech Republic and Poland was made without any consideration of Russian views whatsoever. It was simply the result of technical and military analysis, and the question of how the major power in the region — Russia — might react simply wasn’t considered.

Once again, this is simply not credible.

The issue is not, as the president has put it, one of Russian paranoia. The Russians might well be paranoid, but that paranoia is not a matter of incidental importance to the United States. Unless the United States is abandoning the idea of sanctions and moving to accept Iran as a nuclear power, or has already made the decision to strike Iran, Russia — paranoid or not — is important to the United States. We suspect that it crossed someone’s mind that in making this move now, the United States would be capitulating to a major Russian demand.

Certainly, it could not have escaped the administration’s attention that the decision, regardless of how it was made, would be seen by all as a response to the Russians. This is how the Poles and Czechs saw it; it is how the Russians saw it; it is how any reasonable observer would have seen it. That’s because this was a core Russian demand and because the announcement came two weeks before the meetings on Iran.

Is Obama really this incompetent?

In foreign policy, it is always important to be prepared to pretend that the elephant is not in the room. But there has to be a touch of plausibility to the pretense. In this case, the problem is that the administration’s description of how it made this decision indicates breathtaking incompetence. In saying they took the decision without considering diplomatic consequences, U.S. officials are claiming the administration doesn’t know how to play major league ball — and seem proud of that.

Maybe he is really this incompetent. Let’s look at Israel, another erstwhile ally. Obama promised change we could believe in and he has been as good as his word .

U.S. relations with Israel have had their minor bumps, but Israeli trust of America and respect for the American president have been constant. This was true whether the president was Nixon or Carter, Clinton or George W. Bush.

As a result, Israeli prime ministers — even crusty old war horses like Yitzak Shamir and Ariel Sharon — have struggled mightily to remain on good terms with the U.S. president. It can be argued that when a brash young Benyamin Netanyahu got on President Clinton’s bad side, the price was his office.

But in nine months all of this has changed. A recent survey sponsored by the Jerusalem Post showed that only 4 percent of Israelis believe that President Obama’s policies are more pro-Israel than pro-Palestinian. Considering that the margin of error in the poll was 4.5 percent, one might wonder whether any Israeli, or at least any Israeli Jew, believes Obama is on the side of America’s long-time ally.

Meanwhile 51 percent of those polled believe that Obama’s policies are more pro-Palestinian than pro-Israel. When more than half of the Israeli population believes that the American president tilts towards their sworn enemies, it’s fair to say that Obama has produced a sea-change in this small but important corner of the world.

But this is only the beginning of “change you can scarcely believe” in Israel. For decades Israelis have been bitterly divided, often more or less down the middle, over politics. And throughout much of this period, Benyamin Netanyahu has been among the most divisive Israeli politicians.

When Netanyahu formed a largely “right-wing” coalition government earlier this year, his regime was considered fragile even by Israeli standards. But then the Obama administration insisted that Israel halt all new construction in West Bank settlements, including construction of new homes within large settlements to accommodate natural population. Then it protested plans to build a new apartments in East Jerusalem.

When Netanyahu rejected these demands, his popularity soared. Obama had transformed the least lovable of all Israeli politicians into a leader around whom a strong majority of Israelis could rally.

How has Obama’s change in policy affected the Arabs, his preferred partners in the middle east ? There is no sign of any positive response as the Arabs worry much more about Iran than about Israel, rhetoric notwithstanding. They see the same weakness in Obama as he considers abandoning Afghanistan and accepting Iran as a nuclear power.

This will not end well.

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Posted in Europe, Israel, politics | 1 Comment »

Why “Shall Issue” rules are a disaster.

Wednesday, September 16th, 2009

There is considerable speculation that the Obama administration, desperate for some sort of health bill to pass, will choose to bash health insurance with an “insurance reform” bill. What is this likely to look like ? What does the Baucus bill say ?

Like other proposals in circulation, Baucus’ plan would require insurance companies to sell coverage to all seeking it, without exclusions for pre-existing medical conditions or prohibitively expensive premiums. The Maine experience should be of interest here. Maine has insurance exchanges, shall issue rules that do not allow insurance companies to turn down applicants with pre-existing conditions, and it has been in existence for six years. How did that work out ?

In 2003, the state to great fanfare enacted its own version of universal health care. Democratic Governor John Baldacci signed the plan into law with a bevy of familiar promises. By 2009, it would cover all of Maine’s approximately 128,000 uninsured citizens. System-wide controls on hospital and physician costs would hold down insurance premiums. There would be no tax increases. The program was going to provide insurance for everyone and save businesses and patients money at the same time.

After five years, fiscal realities as brutal as the waves that crash along Maine’s famous coastline have hit the insurance plan. The system that was supposed to save money has cost taxpayers $155 million and is still rising.

Hmmm

Then the state created a “public option” known as DirigoChoice. (Dirigo is the state motto, meaning “I Lead.”) This plan would compete with private plans such as Blue Cross. To entice lower income Mainers to enroll, it offered taxpayer-subsidized premiums. The plan’s original funding source was $50 million of federal stimulus money the state got in 2003. Over time, the plan was to be “paid for by savings in the health-care system.” This is precisely the promise of ObamaCare. Maine saved by squeezing payments to hospitals and physicians.

The program flew off track fast. At its peak in 2006, only about 15,000 people had enrolled in the DirigoChoice program. That number has dropped to below 10,000, according to the state’s own reporting. About two-thirds of those who enrolled already had insurance, which they dropped in favor of the public option and its subsidies. Instead of 128,000 uninsured in the program today, the actual number is just 3,400. Despite the giant expansions in Maine’s Medicaid program and the new, subsidized public choice option, the number of uninsured in the state today is only slightly lower that in 2004 when the program began.

That doesn’t sound like Obama’s promises, does it ?

The sickest, most expensive patients crowded into DirigoChoice, unbalancing its insurance pool and raising costs. That made it unattractive for healthier and lower-risk enrollees. And as a result, few low-income Mainers have been able to afford the premiums, even at subsidized rates.

This problem was exacerbated because since the early 1990s Maine has required insurers to adhere to community rating and guaranteed issue, which requires that insurers cover anyone who applies, regardless of their health condition and at a uniform premium. These rules—which are in the Obama plan—have relentlessly driven up insurance costs in Maine, especially for healthy people.

The Maine Heritage Policy Center, which has tracked the plan closely, points out that largely because of these insurance rules, a healthy male in Maine who is 30 and single pays a monthly premium of $762 in the individual market; next door in New Hampshire he pays $222 a month. The Granite State doesn’t have community rating and guaranteed issue.

So, this is an improvement ?

A program that was supposed to save money by reducing health-care waste and inefficiencies has seen a 74% increase in premiums. But even those inflated payments can’t keep the program out of the red.

This is a preview of Obamacare. These people must not read as the evidence that their plan won’t work is all around them.

Of course, the young voters who put Obama in e White House will pay through the nose. What’s not to like ?

A 2008 study by the Urban Institute found that more than 10 million young adults ages 19 to 26 lack health insurance coverage. For many of those people, health-care reform would offer the promise of relatively inexpensive individual policies, which do not exist in many states today.

The trade-off is that young people would no longer be permitted to bet on their good health: All the reform legislation before Congress would require individuals to buy at least minimal coverage.

Another bill will be introduced Wednesday by the chairman of the Senate Finance Committee. Sen. Max Baucus (D-Mont.) will offer in it a proposal to keep premiums manageable: a bare-bones catastrophic policy that would protect young people from financial calamity while providing basic preventive care.

Drafting young adults into any health-care reform package is crucial to paying for it. As low-cost additions to insurance pools, young adults would help dilute the expense of covering older, sicker people. Depending on how Congress requires insurers to price their policies, this group could even wind up paying disproportionately hefty premiums — effectively subsidizing coverage for their parents.

Hey, I’m old. It sounds good to me.

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Posted in health reform | 3 Comments »

Is the race card next ?

Monday, September 7th, 2009

The LA Times today has a story about Obama’s fall in the polls, but why is this the headline ?

Obama is fast losing white voters’ support

Since whites constitute, depending on your opinion of whether Latinos are white (I think so), the vast majority of the population, any significant drop in Obama’s poll numbers would be a drop in white voters’ support. Blacks, who constitute 13% of the population, are unlikely to change their support. Whites, including Hispanics, are 80% of the population and so will always be the group most represented in polls. Why the headline ?

Among white Democrats, Obama’s job approval rating has dropped 11 points since his 100-days mark in April, according to surveys by the Pew Research Center for the People and the Press. It has dropped by 9 points among white independents and whites over 50, and by 12 points among white women — all groups that will be targeted by both parties in next year’s midterm elections.

“While Obama has a lock on African Americans, his support among white voters seems to be almost in a free fall,” said veteran Republican pollster Neil Newhouse.

OK, that’s fair.

But the drop in support among whites also comes as some conservatives have stoked controversies that have the potential to further erode Obama’s standing among centrists — including some controversies that resulted from White House stumbles.

One such episode came to a head Sunday when Van Jones, Obama’s green jobs czar, resigned after a week of criticism over past inflammatory statements and for signing onto conspiracy theories questioning whether the U.S. government played a role in the Sept. 11 attacks. A White House official acknowledged Sunday that Jones had been vetted less rigorously than other officials.

Still fair.

In another episode, some conservatives have criticized a White House dinner invitation issued to the lead lawyer in the American Civil Liberties Union lawsuits that have forced the government to disclose Bush-era interrogation techniques. The lawyer was invited to an event for the Muslim holiday of Ramadan.

That’s a weird story and I have never heard of this. If I haven’t heard of it, I doubt many others have either.

These controversies have followed conspiracy theories that the president was born overseas and is ineligible to hold office, and that his true religion is Islam — false rumors that some Democrats worry could be affecting the public’s view of the president and his party.

That’s a fringe story and, I suspect, included to discredit the right for concerns, legitimate concerns, about Obama’s agenda. So far, I have seen no major issue described in the story and there have been plenty.

Pew first identified a slippage in white support immediately after a news conference in July, when Obama surprised many by saying that a white police officer had acted “stupidly” in arresting a black Harvard professor.

Now, we see one of the serious concerns arise. A president on national TV attacks a police officer without knowing any facts except the race of the two parties.

One black congressman, Rep. Charles B. Rangel (D-N.Y.), was quoted last week alleging that opposition to Obama’s healthcare policies was “a bias, a prejudice, an emotional feeling.”

“Some Americans have not gotten over the fact that Obama is president of the United States. They go to sleep wondering, ‘How did this happen?’ ” Rangel said, according to the New York Post.

Actually, I haven’t gotten over the fact that Rangel, like many senior members of the administration, doesn’t pay his taxes and gets away with it. Now, we get back to the heart of the story:

Democratic pollster David Beattie conducted a survey last month in one competitive congressional district that found that more than a quarter of independents believed Obama had not proven his natural-born status. The same sentiment was expressed by nearly 6 in 10 Republican women — a group that Beattie said would be important for a Democratic victory.

He declined to name the district because the polling was private, but said that such questions about Obama’s background seemed to be a “proxy” for voters’ growing unease with Obama’s ambitious agenda, which has included a potential push to create a government-sponsored health insurance plan.

This is utter BS but evidence of the plan to discredit criticism by linking it to fringe conspiracy theories.

More than half of whites older than 50 approved of Obama’s job performance in April. But now, after weeks of Republican accusations that the Democrats would seek to cut Medicare benefits, that number is 43%. Among white Democrats, Obama’s approval rating dropped to 78%, from 89%.

Some Democrats are hopeful that Republican opposition to Obama may be firing up core conservatives but failing to win over even skeptical centrists and independents to the GOP cause.

I don’t think it took Republicans to make the point that Obama plans Medicare cuts after he has talked about his grandmother’s hip replacement, which he thought a waste, and giving pain pills to an elderly woman instead of a pacemaker. The Democrats in the Senate committee considering the health reform legislation are talking about $500 billion in cuts. It doesn’t take Republicans to say this:

Baucus has declined to release details. But people involved in the talks said the plan would make more than $500 billion worth of changes to Medicare over the next decade, charging wealthy seniors more for prescription drug coverage, cutting $120 billion in payments to private insurance companies that serve some seniors and trimming projected payments to hospitals by $155 billion in an effort to spur efficiencies.

The Times seems to be turning over the race card as a strategy in case Obama doesn’t pull the rabbit out of the hat this week with his speech. I don’t think he will and I think they will turn more and more to these stories to discredit the criticism.

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The Dutch change their health care system

Tuesday, August 18th, 2009

The Dutch system of providing healthcare has been advocated by President Obama in one of his speeches. Maybe he is not up to date on new developments.

In the early 1990s, the government promoted efficiency through the introduction of market forces. In its role of orchestrator, the government reduced direct controls and increasingly left the running of the health care sector to sickness funds, private and public sector health insurers and care providers, opting for a system of managed competition. This competition applied primarily to the sickness funds that bought health care services on behalf of their members (‘demand control’).

Under the Health Insurance Act of 2006, the sickness insurance funds were abolished and Dutch citizens were required to purchase their health insurance from profit-making private health insurers, which prior to 2006 insured only the wealthiest third of the population. Private health insurers negotiate on behalf of their members with care providers such as hospitals, general practitioners and pharmacies the scale, quality and price of services charged their members. Consequently, the health insurers play a pivotal role in implementing the Health Insurance Act. Insured persons can now ‘vote with their feet’. They may change their health insurer once a year if the premium is too high, or the quality of care, bought on their behalf, is too low. This incentivizes both health care providers and health insurers to be efficient in the delivery (providers) and purchase (insurers) of health care.

Therefore, the Dutch health care system has converted from a centrally controlled, inefficient, and increasingly expensive government run system to a decentralized, private insurance based, competitive system.

Here is more from Health Affairs:

Since 1 January 2006, the Health Insurance Act has obliged each person who legally lives or works in the Netherlands to buy individual private health insurance, with a legally prescribed benefit package, from a private insurance company. Contrary to the previous private insurance scheme, insurers are legally obliged to accept each applicant for a basic insurance contract at a community-rated premium and without exclusion of coverage because of pre-existing conditions. In an international context, the Dutch health system reform is unique: this is the first country that is consistently implementing Alain Enthoven’s model of national health insurance based on managed competition in the private sector.

There are, of course, two major problems here. One is who decides the contents of a basic policy ? Two, how is the pre-existing condition coverage subsidized. Remember, Holland is a small country. I also wonder about the large Muslim population and how many of them are actually self supporting.

Financing. All individuals have to pay an income-related contribution (7.2 percent of the first 31,200 of annual income in 2008) to the tax collector, who transfers these contributions to a Risk Equalization Fund (REF). Employers are legally obliged to compensate their employees for these income-related contributions. These compensations are the same regardless of the chosen insurer and are taxable income for employees. In addition, all adults have to pay a premium directly to the chosen insurer. Each insurer sets its own community-rated premium. For high-risk insured people, insurers receive a high risk-adjusted equalization payment from the REF. For low-risk insured people, insurers have to pay an equalization payment to the REF. According to the Health Insurance Act, the sum of the income-related contributions equals 50 percent of the total insurers’ revenues for the mandatory basic insurance. In 2008 the average premium equals about 1,100 (about US$1,600) per adult (age eighteen and older) per year.

Average premiums are like the average age of a population. It doesn’t tell you much. My youngest daughter was cheap to insure until she reached 18, then her premium quadrupled, I’m sure because of the risk of pregnancy.

About two-thirds of Dutch households receive an income-related subsidy (“care allowance”) from the government, which is at most 1,464 (in 2008; about US$2,200) per household per year.5 Because the allowance is independent of the choice of insurers, consumers are fully price-sensitive at the margin. No premium is required for coverage of children (under age eighteen); government compensates the REF for their health care costs.

People are free to buy voluntary supplementary health insurance for benefits that are not included in the mandatory basic insurance, such as dental care for adults, physiotherapy, eyeglasses, alternative medicine, and cosmetic surgery. For such insurance, insurers may risk-rate premiums and refuse applicants. More than 90 percent of the population buys supplementary health insurance, almost always from the same insurer that provides their basic coverage.

Since 2006 health care is primarily financed through two mandatory universal schemes with different regulatory regimes: a scheme for curative health care services under a regime of managed competition (Health Insurance Act) and a scheme for long-term care services under a regime of price and supply regulation (Exceptional Medical Expenses Act). The rationale for this distinction is based on differences between the types of risks and the feasibility of risk equalization, and between types of care for which the managed competition model is considered to be (in)appropriate. In this paper we focus on the Health Insurance Act.

The universal mandate is something I support as long as the mandate does not force people to buy policies bloated with state and lobbyist devised baggage. It should be high deductible, basic catastrophic coverage which, for the young and healthy, should have a tiny premium, similar to term life insurance for 25 year olds.

Now for the 2006 reforms:

Insurers also have more tools for risk selection at their disposal than they had before 2006. First, they have more tools for managing care, which can also be used to select risks. Second, insurers have more room to define the precise entitlements of their insured groups, which can be used to select favorable risks. Third, insurers are allowed to sell mandatory health insurance together with any other type of non–life insurance (such as supplementary health insurance, sick leave insurance, and car insurance), which prior to 2006 was not allowed. In particular, supplementary health insurance can be an effective tool for risk selection, because insurers are allowed to reject applicants based on their health status. Fourth, insurers are free to give premium rebates to groups for the mandatory basic insurance, which prior to 2006 was not allowed. A group can have any risk composition, and the “organizer” of the group can selectively enroll preferred members only. Although the rebate for the basic insurance is at most 10 percent, insurers can give these groups any rebate on supplementary health insurance or other insurance products.

Groups are inherently selected by the requirements for the group. One reason why we still have employer-based health insurance is that the employed tend to be healthier. Mormons as a group would probably have much lower premiums.

Here is an interesting trend:

Since 2006, several insurers have advertised special supplementary group insurance policies for diabetes patients. These special policies were developed in close cooperation with the national diabetes patient organization. In addition, several insurers are now actively involved in setting up disease management programs for diabetes patients. These activities appear to be the direct effect of the extension of the risk-equalization system with a risk adjuster for type 2 diabetes since January 2006.19 (Type 1 diabetes was already included as a risk adjuster.) In 2007, almost forty patient organizations representing people with various chronic conditions had obtained group contracts with insurers. On the other hand, at least sixteen patient organizations were not able to obtain such a group contract because the risk-equalization payments for these groups were insufficient, according to insurers. Hence, in due course, the ability for patients with specific chronic conditions to negotiate favorable group contracts may provide a good indicator of the quality of the risk-equalization method.

Here is something from the book, The Innovator’s Prescription, which advocates a “solution shop” model for certain diseases. Here is an example where managed care and evidence based medicine can add significant value to a situation where most disease victims have trouble getting any insurance at all.

The Dutch reforms are interesting and seem to be going in the opposite direction from Obama’s agenda. I wonder if he knows ? Maybe he or his allies do know and don’t care. He was willing to lose revenue with a capital gains tax increase. Maybe ideology is driving this regardless of practical economics.

Thomas Sowell has some useful thoughts on this issue.

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Posted in Europe, health reform | 2 Comments »

Obama is losing the PR war on health care

Friday, July 10th, 2009

This column in the NY Post by an Obama supporter misses the point but does show he is in trouble.

When asked to choose the best reason to support health-care reform, 34 percent chose “it will provide stable health coverage that can’t be taken away.” Only 12 percent chose “pay less in premiums,” and 7 percent chose “it will grow the economy.” Eighteen percent said that “health care is a moral right.”

The survey found that “42 percent of people who are currently covered changed coverage at least once in the last five years. For 57 percent of them, this change was involuntary. Among those who are currently covered, 38 percent said they are worried that they will lose coverage over the next five years.”

But that’s not what he is doing. He is telling people he will cut costs by rationing.

Obama’s central message so far has focused on the promise of lower costs for health coverage and more accessibility. But the poll (conducted by the Benenson Strategy Group) suggests that these aren’t the most potent issues.

In fact, a mere 29 percent of respondents agreed with the promise that their premiums would go down as a consequence of reform. And regarding “accessibility,” only 9 percent said that in the last five years they were without coverage all or most of the time.

Moreover, when asked, “Who do you think will benefit most from reform?” a whopping 60 percent chose “other people, but not [me].”

The majority of the country may have been dumb enough to elect him but they’re not this dumb. Mickey Kaus says It’s Obama’s own fault for raising the issue of cost and then getting into the whole issue of “effectiveness research.”

WaPo’s Alec MacGillis notes that Obama’s health care reformers
are clearly spooked by the notion that they could be accused of denying, for example, hip surgery to an 80-year-old.
If so, they largely have themselves to blame. They brought it up! It wasn’t the Republicans who billed health care reform as a cost saving, budget-balancing measure that would start to deny payments for treatments deemed “ineffective,” or (as one acolyte put it) when “a person’s life, or health, is not worth the price.” And to think when they heard that people started to worry about rationing! Fancy that.

The subject has now become rationing and that is not a debate they want to have with Canada next door publishing horror stories every week.

Total waiting time between referral from a general practitioner and treatment, averaged across all 12 specialties and 10 provinces surveyed, fell from 17.9 weeks in 2004 back to the 17.7 weeks last seen in 2003.

So, you want to wait 17 weeks to see a GP. What do you suppose the wait will be for a hip replacement ? Well, the average for all orthopedic surgery is 38 weeks and that includes minor procedures like wrist ganglion that I treat with a heavy book or aspiration.

The median wait for a CT scan across Canada was 4.8 weeks. British Columbia, Alberta, Ontario, New Brunswick, and Nova Scotia had the shortest wait for CT scans (4 weeks), while the longest wait occurred in Manitoba (8 weeks). The median wait for an MRI across Canada was 10.1 weeks. Patients in Ontario experienced the shortest wait for an MRI (7.8 weeks), while Newfoundland residents waited longest (20 weeks). The median wait for ultrasound was 3.9 weeks across Canada. Alberta and Ontario displayed the shortest wait for ultrasound (2 weeks), while Prince Edward Island and Manitoba exhibited the longest ultrasound waiting time (10 weeks).

The other subject that is not being mentioned is the fact that no one is going into general surgery anymore. That’s an exaggeration but the number of people completing general surgery residencies has not increased in 20 years and many of them go into subspecialties with better lifestyles. There were fewer surgeons being certified by the American Board of Surgery in 2008 than in 1981. The type of “reform” that Obama has in mind, with steep reductions in compensation for specialists, will cause a crash in the number of surgeons, just as has happened in Canada.

If you don’t believe that, ask Natasha Richardson.

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Whoops !

Thursday, July 9th, 2009

It seems as though a light is dawning somewhere.

The Rasmussen Reports daily Presidential Tracking Poll for Thursday shows that 30% of the nation’s voters now Strongly Approve of the way that Barack Obama is performing his role as President. Thirty-eight percent (38%) Strongly Disapprove giving Obama a Presidential Approval Index rating of –8.

Hmmm

Sixty two to go.

More whoops !
Independents are deserting the ship.

“This is a huge sea change that is playing itself out in American politics,” said Democratic pollster Doug Schoen. “Independents who had become effectively operational Democrats in 2006 and 2008 are now up for grabs and are trending Republican.

“They’re saying, ‘Costing too much, no results, see the downside, not sure of the upside,’” he said.

The White House denies there’s been any real shift.

Oh oh.

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A serious question for health care reform

Monday, July 6th, 2009

Paul O’Neill has a serious set of questions about health care reform.


1.Which of the reform proposals will eliminate the millions of infections acquired at hospitals every year?

2. Which of the proposals will eliminate the annual toll of 300 million medication errors?

3. Which of the proposals will eliminate pneumonia caused by ventilators?

4. Which of the proposals will eliminate falls that injure hospital patients?

5. Which of the proposals will capture even a fraction of the roughly $1 trillion of annual “waste” that is associated with the kinds of process failures that these questions imply?

So far, the answer to each question is “none.”

Quality improvement is the stepchild of health care today. I spent a year at Dartmouth in 1994-95 to learn the methodology of quality improvement and then learned that no one was interested. The impression, I believe, was that quality improvement would be more expensive and no one wanted to spend the money. O’Neill’s point is that, ultimately, poor quality is more expensive but no one seems willing, with a few honorable exceptions, to learn if that is true.

So far, the health care reform proposed by Congress and Obama ignores the subject.

No one concerned with excellence in health care can trust these people to address the problems.

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Government by Democrats in 2009

Monday, July 6th, 2009

We are in the midst of the worst financial crisis since 1929, being made worse in my opinion by the government’s feckless attempts at stimulus. The states have been called “laboratories of democracy” for many years and our two largest states have been governed the past 20 years by the Democratic Party. Since the Democratic Party has been in power in Washington for only the past three years, perhaps we should turn to the states to see what the future holds for us under Democrat control.

New York is a good example.

During the long years of Republican control, the all-white GOP “conference” would regularly bemoan its lack of diversity, and make extra efforts to recruit minority Senate candidates and hire minority staff.

During the first five months of this year, with the Senate under the control of its first African-American majority leader, Smith, top Democrats bemoaned the lack of minority Senate staffers.

But instead of trying to recruit new hires, they fired nearly 200 almost exclusively white workers and replaced them with a large number of minority employees, many of whom were seen by their fellow workers to be unskilled at their new jobs.

The move produced severe racial tensions, made worse by the fact that, as a high-level Democratic staffer confided, “We’ve been told to only hire minorities.”

We’ll see how much of a precedent that is over the next year. The first Supreme Court nominee by Obama is not reassuring. How does he think the future will play out ?

The Empire State — once a beacon of progressive state government to the nation — is on the brink of ruin. And it doesn’t look like anything can be done to stop it.

In two words: We’re doomed.

Well, California is the other large state with “progressive government.” How is it doing?
Things could be better

California Gov. Arnold Schwarzenegger declared a fiscal emergency and ordered state offices closed three days a month to save money as state officials began paying bills with IOUS on Thursday.

Deep budget cuts have already forced California school districts to cancel summer school programs, moves that have affected — among others — elementary and middle school students in Los Angeles, which has the country’s second largest district.

What is the solution ? Why, raise taxes, of course.

But labor and education groups, health care and social service advocates and (a bit more quietly) some Democratic lawmakers continue to insist that tax hikes should be part of California’s solution to its $24.3 billion budget deficit.
“The solution to this budget problem is not to slash and burn education but to re-evaluate our revenue policy,” Jeff Freitas, a lobbyist for the California Federation of Teachers, told a legislative budget committee last week.

“There are a plethora of options that are being ignored that must be brought to the table.”

Did anyone think the teachers union lobbyist would be in favor of cutting education spending ? What about voters ? You know, the people who pay those taxes ?

voters rejected five ballot measures on May 19 that included $16 billion more in temporary extensions of the February tax increase

Gee, I thought the ballot propositions didn’t include a tax increase ! The ballot argument didn’t mention a tax increase. Maybe voters are starting to doubt the veracity of politicians. Well, they seem to have believed Obama last fall. I wonder how long that will last ? I’m not the only one.

A nice summary of the problems of California.

Is there a state that is not in big trouble ? Yes, Texas. Here’s one reason:

Texas is home to more applications for new nuclear plants than any other state, with more than 9,000 MW of new capacity under development. These investments are a direct result of Texas’ world leading competitive electricity market, which has lead to more investment in electric generation capacity than any other state.

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Obama and the “no-nukes” movement

Sunday, July 5th, 2009

The New York Times has discovered, conveniently too late for the election, a college essay by Barack Obama which may explain some of his beliefs that are otherwise inexplicable.

Realist or dreamer, Mr. Obama has an interest in global denuclearization that arises from what can best be described as a lost chapter of his life. Though he has written two memoirs, he has volunteered few details about his two years at Columbia.

“People assume he’s a novice,” said Michael L. Baron, who taught Mr. Obama in a Columbia seminar on international politics and American policy around the time he wrote the Sundial article. “He’s been thinking about these issues for a long time. It’s not like one of his advisers said, ‘Why don’t you throw this out?’ ”

In a paper for Dr. Baron, Mr. Obama analyzed how a president might go about negotiating nuclear arms reductions with the Russians — exactly what he is seeking to do this week.

The Cold War is over but Obama seems to be stuck in his youthful enthusiasm for a nuclear freeze. I don’t believe for a moment that he has any intention of stopping Iran in their quest for the bomb but he is determined to reduce our own nuclear capability.

Maybe this is behind his otherwise mysterious unwillingness to consider nuclear power, a source of electricity free from the alleged greenhouses gas production.

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