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Obamacare Turning Into Cash For Clunkers

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The most recent news that should worry us regarding the rollout of Obamacare is the news that only a small percentage of of those purchasing plans on the exchanges were without insurance last year.

According to Aetna CEO Mark Bertolini, “Right now we only see that 11 percent of the population is people that were formerly uninsured are now insured, so we didn’t really eat into the uninsured population.”

The argument among progressives was Obamacare would be very attractive to those that had gone without insurance, and would decrease the number of uninsured.  So far, that is not the reality.

Instead, what we are seeing is, in many ways, similar to the miscalculation of Cash for Clunkers.  Most economists now accept that Cash for Clunkers was a failure all around.  A study from the Brookings Institution that using the most optimistic view, it created 1 job for ever $1.4 million spent.  Not exactly bang for your buck.

What is relevant to our discussion of the ACA rollout, however, is why this was the case.

Simply put, what Cash for Clunkers did was subsidize car purchases.  So what happened?  People that were planning on buying a car 1 year or 2 years in the future moved their purchases forward. The government gave them an incentive to spend in the short-term, because they received a huge financial benefit to do so.  The problem? That ultimately did little to stimulate anything, because those same people did not buy cars later.

What is occurring in Obamacare right now is that people who were already purchasing insurance have looked at the exchanges, and now see that they could financially benefit from the subsidies.  Those people thus made a market oriented choice; why turn away free money?

However, here is the rub: if people are making a market oriented choice…what is the incentive for those who didn’t purchase insurance prior to Obamacare to change their mind now?  In many ways, low-cost insurance was cheaper last year than it is this year; so the uninsured, in many cases, have less incentive to purchase insurance today.

Many of these people actually made a market decision prior to Obamacare: they felt the cost was worth the risk.  What we are seeing in the Obamacare marketplace is the same thing.  People that didn’t have insurance are, for the most part, making the same market decision.  On the other hand, those that had insurance before are simply looking for the best deal available…and if the government hands you free money, who is going to say no?  Again…the market always wins.

We are making the same mistake on a macroeconomic level on Obamacare as we did with Cash for Clunkers.  You really want to motivate people to make choices, you must use the marketplace in your favor.  But the government, in both of these cases, was and is fighting the market.  They are giving subsidies, but they are not truly making it financially more attractive for people to buy insurance today than before.  If the uninsured don’t see a huge financial incentive to purchase insurance, no amount of subsidy will change that dynamic.

 

 

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Why The New Obamacare Demographic Data Matters

On Monday, the Department of Health and Human Services released the first nationwide demographic data on those purchasing insurance through the various health care exchanges around the country.  The data largely affirms what many had suspected; that the young, relatively healthier members of the public so far are not buying into the system.

Most estimates, especially those from the Congressional Budget Office, stated that the exchange plans needed approximately 39-40% of their enrollees to consist of people in the youngest age group (18-34 years of age).  This was for a very basic reason:  to enable the financial sustainability of these plans, you needed younger (READ: HEALTHIER) patients to pay into the system, so those older (READ: LESS HEALTHY) patients could be subsidized at lower premium rates.

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The data so far should prove worrisome.  59% of those enrolling so far are age 45 and above.  Only 24% are age 34 and below. 

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To give some perspective, a study by the Kaiser Family Foundation done several months ago ran several different scenarios to calculate the cost breakdown of what would happen with different demographic results. Their chosen ‘worst case scenario’?  25% of the pool would consist of young patients…which is actually a higher number than the demographic distribution as of today.

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The Kaiser study is quite useful in calculating what the cost of such a failure in getting young people to buy into the system is.  For every 10% less than the 40% target, Kaiser estimates the cost of premiums overall would increase by 1-2%.  At first glance, this doesn’t seem to be very significant.  However, once you realize that health insurers on average have a profit margin of around 4%, this could account for up to half of the total profits from health insurers.  And obviously, insurers won’t put up with that, meaning those costs will be passed on to the public.

Jonathan Cohn of The New Republic continues to argue that this is along the same pace as Romneycare in Massachusetts.  And in fact, a superficial examination of the data supports his argument.  In Massachusetts, as the state approached the deadline, more and more youths purchases insurance plans.  This gives hopes to liberals that we will continue to see an upward trend nationally as well.

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Here are the problems however.

First, note the actual number of youth enrollees in Massachusetts.  The maximum monthly percentage of new purchasers of insurance maxed out at 34%.  That is not only below the target of 40% set by the CBO; that is far below the number that the ACA would now need to meet their demographic goals.  By my rough calculations, approximately half of all new purchasers on the exchanges from January 1st through March 31st of this year would need to be age 18-34.  That seems highly unlikely, using Massachusetts as an example.

Additionally, unlike in Massachusetts, where there was one distinct deadline, in Obamacare there are really two practical deadlines. The first was January 1, 2014; this is because people who had insurance previously and wanted to continue their insurance needed to make sure they made their purchase already.  That would also explain the December surge of young buyers that the HHS claimed today.

The problem for ACA proponents is the second deadline, which has now been delayed until March 31st. The second deadline is a legal deadline, after which you are technically in violation of the law.  And theoretically, at that point you would be responsible for paying the Obamacare penalty (tax) based on your income level.

There are a couple of problems with the second deadline. The first is that unlike in Massachusetts, it may actually be in the financial best interest of some young people to pay the penalty (let us put aside whether or not it is a rational decision to go without health insurance; we are talking about a cost decision).  With premiums (even with subsidies) running several hundred dollars a month, a young person with income of less than $24,000 could easily pay the $95 penalty and be free of any other financial obligation.

Furthermore, many people doubt the IRS has the current capability of even levying the fine.  There has been some confusion on this point, but the head of the IRS in congressional testimony late last year admitted that if you were not receiving a tax refund from the IRS, they have no mechanism to levy the penalty at this time. So many youths simply could not be fined even if the IRS chose to do so.

Additionally, because of President Obama’s varying Obamacare delays, including delaying the individual mandate next year for people who had their insurance cancelled, it is fair to say much of the public doesn’t really believe there will be any practical penalty for not purchasing health care in 2014 if they choose not to.

Health care expert Bob Laszewski, in an interview with liberal blogger Ezra Klein, made the point quite clearly:

EK: That brings up two issues. The first is the individual mandate, which begins this year but is a much bigger penalty in year two, and then even bigger in year three. So one question here is how well that works.

RL: I have an interesting answer for that. I think the mandate is almost worthless because the word is getting around that they can’t really collect it. And by year three, it’s really a lot of money. I think there’ll be real pressure to just get rid of it. I don’t think you can force people to buy this insurance. If they don’t want it there’ll be a political groundswell to get rid of it. So in my mind the individual mandate is kind of irrelevant to this.

All that said, let me make a couple essential caveats to this discussion.

The first caveat here is that age is a poor substitute for what is actually most important: the health of these patients.  The risk pools need healthier people to pay into the system in order to pay for those that spend the most health dollars, i.e. the unhealthy.  In general, that means younger patients paying for older ones.  Although using age demographics is a decent substitute for this, it is an imperfect one.

Second, the ACA is a completely new system.  We have no idea if there is any historical analogue that can correlate.  We use Massachusetts and their experiment with Romneycare simply because there is nothing else even closely resembles Obamacare.

Third, and this is very important to remember, is that we are really not talking about a single national system, but 51 state and local systems.  Each state is their own microcosm.  Avik Roy had a nice breakdown:

The states with the biggest skews toward older exchange participants were West Virginia (total skew: 66 percent), Maine (65 percent), Wisconsin (64 percent), New Mexico (61 percent), and Ohio (60 percent). The states with the lowest skews were Massachusetts (28), Utah (29), Kentucky (39), Maryland (39), and Virginia (40).

Whether this becomes significant or not in the long-term is uncertain.  But the larger skewing you see toward the elderly population, the more likely they will see a net effect on future premiums.

On a side note, there is some positive data for Obama and his allies.  A surprising 60% of all plans purchased on the exchanges are Silver level…meaning people are paying more to upgrade their plans, and pay less out-of-pocket later.  This is a political win for Democrats, who thus will not have to be responsible for as many people complaining for hefty out-of-pocket costs in 2014.

One data point that can be a positive or a negative depending on your point of view is the fact that 79% of all purchasers are subsidized.  This aligns with the CBO estimates, which roughly predicted a ration of 6:1.  I personally view this as a long-term negative, as this will drive up the debt on the Federal level, and in three years when the Federal guarantee of subsidization of state Medicaid program ends, this could put a huge burden on the states.  Liberals view this as a major victory, as they feel that insuring these people with tax dollars is beneficial to the country at large.

But the headline today is about the demographics.  What does all of this ultimately mean?  The most likely result of all this is that the risk pools for the exchanges will be mild to moderately worse than anyone predicted a few years ago.  No matter how much certain liberals would like to spin that this is on a similar pace as Massachusetts, the overall numbers tell a different story.  We are looking at risk pools that are worse than predicted; the CEO of Humana, Bruce Broussard, admitted as much at the JP Morgan Health Insurance conference on Monday.

Will this put Obamacare into a death spiral?  Unlikely.  As I have said for months, the death spiral is highly unlikely.  Additionally, because of the risk corridor program within the Affordable Care Act, the government will, for all practical purposes, ‘bail out’ the insurers if the risk pools cause too much of a negative effect on profits.

So what we are looking at is more upward bending of the cost curve, as these costs are passed down from the insurers to the public, with premiums increasing at a 1-2% rate higher than baseline expectations. And that means that going forward, premiums for most Americans will be higher than if we had never passed Obamacare in the first place.  The American people can decide if that extra cost was worth it or not.

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2013 Top 10 Movies Of The Year

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After a strong 2012 season, 2013 was slightly disappointing.  Many of the most anticipated movies were either bombs or fell far short of expectation.  And I honestly can’t name a movie this year that I would call ‘historic’ or ‘transcendent’.

Here are my past selections:  2009, 2010, 2011, 2012.

However, there were still many strong new movies this year, and these are the ones I enjoyed the most.

Honorable Mentions: Fast and Furious 6, Captain Phillips, Before Midnight, Ender’s Game, About Time, Spring Breakers, This is the End, The Wolverine, Inside Llewyn Davis, Monsters University, The Place Beyond The Pines, Iron Man 3, Thor: The Dark World, Man of Steel, Despicable Me 2, Fruitvale Station, Blackfish, The World’s End, Saving Mr. Banks

Worst or most disappointing movies of the year:  Most disappointing: Ender’s Game.  It is listed in the Honorable Mentions, as I still enjoyed it, but it could have been so much more.  Others:  Lone Ranger, The Canyons, The Internship.  Worst Movie?  After Earth.  Will Smith and son, along with  Director M. Night Shymalan, just…failed.  Miserably.  Maybe we should start calling this the ‘M. Night Shymalan Award’?

 

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10.  Kings of Summer

This movie took me by surprise; thought it was going to be a goofball type of movie, but actually had far more depth than I expected.  It’s a coming-of-age movie where 3 teen boys, sick of their families, dream of building a hidden house in the woods. They run around in a weird ‘Lord of the Flies’ sort of way, but their path to maturity is entertaining.

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9. Her

This is a movie that I literally saw a few hours ago. Who would have thought it would be fun to watch Joaquin Phoenix fall in love with his computer?  And is there a sexier computer in the history of cinema than this one voiced by Scarlett Johansson?  This is, surprisingly, one of the more strangely realistic and emotionally driven movies of the year.  It is certainly unique, and I can see some people not finding the frightening reality of what could come in the near future as entertaining as I did.

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 8.  Frozen

This movie surprised me.  The ‘non-Pixar’ movies from Disney have been less hit and more miss in recent years.  Frozen changes that.  For the first time as long as I can remember, I preferred this over Pixar’s Monsters University. Between the classic Disney catchy songs, and the ridiculously lovable characters of the current Disney era, I think there are many people who fell in love with this movie.  “Frozen” is somewhat like The Little Mermaid, with a slightly more modern twist.

7. Short Term 12

NOBODY has heard of this movie…other than movie critics.  I actually saw this with my movie critic friend a while back…and it is excellent. The story centers around several twentysomethings who work at a home for at-risk teens. They help guide and mentor these kids, while facing their own doubts and apparent flaws. It is actually funny and sweet at the same time, and is one of those movies that if you have not seen…take time to do so.

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6. American Hustle

A movie with Jennifer Lawrence and Amy Adams in sexy outfits!  COUNT ME IN!  The remainder of the cast is also fantastic in this 70s flashback story about a con-job that echoes that of the real ABSCAM scandal.  It took me a while to get into the groovy 70s feel, but once I did…I was hooked.

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5.  The Hobbit: The Desolation of Smaug

Yes, it meanders. Yes, Peter Jackson invented characters.  Yes, it takes about 100 pages of the original book and converts it into a 2+ hour movie.  But…it works.  Yes, amazingly, and to my own shock, it actually does work.  Peter Jackson is a marvel; I was dubious of his ability to convert The Hobbit into three watchable movies.  The obvious reality is that this movie is a far better movie than the original, which makes you wonder if he is following his patter from the Lord of the Rings trilogy, with each movie being better than its predecessor.  But this is a worthy sequel, and sets up the final part of the trilogy fantastically.

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4.  The Wolf Of Wall Street

Martin Scorcese’s over the top portrayal of the greed and debauchery of Wall Street may seem to be by some as the classic liberal complaint about greed that we have seen before.  But Leonardo Dicaprio’s portrayal of the adaptation of Jordan Belfort’s memoir is still fantastic fun.

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3.  The Hunger Games: Catching Fire

I honestly believe this is far better movie than the original.  It is darker, it provides better action sequences, and starts to show you the totality of the oppression that Katniss and her friend face in the futuristic land of Panem…setting up the eventual war that must occur.  After Gravity, this is by far the movie I will revisit most in the future.

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2.  12 Years A Slave

This is this year’s entrant as for the ‘Schindler’s List’ Award:  a movie that, as social commentary, must be seen once, is a moving and draining experience, and will probably force you to avoid that movie for the rest of your life.  The portrayal of a free man kidnapped and forced into slavery probably does the best job I can recall of portraying the horrors of slavery.  I think for anyone that loves American History as I do, this is a must watch..at least, once.

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1. Gravity.

I know this is a movie some people did not like, for various reasons. But I think, after reaching the end of the year, this is the one non-superhero movie I will revisit again. If you did not see this movie on IMAX…you missed out.  Alfonso Cuarón’s  12 minute opening scene is, by far, the best cinematic episode of the year, and maybe of many years. And it is one of those rare action movies that results in a true emotional connection with the viewer.

 

 

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The State Of America, Part 1: Tolerance: Why Can’t We Get Along?

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For the Christmas/New Year’s Season, I thought I would do something a little different on a personal note. No hyper-partisan political posts on the blog for a few days.  We have had enough of that, haven’t we? Obama is off in Hawaii, I think we can take a small breather.

I wanted to focus just on my view of where America stands in other ways.

Today my ranting focus on a simple reality I think many of us experience when talking about any controversial subject: the complete loss of tolerance in society.

In many ways, this is ironic.  Tolerance in the classic sense centered around the acceptance of those that were physically and religiously different from us.  It was focused on the external appearance and activities of individuals.  Over the years, we have certainly become more tolerant of other religions and races.  The election of Barack Hussein Obama is simply the greatest example of that tolerance, where we elected a half Caucasian, half African-American male from Hawaii with an Arabic name to the highest office of the land.

But in other ways, we have walking backward in the concept of tolerance.  When it comes to people’s innate beliefs, there has been a movement to squash ideas that are outside the ‘norm’ that our political and media mainstream finds ‘acceptable’.

It is a sad transition that America is making.  In their quest for visual tolerance, they are becoming more intellectually intolerant.  We can list a litany of examples, some recently, where people who were simply asked their opinion, honestly responded…and were treated as villains for that honesty.

Society clearly is in the right when we shun those that truly damage others, whose actions demean and hurt people based on their faith or race.

But commentary, of any sort, does nothing of the sort.  In a free society, we are not free from being offended.  I have often stated that if offensive speech is not free, then there is no freedom of speech.

But today, we apparently want freedom from offense.  Somehow, we have come to a point where we believe that if someone has offended us by a throw away comment on Twitter, or if makes a comment about their religion even though we have never met them in real life…that this means they have infringed on our basic rights in some manner.

This type of ‘victimhood society’ permeates virtually every large discussion that our society has today.  Every issue, regardless of merit, must be considered racist, sexist, homophobic, etc. Is there any issue nowadays that doesn’t reach that ultimate climax?

This type of debate is harmful to a society.  There is nothing intellectual about such debate.  Having a debate about which ideas are useful, and which are not, is healthy.  Labelling any belief that doesn’t fit into your own narrow belief system as bigoted?  That divides and damages a society.

Furthermore, distilling everything down to the level of bigotry clouds the real racism and bigotry that goes on this country.  While we complain about Duck Dynasty or Alec Baldwin, millions of  youths continue to go to schools that are failing them, insuring they have little chance of long-term economic success in the world economy.  Large portions of society languish in jobs that have no potential for upward mobility, and we spend our time talking about what the random millionaire entertainer said this week.  We are becoming a dumber society, day by day.

Another example is the apparent ‘blasphemy’ that the traditional concept of Christmas is to the secular extremists in society.  Arguing whether a manger can be in the public square, a Christmas tree at school, or whether Santa is white or black? Please.  This is all nonsense .  The ‘COEXIST’ symbol at the top of the page?  It is a common one that is shared among many, but I don’t think they really believe in the heart of the concept.

Maybe it was my Hindu upbringing, but I was pretty much willing to accept all religious holidays.  My parents, who grew up in India, regularly celebrated Christmas as kids.  They celebrated Muslim holidays as well.  And their Christian and Muslim friends would celebrate Hindu holidays.  India is certainly not perfect when it comes to religious tolerance, that this simple level of acceptance allows for the huge religious divided to be bridged somewhat.  That is what true acceptance of others beliefs means, but apparently, that is not readily accepted in today’s America. We have forgotten that we choose to become involved in the activities that we like, can choose when we want to pass, and that others should be free to do the same. Today, however, unless everyone conforms, someone is offended.

This is not, in my opinion, a left or right political wedge.  In a large country such as ours, with a diverse and heterogeneous society, there are enough divisions that separate us already that we should not have to create new ones to divide us further.  There was a time we simply accepted that some people disagreed with us.  We used to teach preschoolers and kindergarteners that even if someone disagreed with you, you could shake hands and walk away without hating each other.

Maybe it is time to send the rest of America back to Kindergarten.

Ideological tolerance will be at the heart of what the Free Speech movement will need in the coming decades, because amazingly, he have solved many, but not all, of the physical intolerance in society.  People will continue to try to divide us as a people, because for some, that is all they know.  But we should all hope and pray for a society where we can fundamentally disagree, tolerate those beliefs we object to, find joy in others who are fundamentally different than us, while still treating each other with respect and true tolerance that a free society requires.

Sadly, that is not the America we live in today.

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The Band-Aid Presidency

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Last night, in the most classic way imaginable, the Obama administration dumped a 800 lb of coal into the stockings of liberal America on the eve of the Christmas holiday.

The Administration announced that any person who had their health insurance cancelled late this year are no longer obligated to legally abide by the individual mandate, the central taxation component of the Affordable Care Act.  Additionally, these same people could satisfy the mandate requirement by purchasing catastrophic insurance alone, which previously was not considered sufficient to satisfy the mandate requirements.

The argument that the administration is making is ironic in so many ways.  They argue that the individual mandate, arguably the most important cog to the workings of Obamacare, is a ‘hardship’ to millions of Americans.  Furthermore, they are arguing that because of this hardship, they will simply delay that part of the law.

Think about the legality for a second:  President Obama is issuing a hardship exemption for something the Supreme Court has defined…as a tax.

Can you imagine the fun a Republican President can have with that power?

Let us also remember that this invalidates virtually every Democrat and liberal argument against a deal to avert October’s congressional shutdown.  Let us not forget that Senators Ted Cruz and Mike Lee put a proposal on the table to avert the shutdown if the administration simply agreed to a 1 year delay to the individual mandate.  Yesterday, Barack Obama did just that…proving that much of his stance on the shutdown was political theater, nothing more.

In the larger picture, this type of policy change largely defines the entire Obama Presidency. The pattern is as follows:  Obama and liberals propose a policy that, any common sense would tell you, cannot function in the real world. They pass this policy, often distorting the facts to the American public to get their support.  Once passed, they all of a sudden realize the idiocies contained in their plan, and rush to distance themselves from the plan they were recently advocating.  Once the policy becomes active, they realize that reality is more powerful than ideology, and thus, look for any and all ways to get themselves out of the mess they created.   And they use every ‘Band-Aid’ measure possible to cover-up the mess they have created.

The Band-Aids are piling up, and it does not only refer to health care.  Look no further than foreign policy this.  Obama’s Syria ‘Red line’ policy is a perfect example.  Obama talked a good game, but then realize that there was no way to enforce his red-line in the real world.  He quickly ran away from that policy, only to end up with a policy that, ironically, strengthened the power of a man Obama said was ‘evil’, Bashar Assad.

If you want to go further back, the Obama stimulus often had many of these characteristics as well. They passed statutes for ‘shovel-ready’ projects, and later realized there was no such thing.  They then pumped out the money, regardless of effect, to lackluster consequences.

Think of the fallacy of this latest Band-Aid on Obamacare.  The administration is arguing that they have imposed a hardship on at least 5 million Americans who lost their health insurance because of Obamacare.  So, to help these people, they are going to exempt them from the individual mandate.  However, these same people argued during the shutdown that any delay of the individual mandate would be catastrophic to the functionality of the entire ACA system.

Furthermore, the hardship claim is dubious.  Is Obama actually saying that it is more a hardship for people to lose their insurance and have to purchase it on his own exchange, than the hardship of forcing the previously uninsured to dig deep in their pocketbooks to purchase that very same insurance on the exchanges?  He is saying the previously uninsured have no burden of hardship as well?

Another liberal fallacy also dies: the argument that these were ‘substandard’ insurance policies.  Obama has now stated it is o.k. for people to move to catastrophic insurance, when the majority of this cohort had comprehensive insurance prior to Obamacare coming into effect.  In other words, Obamacare diminished  the quality of health insurance plans in America, and Obama is not legitimizing that change.

Each of the policy changes are chinks in the armor of Obamacare; that armor is now thin and rusting. This is a virtual universal delay of the individual mandate for 2014, no matter how liberals spin it.  They will never politically be able to argue that those that lost their insurance because of Obamacare bear more hardship than the uninsured do, and thus, they will be forced to exempt all Americans.  Ted Cruz wins the policy debate.

Even worse, this fixes nothing long-term.  This is a classic Obama ‘Band-Aid’.  Sure, it theoretically stops millions of people from being required to pay approximately $95 in tax penalty this April. But the real issue is not the tax, but the health care exchange.  By exempting all of these people, the administration makes the entire insurance system much less financially stable.

Insurers who were already dubious of the administration’s competence on this are now outright furious at being lied to, time and again.  They fear this will further push the risk portfolios of their insurance plans to the extreme, and thus, will increase their costs. That further increases cost pressures on health insurance premiums across the board, increasing costs for everyone. The Obamacare upward bending of the cost curve continues.

The ‘Band-Aids’ are all for show.  Ultimately, the problem is that the law itself was inherently broken.  These temporary measures actually fix nothing in the system. They are a political attempt at cover.  But nobody can protect Democrats from the onslaught of public anger that is going to arise when they realize what the ACA does, when the Band-Aids finally come off.

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Freedom Of Speech Is Bigger Than The 1st Amendment

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The latest in our litany of free speech debates comes to us courtesy of…Duck Dynasty?

Well, will wonders never cease.

For background:  the patriarch of the Duck Dynasty family, Phil Robertson, made controversial remarks about homosexuals in the most recent edition of GQ magazine. In response, A&E television has suspended Robertson indefinitely.

Now, the character of his remarks, or if they were really offensive or not, does not interest me all that much.  It is a matter of personal opinion, and let us leave it at that.

But the larger question that arises when we have these controversies is about the nature of the freedom of speech…and I am forever perplexed at how much people fail to understand what that freedom really means.

First and foremost is confusion regarding the 1st amendment.  Why people don’t understand this really is beyond me: the 1st amendment, or in fact the entire Constitution, is about the government’s limitations in restricting the rights of free people.  The First Amendment is not relevant here in the least, unless government gets involved at some later date.

But that, in turn, does not dismiss that this is, in fact, a debate about the freedom of speech and expression.

I think the basic confusion arises in the reality that many people don’t understand the difference between Constitutional rights, and natural rights.  As stated above, Constitutional rights refer specifically to the freedoms you enjoy that the government cannot restrict or remove. Natural rights exist universally, regardless of laws, Constitutions, or governments.

Now, what bothers me most about this is not that Robertson was fired.  I fully believe A&E is in their rights to fire whomever they want for whatever reason they wish.  That is what free association is supposed to mean in a free society.  I don’t believe this is substantially different than other major dismissals of media personalities in recent days, including the firings of Alec Baldwin and Martin Bashir at MSNBC.  We can argue about the morality of each, but legally…the end result is the same.

What bothers me most is the gross hypocrisy of liberals when it comes to defining free association.  That is not to say ‘all’ liberals, but look no further than today’s Democrat Party to understand where that hypocrisy lies.

Let us compare the Duck Dynasty fiasco to another major story that has been circulating.  There have been a litany of cases, in New Mexico, Oregon, Colorado, and elsewhere, where private businesses have been told by courts that they must, under power of law and the government, do businesses with gay couples who are getting married.  The businesses include bakers, photographers, and others. These businesses had moral opposition to gay marriage, and were theoretically using their freedom of speech, religion, and free association to choose not to business when they duly chose not to.  The state, however, thought otherwise.

Both of these cases have to do with society’s understand of freedom of speech and expression.  Both, however, do not, have anything to do with the First Amendment; only that latter case is covered under the Constitution.

But it does go to show how the political Left is redefining what freedom of speech means.  For liberals today, freedom of speech means the freedom to say and do as you wish…as long as that speech is acceptable, non-offensive, and within their vision of morality.

This is why free association is such an important concept, and cannot be separated from the greater vision of freedom of speech, expression, and religion.  If you are not allowed to freely associate (or dissassociate, as the case may be), then your freedom of expression is inherently limited.  One cannot be said to have freedom if those freedoms can be taken away when a specific issue of religion, marriage, or sexuality arises.  That is by its very definition no freedom.

Furthermore, although A&E has every right to fire Robertson…let us also admit that such a firing, based on a religious belief, clearly demonstrates a lack of believing in freedom of speech.  I, for one, would not fire anyone for these beliefs, or others, as long as they don’t directly interfere with their workplace ethic.  It is hard for me to believe that A&E didn’t know that the Duck Dynasty family had some extreme social views; do they not watch their own show?  Robertson himself has said on several occasions that he would quit if the T.V. show infringed on his belief in God and freedom.  So these beliefs are nothing that should surprise the TV executives, or anyone else familiar with the show.

For A&E to now take offense shows, simply, that they are willing to accept the benefits of the Robertsons’ freedom of expression when it brings them easy money, but not willing to face the fire when that same expression is the least bit controversial.

But the mainstream media’s hypocrisy does not end there.  Let us make several comparisons.  What if Walmart decreeed that none of their employees could, publicly or privately, voice a pro-choice opinion, and if found to do so, would be fired?  What if McDonald’s decreed that no woman wearing a Hijab would keep their job?

I personally believe that all the above examples are legal, and the companies have a right to do that.  Liberals don’t, as our gay marriage example above clearly shows.  They want to dictate when companies can be forced into businesses deals, and when they cannot.  That is hypocritical to its very core.

What I believe is corporations and businesses should have every right to make decisions as they see fit, as A&E did here, and as the baker and photographer did in the gay marriage issue.  The correct public response to such behavior is to react with your dollars; individuals at every level have the freedom to associate with whomever they wish, and as such, can hurt businesses who don’t abide by our individual moral standards.

Sure, this is not a perfect system.  Some lewd people will offend others, and feelings will be hurt, families may even be damaged financially, and society will be outraged.  But the concept of freedom of speech, freedom of religion, freedom of expression, and free association don’t come free.  There is a price to everything, and this is the price we pay for freedom.  True freedom.

 

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Doctor shortage – Yes Or No? The Answer Is Yes: Absolutely.

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In an editorial in the New York Times on December 5th, Scott Gottlieb, an internist and fellow at the American Enterprise Institute, and Ezekiel J. Emanuel, a former health policy adviser to the Obama administration, argued that there is no up coming physician shortage to threaten the country in the face of the implementation of the Affordable Care Act.

I beg to differ.

Drs. Gottlieb and Emanuel are both very intelligent and knowledgeable about health care policy in this country.  And I do have the greatest respect for their expertise and their work in this arena.  However, in this case, I think they are largely deluding themselves.

First, let us stipulate that we all agree that most of the major medical associations in the U.S. fully believe a shortage is going to occur in short order, as the authors in this piece state quite openly.  Let us also stipulate that Gottlieb and Emanuel are not the first to deny there is a doctor shortage.  For example, mathematician Linda Green argued in Health Affairs journal last year there was no real doctor shortage, if you made some structural changes.  However, what we see, as we go through their logical progression, is that their assumptions face the cold, hard reality of the real world where doctors actually practice, instead of the theoretical world they seem to exist in.

In the editorial in the NY Times, the authors first point to the Massachusetts experiment with Romneycare as a reason that we should not believe that the doctor shortage will occur.  They state:

Take Massachusetts, where Obamacare-style reforms were implemented beginning in 2006, adding nearly 400,000 people to the insurance rolls. Appointment wait times for family physicians, internists, pediatricians, obstetricians and gynecologists, and even specialists like cardiologists, have bounced around since but have not appreciably increased overall, according to a Massachusetts Medical Society survey.

There are many problems with this statement.  First and foremost is that Massachusetts is a poor analogy for the nation at large.  Massachusetts has the highest ratio of physicians per capita (462 doctors per 100,000 individuals). The national average?  About 300.  This means that Massachusetts has approximately 50% more physicians than the rest of the country on a per capita basis.

Now, even with that built-in advantage, the state had significant access disruption.  Let us put aside the fact that between 2009 and 2011, premiums in the state rose by 9.7 percent while benefits actually decreased by 5 percent. Deductibles during that time period rose 40 percent.  What Gottlieb and Emanuel failed to mention is that there are numerous surveys from the state showing that access to physicians is becoming problematic.

These results from a survey performed by the Massachusetts Medical Society:

The telephone survey of 838 doctors conducted in February and March found that 51 percent of internists are not accepting new patients, up from 49 percent the previous year. Fifty-three percent of family physicians, the other major group of primary care doctors, were also not taking new patients.

Even for patients fortunate enough to have a primary care doctor, waits for appointments continued to be lengthy. The average wait for an appointment with an internist was 48 days, which was five days shorter than last year, but the average wait for family medicine was 36 days, a week longer than in the 2010 survey.

Patients were also waiting longer to see specialists. The average wait for gastroenterologists, obstetricians/gynecologists, orthopedic surgeons and cardiologists were all higher than a year ago, the report said.

Now, Emanuel and Gottlieb are correct that these numbers have fluctuated, but that is to be expected.  Overall, however, access to physicians in Massachusetts has worsened over the past few years.  And don’t forget: Massachusetts is America’s best case scenario in regards to physician access.

Furthermore, even if their claim that there has been no decreased accesss in Massachusetts under Romneycare is true, that still doesn’t necessarily mean anything, because of the huge discrepancy in doctor to per capita ratio stated above.  Additionally, Massachuestts had the highest rate of insured in the country.  Therefore, the number of new patients entering the system that were previously uninsured is less than anywhere else in the nation.  To use a state such as Massachusetts that is skewed so heavily to one side of the scale seems to be foolish.

The editorial authors then go on to make several unsubstantiated claims:

Innovations, such as sensors that enable remote monitoring of disease and more timely interventions, can help pre-empt the need for inpatient treatment. Drugs and devices can also obviate the need for more costly treatments. Minimally invasive procedures, like laparoscopic surgeries, can be done more quickly with faster recovery times and fewer physicians.

There is virtually no evidence, anywhere, for this.This could be true, but it would take a massive improvement in current medical treatment methodologies that cannot be foreseen, and more importantly, are unlikely to occur in the near term.  I can speak for myself, as a radiologist who performs teleradiology on a significant scale; or my wife, who is Clinical Assistant Professor at a major medical center.  Neither of us can see the kind of transformation that Gottlieb, Emanuel, or Ms. Green are suggesting.  In short, these are dreams, not practical realities.

They go on to discuss what doctors call ‘physician extenders’, such as physician assistants, nurse practitioners, etc.  These professionals certainly have a place in the ever-expanding U.S. health care system.  They also can likely serve with more autonomy than they do today, in order to decrease the workload on physicians.  Of course, that would take a dramatic change not only in how we practice medicine, but also extensive changes in the medicolegal landscape of the country.

Even without those considerations, however, what the authors fail to declare is that expansion of the use of these professionals has already been the case for several decades.  As stated by Dr. Richard Cooper in an article in the Journal of the American Medical Association in the November 13, 2013 edition (page 1932), between 1990 and 2012, the number of physicians increased by 50%, while the number of nurse practitioners and physician assistants increased by a whopping 500%.  Therefore, Gottlieb and Emmanuel are suggesting a larger expansion in the use of these professionals than has already occurred.  That kind of dramatic change is not practical, and filling the gap with a huge number of these personnel should be considered unlikely.

The one solution that is advocated by most medical studies, the expansion of medical schools and residencies, is dismissed by the authors here. But one indisputable fact is that the United States is producing far too few physicians.  This started during the Clinton era, when Medicare purposefully capped the number of residency positions funded.  This was done because the argument was that decreasing the number of residencies would push more doctors into primary care; that prediction never came to fruition. In fact, if residency programs had not been capped in 1997, and annual growth in the number of positions had continued at a historical basis, there would be no physician shortage today.

Medical schools, both Osteopathic and Allopathic, have steadily increased medical school seats since 2000.  According to Dr. Cooper, 27,000 medical graduates will be produced by 2020, a 50% increase from 2000.  This is still far too few to close the gap we suffer from today.

Dr. Cooper in his JAMA article pleads for consensus among policy advisors.  He states the following:

To do nothing ignores the powerful economic and demographic trends and leaves future generations to ponder why they and their loved ones must experience illness without access to competent and caring physicians.

Drs. Gottlieb and Emanuel do a disservice to the medical community by distorting the realities of the demographics involved among the physician community of the United States.   We will very likely need far more physicians than they project, and most experts believe that a shortage of 200,000 physicians by the year 2020 is very likely. Depending on wishful thinking and technological advances that cannot even be seen by the most acute vision imaginable is not a thoughtful policy position; it is a Hail Mary.  The government must quickly come to terms with the major disaster that awaits us if we do not respond to this looming health care problem.

 

Links:

http://www.nytimes.com/2013/12/05/opinion/no-there-wont-be-a-doctor-shortage.html

http://www.forbes.com/sites/scottgottlieb/2013/12/05/obamacare-wont-create-a-doctor-shortage-but-that-doesnt-mean-youll-have-ample-access-to-physicians/

http://www.census.gov/statab/ranks/rank18.html

http://www.mass.gov/chia/docs/r/pubs/13/ar-ma-health-care-market-2013.pdf

http://www.wbur.org/2011/05/09/doctors-survey

http://www.washingtonpost.com/blogs/wonkblog/wp/2013/01/15/doctor-shortage-what-doctor-shortage/

http://content.healthaffairs.org/content/32/1/11.full

http://jama.jamanetwork.com/article.aspx?articleID=1769903

 

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Obama On Obamacare: Honesty Is NOT The Best Policy

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This weekend showed the mendacity of the Obama Administration on the continued debacle of the rollout of the Affordable Care Act.

Saturday was the deadline that Obama himself proclaimed for full functionality of the Healthcare.Gov website.  We were told, all last week, that the government was working day and night to achieve ‘success’.  And then Sunday morning, Voila!  The White House proclaimed they had achieved their goals.

Except for one problem:  the reality is that the website is far from fixed.

First, the metrics that the White House themselves have used for ‘success’ has been slowly been moving downward since Obama made his proclamation in early October.  At first, it was that 80% of applicants could complete their insurance purchasing process through the website.  Then, it was that 80% of people could actually complete the application on the website, and have the process completed in steps unrelated to the internet (paper applications, for example).  Now, the criteria is that at 80% of people can sign on to the website.  They no longer even discuss completing the process.

Even more laughable is that HHS states that they have achieved their goal of the website being up and running 90% of the time.  Let us put aside the fact that 90% success of a website is pathetic; what is even worse is that 90% is noninclusive of downtime from scheduled maintenance that the website requires almost daily.  So when the website isn’t down for fixes..it is functioning at 90%.  Not much of an achievement.

“Healthcare.gov on Dec. 1 is night and day from where it was on Oct. 1,” Jeff Zients, who was brought in to oversee fixes to the troubled Obamacare website, declared during a Sunday conference call.  That may be true, but that doesn’t mean we have achieved any level of success.

Furthermore, when HHS was specifically asked by Washington Post Health Care blogger Sarah Kliff whether their problem with the 834 forms (essential data necessary to insurers to complete the purchasing process) have been solved..they refused to answer.

My contacts in the insurance industry have said that there have been small improvements, but overall, the problems persist.  So much so, the insurance industry put out a statements stating that although the website has improved, major problems remain, and are nowhere near to fixed.

Today the White House was proclaiming that 100,000 people have signed up to Obamacare in November, claiming another victory.  Again, this can only be considered a victory if you wear rose-colored glasses.  Yes, it is better than the 26,000 sign ups in October, but a fraction of the 800k expected in November.  At the current pace, Obamacare would need approximately 56k purchasers a DAY to achieve their goal of 7 million by the end of March.

The White House would be better served by admitting the truth.  Admission of the faults in the program such as that the entire program is running well behind schedule, and needs to be delayed, and that the website may need to be rebuilt are simple realities that the public may be willing to forgive.  The administration seems to be unwilling or unable to make such an honest assessment, either because of political or practical realities.  But trying to fool the American people that any of these metrics are any type of ‘success’ is likely a level of mendacity that will only lead to failure.

 

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Hunger Games Catching Fire: Movie Review

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The much anticipated sequel of last year’s hit The Hunger Games arrives just in time for Thanksgiving…and delivers just like a holiday movie should.

Katniss (Jennifer Lawrence) returns home after her victory in the Hunger Games, only to find her world turned upside down.  As the saying goes, you can’t go home again. While she must continue to act as if she is in love with Peeta (Josh Hutcherson), as she did during the Games, she clearly has feelings for her long time best friend Gale (LiamHemsworth). But her life is not the same; she is now wealthy because of her winnings, living in opulence while the rest of District 12 remains in squalor.

As part of their victory, Katniss and Peeta must go on a ‘victory tour’ of the 12 districts of the nation of Panem.  We learn quickly that their victory in the Games has set of a chain of events that will have ramifications for the country, and their own lives.  The pair have unintentionally ignited a slow, burning hatred for the leadership of the dictatorial nation…with Katniss as the symbol of how to rebel against the system.

President Snow (Donald Sutherland) decides that he has had enough of this love crossed pair, and uses the the Quarter Quell (the 25th anniversary of the Hunger Games, which always has a special ‘spin’ to it) in order to rid himself of both problems, as he throws both of them back into the arena for another fight to the death.

This is, in many ways, a transition movie, and as such, you view the characters quite dramatically different in the beginning of the movie compared to the end.  Katniss is fully a different person, with a different fate and expected future, at the end than you foresaw at the end of The Hunger Games.  We no longer can see a happy future for her, but only misery and more conflict and pain. As such, this movie does a nice job showing that transformation, and setting up the last book, which will be made into two separate movies.

I will have to say I enjoyed this movie more than the first.  First and formost, this was always my favorite of the three books. But Director Francis Lawrence has made a darker and more energetic film, that gives us more an innate feel of what the characters are going through, and the largeness of the issues that are revolving around our main characters.

This movie is as highly recommended as the first movie, and for me personally, was more enjoyable.  This series is shaping up quite nicely.

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Kennedy Assassination, 50 Years Ago Today

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I was born a decade after John F. Kennedy was assassinated in Dealey Plaza on November 22, 1963.  My knowledge and understanding of Kennedy’s life of course then comes through the prism of his death, more than his life.

That is largely how the mythos around Kennedy exists to this day: a liberal icon, whose life in ‘Camelot’ was the ideal that all politicians live up to.

We, of course, know this not to be the case today, if we are students of history.  Camelot was largely a post-mortem creation of the Kennedy inner circle, expanded and inflated to greater than life in his death.

His family life was far from perfect.  His political beliefs were scattered, and liberals forget that Kennedy supported what in today’s day and age would be steadfast conservative principles such as low taxes, low federal spending, and a strong worldwide U.S. military presence.

I think some conservatives take it too far; Kennedy was no conservative, but he would not easily find a home in the present Democrat Party either. I mean, truly, what Democrat today would feel comfortable saying this out loud:

“The federal government’s most useful role is … to expand the incentives and opportunities for private expenditures. … [I]t is a paradoxical truth that tax rates are too high today and tax revenues are too low and the soundest way to raise the revenues in the long run is to cut the rates now.”

He would be run out of every progressive group known today.

We also today forget that it was Kennedy that started the Vietnam War.  There has been decades of debate on whether Kennedy would have expanded the war as Lyndon B. Johnson did. Robert F. Kennedy seemed to think so. RFK himself stated before his death that JFK had no intention of pulling out of Vietnam.

But all of these political realities, including ones we have not spoken of (Bay of Pigs, Cold War, Civil Rights) pales in comparison to Kennedy’s death.

Kennedy ultimately died at the hands of an extreme leftist progressive communist, something that we tend to forget today.  Some liberals today want to blame the right-wing of that day, which is plain silly and easily dismissed.

Lee Harvey Oswald was a devout left-wing extremist, who converted to communism, even going so far as defecting to the Soviet Union.  In April 1963, Oswald attempted to shoot Edwin Walker, a retired U.S. Army general, as he sat at a desk in his dining room. Walker was a leading member of the John Birch Society, a right-wing group. That is not the actions of a right-winger; it is the actions of just the opposite.

Maybe it is most fair to say that Kennedy was just another victim of the Cold War. Of course, that reality didn’t suit the liberal intelligentsia of the time.  As James Piereson writes in his brilliant book Camelot and the Cultural Revolution, many of the liberal icons of the era chose to purposefully distort history, and make JFK’s death about civil rights, and not the Cold war.

Of course, the confusion of who actually was resonsible for Kennedy’s death, the murder of Oswald himself, the Warren Commission and the innumerable conspiracy theories that have been created and continue to arise to this day just muddy the waters of the reality of the historical moment even more.

This will continue to be debated forever.  The death of a leader does that to a nation.  But on a societal note, I somewhat understand the profound effect that the JFK assassination had on that generation.  I thought I understood it to some effect by seeing what I thought were life changing events such as the Challenger disaster, or the fall of the Berlin Wall. But 9/11 was transformative in a way that none of those were, and most  likely 38 years from now will have more impact on our lives than the JFK death has for us today.  I wonder if my children will view 9/11 as some distant historical footnote, as in many ways I view Kennedy’s assassination.

But, past the historical and political spin, this was a life of an American war veteran and hero, a man who valiantly served his country, and was taken from the American people in a horrible manner.  Whatever else you think of Kennedy, we should embrace the portions of his life that added to the American nation, and value them for what they were.

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