The Private Option

Despite Trump’s speech Monday, ridiculous, mendacious, inappropriate and embarrassing, as expected, he said something right: the ACA is not a good system of medical care delivery.

It is the worst healthcare system among economically advanced countries. 

There are two worse systems, though. The private insurance hustle without the ACA that the US had before, and all of the vicious tax cut and insurance company subsidy plans that Ryan and McConnell have put forward since Trump told them to make “repeal and replace” not just a battle cry, but actual legislation. 

 After two more defeats last week, McConnell and his deplorable allies are still plotting to Make America Sick Again.

If he succeeds, more of your money will be pumped into propping up the cash flow of the worst system of medical service delivery in the developed world, so they can backwash some of it to McConnell and his political hustle. If that does not really sound like a serious medical service, it’s because it isn’t.

McConnell’s disdain for public opinion is stunning. He is apparently immune to the tested fact that the vast majority of the population detests his nightmarish “healthcare” bills. And he doesn’t care. The donor-sphere fulfills his every political need.

The Public Option

Remember the Public Option? It was going to be a federally owned health insurance company or agency. It was not publicly funded healthcare. The mechanism was to be something like Medicare that you could pay for. It would have competed with private insurance companies. It might have driven premium reduction and less benefit challenging through market operations. Might have – by the time your legislators, following lobbyists’ instructions, got done embedding it in limitations and prohibitions, it might have looked more like something McConnell could be proud of.

At best, it would have been a clumsy compromise, mitigating some of the worst effects of the private insurance cartel while propping up an illogical and inappropriate presence at a healthcare provision system.

It was not Medicare-for-all or “single payer.” One proposed model was Medicare that you could buy. It could have at least had the government’s negotiating power, but under pressure of private hospitals, the AMA and the insurance cartel, congress would probably have blocked that.  It might even have set precedents that would have corrupted Medicare, opening breaches for Republicans to undermine even that part of the country’s weak safety net.

The private health insurance gang went ballistic, of course. They don’t want to have to sell services that you buy on their merits. They want control.

The public option was finally shot down by the chronically repellent fake Democrat and now klepto-family supporter, Joe Lieberman. (Fake Democrat then; now he is a fake Independent.)

Private Corporate Medical Insurance

Connecting right wing objectives to real medical services is a tricky mental exercise, requiring insertion of fictional constants and false assumptions.

The private insurance model is simply an irrational, ineffective way to pretend to achieve the goal.

The pernicious effects of the system are to some extent masked by the the high quality of the US’s medical capacity. It is commonplace that it is marred by overprescription of opioid painkillers and too may tests, probably more as defense against malpractice suits than real necessity, but the quality of the product is real. The problem is not what it can do. The problem is sho it excludes.

One of the results of the tangle of unreason combined with Republicans’ divide and rule instincts is the mad misunderstanding occasionally announced by Paul Ryan, who suggests further subdividing the premium pools of a system already rendered too weak and expensive by being partial. Ryan pronounces these gems of ignorance with one of his brow-wrinkled expressions. He calls that look intelligence.

Some history

During WWII, the US had full employment and high demand for workers. Wage controls were imposed to counter inflationary pressure. Corporations were challenged to attract enough workers to meet demand. The courts decided that fringe benefits were not wages, so corporations designed benefits to attract and retain employees. One innovation was to convert disability insurance that had started in the 19th century to medical insurance. Disability paid the wages of a worker temporarily unable to work. It was capped at a percentage of his wages. Insurance based on medical cost changed the equation, but between the major employers and insurers, they worked it out. Healthcare became a corporate tool.

At this point, it should already be clear that the basic design of American medical service provision was to keep some people in and others out. Employment based healthcare was designed to exclude people. As a loyal house man of the corporate state, Mitch McConnell does not care that his insane healthcare bills push twenty or thirty million people out. In his world, it was always thus, and so shall remain while his masters so order.

“Conservative” fictions imply that European healthcare systems like the UK’s NHS nationalized or socialized traditional insurance models, and that the US never has enough money to support real national medicare. Bogus. European countries got their tax funded medical systems going more or less when the US corporate system was taking shape, when they were destitute after WWII and the US was by comparison fabulously wealthy.

It seemed to work for a while, providing good, even excellent coverage for employees in secure jobs with major employers while cementing workplace and corporate loyalty.

It was partial and exclusionary, but papered over a lot of cracks under conditions of near full employment, high demand for labor and general prosperity. But things changed. Automation and offshoring changed the playing labor/capital equation. A locked in, dependent work force became a liability. General Motors went insolvent on health insurance. Reaganite regressive policies freed corporations from social responsibility. Business schools started teaching “shareholder value” to further detach directors and executives from their workforces and communities.

European and other advanced countries had already sorted out better healthcare delivery, but American conservatives and the successive red scares had so distorted Americans’ understanding of social services that should be the minimum price of politicians’ strut and power that the US often has to be dragged reluctantly into the emerging world. And now that some formerly intelligent countries are dragging themselves backwards, some available models are not performing at their best. When Trump says that one option is to let the ACA – he calls it “Obamacare” – fail, he is following a UK model, in which the Conservative Party progressively starves and weakens the NHS, claiming fiscal responsibility as justification, then points to the failings that they themselves caused to justify progressive privatization.

What makes America backward in these areas? It might be deeply cultural, perhaps rooted in America’s anti-intellectual, anti-logical, media-linked religiosity; but might simply be that other countries do not have to overcome an oligarchic corporatist culture working through a sadistic insurgency like the Republican Party.

The Private Option

What do you think about giving the insurance companies a job to do without giving them license to kill people?

Change their market space and some of them may shrink, go broke or succeed at selling a good idea.

You can have a serious national healthcare delivery system, and still have a commercial insurance market, without a Rube Goldberg idea like the Public Option.

Here’s how to do it.

Set up a proper national health system. Forget the American insurance model. It is a waste of money. Obama and the Democrats took that near to maximum benefit with the ACA, and it is still not good. All other systems proposed for a private insurance based system are worse.

Follow Bernie Sanders idea as a starting point: Medicare for All. Medicare is closer to a clean system with low administration costs. It needs work, to leach out the co-pays, reduce or eliminate charges “at the point of delivery,” as they say in the UK; get rid of the strange “doughnut” that can bankrupt a long-term patient if they don’t or can’t play the system right. For All means there are no pre-existing conditions to fuss about because everybody is in the plan from before birth.

Of course, to do this you are going to have to retire the Republicans. They are too delusional (some call it ideological; I think my word is more accurate) to handle it. I don’t only mean vote them out. Quite a few of them seem to have strange mental disorders of types usually associated with old age. They really need to go fishing, forever. As a warning to the next authoritarian insurgency, Trump and his crime family should be indicted and tried for at least some of their criminal activity. Money laundering would be a good start. A sound prosecutor should find some actionable corruption in McConnell’s game.

But you don’t have to shut down the for-profit insurers. You just take the power of life and death away from them. They should never have had it anyway.

After a satisfactory, complete national healthcare service is in place, the insurers can sell elective products. They would provide access to a limited private system that provides luxury and elective timing for a price.

The deluxe level of hospitals and insurance top-up plans can be paid for by people to whom the service is worth it, or by corporations or employers offering the insurance top-up as a perk.

Private insurance should not be an opt-out, though. Never an opt-out. If you offer tax reductions for the private insurance, it will change from an elective top-up to a replacement, and policy holders will want relief from the tax that supports the national system. No tax relief for the private policies!

You have to ensure that none of this happens at the expense of people who prefer to be in the national system, and that it does nothing to diminish the quality of care in the national system. The insurers must be debarred by law from undermining the basic system in any way. It should be a criminal offense for them to try to initiate or support any action or legislation to weaken the system.

There must be no means-test for the national healthcare system. It must not be a poverty or charity system. In the UK, as an example, for obvious ideological reasons, no Labour politician can be seen ducking out of the NHS. It has to be good enough for members of Parliament and Jeremy Corbyn.

Many doctors will work in both channels. They may have a national hospital contract, a government-funded private practice and some privately remunerated work.

If that sounds like a fanciful idea that could never really work, let me break it to you: I didn’t think it up. I lived in it for a few decades. In the UK’s NHS, pre-existing conditions are not a concept. For the private insurers, they are, but if they won’t give you a policy, you are still covered at no additional cost. In fact, at no cost at all, except your tax bill.

I have seen it work, so it can be done. Insurance propagandists will point out that the NHS is not perfect. No, and neither are the national systems of France, Holland, Spain and Scandinavia. Perfect hasn’t happened yet. But they are all better than here.

So Public or National Medicare: necessary. Not an option.

Private insurance: optional. Make sure it is really optional. Don’t let the industry use medical care as a murder weapon.

Why do Trump and Republicans want to privatize and restrict medical care?

A speculation: economic despair makes a good recruiting ground for the growing American fascism, as it was in Germany in the 1920s and 1930s. The evangelical fundamentalists could extend control over social services and ethics while expanding their net of magical thinking and superstitious oppression.

Either way it goes, whether the ACA lives through today or dies, the United States will not have modern best-practice access to medical service until the people overthrow the Trump kleptocracy and the Republican and Evangelical superstitions.

© Bob Freilich July 2017

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The Riverfront tempest moved to a new teapot

The Riverfront tempest moved to the Council chamber’s teapot Tuesday, for a match before the City Planning Commission.

But just before we raise the curtain, I suggest reading the quote below, and the quote within the quote. I lifted it from an email. I’m not sure if I am supposed to say who it is from. Oh, well . . .  if I get sued, with the kind of lawyer I can afford, the case will be over in 20 minutes and we can move on.

. . .  the argument against preserving authentic height is not about preservation. It is not about “tout ensemble”. It is not about protecting a Louisiana landmark. Rather and however well-meaning, it advocates historical revisionism, a fiction of personal preference that seeks to homogenize the genuinely different scale, mass, form, function, land-use and cityscape along the river with an artificial sameness that is achieved by incorporating the riverfront into the creole cottage core of which it was never a part.

The key is to make the most use of the space that is allowed to change and champion excellent design. Smart preservation with great reverence, protects the most important buildings and essential character of the neighborhood but encourages taller, new structures that reduce pressure on prices and tear-down pressure on the older homes.

When neighborhoods and cities restrict new construction, they become more expensive, sometimes pricing out the very creative people, older and poorer residents who made the neighborhood so creative and appealing from the beginning … Limiting height and development generally does not guarantee interesting, heterogeneous neighborhoods. It only guarantees higher prices.”

  • excerpt from Triumph of the City by Edward Glaeser

That first sentence sounds like me. So does the Ed Glaeser quotation, although I am ashamed to admit that I have not read Triumph of the City yet. Have I been committing telepathic plagiarism all this time?

In a scientific age, you can’t validate a hypothesis by recourse to credentials, but Ed Glaeser is a professor of economics at Harvard with years of professional research into the history and function of cities. Teamed up against him at Planning Tuesday was a full squad with a deep bench of some of our most active (ie, regressive) “preservationist” citizens, repeating and embellishing one after another some of the most misguided illogic, wrong assumptions and bad ideas about how cities and neighborhoods work that you could want to hear. You probably can hear it; I think the sessions are recorded and available on their web site.

As you can see in just the two clear, logical quoted paragraphs, if our institutions pay attention, Professor Glaeser has them outnumbered.

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There were many more of them than us. People who have a job to be at tend not to come to these daytime sessions, unless they are officers or paid execs of the neighborhood associations. The No! folk were well represented. We were outnumbered on the floor. They push ideas that would make everything new flat, square, boring, imitative and low, or just bog it all down forever in red tape and eternal “public input” so nothing happens. Their brand of No! is an old fogey position. I was surprised to see a couple of younger people – I’ll come back to them – but this über-preservationism, which extends the meaning of the word from defending a legacy to attempting to block the future – it’s a rocking chair philosophy. Or maybe a last-days religion. Some of the proponents may not be stupid people, but their ideas are sclerotic. They want to convince us and the Commissioners and Council that the Rice Mill and NOCCA and Turn and Latrobe and new buildings with some adventure in their design and some pride in their stature will by a dark art aesthetically damage a Creole cottage on Royal Street. They have withstood the challenge of NOCCA and Turn. They have been okay since 1892 when the Rice Mill went up, but just one more high building could do for them.

The use of fear indicates a religious belief. “No!” is the guiding commandment. Fear is a very popular shared emotion in America. They afflicted can turn aggressive as they associate to fight off enemies born in the shadows of their imaginations.

The biggest hitters for the No! team, one after another, complained about not having public input.

While addressing the Commissioners and staff, speaking into a microphone, being recorded,  doing public input, they complained of not being permitted public input. What was that about?

On CZO day at the back end of 2015, Amendment MJL-6 slipped into the ordinance between the cracks of a legal contradiction. There was some public complaint, but no process. FMIA sued to get it enjoined. They did not win, but might have if their suit had been structured better. Aware that they might be vulnerable to a follow-up attack, Council decided to give the plaintiff and NFB what they wanted – the City Planning Commission process, which would almost certainly result in a full council debate, and public input.

That is what we were watching – public input, including, despite the report, some attempted misinformation, disinformation, tortured non-logic and passionate advocacy for life in the rear view mirror. So what were they complaining about now?

It took a while, but I got it. They don’t want to just block or undermine good guidelines and rules. They want another crack at each and every single project that comes to CPC, Council and the HDLC. They want to public-input each building at each stage. Perpetual war. Afghanistan comes to City Hall. They want a license to obstruct, delay, enjoin and defeat the future by any means including lawsuits enabled by clumsy legislation. They want to make sure that the rules are so bad that every building will be subject to the variance process, which they want expanded from just land use to everything – what passes for design in their restrictive vocabulary, parking, grass, shrubs, trees, handrails, doorbells. Every brick would be subject to censure and control by self-appointed neighborhood clubs.

Give that notion a few seconds’ thought. For every project to require variance hearings, you have to define what is not variant so that no building that is appropriate for the space fits the rules. How crazy is that?

Believe it or not, that is what they asked for. As back in the sound wars of 2013 and -14, the line between preservationism and factional power is getting blurry.

In one proof of that unsavory pudding, CPC staff pointed out that opponents had objected that taller buildings would obstruct views of the river, but that 50 foot buildings would be equally opaque. The church of No! does not flinch at such exposures because their real intention is not 50 or 55 foot buildings. It is no buildings at all. No buildings, no new people, no new anything.

What the “No!” crowd does well, much better than us, is marshal a turnout. They all fill in speakers’ cards, then three of them cede their time to their favorite Alpha-negative performer, who makes a four minute speech. First the speaker commends the staff on its fine report, whose carefully researched facts thoroughly debunk the mythical history this same crowd used to sell us. Then they begin their peroration on why even if well done and true, it is invalid. City Planning is mischievously using facts to betray the citizens of Marigny and Bywater, western civilization, God and country. Torturing reason to express these ideas generates language that no one can understand. The No! audience, however, accepts it, nodding with serious expressions. The voices of their Alpha-Negative leaders, to whom they have ceded their time according to plan, comfort them. They think that warm feeling is wisdom and intelligence, not just the rhythm of their internal rocking chair.

Some of them believe that if your ancestors lived in Louisiana enough generations, your mind is tuned to properly understand these syllables connected in sequence but not by logic. They think they are intrinsically better qualified to judge than benighted rationalists like us. This seems to be independent of whether their esteemed ancestors were plantation slave-owners, slaves, snake oil salesmen or horse thieves. If you can hook yourself to a trace of DNA that lived in Louisiana in the 19th century, by the miracle of a spiritual Lamarck you have been granted the gift of truth.

Unless the genetic scion of the swamp is on our side. Then it doesn’t count.

Others, not in the priestly line, know The Truth by revelation – a lively tradition in American revivalism. Perhaps they meditate upon a cottage, a shotgun or a carved bracket until the Angel Creole appears and tells them it is okay to pursue the cranky limitations imported by the Yanqui takeover. I don’t know; I merely observe and report.

So the Alpha-negs, in the middle of their four minutes, ritually bemoaned the lack of public input. While they were publicly inputting.

Do you remember something CM Jason Williams told an almost full chamber from his council president’s seat one day, when a chapter of the eternal saga of the Habana Café was in play? He had asked Trader Joe’s why they sited their wildly popular store in Metairie not New Orleans. They told him that they would have preferred New Orleans, but between the city’s administrative Byzantinism and the NIMBY warriors, it would have cost too much time and money. So to shop at Trader Joe’s, we have to take the I-10.

So that was Tuesday’s match: the massed hassle of Marigny and Bywater, with a few visiting warriors from the French Quarter in support, against the few virtuous knights of the light.

My favorite No! was Ray Kern. Mr. Kern is a Marigny property owner and activist who turns up at these shindigs, usually to support very conservative positions. Kern, though, is refreshingly honest. He didn’t embed his preference in polysyllabic pseudo-reasonable faux-urbanist padding.

Ray said the right thing to do is do nothing.

Do nothing, Mr Kern said, and the city will progress “organically.” So the city should not alter the zoning rules. Whatever is, is the Panglossian best. Leave everything alone and the riverfront will emerge like organic kale and quinoa from the fertile alluvium on the town side of the flood wall.

I don’t agree with a word of it, of course. The city and the neighborhoods cannot progress toward their best futures if there is a law against it. But I would doff my straw hat, if I had one, to Ray Kern’s straightforward statement of what they all really meant. A refreshingly uncompromising Alpha-negative.

I said I would get back to the younger faces. No names, to spare the guilty and innocent alike. Let’s call them unnamed faces. I asked some questions of a young woman, fit, healthy, projecting energy, who had spoken for the No! team and was chatting cheerfully with the club members.

“Do you really believe this stuff? I asked. These are old fogey ideas. Why does an energetic young person like you side with a mantra of Stop here! New Orleans is finished. We live in a museum. The future is a violation of our sacred mythical history and our comfort zone.”

Bad approach. I wanted to explore the belief system. Since there would only be a minute or two, I tried to crack the surface fast. But it went wrong.

“Of course I believe it,” she said. “Otherwise I would not be doing this.”

“But why advocate positions that will help ensure that nothing happens, no new people, no improvement?”

“Because I care about the city.”

“Okay, I accept that. But that doesn’t explain the set of beliefs. Mary Ann Hammett and BNA on the opposite side care about the city. Sean Cummings and Pres Kabacoff care about the city. City Council and the administration care about the city. (As its designation indicates, MJL-6 was an administration bill.) Don’t you think they care about it just as much?”

She said Yes reluctantly, but I don’t think she really thought so.

“I am committed here, she said sharply. Sixth generation!”

I might have betrayed an involuntary eye roll. The claim that if your great-great-great gran’pappy survived the Civil War, then your idea of how the Mississippi riverfront should look in 2025 is more valid than Bob Rivers’ CPC staff’s, or BNA’s, or the developers’, or the Mayor’s, simply on that account, rings so many cracked alarm bells, it is hard to know which fire wagon to send out first. What kind of society are we looking for here, a new empowerment of Patricians and Plebs, Optimates and Populares? On this premise, the DAR would know best.

I had handled it badly, so at this point, she walked off, annoyed. But she had confirmed some of my perception: the congregation of No! can be uncomfortable with logic. It makes them angry. They do not like to test assumptions or emotions against experience, reality, reason or history. Her response was tribal and emotional. Expecting her to defend any point was offensive because ancestors she had never met conferred an a priori inner wisdom that validated her preference over that of others.

Well, sigh. That’s what I say. Sigh.

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What I did say:

  • Excellence of design should never be a penalty imposed on a developer so he can add a story or two to his building. If New Orleans is to remain a city of good architecture, good design must be at the top of the list of standards for new construction. Good design is a minimum standard, not a penalty. Height and setbacks are elements in the architect’s toolkit that must be ranged under good design, not imposed over it.

How do you evaluate design merit? Here is one idea: set it as a standard. Then strengthen the Architectural Review Board of the HDLC. Add an Architectural Review Committee to the CPC, or give the existing staff the mission of judging for design merit. Make sure that members are fully fluent in Jane Jacobs, Edward Glaeser and Andrés Duany. Make sure they understand the difference between preserving the past and choking off the future. Ensure that the nearsighted and fearful cannot turn us backwards.

I have never heard a word from anyone on the Yes! side in this endless debate that wants to lessen the protection of the legacy construction in the Historic Cores, but we do hear loudly and long from the No! people that the future should be banned.

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NIMBY myopia may be a medical condition. Its symptoms are narrowing and shortening the range of vision. Possibilities beyond the limited cone of perception seem ominous, dangerous. Sufferers associate in support groups. They appeal to government to protect and prolong their fears by ensuring them that the space and time outside of their vision will be limited to copies of what they already know. They call their anxiety “preservation.” Drugs which might help this condition are not legal in Louisiana yet.

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The outcome?  Probably inevitable. The Planning Commission sent the report and comments on to City Council. Even if some of the Commissioners sympathized with the Nos and their Alpha-negative champions, the report was too strong, too well done, too factual and reasonable to put it down on its first day out. City Council had instructed the research. It is highly unlikely that they would then have allowed the Commission to deprive them of considering it.

The commissioners added a note suggesting that Council consider banning short-term rental from the Overlay completely. As Mary Ann Hammett of BNA said, we need more residents not more hotel rooms.

© Bob Freilich 2017

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