Category Archives: Health care

Drones, health care and the Constitution

By Steve Brawner

© 2017 by Steve Brawner Communications, Inc.

What do the emerging aerial drone industry and the health care system have in common? They both would benefit from a section of the Constitution that’s largely been ignored in recent years.

That would be the 10th Amendment, which says, “The powers not delegated to the United States by the Constitution, nor prohibited by it to the states, are reserved to the states respectively, or to the people.”

The political science term for this is “federalism.”

I’m bringing this up after reading that Arkansas’ Sen. Tom Cotton and three other senators – two of them Democrats – have introduced a bill that would let states and communities govern aerial drones flying under 200 feet of airspace.

In a co-written column in the Washington Times, Cotton and Sen. Mike Lee, R-Utah, said the nation’s drone industry has been stuck in a hover as it awaits regulations from the slow-moving Federal Aviation Administration. Meanwhile, Chinese manufacturers are beginning to dominate the developing market. Cotton and Lee argued that since it will take forever for the federal government to act, states and communities should be given control. A drone flying less than 200 feet over someone’s farm is a local issue, not a national one.

They’re right. Drones will be a growing part of our lives in the coming years. States and communities will have different uses and different levels of comfort with a technology that is both beneficial and invasive, so local solutions are preferable to a one-size-fits-all approach dictated by Washington.

Cotton also had a hand in a bigger piece of legislation, the Senate health care reform bill. He was one of 13 senators who crafted it behind closed doors but still hasn’t said if he supports the final product.

That’s because the bill is a mess and will never pass. After seven years of demanding Obamacare be repealed, Republicans are being forced to admit they never had a plan to replace it or fix its problems – and no, we can’t go back to the “old system,” either.

Health care is hard. Public policies result in allocating resources, but with health care, what do we want to limit, and for whom? Do we want more government involvement, which means more government control, or do we want health care decisions to be driven by the profit motive? Should health care be refused to people who refuse to work, or should they be treated in emergency rooms, or just given health care for free? As President Trump said earlier this year, “Nobody knew that health care could be so complicated.”

Thankfully, the United States has a valuable feature: its united states. The Senate health care bill does give states some flexibility – just as the Affordable Care Act that created Obamacare did – but maybe this is one issue requiring truly massive experimentation in 50 separate laboratories. Recently, California legislators seriously considered a statewide single payer system where the state government would pay everyone’s health care bills. They couldn’t make the numbers add up, but it’s good that we live in a country where widely varying alternatives can be considered – alternatives such as Arkansas Works, where the government buys insurance for poor people. Through experimentation, maybe an affordable health care system will arise that reflects American values but doesn’t cost 18 percent of the gross domestic product. We must try something, because what we’ve been doing the past few decades isn’t sustainable.

It’s not just drones and health care where a re-emphasis on federalism would be good for the country. As the United States has become more polarized, congressional gridlock is no longer a temporary problem but a permanent reality, meaning long-term problems can’t be solved or often seriously debated. The situation is leaving too much power in the hands of the one official who can act unilaterally, the president, and in the federal bureaucracy. In America, we’re supposed to address issues through deliberative legislative consensus. And that process still happens in state governments.

America’s diversity is one of its strengths. Let states like Arkansas and California try to address more problems on their own, learn from each other, offer lessons for the federal government, and in the end, still be a little different.

It’s OK. We don’t all have to be exactly the same. It’s in the Constitution, after all – about a third of the way through the amendments.

Health care and the 10 Commandments: Two monumental stories

By Steve Brawner
© 2017 by Steve Brawner Communications, Inc.

Sometimes news stories are important, and sometimes they are mostly just eye-catching. It’s important for news providers to offer both if they want to stay in business. It’s important for news consumers to understand which is which, and when a story is both, and why.

This week was a good illustration.

On Tuesday, something important but not particularly eye-catching happened. Senate Majority Leader Mitch McConnell (see, I’ve bored you already) announced that the Senate health care bill doesn’t have enough support to come to the floor, so he’s delaying action.

Health care is perhaps the country’s most vexing domestic issue. The system has been on an unsustainable path for decades. What Congress decides to do about it is literally a life and death matter.

But Americans know politicians will argue and posture about this issue forever, and it’s been pretty clear for a while Republicans aren’t ready to repeal Obamacare, much less replace it. So I’m doubting McConnell’s decision was the lead topic of conversation at dinner tables and baseball fields across Arkansas.

Wednesday’s top story, on the other hand, was definitely eye-catching. The day after workers installed a controversial 10 Commandments monument at the Capitol, a mentally disturbed individual knocked it over with his Dodge Dart, leaving it broken on the ground.

That’s a heck of a visual, and it followed a long process that involved passing the legislation authorizing the monument, a commission determining its placement, hearings where satanists argued for their own statue of a goat creature named Baphomet, and a pledge by the Arkansas chapter of the American Civil Liberties Union that they would sue to take it down. After all that, it stood for less than a day.

I didn’t monitor every conversation at dinner tables and baseball fields across Arkansas, but I suspect more people were talking about this than were talking about Mitch McConnell.

But was it important?

Not as a statement in the country’s never-ending culture war, on either side. The driver is not an agent of supposed liberal intolerance, nor is this the fault of the monument’s outspoken opponents. On the other hand, he is not a hero for religious liberty or a defender of separating church and state. He instead is a seriously disturbed individual with a history of mental disorders who allegedly committed the same crime against a 10 Commandments monument in Oklahoma. A guy who has heard voices in his head telling him that he will be abducted by a UFO is not on either team.

But this part is important: We are a nation of laws.

Hours after the monument was destroyed, the sponsor of the legislation creating it, Sen. Jason Rapert, R-Conway, told reporters that the private organization that funded it, the American History & Heritage Foundation, had already ordered a replacement, possibly with some protective barriers. Money is being raised, and it’s possible the driver’s insurance will help cover the cost, he said.

That’s good news. Regardless of what you think about the 10 Commandments monument, we should all agree its fate shouldn’t be based on the whims of a disturbed individual. The proper way of deciding its future is through the courts, which will determine if it’s an appropriate historical marker or an unconstitutional government establishment of religion.

There’s also this. We live in a world where mentally ill people have easy access to very dangerous things such as assault weapons and 6,000-pound vehicles. That combination can do a lot of damage before authorities or bystanders can act.

We must prevent these people from doing great harm to themselves and others. Public policies must balance the rights of mentally imbalanced individuals with the need for society to protect itself. Meanwhile, the health care system must be part of the solution. It must provide better mental health services.

However, as we all know, it’s hard to change the health care system. Did you see where Mitch McConnell delayed a vote on the Senate health care bill? That was really important.

History and health care

By Steve Brawner
© 2017 by Steve Brawner Communications, Inc.

History repeats itself, and, as we’re seeing with health care, that includes recent history.

In 1993, newly elected President Bill Clinton put the first lady in charge of fixing health care, and the next year the Republicans took over the House and Senate and gained 10 governorships. In 2009-10, newly elected President Obama and the Democrats passed the Affordable Care Act, and then Republicans gained control of government in Arkansas and virtually everywhere else except cities and the big blue states.

Now, newly elected President Trump and Republicans in Congress are trying to pass a health care bill – without any support from Democrats, who are salivating at the prospect of that issue sinking Republicans the way it previously sank them.

The latest Senate effort to repeal and replace Obamacare is called the Better Care Reconciliation Act, but you’d better believe that Democrats are calling it Trumpcare. That effort got some bad news Monday when the Congressional Budget Office said its passage would lead to an increase of 22 million uninsured Americans by 2026. That’s about the same as the American Health Care Act earlier passed by the House – the one that only 16 percent of Americans called a good idea in a recent NBC News/Wall Street Journal poll.

Because Democrats are an automatic no, the Senate version cannot survive if more than two Republicans vote against it. Things can change quickly in politics, but as of this writing more than two are expressing serious misgivings. Even Arkansas’ Sen. Tom Cotton, one of 13 senators who helped draft the bill in secret, hasn’t said if he’s definitely for it, and neither has Sen. John Boozman, though it’s hard to see either bucking the party in the end. If it does pass the Senate, it still has to be reconciled with the House version.

Just looking at the politics, you might wonder why elected officials don’t just ignore the issue. Unfortunately, health care is too big to do that. It’s 18 percent of the economy and growing faster than inflation. Premiums are rising, and insurers are pulling out of markets. Costs have risen so much for so long that policymakers vaguely pledge to “bend the cost curve” because it’s too much of a reach to say “spend less.”

In other words, health care is so big that elected officials must at least pretend to try to solve it, and when they do, they’re probably going to get punished for it. That’s because they cannot provide what voters expect – unlimited care for everyone with no bad outcomes at a negligible price and with no effort on our parts beyond taking a pill, which had better go down easy. Americans expect health care to be cheap if not free, but they don’t want the government to run it, and they don’t particularly like the insurance companies, either. You know the old saying, “Everybody wants to go to heaven, but nobody wants to die”? It’s just as accurate to say, “Everybody wants great health care, but nobody wants to pay for it.”

Meanwhile, the problem of exploding costs could be lessened if Americans simply made healthier choices. A recent Arkansas Center for Health Improvement study of 69,000 state and school employees found insurance plans spent far less in 2015 when employees were not obese or exercised regularly. In fact, the plans spent almost twice as much for employees who said they exercised fewer than 20 minutes per week – $6,043 each – as those who exercised moderately three times a week or vigorously once a week. Those employees cost their health plans only $3,345.

Health care won’t be “fixed” by any bill hatched in secret at the U.S. Capitol – not by Republicans, and not by Democrats. But one potential bright spot in the House and Senate bills is that they offer more flexibility to the states, which offer 50 laboratories to experiment with partial solutions. One such experiment, begun in 2013 and now called Arkansas Works, uses taxpayer dollars to buy insurance for poor people rather than enrolling them in a government program. It insures 300,000 people – more than were expected, so now Governor Asa Hutchinson is seeking to modify the program by adding a work requirement and lowering the income eligibility threshold.

Experiments like Arkansas Works should be encouraged. Good or bad, someday they will be the history others can learn from.

Can work be added to Arkansas Works?

Cindy Gillespie is director of the Department of Human Services.
By Steve Brawner
© 2017 by Steve Brawner Communications, Inc.

Next week, legislators will meet in special session to change the Arkansas Works program to encourage its recipients to work for their benefits and, eventually, no longer need them.

Changing the program will be reasonably easy. Changing the recipients will be much harder.

Arkansas Works, formerly known as the private option, uses federal Medicaid dollars to buy private insurance for 311,000 Arkansans with incomes up to 138 percent of the federal poverty level, or about $17,000 for an individual. The state pays 5 percent of the program’s cost this year and 10 percent by 2020. The federal government pays the rest.

It was created through the Affordable Care Act, otherwise known as Obamacare, which expanded Medicaid. Many Republican-leaning states declined to participate. Arkansas instead obtained a waiver from the Obama administration allowing it to buy private insurance rather than simply enroll recipients in Medicaid.

It has allowed Arkansas to be a national leader in reducing its uninsured population. But it is a government program that has grown bigger than expected, which happens a lot.

Gov. Asa Hutchinson, who wasn’t governor when it was created, wants to keep it but shrink it, so he is asking the Trump administration to change the waiver to reduce the maximum income from 138 percent of the federal poverty level to 100 percent, or about $12,000. That will reduce the rolls by 62,000 to about 249,000. Meanwhile, his administration wants to require some beneficiaries to work at least 20 hours a week, train for a job or volunteer. Those changes require legislators to amend some state laws, which they’ll do next week.

Creating those policies is the easy part. The Legislature is expected to approve the changes quickly. The state has been talking to the Trump administration and expects to be approved. The 62,000 Arkansans bumped from Arkansas Works can buy the same insurance they have now with a federal government subsidy. Their contribution will be $13 to $19 a month, about what they are supposed to pay now, though 75 percent of them don’t because the state can’t enforce the rule. Department of Human Services (DHS) officials think most will pay next year when insurance companies can remove their coverage.

The work requirement? Let’s keep our expectations reasonable.

In a briefing with reporters Wednesday, DHS Director Cindy Gillespie said it won’t affect 161,000 of the remaining 249,000 Arkansas Works recipients. They won’t have to work because they are age 50 or above, are “medically frail,” have a minor living at home, etc. Those exemptions mirror the Supplemental Nutrition Assistance Program, formerly known as food stamps, which also serves many Arkansas Works recipients. Some of the remaining 88,000 won’t have to work either if they are students, pregnant or caring for an incapacitated person.

Most of the 88,000 are not working now. More than three-fourths have zero income. Moreover, less than two-thirds of the 62,000 with incomes between 100-138 percent, the ones who will move into private insurance, have jobs. The rest subsist on government benefits and other means.

Most recipients have not taken advantage of a big opportunity they have now. Under Arkansas Works’ current waiver granted by the Obama administration, recipients are referred to the Department of Workforce Services, which can help them get jobs. But of the more than 37,000 individuals referred to DWS in January, only 628 accessed the services or reported a new job after the referral while 703 had done so beforehand.

Changing Arkansas Works will help some people. Given access to health care and an incentive to work, they’ll begin pulling themselves up by their bootstraps.

But some will not. Regardless of whatever liberal or conservative social engineering the state attempts, some people will not be self-sufficient because of lack of skill or will, addictions or very difficult personal circumstances. And then some people will simply choose to work the system and get by.

When they arrive sick and injured at the hospital doors, society must figure out what to do with them. One option: If they can’t pay, turn them away. Another option is the pre-Affordable Care Act method of letting them use the emergency room for free and then hospitals eating the costs or shifting them to the rest of us invisibly so we can pretend they don’t exist.

The state is opting for door number three: Try to provide enough but not too much, and try to get as many off the program as possible, for their own good and the taxpayers’.

Got a better idea? Call your legislators. They meet next week.