Medicare Part D: Another year, another huge price increase

I signed up for Medicare last month. In addition to standard Medicare, I added Part D, the prescription drug benefit. My 2013  costs, if they had covered the entire year, would have come to $529 for insurance and $330 for prescription copays.

Today's mail brought the rates for 2014. The insurance premium has increased to $650, or by about 23%. Copays have also increased, to $616, or by nearly 87%. The total increase - assuming I won't need any additional medications - comes to 47%.

I was not happy when President Bush proposed and AARP supported Medicare Part D, the prescription drug benefit. The idea of insuring seniors' drugs was good. The resulting law, which specifically forbids the federal government from negotiating prices with pharmaceutical companies, was insane.

Well, "insane" is putting a good face on it. The financiers who supported the companies who bought the politicians who voted for the law were by no means insane. They were lining their own pockets, never mind the rest of us.

It's obvious, isn't it? If the government gives away money without limits and accountability, retail prices rise, insurance premiums rise, and consumers end up paying as much (or more) out-of-pocket than before the government stepped in.

Want proof? Take a look at this chart from the Kaiser Family Foundation. Notice that the U.S. government spends about as much of its GDP on healthcare as other developed countries (without, however, insuring everybody, as the other countries do). Notice that, unlike citizens of other countries, U.S. citizens spend a whopping amount in addition to what the government spends. The difference? Those other countries put strict limits on what pharmaceutical companies and other medical suppliers can charge.

Some Americans suggest that the government should just stop subsidizing things like health care and education. That doesn't make sense unless you think that only rich people should have access to schools and hospitals. But it makes more sense than subsidizing something without putting a ceiling on what the lucky recipients can charge for their goods and services.

I am going to look for a different Medicare Part D insurance company. I don't expect to find one that's much better, however, until our lawmakers learn to say Yes to middle-class and disadvantaged people and a loud, resounding No! to rich institutions and individuals who want to get even richer at our expense.

Money: The God of This World

This week Pope Francis spoke out against the cult of money. Here is how Catholic News Service's Carol Glatz summarized his remarks:

Pope Francis called for global financial reform that respects human dignity, helps the poor, promotes the common good and allows states to regulate markets.

"Money has to serve, not to rule," he said in his strongest remarks yet as pope concerning the world's economic and financial crises.

A major reason behind the increase in social and economic woes worldwide "is in our relationship with money and our acceptance of its power over ourselves and our society," he told a group of diplomats May 16.

"We have created new idols" where the "golden calf of old has found a new and heartless image in the cult of money and the dictatorship of an economy which is faceless and lacking any truly humane goal."

His words reminded me of one of the most significant books I've ever read, Protestant French philosopher Jacques Ellul's Money and Power.

First published nearly 60 years ago as L'Homme et l'argent ("Man and Money"), new French-language editions appeared in 1979 and 2007. I translated the English-language edition in 1984 and have been grateful ever since for the opportunity to immerse myself in this paradigm-bending book.

Money, Ellul argued, is not morally neutral. It is "Mammon, a demigod, a demon, an idol, a power from which we need liberation" (I'm quoting from David Neff's review of Money and Power in the February 15, 1985, issue of Christianity Today--and yes, he may have been biased, but damn, his review was good).

The problem isn't money, we say. The problem is that we don't have enough. Or that somebody else has too much.

No, says Ellul. Money is not neutral. "Jesus personifies money and considers it sort of a god. He does not get this idea from his cultural milieu. … This personification of money, this affirmation that we are talking about something that claims divinity . … reveals something exceptional about money, for Jesus did not usually use deifications and personifications" (p. 75).

Ellul explains that in Matthew 6:24 and Luke 16:13 Jesus shows that money is a power, a law unto itself that acts in the material world but with a spiritual orientation. In the Bible, power is never neutral. And it is often personal. Just as Scripture often portrays death as a personal force, so it also portrays money.

In the 60 years since Ellul wrote Money and Power (and even more in the 30 years since I translated it), the love of Money has taken root throughout the world in ways even Ellul might never have imagined. We fight wars to keep it, and to gain more of it. We damage the earth, deny social services to the poor, and pay ever smaller wages for ever longer hours, because to do otherwise would be bad for business. We don't enforce safety regulations or we outsource production to places with no regulations, so we can make higher profits on cheaper goods. And we have developed a theology of money in which the "free market" is the giver of every good and perfect gift - never mind the evidence.

Perhaps this is nothing new. It's been 2000 years since Jesus identified money with Mammon. But whether our love of Money is worse than ever before in the history of the world, or whether it is just business as usual, Pope Francis joins Jacques Ellul in reminding us that Money is a powerful false god.

If you like to get your reminders straight from Scripture, read Revelation 18, a gorgeously dark and dreadful poem about the fall of Babylon, surely Mammon's capital city, for she has deceived "all nations." As Babylon falls, so do the political leaders who "committed fornication with her" and the business tycoons who "have grown rich from the power of her luxury" and the multinational merchants whose ships "grew rich by her wealth."

The good news in Scripture is not that our stock portfolio has doubled or that our taxes have been cut or even that our nation's GDP is in recovery. The good news comes through an unmarried pregnant teenager: The Mighty One

has brought down the powerful from their thrones,

and lifted up the lowly;

he has filled the hungry with good things,

and sent the rich away empty.

                                                  Luke 2:52-53

FOR SALE: the American free press

(Where print publishing is headed)

My husband has spent over 30 years editing magazines. His company now publishes fewer than half the number of magazines they did a decade ago, and the number of employees has been significantly reduced. He feels some sympathy for the situation described in a recent New York Times article, "Sponsors Now Pay for Online Articles, Not Just Ads," "if the articles are clearly marked," he said, "and they don't promote the companies' products." Right, I said, and the camel's nose under the tent flap isn't hurting anybody.

I understand why magazines are turning to sponsored articles. Most of us would rather read our magazines online, though we have no intention of paying for the privilege of doing so. Unfortunately, advertisers are not willing to pay as much for online ads as they once did for print ads, possibly because consumers have learned how to block them. (I use Adblock Plus, which is great for now, but they're starting to let "more useful and pleasant" ads past their censors, which may soon render them useless to ad-avoiders like me.) With dropping revenue from consumers and advertisers, magazines have a hard time paying for original research, reporting, writing, and editing. The temptation to use sponsored articles is strong.

It's good for spouses to have common interests, so my husband and I both chose careers in a doomed industry that pays poorly. What could possibly go wrong? My work has been in book publishing, which has its own share of problems. A decade ago my little college town had a Borders and a Barnes & Noble. Now we have to get our books from Amazon or, more often, from the public library. Read another recent New York Times article, Scott Turow's "The Slow Death of the American Author," and weep.

Turow, who is president of The Authors Guild, is not complaining about his remuneration: his books have sold over 25 million copies. He simply notes that authors of e-books earn "roughly half of a traditional hardcover royalty"--unless they are pirated, lent, or re-sold, in which case they earn nothing at all. And since an e-book never wears out, why would anybody pay for a new one?

I didn't put a newspaper in my toilet photo, because I don't have an actual newspaper. We stopped subscribing to the Chicago Tribune about the time a good friend of mine, seeing the handwriting on the wall, took early retirement. She's glad she did: during the last decades, hundred of editors, writers, and reporters have been laid off, and pension benefits have dramatically decreased. Like everyone else, I read my news online now. As my mother once asked under other circumstances, why buy the cow if you can get the milk for free?

But what's going to happen now that we all expect to get our news, our magazine articles, and our books free of charge? If newspapers can't afford to hire good reporters and editors, news will deteriorate into shouting matches based on uninformed opinion. If magazines can't afford to pay their writers and editors, they will first try to turn into advertising delivery systems and then, failing that, go out of business. If book publishers lower royalty rates and refuse to take a chance on new or little-known authors (i.e., authors who are not yet "brands"), careful thinking and writing will be replaced by self-published schlock. Oh, right... those aren't predictions. They're descriptions of what has actually happened over the last decade.

Q. So where will our reading material come from? 
A. From businesses with products to sell, of course.

It's an American tradition. The current Supreme Court has decided that businesses have the right to sponsor political candidates. For many years cigarette makers sponsored the research that found no link between smoking and cancer. Nowadays manufacturers of sugary products sponsor dubious nutritional research. Why shouldn't businesses sponsor news, commentary, and entertainment, not only by advertising, but also by providing content? Especially if they're not specifically mentioning their own products in the articles they supply?

Well, one wonders how much of the camel will follow his nose into the tent. And one thinks of the old adage that he who lies down with dogs (or camels) gets up with fleas. For a fascinating first-hand look at how advertising influenced women's magazines before 1990, read Gloria Steinem's (possibly pirated) article "Sex, Lies & Advertising." For a fascinating first-hand look at how advertising is influencing all forms of media today, just stay online.

Please hire me

[Working till she drops]

A couple of years ago my 40-something cardiologist earnestly told me that the Social Security/Medicare problem was a cinch to fix--all we had to do was increase the retirement age. Right, I thought - I'm in my 60s and facing open-heart surgery, but once I recover I can go pound the pavement. My cardiologist is not an economist, however, and he's a good doctor, so I held my peace.

Yesterday's New York Times ran an article by Economic Scene writer Eduardo Porter, who should know better. In "The Payoff in Delaying Retirement" Porter writes:

What if there were a way for the government to ease the strain that the aging place on the budget while actually increasing their income in retirement, at little or no cost to their benefits? A well-designed reform would even improve the nation’s rate of economic growth. The way to do it is simply to encourage older workers to spend a larger share of their increasing life spans in the work force.

 Sometimes solutions that look good on paper don't work so well in the real world.

First, most boomers are already planning to work until they drop, since they have saved practically nothing for retirement. I'm not sure they need any additional encouragement. What they need is reality therapy.

Second, over the last decade or so, a lot of companies have downsized. Their PR departments speak of this as right-sizing. What it means is that (a) fewer jobs are available; (b) older workers--the ones getting the bigger paychecks because of seniority--are in greatest peril of being laid off; and (c) the remaining jobs require much longer work days. Such policies, good as they may be for a business's bottom line, are not conducive toward extending one's working years.

Third, it's hard for laid-off older folks to get entry-level jobs. Not only are they overqualified (whatever that means), but the jobs just aren't there. Ask any recent grad.

Fourth, while some older people can work at full capacity well into their 70s and 80s, many cannot. However cheerfully chirpy AARP publications may be, 60 is not the new 40. Over 70% of Americans between ages 60 and 79 have some form of cardiovascular disease, for example, compared to fewer than 40% of people between ages 40 and 49 (see data here). For every person between ages 40 and 44 who is diagnosed with cancer, more than eight people between ages 65 and 69 are so diagnosed (see data here). And those who plan to die with their boots on should be aware that nearly 14% of people over 70 have Alzheimer's disease (see data here).

But let's neglect all those potential problems and stipulate that those of us who are capable of working really should be working, at least until--shall we say--age 70. OK, I'll offer myself as a test case. 

I am 64 years old. I have a solid work history with excellent recommendations, though I have not had a regular employer for some 13 years and my industry--book publishing--is in a hard place. With three master's degrees and a background in teaching as well as editing, writing, and management, I'm quite versatile. My health has been pretty good since my open-heart surgery a year and a half ago (I will require excellent medical insurance, however). I have an extended network of other aging publishing professionals.  

So keep me off Social Security and Medicare for another five years. Offer me a full-time job with a respectable salary and benefits.

Or isn't "encourag[ing] older workers to spend a larger share of their increasing life spans in the work force" quite as simple as Mr. Porter believes?

Is the West's reckless lifestyle killing our poorer neighbors?

[Africa, with Tanzania highlighted]

I spent all day Monday in an outpatient clinic (I'm fine; thanks for asking). I met a lot of nurses, and every one of them was excellent.

When Velda came to take away the remains of my lunch, I offered her my untouched can of ginger ale.

"I don't drink soft drinks," she replied. Since I rarely do either, we started chatting.

Velda grew up in Tanzania, moved to Belgium, spent several years in London, and finally came to the United States. She returns to Tanzania regularly, and she is not happy with what she sees.

"I grew up eating lots of vegetables," she told me. "We might have had ice cream once every three years. But now people are eating American-style junk food. They don't know it's not good for them."

Tanzania's cigarette industry is big. In spite of national bans on most forms of advertising, Velda vividly recalls a huge billboard for Sportsman - one of Tanzania's most popular cigarette brands - right across from a school entrance where children can't help seeing it every day. And the children are smoking - she's seen them.

Supposedly regulated drugs are easy to buy without a prescription. Velda's 18-year-old nephew, once an honor student, is now a prescription-drug addict and a drop-out.

"The thing is," Velda said, "there's no way to get treatment for most diseases. It's not like here. If people want to be healthy, they have to take care of themselves. When they get sick because of junk food or smoking or drugs, they just die."

I checked the statistics. Tanzania's per capita income is $1700 in U.S. dollars. There is one physician for every 125,000 people (compare America's ratio of one physician for every 375 people; or Cuba's of one for every 156). Tanzanians live, on average, to age 53. Velda's twin sister died at age 23.

Velda, who is a kind and gentle nurse, gets angry when she thinks about what's happening to her people. "Why?" she kept saying. Why are international companies so aggressively promoting foods and cigarettes and drugs that will shorten people's lives and even kill them? Why is nobody stopping them? Why?

Mr. Metz's 5% health-insurance surcharge

I'm having trouble understanding today's news about "Florida based restaurant boss John Metz, who runs approximately 40 Denny's and owns the Hurricane Grill & Wings franchise." According to an article in the U.K.'s Mail Online, Mr. Metz "has decided to offset [the extra cost Obamacare will bring] by adding a five percent surcharge to customers' bills and will reduce his employees' hours."

Here's what scares Mr. Metz: By 2014, Obamacare will require employers (of more than 50 workers) to provide adequate health insurance for full-time employees or risk paying a penalty (you can learn the details at the Kaiser Family Foundation's website).

If he's scared, it must be because his restaurants do not provide adequate health insurance for their full-time workers. Actually, Denny's does provide what their New Employee Enrollment Guide calls "affordable limited benefit medical plans to all eligible employees." (That was from their guide for hourly employees; salaried employees also get health insurance.) Is Mr. Metz ignoring Denny's benefits package? Or does he believe that the insurance is so inadequate that employees will choose to get insurance elsewhere? Or are his workers paid so poorly that they can't possibly afford even the low-cost option? Or does his own chain, Hurricane Grill & Wings, not offer this benefit at all? Because if he's providing decent health insurance that his employees can afford, he will not have any extra charges and so has no reason to add a surcharge to his meals.

So why is he adding a surcharge and downgrading his workers to part-time status?  According to Fox News, "To further offset the costs, Metz, who oversees roughly 1,200 employees as president and CEO of RREMC Restaurants, LLC, said he also will slash most of the staff's time to fewer than 30 hours per week." If Mr. Metz is providing inadequate insurance - or no insurance at all - to his full-time employees, I can understand why he would want to make all jobs part-time. That way he would face no government penalties for his miserable benefits policy. But if by reducing hours (and hurting his workers even more than he's already doing) he manages to escape the penalties, then why is he adding the surcharge?

Mr. Metz seems to be sending the message that he hates Obamacare. He may not realize it, but he's also sending the message (whether true or not) that he's a rotten employer who provides inadequate employee benefits, would rather cut workers' hours than be required to treat them humanely, and then is willing to make diners pay more for supposed additional costs - even though he has managed not to incur them.

I was going to end there, but then I got to thinking: maybe this isn't only about Mr. Metz. Maybe he really can't give his workers adequate pay and benefits and still stay in business. Maybe this is really about us.

We Americans in the upper 53% have relatively inexpensive houses and cars and clothing and groceries and restaurant meals (when compared with the rest of the world). We manage this by sending much of our manufacturing overseas and by paying squat for services

The people who grow our food, process our meat, bring the food to our tables, wash our dishes, clean our offices, and care for our aging parents often do not earn enough to support their families and must rely on tax-supported programs just to survive (in Florida, Mr. Metz's home state, a person working two 24-hour-a-week minimum-wage jobs, 52 weeks a year with no time off, would bring in $19,144 before payroll taxes; in neighboring Georgia, where Mr. Metz has a few restaurants, the minimum-wage two-job worker would make just $12,854).

But we Americans have relatively low taxes - which means that our social safety net has a lot of holes in it.

Did you know, for example, that "Wal-Mart's poverty wages force employees to rely on $2.66 billion in government help every year, or about $420,000 per store[?]. In state after state, Wal-Mart employees are the top recipients of Medicaid. As many as 80 percent of workers in Wal-Mart stores use food stamps" (check it out here).

So what happens to these underpaid workers if we continue to demand lower prices and lower taxes?

Obamacare, though it needs improvement, is an important step toward justice. Mr. Metz's surcharge could be another step in the right direction if it enables him to insure all his employees.

However, if diners reduce their tips by the amount of the surcharge, restaurant workers will end up with even less take-home pay than before. If Americans continue to push for lower taxes, more and more of the working poor will fall through the safety net. And if Mr. Metz goes ahead and reduces the hours of his full-time workers so that they won't qualify for health insurance, the extra 5% will go directly into his pocket.

Our nonpartisan American runaway train

Art by Stephen Slade Tien
via Wikimedia Commons

I freely admit what you already know: I am a wonk. So when the book I'm reading, The Moral Measure of the Economy, laid out a bunch of fearsome statistics going up to 2005, I was compelled to update them. I'm not going to bore you with all the stats. I'd just like you to notice one thing that seemed odd to me. Maybe you can tell me what's going on.

We all know that the gap between rich and poor is getting wider. What I didn't know was that, whatever the forces may be that are driving rich and poor apart, they don't seem to be related to one party or the other.

Here's what the book says:

In 1985, the average income of the top 5 percent of families was 13.5 times as much as the average income of the bottom 20 percent. In 2004, the top 5 percent made almost 21 times as much as the bottom 20 percent.

So I looked up the Census Bureau table that gives this information (it's here; go to Table F-3 and click "All Races" for the Excel file), and I calculated the ratio for each year since 1966, and I made this chart. The short silver bars at the bottom represent the average income of the bottom 20%. The long green bars represent the average income of the top 5%. See the gap widen ...

Here's what seems odd to me:

• From 1966 to 1981, the ratio is pretty stable: seven years of stable Democrats, nine years of stable Republicans.
• In 1982 the gap starts to increase. It gets steadily larger through eleven Republican years.
• In 1993 the gap suddenly jumps from 1:16 to nearly 1:20. From then on, through ten Democratic years and eight Republican years, it never goes below 1:18. Since 2000, it has always been nearly 1:20 or higher.

Something is causing our nation to become more and more unequal (in opportunity as well as in income, as Joseph Stiglitz points out in The Price of Inequality: you can read an excerpt here). Whatever it is, neither Democrats nor Republicans have effectively dealt with it.

Economics is a complicated science: 

     - is our rising inequality a failure of understanding? 

Tax hikes, even for the rich, are hard to get through Congress: 

     - is it a failure of will?

The princes of Wall Street, Wal-Mart, and multinational corporations are doing just fine: 

     - is it a triumph for their lobbyists, who spend more and more every year?

And if we find it distressing, who are we supposed to vote for, anyway?

Romney's plan covers preexisting conditions - for the rich and the lucky

"You shouldn't have let his health insurance lapse."

For just a moment I thought Romney was actually moving toward the middle. On Sunday's Meet the Press he said he wouldn't get rid of all health-care reform. One thing he planned to do, he said, "is to make sure that those with preexisting conditions can get coverage.”

And then later, of course, his campaign clarified: He would make sure that those with preexisting conditions would be covered if they had continuous insurance coverage. In other words, he would continue to enforce the Health Insurance Portability and Accountability Act of 1996. Well, whew.

Yesterday Washington Post blogger Ezra Klein asked, "Who would be left out of Romney’s preexisting conditions plan?" Answer: "About 89 million Americans."

If you have a pre-existing condition, are covered by a good insurance policy, and qualify for and can afford a COBRA policy, you'll be OK for 18 to 36 months. After that you're on your own.

But people buy COBRA policies because they are out of work, and COBRA's rates are steep for the unemployed: about $500/month for an individual and nearly $1400/month for a family.*

If you have a preexisting condition and can't  afford COBRA, you could lose or be unable to get health coverage under Romney's plan:

• if you're the nonemployed wife or child of a man who retires or dies or loses his job
• if you stop working for several months to care for an aging parent or an ill family member
• if you lose your job due to serious illness or injury
• if you are unemployable due to mental or physical disabilities
• if you take an unpaid maternity leave
• if you're looking for your first job and you are not covered by your parents' insurance
• if your company decides to stop offering a health-insurance benefit
• if the only company who will hire you does not offer a health-insurance benefit
• if your company goes out of business, and it takes you longer than 63 days to find a new job

I understand why preexisting conditions must be tied to continuous insurance coverage: you can't have people signing up for insurance only after they've had the diagnosis or the accident. And indeed, preexisting conditions are tied to continuous insurance coverage in Obamacare (to use the Republicans' preferred term), in socialized medicine (to use another term they favor, even though they usually use it erroneously), and in those developed nations who finance health care through private insurers.

The difference between Romneycare and all those other plans is this: With the other plans, everybody has continuous insurance coverage. With Romneycare, you can have continuous insurance coverage if you can personally afford it, if you are able to work, and if you're lucky.

_______________________________
*In 2010 an individual policy cost $429 a month and a family policy cost $1170. Those are the latest figures from the Kaiser Foundation; since health-care insurance rates have been rising between 8 and 9% a year for several years, it is reasonable to assume that the average Cobra policy now costs about $505 (individual) or $1377 (family) per month.

A financial report from someone who has been on Mr Ryan's Medicare plan since 1999

For details, check out "The Dog Maxed Out My Credit Card" from the November 2, 2011, Wall Street Journal.

Uh oh. Will we be able to afford Medicare?

We'll be hearing a lot about Medicare between now and November. Obama wants to tweak it. Romney wants to reinvent it. Everyone who wants to get elected, however, agrees on one thing: nothing will change for the current crop of seniors and soon-to-be seniors.

Whew. Six months and Mr Neff will be home free! Less than a year and a half and we'll both have free health care! And then we can afford to retire, right?

Wrong.

Last week a friend and I - let's call her Dorothy - compared health-care costs. We have a lot in common. Both of us are married. In both couples, one spouse's medical expenses are low while the other spouse's are high. We both live in Wheaton, Illinois, and have access to the same hospitals and doctors and pharmacies. We both are compulsive record keepers. Here's the difference: Dorothy and her husband - let's call him Dale - are retired and on Medicare. My husband and I have a Blue Cross Blue Shield PPO through his employer.

Last year Dorothy and Dale paid $8,874.60 for health insurance. That included Medicare plans A, B, and D ($2988), plus a Medigap policy, plan F, to handle what Medicare doesn't cover ($5,886.60). In addition, they paid $1588 for dental care, vision care, and prescription co-pays. Add those expenses to their insurance costs, and Dorothy and Dale paid $10,462.60 for health care in 2011.

For comparison, last year my husband and I paid $3,185 for health insurance. In addition, we paid $4,447.51 for co-pays, deductibles, vision care, and the percentage that Blue Cross doesn't cover. Add these expenses to our insurance costs, and my husband and I paid $7,632.51 for health care in 2011.

That is, my retired friends on Medicare paid $871.88 a month on health care compared to our $636.04 - a difference of $235.84 a month. In fact, health care costs eat up about 30% of their Social Security income. Something to look forward to!

Still, I'm thankful for Medicare. Once my husband retires and the company contribution stops - another $12,740 beyond our own payments - there's no way we could pay for private insurance plus out-of-pocket expenses. Half a loaf is better than none. But do keep us geezers in mind when you go to the polls in November. Most retired folks have less income than they did when they were working. They also often have much higher medical expenses, even if their health status has not changed.

Yes, I know that health-care costs have spiraled out of control. Yes, I understand that the government will not be able to afford Medicare much longer, especially since the ratio of workers to retired people has dramatically shifted. Clearly something has to be done - but what?

A government website touts the Affordable Care Act's provisions to fight waste, fraud, and abuse in Medicare, and to slow cost growth - worthy goals all, but inadequate to the task of reforming senior health care. Mr. Romney offers a private-enterprise-based solution that could actually make the situation worse. Our current for-profit health-care system has made U.S. health care more expensive than health care in all other developed nations, twice as expensive as most. Allowing it to take over an even greater percentage of our health care system seems foolhardy at best.

The truth is that we won't solve Medicare until we solve health care for everybody.

Meanwhile, why do politicians of every persuasion promise not to touch Medicare for Boomers and seniors, even as they suggest overhauling the program? Because we don't know what we'd do without it, and they don't know what they'd do without our votes.

But if our lawmakers don't start ignoring their pet lobbyists and corporate sponsors pretty darn soon and come up with a really workable health-care plan for young and old alike, we're going to find out exactly what we'll do without Medicare: If we or our children can afford to pay several thousand dollars a month for health care, we'll live as long as our European friends. If not, well, too bad.

How soon can we come up with a health-care policy that makes sense?

The U.S. Supreme Court

Maybe the Affordable Care Act is constitutional and maybe it's not. If it turns out to be constitutional, maybe it's good legislation and maybe it's not. In any case, it's looking increasingly likely that the Supreme Court, come June, will strike down at least the requirement that everyone buy health insurance. And if the mandate goes, two other requirements will most likely go with it: Once again insurers will be able to reject or refuse to renew applicants. And once again Americans with pre-existing conditions will be uninsurable.*

Let me tell you four short stories about friends of mine. These are true stories, not hypothetical examples. I have changed nothing but the names of the people involved. I am not arguing on behalf of the constitutionality of the Affordable Care Act. I'm just saying that all of these people had serious problems before it was passed, and some of them are doing much better now because of it.

1. John, a pastor, was married to Jane, who worked in publishing. They were well insured - until John came down with a debilitating disease. They would have to rely on Jane's insurance, even though her job was over an hour's drive from their home and John's health-care provider. Changing jobs was out of the question; no new insurer would consider adding John to their policy. So for some 10 years, Jane worked full time, commuted over two hours a day, and worked evenings and weekends as her husband's primary caregiver. When he died, she quit her job and applied for insurance on her own. Every insurer turned her down.

2. Bill and Betty have a child with a learning disorder. When he finished high school, he went to work, but the only jobs he qualifies for are low-paying, without benefits. In addition, the nature of his disorder makes it hard for him to keep a job. He has persisted, however, and he is gradually learning how to be employable. Thanks to the Affordable Care Act, his parents' insurance pays for the medications that allow him to work. They wonder what he will do if his insurance is taken away.

3. Dan and DeAnn have a similar story. Their daughter, in her early 20s, had a life-threatening physical problem that was correctable by expensive surgery. Until it was corrected, she was unable to work and earn her own insurance. Before the Affordable Care Act, she would have been too old to benefit from her parents' insurance, but once the act went into effect, they were able to put her on their policy. This story has a happy ending: she has had the surgery and is doing well.

4. Martin was a truck driver and Melissa was a secretary until a series of illnesses - heart disease, strokes,  ulcers, dementia - forced Martin to quit work and go on disability. Fortunately for him, he is a veteran with excellent health benefits at a nearby veterans' hospital. Melissa took over the full-time home care he now requires. Unfortunately for Melissa, she had no insurance and was too young for Medicare. A strong believer in self-sufficiency, she tried to ignore her arthritis and diabetes. After ten years of giving her husband excellent care, she finally turned 65 and was able to sign up for Medicare.

My stories are all about hard-working, responsible people who would eagerly buy health insurance if they possibly could. Before the Affordable Care Act, sadly, they could not. People on the left and on the right agree - the Act is flawed. But if it is thrown out, what will happen to people like my friends? What will we put in its place? And how soon can we come up with a health-care policy that makes sense?
___________________________

*If the mandate to buy insurance is struck down but these two requirements are allowed to stand, you can be sure that insurance premiums will skyrocket and the number of uninsured Americans will reach new highs.

David Brooks, Charles Murray, and the Reign of Mammon

Today's New York Times carried a thought-provoking op-ed by David Brooks called "The Materialist Fallacy." I recommend that you read it: it's only 764 words long. Brooks argues that "in the half-century between 1962 and the present, America has become more prosperous, peaceful and fair, but the social fabric has deteriorated." This is not just because of job loss (the liberal explanation) or government intrusiveness (the libertarian explanation) or "the abandonment of traditional bourgeois norms" (the neo-conservative explanation).

It has more to do with declining social context and social capital, says Brooks, who never met a financial capitalist he didn't like. He really likes Charles Murray's new book, however: Coming Apart: The State of White America, 1960-2010. (If you're not up for the 416-page book, you might want to read Brooks's January 30 column in praise of it.) Both authors worry about nefarious social forces that are driving a wedge between rich and poor, productive and non-productive, law-abiding and outlaws.

Brooks is partly right, and so are his critics. Yes, there's a rip in our social fabric. Yes, it is caused or made worse by job loss, ill-advised government programs, and shifting (or abandoned) values. Yes, it diminishes social capital and impoverishes social context. But also, Mr Brooks, and perhaps fundamentally, our decaying social fabric is the direct result of our enthusiastic worship of Mammon--the love of money that is the root of all evil (1 Timothy 6:10).

I don't need to remind anybody about rapacious financiers, bloated CEOs, unscrupulous lobbyists, and corrupt politicians. But there were plenty of those in the 1890s and the 1920s, and, as Brooks points out, the social fabric still stayed more or less intact back then. Even two World Wars and a Great Depression didn't unravel it. People still finished school, still got jobs, and still got married before having children, if not always before getting pregnant. Why did things start to break down in the 60s?

It's all the Boomers' fault, right? I mean, the first Boomers were getting their driver's licenses in 1962, the very year Brooks chooses as the beginning of the end. And once we had wheels, and cars with back seats, and, hey, the Pill!--it was all downhill from there.

Nope. Brooks doesn't think it's that simple. But I don't see him fretting about the sea change in the cult of Mammon that took place in the 1950s when we older Boomers were children. For the first time, kids--millions of us--became a market segment. With a brand-new television set planted in nearly every living room in America, we were sitting ducks for anyone who had a product to sell and money to buy air time. We were as plankton to whales, as baby seals to sharks.

The marketers told us we were fantastic, and we believed them. They told us we deserved whatever we wanted, and we agreed. They warned us, sometimes not so subtly ("often a bridesmaid, never a bride"), that if we didn't buy their product, we might face some diminution of our social capital, and we trembled. And they encouraged us to buy their product right now, whether or not we had cash on hand.

Believing them, we stopped thinking about tomorrow. Sha la la-la-la-la, live for today--never mind that what we did today might get us in debt, or destroy our brains, or produce babies. We were the "Now" generation, and proud of it.

But what do you get when people start wanting everything now, so much so that they stop making and carrying out long-range plans, that they defer commitment indefinitely, that they heedlessly risk future solvency in favor of present satisfaction? Well, at the front end, you get a great economy based on thriving businesses with ever-expanding sales volumes. Then, when the rush subsides, you get fatherless children, inadequate education, declining health, a hazardous environment, crumbling roads, and joblessness. You get a social fabric shot full of holes.

So whom shall we blame for the present sad state of so many Americans? Government? Big business? Mysterious social forces? Our own lack of moral fiber? Sure, why not. We've all sold out to Mammon. Our society's organizing principle is the love of money.

Alas, until we as individuals and as a nation stop worshiping at Mammon's altar, all attempts to fix the social fabric--be they Republican, Democratic, socialist, anarchist, moralist, religious, or academic--will be about as effective as sewing "a piece of new cloth on an old garment" (Mark 16:21). Still, a patched garment, if no new fabric exists, is better than no garment at all.

Yesterday in U.S. health care policy - a step in the right direction

Yesterday a provision in the Affordable Care Act went into effect: health insurers' profits must now be limited.

In response, Rick Ungar, a journalist specializing in health-care policy, posted a feisty column on Forbes's Policy Page. Provocatively titled "The Bomb Buried in Obamacare Explodes Today - Hallelujah!," the article looks at "the provision of the law, called the medical loss ratio, that requires health insurance companies to spend 80% of the consumers’ premium dollars they collect—85% for large group insurers—on actual medical care rather than overhead, marketing expenses and profit."

Knowing how much Steve Forbes hates the Affordable Care Act (see, for example, my November 10 post), I started reading Ungar's post with trepidation. Was his "Hallelujah" sarcastic? Was he wincing when he wrote that the medical loss ratio provision would lead to "the death of large parts of the private, for-profit health insurance industry"?

Evidently not. Insurance companies can't possibly make a profit once this provision is enforced, Ungar writes, and their parent companies are "fleeing into other types of investments. They know what we should all know – we are now on an inescapable path to a single-payer system for most Americans and thank goodness for it." Ungar thinks the results will be good for the rich, who will still be able to buy expensive insurance for luxurious care; and good for the poor, who will finally be able to "get their families the medical care that they need." His Hallelujah is genuine.

I completely support the medical loss ratio provision, but I believe Ungar should have mentioned that the poor are unlikely to be able to get the medical care they need unless there is a federally enforced mechanism for limiting costs. As far as I know, there is no such mechanism in the Affordable Care Act - the providers' lobbies saw to that. So federal funds will continue to subsidize providers' profits (as long as the providers aren't insurance companies), and prices will continue to rise way beyond the means of poor and middle-income families.

I also believe he is mistaken when he suggests that "the death of large parts of the private, for-profit health insurance industry" will lead to the advent of a single-payer system. As T.R. Reid points out in his excellent 2009 book, The Healing of America, "the United States is the only developed country that relies on profit-making health insurance companies to pay for essential and elective care." Those other OECD countries, however, do not all have single-payer systems. Britain, Canada, Sweden, Denmark, Norway, and Spain do. France, Germany, Japan, Belgium, the Netherlands, and Switzerland do not. Like us, they finance health care through competing private (but not-for-profit) insurers. There is no reason we could not do the same.

The United States has taken an important step forward by limiting insurers' profits. We now need to do something about profiteering in other parts of the gargantuan health-care industry. If we truly want to improve our health-care outcomes, provide health care for all Americans, and still spend less money per capita on health care, we need to take lessons from other developed nations, all of whom are ahead of us in all categories (see, for example, this 2010 article on a Commonwealth Fund study, or check out the facts and figures yourself at the World Health Organization's detailed database search page).

Or we can continue down our present path of allowing lobbyists to finance elections and line the pockets of our elected representatives in hopes of reversing or indefinitely deferring any meaningful health-care reform.

Steve Forbes's Prostate vs Mehmet Oz's Heart

Last week two articles highlighted America's split over health-care policy. One likened the U.S. Preventive Services Task Force* to a "death panel" and argued that we need more free enterprise in our health-care system. The other lamented the tens of millions of Americans who do not have adequate health care and argued that our inability to come up with "a health care reform law that we can all live with" is "a failure of basic morality."

The first article, "The Department of Health and Human Services' Death Panel" (Forbes magazine, 21 November 2011), is by Steve Forbes, a publisher and businessman whose net worth is estimated at $430 million.

The second article, "Enough Is Enough" (Time Ideas, 31 October 2011) is by Mehmet Oz, a cardiothoracic surgeon and media personality whose net worth is estimated at $7 million.

I'm pretty sure both writers are part of the 1%. Both were graduated from Ivy League universities: Mr Forbes with a history major from Princeton, Dr Oz with an undergraduate degree from Harvard, an MD from the University of Pennsylvania Medical School, and an MBA from the Wharton School of Business. Both are Boomers: Mr Forbes was born in 1947, Dr Oz in 1960. But despite the similarities, their views on health care couldn't be further apart.

Steve Forbes is irate with what he calls a "committee of 'experts' [scare quotes in original] appointed by the Department of Health & Human Services," because "this group recently declared that men should not be routinely screened for prostate cancer." See, Mr Forbes recently had a routine exam which led to removal of his prostate, and he is convinced - medical research be damned - that routine prostate exams save lots of lives. What is more, he is sure that the HHS research is all about "rationing and saving money," and that "what we need in health care is more free enterprise, not Soviet-style controls." He does not explain why he is opposed to the government's saving money, or why he thinks free enterprise would be less interested than the government in doing so.

Let's say Mr Forbes is right, the researchers are mistaken, and all men should get regular prostate exams. I am wondering how free enterprise will encourage that, given the ever-increasing number of uninsured Americans. Mr Forbes has endorsed Rick Perry for president; both men believe that health care is best handled by the private sector. It's not working so well in Governor Perry's Texas, however, according to a September 8, 2011, article in the L.A. Times. Insurance premiums are up - "when compared with incomes, insurance in Texas is less affordable than in every state but Mississippi" - as is infant mortality. "More than a quarter of Texans lack health insurance, the highest rate in the nation." Texas has some of the best hospitals in America for the rich and the well-insured, but "nearly a third of the state's children did not receive an annual physical and a teeth cleaning in 2007, placing Texas 40th in a state ranking by [the nonprofit Commonwealth Fund]." I don't imagine Texas, despite its governor's faith in private enterprise, will be offering free prostate exams any time soon.

Looked at another way, how would a federally managed health-care system prevent men from getting regular prostate exams if they really want them? A PSA test can cost as little as $45. If insurance companies, those pillars of private enterprise, stop subsidizing such tests on the grounds that the federal government says they have no proven value, will it be such a hardship for men to pay for their own tests? The poor might not be able to afford them, of course, but they're mostly uninsured and aren't getting them anyway - unless they are enrolled in some government program like Medicare or Medicaid. Yet Mr Forbes doesn't seem worried that those very programs may be cut back by politicians who favor a free-enterprise-based health-care system. His logical contradictions make the head spin.

Mehmet Oz, by contrast, doesn't serve up any ideology in his article. If he cares whether our health-care system is based on free enterprise, a single-payer system, or some combination of government and private business, he doesn't say. His article was sparked, not by a personal health crisis, but by what he saw when he volunteered at the "CareNow Free Clinic in the Los Angeles Sports Arena, where more than 700 doctors, nurses and health professionals had turned out to serve the local community."

During this four-day event, according to the CareNow website, "1,000 patients per day [were provided] with medical, dental and vision care they would not otherwise have received. A total of 7,200 procedures were performed, from dental fillings and root canals to medical exams and podiatry; from eye exams and prescription glasses to mammograms, Pap smears, immunizations and other services. Everything was offered at no cost to the patient."

Dr Oz, who has also volunteered at free clinics in Arkansas, North Carolina, and Texas, saw a "tide of disease and despair" in Los Angeles. A young mother whose children were insured by the state but who had no insurance herself. A young man with untreated, out-of-control diabetes who had no idea how to treat it. A woman who had lost her job and her insurance two years before, and was "too ashamed to seek help for a mass she felt in her right breast. Now the tumor had replaced her entire breast and blasted through the skin." Dr Oz writes:

At what point, I wondered that day and still wonder now, will we finally say enough? ...  I don’t underestimate the complexities of implementing a health care reform law that we can all live with. As with most entitlement programs since the Great Depression, we will have to perfect health care reform over time, just as Social Security, Medicare, veterans’ benefits and others were.

But we’re not perfecting the law; we’re fighting over it. Politicians dither and people die. Lawyers argue the merits of this or that technical point, and more blameless Americans grow sick and slip away.

Which is the real "death panel" - a government agency concluding that routine PSA screenings save few lives, or a health-care system that, favoring industry profits over human needs, leaves 50.7 million Americans uninsured?
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*The USPSTF, according to their website, is

an independent panel of non-Federal experts in prevention and evidence-based medicine and is composed of primary care providers (such as internists, pediatricians, family physicians, gynecologists/obstetricians, nurses, and health behavior specialists). [It] conducts scientific evidence reviews of a broad range of clinical preventive health care services (such as screening, counseling, and preventive medications) and develops recommendations for primary care clinicians and health systems. These recommendations are published in the form of "Recommendation Statements."

Why can't illegal phone sales calls be stopped?

Emailed response to one of my many complaints to the FCC

I'm getting more and more annoyed at the alleged enforcers of the Do Not Call list and, for that matter, at AT&T.

Like all 312,530,648 people living in the United States, I hate phone sales calls. All of them, without exception. Especially when they interrupt a nap or a meal or a visit with friends.

Of course I have caller ID. Of course I don't answer numbers I don't recognize. Of course I have put my numbers - landline and cell - on the Do Not Call list. In addition, I have filed many complaints at the DNC website and with the Federal Communications Commission.

And the calls keep coming. More and more of them. Even on my cell phone.

I'm not talking about equally annoying but legal calls, such as political nonsense from Congressman Peter Roskam, whose every recorded phone call makes me cringe. I'm talking about plainly illegal calls - recorded messages from people wanting to wipe out my debts (yeah, right), or incessant calls from numbers that simply hang up when they get my answering machine.

I have started Googling the supposed phone numbers to see what I can learn about the callers. I have learned that most of the annoying callers are listed many times on sites such as 800notes, WhoCallsMe, and NumberInvestigator. The numbers have been reported countless times to the proper authorities. Some of the callers have been annoying people for years.

Why is nothing being done to stop them?

I know, I know - the numbers on my Caller ID are probably spoofed. It's illegal to spoof a phone number "for the purpose of defrauding or otherwise causing harm," but apparently not if all you're doing is selling dubious services. And no doubt some of these calls originate outside the United States, so perhaps the FCC has no way to stop them. But hey - the phone companies could trace these calls if they really wanted to, couldn't they? And if not - maybe the call is being made with a prepaid phone card, for example - couldn't they come up with an app that would allow us to instantly block any caller we never want to hear from again?

Note to geeks: invent such an app, and you could retire comfortably by next summer. Be sure to include a version that works on landlines.

Ethical business : 10 field marks

In a speech to the U.S. Chamber of Commerce two days ago, President Obama appealed to some 200 business leaders to act responsibly. "I want to be clear, even as we make America the best place on earth to do business," he said,  "businesses also have a responsibility to America."

Now, I understand the challenges you face [the president said]. I understand that you're under incredible pressure to cut costs and keep your margins up. I understand the significance of your obligations to your shareholders. I get it. But as we work with you to make America a better place to do business, ask yourselves what you can do for America. Ask yourselves what you can do to hire American workers, to support the American economy, and to invest in this nation. 

A blogging friend of mine - a man who automatically opposes or is cynical about anything Mr. Obama says - responded predictably: "Amazing. The president (apparently hearkening back to JFK) tells these CEOs to ask what they can do for their country, as if providing jobs, goods, and services in a very uncertain economy is not enough. What an insult!"

My friend does not really believe that providing jobs, goods, and services is all a business needs to do, of course. He does not support pimps or drug pushers, for example, even though they provide jobs and goods or services; and I suspect that he's not fond of gambling casinos or abortion clinics either, even if they are entirely legal.

His comment, though, got me thinking, and for that I thank him. What, exactly, does an ethical business do beyond providing jobs, goods, and services? Here are some preliminary thoughts - please improve on them.

An ethical business ...

1. exists to provide life-sustaining jobs and useful goods and services.
2. makes a profit so that it can continue providing jobs, goods, and services; but rather than sitting on excessive earnings or turning them into fat bonuses, creates new products or hires more workers or increases overall employee compensation.
3. manages its affairs so that not just executives and shareholders but also rank-and-file employees are adequately compensated.
4. keeps honest and transparent accounts so that its directors, contractors, shareholders, and employees can make informed decisions.
5. markets its products honestly, not making misleading claims or delivering shoddy merchandise or poor service.
6. assures healthy working conditions for all of its employees at home and abroad, refusing to outsource to anyone who uses child labor, sweatshops, toxic working environments, or slave labor.
7. makes sure that its methods and materials preserve the environment for future generations at home and abroad, and takes responsibility to clean up any environmental disasters it inadvertently causes.
8. does not attempt to profit through taking advantage of consumers' ignorance, addictions, or desperation.
9. does not lobby or bribe lawmakers so as to be excused from ethical behavior in any of the above areas, or so as to gain an advantage over other companies.
10. gives back to the community not only through creating jobs, goods, and services; but also, whenever possible, by providing funding for community projects, rewarding employees who engage in community service, and supporting legislation that fosters the common good.

When President Kennedy challenged us to ask what we could do for our country, none of us took it as an insult. Rather, his words were an affirmation that we could, with vision and hard work, make the world a better place. I take President Obama's words to the U.S. Chamber of Commerce in the same way. Ethical businesses are a tremendous force for good, and the world needs them now more than ever.

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For further reading: Bill George, professor of management practice at Harvard Business School and a director of ExxonMobil and Goldman Sachs, has written an interesting op-ed piece listing over a dozen concrete actions President Obama has recently taken in support of the business community. Check out "President Obama's Challenge to Business: 'It's Time to Invest in America.' "