Archive for February, 2022

Ukraine, Still Standing Against All Odds

Monday, February 28th, 2022

Frustrated by his inability to conquer the people of Ukraine thus far, Russia’s President Vladimir Putin reportedly resorted today to carpet bombing and cluster munitions in Kharkiv in the east of the country. Russian forces have been attacking Kharkiv since he gave the order for the invasion, but have been repeatedly repulsed.

Carpet bombing of cities, towns, villages, or other areas containing a concentration of civilians is considered a war crime as of Article 51 of the 1977 Protocol I of the Geneva Conventions. Cluster munitions were banned by the Convention on Cluster Munitions in 2008. After ratification by 130 countries, including Russia, the Convention became International law in 2010.

A shopping center in Kharkiv and a school in Okhtyrka were destroyed indiscriminately, leaving dozens killed and hundreds wounded at the shopping center and three dead at the school.

According to reporters for the Daily Mail, the bombs were fired using the Bm-21 Grad Rocket system, which is a multiple launch weapon. If carpet bombing and/or cluster munitions were used on Ukraine’s civilian population Vladimir Putin has committed a war crime, and, according to ABC News, the chief prosecutor of the International Criminal Court at the Hague says he plans to open an investigation “as rapidly as possible” into possible war crimes and crimes against humanity in Ukraine.

Nearly the entire world is united in opposition to Putin’s monstrous invasion. It seems the Russian Federation President has done the one thing all observers thought impossible: He has united Europe, North America and Australia as never before. The economic sanctions leveled over the weekend, which I feared would be no more than a slap on the wrist, have turned out to be a kick in the gut and a punch to the side of the head. The Russian stock market was ordered to remain closed today, the value of the Rubel dropped by more than 30%, and there were long lines at ATMs.

Putin’s only ally appears to be Alexander Lukashenko, President of Belarus, which sits on Ukraine’s northern border. In the invasion, a third of Russia’s forces attacked from Belarus, and today Belarussian forces joined the Russians in bombing and attacking Kharkiv. Lapdog Luka continues in power because of his fawning willingness to serve his lord and master, Vlad the Invader. One hopes he will also pay a heavy price for the devastation he is helping to wreak on the innocent citizens of innocent Ukraine.

Meanwhile, back in the U.S., Republicans (most of whom were their own kind of lapdog to Putin’s good friend and admirer, Donald Trump) have been keen to say how awful the whole situation is, and, by the way, it never would have happened on their watch, and isn’t it terrible that Joe Biden is rolling over for European leaders. Some have excoriated him, because he is letting Europe have too much of the credit for the world’s response. He’s not America First enough. These Republicans, of course, are the same people who voted to deny Ukraine the weapons so necessary for its defense. Those would be the Javelins that are now destroying so many Russian tanks and armored vehicles. Like the ever-expanding universe, there seems to be no limit to opportunistic hypocrisy.

And what can we say about Volodymyr Oleksandrovych Zelensky, Ukraine’s President? This is a man who was trivialized and mocked by many after his election in 2019. This is a man who had to suffer the indignity of being on the other end of the line for Donald Trump’s “perfect call.” This is a man who, more than anyone else, has shamed Europe into uniting to combat Putin’s horrific, criminal, and inhumane invasion. A man, no, a leader, who leads by example in the face of near certain death if he is captured.

A man who has now become the George Washington of his country.

And My Guitar Gently Weeps

Friday, February 25th, 2022

I look at the world and I notice it’s turning
While my guitar gently weeps
With every mistake we must surely be learning
Still my guitar gently weeps.
-George Harrison

If the great George Harrison were alive today, his guitar would be weeping over the Russian invasion of Ukraine. Vladimir Putin’s troops have blitzed their way to the major cities and, as of this morning, have encircled and shelled Ukraine’s capital Kyiv. Resistance has been strong. Reports suggest the invasion isn’t going as smoothly as Putin imagined it would. Ukrainian troops are fighting valiantly, as did so many in Hitler’s way in 1939, but, as with those long ago heroic defenders, they fight alone and their cause is hopeless. True, they will make Putin pay a high cost in Russian blood, but it seems inevitable that Kyiv will fall. Putin will decapitate the government, assassinate the leaders he can find, install a puppet regime, declare Ukraine restored to its rightful place in the arms of Mother Russia, and that will be that.

Russian heavy troop presence will remain, and a “leader” like lapdog Belarusian President Alexander Lukashenko will sit at the head of government. Maybe Putin’s friend Viktor Yanukovych, thrown out in 2014’s Revolution of Dignity will return. It’ll be easy to reach him; he’s been living in Moscow ever since. That will be irony, indeed.

It certainly seems Putin has outfoxed America and the rest of NATO and the European Union.

How can I say that?

First, as I reminded readers yesterday, former Secretary of State Madeleine Albright noted in a New York Times Guest Essay that Putin is a planner and plays the strategic long game. Right now, it’s becoming obvious that the current invasion has been in the planning for more than eight years, perhaps going all the way back to the early 21st century when he first took power. Since then, everything he has done has been geared toward a return of Imperial Russia. Remember, as far back as 2005, he called  the breakup of the Soviet Union “the greatest geopolitical catastrophe of the century.”

Second, in keeping with that, I urge you to read a brilliant column in today’s Washington Post by Sebastian Mallaby, the Paul A. Volcker senior fellow for international economics at the Council on Foreign Relations and a contributing columnist. Mallaby’s point is that by forcing Russians to sacrifice since prior to 2014’s invasion of Crimea, Putin has built up a tremendous economic reserve, much like the Bible’s Joseph in ancient Egypt preparing for seven years of famine. In contrast, Mallaby describes how the West has sacrificed nothing in response.

Perhaps a couple of excerpts would help:

1. As Matthew C. Klein observes in the Overshoot newsletter, Russia has used the past eight years to reduce its vulnerability to sanctions. The Russian people have accepted a drop in living standards, cutting their consumption of imports by more than a quarter. Russian businesses have paid off overseas creditors, reducing their foreign debt by one-third. The Russian state has tightened its belt, allowing it to build up its reserves of gold and foreign currency.

2. By embracing these sacrifices, Russia has fortified itself against the West’s economic weapons. The central bank has a $630 billion rainy-day fund. Even if sanctions blocked 100 percent of Russian exports for an entire year, the country could continue to import at its current pace and have foreign-exchange reserves left over. President Biden’s initial response to Putin’s incursions was to bar U.S. investors from buying Russian bonds. But Russia has no need to borrow from Americans.

So, as a good friend suggested to me yesterday, is our big song and dance about levelling crippling sanctions in unity with NATO and the European Union nothing more than Kabuki Theatre? Have we dug into the armory of our considerable weapons and unleashed a pack of snarling paper tigers? In the march to the takeover of Ukraine, will Vlad the Invader stare into the eyes of our paper tigers and then simply shrug and move on?

This is all so very sad.

My guitar gently weeps.

War And Death In Ukraine – And Sanctions

Thursday, February 24th, 2022

So, here we are.

Last night, moments after a threatening and vitriol-laden speech by Russian Federation President Vladimir Putin, the massive army he had assembled on the north, east and south of Ukraine’s sovereign borders began the full-out invasion all had been expecting. And innocent people began to die.

This afternoon, after conferring with the other 29 NATO countries, as well as the G-7, President Biden ordered profound economic sanctions intended to cripple the Russian economy. Today, even before the President announced those new sanctions, Russia’s stock market had dropped 45%. Will it matter?

For four years, Putin had a subservient partner in Donald Trump, but when Trump lost to Joe Biden Putin had to reevaluate his strategy. It appears 2021 was devoted to that reevaluation, and in 2022 he began revealing his true self.

On Monday of this week, the cover came off and the world got to see the real Vladimir Putin, the one former Secretary of Defense Bob Gates saw 16 years ago: “When I looked into his eyes I saw a stone cold killer.”

In a rambling, paranoid, seemingly-off-the-cuff, one-hour monologue filled with revisionist history, Putin laid out his case for the invasion of Ukraine. In the view of the Russian Federation President, Ukraine is part of Russia; always was, always will be, and wishing something else won’t make it so. He intends to return Ukraine to the bosom of Mother Russia, where it has always belonged. Same with the rest of the former Soviet Union. He blamed the unfortunate circumstance of Ukraine’s independence on mistakes made by Lenin following the 1917 revolution. He made it seem as if being part of Russia would be the best thing ever to happen to Ukraine. Of course, during his rant he conveniently forgot to mention anything about the millions of Ukrainians Stalin starved with cavalier cruelty during the famine of 1932-33. Thirteen percent of the population wiped out by another megalomaniac.

I know it’s asking a lot, but if you haven’t read his speech, you really should. It’s reminiscent of Hitler’s harangues prior to the annexation of the Sudetenland in 1938, which was the first step on the path to World War II. In a speech at the Sportpalast in Berlin prior to annexation, Hitler claimed that the Sudetenland was “the last territorial demand I have to make in Europe.” Sound familiar?

Putin has bent to his will the Russian Duma, the armed forces, Russia’s police, and what passes for a “news media.” However, the ultimate success of his invasion of Ukraine rests on his ability to continue to persuade the Russian people that Ukraine belongs to Russia and is vital for the country’s security.

It won’t be all smooth sledding for Mr. Putin. Last night, more than 1,000 anti-war protesters descended on Moscow’s Red Square demanding the troops leave Ukkraine. Russian police immediately began arresting them.  Mr. Putin will brook no protest. Which is one reason why Alexei Navalny is about to enjoy another 15 years of penal servitude. Putin failed to kill Navalny, so prison will have to do.

And what about those sanctions? Obviously, Putin has been planning this invasion for quite some time. As I’ve written before, he knows it would be foolish to move against a NATO country and risk the invocation of Article Five. But Ukraine is not a NATO country, so, in his mind, he can do pretty much what he wants. He doesn’t have to stand for any kind of legitimate re-election, so he can afford to play the long game. As Madeleine Albright wrote in a guest essay in this morning’s New York Times, “Mr. Putin is a planner.” She had first met him in early 2000, and was the first senior official in the Clinton administration to do so. Following that meeting she wrote in her notes, “Putin is embarrassed by what happened to his country and determined to restore its greatness.”

As a “planner” he must have taken full consideration of what the West can do to him economically. His apparent response? Sanctions? Shmanctions! They’re worth it for Ukraine, Europe’s second largest country (after Russia).

I am afraid this will not end well for anyone, least of all Russia. But Putin has gone all in. Given his history and his recent behavior, do you see him changing course anytime soon?

Neither do I.

Quo Vadis, Ukraine?

Monday, February 14th, 2022

A few years ago, a television interviewer asked former Secretary of Defense Bob Gates his impression of Russian President Vladimir Putin. Gates said, “I looked into his eyes and saw a stone cold killer.”

Today, that stone cold killer has more than 134,000 Russian troops and all the military hardware that goes with them massed on three sides of Ukraine’s borders, effectively putting the country in a straightjacket. For all practical purposes, the country’s capital, Kyiv, is encircled.

No one knows how this will turn out, but one thing can be said right now: This is an even bigger game of political chicken than the Cuban Missile Crisis of 60 years ago, which brought Russia and the U.S. to the brink of catastrophe. If a diplomatic solution isn’t found that gives Putin a face-saving off-ramp, Russia, Ukraine and all 30 NATO countries, including the U.S., could easily find themselves in another World War.

Article Five of the NATO Treaty begins, “The Parties agree that an armed attack against one or more of them in Europe or North America shall be considered an attack against them all…” Ukraine is not a member of NATO, and guaranteeing it never becomes one seems to be one of Putin’s major demands.

Only a fool would want to go to war against 30 NATO countries, and Vladimir Putin has never demonstrated he’s anybody’s fool. His build-up of troops has been precise and methodical. Keeping that kind of approach, it is entirely conceivable that without ever firing a single shot in a NATO country, Russia invades Ukraine, captures Kyiv, takes total control of the country, installs a provisional government, along with a puppet “president,” announces stability has returned to the area, withdraws most of its forces, and leaves Ukraine in much the same position it was prior to the breakup of the Soviet Union, which Putin has always maintained was the worst thing ever to happen to Russia. As far back as 2005, he called it “the greatest geopolitical catastrophe of the century.”

But once an invasion begins, anything can happen. Poland, Romania. Slovakia and Hungary, NATO members all, sit on Ukraine’s immediate western border, and Latvia and Lithuania lie on the border of Belarus, just to the north of Ukraine, where Russia is conducting “war games” right now.

What can the U.S. and the rest of NATO do about this? As the Biden administration has said repeatedly, no American troops will fight alongside Ukrainians. Instead, it and its NATO allies will levy the severest economic sanctions possible. Our weapons will be….economics.

Now, does anyone really believe that if Russia annexes Ukraine (much like it annexed Crimea in 2014), the threat of the severest sanctions will deter it? It’s just a guess here, but it seems likely to me that Putin will find sanctions well worth it in return for the entire country of Ukraine.

This is tremendously sad to me. I have immediate family who spent a lot of time in both Ukraine and Russia and who wrote an award-winning Doctoral Dissertation on Ukraine’s Orange Revolution of 2004. I have learned that Ukrainians are courageous people who always seem to come up with the short end of the stick, but who persevere, nonetheless. They’ve always been somebody’s pawn, and today is no different. Many Americans probably never knew Ukraine existed until Donald Trump decided to mess with its national security by denying it essential, congressionally-approved and appropriated military equipment to defend itself against just this kind of exigency, all for his immoral personal gain.

Perhaps if the world had taken stronger action in 2014 when Russia took Crimea we might be in a better position now. But things have gone too far, right to the edge of the cliff, and it doesn’t appear anyone is willing to build a hammer big enough to deter what is more and more looking inevitable. The Ukrainians are determined to defend themselves to the last breath, but they’ll need a lot more than determination.

If Ukraine falls, it will change the face of Europe and  increase significantly the reach and power of Putin’s Russia in ways all of us will regret for a long time.

I fear this will not end well.

And The Nominee Is?

Wednesday, February 9th, 2022

More than 20 years ago, C-SPAN and its academic advisors decided to create a survey instrument, by which “historians, professors and other professional observers of the presidency” would be asked to rate all presidents in ten areas from best to worst. They conducted the first survey in 2000 and, using the same criteria, have repeated it since then every time administrations changed.

This year, 142 scholarly elites completed the survey that asked participants for evaluations in the following ten categories:

  • Public Persuasion
  • Crisis Leadership
  • Economic Management
  • Moral Authority
  • International Relations
  • Administrative Skills
  • Relations with Congress
  • Vision/Setting an Agenda
  • Pursuit of Equal Justice for All
  • Performance Within the Context of the Times

Abraham Lincoln has finished on top in every one of the surveys, including the fifth one just conducted following the change to the Biden administration.

It will come as no surprise to many that Donald Trump finished fourth from the bottom in this year’s survey, his first. He finished ahead of Franklin Pierce, Andrew Johnson and James Buchanan, and behind all the others. Even Warren Harding got more respect from the raters.

However, the historians, et al, were not asked to rate Presidents in terms of how consequential they were. And it is here I suggest Trump would finish in the top ten, perhaps even the top five. I base this on one thing and one thing only: His fundamental change of the American Judiciary, principally at the Supreme Court level. Trump succeeded in locking in a deeply conservative bench for decades to come. That was the result of the grifter and reality show star’s Faustian Bargain with Mitch McConnell, senate Majority Leader during the Trump years. Trump craved power and being adored by people who were in need of someone to adore, and McConnell wanted his legacy to be the establishment of a profoundly conservative court. They each got what they bargained for.

Trump had two other monumental accomplishments, of course. The first was passage of the Tax Cuts and Jobs Act of 2017, which was a Christmas present of the first order for the nation’s wealthy, a knife in the back for everyone else, and a means to a significant widening of the ever-growing divide between the haves and have nots. Trump’s second accomplishment was to give the Republican Party an opportunity to exercise noble leadership in the face of his insane narcissistic nationalism and autocratic desires culminating in the January 6th insurrection. Unfortunately, only two Republican leaders, Representatives Cheney and Kinzinger, answered the call. The rest of them, every one of them, became profiles in cowardice.

However, these other two Trumpian achievements can be changed. Congress can change tax laws, and Republicans can grow spines. But that Supreme Court thing? That is here to stay.

Which brings us to the imminent Supreme Court vacancy caused by the announced retirement of Justice Stephen Breyer.

When he was campaigning for President, Joe Biden promised if he had the opportunity to nominate a Supreme Court Justice, he would nominate a highly-qualified black woman. With Justice Breyer’s announcement, Biden has reaffirmed that pledge. He will submit his nomination to the Senate in the very near future. It will be a black woman.

How will Republican Senators react to the nominee, whoever she is? How will they approach the hearings to be held by the Judiciary Committee, chaired by Illinois senator Dick Durbin? Will they be able to restrain the natural gravitational urges of their more ambitious and inflammatory members to grandstand opportunistically? Will they be able to keep Trump out of it?

Nominations to the Supreme Court are highly political. History is replete with examples, and this one will be no different. But from here, deep in the winter of the Berkshire mountains, my guess is that with a few unavoidable histrionics from the grandstanding children, Biden’s nominee will sail through like a battleship through fog, with Republicans, trying to appear as honorable adults, saying they refuse to do to Biden’s nominee what the Democrats did to Bret Kavanaugh.

Not that it will make a bit of difference to the future rulings of the Supreme Court.

Easy Enough

Tuesday, February 8th, 2022

There have been eight presidential elections in the 30 years since the election of 1992. While Republicans have won three of those elections, they have only won the popular vote once, in 2004 when George W, Bush narrowly defeated John Kerry by 35 Electoral votes with 50.7% popular vote plurality. In the other two Republican victories, George W. Bush lost the popular vote to Al Gore by a little more than 500 thousand votes in 2000 and Donald Trump lost the popular vote to Hilary Clinton in 2016 by nearly 2.9 million votes. And, as all of us know, and most of us believe, Joe Biden won the election of 2020, defeating Trump by about 8 million votes and winning the electoral college 306 to 232.

Gore and Clinton left the field gracefully, congratulating both Bush and Trump. Gore could have continued the fight, but conceded for the good of the country.

How far we have come from those days.

Donald Trump has never conceded (and never will), and it’s safe to say he did not leave the field gracefully.

A few points to consider as we ponder our journey from sanity to where we are now.

“In addition to winning the Electoral College in a landslide, I won the popular vote if you deduct the millions of people who voted illegally,” Trump tweeted in November, 2016, following his victory over Mrs. Clinton. This was a lie. To attempt to prove his point, though, Trump set up a voter-fraud commission, budgeted at $500,000 and headed by Kris Kobach, the Kansas secretary of state whom the American Civil Liberties Union dubbed “the king of voter suppression.” Months later, Kobach quietly folded his commission’s tent and slinked off in the dead of night. The Commission never submitted a report and it never released its documents to the public; they were turned over to Maine’s Secretary of State Matthew Dunlap by court order and contained no evidence of voter fraud. However, and it’s a big “however,” polls taken after the 2016 election, as Trump was repeatedly claiming he’d won the popular vote, concluded nearly half of his voters and 25% of Independents actually believed him. Here’s the result of a Morning Consult poll taken in July, 2017, a full eight months after the election.

Following the release of the Morning Consult poll, Allan Lichtman, a history professor at American University, said Trump has “perfected the technique of the Big Lie”*  — which, as Lichtman wrote in an op-ed in the fall of 2016, is to “repeat a lie loudly, over and over until people come to believe it.”

“These results show that again, like ‘Birtherism,’ which launched Trump’s political career, the Big Lie continues to work, at least among those who want to believe it,” noted Lichtman.

As I have written before, Joseph Goebbels could have learned a thing or two from Donald Trump.

My point in dredging up this history is to suggest that Trump’s intentional Birtherism falsehoods and 2016 Big Lie were merely conditioning for his followers. Believing him then made it so much easier to believe him now.

Easy enough to mount an insurrection on 6 January 2021, the first time the Capitol had been breached since the War of 1812.

Easy enough for six in ten Republican voters to declare they’ll not vote for any candidate who asserts Joe Biden won the 2020 election and is our legitimately elected President.

Easy enough for Ronna McDaniel, Chairwoman of the Republican National Committee (RNC), with a straight face, to claim the select committee investigating the January 6 attack on the US Capitol is a “Democrat-led persecution of ordinary citizens who engaged in legitimate political discourse.” And the RNC put that in writing.

Easy enough to believe it was “ordinary citizens” who ransacked the Capitol leading to nine deaths, who attempted a  coup d’état that included building a gallows from which to hang the Vice President of the United States, who made a “tourist visit” complete with bringing a Confederate flag into the building for the first time in history and smearing feces on the walls of that hallowed place, and that all of this and more, was “legitimate political discourse.”

Easy enough, indeed.

I leave you with one question. It’s hypothetical, but you might want to think about it: On 6 January 2021, what do you think would have happened if the mob had actually caught Mike Pence?

*The Big Lie — Originally a German expression (große Lüge) coined by Adolf Hitler to describe the use of a lie so colossal no one would ever believe someone “could have the impudence to distort the truth so infamously.” Hitler came up with the term in prison as he dictated his 1925 book Mein Kampf to his sycophant Rudolph Hess.

News You Might Have Missed To End Your Week

Friday, February 4th, 2022

Interesting weather today, here in the heart of the Berkshire mountains. A little rain, a little sleet, a little freezing rain, a little snow and a lot of ice. The very definition of my newly coined word, quinaryfecta (I toyed with pentafecta).

Governor Baker has asked everyone to stay off the roads, so, here I sit putting together a few stories that might have slipped under your radar.

The cost of health care continues it ever-upward trajectory

In November, the Kaiser Family Foundation published the results of its annual Employer Health Benefits Survey, and 2021 continued what appears to be an unstoppable trend.

More than 155 million Americans get their health care from Employer Sponsored Insurance (ESI). That’s 55% of the working population. There are two facts about this year’s survey I would like to highlight:

First, the annual cost of health insurance for a family is rising faster than both wages and inflation.

To their credit, employers have been absorbing most of the rise in premium costs, but this prevents them from using those funds now going to health care insurance for other worthwhile endeavors, like growing their companies, enhancing their risk management programs, or raising wages.

Second, annual premium costs in 2021 rose 4% over 2020 to a record high $22,221. That’s $1,852 per month. Workers are paying an average of 28% of the cost, or about $500 per month. But that’s before a 2021 average deductible of $1,669, which is 92% higher than ten years ago. In 2021, 85% of workers in ESI plans were subject to a deductible.

As these costs continue their stratospheric rise it’s like employers and employees are side by side trying to outswim a Navy Destroyer ―  with every stroke they fall farther behind.

Speaking of upward trends, let’s consider traffic deaths in 2021

The Department of Transportation just released a statistical projection of traffic fatalities for the first 9 months of 2021 showing an estimated 31,720 people died in motor vehicle traffic crashes nationwide. This represents an increase of about 12% as compared to 28,325 fatalities that were projected in the first nine months of 2020. This is the highest percentage increase over a nine-month period since the Department began recording fatal crash data in 1975. The numbers in 2021 are 32.5% higher than they were a decade ago.

Something weird is happening on our roads. Over the last 45 years, traffic safety engineers and automakers have made remarkable progress in improving the safety of our roads and cars. But they haven’t been able to change the human element, about which we wrote a week ago.

Don’t go by raw numbers, however. The important statistic is the rate of traffic fatalities per million miles driven. From 2011 through 2019, the rate didn’t waffle much, going from 1.09 to 1.10, with a blip up to 1.17 in 2016.

All that changed in 2020, when the rate jumped to 1.35. In 2021, it inched up to 1.36 to prove 2020 wasn’t a momentary aberration.

Secretary of Transportation Pete Buttigieg announced the Department will dedicate significant resources to attack these daily tragedies. We will be paying close attention to this.

Another example of our fragmented health care

The Biden Administration has made it easier for people to get free at home rapid tests. Here at our home, we applied on Day One of the program, and four days later our tests arrived. And the Administration has distributed millions of tests to pharmacies and states. People can go to CVS or Walmart or any other participating entity, buy tests, and get reimbursed by their insurance company. That’s not how other countries are doing it, and they’ve been doing it longer. They’ve cut out the insurer middleman, and have just gone directly to their people with the tests. In the the UK, for example, testing has become a way of life.

The insurer reimbursement issue has become a Medicaid problem for the states. The rules of Medicaid do not allow for it, and, because each state administers the program in its own way, they’re all approaching the problem differently.

Some states have made it easier for the safety net program to reimburse pharmacies for providing the tests at no cost. Others are experiencing what CMS described in an 11 January call with the states as “operational considerations and challenges.” Here’s one such challenge: Some states require a prescription for Medicaid enrollees to get anything from a pharmacy. To deal with this, states are making what they are calling “standing orders” to allow enrollees to get free tests at pharmacies without a prescription.

Another challenge for the states: How to get tests to homebound enrollees. Some states are attacking this by setting up temporary mail order programs.

My point here is that each state has to create its own solution. That is counterproductive. All the states are facing the same COVID problems, but each is attacking those problems differently. Throughout, one thing has become clear to the various Medicaid State Directors: the more they communicate with each other, the better off they are.

It is becoming more and more evident that the absence of one cohesive system to guide everyone wastes time and money, and jeopardizes the health of Medicaid enrollees all over the nation.

Have a nice weekend.

 

Medicaid Expansion: An Addendum To My Two-Part Series

Thursday, February 3rd, 2022

Long ago in 2009, I wrote about  a PBS special hosted by Journalist T. R. Reid, in which Reid analyzed the health care systems in five other countries: The UK, Japan, Germany, Taiwan and Switzerland. Reid had spent a full year in those five countries trying to figure out how they provided universal health care at much lower cost than the U.S. with better results. He later published a book about it, The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care (available on Amazon).

The good news is Reid did a wonderful job, both in his book and on his PBS special. The bad news is things in the U.S. have only gotten worse since then. Health care costs as a percent of GDP have increased three percentage points since 2009 to about 20% (the Opioid epidemic and COVID haven’t helped), and our health care outcomes have remained sub-par to the rest of the Organization for Economic Co-operation and Development (OECD), the 38 country organization of which the United States was a founding member 60 years ago.

I was reminded of Reid’s work while preparing my two-part Medicaid expansion series published over the last two days, and I couldn’t help thinking the ACA’s Medicaid expansion provision, for all the good it has done, only aims to put a band-aid on a mortally wounded patient.

In America, health care has become a commodity, a market-driven enterprise. Throughout the rest of the developed world, it is an essential human right; something governments were created to provide and protect. In America, 55% of us have earned the right to health care by working for an employer who provides it. Another 18% of us have earned health care by reaching the age of 65. A further 3.7% have earned it by serving in the military. The remaining 23.3% are on their own, which is where Medicaid comes in. Sadly, it appears many powerful people resent that final group and our inclination to provide them what the rest of the world views as a moral duty.

In America, legend, myth and vulnerable gullibility influence many of our citizens, who have been led to believe any government intrusion into health care will lead to draconian tactics typical of a fascist state (remember Sarah Palin’s death panels?). They don’t seem to realize that health care provided by our Veterans Administration, treating millions of our veterans every year (including this one), is a direct copy of Britain’s. Or that Medicare, our largest insurer with more than 62 million members who, in poll after poll, report high satisfaction with their health care, is modeled on the health care system of Canada.

Maybe American health care is just too big to be redesigned into something that would make us all proud. Too many vested interests, each making boatloads of cash. Each saying they support creating a better system ―  just as long as we don’t touch their sacred slice of the profitable pie.

But when I’m tempted to say, “A plague on their houses,” I think of the Taiwanese, who went from nothing to one of the most technologically advanced, yet inexpensive, health care systems in the world in just fourteen years. And I think of the Swiss, the bureaucratic, economically driven, bankers-of-the-world Swiss, who took off their stuffed shirts and came to see high-quality, affordable health care as the absolute right of every Swiss citizen.

The health care systems in Taiwan and Switzerland have flaws, but, even so, they are light years ahead of the U.S. in terms of quality, cost and universal coverage. If these two totally different countries can do that, I ask you, why can’t we?

Eventually, America is going to have to decide if good quality health care is a basic human right, or a privilege to be earned.

ACA Medicaid Expansion — Part 2: The Opposition

Wednesday, February 2nd, 2022

Yesterday, I wrote about the proven benefits of the Affordable Care Act’s expansion of Medicaid to provide health insurance to millions of our previously uninsured fellow citizens. By way of background, I began yesterday’s column with the following:

According to the Department of Health and Human Services (HHS), there were 48 million uninsured in 2010 when the Affordable Care Act (ACA) became law. Over the next nine years, 38 states, using ACA funding, expanded their Medicaid programs. During that time, the numbers of uninsured fell to 28 million before rising to 30 million in the first half of 2020 due to policy changes to the ACA by the Trump Administration that made it harder to qualify for coverage.

There are now twelve states left that have refused to take advantage of the ACA’s provisions to expand Medicaid, a move that would significantly lower the number of uninsured people within their borders.

The states in orange are the states that have refused to accept Medicaid expansion and the significant federal dollars that go with it. The orange states are all “red” states.

Today, we’ll examine the reasons governors and legislatures in those 12 states give for not accepting the massive federal funding coming with ACA expansion. Tomorrow, I’ll offer an opinion and a plea for building a better system.

But first, we’ll need to set the stage.

The rate of uninsurance in non-expansion states is nearly double that of expansion states.

A word about the uninsured in non-expansion states. As the above chart shows, nearly 22% of them live in rural areas. The majority of these Rurals are registered Republican voters. They are also white/non-Hispanic and less educated than their urban counterparts. Medicaid expansion would be of great benefit to them. But their governors and legislators refuse to expand Medicaid to help these people and the rest of their uninsured populations. Why?

What is even more perplexing is why the rural uninsured continue to vote for people who refuse to help them improve their health care lot in life.

There is another darker result of not expanding Medicaid, and it concerns people of color. People of color, especially the uninsured, have faced longstanding disparities in health coverage that contribute to disparities in health. The states that expanded Medicaid following passage of the ACA saw significant decreases in these disparities from 2010 through 2016; the non-expansion states did not. Beginning in 2017, the Trump administration implemented policy changes that made it harder to qualify for Medicaid. The result was a reversal of progress made during the prior six years; the number of uninsured began growing again, and, once again, people of color were the hardest hit.

Just another example of the cultural and moral divide in America.

Governors and legislators opposing expansion offer 3 primary arguments:

The state cannot afford it.

This is political theatre. The federal government pays 90% of the cost of expansion, the state the remaining 10%. States that have expanded coverage have demonstrated affordability by moving  funds from other areas that, because of expansion, will not need as much money. In Michigan, for example, the state budget realized substantial savings in correctional health care and community mental health when some of the expenses of these programs were shifted to Medicaid. Taking into account other economic effects of expansion, such as increased tax revenues from increased economic activity, Medicaid expansion was a net benefit to the state’s budget. Moreover, the Families First Coronavirus Response Act, which was signed into law on 18 March 2020, included a provision for the federal government to assume a larger share of existing Medicaid obligations in every state, freeing up state Medicaid funds for other uses — like expanding coverage. The “We can’t afford it” line does not hold water.

Allowing people to access Medicaid will discourage them from working.

Multiple studies have found no evidence that expanding Medicaid is a disincentive to working. A typical finding is, “We find that although the expansion increased Medicaid coverage by 3.0 percentage points among childless adults, there was no significant impact on employment.”*

Expanding Medicaid will only add more people to a broken system.

Opponents of expanding coverage often deride Medicaid as a low-quality program. Yet a majority of people in the U.S. — Democrats, Republicans, and independents alike—believe that the program is working well. In states that have not expanded Medicaid, a clear majority favor doing so. Most Medicaid enrollees are quite happy with their coverage, reporting higher rates of satisfaction than people with private insurance.

The arguments listed above are the three reasons most often cited by leaders in the 12 non-expansion states for their opposition. There is one argument that goes unexpressed, but is often present: People who are uninsured are uninsured because they lack the money to become insured. They lack that money because they never worked hard enough to get it. They are irresponsible. Consequently, society does not owe them a free health care lunch.

Over the last two days, I’ve tried to counter that “thinking” with clear, hard, proven, factual data. None of it has been opinion (if you ignore my comment yesterday about Senator Ron Johnson, that is). I’ve tried to demonstrate that all the arguments in opposition are nothing more than groundless opinion.

I end with these questions: Is health care a basic human right? Does society owe its poorest decent health care, or must they earn the privilege? How do we answer the murderer Cain’s question in Genesis 4:1-13, “Am I my brother’s keeper?”

We need answers to those questions.

*Leung and Mas, Employment Effects of the Affordable Care Act Medicaid Expansions, 25 March 2018, in Industrial Relations, A Journal of Economy And Society.

 

 

 

The Proven, Credible Benefits of ACA Medicaid Expansion — Part 1

Tuesday, February 1st, 2022

According to the Department of Health and Human Services (HHS), there were 48 million uninsured in 2010 when the Affordable Care Act (ACA) became law. Over the next nine years, 38 states, using ACA funding, expanded their Medicaid programs. During that time, the numbers of uninsured fell to 28 million before rising to 30 million in the first half of 2020 due to policy changes to the ACA by the Trump Administration that made it harder to qualify for coverage.

There are now twelve states left that have refused to take advantage of the ACA’s provisions to expand Medicaid, a move that would significantly lower the number of uninsured people within their borders.

The states in orange are the states that have refused to accept Medicaid expansion and the significant federal dollars that go with it. The orange states are all “red” states.

The ACA was passed in 2010. We now have 404 studies in the seven year period 2014 through 2020 producing 440  findings resulting from Medicaid expansion (A number of studies looked at more than one area).

There have been five studies concluding ACA Medicaid expansion has brought negative results in two areas ―  Provider Capacity and Positive Health Outcomes; remember that; they’re the ones in orange in the chart below (Good luck finding them). This is opposed to 435 findings of positive results in eight areas. These include 25 positive findings in Provider Capacity and Positive Health Outcomes (compare to the five mentioned above). The Kaiser Family Foundation summarized the studies in this chart:

There are three overarching benefits to Medicaid expansion nearly all experts agree on:

Expanding Medicaid helps low-income families’ health and financial well-being, especially those in which someone has lost a job.

In states that expanded Medicaid under the ACA, unemployed workers experienced large gains in coverage. Further, there are spillover benefits for economic well-being: lower debt and better credit scores. Physical health and financial health are inextricably linked. Expanding Medicaid improves both for low-income families. This has been doubly so in the time of COVID.

Expanding Medicaid reduces hospitals’ uncompensated care.

I write from experience. I was once a Director at a Massachusetts major hospital system. At one meeting, I asked our CEO what the system did when an indigent person showed up in the ER very sick or injured. By law we had to take care of them. So, given that, how did the system get paid? He replied, “We charge them the most we possibly can.” I said, “But they can’t pay.” He said, “That’s right, but the state’s Uncompensated Care Pool can.” This was a big drain on Massachusetts, eye-opening to me, and an obvious wrinkle in health care policy. Medicaid expansion dramatically reduces this burden for hospitals. In Michigan, uncompensated care was cut in half after Medicaid expansion in 2014. In 2016, Dranove, Garthwaite and Ody, publishing in Health Affairs, found uncompensated care decreased at hospitals in Medicaid expansion states but not at hospitals in non-expansion states. Moreover, in April 2021, Karpman, Coughlin and Garfied found significant reductions in uncompensated care in ACA expansion states:

Reflecting a significant decline in the share and number of people who were uninsured at any point in the year, the average annual share of nonelderly individuals who had any uncompensated care costs fell by more than a third following ACA implementation, going from 7.3 percent in 2011-2013 down to 4.8 percent in 2015-2017. This change represents a decline in the number of people with uncompensated care costs from 20.2 million to 13.1 million.

Correspondingly, the aggregate annual cost of uncompensated care provided to uninsured individuals dropped by a third following implementation of the ACA’s coverage provisions, from an average of $62.8 billion per year in 2011-2013 to $42.4 billion in 2015-2017. The cost of implicitly subsidized uncompensated care—or care that had no payment source, including a non-health insurance source—dropped from $21.6 billion to $15.1 billion per year on average before and after the ACA, respectively.

Expanding Medicaid is a highly effective form of economic stimulus.

An often-overlooked benefit of Medicaid expansion is that it creates jobs. During a recession, the infusion of federal spending gives a boost to a state’s economy. Evidence from the Great Recession shows that Medicaid spending is a highly effective form of stimulus: for every $100 000 of additional federal Medicaid spending, two workers gained a year of employment.

There are other intangible benefits, but we won’t go into them here, because they’re fuzzy, and it will give naysayers a hook, albeit a painted one, on which to hang their negative opinions. Let’s just say that being able to provide health care for your family, not having to forgo necessary care for you or your child because you need that money to eat, is psychologically significant. Contrast this with a recent statement from Senator Ron Johnson (R, WI): “People decide to have families and become parents. That’s something they need to consider when they make that choice. I’ve never really felt it was society’s responsibility to take care of other people’s children.” Compassion like that is disgustingly reminiscent of Ebenezer Scrooge before the spirits arrived.

Tomorrow, we’ll dive into the reasons governors and legislatures give for rejecting ACA funding to expand Medicaid in the remaining 12 non-expansion states. Hint: There are three reasons most often cited. They are opinions only without any credible supporting data, but in those orange collared states in the map at the beginning of this column, that doesn’t seem to matter.