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Tag: Public Policy

The Hurricane Next Time

The Hurricane Next Time

Another week, another hurricane. There was Harvey. And then Irma. Jose is heading north. Maria has worked its devastation. Hurricane Season being what it is, the storms line up across the Atlantic and the Pacific. Whatever the next time is, there will be a next time. And another hurricane.

I’m back aboard my boat after evacuating to Destin in the Florida Panhandle to get out of the way of Irma. Part of my excuse for the delay in posting to this blog. Irma, it turned out, was accommodating and jogged northeast just before it hit the Tampa Bay area. Good news for me and my neighbors. Bad news, very bad news, for people in the interior of the state and further to the northeast. Storms create winners, and losers. Mostly losers.

Ask the people of Houston and elsewhere in Southeast Texas. Ask the people of the Florida Keys, or Southwest Florida, and lots of other places in the state. Ask the people of Barbuda and St. Thomas, of Sint Maarten and Saint-Martin and Puerto Rico. And before them, ask the people of the Philippines, of Mississippi and Louisiana, of Mexico and Honduras and South Carolina and New Jersey and even New Hampshire and numerous other places.

Hurricanes aren’t picky and they don’t discriminate. They’re equal opportunity destroyers and, given enough time, they spread their devastation around. Of course, the planet would have worse problems were it not for the big storms that redistribute the earth’s heat energy, but try telling that to someone who can’t get out of their house without a boat, or no longer has a house at all, or who has no water, food, or electricity. Or lost a loved one. It’s a tough sell.

I’ve been around hurricanes almost my whole life, in their projected path several times but, if you ignore passing through two of them during one sea transit of the North Atlantic as a kid, I’ve never been in the middle of one. I guess that’s my hurricane karma. But I’ve seen the aftermath of them, spent weeks that turned into months that turned into years living with the after effects of Katrina, and I’ve had a chance to observe both close-up and at a distance the preparations for their arrival and dealing with what they leave behind.

It’s those two elements – advance preparations and dealing with hurricane aftermaths – that I want to focus on here. Some of what I have to say is based on observation of those two things in several storms, and some is based on a plan I developed while living with the protracted recovery from Katrina.

Based on the events of recent weeks, at least in the U.S., I think some lessons have been learned. Some are partly learned. But we still have a continuing learning curve to go up and more work to be done.

The debacle that was the overland evacuation in Texas from the approach of Hurricane Rita in 2005 taught us some things about evacuations. Rita, the Atlantic’s fourth most intense hurricane ever recorded, the most intense storm ever seen in the Gulf of Mexico, and coming just three week’s after Hurricane Katrina’s onslaught, prompted fears the storm would devastate the Texas Coast. This led to an uncoordinated series of evacuations that poured between 2.5 million and 3.7 million people onto the state’s highways, leading to total gridlock. While the concept of contraflow, to reverse all inbound lanes on the Interstates to outbound, was already known, the order to implement it came too late and it took more than eight hours to make the change-over. Of the seven people in the U.S. who died directly as a result of Rita, only one was in Texas. But an estimated 113 people died in the botched Texas evacuation, including 23 nursing home residents who were killed when the charter bus they were on caught fire on the Interstate.

In advance of Hurricane Harvey this year, Houston Mayor Sylvester Turner decided not to issue any evacuation order for the city. Not mandatory, not voluntary. Turner, looking back at Rita, reasoned that you can’t put 6.5 million people on the highways without creating mayhem. But virtually the entire city wound up inundated, with many left homeless, or stranded in flood-damaged houses from record rainfall. Some were electrocuted when, for reasons that are not apparent, the power was not cut off as a precaution as is normally done. It seemed the city was far from prepared for the storm to come.

As for evacuations, the answer, of course, is not to evacuate an entire city the size of Houston, the nation’s fourth largest, but to evacuate the most vulnerable areas. To provide local shelters. To move some people in buses and not everyone in private vehicles. And to do the necessary to avoid ancillary deaths, to the extent possible. It wasn’t a mystery that Houston was going to be pummeled with massive rainfall. The path and potential of the storm was known, as was Houston’s topography and propensity to flood. And yet, there was no evacuation order.

Contrast that response with the response of Florida Gov. Rick Scott and state, county, and local officials in Florida. With Irma on its way and a high likelihood it would hit the state in some place or other, Scott went on what was almost a personal campaign to get people to evacuate the most vulnerable areas, and made it as easy as possible for them to do so. Tolls were removed from the state’s toll roads – they are about to be reinstated at this writing – hotels were ordered to accept pets, the Florida National Guard was partially mobilized, and state troopers were used to escort fuel trucks.

The first priority was evacuating the Florida Keys, which are tethered at the bottom of the state by 90 miles of the Overseas Highway, the sole land access to the Keys. Other areas deemed most vulnerable, the low areas of Southeast and Southwest Florida, were the next priority. And then other vulnerable areas came after that. Scott’s campaign launched a week before Irma’s arrival, and kept up throughout the storm and in its aftermath, and continues even well after the storm. Florida’s evacuation was not perfect – there were serious fuel outages, long delays at times on the state’s Interstates and other highways, and Irma’s vagaries wound up unexpectedly sparing some areas while hitting others, hard – but overall it went pretty well, given the enormous number of people affected.

Not everyone followed the evac. orders, and authorities said they would not arrest anyone for not complying. While a major reason for an evacuation is so first responders don’t have to risk their lives searching for stragglers in trouble, authorities also said that after a certain point no one should count on a rescue. Whatever the factors involved – in part, at least, the euphoria and excessive confidence that pervades many Keys residents – those who stayed behind in the islands came to find out the devastation a Category 4 hurricane can bring. It’s not yet known what the death toll is in the state as teams go through the destroyed housing of the Keys looking for survivors and casualties.

Of the points where preparations for the storm failed, perhaps the most telling and disturbing was the lack of back-up plans, power, and action by some nursing homes, both in Texas and Florida. The incident that has gotten the most attention was a nursing home in Hollywood, Fla., where so far 14 elderly residents have died. With a hospital just across the street, it’s hard not to assign negligence to the managers and owners of this facility. The state has opened an investigation and alleged criminal negligence, but meanwhile the horse – 14 of them so far – has left the proverbial barn and can’t be brought back.

A spokesperson for the nursing home association said that nursing homes are not required to have generators, only a back-up power supply. Whatever the hell that means. From my perspective, based on what happened in these and other storms and the personal experience of my own mother when she was alive, there is entirely too little oversight of nursing homes and assisted-living facilities. This paucity of oversight applies in other times, too, not just when there are storms. But certainly things need to be beefed-up to deal with natural disasters. Every nursing home and assisted-living facility should be required to have an emergency action plan (EAP), which should be reviewed by regulators, and also to conduct drills practicing the EAP, to the extent practical. There also has to be more attention paid to those “back-up power supplies” and sufficient generation capability should be required to not just keep the lights on, but also run the air conditioning in hot areas and heat in cold ones.

As I mentioned, I lived on the Mississippi Gulf Coast through most of the recovery from Katrina. The very slow pace of recovery in both Mississippi and Louisiana was a source of frequent frustration to me, but it was a true bane to those who had to suffer through it. In some cases, people have never recovered. Burdened with too much bureaucracy and red tape and some truly bone-headed decisions, FEMA proved to be largely inefficient and, for many, ineffective in its response. In the end, someone calculated that for all the money spent on FEMA and other agency responses, the government could have built a new house and put two new cars in the driveway for each affected family. That is a scandal of the first order.

What I have seen, and experience has borne out, is that a multi-pronged approach is needed to respond to any natural disaster of this magnitude. In the plan I previously developed, this approach would be more forward looking than backward looking. At the head of the effort would be a disaster council combining federal government agencies, non-profit relief organizations, faith-based groups (which often provide a major portion of recovery efforts), and the profit sector. All these groups have a stake, and a contribution to make, both in preparing for natural disasters and in recovery. And this applies not just to hurricanes, but to other natural disasters, such as tornadoes, earthquakes, and major fires.

Similar councils should be established at the state level in the most affected states, with coordination between the state and national councils. And under my plan, Congress and state governments should consider establishing a disaster fund into which both public and private funds would be deposited in advance of disasters, not leaving things to allocations after the fact, which often come too late to deal with the worst immediate effects of a major storm or other disaster. This approach makes the response both prospective – looking ahead to future disasters – and retrospective – looking back in the aftermath of those that have already occurred. The cost will be there in any event, but by having funds already allocated they can be assigned quicker and will offer the most and most efficient benefit to those affected.

We tend to avoid thinking about what might happen tomorrow, even less about paying for it. But just as our learning curve in preparation and recovery has continued to go up with each major storm, I see this as a logical next step in our approach to dealing with hurricanes and other natural disasters, which are not just going to go away.

Pointing Immigration in the Right Direction

Pointing Immigration in the Right Direction

My service as a U.S. consular officer in the late 1980s and early1990s quickly debased me of any previous open-borders ideas I might have had prior to that time. While serving as vice consul for the geographically largest consular district in the world, covering most of the South Pacific and part of the North Pacific, I came to realize how poorly our immigration system served the country. Our two-officer office – me and the consul, my immediate boss – processed some 21,000 non-immigrant visas (NIVs) and about 6,000 immigrant visas (IVs) annually. I personally handled about two-thirds of the NIV applications and about a third of the IV applications. To say that some of those IV interviews verged on the scary would be an understatement, and made me wonder about the quality of people we were admitting for permanent residence in the U.S.

What occurred to me then was that the U.S. badly needed to implement a points-based immigration system similar to what already was long in place in Canada as well as in Australia and New Zealand, and has since even been adapted by the UK. Not that it would supplant this country’s family-based immigration system, but rather would supplement it, while revising the family-based system of preferences. While other countries were getting the cream of the crop of immigrants, we were limited basically to what came over the transom with our chain-migration policies, and that was not always beneficial to the U.S.

During my tenure as vice-consul in Fiji, yet another seemingly hair-brained idea was introduced, the so-called Diversity Visa Program (DVP), better known as the visa lottery program. A brain child of Congress, it allowed people from many countries deemed to be “under-represented” among U.S. immigrants to compete in a lottery to obtain the right to apply for permanent residence status. Besides debasing the whole concept of U.S. residency, this scheme essentially opened up a new category of immigrant visas to anyone who could fill out a postcard or pay someone to do it for them, as if we didn’t already have enough immigrants coming to the U.S., many with no discernible skills.

Over the intervening quarter century I have seen limited progress in immigration reform, combined with some steps in the wrong direction, acerbated by an ill-informed and prejudiced public and media debate over immigration. With this past week’s introduction of the so-called RAISE Act (RAISE – not Reyes – standing for Reforming American Immigration for Strong Employment), I am for the first time in more than 25 years seeing reforms introduced that actually seem to make some sense. And of course the naysayers immediately came out in force, spouting the same sorts of nonsense that have kept our immigration system stuck under a law that dates back some 65 years, the Immigration and Nationality Act of 1952, as amended and modified by some less overriding intervening laws.

To begin to understand the forces arrayed against any real reform of our outmoded and ineffectual immigration policy, one needs to understand two truisms about what the major political parties hope to gain from immigration: The Democrats want cheap votes, and the Republicans want cheap labor. These two impulses are the biggest factors keeping things pretty much where they are, if not pushing them further in the wrong direction. And it is these same factors that are the biggest enemies of the American people at large and which help keep our economy in a low-growth mode in which real wages remain stagnant while the costs of the welfare state continue to grow.

It’s also important to understand that the U.S. is not a laggard when it comes to immigration. While it may no longer be strictly true that we admit more legal immigrants than all other countries in the world combined, it is true that we admit, by far, the largest number of legal immigrants each year – more than a million people – and that number does exceed the total number of immigrants admitted by all the other largest immigrant-welcoming countries of the world combined. At present, close to 45 million immigrants (both legal and illegal) live in the U.S. There are some 85 million people, or about 27 percent of the total population, who are immigrants or the U.S.-born children of immigrants.

There are a lot of myths and stereotypes about immigration and these help perpetuate our current system. One of those myths is that immigrants strengthen the economy and do better than native-born Americans. While this was once true, it has not been true in more than a quarter century, and since then, in general terms, immigrants tend to fare worse than the overall population. This fact is buttressed by the numbers that show that immigrants to the U.S. are far more likely to wind up in poverty than the native-born population. Here are some disturbing figures from the Center for Immigration Studies:

Despite similar rates of work, because a larger share of adult immigrants arrive with little education, immigrants are significantly more likely to work low-wage jobs, live in poverty, lack health insurance, use welfare, and have lower rates of home ownership.

  • In 2014, 21 percent of immigrants and their U.S.-born children (under 18) lived in poverty, compared to 13 percent of natives and their children. Immigrants and their children account for about one-fourth of all persons in poverty.
  • Almost one in three children (under age 18) in poverty have immigrant fathers.
  • In 2014, 18 percent of immigrants and their U.S.-born children (under 18) lacked health insurance, compared to 9 percent of natives and their children.
  • In 2014, 42 percent of immigrant-headed households used at least one welfare program (primarily food assistance and Medicaid), compared to 27 percent for natives. Both figures represent an undercount. If adjusted for undercount based on other Census Bureau data, the rate would be 57 percent for immigrants and 34 percent for natives.
  • In 2014, 12 percent of immigrant households were overcrowded, using a common definition of such households. This compares to 2 percent of native households.
  • Of immigrant households, 51 percent are owner-occupied, compared to 65 percent of native households.
  • The lower socio-economic status of immigrants is not due to their being mostly recent arrivals. The average immigrant in 2014 had lived in the United States for almost 21 years.”

While laws are in place that are supposed to limit immigrants’ access to welfare and other public assistance programs – the idea being that newcomers to the country are supposed to be able to support themselves, or have sponsors that will support them until they can support themselves – so many exceptions are made, so many jurisdictions overlook the rules, and so many benefits are obtained through the U.S.-citizen children of immigrants, that immigrants tend to use social welfare programs at rates in excess of the native population. The two charts that follow (also from the Center for Immigration Studies) clearly demonstrate the numbers. The first one compares legal immigrants with the native population while the second one compares illegal immigrants, who do even worse and aren’t even supposed to be here, with the native population.

Welfare Use Legal Immigrants

Welfare Use Illegal Immigrants

Another key element that is widely misunderstood, further evidenced by some of the silly things said in the days since the RAISE Act was unveiled, is the system of preferences under which our current immigration system operates. This system imposes strict numerical caps on different categories of immigrants from various countries, and creates serious distortions that those only peripherally familiar with the rules don’t understand. For instance, while there is no cap for the spouses or unmarried minor children or the parents of U.S. citizens, 21 years old and older, there are limits for just about every other category of immigrant.

The chart below shows the current (August 2017) preference limits for the various preference categories. It shows the dates when petitions would have had to be filed for intending immigrants in those categories, or preferences, to file their applications this month to be approved for immigrant visas. Depending on the country, these dates can vary significantly.

Preference Chart August 2017

For instance, for the first preference, the unmarried son or daughter, 21 years or older, of a U.S. citizen (native-born or, more commonly, naturalized), their petition would have had to be filed prior to 2011 in most countries of the world to file their applications for visas beginning this month. But if they are a citizen of the Philippines, the petition would have had to have been filed in 2007, or in 1996 if they are a citizen of Mexico. In other words, perhaps the beneficiaries were 22 or 25 or 27 when the petition was initially filed, but now they are anywhere from 10 to 21 years older. And these time periods don’t include processing times, which can be a year or more, once the application is filed.

If the applicant subsequently marries after the petition is filed, they drop to the F3 category and the preference dates of it.

For a second preference applicant in the F2A category – the spouse or unmarried minor child of lawful permanent residents (LPRs) – the wait has been a little more than a year worldwide. Not too bad. But for the unmarried son or daughter of an LPR who was over 21 when the petition was filed, the wait jumps to six years for most countries, 10 years for citizens of the Philippines, and 21 years for citizens of Mexico. If that unmarried minor child subsequently marries, they’re completely out of luck since there is no category for married children of LPRs.

As the chart shows, things get worse as one goes down the preference categories, until reaching F4, the preference category for brothers and sisters of U.S. citizens, when the wait can be as long as 22 years. Now that is a lot better than when I was a consular officer, when the wait for some countries was as long as 120 and 150 years, but it’s still a very long time. In practical terms, what these very long wait times do is encourage people in those categories to come on visitor visas to the U.S. and then overstay their visas, hoping to find some other mode to become legal.

In fact, more than half of those qualifying for immigrant status are already in the U.S. in some sort of temporary or illegal status, changing status when their preference comes up or simply remaining illegally if their preference never comes up, which distorts the entire system and enables those who are willing to jump the queue and break our laws to gain an advantage.

Seeing the effect these very long wait times have on people, it has been my contention since my consular days that the brother/sister category should be eliminated altogether. And that is one of the things the RAISE Act sensibly does, along with dispensing with the DVP, which never should have been introduced in the first place. I’d further argue, to cut out much of the incentive for overstaying, that changing status in the U.S. also should be strictly limited to those categories of immigrants for which no preference limits exist.

What is very difficult, if not impossible, under our current system of chain migration is to migrate independently to the U.S. – something that once was allowed and frequently done. There are many highly qualified potential migrants who would love to immigrate here, but who are blocked by our system of family preferences. So what happens with many of these people? They wind up migrating to another country, and our loss is Canada’s or Australia’s or New Zealand’s gain. The same applies to graduates of U.S. colleges and universities who study under student visas and then are forced to go back home after graduation. We’ve educated these people, and then don’t reap the benefit of that education, passing it on somewhere else. Again, these are exactly the kinds of people we should be seeking through our immigration system, and who will gain points under the RAISE Act.

One of the dumbest arguments I heard this week came from U.S. Sen. Lindsay Graham of South Carolina. He said that the RAISE Act would destroy his state’s economy by blocking lower-level employees who work in hotel and agricultural jobs. First of all, if those are the only kinds of jobs available in the Palmetto State, South Carolina has more serious problems than the RAISE Act would cause. Of course, that’s not true, and there are more jobs in South Carolina and across the land that can use more highly skilled people to fill them. Additionally, there already are programs, such as the H-2A temporary agricultural worker visa, to address the demand for agricultural workers, not to mention a ready supply of illegal workers that Republicans like Sen. Graham seem all-to-eager to tolerate. Sen. Graham’s assertion actually reinforces the argument that our current immigration system funnels people into lower-level positions and helps depress wages across the board while forcing lower-skilled U.S. workers to compete with immigrants, legal and otherwise, for scarce jobs. It also fits neatly into the theory that Republicans support cheap labor.

Meanwhile, we’ve heard a chorus of objections from the Democrats, reinforcing the theory that nothing suits them better than easy, low-level immigration from which they hope to harvest cheap votes. Perhaps encapsulating some of the lame arguments on the left side of the house are that the RAISE Act invalidates the poem on the Statue of Liberty welcoming the world’s huddled masses – never a tenet of U.S. immigration policy or law – or that immigration would be limited to Anglophone countries, such as the UK or Australia, since knowledge of English would be one of the requirements for independent migration. As White House Senior Policy Adviser Stephen Miller ably pointed out, there are many English-speaking people around the world in just about every country, and all would be meet the language preference. Additionally, knowledge of English has long been a requisite for naturalization, and at one time in our more distant history was even a requirement to immigrate here.

In the past few days I’ve also heard some media people saying, well, they wouldn’t be here if the changes proposed in the RAISE Act were in place when their grandparents migrated here, and I fail to see the logic of this. First, they are here. Second, while they might be here, someone else, perhaps equally worthy, was excluded. And third, what might have been good for the country 100-some years ago isn’t necessarily good for the country today. Ironically, some of the people making the argument that we should keep our current system are the first ones to argue that the country is a different country today than it was in the past and it needs to change to keep up with the times.

The other argument that is raised is that the actual numbers of immigrants admitted would be cut from the current million-plus to about two-thirds that number, or roughly back to mid-1980s levels. This might be more in keeping with the ability of the country to absorb new immigrants, but in any case this number seems reasonable and can be adjusted over time. It is argued that the high level of immigration has kept the U.S. relatively competitive with European countries and other nations, but what is missing from that argument are the details that it is both younger immigrants and more highly skilled immigrants who can contribute to economic growth, rather than draw down on it. We need to regenerate a period when immigrants do better than the general population, as in the past, than worse than the general population, and the RAISE Act is a step in that direction.

Like any piece of proposed legislation, there should be debate and discussion, and probably some tweaks made, to the RAISE Act, which is sponsored by Sen. Tom Cotton of Arkansas and Sen. David Perdue of Georgia. But what I fear will happen will be bipartisan support to kill the proposed reforms, never letting the bill out of committee, in keeping with the divergent desires of the two parties that I stated above: The Dems will want to keep their cheap votes and the Republicans will want to keep their cheap labor, and the rest of us, and the country, will continue to suffer as a result.

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The Biggest Shell Game in the World

The Biggest Shell Game in the World

Healthcare has been all in the news these days with the U.S. Senate considering its version of whatever is to replace Obamacare. So it seems fitting to take a look at the intractable morass that is the American healthcare system. Which, as I see it, is better seen as the biggest shell game in the world, and as long as it is, resolving the issues surrounding it are likely to remain intractable.

You probably know what a shell game is. That’s the scam that sometimes crops up on city streets where the scammer, also known as a tosser, places a small ball or pea under one of three shells or cups, and then moves the shells or cups around on the table. The marks – people betting they can beat the tosser – have to guess which shell or cup contains the ball or pea. But of course the game is rigged, often with the ball or pea surreptitiously removed from the table altogether, so the marks lose their money. And that, of course, is the scammer’s objective. They’re not in the game for their health.

Now I don’t claim to be an expert on our healthcare system, but I’ve engaged with it enough and watched some of its inner machinations over the years to see how it resembles a classic shell game. You’ve probably seen it, too. How about those band aids that show up on the hospital bill for $8 (or whatever the current going rate is – a hospital in New Jersey charged a patient $8,200 for a band aid on a cut finger, plus $800 for a tetanus shot and a few other basic things). Or those $15 Tylenols, which can add into the hundreds of dollars during a typical hospital stay? And what about those nameless “specialists” who rush up to patients as they’re heading into the operating room so they touch the patient’s arm, crack a joke or two, and then send a sizable bill for hundreds or thousands of dollars for their “services.” And then there are those “itemized” hospital bills that can run pages long. Ever try checking one of those for “errors”?

I’ve done some research, too. For instance, the average cost of an MRI in the U.S. is $2,611. But price around to various hospitals and health centers, and you’ll find costs ranging from about $1,000 up to twice the national average (that’s what I found). Doing some number crunching, I determined the actual cost, depending on the rate of utilization and maintenance costs for any given installation, should be in the $250 – $500 range, which is close to what an MRI costs in Canada when paid for privately or with private insurance. The national average cost of a CT scan is $1,200, but the actual cost can range from $250 to $4,600. And during the discussion going on in the past week, I heard one person say they actually paid $9,000 for a CT scan. And that was after pricing around and driving something like 60 or 80 miles to get to it. What a deal!

The shell game doesn’t end there. A three-day hospital stay costs, on average, $30,000, and the average emergency-room visit runs $1,233. But I personally know of a case where someone was billed $6,300 for a four-hour visit where she spent most of that time sitting in a room by herself with a monitor draped around her neck. And that was 10 years ago. Yet, there are community health centers where one can be seen and treated for $20, or less. I’ve even had minor surgery at one of these centers, performed by a doctor, for $20. I can’t imagine what the same procedure would have cost had I gone to a hospital or private clinic.

Costs can also vary enormously, depending on whether one has insurance, the kind and terms of the insurance, is on Medicaid, pays cash, pays on time, or doesn’t pay at all. All these factors, which go to the heart of how our healthcare system is run and costs are assigned, guarantee these results. And the problems go beyond healthcare, reaching down into our educational system, where the outrageous costs of medical school cause medical students to run up enormous student-loan debt, often of a quarter of a million dollars and more. While eventually many of these medical graduates will earn significant salaries, the salaries for recent graduates and residents are a far cry from generous, falling in the range of $51,000 to $66,000 per year, before taxes, for an 80-hour work week. Taking that $51,000 figure, a new doctor working 48 weeks a year is averaging $13.28 an hour, less than many retail employees.

While the House, the Senate, the Administration, the Congressional Budget Office, and commentators on all sides of the current healthcare debate parse the finer points of the various bills and proposals on the table, the bigger issues seem to be lost in the cacophony. I can’t help but think that the special interests, the insurance companies and industry lobbyists, are given more consideration than the lowly patient. And whenever one hears the word “comprehensive,” it’s time to run for the exits since the fix is almost certainly in.

Perhaps the biggest issue of all concerns the near-complete divorce of healthcare costs from market forces. Healthcare providers, whether hospitals, private doctors, diagnostic labs, or clinics, are essentially businesses and, in aggregate, they form an enormous industry. In what other business or industry are costs not known, not set out in formal tariffs or schedules, and not subject to public scrutiny? Even airlines, for all their multitudinous fares and conditions, are forced to lay out their tariffs, and before customers buy tickets they know exactly how much they will cost.

While government regulates – to various degrees of effectiveness – the nature and quality of healthcare and medical practice, it does little to promote market forces. It is my contention that any healthcare provider should be required to post the rates or costs for any given procedure, action, or item. Even if there are different tariffs for different methods of payment, the consumer will at least have something to go on in deciding how and where to spend his or her healthcare dollar. And this will inevitably lead to price competition between providers and a brake on upwardly spiraling costs.

This divorce of healthcare costs from market forces also stems from how many Americans obtain their insurance, which is paid for or subsidized by their employers. There is no incentive for many Americans to price around (even if they could, given the price morass) and obtain the best bang for their buck. “Oh, the insurance will cover it,” is often the refrain. Now some insurance policies and plans do enforce certain limits on what providers within the plan can charge or be reimbursed for, and that helps control costs to some degree, but there is often a downside to the insured.

One downside is a limitation of choice, but the other side is the cost of administering these various insurance plans, approvals, billing, and so forth. In the U.S., 25% of healthcare spending goes to administrative costs. A full quarter of what we spend on healthcare. In our neighbor to the north, Canada, the administrative burden is half that – 12% – and most other countries have far lower administrative burdens than ours. Perhaps the only country that comes close to our burden is The Netherlands, with a 20% administrative burden.

While the U.S. often is criticized for lack of public support for healthcare, in fact our governments, federal, state, and local, spend more on healthcare than that spent by the governments of most other OECD countries. Overall per capita spending on healthcare puts the U.S. at the top of a list of 13 high-income countries – more than $9,000 per year, nearly three times the OECD average and more than double the next biggest spender, France – it is also near the top of the list of countries in public per capita spending on healthcare. Only Norway and The Netherlands spend more public funds on healthcare than the U.S., while Switzerland and Sweden rank just below the U.S. In fact, per capita public spending on healthcare in the U.S. is a third higher than in Canada.

What this indicates is that the U.S. does – and doesn’t – have a spending problem when it comes to healthcare. We’re certainly spending much more than what other countries are spending on healthcare overall, and even our public spending on healthcare exceeds what most other countries spend. But we’re not getting the results of some other countries in terms of total coverage of the population. And while it’s true that U.S. health results, measured in terms of life expectancy, infant mortality, and some other indicators, are below those of other countries even with our high outlays, there are mitigating factors influencing those results that are not as present in other countries.

By most standards, the quality of care in the U.S. is good, even excellent. And compared with other countries – including, again, our neighbor to the north – waiting times to see doctors, referrals to specialists, and to receive diagnostics and operations are significantly lower overall, though these can vary significantly from one area or region to another. While gaining access to the healthcare system can pose a challenge to many Americans, once that access is gained things tend to work pretty well, and better than in some countries with so-called universal coverage.

So where do we go from here? Okay, I have some ideas. These are my proposals, and while I can’t cite empirical data supporting their efficacy, I think they merit serious consideration and may allow us to gain control over this nationwide shell game:

● Introducing market forces by requiring all healthcare providers to develop, publicly post, and operate under specific costs and tariffs;

● Instituting public oversight of costs and charges of healthcare providers, including hospitals, clinics, private practitioners, and diagnostic labs, and allowing private suits and administrative processes challenging unreasonable or unsupportable costs;

● Encouraging individual initiative by expanding health savings plans where people can set aside a portion of their income to be applied to healthcare costs, and allowing them to roll over funds not expended from year-to-year;

● Encouraging employers to offer their employees allowances which employees can use to shop around and acquire their own insurance plans (often at lower cost than group policies), and further allowing tax deductions to cover insurance premiums and other healthcare costs;

● Allowing insurers to offer a variety of plans covering a range of services, and not requiring services that a given insured determines he or she is unlikely to need, such as mental health services or pregnancy coverage;

● Not restricting insurers to certain states but allowing them to operate across state lines;

● Taking steps to reduce the administrative burden and associated costs;

● Directing greater public funding toward community health centers and using these centers to provide health care, on sliding cost scales, especially to lower income and uninsured parties;

● Encouraging formation of healthcare cooperatives, both private and public, and allowing both insured and uninsured people to join them;

● Developing public policies and pressure to reduce the cost of medical education;

● Allowing write-offs of most or all debt or costs incurred by medical students in return for a certain period of service, at reduced salary levels, in rural and other under-served areas (as is done in some countries);

● Developing policies increasing the numbers of medical, nursing, and allied health students to address national shortages in these fields, applying the law of supply and demand to reduce costs and improve access;

● Applying both public and private initiatives to controlling the cost of pharmaceuticals;

● Instituting reasonable limits on medical malpractice claims to help contain the cost of malpractice insurance.

Again, I don’t claim to be an expert on healthcare, and I don’t claim to have all the answers. But I think these steps could go far toward expanding access to healthcare, controlling costs, and getting the runaway train of American healthcare back under control, without further straining public budgets. And it’s time we put a stop to the shell game inherent to the American healthcare system.

I welcome comments, criticisms, and other suggestions to what is said and proposed here. And please share this posting with your social networks and others who might have interest in the topic.

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