Healthcare needs reform, not reckless cuts or impossible extremes

In the 2020 election campaign, healthcare looms as a major issue. 

Many Republicans want to repeal the Affordable Care Act and slash Medicare.  Eliminating Obama's signature policy and reducing Medicare are centerpieces of their effort to end Democratic "big government."  They like the traditional system based mainly on insurance provided by employers. 

Many conservatives believe healthcare should be left to private sector insurance and emergency care.  The U.N. World Health Organization rates U.S. medical services as only average, except for its top-flight emergency rooms.  The country also ranks first world-wide with the highest healthcare costs.

Medicare gives most older Americans, who lack coverage under employer plans, regular access to hospital and doctor care.  Drug costs are subsidized.  If they cannot afford the program's premiums or co-pays, Medicaid can help.

Under Medicare, people can choose their doctors.  In addition to Medicare payments, they either come up with cash or use supplementary coverage, provided by private insurers. 

Medicare Advantage, a popular form of the program, tempts insurers to cheat the government by claiming they paid doctors for more care than they actually did.  Last week, the massive extent of this cheating was revealed, with more bad news expected.  Many major insurers appear to be involved.

Congress has blocked Medicare from selecting drugs based on their price.  Suppliers have an incentive to charge as much as the market will bear, far above actual cost.  Their prices are not regulated.  They may expect that co-pays would be raised.  

Because Medicare covers so many people who might otherwise have no protection, some Democrats propose universal health insurance – "Medicare for all."  Most likely, they would propose to fix it first, piling one unlikely promise on top of another.  But it sounds politically appealing.

This proposal is a form of so-called "single payer" insurance.  A government agency pays all bills with some co-pays to screen out those not truly ill.  "Single payer" raises taxes but eliminates insurance premiums, and is thus expected to lower net outlays by individuals.

But the cost of hospitals and doctors remains uncontrolled.  The single payer may still face higher prices.  One obvious solution is that the single payer also employs the doctors and owns the hospitals.

Such a system exists in the U.S. – the Veterans Administration.  Because any system is only as good as the people who run it, it works better in some places than others.  In Maine, it works well.  Full disclosure: I'm a participant.

Because some managers elsewhere falsified their records and delayed service, the VA system has come under pressure.  The Trump Administration's solution is to make it easier for veterans to use outside doctors at government expense.  This outsourcing is part of the GOP effort to reduce government programs.

The ACA is a hybrid between the traditional insurance system and a government payer.  It is supposed to control prices through the operation of an open market in which people can choose their coverage.  Insurers are required to cover more people.

After a recent change, made when the GOP Congress went after the ACA mandate, individuals no longer must buy insurance or pay a penalty.

If not covered by employer plans, individuals may exercise their choice through state exchanges in which insurers compete.  Originally, a non-profit public option was proposed in each exchange, but it was blocked by a single senator representing insurance interests.  The obvious fear was that people would turn the lower-cost public option into a single payer.

The ACA has its problems.  It has survived because of a handful of GOP senators, including Susan Collins, and Chief Justice John Roberts' swing vote on the U.S. Supreme Court.  The lack of cost control and the loss of required participation make it an imperfect solution.

Recently, a Columbia University expert has suggested that, instead of the ACA or copying single-payer Canada, the U.S. should consider the German model, the world's oldest health insurance plan.  Less costly than the American system, it uses a combination of employer, employee and government financing.

Private insurers in Germany are subject to strong regulation, and they compete on price and quality.  An individual's co-pays are capped at a fixed percent of annual income, less than co-pays in the U.S. 

Americans prefer choice and competition, and the German system provides it.  Government regulates prices but does not replace insurers. Along with adding drug price regulation, this plan merits more attention.

Healthcare is an immediate and costly problem.  Candidates need to skip anti-government cost-cutting bravado on the right or unrealistically generous promises on the left and look for real solutions.

Congress lets president do its job; reform of national emergencies needed

Declaring a national emergency, President Trump's way of rounding up funds for the Wall, is either a national scandal or a routine political maneuver.  Voters may get to make their choice.

Whatever it is, the fault for the latest crisis is squarely owned by Congress.  By blithely passing off its constitutional powers to the president, it is now faced with a president making the most of the opportunity.

Sen. Lindsay Graham has said that Congress refused to allow Trump to spend funds in ways it had authorized previous presidents, so he had to act on his own.  That's not how it is supposed to work.  When Congress sets spending priorities, the president cannot flout that decision just because he favors another policy.

The problem is not that Congress has rejected more wall-building.  The problem is that Congress has given the president the tool to ignore its constitutional control of federal spending.

Another understanding about how the federal government is meant to work within the terms of the Constitution has been eliminated.  Its disappearance joins a growing list of evaporating constitutional customs, altering the American system of government.  People voted for change, and they are getting it.

Presidents have used their power to declare a national emergency for a wide variety of reasons, from blocking the assets of certain enemies to prohibiting the import of "blood" diamonds to responding to the 9/11 terrorist attacks.

Trump has been criticized because the immigration threat is not newly urgent and has been diminishing in recent years.  

So why call it a national emergency now?  It looks like a mere political ploy.  Even so, it takes advantage of the possibly unjustified precedents established by assertive presidents acting in the absence of Congress.

What's different about Trump is that he has acted right after Congress expressly rejected the spending and precisely because of the congressional rejection.  That had not happened previously.  And his declaration was based on inaccurate or false data.

A national emergency should be an urgent situation that can be easily recognized by members of Congress and average voters.  It should not be a matter of politics, which this declaration surely is.  Consistent with his approach throughout his presidency, Trump wants to keep the political promises he made when he ran.

Congress may try to reject his declaration.  Much will depend on how Republican senators vote.  There must be enough of them to override his inevitable veto.  It is a virtual certainty that GOP senators will not abandon their loyalty to their president, though he shows them no such loyalty.

The declaration has also gone to court.  Opponents claim that Trump's action violates the separation of powers and that he cannot ignore the congressional power of the purse.  

They will expect a conservative Supreme Court to be more supportive of the Constitution than of the president.  Maybe.

The Court could well refuse to decide the matter.  It could simply say that Congress can pass laws about national emergencies, as it has in the past, leaving it up to the lawmakers to decide this matter, not the judiciary.  It might find that nobody has standing to make a legal challenge.

Dealing with Trump's declaration or at least future so-called national emergencies places the issue directly before Congress.  Senators Susan Collins and Lamar Alexander of Tennessee, both Republicans, say they oppose Trump's declaration.  They should come forward promptly with a bill to limit presidential power.

New limits in declaring national emergencies could be enacted.  They might be required to sunset in two weeks or a month.  That would give Congress the time to consider legislation authorizing further action.  These days Congress can reconvene quickly.  There's no need for give the president a blank check. 

This approach could be especially useful where the president is using funds that had been appropriated for other purposes.

Two classes of emergency might be established, cutting down on the use of a broad declaration to cover targeted issues.  A two-tier approach would reserve the declaration of a national emergency to events having national effect.

As for the Trump declaration, Congress could ban using any funds under any appropriation for spending on a border barrier above the level set in the Homeland Security budget.  

Even if the president vetoed it, the bill would give political wiggle room to Republicans who want to put some space between themselves and Trump in the 2020 elections. 

Reversing Trump would be a declaration that Congress is beginning to reassert its lawful powers.  The Wall is not what's most important.  The Constitution is.

Supreme Court makes big waves with little orders; Collins gets blame, Roberts gets credit – both mistakes

The Supreme Court has stirred controversy with two procedural orders.  They revealed much about the state of our political world.

In one case, the Court decided to suspend a Louisiana law that requires doctors performing abortions to be admitted to practice at a hospital.  The law could have the effect of eliminating all but one of the clinics and doctors providing abortions.

The factual question was whether three doctors could obtain hospital admission privileges.  The state promised to give them 45 days to try, deferring enforcement of the law.  It acknowledged that if only one doctors remained, that would not satisfactorily protect women's health.

In effect, the Court decision lengthened the 45-day period.  It did not decide on the law itself, though it will later.  Among the five-member Court majority were the four liberal justices and Chief Justice John Roberts.

Justice Brett Kavanaugh was among the four conservatives opposing the suspension, but was alone in providing a written explanation.  He took no position on the law, but said that the three doctors should continue performing abortions and make a “good faith effort” to gain hospital privileges in the 45 day window.

If they did not succeed, a stay suspending the law could then allow the Court to review the law itself.  In short, he said nothing about supporting the obvious effort to drastically limit abortions.

Two conclusions immediately emerged from the decision, both most likely wrong.  One was that Sen. Susan Collins had been fooled when she said Kavanaugh would respect precedent, presumably the Roe v. Wade decision allowing abortions.  The other was that Roberts was emerging as the Court' swing vote.

Abortion advocates would not trust Louisiana's assurances which Kavanaugh had accepted.  Because he was not suspicious, he was complicit.  That meant he opposed Roe.  Distrusting any statement from those you oppose is how politics works these days.

Collins took him at his word in his dissenting opinion.  The media reported that opponents of Kavanaugh's confirmation had “slammed” her with the obvious intent to weaken her reelection chances. 

As for Roberts, as much as we want a new swing vote, he showed his credentials for the title are limited.

In Alabama, a convicted criminal was slated for execution.  A Muslim, he asked for an imam to be present.  The state refused, saying only its Christian staff chaplain may attend.  Otherwise, it claimed, without proof, the event might be unsafe.  The state claimed he should have known the rules, though his request for them had been refused.

The Court of Appeals had suspended the execution so that it could hear arguments on both sides.  The Supreme Court overruled the lower court and allowed the execution to take place.  The five member majority included the five conservatives, including the Chief Justice. 

Justice Elena Kagan said the decision was a direct violation of the clause in the Constitution that prevents the government from favoring any single religion or religion itself.  She said the state's reason for its rule should have been examined in court.  After the decision, Alabama quickly banned any religious counselor from executions.

Roberts had fallen in line with the conservatives, not on procedure as was the case on abortions, but on a basic constitutional question.  That raised a question about the quality of his status as swing justice.

Both decisions could affect millions of people.  The Court owed people more than the short, procedural orders, providing little detail and judgment.  It left the explanation to the media, which could easily misinterpret the abortion order, making more out of it than justified and while ignoring the true meaning of the religion case.

As a result, people were misled or ill-informed.  That undermines democracy.  The Court deals with the law, but it also affects the people.  It might remember that.

A note.  This column during the week near Washington's Birthday traditionally is devoted to the exceptional man who embodied the American nation and was its first president.  Because last fall, a column was devoted to his words, relevant in light of the Pittsburgh massacre, this column does not focus on him.

But we have heard recently from our current president that his first two years in office were the greatest in history.  In his first two years, George Washington created the American executive branch of government, balancing conflicting views.  He was well aware that he was setting precedents that might last as long as the Republic.  And he displayed great modesty, even reticence, at times. 

These days, his exceptional accomplishments are worth remembering, especially in the White House.