March 25, 2017

Trump, 1999: "I'm quite liberal, and getting much more liberal, on healthcare"

For the past week here we've seen that Trump's big-picture vision for healthcare has always been single-payer. To appreciate just how deeply committed he is to this form of healthcare, watch this interview with Larry King from 1999, when he was forming an exploratory committee about running for President under the Reform Party that Ross Perot founded earlier in the decade.

The entire interview shows how little he has changed, so we can be sure what he's expressing right before potentially running for President is what he has totally committed himself to. Although most of it will sound uncannily familiar, listen to this exchange on healthcare:

Larry King: Patient's Bill of Rights. You mention healthcare as one of the social issues. You for it?

Donald Trump: I think you have to have -- and again, I said I'm conservative, generally speaking I'm conservative, and even very conservative. But I'm quite liberal and getting much more liberal on healthcare and other things. I really say, What's the purpose of a country if you're not going to have defense and healthcare? If you can't take care of your sick in the country, forget it, it's all over, I mean it's no good. So I'm very liberal when it comes to healthcare. I believe in universal healthcare. I believe in whatever it takes to make people well and better.

LK: So you believe, then, it's an entitlement of birth.

DT: I think it is. It's an entitlement to this country, and too bad the world can't be, y'know, in this country. But the fact is it's an entitlement to this country if we're going to have a great country.

LT: So you are for this measure?

DT: I am for whatever it takes. We have the money, the fact is that the world is ripping off this country. Germany is ripping us off big-league, Saudi Arabia is ripping us off big-league, France -- I mean, they're the worst team player I've ever seen in my life. You look at what's happened -- Japan for years, I mean we're like a whipping post for Japan.

He goes on to say that if we negotiate fair trade deals, we'll have more than enough money pouring into our economy that we can lower taxes and still provide goodies like universal healthcare.

If everything else he says has stayed the same, we have to conclude that he still feels this way on healthcare. Trump the impulsive flip-flopper is just a media fabrication (a projection of their own temperament). From these ancient interviews, we know he is strategic, cautious (won't run unless he could win), and committed to where he stands on what he thinks are the most important issues facing the nation.

Populists will breathe a sigh of relief that Trump has always had his sights set on single-payer, while conservatives will have to "trust Trump" as he pitches the system that every other rich country enjoys, with far better health outcomes at far lower prices.

Corporate propaganda has so thoroughly brainwashed conservatives about healthcare, where single-payer is the apocalypse, so admittedly the Trump team has their work cut out for them. On the other hand, he will easily draw in moderates and liberals who have been crying for single-payer for decades.

With the Congressional Republicans forever torn between moderate vs. high levels of sociopathy on entitlements, this provides Trump with the first real opportunity to "pivot" toward the center.

Hopefully Pelosi and Schumer vote against single-payer, putting them on the record as phony sell-outs, and allowing Trump to rake in even more former Obama voters during his re-election. Although perhaps they will vote for, and try to spin it as having won over even a Republican President on healthcare, and from a minority party position.

March 23, 2017

Trump never forgets: R's blocked negotiating drug prices under W. Bush

The only position on healthcare that Trump has consistently taken is an overall lean toward single-payer.

However there is one specific thing that he keeps hammering home, and that is the absence of negotiation on the prices of prescription drugs, despite the US government being the largest single buyer (Medicare Part D).

"Who da hell would buy wholesale and pay retail?"

He knows it's because the drug companies and insurance companies have bought off the politicians, and has said so often on the campaign trail. Some politicians are "incompetent," but probably they're "taken care of" by the lobbyists.

If the federal government threatened to walk away from a certain supplier for charging too much, that company would lose access to nearly half of all dollars spent on healthcare in the US (i.e., what the government covers) -- a sector that accounts for nearly 20% of our GDP. We have their balls in a vice, and all we have to do is squeeze.

Trump knows that when Medicare Part D was signed into law by W. Bush in 2003, there was an explicit provision in it that there would be no negotiation of prices on prescription drugs. This was back when the Republicans still thought that championing corporate rape was a long-term winning strategy.

That law went into effect in 2006, and by 2007 the Democrats who barely controlled the House decided to push back in a follow-up bill that would have required the Secretary of HHS to negotiate drug prices.

It passed the House without a single Democrat defection, along with a couple dozen moderate Republicans. But most House Republicans decided that corporate rape was still the winning strategy, and voted against. When it reached the Senate, the only Dem defector was Harry Reid -- a harbinger of how disastrous Obamacare would turn out. And although 6 Republicans voted in favor, 41 of them did not, and it was killed by filibuster 55-42.

Of course, even if it did barely pass, Bush would have vetoed it and withstood an override challenge. So the Democrats were just posturing, trying to score populist points with voters, while assuring donors and lobbyists that there was ultimately nothing to worry about. That's how Obamacare played out, when they actually had the chance to make their wishes come true with a filibuster-proof supermajority in the Senate and one of their own in the White House.

Still, why did Congressional Republicans allow themselves to be branded as the party of corporate rape in healthcare? Out of sheer partisan polarization? Well congratulations, geniuses: if the other party knows that you're going to reflexively naysay any of their policies whatsoever, all they have to do is make an insincere gesture of populism, and without thinking you'll make yourselves the proud sworn enemies of the American people. Gee, how do we explain your abject pathetic failure in the next year's elections?

(Thankfully that shoe is now on the other foot. "Wouldn't it be great if we got along with Russia to fight Islamic terrorism?" IMPEACH THE KREMLIN-PUPPET TRAITOR!)

The utter failure -- indeed the fanatic insistence on not negotiating prices for something that you are by far the largest purchaser of, is so offensive to the common sense of a businessman like Trump, that he must have been howling for all of them to have been fired. The vote was reported by the media, so it's possible he heard about it ("I never forget").

Rather than be rewarded for populist gestures, the moderate Republicans have been slowly voted out, and only one of the Republican Senators who voted to negotiate drug prices is still there -- Susan Collins of Maine -- while many of the naysayers have easily held onto their seats. Same story in the House.

Fun fact: hardcore libertarian Ron Paul was one of the few Republicans in favor of negotiating prices. There may be a fault-line there to hammer on, where libertarian-leaning Republicans will have to prove their basic business sense.

Unfortunately, the list of "Republicans for corporate rape in healthcare" included those who would become major figures of the Trump era, other than the man himself -- Leader McConnell and AG Sessions from the Senate, and from the House, VP Pence, Speaker Ryan, Leader McCarthy, and worst of all HHS Secretary Price.

Since Trump has single-mindedly focused on negotiating prescription drug prices for Medicare, he has to know his point-man in the Cabinet has the wrong voting record on the issue. It's one of the first things he would've looked into.

It makes me think Trump is planning on digging up this corpse of a voting record and shaming the Congressional Republicans if they don't fall in line behind negotiating drug prices, if not yet full-on single-payer.

"What da hell kind of business sense do they teach you guys when you show up first day on Capitol Hill? ... Or maybe you were being taken care of by the drug companies' lobbyists? I dunno, folks, you think maybe that happened? Oh nooo, nooo, that never happens, especially not with the principled people in this room..."

If the majority of Congressional Republicans from 10 years ago were merely going against the idea out of partisan polarization, they can now safely go along with it since Trump is pushing it.

And since Nancy Pelosi, Chuck Schumer, et al. already voted for it then, they'll have to either go along with it again, or face a bloody revolution from their constituents, who want nothing more than universal healthcare. They would have to worry about far more than a tweetstorm from Trump -- he would camp out on their home turf, inflaming the rage of local liberals about how he's promising cheap drug prices and Pelosi and Schumer are getting in the way and going back on their voted promises from just 10 years ago.

He's got enough leverage over both sides to make it happen, although it would be easier to pass with a bare majority in the Senate. Ideally some other topic would force the nuclear option first -- no way McConnell would use it first for a populist cause.

Once he gets citizens used to the idea that we're going to use our collective bargaining potential to get killer deals and enjoy a higher standard of living, it'll soften them up to a gradual move toward single-payer. That could be his major issue for re-election -- "better than ever before" because we've never had a first-rate healthcare system like the other rich countries have for decades now.

March 21, 2017

Price transparency for healthcare is not a problem in single-payer

A major concern that people on the Right have raised about fixing the healthcare system is the lack of transparency in pricing.

The drug companies and hospitals don't have a menu posted like they do when you walk into a McDonald's, and if you try to press anyone there for the information, they either do not have it or will refuse to give it to you. Perhaps you'll only find out how much something cost after the fact and they've stuck you with the bill for a $20 cup of orange juice. Then you either pay it, or pay the various costs of fighting off a collection agency, or pay the costs of filing for bankruptcy.

The exact same drug by the same manufacturer in the same quantity may cost orders of magnitude more in America than in another first-world country. We don't know how much it costs here before we get the bill, and we certainly don't know how cheap it is to buy in other countries.

This opacity allows the healthcare providers to drive up prices, just as we've seen over the past several decades.

But is the lack of transparency in pricing a cause or effect of our terrible healthcare system?

The argument on the Right assumes that if we could make prices more transparent to the customer, it would go a long way toward bringing down expenditures. They would now have the information needed to shop around, play competitors off against each other, and so on.

The trouble is that people do not want to even think about prices when it comes to healthcare. Five years or so ago, the libertarian autists at George Mason economics were discussing this aspect of rising healthcare costs. Some of them (Hanson, I think) pointed out that people are in a different mindset when it comes to things like life and death, so they don't apply the same behaviors to navigate their way through healthcare decisions.

If our health is sacred and taboo, especially on the insides of our bodies where we can't really see what's going on, we just aren't going to "go there" and view it like a mundane mechanism. To the human mind, the body is not like a car with its parts and systems, so we aren't going to ask multiple health providers for quotes, ask which provider has the best reputation, haggle about the price, and so on.

It's part of the sacred realm where mechanisms and price haggling are not allowed. So we just accept whatever it costs to get better, and hope it won't cost too much.

Parishioners, sitting in the pews on Sunday morning, are not wondering if the Church scored a killer deal with whatever furniture makers made their pews. They aren't thinking, Is all that money in the collection plate going to waste because the leaders didn't negotiate a good deal on the pews? It's part of the sacred architecture, and is beyond questions of pricing when you're in the worshiping mindset.

So, even when you experimentally give people the kind of information about healthcare that they'd need to shop around, they tend not to make use of it. Those facts, figures, and spreadsheet calculations put them into the profane mindset when they're facing decisions about something sacred like their health.

This will remain a problem as long as the recipient of price information is the end consumer of healthcare. If it's a close friend or relative, it reduces to the same problem. They're too emotionally invested in their loved one's sacred health to even think of getting into the profane haggling mindset.

Single-payer systems solve this problem by making the national health boards the recipient of price information. First as an opening offer, then lowering it through aggressive negotiations by the national board. The board could also demand to see the recent or long-term history of prices for various things -- are prices going up disturbingly quickly?

These board members are in total bean counter and negotiator mode, as they are not the end consumers of healthcare goods and services being considered. Occasionally they'll be using the public system, but not at that moment for those services being examined. This allows them to keep a much cooler and rational mindset while considering prices, and trying to get a better deal from the providers.

It's no different from how those pews got purchased for the Church -- somebody somewhere in the organization looked at how much there was in the budget for pews after the collection plate had been sent around, then they sent out a request for bids to manufacturers, inspected their track record for quality, played them off each other, and negotiated a decent deal. Nobody in the sacred services had to know anything about it -- and would not want to know.

So, relying primarily on a single-payer system not only allows all the isolated little taxpayers to pool their resources and throw their collective weight around at the negotiating table. It also allows them to not make serious financial decisions when they're in sacred mode, where price is no matter, sending it off instead to someone who will be in profane mode.

You could always try to get someone else to haggle on your behalf, while not pooling resources with anyone else to do so. But then you'd have as many hagglers as patients -- why waste all those resources, when it can be consolidated into a specialist team that haggles on behalf of the entire population? Especially when a national haggler can make a more serious threat by walking away, compared to an individual haggler.

Nobody in the first world knows what most of the prices are for their healthcare services -- whether they live in America where they get raped, or in the other rich countries where they do not. Somebody other than the end consumer is thinking about prices, if anyone is at all. So price transparency is not a necessary factor in explaining why our system sucks, and fixing that problem would not be sufficient to deliver good healthcare outcomes at low prices.

The more you look into it, the more reasonable the single-payer system is, whether Canada, Australia, England, France, or wherever.

March 18, 2017

Trump for single-payer healthcare, by letting both parties prove their plans are catastrophes?

First, let's note that Trump would have to be suicidal to want his name or political brand to be tethered to the fate of the Republican reform of Obamacare.

Without 60 votes in the Senate, there can be no true, substantial repeal of Obamacare nor replacement with entirely new things like selling insurance across state lines. Even if the Senate lowered the bar to a simple majority to pass substantial legislation, there would be enough defecting Republicans (3 would be sufficient) to prevent the bill from landing on the President's desk.

So the only possible outcome is a superficial reform of Obamacare, and since the structural weaknesses of Obamacare are deep, the reformed version would also implode in short order.

Because the Republicans in Congress would have been the last to have touched the healthcare system, they would be easily blamed for its implosion. "It may not have been a perfect system, but at least Obamacare didn't fall to pieces -- you can thank the Republicans for fumbling the pass, causing the healthcare system to shatter into a million broken pieces."

That's why the Democrats and the media are not pushing that hard against Obamacare 2.0 -- just trash-talking the lack of cohesion on the other team, and trying to brag about how great their own plan has been. But not pulling out all stops as they do when Trump threatens something they truly love, like proposing the Muslim ban.

The enemy wants us to be the last party to be seen on camera handling the healthcare system right before it imploded, so that they can own all of the upside of Obamacare (covering the uninsured) and none of the downside (destined to implode). The Party of Stupid will face the opposite fate -- owning none of the upside (they showed heartless obstruction toward covering the uninsured) and all of the downside (their fault it broke if they touched it last).

Fortunately our President is not that stupid, and actually campaigned on not being the typical stupid Republican with typically stupid Republican solutions. He knows damn well how deadly it would be to own a reformed healthcare system that was still destined to implode because not enough votes in the Senate could be garnered in order to pass true, substantial "repeal and replace".

Nor is Trump, like Congressional Republicans, addicted to losing. And taking the blame for Obamacare's inevitable demise would be the ultimate own-goal.

I'm not the blackpill type, and yet I couldn't see what Trump's longer-term goal could have been, given his apparent support for the GOP's healthcare legislation. I didn't want to rush to publish a downer post about how Trump is being led into the abyss by Paul Ryan et al. Then I ran across this from Daniel Horowitz at Conservative Review:

If this bill does not bring immediate relief, and in fact exacerbates the death spiral, the private market, along with GOP political capital, will be dead by 2020. The new regime will never be in place, especially not during the reelection of President Trump. We will either have a massive bail out or a single-payer system by that point.

Of course he says that like single-payer is a bad thing, and why Trump must reverse course. But then Trump is not an ideologue about single-payer, which the True Conservative (TM) crowd never tired of reminding us during the GOP primary. Take this example from February 2016 at Independent Journal Review (going after the closeted gay young Republican audience): "5 times Donald Trump praised socialized healthcare", with examples going from the late '90s through 2015.

Like Horowitz, he wrote that post like it's axiomatic that single-payer is a bad thing, and that's why no true Republican can vote Trump over Bush, Rubio, Cruz, et al.

Trump has never railed against single-payer, only saying it could have worked in an earlier time but not now, when the country is not that different from 2000 when he was praising it in detail. He used to note how much healthier Canadians are, while paying less, even when you control for demographics. He has recently said he "doesn't want" single-payer, but he's not a puritanical ideologue, so perhaps that only means he'll accept that outcome while not being the biggest fan of it.

And it's also possible that, yet again, Trump is playing dumb and letting his enemies destroy themselves, so that he can get his way easily in the aftermath.

The Democrats are bought off by the drug companies, insurance companies, and healthcare providers, so like hell they would ever advance single-payer on their own. Also, they're such kneejerk partisans that, as Trump keeps saying, they'd vote against their own utopia if Trump were the one who gave it to them.

They are easy to dispatch, by pointing out what a disaster Obamacare had always been and would have continued to be. Skyrocketing premiums and deductibles, shrinking choices, etc. -- those began long before the Republican Congress' attempts at reform.

It's the Republican opposition to single-payer that would prove more difficult. He did not defend the idea against True Con types like Ted Cruz during the primaries because he feels like abstract hypothetical debates would not drive the point home to the voters. Trump can point to the better health and lower costs for Canadians and Australians, but then Lyin' Ted can respond that America is different, we can't go for totalitarian government-mandated socialism in healthcare, and so on and so forth.

Trump would get bogged down in pointless debating, and have little to show for it. He might pick up some sympathetic Democrats in the Senate, but he would alienate many more Republicans, not to mention turn off Republican voters for whom single-payer is an abstract taboo topic.

By letting the Republican Establishment -- both the corporate wing and the libertarian wing -- have their way with the reform of Obamacare, Trump can make the case that he's been not only open to their True Con ideas, but has actively encouraged them. He looks like a negotiator in good faith, not an infiltrator and usurper of the Republican orthodoxy. More importantly, he doesn't turn off legions of Republican voters.

But since any version of Obamacare is destined to fail, Trump can let the Republican Establishment prove directly that their plans are just as disastrous as the Democrats'. It will no longer be a hypothetical debate -- I gave you guys in Congress the chance to come up with something great to replace Obamacare, and this is what happens? Folks, it looks like we can't trust the Establishment's plans for healthcare, no matter which side of the aisle it's coming from.

Then with Obamacare / Ryancare having imploded, Trump can use the emergency atmosphere to propose a bold new direction to lead us away from the failed policies of the past from both parties. "We're going to look into" a system like Australia's -- it's not going to be exactly like that of any other country, but they seem to be doing a lot better than we are, so we're going to look into what they're doing that we are not.*

Trump loathes the endless wheel-spinning of adversarial debate (he's not a lawyer), and prefers to Socratically prove that your so-called genius plan is a total horrorshow -- by letting you go right on ahead with it. Then when it blows up in your face, we'll do something different or even the opposite, and get a much better result. It's an experiential take on arguing from a reductio ad absurdum. You're so against single-payer? OK, you're such geniuses, hit us with your best shot in the opposite direction. Gee, that was an utter disaster -- looks like single-payer it is.

If Trump can lead the charge to push for a bold new system after Obamacare / Ryancare implodes, he might just be able to pick up enough liberal Democrats in the Senate to pass 60-vote legislation, or failing that, rope the Republicans into an Australian system in order to preserve what little credibility they will have after passing failing legislation. At that point, they could lower the bar to 50 + Pence, and afford a few defections. Even if an Australian-style system cost him 5 Republicans who think single-payer is tyranny, he would only need to pick up 3 sympathetic Dems like Bernie to hit 50.

Trump has been saying all along that the best thing politically is to do nothing, let Obamacare implode, and then its creators will come begging to the negotiating table.

But then Trump must be thinking the same about the worthless do-nothing Republicans as well -- let them finally get Presidential approval for their discredited corporate / libertarian plans, and then when it blows up and they face losing the Congress in mid-terms or in 2020, they will come begging for Trump to give them a winning replacement -- like the Australian system he has already had in mind for several decades. They will have no choice but to go along with it, and will be rewarded when voters see better quality at lower prices in their healthcare.

Finally, for the Americans who may have ever had a kneejerk reaction against single-payer: ask yourself why your counterparts outside of America are not agitating to destroy their own single-payer system, and why they either make fun of us or take pity on us for not enjoying such a system? They are otherwise 100% on board with the populist / nationalist movement led by Trump and others. So why aren't they harping on "socialized healthcare"?

Probably because it isn't that bad, and at any rate is better than what we have here -- admittedly not a very high bar to clear. As much as they gripe about their own system, they'd never want our own system, unless they're very rich. For everyone else, "how they do it outside America" sure looks like it gets better results at lower prices.

The working-class voters who put Trump over the top, in particular will not have a kneejerk reaction against single-payer. Not that they're kneejerk in favor of it either, like well-to-do progressives. They're simply willing to give it a try, after so many failures of conventional thinking.

Let this be a corrective to the previous post about not expecting much populism in domains where there is not a natural angle about globalism vs. nationalism. If Trump can let both Establishment sides prove their policies are garbage, he's got carte blanche for a bold new populist solution.

* I think Australia would be the best example to point to, since the Republican voters and politicians do not have a kneejerk association of Australia and the Australians with wimpiness, socialism, tyranny, etc. It would be poison to use France or Sweden as the example, for branding reasons only. It would be easier for them to accept a system that is 90% single-payer and 10% private healthcare, since they have no preconceived notions about Australia's healthcare system, but have dystopian views of "European" healthcare due to lobbyist propaganda here in America.

And certainly he would brand it with something other than "single-payer," which is too toxic among Republican voters. He's an expert brander, though, so whatever the phrase is, it'll sell.

March 10, 2017

Don't expect populism (healthcare) unless it is part of nationalism vs. globalism

Early on in the Trump campaign, I discussed how the nationalist focus would take precedence over the populist focus. That's how it unfolded during the previous incarnation of where we are now, the shift away from the Gilded Age and into the Progressive Era -- from laissez-faire and open borders to closed borders and economic nationalism.

See earlier posts here and here about income tax and the minimum wage, both of which only took off during the New Deal, after the nationalist goals had been largely achieved during the Progressive Era.

The basic logic is that the government will only be able to deliver populist outcomes when there is a high level of civic cohesion, which requires a nationalist rather than globalist focus. When millions of foreigners were pouring into the country during the Gilded Age, the founding stock Americans did not want to blow taxpayer money on subsidizing their job competitors and cultural replacements. Only when the Ellis Island people were assimilated (to the degree they were) did the founding stock feel OK with using the government to provide nice things to "all Americans".

History cannot be reversed, for example going from the neo-Gilded Age back to the New Deal. It can only run through phases of a cycle. If it goes A-B-C-D, you cannot go from D "back to" C. You have to run through A and B all over again before you find yourself in C again. This is what we ought to expect regarding the rebirth of populism and nationalism. The pure populist phase comes after the nationalist phase.

Concretely, that means we should not expect much to improve in healthcare, which is more of a pure populist battle of the general public against the greedy mega-corporations that control pharmaceuticals, insurance, and hospitals.

Trump is making major gains on economic nationalism, for instance stopping the TPP dead in its tracks and threatening big companies to bring back their manufacturing jobs and plants rather than exploit cheap labor abroad. If they refuse, they side with the anti-American side of the anti vs. pro American fault-line -- putting them in league with those who want open borders even for violent gangs and terrorists.

Already without a stiff tariff being levied, many big players are moving production back to America so that they do not run afoul of the nationalist movement. They would rather have a decent profit than no profit, if sky-high profits are no longer possible because of public hatred of off-shoring and the government now willing to act strongly on behalf of such nationalist fervor.

And it's not only the senior management at big companies who are bending to the nationalist will -- Trump can threaten any Republican in Congress with their job if they side with greedy globalist corporations over the American worker and middle class. All he has to do is launch a broadside on Twitter and roll into their home district or state -- and poof, there goes their career. No Republican can take the anti-American side, when Republican voters have chosen nationalism as their primary focus, so they will gradually come around to tariffs and other measure to re-patriate manufacturing jobs.

But what is the pro vs. anti American angle to healthcare? It's not as though white Americans have pathetic healthcare for their money compared to other white Westerners because we're being taken advantage of by foreigners or foreign governments. It's an entirely domestic battle between sociopathic big corporations and isolated citizens who have no weight to throw around at the bargaining table.

The Trump administration and the Trump movement will have little success in trying to spin the healthcare battle as one between America-first vs. globalist camps. Likewise, Trump will not be able to bully Congressional Republicans very much by painting them as anti-American, in the sense of globalists callous to the needs of their countrymen, for siding with the greedy corporations rather than the people. And given that it's the corporate lobbyists who pay Congress' salaries, they have every motive to obstruct pure populism in legislation.

There are some Democrats and Independents in Congress, such as Bernie Sanders, who would align more with Trump than the Congressional Republicans would on pure populism. However the numbers are not that great, and could be off-set by defecting corporate elitist Republicans. In general, though, there is such a high degree of partisan polarization that Trump has to choose either the Democrats or the Republicans to work with, being unable to build a big coalition between the parties. And since the Democrats are sworn enemies of Trump, they will not be the side in Congress that he works with.

Trump could only get pure populist outcomes from executive orders and the federal agencies (e.g., antitrust division of Justice Dept). If it involves actual legislation in Congress, including substantial repeal and alteration of existing laws, populism will have to wait until we achieve the nationalist goals and build a greater civic cohesion. It's conceivable that on some economic matters -- tax cuts on the ill-gotten wealth of our parasitic elites -- we will get worse outcomes in the short term.

My advice is to temper expectations about matters of pure populism, and focus more on the "intersectionality" between nationalism and populism. Issues that lie along the fault-line of America-first vs. globalism is where we currently hold the leverage against the enemy.