Health Insurance Drives Sky-Rocketing Health Care Costs

My girlfriend, Sandy, and I had our first springtime “spa-day” last week.

Being “girls” we talked about our travels, our families, and fashion while enjoying a pedicure.

Sandy worked in the health care industry before her recent retirement, and I have consulted extensively to large health care organizations over the years.

Not surprisingly the conversation quickly turned to health care – the Republican proposal to repeal and replace “Obamacare” and the just published Congressional Budget Office analysis of that proposal.

Beyond our professional experience, we are consumers. We are experiencing the increasing cost of health care insurance, co-payments, drugs and other expenses.

Spending Other People’s Money

Over our sun-drenched lunch, Sandy and I talked about the growing role of government into our health care system and about some of the unintended consequences.

During his very wonky Power Point press conference, Paul Ryan accurately pointed to the spending of “other people’s money” as a powerful driver in the alarming rise in the cost of health care. http://www.cnn.com/videos/politics/2017/03/09/paul-ryan-full-health-care-bill-powerpoint-presenation.cnn

Let’s break this down.

  1. Obamacare requires that every American citizen must be covered by health insurance. Americans are required by force of law buy to insurance from a private insurer if they are not covered by an employer plan and have an income above the Federal Poverty Line.   That insurance must include benefits you or I might or might not want.
  2. Your individual premium is calculated on age, number of insured in the family, and the average cost of all the mandated benefits – whether you may use them or not – because someone else insured by the same company may – indeed – use those benefits. That is called sharing all the risks.
  3. If you do not buy insurance, the Internal Revenue Service will impose a penalty (i.e. a tax on you) that is used – in theory – to help pay for health insurance or Medicaid for your neighbor whose income and family size qualify them for help paying their legally required insurance premiums.
  4. All insurance payment premium payments for health insurance are paid into the insurance companies’ premium account(s). Premium accounts  are a pool of money in which your individual contributions can no longer be identified or separated out for your specific use.

Once our dollars are pooled with every other tax payers’, we have no control over how they are invested or spent.  They become someone else’s to spend on any person or any benefit – at any price the insurer agrees to.

The more services the government mandates insurers to cover from first dollar or after a minimum co-payment, the less sensitive the consumer is to how much that service costs.

For example, last Tuesday my allergy doctor suggested a vapor treatment for my pollen-driven chest. I said okay. It never occurred to me to ask how much does the treatment cost because I won’t get a bill. The charge will merely be an object of curiosity when the insurance company sends me an explanation of benefits they paid.

If I had to pay the bill for that treatment, I would have asked more questions about the cost and efficacy.

Are government bureaucrats creating an almost irresistible temptation for the health care providers? In a word, YES!

If the insurer is required to pay – no questions asked – for tests and treatments, the profit-making health care eco-system is going to prescribe more tests and charge more for them.

The Affordable Care Act (Obamacare) mandates for first dollar coverage of preventive and diagnostic testing exaggerate these consequences.

The more services are mandated without adequate cost controls, the more the insurers must charge in premiums and co-pays.

Faced with exploding insurance costs for all of us, is it time to change the assumptions about personal responsibility for your own health care and government’s power to mandate that responsibility be underwritten by the taxpayer?

The Purpose of Health Insurance

“Sandy, I think I remember paying bills from the pediatrician when Craig was a kid – like his well-baby care? What do you remember from your children?”

“Yes”, she replied “I remember paying the pediatrician”. Sandy was living in the mid-west at that time and remembers she took her children to community childhood immunization clinics that were “much less expensive” than the pediatrician.

When Craig was born, insurance paid for hospital costs for both of us – but I paid a contracted amount – directly – for my obstetrical care – spread over the pregnancy.

I was in graduate school and working for the University of California’s Statewide Office of Administration at the time. That meant I had really good (state employee good) health insurance.

What I experienced was normal practice in the 1970s.

I don’t remember when the practice changed and I stopped paying doctors’ bills and started paying only a co-payment – and it doesn’t matter. The point is health insurance started out as hospitalization or serious illness insurance – not the primary vehicle for obtaining routine care.

Health care coverage, today, is not only protection against major illness, major accident or hospitalization. It is, also, really pre-payment of anticipated routine services – an indeterminate number of services each at an indeterminate cost. Indeterminate is driving rising premiums and deductibles.

Necessity is Driving Innovation

While Congress is debating how to insulate more people from a price and service model no longer affordable for either the American tax payer or the individual middle class consumer, a few health care practitioners are developing real solutions in real time for real people.

Here are two examples I found – without even trying – that are working in local practices today.

As of January of this year, my dentist is offering patients an annual contract for care. For a monthly fee paid automatically via credit card, the dentist will provide all preventive care and fillings. Other services are paid by the patient at a discounted price – determined before service.

The monthly expense is two-thirds of what my previous dental insurance company charged for a smaller benefit. If I were to need a crown, I would still pay less, out of pocket, than the previous premium plus co-pays.

Not only is this a good deal for the patient, it is a good deal for the dentist. If a majority of his patients subscribe to his plan, it smoothes out the cash flow peaks and valleys of a traditional small business and it allows him to schedule his employees – hygienists, dental assistants and office staff –efficiently.

This efficiency removes time consuming disputes with insurance companies.

Taken as a whole, the dentist can grow his practice while, at the same time, controlling his payroll costs. In other words, he can make a larger profit on same or lower revenue.

While we were talking, Sandy remembered a friend whose family practitioner has a similar program for healthy patients not yet eligible for Medicare. That doctor charges a flat fee of $2000 a year for all routine and sub-acute office visits plus annual preventive care – including blood draws and other routine laboratory testing.

That patient must still purchase major medical (i.e. hospitalization and catastrophic illness) coverage. But, according to my quick Google search, those policies start at about $600 a year. https://healthplans.com

This approach is definitely a money saver. It’s less than the cost of Medicare plus a Medicare Supplemental Plan for someone who meets the health criteria implied in the contract.

Here, too, the regular payments help to smooth the doctor’s cash flow and simplify insurance claims processing – benefitting the bottom-line.

Both of these patient/provider contracts are treated equally with employer-based health care premiums for tax purposes through the use of Health Savings Accounts – an objective of the GOP sponsored plan. http://www.hsacenter.com

Could these be early signs of return to a health care model more typical in the 1970s? A model middle class Americans and their health providers can afford.

When routine health care was something consumers paid out-of-pocket, we paid attention to how much it cost. We shopped around for the best deal.

Old fashioned competition is the elixir of innovation – a tonic the American health care system urgently needs.

Graphic — screen shot by author.  With all thanks to MSNBC and my Samsung Smart TV

House Intelligence Committee — the Schiff “Indictment”

For listeners of my March 25 AM 860 Radio Program here is the link the House Intelligence Hearing from March 20.

Ranking Member Schiff’s “indictment” is in the first 20 minutes of the total 5 hour recording

https://www.c-span.org/video/?425087-1/fbi-director-says-hes-investigating-links-trump-campaign-russia

 

This information is offered for your private use with all rights and copyright belonging to CSPAN.Org

With my thanks to CPAN!

CBO Waves Yellow Flag at GOP Healthcare Bill

By the time I had printed out a copy of the just released Congressional Budget Office (CBO) cost estimate of the GOP proposal to “repeal and replace Obamacare” my inbox had filled up with draconian headlines and alerts:

A complete reading of the 27 page report paints a more complicated picture but does urge caution as the House of Representatives moves to debate, amend and attempt to pass the American Health Care Act (AHCA).

Assumptions

To reach the cost estimate, the CBO had to begin by making a set of assumptions.

1. Health care is an entitlement – just like Social Security and Medicare.

2. The nation’s health care eco-system is a permanent fixture that cannot be evolved and made more cost-effective.

3.  Health insurance is and should be the future primary source of payment for an individual’s health care.

4.  The non-group insurance market place will see a smaller portion of premiums returned as benefits to insured individuals – resulting in higher out-of-pocket expenses for the insured.

5.  Higher out-of-pocket expenses are, by definition, bad for the insured individual.

      6.  Absent a government mandate and associated tax penalty, about 14 million Americans will choose to go without health insurance.

7.  Absent a government mandate, many employers will stop offering health insurance to their employees.

Everyone in business knows step one in making a go/no go decision on any proposed project or product rollout is to validate the underlying assumptions. If even one of the assumptions is proven to be invalid, then the rest of the analysis is immediately called into question.

The project cannot be green lighted until all of the assumptions are deemed valid – either by addressing the flaw in the proposed project that invalidated an assumption or by proving the assumption, itself assumed the wrong input or outcome.

Below I’ve made a quick pass at whether the American Health Care Act should be “green or yellow lighted” – based on CBO assumptions.

Health Care Is an Entitlement

Let’s give the Democrats their due. Regardless of its flaws, the Affordable Care Act of 2009 firmly established health care as an entitlement due every American.

Other entitlement programs – i.e. veterans’ benefits, government pensions, Social Security and Medicare all require some prior contribution by the individual beneficiary. The beneficiary is said to have “paid into the system”– before receiving a specific and defined benefit.

For example, in Social Security there is a legally defined, published maximum benefit paid monthly regardless of how many additional dollars the recipient may have (or is) paying in Social Security taxes.

Payroll taxes (Medicare, Social Security etc.) deducted from your wages are deposited into a trust fund to be used to pay your benefits in retirement. Congress considers these benefits to be “earned”.

Contrast the new health care entitlement. It is paid for entirely by current income tax payers, in addition to taxes paid for their own future Social Security and Medicare benefit (or taxes on these benefits), and by future tax payers (borrowing). Borrowing that is moving the nation ever closer to the “fiscal cliff”.

There is no dedicated new funding source to pay for this new entitlement.

The taxes – now suggested for repeal by the GOP bill – are a mirage. They “move the chairs around on the deck of the Titanic”. The tax paid in column A is credited back in column B or passed on in higher health insurance premiums. There’s no new money except borrowed money!

Show Us the Entitlement Money

Republicans in the House of Representatives need to affirm healthcare is an entitlement and then develop a new funding source to pay for it. They are, after all, the “party of fiscal responsibility. Or, they’d like to have us believe they are?

The GOP (Study Group) should recognize that voters’ theoretical – i.e. gut reaction – to the idea of “government controlled health care” (2010) and their opposite reaction to getting a new health care “benefit”(2012) are both rational.

Voters are afraid of government mandates but will punish anyone who tries to take away a benefit bestow by those mandates once they’ve experienced it.

In 2016 voters supported “repealing” the higher cost of Obamacare era insurance premiums, co-pays and deductibles. They did not vote to give back the additional benefits received from Obamacare!

Accepting that a new entitlement exists does not mean the entitlement cannot be changed. The fact is that there are too many mandates, rules, and required benefits under the current law.

But any change made must demonstrate that is a fairer, better deal for a majority of Americans. Most Americans must be able to see and feel – experience – that the change is a better deal and be willing to pay for it, directly, or it is not going to work in practice.

Health Care Eco-System is Static

The CBO analysis completely misses the most compelling problem. Their analysis assumes the current structure is here to stay and that all reforms will be made through and not to the existing health care delivery model.

That assumption is incorrect.

The cost of health care services, drugs, appliances and anything else associated with the delivery of health care in America today must be changed – lest it bankrupt the nation.

The government is consumed by the question: How to pay for insurance premiums covering the unaffordable existing health care model?

At the same time, the American private sector (the consumer) is already experimenting with new models – more efficient and less costly.

Twenty of the nation’s biggest employers are banding together to create the Health Transformation Alliance aimed at using modern technology to control the rising cost of employee health care benefits. These employers, including American Express, Verizon and IBM (Watson) all understand the power of information to spearhead innovation.

These major employers are making an investment in reform because they remain committed to maintaining health insurance as a necessary employee benefit – calling into question, as well, the CBO’s 7th assumption.

These two CBO assumptions are incorrect. That means the 10 year projected cost estimate is reduced to pure conjecture.

14 Million More Uninsured in 2020

Not even the CBO “believes” this assumption.

Instead, they argue that an expanded range of choices in insurance products available to younger Americans – after the expiration of government mandates – will actually attract more young and healthy Americans to the non-group insurance market after 2020. This will positively impact the ratio of younger/to older Americans involved in the market place.

CBO projects a 10 percent reduction in overall insurance premiums as a result.

But – and here I agree with the CBO – the American Health Care Act – needs to be improved for older Americans still too young to qualify for Medicare.

These are people whose income exceeds the ridiculously low federal poverty guidelines – making them ineligible for Medicaid – who cannot afford health insurance premiums of $12,000/yr or more – that are only slightly reduced through $4000 “tax credits”.

Some of these people are, also, sicker and more expensive to care for.

A Roadmap for Dialogue

To their credit, the CBO has done an extraordinary job of laying out the challenges not just to the current House AHCA proposal but to the underlying problem of health care delivery costs, as well.

How much better off would the nation be if Congress – both Republicans and Democrats – were to embrace the cost estimate as a starting point?

“What-if” the ACHA were viewed as a bi-partisan starting point from which our health care eco-system is encouraged to evolve?

  • “What-if” Medicaid could be reformed and modernized into an attractive, affordable option for some middle-aged, middle income Americans as well as those too poor to pay health care?
  • “What-if” members of Congress were to work with all the stakeholders (from the President to the smallest tomato grower) to examine, question and rethink each CBO assumption?
  • “What-if” Congress started a discussion that engages provider, payer and patient in a singular effort to achieve better quality and lower cost health care for all – i.e. those who must rely on the health care entitlement and those who must pay for it?

But, as the CBO report cautions, it’s not possible to put such far-reaching improvements into place by 2020 as the AHCA requires.

Congress must learn from its past mistakes. Reforming the healthcare entitlement must be both bi-partisan and implemented over a 10 year time horizon that allows for intermittent adjustments as circumstances require.

Photo at US Capitol by Author — March 2,2017

Here’s What GOP American Care Act is not — Affordable

“If you want your legislation to last, it has to be bi-partisan,” — Ron Johnson, Republican Senator from Wisconsin, told the No Labels Problem Solvers Conference in Arlington, Virginia, on March 1.

He illustrated his observation, echoed the next day by my own Congress member, Anna Eshoo (Democrat – California), by pointing to Obamacare and Dodd-Frank. Both were rammed through Congress without a single Republican vote and are now targets of a Republican majority in Congress. Sadly, it appears the House Republicans have not learned the lesson.

Every comment made by House GOP leadership, the White House, and Republican members of the Senate point to a decision to ram the Budget Reconciliation Legislative Recommendations Relating to Repeal and Replace of the Patient Protection and Affordable Care Act through Congress on a party-line vote.

Once again, the victory will be pyloric and short-lived.

Healthcare is 20 percent of the United States economy. It impacts each and every American. It’s a huge problem and it can only be solved through a bi-partisan debate in full view of the American people.

Obamacare Impacts 330 Million Americans

Right after the conference, I shared a lunch table in the Longworth Congressional Office Building cafeteria with a couple from Mississippi.

Just as it does in almost every conversation in the Capitol, healthcare costs came up as we were just sharing our experiences from meeting with our representatives.

Owners of a small business, the Smiths described the difficulty they have in providing health insurance to their employees. The individual monthly premium is $400 a month – split 50/50 between the employee and the employer. “It’s the most we can do to pay half the cost.”

The median income in Mississippi is about $37,000/year – meaning a family of four participating in employer-based health insurance is paying 17 percent of their pre-tax income for health insurance. The policy has very high deductibles. In a word it’s “unaffordable”!

An average family of four in Mississippi is only a few dollars above the federal poverty line. But if their employer offers health insurance, they are not eligible to enroll in Obamacare – where the same monthly premium would be heavily subsidized.

Friday, standing, jet-lagged at my regular grocery store I was chatting with the man standing behind me in line. I said I’d been in Washington and the conversation, inevitably, turned to healthcare. He said he pays $1000 a month to cover his healthy family of four on an employer-based plan.

Before the Obamacare mandated changes in his coverage, he complained, he always had an annual preventive physical. Now, he has to pay $40 for the initial visit, $40 dollars for each of the routine tests and $40 for the follow-up visit. He concluded his prevent care is too expensive when prioritize against co-pays for his children. He figures he will go to the doctor when he gets “really” sick.

Nothing in the newly released GOP plan addresses either of the problems which these accidental meetings illustrate.

  • It does nothing to reduce the cost of health insurance because it does nothing to change the underlying healthcare cost crisis.
  • It does nothing to reduce the employer-based premium increases triggered by Centers of Medicare and Medicaid (CMS) Obamacare mandates.

Healthcare is an Entitlement

The Republicans’ most conservative members are still resisting reality. They claim that they must repeal Obamacare because the country cannot “afford another entitlement”.

Get over it.

  • Supreme Court ruled there is a universal right to care for all people at the emergency room door.
  • Once the government provides a benefit to some portion of the people – it cannot be taken away – only expanded in the name of equity.

But the conservative wing of the Republican caucus is partially right: The USA cannot afford another entitlement that is not paid for before and after it is granted.

Rather than repeating the mistake the Democrats made when they enacted Obamacare on a party-line vote the Republicans should take the time necessary to craft a bill that clearly addresses the coverage issues and is paid for.

A Down Payment on Reform

Paul Ryan must have been joking when he said “every American should read the bill”. Take a look here.

I read it but I didn’t understand all of it – just like most members of Congress!

Speaker Ryan surely recognizes the importance of slowing down the process of moving the proposed legislation to give his team a chance to garner at least some bi-partisan support for the plan.

That begins with the Congressional Budget Office (CBO) “scoring the bill”. How many people will get coverage under the American Health Care Act (AHCA) at what cost to the tax payer, and what’s the indirect impact be on employer-based insurance health insurance premiums?

CBO scores are notoriously inaccurate – over-estimating the benefits of legislation and under-estimating the costs. But they offer a starting point for a negotiation.

The current 120 page bill is nothing more than a “strawman” that will be modified by the long process of moving legislation into law.

In business the “strawman” plan is assumed to be a “starting point” — something that every member of the team can “take shots at” (debate and amend) in an effort to improve the proposal and, through participation, to encourage skeptics to “buy-in”.

For example, what-if Republicans (based on CBO estimates) offered to improve out-year Medicaid funding in exchange for Democrats supporting equal tax treatment for Americans with employer-based and private purchased health insurance?

No Democrats may come around to voting for the plan but, at least, the American people will see Ryan and his team willing to compromise to improve the bill.

Because of the limitations of the Congressional Budget Reconciliation process, the AHCA cannot address the underlying problem: the cost of health care. The reality is that no health insurance plan Congress generates can be affordable and effective without addressing the underlying problem.

To insure that Congress takes on the larger problem with urgency, the current bill must be amended to include concrete triggers guaranteeing healthcare cost containment legislation is written, investigated, debated and passed prior to the effective dates of AHCA.

For example Democrats get stronger drug pricing controls and the Republicans get malpractice reform.

Only by incorporating these guarantees in this first bill can we, the people, be assured the subsequent legislation will ever be introduced – let alone passed.

The battle ahead will be fierce — fiery.

Reimagineamerica will continue to observe, educate, clarify (if possible) and prepare each of you to be an active advocate in the battles to come.

Photo Credit: the author’s iPhone with thanks to MSNBC live broadcast

What Americans Don’t Want to Hear About Healthcare

I decided against going to a Healthcare Town Hall Meeting with a local Congressman because I knew the outcome before the gavel went down.

There will be a lot of speculative hysteria surrounding potential changes to Obamacare benefits or changes to Medicare.

Let’s relax. Entitlements once granted never go away – they take on a life of their own.

What attendees won’t be told is that Obamacare is collapsing under its own weight – insurers are fleeing in droves unable to sustain the coverage losses they’ve experienced over the last few years.

Nor will they hear the Congressional Budget Office prediction; Medicare Hospital Trust Fund will be bankrupt in 2020 and the larger Medicare Provider Trust Fund will be exhausted in 2028.

But Obamacare and Medicare are not the problem – they are just a symptom.

Medical Bills Are Killing Us

In a seminal piece written for Time Magazine in the summer of 2013 Steven Brill laid out the problem in detail.

Medicine in 21st century America is big business. It’s very profitable for employees and stockholders.

The United States of America spends more on healthcare than the next 10 biggest spenders combined! Based on exhaustive comparative studies of Adult Welling Being the additional $650 billion a year does not result in better outcomes for Americans.

McKinsey Consulting studies have shown that the average private healthcare employer has a net operating margin (profit) of 16.2 percent compared to ExxonMobil’s 8.2 percent.

Spending for healthcare services, drugs, devices and facilities equals 20 percent of total USA Gross Domestic Product (GDP) or about $4 TRILLION a year – every year.

By comparison, the American Association of Civil Engineers estimates the total national backlog of needed infrastructure (airports, trains, highways, energy grids, etc.) will equal only $3 trillion by 2020.

Healthcare Spending is Out of Control

We see the headlines – EPIPEN price increases from $57 to $600 per prescription in a decade.

New York is the financial capital of the world – right? Wrong, of the 18 largest employers in New York four are banks and eight are hospitals.

We have heard for years that employer based (and private) insurer payments to doctors, laboratories and hospitals needed to be increased to cover the losses health care providers experience in serving Medicare patients, Medicaid patients and the uninsured.

If Medicare is “unprofitable” why does every major for-profit healthcare system aggressively pursue those patients? It’s simple. The Medicare payment formula includes a guaranteed percentage of profit!

It stands to reason, then, that if there are 23 million more insured patients the providers’ need to recover “uncompensated care” costs has decreased but medical spending continues to increase dramatically.

While healthcare is something we all need; we’ve come to expect someone else to pay for. On average, the patient pays only about 12 percent of the total bill.

That’s made us insensitive to prices and providers greedier. The escalating greed is reflected in the skyrocketing price of health insurance.

Medicare Cost Data for All

If we want good healthcare coverage with reasonable insurance premiums, Americans must become active consumers. We must advocate for a system without hidden costs.

If we want the impending debate in Congress to conclude with a better outcome than just “Obamacare2.0”, we, the people, are going to have to hold our representatives’ feet to the fire!

We must insist they begin with a comprehensive investigation of the underlying costs of healthcare.

Rather than focusing on perpetuating yet another “entitlement”, Congress’s objective must be to reduce the cost of care for all Americans – not just those who receive government subsidized care.

Brill argues that Medicare can compute the real (true) cost of delivering each health care benefit they cover. They reimburse providers based on cost of service delivery in the provider’s region in the country – i.e. cost of a day in hospital costs more in California than in Idaho.

Then Medicare applies a percentage of profit authorized by Congress to the provider. Cost plus profit is the contracted price Medicare pays to providers – no negotiation.

But Medicare is prohibited by Congress from sharing that cost data.

As consumers we have to start to shop for the best deal even if someone else is going to pay the bill!

As voters we must insist Congress allow Medicare to share their cost data — putting other insurers in a stronger negotiating posture with healthcare providers. The result would be a better deal for both patient and insurance carriers.

Manage Costs or Ration Care

As a nation, we cannot continue to fund a healthcare system that has no self-discipline. To do so would pass an immoral debt onto several generations of Americans not yet born.

If we are going to make the promise universal health care (not single payer health care) an affordable reality for all we must be willing to make changes in the ways we consume and pay for healthcare – that includes Medicare patients.

  • A redefinition of what health insurance is and what it pays for.
  • A reorganization of how we deliver healthcare to increase efficiency and reduce costs.
  • Rapid adoption of technology to both better determine diagnosis and treatment and to manage chronic disease
  • Greater transparency so that patients can make smarter decisions about where and how they will receive necessary care.
  • Greater transparency around the relationship of drug development costs and drug prices
  • Medical malpractice tort reform.
  • Identification of realistic funding sources for health insurance subsidies, Medicaid, Medicare and veterans’ health care.

The good news is there is a great marketplace of ideas about how to tackle all of these issues.

The bad news is that all of the good ideas are being drowned out by the political rancor on both sides of the aisles of Congress and the army of special interest lobbyists who feed that rancor.

Over the next few weeks, I’ll explore each of these opportunities with you – so that we can help our fellow citizens understand both their possibilities and possible perils.

It is up to us to engage our elected representatives in “fixing healthcare for all”, not fighting to score political points for the 2018 mid-terms.

Will Trump Administration End before February Does?

Melania Trump’s decision to remain in New York until late spring may turn out to be prescient. Donald Trump may be joining her in New York sooner than any of us thought possible.

Every new administration makes a certain number of “rookie” mistakes in the first few weeks in the White House, but the Trump Administration’s errors in judgment and substance have no historic precedent.

This administration has become a Saturday Night Live skit – rendering the television show’s weekly realistic rather than comedic recaps – all-the-more frightening.

Many were alarmed by the chaos of the first two weeks that included unnecessarily inflaming our relationships with Mexico, Canada, China and NATO. http://www.reimagineamerica.org/good-grief-president-trump/

Twitter and other attacks on the judiciary were rebuked by the Administration’s own Supreme Court nominee.

On the Sunday news shows, junior adviser Steven Miller — made a maniacal claim that President Trump’s national security powers “will not be questioned” instead of apologizing for the botched rollout the President’s refugee pause. His performance was chilling rather than reassuring.

National Security Adviser – General Michael Flynn — deliberately lied to the sitting Vice President of the United States but was only forced to submit his resignation three weeks later after government officials “leaked” the facts to the Washington Post.

White House Chaos

It is axiomatic in our history that military leaders do not speak in public about their civilian leadership.

But only days after a meeting with President Trump, General Tony Thomas, the head of Special Operations Command, put his job on the line saying at a military conference “our government continues to be in unbelievable turmoil” while the nation is at war.

The general speaks for many in government and out.

It is apparent to anyone who has any management experience in either business or government that this White House lacks all the requisites for success – a strategy that the nation “buys into”, an experienced, competent, honest — and in this case unquestionably patriotic — leadership team and a disciplined management process.

Reorganize or Resign By February 28

Speaker Ryan has invited President Trump to address a joint session of Congress on the evening of February 28,2017.

If the President cannot turn White House disorder and disarray into order and calm plus resolve the lingering questions about both his and his aides competence and loyalty to the Constitution – his speech to Congress should be cancelled.

Instead he should resign.

In order to avoid a constitutional crisis the President needs to take a deep breath and start over again. He has to have the humility to ask for advice and help.

He has to have the good sense to follow the advice – especially when it comes from multiple sources within his inner circle, his administration, his political party, and from his constituents.

If I were Chief of Staff today, I’d give the President six pieces of advice:

  1. Lose the Twitter Account! Public policy cannot be conducted by stream-of-conscience.
  2. Develop a “thicker skin”. Whatever the issue, it’s really not about you, it’s about the American people
  3. Build on your strengths and minimize your weaknesses. Be a CEO — delegate operational management to (COO)Mike Pence retaining responsibility for setting the strategy, making “big deals, and messaging.
  4. Engage the “Presidents’ Club”. Ask each of the five living ex-Presidents for their candid advice and their help in finding the experienced people needed to “shore-up” the administration.
  5. Develop positive working relationships with leadership of both parties in Congress.
  6. ABOVE ALL, come completely clean today about any relationships with Russia or Russian interests that you, your family, your campaign team or anyone remotely associated with your government has now or has ever had.

Breach of Trust

If you are to govern the United States and to have the respect of world leaders – friend and foe, alike – you must have the absolute trust of the national security and intelligence communities and the American people.

Leaks over the past few days from various intelligence sources to respected news media outlets are nothing short of alarming. The leakers claim they are withholding information for fear that sensitive intelligence could be compromised. https://www.wsj.com/articles/spies-keep-intelligence-from-donald-trump-1487209351?mod=djemalertPolitics

Congress and the FBI must have immediate access to whatever people and documents are required to conduct public hearings that will allay the concerns of all Americans about any possible connections to Russian intelligence organizations and personnel by any member of your campaign team, the Trump Corporation, the Trump Administration or Trump family members.

This includes release of all Trump tax returns!

With all due respect, Mr. President, if you are not willing to cooperate completely to resolve all possible conflicts that could compromise the Trump Administration in dealing with the Russian government – at noon on February 28,2017, you should board the Trump Inc. plane and return to your private life in New York.

We’ll be just fine without you!

Good Grief President Trump!!

Since your Inauguration barely a week ago – President Trump – you have managed to upset important allies and trading partners, blindsided your national security team, frightened legal immigrants, and angered your own GOP majority in the Congress.

The majority of voters in over 30 states voted for you because they believed you would create jobs — not nationwide and global chaos!

I am troubled by both the pace of activity and the lack of strategic direction in your early actions. What’s the goal?

I was troubled enough to throw down $12.95 for a Kindle copy of your oft referenced “Art of the Deal” to see if I could make sense of the chaos.

Any Art in Your Executive Orders?

So far I’ve learned that Trump, the builder, sees himself as an “idea machine”; an entrepreneur who leaves the details to other people. He dislikes structure. He sometimes enjoys playing the “bad cop”.

His “bad cop” has stirred more global protest in just one week than the United States has seen since the end of the Vietnam War – over 40 years ago.

For a year and half you talked about all the “good deals” you were going to make for America.

It is time to stop stirring up the pot and start delivering DEALS that will keep Americans safe and prosperous at home and abroad.

Those are deals that heal the divisions within the United States as well as between the United States and its allies and “friendenemies” around the world.

Confrontation Does Not Lead to Good Deals

Good deals can be defined as deals where both sides in a negotiation get something they need by giving up something they want.

In my world we call it “finding the win/win”.

In the senior ranks of management consulting firms, my performance was judged on the ability to develop new business and manage executive relationships (i.e. new clients and new projects with existing clients). Execution – getting results – was always the foundation of success but revenue and relationships were the bottom-line.

Building a good deal does not start with a confrontation – as have so many of your actions in the last 10 days.

The art of building relationships and negotiating good deals starts with being a good listener and empathizer – not a frenetic actor!

Robert Gates, the highly respected former CIA Chief and Defense Secretary to both Presidents Bush and Obama, did not support you before the election. But – a patriot – he met with you at Trump Tower after the election.

Gates has generously described you as “thoughtful” and “open to advice”.

I found that description comforting – those are absolutely necessary characteristics in the President of the United States.

But, if you are a good listener, then the next two questions should raise alarm: Who have you asked for advice and – more importantly — who should you ask for advice as the “leader of the free world”?

Why Experience Matters

Based on the public evidence, you appear to be listening less to the experienced generals you’ve appointed to lead your national security team and more to the under skilled sycophants in the White House.

Is proximity the only source of power in your White House?

Press reports and the actions of General Kelly suggest that Homeland Security was not consulted before you issued new travel and immigration restrictions on Muslims from seven countries already under strict review.

Who persuaded you that announcing Mexico would pay for the southern border wall “one way or another” was the way to open negotiations or improve our relationship with Mexico?

Humiliating the Mexican president publicly instead of meeting with him privately this week in Washington makes NO sense!

Your actions and words will make it more difficult from Rex Tillerson (when he is confirmed) and General Kelly to negotiate a border security deal that serves the interests of both Mexico and the United States:

  • Stop illegal immigration transiting Mexico into the United States whether Mexican, Central American, Chinese or would-be terrorists and
  • Stop the drug smuggling that has cost countless lives on both sides of the border.

The reaction by the Mexican people and their political establishment to those words will, also, complicate renegotiation of NAFTA.

Nothing was gained. You can’t even check-off a campaign promise kept.

Start Firing the Right People

This week, President Trump, you need to restart your administration. The success of your Presidency hangs in the balance.

Bold action is required.

You’ve got to eliminate the people who have proven their advice is bad advice.

Time to tell physically and intellectually over-inflated Steven Bannon and the self-aggrandizing political errand boy Stephen Miller “you’re fired”.

Next ask the “4 Stars” what to do with “3 Star” General Michael Flynn. Then follow their advice!

Good luck – the nation is counting on you not to screw this up beyond repair in just two weeks.

Trump Inc. Must Be Walled-off

Donald Trump’s children serving on the Presidential Transition Team is inappropriate.

Their loyalty to the country is not in question. But they can be accused of undue influence or

Donald Trump accused Hillary Clinton — during the presidential debates – of a corrupt relationship between her role as Secretary of State and foreign contributions to the Clinton Foundation.

As long as the Trump children sit in on meetings with potential cabinet picks, leaders of major American business sectors and the foreign heads of state – the same charges will be made immediately and often against the Trumps.

Can’t Drain the Swamp while Distracted by Scandal

President-elect Trump cannot keep his campaign promise to “drain the swamp”, to “change Washington”, to be more citizen-centric and “end lobbyist corruption” if he, himself, and his family are constantly embroiled in scandals relating to the appearance that they are profiting from the Presidency.

Some have called for the President-elect to “liquidate all his assets” before the Inauguration.

But that is not reasonable. Selling off properties – each worth billions — cannot be accomplished during the 120 day or so transition from private citizen to President. It would take years to unwind the business and there would be constant claims of impropriety in the process.

But Donald Trump cannot become President of the United States until he completely walls himself off from Trump Inc..

It’s Time to Build a Different Type of Wall

This wall wouldn’t be built of steel or barbed wire, but built of brain-power held together by a strong mortar of publicly accountable policy:

The three sections of fencing are:

1. A CEO who can say “no” to the Trumps and others in the company’s operational management when there is any possibility, any hint of impropriety

2. A firm policy against any foreign government entity staying at or using any Trump property for any purpose.

3. A ban against either the acquisition of new properties or the divestment of existing properties during the Trump Presidency.

President Trump Needs an Umpire

The new CEO at Trump Inc. would not “run the company” – the Trump children have already demonstrated their capabilities in operational management.

There’s a team of hundreds of lawyers and accountants at Trump Tower and in the White House to make sure that every law – or nuance of law is followed.

The CEO/Umpire would protect the Trumps from themselves with the authority to stop any policy, practice or transaction that he/she deemed either diplomatically, economically or politically unwise or improper.

The CEO must report the basic details of revenue, profit and loss quarterly to the American people in a manner that honors the privacy of the Trumps and the public’s “right to know”. The report would be modeled on a publicly traded corporation’s quarterly conference call with the financial analysts who follow their market segment.

In other words, the CEO/Umpire’s job would be to keep Trump Inc. boring and out of the headlines.

The first people who jump to mind are Mitt Romney, Jon Huntsmen, and William Weld — all successful businessmen, later successful governors, all Republicans and none of them Trump supporters during the election.

Even better, how about a Democrat – for example Wall Street Democrat Steven Rattner who guided the delicate relationship between the Obama Administration and the American auto industry during the “Bailout”? Another possibility might be William Daley, former Obama White House Chief of Staff, a past JP Morgan executive and current board member at Boeing?

To succeed the person must have the confidence of the Trump family AND the Congress. But it cannot be someone who has an established business relationship with Donald Trump.

Good Public Policy Must “Trump” Trump Inc.

Once the “brick” is in place, the mortar of policy can quickly be spread to solidify the wall.

Trump Inc. must have a firm policy to “refuse service” to any foreign government entity, foreign diplomat or relative of foreign diplomat, member of any royal family, or foreign business person with business before the U.S. government. No exceptions, no excuses.

The State Department would conduct routine audits to insure the policy is followed to the letter!

The President-elect has already said, during his presidency, Trump Inc. will not enter into any new “deals” to build or buy additional properties. That’s a promise that must be adhered to.

But, equally important, no property can be divested during this same time period.

There can never be an appearance that the President’s family “dumped” a property in anticipation of some domestic or foreign cataclysm – i.e. based on some “insider” knowledge.

If an unfriendly government takes action against a Trump property – including confiscation – no action can be taken by the administration without the specific authorization of Congress – i.e. unless there is a larger national security interest at stake.

Public Accountability

Millions of people voted for Trump because they saw him as a successful businessman – a wheeler and dealer who can get things done.

But to get things done for the American workers and American business – President Trump must be personally and financially above reproach.

He must set an example of good government that may encourage other successful business people to enter the political arena for the right reasons.

He must avoid giving Democrats in Congress an opportunity to make charges of corruption and bottle up the new President’s agenda in round after round of investigations, hearings, charges and counter charge instead of forging a new national consensus to strengthen our economy and our national security.

Trump Inc.’s transparency and public accountability will determine whether the next four years see four percent annual GDP growth or four years of scandalous headlines and increasing national debt and discontent.

Modernize the Electoral College and Revitalize Democracy

I am officially sick of the media drumbeat for dumping the Electoral College after Hillary Clinton’s loss.

A one-time divergence between the popular and Electoral College votes of a couple million is not a reason to dump an institution that has insured the peaceful transfer of presidential power for more than two centuries. http://www.reimagineamerica.org/2016-electoral-college-worked-as-designed/

The actual difference turns out to be a 2 percent advantage for Mrs. Clinton nationwide in a total of 126 million votes cast — concentrated in Southern California.

Coincidentally that’s the margin of victory Mr. Trump enjoyed in the 13 so-called “battleground” states.

These facts do not make a compelling case against the continuing utility of the Electoral College.

Dragging Electoral College into 21st Century

Amending the Constitution to eliminate the Electoral College won’t happen. It is obvious that the small states in the country’s center would not ratify any proposed constitution amendment.

Modernization must retain the original rhythm written into the Constitution –checks and balances

Happily there’s a lot of room for improvement – changes — the large and small states can agree to.

First, we must minimize the ability of state legislatures to interfere with the voters’ freedom to directly select the electors from their state.

Second, we can increase voter participation by showing each voter how their individual vote matters.

Third, a revitalized system may encourage better candidates to run by re-engaging the center of the American body politic – which is turned off by expensive media campaigns dominated by negative advertising and fear mongering.

Let’s Have a 50 State Election

The Electoral College is made up of 538 members:

Each state is awarded a number of electors equal to the number of their House members. Based on the most recent national census, each House member represents 720,000 people – or less.

Additionally, each state is awarded the same two additional electors.

The total electors representing the 50 states total 535. The remaining three electors represent the District of Columbia.

Currently, the states’ electors are “block-granted” to the candidate who wins the statewide popular vote in that state. The votes cast in one or two large urban areas in the state drowning all other voters in the state. This tends to decrease the incentive of suburban or rural voters to go to the polls.

What if –

State officials apportioned their state’s Electoral College votes – one elector to each House District in that state. The elector would be awarded to the candidate who won the most votes in that House District. The last two electors would be awarded to the winner of the statewide popular vote.

For example: California would apportion our 55 electoral votes 41D/14R based on the votes cast in 2016.

  • 39 urban votes to the Democratic candidate
  • 14 suburban/rural votes to the Republican candidate
  • 02 statewide Democratic majority popular vote

The Democratic candidate would need to make-up 14 votes from another state. Perhaps they would come from – predictably Republican – Texas (11 Democratic House Districts)?

One of the lessons learned from the 2016 election is that nothing is guaranteed. In Michigan at least one district re-elected their Democratic House member even though her district voted majority Trump in the Presidential race. Voters do “ticket split”.

Winning would require a 435 district campaign — the 21st century version of the Truman whistle stop campaign of 1948.

Like 1948, the 2016 election defied all polls and predictions for the same reason – President Truman and Donald Trump both “went over the heads” of the political and media elites with a direct appeal to voters.

The heart of America beats in what coastal elites deride as “flyover country” while rushing from one big donor meeting to another – New York to Los Angeles or San Francisco to Washington.

The “30 thousand foot candidate” should not be surprised when these states’ voters don’t embrace him/her.

Reaching the Voter through Retail Politics

The more suburban political culture in the United States depends less on Facebook and television and more on retail politics – the Jefferson Day or Lincoln Day dinner, the Town Hall meeting, etc..

The folks who attend these events are not big donors to the party – Hollywood movie stars or Wall Street bankers.

The people who attend these functions are middle class Americans who worked — all day before coming to the event –to earn the $100 it costs to buy a ticket.

The presidential candidates themselves – not their surrogates — would need to convince a lot of individual voters they care about the individual and not just the statistic –less black or white or Hispanic, male or female –more as a three dimensional human being with real dreams, fears, and possibilities.

To win the Presidency, a candidate would have to be a great retail politician with high energy as well as 21st century media skills. Relative youth would be a distinct advantage.

Policy positions and proposed solutions might change as a result of meeting the people they’d impact.

Better government could be one potential result of this modernization.

Leveling the Playing Field Will Increase Voter Participation

The Constitution places no limit on the number of Presidential candidates who can compete for Electoral Votes.

The limitations are imposed by the cost and infrastructure required to mount a campaign based on the current major media market, winner-take-all model.

The 50 State Electoral College Model could, over time, level the playing field for third party candidates who lack the $1 billion available to our current political duopoly.

Retail politics are less costly to conduct. Don’t need big hotels or stadiums or celebrity “opening acts” – just a Facebook post, a few Tweets and a corner Starbucks.

Reporters for local media will show up to cover the story free – “earned media” is just that – earned by action not paid for as advertising.

Citizens inspired by a handshake could grow into an army of volunteers to post on Facebook, share on Instagram, knock on doors, recruiting their friends and families.

Inspiration would lead to higher rates of voter participation – perhaps bringing back balance between the unofficial popular vote and the official Electoral College vote.

Photo Courtesy JeffersonheritageTrail.com

2016 Electoral College Worked as Designed

Ever since it became clear that President-Elect Trump had a commanding lead in the Electoral College (306 votes to 232 for Mrs. Clinton) the main stream media has been focused on the “growing Hillary Clinton advantage in the 2016 Presidential Election popular vote”.

Look a little deeper and it becomes clear the advantage is coming from entirely from Southern California where we are still counting ballots today.

Trump’s voter tally exceeds Mrs. Clinton’s in the 13 battleground states where the Electoral College was won and lost.

Why We Still Need the Electoral College

The Founding Fathers designed the Electoral College to assuage the fears of the smaller states that they would be reduced to serfdom by the big states – New York and Virginia at that time.

Without those assurances the US Constitution would never have been ratified by 9 of the original 13 states.

In the 2016 Election, the Electoral College worked exactly as it was designed.

It balanced the interests of the large coastal, consumer-driven cities — for example Los Angeles and New York — with the interests of the smaller, producer cities and rural farming and industrial populations — for example the Southern Appalachian Mountain region.

But the founders had a second purpose in fashioning the Electoral College: establishing an “institution” that would blunt an impulse toward “mob rule”.

Fact is – setting aside nearly a century of revisionist history — the Founding Fathers did not believe in universal suffrage. In the earliest days of the Republic not everyone could read or write – i.e. participate in the political debate.

Even Thomas Jefferson, the original Democrat, believed only a white man who owned property – i.e. a doctor/lawyer, a shop keeper or a farmer owning at least 5 acres — should be eligible to vote.

States Elect President

The Founding Fathers believed the job of electing a President was too important to be left to the people.

Both under the original Constitution and the 12th Amendment, that task was delegated to states – not the citizenry.

Popularly elected members of the state legislatures — the more respectable, reasonable men of substance and public repute – were given the responsibility to select electors to the Electoral College.

The practice of pledging an individual state’s Electoral College electors to a candidate based on a popular vote of that state’s citizens evolved as the nation matured. Literacy became common place and the right to vote expanded.

The various state legislatures passed laws that updated how their electors are chosen.

Each state, also, specifies whether the electors have any flexibility to cast their votes in any way other than as instructed by the popular vote of the people of that state.

The (aggregated national) people’s popular vote for President – still today – has no meaning under the Constitution – the states elect the President.

Subverting the Founders Intent

Disgruntled Democrats, along with Green Party Candidate Jill Stein, are attempting to use the Electoral College as a Constitutional Alamo – a fight to the death to deny Donald Trump the Presidency – whatever the consequences to Constitutional principles.

Since the polls closed on November 8th, disgruntled Democrats have tried to use Clinton’s lead in the popular vote as an argument to persuade and, in some cases harass, Trump Electors. They argue these electors should ignore their states’ voters and vote for Clinton when the Electoral College meets in December to formally elect the 45th President.

The argument they make is commonly called the National Voter Plan. It’s not a new proposal.

The argument in favor: The value of every individual vote should be the same in every state.

The counter argument: one state or one portion of one large state should not have greater weight than the votes of any other geography – is illustrated by Mrs. Clinton’s plurality coming entirely from Los Angeles County, California.

The counter argument gains strength when no candidate has a national majority (50 percent plus one vote).

If the National Voter Plan were ever enacted into law – the President would be the absolute choice of only the six large bi-coastal urban media markets including New York and Los Angeles – exactly the circumstance the Founding Fathers sought to avoid in crafting the Electoral College.

Room for Reform

The wide divergence between the popular and electoral votes — and the unseemly attempt the thwart the Electoral College — at the end of a bitter and divisive 2016 campaign underscores the urgent need to modernize the Electoral College.

We can agree at the outset, amending the Constitution to eliminate the Electoral College won’t happen. It is obvious that the small states would not support such an effort.

Reform must honor the original intent of the Founding Fathers – to insure a balance between large and small states is maintained.

Reform must block the National Voter Plan – it would legitimize the “mob” our Founders feared.

Reform begins with the question why did 90 million registered voters not go to the polls and vote?

  • Were they discouraged by the barrage of polls predicting a certain outcome?
  • Were they discouraged by the quality of the candidates and the polarizing campaign rhetoric they used?

More likely, no candidate asked for their vote in a persuasive manner?

No candidate offered them an affirmative case to vote for?

That is the point at which Electoral College reform must begin.