No Teenager Next Door Should Own a Gun

The children of Florida are demanding #NeverAgain.

Never may not be possible in a society awash with guns — but America can do much more to prevent school children from being murdered in their classrooms.

The students of Marjory Stoneham Douglas High School are showing us the way. Through articulate arguments and determination, they (and their parents and teachers) are turning their grief, fear and anger into action.

Florida politicians would be wise to heed their resolve and their promise to use their first vote to insure that “something changes”.

It’s not just Florida politicians who should take notice.

In 2020 3.9 million children born since the 1999 Columbine Massacre will vote in their first presidential election. These young people have grown up accustomed to “active shooter” drills in their schools. In the 13 years since Sandy Hook there have been 200 school shootings and 400 students have been killed.

 

Their fear is our shame. When our legislators took campaign contributions from the National Rifle Association (NRA) instead of passing reasonable gun safety legislation after Columbine, after Sandy Hook, after any one of 198 other school shootings – voters should have voted them out of office. But we didn’t.

In business when we see a pattern of adverse activity, we quickly work to identify the potential corrective action and implement them to alter the trajectory of the pattern.

For example, most of these child killers have a lot in common:

  • All of them exhibited signs of social alienation or mental illness
  • All of the school shootings were student on student violence
  • Most of them obtained their weapons legally
  • Many had parents who overcompensated — repeatedly – effectively covering-up and excusing for their child’s abnormal behavior
  • With few exceptions, they were able to pass a National Instant Criminal (Background) Check (NICS).

It’s time to implement sensible corrective action:

  1. Raise the National Gun Ownership Age to 21.

Science tells us that the adolescent brain is not fully formed – that impulse control is not yet mature. It makes zero sense to allow an adolescent who cannot buy a beer to buy a powerful semi-automatic gun and high capacity ammunition magazines. Congress should raise the national age limit for gun ownership to 21.

The lack of impulse control magnifies the normal angst teenagers experience as they evolve from childhood toward adulthood.

The lack of impulse control leads teenagers to sometimes treat one another cruelly. Bullying is not new, but bullying magnified hundreds, thousands of times through social media can have deadly consequences.

  1. Include Juvenile Mental Health Records in NICS

Pediatricians no longer believe that children who exhibit mental illness as early as during their toddler years will “grow out of the problem”– mental illness – ranging from Asperger Syndrome to bi-polar disorder (manic depressive) to attention deficit disorder and anxiety disorders.

While juvenile criminal records might appropriately be sealed in most states the same is not true of mental health records because those illnesses are likely to follow the child into adulthood.

It is not necessary to unseal those records to put a “flag” into NICS requiring further investigation for juvenile offenders and diagnosed mental illness.

Such a flag would not preclude gun ownership, but would require further investigation before granting the permit to purchase.

  1. Authorities Must Follow-up On Every Credible Threat Reported

The FBI was warned twice about Nikolaz Cruz and did not follow-up. The FBI has committed to improving their threat evaluation process.

Many states have laws that require the temporary surrender of fire arms in cases of spousal abuse or if law enforcement deems the gun owner to be a danger to themselves or others. These are called “Red Flag Laws”.

Florida does not have such a law. Even if the Miami Field Office of the FBI had contacted Nikolaz Cruz – it is not likely they could have disarmed him.

  1. Implement Strict Training and Licensing Requirements

A gun is a powerful weapon. A life can be transformed or lost in an instance – deliberately or by accident. No one should be allowed to own or use such an instrument without rigorous training and evaluation.

No state would issue a driver’s license to an adolescent (or adult) who cannot demonstrate the ability to drive a car – cars can (and do) kill.

Why is it different for guns?

An examiner testing an applicant’s ability to use a gun safely might, also, be able to pick-up signs of a potential risk.

A gun licensing program would not be a guarantee against gun violence but it might reduce the number and frequency of shootings.

None of these measures would infringe on the Second Amendment right to bear arms.

March in Solidarity #Neveragain

Strengthening the NICS background check system and, even licensing firearms, wouldn’t guarantee the elimination of gun violence in our schools, churches, concerts, or airports, but tighter controls might save lives?

A complex, urban society needs realistic checks and balances between personal liberty and the common good.

That’s why all of us need to mark March 24 on our calendars.

It’s time to MARCH in solidarity with the students of Parkland, Florida, our own children and in memory of the 400 school children killed over the last decade.

Graphic courtesy of (WKYT TV) Nicholasville, Kt.

Perverting the Purpose of Congressional Oversight

Early in my son’s elementary school career I routinely got notes from his teachers asking me to stop by the following morning.

“What happened,” I would ask him? I’d listen to his story.

The next morning I would talk with the teacher.

Only after I’d heard both sides, I’d make up my own mind about what actually happened and how I should react.

You will find an analogy in the charges and counter-charges between the Democrats and Republicans on the House Intelligence Committee over the FBI’s surveillance of Carter Page.

I am convinced that the truth lies in the middle – between what I call “dueling memos”.

The specifics of the Carter Page FISA warrant and the two memos that claim to interpret that surveillance are of less consequence. The incontrovertible fact is that both Democrats and Republicans on the Committee have abused Congress’s important oversight role for transparently political motives.

The committee’s objective should have been to determine the facts on a bi-partisan basis and in co-operation with Department of Justice (DOJ) and FBI.

If they concluded the foreign intelligence surveillance process permitted an abuse of Mr. Page’s constitutional rights, they should have worked with DOJ and the FBI to craft a legislative remedy to prevent similar future abuse and then brought an amendment to the Foreign Intelligence Surveillance Act (FISA) during the recent Patriot Act renewal process. https://www.cnn.com/2018/01/18/politics/fisa-reauthorization-senate-vote/index.html

Putting the Brakes on Intelligence Activities

The Foreign Intelligence Surveillance Act (FISA) was passed in 1978 — in the wake of disturbing revelations of US intelligence abuses leaked to the press associated with the Vietnam War and the Watergate scandal – writ large.

In testimony before a 1975 committee chaired by Idaho Senator Frank Church (D), Americans were shocked to learn the US Army had spied on Americans in America.

Further, the Church Committee and other Senate committees – including the Watergate investigation — uncovered CIA domestic operations against anti-Vietnam War protesters. These activities violated several US laws.

More alarming, press leaks and Congressional investigation found the 1961 Bay of Pigs fiasco was not the only CIA conducted attempted coup against a foreign government or assassination of foreign leaders.

It was clear to Congress much closer oversight over the national intelligence community was urgently needed. Intelligence oversight that strictly balances national security with protecting the rights of individual Americans began with the first Permanent Senate Select Committee on Intelligence in 1976 leading to the 1978 legislation.

To protect the national security, the legislation established a system of permanent congressional oversight of each individual intelligence agency in the US government and over any co-operation or co-ordination between the separate intelligence agencies.

To protect the rights of individual Americans who might come under scrutiny from one or more of these intelligence agencies, Congress established the Federal Intelligence Surveillance Court system.

CLICK HERE FOR FISA COURT PRIMER

The nature of intelligence assumes that most of the oversight would be conducted “behind closed doors” by members of Congress and others with appropriate security clearances and safe guards.

As citizens, we should be able to trust the committee members are acting in our (collective) best interests.

Oversight is intended to continuously improve the performance of our intelligence agencies:

  • Insure sufficient resources (budget) are allocated to each agency’s mission
  • Insure each agency is fully compliant with Constitutional and lawful restrictions
  • Insure investigation of any potential overreach or unlawful conduct by any agency personnel is dealt with through civil service administrative practices
  • Identify any opportunities for improved outcomes for the national security

Dueling Memos

In my career, I have taken many corporate management teams through detailed post-mortems. These exercises are conducted after situations that have perceived to be extraordinarily successful of to have failed.

The objective is not to find fault or award promotions.

The objective is to find facts and to use those facts to develop corrective actions driven by those facts.

The facts of the FISA warrant to monitor the electronic communications of Carter Page should have been investigated and adjudicated by the House Intelligence Committee exactly in the manner suggested by FBI Director Christopher Wray. He asked for, and was refused, an opportunity to provide a briefing to clarify why and what triggered the FBI interest in Mr. Page.

In closed door testimony a flow chart of events should have been examined — each step in the flow chart annotated with the factual evidence and surrounding circumstances.

Those circumstances would, obviously, include any discipline meted out to FBI officers determined to have violated policy or law.

The FBI Director would, also, have pointed to any steps in the process requiring procedural or legal improvement.

Whether or not the new FBI Director and the oversight committee found process or legal improvements were required:

  • there’d have been no need for disclosure of national security secrets
  • no loss of public confidence in the FBI and
  • no personal platform for either Devin Nunes (R) or Adam Schiff(D) individual political ambitions

Most importantly, the American people would be reassured that all the elected representatives and the government agencies were working effectively protect national security and individual privacy — simultaneously.

FISA PRIMER

The media frequently mentions the “FISA Courts” while reporting on National Security Agency (NSA), FBI and other intelligence activities that may involve US citizens.

Below is a brief description of the court’s purpose and how it works.

FISA Courts

The Federal Intelligence Surveillance Courts are commonly referred to as FISA Courts – because they were created by the FISA legislation.

The judges of the FISA Court hear and rule on requests for warrants to allow domestic national law enforcement and counter-intelligence agencies to conduct electronic surveillance of a US citizen who they claim could be or could become an agent of a foreign government or non-state actors (terrorists).

FISA Court judges are chosen by the Chief Justice of the Supreme Court from the various US District Courts around the nation and serve a 7 year term before returning to US District Court responsibilities.

Under the law, the judges are bound by law to apply a much higher standard than a normal criminal surveillance warrant. Criminal courts require a reasonable investigative suspicion to prove the need for the warrant. The FISA Court judge must see concrete evidence that a surveillance warrant against an individual is justified.

To further protect the rights of the individual suspect, FISA warrants expire after 90 days. If the FBI or the National Security Agency (NSA) applies for a renewal of a surveillance warrant, they must show the judge that the expiring warrant got results – i.e. added new evidence to the initial affidavit to the court.

FISA Abuses

FISA judges are not perfect people, either. It is possible that they make mistakes.

There have been a number of instances in which Congress has stepped in to place limits on the FISA Courts.

In 2002 and 2005 when the Bush Administration went beyond the letter of the law in pursuing terror suspects Congress stepped in limit NSA surveillance activities.

Similarly, in 2011 Congress felt that the Obama Administration had abused its power when it secretly authorized the National Security Agency to conduct bulk searches of the “meta-data” of US citizen’s phone records.

While partisan members of the Intelligence Committees expressed concern over the “excesses” of these previous administrations, the investigation of the alleged abuse and the drafting of corrective legislation was performed thoughtfully and in a bi-partisan manner committed to properly protecting the privacy of American citizens – while, also, protecting the national security.

 

Time for a Four Star Cyber General

Cyber is everywhere in our lives today and it is our greatest strategic weakness.

In 2015, the FBI and Department of Homeland Security determined Chinese sources, likely the Chinese Army, hacked the federal government’s Office of Personnel Management stealing 21.5 million applications for security clearances. Not only were vital statistics like social security number and credit history vacuumed up but, also, family relationships and social networks. Not even such a blatant and dangerous data security breach spurred the government beyond holding a couple of face saving Congressional hearings. —

Wikileaks disclosed information hacked from the CIA that exposed our ability to track terrorists through their cell phones. The result tipped off the terrorists who’ve returned to more primitive but harder to track methods of communication.

Global “ransom ware” attacks on hospitals have done little to prompt even a single Congressional hearing.

Equifax Credit Bureau was so careless with data they collect from all Americans involuntarily that hackers roamed undetected through their huge credit databases for nearly four months stealing the information of nearly half of the American people – using — what appears to be — a specific set of selection criteria. The government’s response: Consumers can sue Equifax.

The Security and Exchange Commission’s EDGAR System was hacked a year ago (August, 2016). It is likely that some person or persons or country unknown had access to the financial reporting data of every publically traded American or multi-national corporation before that information was made public, as required by law. Congress and the American people were not told until the appointment of a new SEC Chairman in September, 2017.

For almost a year, hackers were able to use (or sell)”insider trader information” to trade on specific stocks before the company’s public announcement of earnings. Such trading is a federal crime.

Just last week, the Department of Homeland Security released a list of 21 states where Russians successfully or semi-successfully hacked into state election systems prior to the 2016 Presidential election.

Taken together these are hostile acts against the nation and the people of the United States – as surely as if those bits and bytes were bullets.

In this war of bits, bytes, and the dark web, there is no “frontline” and Congress is not doing its job: Building an army to protect you and I – the American people – from a nefarious global network of economic terrorists.

No American is Safe:

Almost every aspect of daily American life is connected to the World Wide Web.

When you:

  • Apply for a job
  • Apply for a mortgage or rental approval
  • Watch television
  • Shop – online and off
  • Buy groceries at the local grocery store
  • Dial 911 an emergency
  • Catch up with friends
  • Make a medical appointment
  • Pay the basic monthly bills
  • Save for retirement etc.

The details of every transaction are collected by numerous public and private interests – irrespective of your Constitutional right to privacy. Under the best of circumstances, this data is summarized and sold to better “target” you as a customer.

In the hands of a criminal this data can be used to steal your identity. It can be used to blackmail you into – for example — spying against your employer, your neighbors or friends. It might allow a health insurance company illegal access to your genetic profile.

Protect Our National Infrastructure

There is no part of the infrastructure that we all depend on that does not, also, depend on technology:

  • Weather forecasting
  • Water storage and transport
  • Power generation and transport
  • Farming
  • Air travel
  • Rail travel
  • Ocean and river craft
  • Your family car
  • Corner gas station
  • Hospitals
  • Police Stations
  • Jails
  • Military Installations and Military Hardware etc.

It is not classified information that our government, private and public utilities and other quasi-government agencies have acknowledged their vulnerability to cyber attack.

Stop for a moment and think what the consequences would be if, for example, your electric utility provider were held for ransom by a hostile government or non-state-actor. Denied electric power, many activities we take for granted would quickly stop. What would the social consequences be if gasoline pumps stopped pumping, grocery stores couldn’t refrigerate or even checkout your groceries, ATMs could not dispense cash, and credit card transactions could not be verified across a wide section of America.

Every automaker and others including Apple and Google are working on the “inevitable” driverless car — navigation via the Internet. WHAT IF a terrorist or state actor hacked into the driverless car fleet and turned our interstate highways into real-time bumper cars?

CYBER WARFARE IS NOT STAR WARS

Several states have started to regulate autonomous vehicles, remote home security and other technologies that could put Americans at risk. Not so Congress.

Congress is worried about other things: for example, to build or not to build a wall on our southern border.

Daily reports of massive data breaches, repeated theft of Americans personal data by criminals and hostile state actors, over several years, haven’t prompted Congress or the President – past or present – to take the necessary steps to protect every day Americans from this new and potent threat.

Congress and state governments have been repeatedly briefed on the vulnerabilities of our power grid and communication systems to cyber attack. But none of those briefings have moved Congress to debate or legislate additional cyber security measures outside the reactive Homeland Security Department’s Computer Emergency Reaction Term.

It is well past time that Congress acts pro-actively to establish a cabinet level CYBER SECURITY Department to coordinate all military, intelligence, law enforcement and private sector cyber security initiatives.

Every American has a right to expect Congress to take all steps necessary to protect the life, liberty, privacy and security of every citizen.

As much as we expect our military to be one step ahead of our potential enemies – so must our cyber sleuths.

Graphic courtesy of us.123rf.com

A Crucial Balancing Act: DACA and Enhanced Border Security

President Trump has invited an explosion in Congress with his recession of the 2012 Obama Executive Order that protected undocumented aliens who were brought to the United States by their parents when they were still children and before 2007.

There is majority public support for legislation to protect the “DACAs” (Deferred Action [for] Childhood Arrivals).

Three bills have been entered into Congressional hopper – the bi-partisan Senate Dream Act 2017, the House Recognizing America’s Children Act and the House Dream Act.

Nancy Pelosi, embolden by her meeting with President Trump, insists House Democrats will settle for nothing less than their Dream Act – which broadens the categories of eligibility beyond President Obama’s Executive Order and offers Dreamers a direct path to American citizenship.

The two other bills take a more measured approach — offering at first provisional legal status to work, travel, go to school, etc. Only after serving several years of provisional status would “Dreamers” earn a right to apply for permanent residency and eventually citizenship — hardly a “get out of jail free” card.

Initial reaction on Capitol Hill suggests that there is broad support, in Congress, for DACA-fix legislation – limited in scope and purpose.

After sixteen years of bi-partisan failure to pass such a bill what is different this time?

Passing a small, targeted immigration bill will benefit both political parties going into the 2018 mid-term elections.

Politics Makes Strange Bedfellows

Does President Trump think he can trade a DACA law for his often promised southern “border wall”? It’s possible but not realistic.

More realistically — the Republican majority in Congress knows it cannot afford to lose this opportunity to partially rebuild its relationship with Hispanic voters. But the GOP must also be responsive to its own base – which has used its votes repeatedly to demand enhanced border security first and granting legal status second.

Democrats will seek political advantage in the mid-term elections by supporting a “clean DACA law” (effectively an amnesty) that would attract more Hispanic support from the US citizen brothers and sisters of the Dreamers — even at the expense of further erosion of their traditional organized union, blue collar base in the mid-west.

Representatives and senators in the center of both parties have a clear common interest. The majority want a bill they can pass, the President will sign, and that they can defend to their constituents during the 2018 primary and general elections.

Senators as philosophically opposed as Lindsey Graham (R-South Carolina) and Diane Feinstein (D-California) have both acknowledged that only a DACA Fix that includes steps to strengthen our border security meets all three conditions.

Effective Border Security Doesn’t Mean Walls

A wall on our southern border — even if Mexico or Congress was willing to pay for it – will not secure our borders.

Fact is every year since 2007 more than half of the illegal immigrants to the USA have been airport arrival “visa overstays”.

Technology, not concrete, is the solution to our 360 degree land, air, and sea border security problem.

  1. Strengthen E-Verify

The 1986 Immigration Reform Act (aka Simpson Mazzoli) attempted to balance compassion for some two million illegal aliens who had been in the country for many years with stronger border security and enforcement measures.

The 1986 legislation defined as a crime any USA employer hiring/employing a person who could not prove they had the legal right to work (and live) in the United States.

To help employers stay “on the right side of the law”, Congress mandated the development of an electronic verification system – E Verify — every employer would need to use to verify every new employee’s “work authorization status”.

The bureaucracy took a different approach than the law required while subsequent Congresses just looked the other way.

Participation in the E-Verify System is voluntary unless the employer is a federal contractor – or in some states a state contractor. There is only limited enforcement even for federal contractors.

Any other employer can enroll to use the system on a voluntary basis with little risk of being subjected to enforcement action by Homeland Security.

Under current Homeland Security policy, even if a new hire is “non-compliant” – determined not to have work authorization – termination is not required only strongly suggested.

Congress should give Homeland Security twelve months from date of passage of new Border Security legislation to deliver an E-Verify System that is tested, proven and works.

Once tested and proven, the system must be made mandatory for all newly hired workers – every employer, everywhere – with significant civil and criminal penalties for employers that violate it.

Restricting the E-Verify mandate to new hires will protect those working without papers in the USA today – i.e. DACA’s parents – from termination because of status.

No DACAs could move from provisional status to permanent resident status until E-Verify is successively implemented, rolled out nationally and demonstrated to work – including employer enforcement.

  1. Discourage Illegal Entry with Improved Tracking Technology at Every Border

Simultaneously, Customs and Border Security must
improve its ability to electronically track arrivals and departures of tourists and other foreign nationals with temporary (time fenced) visas.

Currently, a photo is taken of every airport arrival and stored with passport information collected prior to and upon arrival.

Today, Homeland Security has no way to track where a “visitor” goes once they cross the border or walk out of the airport. It’s just too easy to blend in and stay – get a job, rent an apartment, or buy a car.

  • Congress should authorize the Attorney General to determine the Constitutionality of attaching a GPS tracking device to all foreign passports in the United States to ensure timely departures.
  1. Eyes in Sky

High tech surveillance is part of 21st century life – at the mall, the airport, the stop light, on the freeway – rendering walls historic artifacts.

Congress needs to increase funding for technology already used by Border Patrol including satellites, in the ground sensors, and drones to patrol remote stretches of both the southern and northern borders.

  • More drone operators, for example, to spot irregular arrivals faster and guide border patrol agents to apprehend them.
  • Ground level sensor technology can be more effective than walls.
  1. A Tamper-proof Internal Identification System

Homeland Security must be given a deadline to negotiate a plan with the states to issue technically sophisticated drivers’ licenses and other internal identification documents.

  • Congress first mandated a tamper-proof “National ID” following 9/11 but it has never been implemented.
  • Adding technical sophistication to our (state issued) internal identity documents will prevent the possibility of unauthorized immigrants using our air travel system – reducing the terrorist threat as well.
    • Some states currently issue Driver’s Licenses to undocumented aliens but those licenses must meet federal guidelines that insure TSA can quickly identify them as not authorized for air travel.

Tamper-proof national identification documents are, also, a defense against the growing national threat from counterfeiting and identity theft.

None of these four steps would deny sanctuary to anyone currently in the United States.

Build Public Confidence for Immigration Reform

If the public saw each step implemented, tracked and succeeding — public confidence in the government’s ability to secure our borders would grow.

Simultaneously, Congress could use the two or three years required to implement and assess the effectiveness of these first border security steps to develop a thoughtful set of next steps to fairly resolve the status of DACA’s parents and other undocumented immigrants.

Securing the border along with resolving the legal status of those who have been living in the shadows of America for many years would
build public confidence in the government’s ability to manage our immigration system.

Public confidence is the necessary pre-requisite to a comprehensive 21st century immigration reform plan.

Graphic courtesy of iconfinder.com

 

The Real Truth Behind the Health Care Battle

I was in Washington DC for meetings last week.

Washington is not America!

Nowhere in America could a restaurant catering to the business traveler charge $23.00 for a first course Caesar salad and stay in business.

But in central Washington that’s the common price at every day restaurants – not white table cloths, tuxedoed waiters and elegant French cuisine — but the type of place a business traveler goes for a quick bite and a glass of wine at the end of a long day.

And those restaurants are packed – not by the tourist families who crowd the Capital Mall — but by government workers and lobbyists.

The average government worker in Washington earns $112,000 a year before benefits.

Contrast the national median income for a family of four — $55,775 — against the average bureaucrat or congressional or presidential staffer, who earns twice what the average American family does (members of Congress earn 3.2 times their average constituent), and the picture becomes clear.

They can’t possibly understand the daily life of the average American.

In this context, the GOP proposal to “repeal and replace Obamacare” makes perfect sense. From their cushy perch — $16000 a year for health insurance is not such a big number.

This difference in earnings and benefits, also, explains why they see Medicaid spending as just numbers on the ledger rather than the human lives protected. Debit the rate of Medicaid spending and credit income tax rate reduction by the same amount and federal budget deficit remains the same.

Medicaid is Largest Health Care Insurer in America

In the roaring US economy of the 1960s, Medicaid was an afterthought – an amendment to the original Medicare hospital insurance (Part A) proposal – a few dollars to protect “poor women and children”.

Today, Medicaid is the largest health insurance program in the United States – 40 percent larger than Medicare.

Medicaid enrollment grew from 4 million (of 196 million) in 1966 to 73.5 million (of 326 million) in 2017 as a series of economic shocks took a toll on the American middle class.

  1. The wide-spread loss of employer based pensions and cuts to union sponsored pension programs beginning in the 1980s.
  2. The erosion of semi-skilled mining and assembly-line manufacturing jobs through automation and outsourcing to lower wage countries
  3. A reduction in family savings
  4. Reduced capital investment in innovation and technology by both private investors and the government.

Over the last quarter century quality jobs have declined — resulting not just in fewer jobs but lower wages, shorter hours, and fewer employee benefits. Fully 25 percent of US jobs, today, are in the retail sector.

The Kaiser Foundation reports in 30 of the 50 states the median income for a family of four has fallen below the national average of $55,000.

The twenty states at or above the national average tend to be the large coastal states where concentrated pockets of wealth mask the overall condition of their populations (California, New York and Virginia – buoyed by technology, global banking and an overpaid federal work force).

Lower wages, fewer employee benefits, less job security and lower savings add up to more families who need government help paying for necessary health care.

Medicaid is the primary health insurance for forty (40) percent of US children. These are the children of the shrinking middle class plus the “birthright citizen” children born in the United States to undocumented/illegal aliens.

For too many Americans whose jobs and job prospects deteriorated or vanished in mid-life (along with guaranteed pensions, good wages and employee based health insurance), Medicaid has become the necessary bridge to Medicare.

Medicaid is Just a Symptom of the Real Problem

Since the 1990s, Congress, and both Republican and Democratic administrations, papered over the drip, drip, drip of declining job prospects for millions of Americans with “temporary help” government programs – tax cuts, college loan programs, 60 separate federal job retraining programs, extended unemployment insurance and – most recently – subsidized health care – leading to an explosion of the national debt.

The solution to the mushrooming Medicaid program cost is not to punish the vulnerable dependent upon it. Medicaid pays 2/3 of all old age and dementia patient nursing home bills.

The challenge to Congress is to reform Medicaid — bend the cost curve without cutting access or benefits to the growing number of Americans who need the help.

Three Potential Reform Ideas:

1) Ban All Political Contributions: Shift Congress’s focus from the stake holders to the shareholders and customers by banning all political contributions from health care providers, drug and device manufacturers and other profit centers in the health care eco-system.

Once freed from deference – their first question to their former donors should be “why does health care cost so much”? Why does health insurance, health care devices, drugs, surgery, laboratory tests, even a visit to a primary care physician cost Americans 50% more than any other developed nation’s citizens?

The next question should be – what are you going to do about it?

2) Federalize the Program: Allow states to design delivery systems that are specific to their environment and patient population.

The states are laboratories of innovation. States have stronger incentives to use Medicaid dollars efficiently. They pay as much as forty (40) percent of their Medicaid costs and must balance their budgets.

Plus, if the program were federalized, the number of Center for Medicare and Medicaid Services bureaucrat rule writers in Washington would decline – saving $112,000 plus benefits times several hundred individuals.

3) Hold the Bureaucrats Accountable: Medicaid fraud rises every year. In 2016 it amounted to $33 billion. Congress must hold federal and state bureaucrats collectively and individually accountable to reduce the rate of Medicaid fraud to zero over the next 10 years.

Eliminating Medicaid fraud over the next 10 years would save at least $333 billion — more than the $319 billion savings the Congressional Budget Office projected from the first Senate healthcare reform.

Added together these simple reforms would save as much as half a trillion dollars over the next decade without cutting one penny from beneficiaries.

After all, aren’t the beneficiaries the purpose of Medicaid?

 

Thanks to 101Clipart.com for the graphics

Biggest Hurdle Standing in the Way of Obamacare Reform

During the two recent Congressional Recesses, we’ve seen countless pictures of angry town hall meetings where people with so-called “pre-existing” health “conditions” have expressed their fear that the Republican Congress is working to take away health coverage they gained under Obamacare.

Some of the shouting and finger-pointing are manufactured by the Democrats’ “Resistance Movement” but some of it is genuine fear from people who suffer from debilitating diseases with no possible “cure” but – potentially — years of expensive control.

These are exactly the people Congress wanted to help when they created Obamacare.

The people who are coming to town halls have a point. Their justifiable anxiety (some of it sparked by politicians and the news media) stands in the way of a down-payment on reforming Obamacare in short run and reforming our health care delivery system in the medium to long term.

Their small numbers are magnified because it is an axiom of American democracy that we have a collective responsibility to care for those who cannot care for themselves

Obamacare Redefined “Pre-existing Condition”

These vocal town hall participants are part of the 1 percent of the USA population that incur 23 percent of the cost of health care in the United States.

Numerous studies have demonstrated that 5 percent of the population incurs 50% of the cost of health care in the United States.

Prior to Obamacare many states set up “high risk insurance pools” to help these people who were considered “uninsurable” in the private, non-(employer) group health insurance market because they had a serious and significant “pre-existing condition”.

The pools were narrow in coverage, exorbitantly expensive, limited to a pre-determined number of people regardless of the number who needed this assistance and capped maximum payments.

Other patients with – for example “seasonal allergies” were not considered to be “high risk” but were “rated” by private insurers.

“Rating” meant that the insurance company charged an additional premium for every “rated” condition that specific insured person might ever had symptoms of – even without a diagnosis – or sought treatment for.

The result was that the many of the most seriously ill Americans could not afford health insurance or, as a result, adequate health care.

How “Community Rating” Increases Risk to All

Obamacare changed this by imposed “community rating” regulations which limit insurance companies to considering only age and continuous coverage before application (no gap in insurance greater than 63 days) when determining the premium for that patient or family.

Now, any person between the age of 26 and 64 is charged the same premium – regardless of their individual health or claims experience.

Employer-based health insurance uses “community rating”. Every employee pays the same insurance premium per individual or family covered regardless of age or health. “Pre-existing conditions” can be excluded only if the insured has a 60 day “gap” in coverage.

Medicare uses a similar eligibility formula but their “community rating” is dependent on insured’s income during the previous calendar year – everyone with the same income in that calendar year pays the same Medicare premium.

Generally, employer-based insurance and Medicare “forgive” such a “pre-existing condition” after 12 months of continuous insurance coverage.

Theoretically, if the “community rated” pool is large enough and diverse enough the insurance company can absorb the cost of any single large claim because there are relatively few large claims as a percentage of the total claims paid.

Why Obamacare Insurance Mandate?

This theory is behind the “insurance mandate” in Obamacare. Everyone in the United States must obtain health insurance or pay a fine to enlarge the size of the insurance pool.

But this theory has not played out in practice.

Average estimates are that 5.2 million Americans with incomes over 138% of the Federal Poverty Line (included those turning 26 and no longer covered under their parents) bought Obamacare approved private health insurance policies in 2016.

That is fewer than the 8 million who decided it is cheaper to pay the IRS fine than buy insurance under Obamacare.

Those Americans are “betting” they won’t need health care.

The result is a smaller pool of people who know they are going to file health care claims; older people, people with more health issues – i.e. people with “pre-existing conditions” or “chronic” diseases (for example Type II Diabetes).

Smaller pools and proportionately higher utilization of increasing costly care left insurance companies with little choice but to increase “community rated” premiums for everyone or to exit the Obamacare market entirely.

The result is a pool of beneficiaries in a state of uncertainty exasperated by the uncertainties created by a Republican Congressional effort to “replace” Obamacare with something more “affordable” for more Americans in the private and employer insurance market places.

To Lower Insurance Premiums, Share the Risk

Instead of creating hysteria and fear among those who most need help to pay their health care bills and, in-so-doing, delay relief for 95% of Americans, let’s take a cue from Medicare and create a program tailored to these special cases.

Presently, the poorest older Americans are assured of care through a joint Medicare/Medicaid program.

Why can’t Congress similarly “guarantee” coverage to people under 65 with “pre-existing conditions”?

Instead of paying the Obamacare subsidies to private insurance companies, Congress should create a special category under Medicaid to manage care for at least the 1 percent – if not the 5 percent – of “high risk” patients.

Enrollees in the special group would contribute to the cost of their care according to their ability to pay, just as they do under current Obamacare, in exchange for a guarantee of access to quality care. The government would pay their claims (at Medicare rates) through the Centers for Medicare and Medicaid services.

The risk of a disproportionate number of catastrophic claims would be dramatically reduced for private insurers.

The reduction in risk should lower the cost of insurance premiums by as 25% for the average American.

The less expensive the cost of “peace of mind” health insurance brings the more premiums the insurance companies could sell further sharing the risk.

Equally important, politically, this approach – which addresses the heart of the problem Obamacare set out to “fix” — should be able to attract at least some moderate Democratic support in the United States Senate.

Bi-partisan support for any Obamacare repeal or repair is a pre-requisite to attacking the real problem — the unsustainable cost of health care in America.

Public Option is Part of Fix for America’s Broken Health Care System

In the aftermath of the latest Republican House of Representatives’ attempt to “repeal and replace Obamacare” two things are certain.

  1. Health care is an entitlement due to all American citizens and a smaller group of legal non-citizens.
  2. Health care costs too much for too many people.

Quinnipiaq polling found only 17 percent of people approved of the Republican health care bill after hearing Congressional Budget Office projections that 14 to 24 million Americans might lose their health care coverage if the American Health Care Act became law.

Only eight percent of respondents supported just repealing Obamacare without replacing it.

But more than 50 percent want significant changes to the program.  Changes that will reduce cost – the cost of insurance and the underlying cost of health care.

Americans Reject Government-Run Health Insurance

It is an axiom of American politics that Americans reject a public health care option.

I don’t know whether to be worried or amused that members of Congress do not recognize the USA has a defacto public option?

Rhetoric to the contrary: 49.6 percent of the American people get their health care paid for by a government-run insurance program. The dictionary definition of a public option!

Consider the facts.

There are 47.2 million Americans on Medicare.

More than 70 million Americans are covered by Medicaid through a variety of programs that have been added over the last half century.

  • Medicaid covers about 40% of all children in the United States
  • Medicaid pays for about 50% of maternity expenses in the United States
  • Medicaid pays for 2/3 of nursing home expenses in the United States

The Veterans Administration claims 8.9 million health care plan participants.

The Bureau of Indian Affairs provides health care for approximately 2.2 million American Indians and Eskimos who live on traditional native lands.

The United States military insures +/- 14 million uniformed active duty and retired service members and their families.

The Obamacare private health insurance exchanges subsidizes premiums for 11 million Americans without employer based health insurance who are not eligible for either Medicare or Medicaid.

Approximately 4.8 million federal employees including civil service, executive and legislative branches and the courts participate in the federal government (employer) health insurance program

Add it all up — 154.8 million Americans get their health insurance from the federal government at a cost of +/- $2 trillion (about 64% of all health spending in the United States).

Embrace Reality with Public Option

What if Congress seized on the opportunity instead of railing against “government intrusion into health care”? They could turn the USA public option into a benefit instead of a financial sink hole with a bad reputation – an excuse for the escalating cost of care in America.

Let’s start with a new piece of legislation that all Americans without a law degree can understand:

A public option health insurance program open to everyone from age 0 to 64 years not covered by private employer health insurance. The plan would cover all currently mandated Essential Health Care Benefits.

To succeed Congress must remove the “Medicaid stigma”— the broad public perception that Medicaid is health care for only the poorest people delivered by less skilled personnel in substandard facilities. The insured cannot be embarrassed to “show their card”!

The new product must appeal to the 11 million who are currently insured under Obamacare exchanges and to some portion of the remaining 23 million Americans in the private insurance market. People must be willing to pay out-of-their-pocket to belong to the program.

This alternative begins with assuring prompt access to current-in-industry standard treatment in first class facilities – for example, Kaiser, Humana, Cleveland Clinics, and Sutter Hospitals – probably operating only as health maintenance organizations.

Congress should “guarantee” the plan offers best-in-class care options by enrolling themselves, their families and their staffs in the new public option.

The public option must be a good enough product to compete as one of the choices for Federal employees and their families.

Access to a public option health insurance card could bring the nation’s 8.9 million veterans improved care in their home communities.

How to Create a Realistic Funding Source: Follow the Money

A new and realistic funding source must be a cornerstone of the new legislation — fair to all, affordable and paid for now and into the future (not adding to the national debt).

There’d be some savings to be recouped into the public option funding pool from existing government activities:

  • Collapsing the five or six government insurance bureaucracies into a single department.
  • Eliminating the Obamacare guaranteed profits to private insurers.
  • Claims processing through Centers for Medicare and Medicaid Services (CMS) at .84 cents a claim

There would be new funds earned from premiums paid by insured – based on income.

But these savings and premium payments would not come close to paying for the subsidized care of close to one-third of Americans = +/- $1 trillion/year

Every American has to know where the $1 trillion is coming from, how it will be collected, and how it will be spent.

Since the 1980s there has been a shift in our economy from production (30%) to consumption (70%).

Fewer good paying manufacturing and other semi-skilled jobs have swelled the rolls of Medicaid and reduced the role of employer-paid insurance.

Logically, then, the new source of revenue to pay for public option health care (even to continue to pay for Obamacare and Medicaid) must come from the consumption side of the ledger – taxes paid by the ultimate consumer.

Take a Small Step First

Congressional Republicans should acknowledge reality — pass legislation authorizing the development of a public option health insurance program effective January 1,2019.

Force Democrats – who have long argued for a public option — to “come to the table” leading to lasting, bi-partisan legislation.

Establish a budget line item and allow tax reform legislation to move forward.

Provide certainty to the current health insurance market and warn against unjustified 2018 insurance premium increases.

Encourage the health care industry, fearing further regulation, to come to the table with alternatives to ever escalating health care costs.

Isn’t that the bottom-line for all Americans?

Health Insurance Drives Sky-Rocketing Health Care Costs

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

CBO Waves Yellow Flag at GOP Healthcare Bill

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