Five Reasons Obamacare Legislation Failed; The Worst Legislation Money Can Buy; Putting the Patient in the Driver's Seat

Here's an exceptionally well written, on-target email from Claudette, an occupational therapist from Michigan, in response to my post Physical Therapist in NY Chimes in on Health Care Costs.

Claudette wants to "Put the Patient in the Driver's Seat".

Claudette writes ...

Hello Mish

I do not disagree with the PT who wrote to you about consolidation of hospital systems resulting in increases in cost of care, but there are other pertinent problems to consider.

For example, in the current system, the physician and hospital make more money if they perform more services...so there is an incentive to order more tests, do more therapy and generally "do more to make more".

Under the ACA, there should be one bundled payment per diagnosis/incident.

What I suggest is not new, or radical. Medicare instituted DRGs or Diagnosis Related Groups with inpatient day and dollar limits per diagnosis 38 years ago (I was just beginning to work as an OT then).

DRGs drastically cut the cost of inpatient care and spawned the development of new service models including inpatient rehabilitation centers, Homecare and rehab in nursing homes, none of which fell under the constraints of the inpatient DRG.

Was this good? Yes, getting out of the hospital earlier is less expensive and healthier. There is no better place to get really sick than in a hospital.

Healthcare will not be truly competitive or cost effective until the patient is the one in the drivers seat. The patient should be informed, empowered to make care decisions and should pay the bill.

The bill should be discussed and agreed upon before service, whenever possible. Service prices should be posted so that consumers can comparison shop.

Right now patients are the point of service but are not part of the decision process. ACA did not change that and, in my mind, that is its greatest shortcoming.

Claudette

Obamacare, the Worst that Money Can Buy

As I reflect on all the emails that I received, it is readily apparent that numerous healthcare professionals understand precisely what is wrong with the current system.

So, how come none of the numerous existing problems were fixed?

Five Reasons Obamacare Legislation Failed

1. Lobbyists wrote the ACA legislation. When Nancy Pelosi stated "We have to pass the health care bill so that you can find out what is in it", she was referring to you , me, and Congress. An extremely tiny number of people knew what was in the bill: lobbyists for hospitals, lobbyists for insurance companies, lobbyists for HMOs, and lobbyists for major pharmaceutical companies. 
2. President Obama was more concerned about his legacy than anything else. He wanted Obamacare at any and all costs and was willing to sign any piece of legislation, no matter how poor.
3. Politicians in general do not have the public's vested interest in mind. They have their own reelection efforts in mind. That statement holds true regardless of which political party you support. 
4. Lobbyists and industry PACs donate massive amounts of money to politicians from both parties. That is why we do not allow drug imports from Canada. That is why there is an explicit law that prevents government from bargaining with drug companies on prescription drugs. That is why the US pays the highest drug costs and highest healthcare costs of any nation on the planet. 
5. Republicans for the most part were more concerned over stopping Obamacare than improving the healthcare of citizens of the United States. The irony here is Obamacre is essentially the same as Romneycare.

So here we are, stuck with the worst legislation imaginable.

As Claudette suggests, we need to put the patient in the driver's seat. Unfortunately that is in the vested interest of only the patient.

Who speaks on behalf of the patient? The sad answer is all too apparent: no one that the president or Congress listens to. They are all beholden to lobbyists, their legacy, and their reelection campaigns.

Mike "Mish" Shedlock
http://globaleconomicanalysis.blogspot.com

Hollande's Tax Everything Plan Blows Sky High With Riots by Farmers; Hollande Backs Down on Ecotax, on a Tax on Savings, On Corporate Earnings; Something For Nothing

President Francois Hollande wants to balance the French deficit by taxing the rich, taxing the poor, taxing trucks, raising the VAT, and increasing the tax on corporations.

That policy blew sky high this week in a storm of riots by Brittany farmers.

Please consider French Gov't Backs down on Truck Tax After Riots

French Prime Minister Jean-Marc Ayrault on Tuesday indefinitely suspended the introduction of a green tax on trucks following riots at the weekend in the Brittany region.

 The move comes three days after a protest by hundreds of food producers, artisans and distributors in the western Brittany region ended in the worst riots in the area in years.

One person was seriously injured in clashes between police and a group of around 1,000 demonstrators, who blocked a national road with convoys of vehicles and tonnes of produce on Saturday in protest over the tax.

Bretons say the levy will squeeze the already wafer-thin margins of the region’s struggling chicken, pork and other food producers.

The protests were seen as the expression of growing frustration nation-wide with the escalating tax burden on businesses and households.

Taxes have risen 70 billion euros (96 billion dollars) in the past three years, as France battles to shrink its budget deficit.

The truck tax, which is to apply to all vehicles of over 3.5 tonnes that use French roads, aims to raise 1 billion euros a year towards the development of rail and river transportation.

French Way of Getting Your Message Across

Mr. Ayrault denied that the government had caved in to the protesters.

“To be courageous is not to be obstinate; it’s to listen and understand,” he said after a meeting with Breton lawmakers and several Cabinet Ministers.

In France, riots, strikes, and mass protests work.

This is the second time this week, and third time in a month that France rolled back a tax.

Hollande Backs Down on Ecotax, on a Tax on Savings, On  Corporate Earnings

Bloomerg reports Tax Revolts Hit Hollande as Farmers, Soccer Clubs Protest.

French President Francois Hollande’s taxes, among the world’s highest, have made strange bedfellows out of the country’s soccer clubs and farmers in Brittany.

Revolts against a series of levies have erupted with protests by farmers in Brittany against a trucking tax on Oct. 27 leaving several people injured, and soccer clubs refusing to play a round of league matches in November to oppose a tax on salaries of more than 1 million euros ($1.38 million). Hollande has said he won’t budge on the millionaire tax, while Prime Minister Jean-Marc Ayrault said today he’s suspending the levy on truckers transporting agricultural products for now.

The Socialist president, who turned to increased taxes to narrow the country’s budget gap, has backed down on other levies in the face of objections. On Oct. 27, he gave up on a plan to lift taxation on savings, just weeks after backing off a new levy on corporate earnings.

“The cumulative effect of these retreats is that they confirm in many voters’ eyes that the government is struggling to govern,” said Bruno Jeanbart, a director of Paris-based pollster OpinionWay. “Even Hollande’s own supporters question if he’s up to the job. The problem for the president is that every time there’s good news, it’s marred by political errors.”

Hollande’s ratings in polls have sunk, making him the country’s most unpopular president. A BVA poll published last night showed Hollande’s approval rating dropping six points in the past month to 26 percent, the lowest level for any president under France’s current constitution.

The revolts reflect discontent with taxes that have risen by 70 billion euros in three years. France’s tax burden was 46.3 percent of gross domestic product last year, up two percentage points from 2011 when it was already the third-highest in the world behind Belgium and Denmark, according to the Organization for Economic Cooperation and Development.

“There’s no more room to raise taxes,” said Laurent Dubois, a professor at the Institute of Political Studies in Paris. “The French feel taxes are going up and purchasing power is going down. They voted for Hollande thinking they’d afford austerity; that the rich would pay. They realize now that that’s not possible. There aren’t enough rich people.”

Not Enough Rich People to Tax

Socialists are all in favor of raising taxes (on somebody else). When Hollande ran out of rich people to tax, he simply taxed everybody.

Those generally supportive of tax hikes then revolted in a riot of "not me" protests.

Support for Tax on Soccer Players is 83%

Apparently there are not enough soccer players to matter. By a massive margin, the "Not Me" protesters support Hollande's 75% tax rate on millionaire soccer players.

On soccer clubs, Hollande has said he intends to hold his ground on a pledge to tax salaried earnings of more than 1 million euros at a rate of 75 percent for two years. French soccer clubs said last week they won’t play a round of league matches during the last weekend in November to protest the tax.

For some unprofitable clubs, the extra burden is a threat to survival, according to the Ligue de Football Professionnel.

“The consequences of this measure will be dramatic,” said Frederic Thiriez, head of the LFP, said in a statement. “France must be the only country that taxes money-losing companies.”

The clubs, which are canceling matches between Nov. 29 and Dec. 2, are asking the government to abandon the tax.

The million-euro salary levy is one that is popular. About 83 percent of French say the soccer strike is unjustified, according to a poll by Opinion Way for LCI television.

For now, Hollande says he is not backing down on taxing soccer players. I guess there are not enough of soccer players to matter (at least until games are cancelled, tax revenue plunges, and people who want to see the games riot).

French Want Something For Nothing

Hollande has promised to cap the deficit mostly by shrinking spending next year. That won’t make the French happy either, said Emmanuel Riviere, a pollster at TNS Sofres in Paris.

“The French want the deficit addressed and spending reduced but they don’t want to give up their services and social protection,” he said. “Faced with this contradiction, Hollande has been ambiguous. The result is that the French are now suspicious that the government isn’t telling them the truth.”

Making a Choice

“If we don’t have the tax we can no longer restart public works projects, renovate roads including the high-speed train links that all lawmakers are asking us for,” he said. “We will have to make a choice. We will have to find an agreement.” said Industry Minister Arnaud Montebourg.

Well, perhaps Montebourg should ask if people want tax hikes to support those things. Then again, the answer would likely be "Yes, But ... Not On Me!"

Mike "Mish" Shedlock
http://globaleconomicanalysis.blogspot.com

Physical Therapist in NY Chimes in on Health Care Costs

Reader "Chris", a physical therapist in private practice in New York, pinged me about Obamacare and rising health care costs in general.

Chris writes ....

Hello Mish

I wanted to comment on your recent posts regarding Obamacare. Most of the criticism from you, and others, has focused on the issues and difficulties surrounding the website, dropped coverage, legal disputes, and rising costs you called "Obamashock!"

As a healthcare provider, I would like to point out a seldom heard critique regarding competition and hospital consolidation.

A cornerstone of ACA (Obamacare) is promotion of Accountable Care Organizations (ACOs) intended to be fully integrated systems, capable of taking patients through a complete continuum of care.

Allegedly, ACOs would reduce price.

However, a recent study on the Impact of Hospital Consolidation by the Robert Wood Johnson Foundation found the opposite was true.

Providers and the specialty groups remain in isolated silos. The hospitals merge simply to increase their market share and ability to leverage higher fees from insurers, which they have done.

Four Points From the Study

1. "The Patient Protection and Affordable Care Act (ACA) promotes Accountable Care Organizations (ACOs) and the bundling of payments across providers for an episode of care (bundled payments), both of which encourage consolidation between hospitals and physician practices."
 
2. "Hospital consolidation generally results in higher prices. This is true across geographic markets and different data sources. When hospitals merge in already concentrated markets, the price increase can be dramatic, often exceeding 20 percent."
 
3. "Hospital competition improves quality of care. This is true under both administered price systems, such as Medicare and the English National Health Service, and market determined pricing such as the private health insurance market. The evidence is more mixed from studies of market determined systems, however."
 
4. "Physician-hospital consolidation has not led to either improved quality or reduced costs. Studies find that consolidation was primarily for the purpose of enhanced bargaining power with payers, and hence did not lead to true integration. Consolidation without integration does not lead to enhanced performance."

Contrary to the success of these hospital systems in raising their rates, private practice physical therapy, the sector that I work in, has seen inflation adjusted reimbursement down 40% between 1992 and 2012.

Medicare has cut physical therapy reimbursement an additional 16% more since 2012. 

Private payers (insurers) also continue to cut our reimbursement each year. The difference between private practice and these large hospital systems remains the relative leverage they each have in negotiating for higher reimbursement rates.

Private practice has no leverage and major systems have an unreasonable amount of leverage. This is why physicians across the US have migrated in record numbers towards hospital systems.

Competition of private practitioners and smaller hospital systems has historically kept prices lower. That competition is now being done away with by Obamacare in the name of cost savings, but it is having the opposite effect.

Obamacare is a disaster on so many levels its frightening.

Regards,
Chris

Mike "Mish" Shedlock
http://globaleconomicanalysis.blogspot.com

Scathing Attack on Rajoy in Spanish Press; Spain on Brink of Deflation, CPI Goes Negative

Spain's CPI has declined for four consecutive months and eight out of the last twelve. A decline of .4 percentage points in October pushed the CPI negative for the first time since 2009.

Via translation from El Economista

The Consumer Price Index (CPI) fell four tenths of a percent in October to -0.1% due to falling prices of food and non-alcoholic beverages and the lower rise in university education, according to the leading indicator of the evolution of prices in Spain released Wednesday by the National Statistics Institute (INE).

Deflation requires a fall in prices over an extended period of time, but with the decline in October, the annual chained CPI shows four consecutive months of declines.

"It's not the first time that consumer prices fall in annual figure in Spain during the crisis. But it is striking that they do when the optimism about the recovery takes hold among economic agents and authorities," said Jose Luis Martinez, a strategist Citi in Spain.

Scathing Attack on Rajoy

Rarely does one see a scathing attack of government officials in mainstream media, but this attack by El Confidencial (mainstream to Spain) qualifies.

Via translation please consider Recession Continues and Spain on Brink of Deflation

Liars, irresponsible and heartless have brought misery to the poor and middle class crushed with confiscatory taxes. These are the qualifications of prime minister Rajoy and his henchmen who hypocritically celebrate deception to a people. They have not taken Spain out of the recession, but they have brought us to the brink of deflation that will bring more poverty, pain and tears.

The reported GDP and employment figures for the third quarter of 2013 are clearly incompatible. A job loss of 70,000 people in seasonally adjusted terms is not compatible with a rise of GDP (albeit marginal) given the fall of 98% of its components. It's an impossible metaphysical.

As Jean Claude Trichet, former ECB president said "Spanish statistics are hard to believe." Since then Spain's official GDP figure exceeds actual around 30%.

Nonetheless, Rajoy has started marketing the same lies as Zapatero regarding green shoots of 2009, that have not yet arrived.

Even though taxes have risen to a confiscatory level, they have cut wages, pensions, unemployment and imposed all kinds of misery on more than 3 million people.

Job losses continue at an unaffordable rate: 500,000 people through September and more than a million since Rajoy became prime minister. Social Security contributors are down 1.1 million workers. And if we go into the fine print, the issue is even worse: The number of permanent contracts in the third quarter fell by 146,300 while that of temporary workers increased by 169,500.

How can the stock market go up when the results of the Ibex are the worst in the Western world? The reason is simple: the entry of speculative money, by the enormous amount of liquidity but not moving the debt market.

Yet, Rajoy and his minions tell us that "the recession is over, we grow at 0.1%.

We're not coming out of recession. It's impossible. No country can get out of a recession with annual wastage of 10% of GDP by corrupt state officials and a financial system that has already cost us over 40 billion euros with guarantees of another 280 billion of which a good portion is not viable.

It's impossible with interest rates of 12 to 16% solvent customers.

Many analysts applaud the Government's actions more taxes, lower wages and drastic cuts to the weakest. These pseudo-experts overlook that confiscatory tax policy, the government deficit, and the lack of credit.

The crisis is not only unseemly, it is also vile.

Mike "Mish" Shedlock
http://globaleconomicanalysis.blogspot.com

How the NSA Hacked Google and Yahoo! - Part Two - Man in the Middle - "Flying Pigs", "Hush Puppy"

In response to NSA Breaks Into Secure Communication Links of Google and Yahoo I received a few comments worth exploring.

Reader "Fury" commented "True encryption using the RSA algorithm is unbreakable today. No way can the NSA break the prime number encryption that is used, I don't care how many supercomputers they have."

A knowledgeable friend commented "The secure parts are impenetrable by computer technology. A break-in is impossible unless Google let them in or the NSA somehow got the encryption key. The latter would require human agents."

The article I linked to above came from an October 30 article in the Washington Post. Here is the chart in question.



Man in the Middle

Mainstream media is nearly always late to these stories, and so was I. The answer to how the NSA hacked Google and Yahoo! comes from Schneier on Security a "blog covering security and security technology".

With thanks to reader "marvinmartian" for the link, please consider Bruce Schneier's September 13 post New NSA Leak Shows MITM Attacks Against Major Internet Services.

The Brazilian television show "Fantastico" exposed an NSA training presentation that discusses how the agency runs man-in-the-middle attacks on the Internet. The point of the story was that the NSA engages in economic espionage against Petrobras, the Brazilian giant oil company, but I'm more interested in the tactical details.

The video on the webpage [NSA Documents Show United States Spied Brazilian Oil Giant] is long, and includes what I assume is a dramatization of an NSA classroom, but a few screen shots are important. The pages from the training presentation describe how the NSA's MITM attack works:

However, in some cases GCHQ and the NSA appear to have taken a more aggressive and controversial route -- on at least one occasion bypassing the need to approach Google directly by performing a man-in-the-middle attack to impersonate Google security certificates. One document published by Fantastico, apparently taken from an NSA presentation that also contains some GCHQ slides, describes “how the attack was done” to apparently snoop on SSL traffic. The document illustrates with a diagram how one of the agencies appears to have hacked into a target’s Internet router and covertly redirected targeted Google traffic using a fake security certificate so it could intercept the information in unencrypted format.

Documents from GCHQ’s "network exploitation" unit show that it operates a program called "FLYING PIG" that was started up in response to an increasing use of SSL encryption by email providers like Yahoo, Google, and Hotmail. The FLYING PIG system appears to allow it to identify information related to use of the anonymity browser Tor (it has the option to query "Tor events") and also allows spies to collect information about specific SSL encryption certificates.

Flying Pig Screenshot



Spying on Petrobras – Brazil’s Largest Company

Let's take a closer look at NSA Documents Show United States Spied On Brazilian Oil Giant

One of the prime targets of American spies in Brazil is far away from the center of power – out at sea, deep beneath the waves. Brazilian oil. The internal computer network of Petrobras, the Brazilian oil giant partly owned by the state, has been under surveillance by the NSA, the National Security Agency of the United States.

These new disclosures contradict statements by the NSA denying espionage for economic purposes.

The information was found by journalist Glen Greenwald, co-author of this story along with TV Globo Reporter Sonia Bridi, amid the thousands of documents given to him by Edward Snowden in June.

This statement addressed to “The Washington Post” this week highlights that 'The department does ***not*** engage in economic espionage in any domain, including cyber.'"

 However, a top secret presentation dated May 2012 is used by the NSA to train new agents step-by-step how to access and spy upon private computer networks – the internal networks of companies, governments, financial institutions – networks designed precisely to protect information.

The name of Petrobras – Brazil’s largest company – appears right at the beginning, under the title: “MANY TARGETS USE PRIVATE NETWORKS.”

The documents are classified as “top-secret”, to be seen only by those named by the Americans as “Five Eyes” – the five countries allied in spying: the United States, Australia, Canada, Great Britain and New Zealand.

The name of Petrobras appears on several slides, as the training goes deeper in explaining how data from the target companies is monitored.

Individual folders are created for each target – and contain all the intercepted communications and IP addresses – the identification of each computer on the network – which should be immune to these attacks.

Petrobras has two supercomputers, used mainly for seismic research – which evaluate oil reserves from samples collected at sea. This is how the company mapped the Pre-salt layer, the largest discovery of new oil reserves in the world in recent years.

There is no information on the extent of the spying, nor if it managed to access the data contained in the company’s computers. It’s clear Petrobras was a target, but no documents show exactly what information the NSA searched for. But at any rate, Petrobras has strategic knowledge of deals involving billions of dollars.

The NSA presentation contains documents prepared by the GCHQ – the British Spy agency, from a country that appears as an ally of the United States in spying. The British agency shows how two spy programs operate. “Flying Pig” and “Hush Puppy” also monitor private networks which carry supposedly secure information. These networks are known as TLS/SSL.

The presentation explains how data is intercepted, through an attack known as “Man in the Middle”. In this case, data is rerouted to the NSA central, and then relayed to its destination, without either end noticing.

A few pages ahead, the document lists the results obtained. “Results - what do we find?” “Foreign government networks”, “airlines”, “energy companies” – like Petrobras - and “financial organisations.”

TLS/SSL networks are also the security system used in financial transactions, such as when someone accesses their bank account through an ATM. The connection between a remote terminal and the bank’s central goes through a sort of secure tunnel through the internet. No one is supposed to see what travels through it.

Later, the NSA presentation shows in detail how the data of a chosen target is rerouted through spy filters beginning at the very source, until they reach the NSA’s supercomputers.

In this document the NSA names Latin America as a key target of the "SILVERZEPHYR" program, which collects the contents of voice recordings, faxes, as well as metadata, which is the overall information being transmitted in the network.

"Flying Pigs", "Hush Puppy", "SILVERZEPHYR" 

The NSA was clearly caught lying.

What else besides corporate espionage? Political enemies? (Why not given the target on friends?) State trials? Client attorney privileges?

Once again, I praise Edward Snowden as a national hero for leaking these documents. We would otherwise not know about any of this stuff, and without that leak, it is 100% certain nothing about this would have been done.

Instead, Big Brother would likely have expanded to look at every document, every phone call, every corporation, every blog, and literally everything written or said by everyone on the planet, with taxpayers footing the bill.

My fear is that happens regardless.

Mike "Mish" Shedlock
http://globaleconomicanalysis.blogspot.com

NSA Breaks Into Secure Communication Links of Google and Yahoo; Italian Magazine Claims NSA Monitors Pope

The Washington Post reports NSA infiltrates links to Yahoo, Google data centers worldwide, Snowden documents say

In this slide from a National Security Agency presentation on “Google Cloud Exploitation,” a sketch shows where the “Public Internet” meets the internal “Google Cloud” where user data resides. Two engineers with close ties to Google exploded in profanity when they saw the drawing.



According to a top secret accounting dated Jan. 9, 2013, NSA’s acquisitions directorate sends millions of records every day from Yahoo and Google internal networks to data warehouses at the agency’s Fort Meade headquarters. In the preceding 30 days, the report said, field collectors had processed and sent back 181,280,466 new records — ranging from “metadata,” which would indicate who sent or received e-mails and when, to content such as text, audio and video.

The NSA’s principal tool to exploit the data links is a project called MUSCULAR, operated jointly with the agency’s British counterpart, GCHQ. From undisclosed interception points, the NSA and GCHQ are copying entire data flows across fiber-optic cables that carry information between the data centers of the Silicon Valley giants.

The infiltration is especially striking because the NSA, under a separate program known as PRISM, has front-door access to Google and Yahoo user accounts through a court-approved process.

At Yahoo, a spokeswoman said: “We have strict controls in place to protect the security of our data centers, and we have not given access to our data centers to the NSA or to any other government agency.”

Note the Smiley

Please note the Smiley in the lower center part of the image. The adjacent text says "SSL added and removed here!".

For those interested in "SSL" technology, Wikipedia offers this explanation.

Transport Layer Security (TLS) and its predecessor, Secure Sockets Layer (SSL), are cryptographic protocols which are designed to provide communication security over the Internet. They use X.509 certificates and hence asymmetric cryptography to assure the counterparty whom they are talking with, and to exchange a symmetric key. This session key is then used to encrypt data flowing between the parties. This allows for data/message confidentiality, and message authentication codes for message integrity and as a by-product message authentication. Several versions of the protocols are in widespread use in applications such as web browsing, electronic mail, Internet faxing, instant messaging and voice-over-IP (VoIP). An important property in this context is perfect forward secrecy, so the short term session key cannot be derived from the long term asymmetric secret key.

The diagram suggests the NSA is somehow able to add its own "secure" layer or simply remove the security layers of Google and Yahoo!

Italian Magazine Claims NSA Monitors Pope

This story is not yet confirmed but Reuters reports Italian magazine says U.S. spies listened to pope, Vatican says unaware.

An Italian magazine said on Wednesday that a United States spy agency had eavesdropped on Vatican phone calls, possibly including when former Pope Benedict's successor was under discussion, but the Holy See said it had no knowledge of any such activity.

Panorama magazine said that among 46 million phone calls followed by the U.S. National Security Agency (NSA) in Italy from December 10, 2012, to January 8, 2013, were conversations in and out of the Vatican.

In a press release before full publication on Thursday, Panorama said the "NSA had tapped the pope". It cited no source for its information.

Panorama said the recorded Vatican phone calls were catalogued by the NSA in four categories - leadership intentions, threats to the financial system, foreign policy objectives and human rights.

Reflections on Monitoring "God's Work"

The humorous comment of the day goes to Zerohedge who said "We can only assume this means keeping on top of Goldman's activities around the globe: after all, when one intercepts god's phone calls, one is mostly interested what the bank that does god's will is doing."

In case you missed the connection, in November 2009 Goldman Sachs' CEO Lloyd Blankfein claimed "Goldman is doing God's work". For details, please see God's Work and Goldman's Prayer.

Mike "Mish" Shedlock
http://globaleconomicanalysis.blogspot.com

Illinois Teachers Pension Fund is 40% Funded, Drops Deeper Into Hole Despite Investment Return of 12.8%; What's the Solution?

In spite of a 12.8% annual return, with an 8% return assumption, the Illinois Teachers Retirement System (TRS) fell another $3.5 billion in the hole. TRS pension underfunding grew to $55.73 billion as of June 30, 2013.

Via email, the Illinois Policy Institute explains the growing liability.

First, TRS only has $0.40 in the bank for every dollar it should have today to make necessary pension payouts in the future. That means the high investment returns in 2013 were earned on less than half of the assets that TRS should have

TRS acknowledged this in a recent press release:

"Despite these strong returns, TRS cannot invest its way out of the funding hole we are in,” Ingram added. “This increase in the System’s unfunded liability, even with good investment results, is another wake-up call to state officials and our members that TRS long-term finances continue to head in the wrong direction."

"Without changes to the pension code to ensure sustained and adequate funding, TRS faces the very real possibility that in a few decades the System will not have enough money to pay benefits to retirees. We cannot guarantee that TRS will have enough money to pay the pensions promised to every member in the System."

Second, the inherent flaws of the state’s defined benefit pension system have driven up the shortfall significantly. According to the Commission on Government Forecasting and Accountability, the state’s pension shortfall grew by $41 billion from 1996 to 2012.

Of that amount, nearly $23 billion came from some form of missed “assumption” that continually plagues defined benefit pension plans:

• The investment returns for the state’s five pension funds were lower than their assumed 8% expectation. Cost to taxpayers: $9.5 billion.
• Unplanned benefit increases for employees. Cost to taxpayers: $1.1 billion.
• Changes in actuarial assumptions. Cost to taxpayers: $4.9 billion.
• “Other” actuarial factors. Cost to taxpayers: $7.2 billion.

TRS fails to acknowledge the failures of the defined benefits plan and instead chooses to blame taxpayers for not contributing enough to the system.

Who is to Blame for Shortfalls?

Please consider the Illinois Policy Center report State pension contributions: Taxpayers bear the brunt of increasing pension costs

A common refrain sounded by public sector unions is that government workers have consistently “paid their share” into Illinois’ pension systems and the state has not. However, the facts tell a different story.

While government worker contributions to Illinois’ five pension systems have increased by 75 percent since 1998, taxpayer contributions have increased by 427 percent over the same period. In 2012 alone, Illinois taxpayers contributed $3.5 billion more to the pension systems than state workers did.



Government workers’ share, as a percentage of total contributions, has continued to decline when compared to taxpayers’ contributions. In 1998, government workers paid for 47 percent of the state’s total pension contribution; today, they only pay 21 percent. By 2045, government workers will be expected to pay only 17 percent of total pension contributions.

Illinois' Five Pension Systems

Illinois has five state pension systems, and all of them are seriously underfunded:

1. The Teachers’ Retirement System, or TRS, manages pensions for teachers across Illinois (excluding Chicago).With more than 130,000 active members and nearly 95,000 retirees, TRS is the largest pension system in the state. Unfortunately, TRS also has the highest unfunded liability of the state’s pension systems. In 2012, TRS was only 40.6 percent funded and officially had more than $53.51 billion in unfunded liabilities. TRS members contribute 9.4 percent of their salary to the pension system.
2. The State Employees’ Retirement System, or SERS, manages pensions for state-level employees across Illinois. It has 62,000 active members and 50,000 retirees. In 2012, SERS was only 33.1 percent funded and had officially $22.13 billion in unfunded liabilities. Under its regular pension formula, SERS members covered by Social Security contribute 4 percent of their salary, and those not covered by Social Security contribute 8 percent of their salary to the pension system.
3. The State Universities Retirement System, or SURS, manages pensions for employees working at state universities. It has 71,000 active members and more than 45,500 retirees. In 2012, SURS was only 41.3 percent funded and had officially $19.46 billion in unfunded liabilities. SURS members contribute 8 percent of their salary to the pension system.
4. The Judges’ Retirement System, or JRS, manages pensions for judges throughout the state. It is one of the two smaller pension systems, with only 968 active members and 725 retirees. Despite its small size, in 2012 JRS was only 28.6 percent funded and officially had $1.44 billion in unfunded liabilities. JRS members contribute 11 percent of their salary to the pension system.
5. The General Assembly Retirement System, or GARS, manages pensions for members of the Illinois General Assembly. Despite having only 176 active members and 294 retirees, GARS has the dubious honor of being the worst-funded pension system in the state. In 2012, GARS was only 17.4 percent funded and officially had $251 million in unfunded liabilities. GARS members contribute 11.5 percent of their salary to the pension system.

All Five Systems Bankrupt

TRS, SERS,SURS, JRS, and GARS are all insolvent. None of them can possibly meet their pension obligations. With 10-year treasuries yielding a scant 2.5%, plan assumptions of 8% are preposterously high on a sustained basis.

Yet, TRS went another $3.5 billion in the hole in spite of a 12.8% annual return.

What the hell is TRS going to do in the face of a stock market plunge, a bond market plunge, or both?

GARS, the General Assembly Retirement System is only 17.4% funded. Is it any wonder that state legislators are pressing for more tax hikes?

Beware Tax Hikes!

On October 18, I reported Illinoisans Beware: "Progressives" Seek Massive Tax Hike Again; Fight the Hike!

Pension shortfalls are the reason for the proposed hikes.

A few people commented the "progressive" tax was not as much as they pay. Here is Rep Naomi Jakobsson’s proposed scheme.



Property Taxes

What I failed to point out previously is that I pay $14,000 annually in property taxes on a home I can sell for $400K or so.

Sales Taxes

My sales tax rate is  7.75%. But hey, that could be worse. Cicero tops the state with a 9.5% tax. In Chicago, the sales tax is 9.25%.

In spite of all these massive taxes, the entire state is bankrupt!

The Solution

Raising taxes for the benefit of legislators and seriously undeserving public unions is certainly not the answer. The solution is twofold:

1. Immediately kill all Illinois public defined-benefit pension plans
2. Drastically lower existing pension plan expectations, via default if necessary

Nothing else can possibly work, and the numbers prove it.

Mike "Mish" Shedlock
http://globaleconomicanalysis.blogspot.com

Four New Challenges to Obamacare: Can Any of Them Possibly Work?

A few days ago an article the LA Times announced LA Times More legal trouble for Affordable Care Act.

The Affordable Care Act proposes to make health insurance affordable to millions of low-income Americans by offering them tax credits to help cover the cost. To receive the credit, the law twice says they must buy insurance "through an exchange established by the state."

But 36 states have decided against opening exchanges for now. Although the law permits the federal government to open exchanges instead, it does not say tax credits may be given to those who buy insurance through a federally run exchange.

Apparently no one noticed this when the long and complicated bill worked its way through the House and Senate. Last year, however, the Internal Revenue Service tried to remedy it by putting out a regulation that redefined "exchange" to include a "federally facilitated exchange." This is "consistent with the language, purpose and structure … of the act as a whole," the Treasury Department said.

But critics of the law have seized on the glitch. They have filed four lawsuits that urge judges to rule the Obama administration must abide by the strict wording of the law, even if doing so dismantles it in nearly two-thirds of the states. And the Obama administration has no hope of repairing the glitch by legislation as long as the Republicans control the House.

This week, U.S. District Judge Paul Friedman in Washington, a President Clinton appointee, refused the administration's request to dismiss the suit. Instead, he said the challengers had put forward a substantial claim, and he promised to issue a written ruling.

"This is a problem," said Timothy Jost, a law professor at Washington and Lee University. "This case could have legs," although "it was never the intent of Congress to establish federal exchanges that can't do anything.

Might Such a Challenge Work?

After reading the LA Times article, I pinged a couple of very bright lawyers and asked if there was any chance such a strategy might work. One of them replied ....

Hello Mish

It's hard to say, especially since there were probably matching changes in the Internal Revenue Code as well.

Usually you can make arguments to help interpret language like this from its context by reading other sections of the law. But what if other sections of the law are worded similarly?

I tend to think that no one intended this result. Will the court rule on intent?

This is highly political charged and tight legal analysis goes out the window when politics enters the room.

It will be interesting to see what happens.

More Constitutional Challenges

In addition to the above legal challenge, the Constitution Daily discusses three additional complications. Please consider Is Obamacare’s legality still in doubt?

From the very day in March 2010 that the President signed that measure into law, it has been under assault on three fronts: in the courts, in Congress, and in nearly three dozen states.   Its central feature is a mandate that individuals obtain health insurance, or pay a penalty to the Internal Revenue Service. Many Americans believe, and even President Obama has been known to say, that the Supreme Court has upheld that mandate.   Perhaps only lawyers and judges can draw a point so finely, but the Court last year actually upheld the penalty without explicitly upholding the duty to obtain insurance, and now both are scheduled to go into effect next year.

One of the reasons why Obamacare cannot escape repeated challenges in court is that it has so many parts to it, and arguments can be made against a good many of them. And one of the reasons that it may continue to be vulnerable, in a potentially devastating way, is that so many of the parts are interacting, and a court decision against one may have a spreading impact on others.

The reality is that the Supreme Court has only begun to be asked to reject key parts of the law, with more cases making their way through the lower courts.  There are four potentially very significant new challenges under way.

Within coming weeks, the Justices are expected to act on the first of this new round of challenges. That is a case being pursued by Liberty University, the religious college in Lynchburg, Va., which contends that the individual insurance mandate interferes with its and its workers’ religious beliefs – a point that the Supreme Court did not consider last year.
 
The administration itself has asked the Court to review, in the current term, the part of Obamacare that requires employers with more than 50 employees to provide their workers with coverage for a variety of birth-control drugs and pregnancy screening methods. This second challenge developed in more than five dozen lawsuits across the country, with conflicting results that the Supreme Court is likely to step in to resolve.

The third new legal protest that may reach the Justices in coming months is a claim, now under review by a federal appeals court in Washington, that the penalty provision that the court upheld last year is itself unconstitutional.  The argument is that, since the Constitution requires that all tax and revenue measures must get their start in the House of Representatives, this provision is invalid because it originated in the Senate. A federal judge blocked that claim, on procedural grounds.

The fourth new challenge is just getting started in several federal courts around the country, and it apparently has major potential for disrupting Obamacare’s interdependent scheme of coverage and thus is growing in popularity with the law’s critics.

Under the law, if individuals’ income is too low for them to afford insurance coverage, they are exempted from the mandate to buy it and can expect to be eligible for government-provided medical care for the poor.

But the government wants many of those individuals to be able to shop for affordable coverage on the new “exchanges,” or insurance marketplaces, that the law creates.   To make them eligible, Obamacare provides a tax credit they can apply toward insurance premiums.  The tax credit offer is considered vital to making the exchanges work, to assure that many of the nation’s lower income families get covered, and to assure that there are enough customers to keep insurance companies offering affordable policies in those exchanges.

The Internal Revenue Service has ruled that this tax credit will be available to lower income people in every exchange across the country. But the new lawsuits contend that the IRS has simply misapplied the law. The law, as they read its wording, says that the tax credit only applies to those shopping at an exchange run by a state government, not at the federal substitutes.

Will Any Challenges Work?

I am not a lawyer, but the first two attacks presented in the Constitution Daily seem narrow enough in scope the court could easily uphold Obamacare but allow individuals to opt out of aspects of the law for documented religious beliefs.

If someone has no insurance now, corporate or otherwise, and can prove on religious grounds that religion is the reason, let those persons opt out, under the proviso they never take medical care at taxpayer expense. How many individuals will that be?

The second attack is even sillier. After all, the law does not force anyone to take birth-control pills or undergo pregnancy screening. If a person does not want those procedures, the remedy is easy: Don't take birth control pills and don't undergo medical procedures you don't want!

The second challenge is so ridiculous it's no wonder Obama actually wants a Supreme Court ruling.

The fourth challenge is the same one presented by the LA Times. My friend offered an educated guess worth repeating "This is highly political charged and tight legal analysis goes out the window when politics enters the room."

I suggest the same may apply to the third argument "Obamacare is invalid because it originated in the Senate".

It is the third and fourth challenges that may have legs.

Second Thoughts?

One California resident with second thoughts says "I was all for Obamacare until I got the bill".

Recall that the Supreme court ruling was 5-4. Is it inconceivable that one of the 5 has second thoughts? If so, Obamacare may die a sudden death and we can start all over.

Let's hope so. This law, as passed is a clear boondoggle in more ways than one.

As many as 16 million Americans will lose their existing coverage that they want to keep. For details, please see More Obamashock! Glitches Hit Paper, Phone Applications; Obamacare Glitch Great Quotes.

Mike "Mish" Shedlock
http://globaleconomicanalysis.blogspot.com

Need a Hand? Boy Gets Prosthetic Hand Made by 3-D Printer (Cost $5 vs. $30K Medical Device)

What do you do when you cannot afford a $30,000 prosthetic hand that your son needs?

Two years ago, Paul McCarthy began searching for an inexpensive yet functional prosthetic hand for his son Leon, who was born without fingers on one of his hands.

McCarthy came across a video online with detailed instruction on how to use a 3-D printer to make a prosthetic hand for his son. McCarthy made a prosthetic hand for his son for a cost of $5 and free time on a 3D printer.



Link if video does not play: prosthetic hand made by 3-D printer

Large Mechanical Hand

A "large mechanical hand" invention by Ivan Owen is what kicked off the technological progression to "Robohand".



Here is an interesting, 49 second Video on Owen's Mechanical Hand

Dexterity To Children With No Fingers

As noted by NPR, 3-D Printer Brings Dexterity To Children With No Fingers followed "Mechanical Hand". Here are a couple of images.





From NPR ...

Richard Van As was working in his home near Johannesburg, South Africa, in May of 2011, when he lost control of his table saw.

The carpenter lost two fingers and mangled two more on his right hand. While still in the hospital, he was determined to find a way to get back to work. Eventually, solving his own problem led him to work with a stranger on the other side of the world to create a mechanical hand using a 3-D printer. Other prosthetics, including a lower jaw, have been made with the technology before, but making a hand is particularly tricky.

In time, Van As from Ivan Owen. In the video, Owen, a special effects artist and puppeteer in Bellingham, Wash., was demonstrating one of his creations, a big puppet hand that relies on thin steel cables to act like tendons, allowing the metal digits to bend.

The two began working together long distance — Skyping, sharing ideas, even sending parts back and forth. Finally, Owen flew to South Africa to finish the work in person with Van As. And today, Van As has a working mechanical finger to assist him with his work.

But something else happened on Owen's visit to South Africa: While he was there, Van As received a call from a woman seeking help for her 5-year-old son, Liam Dippenaar, who was born without fingers on his right hand. The cause was a rare congenital condition called amniotic band syndrome. In ABS, fibrous bands can wrap around a hand or a foot in utero and cut off circulation.

Van As says he and Owen looked at each other and were of one mind: " 'Yeah, easy, no problem.' "

Within days, they developed a crude mechanical hand for Liam, with five aluminum fingers that opened and closed with the up and down movement of Liam's wrist. Owen still remembers the 5-year-old's reaction when they rigged up the device for the first time.

"He bent his wrist and made the fingers curl," Owen says. "You could see the light bulbs go off and he looked up and said, 'It copies me.' It was really an incredible moment."

When Owen flew back to the United States, he wondered if the device could be turned into printable parts.

So he emailed MakerBot, a firm that makes 3-D printing equipment, to see if the company would help out. It did, offering both Owen and Van As a free 3-D printer. "Then there was no stopping us," Van As says.

What had previously taken the pair a week's time or more — milling finger pieces, adjusting and tweaking parts — now took 20 minutes to redesign, print and test.

Eventually, Liam's crude hand was replaced with the improved 3-D printed version, which Van As and Owen call "Robohand."

"After practicing with it for a little while, Liam was able to pick up a coin, grab objects of different shapes and sizes," Owen says. "He's a really determined little guy."

Need a Hand?

If you literally "need a hand" you can Download the Plans and Instructions for Robohand on Thingiverse.

With a 3-D printer and about $150 in parts, you can make a hand. It will work better than the $30,000 prosthetic hands you can get from medical sources.

Strike that. 3-D printers can now make a newer "Lego-style" Snap Together Hand for about $5. Here is an image.



Before any insurance companies approve $30,000 devices, they ought to look into what they can get for $5.

Mike "Mish" Shedlock
http://globaleconomicanalysis.blogspot.com

Senator Harry Reid Supports Giving Illegal Aliens Tax Credits for Kids Not Even Living in US

U.S. Rep. Sam Johnson, R-Texas, left, wants to end the practice of giving illegal immigrants tax credits for kids, but U.S. Sen. Harry Reid, D-Nev., won’t let the House-approved measure H.R. 556 through the Senate.

"The System is Working Fine" says Senator Harry Reid, even though the Joint Committee on Taxation calculates that enactment of H.R. 556 would save taxpayers $24.4 billion over the next decade.

The House of Representatives repeatedly has passed an IRS bill that could save U.S. taxpayers up to $24.4 billion over the next 10 years — but Harry Reid’s Democratic Senate will not hear it.

The Refundable Child Tax Credit Eligibility Verification Reform Act, or H.R. 556, would require tax filers to provide Social Security numbers to claim child tax credits.

Currently, the IRS allows undocumented residents to collect the $1,000 credits for dependents not even living in the country. Watchdog reported that illegal immigrants received $4.2 billion from the tax agency in just one year.

“My bill (targets) billions of dollars in waste, fraud and abuse. Instead of hitting up taxpayers for even more taxes, Washington needs to go after these billions of dollars,” said U.S. Rep. Sam Johnson, R-Texas.

Though the GOP-controlled House has passed Johnson’s measure three times, Senate Majority Leader Reid, D-Nev., refuses to allow the bill to come up for a vote in his chamber.

“The IRS has been doling out the credit to tax filers claiming children who do not even live in the country,” Johnson charged.

Tax preparers agree that the system is broken — and that the IRS must fix it. They say the agency has to stop disbursing ACTC refunds based on Individual Taxpayer Identification Numbers, which are available to undocumented residents.

Tax preparers told Watchdog they have seen clients from Guatemala, El Salvador, Honduras and Nicaragua claiming Mexican children as dependents.

A 2009 TIGTA audit concluded that the child tax credit “appears to provide an additional incentive for aliens to enter, reside, and work in the U.S. without authorization, which contradicts Federal law and policy to remove such incentives.”

Johnson’s bill would impose a 10-year ban on tax filers who commit fraud and a $500 penalty on tax preparers who knowingly bilk taxpayers through the ACTC program.

“I just think the child tax credit is working just fine, and there’s no need to punish children,” the Democratic leader told the Associated Press in February.

Better Ideas

Johnson’s bill would impose a 10-year ban on tax filers who commit fraud and a $500 penalty on tax preparers who "knowingly" bilk taxpayers through the ACTC program.

Proving that a tax preparer "knowingly" sent in a fraudulent return would be next to impossible. What if we paid tax preparers $250 for every illegal immigrant removed from the system?

Active incentives to weed out existing fraud would certainly work better than passive incentives to stop further abuse. If Johnson's bill would save $24 billion, my idea would surely save more.

One could reasonably go further and kill the program in entirety.

Hypocricy and Partisan Politics

One would hope that with budget deficits wildly out of control and with interest on the nation's debt piling up even with historic low interest rates, that common sense measures to save $24 billion would get easy passage.

But such hopes are dashed on the hard rocks of partisan politics. What one party wants, the other doesn't.

Moreover,  I am quite sure enough Democrats would vote for this bill if they were allowed. But they aren't. Reid has blocked the measure.

Recall the outrage by Senator Reid, the media, and the Democrats when House Speaker John Boehner would not allow a vote on a clean budget resolution bill.

Now Reid is doing the same thing, and it's costing taxpayers $24 billion. Where's the media outrage?

Mike "Mish" Shedlock
http://globaleconomicanalysis.blogspot.com

Unnecessary Surgeries? You Bet! Doctors Treat Patients as ATMs; US Healthcare System Explained in Six Succinct Points

There is little to no incentive in the healthcare industry to hold down costs. Worse yet, the rewards for performing unnecessary surgeries is huge, while the risks of doing them are essentially nonexistent. Here are a couple of articles that show what I mean.

Prostate Cancer Radiation Therapy Rises as Doctors Profit

Bloomberg reports Prostate Cancer Radiation Therapy Rises as Doctors Profit.

Urologists who buy their own equipment to provide expensive radiation treatment are more likely to use it to treat prostate cancer even when the benefit for patients is unclear, research shows.

Prostate cancer is the most common tumor diagnosed in the U.S., where an estimated 238,590 men were told they had the disease this year. While only about 12 percent, or 29,270 men, will die from it this year, all will have to decide how, and whether, they want to treat the cancer.

A study published in the New England Journal of Medicine suggests that profits urologists make from referring patients to their own radiation facilities play an outsized role in the treatment decisions. One third of men whose doctors own radiation equipment get the therapy at a cost of about $35,000 per treatment course. The same doctors prescribed the therapy for just 13 percent of their patients before they had their own equipment and could profit directly.

“The results are striking,” said Jean Mitchell, the author of the report and a professor of public policy at Georgetown University in Washington, D.C. “It does appear that what’s driving this is financial incentives linked to ownership. Their behavior changes dramatically.”

Claims Data

Using claims data from the U.S. government’s Medicare insurance program for the elderly, Mitchell found that urologists who didn’t own the equipment prescribed IMRT for 15.6 percent of their patients in 2010, compared with 14.3 percent five years earlier. Its use among the NCCN doctors stayed constant at about 8 percent, while it soared to 44 percent among a matched-group of doctors who started to refer patients to their own radiation treatment facilities.

Self-Referral

“It’s crazy the way the system is set up,” Mitchell said in a telephone interview. “The patients are going to do what their physician tells them to do. The patient becomes almost like an ATM machine, with the doctor extracting as much revenue as they can.”

Ethical Practices

Physicians in general aren’t allowed to refer their patients for treatment in facilities that they also own, because of the financial conflict of interest. However, radiation, as well as in-office ancillary services, such as doing blood work and x-rays, are exempted under U.S. law.

The analysis found that doctors who owned the IMRT therapy were treating men ages 80 and older just as aggressively as younger men with early stage prostate cancer. Since the cancer is generally slow-growing, and radiation can carry immediate side effects, including erection problems and urinary symptoms, the older patients may experience only the harms and no benefits.

The study bolsters similar findings with other forms of self-referral. In fact, some urologists have incorporated pathology labs into their practices, boosting the number of biopsies they perform, Mitchell said. Research has found similar results in other areas, including advanced imaging and surgery at physician-owned specialty hospitals.

Spinal Fusion Cash Cow

The Washington Post reports Spinal fusions serve as case study for debate over when certain surgeries are necessary.

By some measures, Federico C. Vinas was a star surgeon. He performed three or four surgeries on a typical weekday at the Daytona Beach, Fla., hospital that employed him, and a review showed him to be nearly five times as busy as other neurosurgeons. The hospital paid him hundreds of thousands in incentive pay. In all, he earned as much as $1.9 million a year.

Yet given his productivity, some hospital auditors wondered: Was all of the surgery really necessary?

To answer that question, the hospital in early 2010 paid for an independent review of cases in which Vinas and two other neurosurgeons had performed a common procedure known as a spinal fusion. The review was conducted by board-certified neurosurgeons working for AllMed, a company accredited to audit health-care businesses.

Of 10 spinal fusions by Vinas that were selected, nine were deemed not medically necessary, according to a summary of the report.

More than 465,000 spinal fusions were performed in the United States in 2011, according to government data, and some experts say that a portion of them — perhaps as many as half — were performed without good reason.

The rate of spinal fusion surgery has risen sixfold in the United States over the past 20 years, according to federal figures, and the expensive procedure, which involves the joining of two or more vertebrae, has become even more common than hip replacement.

Washington Post analysis of 125,000 patient records also shows that roughly half the tremendous rise in spinal fusions in Florida has been on patients with diagnoses that experts and professional societies say should not routinely be treated with spinal fusion.

In 2009, a former compliance official at the hospital filed a whistleblower lawsuit alleging illegal financial incentives for doctors. The court filings make available an array of documents — e-mails, testimony, audits. These and other sources allow a fuller depiction of the financial rewards and relationships that depended on treatment decisions. They also show how hospital administrators responded when suspicions arose that a doctor, who was generating millions in profits, may have been performing unnecessary surgery.

Vinas and his colleagues in neurosurgery earned as much as thousands of dollars extra — above their base salaries — for each procedure after a certain threshold. The vast majority of Vinas’s earnings came from such incentive pay, according to legal filings.

According to government estimates, each neurosurgeon at Halifax Health was generating more than $2 million a year in hospital profits. The hospital charged fusion patients an average of about $80,000, according to Florida records on Halifax Health analyzed by The Post, ranking the procedure as one of the more expensive.

Baklid-Kunz detected Vinas’s rapid pace of work in an audit and asked for further review of his surgeries, documents show.

But she was discouraged from investigating further, she said.

“Hospital administrators didn’t want to touch Dr. Vinas,” she said in an interview.

Instead, they referred to Vinas and the hospital’s two other neurosurgeons as “our high rollers,” she said, and told her that rather than cracking down on their billing that “we need to make them happy.”

Medicare In the Spotlight

Medicare, the nation’s health-care system for people older than 65, is at the center of the debate.

The agency estimated the amount of money spent improperly on spinal fusions was more than $200 million in 2011, for example, and most of that was because the treatment was deemed unnecessary, often because a more conservative course hadn’t been tried, officials said.

How could this happen?

The answer, in part, is that the Medicare system is not designed to discourage doctors from performing it, according to past and present Medicare officials.

At a very practical level, the bureaucracy offers little incentive to weed out unnecessary treatment: Medicare hires contractors to issue payments to doctors, and those contractors are paid based not on how many claims they reject but on how many they approve.

above emphasis mine

US Healthcare System Greased for Fraud

Medicare pays contractors based on how many claims they approve. Good grief!

Very expensive prostate radiation therapy is conveniently exempt from self-referral laws.

Although physicians in general aren’t allowed to refer their patients for treatment in facilities that they also own (with the exception of radiation therapies), the problem of incentives is universal, across the board.

Physicians paid on an incentive model, like spinal fusion star surgeon Federico C. Vinas, have every financial incentive to perform needless operations.

Every step of the way, the US medical system is greased to perpetuate fraud against taxpayers, against patients, against insurers.

US Healthcare System Explained in Six Succinct Points

1. A constant battle is underway between insurance companies that do not want to pay any claims, even legitimate ones, and doctors and hospitals incentivised to rip off patients, insurers, and taxpayers with unnecessary surgeries and Medicare fraud.
2. Insurance companies demand massive amounts of paperwork out of rational fear of fraud and unnecessary treatments. Doctors perform for-profit (as opposed to for-patient) procedures that guarantee more explanations and more paperwork.
3. Doctors and hospitals have direct personal contact with patients, but insurance companies don't. In cases where doctors put patients at huge risk with needless procedures and surgeries, it's easy for hospitals and doctors to point their finger at insurance companies. On the other hand, many sincere, honest doctors have difficulty getting patients the care they should have because insurers believe they are getting ripped off by unnecessary procedures, even when they aren't.
4. Doctors make needless tests out of fear of being sued for not doing them. 
5. The vast majority of healthcare costs occur in final last year or so of someone's life. Politicians who want to do something sensible about this issue get accused of "rationing healthcare". 
6. Doctors not only have a financial incentive to prolong life needlessly, they also worry about not prolonging life out of fear of being sued by family members unless there is a living will, and perhaps even if there is a living will.

Obamacare Failings

It would have been nice if Obamacare fixed some of the above problems. Unfortunately, Obamacare did not fix any of them.

Fraud, ridiculous amounts of paperwork, and incentives to do the wrong thing were everywhere you looked before Obamacare. The same problems exist now.

Worse yet, Obamacare added to the mess by over-charging millennials and their kids, and undercharging smokers and others with unhealthy lifestyles. Except for those below certain wage thresholds, insurance costs are likely to increase.

Mike "Mish" Shedlock
http://globaleconomicanalysis.blogspot.com

Food Inflation in India Hits 18.4%; RBI Expected to Hike Rates; Pause Before Rupee Collapse?

As food inflation in India soars out of sight, Yahoo! Finance reports India expected to raise interest rates, roll back rupee support

India's central bank is expected to raise policy interest rates for the second time in as many months on Tuesday to fight stubbornly high inflation, while rolling back further emergency measures put in place recently to support the slumping rupee.

Despite the risks to an already sluggish economy, the Reserve Bank of India (RBI) is forecast to lift its policy repo rate by 25 basis points (bps) to 7.75 percent, according to 29 of 41 economists polled by Reuters.

"Given that food price inflation is at a 38-month high, there is a risk that it could spread to generalized inflation expectations," said Samiran Chakraborty, head of research at Standard Chartered in Mumbai.

Annual food inflation accelerated to 18.4 percent in September, its highest since mid-2010, pushed up by prices of vegetables including onions and stirring public discontent ahead of national elections which must be held by next May.

While the central bank looks set to raise its repo rate, it is likely to cushion the blow to credit markets by further unwinding liquidity tightening measures implemented this summer as it struggled to shore up the tumbling rupee.

The rupee slumped to record lows in August, at one point sliding some 20 percent for the year, on concerns about the country's gaping current account and fiscal deficits, and as global investors dumped emerging market assets for fear the U.S. Federal Reserve was set to start tapering its massive stimulus program.

The RBI had jacked up the MSF by 200 bps in July as the rupee sagged. It rolled back 75 bps of that at its September 20 review and another 50 bps earlier this month. The combination of a repo increase and further MSF cuts would restore the gap between the two rates to its usual 100 bps.

The rupee closed on Monday at 61.52 to the dollar, down 10.6 percent on the year, after stabilizing in recent months on the back of India's support measures as well as the delay in the Fed's expected winding-down of its stimulus.

"The strategy will be to continue on the path of dismantling the extraordinary measures taken during the rupee crisis. I don't think he (Rajan) will be ultra-hawkish and will emphasize that growth is a concern and that also needs to be tackled," said Abheek Barua, chief economist at HDFC Bank.

The headline wholesale price index (WPI) unexpectedly hit a seven-month high in September of 6.46 percent as food prices surged, while the consumer price index jumped an annual 9.84 percent, spurring expectations for another rate hike.

Rupee vs. U.S. Dollar



Pause Before Rupee Collapse?

With consumer prices rising at nearly 10% annualized, and food inflation over 18%, a hike to 7.75% is hardly tight economic policy. Moreover, India's property and stock market bubbles are both still going strong.

Supposedly the RBI wants to maintain "growth". But what growth is that? Supposedly real growth takes into account inflation, but I am hard pressed to believe it.

Regardless, this dam may be about ready to collapse, even if India's stock market hits new highs in nominal terms.

Mike "Mish" Shedlock
http://globaleconomicanalysis.blogspot.com

Expect to Be Paid in Spain? This Year? By the Government? Then Take a Haircut!

Here's an interesting post about service providers in Spain, owed money and interest by the government. Via translation from Cinco Dias, please consider Providers Who Want Payment This Year Have to Accept a Haircut

The Delegate Commission for Economic Affairs gave the green light to the last phase of the plan to settle the commercial debt.

€6.5 billion has been allocated to settle unpaid debts to suppliers for outstanding bills prior to December 31, 2011.

The last phase corresponds to unpaid accrued invoices between January 1, 2012 and May 31, 2013. Early estimates suggest that the total could exceed €14.0 billion.

The problem is that the government only has additional €1.7 billion in the current year to meet those debts. The remaining money will be paid starting January 1, 2014 and shall come primarily from Treasury reserves and surpluses that have accumulated in the various issues of bonds and notes recent months.

The government has chosen to prioritize payments to those companies that have major problems or liquidity needs. The Ministry of Finance and Public Administration has reached an agreement with the five big banks (Santander, BBVA, CaixaBank, Popular and Sabadell) to companies that want to get their invoices paid at a discount in December.

Mike "Mish" Shedlock
http://globaleconomicanalysis.blogspot.com

NSA Monitored 60 Million Phone Calls in Spain; Drowning in Useless Data; Hello NSA!

Is there anything the NSA is not monitoring?

That's the question of the day as I note the Financial Times article NSA monitored 60m phone calls in Spain, say media

The US National Security Agency secretly monitored as many as 60m phone calls in Spain in just one month, Spanish media reported on Monday.

The reports, in the El Mundo daily newspaper, are based on information supplied by Edward Snowden, the NSA whistleblower. They refer to the period between December 2012 and January 2013, and again highlight the sheer volume of phone traffic monitored and recorded by the NSA. Spain has about 47m inhabitants.

The documents also revealed that the surveillance was carried out by one of a network of secret US mobile phone listening stations that extends around the world, with manned posts – often in diplomatic missions – in European cities including Berlin, Frankfurt, Rome, Milan, Paris, Geneva and Madrid.

Ms Merkel is sending intelligence chiefs to Washington to seek answers this week. The White House’s own internal review of the National Security Agency is due to provide Mr Obama with an interim report in the week starting November 11.

Drowning in Useless Data

A friend of mine writes

The NSA is currently drowning in data. The approach of grabbing all transmissions is futile. Computer programs to sort through it are futile as well.

For example, this email will probably be caught in the NSA web, simply because of references to the NSA. Because of my frequent international travel which is undoubtedly logged, this email will make it past another filter. Because of my circle of friends in DC, this email may pass another filter.

Because Mish is likely monitored and because I copied someone who frequently visits China, all three of us are likely monitored.

Finally, given this email passed a number of programmatic filters, a human being might actually be reading the entirety of this conversation.

Hello NSA!

Hello NSA agent ... How you doing? Having a good time sorting through useless data, day after day, after day, and wasting taxpayer money in the process?

Mike "Mish" Shedlock
http://globaleconomicanalysis.blogspot.com

Pettis: "Abenomics Likely to Fail in Medium Term, Debt Matters"

Michael Pettis, at China Financial Markets, discusses Abenomics, Japan's shrinking (for now) current account surplus, debt, and interest rates in an interesting email. From Pettis ...

Abenomics in Japan is likely to put upward pressure on the national savings rate in Japan (but not necessarily on the household savings rate). This implicitly requires that over the next two or three years Japan run a higher current account surplus. In a world struggling with excess capacity and insufficient demand, pressure to increase the Japanese current account surplus is likely to result in higher unemployment – either abroad, if Japan’s trade partners do not take steps to protect themselves from the counterbalancing deficits, or at home if they do.

It may seem a little quixotic to worry about a surging Japanese current account surplus just now when in fact Japan’s external balance has declined substantially and is surprising analysts on the downside.

As I discuss in the first two chapters of my January book, "The Great Rebalancing", currency depreciation does not affect the trade balance directly by changing relative prices. It does so indirectly by changing the relationship between savings and investment.

As production rises relative to consumption, the difference between the two – the national savings rate – must also rise. This means that as the yen depreciates, the consequence is likely to be an increase in the Japanese savings rate.

But it doesn’t end there. Japan seems to be taking other steps to force up its domestic savings rate. Here is last Tuesday’s Financial Times:

Shinzo Abe, Japan’s prime minister, pledged to press ahead with the first increase in sales tax for over 15 years despite objections from some of his closest advisers, gambling that measures to address the country’s massive debts would not hinder his attempts to jump-start the economy.

The increase in the consumption tax, part of the proceeds of which will be used to increase infrastructure investment, will accomplish many of the same results as the deprecation of the yen. A consumption tax, like a tariff, is effectively a kind of back-door currency devaluation, with a slightly different mix of losers among the household sector and winners among the producing sector.

By boosting production and reducing consumption, however, it automatically forces up the national savings rate in the same way as does currency depreciation.

So far, this all looks like an attempt by Abe to increase Japanese competitiveness and so increase its total share of global demand, but not by increasing Japanese productivity, which is the high road to growth, but rather by reducing the real Japanese household income share of what is produced. This effectively means Japan will be growing at the expense of its trading partners. As the Japanese become less able to consume all they produce, the excess must be exported abroad.

If the world were in ruddy good health, we might not worry too much about policies aimed at Japan’s pulling itself out of the mess created in the 1980s, but with the whole world struggling with weak demand and with country after country trying to reduce domestic unemployment by selling more abroad – effectively exporting unemployment (with Germany in particular hoping to resolve the European crisis not by increasing its net domestic demand, as it should, but rather by forcing German surpluses outside Europe) – there is a real question in my mind as to how successful the Japanese program of Abenomics is likely to be if it implicitly requires a burgeoning trade surplus.

Expect Higher Unemployment

If Japan forces up its savings rate, and assuming that we are unlikely to return in the next few years to a credit-fueled consumption binge, the only way the world can respond to a structural forcing up of the Japanese savings rate is either by higher unemployment outside Japan or, if Japan’s trade partners take steps to protect themselves from higher Japanese trade surpluses, higher unemployment inside Japan.

Enormous Debt-Servicing Cost

Japan is struggling with an enormous debt burden, and perhaps this explains why Tokyo is so eager to engage in policies that force up the Japanese savings rate. As long as more than 100% of Japanese borrowing is funded by domestic savings (if Japan runs a current account surplus it must be a net exporter, not importer, of capital), it doesn’t have to rely on fickle foreigners, who might not be satisfied with coupons close to zero, to fund its enormous debt burden.

But the debt burden creates its own very dangerous source of trade instability. To understand why, we need to consider what happens to interest rates in Japan if nominal growth rates rise.

In Japan, interest rates are currently very low, close to zero. With total government debt amounting to more than twice the country’s GDP – which puts it among the most heavily indebted governments in the world – it is not hard to see how low nominal interest rates benefit Japan. With interest rates close to zero, there is very little cashflow pressure on the government from servicing its debt.

Real vs. Nominal Interest Rates

Some people might argue that nominal interest rates do not matter. We should be looking at real interest rates, they would argue, and with Japan’s having experienced deflation for much of the past two decades, real interest rates in Japan are high and the nominal rate is largely irrelevant.

This is true, real interest rates do matter, but it doesn’t mean that nominal interest rates do not. In fact both real and nominal interest rates matter, albeit for different reasons. Real rates matter for all the obvious reasons – they represent the real cost to the borrower in terms of a transfer of resources from the borrower to the lender. But nominal rates also matter because they effectively determine the implicit amortization schedule of principal payments.

When the nominal rate is zero or close to zero in a deflationary environment, in other words, interest is effectively capitalized in real terms. In fact, whenever the real rate exceeds the nominal rate, as it has in Japan for much of the past two decades, the cashflow cost of servicing the debt is lower than the real cost, and the difference is effectively converted into real principal and deferred. In real terms, in other words, Japanese debt is growing by the difference between the real rate and the nominal rate, and this effectively represents a reduction in the cashflow cost of servicing its debt.

When nominal interest rates are positive and higher than the real rate, however, there is effectively an acceleration of real principal payments. This means that as long as nominal rates are very low, the real cost of servicing the debt is low and the principal payments are postponed, with some of the interest even being capitalized. As nominal rates rise, however, the real cost of servicing the debt during each payment period consists of interest plus some real principal.

This is just a long, perhaps pedantic, way of pointing out that even if the real interest rate in Japan declines, debt servicing is likely to be much more difficult as the nominal rate rises. Japan might be paying a lower real rate, but it is also implicitly paying down principle, instead of capitalizing it. Tokyo would need a significant increase in revenues, or a significant decrease in expenditures, to cover the cost.

So what would force Japan to raise its nominal interest rate? In principle the nominal interest rate should be more or less in line with the nominal GDP growth rate. If it is higher, growth generated by investing capital is disproportionately retained by net savers (including mainly the household sector). There is, in other words, a hidden transfer of resources from net borrowers to net savers.

If the nominal lending rate is lower than the nominal GDP growth rate, as is the case in China today and Japan during the 1980s, the opposite occurs. There is a hidden transfer from net savers to net borrowers, and because net savers are mainly the household sector, this will put downward pressure on the household share of income even as it gooses investment growth. This hidden transfer has been at the heart of the rapid economic growth that typically occurs in financially repressed economies during the earlier stages, and is also at the heart of the investment misallocation process that typically occurs during the later stages. We have seen this very clearly in China.

Will Tokyo Raise Interest Rates?

Japan is trying to generate both positive inflation and real GDP growth, so that it is trying urgently to raise the growth rate of nominal GDP. What happens if and when it is successful? For example let us assume that Japan’s GDP is able to grow nominally by 4-5% a year – what will happen to the nominal Japanese interest rate?

Tokyo can either raise interest rates in line with nominal GDP growth rates or it can keep them repressed. In the former case, debt-servicing costs would soar, ultimately to 8% of GDP or more. This would create a problem for Tokyo in its ability to service its tremendous debt burden. It would need a primary surplus of around 8% of GDP just to keep debt levels constant, and it is hard to imagine how such a huge surplus would be consistent with nominal GDP growth rates of 4-5%.

If it were to raise income taxes it would create a huge burden for the household sector and almost certainly force up the national savings rate by forcing down the household share of GDP.

On the other hand if, in order to make its debt burden manageable Tokyo represses interest rates to well below the nominal GDP growth rate, it is effectively transferring a significant share of GDP from the household sector to the government in the form of the hidden financial repression tax. This is what Japan was doing in the 1980s, with all of the now-obvious consequences.

Japan’s enormous debt burden was manageable as long as GDP growth rates were close to zero because this allowed both for the country to rebalance its economy and for Tokyo to make the negligible debt servicing payments even as it was effectively capitalizing part of its debt servicing cost. If Japan starts to grow, however, it can no longer do so. Unless it is willing to privatize assets and pay down the debt, or to impose very heavy taxes of the business sector, one way or the other it will either face serious debt constraints or it will begin to rebalance the economy once again away from consumption.

As this happens Japan’s saving rate will inexorably creep up, and unless investment can grow just as consistently, Japan will require ever larger current account surpluses in order to resolve the excess of its production over its domestic demand. If it has trouble running large current account surpluses, as I expect in a world struggling with too much capacity and too little demand, Abenomics is likely to fail in the medium term.

Perhaps all I am saying with this analysis is that debt matters, even if it is possible to pretend for many years that it doesn’t (and this pretense was made possible by the implicit capitalization of debt-servicing costs). Japan never really wrote down all or even most of its investment misallocation of the 1980s and simply rolled it forward in the form of rising government debt. For a long time it was able to service this growing debt burden by keeping interest rates very low as a response to very slow growth and by effectively capitalizing interest payments, but if Abenomics is “successful”, ironically, it will no longer be able to play this game. Unless Japan moves quickly to pay down debt, perhaps by privatizing government assets, Abenomics, in that case, will be derailed by its own success.

Mike "Mish" Shedlock
http://globaleconomicanalysis.blogspot.com