Normative Narratives


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How to Compromise and Fix the ACA

 

Time to Replace Those Repeal Attempts

The Senate’s latest attempts to repeal and replace the Affordable Care Act (ACA) have all failed to pass.

The most comprehensive attempt, the Better Care Reconciliation Act, was voted down 43-57. Defections came from both sides of the GOP–some thought the bill was too hard on low and middle income people, while others thought it left too much of the ACA in place.

With repeal and replace off the table, President Trump changed his tune from “repeal and replace” to “repeal, then [try to] replace”. The Congressional Budget Office (CBO) forecast that “a plan to repeal Obamacare without replacing it could cost 32 million Americans their health insurance by 2026…at the same time, premiums on individual insurance plans would rise 25 percent next year and double by 2026 if Obamacare is repealed.” This effort also failed to gain enough support in the Senate, as it was defeated 45-55.

These CBO projections and Senate votes reflect the fact that people do not want to go back to the pre-ACA days when they could be denied coverage due to pre-existing conditions. As the reality of the modern economy pushes back the typical age of financial independence, the ACA provision allowing young adults to stay on their parents health insurance until 26 has bipartisan support. Minimum standards ensure people who pay for coverage are actually covered when it is time to receive treatment. The individual mandate, while unpopular, ensures a reasonably healthy risk pool for insurers.

All this is to say that the ACA, while imperfect, was designed the way it was for a reason. “A la carte ACA” or the “skinny repeal” would not work, particularly without the individual mandate. Sicker risk pools would lead to a “death spiral“, driving up premiums for middle class customers and subsidy costs for the Government, all while increasing the number of uninsured. For those still keeping score at home, the CBO estimated the “skinny repeal” would result in 16 million Americans losing health insurance over a decade and raise insurance premiums by 20 percent in January. Thankfully, the “skinny repeal” also failed in the Senate, 49-51.

[In other news, the GOP wants to gut the CBO–talk about shooting the messenger]

With so many failed repeal efforts, it is clearly time to try to work towards improving the ACA. Many of the ACAs problems are the result of a lack of competition (see the map above)–private insurers are simply not participating in certain markets, particularly in rural areas (a problem that is expected to get worse in 2018).

The solution to this market failure is to create competition by allowing people to buy into the Medicaid “Public Option”.

I can already hear the outrage from Conservatives–“of course a liberal’s answer is more government”–but hear me out. The Public Option need not increase government spending drastically; people would receive healthcare at cost, but they would still pay–this is not a Medicaid for all as an entitlement proposal. Sure, administrative costs for the government would rise as the program absorbed more people, but the marginal cost of providing care for people who are currently ineligible for Medicaid should be close to zero (some scaling would be needed to smooth costs for people just above Medicaid thresholds).

Furthermore, with the Public Option in place, Medicaid would be in even better position to negotiate lower drug prices with pharmaceutical companies, a cost-saving idea championed by many, including President Trump.

Of course, in order to garner support for a Medicaid Public Option, concessions must be made to conservatives.

Removing the employer mandate:

With a reliable, affordable option that covered all essential health benefits, people would have a much clearer economic decision to make–accept a job that pays less but offers insurance, or take a job that pays more knowing they have to set aside a certain amount for insurance. The Public Option would make buying health insurance a predictable financial choice for the first time in American history.

This concession tackles a major criticism of the ACA–small businesses would no longer be required to factor in the cost of providing health insurance when deciding whether or not to hire more employees.

A higher employee threshold could also be kept in place to ensure larger corporations offer a health insurance option to their employees

Reviving Ted Cruz’s Essential Benefits Plan:

For those not familiar with it, Ted Cruz proposed a plan in which health insurers would be able to offer non-ACA complaint plans–ones that do not cover all essential health benefits–as long as they offer a plan that does cover them as well.

Clearly marking which plans do and do not cover all essential health benefits would be important, but it would also be easy enough. The real issue with Cruz’s plan was there was no way to ensure the ACA-compliant plan was being offered at a reasonable rate, and not just as a token to unlock the right to sell non-compliant plans. 

But with the Public Option, it wouldn’t really matter; if the ACA plan was offered at an unaffordable rate, people would have the choice to opt-in to the Public Option. 

This concession tackles another major criticism of the ACA–people would no longer have to buy insurance covering care they don’t feel they need.

President Trump said “Obamacare is Death”, while Senate majority leader McConnell called it a “nightmare”–empty hyperbole meant to scare people who do not know better. In the darkest of ironies, their very replacement ideas would have truly be a living nightmare for millions, and would have lead to many preventable deaths.

In defeat, President Trump tweeted (of course he did) to just let Obamacare fail. There is much his administration can still do to undermine the laws effectiveness if it truly prioritizes political vendettas over the well-being of American citizens. The GOP has (thankfully) proven it can still be the party of “No” when it comes to Healthcare, even when it is the majority party. Now is the time to see if it can be the party of “Yes” for a stronger, bipartisan plan, the American people want and deserve.

Update (8/24)

Every U.S. county is expected to have an insurer in the 2018 Obamacare marketplaces. However, having one insurer does not mean there is competition or choice. 1,478 counties could have only one insurer in 2018, potentially leaving customers without an affordable option.

Expect more updates as 2018 plans are finalized in the coming weeks.

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Transparency Report: Youth Unemployment and Depression

https://i2.wp.com/www.nhs.uk/Conditions/stress-anxiety-depression/PublishingImages/C%20to%20D/Depression-support-groups_364x200.jpg

According to a recently release United Nations report, depression is the number one cause of illness and disability globally among adolescents (10-19 yrs old):

We hope this report will focus high-level attention on the health needs of 10 to 19-year-olds and serve as a springboard for accelerated action on adolescent health,” said Flavia Bustreo, Assistant Director-General for Family, Women and Children’s Health at the UN World Health Organization (WHO).

An estimated 1.3 million adolescents died in 2012, largely from preventable causes, according to the UN agency’s Health for the world’s adolescents online report released today.

Depression was found to the be the greatest cause of illness and disability in this age group, with suicide raking third as the cause of death among young people.

This report reminded me of a journal article I read during my studies, “Development Economics Through the Lense of Psychology” (abstract excerpt below):

Economists conceptualize a world populated by calculating, unemotional maximizers. This view shapes our understanding of many crucial elements of development economics–from how rural villagers save, to how parents decide on whether to send their children to school.

Psychological research, however, has documented the incompleteness of this perspective. Individuals have self-control and time inconsistency problems. They can give into shortrun temptations and later regret it. They can have strong feelings about others that drive them to commit both generous and spiteful acts. They often passively accept defaults rather than make active choices. They let the institutions around them make choices for them. And they may misread new data in a ways that fit their beliefs. In short, the rational maximization model may not be a very good approximation of human behavior.

While this journal article does not explicitly cite mental illness or depression, due to my own experiences with depression my thoughts turned to the subject. There is no one cause of depression; there are elements of both “nature” (genetic predisposition) and “nurture” (experiences in life). However, “nurture” causes tend to be more direct and therefore preventable: dehumanization / pessimism related to poverty, uncertainty about the future, and unemployment:

In the shadow of the Great Recession lies a deep depression: Youths in their 20s and early 30s are hitting new lows. Compared with older workers who have lost their jobs, young people face more complex and layered hardships that could last most of their lives. They are experiencing disproportionately high unemployment, stretching indefinitely into the future, in an increasingly unequal and uncertain social landscape. And just when they are most in need of social support, the recession has led lawmakers to erode the welfare and employment programs that youths need to move themselves — and the economy they have inherited — toward recovery.

For young people in the United States and Europe, there is an emotional layer to this economic malaise. According to a recent U.K. survey of 2,161 people ages 16 to 25 by nonprofit advocacy group the Prince’s Trust, the unemployment epidemic is driving a mental-health crisis. While overall happiness levels for the surveyed youths stayed about level over the past year, reported emotional health fell significantly for the segment that is out of the workforce and not in school or job training. These young people experienced feelings of despondency and hopelessness at a higher rate than their peers. Chronically unemployed youths were more likely to have experienced panic attacks, engaged in self-harming behavior or felt suicidal. Mental-health problems struck 4 in 10 jobless young people “as a direct result of unemployment,” according to the Prince’s Trust.

One woman interviewed for the study said, “Being out of work stripped away my self-worth and made me feel like a waste of space.”

While this study considers young people in the U.S. and Europe, one can assume that young people in the developing world experience similar issues, as  youth unemployment is expectedly worse in many less developed countries.

Depression stunts personal development; how can someone invest in themselves or act as a long-term “rational maximizer” when they cannot see any hope in their future? But children are the future, and the number one illness affecting them is depression. To not pay the price to treat depression in adolescents is incredibly shortsighted–perhaps policy makers also do not act as “rational maximizers”, at least if the thing we hope to maximize is long-term social welfare.

The costs of inaction are not limited to lost economic output, human suffering and suicide, there are also security risks associated with leaving depression untreated:

Adam Lankford, a professor from the University of Alabama, concluded that many suicide terrorists weren’t ideologues at all—but were, in fact, classically suicidal. He cited Israeli scholarly research of would-be Palestinian bombers: Forty percent of them exhibited suicidal tendencies; 13 percent had already attempted suicide, unrelated to terrorism. Lankford went on to mention a 9/11 hijacker who wrote a final note to his wife and lamented how he never lived up to her expectations. Lankford described other terrorists in Palestine and Chechnya who were in poor health, recently divorced, or financially insolvent in the months prior to an attack. He also talked about the terrorist recruiters who admitted to looking for the “sad guys” for martyrdom.

While this study is far from conclusive, it would be closed-minded to refuse to consider the relationship between mental illness and terrorism. People with depression are often looking for meaning and companionship; joining a terrorist organization provides both.

And this security risk is hardly confined to the developing world; one would be hard pressed to find a mass killing anywhere in the world that is not linked to some form of mental illness. To be fair, no statistical relationship between teen depression and violent crime has been established, although this does not rule out the strong possibility that there is some relationship between mental illness and violence.

As someone who has experienced depression, this reports findings hit close to home. I am fortunate to have been born into an upper-middle class American family and receive top notch treatment–most people are not so lucky. Depression and other forms of mental illness are often seen as a “rich person’s disease”, and treatment as a luxury. This study refutes this misconception–depression can affect anyone; old or young, rich or poor. The universality of depression gives hope that it is an issue the global community can rally around and adequately address.

Increased access to mental healthcare must be part of healthcare reforms in both developed and developing nations. This is not an abstract concept, inaction has real costs that affect many people. Further compounding this problem is the existence of a stigma against people with mental illnesses (which is likely more prevalent in less developed places). When one feels ashamed of having a mental illness, the condition generally becomes worse and treatment is not sought. Part of the solution may be educating people to break this stigma.

The prevalence of depression amongst the world’s youth is alarming, but unfortunately to this social scientist / previously depressed young adult, it is not surprising. If depression can affect people who have had all their needs met, imagine how prevalent (and under-diagnosed) it must be the world’s most impoverished areas. Failure to treat mental illness not only impedes an individual’s positive liberties, it can also result in the most grievous violation of ones negative liberties possible–murder.

For some, finding employment is enough to alleviate the symptoms of depression. For others, treatment and therapy are required. Many anti-social behaviors can be tempered by a global push to address depression in adolescents, hopefully this U.N. report focuses a stronger spotlight on preventing and treating adolescent depression.


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Transparency Report: Notification, You Have 5 Billion New FB Friends; The Human Right To Internet Access

At the beginning of my internship at the UNDP, I was lucky enough to get the chance to volunteer at and then attend the ECOSOC Partnerships forum. I was assigned to write a few blogs for the event, among a number of other blogs I have written about events at  the UN which for some reason I have never shared on NN. Perhaps someday I will release the rest of the “lost UNDP blogs”, but that day is not today. Here are notes from the event Policy Dialogue: “The Changing Face of Technology and Innovation” (full blog):

The second policy dialogue at the ECOSOC youth forum focused on how technological innovations in recent years have helped bridge the “digital-divide” between developed and developing countries. While the gap has not been fully closed, partnerships between the private sector, governments, non-governmental organizations and civil society groups have helped identify challenges and opportunities in the developing world. By creating differentiated products at lower costs, private companies can gain access to new markets while simultaneously empowering the people in those markets.

Internet access is considered one of the great technological advances of our time. Internet access empowers people; the possibilities are constantly evolving and literally endless. It is an essential component of “E-Governance”, which includes the dissemination of information and a more inclusive and democratic government agenda-setting process. With a greater push for accountability and inclusiveness mechanisms in the Post-2015 Development Agenda, internet access, bolstered by innovations in mobile technology, has become an increasingly important tool for achieving sustainable human development.

But not enough has been done to make internet access affordable for a large portion of the world’s population. According to Mr. Tuli, 3 billion people have mobile phones but no internet access. This is not because of a lack of electricity or communication networks (as evidenced by the fact that they do have cell phones), but because they are priced out of the market. Mr. Tuli went on to call basic internet access a “human right”, to resounding applause from the hundreds of participants in the ECOSOC chamber.

While mobile technology was originally thought of as an educational tool, it has since evolved beyond that (although mobile education is still a proposed root for overcoming education deficits in Least Developed Countries (LDCs)). E-Governance can help disseminate information and promote inclusive governance, creating an enabling environment for sustainable human development. Healthcare providers can connect to information and expert advice in ways that can save lives. E-Finance can help provide capital in a much cheaper and convenient way to previously isolated groups, unlocking the entrepreneurial spirit in the developing world (and making such endeavors potentially much more profitable). Even people who are off traditional power grids (the least developed places in the world without basic infrastructure), mobile renewable energy generators and wireless internet capabilities can help bring ICTs virtually anywhere in the world.

Mobile technology penetration can be very rapid. Competition between private sector actors can drive prices down to affordable levels, and in some cases subsidies can help. Mr. Ogutu told the story of mobile phone penetration in Kenya; 5 years ago there were 20,000 users, today there are over 30 million users. This was made possible by M-Kopa, a company that utilized E-finance to provide pay-as-you-go mobile solar powered electricity to poor people who are not on a conventional power grid. Financing—secured through PPPs—allowed the founders of M-Kopa turn their vision into reality.

The narrative on bringing internet access to the least developed areas of the world continues a few months later. Not surprisingly, behind the initiative is a large-scale public-private partnership, with publicity magnet Facebook at its core (original article):

Mark Zuckerberg, chief executive of Facebook, announced the launch of Internet.org Wednesday, a project aimed at bringing Internet access to the 5 billion people around the world who can’t afford it. The project is the latest initiative led by global-communications giants to combat market saturation in the developed world by introducing the Internet to remote and underprivileged communities.

“The goal of Internet.org is to make Internet access available to the two-thirds of the world who are not yet connected and to bring the same opportunities to everyone that the connected third of the world has today,” Zuckerberg said.

“There are huge barriers in developing countries to connecting and joining the knowledge economy,” he added. “Internet.org brings together a global partnership that will work to overcome these challenges.”

The project will develop lower-cost, higher-quality smartphones and deploy Internet access in underserved communities, while reducing the amount of data required to surf the Web. Other founding partners include Samsung, Qualcomm, Ericsson, MediaTek, Nokia and Opera.

Facebook and other tech giants, of course, have a significant financial stake in expanding in the developing world. With tech companies reaching market saturation in the United States, countries in Latin America and Africa, for example, offer a big opportunity to attract a steady stream of new users, whose data can be mined by advertisers.

Connecting more people globally has important implications for how people organize their lives, said Patrick Meier, co-founder of the Harvard Humanitarian Initiative’s program on Crisis Mapping and Early Warning. Social media has become a lifeline to people affected by earthquakes, floods and conflicts in the developing world, he added.

In places where the state is limited, Meier added, the Internet becomes a way to make up for services the government fails to provide. “When the state is not there, when you talk about limited statehood, you get a void,” he said.

In addition to acting as a substitute for the state in the context of “bad governance” / conflict / crisis environments, mobile technology should be a tool utilized by the state to promote inclusive and indiscriminate human rights based governance for sustainable human development. ICT connects people, enabling social accountability (people claiming their rights) by overcoming collective action problems. There are also myriad standard of living benefits associated with bringing ICT in the developing world–micro-financing, healthcare, education, media, etc. (OK maybe I am a little biased, I want those 5 billion readers too 😛 ).

Furthermore, by utilizing open-source technology and the collective will and creativity of 5 billion people facing similar problems, innovations in one part of the developing world can be adapted to the local needs of other developing regions. This would further expedite the global development process–open-source technology should be a core feature of the global internet connectivity push.

The possibilities are literally endless, as the utility and functions of the internet continue to evolve at ever faster rates. It should also be noted that new technological capabilities in LDCs will necessitate new policies, laws and oversight mechanisms to ensure gains are shared fairly. However, since these technologies are only new to certain regions, digital accountability mechanisms already exist for these regions to build on.   

I cannot stress enough how important bringing mobile ICTs to least developed countries is for sustainable human development, nor can I know how the technology will evolve in the future. Providing access to mobile information and communications technology empowers people, creating an enabling environment for a multitude of interrelated development objectives. These positive forces will naturally synergize, empowering people to challenge power-imbalances and hold powerful groups accountable for their human rights obligations.

ICTs are a natural fit for a large scale public-private-partnership (PPP). Companies can provide most of the start-up capital and technical know-how. Governments can create an education campaign about the benefits of ICTs and how to use them, while also guaranteeing companies market access and security of any capital / infrastructure installations (extremist groups will not like this idea as closing government service gaps will restrict their ability to buy goodwill and recruit new members). As ICTs help sustain the development process, new markets will emerge for communications companies to sell their products and services. This means more profits for companies, more tax revenue for governments, and a higher standard of living for people in LDCs. Not to suggest vested interests will not try to play spoiler (my regular readers by now know this is not the case), but overall a this is a win-win-win partnership.

Due to the indisputable importance of ICTs for sustainable human development, internet access should become an internationally recognized human right. Human rights obligations are primarily the responsibility of the state; in this case however, it seems that states have a willing and capable partner in the private sector. I will continue to keep the NN community up-to-date on this potentially-world-changing initiative.


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Transparency Thursday: Generic Drugs in the Developing World; Is Access to Quality Healthcare a “Human Right”?

As the partisan fight over the right to healthcare rages on in America, significant steps are being made to ensure that the world most impoverished receive access to life saving drugs at affordable prices:

“The two companies that make vaccines against cervical cancer announced Thursday that they would cut their prices to the world’s poorest countries below $5 per dose, eventually making it possible for millions of girls to be protected against a major cancer killer.

Thanks to Pap tests, fatal cervical cancers are almost unknown today in rich countries. But the disease kills an estimated 275,000 women a year in poor countries where Pap tests are impractical and the vaccine is far too expensive for the average woman to afford, so the price cut could lead to a significant advance in women’s health.”

“The low price will initially apply to a few million doses for demonstration projects in Kenya, Ghana, Laos, Madagascar and elsewhere, but Dr. Seth Berkley, the alliance’s chief executive officer, said he hoped that by 2020, 30 million girls in 40 countries would get the vaccine at that price or less.”

“The vaccines cost about $130 a dose in the United States, and each girl needs three doses. The lowest price that any other agency or government has negotiated, Dr. Berkley said, is the $13 paid by the Pan American Health Organization, which negotiates a bulk price for Latin American countries.

Since Latin America includes a mix of poor and middle-income countries, the manufacturers do not offer rock-bottom prices there, he said. The alliance subsidizes vaccine costs for the poorest countries in Africa, Asia and elsewhere, with the subsidies shrinking as the countries get richer.”

“Dr. Julie Gerberding, a former director of the Centers for Disease Control and Prevention who is president of Merck’s vaccine division, said $4.50 was Merck’s manufacturing cost, with no previous research, marketing or other costs built in.

‘The price is what we calculate to be our cost of goods — we could be off by a few cents but not more,”’ she said. ‘As we expand volumes, the cost per unit can go down. Our intent is to sell it to GAVI at a price that does not bring profit to Merck.’”

“Dr. Berkley described the new prices as a ceiling, and said he expected them to go down as millions more doses were ordered and as rival vaccine makers from lower-cost countries like India and China entered the field. Other companies, including the Serum Institute of India, the world’s largest vaccine manufacturer, are developing papillomavirus vaccines, but at the moment only the Glaxo and Merck vaccines have approval from the World Health Organization.

The alliance, Dr. Berkley said, has already negotiated sharp price drops in the cost of pentavalent vaccine, a shot that protects against diphtheria, tetanus, whooping cough, hepatitis B and Haemophilus influenzae B.

That shot costs about $30 in wealthy countries and the alliance first started purchasing it at $3.50. “Now we’ve got it down to $1.19,” he said.”

The “spotlight effect” continues to be one of the main drivers influencing prescription drug maker’s decisions in the developing world. The Access to Medicine Index is one example of how much company’s value the goodwill they receive from socially conscious operations. A Google search of “pharmaceuticals CSR” (corporate social responsibility) yields results from many major pharmaceutical companies highlighting their work in the field.

It is no secret that the Pharmaceutical industry, which is dominated by large multinational corporations, realizes very large profit margins. There is nothing wrong with large profit margins (despite what some may think based on the content of this website, I am a great supporter of capitalism and it’s self-perpetuating innovative mechanisms, as long as there are rules to make sure companies are not taking advantage of society as a whole in the name of maximizing shareholder earnings), as there are significant research and development costs associated with creating new medicines.

On moral, ethical, and even economic grounds, it is difficult to defend companies not allowing developing countries to produce generic versions of their drugs. There is no loss of revenue for the drug companies; these people are not sitting on cash waiting for handouts, they would not be able to afford the drugs at a higher cost. Economics calls this “third degree price discrimination”; selling a good at a lower cost based on the realities of the targeted market. The goodwill and positive press these companies receive is just icing on the cake if pharmaceutical companies sell their drugs at cost (zero profits, but all costs are covered; financially it is a wash and in so many other ways beneficial).

One of the main concerns is that, by allowing developing countries to produce generic versions of drugs, “black markets” will form as criminals in these countries–which tend to lack the oversight capacity—will export these cheaper drugs to wealthy nations. A study by the Universities Allied for Essential Medicines refutes these claims, “pharmaceutical arbitrage from poor countries to the high income was “still largely theoretical.”

But the “spotlight effect” is not a sustainable way to ensure the poor have access to life saving vaccines. “According to the WHO, 10 million people die every year that could be saved by existing drugs.” To this end, India’s Supreme Court recently set legal precedent for protecting generic drug producers:

“Production of the generic drugs in India, the world’s biggest provider of cheap medicines, was ensured on Monday in a ruling by the Indian Supreme Court.”

“The ruling will also help India maintain its role as the world’s most important provider of inexpensive medicines, which is critical in the global fight against deadly diseases. Gleevec, for example, can cost as much as $70,000 a year, while Indian generic versions cost about $2,500 a year.”

“In Monday’s decision, India’s Supreme Court ruled that the patent that Novartis sought for Gleevec did not represent a true invention.”

“I think other countries will now be looking at India and saying, ‘Well, hold on a minute — India stuck to its guns,’ ” said Tahir Amin, a director of the Initiative for Medicines, Access and Knowledge, a group based in New York that works on patent cases to foster access to drugs.”

Essentially, the Indian Supreme Court ruled that in order for a drug to receive a renewed patent (and thereby disallowing generic version to be produced), a “true innovation” in the drug has to be proven. Simply changing proportions of minor ingredients, or repackaging an existing drug as something new, will not allow companies to get new patents.

Some in the pharmaceutical industry have tried to protect their interests, saying this ruling will compromise their “ability to develop and manufacture innovative medicines.” I believe we will see the opposite effect. Companies, knowing they need truly innovative breakthroughs to receive new patents, will focus their efforts on creating these new drugs, instead of tinkering with existing drugs in hopes of extending their IP rights on drugs they have already greatly profited off of.

What do you think? Certainly Pharmaceutical companies have reaped huge profit margins, and benefit from an implicit oligopoly (various barriers to entry make new Pharmaceutical companies almost non-existent).

Is there a moral obligation for pharmaceutical comapnies to allow cheap generic alternatives to be produced for people in the developing world? Or is it just an act of charity when these companies do something socially responsible, but not something those in the developing world should count on? Or is it up to the legal systems in the developing world to stand up to vested interested, and uphold the right to access to affordable medicine for their citizens, as the Indian Supreme Court recently has done?