Monday, September 30, 2013

Six Political Games People Will Play with ObamaCare
Game theory applies to a whole range of behavioral relations and has developed into an umbrella term for the logical side of decision making to include both human and non-human activities, like computers
Game Theory
ObamaCare  officially starts tomorrow, October 2. 
With this auspicious start,  let the games begin.
·         Game One - Here It Comes,  Ready or Not -   This was originally a child’s game but it has been transformed into a childish  game for political grownup.  Democrats are adept at this game.  Their computer systems are not ready,  but they claim they will be, given a few hundred glitches or so, and confusion among businesses, and especially  among  those 48 million uninsured or underinsured, who  are being asked to sign up electronically  on those online marketplaces,  even though many have no online access.

·         Game Two – Chicken - The game of chicken, also known as the hawk-dove game or snow-drift game, is a conflict for two players in game theory. The principle of the game is that while each player prefers not to yield to the other, the worst possible outcome occurs when both players do not yield. In this case, the worst outcome is a government shutdown  with the government being unable to pay its bills.   

·         Game Three – Blame Game -  This is a situation  in which one party blames others for something bad or unfortunate rather than attempting to seek a solution.   It is characterized by each party saying the other is acting in bad faith and using personal expletives to explain their bad behaviors – “extremists,” “anarchist,”  “extortionists,” “terrorists,”  “socialists,” or  “tea-partyists.”  A variation of this game is “Pin the Tail on the Donkey,”  where-in blindfolded politicians seek to cast blame on the other for having closed or irrevocably biased mindsets.

·         Game Four – Budget Games -  This is an arcane  game perfected inside the Washington Beltway.   It pits those decrying  the current budget deficits ($17 trillion and growing) against those describing the budgetary slowdown and assuming future budget projections by a responsible government.  The latter are known as Rosy Scenarios.    In the case of ObamaCare, its backers assume “government savings” will offset health inflation.  It also assumes most ObamaCare provisions are “mandatory,” untouchable politically, rather than “descretionary,” negotiable between parties. 

·         Game Five – The Waiting Game – This is a stratagem of deferring actin and allowing the passage of time to work in one’s favor.   The Republican bill delaying ObamaCare for a year is an example.   The Waiting Game may include action points, such as repealing the medical device tax, which is favored by 75 senators,  to  make it more credible and to curry the vote of Red State Democrats, whose states contain  vibrant  medical device industries which may close down or not expand because of the tax.  On the GOP side,  a variation of the game is to let ObamaCare proceed and hope it collapses or results in a monumental mess before the 2014 midterms.  Democrats dislike the ObamaCare Waiting Game, preferring to chance a rapid introduction with a a subsequent irreversible public addiction. 

·         Game Six -  Computer Games -  These games used to be called PC or video games, played mostly by the young or consenting adults.   But now Iphones, smartphones, tablets, and other forms of mobile devices have eclipsed the older information technologies.  It is assumed in the near future, smartphones and their variants will link more than half the population with government websites telling them where to shop for government-approved health plans and where to sign up for these plans.   In this way,  centralized government will become capable of controlling the health care action.
Health care gamesmanship and one-upsmanship are  afoot.  These health  games are serious political gambits   They designed to give one party an advantage over the other without really admitting it.
Tweet:   With tomorrow’s introduction of ObamaCare, a series of health care games are underway which will the determine the fact of health care law.


Sunday, September 29, 2013

Noble and Quotable: Taking the Temperate of The New York Times Two Days before ObamaCare Implementation
I regularly peruse the New York Times to take the temperature of U.S. liberals on health care reform.  The Times, the Bible of American liberalism   supports the health reform law  as directed from Washington and as espoused by  Obama. 
My conclusion from three articles and an editorial  in today’s September 29,  Times  might be summarized as follows: “Warily, Warily, but Resolutely , I say unto you,  the long awaited Revolution has arrived.”
Quote One: Katie Thomas and Reed Abelson, “ On the Threshold of ObamaCare, Warily,”   The Insurance marketplaces that form the centerpieces of President Obama’s  health care law are scheduled to open on Tuesday, the watershed moment for the Obama administration , but also the turning point for millions of Americans who will finally get the chance to square the law’s lofty ambitions with their own personal needs.”
Quote Two: Jonathon Weisman and Jeremy Peters, “ House Leaves U.S. on Brink of Shutdown; Demands 1-Year Delay of Health Care Law, “ The federal government on Saturday barreled toward its first shutdown in 17 years after House Republicans, choosing a hard line, demanded a one year delay of President Obama’s health care law and the repeal of a tax to pay for the law before approving any funds to keep the government running.”
Quote Three:  Elisabeth Rosenthal,  “ ‘Affordable Care’ or a Rip-off ?”,  “As Americans begin signing up this week to buy insurance, they will begin to test the legislation’s tantalizing promise to make health financially viable.  Will the policies deliver care at manageable prices, or will ‘affordable’ seem like a hollow promotion’?”
Quote Four: Editorial board, “Dawn of a Revolution in Health Care,”  “The United States is embarking on a truly historic journey this week.  Staring Tuesday, the federal government  will make it possible for millions of uninsured Americans who can’t get insurance , or can’t afford it, to obtain coverage with aid of government subsidies.  It is a striking example of what government can do to help people in trouble…After decades of debate and bitter political battles, millions of uninsured Americans will soon be able to get health insurance they can afford, a right that has long been universal in other advanced nations.”
Closing Prayer
Let is pray Obamacare is not like the purse of gold in Shakespeare’s King Henry the Fourth which was “resolutely snatched on Monday night and most dissolutely spent on Tuesday morning” or like Solomon Grundy of nursing rhyme fame, who was “Christened on Tuesday, Married on Wednesday, Took ill on Thursday, Worse on Friday, Died on Saturday, Buried on Sunday.”

Tweet:  The New York Times is cautiously optimistic about the prospects of Obamacare for affording affordable health care.

Government Shutdown.  Beyond Human Scale?
A large organization that does not make effective use of its human resources will inevitably suffer further erosion of its position. It will no longer be able to enhance its values and its goals.
Eli Ginsberg and George Voyta, Beyond Human Scale,  Basic Books, 1983
Early this morning the House passed a bill funding the government through December 15 but defunding Obamacare, delaying its implementation for a year, repealing the medical device tax, and  assuring pay for the military.  
Harry Reid, the Senate majority leader,  has already said the Senate will not approve it, and President Obama says if passed by the Senate,  he will veto it.  Government shutdown, without a  last minute compromise, seems inevitable.
This shutdown is understandable when one considers the fixed ideological positions of the political combatants – one believing big government can fix all social ills, the other saying the solution lies in the marketplace. 
Both may be wrong.  The complexities of managing and constraining the costs  of  health and economic affairs of a large national society, complicated by its interaction with the global economy, and the peoples’ desire for the best health care, particularly if ti comes at somebody else’s expense, namely, the federal government,  may be beyond human scale.
The official name of Obamacare,  the Patient Protection and Affordable Care Act,  may be an oxymoron.   Because of complexities of the human condition and the quest of humans to prolong and improve their lives at any cost,  it is difficult to control costs while protecting us against all eventualities.   Containing costs while expanding access to all may be an unrealistic goal.
This is not the fault of either political party.  It is inherent in our biological destinies and our yearning for the best health and the best lives we can possibly have.  As Milton Berle, the American comedian said, “When it comes to my health, money is no object.”
As for the President,  it may be beyond his human  capacity to expect him to downgrade his signature domestic achievement, and to make complex, often contradictory decisions, that grow the economy, manage a huge bureaucracy, keep his subordinates in line, and please his critics, foreign and domestic.
Patient protection and health care affordability are noble, praiseworthy goals.  They are worth working towards, but in the end they may be unachievable.
Disease prevention and wellness are admirable movements, but in the end,  we shall all develop chronic diseases, and we shall all die.  The limits of human life and longevity are fixed, and no amount of money or investment in research are going to avoid chronic conditions or death.   Managing prevention and promoting wellness will help at the margins, but cancer and arteriosclerosis and other life-shortening conditions,  will always be with us.
It may be that government rationing  with all the bells and whistles of modern management science and big data apps  will decrease costs to a manageable level by making health care more efficient.   It may be that cutting $700 billion out of entitlement programs and transferring the money to Obamacare will redistribute benefits and give everybody a “fair share” of federal monies and  health benefits.  It may be that accountable care organizations,  bundled payments, comparative outcome data, paying only for what works,  ending fee-for-service,  putting doctors on salaries paying them less,  replacing them with coordinated teams,  and reimbursing hospitals for episodes of care, will decrease strains on the federal budget.
That said,  none of these governmental steps will significantly change human behavior.   People will continue to engage in activities harmful to their health, they will eat the wrong foods,  exercise too little, and they will continue to want choices of doctors, hospitals, and health plans; to  insist upon the best treatments that medicine has to offer.  

Physicians will continue to enter specialties that give them the best prospects for paying off their educational debts and their creditors, maximize their incomes, master the knowledge for their fields, maximize the health of their patients.  and allow them to  lead balanced lives.   Innovators and entrepreneurs will continue to innovate and to seek venture capital to promote their ideas and to improve care,  no matter how disruptive or inconvenient  to the government or health establishment.   
Tweet:  Preventing a government shutdown due to entitlement and health costs may be impossible given the human scale and desires for the best care.

Saturday, September 28, 2013

The Psychology behind Fault-Finding and Government Shutdown
Faults are thick where love is thin.
James Howell (1594-1666), Proverb
The blame game over the impending government shutdown  over ObamaCare in three days is peaking  on both sides of the aisle.  It is getting nasty.
·         President Obama blames Republicans for “extortion,” “extremism,” and “hostage taking.”   He accuses Fox News of “misinformation.”   Senator Harry Reid is transparently dismissive of any GOP efforts to defund the ObamaCare .Minority leader Pelosi  labels Republicans as “legislative arsonists.” Tea Party “terrorists” are the butt of much of the criticism, which is growing quite personal. 

·         The Republicans say President Obama’s refusal to negotiate is the source of the problem, and surely some sort of compromise is possible if only the President would talk with them.  If he can negotiate with the presidents of  Russia and Iran, why not with us, why not  his fellow Americans  And if his law is good enough for  Congressional lawmakers and their staffs,  why not for ordinary Americans.  And why not delay it for a year if the public is so adamantly against it.
Commentators carry on endlessly on the budget blame  game, House-Senate counter moves, and President Obama’s refusal to negotiate, meet, or even discuss how to resolve the impasse.

To my mind, the whole standstill is quite simple.  It's a love-hate thing. It dates back to the unilateral passage of Obamacare and questionable tactics behind the passage.  The law passed without a single Republican vote. Its passage fostered a love-hate relationship between Obama and the GOP.  The feelings have not gone away.  The method of passage poisoned the political well. It  created the Tea Party movement, and it illustrates why Obama’s rigid ideological policies and his political  and personal isolation, have disturbed not only its opponents but his Democratic allies, such as national unions.
The Obamacare  passage and its subsequent adverse consequences are at the core of the personality disputes between the President and the Republicans. 
Compounding  the difficulties a slow economic growth under Obama,  and his dicey relationships with the business community,  Catholic organizations,  unions,   the health care community,  and those who espouse limited government, market-driven solutions, and individual choice. 

It’s a classic clash between liberals and conservatives.   The failure of Obamacare policies to decrease costs,  increase access, and maintain choice of hospitals,. doctors, and health plans ;  and the number of businesses dropping coverage  add to political  animus and skepticism.  Then there are growing uncertainties as to the effectiveness and long-term costs of the law.   Add to this the  hostility of the majority  of  GOP governors who say Medicaid expansion is  unaffordable,  and you have a love-hate relationship of the first magnitude on your hands.
Many segments health care stakeholders are ambivalent about the law.    Doctors like having mofre  paying patients, but they resent the low payments and regulations imposed by the Medicare and Medicaid bureaucracies.   Health insurers like the fact that the law requires most Americans to carry insurance or pay a penalty. That’s new business for them.  But they rebel against regulations telling them whom they must cover and which drive up their costs of doing business  and the dislike  cuts in payments.
Like all quarrels,  the Obamacare budget dispute has two sides.  Obama did get reelected. His  reform law is the law , and it does help certain segments of the population.   But costs are going up, not down,  access for the employed are going down,  health plans are being dropped. Half of its provisions have been delayed.   This  has triggered  a steady stream of criticism   By a 56% to 40% margin,  Americans disapprove of  the health reform plan.  But they do not oppose it enough  to defund it at the cost of  government shutdown, but enough to want it either repealed or fixed.
That Democrats lost 63 House seats in the 2010 midterms and control of the House  That  loss still rankles President Obama.  The rise of the Tea Party and opposition to Obamacare were deciding factors in that election. This time around, Obama  believes  a government shutdown over defunding Obamacare would play to his political advantage.  He figures the odds are the public would blame Republicans.  He may be betting that disfavor with Tea Party activists within the GOP would carry over to the 2014 midterms and restore Democratic  control of the house.   That would be a tremendous setback for the Tea Party and sweet revenge for President Obama and the Democrats.
Tweet:   The love-hate relationship between President Obama  and his party is psychological and dates back to the unilateral passage of Obamacare without a single

Friday, September 27, 2013

Of  ObamaCare’s Tweaks, Twitter, Tweets, Hitches, Glitches, and Pitches
Words matter.
Yes,  I know now might not be a time for word play. Shutting down the government because of Obamacare is not a trivial matter.  
But it seems to me these words – tweaks, twitters, tweets, hitches, glitches, and pitches - keep cropping  up and deserve attention to illustrate the temper of the times.
·         Tweaks: “Tweaks  to Health Law Lure Some  Democrats,”  Wall Street Journal, September 27, 2030:   Here Red State Democrats,  whose constituents overwhelming oppose the law,  and fearing election defeats,  are showing interest in fixes,   such as ending the medical device tax,   scrapping rewards for lawmakers and their staffs, and protect Independent insurance agents and brokers against unqualified navigators

·         Twitters: “Defunding Obamacare Twitter Campaign Explodes,” International Business Times,  September 25, 2013,  Thousands of Twiiter supports ar beseeching their Senators to  defund the Affordable Care Act  as unaffordable.

·         Tweets: “Ten  Tweets about Obamacare,”, September 26, including these.  “We probably wouldn’t be in this mess if they called it the Adorable Care Act, “ and “I was just downtown and federal agemts are forcibly  monitoring people blood pressure at bayonet-point.”

·         Hlitches: “New Hitch Hits Health Rollout Of Small Business Exchanges, “ Wall Street Journal September 27, The Journal article has  this lead-in, The Obama administration acknowledged for the first tme that a technological problem ios forcing it to delay part of of the new health-care law, saying insurance exchanges won’t be ready to accept  online applications from small busnness when the program launches Tuesday.

·         Glitches:   “Obamacare Glitches Mount as Launch Day Nears,” September 26, The Huffington Post,   Obama says, “There are going to be some glihes around the country. There’s going to be a computer glitch.” I’ve never ben mounted by a glitch. I hope it is not too painful’

·         Pitches;  “ a Final Pitch for ObamaCare,” Politico, September 25,  “It Takes Two Presidents to Pitch Obamaare,” MSNBC, Septembeer 24. Democrats know  that delaying ObamaCare carries more risks than rewards.  This thing is not going to look better as it ages.
Tweet:  Six words – tweaks, twitters, tweets, hitches, glitches, and pitches – tell you everything, well, almost everything,  you need to know about ObamaCare,

ObamaCare Collapse, an Example of Wishful Thinking
Wishful thinking is the formation of beliefs and making decisions according to what might be pleasing to imagine instead of by appealing to evidence, rationality, or reality
Wishful Thinking, Wikipedia
As ObamaCare hurdles towards implementation four days from now, on October 1,  a school of thought if growing  that says:  Let it go.  Let it collapse of its glitches.   The American public will see it for what it is, a bungled monstrosity.  ObamaCare will collapse like a House of Cards.

I went to the Internet today, typed in “ObamaCare collapse”, and these titles appeared.

·         “Let ObamaCare Collapse”

·         “Just Let ObamaCare’s House of Cards Collapse”

·         “The Rapid Collapse of ObamaCare”

·         “This is the Beginning of Collapse of ObamaCare”

·         “ObamaCare Collapse”

·         “ObamaCare will Collapse”

·         “ObamaCare Could Collapse”

·         “Will ObamaCare Collapse under Its Own Weight”

·         “Republicans Should Let ObamaCare Fail”

Among those in the “Let ObamaCare collapse” school,  are Daniel Henninger of the Wall Street Journal,  Dr. Ben Carson of Johns Hopkins School of Medicine,   and George Will in his Washington Post column.
As much as I admire these gentlemen,  I  do not share their view.   I do not think ObamaCare  will collapse.   It may be delayed.    Parts of it will be deleted or altered.   It will remain controversial right up to the November 4, 2014 mid-terms.  It will continue to trigger “future shock” premiu increases, particularly among the young.  It will result in employers ceasing coverage or handing coverage off to private exchanges,  to defined benefit plans,  or to government exchanges.  Its software will develop innumerable glitches.   Fraud and abuse may run rampant when government does not check the eligibility of those seeking to qualify for subsidies.  It will still contribute to the transformation of America to a part-time nation.   
It will not thrive,  but it will survive.   The Democrats have too much at stake,  namely their reputation as compassionate creators of national programs protecting  the populace, for it to fail.   The President’s second term and his future legacy hinges upon his namesake,  ObamaCare, surviving the travails, troubles, and tribulations  of implementation .
Here is how Daniel Henninger explains what is at stake (“Henninger: Let ObamaCare Collapse,” Wall Street Journal, September 24, 2013."
As its Oct. 1 implementation date arrives, ObamaCare is the biggest bet that American liberalism has made in 80 years on its foundational beliefs. This thing called "ObamaCare" carries on its back all the justifications, hopes and dreams of the entitlement state. The chance is at hand to let its political underpinnings collapse, perhaps permanently.
If ObamaCare fails, or seriously falters, the entitlement state will suffer a historic loss of credibility with the American people. It will finally be vulnerable to challenge and fundamental change. But no mere congressional vote can achieve that. Only the American people can kill ObamaCare.
No matter what Sen. Ted Cruz and his allies do, ObamaCare won't die. It would return another day in some other incarnation.
A political idea, once it becomes a national program, achieves legitimacy with the public. Over time, that legitimacy deepens. So it has been with the idea of national social insurance.
But ObamaCare's Achilles' heel is technology. The software glitches are going to drive people insane.
Creating really large software for institutions is hard. Creating big software that can communicate across unrelated institutions is unimaginably hard. ObamaCare's software has to communicate—accurately—across a mind-boggling array of institutions: HHS, the IRS, Medicare, the state-run exchanges, and a whole galaxy of private insurers' and employers' software systems. “
I am not as eloquent as Henninger,   My reasons for thinking ObamaCare will survive are more prosaic and pragmatic.
  • The government is incapable of handling failure. It cannot accept defeat when its political reputation and future is at stake.
·         It seldom abandons a project, much less a national law  which reflects its political ideology and to which it is committed.

·         It is not dealing with its own money, but that of political allies and taxpayers.

·         Its success is measured in good intentions, not results, such as providing good care and access to Medicaid patients.

·         It succeeds by growing too big to fail and too influential to stop.

·         It cannot go out of business, can print money to keep on going, and is propped up by taxpayer money.

Tweet: ObamaCare will fumble, stumble, be delayed, prove costly, not deliver on its promises. Survival is the nature of the bureaucratic  beast.

Thursday, September 26, 2013

The Constituents
In government offices which are sensitive to the vehemence and passion of mass sentiment public men have no sure tenure.   They are in effect perpetual office seekers, always on trial for their political lives, always to court their restless constituents.
Walter Lippmann (1889-1974), Essay on the Public Philosophy

Have you heard of Senator Ted Cruz’s 21 hour quasi- filibuster,
He claimed Obamacare did not meet U.S. Constituents’ muster.
Constituents, said he, represent the public’s sentiments.
They should not be considered political impediments.
Their collective will should not to be denied,
Or in any other way decried or deprived.
Obamacare therefore must immediately be defunded,
No way, said Senate leaders, Cruz must be obtunded.
The nation’s constituents may be restless,
But Cruz himself is  being totally reckless.
The Senate and the President have spoken.
The law is the law and cannot be broken.

Of the filibuster, said Harry Reid,
The Senate's  head mime,
”It’s a waste of time.”
The Senate and the President,
Is the final litmus test?
To hell with all the rest.
And so on October first,
Put the pedal to the metal,
Sign up for your favorite federal medium,
A bronze, silver, gold, or platinum premium.
And never forget, a national law.
Although it may be appealed,
It can never be  repealed,
In any situation,
under any condition,
Aha,  said Cruz and his constituents,
The Senate  forgot Prohibition.
Tweet:  On October 1,  come hell, high water, or Republican opposition, Obamacare begins. the Senate says.

Wednesday, September 25, 2013

Summing Up:  Ten Reasons Why Obamacare Remains Controversial
Still one more thing, fellow citizens – a wise and frugal government, which shall restrain men from injuring one another, which shall leave them otherwise free to regulate their own pursuits of industry and improvement and shall not take from the mouth of labor the bread it has earned.  This is the sum of good government, and this is necessary to close the circle or our felicities.
Thomas Jefferson (1743-1826),  First Inaugural Address,  1801
All human wisdom is summed up in two words – wait and hope.
Alexander Dumas (1802-1870), the Count of Monte Christo
Why is ObamaCare so controversial?  Why are Democrats and Republicans at each other’s throats over forwarding or halting the health law, even though it is likely to be implemented?   We shall have to wait and hope things turn out for the best for most of us.
Here are ten points of controversy.
One,  the Founding Fathers created the Constitution to minimize radical change by inserting checks and balances between the three branches of government.  When Democrats passed ObamaCare  without a single GOP vote, the violated this Constitutional premise by saying in essence, “It’s our way or the highway.” 
Two,  Obamacare, as written, radically changes the health care system,  for better or worse, by giving government the power to set the rules for administering, paying for, and regulating health care,  now nearly one-fifth of the nation’s economy and its fastest growing segment. 
Three,  according to its critics,  ObamaCare threatens and diminishes the individual liberties of all Americans  - physicians, patients, employers, the well, the sick, the young and the old – by mandating  and regulating what they can and cannot do, and advancing the principle that government, not individuals,  know what is best for their welfare. 
Fourth,  ObamaCare sends mixed messages and produces mixed consequences among different economic groups.  Short-term consequences, already apparent,  include rising costs for families, less choice of health plans and doctors,  employer uncertainties,  physician shortages, and a rush of hospitals and doctors to consolidate with resulting cost increases.  Long term-consequence, which  ObamaCare promises to remedy, remain unknown.
Five, because of its long introductory period and its mixed signals, ObamaCare consequences allow ample room for controversy.   The law is not a single coherent program, but a potpourri of mandates,  Medicaid expansions, and regulations that impact different groups of Americans in different ways at different times which leads to differences of opinions. 
Six,  ObamaCare is a political minefield loaded with explosives exemptions, waivers, bear traps, pitfalls, and pratfalls  for political cronies, the most notable and hypocritical  of which are the subsidies provided for Congress and its staff,  who apparently are favored over the rest of us.
Seven,  Obama vowed  a “Transformational Presidency,” a redistribution of health and wealth benefits, as dictated by the people and not the Washington establishment; his presidency has so far not delivered on promises to reduce health costs, improve access, allow one to keep one’s doctor and health plan, to level the playing field rich, middle class, and poor.
Eight,  directly or indirectly, rightly or wrongly,  Obama’s economic and health care policies are perceived to have had a negative effect on economic growth, which has averaged  2% GDP growth, compared to 3% to 4% needed for recovery of financial health and full-time employment enjoyed in previous bounce-backs from previous recessions.
Nine,  the Obama and Democratic argument that ObamaCare  is the law, get over it, move forward, and in time, you will welcome and accept its bountiful benefits, is stale and no longer selling well. It strikes at heart of Americans’  belief in free enterprise.   As I noted in a previous book ,  The Health Reform Maze,
Government may think it knoweth,
What is best for most of us,
But the market bestowth,
What is good for the rest of us.
Ten,  partisan wars  over Obamacare and liberals’ pure faith in government “programs” with Obamacare as the equivalent of Medicare and Social Security as universal antidotes to social ills  will continue to be contested if the economy continues its slow recovery. One man’s macroeconomic fair share is another man’s economic nightmare.  We shall have to wait and hope ObamaCare does not collapse from own faults.  We shall have to wait and hope for the best.

Tweet:  Summing up: ObamaCare’s fate hangs on whether it can deliver on its promises to lower costs, increase access, and improve quality.