Like many Americans, I was first stunned and then unsettled by the shootings that took place last week in Tucson. Since then, we’ve heard lots of debate about Jared Lee Loughner's motivations. Partisan media hyperbole? Targets on an election map?

Most recently, there has been a chorus of pundits singing about the ills of the mental health system. Michael J. Fitzpatrick, Executive Director of the National Alliance on Mental Illness, said, “The plain truth is that America's mental healthcare system is horribly broken and horribly underfunded. And across the nation, budget cuts continue to eviscerate community mental health programs that reach out to vulnerable individuals and put them on a path to recovery.”

But more surprisingly, have been the statements of key Republicans:

• Republican advisor Mike Murphy said on the Bill Mahar Show on January 14, 2011, "I'd like to see a better linkage between the gun control stuff we have now and the crazy-filter. Because if you look at Virginia Tech and you look at this guy, it is too easy for mentally ill people to get guns; because there’s no mental screening anymore."
  
• Virginia Republican Senate candidate Jamie Radtke (and head of the Richmond Tea Party) told ABC’s Top Line that "instead of it being about the political part, it’s really about needing to get our arms around our health care, the mental health policy here."
  
• Representative Mike Rogers (R-MI) said, "What we have to do is intervene earlier in that cycle of violence when they have this kind of disability. . ."
  
• Newly-elected Representative Allen West (R-FL) said, "The shooter was a very disturbed individual and it appears there were so many warning signs that he was going to do something horrible.  We should be focusing on the mental health crisis in our country, not politics."

Well, I have a simple piece of advice: if we want to stop tragedies like this from happening again, we should not repeal health care reform. Two years ago, national legislation passed that (finally) guaranteed that most individuals with insurance will have coverage for assessment and treatment of mental illness. The health care reform legislation builds on that non-discrimination parity legislation and assures that most Americans will have some form of health coverage that includes coverage of mental health conditions.

Earmarked funding for community mental health services will not solve the problem. We need to end fundamental discrimination against people with mental illnesses, and ensure that they have consistent access to the health care services that they need.

Americans are not of one mind about health care reform— a recent Gallup survey showed that 46% were in favor of repeal and 40% wanted to move forward with the law being enacted. (Interestingly, there were great differences in support of the law based on age – with the under 30 crowd clearly in support and the 50+ crowd favoring repeal.)

I can understand having qualms about some provisions of the health care reform law. If I were queen, I would have done things slightly differently. But, I am absolutely opposed to repeal. And what I don't see coming from the repeal advocates is a plan—for anything.

Our health care status quo isn't working for anyone—not for consumers, employers, governments, or anyone else. Last Thursday, the Congressional Budget Office concluded that between 2012 and 2021, repealing the law would increase the national debt by approximately $230 billion (more on that in a future blog post…). And so when I talk to the folks looking for repeal, my question for them is always: what's your plan?

On October 11th, John Boehner (R-Ohio), the current House Minority Leader—and the presumptive Speaker of the House in the 112th Congress—warned that we should not expect funding to implement health care reform if the Republicans become the majority in Congress – “They’re going to need money from us to hire those 22,000 federal employees we think it’s going to take to run this monstrosity. And I’ll just tell you, they’re not going to get a dime from us.” 

Representative Boehner went on to acknowledge that an all out repeal of the health care law is unlikely, as President Obama will still hold veto power from the White House. But even if an outright repeal isn’t possible, Republicans will still have the ability to hold up funding for many aspects of the reform legislation through the annual budget process. If Republicans take control of the House (as most polls indicate is a very likely scenario), Boehner stated that it will be the Republicans “job to do everything we can to keep it from being implemented, to keep it from moving ahead.”

So, as I see it, the choice in this election regarding health care is a clear one.  Flawed or not, do you want health care reform?  The bill has many great features—elimination of preexisting conditions clauses and recission, access to minimum coverage for the poorest Americans, etc. But, I think we all recognize that it also comes with a range of problems to be fixed.

Which leaves one question to think about: If the Republicans are in the majority, what is their alternative proposal?

In a recent speech, Kentucky Republican Senate Candidate Rand Paul said that Medicaid is “intergenerational welfare.” His stated rationale was that coverage has spread beyond those “truly in need” and citing the fact that 800,000 people out of Kentucky’s approximately 4.314 million citizens (18.5%) were on Medicaid. Given Kentucky’s Medicaid eligibility requirement—$13,671 in annual household income for family of 4 (62% of the federal poverty level)—I would say that has more to do with the income distribution in Kentucky.

I find Dr. Rand’s comments a bit hypocritical. This is coming from a candidate who is an ophthalmologist (an ophthalmologist who invented his own board certification, no less) and has 50% of his income coming from Medicaid and Medicare. This is the candidate who said in an interview on October 3, 2010 that he would cut Medicare benefits and raise the retirement age for Social Security in order to keep the full Bush-era tax cuts. So while depending on your perspective, I suppose you could consider this to be intergenerational welfare; I would maintain that it is, in fact, intergenerational war.

I’ve been a bit perplexed by this election season. I’ve decided we’re stuck in a real-life version of the 1989 film classic, Indiana Jones and the Last Crusade. You remember the one—the globe-trotting, action-packed search for the Holy Grail. I’m reminded of those prophetic words near the end of the film, “...choose wisely, for while the true Grail will bring you life, the false Grail will take it from you...”

These would be good words for voters to heed on November 2nd. Unfortunately, we’re caught between a false set of choices due to the political messaging that we’re bombarded with via every type of media on a 24-hour basis.

The Republican messaging, with its recent “Tea Party” flavor, is generally “All government is bad.”
The Holy Grail – Eliminate government and let the free market rein. 

The Democratic messaging, with its recent panic attack at the loss of the public popularity contest, is “Save government. It’s best for the little guy.”
The Holy Grail – Let’s keep our government operations on track.

I think the Republican Party is at its most disingenuous these days when compared to the past two decades, using those poor “Tea Party” chumps (most of whom are on Social Security and Medicare) to try to prevent government from curbing the worst of the free market abuses (I’m a free market person – and I can tell you that the ethical among us want protection from all of the unethical business entities).

I think the Democratic Party seems to be populated by fearful sycophants. They’re afraid to be the party of ‘good government’ (which is what we need) because introducing a accountability and good business practices would cause consternation among their traditional supporters.

My advice to voters: Choose wisely. Look for candidates who believe in good government – government that provides reasonable protections (regarding health, land use, safety, economics, etc.) to us all – government that is willing to apply standards, accountability, and good business practices. The candidates are out there in both parties, Republican and Democrat.  But we need to turn off the campaign advertising and look beyond the party-line messaging. If you take the time to explore each candidate’s positions and background, you should be able to choose wisely.

I've had a hard time putting the current unemployment data into context based on my own experiences – at OPEN MINDS, we've been on a hiring frenzy…and having trouble getting responses to our ads. Then, one Sunday morning a couple months ago I was watching Laura Tyson in an interview on ABC's This Week with Christiane Amanpour, and I had a flash of revelation. Ms. Tyson, former Chair of the President's Council of Economic Advisers during the Clinton Administration, said that "unemployment for those with college educations is now 4.5 percent." She went on to cite Bureau of Labor Statistics data that for those with less than a high school diploma, the seasonally adjusted unemployment rate was 13.8 percent during July. For those with a high school diploma but no college, the rate was 10.1 percent.

After thinking about that data, I have a new take on the unemployment situation. We have a structural unemployment problem, which is how labor economists refer to a mismatch between the skills of the people who of are out of work and the skills needed for the jobs that are available. And what this really boils down to is an education problem. A fundamental part of the long-term solution to our high unemployment rates is to improve our education system at every level – not only improving the graduation rates from high school and college, but also increasing the academic rigor of those programs. While it is certainly a valid point that "not everyone should go to college," given this employment situation, we also need to think of improvements to non-college technical/vocational training programs. Those training programs need to be relevant in the current context of a global economy and focused on areas with growth-potential that can provide a continuous living wage.

Diving deeper into the nationwide unemployment statistics and the prominence of the education attainment-aspect of the numbers led me to wonder what the implications of this situation would be for individuals with cognitive and mental disabilities. While assistive technologies are increasingly available to facilitate completion of advanced degrees by individuals with physical disabilities, disabilities that interfere with the thought processes are more punitive. In an economic environment where advanced degrees and related skill sets directly correlate to economic well being, the challenge of independently maintaining economic viability is becoming more and more insurmountable for these individuals.

I thought the best summary of the situation was in an article by Steven Pearlstein, The Bleak Truth About Unemployment. Mr. Pearlstein notes: "Somewhere between the rantings of the Republican right, which is peddling the nonsense that excessive government spending is to blame for high unemployment, and the Democratic left, which clings to the false hope that another helping of fiscal stimulus is all that is needed to get millions of Americans permanently back to work, is this stubborn reality: The loss of 8 million jobs reflects problems that are largely structural, not cyclical, which means they won't be brought back by fiddling with a magic dial in Washington that controls how much the government spends."

As Americans are pushed to develop a better-trained and more highly-educated workforce, the employment space for individuals with cognitive and mental disabilities will get smaller and smaller – leaving a population that will struggle to find a viable place in the fast-paced global market economy that we are heading towards.

One of my greatest personal and professional peeves is the “constant critics.”  These are the folks who constantly complain and critique what you do – but have no proposed solutions and rarely get things done themselves.  My experience as the founder and executive of a small business is that while it is easy to play the role of critic, it is quite difficult to develop and implement real, workable solutions.
 
These days, I consider the Republican Party to be playing the role of the “constant critic” when it comes to health care.  They had eight years when they controlled all branches of government, and did nothing.  And now that someone else has taken a swing, all they have managed to do is complain.  This “constant critic” position was perfectly captured in a piece by Grace-Marie Turner, “Putting the Brakes on Obamacare: How a Republican Congress Could Begin the Process of Repealing This Unpopular Law,” in the August 25, 2010 edition of The Wall Street Journal.  Ms. Turner outlines “the six key strategies that a Republican Congress could employ to put on the brakes.”  Her plans for health care reform? – Defund it, dismantle it, delay it, disapprove regulations, direct oversight and investigation, or delegate to the states.
 
Clever alliteration, but did you notice any solutions listed among those Republican “key strategies?”  

One of the big ‘war of words’ in health care is the issue of Medicare managed care – namely the Medicare Advantage program. President Obama and many Democrats want to scuttle the program because the cost of the managed care version of the Medicare program is purportedly 13% above the costs of the same beneficiaries in the fee-for-service version. Many consumers, and many Republicans, like the features and benefits and the voucher-like market orientation (respectively) of these plans.

The basic objections are captured quite succinctly by Ezra Klein in a piece in the The Washington Post, A private Medicare System Would be a Costlier Medicare System. He states, “They save money by limiting the generosity of the vouchers. Because the dirty little secret is that turning Medicare into a voucher program would actually make it cost much, much more. How do we know? Well, putting aside the fact that Medicare currently costs much less than private insurance, we actually have a private voucher program in Medicare as we speak. [...] But today, the market-based arm of the program costs more, not less, per beneficiary. Those fixed monthly payments to Advantage plans are, on average, 13 percent above fee-for-service Medicare costs.”

I think Medicare Advantage plans are an inevitable solution for the Medicare plan. The current fee-for-service system is an ungainly muddle of rules, with only the reduction in benefits (not politically feasible) and reduction in provider fees as its cost containment mechanisms. Even the health care reform initiative recognizes this through the creation of “accountable care organizations,” which are essentially provider-owned managed care plans. (And, it won’t take long for those provider-owned plans to “buy” managed care infrastructure from the current managed care programs.) Only this change in financing, moving us away from fee-for-service, permits the health care system to move beyond the current silos of reimbursement and allows for the rationing of services, which is an inevitability with, or without, health care reform.

That said, the failure that we currently have in the excessive rates mentioned by Mr. Klein is not a failure in program design, but rather a failure in contract negotiations and management. Medicare Advantage plans should not cost 13% more (or any more) than their fee-for-service alternatives. And, the medical loss ratio reporting requirements absolutely must be applied to Medicare Advantage plans to permit true transparency for consumers and a contract management tool for Medicare.

The process of participating in the political process has changed dramatically over the course of the past year.  In January 2010, the U.S. Supreme Court decided in Citizens United v. Federal Election Commission that, for the purposes of campaign contributions, organizations are citizens and have the right to "unlimited spending in pursuit of political ends."  This is a change of titanic magnitude in our political system.

I have very mixed thinking about the decision.  I generally support free market and libertarian sorts of ideas—including completely unlimited freedom of speech.  But, the power of unlimited corporate contributions in politics does daunt me.  In the wake of this decision however, there is one absolute – we must have transparency in these contributions. Whether by individuals or corporations, all donations to political campaigns, political action committees, the 527 advocacy groups, and the host of non-profit organizations that have grown up doing the bidding of political movements, must be publicly disclosed immediately.  Without transparency, what we have is a political system driven by propaganda (which is commonly differentiated from ‘advertising’ by its lack of identifiable source).  

This issue has new interest in the wake of some recent events.  We had the humorous ‘mock news’ reporter Jon Stewart on the  “The Daily Show” pointing out that the supposedly terrorism-tainted Saudi prince (whose foundation might contribute to the Islamic center much maligned on Fox News), Walid bin Talal, is not only the biggest non-Murdoch shareholder in Fox News’s parent company (he owns 7 percent of News Corporation), but is also the recipient of Murdoch’s mammoth investments in Saudi Arabia.
 
Then, there was a great analysis, “Covert Operations: The Billionaire Brothers Who are Waging A War Against Obama,” by Jane Mayer appearing in The New Yorker.  Its examination of the political funding apparatus of industrialists Charles and David Koch (Charles G. Koch Charitable Foundation, the Claude R. Lambe Charitable Foundation, the David H. Koch Charitable Foundation, KochPAC, and Koch Industries) is fascinating.  These two men, alone, are responsible for a host of ‘political brands’ that we are exposed to every day –  the Cato Institute, George Mason University, the Mercatus Center, Citizens for a Sound Economy, Citizens for the Environment, Americans for Prosperity, Century Strategies, and “Tea Party Talking Points.” 

I support the right of these individuals to say whatever they want, and to fund the means to move their message forward.  However, it is full disclosure and transparency that are a necessity.  Unfortunately, the very modest Disclose Act, which requires corporations to show how they spend money in elections, was recently defeated by Republican filibuster.  Without that, we are left with citizen action—which frequently comes in the form of consumerism—as our only recourse.  Target is one corporation that recently learned exactly how their political investments can impact their relationship with their customers.  It donated $150,000 to Minnesota Forward, a group channeling funds to Minnesota Republican gubernatorial candidate Tom Emmer—known for his opposition to lesbian, gay, bisexual, and transgender rights.  As a result, the company now faces both a consumer boycott and a movement by institutional stakeholders asking for a "comprehensive review" of Target's political donation process.  Still, I think that to rely solely on investigative journalism and institutional investor actions is silly.  We need transparency and disclosure.   After all, why would political contributors want to hide what they really believe?

A few weeks ago, Newt Gingrich with the president/CEO of the National Center for Policy Analysis John C. Goodman jointly responded to President Obama's challenge for Republicans to show him a better idea on health care reform. Their ten ideas, outlined in the Wall Street Journal’s “Ten GOP Health Ideas for Obama” are as follows, with my reactions in red.

1. Make insurance affordable. This could be done by reforming the "arbitrary and unfair" taxation on health insurance. (Read: no more tax exemptions on employee health benefits)
2. Make health insurance portable. Employers should give employees insurance that can be brought from job to job, and people should be able to buy insurance across state lines. (Read: eliminate state-specific regulation of insurance comapnies and move to interstate insurance)
3. Meet the needs of the chronically ill. Help them take charge of their own care with Health Savings Accounts. (Not sure what this means)
4. Allow doctors and patients to control costs. Doctors and patients should be liberated from government-imposed payment rates that reward physicians for treating the sick but not for keeping healthy people healthy. (Not sure what this means)
5. Don't cut Medicare. Medicare's on an unsustainable course, but the $500 billion in cuts the Democrats propose are not the answer. (Interestingly odd for Republicans)
6. Protect early retirees. A bridge to Medicare can and should be built to help the millions who retire before they qualify. (Not sure what this means)
7. Inform consumers. Government data on cost and quality should be made public. (Of course. . .)
8. Eliminate junk lawsuits. "We do not need to study or test medical malpractice any longer," Gingrich and Goodman write, pointing to Texas' liability protection efforts as a model. (As a consumer, I'm skeptical of eliminating legal redress for medical malpractice without more regulation to 'disbar' bad physicians. As a health care analyst, the savings are only in the 1.5% range.)
9. Stop health care fraud. Approaches including third-party liability verification, and electronic payment can help cut the $120 billion lost to fraud every year, (Of course...)
10. Make medical breakthroughs accessible to patients. Red tape should be cut to get new drugs and treatments to patients faster. (Good on paper but full of practical, legal, and scientific problems.)

So what do you think? Can this GOP hit list be married with the existing bills to give us something resembling universal coverage with cost containment? Let me know what you think!