20th January, 2017

[Alan Goldhammer]

No, I'm saying there are two sides to this issue and both some have merit. I believe the CRA had a huge hand in the crash of 08.  Alan seems to believe otherwise.

I would appreciate seeing some primary sources on this.  My sources debunking this are:
http://economistsview.typepad.com/economistsview/2008/09/it-wasnt-the-co.html

[Craig Lamson]

I would appreciate seeing some primary sources on this.  My sources debunking this are:
http://economistsview.typepad.com/economistsview/2008/09/it-wasnt-the-co.html

Krugman, really.?

Let's keep it simple to start.

http://www.businessinsider.com/the-cra-debate-a-users-guide-2009-6

[Alan Goldhammer]

Krugman, really.?

Let's keep it simple to start.

http://www.businessinsider.com/the-cra-debate-a-users-guide-2009-6

Funny, I thought I had linked to Mark Thoma's blog where he aggregated comments from a number of sources.  I didn't see any links to a Krugman comment.  Anyway here is a statistic from Janet Yellen when she headed up the San Francisco Fed,

 "    Most important, the lenders subject to CRA have engaged in less, not more, of the most dangerous lending. Janet Yellen, president of the San Francisco Federal Reserve, offers the killer statistic: Independent mortgage companies, which are not covered by CRA, made high-priced loans at more than twice the rate of the banks and thrifts. With this in mind, Yellen specifically rejects the "tendency to conflate the current problems in the sub-prime market with CRA-motivated lending." ...

    Yellen is hardly alone... One of the only regulators who long ago saw the current crisis coming was the late Ned Gramlich... But Gramlich praised CRA...

    It's telling that, amid all the recent recriminations, even lenders have not fingered CRA. That's because CRA didn't bring about the reckless lending at the heart of the crisis. Just as sub-prime lending was exploding, CRA was losing force... And the worst offenders, the independent mortgage companies, were never subject to CRA -- or any federal regulator. Law didn't make them lend. The profit motive did. ..."

[JNB_Rare]

When I read through the comments here, it makes me wonder if the real legacy of President Trump will be the "normalization" of his tactics and style of rhetoric. It's difficult to deny that they are very different than what people are used to from a President of the United States. And no one can deny that there are many people who find them deeply offensive (including here, in a photography forum). Throughout the campaign President Trump resorted to tactics such as blame, belittling, bullying, bluffing, and blurring of issues and facts. And that's just what the Republican establishment said about him (never mind the Democrats), though many voted for him anyway. Perhaps the end (promise of more jobs, end to Obamacare, etc. etc.) justified the means (the wild-card of Trump).

The President shows little sign of changing his approach. Will his precedent embolden others? Personally, I think the world needs fewer blamers, belittlers, and bullies, and not more. The President seems to be setting a tone of confrontation and unpredictability. Once again, I'd rather have less than more of that in the world.

It has been suggested that President Trump has/will restore the reputation of the United States. I guess my question might be which reputation? For the United States certainly has many different reputations around the world. I wonder if Americans working or travelling abroad might be more or less welcome, more or less at risk, as a result of President Trump's rhetoric?

It has even been suggested that President Trump has "insulted the right people". I wonder who the right people are? I suspect that if President Trump were asked, he might deny insulting anyone (well, not intentionally). But certainly there are many who have felt insulted -- Republicans, Democrats, women, Mexicans, Muslims, parents of a deceased serviceman, the intelligence community, scientists, auto-executives, etc., etc.

Whether or not Trump mimicked a reporter's disability is moot. The video shows him trying to belittle the reporter by mimicking his response in a whiny voice and exaggerated gestures. Schoolyard stuff, really. Perhaps to go along with his locker-room stuff. 

Only time will tell how President Trump's legacy will be written: more American jobs (or not)? better health care (or not)? more security (or not)? a wall? fights over women's and LGBT rights? But I think the real story is the emergence of a style of politics that I find very troubling.

[Alan Goldhammer]

Hillary's plan had traction until the prospect of lost freedom was brought up. Her program could not promise it and its popularity fell immediately. Putting everyone on a Federal program would never had been sustainable. It would have sunk under bureaucratic burden.

There is no bureaucratic burden with the FEHB Program other than paying the premiums to the insurer.  All OPM does is analyze and certify the eligible programs and leaves it up to the employees to choose.  That's it.  Can you explain how this bureaucratic or a burden?

Are you kidding? Large systems negotiate higher payments for themselves because they are large. Small providers get screwed. If a large healthcare system has large market penetration then the prices soar, as they have done in the market I work in.

Fortunately the FTC has stopped the Aetna/Humana merger but it remains to be seen what Trump will do.  Small providers are exiting the market in any event as their risk pools are not large enough.

second, the insurance companies would have to simplify because they would be selling directly to us. Think IBM vs Macintosh in 1984.

Have you taken a recent look at insurance offerings on the Internet?  They are not very simple at all.

I know they will and they already are. Direct Primary Care is a new (very old concept) in which you pay cash for primary care visits. No insurance is accepted, no Medicare is accepted. Ever. You either pay for office visits or you pay, on average, $1000 a year for unlimited primary office care. Office visit rates are around $50. That's 1/3 what I charge under the current system. Those with large deductibles pay that out of pocket. Those on managed care plans have copays that range from $20-$40. I have two former partners doing this now. Super low overhead, 24/7 access for patients. For $500 a year for young patients. The patients will still need a catastrophic plan and hopefully under Trump those will become available again.

  I've seen higher concierge fees in my area than what you cite.  $50 is 1/3 of what you charge, are you a specialist.  My internist also an endocrinologist charges $85 an office visit.  He has never accepted insurance and only files with Medicare, he doesn't accept Medicare reimbursement.
 

I don't think people know what the AMA is. The AMA is almost irrelevant and has suffered low and/or declining membership for years. They are extremely liberal, advocated the ACA and actively seek a single payer system. They have little or no lobbying clout. They make no decisions whatsoever that affect physicians in any legal or binding sense. They certainly care nothing about physician compensation.

I would be most interested in seeing where the American Medical Association has advocated for single payer  or that they are an extremely liberal organization.  I'm sure this would come as a surprise to Dr. Price the HHS nominee and longstanding AMA member. 

[N80]

There is no bureaucratic burden with the FEHB Program other than paying the premiums to the insurer.  All OPM does is analyze and certify the eligible programs and leaves it up to the employees to choose.  That's it.  Can you explain how this bureaucratic or a burden?

No. But do you really believe that if it was nationalized that it would not create its own bureaucratic burden like all other large government agencies, bar none and including Medicare, Medicaid, CHS, DoD, the VA, and EVERY aspect of the ACA.  I suspect if you think it would not become a bureaucratic nightmare like all the rest of these you may either be naive, or an actual bureaucrat.

Fortunately the FTC has stopped the Aetna/Humana merger but it remains to be seen what Trump will do.

Trump is the wheel of fortune. As I've mentioned before, I do not hold any hope in Trump but doubt that he could mess it up any worse than it is now even if that were his expressed goal.

Have you taken a recent look at insurance offerings on the Internet?  They are not very simple at all.

They are terribly complex. That's my point. The interaction between employers, the government and insurers is the reason. There should only be the interaction between the insured and the insurer. Then things would be simplified. At least no worse.

I've seen higher concierge fees in my area than what you cite.  $50 is 1/3 of what you charge, are you a specialist.

I'm not talking about concierge medicine. Direct Primary Care is not the same. DPC programs only accept payment from the patient. I am a specialist in the technical sense (3 year residency program) but as a Family Physician we're considered by most to be GP's. Our board is considered a specialty board. But no, I do not charge specialist prices. My two former partners charge about $1200 per year for a person over $65. They do not pay for anything else done in the office.

My internist also an endocrinologist charges $85 an office visit.  He has never accepted insurance and only files with Medicare, he doesn't accept Medicare reimbursement.

I do not understand how that is possible. Not the $85 but filing Medicare but not accepting payment. I did not think that was possible. It is not for DPC. But good for him if he has found a way.

I would be most interested in seeing where the American Medical Association has advocated for single payer  or that they are an extremely liberal organization.

The AMA lost its way a while back. Mostly because of sub specialization. If you are an ENT you likely belong to your various ENT associations that are more relevant to you. The AMA also suffered for its liberal ivory tower views. They openly endorsed the ACA. No conservative organizations of physicians did. So maybe not "extremely" liberal. But liberal. My association, the AAFP also supported the ACA. There has been a backlash, but not of much substance.

But, you're probably right. In black and white they probably do not advocate, specifically, a single payer system. They advocate, explicitly, universal healthcare. A noble hope, but everyone knows it is a euphemism for socialized medicine.

I'm sure this would come as a surprise to Dr. Price the HHS nominee and longstanding AMA member.

It would not surprise him one bit. Many academics and policy makers are members of the AMA. Lots of average trench workers like me are members too. I might have been a member years ago myself. They still think I'm a member because they have been sending me JAMA for years along with a dues statement that hasn't been paid in years. Makes me wonder about their claims of membership numbers. The only physicians who wouldn't call the AMA liberal are....liberal.

[N80]

$50 is 1/3 of what you charge,

I'm tackling this separately to demonstrate how broken the system is. So take a large regional hospital/healthcare system. They contract with insurance companies to accept payment from them or not. The most common of these sorts of contracts (the intricacies of which I do not understand) is discounted fee for service.

The advertised fee for a complex office visit might be $300. But since it is "discounted fee for service" there is this mythical "discount".  This is usually determined by a contracted percentage of what Medicare pays, which is how Medicare, via the federal government, dominates the market. (How have they done? Not too good. Obviously). So what they actually pay the physician is far less than $300. But that $300 is what the patient sees on the bill and thinks his insurance had to pay. All of this, both sides of it, are revolting to me. What is even worse, if someone comes into my office without insurance and wants to pay cash, I'm technically required to bill him $300 or the contract with the insurance company was not technically "discounted". There were ways around this. I used to see at least 4-5 indigent patients a week for free. That was allowed. I think things have changed in this regard in the last few years. Maybe because of the ACA, I don't know. But also because of the ACA most physician contracts are now based on "work relative value units" or wRVUs. This takes the physician out of the equation in terms of how patients pay. In some ways it is liberating. In other ways it ties our hands in regard to how we help our patients. Under an RVU contract I can no more see a patient for free than a car salesman can give a customer a car for free. I can get away with not billing some patients. Corporate has given a wink and a nod to it. But if your chart audits show that you do it a lot, they will stop you.

This is just a small example of how the interaction between government, healthcare systems, insurers and patients is badly, deeply broken.

[Alan Goldhammer]

This is just a small example of how the interaction between government, healthcare systems, insurers and patients is badly, deeply broken.

I'm in total agreement with you.  As I've noted in earlier posts, I've been working on this issue on and off since 1990 and don't see any good choices out there other than an NHS model or an insurance model with vouchers.  both approaches work in Europe and there tends to be satisfaction with those models.  Similarly the provincial model of insurance in Canada works well.  We have a number of friends who live in both Ontario and Quebec and they are extremely satisfied with their healthcare.  A couple of them had critical care in the hospital and it was delivered in a timely manner and with a positive outcome.  I cannot see how any of the past proposals from the Republicans (health savings accounts, insurance across state lines, high risk pools, etc) will work.  As I've noted, Obamacare was a kludge and not my preferred way of doing things but it worked for my daughters and a number of their friends who are self-employed.

[JoeKitchen]

I'm in total agreement with you.  As I've noted in earlier posts, I've been working on this issue on and off since 1990 and don't see any good choices out there other than an NHS model or an insurance model with vouchers.  both approaches work in Europe and there tends to be satisfaction with those models.  Similarly the provincial model of insurance in Canada works well.  We have a number of friends who live in both Ontario and Quebec and they are extremely satisfied with their healthcare.  A couple of them had critical care in the hospital and it was delivered in a timely manner and with a positive outcome.  I cannot see how any of the past proposals from the Republicans (health savings accounts, insurance across state lines, high risk pools, etc) will work.  As I've noted, Obamacare was a kludge and not my preferred way of doing things but it worked for my daughters and a number of their friends who are self-employed.

Alan, I have to respond to this. 

First, I do agree that what the Republicans are currently proposing, or at least have in the past, is not really going to effect the pricing.  Buying across state lines never made any sense since all states have different health care regulations that need to be followed.  The exception might be those whom live at a border and can easily travel to a neighboring state for health services.  Also, high risk pools only work if low risk people join as well, but that was the intent of the ACA exchanges, and we all see what that is turning into, a kludge as you put it. 

However, I do remember you writing that your daughters purchased their insurance from the private market place.  Unless your daughters have pre-existing conditions, how could the ACA have actually helped? 

Prior to the ACA, you could just as easily purchased insurance in the private market as you can now. 

Additionally, if you mention geography issues, I also remember you mentioning they (or at least one) use to live in Philly, my current home, and I had no problem finding insurance prior to the ACA. 

[Alan Goldhammer]

Alan, I have to respond to this. 

First, I do agree that what the Republicans are currently proposing, or at least have in the past, is not really going to effect the pricing.  Buying across state lines never made any sense since all states have different health care regulations that need to be followed.  The exception might be those whom live at a border and can easily travel to a neighboring state for health services.  Also, high risk pools only work if low risk people join as well, but that was the intent of the ACA exchanges, and we all see what that is turning into, a kludge as you put it.

I still don't understand the across state line thing.  The greatest number of companies in the country are the BlueCross/BlueShield plans.  Some are non-profit other not.  Most are confined to very narrow geographic territories except the Texas one which I think is one of the four largest insurers in the country.  I find it difficult to believe that a BC/BS plan in Minnesota would want to operate in Wisconsin.  they would have to establish new networks and so on.  The other main point is that most of the big corporate insurers already operate in multiple states.  I think you don't understand the high risk pools.  These are ONLY for high risk people and would be underwritten by the state.  This concept was tried in the past and was pretty much a failure as the states that ran them quickly ran out of money.  Maybe this is something the Federal government would do.  Some patients cost $100K/year to take care of. 

However, I do remember you writing that your daughters purchased their insurance from the private market place.  Unless your daughters have pre-existing conditions, how could the ACA have actually helped? 

Prior to the ACA, you could just as easily purchased insurance in the private market as you can now. 

Additionally, if you mention geography issues, I also remember you mentioning they (or at least one) use to live in Philly, my current home, and I had no problem finding insurance prior to the ACA.

Both of their policies are ACA compliant and cover women's health things which was not a requirement prior to the ACA.  They did not purchase them through an exchange as they did not qualify for a subsidy (which in my mind would be the only reason to do it that way).  Their premiums were lower than they would have been pre-ACA.  Now I can understand that a man of the same age would be paying more for ACA compliant policies as he would not need those services.  Yes, you are correct that people living in large Metro areas usually did not have any issues purchasing insurance before the ACA.  The lack of choice of insurers through the ACA is really a function of large insurers not wanting to service small population areas.  Most of the complaints about the ACA come from those living in more rural areas and likely they had issues getting insurance prior to the ACA.

I wish there were an easy solution to all of this.  Part of the problem with US competitiveness is that we pay too much for health care.  It used to be a contentious issue during union negotiations but since unions are disappearing these days, management pretty much can do what they want.  There was a story some years back on a GM plant in Ontario Canada (Buick, I think) and it was the most productive of all the GM plants.  They were talking with the union representative about this and he said it was pretty simple, then never had to discuss health care.  It's the same with many EU industries, health care is already taken care of.  A lot of conservatives tend to overlook this fact.

[dreed]

Surely the important questions that remain are...

... will Trump's presidency lead to civil war? It seems inevitable that there will be riots at some stage.
... will Trump's presidency lead to states leaving the union? It's becoming more and more clear that there are very different ideals between the coasts and the heartland, perhaps irreconcilable differences.
... will Trump's presidency lead to things being fixed in what presidents can achieve via executive order? And will any of those that Obama signed off on that Trump is now exploiting be ear marked for being dissolved?
... how quickly will Trump's presidency lead to NATO being broken up? Look at how Europe is reacting to Trump.

and finally...

... will Trump's presidency lead to World War III?

I'm just waiting for Russia to fully invade Ukraine and for Trump to go "Not My Problem" and for the USA to be too caught up in dealing with Trump to care. Where will Putin stop?

Trump is going to be a gift from God to Putin.

Yes, there's lots of flame bait and maybe trolling in the above questions, BUT, when you look at how the country is reacting, you can't help but wonder if it is really all that far fetched.

Come back and tell us in 10 years, that is if Emperor Trump hasn't decided to ignore the 2-term limit. He filed with the FEC for re-election in 2020 just 5 hours after he was sworn in - even without the Republican party deciding if they want to back him. Have you seen the "Dial 1-800" TV ads for donations to support Trump because he is being attacked?

[dreed]

Are you telling me he can't fire the head of the National Park Service?

When people are being fired because they are doing The Right Thing in disobeying orders, then something is very wrong. In times like this disobedience is essential to making people aware that the orders being given are wrong.

Look at what is going on with the airports and DHS.

The CBP/DHS are ignoring judges and judges are ordering in federal marshals in. How do you think that is going to go down? That the CBP/DHS are blindly following orders from the president and not the courts means that "rule of law" has broken down.

When "rule of law" breaks down in a country, you have a regiem. When most news services talk about foreign countries and regiems, said countries have dictators running them.

The 2nd amendment exists for a reason and that reason is not to do with defending your home, it is to do with overthrowing tyrannical governments.

[Otto Phocus]

... will Trump's presidency lead to civil war?

No.  We will complain/bitch/whine as is our right.  When the mid-term congressional elections come around, there will probably be a change in power just like in 2009.  Americans tend not to like having the same party holding the Executive Office and both houses of Congress. 

... will Trump's presidency lead to states leaving the union?

No.  States do not have the legal ability to unilaterally leave the union.  Texas V White (1869)

... will Trump's presidency lead to things being fixed in what presidents can achieve via executive order?

Probably not.  An EO is a statement on how the Executive Branch will enact existing laws. There can't be an EO without supporting legislation. Executives on both sides use and abuse EOs.  Neither side will insist on rule changes that can ultimately, in the future, affect their candidate. 

... how quickly will Trump's presidency lead to NATO being broken up?

NATO will continue to exist.  The US involvement may change and certainly our influence may change.

... will Trump's presidency lead to World War III?

Impossible to tell how some other country may decide to start a war.  It is doubtful that the US will start a world war.  Small OOTW are more to our advantages.

"Come back and tell us in 10 years, that is if Emperor Trump hasn't decided to ignore the 2-term limit."

People said the same thing about Bush and Obama.  Neither of them even hinted at ignoring the law.  We do not need the president's consent to limit their terms to two.

[Alan Goldhammer]

Come back and tell us in 10 years, that is if Emperor Trump hasn't decided to ignore the 2-term limit. He filed with the FEC for re-election in 2020 just 5 hours after he was sworn in - even without the Republican party deciding if they want to back him. Have you seen the "Dial 1-800" TV ads for donations to support Trump because he is being attacked?

My feeling and a lot of friends here in Washington who are also politically astute do not believe Trump will serve out his first term.  Unless he does something more than he has about his business interests he may get caught up in an ethics issue that he cannot get out of.  There is increasing pressure on him to release his tax returns (437K have signed a petition on the White House website requesting that he release his tax returns.  The petition is active for 30 days after which the White House is supposed to respond providing a 100K threshold has been met.  this shows that his statement that "only the press cares about my tax returns" is false).  We don't know what his tax returns contain but there could be some embarrassing information about loans from foreign banks.  His family is being savaged on social media.  Perhaps that doesn't matter to him but I wonder what the family members feel.

There are a fair number of Republicans who are tired of all the antics and they may also put pressure on him.  I'm skeptical that he will be impeached but some experts believe that's possible.  Anyway, him running for a third term is as close to zero possibility as there is in the world.

[Otto Phocus]

In order for a president to be impeached and removed from office, the president has to be found guilty, by the Senate, of committing "High Crimes and Misdemeanors" and that bar is pretty high. So high that we have never done it in our history.

Being stupid, ineffectual, biased, egotistical, worthless, or a danger to humanity itself are not causes for impeachment.  A good thing or we would be going through presidents like M&Ms.

[Bart_van_der_Wolf]

In order for a president to be impeached and removed from office, the president has to be found guilty, by the Senate, of committing "High Crimes and Misdemeanors" and that bar is pretty high. So high that we have never done it in our history.

Being stupid, ineffectual, biased, egotistical, worthless, or a danger to humanity itself are not causes for impeachment.  A good thing or we would be going through presidents like M&Ms.

Well, he seems to be providing homegrown and Middle-Eastern terrorists enough reasons to act upon.
Let's make discrimination great again ..., but try to frame it in a way that it looks legal.

Also strange is that he's targeting people from countries that have not committed any attacks inside the USA, unlike countries where he seems to have personal business interests, like Saudi Arabia, and other Gulf state sponsors of terrorism. Here's some more factchecking.

Cheers,
Bart

[Rob C]

Perhaps leaving a question mark over tax declarations is being maintained as a rapid - and possibly convenient - exit strategy, should he tire of playing politics within a month or so.

After all, once you've achieved the goal of being the most powerful employee in the world, could be that the "freedom" of self-employment becomes irresistible again - and far more enjoyable (and much less aging). A plus might be that he will end up with a better security guard than might be available via the private sector, too. If you have to have one anyway, then what's not to like about a connected one?

I wonder if those chaps need to buy more jackets than trousers: the way they appear permanently to be clutching the lapels of their suits must wear the fronts out far more rapidly than the rest of the garment. Just an observation; you know, the paparazzo-in-the-soul bit showing through...

;-)

Rob C

[dreed]

Well, he seems to be providing homegrown and Middle-Eastern terrorists enough reasons to act upon.
Let's make discrimination great again ..., but try to frame it in a way that it looks legal.

Also strange is that he's targeting people from countries that have not committed any attacks inside the USA, unlike countries where he seems to have personal business interests, like Saudi Arabia, and other Gulf state sponsors of terrorism. Here's some more factchecking.

Cheers,
Bart

That list of countries is also predominantly those that are Shia Islam, not Sunni Islam and as such, looks more like a continuation of the "Saudia Arabia vs Iran" problem in the middle east.

Why the USA continues to get involved in that little family/religious spat, I do not know.

Compare the map of banned countries with the map of Islam relgious houses:

[scyth]

Well, he seems to be providing homegrown and Middle-Eastern terrorists enough reasons to act upon.

http://www.theonion.com/article/fbi-uncovers-al-qaeda-plot-to-just-sit-back-and-en-35788

.

[Craig Lamson]

Funny, I thought I had linked to Mark Thoma's blog where he aggregated comments from a number of sources.  I didn't see any links to a Krugman comment.  Anyway here is a statistic from Janet Yellen when she headed up the San Francisco Fed,

 "    Most important, the lenders subject to CRA have engaged in less, not more, of the most dangerous lending. Janet Yellen, president of the San Francisco Federal Reserve, offers the killer statistic: Independent mortgage companies, which are not covered by CRA, made high-priced loans at more than twice the rate of the banks and thrifts. With this in mind, Yellen specifically rejects the "tendency to conflate the current problems in the sub-prime market with CRA-motivated lending." ...

    Yellen is hardly alone... One of the only regulators who long ago saw the current crisis coming was the late Ned Gramlich... But Gramlich praised CRA...

    It's telling that, amid all the recent recriminations, even lenders have not fingered CRA. That's because CRA didn't bring about the reckless lending at the heart of the crisis. Just as sub-prime lending was exploding, CRA was losing force... And the worst offenders, the independent mortgage companies, were never subject to CRA -- or any federal regulator. Law didn't make them lend. The profit motive did. ..."

We can trade quotes forever Alan.  I can muster just as many to support my positon as you can to support yours. 

You opening position on this is was:  "Other than Peter Wallinson at AEI who is delusional on this point, numerous experts on the housing industry have totally debunked this viewpoint."

Well, its not totally debunked at all.  Opinions differ.  No one it taking the banks off the hook.  Rather some are pointing out that abused governmental policy and the law of unintended consequence had a big part to play. It does not suprise me at all to see liberals and big government types looking to absolve the goverenment of blame.