Unaffordable Care Act

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Many think President Obama's Affordable Care Act (ACA) has provided a medical salvation to a large proportion of the 47 million heretofore uninsured non-elderly Americans. In fact, it has compelled perhaps 1.6% more people to buy insurance in 2014 than were insured in 2013.

Even taking the rosier figure of 5.4% of the number of previously uninsured, this is hardly a success story.

Moreover, having insurance coverage is not the same thing as being able to pay for actual healthcare. To risk stating the obvious: Beyond paying one's insurance premiums, one must then pay for the actual medical care one seeks. It should seem obvious that many of the people who failed to buy health insurance failed because the cost of seeing a doctor was beyond their purview.

The big story, however, is the "ugliness of spirit" (to quote Paul Krugman from his "Health Care Nightmare") in the United States which the ACA has revealed. Over half of our State's governor's are rejecting additional Medicaid coverage, Florida's Gov. Rick Scott being one. Odd considering our not-compassionate conservative Governor Rick Scott made his money in the legally contentious, once-largest for-profit health care company in the U.S. (Columbia/HCA); one would think he had a heart for such issues.

From Krugman's piece:

The health economist Jonathan Gruber, one of the principal architects of health reform — and normally a very mild-mannered guy — recently summed it up: The Medicaid-rejection states “are willing to sacrifice billions of dollars of injections into their economy in order to punish poor people. It really is just almost awesome in its evilness.” Indeed.

Florida CHAIN, a group lobbying for "increasing the access to affordable quality healthcare, published an informative piece on what the legislators "hope you don't read and remember." From that brief round-up is this on the "spite tax":

• $500 million: A conservative estimate of the “spite tax” that Floridians will pay in 2014 – i.e., the amount of STATE taxes and fees that Floridians must redundantly pay to block access to what they already paid for with federal taxes

How Obamacare has played out in Florida is that the Medicare - Medicaid population can no longer access medical care from the same doctors they had previously seen. Bottom line: doctors are unwilling to accept the 80% remuneration from Medicare when they will not have access to the 20% previously covered by Medicaid. (Meanwhile, many of those accepting full Medicare reimbursement grow rich from providing often unnecessary procedures or prescribing unnecessary or unproven medications hawked by their friends representing the interests of Big Pharma.)

What is the linkage between Obamacare and the refusal of doctors to accept patient who are enrolled in both Medicare and Medicaid?

Whatever the linkage, signs were in place in doctor's offices in 2012 stating that should the healthcare act pass, they would no longer be treating their patients who were dual Medicare + Medicaid recipients. These are the patients who will neither be able to afford the ACA coverage nor the medical care itself -- our neediest citizens who should be protected by such governmental programs.

The best parsing of the 1,163 pages of the “Patient Protection and Affordable Care Act” (HR3590) and the 337 pages of the “Health Care and Education Reconciliation Act of 2010″ (HR4872)—known collectively as the Affordable Care Act— can be found at this post on Dr. Lickerman's blog. A liberal M.D., he explains clearly why the Act will not be a boon to the average health insurance customer.

There is no need to compress his compression, but this is an example:

"Consumers currently have almost no ability to “vote with their feet. Thus, no competitive pressure exists to motivate insurance companies to lower their premiums at all (remember, just because there are multiple plans on the exchanges doesn’t mean they’re being offered by as many companies)."

The insurance companies grow rich, the doctors grow rich, and the poor go without care. A Federal mandate that people buy health insurance ≠ being able to afford health care.

Medicare patients who also qualify for Medicaid are being turned away from their doctors in Florida -- is this how Obama's vision was supposed to play out?

We need a new law that requires all doctors to honor Medicaid patients (bureaucracy rules.) If Congress would provide this legislation, then then Mr. Obama should use his flanking policy by issuing an Executive Order. If a doctor accepts Medicare, he should be required by law to provide care to Medicaid patients. To do otherwise is simple money-grubbing.

Ranger will bet the farm that our leadership class does not have a problem finding premium health care, paid for with our tax dollars.

Addendum: Yesterday's press covered the death of young Florida mother Charlene Dill who collapsed at one of her three jobs for want of healthcare for her documented heart condition. She fell into the "Medicaid Gap" because she lived in a state which would not expand Medicaid coverage. Her case is not an isolated one.

--Jim and Lisa

[cross-posted @ RangerAgainstWar.]

Cheneyism: The Dominate Ideology in US Policy/Politics Today

Todd E Pierce has a very important article up at Unz Review . . . which was republished from Consortium News. The comments on both sites are worth reading.

"Cheneyism" is an accurate term and describes much of our current US political reality. In fact with this concept, much of our recent history becomes comprehensible.

As I have mentioned before, there are additional knock-on effects that are not so obvious at first. For instance, from a Clausewitzian strategic theory perspective, for a country/political community to act strategically there has to be a political context, a potential opponent against which the country/political community orientates. This opposition in turn has a specific context and capabilities which allow for contingent actions/reactions to take place over time. With Defense Planning Guidance or "DPG" this ended. No longer was there a specific opponent in mind, the context became global with even former allies in line to become potential adversaries. Defense planning (and procurement) went from threat assessment to capabilities enhancement which is essentially limitless . . .

Instead of containing the Soviet Union, with DPG the goal was the unlimited maintenance of global dominance, which from a strategic theory perspective is incoherent since the scope is simply too broad and complex to plan for in any realistic way, not to mention beyond the material and moral means the US possesses. So, we see strategy giving way to notions of US exceptionalism and the proclivity to see the use of force (in various forms) as the preferred means in international relations. This explains why the US today has lost the ability to act strategically and has been acting astrategically since at least 9/11.

This maintenance of global dominance in turn required the demolition of much of the international structure that the US had so carefully constructed after World War II, since the assumption (although not always followed) was that the US was first among equals; thus alliance relationships have decayed and shared values have been replaced by narrow interests of "allies" often operating at cross purposes . . .

Notice too the mention of Carl Schmitt. On the Torture as Stalking Horse thread I used a quote from Schmitt to introduce his concept of "sovereignty". This consists of the ability to identify the enemy of the political community in question and wage war against that enemy. Cheneyism and its followers have been doing that since 9/11 and in fact much of what they have done has been in the name of "keeping us safe" from a projected "existential threat", which is what the Global War on Terror or current War on Extremeism has been all about. Both are struggles against abstractions or methods (as in terrorism) not against a specific political community at all.

Cheneyism operates according to a politics of subversion and obfuscation. Nothing is as it seems, publicly stated policy goals are formulated for propaganda effect, while the actual goals remain hidden, unstated, even deniable. Much of what is going on in the world today follows in tow of this political approach with countries in the thrall of Cheneyism taking on many of its political characteristics. This fascistic ideology is perhaps best seen as a malignant social/political virus.

This all has also had a serious knock-on effect on our national intelligence collection, in that the purpose of that collection has become providing the justification for actions already decided upon, rather than accurately reporting on foreign relations/conditions.

Finally, the notion of US exceptionalism, upon which Cheneyism rests, assumes that the US cannot actually be defeated militarily. "We can only beat ourselves" or rather the people lose interest in carrying on "their fight". For this reason, domestic information operations become a military necessity, the main stream press becomes essentially a "ministry of truth" and elements of a police state are systematically put in place to restrain and punish an ungrateful populace . . . who are purposely kept unaware, but also assumed unworthy or even hostile to the attainment of the maximum plan. Exceptionalism thus applies not to Americans as a political community, but to the Cheneyite elite who guide and control the state unaccountable in any meaningful way.

Spot on predictions in 1970

In the late 60's, it was difficult for Aviators to advance beyond O-5, as the demands of Viet Nam and the Training Base precluded assignments in our Basic Branch that were necessary for advancement.  Being an Aviator was just a special skill identifier for officers in the various Branches.  As I have mentioned elsewhere, in 1969, CSA William Westmoreland decided that a shortfall in O-6 Aviators should be "cured" not by special instructions to promotion boards to advance highly qualified Aviators based in OERs and responsibility levels in lieu of "Branch Material" assignment, but to put 70 Colonels through Flight School.  Within the established Aviation community, we quietly referred to these Colonels as "Change of Life" or "Manopause" Aviators.  Some were quite good, and some were a farce.  I was an Instructor at Ft Wolters at the time, and chosen to instruct some of these Colonels.  Fortunately, the four assigned to me (two at a time) were first rate, and were very valuable mentors for learning the ins and outs of the rarefied air of DA and Army policy.  The second pair (both WWII, Korea and VN combat vets) were students when Nixon sent his Special Message to Congress on Draft Reform.

Shortly after the above message, after giving the two Colonels a Saturday morning tour of the maintenance facilities and fleet management operations for the School (we operated some 1,300 helicopters), one Colonel put on a barbeque for our families.  While gathered around the fire, beers in hand, the three of us began to discuss the President's plan.

Both COLs saw it as our "marching orders", and while they expressed their views on the future impact of an AVF, neither was judgmental.  Rather, they were looking at what they saw that leaders in the future would have to contend with.  Of course, none of us could predict the future conflicts our nation would be involved in, and most assuredly not the past 11 years.

First off, one COL addressed the magnitude of the opening round of increase in pay and benefits Nixon put on the table to be able to recruit and retain sufficient numbers of troops.  He predicted that the day would come when force structure will be significantly limited by personnel costs versus strategic needs. He also predicted that increasing pay would begin to cause an erosion in benefits, due to 1) the pay being seen as sufficient for the troops to do without subsidized benefits and 2) the burgeoning personnel costs of the AVF.

If we were going to pay "competitive"  wages that recruited and retained, the COL said, we would be locked into an ever increasing upward spiral.  When the economy is strong, higher wages will be needed, but when the economy is weak, there would be no way to decrease wages.  Thus, from a "market standpoint", the odds are that DOD would be always paying a premium wage.  And his prediction was pretty much spot on.

We have seen the force structure limits of personnel costs.  Rumsnamara vigorously fought end strength increases to preserve funds for fancy hardware, without regard to the impact it was having on the troops who had to face repetitive tours in hostile fire zones.  And, we are again trimming back end strength to meet funding constraints, while pay increases are suggested to be seriously capped for the next few years.  The payroll tab is just too high.

One benefit which he saw as being "fragile" was our newly received CHAMPUS (1966) which was the very first national program of civilian health care funding for dependents and retirees.  We are all aware of the various proposals floating to shift more of the cost of TRICARE (CHAMPUS' descendant) onto retirees, no less active duty dependents.

Another was retiree pay.  Since 1980, there have a couple of pieces of legislation to try to bring down pension costs, not the least of which was the recent attempt to cap COLA prior to age 62 for currently serving and retired personnel.  Congress has been basically schizoid about pension computation.  Do you reduce the pension tab and hinder retention?  So far, they have been very reluctant to find out.  The one attempt to seriously reduce pension rates, REDUX in 1986, didn't last long, and was made effectively voluntary, drawing few takers.  Another decrease in pension liabilities took place when military pay increases were spread across base pay, meals and quarters allowances, versus solely on base pay.  That took the portion added to allowances out of the pension computation.

While it wasn't a major personnel cost in 1970, Housing Allowances in subsequent years rose dramatically to match the average community rental costs plus insurance and utilities.  This year, they are being scaled back a fair bit.

Additionally, that COL saw various appropriated fund (tax supported) activities being shifted to non-appropriated (no tax support) status as well as commissaries coming under attack.  Again, spot on.

On a "lighter note" he also foresaw base closures for cost savings that would reduce the number of "enjoyable duty stations", no less result in fewer opportunities for "compassionate assignments", thus reducing the "attractiveness" of military service, which would only raise the costs of recruiting and retention.  We have seen several BRAC rounds, and DOD is now pleading with a highly reluctant Congress for more.

After all has been said and done, it has been end strength that has been the major tool in keeping personnel costs and thus DOD costs down, and there are definitely limits to end strength reductions if you wish to have a standing military of any capability.  So, where does DOD go from here?


However, it was the other COL who raised the most interesting notion.  In 1970, junior enlisted and junior officers looking forward to "getting out" was an every day occurrence that had been in place for 25 years.  After all, the draftee or three year enlistee was definitely going to be able to earn more on the outside, as would, most likely, the first tour Lieutenant.  Turn over was a natural course of military life.  Would a well paid AVF result in greater pressure to stay in, both in terms of finances and peer pressure?  What would be the psychological impact of such pressure to stay in on an all volunteer population versus a draft motivated population?  (BTW, it was from these two COLs that I first heard the term "draft motivated military").

It is this last question that intrigues me, as along with the pressures suggested by the COL, another new factor arose, that of long term assignments to the same unit.  In the Army, the same groups have been rotating into and out of Iraq and Afghanistan, pretty much together, for 10 years.  Has a notion of "responsibility" to one's comrades pressured Soldiers to remain in service even when they would prefer to do otherwise?  Are the combined uncertainties of civilian life and a sense of loyalty to one's fellow soldiers placing a new stress on AVF troops that wasn't there before?  Added to that is the impact of "Stop Loss" extending ETS dates, making another tour overseas guaranteed for many troops.  Does that further raise the pressure to just "stay in" after returning to CONUS?  Have we effectively created a personnel "meat grinder", and has this "meat grinder" contributed to PTSD rates?  Are there a significant number of troops who feel that there is effectively no "escape" without "turning on their comrades"?

I don't pretend to know the answer to the "stress" questions, but I do think they are in play.  Have we painted ourselves into both a fiscal and psychological stress corner?   Can we attempt to be a "world class military" power without breaking the bank in both fiscal and personnel terms?  Has our love affair with military adventures gone too far?  Is anyone even asking these questions or just accepting unchallenged "givens"?

BTW, the one issue I do not recall being discussed was an increased reliance on women in the military!

The Weakest Link

When she was good,
She was very good indeed, 
But when she was bad she was horrid 
--There Was a Little Girl, 
Henry Wadsworth Longfellow 

What are little girls made of?
What are little girls made of?
Sugar and spice
And everything nice,
That's what little girls are made of 
--19th cen. nursery rhyme 

She may be weary, women do get weary,
wearing the same shabby dress
And when she's weary,
try a little tenderness.
--Try a Little Tenderness, 
Frank Sinatra

~I think ugly girls should be
shot at birth by their parents.
It's bad enough being born a girl...but ugly and clever...
~fancy you're clever, do you?
  ~I rather hope so. I'm done for if I'm not! 
--My Brilliant Career (1979)
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Myth, media and reality: Tough Grrrls

The Marines recently pushed back the requirement that female recruits successfully accomplish 3 pull ups as more than 50% could not manage that feat, "delaying the prerequisite as it tries to integrate thousands of women into combat roles by 2016, the Associated Press reports."

The myths surrounding female vigor have shifted over time. There were the fabled Amazons who possessed physical prowess and goddesses who wielded the power to command others to do their killing. There was Boudica and Joan of Arc, and the rare women throughout history who went to war under cloak of male's clothing.

Patriarchy emphasized female reliance upon the male's brawn, and diminished her further through representations of the hysterical woman at once enslaved to her hormones and therefore a threat to the male's surety of his lineage, while at once ensuring the male's place as the satisfier of her wanton lusts.

Freud introduced us to the male's fear of engulfment and the vagina dentata, and the ever-receding possibility of sexual parity issuing not only from the inherent structural differences between the sexes but also our own particular neurosis and psychoses. It would seem the sexes would be forever consigned to opposite sides of the cave, cowering, glowering and licking their chops. The agreement allowing for one-on-one cohabitation was the marriage contract, a prospect based upon the distribution but not equalization of labor.

The 20th century ushered in film, actors, computer graphics and a social ethos which says, "Free to Be ... You and Me." In a generation we went from female cops like "Cagney and Lacey" -- of indeterminate sexual orientation -- to sexy killers like Ziva David on the popular television series NCIS. The boys can play with dolls, and girls can watch G. I. Jane and Lara Croft Tomb Raider. It's all good.

Fast forward 30 years and the new tough females are borderline or straight-out psychotic killing machines, like the female characters on the t.v. series Person of Interest. Forget bringing home the bacon and frying it up in a pan -- she does not care about making you feel like a man, because she's too busy co-opting your positions. Or so the media would have you believe.

The press hypes the new aggressive Alpha female and most accept the idea of women in combat and the death of the draft. But Ranger's position has remained steadfast: women should not be in the combat arms or maneuver or deployable units.

He does not hold this position because he is a misogynist or a dinosaur, but because the facts bear out his position. He is sorry to stomp on the parade of those who maintain the happy thoughts like "anyone can grow up to be President." 

The Army teaches that a unit is as strong as its weakest link. Soldiers train hard to achieve a strong chain that can pull a heavy load. Individual training strengthens the individual, and these single units are integrated into unit training after which they become deployable assets. This is the basis of all combat effectiveness and unit cohesion.

Combat is neither glamorous nor does it have redemptive value. In training, men frequently lose weight and get beaten down hard. It is doubtful that women could perform on the brute physical level of men like Medal of Honor recipients Staff Sergeant Jon Caviani and SSG Roy Benavides, who killed enemy in close quarters combat with their fighting knives after having suffered grievous wounds (Caviani put his knife in a man's brain and was forced to leave it as it became bone welded and would not extract.)

SSG Fred Zabitowsky broke his back and ribs but managed to pull three men out of a downed helo and drag them to an extraction area. He was burned, broken and gunshot, yet he hefted soldiers onto his back. Like so many MOH recipients, Zabitowsky accepted the award on behalf of his fellows, whom he credited with operating at the same level of heroism. (We have written about Ranger associate Paul Longgrear, who led his men out of the Battle of Lang Vei with a broken ankle and head wound.)

These acts are those of the fighting male operating full bore. Unlike Title IX in women's sports, the battlefield may not be arrayed so that women fight only their physical peers. The fact is, most men who qualify for military participation can physically dominate most women in a fight scenario. This is why most Olympics sports are segregated by gender -- it is not to give them the disadvantage, but rather to offer them parity in competition. This "separate but equal" is fair.

Ranger anticipates objections that these are extreme scenarios, but this is what the military's "chain" concept is all about. 

Twenty-four Medals of Honor were recently belatedly awarded to men who had been denied their awards due to racial or religious prejudice. Ranger challenges anyone to read these MOH citations and image a female performing the same deeds. It does not come down to bravery or patriotism alone, it comes down to sheer physical capabilities.

So what's the solution? Put women on 155, 8 inch, 4.2 mortars? Will they pull motor stables with the mechanized and Armor? Will they carry a Barrett 50 or a GPMG? Will women hump ammo as assistant gunners? Can they throw a grenade and fight with men in close quarters combat? Endure the filth and privations of the battlefield?

Ranger does not believe combat effectiveness should be compromised in the name of raising the glass ceiling.

[cross-posted @ RangerAgainstWar.]

Same Sh#t, Different Day

Seems that the proliferation of camo uniforms amongst the services and the attendant costs has Congress asking questions.

Probably the most confusing part of transferring from the Corps to the Army in 1966 was the notion of "dressy" fatigues.  In the Corps, as far as Utilities were concerned, enlisted folks had dull black collar insignia of rank, and officers wore their metal rank insignia - in garrison.  In "the field", it was common practice to remove all rank insignia, especially officer type.  Made the identification of "high value targets" a bit harder for the bad guys.

In the Army, on the other hand, the uniform worn in combat had a nice white name tag, bright gold sleeve insignia for enlisted, silver/gold collar insignia for officers, silver skill badges and lovely, multi-color shoulder sleeve unit patches.  So much for camouflage, cover and concealment.

However, by 1967, USARV had realized that the fatigue uniform was far too colorful, and locally authorized "subdued" insignia, while Stateside, "technicolor" was all that was authorized.  The old "Quartermaster Uniform Store" could not sell subdued insignia, but laundry shops off base could get you a supply before you shipped out. Vietnamese shops also catered to the quasi-legal subdued insignia trade if you needed some.

The standing joke was that we had "dress fatigues" and "combat fatigues".

Fast forward to the 21st Century, and the promotion of off base wear of combat uniform by all "Warriors" by the Bushies.  Well, surely the USAF and USN did not want their folks running around town looking like "pogues" in less than exotic fighting attire.  They had to have their "Warriors" dressed like "Warriors", but of course they did not want them to be confused with Army or Marine "Warriors", so they came up with their own blue camo designs.  Not sure what blue blends in with, but it sure can't be confused with the Army or the Corps.

God bless our Beloved Corps, but it does appear that they did the only proper job in developing a useful camo Utility Uniform back in 2002, and at a bargain price - $319K in development costs.  But then, they had a long, long tradition of understanding the difference between "dress" and "combat" uniforms.  They were even able to discretely incorporate the Eagle, Globe and Anchor into their very effective "pixilated" design.  Meanwhile, the Army and USAF each spent over $3 million in developing their answer to the Marine uniform, and still did not produce a satisfactory item.

Also brings to mind the Army's refusal to adopt the one piece, flame retardant, Nomex flight suit, but rather developing a two piece, Nomex, fatigue uniform looking affair.  It took forever to field it successfully in Viet Nam, because of the multitude of size combinations involved in a two piece uniform.  Fortunately, our Group commander authorized the wear of "government issue fire retardant flight uniforms as available" as preferred to jungle fatigues, specifically to allow us access to Nomex from other services.  Thus, we would scrounge Nomex flight suits from the other services while awaiting our Army two piece uniform.

Aren't there more important issues to address, no less higher priorities for available funds, that having "dress fatigues"?

Something I've always wondered

Not sure if I'm alone in this, but I know that while in there were a number of words that were used on a regular basis that I have never ever known the actual proper spelling or origin.

Figured I'd ask if anyone had any knowledge, especially some of you Vietnam vets.  Not sure if the terms pre-date the war there or what.

Pog/Poege/Poge - pronounced: POE-GUH - anyone who's in a non-combat MOS or someone who is but who does not do that job, or literally anyone who you think isn't carrying his load.
I've heard that it's origin is 'Persons Other than Grunts', but that seems significantly more complicated than I'd expect.  It sounds like something someone thought of after using the term.
The other explanation was that it comes from either Vietnamese or Tagalog term for pussy, 'poegee,' and is a bastardization from that term.
(There was also a claim that poegee bait comes from the idea of something to lure in pussy)

Stand 2/Stand too/Stand to - pronounced like it looks - 100% manning at the dusk and dawn hours.
Never heard a really good explanation why it's called this.  The only thing I've heard is that it's a shortened version of Stand to Arms and so it'd be written 'Stand to' but this seems somewhat hollow to me.

Anyone have any insight?

Any other terms that are interesting/confusing?

The gunners have this plan, sir, but...

From a 1530ish manual on military ordnance; rocket cats.

The work is by one Franz Helm of Cologne, who was an artillerist and ordnance specialist during the early gunpowder warfare period. And Franz had some ideas that seem to be some pretty outside-the-box thinking.

"Helm explained how animals could be used to deliver incendiary devices: "Create a small sack like a fire-arrow . if you would like to get at a town or castle, seek to obtain a cat from that place. And bind the sack to the back of the cat, ignite it, let it glow well and thereafter let the cat go, so it runs to the nearest castle or town, and out of fear it thinks to hide itself where it ends up in barn hay or straw it will be ignited."

In other words, capture a cat from enemy territory, attach a bomb to its back, light the fuse and then hope it runs back home and starts a raging fire."

So far as I know there is no actual evidence that Helm, or anyone else, actually tried this.

Probably not a good idea whenb you think about it, given that a flaming cat, or crow or pigeon, is just as likely to flee in panic towards the nearest cover - the nearest probably being your own mess tent.

Still. Just goes to show that the whole "bizarrely useless defense contractor gimmick" wasn't invented by Raytheon.

(Big h/t to TPM and Lawyers, Guns & Money for finding this bizarre piece of semi-military historical trivia...)