Monday, March 13, 2017

Simplify

As we approach the coming equinox, thoughts turn to spring cleaning. It’s a tradition, is it not: spring cleaning? Not my tradition, mind you. My seasonal thoughts turn to spring peepers and leaves popping on trees and migrating birds, many freshly attired to attract a mate, and <groan> income taxes. I don’t notice the dirt I’ve tracked into the house until it’s pointed out to me. Nor do I notice overfilled closets, file cabinets, or newsletter mailing lists until there is no room for the addition I want to make.

With that introduction, you’ll not be surprised to learn I am a packrat. Aphorisms I grew up with and still repeat include, “Waste not, want not,” and “You never know when you might need it.” It’s a family tradition. When my father died, I “inherited” a ton (figuratively and probably literally) of family papers and such—mainly because I was the child with room to store all the material. I remember hearing about my grandmother joking to my father when my grandparents transferred the papers to him as part of their downsizing, “From our attic to yours.” I assume my children know what that means for their future.

I recognize this proclivity of mine. I often joked that I kept buying bigger (or more) houses because I needed more room to store books. A couple of years ago, I instituted a new practice regarding my personal library. For every new physical book I buy, one must find a new home. Down south, our church’s youth have a book sale to support their going to the denomination’s summer camp. Up north, we donate books to one of the local libraries. I look at it as giving someone else the opportunity of reading words I will not read again (at least in this lifetime). Electronic books are exempt from the physical storage constraint.

The digital age creates both opportunities to eliminate much of the physical records I keep and an almost limitless opportunity to keep more stuff that no one will ever use. For example, I kept in a file cabinet copies of all my tax returns—the earliest was while I was in high school! Legally, it makes sense to keep the most recent seven years; I filed the remainder because you never know who might be interested. Wouldn’t it be cool to see your grandparent’s or even great-grandparents’ taxes? Or my parents’ taxes the year I was born. (Back when we really were making American great again by investing in education and infrastructure. The highest marginal Federal personal income tax rate was 91%, although my parents’ marginal rate was probably only 22%).

So, I converted my historic tax returns to PDFs and stored them on an external hard drive. Now, if someone wants to know how much I made as a camp counselor in 1969, the answer is still available! That project emptied an entire cabinet drawer. And sometime in the future when my children look at a directory of that hard drive, they can clean the whole thing with one command. So easy.

Photographs are something else again. When film and processing cost serious dollars (at least for my budget at the time), I was parsimonious with my picture-taking. With digital cameras, I’ll shoot multiple frames—you never know which shot will be the keeper. This leads to resource problems. I need to spend time going through all the pictures to determine which are best. But can I delete ALL the others?

Are you kidding? This is me, we’re talking about. Sure, I delete the out-of-focus shots and the ones with someone’s elbow taking up half the frame. But the others? Well, you never know when . . . But I haven’t the time or interest in labeling the thousands of photos I electronically keep, so who am I really kidding here about the usefulness of the thousands of stored images. And yet, you never know . . . Not all that long ago one of my WWK blog mates wanted to use a picture of a house finch to illustrate her blog. Of course I had some to share. It’s that random variable positive reinforcement that feeds my hoarding addiction.

So with that as background, you may be surprised that I recently removed about 30% of the names from my author newsletter mailing list. I use MailChimp, which is free for me, provided my list includes fewer than 2,000 addresses. I was about to add another 100+ names gleaned from a contest, which would put me over 2,000. Faced with the choice of paying to email my newsletters or making room in that virtual closet, I made room.

I figured that the chances of someone who had not opened any of my last five newsletters would suddenly become a rabid fan were dismally small. Turns out using that criterion produced almost 600 email addresses. I admit when I saw how large the number was, I hesitated before pulling the trigger and assigning those 600 people to the terrible fate of not giving them the choice to ignore my newsletter for another year.

[There is room in my newsletter if you want to sign up. Here’s a link.]

I used to have a sign in my office that said, SIMPLIFY. It was meant as reminder that if I did not actively simplify, I would fall into the trap of spending inordinate time and energy managing my complications. I know I kept that sign someplace, because you just never know when it would be useful again. Oh wait, I just did a search of my computer’s hard drive and in two seconds it gave me the link to a PowerPoint file titled “Simplify.” See, you just never know . . . 

~ Jim

This post originally appeared on the Writers Who Kill blog 3/12/17

Thursday, March 9, 2017

Cowriting a Short Story

As a writer of the Seamus McCree Mystery/Suspense series, my marketing aim is to expose more potential readers to my novels. When Teresa Inge asked if I’d be interested in submitting a story for the 50 Shades of Cabernet anthology, I immediately agreed. It fit my marketing needs: a Seamus short story in an anthology with lots of excellent writers that would expose a new group of mystery readers to him. [Pre-order links for Amazon and B&N.]

Over the last few years I had worked closely with Tina Whittle in founding the Low Country Sisters in Crime Chapter and become a fan of her Tai Randolph series. In the back of my mind, I hoped we might find an opportunity to work on a joint project. After receiving permission from Teresa to submit a cowritten story, I approached Tina and she agreed. Now we had to figure out what to write.

Tai is a southern girl born and raised. Seamus is a guy of the north and was going to have to travel south for this adventure to happen. Tai buys and sells Civil War antiquities in Atlanta; Seamus is a Civil War buff. That was enough of a nexus, and at the end of two email exchanges, we had the basic outline of the story. Now, how to write it?

Having talked to writing duos at mystery conferences, I knew there were as many ways to approach the writing as there are pairs who write. Tina’s series is written from Tai’s point of view in first person. My series often uses multiple POVs, but scenes in which Seamus has the POV are also written in first person. We agreed to write the first draft of those scenes in which our character was the more important POV character. We’d write the scenes in order of the story and write everything in first person. To remove reader confusion about who the “I” in the scene was, we stole a technique from the 19th century and introduced each scene with a very brief descriptor. For example, the opening scene is introduced as Seamus McCree Meets a Daughter of the Confederacy at a Soiree.

Tina Whittle
I had responsibility for writing the first scene. Tina provided me background information on what Tai and Trey would wear and how they might act in the setting I planned. After I completed the first scene, Tina composed the second, at which point we agreed to straighten out little plot inconsistencies after we had a first draft completed. (I was happy with that solution because even though I outlined the story, I’m a pantser by nature and don’t want to be strictly constrained by any outline.)

After we wrote “The End,” it was time to revise. I took the first crack to straighten out a couple of plot bobbles and smooth our first draft writing. We traded the manuscript back and forth until we both liked what we had. Version four became our submitted.

The editor had only small suggestions. Looking through the edits, it was as if we had performed a Vulcan mind-meld. (Which you understand if you are a Trekkie fan; otherwise replace with “we thought exactly alike.”) Tina and I were pleased to discover we agreed on which of the editor’s suggestions to take, which to agree she had diagnosed a problem but to develop our own solution rather than accept her suggested approach, and which ones we felt needed push-back. One sentence proved particularly troubling, and we batted that one back and forth in a series of emails until we wrestled it to the ground.

Bottom line, would I do it again? Any time Tina wants, I’m up for it. I not only enjoyed working with her, I believe that our combined story was stronger than either of us might have produced on our own. (Now, of course, she might think that’s because I dragged her brilliance down, but if she thought that, she was kind enough to never mention it!)

Would I partner with anyone? I’d be open to discussing a project, but I’d have to feel comfortable that our styles were compatible. Check out how we did. [Pre-order links for 50 Shades of Cabernet: Amazon and B&N.]

~ Jim

Monday, March 6, 2017

Put Up or Shut Up (An Open Letter to President Trump)

Dear President Trump:

You won the electoral college election and, having been duly sworn into office, are the president of the United States of America.

Act like it.

Presidents represent all the people of the United States. They give up their personal right to voice unproven beliefs to the public as though they are facts because their pronouncements now come from the head of the executive branch of government, not from a private citizen.

Illegal Voters

When you claim to have won the popular vote had illegal votes not been counted, you are saying that at least 2.8 million more illegal votes were cast for Hillary Clinton than were cast for you. This is massive voter fraud. It means more than one in every 24 votes cast for Clinton was illegal. If true, this is a crisis for democracy in the United States. It is much more serious to address this problem than to fix the tax code or repeal and replace Obamacare or even tackle the problem of an insecure border.

Well over a month after you made the claim, we have heard nothing more about the investigation you planned to order. Why is that, President Trump?

Illegal Wiretaps

This past week you tweeted, Terrible! Just found out that Obama had my "wires tapped" in Trump Tower just before the victory. Nothing found. This is McCarthyism! and How low has President Obama gone to tapp (sic) my phones during the very sacred election process. This is Nixon/Watergate. Bad (or sick) guy! If true, this is extremely serious.

Either President Obama has broken the law in a truly frightening way (he’s circumvented the process that requires Justice Department officials to obtain a judge’s permission before allowing them to execute a wiretap, or he’s circumvented the FISA court by not obtaining a legal order to surveil with respect to a foreign entity) or the Federal Government has acted legally (implying someone(s) in Trump Tower, or the Trump Organization, or the Trump Campaign acted in such a way as to justify a court ordering the surveillance).

You must have factual evidence to justify accusing a former president of usurping power from the courts and illegally obtaining information about a presidential candidate and his associates. With such a serious charge about the power of the presidency in a democratic country with supposed checks and balances, it is critical that the public understands exactly what has happened and how we can prevent any future president from committing similar nefarious actions.

The time, President Trump, has come for you to PUT UP OR SHUT UP.

Because you have stated that Administrative leaking is a security issue, and you have tweeted that nothing was found on the wiretaps, I must assume no secret material is involved. Please release the verifiable details of the wiretaps. How were they issued? Who carried them out? What was discovered?

And tell us who is performing the critical inquiry into your claim of voting fraud. What specifically is their charge? When is their report due to the American people?

Regarding any further statements you make:

Please provide the proof prior to or simultaneously with your presentation of the issue you choose to address. In the vernacular of the playground, PUT UP or SHUT UP.


~ Jim

Thursday, March 2, 2017

A Primer on Replacing Obamacare

“For every complex problem, there is a solution that is clear, simple, and wrong.” – HL Menken

“Nobody knew that health care could be so complicated.” – President Donald J. Trump

For the last six years, congressional Republicans have had a clear, simple, and wrong solution to fixing the Affordable Care Act (ACA or “Obamacare”). They voted umpteen times to repeal it and offered no measure to replace it.

The law, as many laws are, is a complex compromise between aspiration (mostly by Democrats) and legislative reality. It was not perfect at birth and, like a six-year-old car that has had no maintenance, is in worse shape today. Had Republicans spent the last six years fixing the problems in Obamacare, it would be in much better shape. But that is all past. We must look to the future.

With Trump’s election as president, Republicans suddenly became the dog that caught the Obamacare car. What do they do with the thing? In my Open Letter to President-elect Trump and the Members of the 115th Congress (on repealing Obamacare) I closed with these words:

If you do not have sufficient experience with the actuarial and underwriting principles that underpin the individual insurance marketplace, I urge you to work with the American Academy of Actuaries to understand how those principles relate to any proposed legislation before casting your vote.

Perhaps had President Trump reflected on my open letter he would not have been so surprised about the complexity of health care.

Fortunately, Congressional leaders recognized that the wrong approach of repealing without replacing a law that runs to 906 pages (and tens of thousands of pages of regulations) would lead to multiple disasters. With healthcare, even the minutia has minutia.

However, there are several broad truths about heath care that are important to keep in mind as we evaluate the Republican’s proposed replacement.

The total cost of medical insurance =
the total cost of medical benefits provided, plus
administrative costs, plus
profit

To reduce the cost of medical insurance requires reducing some or all of its three components.

Reducing corporate profits is not part of the Republican (or Democratic) agenda.

Everyone would like to reduce administrative costs, which everyone agrees are too high. There are very few incentives in place to reduce administrative costs. Obamacare forced certain insurers to rebate to their policyholders a portion of paid premiums if overhead, including profits, exceeded 20% (15% in the large-employer market) of premiums collected. I received a rebate related to my premiums for 2015 from my large-deductible medical care policy.

Moving to a one-payer system would probably reduce administrative costs. It has for other countries; but the U.S. has its unique issues, so I am not making promises. Shifting policies to give consumers a larger choice of insurance options will not materially affect administrative costs—and may increase marketing costs.

Which leaves us with reducing medical costs as the only practical method to reduce overall premiums.

Reducing the cost of medical benefits provided can be achieved by
(a) reducing costs charged to patients or their intermediaries (insurance companies or the government),
(b) shifting the costs from covered insurance to some other source of payment, or
(c) eliminating utilization of the benefit.

Reducing Costs Charged: Competition without collusion usually reduces costs. Republican proposals to allow insurance carriers to operate over state borders could offer additional competition and marginally reduce administrative costs. (Insurance companies often must keep separate corporate entities and books for each state in which they operate.) Changing laws to provide greater competition on drug prices would address that aspect of cost. Three steps Congress could take to reduce drug costs incurred are to allow Medicare to negotiate costs with drug companies, to outlaw the ability of a drug patentholder from paying another company to withhold a generic from the market, and to allow the public to import drugs from other countries when they are the same drug sold at a lower price.

Regulating provider prices (as Congress has tried with Medicare reimbursement rates) often leads to shortages of providers when doctors make the economic decision to stop accepting Medicare patients and concentrate instead on private insurance payments.

Shifting Costs from Covered Insurance: One of the most popular approaches to reducing medical insurance premiums is to shift costs from the policy elsewhere. The two major approaches are to increase the policy deductible and to cap expense reimbursements.

Before I became Medicare eligible, I purchased high-deductible insurance. I was healthy and gambled that my out-of-pocket medical costs would be less than the insurance costs of a low-deductible plan. However, if something major happened, I didn’t want to pay for that out-of-pocket. My insurance costs were significantly reduced – BUT at the cost of taking on considerable risk. (My gamble paid off for the fourteen years I had individual coverage.)

My behavior was affected, however. I thought twice before going to a doctor or agreeing to a test or procedure. This is a double-edged sword. Because I had monetary skin in the game, I was a more careful consumer. However, studies have shown that when people defer routine healthcare, the long-term costs of chronic diseases increases because the individual enters the health care system at a more advanced stage.

The two ways of limiting reimbursement is to impose a lifetime maximum or reimburse fixed amounts for a particular benefit (for example $200/day in the hospital). As costs increase and reimbursement does not, more of the total costs are shifted from the plan to the covered individual. (The same will happen to states if they receive block grants. Unless Congress continues to increase the block grants to match cost increases, the states must either pick up the tab or cut benefits to those covered.)

Eliminating Benefit Coverage: There are multiple ways to decrease benefits and reduce costs. Health care policies could exclude certain procedures now covered. They could decide to eliminate coverage for organ transplants, or abortions and birth control, or sex-change procedures, or wellness exams, or any drug that costs over $1,000 a year, or whatever was deemed legal. The United States could effectively ration health care by limiting the number of procedures performed each year. This is the approach Canada has taken to reduce costs: fewer procedures equals lower costs.

Reducing the number of covered individuals: Finally, the easiest way to reduce costs is to reduce the number of individuals covered. Increase Medicare’s eligibility age to seventy from sixty-five and you’ve eliminated five years of costs. Eliminate medical coverage for Medicaid-eligible individuals, and cut those costs.

Obamacare increased overall covered costs by including additional benefits in plans, decreasing the acceptable size of deductibles in order to avoid a tax-penalty (I had to pay a penalty the first year because my high-deductible plan did not qualify), and significantly expanding the number of individuals covered under medical insurance by allowing children to remain much longer under their parents’ policy and expanding Medicaid edibility for those states who accepted it.

Republicans currently claim their proposal will decrease medical costs. The question that we need to answer is how will they do it? What are the tradeoffs they are proposing? Whose ox is gored?

The truth about pre-existing conditions

I pay house insurance every year and I hope to lose money every year because I don’t want my house to burn down just so I can win. Even though I have “lost” money on my housing insurance every year, it’s reasonably fair. Actuaries and underwriters price my insurance based on my house’s size, structure, safety measures, type of wiring, how far it’s away from a fire hydrant and fire station, and so on. They can reflect all the pre-existing conditions of my house in determining the premium.

In the past, we have done the same thing with individual medical insurance. If you are a young, healthy male, don’t smoke, do drugs, or engage in risky avocations (motocross racing, for example), your medical insurance can be inexpensive. Your biggest risk is from accidental injury; you rarely get sick. And you don’t get pregnant, which is why individual insurance for women used to cost more than for men.

Until as a society we decided that wasn’t fair, and eliminated sex as a basis for determining premiums. Men now subsidize women in this regard.

Many group medical insurance plans charge the same premium regardless of age. Older folks have more medical issues than younger ones. The young subsidize their elders. This is also the case for Medicare. Young(er) beneficiaries generally cost less than their older compatriots, yet premium costs are the same.

Even where plans reflect age in their premiums, they may not reflect health status. All Medicare beneficiaries pay the same premiums (ignoring extra premiums paid based on income status). Healthy beneficiaries subsidize sicker ones.

When we turn to the individual insurance market, healthy people think premiums should be based on their age and health. Why should they pay to cover someone who is older, or overweight, or has diabetes? It’s a fair question and one that needs an answer.

Under Obamacare, the answer was essentially that the young and healthy had to join plans and pay more than their fair share as part of a societal good. The same extra costs that are buried in group plans now became embedded in individual plans. Younger individuals either joined and paid these extra costs through their premiums or chose not to join and paid the costs through a tax. Because Obamacare provided a financial mechanism for supporting the extra costs of those with pre-existing conditions, they could require insurance companies to provide coverage for those sicker people. It was up to insurance companies to enroll enough of the younger, healthy individuals to break even on the deal.

What happens under such a system? The sick sign up in a New York minute: it’s a great deal for them. It’s up to insurance companies to enroll enough healthy folks to pay the tab for the sick ones. Insurance companies set rates based on an assumption of how many sick and healthy people they could attract. Where they were unable to enroll as many younger healthy individuals as they planned, they lost money. To make up for those losses, they raised premium rates. In those areas of the country where states supported the new marketplaces, lots of younger people joined the plans. Competition remains and premiums increases are moderate. Where states did not support the new marketplace, enrollment was well below expectations, resulting in subsequent huge rate increases and carriers dropping out of the market.

The death spiral of individual plans

Those of us involved in employer group medical insurance saw this death spiral when employers first introduced optional higher-deductible plans in an attempt to lower their insurance costs. Back in the 1970s and early 1980’s, most plans had no or very small ($100 individual/$300 family) deductibles. Increasing the deductible to $250 or $500 produced significant savings relative to the costs at the time. Employees chose the plan that made the most economic sense to them. Healthy individuals and families rushed to the higher-deductible plans. Older and sicker individuals stayed with the old no-deductible plans.

At the same time, companies first introduced Flexible Spending Accounts, seeding them with money for those employees choosing the higher-deductible plans and allowing employees to set aside tax-free money to pay for the costs they would now need to pay out-of-pocket.

Note what employers did: they lowered plan costs and provided “tax credits” to help pay for the plans. The very same elements Republicans currently promote (although we do not yet know the details). How did that work?

The next year, the costs of the no-deductible plan increased significantly. It included sicker folks after all, and in the second year, those on the margin dropped their expensive coverage and selected the higher-deductible plan. Those folks in the high-cost plan were on average even sicker. In a short time, the high cost plan had astronomical premiums and the companies dropped those plans altogether.

Deductibles for everyone have continued to increase, as have premiums, but at least under the group plan concept, those with pre-existing conditions can still receive coverage, and that coverage is subsidized by their fellow employees.

Take the same scenario to the individual market and no such protection will exist for those with pre-existing conditions. With multiple insurance plans to choose from, the healthy will make economic decisions that will cause people with pre-existing conditions to experience that same cost death spiral. Sure, they won’t be denied insurance, but they won’t be able to afford it.

Squeeze the Balloon

Visualize medical costs as a balloon. Each new drug, each new treatment, each new test, each new procedure, each administrative change either blows more air into the balloon or lets a little out. Total U.S. medical expenses only decrease if we find ways to let air out of the balloon. Squeezing the balloon simply shifts who pays for it and makes the one doing the squeezing “good” by pushing costs away from their sector of the balloon.

Propositions such as changing Medicare from a single-payer system to a system in which all covered members receive a credit grant to allow them to shop for their own insurance does not affect the size of the balloon. It will affect who pays the costs, and, depending on its implementation, may create its own death spiral similar to the corporate experience of the 1970s and 1980s. Block grants shift responsibility and burdens from the Federal government and introduce additional inequities between states.

Conclusion

Above all, ignore the pretty words (and titles) politicians use to describe their laws.

When evaluating health care proposals, consider the specifics: how costs are being reduced, who will subsidize whom and by how much, and what incentives will counteract the inherent inequities in paying for medical plan costs.


~ Jim