Conservative Groups Fight Back To Preserve Surprise Billing

There is no stronger incentive than the profit motive.  Public good vs. private gain?  Capitalists will go for the latter over the former every time. 

What is the answer?  It could be regulation, but only if the government were stronger than it is.  It's really hard to think that anything positive is possible without election financing reform.

Here are the details of how reform of surprise billing is looking worse and worse.  The alternative to the Pallone-Alexander-Walden-Murray solution mentioned here, sponsored by conservative forces, which would force a bill by bill review of disputed charges, rather than a systemic revision of the system of billing out of network, is clearly unworkable, as I detailed earlier -- http://buddshenkin.blogspot.com/2019/03/regulating-to-fix-surprise-billing-and.html.

Here are the details: https://thehill.com/policy/healthcare/478818-conservative-groups-aim-to-sink-bipartisan-fix-to-surprise-medical-bills.

And to save you the trouble of clicking the link, here is the text of their account: (by the way, note involvement of Democrat Richie Neal, Chairman of Ways and Means, who has gone so easy on the Trump Administration.  (https://prospect.org/power/democrats-richie-neal-problem/)

Conservative groups are gearing up for battle with GOP leaders over bipartisan health care legislation that lawmakers view as one of the few election-year bills that has a shot at making it to President Trump’s desk.

A broad swath of free-market conservative groups is mobilizing to oppose a measure that would ban the so-called “surprise” medical bills patients sometimes receive from hospitals and providers when their services aren’t covered by insurance.

The strategy, in part, is to link the bipartisan proposal to “Medicare for All,” the single-payer health care plan backed by some progressive presidential candidates like Sens. Bernie Sanders (I-Vt.) and Elizabeth Warren (D-Mass.).

“There’s not much legislation out there that will make it to the president’s desk this year and this has a chance,” said Brandon Arnold, president of the National Taxpayers Union (NTU), which has spent more than $1 million attacking the bill.

Arnold warned that proponents of the measure are “going to run into broad opposition from a wide array of conservative groups who are united on this.”

“We plan to have an impact,” he added.

Patients are subject to surprise bills when they go to a hospital or emergency room that is in-network but treated by an out-of-network doctor.

A bipartisan deal reached last year by the leaders of the House Energy and Commerce and the Senate Health, Education, Labor and Pensions (HELP) committees would essentially ban providers from sending surprise bills and instead require insurers to pay them. The cost would be based on the average price for the services provided, a method called “benchmarking.”

But groups like NTU and Heritage Action argue the legislation is on par with “price controls” or “rate-setting” that would give the government too much power in the private sector and pave the way for Medicare for All, even though Republican backers of the bill proposal fiercely oppose Medicare for All.

“I’ve heard all the terminology,” said Rep. Greg Walden (Ore.), the top Republican on the Energy and Commerce Committee, in response to the “rate-setting” criticisms.

“It’s not. That’s an easy moniker to throw at it,” he said. “At the end of the day, we didn’t ask for this problem, but we’re going to solve it. We just see it as good policy.”

About a dozen right-leaning groups have come out against the bill, including some of the most well-known fiscally conservative organizations in Washington, like Club for Growth and FreedomWorks. The groups join a high-dollar fight launched last year by hospitals, insurance companies, doctors and private equity groups that are all trying to tilt the measure in their favor. 

After facing angry lawmakers and headlines about patients getting saddled with expensive bills, insurers and providers now agree patients shouldn’t be receiving them. But the two sides have engaged in an all-out war over who should take the biggest hit if changes are made.

Insurers favor the proposal offered by Walden, Energy and Commerce Committee Chairman Frank Pallone Jr. (D-N.J.), Senate HELP Committee Chairman Lamar Alexander (R-Tenn.) and Sen. Patty Murray (D-Wash.), the ranking member on the HELP panel. The lawmakers had planned to include their bipartisan measure in the 2019 year-end government funding package, but it was left out amid opposition from hospitals and providers and after a rival proposal was offered by the House Ways and Means Committee.

Lawmakers are now pushing to include the legislation in a May spending package, setting the stage for a new round of fights with conservative groups.

Alexander and Walden are retiring at the end of this term, putting extra pressure on them to get the legislation passed.

“I get it. You serve for a long time and think you’re doing what you should for your constituents, and I respect that. But we disagree with this legislation,” said David Williams, president of the Taxpayers Protection Alliance, which opposes the bill. “But it’s not the right thing for the health care industry. I won’t begrudge the effort, but I’ll disagree and make sure it won’t get passed.”

The concerted effort of influential conservative groups has irritated GOP lawmakers who had already been hearing from constituents about separate ads airing in their districts sponsored by private equity groups.

Envision and TeamHealth - staffing firms backed by Blackstone Group Inc. and KKR & Co. - spent a combined $54 million on ads last year targeting the proposal.

NTU piled on, spending more than $1.2 million since early December on radio and television ads across the country, including in states and districts represented by lawmakers who are working on the legislation.

Last month, NTU spent $38,000 on 165 radio spots that aired in Nashville, Tenn.
“The only people who don’t want to protect innocent patients from unaffordable surprise medical bills are the people profiting from this anti-competitive flaw in our health care system,” said a GOP official for the Senate HELP Committee.

“Chairman Alexander will continue to keep his bipartisan, bicameral agreement to end the practice of surprise billing at the top of Congress’ to-do list until it is done,” the official said, noting that the measure has President Trump’s backing.

NTU also spent more than $261,000 on ads in the Houston market, which is in part represented by Rep. Kevin Brady (Texas), the top Republican on the Ways and Means Committee.

That spending included $112,000 for an ad that ran Jan. 12 on local TV station KHOU during a Houston Texans playoff game.

In December, Brady and Rep. Richard Neal (D-Mass.), the chairman of the Ways and Means Committee, released a competing approach to ending surprise billing favored by doctors and hospitals. Their measure would still ban providers from sending surprise bills to patients, but it would let a neutral, outside party determine how much the insurer will pay the doctor if an agreement can’t be reached privately.

The proposal is cautiously backed by some of the conservative groups opposing the Pallone-Alexander-Walden-Murray measure, though they are reluctant to offer their full-throated support until the legislative language is introduced.

“The early outline provided by Ways and Means is a step in the right direction and we look forward to working with them more closely,” said Heritage Action Executive Director Tim Chapman in a statement.

Regarding the other measure, Chapman said, “We view this as a direct step towards Medicare for All and government-controlled healthcare.”

The introduction of the Ways and Means proposal complicates matters since the committee also has jurisdiction over health care.

Pallone and Neal are to meet soon to discuss their plans and find a path forward, Neal said this past week. Walden and Brady’s teams are also talking.

“I actually think we are closer together than people realize,” Walden said. “Our teams are talking. Frank [Pallone] and I remain joined at the shoulder, the hip and probably the ankle too on this matter because consumers are getting ripped off and it’s time to move.”

Budd Shenkin

I Meet Emma Bovary Again

I met Emma for the first time maybe 15 or 20 years ago. Catching up on my education, I took the Teaching Company course on great books, and of course Emma was rightfully there. I didn't like it much. Such disagreeable characters and such a confined, judgmental society.

But that was then and this is now – and as Heraclitus said, “No man ever steps in the same river twice, for it's not the same river and he's not the same man.” For one thing, this time around I read it in French, in a dual language book with French on the left hand page and English on the right. (My edition's English translation was from 1886 by Eleanor Marx-Aveling, Karl Marx's daughter – imagine their dinner table conversations about the bourgeoisie!)

This second time through I liked it a lot more! I'd like to say that reading it in French made all the difference, appreciating Flaubert's style and his famous “le mot juste.” But truthfully, since I'm still just an intermediate French student, hopefully on the way to advanced, I have to say that the real difference was probably that I had to go slower, and had time to think and notice and to wonder. And then there's the “me” part of it. They say you decline with age, but I actually feel smarter and wiser (except for math), and I've read a lot more literature and experienced a lot more life since I first met Emma et al.

It's an amazing book. You always want to keep reading, but all the characters, emphatically including Emma, are famously unsympathetic. Julian Barnes called Madame Bovary “the greatest shopping and fucking novel of all time,” which is of course a great line. “Great novel” paired with “shopping and fucking” is a master statement, certainly more overt than Flaubert's more subtle combination of base characters and masterpiece prose. It's really amazing: no character wishes anyone else well, no one thinks of helping anyone else, no one expresses any ideals or much ambivalence about anything, no one seems to empathize or understand anyone else.

Maybe this is Flaubert's “realism.” Forget the ideals, forget the melodrama, what are people really like, what really happens? Flaubert paints them as all underside, always looking out for themselves. Emma inflates her first love affair, with her first lover Rodolphe, into a great passion with a dramatically envisioned course of running away and living on love, but he is already thinking how he will get rid of her before he has even bedded her. Homais the pharmacist eggs on Emma's physician husband Charles to try an experimental surgical cure on a servant's club foot that costs him his whole lower leg, all in the hopes of admirable postings about their fair city of Yonville in the regional newspaper. The base villain Lheureux (the happy one? Come on, Gustave, give me a break!) lures Emma into debt, bankruptcy and suicide in pursuit of filthy lucre. The gossips of the town spy maliciously. The justly famous public holiday scene displays the fatuous mediocrity of speaker and listeners without compassion – only the peasants get off easy as mindlessly happy at an event. No one, no one helps anyone else, except Emma's deadly dull physician husband Charles who, in the process of doing good and working hard, and I don't know if Flaubert suspected this, couldn't do much good at all in an era of medical ignorance – and neither could the self-important uncaring consultant physicians and surgeons who appear. My God, what a group of no-goodniks! Only the ignorant peasants are happy in their simplicity. You can understand why “bourgeois” is an epithet.

I guess most people are very critical of Emma – prideful, deceitful, adulterous, shallow, selfish, cruel, and worst of all, an unloving mother. It's warranted, although I would give her a pass on what the book makes the most of, adultery. But still, for all her shortcomings, I found myself being sympathetic to Emma. I thought, what were the alternatives offered to a spirited, highly-sexed, not naturally conforming woman in 19^th century provincial France? What else was she supposed to do, being who she is, and living where she does? Raised in the provinces, reading romances secretly as she is educated in a convent, reading the Parisian ladies' magazines after that, is she going to let life go by, her with her dull husband and some needlework? She grabs what the winds of chance provide her. She is criticized for being self-conscious when she sees her reflection and the physical signs of her fulfillment and says, “J'ai un amant ! Un amant !” In other words, “I did it!” Well, good for her, I say! Give it your best! It's not an aberrant reaction. I remember my son Pete when he got his first acceptance to a law school – he looked at me, he looked at the sky, he said with some wonder in his voice: “I'm going to be a lawyer.” It's not that big of a difference, and I don't mean as a cynical lawyer joke. Dreams are dreams, who are we to judge?

It turns out the guy Emma chooses first is a turkey, but that's life. Then she tries again with the younger Léon, where they have a regular room at a hotel in Rouen. I've often thought we should have the right to health, education, and sexual fulfillment. Why not? I'm on her side. Again it works out badly, but again, you do what you can do in the circumstances you find yourself, with whatever resources you have. At least she tried. I remember my wife's comments when Clinton got into his Lewinsky trouble – she said, if he wanted some action on the side, couldn't he have found someone with class, who knew how to keep a secret? You do what you can do.

(Just as aside, I wondered what the clerks at the hotel thought, what their views of life were as they saw all that happened in their hotel. Maybe it was like Love Boat. I remember that when I was first in practice the older pediatrician who was my office mate had certain patients that his staff booked for longer visits, calling them GLM visits – good looking mothers. Propriety can be just a question of how far you go.)

And the fact that Emma was lured into being a spendthrift just makes me sad, and angry at the perpetrator. I thought, at least Flaubert didn't make him Jewish. I think about Emma being led down the garden lane by this slime – who was there to help her? Who was there to consult with, someone who knew more and wished her well? What do you do when no one prepares you, when your parents were no help at all? It's so sad when you are all on your own, YOYO. What a wasteland when no one cares for anyone else or helps anyone else.

Of the millions of words that must have been written about Madame Bovary, I sampled some on Google. I was surprised that my readings didn't emphasize the feminist issue more – I just missed them in my cursory search, I'm sure. But the plight of the woman in provincial society is so obvious. Talk about oppression! I mean, what were the choices?

(Just one more by-the-way comment before I set out what I thought most interesting of the comments I read – how come there isn't more talk about pregnancy, not here, not in The Red and the Black, nowhere. What did these people do? Propriety reigns not only in the provinces but on the page. To be fair, in Les Liaisons Dangereuses, the sixteen year old does get pregnant.)

I enjoyed the articles I read on Google, and here are a few for your interest:

Nick Fraser, The Guardian, 2010

https://www.theguardian.com/books/2010/nov/28/madame-bovery-flaubert-lydia-davis-review

But I also know that I shall never really comprehend the full extent of the damage done to our illusions by Flaubert's great book.

Are we capable of being truthful? Do human beings ever really tell the truth about the things that really matter?

Me: I guess others feel this way, but I don't. My problem is always the opposite – I do good things, and then I'm suspicious I did them for selfish reasons that I am hiding. I suspect my own generosity. Flaubert's conceit was that he revealed the selfishness by finding it everywhere, pervasive, and exclusive. I think that's excessive. What would he have done with righteous gentiles who hid and saved Jews, who must have existed even there in Normandy?

"... None of us can ever express the exact measure of our needs," he observes in what must be the book's most celebrated mot, "or our ideas, or our sorrows, and human speech is like a cracked kettle on which we beat our tunes for bears to dance to, when we long to move the stars to pity."

Me: Reminds me of Robin Williams saying “Everyone you meet is fighting a battle you know nothing about. Be kind. Always.”

Me: I don't know where I got these quotes below, which speak for themselves

The art of writing is the art of discovering what you believe.

acknowledged before anyone else: that the single-most important character in any novel is the narrator.

the very last stages of composition when, in a portentous gesture, Flaubert excised what had long served as the novel’s opening sentence in favor of a first-person plural pronoun that suddenly emerges out of nowhere. It’s arguably the world’s most famous last-minute revision of a canonical text’s opening line: What in the copyist’s final-stage typescript is still “The school clock had just struck 1:30 when the Prefect came in followed by a new boy” becomes, in the novel’s published version: “We were in class when the Prefect came in followed by a new boy”: Nous étions à l’étude quand le Proviseur entra suivi d’un nouveau (included below). The impersonality of the classroom clock is replaced by an unidentified we, not because the narrator wants this particular classroom to appear any less depersonalizing, but because he wants all of us all inside that classroom even as the author himself, slyly, cruelly, maintains his distance from the proceedings under way, like a clinician who registers but does not judge.

Reading Madame Bovary in the Provinces, Birger Vanwesenbeeck LA Times 2016

https://lareviewofbooks.org/article/reading-madame-bovary-in-the-provinces/

Madame Bovary is in part a long novel because boredom, and how it so fatally affects its protagonist

For what’s beautiful about Madame Bovary is ultimately less its stylistic bravura than its author’s deeply felt ambivalence about provincial life.

Me: Interesting point that boredom is best portrayed in a long book. I didn't get the ambivalence about provincial life, I thought Flaubert just skewered it, but on second thought, ambivalence is probably right.

Book Blog in Considering the Classics Madame Bovary, c’est toi!Dorothy Reno June 12, 2017

http://www.washingtonindependentreviewofbooks.com/reviewer/dorothy-reno

But as critics have pointed out, these are Flaubert’s thoughts, not Emma’s. And as the book carries on, the humor feels increasingly weaponized. Had this cutting wit been her own, Emma might have used it to better forge a resolve against the confines of her unhappy marriage. Instead, she takes herself all too seriously amid the grunting weasels and plopping sounds of overripe fruit. Emma Bovary lacks the comic instinct to cope with life’s follies, so it’s only natural she’ll eat arsenic.
The nothingness at the center of most hearts can be spontaneously filled with delight and the occasional act of kindness. But there is none of this in Flaubert’s masterpiece. What we find instead is a world not so much real as hypo-real, a dimension sapped of joy where misery is never instructive, where authentic human connection — of which even the unhappiest among us can experience — is missing. Madame Bovary is at once a painful correction to the romantic movement and an ever-relevant stripping down of middle-class hypocrisy.

Me: Interesting in pointing out the lack of humor of Emma, and indeed all the characters. What a vital thought. Also, apparent lack of being able to view themselves objectively, judge themselves, second guess themselves. I guess you could say all the characters are pretty stupid. I really like thinking of the book as hypo-real. I don't know if she thought of this word herself, but I find it very interesting.

Well, that's it for Emma and me. Great books can be talked about forever. Emma has certainly met that test. I'm so glad I read it again.

Budd Shenkin

Romance vs. Realism

My assignment for my weekly French lesson is to write something on a subject of my teacher's choosing.  This week's subject, for example, is les étoiles - stars.  I've interpreted the assignment to mean that the page and a half I write has to have that subject mentioned, from being a subject to be addressed en passant.

When I started I wrote an essay each week, because essays are what I could write.  Then I deviated and started writing a police procedural, called in French un polar.  After 60 or so chapters - each week was another page and a half chapter - I wrapped it up in a final scene and someone in jail, but then I still had my weekly assignments, I had my characters, and what to do?

It seems that my polar has turned into more of a light-hearted somewhat romantic novel, darting here and there, seeking to interest Claude, my teacher, and to make her laugh.  So far I've been successful - she looks forward to each week's installment!  I love having someone to write for!  The errors I make in French composition?  They are many, but what does one expect from an intermediate French student?  I think I'm getting a little better with my French.  I think.

 At the same time I've been reading the 19th and early 20th century French novelists, realists and modernists and post-modernists.  Candide, Madame Bovary, The Red and the Black, Maupassant, The Immoralist, modern short stories, and of course L'Étranger. I've loved reading all of them, and I've loved writing my pseudo-novel.

My conclusion: who wants real life?  You get enough of that in real life.

Budd Shenkin

The Gerund - Beauty And Its Violation

It's true, not all my thoughts are deep ones, not all my concerns are worthy of the cogitation and time I put into it. Sometimes, I indulge in foibles. A “foible” is “a minor weakness or eccentricity in someone's character.” “Minor eccentricity.” I plead guilty.

Sometimes, the smallest issues can just reach up and grab you – who knows why? In this case, I happened to be exposed to the logic of grammar early in school, and it stuck. In its own way, and I don't claim that it's world-shaking, grammar is just so beautiful. The brain is wired for it; no matter the particular language, the basics of grammar are universal, not to say that the details are. Grammar is, again in its own way, a mirror of who we are, because a great deal of who we are is how we think.

In fact, not to put too fine a point on it, the great sociobiologist, E. O. Wilson, who writes spare little books making trenchant and insightful points, in his recent great book Genesis places the invention of language among the six most important achievements of evolution – right up there alongside the beginning of life itself and the development of the cell. Imagine that!

https://www.amazon.com/Genesis-Origin-Societies-Edward-Wilson/dp/1631495542/ref=sr_1_1?crid=2XN22KJT4F5AV&keywords=genesis+wilson&qid=1578851462&s=books&sprefix=genesis+wilson%2Caps%2C261&sr=1-1

And so it is, not to leave you in further suspense, nor to lose your interest with a perhaps already overlong introduction, that somehow, by some unknown means, I have developed a foible. This foible involves a violation, a violation of language, a persistent and extensive violation of the English language itself. This violation is happening to, as is often the case with violations, a frequently overlooked and underappreciated and apparently unprotected element of society in this case, the society of the English language.

What is this small and unprotected element? I am speaking of the gerund. What is a gerund, that element of grammar that lurks in the back pages of the grammar books? It is “a form that is derived from a verb but that functions as a noun, in English ending in -ing, e.g., asking in do you mind my asking you?”

This example illustrates the point of my foible. Notice that, since “asking” is a nominative form, it requires an adjectival modifier. The example correctly uses “my,” a possessive pronoun. But increasingly common usage would employ “me” rather than “my,” a small difference, but one that grates on my language-sensitive ears and rattles my grammar-sensitive mind, and impels me to respond and to set the world aright. I hear it on TV and I yell at the TV, “It's a gerund! Not “me,” it should be “my!” The TV doesn't seem to respond, although my wife sitting beside me, with her capacity for patience, looks at me askance and suffers me, although I wish it were “suffers along with me,” but I'm afraid it's not, even though she was an English major.

But then the other day I saw it in print, in the Chronicle sports section, utilized by the fine writer Bruce Jenkins. “Ah hah!” I thought, a chance to make some headway! So I launched this email sally in hopes of stemming the tide.

Dear Bruce:

Although I hesitate to raise an issue of grammar with such a fine professional writer, my consuming mania in defense of the fading recognition of the gerund compels me to do so. In your latest article, written with your characteristic engaging style and high intelligence, you write of Milwaukee and Giannis, and I quote: “...they might forego the trade option and gamble on him staying....”

While this is an acute basketball analysis – I myself would take the gamble, were I the Bucks, if I thought it had even a 25% chance of succeeding – the grammar is less accurate. “Staying” is a gerund, which, although derived from a verb, is actually a noun. As a noun, it requires an adjectival form as a modifier. “Him” is not such an adjectival form, but rather a pronoun. It should be replaced by “his,” which, as a possessive pronoun, is an adjectival form. Actually, if you think about it, “him staying” is a double error – if “staying” were actually a verb, then using the accusative form “him” instead of the nominative “he,” would be a second error.

I think I have this point right, but you never know, since I am simply an obscure retired pediatrician from Berkeley, although I did have several excellent English grammar classes in 8^th and 9^th grades, and took Latin for four years.

This observation is not to pick on you, I should add. In fact, lack of respect for the gerund is a national problem, not to say a disgrace. It is most jarring on my ears and in my brain when I listen to the otherwise excellent Rachel Maddow (a product of nearby Castro Valley and Stanford, to maintain the local angle), who butchers the gerund every night in what appears to me to be virtually every other sentence, but then as I have confessed, this is my mania and thus exaggeration is to be expected.

In fact, Rachel is far from the only violator or violatresse of the gerund. It is rare to find the gerund receiving the respect it is due, either on air or in print. What I am asking of you, then, in requesting that you clean up your language act in regards to the gerund, might be asking you to put your finger in the dike of the pressure and onslaught that has changed so many rules of English by common misuse. That would be unfair if I thought anyone would notice and that you might therefore receive criticism for acting superior and elite. But of course no one would notice. And in fact, in asking you to leap to the defense of the gerund, I could well imagine that Haywood Hale Broun and A. J. Liebling and Roger Angell might well be moved to do the same, so your moving to join that imagined company somehow does not appear to be too much to ask.

Yours in respect for both sports and language,

Budd Shenkin

It pains me to report that I have had no response.

The world goes on, language changes, problems are solved by some of the language adjustments, as when “they” is substituted for “him” or “her” or “him or her” following a singular “someone,” for instance – this change is grammatically incorrect but serves a greater purpose of gender equality. Alas, sadly, I'm afraid that the increasing tide of disrespect for the gerund serves no greater purpose, and even when I turn to that bastion of fine writing, the sports section, my poor foible can find no relief, no dawning of recognition, no inkling of correction and improvement, no sense of impending justice.

In time, all language simplifies, inflections disappear. Students of Latin realize how lucky we English speakers are that we don't have to match so many cases and declensions and conjugations as the ancient fellows (and gals) did. It's hard to think that anything significant has been lost.

But however small the case of the gerund may be, let it be known, there are those of us who love it, and will mourn its passing.

(Not to put too fine a point on it, but “passing” is a gerund, and proper respect is given to it by utilization of the possessive “its.”)

Budd Shenkin

La Femme Abandonnée, by Honoré de Balzac

Don't ask me why, after all this time, I have finally gotten around to reading Balzac. It's a long story. But here I am, reading his selected short stories in a Dover Dual Language edition, French on the left page and English on the right. My friend Angela, a Professor of French Literature, specializing in the 18^th century, when she was reviewing the great writers for me last September, simply said, “Ahhh, Balzac!”

What I have just read is the 5^th story in the book, The Forsaken Woman, or La Femme Abandonnée. Balzac is a “realist,” OK, but this is such a romantic story. You discover who you are when you read, and especially when you write, and it turns out that I have distinctly romantic tendencies. I believe in love at first sight, for instance – does that qualify me? I don't know.

I'm not sure whether it's the story or the story-telling that entrances me; I guess it's both. I won't go into the story-telling part, except that the man can write like no one else, what they're thinking, what they're writing, how they size up their alternatives, how what they say is just an opening for the alternatives of the other, the chances they take.

Here's the story, and spoiler alert – I'm doing the plot fully, including the shocking ending.

It's about 1832. Young Parisian baron Gaston age 21 goes to Normandy for his health, finds older woman, age 30, countess, living in solitude there, perfect grace and manners and intelligence, excluded from even provincial society for the sin of having had intense love affair with married man who then abandons her in murky circumstances, and for whom she continues to carry torch and accuse society. The young man sees her briefly without meeting her, falls intensely in love, inveigles himself to an interview at her chateau, she is frank with him with knowledge they will never meet again, he writes to her to declare his love, saying she either accepts him or he leaves the country, she answers back that he is being ridiculous and typical of his age and should stay and follow his illustrious destiny, he says that choice she wishes for him is to be a nobody and be ridiculous, she leaves area clandestinely but he finds out and follows her to Lake Geneva, where she discovers that this is what she was hoping for and they live together in indescribable love and harmony for nine years when they need to come back to France for family reasons, where they have adjoining estates and live together but his mother objects and won't even meet her but insists on introducing her son to a young rich airhead. Countess then writes letter to Gaston saying that at 40 she is washed up but at 30 he still would have inestimable possibilities and she will let him be free, he responds by saying no but she knows that his phraseology means he is wavering and she sends letter back declaring him free, and within two weeks he marries the airhead and she becomes pregnant in one month, following which Gaston realizes he can't live without the countess and sends her letters which she won't open, he arrives clandestinely to her castle and sees her near-death distress, enters the room and she threatens to jump to her death if he advances farther, he returns home to his airhead and the estate and shoots himself dead. Balzac observes that a wife may endure sharing a man out of higher social considerations but a mistress must loathe it, because in the purity of her love resides its entire justification.

Reading this exquisitely written story – if it weren't exquisitely written, who would care? --breaks my heart. She is so wonderful and so is he. It is so romantic. What am I, a girl? My father would kill me, my mother would look at me askance, who knows who would take me seriously? What will I do, watch soap operas next?

But I can't help it. I'm a sucker for Casablanca, too, and for North by Northwest. Classy and romantic. Is this really why I am studying French? They say, and my French teacher Claude (Swiss!) asks me if I believe that when you learn a foreign language you become another person when you are speaking and being with it. I believe that is true.

But truth be told, I might be at my best when I'm listening to and speaking Swedish. Now, that's an underrated language! But my French is coming along, and I don't think there is a Swedish Balzac. So I'll just take it as it comes.

Budd Shenkin

Ambushed by Schumer: Surprise Medical Billing Bill Bites The Dust

Being ambushed by “surprise billing” is often a legal form of patient abuse, immorally and outrageously administered by the powerful to the powerless. The thoughtfully developed and widely supported bipartisan Murray-Alexander bill would have helped a lot.

How depressing it was to read that it was the Minority Leader of the Senate, Chuck Schumer, tightly tied to the concentrated powerful medical institutions, who scotched this example of rare cooperation in giving succor to the oppressed.

Is Senator Schumer's “wait 'til next year” really an appropriate expression of empathy for the harm that he has just done, allowing once again the swampy adage, them that has is them that gets?

Despicable.

I have the honor of having my article to this effect posted on Benj Demott's interesting FirstoftheMonth.org. Here is the link http://www.firstofthemonth.org/surprise-medical-billing-outrage-and-betrayal-thy-name-is-schumer/

And here is the text:

Surprise Medical Billing: Outrage and Betrayal (Thy Name is Schumer)

December 23, 2019 by Budd Shenkin
Congress can rarely ameliorate even patent outrages.  We know this.  One person’s outrage is another person’s profit, and the profiteer usually has more cash and more leverage than the outragee.  But, it looked like one medical outrage was actually about to be solved, at least partially, by this highly partisan Congress, and highly partisan administration.
The outrageous problem they were on the verge of solving is so-called “surprise medical bills.”  I’ve posted about it here. The surprise bills come when you dutifully report to a hospital that is in-network to you, or in the case of my son who had a tree fall on him in the middle of the night, a state-assigned trauma center, and the hospital is paid by your insurance as it should be. But then it turns out that the ER doc, or the anesthesiologist, or the radiologist, or the trauma surgeon, or the pathologist – in short, all those specialties that you need for your case, are not in the network.  They didn’t need to be, because what’s in it for them?  The hospitals join the insurance network because they have to, to ensure that patients come to them.  But once you’re there, the docs don’t have to compete with anyone for your business, you’re their red meat.  So they remain “out of network,” and they send you a huge bill that your insurance will only pay part of.  That’s the surprise.  It’s not like it’s a birthday surprise, it’s more like legal robbery.  And it can amount to a very large amount of money.
This has been a problem for a very long time, but somehow it has come to a head and, along with the scandal of how expensive medicines have become, it made its way onto the congressional agenda. And, notwithstanding the terribly partisan environment, progress was made with Patty Murray (Dem) and Lamar Alexander (GOP) coming up with a plan whereby the docs’ permissible bills would be related to the average in-network bills for their services.  The plan had wide support.
Until it didn’t. The fix was set to be included in the recently passed appropriation bill, until at the last minute, the very last minute, it was dropped.  There was opposition from those to whom the outrage was a source of profit. That would be many large medical centers, and notably, the large private equity groups who have bought groups like ER docs, put them together nationwide, had each one of the docs drop out of all networks, and raise their standard charges by as much as nearly 100%.  One person’s outrage is another person’s – or corporation’s – profit.
I’ve been waiting to see who succumbed to the pressure, and the bribes of contributions to campaign funds.  I wasn’t sure, but here is the story in the WaPo: https://www.washingtonpost.com/business/economy/congress-showers-health-care-industry-with-multi-billion-victory-after-wagging-finger-at-it-for-much-of-2019/2019/12/19/9422aa6a-2028-11ea-9146-6c3a3ab1be6c_story.html
Turns out a major villain of the piece is our old friend, the ever-ingratiating Chuck Schumer.  “A bipartisan push to curb the practice of surprise medical billing was delayed until next year, with Senate Minority Leader Charles E. Schumer (D-N.Y.) working behind the scenes to raise objections to the package, according to three people familiar with the talks who spoke on the condition of anonymity to share details of private negotiations.”
I might have known.  He who makes his points with glasses on end of nose, convincing the podium of his case as he reads what has been prepared for him, occasionally “with expression,” occasionally looking up and looking around…He who takes every cue and every dollar available from our Bibi supporters at AIPAC.  The article says that Chuck has deep ties to the large medical institutions of New York City. As Gomer says, surprise, surprise, surprise.  They’re making the money from surprise billing – through the docs – and they’re supporting those docs as the docs support them.  The public?  “Next year” we’ll consider it.  Right.  But meanwhile big time capitalistic monopolistic government-owning big medicine is getting everything it wants.
Every study of the problems of health care organization points to primary care as needing the most bolstering, and excess profits of concentration centering on large medical centers and specialty groups as the problem.  Doesn’t matter to Chuck, it seems.
I’m just seething.  More fleecing of the American ordinary person by large corporations in concert with paid off politicians.
They’re not all like that.  Elizabeth Warren recounts how she found out what it meant to be “at the table” when she sat down with Barney Frank as they put together Dodd-Frank.  She wanted something, Barney looked around the table, saw no objection, so he told her, “Ok – you’ve got that.”  Chuck is the definition of the table.  No matter the wide support, the bipartisanship, the outrage.  Let’s get some money for the DCCC or whatever, let’s keep those relationships with the monopolists going, we’re at the table.
Don’t watch them making sausages, they say.  There are lots of trade-offs to be made.  Don’t concentrate just on your one issue, take a broad view.
That may be wise.  But to me, concerned as I am about the health care system, this schmear looks like an unholy payoff to monopolists for legal bribes.

Addendum: This article about medical bills and insurers is relevant. Fraud is involved here, but being “out of network” is key.  And notice how little insurance surveillance matters.

Second addendum: This article shows that certain hospital based specialties especially prone to surprise billings - especially diagnostic radiology, anesthesiology, emergency medicine, and pathology -- have especially high standard charges.  https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health-policy/2019/12/05/provider-charges-relative-to-medicare-rates-2012-2017/

Third addendum (1/7/2020): This article shows how legal challenges can help individuals contest surprise bills.  Now all we need is a national legal service that advertises on TV -- call this number and we'll help you contest your surprise bills!  https://www.statnews.com/2020/01/06/3-legal-challenges-derail-surprise-medical-bills/

Budd Shenkin

Presidential Pardon - A Long Article, and an Oped

Back in February I wrote a blog post suggesting that the power of the Presidential pardon has run into problems of abuse, and needs to be reformed.  I suggested requiring each pardon to be co-signed by the Speaker of the House.  Here's that post:

http://buddshenkin.blogspot.com/2019/02/proposal-presidential-pardon-reform.html.

Then I acquired an excellent co-author, my friend of 30 years David Levine, who is Raymond Sullivan Professor of Law at UC Hastings College of the Law in San Francisco.  Together we wrote a 6,000 word article advocating this proposal, which was published in the Hastings Constitutional Law Quarterly:

https://repository.uchastings.edu/cgi/viewcontent.cgi?article=2099&context=hastings_constitutional_law_quaterly

And now we have reduced those 6,000 words to a succinct 650 words oped, which has just been published in the East Bay Times:

https://www.eastbaytimes.com/2019/12/15/opinion-reform-presidential-pardon-after-ford-bush-clinton-trump-abuses/.

Frankly, it's a thrill for David and me to see our work make it to both legal and popular publications.  Beyond that, maybe it's even possible that the idea will make it to the stage of formal consideration when post-Trump reforms are being entertained.  That would not only be a thrill for us, but a source of great satisfaction for helping to support the idea of America, which animates both of us.

Here is the text of the oped:

A few weeks ago, President Trump pardoned convicted or accused war criminals over the profound objection of his most senior military officials, one of whom, the Secretary of the Navy, resigned in protest.

Obviously, this is not the only presidential power the President has used in an innovative and personal manner, rather than as originally intended and customarily exercised.  In each case, he is forcing the country to ask itself – is this a power that should be retained, be modified, or be further protected?

We believe that the answers to these questions in the case of the power of the pardon are yes, yes, and yes.  And the way to do it, we think, is to modify it by passing a constitutional amendment to require an additional signature for each pardon.  That signature would come from the highest ranking independently elected constitutional official in the line of succession, the Speaker of the House.

Let us explain.

We inherited the power to pardon from the English monarchy. Alexander Hamilton explained in Federalist 74 that sometimes mercy from on high is necessary to improve justice, and sometimes to secure civil harmony by forgiving and forgetting.  Examples of the latter are Washington’s pardoning members of the Whiskey Rebellion,  Lincoln’s and Johnson’s pardoning of Civil War soldiers, and Carter’s pardoning of Vietnam draft resisters.

Presidents largely fulfilled Hamilton’s goals until Ford’s controversial pardon of Nixon after Watergate, to end “our long national nightmare.”  Then in 1992, taking the advice of his Attorney General, William Barr, George H. W. Bush pardoned his friends and colleagues, the Iran-Contra conspirators, which cut short the investigation and shielded him from inquiry into his own possible complicity.

In the waning hours of his presidency in 2000, Bill Clinton pardoned 177 miscreants, over 60 of whom had not been vetted by the Justice Department’s Office of Pardons, including fugitive arms dealer Marc Rich and his wife Hillary’s brother.   George W. Bush commuted the sentence of Scooter Libby, preserving Libby’s right to use the Fifth Amendment to constrain any further investigations.

And now we have President Trump, who, in addition to the war criminal cases, has also pardoned racial profiler Sheriff Joe Arpaio from his criminal contempt of court conviction and right wing provocateur Dinesh D’Souza for illegal Republican campaign contributions. Most ominously, Trump has dangled pardons before potential witnesses against him, has claimed he can pardon himself, and  few doubt he will pardon his family and other close associates if it becomes necessary.

Clearly, although Trump’s excesses are the most extreme, Hamilton’s hopes for the pardon have been thwarted too often since Watergate.

What to do?  We should not repeal the pardon power, because its value has been proved over centuries.  We don't think it would work to add specific restrictions, such as forbidding preemptive pardons, or pardons of close associates and family; such restrictions could never be complete and could be evaded.  Much more protective, we think, would be the  co-signature requirement.

If this requirement had been in force, would Speaker Carl Albert have co-signed for the Nixon pardon, Tom Foley for Iran-Contra, Dennis Hastert for Rich and for Libby, Paul Ryan for Arpaio, or Nancy Pelosi for the war criminals, and for what may come?  We can't know, of course, but bringing a second high official into the process would increase the odds of screening out many questionable pardons.

Constitutional amendments are notoriously and rightfully hard to enact.  We believe, however, that our proposal would not have strong entrenched interests against it, and if worse is still to come from Mr. Trump, the urgency of reform might carry the day.

If unreasonable and self-serving pardons were just a momentary lapse with this president, we could hope that traditional norms would reappear with the next. Given the post-Watergate trend, however, we should require another signature to secure Hamilton's vision.

Budd Shenkin