The Highlanders Take Care of Their Own


Scotland is the first country to introduce a program to provide free tampons and pads to poor women.

It makes sense. That’s a “tax” if you would on being female, and a cost that’s unavoidable even on a very limited budget.

The program is simple, low cost, easy to implement, and doesn’t require massive audit or oversight. After all, what sort of black market is there for tampons? Really?

Sometimes, you don’t need complexity, technology or a lot of money to do good. Very Scottish.


Jenavieve Hatch, “Scotland To Give Low-Income Women Free Menstrual Products In New Pilot Initiative,” Huffington Post, 12 July 2017.

Food stamp cuts


Per capita annual spending on food in the US was $4,575 in 2014, the latest year for which figures are readily available. (1)

If you’re one of the unfortunate 10% of Americans with an income of less than $10,000 per year, food becomes a huge part of your budget. The Food Stamp program makes a difference for these people. With an average monthly amount per person of $126, it can offset perhaps 25% of what a careful shopper spends on food, and for the very poor, make a difference between eating and not eating.

The amount allotted to food stamps by the Federal Government has been cut each year starting with 2013. The Trump administration is now proposing a further 31% reduction in this benefit. Meanwhile, food prices are rising by between 1 and 2 percent per year.

The benefit cut is going to hurt the poor. However, it’s also going to bite some Trump supporters. The four largest grocery chains (Wal-Mart, Target, Kroger and Aldi) can all expect to see revenue reductions of over $1 billion from these cuts.

Wal-Mart itself receives 18% of the money allocated to food stamps, and so will be the biggest loser from these cuts.(2)

These cuts will impact profits, stock prices and shareholders.

If you still have Wal-Mart stock after all the negative news in retail, it’s time to reconsider.


  1. USDA, “FoodExpenditures_table1.xls”
  2. Courtney Reagan, “Retail stands to lose $70 billion over 10 years if food stamp benefits are slashed, and here’s who gets hit the most,” CNBC, 29 June 2017.
  3. Center on Budget and Policy Priorities, “A Quick Guide to SNAP Eligibility and Benefits,” 30 September 2016.
  4. Trading Economics, “United States Food Inflation, 1914 to 2017,” undated.

Your Health: The Right to Life?


The US was founded on the promise of “the Right to Life, Liberty and the Pursuit of ben_franklinHappiness” in Jefferson’s Declaration of Independence.

From the start, the relationship between the country and this promise has been at best inconsistent and sometimes ironic. After all, the principal writer of the Declaration, Jefferson, was a slave-owner.  So for whom was this promise made? Everyone? Or the wealthy, the planters, the slave-owners and the merchants? (Remember, there were no factories — that was before the industrial revolution.)

The inconsistency continues to this day.

We have groups concerned with whether babies or born, but not with what happens to them after they are born. How long do they live? What’s their quality of life? As Ed Cara notes, in some areas of the US, children will now have shorter lives than their parents. (2)

A new study in the Journal of the American Medical Association talks about discrepancies in life expectancy. I’ve blogged about this before, but it’s nice to see authoritative sources recognizing the issue.

The new statistical analysis shows that there is a difference in life expectancy of up to 20 years based on the county in which you live. In this analysis, the issues affecting life expectancy are

  • Income and poverty
    • The wealthy live longer
  • Race/ethnicity
    • Both Native Americans and African Americans have a shorter life expectancy
  • Regular exercise
    • Those who do live longer
  • Obesity, Diabetes and Hypertension
    • Shorten life expectancy
  • Education
    • Each level completed adds to life expectancy
  • Quality of health care
    • Higher quality is associated with living longer
  • Having health insurance
    • Having health insurance promotes longer life
  • Access to physicians
    • Having more physicians in an area helps

These factors translate into differences in life expectancy in the US based on where one lives:

  • Residents of central Colorado, coastal California and the New York Metro area live longer
  • Residents of eastern Kentucky and much of the Old South, especially along the lower Mississippi River, have a shorter life expectancy
    • The Old South in this case includes Alabama, Arkansas, Georgia (outside of Atlanta), Louisiana, Mississippi, Oklahoma and Tennessee (outside of Nashville)
    • The two metro areas, Nashville and Atlanta, offer much better life expectancy than the rest of their states

The states with the lowest life expectancy are those with the lowest spending on public health and health education.

One limitation of this study is that the analysis is at a county level, and there is only selected data available at that level regarding health. In particular, suicide is now one of the top 10 causes of death in the US. Suicide isn’t reported accurately or consistently, and there is limited data available on the causes of suicide.

A second limitation is the inter-relationships between some of the factors measured. For example, wealth is associated with having health insurance, with less use of cigarettes, and with living in an area with better access to medical professionals. By breaking the analysis into this much detail, does the report understate the role of wealth in life expectancy?

By the way, I use the image of Ben Franklin on some of these posts for the following reasons:

  • His brilliance
  • His common sense
  • His skill at negotiation
  • And among the Founding Fathers of the US, he became a profound opponent to slavery


  1. Laura Dywer-Lindgren, et. al., “Inequalities in Life Expectancy Among US Counties,1980 to 2014,” JAMA Intern Med. Published online May 8, 2017. doi:10.1001/jamainternmed.2017.0918.
  2. Ed Cara, “Kids Will Die Younger than Their Parents in Some Parts of the US,” Vocativ. 9 May 2017.



Where are the people who want to get into the US?


The US population grew by less than 1% last year. The Census estimate is for growth of 0.82%, with most of that increase coming from births in the US – 1.38 million births versus 1.25 million immigrants.

The Census forecast is that population growth rate will decrease, reaching a low of 0.45% in 2048.  Deaths among the Baby Boomers will offset both births and immigration.  In fact, if we had no immigration, the US population would decline.

As we have seen in both Maine and Japan, a population decline is a problem. It means slowing of economic growth and employers take jobs to other regions where labor is available.  It means there are fewer workers to pay for benefits for the elderly and disabled.

This forecast predates the last election and the entire discussion of a wall and restructuring of the H1-B visa program.

What you need to consider:

  • Know the facts before you listen to politicians and TV commentators.  Intentionally or not, a good portion of what they say is wrong.
  • Immigration restrictions won’t help people with the wrong job skills get work. Unless people recognize that old jobs are gone and they need to retool for what’s available, they’ll be stuck. There’s no future in unskilled labor.


  1. US Census Bureau.
  2. Ben Fifield, “Many Northeast, Midwest States Face Shrinking Workforce,” Pew Charitable Trust, 27 May 2016.

What the CBO Report on the American Health Care Act Actually Says (updated)

Photo Courtesy of Holden Police Department

By now. most people have seen headlines or soundbytes about the report.  The Congressional Budget Office is a nonpartisan group. The head of the CBO was actually appointed by the GOP. The purpose of the office is to provide Congress with a source of “objective” information about the financial impact of legislation that is independent from information provided by the Executive Branch. In a complex world, this actually makes sense.


What the CBO report actually says:

  • Health insurance costs for individuals will under the new act (the AHCA is also known as “Trumpcare”), will increase through the year 2020 and may decrease after that.  The CBO expects increases in health insurance premiums under the new law of between 15% and 20% for 2018 and 2019 under the new law.  However, the CBO argues that by 2026, premiums might be 10% lower than under the ACA.
    • Some professionals refer to these as “hockey stick” forecasts, with a positive result occurring sometime in the remote future.  That could happen, but usually unforeseen events preempt the desired result.
  • Healthcare costs should decline for people in their 20s, but will increase sharply for older Americans.  The proposed tax credits will be insufficient to cover the cost increase.
  • The CBO estimates a $337 decrease in the Federal deficit from the AHCA law, mostly due to the repeal of Medicaid expansion and the end of subsidies for health insurance.  (As noted, the tax credits are smaller than the current subsidies.)  That averages out to about $33.7 billion per year.
    • The current US deficit is $441 billion in the current fiscal year.  Obviously, any reduction is good, but a savings of less than 10% of the deficit isn’t a cause for celebration.
    • The US budget deficit is expected to expand by over $10 trillion over the next decade, after shrinking during the Obama administration.
  • The Medicaid rollback will cost 14 million people their healthcare coverage immediately.  That plus the increase in out of pocket expense will ultimately mean that 24  million people will be forced to do without health insurance.
    • The CBO expects that some states will lose Federal funding for Medicaid in 2020 by their failure to provide the matching funds required under the new law.  That will further reduce Federal spending.
    • The matching funds requirement simply moves part of the tax burden from the Federal government to the states, and may require increases in state taxes.
  • Existing law requires the CBO to provide guidance on the impact of the law on the economy.  However, the CBO claims it has not had sufficient time to do this.
    • My argument is that anything that takes money away from consumers will be a drag on economic recovery.  This law does, by raising health care out-of-pocket expenses for most people.


  1. Congressional Budget Office, “Cost Estimate,” 13 March 2017. I’ve downloaded a pdf of the report from the CBO website, and will share it on request.
  2. Emily Stephenson, “U.S. deficit forecast to shrink in 2017 but climb over next decade,” Reuters, 24 January 2017.

How Healthcare Reform Will Hurt Medical Professionals and Patients


The Affordable Care Act is a complex piece of legislation with multiple goals:

  • Universal access to health care regardless of pre-existing conditions17456_1269532813224_1076952025_30803996_7657050_n
  • Reduction of costs of health insurance by averaging costs between healthy and unhealthy individuals
  • Reduction in actual outlays for medical services by
    • Reducing use of expensive emergency room services
    • Screening and earlier identification and treatment or prevention of major illnesses

The “repeal” effort to date addresses none of these goals, and in fact backtracks on them.

In addition, there is a continuing expansion of “cost sharing,” a euphemism for the shifting of costs from employers to employees for those workers who have access to group health insurance.

Physicians saw increased office traffic in 2016, but this is not likely to continue in the future.  Alicia Ault, writing for Medscape, comments,

Use and intensity of services and prices are the two biggest components of American health spending growth, the economists said. Overall use and intensity of healthcare goods and services continued to grow in 2016 as more people gained healthcare coverage through Medicare, Medicaid, or private insurance, and as disposable personal income rose. (1)

As the amount of money consumers have to spend for healthcare increases, their use of health services will decrease.  Economists with the Centers for Medicare and Medicaid Services (CMS, the agency that administers the Federal Marketplace as well as children’s programs) are expecting a reduction in use of physician services just in response to increased cost sharing, even without changes or repeal of the ACA.

Historical data show that greater cost sharing leads to less use of healthcare, Sean Keehan, a CMS economist, told Medscape Medical News. “People think twice about seeing the doctor if it’s going to be much more than it was before,” said Keehan, who is also lead author on the article in Health Affairs.(1)

Other factors will drive down use of health services over the next several years:

  1. Inflation which will reduce what consumers have available to spend
  2. Relatively stagnant wage growth, meaning that wages will not keep up with inflation

The CMS estimates are optimistic, excluding any impacts of ACA repeal.  A sharp increase in the number of people who cannot afford health insurance would be a game changer, and, frankly, could force some primary care physicians to close their practices.  The areas likely to see the greatest impact are poor and rural communities.

What you need to consider:

  • For most people, money is going to be a problem.  Do you need to improve or acquire skills to allow you to get a higher paying job?
  • Relocation to an area with better local public health services? 
  • How will you deal with older relative who may find themselves in trouble?


  1. Alicia Ault, Physician Services to Decline With More Cost-Sharing, CMS Says. Medscape. Feb 15, 2017.

Healthcare Changes — Updates


There were some ideas floated yesterday by GOP Congressional leadership, but nothing definite.  While Paul Ryan is expressing optimism that there will be a concrete proposal by17456_1269532813224_1076952025_30803996_7657050_n the end of February, others in the GOP are saying that it won’t happen “overnight” or are waiting for cost estimates from the Congressional Budget Office (CBO).


The ideas being discussed include:

  • Paying for repeal of the Affordable Care Act by levying a tax on healthcare insurance offered by employers.  Some versions of this proposal would limit the tax to higher end plans (gold, platinum or concierge plans), but that would go against Trump’s stated intention of giving tax breaks to the wealthy.
  • Subsidies for healthcare would be eliminated, and replaced by tax credits for people who don’t have employer provided care.
  • Elimination of some business taxes used to support the Affordable Care Act.
  • Expansion of Medicaid to more of the poor would be withdrawn.  Federal funding for expansion of Medicaid benefits would be eliminated.
  • Penalties for not having insurance will be eliminated.

The withdrawal of subsidies and removal of penalties will drive up the cost of health insurance for individuals who need insurance.  You should expect increases for 2018 that may be in the range of 20% or higher.

Removal of subsidies (for most people, an advance on a tax credit) means that more people will not be able to afford health insurance.  However, some in the GOP would prepay these tax credits — basically keeping much of the current system under a different name.

But Kenneth E. Raske, the president of the Greater New York Hospital Association, expressed alarm, saying the proposals would “put a huge amount of pressure on state budgets and put many Americans at risk of losing health care coverage.”(3)

The Medicaid change might be the most important of all of these provisions.  Many middle class Americans depend on Medicaid now to pay for nursing home care when that time comes.  At a national average of more than $92,000 per year, most people don’t have the savings to cover that.  The proposed revisions would “put Medicaid on a budget” and allow states to eliminate payments to nursing homes.

Of course, if the cost of ACA repeal is too high, none of this may go anywhere.

So the next step is to see what the CBO projections are.  We wait.


  1. Alan Fram, “GOP leaders unveil new health law outline, divisions remain,” Associated Press, 17 February 2017.
  2. Ana Radelat, “GOP gives House members proposal to repeal, replace the ACA,” The Connecticut Mirror, 16 February 2017.
  3. Robert Pear and Thomas Kaplan, “House G.O.P. Leaders Outline Plan to Replace Obama Health Care Act,” The New York Times, 16 February 2017.