TRUMPING HEALTHCARE

The blamestorming has begun over the failure to repeal and replace Obamacare.

Congressional Republicans have only themselves to blame.  Since returning to majority in the House in January 2011, Republicans have formally voted 54 times to address all or part of Obamacare.  Six were votes on full appeal.

In 2015, H.R. 132 is typical of these efforts.  It simply stated: “such Act is repealed, and the provisions of law amended or repealed by such Act are restored or revived as if such Act had not been enacted.”  Why didn’t Republicans vote on this last week?

Republicans did not vote on simply going back in time, because they thought government should play a significant role in healthcare.  It should not. Crippling regulations need to be changed and the private sector needs to be encouraged.  Last week’s legislation did not clear the way for these solutions.

The Republicans’ problem is squandering six years with legislation designed more for fundraising and campaigning than governing.  Instead, they could have viewed their repeal & replace efforts as prototyping or beta-testing a new product or APP.  They could have tested ideas and built Republican consensus.  Not doing this led to disaster.

What next?

In 2013, I outlined a patient-centric versus politician-centric approach.  Maybe now it will be followed.

Those wanting an expanded governmental role in healthcare and those opposing it are fighting the wrong battle in the wrong way.

The debate over national healthcare policy has lasted over a century – intensifying during the Clinton Administration. It has always been about coverage, liability, and finance, never about care protocols and patients. http://kaiserfamilyfoundation.files.wordpress.com/2013/01/7871.pdf

If making health affordable is everyone’s stated goal then why not focus on the actual care, health, and wellness of Americans?

America remains the best place on Earth to have an acute illness or shock-trauma injury. Our nation’s emergency rooms and first responder protocols are unequaled. Princess Diana may have lived had her car accident happened in New York City instead of Paris. America’s diagnostic methods and equipment are unequaled. That is why patients from all over the globe seek answers to complex symptoms by visiting the Mayo Clinic, the Cleveland Clinic, Johns Hopkins, Sloan Kettering and countless other world class facilities.

The other side of American healthcare is its failings in chronic care, expense, and a system that is controlled by the medical profession, pharmaceutical companies, and insurance industry. This triad of entrenched interests has prevented the widespread use of substances and therapies deemed effective in most of the world.

Thankfully, an increasing number of healthcare professionals are embracing global best practices, virtual technology, and patient-centric methods. Some are even exploring homeopathic and nutritional treatments that are common place around the globe, but viewed as “nontraditional” in America. These innovations are improving the health of patients while driving down costs. This is the arena where policy-makers should check their partisanship at the door. Seeking ways to improve healthcare, not health financing, will ultimately make health affordable to us all.

I have personal experience with the convergence of these worlds. Since 2007, I have been the primary caregiver to several family members with serious chronic conditions. These conditions have been punctuated by emergency care and major surgeries. Making decisions and managing treatment across this spectrum has been a real education.

This education has helped me identify four major areas of opportunity for healthcare improvement. These four areas will improve our health and healthcare, while addressing the affordability of private and public health services.

First, not all ailments require doctors and prescription medications. Government and industry policies drive people away from cheaper and more effective natural remedies. Herbal remedies have been successfully used since the first humans. For example, Apple Cider Vinegar has completely solved acid reflex. Cayenne Pepper has improved heart function. However, natural substances are not covered as a medical expense either by insurance or tax deductions. Instead, acid reflex sufferers must pay for over-the-counter treatments (which are also not covered by insurance or tax deductions), or must obtain expensive prescriptions after paying to see a doctor or a specialist. Being a natural treatment, the vinegar regime also avoids side effects and drug interactions. http://www.healthcentral.com/diet-exercise/c/299905/155581/potential?ic=506048  Why not go “back to the future” and find ways to support these more affordable and effective treatments?

Second, nurse practitioners form one of the new front lines of care http://www.aanp.org/. The overwhelming majority of my family’s office visits are with a nurse practitioner interacting with the patient and the lab technicians. Occasionally, a doctor will review the information and discuss treatment options with the patient. Supporting the evolution to Nurse Practitioners through education, professional certification, protocol modifications, and pricing would bring down costs and expand health opportunities both for professionals and patients.

Third, community caregiving is another new frontline of achieving and sustaining wellness. In 2009-2011, I was part of the planning team for developing a community-based care system for the Atlanta area. We found a disturbing pattern - patients, especially Medicare/Medicaid patients, arrive in hospital emergency rooms when their chronic conditions, such as Diabetes, congestive heart failure, and Chronic Obstructive Pulmonary Disease (COPD), become acute. These patients are treated at the most expensive point of care (emergency room). Once they are released, many do not have the support (family, friends, neighbors) or the capacity (some form of dementia) to follow a treatment regime that would prevent the next emergency room visit. These revolving door patients drive-up costs and end-up in a cycle of deterioration.

Our solution was to develop a community-based healthcare network. Such networks are known as “Accountable Care Organizations” (ACOs) http://innovation.cms.gov/initiatives/aco/.

They break-out of traditional hospital and doctor office environments to forge partnerships with the community – churches, social workers, local government, neighbor associations, and nonprofits. A needy patient with chronic conditions is assessed holistically. This includes risk factors (i.e. smoking, alcoholism, drugs) and environmental factors (family & home environment). A care plan is developed and assigned to a multi-faceted care team (comprising community resources) and a care manager. Doctors and nurses are part of the team. The majority of health actions take place among family and community - driven by Electronic Medical Records, aided by remote sensors and virtual care, and guided by the managed care team.

The result of this holistic approach is improved care, sustainable health, and reduced costs. It is the one way Medicare and Medicaid costs can be substantially reduced while enhancing quality of life. There are initiatives to promote this methodology within the Center for Medicare and Medicaid Services (CMS), but it is occurring too slow and is too isolated.

ACOs are making a difference, but no major politician has embraced the concept and neither party has promoted them as a way to reduce Entitlement costs.

Fourth, families have always been a pivotal component in healthcare. Whether it is a parent staying home to care for sick children, or adult children caring for ailing parents, family caregiving is vital, but also emotionally and financially draining.

Having been the care manager, Medical Power of Attorney, and patient advocate for both my parents and my wife, I know how much time is spent with ailing family members. Current IRS regulations provide for listing parents as dependents based only upon financial support. http://www.irs.gov/pub/irs-pdf/p501.pdf

However, there are no tax credits or deductions for those who have the Medical Power of Attorney and devote countless hours to direct care or acting as the patient’s advocate for managing their care. Politicians at both the state and federal levels should provide relief for this indispensable and growing volunteer service sector.  Supporting Family-based assistance will save billions in public assistance.

According to the National Alliance of Caregiving, 70 million Americans provide unpaid assistance and support to older people and adults with disabilities. Forty percent of these caregivers provide care for 2-5 years, while approximately 29 percent provide care for 5-10 years. Unpaid caregiving by family and friends has an estimated national economic value (in 2004) of $306 billion annually—exceeding combined costs for nursing home care ($103.2 billion) and home health care ($36.1 billion). This value is increasing as the population ages. http://www.caregiving.org/data/CaregivingUSAllAgesExecSum.pdf

These four areas of opportunity will not address every health issue or entirely diffuse the fiscal bombs strapped to medical entitlements, but they are a good nonpartisan start. It is time for politicians to focus on the wellbeing of patients, not themselves.

[Scot Faulkner was Chief Administrative Officer for the U.S. House of Representatives. He served on the ACO team for the Southeast Atlanta Health Care System [SAHCS], as an advisor to Kinexum, a medical research consortium, and as an advisor on professional standards and ethics to the American College of Dentists. He has been the Medical Power of Attorney and primary caregiver for his spouse and parents since 2007. http://citizenoversight.blogspot.com/ ]

DEADLY OBAMACARE

[GUEST CONTRIBUTOR - PAUL BURKE]

Obamacare causes 8,000 deaths per year, because of penalties it puts on hospitals The penalties started in October 2012. Death rates from heart failure have risen ever since, because hospital treatment for heart failure has fallen.

Obamacare fines hospitals when they treat Medicare patients for heart failure, if the patients need another hospital stay within a month. Hospitals need to avoid the fines, so now they treat 20,000 fewer patients for heart failure, compared to four years ago, before the penalties.

Do patients survive the loss of treatment?

No. CDC says death rates from heart failure rose after 2012, though these deaths had fallen every year from 2000 to 2012. Higher death rates in 2013 and 2014 mean 7,200 and 9,600 more people died from heart failure in these years than would have died if the 2012 death rate had continued.

http://cdc.gov/nchs/data/databriefs/db231.pdf

The term "heart failure" is also called "congestive heart failure" or cardiomyopathy. It refers to weak pumping because of muscle deterioration, stiffness, leaking valves, etc. It is not the same as a heart attack or heart stopping. It is a major cause of death in the US.

These are the latest national figures, but five earlier studies from 2010-2014 also showed that hospitals which had fewer re-hospitalizations had more deaths, especially among heart failure patients.

http://globe1234.info/medicare/category/research

Medicare said in August 2012, "We are committed to monitoring the measures and assessing unintended consequences over time, such as the inappropriate shifting of care, increased patient morbidity and mortality, and other negative unintended consequences for patients." They have not reported any of these monitoring results in 4 years.

http://federalregister.gov/d/2012-19079/p-1799

Re-hospitalization penalties give hospitals an incentive to treat fewer seniors. Medicare even gives hospitals an online tool to predict re-hospitalization risk for each potential patient.

Hospitals can avoid penalties by any mix of the following:

·         Avoid admitting the sickest Medicare patients with heart failure ("There's not much we can do for you. Treatments are risky. You're better off at home.")

·         Treat as many as possible of the least sick outside of hospitals

·         Improve subsequent care for those admitted, to reduce re-hospitalizations

It is easier to give less care than to improve it, though hospitals certainly are doing both. And the result we see is that death rates have started to rise.

The figures here count hospital admissions in July 2008-June 2011, compared to July 2012-June 2015. These are the oldest and newest comparable data available. Medicare released the older data in a comparable form in May 2013.

http://globe1234.com

Re-hospitalization penalties are large. Hospitals get $6,000 for treating a Medicare heart failure patient, but pay a $27,000 penalty for each re-hospitalization within 30 days, above the national average rate. So every hospital tries to be below the average, driving the average down and the risk of penalties up every year. There are also minimal adjustments for the mix of patients each hospital serves.

Penalties total $71 million this year, down from $76 million last year, because hospitals treat fewer Medicare patients for heart failure. The only way hospitals as a group can reduce their penalties is by treating fewer patients. And they do.

The penalties apply to patients treated under Medicare Part B. Hospitals which face the re-hospitalization penalties now admit 5% fewer Part B patients for heart failure than four years ago, even though the total number of seniors covered by Part B increased 12% in the same period.

There are also penalties for re-hospitalizing patients after coronary bypasses. The penalty is $188,000 for each one above the national average rate; penalties began October 2017. Penalties after elective hip and knee replacements are $239,000 and began October 2014. The penalty calculations are written into Obamacare. It is too early to see if the number of people treated has fallen, but the American College of Surgeons warned Medicare that treatment would be cut: "the potential that these hospitals will decrease their care for such patients, thereby creating an access issue."

One state is exempt from the penalties: Maryland, where Medicare has its headquarters, and where many of its retirees live.

Medicare penalizes all unplanned re-hospitalizations, even if they are unrelated to the original care. The law only lets Medicare penalize readmissions related to the initial care, but Medicare found that law, "difficult to implement." So they decided not to follow the law. Obeying the law would help, but penalties would still discourage treatment of frail seniors, who have above-average risks. The law and the penalties themselves are wrong.

http://federalregister.gov/d/2013-18956/p-2129

In 67 metro areas, Medicare has a second way to discourage hip and knee replacements, especially for the frailest patients who may need them most: hospitals must pay nearly all medical expenses for 90 days after treatment, though they have almost no control over these costs. After coronary bypasses next year, hospitals will similarly have to pay for 90 days of costs. Fewer hip and knee replacements and coronary bypasses, when Medicare patients need them, condemn seniors to reduced activity and faster decline.

Medicare and Social Security do save money when patients die sooner, but that is not how the country wants to save money. 

AFFORDABLE HEALTHCARE 2.0

Published in http://hnn.us/article/154172

Those wanting an expanded governmental role in healthcare and those opposing it are fighting the wrong battle in the wrong way.

The debate over national healthcare policy has lasted over a century – intensifying during the Clinton Administration. It has always been about coverage, liability, and finance, never about care protocols and patients. http://kaiserfamilyfoundation.files.wordpress.com/2013/01/7871.pdf If making health affordable is everyone’s stated goal then why not focus on the actual care, health, and wellness of Americans?

America remains the best place on Earth to have an acute illness or shock-trauma injury. Our nation’s emergency rooms and first responder protocols are unequaled. Princess Diana may have lived had her car accident happened in New York City instead of Paris. America’s diagnostic methods and equipment are unequaled. That is why patients from all over the globe seek answers to complex symptoms by visiting the Mayo Clinic, the Cleveland Clinic, Johns Hopkins, Sloan Kettering and countless other world class facilities.

The other side of American healthcare is its failings in chronic care, expense, and a system that is controlled by the medical profession, pharmaceutical companies, and insurance industry. This triad of entrenched interests has prevented the widespread use of substances and therapies deemed effective and traditional in most of the world.

Thankfully, an increasing number of healthcare professionals are embracing global best practices, virtual technology, and patient-centric methods. These innovations are improving the health of patients while driving down costs. This is the arena where policy-makers should check their partisanship at the door. Seeking ways to improve healthcare, not health financing, will ultimately make health affordable to us all.

I have personal experience with the convergence of these worlds. Since 2007, I have been the primary caregiver to several family members with serious chronic conditions. These conditions have been punctuated by emergency care and major surgeries. Making decisions and managing treatment across this spectrum has been a real education.

This education has helped me identify four major areas of opportunity for healthcare improvement. These four areas will improve our health and healthcare, while addressing the affordability of private and public health services.

First, not all ailments require doctors and prescription medications. Government and industry policies drive people away from cheaper and more effective natural remedies. Herbal remedies have been successfully used since the first humans. For example, Apple Cider Vinegar has completely solved acid reflex for two of my family members. However, natural substances are not covered as a medical expense either by insurance or tax deductions. Instead, acid reflex sufferers must pay for over-the-counter treatments (which are also not covered by insurance or tax deductions), or must obtain expensive prescriptions after paying to see a doctor or a specialist. Being a natural treatment, the vinegar regime also avoids side effects and drug interactions. http://www.healthcentral.com/diet-exercise/c/299905/155581/potential?ic=506048 Why not go “back to the future” and find ways to support these more affordable and effective treatments?

Second, nurse practitioners form one of the new front lines of care http://www.aanp.org/. The overwhelming majority of my family’s office visits are with a nurse practitioner interacting with the patient and the lab technicians. Occasionally, a doctor will review the information and discuss treatment options with the patient. Supporting the evolution to Nurse Practitioners through education, professional certification, protocol modifications, and pricing would bring down costs and expand health opportunities both for professionals and patients.

Third, community caregiving is another new frontline of achieving and sustaining wellness. In 2009-2011, I was part of the planning team for developing a community-based care system for the Atlanta area. We found a disturbing pattern - patients, especially Medicare/Medicaid patients, arrive in hospital emergency rooms when their chronic conditions, such as Diabetes, congestive heart failure, and Chronic Obstructive Pulmonary Disease (COPD), become acute. These patients are treated at the most expensive point of care (emergency room). Once they are released, many do not have the support (family, friends, neighbors) or the capacity (some form of dementia) to follow a treatment regime that would prevent the next emergency room visit. These revolving door patients drive-up costs and end-up in a cycle of deterioration.

Our solution was to develop a community-based healthcare network. Such networks are known as “Accountable Care Organizations” (ACOs) http://innovation.cms.gov/initiatives/aco/. They break-out of traditional hospital and doctor office environments to forge partnerships with the community – churches, social workers, local government, neighbor associations, and nonprofits. A needy patient with chronic conditions is assessed holistically. This includes risk factors (i.e. smoking, alcoholism, drugs) and environmental factors (family & home environment). A care plan is developed and assigned to a multi-faceted care team (comprising community resources) and a care manager. Doctors and nurses are part of the team. The majority of health actions take place among family and community - driven by Electronic Medical Records, aided by remote sensors and virtual care, and guided by the managed care team.

The result of this holistic approach is improved care, sustainable health, and reduced costs. It is the one way Medicare and Medicaid costs can be substantially reduced while enhancing quality of life. There are initiatives to promote this methodology within the Center for Medicare and Medicaid Services (CMS), but it is occurring too slow and is too isolated.

ACOs are making a difference, but no major politician has embraced the concept and neither party has promoted them as a way to reduce Entitlement costs.

Fourth, families have always been a pivotal component in healthcare. Whether it is a parent staying home to care for sick children, or adult children caring for ailing parents, family caregiving is vital, but also emotionally and financially draining.

According to the National Alliance of Caregiving, 70 million Americans provide unpaid assistance and support to older people and adults with disabilities. Forty percent of these caregivers provide care for 2-5 years, while approximately 29 percent provide care for 5-10 years. Unpaid caregiving by family and friends has an estimated national economic value (in 2004) of $306 billion annually—exceeding combined costs for nursing home care ($103.2 billion) and home health care ($36.1 billion). This value is increasing as the population ages. http://www.caregiving.org/data/CaregivingUSAllAgesExecSum.pdf

I know how much time is spent with ailing family members. Current IRS regulations provide for listing parents as dependents based only upon financial support.

http://www.irs.gov/pub/irs-pdf/p501.pdf However, there are no tax credits or deductions for those who have the Medical Power of Attorney and devote countless hours to direct care or acting as the patient’s advocate for managing their care. Politicians at both the state and federal levels should provide relief for this indispensable and growing volunteer service sector.

These four areas of opportunity will not address every health issue or entirely diffuse the fiscal bombs strapped to medical entitlements, but they are a good nonpartisan start. It is time for politicians to focus on the wellbeing of patients, not themselves.

[Scot Faulkner was Chief Administrative Officer for the U.S. House of Representatives. He served on the ACO team for the Southeast Atlanta Health Care System [SAHCS] and as an advisor on professional standards to the American College of Dentists. He has been the Medical Power of Attorney and primary caregiver for his spouse and parents since 2007. http://citizenoversight.blogspot.com/ ]

FACES OF FAILURE

Every President confronts moments of truth that expose their inner weaknesses or strengths. The disastrous roll-out of the Affordable Care Act (ACA) has ripped apart Obama’s curtain of competence.

The bane of any powerful person is becoming insulated from reality. Sycophants and courtiers have swirled around leaders since the first hunter-gatherer campfires. The question about President Obama is whether he is the victim of this truism or its architect.

Obamacare’s implosion has generated parallels to other Presidential tipping points. The Tet Offensive exposed LBJ’s credibility gap on Vietnam and sank his Presidency. The Iranian Hostage crisis became a daily reminder of Carter’s ineptitude. His Desert One disaster opened a trap door of public revulsion, from which he never recovered. These faces of failure form a depressing portrait gallery of American Presidents, leading up to the most recent comparison of Bush’s Katrina debacle with Obama’s Obamacare.

In one aspect President Obama is a lucky man. There are no vivid visuals for his humiliating management meltdown. Thankfully for Obama, except for screen images of locked and crashed websites, there are no searing images of his disaster, like Katrina refugees in the Superdome and the flood waters swirling around New Orleans. That being said, the ACA is definitely Obama’s Hurricane Katrina. Everything that could go wrong - has. Everything that went wrong could have been avoided.

Beyond imagery, there are stark similarities between the ACA and Katrina. Both were predicted. Both were failures of leadership. Both revolve around a callous disregard for suffering. Both have Presidents who were at best clueless and at worst complicit. Both disasters are defining moments occurring eerily around the same time in their respective tenures. Neither handled the subsequent damage control very well. Bush watched his fellow Republicans sail into oblivion in the 2006 off-year elections. The fate of Obama’s Democrats has yet to be determined.

What makes these two disasters worthy of comparison is that their epic failures transcend ideology. While supporters parse and spin and opponents gleefully exploit the moment, the vast majority of Americans gasp in disgust at another failed Presidency.

Success or failure of a President revolves around competency and credibility. Events like Katrina, ACA, Tet, and Desert One do not, in isolation, destroy a President’s reputation. Rather, they crystallize a cumulative sense of unease that has been building over time. Public perception of a President’s competency and credibility are irretrievably altered once these events occur.

COMPETENCY

Katrina was a natural phenomenon, but a very predictable one. Four days before it hit New Orleans every forecast model showed this historic devastating storm heading straight for Louisiana. By Saturday morning, 36 hours from landfall, the radar images showed Katrina as a category 5 storm, filling the Gulf of Mexico with a highly defined “eye”. While Walmart and other private companies immediately initiated their disaster protocols, the Bush Administration dithered until two days after the levees broke. It was not until the next weekend that Navy and Coast Guard ships put to sea and another four days before they reached the scene. The federal government was also amazingly deferential to incompetent local officials regarding their lax preventive actions and first responses.

Katrina was the last straw for most Americans. Republican politicians and pundits swooned over Bush while turning blind eyes to his Administration’s lengthening record of incompetence. This ranged from bungling the rebuilding of Afghanistan, to invading Iraq on at best “cherry picked” intelligence, to multi-billion dollar sole-source deals for cronies, to collective Republican complicity in rampant spending and earmarks. In 2005, Katrina broke the levees both in reality and politically. The anti-Republican deluge only ended when Obama and the Democrats overplayed their hand and paid the electoral price in 2010.

The implementation of the ACA, or Obamacare, has crystallized concerns over Obama and his Presidency. Nearly everyone uses online commercial websites. The Christmas shopping season is already underway, meaning that Americans are using trouble free, consumer friendly websites 24-7. New versions of existing commerce sites and new ventures launch daily, with only an occasional hiccup (most notably Netflix’s July 2011 pricing debacle). It is totally inconceivable that Obama did not reach out to any of the millions of web designers and digital commerce experts to advise, oversee, design, implement, or test his central legislative achievement. Why didn’t Obama tap those who revolutionized his online campaigns in 2008 and 2012?

Also, most adults have served on project teams either professionally or with volunteer groups. They know the basics of planning, resourcing, measuring progress, adjusting plans & schedules, and the fundamentals of dry-runs, rehearsals, prototyping, and beta testing. It is therefore mindboggling that Obama did none of these on behalf of his signature policy initiative.

These systemic failures on such basic levels expose the inconvenient truth that state senators do not make good Presidents. This is especially true when they serve less than two years in higher office before running for President full-time.

Ultimately, Obama’s management failure is far worse than Bush’s Katrina. Katrina started as a natural phenomenon and time was finite. Obamacare was wholly manmade with arbitrary deadlines. Katrina’s human toll is well documented. ACA’s impact on people’s wellbeing is still to be tallied.

CREDIBILITY

One failure does not define or sink a Presidency. The failures of recent Presidents Johnson, Nixon, Ford, Carter, Bush 41 & 43, Clinton, and now Obama were cumulative - ranging over time and many different issues.

Obama has piled-up an amazing array of baggage since his re-election – Benghazi, IRS, Syria, Iran, the NSA, and the ACA. Once again the questions must be asked – is he a victim or an architect of his demise?

Whether victim or architect other imagery comes to mind. Obama’s rote response to each exposé has been he did not know. This mantra echoes “Chance the Gardener” in the movie “Being There”. http://www.imdb.com/title/tt0078841/ Chance remains clueless while his ill-formed utterances are deemed brilliant. The willingness of others to anoint Chance as a world leader is a biting satire on the group think of Washington power circles. Is Obama Chance?

However, being caught in his multi-year lie, “If you like your health insurance you can keep it”, also casts Obama as Elmer Gantry – a con artist flimflamming the world with golden words hoping reality will never catch him. http://www.imdb.com/title/tt0053793/?ref_=nv_sr_1

Chance or Elmer?

Either alter ego is fatal to Obama’s Presidency and its standing in history.

MESSAGE DISCIPLINE

Republicans need a remedial communications course. They have flunked every test during the budget/shut down battle.

Republicans have also failed political strategy 101. They are fighting the wrong battle, in the wrong way, at the wrong time. A key element to any political struggle is advocating viable alternative actions and/or policies to those you oppose. Kicking the table over is not a policy.

The most embarrassing aspect of the government shutdown is how it is undoing Republican assertions. This shutdown was supposed to stop Obamacare in its tracks, when, in fact, Obamacare is being implemented. Signing-up on health exchanges opened the very day the government shut down to stop Obamacare. Worse, media coverage of the shut down drowned-out news stories on the wobbly start to Obamacare. Media 101 – you never step on your own headline. Obamacare’s glitches would have helped build the Republican case for strategic action toward a complete overhaul or repeal. That story is now lost to the ages.

The embarrassments continue hourly. Republicans rail against Public Broadcasting - voting to defund it every year. The government is shut down and PBS and National Public Radio are providing full programming. Such disconnects between rhetoric and reality makes the GOP look clueless on how government is actually funded. That is not the best place from which to launch a fiscal fight over the debt.

Republicans are also displaying their utter powerlessness to impact the Executive Branch. President Obama can pick and choose what to shut down with impunity. He knows it will be months before the House Oversight Committee or the Government Accountability Office (GAO) will second guess his actions. So what if they find he was arbitrary and capricious? There will be no consequences, political or legal. So America gets to watch as National Parks are shut down (a list of the more over the top closings may be found at: http://www.breitbart.com/Big-Government/2013/10/05/list-obama-closures-for-shutdown), while pro-Obama political rallies are allowed on the “closed” National Mall (immigration reform). Government websites that serve Americans are offline (even Pandacam), but the primary government website that serves the government – www.USAJobs.gov is still scooping up applications for currently unfunded federal jobs.

The current budget battle began in the summer of 2011. Republicans have always been on shaky ground because of their own 14-year binge of spending and earmarking (1997-2011). They have never done anything to counter their fundamental lapse in Republican fiscal orthodoxy. Shouting within the conservative media echo chamber is not winning the broader argument with all of America.

One major Republican mistake was making reasonable fiscal management a partisan issue. In the 1970’s, Rep. John Ashbrook, one of the most conservative members of Congress, and Senator William Proxmire, one of the Senate’s most liberal members, coordinated their exposing of government waste. Ashbrook spoofed “goofy grants” while Proxmire issued monthly “Golden Fleece” awards. They both understood that “waste is waste” no matter which Party is responsible. Today only a handful of politicians and pundits transcend partisanship for true spending oversight and accountability, notably Senator Tom Coburn and journalist John Stossel. Unfortunately, neither receives the attention they deserve.

Many so-called conservative pundits and think tanks remained silently complicit during the Republican spending binge and the gross mismanagement of the executive branch under George W. Bush. The moment a Democratic President and Congress picked up where Bush and his GOP Congressional allies left off it was like Rip van Winkle awakening from a long slumber and wondering how things got so bad.

The Tea Party is filled with Rip van Winkles. They poured into Congressional town hall meetings in August 2009 screeching about a health program that was originally the Republican’s multi-payer alternative to Hillarycare’s single-payer system. Multi-payer healthcare was trumpeted by the Heritage Foundation and implemented by Governor Mitt Romney in Massachusetts. It was the preferred GOP way forward – until Obama’s name was attached to it. Even now, the “Affordable Care Act” polls better than “Obamacare” even though they are different names for the same program. One’s arguments lose all credibility and integrity when it is all about who proposes something, not what is being proposed.

So what can Republicans do?

First, they can get off their treadmill to oblivion. As proposed in [http://citizenoversight.blogspot.com/2013/09/kamikaze-congress.html], Speaker Boehner can allow a clean Continuing Resolution to be voted on in the House. He can hold his Republicans off the Floor and not have them vote on it. This means the Democrats “own” the CR and Obamacare funding. The focus shifts back to the flawed launch of the Affordable Care Act and making a reasonable case for reform or repeal.

Second, shift the focus to raising the debt ceiling. Cede the fact that the debt ceiling is driven by previous spending actions. America has to pay the bills it rang up. That said, there are ways to add reasonable and rational provisions to rein-in spending.

Three ideas come to mind.

- Control the fourth quarter spending binge. Put a 25% of fiscal year spending cap on the 4th quarter of each fiscal year. [http://citizenoversight.blogspot.com/2013/08/budget-bacchanal.html]
- Mandate a budget sweep of unspent and unobligated accounts. [http://citizenoversight.blogspot.com/2013/07/congressional-coinstar.html] Over $687 billion sits unused in accounts across the government. Put it to use.
- Start managing the federal workforce. [http://citizenoversight.blogspot.com/2013/02/fear-loathing-in-washington-dc.html ] As referenced earlier in the column, federal jobs are still being advertized and applications being collected. How many of these jobs are considered “non-essential”? Instead of furloughs, do hiring freezes, and job eliminations via the 60,000 retirements each year. Over $350 billion would be saved from these actions.

No thinking human being will be able to counter these prudent nonpartisan steps toward fiscal sanity. The only exception is Rep. Nancy Pelosi, who recently declared the cupboard bare of places to cut spending.

These simple and immediate acts would help Republicans reclaim the high ground of sound fiscal management, transcending partisanship. Whether you love a program or hate it, you should not want even one penny misspent. Accountability, transparency, and efficiency attract adherents across the entire political spectrum.

Finding and eradicating waste is just the first step. After recovering their footing, Republicans could revisit the Simpson Bowles debt reduction plan and Senator Coburn’s annual “Waste Book”. Some of these items are more partisan, but these vetted ideas can guide the foray into deeper political waters. Those who lead such a realistic and rational effort will find followers among the 230 million registered voters, not just the Tea Party and Fox News. Republicans – the choice is yours.

KAMIKAZE CONGRESS

Republicans in Congress are once again in a bind over how to fund the Federal Government while not acquiescing to policies and programs they dislike.

Many House Republicans want to sink Obamacare. They point to selective implementation delays, waivers, and the general erosion of public support for the program. However, House Republicans only control one of three components needed to make laws and pass a budget. Democrats hold the Senate and the White House. Any defunding of Obamacare dies in the Senate and on the President’s desk.

Threats to block continuing resolutions to fund the Federal Government revisits the sorry record of Republican led government shut downs. Except for the November 23, 1981 shutdown, ushered in by President Reagan vetoing a continuing resolution, none have ended well for Republicans.

The most infamous was the back to back shutdowns in November 1995 through January 1996. The newly resurgent Republicans wanted to flex their muscle against a President they assumed was a spent force. The GOP fully controlled the Legislative Branch for the first time since 1954. Speaker Gingrich thirsted for a budget show down that would reshape the budget battles. He failed miserably because he and House Republicans did not make their case for such brinksmanship. This flawed messaging took a bizarre turn when Gingrich went completely off topic to complain about having to sit in the rear of Air Force One on the return flight from the funeral of Israeli leader Yitzhak Rabin. Republicans now confronted the perception that the budget meltdown was about personal grudges not real policy.

After the 1995-96 shutdowns, Clinton shifted to the center for his domestic agenda, a slight victory for Republicans. However, Clinton regained his pre-1994 election momentum while Republicans faltered. It would take until the summer of 2011 for budget “hawks” to once again dominate Republican fiscal policy. During the fifteen year hiatus, Republicans lost all credibility on spending as they outdid the Democrats on appropriation earmarks, government growth, and executive branch waste. Obama has certainly added to the deficit and the growth of government, but Republicans, both in Congress and the White House, gave him a running start.

Republicans now have a dilemma of their own making. Since the budget battles of mid-2011, they have done a terrible job at making the case for cutting the size of government. Except for Senator Tom Coburn (R-OK), Republicans and their media allies have defended Defense Department spending (which is as wasteful as any domestic program), and proposed ideological cuts not management based cuts. The moment you select which sacred cows to slaughter, while protecting others, you slide onto ideological thin ice. The public’s wide spread cynicism of politics is currently hurting Republicans far more than Democrats.

The other dilemma is Republicans assailing Obamacare without proposing a viable alternative. America is the best country in the world if you need shock-trauma treatment or complex diagnostics. It falls to 30th or worse if you need chronic care or are uninsured. Demographics are driving chronic care. Americans are getting older and living longer. Medicare is already sailing over the fiscal cliff. The economy is driving the other crisis. The era of forty hour a week “W2” employment is giving way to part time “1099” jobs where benefits do not exist. A real mature discussion about standards of care, alternative treatments, and family caregiving should have occurred prior to debating the role of government. Unfortunately, the hyperpartisan environment poisoned that potential dialogue in the early 1990s. It has been a snake pit of snark and snipe ever since.

So where does this leave Republicans? Defunding Obamacare and forcing a government shut down is a “kamikaze” mission. It will only end with Republicans self-immolating. A better course of action is the following:

[1] Republicans in the House not do show up to vote on any fiscal legislation. Except for House leaders and a few other Republicans, let the Democrats casts all the votes. You establish a quorum and let the Democrats vote through the continuing resolution. That way the Democrats “own” Obamacare.

[2] If Obamacare is as dysfunctional as many now think, then it will fail on its own. President Obama, the Democrats in Congress, or their key constituencies will blink and seek ways to either fix or scrap Obamacare.

[3] Republicans spend their time and political capital developing a viable alternative to Obamacare. An aging America filled with “1099” part time workers is a reality and must be addressed. Looking for real solutions and building positive consensus around those solutions would re-energize the Republican brand as caring and rational.

[4] Republicans need to revisit Simpson-Bowles http://www.fiscalcommission.gov/ and the various reports developed by Senator Coburn. Putting forward a management based budget that addresses underlying fiscal issues would also help rebrand Republicans as caring, rational, and reasonable.

These four steps will be anathema to the “conservative” pundits and their audience of zealots. They will all rail against anything less than Republican Members crashing into public opinion. On the other hand, the rest of the 230 million voting Americans may take a second look at a rational Republican movement and reward it not only in 2014, but 2016 and beyond.