Thursday, November 24, 2016

The Fear of Aging in Trump’s New World

We cannot escape America’s rising nationalism. Ever- -distant Russia and China are marching further away to their own drumbeat, both headed by strong nationalist leaders. We’re seeing our close U.S. allies, Japan and Turkey becoming more independent and autocratic. Closer to home, the European Union continues to disintegrate in slow motion. Greece’s imploding bankruptcy will soon claim its financial membership to the EU. Followed by the freefall collapse of Italy’s banking. However, the coup de grâce will come on May 7, when France selects one of two rightwing contenders—no way Brexit, no way Trump, take away Italy, take away France—the fate of the EU will be sealed. But we have our own problems here in the US.

A class war has erupted, pitting older adults against the young and the military-industrial complex. As dramatic as this sounds—picture flash mob with walking canes in the air in lieu of pitchforks—the facts are starkly sobering. With the election of Donald Trump, the crystal ball has long been broken. Little conjecture is required however, as we have been inching toward a class clash for more than five decades. On January, it will culminate with a refreshed zeal. And now there is a public acceptance that “there will be blood’—the economic blood of the poor and elderly.

Trump’s “Contract with the American Voter”1 will, if fully enacted, bring an end to the Affordable Care Act (Obamacare), replacing it with Health Savings Accounts (HSAs). Obviously, serious repercussions will ensue for Medicaid—a joint state and federal government program—the backbone of Obamacare. Medicaid will be radically changed by giving states unfettered authority to decide what services they need to offer. The stark inequities that exist today across states will become even more unequal for services to the poor and aged. An immediate concern becomes the shift of funding for health care through HSAs. Since HSAs are not available for seniors on Medicare or those who are claimed as dependents, the replacement program will not serve them. With a ceiling of tax deferred contribution of $6,750 per month, rich middle-aged adults become the sole beneficiaries.

Clutching onto the coat tail of his master, Paul Ryan, the Speaker of the House during a limited surge in popularity, reignited his war on Medicare. Ryan—himself the beneficiary of Social Security survivors benefit as a young adult—wants to “modernize” Medicare—the Federal Government’s single most expensive program.   Within this program, the largest part is Medicare Advantage (MA). MA—a type of privately run, subsidized managed health care—consumes more than a quarter of Medicare’s total budget. Through MA, with a public option, the new administration can easily privatize Medicare.

Let’s face it, the details all seem terribly boring. And that is the beauty of this type of war—it remains imperceptible to most people. The war America faces remains nuanced, hidden because most people are looking for binary answers. The fact that it is fought with the money generated by and for older adults makes it that more obscure.

The finances of the U.S. government come not from Apple, Google, Goldman Sachs, Chevron, and other US industries and services that generate an annual turnover of $18.5 trillion—but from your average Joe. The poorest residents (not all of them citizens) pay for our government—a trend that started with Ronald Reagan and that has continued even through four administrations.  Both parties have colluded against the poor.

In 2016, most of the federal budget comes from Income Taxes (45% of total budget) it is quickly being overtaken by payroll taxes (35%). At one point in 2008, at the peak of the most recent depression, our payroll taxes became the primary source of income for the federal government. Out of all the economic activity of the United States, the federal budget was primarily funded by people’s contributions to their Social Security and Medicare. We need to let that sink in.

In contrast to this increasing reliance on our insurance payments to run the government, corporate taxes have been virtually abolished (less than 10% of our total federal budget).  In addition, estate, excise and all other types of taxes make-up less than 10% of the federal budget.  Payroll taxes—which comprise 15.3% of earnings which is shared equally by the employee and the employer—are not meant to be taxes, but to contribute to our insurance funds (hence why it is called the Federal Insurance Contribution Act-FICA). But the rich do not pay FICA, as it is not imposed on investment income such as rental income, interest, or dividends. The rich are also protected from paying their fair share of FICA—payroll taxes.  Because in 2016 we only pay part of FICASocial Security taxes (OASDI)on income of less than $118,500 (the amount remains constant at this level) the more you earn the smaller the percentage becomes. As such, OASDI taxes are regressive. Rich people, when they do pay payroll taxes, pay a smaller percentage then US residents who earn less than $118,500.

This would not be all bad, except that FICA funds which are supposed to be saved in trusts for our old age (OASDI-Old Age, Survivors and Disability Insurance) and medical coverage (HI-Hospital Insurance funds Medicare) are instead all spent as part of the budget, every year.

Numerous attempts to stop this misappropriation have to date failed. Allen Smith, a professor of economics, emeritus, from Eastern Illinois University has waged a valiant fight to publicize the illegality of how these funds are misappropriated. Starting in 1969 in the Johnson Administration, payroll taxes were co-mingled in a unified federal budget. To stop this and assure that these payroll taxes would be invested in Baby Boomers’ (1946-1964) benefits,  a law was needed. In 1990 the Omnibus Budget Reconciliation Act (OBRA) stopped the use of payroll taxes in the unified budget—the funds were designated as off-budget. But whether payroll taxes are calculated as "on-budget" or "off-budget" remains real only for accounting purposes—in practice, Congress spends payroll taxes, all of the annual budget, and then some each and every year.

As I said, it’s nuanced, except for the large amount of money involved. Payroll taxes are worth $1.07 trillion every year.

The budget clash involves increasing Federal discretionary spending by reducing mandatory spending. The mandatory budget is 60% of the total budget with $4.1 trillion. It is mandatory because there are some obligations that the government has to pay such as, social security, Medicare and also some military personnel costs. Mandatory budget was created in 1935 by the Social Security Act. In contrast, then there is the discretionary budget with $1.15 trillion. This budget is dependent on congressional approval and mainly funds military costs with 54% of discretionary budget. The transformation is to decrease the funds in the mandatory budget and move it to the discretionary budget. Hence the clash between spending on older adult and replacing it with military spending.

By becoming increasingly reliant on payroll taxes—while at the same time reducing the solvency of Social Security and privatizing Medicare—the incoming administration will directly assault poor older adults. Especially with the privatization of Medicare. Health insurance companies are quickly aligning themselves for this bonanza. They are busy consolidating to gain a monopoly. For now, the Justice Department continues to opposing  the mergers between Anthem and Cigna and between Aetna and Humana.  WellCare Health Plans has also announced its intention to buy Universal American. In less than two months, these mergers are likely to be approved and Medicare Advantage will be their prize. Medicare will be sold to the highest bidder, who will then have a monopoly on our health.

Although we cannot change this policy--which has been evolving for more than five decades--we can, however, make the system more solvent. Congress might adopt a policy of greater equity in the system if it brings more money. Elimination the ceiling for taxing Social Security would represent one big step. Although previously, Medicare (HI) taxes had the same restriction as Social Security, Bill Clinton passed a 1993 law removing the taxable maximum for Medicare--thus making all earnings subject to these taxes. Health Insurance taxes are therefore progressive, but still only represent 2.9% of the income compared to 12.4% of OASDI. By removing the ceiling for OASDI taxes and making it more equitable so that all income—including rental income, interest, or dividends are taxed—then payroll taxes morph into a more equitable income tax.  Which is how it is used by the federal government.

Arguments involving pitting of one generation against another are for show. The attack is on the poor and across all generations, since this administration will be selling-out our civic structure of care and social insurance. Our federal insurance payments benefit future generations. Whether couched as an income tax or a payroll tax, we deserve assurances that we are investing in our future as one nation.

© USA Copyrighted 2016 Mario D. Garrett            



Saturday, November 5, 2016

Brain Plasticity is Key to Surviving a Stroke

Although we think that the adult brain remains formed and static, we are finding that the brain changes and heals itself. Even early psychologists like William James (1890) argued that our brain is flexible and changing when he wrote The Principles of Psychology.  He called this “plasticity”. But it took another 70 years to provide evidence for this concept. One of the first pioneers was Joseph Altman who first discovered brain cell regeneration—or neurogenesis—in 1962. More recently, by 1999 the psychologist Elizabeth Gould of Princeton University reported that memories can be recorded in neurons that are generated daily.

We are now in the age of bran plasticity. Neurologists and psychologist accept the idea that the brain and its function are not fixed throughout adulthood. Brain plasticity refers to the brain's ability to change throughout life. We continue to learn because the brain keeps reorganizing itself and forming new connections between brain cells. And we have come to understand the method the brain uses to change. Donald Hebb in 1949 wrote The Organization of Behavior and provided us with the Hebbian Theory which specifies that neurons that fire together wire together. If I reward a behavior, my brain will associate that behavior with the reward and encourage that brain connection. In the 1950, after his father suffered a massive stroke, the New York neurologist Paul Bach-y-Rita become interested in how the brain can receive information from different organs. He invented an electrically stimulated chair. Behind the chair, a large camera scanned the area, sending electrical signals of the image to four hundred vibrating stimulators on the chair against the patient's skin. The blind patient could “see” the diffuse image from the senses on his back. He developed this technique into a tongue sensor that goes on top of the tongue while wearing a camera that translates the image to these tongue sensors. The tongue replaces the eye and receives the feedback that the brain “sees”. More recently these techniques have been popularized by Michael Merzenich and Norman Doidge. They developed the idea of both positive and negative plasticity.

We all appreciate positive plasticity. We develop memories and learn new things. Our neurons and white matter that comprise our brain organize in such a way that we form an internal representation of learning and experiences. Representing multiple impressions of the same event under different criterion (smell, look, feel, association, importance, relevance etc.) With positive plasticity we learn new skills and improve our thinking by developing better and more efficient communication between sensory and motor pathways. But with negative plasticity we have followed exactly the same growth but for the wrong outcome. We learn how to behave in ways that are not helpful, and this is not intentional. Negative plasticity causes an increased sense of pain, drug use and compulsive behavior among other negative behaviors. Pain, for example, is generated in the brain, and the only way to stop pain is to retrain the brain. Opioids lead to morphine and eventually leads to a situation where no medication is able to stop the brain from feeling the pain. We have retrained the brain to develop more neural pathways to feel the pain every time we try and numb the pain by medication. The death of Prince and Michael Jackson is a testament to how strong the brain is in feeling pain.

Stroke offers us a window into how fast and dramatic brain plasticity can be. A stroke occurs when a part of the brain dies. It can be caused by a blood clot or obstruction of an artery (Ischemia). Or alternatively where a ruptured artery and the neurons are flooded (Hemorrhage). There are other repercussions from these two events, with an accumulation of fluid/pressure on the brain (Edema) and the disruption of the sodium-potassium pump.

In the Copenhagen stroke study, a study headed by Henrik Jørgensen from Bispebjerg Hospital, Copenhagen, Denmark reported that one in five stroke patients died during hospital stay, one in seven were discharged to nursing home, and over half of stroke patients were discharged to their own home. Half of those that went home improved. What happens to these lucky quarter of the stroke victims who improve is a testament about brain plasticity. With all strokes there is a shadow that surrounds the dead tissue in the brain--penumbra. Penumbra are cells waiting to die. Whether these cells die or recover is dependent upon how fast the brain uses these cells for learning. And the clock is ticking. Every minute of delay to treatment is said to cost a patient 1.9 million brain cells.  By early referral to physiotherapy, occupational therapy, and speech language pathologist services the brain heals itself.

We have an ageist view of health. Instead of referring older adults to therapy we instead shuffle them over to wards. Brain plasticity is still available for older adults. But in our ageist view we judge older adults as ready to die and we fulfill this judgement by not helping their brain become re-engaged.

© USA Copyrighted 2016 Mario D. Garrett