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Froma Harrop - Often you don't really need to see a MD

You want a routine checkup. Or your throat is sore. It's probably nothing, but you're concerned. Do you need a full-fledged MD with all those certificates and perhaps a God complex?
Even if you want to see a physician, there's a shortage of family doctors these days. And it will only get worse as the Affordable Care Act (Obamacare) brings health coverage to 30 million more Americans. If you do have a primary care doctor, it may be hard to get an appointment.
A nurse practitioner may be in your future — if he or she is not already in your present. This is a kind of super nurse, who's gone through four years of nursing school plus at least two more years of training in diagnosing and treating disease. Nurse practitioners may specialize in women's health, pediatrics or cardiac care.
"A lot of people view them as a pretty obvious way to help deal with the number of people expected to get insurance," Joanne Spetz, professor at the Institute for Health Policy Studies at the University of California, San Francisco, told me.
But the extent to which they can fill the gaps depends on where you live. States regulate health care, so the latitude given nurse practitioners varies widely.
In Missouri, for example, nurse practitioners may not see patients unless a physician is under the same roof. In New Mexico, by contrast, they don't have to work with a physician at all. In some states, they are restricted from prescribing narcotics. In others, they may prescribe certain kinds of narcotics and not others.
Western states tend to give nurse practitioners the greatest autonomy. Perhaps it's the libertarian spirit, or perhaps their vast rural areas, where doctors are few and far between. Colorado is considered "the cradle of nurse practitioner practice," according to Spetz.
A personal note: I went to a superb nurse practitioner for years, seeing the doctor she worked with only at parties. When I had a complaint she considered beyond her expertise, out came her pad and the name of a specialist to call.
Her accessibility was a big plus. She had time to shoot the breeze about my every little ache and whether running is bad for the knees.
Health economists see primary care providers as key to curbing medical costs. Americans overuse expensive specialists. For example, they run off to gastroenterologists and have endoscopes shoved down their throats when their problem is simple heartburn. Primary care providers could have saved these patients money, discomfort and anxiety by prescribing Tums as a first step.
"They know what they know, and they know what they don't know," Spetz said. "If a complicated diabetes situation is going on, they will send the patient to an endocrinologist."
We're talking money here, hence some heavy turf battles. The American Medical Association worries about nurses taking business from its doctor-members and lobbies in state capitals against giving nurse practitioners more independence. The AMA argues that patients' health may be jeopardized if doctors don't monitor nurse practitioners.
Obamacare provides some money for training nurse practitioners but sidesteps the matter of what role they might play. Early in the deliberations, there was reportedly talk of requiring states to give them more independence in return for Medicaid money. The AMA is said to have stopped that line of inquiry.
Cutting health care costs — and making health care services more convenient for consumers — demands moving basic medical services away from hospitals and, in many cases, doctors' offices. Sometimes we need a doctor; sometimes we don't. A well trained nurse practitioner can help point us in the right direction.
(A member of the Providence Journal editorial board, Froma Harrop writes a nationally syndicated column from that city. She has written for such diverse publications as The New York Times, Harper's Bazaar and Institutional Investor.)

Last Updated on Wednesday, 31 December 1969 07:00

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Pat Buchanan - Death by (largely) self-inflicted wounds

The Republican National Committee has produced an "autopsy" on what went wrong in 2012, when the party failed to win the White House and lost seats in Congress. Yet, the crisis of the Grand Old Party goes back much further.
First, some history. The Frank Lloyd Wright of the New Majority was Richard Nixon, who picked up the pieces of the party after Goldwater's defeat had left Republicans with just a third of the House and Senate. In 1966, Nixon led the GOP back to a stunning victory, picking up 47 House seats. In 1968, he united the Rockefeller and Reagan wings and held off an October surge by Hubert Humphrey, which cut a 13-point Nixon lead to less than a point in four weeks.
In 1972, Nixon swept 49 states. The New Majority was born. How did he do it?
Nixon sliced off from FDR's New Deal coalition Northern Catholics and ethnics — Irish, Italians, Poles, East Europeans — and Southern Christian conservatives. Where FDR and Woodrow Wilson had won all 11 Southern States six times, Nixon swept them all in '72. And where Nixon won only 22 percent of the Catholic vote against JFK, he won 55 percent against George McGovern in 1972.
What killed the New Majority?
First, there was mass immigration, which brought in 40 to 50 million people, legal and illegal, poor and working class, and almost all from the Third World. The GOP agreed to the importation of a vast new constituency that is now kicking the GOP into an early grave. When some implored the party in 1992 to secure the border and declare a "timeout" on legal immigration to assimilate the millions already here, the party establishment repudiated any such ideas.
"We are a nation of immigrants!" it huffed. Well, we sure are now. And when amnesty is granted to the 12 million illegals, as GOP senators are preparing to do, that should advance the death of the GOP as a national party by turning Colorado, Nevada and Arizona blue, and putting even Texas in play.
Second came party acquiescence in dropping half the nation off the income tax rolls, while making half dependent on government for food assistance, income support, rent, health care and the education of their kids from Head Start through Pell Grants. Why should the half of America that pays no taxes but survives on federal benefits vote for a party that will cut taxes they do not pay but roll back benefits upon which they do depend?
Third, to accommodate its K Street bundlers, the GOP embraced globalism, empowering Corporate America to shed its U.S. labor force, move its plants to Mexico, Asia and China, bring its foreign-made goods back to the USA free of charge and pocket the difference. Profits, stocks, dividends soared. But the Reagan Democrats of industrial America — who paid the price in lost jobs and shuttered plants from the $10 trillion in trade deficits America has run since George H. W. Bush — have now gone home to the party of their fathers. And they are not coming back.
Fourth, rather than bringing the troops home after our Cold War triumph and telling our allies the free rides were over, Bush I and II went crusading for a "New World Order" to "end tyranny in our world." After three wars and half a dozen interventions, we are bankrupt at home and hated abroad. And Americans, sick of seeing their best and bravest brought home to Dover or being fitted at Walter Reed for prosthetic arms and legs, have twice voted for an ant-interventionist president.
Yet, one matter over which the GOP had no control is the triumph of the counterculture. What might be called the old morality — that abortion is the killing of an unborn child, an abomination, that homosexuality is unnatural and immoral — has been relegated by scores of millions, especially among the young, to the dark ages of the 20th century. Americans who adhere to this traditional morality, rooted in Christian tradition and Biblical truth, are culturally outgunned and may now be outnumbered. They may have lost America for good.
What can the GOP do about this? Nothing.
What will the GOP do? Probably what comes naturally — declare itself "tolerant" and respectful of all views, pro-life and pro-abortion, pro-gay marriage and pro-traditional marriage.
Reality must be faced. A generation has grown up rejecting the truths that its grandparents lived. And while population growth among our native born halted decades ago, scores of millions have come in from abroad to fill the empty spaces. And they are still coming. They like what Big Government has to offer, and seem uninterested in what the GOP has to sell.
In that case, you try harder to sell your product, change your product, or go out of business. Yet, if the GOP changes its product, it may just lose its most loyal customers.
When the obituary of the party is written, the subhead will likely read "Dead of Self-inflicted Wounds."
(Syndicated columnist Pat Buchanan has been a senior advisor to three presidents, twice a candidate for the Republican presidential nomination and the presidential nominee of the Reform Party in 2000. He won the New Hampshire Republican Primary in 1996.)

Last Updated on Wednesday, 31 December 1969 07:00

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Roy Sanborn - PMI: Prime Minister of India

Residential home sales in the Lakes Region towns covered by this report in February were not very spectacular. There were just 46 homes sold at an average price of $268,188 with a median price point of $169,000. We had 59 sales last February but with a lower average price of $209,025 and a lower median price point of $145,000. Sixty six percent of the sales were below the $200,000 mark. It is really great to see the average sales price up for the month and there was a big cheer in the press about it, but on a rolling 12 month basis our average sales and median price is still a bit lower than the previous 12 months. I wish we could get both the ying and the yang going in the right direction every month, but that might be asking for a little too much.
So what is PMI? PMI stands for a lot of things. There's the Prime Minister of India who everyone knows is Manmohan Singh, a household name... maybe in New Delhi. In business, it stands for Phillip Morris International, in the computer world it can stand for Portable Management Interface, and there are those in certain circles that recognize it as the Plumbing Manufacturers International association. In the wonderful world of real estate PMI stands for Private Mortgage Insurance which is exactly that; a privately issued insurance policy that partially protects the lender who has loaned money to a homebuyer who could not come up with a 20 percent down payment to buy a home. While PMI is an additional cost, it has helped many buyers get into a home who otherwise would not get a loan. After all, lending someone a couple hundred grand to buy a home when the buyer has only a few thousand dollars, a ball of lint, and a marble collection as a down payment does not seem like a wise investment for any bank or mortgage company.
In today's market, a majority of the loans we see are FHA and require only a 3.5 percent down payment. These loans do not have Private Mortgage Insurance, but rather a type of Mortgage Insurance (MI) backed by good old Uncle Sam (MI also stands for Mission Impossible...which it would be for some home owners without it.) Historically, homeowners that have FHA loans and were in their homes for five years had been able to get rid of their MI Premium when the value of the property they purchased reaches 78 percent of the loan (LTV.) That happens as the principal is paid down or when the value of the property increased (remember the good old days?) The problem is that the FHA is still on the hook for the full amount of these federally insured loans even after the MI is cancelled upon reaching that 78 percent Loan to Value. One government analysis showed that 10-12 percent of the claims come after the MI is cancelled, leaving Uncle Sam holding the proverbial bag of do-do. The "claims" really means that someone lost their house. In order to avoid these losses, any loans registered with HUD after June 3, 2012 will require the borrower to pay PMI for the entire life of their loan. The only exception is if the borrower puts at least 10 percent down and then the MIP will last for a minimum of 11 years. That may seem like a big deal, but it really isn't as most homeowners will end up refinancing anyway or perhaps even selling and buying another home down the road.
Maybe the bigger news is that as of April 1, 2013 FHA is also going to increase the size of its bite on the Mortgage Insurance Premium by 10 basis points or by .10 percent. Right now, FHA has an upfront MI Premium of 1.75 percent and a monthly MI Premium of 1.25 percent. On a $150,000 home purchase this is what the MI looks like: The buyer is required to have a 3.5 percent down payment or $5,250, making the base loan amount of $144,750. The upfront MI Premium of $2,533.13 is added to that making the total loan amount of $147,283.13. This is not really an out of pocket upfront cost as it is rolled into the loan so the buyer doesn't really feel it. The current monthly MI Premium of 1.25 percent of the loan amount in this case would be $147,283.13 X 1.25 percent or $1,841 per year or $153.42 per month. After April 1, the rate becomes 1.35 percent which increases the monthly premium to $165.69. So basically, it's another $12 out of a buyer's pocket every month on this size loan. Now that may not be earth shattering by itself, but nothing else is going down in cost either!
What else can you do? There are other options out there such as Rural Development loans which have a 2 percent upfront "guarantee fee" and only a .40 annual MI rate so that may be a better option for some buyers. There are some programs on conventional loans where lenders pay the PMI but the borrower pays a higher interest rate which can also save you some money. VA loans have no PMI so perhaps you can do a short stint in the Navy, see the world, and then buy a house. To qualify for a lower PMI rate on a conventional type loan you need to have a good credit score and the bigger the down payment you have the better. How do you completely avoid PMI or MI? The best way, obviously, is to scrimp and save to get the 20 percent down payment that once was the standard for buying a home. Hey, we all know how easy it is to save, right?
Thanks to Jen McCall at Merrimack Mortgage for clarification on mortgage insurance and invaluable insight about Manmohan Singh. Please feel free to visit www.lakesregionhome.com to learn more about the Lakes Region real estate market and comment on this article and others. Data was compiled as of 3/18/13 using the Northern New England Real Estate MLS System. Roy Sanborn is a REALTOR® at Roche Realty Group and can be reached at 603-677-8420

Last Updated on Friday, 22 March 2013 10:11

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Michael Barone - Republicans must show support for Hispanic dreams

Rarely does a political party issue a document so scathingly critical of itself and its most recent presidential nominee as the report of the five-member Growth and Opportunity Project of the Republican National Committee. It refers to Mitt Romney on occasion as "our presidential nominee" and notes disapprovingly of his reference, in the debate about immigration, to "self-deportation." And while the report states modestly, "We are not a policy committee," it does call for a policy — "comprehensive immigration reform" — that many, perhaps most, Republican members of Congress oppose.
I think there's some risk here for the Republican National Committee. But there also may be some reward for Republicans generally.
The risk is of turning off officeholders and voters Republicans need to win elections and prevail on issues. The reward is Republicans might be able to win some elections they'd otherwise lose.
"If Hispanic Americans perceive that a GOP nominee or candidate does not want them in the United States (i.e., self-deportation), they will not pay attention to our next sentence," the report says. "It does not matter what we say about education, jobs or the economy; if Hispanics think we do not want them here, they will close their ears to our advice."
To this they contrast George W. Bush's 2000 and 2004 campaign refrain: "Family values don't stop at the Rio Grande, and a hungry mother is going to feed her child."
Let me put it another way. To win someone's vote, you need to be friendly to them and those they identify with.
My observation in travel over the years is that Hispanics are treated very differently by Anglos in Texas than in California.
In Texas, white Anglos see people with Hispanic features as fellow Texans. They smile and say howdy. They know, because they have to take Texas history in high school, that Hispanics have been living in Texas for more than 200 years and that some fought for Texas independence against Mexico.
In California, white Anglos, liberal or conservative, treat people with Hispanic features as landscape workers or parking valet attendants. They look past them without speaking or hand them their car keys.
George W. Bush's words about family values were very Texan, down to the reference to the Rio Grande. That enabled him to win about 40 percent of Hispanic votes in 2004 (examination of county returns suggests that the exit poll number of 44 percent is a little high).
As for Romney, when he said "self-deportation," he was actually describing something real. The folks at the Pew Hispanic Center have concluded, I think with some reluctance, that net migration from Mexico to the United States fell to around zero in the recession year 2007. There may have been more reverse migration than inward migration since then. But "self-deportation" and "reverse migration" are cold, abstract terms. Politicians (and pundits) need to look beneath unfeeling statistics for the effect on the lives of actual human beings.
And when you look at the RealtyTrac numbers of foreclosures in the peak years of 2007 and 2010, you find that a majority were in four states — California, Nevada, Arizona and Florida.
When you look at the counties with high foreclosure rates, you're looking at the Central Valley, the Inland Empire east of Los Angeles, metro Las Vegas and metro Phoenix.
You're looking at tens of thousands of Hispanic homebuyers who were granted mortgages with little or no money down and that proved to be far beyond their capacity to service when housing crashed and the construction industry shut down. Many such mortgages were issued because of government policy favoring minority homeownership and because Fannie Mae and Freddie Mac pushed this policy hard.
This was bad public policy that shattered people's dreams. Homebuyers had assumed they would amass wealth through supposedly inevitable housing price gains. Instead, many — and others who witnessed this tragedy — gave up on the United States and moved back to Mexico.
Republicans can perhaps gain entree with Hispanic voters by supporting comprehensive immigration reform. At the very least, they need to avoid approaching this issue with the angry hostility you hear from too many callers on talk radio. But they also need to show an understanding of the realities these people are facing. They need to show the how their policies can help them achieve their dreams.
The Republican National Committee report is not a bad start.
(Syndicated columnist Michael Barone is senior political analyst for The Washington Examiner, is a resident fellow at the American Enterprise Institute, a Fox News Channel contributor and co-author of The Almanac of American Politics.)

Last Updated on Wednesday, 31 December 1969 07:00

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Mark Fernald - Right-sizing the federal government

Washington is trapped in an endless fiscal debate. Republicans argue that the federal government is too big. Democrats argue that revenues are too low. The fight is over money, but the larger debate is over the size and scope of the government.
Before we line up on one side or the other, we should look at recent history.
Over the past 40 years, federal spending has averaged a little over 20 percent of Gross Domestic Product (GDP). When the economy has been strong, federal spending as a percentage of GDP has dipped below 20 percnet. When the economy has been weaker, that figure has been several points higher.
During the same 40 years, federal revenues have averaged about 18 percent of GDP. As a result, the federal government was in deficit for all but three of those years.
This fluctuation is to be expected. When times are tough, spending increases for safety net programs, such as Medicaid, food stamps, and unemployment benefits. The opposite happens when the economy booms, such as in the 1990s.
During the Clinton budget years (1994-2001), federal outlays as a percentage of GDP declined from 21 percent to 18.2 percent. During the following eight Bush budget years (2002-2009), that percentage rose from 19.1 percent to 25.2 percent, as the Great Recession, and spending for two wars and Medicare drug coverage, all had an effect. (The Obama stimulus increased spending by 1.5 percent of GDP.)
During the three Obama budget years that have been completed (2010-2012), spending as a percentage of GDP has been 24.1 percent, 24.1 percent, and 22.9 percent, while revenues as a percentage of GDP have been 15.1 percent, 15.4 percent and 15.8 percent. (estimate).
As the economy improves, the gap between spending and revenues will narrow, but there will continue to be a significant gap.
Social Security and Medicare are not part of our current deficit problem. Revenues for those programs are about equal to spending. As the retirement of the baby boomers continues, expenses will rise faster than revenues, and those programs will have to use their surpluses to maintain benefits. Medicare is projected to exhaust its reserves and be unable to pay all its bills in 2024 while Social Security is projected to exhaust its reserves and be unable to pay full benefits in 2033.
By 2040, Medicare costs are projected to increase from 3.7 percent of GDP to 6 percent of GDP. Social Security will increase from 4.9 percent of GDP to 6.4 percent of GDP in 2035.
If we are to keep our promises to our seniors, the size of the federal budget, relative to GDP, will have to increase by several percentage points.
Republicans have other ideas. In 2011, every Republican in the Senate voted for a constitutional amendment that would mandate a balanced budget, and that would limit federal spending to 18 percent of GDP. If implemented, this amendment would require huge cuts in Social Security and Medicare, or huge cuts in everything else, or a cut of 17 percent across the board. Such a cut would be seven times as large as the sequester.
The 2012 Republican Party platform also calls for a constitutional amendment limiting federal spending to a fixed percentage of GDP.
The goal of the Republican Party is to reduce the size of the federal government to a size we have not seen since before the days of Medicare, Medicaid, the EPA, food stamps, Head Start, and student loans. Do we really want to go back to those days?
There are alternatives. Cuts can be made to eliminate federal subsides for agribusiness, ethanol, and fossil fuels. The defense budget can be cut by eliminating weapons the Pentagon does not want, and by bringing homes troops that are stationed in countries that no longer need our military assistance.
On the revenue side, we could eliminate special tax rates for hedge fund managers and investment income, enact a financial transaction tax (which will raise revenue and cut down on speculation in the stock market), and limit or eliminate deductions for luxuries, such as the mortgage interest deduction on second homes and mansions.
These changes would reduce the deficit by hundreds of billions of dollars a year.
Changes are also needed for Social Security and Medicare so that they can be self-sustaining programs in the long term. A balanced approach of revenue increases and benefits adjustments makes sense to many — unless you are a Republican sworn to oppose all tax increases, which then leaves only benefit cuts.
It's budget season in Washington. The media will focus on the clash between the parties. You should look for the alternate visions of the parties.
Democrats want to gradually decrease spending, and increase revenue, so that the two balance somewhere near 21 percnet of GDP. Republicans want to radically change the scope and mission of the federal government, reducing it to a size not seen in a couple generations.
You get to weigh in again on election day, 2014.
(Attorney Mark Fernald lives in Sharon. He was the Democratic nominee for governor in 2002. He can be reached at This email address is being protected from spambots. You need JavaScript enabled to view it. . This column, with supporting footnotes, can be found at www.markfernald.com.)

Last Updated on Wednesday, 31 December 1969 07:00

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