While relatively few Americans rely on Obamacare for health insurance, virtually all of us have a stake in how the debate over repeal of the Affordable Care Act plays out.

When it was signed into law in 2010, the ACA changed the landscape of health care.

Not only did the new law provide a means for Americans to purchase insurance through state exchanges, it also significantly altered the way in which the health care industry conducted business. Hospitals, doctors, patients, insurance companies – pretty much all Americans were affected.

Among the myriad of provisions in the complex and ambitious law are the following:

• A mandate that all Americans have health insurance.
• A mandate that insurance companies offer insurance to people who have existing medical conditions.
• The establishment of state insurance exchanges that offer subsidies to many low and middle-income families.
• A requirement that insurance policies offered through state exchanges limit out-of-pocket expenses for customers.
• The elimination of caps (typically $1 million) on lifetime insurance coverage.
• Mandates that health care providers maintain electronic records and offer patients access to those records.
• Rules that move the industry to a value-based system in which the federal government and insurance companies pay health care providers based on the efficacy of treatments and the quality of care. The plan is to move away from a fee-for-services system.
• Penalties for bigger businesses that fail to provide health insurance to full-time employees.
• New taxes and surcharges designed to pay for the ACA. Companies that are self-insured, insurance companies, makers of medical devices, employees and retirees with extraordinarily generous health care benefits, and people who don’t have health insurance all face fines, fees or taxes under the law, although some of these have been postponed or dropped.

That’s just a partial list.

Republican leaders have vowed to repeal the ACA and provide Americans with an alternative. President Donald Trump told the crowd at a campaign rally in Florida Feb. 18 that “our plan will be much better health care at a much lower cost.”

Trump has not disclosed any specific information about the GOP plan. Similarly, Health and Human Services Secretary Tom Price has failed to describe what provisions Republicans will include in their legislation.

Republicans in Congress talk about eliminating mandates, including those requiring people to buy insurance and those that affect manufacturers, providers and health insurance companies. There also is talk of tax credits and health savings accounts.

As a physician and a Republican, HHS Secretary Price has long opposed the ACA, arguing that it intrudes on doctor-patient relationships and comes with excessive paperwork and rules.

His support of value-based systems is doubtful.

While serving as a representative from Georgia in the U.S. House, Price at least twice pressured federal officials to quash recommendations regarding unnecessary screenings and tests, according to a report from ProPublica.

A panel of doctors and researchers had found that the tests were overused and often led to unnecessary or even risky medical procedures. Under the ACA, the panel’s findings would become the basis for determining how many screenings and tests insurance should pay for.

Price disagreed with the panel’s conclusions, arguing that the government and insurance companies should pay for all testing and treatment the doctor deems necessary.

That’s not a surprising argument from a doctor. And it underscores the difficulty of trying to control health care costs while ensuring good care.

It will be virtually impossible to rein in health care costs if the efficacy of treatments is to be ignored.

The federal government is by far the biggest customer of health care, through its payments for Medicare and partial funding of Medicaid. Even before the ACA, the government made decisions regarding the effectiveness of specific treatments and whether they would be covered.

The government and insurance companies also set limits on how much they will pay for certain procedures, hospital stays and providers’ services.

As Republicans craft their plan, consumers should press them to ensure access and affordability for sure. But they also should demand that health care continue to move toward a model that pays for value rather than volume.

The state’s credit rating recently was downgraded yet again amid concerns about Kansas’ ability to repay mounting debt.

On the same day that S&P Global Ratings announced the downgrade, Gov. Sam Brownback and his aides used social media to proclaim 2016 an economic success.

This kind of disconnect has become common in Topeka. Faced with information he doesn’t like, Brownback digs through mountains of data to find a nugget he can polish for show-and-tell.

That makes the job facing Kansas legislators harder than it should be. If lawmakers could count on assistance from the governor, it would be easier to garner support for a sound fiscal plan.

Instead, the state Senate and House have been left to do the heavy lifting – trying to be financially responsible while remaining responsive to the needs of constituents.

And the weight they managed to carry last week was impressive. The tax legislation they approved is not perfect, but it does recognize the state’s fiscal crisis.

For years, Brownback’s tax policies, adopted with lawmakers’ approval, have left the state with chronic and massive budget holes. The state simply has not generated enough revenue to pay its bills.

The governor’s solution has been to create more debt for future Kansans. He also has stripped funds from highway programs, put the squeeze on health-care providers, and left many critical state services undermanned and under-funded.

Brownback’s latest budget proposal would again raise taxes and fees on some Kansans – although he condemns lawmakers’ proposals for a tax structure that raises taxes more generally.

The governor is not the only obstacle lawmakers face as they attempt to return common sense to state finances. They also are opposed by the far right and the far left.

From the right come threats of big-money challenges if lawmakers restore – in part or totally – income tax rates to former levels.

On the left are those who not only object to cuts, but who demand that legislators increase funding for education, health care and other popular causes.

A look at the numbers shows that the best means of fixing Kansas’ fiscal problems will require both short-term budget cuts and long-term tax increases.

It’s vital that Kansans understand that both are needed. And they should let legislators know they are willing to accept the pain if it will fix the state’s finances.

Now that lawmakers have adopted legislation that requires residents to share more equally the costs of government, they will need to look at other aspects of the state’s finances.

Cuts will be needed because of the lag between passing an increase in taxes and actually collecting the money.

To get the state through the time between now and when significant new revenue arrives, lawmakers also may need to delay, shift or borrow to keep the state solvent until it gets back on solid financial ground.

Support from Kansans for such moves should come with conditions.

First, any cuts to education should be short-term, rather than ongoing. The first focus should be on temporarily withholding or reducing funding for capital improvements and other projects.

Further, efforts to force school districts into statewide programs that cut benefits to teachers and other personnel must stop.

Universities and K-12 schools should share the pain. But lawmakers should not further undermine local control and use “state pools” to disguise pay cuts to public employees.

Second, while more debt might be needed to bridge the funding gap, more borrowing should be tolerated only in exchange for a structurally balanced budget, one in which recurring revenue covers recurring costs.

Third, metrics are needed to gauge how well new policies are working.

Tax changes over the past five years not only left the state short of funds, but they also shifted Kansans’ tax burden substantially.

Taxes increased substantially for low-income Kansans after state officials raised the sales tax to try to fill budget holes. Property taxes also rose broadly after the state shifted costs to local government. For many farmers and homeowners, savings gained with income tax breaks are outweighed by jumps in property tax bills.

Lawmakers should track revenue and spending carefully to ensure the state remains on a course that returns it to solid financial ground.

 

Fame has gained such political currency that the opinions of actors often are treated as more valuable than the views of experts with decades of experience and volumes of research.

Nothing highlighted our nation’s star-struck silliness more than the reaction to Meryl Streep’s criticism of President Donald Trump. Streep delivered her rant during the Golden Globes, where she was being honored for a long and lustrous career.

Immediately, TV, radio and the internet seemed to fill with stories about Streep’s comments. Even Trump responded – using Twitter to call Streep a “Hillary flunky” and “over-rated.”

What seemed overrated was the attention given an actor’s opinion about the president. What Streep thinks of Trump is of no more consequence than what Clint Eastwood said in 2012 about Barak Obama.

As Americans try to make sense of an increasingly confusing and overwhelming flow of information, it would be useful to pay attention to sources who add to our knowledge and understanding. It is folly to pretend that celebrities are often among that group.

Admittedly, it’s hard to discern credible sources now that we have a White House that either will not or cannot distinguish between truth and fiction. That makes it plausible to argue that many actors and celebrities are as credible and knowledgeable as current administration officials.

But Americans interested in their own welfare and that of the country should set their standards higher than that. So should the news outlets that want to serve them.

As consumers of news, we should look for media that provide sources with first-hand experience and years of study to back them up. Our “go-to” news outlets should give us names, dates and places that can be checked. And they should provide information about the data used to either support or refute claims being made.

It would be easy to blame TV for turning celebrities into political heavy-weights. But the germs of this epidemic were spread before the advent of television.

The ties between politics and entertainment are as old as history. Even the earliest playwrights used their talents to promote or criticize their countries’ rulers.

During World War II, actors were used extensively to promote the U.S. cause. They acted in movies that promoted the war effort, of course, but they also took on other roles, including selling war bonds on national tours.

Over the past 60 or 70 years, the ties between fame and politics have grown.

By the 1980s, members of Congress were calling actors such as Jessica Lange and Sissy Spacek to Capitol Hill to testify on agriculture policy. Their expertise? They had played the roles of farmers’ wives in movies.

Since then, parades of celebrities invited to the Capitol have offered their opinions on a wide variety of topics, including Sudan’s civil war, cloning, gun rights, the Congo, domestic violence, global warming and the treatment of elephants in captivity.

Almost all of them got more attention – from Congress, media and the public – than people with true expertise about the topics being considered.

While we can applaud celebrities for caring about the world in which they live, it is puzzling why government officials would spend taxpayers’ money to hear from people with no special knowledge or insight into the issues Congress is attempting to address.

For the most part, celebrities are no more knowledgeable about the causes for which they campaign than your next-door neighbor. Which is to say: They may have some interest and knowledge in the topic, but fame does not confer expertise.

This infatuation with fame is not just a waste, it can be counterproductive.

On health care issues, for example, we would be better served if we were as familiar with Dr. Anthony Fauci as we are celebrities Gwyneth Paltrow and Jenny McCarthy. Fauci’s work involving immunology at the National Institutes of Health has made the world a healthier and safer place, while Paltrow and McCarthy use their fame to spread misinformation and unsupported claims.

Treating actors and other celebrities as authorities diminishes our ability to make good decisions that are based on the most accurate information and sound analyses available.

I admit it: I’m among those responsible for a trade deficit with Mexico.

Avocados, onions, hot peppers, limes and Mexican beer are usually on my grocery list.

But perhaps not for long. Prices for those products and others could rise dramatically if President Donald Trump’s proposed 20 percent tariff is adopted.

While the United States produces much more food than its residents can eat, Mexican-grown produce is common in our grocery stores this time of year.

Depending on your age, you may remember when the fresh vegetables and fruits available at the supermarket were much more limited.

Avocados and strawberries, for example, were available only seasonally, during their U.S. harvest and a few weeks after.

But over the last two decades, growers and grocers have expanded their markets, creating an abundance of fresh produce and other products 12 months a year.

Costs are reasonable, in part because of the North American Free Trade Agreement, which made it easier for companies to do business across international borders.

These days, that’s supposed to be a bad thing.

Trump argues that NAFTA is among the many trade deals that have ruined America. He says he will trash the current deal and renegotiate.

It is true that growth in international trade has created pain for some U.S. workers, as companies move plants and shift or eliminate jobs.

But it’s a mistake to view trade pacts as the cause of the pain.

No economy is static. And international trade dates back thousands of years.

Trade agreements have been a means of dealing with the complex economies and continually changing interactions that take place among nations.

But Trump doesn’t view trade pacts as a way to manage evolving economies.

He thinks pacts create change – change he doesn’t like.

Already, the president has withdrawn the United States from the Trans-Pacific Partnership, which was negotiated during Barak Obama’s administration.

Ditching TPP means Kansas agriculture and manufacturing are losing out to other nations that will export goods and services to a large network of nations with Pacific ties.

Trump’s call for a 20 percent tariff on products from Mexico will cost Kansas again, as consumers pay higher prices for everything from limes and strawberries to cars and TVs.

Kansans especially should worry about the destruction of international trade deals. The agreements have helped build export markets for Kansas-grown crops, the state’s aviation industry, and farm and industrial equipment made here.

Our trade balance with Mexico provides an example. In 2015, the U.S. imported $316 billion worth of goods and services from Mexico. We exported $267 billion worth of goods and services to Mexico that same year, according to federal data.

While it’s true that we had a $49 billion trade deficit with Mexico, on a per-capita basis, the United States is far ahead.

Mexico, which has a much smaller population, spent $2,170 per capita on U.S. imports in 2015, while U.S. residents spent an average of $975 on Mexican goods and services.

Anti-trade advocates, including the president, argue the United States can fuel its own economy by curtailing imports.

That’s part of Trump’s “America First.”

But don’t confuse a slogan for a trade strategy.

Strategy requires precepts regarding international trade. Trump has none. He merely argues he can cut better deals with countries on a one-by-one basis.

Doubtful. But even if he can, the deals would be no more binding than the ones Trump is trashing.

Similarly, it is unclear that the United States will abide by the rules of the international community as governed by the World Trade Organization. Trump has made clear his disdain for the WTO.

“America First” definitely could mean fewer imports. It almost surely means fewer exports, as other countries find more reliable and reasonable trading partners.

Kansas farmers and businesses stand to lose billions of dollars every year.

Whether it’s corn headed to China, beef exported to Japan, planes sold in Europe or agricultural machinery marketed in Mexico – Kansas depends on exports.

Our best bet for growing the state’s economy is to expand export markets through international agreements. To work, the pacts must recognize the rights and needs of all the players – not just our own.