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Guess What? Grandma is Moving In. She’s Got Medical Bills. Maybe to Share. It’s Medicaid Brought to You by Kochcare.

Is kicking senior citizens out of nursing homes good politics? That’s a question GOP asking itself these days. One of many questions related to the politics of health care. Although not many are asking it since the public largely has no idea the question is being asked at all as recent polls show. With the Senate’s version of ‘Trumpcare’ finally released to the public, we’re now learning that, yes, the GOP appears to think kicking seniors out their nursing homes is good politics. Because transferring Medicaid costs to states and individuals has been a key GOP goal of Trumpcare’s congressional authors the entire time and nursing homes are paid for by Medicaid for the vast majority of people. So in addition to the many profound moral questions raised by the GOP’s health care ‘reform’ plans, a growing number of profound political questions are being raised the more we learn about Trumpcare as it takes form. Including whether or not putting nursing home coverage on a fiscal death spiral makes for good politics. Granny would probably say ‘no’, but she’s got competition.

******

But despite the deep antipathy polls showed towards the House version of Trumpcare, the American Health Care Act (AHCA), the question of how Americans will respond to the GOP’s proposal to dismantle American’s medical safety-net is still an open question. Why? Because the vast majority of Americans still don’t know that Medicaid is on the chopping block:

Think Progress

New poll shows majority of Americans are unaware Trumpcare slashes Medicaid
Just 38 percent of people polled knew the Republican health care bill makes major cuts to Medicaid.

Kiley Kroh
Jun 24, 2017

As Senate Republicans aim to force a vote on their version of Trumpcare—a bill that was written in secret, without public hearings, despite the fact that it will reshape one-sixth of the U.S. economy and impact the lives of millions of Americans—most people have been left in the dark.

Last month, the House passed their version of the bill, which would strip health care from 24 million people, according to the nonpartisan Congressional Budget Office. The bill also makes major cuts and structural changes to Medicaid, a health insurance program relied upon by nearly 75 million Americans—primarily low-income, disabled, and elderly.

The Senate version of Trumpcare goes even further, according to the draft released by Sen. Majority Leader Mitch McConnell (R-KY) on Thursday, effectively phasing out Medicaid entirely.

But according to a new poll released by the Kaiser Family Foundation on Friday, only 38 percent of Americans are aware of the significant cuts to Medicaid that would be delivered by the House-passed bill (the poll was conducted before the details of the Senate bill were made public). Seventy-four percent of those polled, meanwhile, said they have a favorable opinion of Medicaid.

The Senate’s harsher Medicaid cuts were immediately met with fierce objections, however. Roughly 60 members of ADAPT, a U.S. disability rights organization that strongly opposes the Republican health care bill, staged a die-in outside of McConnell’s office on Thursday. Wheelchair users were arrested and dragged from the Capitol by police.

Moderate Republicans have also expressed their discomfort with the severe cuts to Medicaid, with the strongest objection thus far coming from Sen. Dean Heller (R-NV) on Friday. “I cannot support a piece of legislation that takes away insurance from tens of millions of Americans and hundreds of thousands of Nevadans,” the senator said at a press conference in Las Vegas.

Hours later, America First Policies—a pro-Trump group run by several of the president’s top campaign advisers—announced it was launching a seven-figure advertising campaign against Heller, Politico reported. Heller is widely viewed as one of the most vulnerable incumbents up for reelection in 2018.

Ironically, President Donald Trump made protecting Medicaid a key component of his campaign, vowing to “save Medicare, Medicaid, and Social Security without cuts” in the speech announcing his candidacy.

Trump told the Washington Post’s Abby Phillip that the Senate version of Trumpcare needed “a little negotiation, but it’s going to be very good.” The president reportedly made calls to Senate Republicans on Friday to try to gin up support for the measure. Trump acknowledged there is a “very, very narrow path” to passage, but that “I think we’re going to get there,” Reuters reported.

———-

“New poll shows majority of Americans are unaware Trumpcare slashes Medicaid” by Kiley Kroh; Think Progress; 06/24/2017

“But according to a new poll released by the Kaiser Family Foundation on Friday, only 38 percent of Americans are aware of the significant cuts to Medicaid that would be delivered by the House-passed bill (the poll was conducted before the details of the Senate bill were made public). Seventy-four percent of those polled, meanwhile, said they have a favorable opinion of Medicaid.”

Yep, even though only about 1 in 5 Americans approved of the House version of the House version of Trumpcare, only 38 percent of them even knew about the most extreme parts of proposal, the plan to severely cut and fundamentally change Medicaid. So unless the public actually wants Medicaid to be gutted, it’s hard to see how growing awareness of the planned Medical cuts are going to increase public support, making the GOP’s ongoing push to pass Trumpcare an remarkable political risk. Especially when you consider that, while Trumpcare will have a profound (largely negative) impact across the US health care system, it’s primarily a Medicaid phase out scheme and Medicaid covers even more people than Medicare:

The New York Times

G.O.P. Health Plan Is Really a Rollback of Medicaid

Limiting the amount that the federal government would pay for each person would leave states with difficult choices, and would be a fundamental shift of financial risk.

By MARGOT SANGER-KATZ
JUNE 20, 2017

Tucked inside the Republican bill to replace Obamacare is a plan to impose a radical diet on a 52-year-old program that insures nearly one in five Americans.

The bill, of course, would modify changes to the health system brought by the Affordable Care Act. But it would also permanently restructure Medicaid, which covers tens of millions of poor or disabled Americans, including millions who are living in nursing homes with conditions like Alzheimer’s or the aftereffects of a stroke.

“This is the most consequential change in 50 years for low-income people’s health care,” said Joan Alker, the executive director of the Center for Children and Families at Georgetown University. “This is a massive change that has hardly been discussed.”

Since its founding, Medicaid has operated as a partnership between the federal government and the states. Each pays a share of patients’ medical bills, with no overall limit on spending. The American Health Care Act would try to slim down the federal share of that spending, by limiting how much the federal government would pay for each person enrolled in the program. The Senate version of the legislation, expected this week, is likely to make the payments still leaner in later years.

The results, according to independent analyses, would be major reductions in federal spending on Medicaid over time. States would be left deciding whether to raise more money to make up the difference, or to cut back on medical coverage for people using the program. The Congressional Budget Office estimates that the changes would lead to a reduction in spending on Medicaid of more than $800 billion over a decade. (That figure also includes additional cuts to the Obamacare Medicaid expansion.)

[see chart showing percentage of Americans covered by Medicaid in different categories]

Medicaid is the country’s largest government health care program, covering more Americans than its better-known sibling, Medicare.

Its reach is broad: About half of all births in the country are covered by Medicaid, and nearly 40 percent of children are covered through the program. Medicaid covers the long-term care costs of two-thirds of Americans living in nursing homes, many of them middle-class Americans who spent all of their savings on care before becoming eligible.

It covers children and adults with disabilities who require services that most commercial health insurance doesn’t include. It covers poor women who are pregnant or raising young children. Those populations were all included in the program before Obamacare became law.

It also provides insurance for poor adult Americans, and recent evidence shows that its expansion under Obamacare has given more poor people access to health care services and reduced their exposure to financial shocks.

The Republican approach would set a formula for determining a maximum payment for each person in the program. Then that cap would grow by a set rate each year. Lawmakers are negotiating about the rate to use, but all of the options are intended to grow more slowly than expected under the current system. The gap would be left for states to fill — or cut.

“While details remain elusive, this is shaping up to be the largest intergovernmental transfer of financial risk in our country’s history,” said Matt Salo, the executive director of the National Association of Medicaid Directors, in an email. Mr. Salo said that some of his directors would welcome caps if they came with more program flexibility, but said the current approach amounted to a funding cut.

The growth in medical spending tends to be uneven year over year, which means states might hit the caps in one year and fall under them in another, even without any program changes. Researchers at the Brookings Institution recently looked back at historical Medicaid spending to see what would have happened under a cap. They found that random variation was substantial.

Medicaid advocates worry particularly that a fixed growth rate doesn’t account for this varying pattern of health expenditures, which might shoot up in a year where there’s an epidemic or an important new treatment. Many Medicaid budgets increased in recent years after the introduction of expensive but effectivemedications for hepatitis C, for example. States had to pay more for the drug, but federal spending also increased to match it.

Advocates for the structural change point to inefficiencies and waste in the current program. There is some evidence that Medicaid programs enroll some people who are not eligible and sometimes cover some services that are not medically necessary. James Capretta, a fellow at the conservative American Enterprise Institute, said that the current system, where the federal government matches all state spending, discourages efficiency.

But he and co-authors have also suggested a different, more generous approach than the one in the Republican legislation.

Most researchers who study the program closely say that it is already quite lean. Major savings, they say, will be hard to achieve without reducing medical benefits or cutting higher-cost patients from the program.

Trump administration officials and Republican members of Congress have argued that the Medicaid changes won’t cause anyone to lose insurance coverage directly. That statement is true in only the narrowest sense.

Because the funding cuts would fall to states, it is state officials who would decide whether to save money by raising taxes, reducing payments to nursing homes or eliminating benefits like home-based care for disabled beneficiaries, a few available options under the law.

The Congressional Budget Office estimates that enrollment in Medicaid would decline substantially over a decade, as states pursued a variety of strategies to save money, some of which would push people out of the program.

Still, the Medicaid caps have not drawn the same public outcry as other provisions of the law that would cut back on coverage more directly. Several Republican senators have expressed concerns about changes to Obamacare’s Medicaid expansion, which broadened the program to include more low-income adults in 31 states.

Others worry about changes to private insurance subsidies that would make insurance less affordable to older, middle-class Americans. Fewer have spoken out about the cuts to Medicaid’s legacy beneficiaries. That means that, as the Senate works out final details, the forced diet for Medicaid is likely to stay in the bill.

———-

“G.O.P. Health Plan Is Really a Rollback of Medicaid”
by MARGOT SANGER-KATZ; The New York Times; 06/20/2017

The results, according to independent analyses, would be major reductions in federal spending on Medicaid over time. States would be left deciding whether to raise more money to make up the difference, or to cut back on medical coverage for people using the program. The Congressional Budget Office estimates that the changes would lead to a reduction in spending on Medicaid of more than $800 billion over a decade. (That figure also includes additional cuts to the Obamacare Medicaid expansion.)”

Is America’s health care safety-net going to be primarily a state-by-state issue? That’s the plan. With large state-by-state cuts to Medicaid expected. At least expected by health care experts who study these issues. But for the Americans either on Medicaid or with family members on Medicaid it’s hard to see how they can expect these dramatic changes to the saftey-net if they don’t even know about them. It’s going to be a horrible surprise. And that’s part of what makes Trumpcare such a remarkable political risk for the GOP: it’s bound to be far worse than people expect because most people have no idea how bad it is.

Beyond that, note one of the populations set to be directly impacted by these proposed Medicaid cuts: people in nursing homes. Yep, Trumpcare isn’t simply planning on metaphorically ‘throwing granny off the cliff’. It’s a plan to literally throw granny out of the nursing home:


Medicaid is the country’s largest government health care program, covering more Americans than its better-known sibling, Medicare.

Its reach is broad: About half of all births in the country are covered by Medicaid, and nearly 40 percent of children are covered through the program. Medicaid covers the long-term care costs of two-thirds of Americans living in nursing homes, many of them middle-class Americans who spent all of their savings on care before becoming eligible.

It covers children and adults with disabilities who require services that most commercial health insurance doesn’t include. It covers poor women who are pregnant or raising young children. Those populations were all included in the program before Obamacare became law.

“Its reach is broad: About half of all births in the country are covered by Medicaid, and nearly 40 percent of children are covered through the program. Medicaid covers the long-term care costs of two-thirds of Americans living in nursing homes, many of them middle-class Americans who spent all of their savings on care before becoming eligible.”

Two-thirds of Americans in nursing homes are there because Medicaid is covering their expenses. But under Trumpcare there’s going to be less and less federal funding available for those costs every year.

Throw Granny Off the Cliff Out of the Nursing Home

So while today’s nursing home recipients may or may not live long enough to see an impact from these cuts, the grannies of tomorrow are set to be increasingly in peril. The younger you are now the more Medicaid will be gutted by the time you’re old enough for a nursing home. Which, again, is part of what makes Trumpcare such a remarkable political gamble: If Americans actually learn about these planned ever-growing cuts to Medicaid it might dawn on them that almost everyone is potentially impacted. Including younger people financially well-off today. Eventually. Because even today’s affluent can become tomorrow’s destitute elderly in need of Medicaid just to live. That’s what happens if you simply live long enough and you’re not rich. And maybe if you are rich:

The New York Times

Cuts to Medicaid May Limit Access to Nursing Homes

By JORDAN RAU
JUNE 24, 2017

ORANGE, Va. — Alice Jacobs, 90, once owned a factory and horses. She raised four children and buried two husbands.

But years in an assisted living center drained her savings, and now she relies on Medicaid to pay for her care at Dogwood Village, a nonprofit, county-owned nursing home here.

“You think you’ve got enough money to last all your life, and here I am,” Ms. Jacobs said.

Medicaid pays for most of the 1.4 million elderly people in nursing homes, like Ms. Jacobs. It covers 20 percent of all Americans and 40 percent of poor adults.

On Thursday, Senate Republicans joined their House colleagues in proposing steep cuts to Medicaid, part of the effort to repeal the Affordable Care Act. Conservatives hope to roll back what they see as an expanding and costly health care entitlement. But little has been said about what would happen to older Americans in nursing homes if these cuts took effect.

Under federal law, state Medicaid programs are required to cover nursing home care. But state officials decide how much to pay facilities, and states under budgetary pressure could decrease the amount they are willing to pay or restrict eligibility for coverage.

The states are going to make it harder to qualify medically for needing nursing home care,” predicted Toby S. Edelman, a senior policy attorney at the Center for Medicare Advocacy. “They’d have to be more disabled before they qualify for Medicaid assistance.”

States might allow nursing homes to require residents’ families to pay for a portion of their care, she added. Officials could also limit the types of services and days of nursing home care they pay for, as Medicare already does.

The 150 residents of Dogwood Village include former teachers, farmers, doctors, lawyers, stay-at-home parents and health aides — a cross section of this rural county a half-hour northeast of Charlottesville. Many entered old age solidly middle class but turned to Medicaid, which was once thought of as a government program exclusively for the poor, after exhausting their insurance and assets.

A combination of longer life spans and spiraling health care costs has left an estimated 64 percent of the Americans in nursing homes dependent on Medicaid. In Alaska, Mississippi and West Virginia, Medicaid was the primary payer for three-quarters or more of nursing home residents in 2015, according to the Kaiser Family Foundation.

“People are simply outliving their relatives and their resources, and fortunately, Medicaid has been there,” said Mark Parkinson, the president of the American Health Care Association, a national nursing home industry group.

With more than 70 million people enrolled in Medicaid at an annual cost of more than $500 billion, the program certainly faces long-term financial challenges. Federal Medicaid spending is projected to grow 6 percent a year on average, rising to $650 billion in 2027 from $389 billion this year, according to the Congressional Budget Office.

Even if Congress does not repeal the Affordable Care Act, Medicaid will remain a target for cuts, experts say.

“The Medicaid pieces of the House bill could be incorporated into other pieces of legislation that are moving this year,” said Edwin Park, a vice president at the Center on Budget and Policy Priorities, a Washington nonprofit that focuses on how government budgets affect low-income people. “Certainly, nursing homes would be part of those cuts, not only in reimbursement rates but in reductions in eligibility for nursing home care.”

While most Medicaid enrollees are children, pregnant women and nonelderly adults, long-term services such as nursing homes account for 42 percent of all Medicaid spending — even though only 6 percent of Medicaid enrollees use them.

“Moms and kids aren’t where the money is,” said Damon Terzaghi, a senior director at the National Association of States United for Aging and Disabilities, a group representing state agencies that manage programs for these populations or advocate on their behalf. “If you’re going to cut that much money out, it’s going to be coming from older people and people with disabilities.”

The House health care bill targets nursing home coverage directly by requiring every state to count home equity above $560,000 in determining Medicaid eligibility. That would make eligibility rules tougher in 10 states — mostly ones with expensive real estate markets, including California, Massachusetts and New York — as well as in the District of Columbia, according to an analysis by the Center for Budget and Policy Priorities.

Dogwood Village receives about half of its $13 million annual operating costs from Medicaid, with rates from $168 to $170 a day. Some residents who come to the nursing home after a hospital stay are initially covered by Medicare, but if they stay longer than 100 days, that benefit ends, and those without savings move to Medicaid.

Medicaid helps pay for care for people with disabilities, like Nancy Huffstickler, 65, who has been here for four years and regards herself as “a medical disaster.”

She listed her ailments: spinal cancer in remission, restless leg syndrome, high blood pressure and multiple ulcers. She has had spinal reconstructive surgery and a hip replacement. She is undergoing physical therapy with the hope that one day she will be able to leave her wheelchair and use a walker.

Ms. Huffstickler is fearful of Republicans’ health care changes. “It may save the federal government money, but what about us?” she asked.

Major Medicaid cuts would compel Dogwood Village to cut staff, supplies and amenities — changes that would affect the quality of care for all residents, not just those on Medicaid.

If that does not save enough money, the nursing home might have to reduce the number of Medicaid residents, said Vernon Baker, who resigned as administrator in April. “It’s not like our toilet paper or paper towels are like the Ritz-Carlton’s,” he said.

Some residents do not even know they are on government insurance; administrators often complete the paperwork to start Medicaid once other insurance expires. Others are embarrassed that they are dependent on a program that still carries stigma.

They should not be, said Jennifer Harper, the assistant director of nursing. Relying on Medicaid for nursing home care has become the new normal.

“These folks have worked their whole lives, some with pretty strenuous jobs, and paid into the system,” she said. But with changes looming, she said, “it may be a system that fails them.”

———-

“Cuts to Medicaid May Limit Access to Nursing Homes” by JORDAN RAU; The New York Times; 06/24/2017

“People are simply outliving their relatives and their resources, and fortunately, Medicaid has been there,” said Mark Parkinson, the president of the American Health Care Association, a national nursing home industry group.”

For over half a century now, when elderly Americans in need of nursing home services outlived their savings at least they weren’t completely screwed. Medicaid was there. But once Trumpcare becomes law, the question of whether or not granny gets to stay in the nursing home, or gets admitted in the first place, its going to become an increasingly expensive question for the states. And answer just might include things like forcing family members to start paying to cover the costs the federal government used to cover. So it’s going a state issue and a family issue…are you willing to pay the state to help give your parents or grandparents nursing home care? That’s the question the GOP would like you to start answering soon:


Under federal law, state Medicaid programs are required to cover nursing home care. But state officials decide how much to pay facilities, and states under budgetary pressure could decrease the amount they are willing to pay or restrict eligibility for coverage.

The states are going to make it harder to qualify medically for needing nursing home care,” predicted Toby S. Edelman, a senior policy attorney at the Center for Medicare Advocacy. “They’d have to be more disabled before they qualify for Medicaid assistance.”

States might allow nursing homes to require residents’ families to pay for a portion of their care, she added. Officials could also limit the types of services and days of nursing home care they pay for, as Medicare already does.

States might allow nursing homes to require residents’ families to pay for a portion of their care, she added. Officials could also limit the types of services and days of nursing home care they pay for, as Medicare already does.”

This is part of the new Trumplandian America and the vast majority of Americans have no idea this is about to become reality. Young parents won’t just have to start the college fund for their children as early as possible. They’re going to need a “mom and dad’s future nursing home fund” too. Soon. Maybe. Sure, that’s just the opinion of a Medicare Advocacy group attorney, but claiming the assets of Medicaid recipients after they die or charging relatives monthly fees is bound to get increasingly tempting to states as the federal participation in Medicaid erodes year after year. And in Trumpcare, states are going to be given lots of the “flexibility” to “experiment” with new ways to transfer the cost of medical services and other safety-net programs back onto the public. Especially the poor. If slowly killing Medicaid becomes a new national pastime, charging families for Medicaid nursing home costs is just a matter of time. And not just for nursing home services but potentially anything Medicaid related. Why not? That’s another tax cut for the Koch brothers. It’s possible. One state at a time.

And if you think, “well, since the elderly are such an important voting block, especially for the GOP, there’s no way they’ll actually implement all these cuts for nursing homes. Surely there must be some sort of loophole they’ll add in at the last minute,” take a look at just how much of the total spending on Medicaid is spent on long-term services like nursing homes: 42 percent. So unless the GOP is planning on significantly curtailing the tax cuts for the rich in Trumpcare – and don’t forget that Trumpcare is basically a tax cut for the rich paid for by cutting primarily Medicaid – there’s almost no way they’re going to give poor seniors anything other than token help. Cutting seniors off Medicaid is where the big money is at:


While most Medicaid enrollees are children, pregnant women and nonelderly adults, long-term services such as nursing homes account for 42 percent of all Medicaid spending — even though only 6 percent of Medicaid enrollees use them.

“Moms and kids aren’t where the money is,” said Damon Terzaghi, a senior director at the National Association of States United for Aging and Disabilities, a group representing state agencies that manage programs for these populations or advocate on their behalf. “If you’re going to cut that much money out, it’s going to be coming from older people and people with disabilities.”

Moms and kids aren’t where the money is. Grandma and grandpa had better get their checkbooks.

Throwing Granny Out of the Nursing Home Isn’t a New Idea. Or a Popular One. for Obvious Reasons

So what’s the public response to this going to be once they finally figure Trumpcare’s plans for elderly Americans? Well, while we don’t have current polling data available given the public ignorance on this matter, we do have past polling data for similar GOP proposals. After all, Trumpcare is Ryancare. And House Speaker Paul Ryan has been trying to do this to Medicaid for years. So while Americans don’t know what’s in Trumpcare today, the did learn about Ryancare’s very similar plans for Medicaid in 2011. And boy oh boy did seniors hate Ryancare. And what did they hate the most? The Medicaid cuts to nursing homes:

The Huffington Post

Americans ‘Very Concerned’ GOP Budget Will Force Elderly From Nursing Homes: Poll

By Michael McAuliff
06/23/2011 10:39 am ET | Updated Aug 23, 2011

WASHINGTON — Democrats are getting set to ramp up the budget cut rhetoric with a new message: Don’t throw grandma from the nursing home.

The messaging comes after new polling by a Democratic-aligned polling firm found that messages about the impacts of the House Republican budget plan on elderly Medicaid recipients resonate even more powerfully than criticism about its impact on Medicare.

The budget blueprint crafted by House Budget Committee Chairman Paul Ryan (R-Wis.) turns the healthcare system for the elderly into a private program, which will double the cost of healthcare in 10 years for future seniors, according to the Congressional Budget Office.

The Ryan privatization plan is deeply unpopular:: Fresh polling by Bloomberg released Thursday found that Americans think they would be worse off if Ryan’s Medicare proposal is adopted by a margin of 57 percent to 34 percent — including 58 percent of electorally key independents who dislike the plan.

But the new polling by Anzalone Liszt Research, the Democratic-aligned polling firm, found an even more dramatic response on Medicaid if respondents are told of the impacts seniors face.

Told that the Ryan budget “would cut $750 billion from Medicaid, including funding for 80 percent of nursing home residents, forcing many seniors to be kicked out of their nursing homes,” 63 percent of respondents said they were “very” concerned. That figure was 69 percent for seniors and 64 percent for independents.

About 64 percent of senior nursing home residents depend on Medicaid as the primary means of paying for their housing. Still more rely on Medicaid for other expenses or to be able to stay in their own homes.

The polling firm concluded those numbers make the issue a winner for Democrats, and they advise using similar language to bring the message home to voters.

Democrats, however, are not about to drop the complaints about the impacts of Ryan’s plan on Medicare, which are widely credited with helping Democrats win the New York special election that propelled Rep. Kathy Hochul into a seat long held by the GOP.

———-

“Americans ‘Very Concerned’ GOP Budget Will Force Elderly From Nursing Homes: Poll” by Michael McAuliff; The Huffington Post; 06/23/2011

“Told that the Ryan budget “would cut $750 billion from Medicaid, including funding for 80 percent of nursing home residents, forcing many seniors to be kicked out of their nursing homes,” 63 percent of respondents said they were “very” concerned. That figure was 69 percent for seniors and 64 percent for independents.

69 percent of seniors were “very” concerned about the Medicaid cuts. Even more concerned than they were about the Medicare cuts. And unless something dramatically changed in senior attitudes over the last 6 years it’s hard to see why we wouldn’t see the same level of concern today…at least among ~38 percent of seniors who are actually aware today of what’s in Trumpcare.

Don’t Worry Granny. Here’s a Tax Credit (Granny Should Probably Worry).

So since the Senate bill is hurtling towards passage and Trumpcare’s dire implications loom large on a largely unsuspecting populace how is the GOP planning on explaining all this to a public that largely loathes the ideas of Trumpcare? And in particular, what is the GOP going to tell seniors, a critical and reliable voting bloc, about how the 2/3 of nursing home residents are either going to be increasingly at risk of getting kicked out or forced to beg their families for the money in coming years and decades? People can end up in nursing homes for decades if they live long enough and the way Trumpcare works those federal funds available for nursing home care is going to keep shrinking every single year. And not just nursing home care but any other medical services too. There’s a pretty clear ‘hurry up and die’ element to it all. How is the GOP going to explain this? We’ll see, but it will probably involve asking poor seniors to cover the costs themselves with the help of tax credits. Seriously:

Think Progress

Republican Senators pretend people who get kicked off of Medicaid will just start buying insurance
Senate Republicans are trying (and failing) to justify cuts to Medicaid.

Amanda Michelle Gomez
Jun 23, 2017

The day after the Senate’s draft health bill was released, supporters looked to defend a key component of bill: cuts to Medicaid. Republican lawmakers will need to answer to its beneficiaries, who’ve grown dependent on this program for coverage.

On Friday, Senator Bill Cassidy (R-LA) on Morning Joe reconciled the Senate’s Medicaid cuts the following way: “If Medicaid expansion goes away and if there is no coverage, that’s a bad thing, Willie. On the other hand, if they move from Medicaid to private insurance, that could be a good thing.”

Cassidy claimed that Medicaid enrollees could join the individual marketplaces, which have been doing poorly because not enough people are opted in. They’ll be able to afford such plans with tax credits, which he characterized as “more generous” than the House.

Senate Rand Paul (R-KY), who does not support the bill as it currently stands, also appeared on the show and said he would like to “legalize inexpensive insurance,” and ultimately have Medicaid patients go on “inexpensive” plans—likely private plans.

Both senators believe that Medicaid enrollees could obtain coverage elsewhere. But health experts say Medicaid enrollees will likely forgo coverage altogether under the Senate Republicans’ health care bill, leaving them uninsured.

The Senate Republicans’ Better Care Reconciliation Act (BCRA) ends Medicaid expansion by 2024, and also makes additional cuts to the overall program starting in 2025. The entire Medicaid program as Americans know it could end, and for many Republicans, that’s the entire idea. Medicaid overhaul has been a point of motivation for health care reform. House Speaker Paul Ryan (R-OH) had previously told the National Review that he has been dreaming about making cuts to the Medicaid program since his keg-days in college.

The Senate bill, like the House bill, looks to undercut the Medicaid program in the following way: the current model, which is an open-ended commitment to states to pay most Medicaid enrollee’s bills, would become a per capita cap system. Under this system, states can get a lump sum from the government for each enrollee or request a block grant. The Senate bill breaks away from the House version of the bill after 2025. At that point, the rates at which the federal government assists states changes and becomes tethered to the consumer price index. The adjusted growth rate funds less than what Medicaid requires and could lead to a non-functioning program, according to the Urban Institute.

Tax credits under BCRA will not be helpful to Medicaid beneficiaries, Tara Straw, senior health policy analyst at the Center on Budget and Policy Priorities, told ThinkProgress.

Under the Senate bill, premiums tax credits are based on income, age, and geography. Cassidy is right in that credits under the Senate are more generous than the House, which is based solely on age. However, the Senate bill changes the Obamacare formula for credits, making them less generous. The Senate plans are set up like bronze plans under Obamacare. Essentially, plans would see lower monthly premiums but raises costs when patients need care. And deductibles—the amount of medical costs patients pay themselves before the insurance plan starts to pay—could become more expensive. A median bronze plan deductible is $6,300, said Straw. Under the senate bill, cost sharing reductions?—?that help pay for out-of-pocket costs are repealed by 2020.

Straw says that even if Medicaid patients agree to funnel 2 percent of their income to pay for these insurance plans, the plans cover less because states could waive coverage requirements.

When Cassidy says Medicaid enrollees will see lower premiums under the Senate’s restructure, that’s likely true. But what he neglects to mention is that patients will instead see expensive co-payments and deductibles.

“Someone could scrap to pay for premiums. But could they ever use?” asked Straw, “No because deductibles.”

———-

“Republican Senators pretend people who get kicked off of Medicaid will just start buying insurance” by Amanda Michelle Gomez; Think Progress; 06/23/2017

Both senators believe that Medicaid enrollees could obtain coverage elsewhere. But health experts say Medicaid enrollees will likely forgo coverage altogether under the Senate Republicans’ health care bill, leaving them uninsured.”

And how do Senators Cassidy and Paul propose Medicaid recipients – people who make less than the poverty line – afford to buy their own private medical services? Tax credits. That’s seriously their response:


On Friday, Senator Bill Cassidy (R-LA) on Morning Joe reconciled the Senate’s Medicaid cuts the following way: “If Medicaid expansion goes away and if there is no coverage, that’s a bad thing, Willie. On the other hand, if they move from Medicaid to private insurance, that could be a good thing.”

Cassidy claimed that Medicaid enrollees could join the individual marketplaces, which have been doing poorly because not enough people are opted in. They’ll be able to afford such plans with tax credits, which he characterized as “more generous” than the House.

Senate Rand Paul (R-KY), who does not support the bill as it currently stands, also appeared on the show and said he would like to “legalize inexpensive insurance,” and ultimately have Medicaid patients go on “inexpensive” plans—likely private plans.

It’s kind of hard to see how that isn’t going to be perceived as a ghastly insult to elderly GOP voters. But that ghastly insult, tax credits for the poor appears, really does appears to be the likely GOP explanation for what people are supposed to do. And it’s the response that will presumably not just apply to medical services but nursing home services too.

The GOP’s Trumpian ‘New Coke’ Sure Tastes LIke ‘Old Koch’

Ok, so could tax credit’s for poor seniors seriously be the GOP’s plan? Is that really about to become the new safety-net for elderly Americans? Well, unless those plans change, and change very soon since Senate Majority Leader Mitch McConnell is trying to pass it in the Senate by July 4th, it looks like that’s the plan. And if the plan does change it’s probably going to become a worse plan:

Bloomberg Politics

Koch Group Says Republican Health Plan Doesn’t Go Far Enough

By John McCormick
June 24, 2017, 9:30 AM CDT June 24, 2017, 6:24 PM CDT

* Americans for Prosperity says it will work to improve measure
* Bill faces perilious path with five Republicans doubtful

Leaders from the influential Koch political network expressed concern about the Senate Republican plan to reshape the nation’s health system, saying as they met with donors at a Colorado resort that the measure isn’t sufficiently conservative.

<b>“We’ve been disappointed that movement has not been more dramatic toward a full repeal or a broader rollback of this law, Obamacare,” Tim Phillips, the president of the Koch-affiliated political advocacy group, Americans for Prosperity, told reporters.

“We worked to make the House bill better and it did get better,” he said. “We’re doing the same thing on the Senate front.”

Unveiled on Thursday as a discussion draft after weeks of work done in secret by a small number of lawmakers, the Senate plan was immediately criticized by Democrats and some Republicans. Five Senate Republicans have said they oppose the bill in its current form.

Senate Majority Leader Mitch McConnell can only afford two defections from his party to pass the bill in the 100-member chamber.

Opposition from the Koch network, which has delivered tens of millions of dollars to Republican candidates and causes in recent years, promises to further complicate the perilous path McConnell faces.

‘Can Get Done’

“We still think this can get done,” Phillips said. “It has to get better.”

Phillips spoke on the first day of a three-day donor retreat at a luxury Rocky Mountains resort. He was also among those who met Friday evening with Vice President Mike Pence ahead of the event.

“It was a good, cordial discussion of issues, including health care,” Phillips said of his talk with Pence.

———-

“Koch Group Says Republican Health Plan Doesn’t Go Far Enough” by John McCormick; Bloomberg Politics; 06/24/2017

““We still think this can get done,” Phillips said. “It has to get better.”

It has to get better better. And by better, the president of the Koch network means much, much worse health care for Americans. Any good parts of Obamacare that were left in the Senate GOP’s draft version of Trumpcare have to go for things to “get better”:


“We’ve been disappointed that movement has not been more dramatic toward a full repeal or a broader rollback of this law, Obamacare,” Tim Phillips, the president of the Koch-affiliated political advocacy group, Americans for Prosperity, told reporters.

“We worked to make the House bill better and it did get better,” he said. “We’re doing the same thing on the Senate front.”

“We’ve been disappointed that movement has not been more dramatic toward a full repeal or a broader rollback of this law, Obamacare”

And don’t forget, it’s not just that Trumpcare is repealing almost all the good parts of Obmaacare. It’s repealing the good parts of the New Deal and Great Society that are still left. This is a deep gutting. Nursing home vouchers are a serious possibility. Steadily shrinking nursing home vouchers.

Again, it’s truly amazing just how massive a political gamble Trumpcare is turning out to be be for the GOP but it’s a gamble the party is clearly intent on making because Trumpcare is Ryancare and Ryancare is Kochcare. The GOP is in control of everything so there’s almost no way the Kochcare isn’t going to become a reality. Unless GOP voters suddenly turn anti-Koch. Which could happen. That’s sort of what the Trump phenomena in the 2016 GOP primary was all about: the rise of the anti-Koch wing of the GOP. And here we are, with the Senate on the verge of passing TrumpRyanKochcare and the only real obstacle is the handful of hold out GOP Senators who are just doing a song and dance ‘negotiation’ – mostly with demands that it be more Koch-ish. So unless being anti-Koch suddenly gets bach in vogue in the GOP base giving political cover to at least three GOP Senators to vote against it, grandma is moving into the basement room. With large medical bills. And the state might start charging grandma’s relatives for her new awesome Medicaid services.

At this point one of the big questions is whether or not the GOP will expand its extensive voter suppression efforts to include seniors on Medicaid now too? That seems like a real possibility although considering that the elderly people most negatively impacted by Trumpcare are also the most likely to die prematurely as Medicaid gets increasingly underfunded maybe voter suppression efforts won’t be necessary. Still, in terms of political risks, when you consider just how much TrumpRyanKochcare presents a mortal danger to the most reliable voting demographic in America – a demographic that most people will join someday, although a lot fewer if this becomes law – and how that demographic largely has no idea what’s in store for it, the TrumpRyanKochcare tax cut gambit is turning out to be truly breathtaking.

Discussion

8 comments for “Guess What? Grandma is Moving In. She’s Got Medical Bills. Maybe to Share. It’s Medicaid Brought to You by Kochcare.”

  1. Connecticut Senator Chris Murphy, a Democratic member of the Senate Health, Education, Labor & Pensions Committee, recently commented on the potential impact the Trumpcare(Kochcare) health care ‘reform’ bill could have on nursing home residents in Connecticut, a state where over 70 percent of nursing home residents are on Medicaid, and he makes a critical point to be made during the current health care ‘reform’ debate: Medicaid isn’t just for poor people. By covering the costs that would otherwise fall on family members, like costs for nursing home care, Medicaid is effectively a benefit program currently protecting all Americans. And it’s about to be shredded:

    New Haven Register

    Health bill could present challenge to Connecticut nursing home care

    By Dan Freedman

    Posted: 06/25/17, 12:20 PM EDT | Updated

    WASHINGTON >> Deep cuts to Medicaid embodied in Senate and House versions of the GOP GOP health care bill could sharply reduce critical payments to nursing homes, potentially leaving many middle-class families in Connecticut to foot the bill for elderly relatives.

    Both bills envision ending Medicaid as an open-ended entitlement providing health insurance primarily for low-income families. Instead, federal Medicaid distributions would be capped.

    The Congressional Budget Office estimated the formula in the House bill would eliminate more than $800 billion over the next decade.

    Matthew Barrett, CEO of the Middletown-based Connecticut Association of Health Care Facilities, said the Republicans’ Obamacare “repeal-and-replace’’ measure would be a “catastrophe’’ for the state’s nursing home operators, as well as residents and their families.

    “Medicaid for nursing homes is very much a middle-class benefit,’’ he said, noting it is the only national program that covers long-term care in a nursing home. “The common perception is that Medicaid is for somebody else, but it’s actually a program for all Americans.’’

    Medicaid also can cover home and community health services.

    POSSIBLE CHANGE OF RULES

    In Connecticut, there are more than 24,000 mostly elderly nursing home residents, according to federal data compiled by the non-partisan Kaiser Family Foundation. Close to 70 percent of them are subsidized by Medicaid, which is funded through a combination of state and federal money. The national figure is 62 percent. Total Medicaid nursing-home expenditure in Connecticut topped $1.2 billion in 2016.

    Connecticut’s rate of Medicaid-covered nursing-home residents is one of the higher ones in the nation. Only Alaska and deep-Southern states like Mississippi, Louisiana and Georgia have higher rates.

    Connecticut’s aging population is on the rise, with a 51 percent increase in those over 65 projected by 2025.

    Also on the rise is the incidence of difficult-to-manage conditions such as diabetes, Alzheimer’s and dementia, Barrett said.

    To qualify for Medicaid, nursing home residents must first exhaust all their savings and assets, including the sale of homes. Once on the program, family members are not obligated to pay. But if the Republican bills become law, that might change.

    U.S. Sen. Chris Murphy, D-Conn., a member of the Senate Health, Education, Labor & Pensions Committee and a bitter opponent of the GOP legislative effort,, said the GOP measure would mean states like Connecticut ultimately have to ration nursing home care.

    Doing so might end up throwing the financial burden onto families if they want loved ones to stay in these facilities, Murphy said.

    “Medicaid is no longer a program for poor people; it probably touches an equal number of middle-class families,’’ he said in an interview Friday. “You’re not guaranteed that if Mom runs through her bank account that Medicaid will pick up the cost. That should freak out every son or daughter in this country.’’

    A STRUGGLING STATE

    Theoretically, cuts to the federal side of Medicaid financing could be offset by increased state spending. But such money is unlikely to flow from Hartford, which faces a projected $5 billion deficit over the next two years.

    Medicaid payments to nursing homes are already insufficient, said Barrett. He calculated the shortfall at about $25 a day, per resident.

    The GOP Senate bill in many ways is more moderate than the House counterpart. But it bends the downward cost curve of Medicaid over 10 years more radically by pegging it to the regular consumer price index, instead of more-generous medical inflation.

    ———–

    “Health bill could present challenge to Connecticut nursing home care” by Dan Freedman; New Haven Register; 06/25/17

    ““Medicaid is no longer a program for poor people; it probably touches an equal number of middle-class families,’’ he said in an interview Friday. “You’re not guaranteed that if Mom runs through her bank account that Medicaid will pick up the cost. That should freak out every son or daughter in this country.’’”

    And as Senator Murphy warns us, if the GOP bill becomes law, the provisions in Medicaid that cover all the costs required for services like medical care and nursing homes could fade away and protect might effectively be forced to cover the costs of their parents’ health care/nursing home costs:


    To qualify for Medicaid, nursing home residents must first exhaust all their savings and assets, including the sale of homes. Once on the program, family members are not obligated to pay. But if the Republican bills become law, that might change.

    U.S. Sen. Chris Murphy, D-Conn., a member of the Senate Health, Education, Labor & Pensions Committee and a bitter opponent of the GOP legislative effort,, said the GOP measure would mean states like Connecticut ultimately have to ration nursing home care.

    Doing so might end up throwing the financial burden onto families if they want loved ones to stay in these facilities, Murphy said.

    “Medicaid is no longer a program for poor people; it probably touches an equal number of middle-class families,’’ he said in an interview Friday. “You’re not guaranteed that if Mom runs through her bank account that Medicaid will pick up the cost. That should freak out every son or daughter in this country.’’

    It’s a reminder that when TrumpRyanKochcare threatens to give granny a ‘one-way ticket to the cliff’, it’s not just Paul Ryan or Mitch McConnell giving granny the ride. By transferring everyone costs previously covered by the federal government to states and states likely to transfer them to families, it’s going to be family members who are going to be facing the question of how much they can afford to cover for their relative’s costs to simply live. And that’s going to effectively be a ‘cliff’-like decision in many circumstances. And it’s going to be voters in state elections who are going to be facing questions of how much of the cost burden to push onto families. So as we enter an era of more or less permanent federal annual Medicaid cuts, we’re creating a situation where all voters are pushed into a position to push everyone off ‘the cliff’. The ‘feel free to die’ cliff. That’s what happens when states and families suddenly have to decide if they’re going to cover those lost federal funds. That ‘cliff pushing’ decision might be at the ballot box, or it could be your family member, but cliff pushing is scheduled to become American’s most popular new extreme sport. It’s not actually going to be very popular but lots of people will do it. Try not to get too pushy. But that’s where we are. Collectively setting up residence next to the ‘feel free to die’ cliff. Somewhere a lemming is shaking its head.

    A lot of lemmings are probably shaking their heads.

    Posted by Pterrafractyl | June 25, 2017, 4:14 pm
  2. You can stop cleaning the spare bedroom. For now. At least until Trumpcare is back on track after getting derailed today. No, this doesn’t mean Medicaid isn’t going to be gutted and nursing home residents aren’t going to be forced to move in with their relatives. That could still definitely happen. But now that Senate Majority Leader Mitch McConnell suddenly withdrew the Trumpcare legislation from consideration after concluding he didn’t have the 50 votes he needed today, it’s unclear when that’s going to happen. Or even if it will ever happen. Grandma’s extended visit is temporarily on hold.

    And while you might be celebrating, and grandma might be celebrating, the GOP in DC certainly isn’t going to be celebrating and that leads us to one of the more interesting dynamics emerging from Trumpcare’s troubles: the legislative failures of Trump and the GOP appear to be creating the impression within the party that their leader, Donald Trump, is a “paper tiger”. A figure to be denied and not feared. And GOP elected officials are now apparently so unscared of Trump that they’re talking about it to reporters, citing failures like today’s Trumpcare meltdown as an example why they no longer fear their dear leader.

    It’s a pretty amazing diss to come from the GOP, both in terms of substance and timing. But perhaps the most amazing part is that, if you look back at who is doing who a favor with the attempted passage of Trumpcare, it was Donald Trump who was going back on his campaign promises in order to push for a health care bill that embraced establishment/Koch GOP goals at the cost of Trump’s ‘populist’ image. Trump is being mocked by his fellow GOP Senators for not being able to cajole the GOP into supporting a bill that was based on long-held GOP goals. Gutting Medicaid wasn’t a long-held goal of Trump’s. Allowing states to waive all the part of Obamacare the public likes isn’t part of Trump’s political brand. That’s the establishment/Koch brother agenda and Trump is just going along for the ride. Trump is the one doing the favor by catering to the establishment/Koch wing’s agenda. And yet when Mitch McConnell fails to keep his own caucus together to make law something the GOP has been trying to do for years we get reports about how this failure is making the GOP lose respect for Trump. So much that they openly diss him in the wake of this humiliating defeat.

    So beyond all the questions that this significant legislative setback raises about the prospects of the GOP actually repealing Obamacare and fulfilling their decades-long desire to shred Medicaid, there are now some serious questions about what Trump is going to do now that the GOP is openly disrespecting him after the GOP fails to pass its own bill. Is Trump really going to just accept this?

    The Washington Post

    Who’s afraid of Trump? Not enough Republicans — at least for now.

    By Philip Rucker, Robert Costa and Ashley Parker
    June 27, 2017 at 7:37 PM

    Scrambling to line up support for the Republican health-care bill, President Trump got on the phone Monday with Sen. Mike Lee (R-Utah) and urged him to back the measure.

    The president’s personal plea was not enough. On Tuesday, Lee said he would vote against the bill. Senate GOP leaders later postponed the planned health-care vote because too many other Republican senators also opposed — for now, at least — legislation that would deliver on Trump’s campaign promise to scale back the law known as Obamacare.

    Trump had hoped for a swift and easy win on health care this week. Instead he got a delay and a return to the negotiating table — the latest reminder of the limits of his power to shape outcomes at the opposite end of Pennsylvania Avenue.

    History suggests that presidents who have governed successfully have been both revered and feared. But Republican fixtures in Washington are beginning to conclude that Trump may be neither, despite his mix of bravado, threats and efforts to schmooze with GOP lawmakers.

    The president is the leader of his party, yet Trump has struggled to get Republican lawmakers moving in lockstep on health care and other major issues, leaving no signature legislation in his first five months in office. The confirmation of Supreme Court Justice Neil M. Gorsuch is his most-cited achievement to date.

    “This president is the first president in our history who has neither political nor military experience, and thus it has been a challenge to him to learn how to interact with Congress and learn how to push his agenda better,” said Sen. Susan Collins (R-Maine), who opposes the current health-care bill.

    The Senate could pass a revised version of the bill once lawmakers return from their July 4 recess and pick up deliberations. Still, some Republicans are willing to defy their president’s wishes — a dynamic that can be attributed in part to Trump’s singular status as a disrupter within his party.

    “The president remains an entity in and of itself, not a part of the traditional Republican Party,” said Rep. Carlos Curbelo (R-Fla.), a moderate who represents a district Trump lost by 16 percentage points. “I handle the Trump administration the same way I handled the Obama administration. When I agree, I work with them. When I oppose, I don’t.”

    In private conversations on Capitol Hill, Trump is often not taken seriously. Some Republican lawmakers consider some of his promises — such as making Mexico pay for a new border wall — fantastical. They are exhausted and at times exasperated by his hopscotching from one subject to the next, chronicled in his pithy and provocative tweets. They are quick to point out how little command he demonstrates of policy. And they have come to regard some of his threats as empty, concluding that crossing the president poses little danger.

    “The House health-care vote shows he does have juice, particularly with people on the right,” Sen. Lindsey O. Graham (R-S.C.) said. “The Senate health-care vote shows that people feel that health care is a defining issue and that it’d be pretty hard for any politician to push a senator into taking a vote that’s going to have consequences for the rest of their life.”

    Asked if he personally fears Trump, Graham chuckled before saying, “No.”

    Rep. Darrell Issa (R-Calif.), who has distanced himself from Trump on various issues, said few members of Congress fear permanent retaliation from the president.

    “He comes from the private sector, where your business partner today isn’t always your business partner tomorrow,” Issa said. “Just because you’re one way today doesn’t mean you’re written off. That’s the ‘Art of the Deal’ side.”

    One senior Republican close to both the White House and many senators called Trump and his political operation “a paper tiger,” noting how many GOP lawmakers feel free “to go their own way.”

    “Members are political entrepreneurs, and they react to what they see in the political marketplace,” said the Republican, who spoke on the condition of anonymity to avoid alienating the White House.

    John Weaver, a GOP consultant and frequent Trump critic, was more blunt in explaining why Trump has been unable to rule with a hammer. “When you have a 35 percent approval rating and you’re under FBI investigation, you don’t have a hammer,” he said, referring to the probe of possible connections between the Trump campaign and Russia.

    Trump’s approval rating in Gallup’s daily tracking poll stood Tuesday at 39 percent, with 57 percent of Americans disapproving of his performance. But a significant portion of those supporters, particularly in red states and districts, still strongly back Trump.

    White House officials contest the suggestion that Trump does not instill fear among fellow Republicans in Congress. The president’s political shop, meanwhile, is laboring to force more Republicans to bend to his wishes.

    America First Policies, a Trump-allied super PAC staffed by former aides, launched a negative advertising effort against Sen. Dean Heller (R-Nev.) after he spoke out against the bill Friday. Senate Majority Leader Mitch McConnell (R-Ky.) complained about the ads to White House chief of staff Reince Priebus, and the super PAC said Tuesday that it would pull the spots after Heller said he was open to further negotiations, according to two people familiar with the decision.

    America First Policies has been mulling similar ads against other Republicans who have broken ranks, hoping to make lawmakers believe they will pay a price for betraying Trump and imperiling his agenda. The super PAC also is considering grass-roots campaigns across the country to mobilize Trump supporters in key states during the July 4 recess, as a way to ratchet up pressure on wavering lawmakers.

    Trump allies have encouraged major GOP donors to reach out to senators who oppose the bill. Las Vegas casino moguls Sheldon Adelson and Steve Wynn have both spoken by phone with Heller to prod him along, according to people familiar with the discussions.

    Trump has been hungry for a legislative policy victory on Capitol Hill, and he and his advisers see health care as the best chance for one this summer. The president is playing a less public role advocating for the legislation than he did leading up to this spring’s vote on a House bill, when he used his relationship with conservative members of the House Freedom Caucus to eventually bring them to the table.

    In the Senate talks, Trump has been working largely behind the scenes to lobby senators, with personal phone calls and other entreaties. Unlike the House, where rank-and-file Republicans may be likely to follow Trump’s lead, the Senate naturally is a more independent institution.

    Many senators fashion their own political brands and have outsize egos, and some Republicans ran away from Trump in their reelection races last year.

    Chris Whipple, author of “The Gatekeepers,” a new history of White House chiefs of staff, said the tumult inside Trump’s White House — and the president’s lack of a coherent message or vision for his policy agenda — inhibits his ability to enforce party discipline in Congress.

    “Nothing instills fear on Capitol Hill like success, and all this White House has been able to do is one failure after another,” Whipple said. “There are just zero points on the board so far. Who’s going to be afraid of that?”

    Early in President George W. Bush’s tenure, fellow Republicans in Congress saw his White House as a finely tuned machine that could not be crossed.

    “You never wanted to get on the wrong side of the Bush White House because the staff was disciplined, dedicated and extremely loyal to the president,” said Ryan Williams, a Republican operative. “If you crossed or undermined the president or his administration, the Bush die-hards would remember it forever.”

    Trump’s lieutenants, by contrast, have struggled to force Republicans into line. In March, when House Republicans were slow to rally behind the health-care bill, White House chief strategist Stephen K. Bannon told Freedom Caucus members that they must stop waffling and vote for the legislation.

    Bannon was immediately rebuffed by Rep. Joe Barton (R-Tex.), who has been in the House for more than three decades. Barton icily told Bannon that the only person who ordered him around was “my daddy” — and that his father was unsuccessful in doing so, according to several Republicans with knowledge of the meeting.

    In an interview Tuesday, Barton smiled wryly when asked about the incident.

    “I will admit on the record that I took exception to a comment that he made,” Barton said. “There is a separation of powers, and the president has a role and the Congress has a role. That’s all I’ll say.”

    ———-

    “Who’s afraid of Trump? Not enough Republicans — at least for now.” by Philip Rucker, Robert Costa and Ashley Parker; The Washington Post; 06/27/2017

    “One senior Republican close to both the White House and many senators called Trump and his political operation “a paper tiger,” noting how many GOP lawmakers feel free “to go their own way.””

    A paper tiger. Them’s fightin’ words. Issued right after the GOP majority in the Senate failed to pass it’s own bill. And yet Trump is somehow the person “often not taken seriously” as opposed to not taking seriously the establishment GOP/Koch agenda that Trump and the GOP and trying, and failing, to pass because it’s it’s so unpopular:


    In private conversations on Capitol Hill, Trump is often not taken seriously. Some Republican lawmakers consider some of his promises — such as making Mexico pay for a new border wall — fantastical. They are exhausted and at times exasperated by his hopscotching from one subject to the next, chronicled in his pithy and provocative tweets. They are quick to point out how little command he demonstrates of policy. And they have come to regard some of his threats as empty, concluding that crossing the president poses little danger.

    “The House health-care vote shows he does have juice, particularly with people on the right,” Sen. Lindsey O. Graham (R-S.C.) said. “The Senate health-care vote shows that people feel that health care is a defining issue and that it’d be pretty hard for any politician to push a senator into taking a vote that’s going to have consequences for the rest of their life.”

    Asked if he personally fears Trump, Graham chuckled before saying, “No.”

    Rep. Darrell Issa (R-Calif.), who has distanced himself from Trump on various issues, said few members of Congress fear permanent retaliation from the president.

    “He comes from the private sector, where your business partner today isn’t always your business partner tomorrow,” Issa said. “Just because you’re one way today doesn’t mean you’re written off. That’s the ‘Art of the Deal’ side.”

    ““The House health-care vote shows he does have juice, particularly with people on the right,” Sen. Lindsey O. Graham (R-S.C.) said. “The Senate health-care vote shows that people feel that health care is a defining issue and that it’d be pretty hard for any politician to push a senator into taking a vote that’s going to have consequences for the rest of their life.”

    LIndsey Graham is correct, it’s “pretty hard for any politician to push a senator into taking a vote that’s going to have consequences for the rest of their life.” And in this case that would have been a vote for a health care bill written by Mitch McConnell and designed to appease GOP mega-donors, not the GOP base that rallied to Trump last year due, in part, to have much his campaign agenda conflicted with that traditional GOP mega-donor agenda of tax cuts for the rich and spending cuts to everything else. That was the agenda that was going to be threaten the political futures of all those GOP senators and it was written a long time before Trump ever ran for office. And Trump surely recognizes this, which raises the question of just how livid is he right now with the rest of his party? It’s got to hurt. Normally Trump is the one throwing people under the bus.

    But here’s part of what must be enraging Trump and what raises real questions about how well the GOP is going to hold itself together: While Nevada Senators Dean Heller – who was opposing the Trumpcare bill from the left based on its general cruelty – was at the receiving end of a round of TV attack ads by the pro-Trump super-PAC “America First Policies” as some sort of gambit designed to pressure him and strike fear in others who might be thinking about opposing the bill, don’t forget that the there were four Senators who came out in opposition to the bill from the right, saying it wasn’t conservative enough and didn’t repeal Obamacare (the remaining good parts) enough (Senator’s Cruz, Paul, Johnson, and Lee).

    So four senators attack Trumpcare from the right, one from the left, and the one from the left gets attack ads run against him. It certaintly gives us a hint about when the next version of Trumpcare will look like.

    But a much bigger hint comes from the Koch network, which had a big gathering over the weekend where they declared that they were going to make a big push to ensure Trumpcare ends up much more conservative. And Koch network representatives were saying over the weekend that this unique window of opportunity to realize their long-term agenda is open for the 10-12 months. So trashing Trumpcare, and then trashing Trump, may have been a Koch network negotiating tactic. A tactic based on the expectation that there’s time for another attempt to pass health care ‘reform’ later:

    Politico

    Koch network donors eye Trump and Congress warily on health care, taxes

    A combination of hope and concern infused the summer seminar meeting of the Koch brothers’ network of conservative groups.

    By Kevin Robillard

    06/26/2017 01:13 PM EDT

    COLORADO SPRINGS, Colo. — Conservative donors see a major opportunity this year to achieve years-old Republican goals of reforming the tax code and passing a new health care law. But they are also consumed with worry that the GOP will somehow blow the chance it has been waiting for — whether because of an unfocused President Donald Trump or fretful congressional Republicans.

    That combination of hope and concern infused the summer seminar meeting of the Koch brothers’ network of conservative groups. Before a gathering of over 400 donors at the luxury Broadmoor Resort, Koch officials spoke of an enticing but narrow window to pass major tax and health care legislation, even though Republicans control the presidency and both chambers of Congress.

    We have a window of about 12 months until the 2018 election grinds policy to a halt,” said Tim Phillips, the president of Americans for Prosperity, the network’s grassroots organizing group.

    After waiting eight years for another Republican president, some Koch network donors now worry that the current one could end up being an obstacle.

    Trump “doesn’t have a core philosophy that we have,” said Colorado energy executive Chris Wright. Wright, who said he voted for Libertarian presidential nominee Gary Johnson in 2016, added: “We don’t have a clear, consistent direction from the top.”

    “I think we have 10 months and a rare opportunity to shrink the influence of the government on the economy,” Wright said. “The one we have now who can sell the public is Paul Ryan, but he doesn’t have the bully pulpit. The person with bully pulpit is not a great seller of ideas and progress.”

    The Koch network, organized by brothers Charles and David Koch, is a collection of conservative donors who have donated billions over the decades to everything from Republican politicians to school choice efforts to university think tanks in an effort to move the country in their ideological direction. The group’s allies and former staffers hold key positions throughout the Trump administration, and the network announced plans earlier this weekend to spend nearly $400 million on politics and policy over the next two years.

    The Koch network declined to directly back Trump’s candidacy in the election last year. Top network officials have been pleased with his administration’s court appointments and work on tax reform, and were ecstatic about legislation he signed last week reforming the Department of Veterans Affairs. But they were sharply critical of Attorney General Jeff Sessions’ stance on criminal justice reform and the GOP efforts to repeal Obamacare, arguing the Senate bill doesn’t do enough to lower premiums and totally repeal the law. (The network isn’t officially opposing the Senate proposal, but is working to make it more conservative.)

    But individual donors in the network have donated significant sums to Trump and super PACs backing him, including Doug Deason, a Texas-based donor who is the son of IT billionaire Darwin Deason.

    Deason was more bullish on Trump, particularly praising his pick of Supreme Court Justice Neil Gorsuch. “Anything other than Gorsuch is gravy,” Deason said. “Even if he just tweeted and pissed people off now, I’d be happy.”

    But he also said he and a group of about ten other Dallas-area donors planned to withhold checks from out-of-state Senate and House GOP incumbents until Trump’s agenda, including Obamacare repeal and tax reform, made it through.

    Deason said Senate Majority Leader Mitch McConnell needed to “grow a pair.” “We want to send a message about how important this is,” he said.

    At the same time, Deason said he had recently met with leaders from America First Policies, a nonprofit backing Trump’s agenda that launched attacks on Nevada Sen. Dean Heller for opposing the Senate health care bill, arguing it cut Medicaid too harshly and did too little to lower premiums.

    Deason wasn’t the only donor who worried about whether congressional Republicans will ultimately pass major legislation.

    Despite the apprehension, none indicated they were ready to shut off the money faucet into GOP campaign wallets. Even Deason, who said he had organized Texas donors to deny Republicans campaign cash until Trump’s agenda is passed, admitted he might not be able to follow through.

    When a reporter asked if he would donate to Republican senators next summer when McConnell called even if the president’s agenda flopped, he responded with a shrug: “Yeah.”

    ———-

    “Koch network donors eye Trump and Congress warily on health care, taxes” by Kevin Robillard; Politico; 06/26/2017

    ““We have a window of about 12 months until the 2018 election grinds policy to a halt,” said Tim Phillips, the president of Americans for Prosperity, the network’s grassroots organizing group.”

    12 months. That’s the Koch network’s window to strike according to Americans for Prosperity president Tim Phillips. And as the article also made clear, a lot of these Koch network mega-donors are getting impatient. And, more importantly, skeptical. Skeptical specifically of Trump:


    Trump “doesn’t have a core philosophy that we have,” said Colorado energy executive Chris Wright. Wright, who said he voted for Libertarian presidential nominee Gary Johnson in 2016, added: “We don’t have a clear, consistent direction from the top.”

    “I think we have 10 months and a rare opportunity to shrink the influence of the government on the economy,” Wright said. “The one we have now who can sell the public is Paul Ryan, but he doesn’t have the bully pulpit. The person with bully pulpit is not a great seller of ideas and progress.”

    ““I think we have 10 months and a rare opportunity to shrink the influence of the government on the economy,” Wright said. “The one we have now who can sell the public is Paul Ryan, but he doesn’t have the bully pulpit. The person with bully pulpit is not a great seller of ideas and progress.””

    Trump is not a great seller of ideas and progress. Only Paul Ryan can save their agenda. that’s the kind of chatter reported from the Koch network meeting. Ouch. And that article is from Monday, a day before the sudden pulling of of the Senate Trumpcare bill.

    So there appears to be a general feeling of concern about the ability of the GOP to push through a Koch-approved legislative agenda. And Trump is the figure the Koch network is blaming. Not their horrible agenda that the public loathes. Trump was supposed to sell it. And he didn’t (and apparently Paul Ryan could sell it?!). And don’t forget that the Kochs were already in opposition to the Senate Trumpcare bill over the weekend because it wasn’t “conservative” enough and pledged to ensure it would be. And don’t forget that Donald Trump represents the opportunity of a lifetime to put Trump’s brand of ‘populism’ on the long-held Koch-led pro-oligarch agenda that the far-right has been dreaming of making law for decades. And Trump has to recognize the situation he’s in. It’s his historic reputation on the line. Those pleas for the Senate to make sure the bill has “heart” probably were sincere. But it’s hard to see the oligarchy passing on this opportunity to make their nightmare agenda a reality pin it all on Trump. To the Koch network, Trump is just tame a sacrificial paper tiger.

    Given all that, you really have to wonder if widespread mega-donor opposition was, in fact, the primarily source of the sudden decision to delay the Trumpcare vote. Sure, widespread public opposition to the details in Trumpcare was also undoubtedly a significant factor. But the Koch network of mega-donors have made it pretty clear they want a more conservative version of Trumpcare and they don’t appear to be willing to take ‘no’ for an answer. And when the Kochs say “No”, the GOP is going to obey. Especially since they just pledged to spend $400 million dollars on the 2018 mid-term elections during their conference over the weekend:

    Politico

    Koch network ramps up political spending while trying to push Trump team

    Vice President Mike Pence met with Charles Koch the day before a Koch network summit.

    By Kevin Robillard
    06/24/2017 07:11 PM EDT

    COLORADO SPRINGS, Colo. — The leadership of the Koch brothers’ network is brushing off its occasionally chilly attitude toward President Donald Trump, trying to nudge the administration in its direction as the group’s annual summit began Saturday just after Charles Koch met with Vice President Mike Pence.

    The network of conservative donors announced Saturday it plans to spend between $300 million and $400 million on politics and policy during the 2018 cycle.

    “When we look at our budget for politics and policy, it’s our largest we’ve ever had,” said Tim Phillips, the president of Americans for Prosperity, the network’s grassroots organizing arm with chapters in dozens of states.

    The Koch network, led by billionaire brothers Charles and David Koch, rivals the Republican National Committee in size, scope and budget. The alliance of conservative donors has worked for decades to move both electoral politics and the country at large in a libertarian direction with everything from political ad buys to donations to universities.

    The millions from the Koch network and its wealthy allies will boost the Trump administration on some key priorities, especially tax reform and rolling back regulations. It also will help push back against others — especially Attorney General Jeff Sessions’ desire to implement tough-on-crime policies — and working to make Obamacare repeal efforts more conservative. And they could prove critical to Republican efforts to retain the House and expand a majority in the Senate.

    “We’ve made tremendous progress on the federal level that we haven’t been able to make in the last ten years,” said James Davis, a top network official.

    Pence has longstanding ties to the Koch network, while Charles Koch has been openly critical of the vice president’s boss since the early days of the Republican primary campaign. Through Pence, the group’s allies have established a beachhead in the administration. Pence and Koch spoke Friday night for about 45 minutes about tax reform, legislation Trump signed on Friday to overhaul the Department of Veterans Affairs and other topics.

    The meeting included Marc Short, Trump’s director of legislative affairs and a former Koch network official, Pence staffer Marty Obst and several current top Koch officials, including Mark Holden and Phillips, the Americans for Prosperity president.

    The Koch network’s annual seminar, as the group dubbed it, began Saturday at the Broadmoor Resort here and continues until Monday. Officials said the seminar included more donors than ever, and more new donors than ever.

    Kentucky Gov. Matt Bevin, Texas Gov. Greg Abbott and Missouri Gov. Eric Greitens were set to speak to donors Saturday night, with Nebraska Sen. Ben Sasse, a frequent Trump critic, scheduled to deliver a speech Sunday. Arizona Gov. Doug Ducey will discuss education policy on Monday, and another group of lawmakers is set to discuss tax reform.

    Tax reform is arguably the area where the network seems most pleased with the Trump administration. Phillips said AFP plans to hold grassroots rallies in 36 states around the country to push for a tax overhaul. Officials also gave sterling reviews to Trump’s judicial appointments and efforts to roll back regulations.

    But they were openly disappointed with GOP efforts to repeal Obamacare. “At the end of the day, this bill is not going to fix health care,” Davis said.

    Phillips added: “We’ve been disappointed that this has not been more dramatic. We’re seeking to make it better. We’re not walking away. This is too important an issue for too many Americans.”

    The officials said the proposal needs to do more roll back Medicaid expansion, arguing the program didn’t do enough to make health care more affordable for poor people or improve health outcomes. The Senate could vote on its Obamacare repeal before the July 4 recess, and it’s unclear whether Senate Majority Leader Mitch McConnell will be able to round up the required 50 votes for the plan.

    Phillips acknowledged they discussed the proposal with Pence. “It was a cordial discussion of issues,” he said. “But there was not any kind of ask by either side.”

    Of the four conservative senators who announced their opposition to the health care plan, two — Texas’ Ted Cruz and Utah’s Mike Lee — are attending the seminar, as is NRSC Chair Cory Gardner of Colorado, vulnerable Arizona Sen. Jeff Flake and Texas Sen. John Cornyn, the GOP’s number two in the Senate.

    ———-

    “Koch network ramps up political spending while trying to push Trump team” by Kevin Robillard; Politico; 06/24/2017 07:11 PM EDT

    The Koch network, led by billionaire brothers Charles and David Koch, rivals the Republican National Committee in size, scope and budget. The alliance of conservative donors has worked for decades to move both electoral politics and the country at large in a libertarian direction with everything from political ad buys to donations to universities.”

    Yep, the Koch network rivals the RNC. And it just announced the largest planned round of political expenditures in history for the upcoming 2018 elections:


    The network of conservative donors announced Saturday it plans to spend between $300 million and $400 million on politics and policy during the 2018 cycle.

    “When we look at our budget for politics and policy, it’s our largest we’ve ever had,” said Tim Phillips, the president of Americans for Prosperity, the network’s grassroots organizing arm with chapters in dozens of states.

    And the Koch network wants a much more conservative Obamacare repeal:


    But they were openly disappointed with GOP efforts to repeal Obamacare. “At the end of the day, this bill is not going to fix health care,” Davis said.

    Phillips added: “We’ve been disappointed that this has not been more dramatic. We’re seeking to make it better. We’re not walking away. This is too important an issue for too many Americans.”

    The officials said the proposal needs to do more roll back Medicaid expansion, arguing the program didn’t do enough to make health care more affordable for poor people or improve health outcomes. The Senate could vote on its Obamacare repeal before the July 4 recess, and it’s unclear whether Senate Majority Leader Mitch McConnell will be able to round up the required 50 votes for the plan.

    So the Koch network meets days after the Senate reveals its horrible Trumpcare bill, expresses its disappointment with it not being mean enough. Then announces $300-400 million in 2018 political spend. And days later the bill suddenly collapses. Did it purely collapse under the weight of its own unpopularity? Or were the Kochs also putting pressure on Mitch McConnell to call a timeout, regroup, and plan to fight for an even more conservative version of Trumpcare at a later date? A more conservative version that will be pinned in Trump. Don’t forget that an announcement of $300-400 million on spending in next year’s elections is basically code for “don’t worry about voting for a horribly unpopular bill, you’ll have lots of supporting ads to fool the rablle.” And that announcement came during a meeting when the Kochs were declaring their intent on ensuring a more conservative version of Trumpcare is what finally passes.

    All in all, the Koch network has made it pretty clear that, despite the sudden collapse of the Trumpcare push, fear of Trumpcare should not be receding any time soon. Intra-GOP fear of Trump’s wrath should Trumpcare not become law, on the other hand, is more an open question.

    Posted by Pterrafractyl | June 27, 2017, 10:35 pm
  3. White House senior advisor Kellyanne Conway recently echoed an argument that’s becoming a growing right-wing meme as the GOP’s push to ‘reform’ health care and gut Medicaid creeps along: that when Obamacare expanded Medicaid to include some people above the poverty line, all these newly covered people were lazy able-bodied adults who were unjustly sucking away resources from a program intended for other groups like the disabled, children, and the elderly. And when Trumpcare/Kochcare kicks all those newly covered people off of Medicaid, if they want health care they can go get a job. Yes, the vast majority of able-bodied adults on Medicaid already have a job, and yes, one of the big reasons the people above the poverty line who are now covered by the Medicaid expansion (in the states that actually did the expansion) are the working poor, and yes, many low-pay jobs don’t actually offer employer-sponsored health care coverage. And yes, Kellyanne Conway almost certainly knows all of this, but she said it anyway because that’s her job:

    The Huffington Post

    Kellyanne Conway Defends Medicaid Cuts, Says Adults Can Always Find Jobs
    Reality check: Most of them have jobs already.

    By Jonathan Cohn
    06/25/2017 12:29 pm ET | Updated

    White House counselor Kellyanne Conway on Sunday came right out and said what so many Republicans are probably thinking – that taking Medicaid away from able-bodied adults is no big deal, because they can go out and find jobs that provide health insurance.

    Apparently nobody has told Conway that the majority of able-bodied adults on Medicaid already have jobs. The problem is that they work as parking lot attendants and child care workers, manicurists and dishwashers – in other words, low-paying jobs that typically don’t offer insurance. Take away their Medicaid and they won’t be covered.

    Appearing on ABC “This Week” program, Conway faced tough questions about steep cuts to Medicaid in the Better Health Care Act – the bill to repeal the Affordable Care Act that Senate Republican leaders released on Thursday and hope to bring to a vote this week.

    The Affordable Care Act – Obamacare – offered states extra federal matching funds to expand Medicaid eligibility, so that anybody with income below or just above the poverty line would qualify. Under the Senate bill, like its House counterpart, the federal government would withdraw those extra funds, forcing most of the 31 states (plus the District of Columbia) that accepted the money to roll back their expansions partly or entirely.

    When ABC’s George Stephanopoulos asked Conway about this possibility, she offered an increasingly familiar argument – that Obamacare had over-extended Medicaid by taking the program away from its historic mission of covering children, pregnant women, the elderly and the disabled.

    .@KellyannePolls: Obamacare opened up Medicaid to "many able-bodied Americans who should at least see if there are others options for them." pic.twitter.com/fzqvuwXrXB— ABC News Politics (@ABCPolitics) June 25, 2017

    “Obamacare took Medicaid, which was designed to help the poor, the needy, the sick, disabled, also children and pregnant women, it took it and went way above the poverty line to many able-bodied Americans who … should at least see if there are other options for them.”

    She added: “If they are able-bodied and they want to work, then they’ll have employer-sponsored benefits like you and I do.”

    If only it were that easy.

    Among the able-bodied adults that Conway and congressional Republicans have in mind – that is, non-elderly adults on Medicaid who don’t qualify for disability benefits – 79 percent are in families where someone works and 59 percent have jobs themselves, according to the Henry J. Kaiser Family Foundation.

    The problem is that many work in low-paying, temporary, or part-time jobs that don’t offer coverage. In 2014, just 30 percent of working adults with incomes at or below the poverty line had employer-sponsored coverage available to them.

    As for the idea that the House and Senate GOP bills would strengthen Medicaid by focusing on its more traditional populations, that claim would appear to be inconsistent with the other big change they would make.

    Both proposals would fundamentally change Medicaid by ending the federal government’s open-ended commitment to providing its share of funding for the program, no matter how many people become eligible and no matter how much their care ends up costing.

    Federal payments would likely fail to keep up with costs, forcing states to make cutbacks that would inevitably affect all groups that depend on the program – very much including the disabled and elderly, whose predictably high medical needs mean their bills account for roughly half of all Medicaid expenditures, even though they represent a minority of enrollees.

    When Stephanopoulos asked Conway about this, she said, “These are not cuts to Medicaid, George. This slows the rate for the future and it allows governors more flexibility, with Medicaid dollars, because they’re closest to the people in need.”

    After @KellyannePolls says Senate GOP bill doesn't propose Medicaid cuts, @SenatorCollins says "I respectfully disagree with her analysis." pic.twitter.com/QeS8lEWk66— ABC News Politics (@ABCPolitics) June 25, 2017

    That claim, which the Trump administration and its allies in GOP leadership have made repeatedly in recent weeks, has drawn rebukes from Republican senators – including Susan Collins of Maine, who appeared on “This Week” shortly after Conway.

    “I respectfully disagree with her analysis,” Collins said.

    ———-

    “Kellyanne Conway Defends Medicaid Cuts, Says Adults Can Always Find Jobs” by Jonathan Cohn; The Huffington Post; 06/25/2017

    “Among the able-bodied adults that Conway and congressional Republicans have in mind – that is, non-elderly adults on Medicaid who don’t qualify for disability benefits – 79 percent are in families where someone works and 59 percent have jobs themselves, according to the Henry J. Kaiser Family Foundation.”

    Why can’t all those people with a job just go get jobs? That’s the how people about to get kicked off Medicaid should respond, according to Kellyanne Conway and the rest of the GOP:


    “Obamacare took Medicaid, which was designed to help the poor, the needy, the sick, disabled, also children and pregnant women, it took it and went way above the poverty line to many able-bodied Americans who … should at least see if there are other options for them.”

    She added: “If they are able-bodied and they want to work, then they’ll have employer-sponsored benefits like you and I do.”

    Since “get a job, you [already employed] bums!” is apparently going to be the GOP response once the GOP finally guts Medicaid, it’s worth noting one of the more twisted ways Medicaid actually encourages some people get jobs: Some states, like Wisconsin, allow the relatives of Medicaid recipients waiver where they can get a fixed amount of funds for home-care services and hire whoever they want. Including relatives who can become the paid service provider, paying $11,50/hour in Wisconsin’s case. And while that’s a lot less money that many people could get in other jobs, it’s still potentially a money saver for someone to quit a higher-payer career and become a home-care provider for their relative simply to avoid paying the high-cost of having a profession home-care providers do those services.

    So while it’s absurd and just cruel to tell people about to lose the Medicaid coverage to just go get it job, as the following article describes, there are situations where the Medicaid recipients’ relatives might get a job…a very low paying job being the in-home Medicaid service provider for their relatives. And yes, they might have to quit their career to do it. And even that option is threatened by the proposed Medicaid cuts:

    National Public Radio

    Wisconsin Family Stays Together With Help From Medicaid

    June 5, 2017 2:09 PM ET

    Nancy and Dan Gapinski of Glendale, Wis., remember a time when they couldn’t really communicate with their own son.

    “He used to not really have any kinds of conversations with us. He did a lot of echoing things that we said, and scripting from movies,” Nancy Gapinski says as she and her husband wait for their son Ben’s school bus to arrive. “A lot of times kids didn’t know how to respond to him then, and didn’t know what he was trying to say and conversations wouldn’t really go anywhere.”

    But that’s all changed. On a recent Friday afternoon, 10-year-old Ben hops off the bus, greets both his parents and starts chatting about his day.

    “So what I did today was I had an extra recess today, and also I had to do two star math tests,” he reports. He says he did pretty well on those tests.

    When Ben was a toddler he was diagnosed with an autism spectrum disorder. He barely communicated with his parents and needed constant monitoring to stay safe.

    The Gapinskis needed help. They found a therapist to work with Ben for 24 hours a week, which cost more $50,000 a year. Dan’s workplace insurance paid for some of the costs, but not all.

    So they turned to Medicaid.

    Ben’s disability was severe enough – he was deemed by the state to require “an institutional level of care” — that he was eligible for Wisconsin’s children’s long-term care program, funded by Medicaid.

    “They work with the child on basic language skills, trying to learn words, trying to do some intellectual exercises,” Ben’s father Dan recalls. “It eventually graduates into some back and forth conversation, and doing homework and doing things that are more like what normal kids do.”

    While Medicaid is best known as a health care program for poor people, more than 80 percent of its budget goes to care for the elderly, the disabled and children, according to the Kaiser Family Foundation. Only 15 percent goes to health care for able-bodied adults.

    The program has been growing in recent years and it now makes up almost 10 percent of federal spending. That’s why it’s the number one target in President Trump’s proposed budget, and figures prominently in the Republican proposal to replace the Affordable Care Act. Some estimates suggest the program could be cut by more than 1 trillion dollars over 10 years.

    After three years of intense therapy, Ben now goes to his local public school and works on grade level in math and English. He no longer works with his private therapist or uses Medicaid benefits.

    “We just decided not to reapply,” Nancy says. “The need had been met.”

    President Trump and Republicans in Congress have proposed massive cuts to Medicaid’s budget over the next decade, and Nancy and Dan Gapinski worry that the services they used for Ben won’t be there if he needs them in the future, or be there for other families.

    “I don’t know what Ben will need in his lifetime,” Nancy Gapinski says. “Our goals for him are very much like our goals for our daughter Zoe. We really want for them to be active, engaged citizens.”

    Ben’s not the only one in the Gapinski home who has used Medicaid services. His grandmother Evelyn Benjamin is also a beneficiary.

    Evelyn is 84. She’s had a few falls and depends on a walker to get around. She also has heart disease and uses three different inhalers.

    “They take very good care of me,” Evelyn says, sipping tea in the living room surrounded by her family. “I’m very lucky to be one that can stay in my home, and know that I’m cared for.”

    Evelyn has health insurance through Medicare. But after her husband suffered a stroke and needed constant care, she depleted her savings and now qualifies for Medicaid as well. It helps pay for her 12 prescription medications and, through a Medicaid-funded program called IRIS, she gets in-home help.

    Wisconsin’s IRIS program is an example of how states tailor Medicaid to their own needs. It gives beneficiaries a budget to use for the services they need, and it allows people to hire whoever they want.

    So Evelyn hired her daughter, Nancy, who gave up her full-time career to care for her mother and son. She works part-time from home, and supplements that income with $11.50 an hour for 20 hours a week caring for her mother. She says it’s helped keep them out of bankruptcy. And her hourly rate is a fraction of the going rate for such services from an agency. According to a 2015 study by Genworth, home health aides and homemaker services in Milwaukee cost an average of about $22 an hour.

    “It’s just a big, big help for not only me, but for my daughter who worries about me constantly,” Evelyn says.

    Nancy Gapinski worries that help may disappear under the proposed budget cuts. That’s because the services her family uses are considered optional under the Medicaid law. The program is required to pay for doctor visits, hospital care and even nursing home care. But in-home support services that Evelyn uses and therapies like those Ben received aren’t.

    Dan Gapinski says his children love having their grandmother around. When they have nightmares they climb into her bed and they giggle with her in the living room.

    “I don’t think we, as a society, appreciate the value of that,” he says. “There’s a lot of talk about entitlements and how that’s become a bit of dirty word. We don’t take the satisfaction in having made a greater society by making these kinds of situations possible.”

    ———-

    “Wisconsin Family Stays Together With Help From Medicaid” by Alison Kodjak; National Public Radio; 06/05/2017

    “Evelyn has health insurance through Medicare. But after her husband suffered a stroke and needed constant care, she depleted her savings and now qualifies for Medicaid as well. It helps pay for her 12 prescription medications and, through a Medicaid-funded program called IRIS, she gets in-home help.

    84 year old Evelyn gets to stay living at home with her family, with the help of Wisconsin’s IRIS program. But also with the help of her daughter who gets paid by IRIS to be Evelyn’s care provider. Until the GOP’s Medicaid cuts force such “optional” programs to go away:


    Wisconsin’s IRIS program is an example of how states tailor Medicaid to their own needs. It gives beneficiaries a budget to use for the services they need, and it allows people to hire whoever they want.

    So Evelyn hired her daughter, Nancy, who gave up her full-time career to care for her mother and son. She works part-time from home, and supplements that income with $11.50 an hour for 20 hours a week caring for her mother. She says it’s helped keep them out of bankruptcy. And her hourly rate is a fraction of the going rate for such services from an agency. According to a 2015 study by Genworth, home health aides and homemaker services in Milwaukee cost an average of about $22 an hour.

    “It’s just a big, big help for not only me, but for my daughter who worries about me constantly,” Evelyn says.

    Nancy Gapinski worries that help may disappear under the proposed budget cuts. That’s because the services her family uses are considered optional under the Medicaid law. The program is required to pay for doctor visits, hospital care and even nursing home care. But in-home support services that Evelyn uses and therapies like those Ben received aren’t.

    And just to be clear, the fears of the Gapinksi family that the Medicaid cuts will results in cuts to programs that cover home-care aren’t just fears. Home-care services really are considered “optional” under Medicaid and as such are far more likely to be cut than services considered “mandatory”. And as the following article points out, one of the services considered “mandatory” is nursing home services, so one effect of the coming Medicaid cuts might actually be to push people into nursing homes. Of course, nursing homes services are themselves going to be under pressure since all Medicaid services are going to be under pressure given the scale of the proposed cuts, optional and mandatory. But the optional services are obviously going to be cut a lot more so we could be effectively pushing people out of their home and into a shrinking number of nursing home beds. You really don’t want play this version of musical chairs:

    Time

    What Would Happen to Seniors in Nursing Homes Under the Republican Health Care Bill?

    Elizabeth O’Brien
    Jun 29, 2017

    Dawn Burnfin’s 94-year-old grandmother recently had a massive stroke in a Missouri nursing home. She quickly recovered well enough to tell the end-of-life hospice workers caring for her to go home, since she had no plans to die.

    But the Medicaid funds that help pay for her care are now up in the air.

    “I don’t know where she would go,” Burnfin, 43, says of her grandmother, if she loses her bed in the nursing home. “It’s really scary.”

    Included in the Better Care Reconciliation Act, the bill Senate Republicans have proposed to replace the Affordable Care Act, are an estimated $772 billion in federal cuts to Medicaid through 2026, plus a reduction in the funding formula that would sharply decrease spending beyond that. The nonpartisan Congressional Budget Office projected on Thursday that federal Medicaid spending in 2036 would be 35% less than under current law.

    Proponents of the bill say the new Medicaid structure would increase states’ flexibility to design their Medicaid programs around the unique needs of their populations. But the proposed cuts have many like Burnfin wondering who will pay to keep her grandmother cared for?

    While Medicaid is best known for insuring low-income Americans, the government program also provides a vital safety net to elderly Americans who need long-term care, either at home or in a facility. Medicaid covers about 60% of nursing home residents, and according to a 2015 study by Truven Health Analytics, roughly 2.2 million elderly Americans received Medicaid-financed long-term care in 2011. As more baby boomers reach older age, these numbers will only grow.

    Burnfin lives in Chisholm, Minn., not close enough to provide hands-on care to her grandmother, although though she has plenty of expertise: Burnfin herself works as a home care worker, providing in-home assistance to an elderly woman on Medicaid. Her own livelihood depends on the program’s health.

    Medicaid is such an important safety net because Medicare, the federal health insurance program for those ages 65-plus, does not cover the kind of routine assistance that most elderly need: help with dressing, bathing, eating and other activities of daily living. According to government estimates, 70% of people turning 65 will eventually need such assistance in older age.

    When it comes to finding—and financing—long-term care for older loved ones, most families are on their own. And many end up turning to Medicaid when their money runs out. It’s not hard to drain your life savings on nursing home care that runs around $82,000 per year but can go much higher in costlier areas of the country. To qualify for Medicaid for long-term care, applicants need to have depleted most of their resources. Criteria vary by state; in New York, for example, the asset limit is about $14,000, not including a certain amount of home equity.

    Eligibility criteria would likely get even stricter under the Better Care Reconciliation Act, experts say. That’s because the bill would fundamentally change the entire Medicaid program, not just the parts affected by the ACA: it would switch Medicaid financing from an open-ended benefit to one that’s capped.

    Instead of receiving increased federal funding to meet mounting needs—say, to fund opioid addiction treatment or to pay for a new breakthrough drug—beginning in 2020 states would receive a capped amount. This would represent “a transfer of risk, responsibility, and cost to the states of historic proportions,” according to a statement by the National Association of Medicaid Directors, a bipartisan organization representing leaders of state Medicaid agencies nationwide.

    Spending caps would become even more harsh in 2025, when Medicaid spending could only rise each year with general inflation, which tends to lag medical inflation by several percentage points. “The bill’s Medicaid cuts are really about starving the program, and states won’t think about the long-term, they’ll think about surviving until the next year,” says Edwin Park, vice president for health policy at the Center on Budget and Policy Priorities.

    Medicaid finances are already stretched, and there’s not that much fat to cut in the system. “It’s not like Medicaid systems have been rolling in cash under the current system, due to the need,” says Eric Carlson, a directing attorney in Justice in Aging, a nonprofit legal advocacy organization.

    Nobody knows yet how states would respond to the cuts, but experts say all long-term care supports and services are vulnerable–that includes quality care in nursing homes for patients whose needs are best met in such facilities, and also in-home care for patients who can stay at home with assistance.

    Among the limited choices states would have to cope with the cuts: they could restrict Medicaid eligibility, reduce the already-low payments Medicaid makes to medical providers, and reduce the number of services that Medicaid covers. In-home care is generally considered an optional benefit in state Medicaid programs, so it would likely be on the chopping block if the Senate bill becomes law. Nursing home care, by contrast, is considered mandatory. “What’s horrible about the bill is it will force institutionalization,” says Michael J. Amoruso, president-elect of the National Academy of Elder Law Attorneys and a practicing attorney in Rye Brook, N.Y. In other words, the bill would force older, vulnerable citizens out of their homes and into nursing facilities.

    ———-

    “What Would Happen to Seniors in Nursing Homes Under the Republican Health Care Bill?” by Elizabeth O’Brien; Time; 06/29/2017

    “Among the limited choices states would have to cope with the cuts: they could restrict Medicaid eligibility, reduce the already-low payments Medicaid makes to medical providers, and reduce the number of services that Medicaid covers. In-home care is generally considered an optional benefit in state Medicaid programs, so it would likely be on the chopping block if the Senate bill becomes law. Nursing home care, by contrast, is considered mandatory. “What’s horrible about the bill is it will force institutionalization,” says Michael J. Amoruso, president-elect of the National Academy of Elder Law Attorneys and a practicing attorney in Rye Brook, N.Y. In other words, the bill would force older, vulnerable citizens out of their homes and into nursing facilities.

    So if you were hoping that you might be able to get paid by Medicaid (very little) to take care of your parents after they get kicked out of the nursing home, sorry, your home-care programs is probably going to get cut first. It all raises the question of where grandma and grandpa are going to go after the nursing home funds run out and there’s no possible way all these families will be able to cover it. Oh, that’s right…grandma and grandpa move back with their relatives anyway. And the family takes care of them anyway, including by quitting careers to do it. But without anyone getting paid by Medicaid to do it. So, yes, people with “get a job” after these Medicaid cuts. It’ll just be the relatives getting the jobs. Unpaid jobs.

    And for people without a strong familiar network to provide for them? Where do they go? Oh, that’s right…

    Posted by Pterrafractyl | July 1, 2017, 7:42 pm
  4. Under a normal White House administration, it would be really, really, really big news when Walter Schaub, the widely respected head of the Office of Government Ethics – an agency set up in the post-Watergate era with the purpose of helping government employees avoid ethical conflicts – resigned suddenly last week, six months before his term was set to end, as a form of protest over the Trump administration’s openly flaunting conflicts of interests. But this the Trump administration, so it’s not actually big news. In part because the news of active ongoing corruption investigation is drowning out Schaub’s symbolic resignation, but also because, hey, it’s Trump. He’s supposed to be kind of mob-ish. That’s his brand. And somehow that brand got him into the White House. So who cares about things like the head of the agency in charge of policing conflicts of interest resigns in protest, right? At this point we’re just counting down the days until Trump either Trump implodes his presidency or blows up the world.

    But here’s a reminder that Schaub’s symbolic resignation doesn’t just need to be seen as a protest against Donald Trump. The GOP as a party is plenty worthy of a symbolic protest resignation Schaub:

    New York Magazine

    GOP Lawmakers Bought Health-Insurance Stocks While Advancing Trumpcare

    By Eric Levitz
    July 7, 2017 5:26 pm

    It’s hard to imagine how the GOP could have set about reforming the health-care system in a more politically toxic fashion. The American Health Care Act is the most unpopular piece of legislation that either party has pursued in the past three decades. And it isn’t hard to see why: The bill would throw millions of poor people off of Medicaid, so as to finance a capital-gains tax cut for millionaire investors; it would undermine regulatory protections for people with preexisting conditions; and it would massively increase premiums for older, lower-middle-class people, especially those in rural areas — which is to say, a significant chunk of the GOP base.

    In other words, GOP legislators voted to increase their own passive income by condemning thousands of their own voters to preventable deaths. What more could Republicans have done to validate Democratic narratives about who they really stand for?

    The Intercept’s Lee Fang provides one answer:

    Just as the House Republican bill to slash much of the Affordable Care Act moved forward, Rep. Mike Conaway, a Texas Republican and member of Speaker Paul Ryan’s leadership team, added a health insurance company to his portfolio.

    An account owned by Conaway’s wife made two purchases of UnitedHealth stock, worth as much as $30,000, on March 24th, the day the legislation advanced in the House Rules Committee, according to disclosures. The exact value of Conaway’s investment isn’t clear, given that congressional ethics forms only show a range of amounts, and Conaway’s office did not respond to a request for comment.

    It was a savvy move. Health industry stocks, including insurance giants like UnitedHealth, have surged as Republicans move forward with their repeal effort, which rolls back broad taxes on health care firms while loosening consumer regulations which prevent insurance companies from denying coverage for medical treatment. UnitedHealth has gained nearly 7 percent in value since March 24.

    Three months later, as Mitch McConnell and company were rewriting the bill in Congress’s upper chamber, Oklahoma senator James Inhofe purchased between $50,000 and $100,000 worth of UnitedHealth shares. Inhofe’s spokesperson told the Intercept that the transaction was made by the senator’s financial adviser without his consultation.

    It’s worth noting that, for the ordinary investor, it’s rarely wise to buy and sell individual stocks — as opposed to investing in mutual funds — unless one has access to special information. And given that the mere appearance of corruption has a corrosive effect on our republic, it’s difficult to understand why members of Congress don’t restrict their investments to such instruments.

    But then, the Trump-era Republican Party has grown quite comfortable with complicity in manifest corruption — let alone with giving the appearance of it.

    New York congressman Chris Collins has, at best, a singular enthusiasm for the latter. Collins owns 17 percent of the Australian biotech firm Innate Immunotherapeutic, making him the company’s largest shareholder. He is also a member of the House subcommittee that oversees the FDA.

    In his role as a congressman, Collins authored legislation designed to expedite FDA approval of experimental drugs like those Innate specializes in. In his capacity as a big money Innate investors, Collins (reportedly) sold several of his fellow Republican congressmen on the virtues of investing in the company. Among those who took him up on that offer was current Health and Human Services secretary Tom Price.

    In February, Collins mocked the idea that his investment in the company rendered him unfit to rewrite pharmaceutical regulations or oversee the FDA. In an interview with the Rochester Democrat and Chronicle, Collins argued that the company was foreign, and not yet seeking FDA approval — and he promised that he would not own any stock in Innate by the time it sought entry into the U.S. market.

    Last month, the FDA approved one of Innate’s multiple sclerosis drugs for clinical trials in the U.S. As the Daily Beast notes, Collins said last week that he remains an investor in the company.

    ———-

    “GOP Lawmakers Bought Health-Insurance Stocks While Advancing Trumpcare” by Eric Levitz; New York Magazine; 07/07/2017

    “It was a savvy move. Health industry stocks, including insurance giants like UnitedHealth, have surged as Republicans move forward with their repeal effort, which rolls back broad taxes on health care firms while loosening consumer regulations which prevent insurance companies from denying coverage for medical treatment. UnitedHealth has gained nearly 7 percent in value since March 24.”

    As we can see, gutting health care protections like pre-existing conditions creates a lot of savvy investment opportunities in the private health insurance sector. Opportunities that some in Congress appear to be taking.

    Although it’s worth noting that the savvy investment made by current HHS secretary Tom Price and others in Congressman Collins’ biotech company Innate Immunotherapeutic is of a somewhat different nature than investing in UnitedHealth or something since this was literally a case of a Congressman peddling shares in his own company to other Congressmen. Quite aggressive peddling according to numerous accounts. And while Congressman Collins appears to have a real conflict of interest over his past legislation involving the drug approval process and a key drug Innate was working on, it’s unclear he or Secretary Price or the rest of Innate’s Congressional investors are going to see the billions in potential profits Collins was promising was possible after Innate’s stock just dropped over 90 percent. Although it still earned him an investigation from the Office of Government Ethics for insider trading:

    New York Magazine

    GOP Congressman Loses $17 Million on Biotech Stock

    By Eric Levitz
    June 27, 2017 5:30 pm

    It’s been a good few months for brazenly unethical politicians. President Trump has spent his first months in the White House channeling public funds into his personal properties — and putting hilariously unqualified friends and family members into top government positions — with impunity. The administration’s Health secretary won confirmation despite evidence that he may have engaged in insider trading while in Congress, and lied during his appearance before the Senate. And an Oklahoma attorney general who allowed a natural-gas company to literally dictate his office’s position on new environmental regulations is now the head of the EPA.

    Still, even in Trump’s America, (ostensible) acts of soft corruption don’t always pay. As Politico reports:

    The stock value of the Australian biotech firm Rep. Chris Collins championed to fellow lawmakers plummeted on Tuesday, costing the New York Republican $17 million as investigators continue probing his relationship with the firm.

    Innate Immunotherapeutic shares dropped more than 90 percent on Tuesday to 5 cents when markets closed in Australia. The tumultuous fall of the company’s stock followed an announcement that the firm’s star pharmaceutical drug for multiple sclerosis failed to pass clinical trials.

    Collins is a member of the House’s subcommittee on health care and Innate’s biggest shareholder. The congressman reportedly encouraged a number of his fellow Republican lawmakers to invest in the company, and secured them access to discounted shares (this was the point that Tom Price misled the Senate about during his confirmation hearings). Then, Collins helped craft legislation that expedited the FDA’s approval process — a reform that directly benefited Innate, which was working to get its wares onto the U.S. market.

    Those activities have now earned Collins the scrutiny of the Office of Government Ethics (which is investigating him on suspicions of insider trading); a $17 million paper loss; and, presumably, the irritation of several of his (suddenly less wealthy) colleagues.

    Financially speaking, Collins will be just fine — the congressman is worth upwards of $40 million, while his actual losses are reportedly closer to $5 million, the amount he originally invested in the company 15 years ago.

    Those activities have now earned Collins the scrutiny of the Office of Government Ethics (which is investigating him on suspicions of insider trading); a $17 million paper loss; and, presumably, the irritation of several of his (suddenly less wealthy) colleagues.”

    It’s a reminder that Trump’s many scandals aren’t just a distractions from his many scandals. They’re also distractions from Congress’s many scandals.

    And at least Congressman Collins is still really, really rich even after losing millions on his biotech investment. He’s not bankrupt, like all the people that are going to become bankrupt from medical bills after Trumpcare becomes reality. But don’t forget, should any GOPers invest in anything that somehow profits from from a rise in personal bankruptcies, that’s a conflict of interest. Or investments that somehow profits from families suddenly being forced to provide medical services for their relatives, including disabled children. That’s definitely a conflict of interest.

    Coffins and cremation service investments? You almost can’t get more conflicted.

    Posted by Pterrafractyl | July 9, 2017, 7:11 pm
  5. Is Ted Cruz going to save Trumpcare? It’s possible. A lot of people might die as a result, but Trumpcare could be save. All thanks to Ted Cruz. Or rather, all thanks to Ted Cruz’s amendment to the Senate Trumpcare bill that would allow insurance companies to sell ‘bare bones’ health care plans as long as they also offer plans include the various features and protections, for things like pre-existing conditions, that are the among the most popular features in Obamacare. And the Cruz amendment undermines those protections in a particularly underhanded way. By allowing bare bones plans again, the healthy people who help balance out the costs when pooled with older, sicker, and more expensive people create a ‘healthy (not yet sick)’ vs ‘sick-ish or worse’ two-tiered market. Like it was before Obamacare. So health care is going to be priced out of the hands of even more people. Specifically the poorest and sickest.

    Don’t forget that one of the key ways Obamacare was designed to provide affordable insurance even to people with potentially expensive pre-exising conditions is by mandating that all health insurance packages have the “essential benefits” that provide affordable access even to the sick. Providing essential benefits to everyone pools the you and healthy in with everyone else, while also ensuring preventative care is available. And by making people healthier with preventative care and pooling everyone into a large pools of sick and healthy, affordable health care with meaningful coverage was going to be extended to everyone without going to a government run single-payer system. That’s how Obamacare was supposed to work before the GOP repeatedly sabotaged it. This is a very Ted Cruz-ish amendment but it’s also a very GOP-ish amendment. Although in the following article from a week and a half ago it sounds like most of the Senate GOPers don’t even want this amendment because it’s that bad to the constituents. But about 15 do. So it’s a relatively Ted Cruz-ish amendment even by GOP standards.

    But that amendment appears to be the secret sauce required to get the far-right “Freedom Caucus” faction of the GOP on baord. And not just in the Senate but House Freedom Caucus leader has already hinted that the Cruz Amendment is going to be a House Freedcom Caucus demand too. And there’s no way Trumpcare is becoming a reality with the Freedom Caucus’s support. Plus, the Koch brothers’ network is backing it too, so it’s going to be pretty hard to amend away the Cruz amendment from the final version of Trumpcare/Kochcare:

    New York Magazine

    Cruz Amendment to Senate Health-Care Bill Now Dividing GOP

    By Ed Kilgore
    July 6, 2017 11:02 am

    When Ted Cruz first aired his proposal to let insurance companies that sell one Obamacare-compliant health-care plan to sell cheapie bare-bones plans as well, he got lot of praise for perhaps finding a way out of the ideological gridlock that was keeping Senate Republicans short of the votes they needed to pass their version of Trumpcare. The idea was that this approach would give conservatives the avenue for lower individual insurance premiums they were demanding without a frontal attack on protections for people with preexisting conditions.

    As my colleague Eric Levitz noted at the time, however, the Cruz proposal represented a sneaky collateral attack on the risk pools that make insurance affordable for sick folks:

    Under Cruz’s model, many healthy consumers would avoid shelling out for high-cost, comprehensive plans. This would then make the pool of people willing to pay for such coverage disproportionately sick, which would cause the price of such plans to rise, which would make the pool even sicker, which cause prices to premiums to rise further, which would make the pool sicker still, on and on, in a death spiral, until the sick were priced out of the market completely.

    This realization is now spreading among Senate Republicans, along with opposition to the Cruz amendment, as the Hill reports:

    “I would say that if we voted on the Cruz proposal, it would be in the neighborhood of 37 to 15 against, 37 no votes and 15 yeses, and that’s probably generous,” said a GOP aide familiar with the Senate negotiations. “Nobody wants to go home and say to a 45-year-old steelworker with diabetes that you should have to pay a lot more for your health insurance.”

    Frustrations are mounting with Cruz among Senate negotiators because leaders have felt blindsided by his demand that the legislation essentially eliminate the protection for people with pre-existing conditions.

    But it may be too late now to put the genie back in the bottle: Conservative groups like FreedomWorks and the Club for Growth are promoting the Cruz amendment avidly. And perhaps more significantly, House Freedom Caucus chairman Mark Meadows, who has generally been quiet about Senate developments, is suddenly acting as though adoption of Cruz’s idea may be a condition for his own support

    As a practical matter, this debate could be in the hands of the Congressional Budget Office, which Mitch McConnell has asked to provide a “score” for amended versions of the Senate bill with and without Cruz’s proposal. It’s unclear which set of assumptions about the Texan’s handiwork the green eyeshades will adopt:

    Republican aides who say Cruz’s amendment is politically untenable acknowledge that the CBO could report some good news, like that the proposal would send down premiums without significantly affecting coverage.

    But they think it’s more likely that the CBO analysis will be damning.

    “Or CBO will come back and say the market will be destroyed and 45 million people will be left without insurance,” said one staffer.

    However it all turns out, the Cruz proposal has cast a spotlight on one of the underlying problems the GOP has faced throughout its crusade to repeal Obamacare. Giving people with preexisting health conditions access to affordable health insurance has always been one of the most popular features of the Affordable Care Act. To the extent that accomplishing this goal requires broader risk pools that shift some costs to younger and healthier people (with the poorer among them receiving compensatory federal subsidies), it’s “socialist” in the eyes of many conservatives. And so they keep coming up with ways around it, from state “opt outs” of provisions banning price discrimination against sick people (the “solution” in the House-passed American Health Care Act) to the kind of indirect approach Cruz is promoting.

    Conservatives are being honest about one thing: A full repeal of Obamacare would send the health-care system back to the pre-ACA status quo ante. In those days people with preexisting conditions were mostly out of luck (aside from whatever succor they are offered via the health-insurance ghettos states create under the rubric of “high-risk pools”), while healthy people had a wide range of affordable options — including the option of going without insurance. To the extent conservatives prefer that situation to the “tyranny” and “big government” of Obamacare, they will just have to accept the political damage associated with the dramatic unpopularity of their ideas.

    ———-

    “Cruz Amendment to Senate Health-Care Bill Now Dividing GOP” by Ed Kilgore; New York Magazine; 07/06/2017

    “However it all turns out, the Cruz proposal has cast a spotlight on one of the underlying problems the GOP has faced throughout its crusade to repeal Obamacare. Giving people with preexisting health conditions access to affordable health insurance has always been one of the most popular features of the Affordable Care Act. To the extent that accomplishing this goal requires broader risk pools that shift some costs to younger and healthier people (with the poorer among them receiving compensatory federal subsidies), it’s “socialist” in the eyes of many conservatives. And so they keep coming up with ways around it, from state “opt outs” of provisions banning price discrimination against sick people (the “solution” in the House-passed American Health Care Act) to the kind of indirect approach Cruz is promoting

    An amendment to make sure the health insurance markets have a sick vs healthy dynamic that makes it a lot more expensive for the sick pools. And it also gets rid of Obamacare protections by allow companies to offer plans without them that will no doubt be marketed heavily. That’s the Cruz amendment. It’s designed to create a pricing and literal death spiral for the sickest:


    Under Cruz’s model, many healthy consumers would avoid shelling out for high-cost, comprehensive plans. This would then make the pool of people willing to pay for such coverage disproportionately sick, which would cause the price of such plans to rise, which would make the pool even sicker, which cause prices to premiums to rise further, which would make the pool sicker still, on and on, in a death spiral, until the sick were priced out of the market completely.

    And the worst part is, the Kochs love. And their Freedom Caucus pets:


    But it may be too late now to put the genie back in the bottle: Conservative groups like FreedomWorks and the Club for Growth are promoting the Cruz amendment avidly. And perhaps more significantly, House Freedom Caucus chairman Mark Meadows, who has generally been quiet about Senate developments, is suddenly acting as though adoption of Cruz’s idea may be a condition for his own support.

    And it even sounds like most GOP Senators would rather amend it all away (and probably amend Ted Cruz away if they could):


    “I would say that if we voted on the Cruz proposal, it would be in the neighborhood of 37 to 15 against, 37 no votes and 15 yeses, and that’s probably generous,” said a GOP aide familiar with the Senate negotiations. “Nobody wants to go home and say to a 45-year-old steelworker with diabetes that you should have to pay a lot more for your health insurance.”

    Frustrations are mounting with Cruz among Senate negotiators because leaders have felt blindsided by his demand that the legislation essentially eliminate the protection for people with pre-existing conditions.

    According to one estimate only 15 fellow GOPers are likely backers of Ted Cruz’s amendment. At least that was the case as the the time of the article which was about a week and a half ago.

    But that amendment was part of the recently issued new Senate GOP plan so it sounds like Ted Cruz/Freedom Caucus/Koch faction won. So now the health insurance industry is trying to make it clear what this is a bad idea that will result in fewer people being insured:

    Talking Points Memo
    DC

    Insurers Torch New Cruz Provision In TrumpCare: ‘Simply Unworkable’

    By Tierney Sneed
    Published July 15, 2017 9:49 am

    Big players in the insurance industry, which has mostly held back public criticism of the GOP’s Obamacare repeal push, eviscerated a Sen. Ted Cruz (R-TX)-sponsored provision that was included in the latest version of the Senate legislation.

    “It is simply unworkable in any form and would undermine protections for those with pre-existing medical conditions, increase premiums and lead to widespread terminations of coverage for people currently enrolled in the individual market,” Blue Cross Blue Shield and America’s Health Insurance Plans said Friday in a rare joint letter to Senate leaders.

    The Cruz proposal, known as the “Consumer Freedom Option,” would allow insurers to sell plans that would be free of many Affordable Care Act mandates if they were also selling Obamacare-compliant plans.

    Insurers and outside health experts had already been raising their concerns with the idea when it was being discussed in the abstract, warning the it segment the market between healthy people choosing the non-compliant plans and sick people the comprehensive ACA ones. The insurers upped their complaints in the letter Friday.

    “This would allow the new plans to ‘cherry pick’ only healthy people from the existing market making coverage unaffordable for the millions of people who need or want comprehensive coverage, including, for example, coverage for prescription drugs and mental health services,” the insurers said.

    It had been an open question whether Senate GOP leaders would include the amendment in the base legislation they unveiled Thursday, with Cruz promising he would vote against it if it was not.

    The Cruz language in the latest bill was placed in brackets to signify that it was still a work in progress, Senate aides said.

    The insurers also bashed the details of the proposal that became clear after it was unveiled, including an apparent attempt of have the non-compliant plans and the ACA plans share a single risk pool.

    “That is not the case. The Consumer Freedom Option establishes a ‘single risk pool’ in name only. In fact, it creates two systems of insurance for healthy and sick people,” the insurers said.

    They said that the $70 billion added to the new draft to offset premium increases for the sick “is insufficient and additional funding will not make the provision workable for consumers or taxpayers.”

    They went on to predict that the proposal “will lead to far fewer, if any, coverage options for consumers who purchase their plan in the individual market.”

    “As a result, millions of more individuals will become uninsured,” the letter said.

    One more GOP defection from the legislation, which already has two Senate Republican opponents, would kill it even before the Senate could advance it procedurally, in a vote slated for this coming week.

    After the initial vote is taken to advance legislation, there will be an amendments process where the Cruz proposal could be struck, as insurers are urging. The parliamentarian may also find it violates Senate rules concerning the process the GOP is using to push the legislation.

    ————

    “Insurers Torch New Cruz Provision In TrumpCare: ‘Simply Unworkable’” by Tierney Sneed; Talking Points Memo; 07/15/2017

    ““This would allow the new plans to ‘cherry pick’ only healthy people from the existing market making coverage unaffordable for the millions of people who need or want comprehensive coverage, including, for example, coverage for prescription drugs and mental health services,” the insurers said.”

    Millions of people will lose coverage. So says the health insurance lobby. And it’s going to be the people who aren’t going to be helped by Ted Cruz’s bare bones plans because they’ll need actual medical care. To live and stuff:


    The insurers also bashed the details of the proposal that became clear after it was unveiled, including an apparent attempt of have the non-compliant plans and the ACA plans share a single risk pool.

    “That is not the case. The Consumer Freedom Option establishes a ‘single risk pool’ in name only. In fact, it creates two systems of insurance for healthy and sick people,” the insurers said.

    They said that the $70 billion added to the new draft to offset premium increases for the sick “is insufficient and additional funding will not make the provision workable for consumers or taxpayers.”

    They went on to predict that the proposal “will lead to far fewer, if any, coverage options for consumers who purchase their plan in the individual market.”

    “As a result, millions of more individuals will become uninsured,” the letter said.

    “As a result, millions of more individuals will become uninsured,” the letter said.

    Again, that same amendment was in the recently released new GOP Senate Trumpcare bill. And it’s not just the Freedom Caucus and the Koch network backing Cruz up. The Trump administration’s Health and Human Services Secretary Tom Price wants to know what all the health insurance industry opposition is coming from since, as Price puts it, Ted Cruz’s amendment simply allows things to go back to how they were before Obamacare. In other words, its undoes the protections in Obamacare that are so popular most of the GOP Senators are too scared to vote for something that repeals them. Because it’s that harmful to their constituents. Ted Cruz’s amendment is a poison pill designed to kill Obamacare:

    Think Progress

    Tom Price admits that the new Trumpcare is only repeal, no replace
    Trump’s secretary of health and human services says all insurers have to do “is dust off how they did business before Obamacare.”

    Josh Israel
    Jul 16, 2017

    During his presidential campaign, Donald Trump promised, over and over again, that he would replace Obamacare with “something terrific,” that would “take care of everybody” and be “a lot less expensive” for consumers and the government.

    But despite claims by Senate Republican Leader Mitch McConnell (R-KY) that his latest version of Trumpcare would provide “stability” while “improving affordability,” Secretary of Health and Human Services Tom Price made a major admission about the bill Sunday: that the legislation to repeal and replace Obamacare would simply permit insurers return to the ways they used to operate.

    On ABC’s This Week, the longtime Obamacare critic was pressed by Jon Karl about a provision in the bill pushed by Sen. Ted Cruz (R-TX), which would allow insurance companies to offer sub-standard plans. Karl noted that not only do more than 10 medical groups and 32 cancer organizations oppose the Trumpcare bill, “a rare joint statement by the biggest insurance companies in the country called the Cruz amendment ‘unworkable in any form’ [as] ‘it would lead to, ‘widespread terminations of coverage.”

    Price responded that he found that wall of opposition “really perplexing, especially from the insurance companies, cause all they have to do is dust off how they did business before Obamacare.”

    But while much of this bill would return things to the bad old days, it would also hurt consumers in a novel way. Under the Trumpcare bill, customers who purchase a cheapo Cruz substandard plans would not be considered to have had “continuous coverage.” And a provision of the bill states that anyone without continuous coverage would be subject to a six-month waiting period before they could buy any real plan. In other words, it could be even worse than the pre-Obamacare system for people who suddenly become sick.

    ———-

    “Tom Price admits that the new Trumpcare is only repeal, no replace” by Josh Israel; Think Progress; 07/16/2017

    “Price responded that he found that wall of opposition “really perplexing, especially from the insurance companies, cause all they have to do is dust off how they did business before Obamacare.””

    Secretary Price just can’t figure out why the health insurance industry can’t keep its yap shut about how millions are going to lose coverage thanks to the Cruz Amendment since, hey, it will be like before! The Trump Administration and GOP have turned private health insurers into the ‘good guys’ during a major health reform debate. That’s where we are.

    Except the Cruz amendment isn’t just going to return things to the pre-Obamacare era. It’ll make things worse. For the young and healthy who bought those Cruz plans and are suddenly sick:


    But while much of this bill would return things to the bad old days, it would also hurt consumers in a novel way. Under the Trumpcare bill, customers who purchase a cheapo Cruz substandard plans would not be considered to have had “continuous coverage.” And a provision of the bill states that anyone without continuous coverage would be subject to a six-month waiting period before they could buy any real plan. In other words, it could be even worse than the pre-Obamacare system for people who suddenly become sick.

    Yep, thanks to the fact that Cruz’s bare bones plans are so inadequate that they don’t even qualify as being ‘covered’ under the pre-existing condition protection rule. So people with the Cruzcare plans won’t be allowed to buy insurance fore six months if they get ill and suddenly need more comprehensive coverage. It’s the six-month window-of-mandatory-uncare Ted Cruz got introduced into Trumpcare:

    Think Progress

    The Trumpcare provision that could be a death sentence for people who get sick suddenly
    Trumpcare keeps getting worse.

    Lindsay Gibbs
    Jul 15, 2017

    Republican senators are hoping to pass the Better Care Reconciliation Act—a.k.a. Trumpcare—next week, so in the past few days, there has been a flurry of amendments and altercations to the bill in hopes of securing enough votes.

    Perhaps the most egregious change this week was the amendment proposed by Sen. Ted Cruz (R-TX), which will allow insurers to offer bare-bones plans as long as they offer at least one plan that fully complies with existing Affordable Care Act regulations on preexisting conditions and comprehensive coverage. On Friday, insurers said the amendment was “unworkable in any form.”

    But, somehow, it gets even worse. Not only are the bare-bones plans under the Cruz amendment so cheap that they would cause the cost for comprehensive, ACA-compliant insurance plans to skyrocket, but the Cruz-sponsored plans are so stripped down that they don’t even count as “continuous coverage” in the BCRA.

    In other words, if you are a healthy person who purchases the cheap Cruz plan because it’s more financially feasible, but then you become sick and need to upgrade to a better plan, you would be locked out of the insurance marketplace for six full months until you were able to buy a more robust insurance plan.

    The Cruz amendment *could* basically destroy the entire individual health market in America. And they're gonna vote in 5 days.— Christopher Hayes (@chrislhayes) July 15, 2017

    That’s absurd, considering the six-month ban is in place so that people won’t go without insurance until they become sick, and the entire point of the Cruz amendment seems to be to keep healthy people in the insurance marketplace in the first place.

    Former Democratic congresswoman Donna Edwards put a face to this problem on MSNBC’s AM Joy on Saturday morning.

    Last week, Edwards penned a moving op-ed in the Washington Post discussing her battle with multiple sclerosis. She was diagnosed with the disease last summer, and was planning on purchasing insurance through the ACA when her current $800-a-month cobra plan expires next June. However, if the BCRA passes, she may be unable to get insurance due to her preexisting condition.

    On AM Joy, Edwards stressed that if she had purchased one of the cheap Cruz plans last year when she was diagnosed with M.S., she would have had to go six months before being allowed to purchase the (expensive) insurance that would cover her condition.

    “If I had one of these simple bare-bones plans in May of 2016, by the time I was diagnosed with multiple sclerosis in June of 2016, I would not have health care,” she said.

    Cruz plans don’t cover prescription drugs, chemotherapy, hospitalization, or pregnancy.

    ———-

    “The Trumpcare provision that could be a death sentence for people who get sick suddenly” by Lindsay Gibbs; Think Progress; 07/15/2017

    “In other words, if you are a healthy person who purchases the cheap Cruz plan because it’s more financially feasible, but then you become sick and need to upgrade to a better plan, you would be locked out of the insurance marketplace for six full months until you were able to buy a more robust insurance plan.”

    Don’t forget that one of the key ideas in Obamacare for how to ‘bend the cost curb’ and slow down the growth in health care spending is to ensure that people have adequate health care coverage to address medical issues early, when they are far cheaper to address. And now we have the Cruz Amendment that creates “sick vs healthy” pools, makes the sick pools too expensive to afford, and allows for Cruz-style ‘affordable’ plans that cover almost nothing and come with a six month “good luck!” clause if you need to buy one of the expensive plans that actually have meaningful coverage.

    Good luck young and healthy people who can’t afford anything better than a Cruz plan! Try not get sick. Or pregnant. And definitely not cancer:

    Cruz plans don’t cover prescription drugs, chemotherapy, hospitalization, or pregnancy.

    Yep, if you suddenly have a fetus, or tumor, growing inside you, Ted Cruz and the GOP have a fun 6 month window of wonder, followed by some extra expensive pricing options for the “essential benefits” plan you need, planned for you and your new growing thing. Same for all the rest of the stuff not covered by the Cruz plans.

    So that’s all one more reason people hate Ted Cruz. Although obviously not everyone. There are exceptions.

    Posted by Pterrafractyl | July 16, 2017, 5:25 pm
  6. Is Trumpcare once again on life support? It’s looking that way after Elizabeth MacDonough, the Senate Parliamentarian whose responsibilities include deciding which provisions in Trumpcare are allowable under the ‘Byrd Rule’ that allows a bill to pass the Senate with a straight 51 vote majority but only if it doesn’t involve a net change in spending, maybe have just struck down some provisions that could be a deal breaker for a large chunk of the GOP caucus. Especially a deal breaker for the ‘Freedom Caucus’: The defunding of Planned Parenthood was just ruled to be a violation of the ‘Byrd Rule’. And if there’s one thing that would give waiver GOPers a good excuse to explain to their constituents why they voted against Trumpcare, it’s a version of Trumpcare where Planned Parenthood still gets funding:

    The Atlantic

    The GOP Health-Care Bill’s Byrd Rule Dilemma

    The Senate parliamentarian’s rejection of important provisions of the GOP’s Obamacare repeal bill puts its status in further jeopardy.

    Vann R. Newkirk II
    7/22/2017 12:07 PM ET

    On Friday, Senate Democrats released a list of provisions in the Republican health-care bill that the Senate parliamentarian holds can pass via a simple, filibuster-proof majority vote. Among those provisions that didn’t meet her scrutiny are the bill’s plans to defund Planned Parenthood, restrict tax-credit funding for insurance plans that provide abortions, and a six-month “lockout” period from purchasing insurance for people who don’t maintain continuous coverage.

    If this preliminary guidance holds, the Better Care Reconciliation Act—which is already in dire straits—seems likely to fail.

    The final assessment of the parliamentarian, Elizabeth MacDonough, is a critical step in the GOP’s strategy for passing their bill to repeal and replace Obamacare. Republicans have opted to pass their health-care legislation via the special reconciliation process, under which they can cut debate short in the Senate and thus eliminate indefinite filibusters, which Democrats would certainly use in order to block any attempt to repeal Obamacare. But bills have to follow a certain procedure—called the Byrd Rule—in order to pass by reconciliation.

    Broadly, the Byrd rule states that reconciliation legislation can only include changes to laws that directly affect the federal budget, and can be scored by the Congressional Budget Office. So for example, Republicans could “repeal” Obamacare premium tax credits via reconciliation by making the credit $0 for everyone, but couldn’t in theory use the same bill to eliminate the requirement for insurers that take premium tax credits to also take people with pre-existing conditions.

    In practice, the parliamentarian reviews every provision of a reconciliation bill and outlines which ones pass muster under the Byrd rule by her own judgment. In this instance, according to the Democratic outline, MacDonough’s office ruled that “abortion restrictions on the premium tax credit and the small business tax credit, and the language defunding Planned Parenthood, violate the Byrd Rule.” Additionally, other provisions on the chopping block include the BCRA’s six-month continuous-coverage lockout, and its sunset of minimum requirements for alternative private-administered Medicaid plans.

    Still under review are the BCRA’s provisions that allow states to waive certain essential health benefits for exchange plans, increase the age-rating scheme for older adults, and allow Medicaid funding to go to states in lump sum “block grants.”

    Notably, all of these provisions that have either been challenged by the parliamentarian’s office or still await a final determination are those that were included in the BCRA to gain the support of hard-core conservatives, who, like their counterpart moderate faction have often criticized the bill and could harpoon any legislative action. It’s hard to see how a bill that retains Planned Parenthood funding and the use of premium tax-credits for plans that cover abortion would proceed to debate through conservative objections.

    Some Republicans are hinting at more radical steps to get past MacDonough’s review. Senator Ted Cruz of Texas has been floating the idea of simply ignoring the parliamentarian’s review for months now. The presiding officer of the Senate—Vice President Mike Pence—technically makes the final call on parliamentary procedures, and could overrule the parliamentarian’s objections, although this would be a highly controversial break of Senate norms that hasn’t been attempted for over 40 years.

    But this seems to be the era of flouting norms, as evidenced by the increasing willingness of Senate Republicans to challenge the CBO scoring process, and perhaps even consider the filibuster “nuclear option.” It’s hard to rule anything out at this stage.

    ———-

    “The GOP Health-Care Bill’s Byrd Rule Dilemma” by Vann R. Newkirk II; The Atlantic; 07/22/2017

    “If this preliminary guidance holds, the Better Care Reconciliation Act—which is already in dire straits—seems likely to fail.”

    Yeah, it’s hard to see the GOP passing a any health care bill that includes funding for Planned Parenthood. After all, taking a moral grey zone issue people feel very passionately about but with no clear ‘right/wrong’ dividing line like abortion and elevating it to a black and white issue of divine importance is one of the core elements of how the GOP maintains some semblance of moral posturing while implementing its heartless pro-oligarch agenda. The GOP needs very high profile and adamant opposition to abortion as political cover. Which is part of why it’s going to be very interesting to see if the ‘Byrd rule’ becomes the ex-Byrd rule:


    Some Republicans are hinting at more radical steps to get past MacDonough’s review. Senator Ted Cruz of Texas has been floating the idea of simply ignoring the parliamentarian’s review for months now. The presiding officer of the Senate—Vice President Mike Pence—technically makes the final call on parliamentary procedures, and could overrule the parliamentarian’s objections, although this would be a highly controversial break of Senate norms that hasn’t been attempted for over 40 years

    At the same time, if the only thing standing in the way of Trumpcare is something like Planned Parenthood funding, it’s hard to see how key oligarch decision-makers like the Koch brothers are going to let that stand in the way of a bill that would slash their taxes and gut Medicaid. And that’s part of what what’s going to make the push to pass Trumpcare so fascinating now that the defunding of Planned Parenthood was struck down by the Senate Parliamentarian: the GOP might need to ditch the issue that gives ig moral cover in the eyes of its base in order to pass a deeply immoral bill that the party’s real leaders, the Koch brothers and other wealthy patrons, really, really want to see become law.

    And it’s going to be even more interesting if the one provision that is critical for the gutting a Medicaid and destruction of the Medical safety-net, the block-granting of Medicaid to the states that ensures the program wither and dies over time, gets struck down by the Senate’s Parliamentarian too. And that might still happen:


    Still under review are the BCRA’s provisions that allow states to waive certain essential health benefits for exchange plans, increase the age-rating scheme for older adults, and allow Medicaid funding to go to states in lump sum “block grants.”

    Yep, the Medicaid block-granting is still an open question. That’s a very big ‘uh oh’.

    So at that point it’s very possible the GOP seriously isn’t going to pass Trumpcare through the Senate. Of course, it’s also seriously possible that Ted Cruz’s proposal to just ignore the parliamentarian will happen too, and if that happens the Senate effectively killed the filibuster when it comes to passing spending bills. And that could lead to quite of bit of cutting. Into quite a bit of bone.

    Could that happen? Well, the GOP has to pass Trumpcare somehow. And if that means breaking the rules, well, so? This is the GOP we’re talking about. The party has but one rule: follow the money. And as ‘the money’ informed the GOP last month, if the GOP doesn’t pass Trumpcare, soon, ‘the money’ might not give it more money:

    Associated Press

    Koch network ‘piggy banks’ closed until Republicans pass health and tax reform

    Koch officials said that the network’s midterm budget for policy and politics is between $300m and $400m, but donors are demanding legislative progress

    Associated Press in Colorado Springs
    Monday 26 June 2017 07.49 EDT

    At a weekend donor retreat attended by at least 18 elected officials, the Koch brothers warned that time is running out to push their agenda, most notably healthcare and tax reform, through Congress.

    One Texas-based donor warned Republican lawmakers that his “Dallas piggy bank” was now closed, until he saw legislative progress.

    “Get Obamacare repealed and replaced, get tax reform passed,” said Doug Deason. “Get it done and we’ll open it back up.”

    Nonetheless, Koch officials said that the network’s midterm budget for policy and politics is between $300m and $400m.

    The Senate will this week seek to pass its version of healthcare reform – at present it does not have enough Republican support to overcome blanket Democratic opposition.

    “There is urgency,” said Tim Phillips, who leads Koch network’s political arm, Americans for Prosperity, at the industrialist brothers’ retreat in Colorado Springs. “We believe we have a window of about 12 months to get as much of it accomplished as possible before the 2018 elections grind policy to a halt.”

    The window for action may be even smaller, some Koch allies warned at the weekend retreat that drew roughly 400 participants to the heart of the Rocky Mountains. The price for admission for most was a pledge to give at least $100,000 this year to the Kochs’ broad policy and political network.

    In between meetings, Dave Brat, a Virginia Republican representative, predicted dire consequences in next year’s midterm elections should his party fail to deliver on its repeated promises.

    “If we don’t get healthcare, none of us are coming back,” he said in a brief interview. “We said for seven years you’re gonna repeal Obamacare. It’s nowhere near repealed.”

    It’s the same for tax reform, Brat said: “We don’t get taxes through, we’re all going home. Pack the bags.”

    There was a sense of deep frustration from conservative officials and donors alike, decrying the pace of progress in Washington with Republicans controlling both chambers of Congress and the White House for the first time in a decade.

    Deason has already informed a handful of congressional Republicans that the “Dallas piggy bank” is closed until he sees more action. He said he was recently approached by congressmen Mark Meadows of North Carolina and Jim Jordan of Ohio about hosting a fundraiser.

    “I said, ‘No I’m not going to because we’re closing the checkbook until you get some things done,’” Deason said, noting he’s encouraged nearly two dozen major Texas donors to follow his lead.

    While some donors threatened to withhold campaign cash, Koch’s team outlined a broader strategy to help shape the debate. Already, Americans For Prosperity claims a paid staff of more than 400 full-time activists in 36 states.

    The group is actively lobbying Senate Republicans to change their current healthcare proposal, which it views as insufficiently conservative.

    “We are not committed to the Senate bill in its current form, but there is still time to make changes and we’re actively working to improve it,” Phillips said.

    At the same time, Koch’s allies are aggressively pushing forward on the taxes. The network is running what it describes as “a first wave” of digital ads calling on more than 50 House and Senate Republicans in both parties to overhaul the nation’s tax code.

    Later in the summer, Philips said, Americans for Prosperity will begin hosting rallies and other events to generate momentum for a tax overhaul in all 36 states where they have full-time operations.

    Sean Lansing, AFP’s chief operating officer, warned that the Republican party’s House majority could be in jeopardy if the Republican-led Congress doesn’t follow through.

    “If they don’t make good on these promises … there are going to be consequences, and quite frankly there should be,” Lansing said.

    Republicans would have to lose 24 seats to lose the House majority. In a handful of recent special elections, the GOP has prevailed, despite Donald Trump’s low approval ratings.

    Another Koch donor, Chris Wright, of Colorado, says Republicans likely have a 10-month window before any chance of major policy action is suffocated by next year’s midterms.

    “If we don’t get anything done by then, the elections probably don’t go very well,” Wright said. “They may not go well anyway.”

    ———-

    “Koch network ‘piggy banks’ closed until Republicans pass health and tax reform”; Associated Press; 06/27/2017

    “One Texas-based donor warned Republican lawmakers that his “Dallas piggy bank” was now closed, until he saw legislative progress.”

    The natives are getting restless. And they want results soon. And that warning from the Koch network was issued last month, before all the more recent Trumpcare failures. It’s a key factor to keep in mind now that we learned that the defunding of Planned Parenthood is potentially taken off the table: the Koch network of super-wealthy donors wants results. Yesterday.

    At the same time, while no results potentially means a GOP wipeout in 2018 from a demoralized voter base and a demoralized donor base, as one Koch donor acknowledge, even if they do get results, it’s not like the mid-terms are necessarily going to go well:


    Sean Lansing, AFP’s chief operating officer, warned that the Republican party’s House majority could be in jeopardy if the Republican-led Congress doesn’t follow through.

    “If they don’t make good on these promises … there are going to be consequences, and quite frankly there should be,” Lansing said.

    Republicans would have to lose 24 seats to lose the House majority. In a handful of recent special elections, the GOP has prevailed, despite Donald Trump’s low approval ratings.

    Another Koch donor, Chris Wright, of Colorado, says Republicans likely have a 10-month window before any chance of major policy action is suffocated by next year’s midterms.

    “If we don’t get anything done by then, the elections probably don’t go very well,” Wright said. “They may not go well anyway.”

    Yeah, it’s kind of hard to see how the GOP doesn’t well in 2018 if it doesn’t pass an Obamacare replacement since that’s what it’s been promising the GOP base for years. But it’s also hard to see how they do well in 2018 if they do pass it since it’s such an incredibly unpopular proposed law.

    Still, the Koch’s want to see Trumpcare become a reality and they aren’t going to accept defeat casually. If Trumpcare is defeated this year, that’s not going to be the end. If it takes another year, or two years, or 10 or 20, this effort is going to continue. How do we know? Because the Kochs and their far-right oligarch allies have been trying to dismantle any and all government safety-net programs for decades. They think things like Medicaid grievously harm their ‘freedom’. Along with anything else that impinges on the wealth or property of billionaires like themselves. Anything. For real. They actually think this and have been decades quietly putting that moral perspective into law:

    The Guardian

    A despot in disguise: one man’s mission to rip up democracy

    James McGill Buchanan’s vision of totalitarian capitalism has infected public policy in the US. Now it’s being exported

    George Monbiot

    Wednesday 19 July 2017 00.29 EDT
    Last modified on Wednesday 19 July 2017 08.35 EDT

    It’s the missing chapter: a key to understanding the politics of the past half century. To read Nancy MacLean’s new book, Democracy in Chains: The Deep History of the Radical Right’s Stealth Plan for America, is to see what was previously invisible.

    The history professor’s work on the subject began by accident. In 2013 she stumbled across a deserted clapboard house on the campus of George Mason University in Virginia. It was stuffed with the unsorted archives of a man who had died that year whose name is probably unfamiliar to you: James McGill Buchanan. She says the first thing she picked up was a stack of confidential letters concerning millions of dollars transferred to the university by the billionaire Charles Koch.

    Her discoveries in that house of horrors reveal how Buchanan, in collaboration with business tycoons and the institutes they founded, developed a hidden programme for suppressing democracy on behalf of the very rich. The programme is now reshaping politics, and not just in the US.

    Buchanan was strongly influenced by both the neoliberalism of Friedrich Hayek and Ludwig von Mises, and the property supremacism of John C Calhoun, who argued in the first half of the 19th century that freedom consists of the absolute right to use your property (including your slaves) however you may wish; any institution that impinges on this right is an agent of oppression, exploiting men of property on behalf of the undeserving masses.

    James Buchanan brought these influences together to create what he called public choice theory. He argued that a society could not be considered free unless every citizen has the right to veto its decisions. What he meant by this was that no one should be taxed against their will. But the rich were being exploited by people who use their votes to demand money that others have earned, through involuntary taxes to support public spending and welfare. Allowing workers to form trade unions and imposing graduated income taxes were forms of “differential or discriminatory legislation” against the owners of capital.

    Any clash between “freedom” (allowing the rich to do as they wish) and democracy should be resolved in favour of freedom. In his book The Limits of Liberty, he noted that “despotism may be the only organisational alternative to the political structure that we observe.” Despotism in defence of freedom.

    His prescription was a “constitutional revolution”: creating irrevocable restraints to limit democratic choice. Sponsored throughout his working life by wealthy foundations, billionaires and corporations, he developed a theoretical account of what this constitutional revolution would look like, and a strategy for implementing it.

    He explained how attempts to desegregate schooling in the American south could be frustrated by setting up a network of state-sponsored private schools. It was he who first proposed privatising universities, and imposing full tuition fees on students: his original purpose was to crush student activism. He urged privatisation of social security and many other functions of the state. He sought to break the links between people and government, and demolish trust in public institutions. He aimed, in short, to save capitalism from democracy.

    In 1980, he was able to put the programme into action. He was invited to Chile, where he helped the Pinochet dictatorship write a new constitution, which, partly through the clever devices Buchanan proposed, has proved impossible to reverse entirely. Amid the torture and killings, he advised the government to extend programmes of privatisation, austerity, monetary restraint, deregulation and the destruction of trade unions: a package that helped trigger economic collapse in 1982.

    None of this troubled the Swedish Academy, which through his devotee at Stockholm University Assar Lindbeck in 1986 awarded James Buchanan the Nobel memorial prize for economics. It is one of several decisions that have turned this prize toxic.

    But his power really began to be felt when Koch, currently the seventh richest man in the US, decided that Buchanan held the key to the transformation he sought. Koch saw even such ideologues as Milton Friedman and Alan Greenspan as “sellouts”, as they sought to improve the efficiency of government rather than destroy it altogether. But Buchanan took it all the way.

    MacLean says that Charles Koch poured millions into Buchanan’s work at George Mason University, whose law and economics departments look as much like corporate-funded thinktanks as they do academic faculties. He employed the economist to select the revolutionary “cadre” that would implement his programme (Murray Rothbard, at the Cato Institute that Koch founded, had urged the billionaire to study Lenin’s techniques and apply them to the libertarian cause). Between them, they began to develop a programme for changing the rules.

    The papers Nancy MacLean discovered show that Buchanan saw stealth as crucial. He told his collaborators that “conspiratorial secrecy is at all times essential”. Instead of revealing their ultimate destination, they would proceed by incremental steps. For example, in seeking to destroy the social security system, they would claim to be saving it, arguing that it would fail without a series of radical “reforms”. (The same argument is used by those attacking the NHS). Gradually they would build a “counter-intelligentsia”, allied to a “vast network of political power” that would become the new establishment.

    Through the network of thinktanks that Koch and other billionaires have sponsored, through their transformation of the Republican party, and the hundreds of millions they have poured into state congressional and judicial races, through the mass colonisation of Trump’s administration by members of this network and lethally effective campaigns against everything from public health to action on climate change, it would be fair to say that Buchanan’s vision is maturing in the US.

    In one respect, Buchanan was right: there is an inherent conflict between what he called “economic freedom” and political liberty. Complete freedom for billionaires means poverty, insecurity, pollution and collapsing public services for everyone else. Because we will not vote for this, it can be delivered only through deception and authoritarian control. The choice we face is between unfettered capitalism and democracy. You cannot have both.

    ———

    “A despot in disguise: one man’s mission to rip up democracy” by George Monbiot; The Guardian; 07/19/2017

    “The history professor’s work on the subject began by accident. In 2013 she stumbled across a deserted clapboard house on the campus of George Mason University in Virginia. It was stuffed with the unsorted archives of a man who had died that year whose name is probably unfamiliar to you: James McGill Buchanan. She says the first thing she picked up was a stack of confidential letters concerning millions of dollars transferred to the university by the billionaire Charles Koch.

    And what else did Nancy MacLean discover while uncovering the work and influence of James McGill Buchanan and his Koch-backed financing? A house of horrors that are in store for Americans and the world if these schemes come to full fruition:


    Her discoveries in that house of horrors reveal how Buchanan, in collaboration with business tycoons and the institutes they founded, developed a hidden programme for suppressing democracy on behalf of the very rich. The programme is now reshaping politics, and not just in the US.

    Buchanan was strongly influenced by both the neoliberalism of Friedrich Hayek and Ludwig von Mises, and the property supremacism of John C Calhoun, who argued in the first half of the 19th century that freedom consists of the absolute right to use your property (including your slaves) however you may wish; any institution that impinges on this right is an agent of oppression, exploiting men of property on behalf of the undeserving masses.

    James Buchanan brought these influences together to create what he called public choice theory. He argued that a society could not be considered free unless every citizen has the right to veto its decisions. What he meant by this was that no one should be taxed against their will. But the rich were being exploited by people who use their votes to demand money that others have earned, through involuntary taxes to support public spending and welfare. Allowing workers to form trade unions and imposing graduated income taxes were forms of “differential or discriminatory legislation” against the owners of capital.

    Any clash between “freedom” (allowing the rich to do as they wish) and democracy should be resolved in favour of freedom. In his book The Limits of Liberty, he noted that “despotism may be the only organisational alternative to the political structure that we observe.” Despotism in defence of freedom.

    His prescription was a “constitutional revolution”: creating irrevocable restraints to limit democratic choice. Sponsored throughout his working life by wealthy foundations, billionaires and corporations, he developed a theoretical account of what this constitutional revolution would look like, and a strategy for implementing it.

    That’s definitely horrifying. And it’s been horrifying for decades as that vision successfully took over the Republican Party and the Republican Party largely took over government. And now, finally, the previously untouachable entitlements are finally not just touchable but dismantlable. And it’s all being sold as “Saving [Medicaid/Medicare/Social Security]”


    He explained how attempts to desegregate schooling in the American south could be frustrated by setting up a network of state-sponsored private schools. It was he who first proposed privatising universities, and imposing full tuition fees on students: his original purpose was to crush student activism. He urged privatisation of social security and many other functions of the state. He sought to break the links between people and government, and demolish trust in public institutions. He aimed, in short, to save capitalism from democracy.

    MacLean says that Charles Koch poured millions into Buchanan’s work at George Mason University, whose law and economics departments look as much like corporate-funded thinktanks as they do academic faculties. He employed the economist to select the revolutionary “cadre” that would implement his programme (Murray Rothbard, at the Cato Institute that Koch founded, had urged the billionaire to study Lenin’s techniques and apply them to the libertarian cause). Between them, they began to develop a programme for changing the rules.

    The papers Nancy MacLean discovered show that Buchanan saw stealth as crucial. He told his collaborators that “conspiratorial secrecy is at all times essential”. Instead of revealing their ultimate destination, they would proceed by incremental steps. For example, in seeking to destroy the social security system, they would claim to be saving it, arguing that it would fail without a series of radical “reforms”. (The same argument is used by those attacking the NHS). Gradually they would build a “counter-intelligentsia”, allied to a “vast network of political power” that would become the new establishment.

    Through the network of thinktanks that Koch and other billionaires have sponsored, through their transformation of the Republican party, and the hundreds of millions they have poured into state congressional and judicial races, through the mass colonisation of Trump’s administration by members of this network and lethally effective campaigns against everything from public health to action on climate change, it would be fair to say that Buchanan’s vision is maturing in the US.

    Yep, the fight to save Medicaid isn’t just a major element of the fight to prevent and expand on Obamacare and hopefully get single-payer system someday like a compassionate society. It’s one of a handful of climactic battles left in a stealth-war – a war on the New Deal and Great Society and the very idea that government should be helpful – that the Kochs and their allies have been waging and winning for decades.

    It’s all a reminder that while Trump is constantly trying to cast Democrats and “the media” as villains, if anyone should be his enemy is the group of billionaires trying to make Trump the villain of the people by getting him to be guy the fulfills their decades-long plan to undo all those things Trump pledged to protect. Paul Ryan might be an open Koch-head but Trump didn’t campaign on that and it’s not in his best interest in the short or long run to be implementing a Koch-head agenda. And yet there is nothing Trump can do because the Koch network exerts a far bigger influence on the actions and votes of his fellow GOPers than Trump. Trump has to be chief Koch-head because he has no other option. Koch-head legislation is all he’s going to get. Trump isn’t the leader of the GOP. Charles and David Koch are and they do not want to screw up this historic opportunity to put that James McGill Buchanan vision into reality. Trump basically has to sign whatever bills they direct Paul Ryan, Mitch McConnell, and the rest of the GOP to hand to Trump, making him face of the fruition of their decades-long plans, and there’s nothing Trump can do about it.

    Notice how, as Trumpcare advances through one revision after another to placate the various GOP hold outs – some who want it less conservative and some who want it more and have Koch network backing – the newly revised version is the Koch-backed version. That’s how this is happening and Trump doesn’t really have a meaningful voice on the matter. The Kochs, real Big League super-villains, are making Trump, a mid-level super-villain who somehow ended up in the White House, their fall guy. Sure, he might be a willing, and even enthusiastic, fall guy. But that’s clearly what he is at this point since legislation is clearly being written by the Kochs. Legislation that’s so horrible even the GOP can’t fully back it. And if they somehow can’t pass it this year Trump is still the fall guy for that failure. And they try again to gut health care later. That’s how this is going to work because they are serious about bringing James McGill Buchanan’s House of Horrors into every American home. And they might effectively break the filibuster for spending bills by ignoring the Senate Parliamentarian and turning the ‘Byrd Rule’ into a loophole that allows for any spending bill that gets a 51 majority vote to pass without the threat of a filibuster. And if that happens, the gutting of the government is going to get going in earnest. And don’t forget the lesson from Chile: one of the tactics is to enshrine these pro-slavery property-rights extremist views into the constitution, which makes some things almost impossible to reverse:

    In 1980, he was able to put the programme into action. He was invited to Chile, where he helped the Pinochet dictatorship write a new constitution, which, partly through the clever devices Buchanan proposed, has proved impossible to reverse entirely. Amid the torture and killings, he advised the government to extend programmes of privatisation, austerity, monetary restraint, deregulation and the destruction of trade unions: a package that helped trigger economic collapse in 1982.

    And what are the Koch’s working on? Re-writing the constitution in one massive move by triggering an constitutional convention. That is what they are working on to fulfill the Buchanan vision and shred government. 34 states have to call for it. Wyoming became the 29th state in February of this year. And if they succeed they’ll probably be able to constitutionally enshrine all sorts of pro-billionaire property-rights stuff into the constitution, sold to the public as a “fix” for things, and there’s either going to be a new constitutional convention to undo it all or it’s going to be very hard to have a functional government. One of many things they are working on to fulfill Buchanan’s vision. A directing the GOP to do their bidding makes Trump their top fall guy. Even bigger than Paul Ryan which is amazing. And that vision one one that mostly hands almost all the wealth and power to people like the Kochs and the freedom to be enslaved by them to the rest of us. Trump is the face of that now, which is why he’s the fall guy now. It’s a House of Horrors.

    So, yeah, Trump should probably consider the Kochs as worthwhile villains to fixate on. They’re aren’t resisting him. They’re directing him to fall for them. And fall Bigly. And when he does, the Koch/Buchanan agenda will pick him up and tell him to try harder for them next time. Trump definitely has some villains plaguing him and the Democrats and the media aren’t the villains Trump needs to fear.

    Posted by Pterrafractyl | July 22, 2017, 9:18 pm
  7. Following the cliff-hanger failed attempt by the Senate GOP to pass a “Skinny repeal” bill, a vote to pass a politically more palatable version of an Obamacare repeal bill that doesn’t include all the stuff that voters hate in the House version of Trumpcare so they can voter for the House version when the House and Senate get together and create a joint conference bill, two primary questions loom over the GOP:

    1. Will there be a strategic pause in the GOP’s endless quest to repeal Obamacare and gut entitlements or is there going to be another push to make Trumpcare happen before the Senate moves on to other matters?

    and…

    2. What will be the form and impact of Trump’s inevitable tantrum?

    And while it’s unclear what the answer to the first looming question will be: As Trump tweeted Saturday, “Unless the Republican Senators are total quitters, Repeal & Replace is not dead!” And according White House Budget Director Mick Mulvaney, Trump’s rage tweeting wasn’t just talk. Trump seriously wants the Senate to stay focused on Trumpcare:

    Talking Points Memo
    Livewire

    Mulvaney: Trump Wants Senate To Vote On O’Care Repeal Before Anything Else

    By Esme Cribb
    Published July 30, 2017 2:23 pm

    White House budget chief Mick Mulvaney on Sunday said President Donald Trump wants the Senate to hold another vote to repeal Obamacare before moving on to any other legislative business.

    “Is this official White House policy, that nothing should be voted on in Congress, not even the debt ceiling, before the Senate votes again on health care?” Jake Tapper asked Mulvaney on CNN’s “State of the Union.”

    “Well, I think — yes. And I think what you’re seeing there is the President simply reflecting the mood of the people,” Mulvaney said.

    “So in the White House’s view, they can’t move on in the Senate,” Mulvaney said. “They need to stay, they need to work, they need to pass something and I think that’s not only the official White House position on this right now, it’s sort of the national attitude towards it.”

    “Well, polls indicate that the American people — a plurality of them — support Obamacare,” Tapper replied.

    Trump on Saturday urged Republican senators to “demand another vote before voting on any other bill.”

    “Unless the Republican Senators are total quitters, Repeal & Replace is not dead!” he tweeted, a day after Senate Republicans’ latest effort to repeal Obamacare failed in a dramatic early-morning vote.

    ———-

    “Mulvaney: Trump Wants Senate To Vote On O’Care Repeal Before Anything Else” by Esme Cribb; Talking Points Memo; 07/30/2017

    “So in the White House’s view, they can’t move on in the Senate,” Mulvaney said. “They need to stay, they need to work, they need to pass something and I think that’s not only the official White House position on this right now, it’s sort of the national attitude towards it.””

    It shambles on. Assuming the Senate GOP follows Trump’s lead/taunts. And you can bet the Koch network and other mega-donors wouldn’t mind seeing the Senate take another stab at it.

    But Trump’s trash tralk isn’t the only tool he’s employing to persuade the Senate. There’s also the threats. Threat’s that kind of make sense from a political standpoint, like the threat Trump is making to strip away health care coverage for Congress. Also the threats that make no political sense at all, like the threat Trump is making to end the subsidies for insurance companies (“bailouts” as he calls it) that enable the subsidies for lower-income Obamacare recipients and prevent a further destabilization of the insurance market. Yes, he’s actually threatening to simultaneously destabilize markets and cut subsidies for the poor as a means of forcing Congress to get something passed on health care. And no, he doesn’t appear to realize that issuing such threats looks horrible:

    Talking Points Memo
    DC

    Trump Threatens To End Health Care Subsidies For Poor Americans, Congress

    By Allegra Kirkland
    Published July 29, 2017 3:36 pm

    Still blistering over the latest defeat of Obamacare repeal, Trump on Saturday threatened to do away with health care subsidies that affect both the poorest Americans and Congress.

    “If a new HealthCare Bill is not approved quickly,” Trump tweeted. “BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!”

    If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!— Donald J. Trump (@realDonaldTrump) July 29, 2017

    The first part of his tweet is a reference to cost sharing reduction payments, subsidies that allow insurers to offset health-care costs for low-income Americans. Trump has threatened to withhold those subsidies before—a move that insurers and health care providers warn would destabilize the individual health insurance market and cause premiums to soar.

    The second half of the missive indicates that Trump is going to continue to target his own GOP-controlled Congress for their inability to undo former President Obama’s signature achievement. Trump’s comment suggests he’d consider ending the employer contribution for health insurance currently provided to lawmakers.

    Earlier Saturday, he accused Senate Republicans of “looking like fools” and urged them to abolish procedural rules like the filibuster immediately in order to make progress on healthcare.

    ———-

    “Trump Threatens To End Health Care Subsidies For Poor Americans, Congress” by Allegra Kirkland; Talking Points Memo; 07/29/2017

    ““If a new HealthCare Bill is not approved quickly,” Trump tweeted. “BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!””

    Burning the insurance markets down to ‘save’ them – when ‘saving’ health care is really ushering in an era of Paul Ryan/Koch Brothers-style health care nightmare landscape – is a strategy the president openly employs. It’s like a new Bizzaro Pyrrhic victory that only makes sense in Trumpland:


    The first part of his tweet is a reference to cost sharing reduction payments, subsidies that allow insurers to offset health-care costs for low-income Americans. Trump has threatened to withhold those subsidies before—a move that insurers and health care providers warn would destabilize the individual health insurance market and cause premiums to soar.

    The second half of the missive indicates that Trump is going to continue to target his own GOP-controlled Congress for their inability to undo former President Obama’s signature achievement. Trump’s comment suggests he’d consider ending the employer contribution for health insurance currently provided to lawmakers.

    Yep, cost sharing reduction payments that subsidize private insurance for low-income people are now being held political hostage to force through Trumpcare. That’s happening.

    And as White House Budget Director Mick Mulvaney confirmed, that wasn’t just a temporary Trumpian twitter tantrum. It was cold, calculate (yet confused) Trumpian tough-guy tweet Twitter talk:

    Talking Points Memo
    Livewire

    Mulvaney: Trump Thinks O’Care Should ‘Hurt’ Insurance Providers, Lawmakers

    By Esme Cribb
    Published July 30, 2017 12:31 pm

    White House budget chief Mick Mulvaney on Sunday said President Donald Trump threatened to cut Obamacare provisions because he thinks the law should “hurt insurance companies” and lawmakers if they can’t corral enough votes to repeal it.

    Asked on CNN’s “State of the Union” about Trump’s threat on Saturday to end subsidies that affect low-income individuals, Mulvaney said he “talked to the President at length about that exact issue yesterday.”

    “I think his attitude is this, and his attitude is pretty simple,” Mulvaney said. “What he’s saying is, look, if Obamacare is hurting people — and it is — then why shouldn’t it hurt insurance companies and more importantly perhaps for this discussion, members of Congress?”

    “I think the President’s simply looking at this and going, is this fair?” Mulvaney said. “We’ll see what happens as we move forward.”

    ———-

    “Mulvaney: Trump Thinks O’Care Should ‘Hurt’ Insurance Providers, Lawmakers” by Esme Cribb; Talking Points Memo; 07/30/2017

    ““I think his attitude is this, and his attitude is pretty simple,” Mulvaney said. “What he’s saying is, look, if Obamacare is hurting people — and it is — then why shouldn’t it hurt insurance companies and more importantly perhaps for this discussion, members of Congress?”

    Obamacare is hurting people so why not get rid of the insurance company subsidies for keeping costs down for lower-income people. That’s the Trump’s rationale as explained by Mick Mulvaeney. And it wasn’t just Mulvaney. Kellyanne Conway and HHS Secretary Tom Price also made clear that Trump isn’t sure yet if he’s going to sabotage the insurance subsidies for low-income people:

    Bloomberg Politics

    Health Chief Says No Decision on Continuing Obamacare Subsidies

    * Trump tweeted that he plans to end insurance ‘bailouts’ soon
    * Premium subsidies for lawmakers, staff may also be at risk

    By Saleha Mohsin
    July 29, 2017, 1:06 PM CDT July 30, 2017, 9:40 AM CDT

    Health and Human Services Secretary Tom Price said Sunday that “no decision’s been made” on whether to continue key Affordable Care Act subsidies to health-insurance companies, but that the administration’s job is “to follow the law of the land.” A top White House aide said President Donald Trump will decide soon.

    Smarting from the failure of Senate Republicans to pass an Obamacare repeal and replace bill, Trump on Saturday threatened in a tweet to end the subsidy payments, which help make insurance accessible to poorer Americans, a move that could critically destabilize health exchanges if it went ahead.

    The administration has previously floated the idea to stop paying the subsidies that help insurers offset health-care costs for low-income Americans, called a cost-sharing reduction, or CSR. The next payment is due on Aug. 21.

    “If a new HealthCare Bill is not approved quickly, BAILOUTS for Insurance Companies and BAILOUTS for Members of Congress will end very soon!” the president said in Saturday’s tweet. It followed a Twitter message on Friday in which he vowed to “let ObamaCare implode.”

    Law of the Land

    Asked on ABC’s “This Week” how soon the Trump administration could stop the cost-sharing payments, Price said no decision has been made and he can’t comment further because of a pending court case. He also declined to clarify what Trump meant by “implode,” saying the president’s comment “punctuates the concern” he has about changing he direction of the health-care system and getting Congress to act.

    Price said in a separate interview on NBC’s “Meet the Press” that the administration’s “job is to follow the law of the land” and that “we take that responsibility very seriously and we will continue to do so.”

    White House counselor Kellyanne Conway said on “Fox News Sunday” that Trump will soon decide the fate of the subsidy payments. “He’s going to make that decision this week, and that’s a decision that only he can make,” Conway said.

    Trump’s tweet on Saturday also implied that he may target subsidies made available to members of Congress and their staff, who as part of the Affordable Care Act are enrolled in plans on the Washington, D.C., health insurance exchange. Subsidies are similar to those made by employers to pay for their workers’ health insurance premiums.

    Weeks of Brinkmanship

    Mick Mulvaney, director of the Office of Management and Budget, said on CNN’s “State of the Union” on Sunday that the president is weighing such a move, which was urged this month by a coalition of right-wing groups. “It’s not a concept of taking coverage away,” he said. “It’s the approach of actually obliging members of Congress to follow the exact law that the folks that they govern are following.”

    Senator Susan Collins of Maine, one of the three Republicans to sink the Senate bill last week, was asked on CNN’s “State of the Union” on Sunday if a threat from the president to cut off funding for health care plans for members of Congress would change her vote. “No,” she said.

    The months-long effort by Senate Republicans to pass health-care legislation collapsed early Friday after Republican John McCain of Arizona joined Collins and Lisa Murkowski of Alaska to block a stripped-down Obamacare repeal bill. McCain’s “no” vote came after weeks of brinkmanship and after his dramatic return from cancer treatment to cast the 50th vote to start debate on the bill earlier in the week. The “skinny” repeal bill was defeated 49-51, falling just short of the 50 votes needed to advance it.

    Senate Majority Leader Mitch McConnell has said he’ll move on to other legislative business. But in a later tweet on Saturday, Trump suggested he isn’t giving up. “Unless the Republican Senators are total quitters, Repeal & Replace is not dead! Demand another vote before voting on any other bill!”

    ‘Look Like Fools’

    The president said earlier that Senate Republicans “look like fools” after the repeal bill went down, and made a renewed call for the Senate to abolish a rule requiring 60 votes for some bills — although the health-care measure needed only a 51-vote majority to pass, and fell short.

    Trump reiterated that position in a Twitter posting on Sunday, saying, “Don’t give up Republican Senators, the World is watching: Repeal & Replace…and go to 51 votes.”

    “The president will not accept those who said, quote, ‘it’s time to move on,”’ Conway said.

    Republican Senators Lindsey Graham of South Carolina, Bill Cassidy of Louisiana and Dean Heller of Nevada met with Trump Friday on a fresh proposal. Graham said in a statement that Trump had been “optimistic” about the trio’s plan. “I had a great meeting with the president and know he remains fully committed to repealing and replacing Obamacare,” Graham said.

    For more on the efforts to repeal the ACA, click here.

    Ending the CSR subsidies, paid monthly to insurers, is one way that Trump could hasten Obamacare’s demise without legislation, by prompting more companies to raise premiums in the individual market or even to stop offering coverage. The administration last made a payment about a week ago for the previous 30 days, but hasn’t made a long-term commitment.

    Andrew Slavitt, acting administrator of the Centers for Medicare and Medicaid Services in the Obama administration, said the impact of cutting off subsidy payments “will be felt by the middle class who will pay more to subsidize low income” people.

    Health-care analyst Spencer Perlman at Veda Partners LLC said in a research note on Friday, before the president’s tweets, that there’s a 30 percent chance Trump will end CSR payments, which may “immediately destabilize the exchanges, perhaps fatally.”

    America’s Health Insurance Plans, a lobbying group for the industry, has estimated that premiums would rise by about 20 percent if the CSR payments aren’t made. Many insurers have already dropped out of Obamacare markets in the face of mounting losses, and blamed the uncertainty over the future of the cost-sharing subsidies and the individual mandate as one of the reasons behind this year’s premium increases.

    Who Owns It?

    Moments after the Senate voted down the Republican bill on Friday morning, McConnell called on Democrats to offer their ideas for moving forward with health care. But he warned: “Bailing out insurance companies, with no thought of any kind of reform, is not something I want to be a part of.”

    A survey in April by the nonpartisan Kaiser Family Foundation showed that 61 percent Americans believe Trump and Republicans are responsible for future problems with the ACA, while 31 percent said President Barack Obama and Democrats would be at fault.

    Collins on CNN said lawmakers need to go back to committee, evaluate possible solutions through hearings, and produce a “series of bills” to fix existing problems with the ACA, including the potential collapse of the insurance markets.

    “I certainly hope the administration does not do anything in the meantime to hasten that collapse,” she said.

    ———-

    “Health Chief Says No Decision on Continuing Obamacare Subsidies” by Saleha Mohsin; Bloomberg Politics; 07/29/2017

    Ending the CSR subsidies, paid monthly to insurers, is one way that Trump could hasten Obamacare’s demise without legislation, by prompting more companies to raise premiums in the individual market or even to stop offering coverage. The administration last made a payment about a week ago for the previous 30 days, but hasn’t made a long-term commitment.”

    Not to alarm anyone, but yes, Trump alone really can undermine the private health insurance markets by getting rid of those subsidies. And according to all his White House proxies on the Sunday Morning news shows, Trump is seriously considering this. Also, he thinks the Senate should get rid of the filibuster and just go with 51 votes:


    Asked on ABC’s “This Week” how soon the Trump administration could stop the cost-sharing payments, Price said no decision has been made and he can’t comment further because of a pending court case. He also declined to clarify what Trump meant by “implode,” saying the president’s comment “punctuates the concern” he has about changing he direction of the health-care system and getting Congress to act.

    Price said in a separate interview on NBC’s “Meet the Press” that the administration’s “job is to follow the law of the land” and that “we take that responsibility very seriously and we will continue to do so.”

    White House counselor Kellyanne Conway said on “Fox News Sunday” that Trump will soon decide the fate of the subsidy payments. “He’s going to make that decision this week, and that’s a decision that only he can make,” Conway said.

    ‘Look Like Fools’

    The president said earlier that Senate Republicans “look like fools” after the repeal bill went down, and made a renewed call for the Senate to abolish a rule requiring 60 votes for some bills — although the health-care measure needed only a 51-vote majority to pass, and fell short.

    Trump reiterated that position in a Twitter posting on Sunday, saying, “Don’t give up Republican Senators, the World is watching: Repeal & Replace…and go to 51 votes.”

    “The president will not accept those who said, quote, ‘it’s time to move on,”’ Conway said.

    “Trump reiterated that position in a Twitter posting on Sunday, saying, “Don’t give up Republican Senators, the World is watching: Repeal & Replace…and go to 51 votes.””

    So Trump is apparently looking to temporarily uncut the private insurance markets for the poor in the hopes of pressuring the GOP Senate to blow up the filibuster to pass a bill that will permanently undercut public and private insurance for the poor and everyone else.

    If there’s one positive thing aobut this whole situation, it’s that at least it’s going to be harder for the GOP to hide the fact that it’s been systematically undermining Obamacare for years now with things like Marco Rubio’s 2015 gutting of the “risk corridor” subsidies and the GOP’s ongoing lawsuit arguing that the Obamacare subsidies for low-income people aren’t legally funded. It’s a lot harder to ignore that hidden history with Trump threat-tweeting about cutting those subsidies.

    And notice how Tom Price can’t say whether Trump is going to prevent the payment of those subsidies based on the GOP’s own lawsuit:


    Asked on ABC’s “This Week” how soon the Trump administration could stop the cost-sharing payments, Price said no decision has been made and he can’t comment further because of a pending court case. He also declined to clarify what Trump meant by “implode,” saying the president’s comment “punctuates the concern” he has about changing he direction of the health-care system and getting Congress to act.

    That “pending court case” that prevented Price from commenting further is the GOP’s lawsuit against those subsidies Trump is threatening to repeal.

    In other words, the GOP was already trying to get rid of the subsidies via a lawsuit that Trump is now threatening to block.

    It’s all a reminder that, as toxic as Trump’s leadership style has been in terms of its impact on the nation, he’s still a pretty decent GOP standard-bearer.

    It’s also, of course, a reminder that Trump and the GOP are still scheming Bizarro Pyrrhic schemes to ‘save’ America’s health care system by destroying it.

    Posted by Pterrafractyl | July 30, 2017, 11:11 pm
  8. Here’s a good news/bad news/treacherous news story about Kentucky’s health care safety-net and the ongoing attempts to gut Medicaid: Thanks to Kentucky’s 2014 acceptance of the Medicaid expansion the rates of uninsured patients at the University of Louisville Hospital, the city’s safety net hospital for the poor, dropped from 25 percent to 5 to 6 percent. That’s the good news.

    The bad is is that, thanks to that massive drop off in the uninsured, Kentucky’s GOP governor Matt Bevin decided to cut off funds for the Quality and Charity Care Trust Inc., a trust fund set up to help pay for those medical services for the uninsured.

    And then there’s the treacherous news: at the same to the Kentucky GOP is arguing that the Medicaid expansion has eliminated the need for the Quality and Charity Care Trust Inc., Governor Bevin is simultaneously pushing for a major overhaul in the state’s Medicaid system. An overhaul that wouldn’t just impact the people covered under the Medicaid expansion but all Medicaid recipients. Changes including work requirements for “able-bodied” adults without dependents. And that means that if you’re an unemployed able-bodied adult in Kentucky, you’re about to become officially expendable in the eyes of the state.

    Sure, maybe you’ll find a job. Or maybe not. It’s up to you…and the broader Kentucky economy of which you have no control. And sure, emergency room medical services will still presumably be covered…for as long as there are hospitals around that can still cover them. But if, for instance, the state cuts the trust funds dedicated to helping hospitals cover the costs of providing medical services for the uninsured while at the same time spiking the number of uninsured by implementing new Medicaid requirements, you just might not have that many hospitals around to provide those emergency services. And that medical service provider shortage isn’t just going to be a problem for the big cities.

    But that’s apparently Governor Bevin’s plan: implement eligibility requirements that are created under the assumption that unemployed Medicaid recipients are lazy leaches (as opposed to people who can’t find a job or might have some other reasonable reason for being unemployed) and thus designed to spike the number of uninsured. And that’s still the plan after Bevin eliminated the fund designed to help hospitals fund services for the uninsured. And the icing on the cake is that the new work requirements, which might be helpful in a minority of cases be are guaranteed to be cruel and unreasonable in a large number of cases, is being sold as away of helping the individuals kicked off of Medicaid and the larger community. So that’s the good/bad/treacherous news about Governor Bevin’s plans for Medicaid:

    WDRB.com

    Fund that paid for uninsured at University Hospital scrapped after Medicaid expansion changes landscape

    By Chris Otts
    Posted: Jul 27, 2017 7:37 PM CST
    Updated: Jul 27, 2017 7:38 PM CST

    LOUISVILLE, Ky. (WDRB) — A special government fund set up in 1983 to help pay for uninsured patients at University of Louisville Hospital, the city’s safety net hospital for the poor, will be dissolved soon as officials say it’s no longer needed because of Kentucky’s expansion of Medicaid.

    A board chaired by the secretary of Gov. Matt Bevin’s health cabinet voted Thursday to dissolve the Quality and Charity Care Trust Inc., or QCCT.

    The trust had been funded by the state, Louisville Metro government and the University of Louisville.

    But the 2014 expansion of Medicaid to cover more of Kentucky’s low-income population has cut the percentage of uninsured patients at the hospital from about 25 percent to 5 to 6 percent, said Dr. Greg Postel, U of L’s interim president and executive vice president for health affairs.

    That means the hospital is able to bill Medicaid for a lot of care that was previously funded by city and state dollars put into the trust.

    Bevin vetoed state funding for QCCT last year, and the trust has no remaining assets. The hospital’s last request for trust funding was over a year ago.

    The move to dissolve the trust comes despite the fact that changes could be in store for the state’s Medicaid program.

    Bevin is seeking federal approval to add requirements like work or volunteering and premium payments for some of Kentucky’s Medicaid recipients, and Republicans in Congress are making efforts to repeal and replace the Affordable Care Act, which allowed states such as Kentucky to expand Medicaid.

    Postel and Vickie Yates Brown Glisson, secretary of the state Cabinet for Health and Family Services, said the issue of public funding for University Hospital could be raised again down the road, if needed.

    “The hospital is fine as things are today, but if Medicaid changes, then some kind of safety net would have to be reestablished,” said Postel, a member of the board that unanimously voted Thursday to end the trust.

    Glisson, who chairs that same board, said, “I think everybody is going to watch what’s happening on a federal level and if things change, we may need to come back and look at this situation.”

    There’s no point in keeping the trust around without the city and state funding it, and an organization like the trust would not be difficult to recast in the future if needed, Postel said.

    Glisson added that she doesn’t think University Hospital will see more uninsured patients as a result of the Medicaid waiver Bevin is seeking.

    “These individuals (who got coverage through the expansion) are still eligible. The only thought would be that … if you are able-bodied, with no dependents, that you will make that personal choice to now go into the job market … and that they would then be covered by their employer-sponsored insurance,” she said. “…Nobody is losing their insurance; nobody is being pushed off.”

    ———-

    “Fund that paid for uninsured at University Hospital scrapped after Medicaid expansion changes landscape” by Chris Otts; wdrb.com; 07/27/2017

    ““The hospital is fine as things are today, but if Medicaid changes, then some kind of safety net would have to be reestablished,” said Postel, a member of the board that unanimously voted Thursday to end the trust.”

    Yes, the main hospital for the poor in Louisville that just had its special fund to finance care for the uninsured formally closed should be financially fine as long as Medicaid doesn’t change. And, of course, changing Medicaid in a way that increases the number of uninsured is the objective of the Governor’s requested changes to Medicaid. Under the guise of helping people and the community:


    But the 2014 expansion of Medicaid to cover more of Kentucky’s low-income population has cut the percentage of uninsured patients at the hospital from about 25 percent to 5 to 6 percent, said Dr. Greg Postel, U of L’s interim president and executive vice president for health affairs.

    That means the hospital is able to bill Medicaid for a lot of care that was previously funded by city and state dollars put into the trust.

    Bevin vetoed state funding for QCCT last year, and the trust has no remaining assets. The hospital’s last request for trust funding was over a year ago.

    The move to dissolve the trust comes despite the fact that changes could be in store for the state’s Medicaid program.

    Bevin is seeking federal approval to add requirements like work or volunteering and premium payments for some of Kentucky’s Medicaid recipients, and Republicans in Congress are making efforts to repeal and replace the Affordable Care Act, which allowed states such as Kentucky to expand Medicaid.

    But note the soothing, ‘don’t worry’ talk from Vickie Yates Brown Glisson, the secretary of the state Cabinet for Health and Family Services, says that it will be fine because all the people kicked off Medicaid will find jobs and get insurance through their new employers. And if there is a problem with growing numbers of uninsured people impacting the finances of hospitals there’s nothing stopping the state from revisiting the issue and reopening the trust Bevin just defunded:


    Postel and Vickie Yates Brown Glisson, secretary of the state Cabinet for Health and Family Services, said the issue of public funding for University Hospital could be raised again down the road, if needed.

    “The hospital is fine as things are today, but if Medicaid changes, then some kind of safety net would have to be reestablished,” said Postel, a member of the board that unanimously voted Thursday to end the trust.

    Glisson, who chairs that same board, said, “I think everybody is going to watch what’s happening on a federal level and if things change, we may need to come back and look at this situation.”

    There’s no point in keeping the trust around without the city and state funding it, and an organization like the trust would not be difficult to recast in the future if needed, Postel said.

    Glisson added that she doesn’t think University Hospital will see more uninsured patients as a result of the Medicaid waiver Bevin is seeking.

    “These individuals (who got coverage through the expansion) are still eligible. The only thought would be that … if you are able-bodied, with no dependents, that you will make that personal choice to now go into the job market … and that they would then be covered by their employer-sponsored insurance,” she said. “…Nobody is losing their insurance; nobody is being pushed off.”
    ..

    “Glisson added that she doesn’t think University Hospital will see more uninsured patients as a result of the Medicaid waiver Bevin is seeking.”

    Hospitals won’t see more uninsured people after governor Bevin’s plan kicks all these people off Medicaid because they’re all going to find jobs. That’s what the governor’s team is telling people.

    And if you’re wondering whether or not the new work requirements will include the vast majority of nursing home residents on Medicaid, note that the waivers work requirement does of course have the able-bodiness requirement along with a “medical frailty” waiver. But it’s worth noting that when you look at the details they’ve released for Bevin’s proposed changes, the list of waivers for the 20 hour a week work requirement doesn’t appear to include an age cap:

    Kentucky Health

    Helping to Engage and Achieve Long Term Health

    The proposed change is limited to eliminating the increasing scale for the community engagement and employment hour requirements. Suspensions for community engagement and employment non-compliance and all exemptions will remain unchanged. Specifically, the Commonwealth continues to seek an exemption of the community engagement and employment initiative for the following individuals:

    Children under the age of 19 enrolled in Kentucky HEALTH;

    Pregnant women;

    Primary caregivers of a dependent, including either a dependent minor child or disabled adult dependent (limited to only one exemption per household);

    Individuals identified as medically frail; and

    Full time students.

    So part-time students will have a 20 hour a week work requirement, unless they’re pregnant or have a dependent. And individuals identified as medically frail, which will certainly include a large proportion of nursing home or assisted living residents, will get a work waiver. But what about those nursing home residents who are living at a nursing home for a reason that doesn’t somehow make them unable to work 20 hours a week? Are they going to be expected to work for the Medicaid coverage of their nursing home residency? We’ll just have to find out apparently because it’s not like Bevin’s team is being upfront about the real costs of this scheme.

    Of course, since Medicaid is a joint federal and state program with federal requirements, Bevin’s entire scheme is reliant on the federal government giving the go ahead. Which it will, of course, do for Kentucky and any other state that has a scheme designed to throw people off Medicaid:

    Talking Points Memo
    DC

    Republicans Have A New Plot To Gut Medicaid And They Don’t Need Congress

    By Alice Ollstein
    Published August 17, 2017 6:00 am

    A wave of Republican-controlled states are petitioning the Department of Health and Human Services (HHS) for permission to enact measures that will knock more people off Medicaid and the Trump administration has signaled they will give a green light to these efforts.

    After the collapse of Obamacare repeal in Congress, which would have cut hundreds of billions of dollars and millions of people from Medicaid–the public health insurance program for the poor–red states and their allies in the Trump administration are preparing to use a powerful administrative tool as a backdoor route to that same goal.

    Over the past few months, after Trump’s HHS signaled openness to granting these Medicaid waivers, nearly a dozen Republican-controlled states have submitted or are preparing to submit requests that they openly acknowledge will lead to fewer people being covered as a result. In those so-called waiver requests, some states are seeking to impose work requirements and drug tests on the low-income population that depends on Medicaid, while others are proposing cuts in coverage for vision, dental care, and non-emergency medical transportation, lifetime limits, defunding of women’s health clinics, and requiring people below the federal poverty line to pay insurance premiums.

    The governors gunning for the waivers say it will save millions in taxpayer dollars and shore up the Medicaid program. But former HHS officials and health law experts tell TPM that these proposals—which HHS has all but promised to approve—undermine the purpose of Medicaid and could open the Trump administration up to lawsuits in the months ahead.

    Red Lines

    Under federal law, any waivers granted to states to loosen restrictions on how they administer Medicaid have to clear a fairly high bar. States must propose a “experiment” that tests ways to more efficiently and effectively promote Medicaid’s objectives—namely, providing affordable and quality health insurance to low-income people.

    Proposals similar to those submitted this year requesting permission to impose a work requirement and to kick people off the Medicaid rolls after a certain period of time were previously rejected by the Obama administration.

    “I’m not sure how denying coverage for people based on their inability to find work really meets the objective of providing health insurance to low-income individuals,” said Jessica Schubel, a senior advisor in the office that oversaw Medicaid at the Centers for Medicare & Medicaid Services (CMS) during the Obama administration. “As for the time limits, it’s intended to be an open-ended program that is there for people when they need it.”

    Schubel, who now works on health care policy for the Center on Budget and Policy Priorities, noted that the Obama administration was not completely inflexible. Post-Obamacare, when several states were on the fence about expanding Medicaid, they approved waiver applications that allowed some states to make Medicaid beneficiaries pay a share of their health care costs.

    “One example is Arkansas’ private option,” she explained. “It was an innovative approach that the state wanted to test, and it was a pathway forward to getting [Medicaid] expansion through. The same with Montana’s expansion waiver that included cost-sharing and premiums. We worked closely with them to provide exemptions for folks with chronic conditions.”

    But this year, thanks to signals of increased leniency from HHS the early months of the Trump presidency, a host of states have moved forward with an array of waiver requests that never would have won approval before.

    “Previous administrations of both parties had the goal of increasing Medicaid coverage,” said Eliot Fishman, who ran CMS’ office evaluating state Medicaid waivers from 2013 to early 2017. “Remember, the Bush administration negotiated the ‘Romneycare’ demonstration, [a precursor to Obamacare in Massachusetts]. They were actively engaged in trying to expand coverage through that demonstration.”

    Fishman, now the senior director of health policy at Families USA, said what he saw in the early days of the Trump administration was a sharp departure from the historic goal of the Medicaid program.

    “The use of Medicaid authorities to significantly reduce coverage is really novel and really legally suspect,” he told TPM. “Their fundamental principle is that it’s the state’s call in terms of restricting eligibility.”

    Opening the floodgates

    In March, HHS Secretary Tom Price and CMS Administrator Seema Verma wrote an open letter to the nation’s governors promising them “more freedom” from “rigid and outdated implementation and interpretation of federal rules and requirements.” The letter specifically encouraged states to submit proposals for booting unemployed people from the Medicaid rolls, saying HHS is now interested in “meritorious innovations that build on the human dignity that comes with training, employment and independence.”

    With this green light, dozens of states submitted applications.

    Indiana wants to require all able-bodied Medicaid recipients to work at least 20 hours a week. Wisconsin also wants a work requirement and wants to make Medicaid enrollees pass a drug test in order to receive benefits. Maine wants a work requirement and the ability to charge people premiums even when their income is well below the federal poverty line. Kentucky wants a work requirement, the elimination of coverage of vision and dental care, and the ability to kick someone off Medicaid if they fail to report even a small change in their financial situation. Texas wants to deny Medicaid dollars to women’s health clinics that provide abortions.

    Not all states provide projections of how many people would lose coverage if the waivers are granted, though Kentucky estimates that 95,000 will be denied Medicaid, and Indiana predicts that about 25,000 won’t be able to comply with the new restrictions. Taken all together, Schubel estimates, the proposals have the potential to shrink the Medicaid rolls by disqualifying hundreds of thousands of people.

    “The March letter from CMS really opened in the floodgate to proposals that in my view don’t comply with the purpose of Medicaid,” she told TPM. “They’re basically saying, ‘Hey, we’re open for business for any type of proposal.’”

    A spokesperson for CMS declined to comment, saying he could not “speculate on future waiver policy.”

    A decision on the first waiver in the queue, from Kentucky, could come in the next few weeks.

    Sarah Somers, a managing attorney with the National Health Law Program, says if CMS approves it, it will embolden other states to seek similar passes.

    “It’ll be a race to the bottom in some respects,” she warned. “If one state gets work requirements approved, there’s no reason to say a whole slew of new states won’t seek them.”

    Somers told TPM that she believes many of the waiver applications currently pending are “not consistent with goals of Medicaid,” and the National Health Law Program may bring legal challenges if the Trump administration grants them.

    “We are exploring all legal options,” she said. “We feel they amount to burdens placed on people who are already way overburdened, and they weed out people who should be able to get assistance.”

    In particular, Somers expressed concern about Wisconsin’s plan for mandatory drug tests, and the five states that want to impose a work requirement. Wisconsin’s application estimates that they will lead to about 5,102 fewer people being enrolled in the program over five years. But when Wisconsin enacted a similar work requirement for their state food assistance program, it led to more than 70,000 people losing their benefits over just two years.

    It’s a policy, Somers says, that is “based on a negative stereotype of low-income people.”

    “To have a rule requiring people to work is based on a misconception that people covered by the Medicaid expansion aren’t already working,” she said. “This is a majority working poor population, and if they aren’t working, it’s because they can’t.”

    A study by the Kaiser Family Foundation found that only 27 percent of Medicaid recipients are adults without disabilities, and 60 percent of that group are already working. Many of those not employed care for a family member full-time, have a criminal record, live in an area without job opportunities, or face other “major impediments” to employment.

    ———-

    “Republicans Have A New Plot To Gut Medicaid And They Don’t Need Congress” by Alice Ollstein; Talking Points Memo; 08/17/2017

    “After the collapse of Obamacare repeal in Congress, which would have cut hundreds of billions of dollars and millions of people from Medicaid–the public health insurance program for the poor–red states and their allies in the Trump administration are preparing to use a powerful administrative tool as a backdoor route to that same goal.”

    Yep, if the GOP can’t gut Medicaid by passing Trumpcare, it always has the freedom to grant states the freedom to do the gutting themselves, which is something the Trump administration has officials granted back in March along with the suggestion to states they they kick the unemployed people off of Medicaid. Allegedly in the spirit of building upon the human dignity of the very poor unemployed people now without health care. And many states heard that call and responded with plenty of “innovations” designed to kick people off Medicaid:


    In March, HHS Secretary Tom Price and CMS Administrator Seema Verma wrote an open letter to the nation’s governors promising them “more freedom” from “rigid and outdated implementation and interpretation of federal rules and requirements.” The letter specifically encouraged states to submit proposals for booting unemployed people from the Medicaid rolls, saying HHS is now interested in “meritorious innovations that build on the human dignity that comes with training, employment and independence.”

    With this green light, dozens of states submitted applications.

    Indiana wants to require all able-bodied Medicaid recipients to work at least 20 hours a week. Wisconsin also wants a work requirement and wants to make Medicaid enrollees pass a drug test in order to receive benefits. Maine wants a work requirement and the ability to charge people premiums even when their income is well below the federal poverty line. Kentucky wants a work requirement, the elimination of coverage of vision and dental care, and the ability to kick someone off Medicaid if they fail to report even a small change in their financial situation. Texas wants to deny Medicaid dollars to women’s health clinics that provide abortions.

    And remember how Kentucky’s secretary for Health and Family Services, Vickie Yates Brown Glisson, predicted that no one was going to be losing any insurance under Bevin’s proposed Medicaid cuts. Well, it looks like Kentucky is predicting its new plan will deny 95,000 people Medicaid, including 25,000 people who “can’t comply with the new restrictions.” Which is a pleasant sounding way of saying people who don’t have a job and don’t find one. And those numbers are just the public prediction peddled by a governor dedicated to selling poisonous snake oil policy. As Wisconsin reminds us, those numbers could be a lot higher:


    Not all states provide projections of how many people would lose coverage if the waivers are granted, though Kentucky estimates that 95,000 will be denied Medicaid, and Indiana predicts that about 25,000 won’t be able to comply with the new restrictions. Taken all together, Schubel estimates, the proposals have the potential to shrink the Medicaid rolls by disqualifying hundreds of thousands of people.

    In particular, Somers expressed concern about Wisconsin’s plan for mandatory drug tests, and the five states that want to impose a work requirement. Wisconsin’s application estimates that they will lead to about 5,102 fewer people being enrolled in the program over five years. But when Wisconsin enacted a similar work requirement for their state food assistance program, it led to more than 70,000 people losing their benefits over just two years.

    It’s a policy, Somers says, that is “based on a negative stereotype of low-income people.”

    “To have a rule requiring people to work is based on a misconception that people covered by the Medicaid expansion aren’t already working,” she said. “This is a majority working poor population, and if they aren’t working, it’s because they can’t.”

    So after kickings 70,000 people off a state food assistance program after imposing a work requirement (for human dignity, of course), Wisconsin is now estimating that 5,102 will lose Medicaid after also imposing a work requirement. Gee, is it possible that the people willing to kick people off Medicaid would be willing to lie about the numbers? No, no, because that would be wrong. Lying is bad. But kicking poor people off Medicaid , including perhaps Grandma is she’s still got some spring in her step, without any meaningful consideration for their personal circumstances and just broadly assuming that those without jobs are probably just lazy leaches perfectly capable of finding meaningful work is apparently a good thing to do. For human dignity. And the community. Including the hospitals that are about to pay for a lot more uninsured people. It’s all being done for their best interests in mind. Or at least someone’s best interests in mind.

    Posted by Pterrafractyl | August 20, 2017, 9:04 pm

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