- Spitfire List - http://spitfirelist.com -

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 [1]. 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 [2] and indi­vid­u­als [2] 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 [3].

******

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 [4]:

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 [5], 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 [6] 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 [7] 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 [8] 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 [9] 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 [10] 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 [11]. 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 [12] that the Sen­ate ver­sion of Trump­care need­ed “a lit­tle nego­ti­a­tion, but it’s going to be very good.” The pres­i­dent report­ed­ly made calls [13] 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 [4]

“But accord­ing to a new poll [7] 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 [14], 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 [15]:

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 [16], 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 [17]]

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 [18].

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 [19] 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 [20] 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 [21]:

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 [22], 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 [23].

“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 [24], 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 [25].

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 [21]

“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 [26]. 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 [27]. 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 [28]:

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: [29]: 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 [30] 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 [31] 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 [28]

“Told that the Ryan bud­get “would cut $750 bil­lion [30] 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 [32]:

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 [33] (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 [34] 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 [35].

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 [36]. 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 [32]

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 [3]:

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 [37]

““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 [38].