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The GOP Pulls Off the Medicaid Band-Aid. Ouch.

A consequence of last year’s Supreme Court ruling that upheld Obamacare – but allowed states to opt out of the Medicaid expansion – is that we would see GOP state governors placed in a real dilemma: They could either accept the Medicaid expansion and receive billions of dollars for their state health care systems from the Federal government at the risk of enraging their far-right base of supporters. OR the governors could reject the Medicaid expansion, leaving millions without coverage but still being able to say they stood up to that evil socialist plot to destroy America. Decisions, decisions…:

Talking Points Memo
What The ‘Obamacare’ Decision Means For Medicaid
Sahil Kapur June 28, 2012, 4:58 PM

In a surprise move in its decision to uphold the ‘Obamacare’ mandate, the Supreme Court declared that states may opt out of the law’s Medicaid expansion without losing all federal funds for the program.

“In the 47 year history of the program, there has never been a successful challenge to any of the Medicaid expansions, so this was rather unusual,” said Ron Pollack, director of the consumer group Families USA.

The decision is expected to at least slow down implementation of the new Medicaid provisions. If states refuse to participate en masse, it could lead to significantly fewer people than the projected 17 million being covered under the Medicaid expansion.

The Supreme Court held that the Medicaid expansion in itself constitutional. But it essentially decreed it a new program, which means states cannot be punished for turning it down. The court rejected the Obama administration’s argument that states must accept the expansion or risk losing all federal Medicaid funds.

“The practical effect is that it will make the Medicaid expansions go more slowly,” said Sara Rosenbaum, a professor of health law at George Washington University. She added that it may be left to future courts to determine which parts of the Medicaid expansion count as a new program and which parts are merely additions to the existing one.

Republican governors will face pressure to reject the Medicaid expansion or risk being accused by conservatives of willingly embracing a big part of ‘Obamacare.’ But there’s an incentive in the other direction; namely: a huge cash gift from the federal government, which covers the full cost of the first three years of expansion.

One of the problems with not accepting the Medicaid expansion is that a key assumption behind the cost-cutting in Obamacare centers around the idea that Medicaid receipts to hospitals would go down per patient but there would be more people covered by Medicaid overall. Hospitals could make up the lower per-patient revenue with higher volumes. In the states that don’t expand their Medicaid coverage, however, the hospitals will still get paid less per Medicaid patient but they won’t get the increased volume of patients due to the increased coverage. So it isn’t just uninsured poor people that are in the cross-hairs of this fight. The hospitals get hurt too, along with their staff and patients. Non-profit hospitals that serve large numbers of Medicaid patients will be especially hurt:

Bloomberg
Hospitals Prepare to Cut Care in Medicaid Opt-Out States
By Stephanie Armour – May 14, 2013 12:06 PM CT

With 15 U.S. states opting out of President Barack Obama’s Medicaid expansion, hospitals that treat poor and uninsured patients are asking the government to delay $64 billion in planned funding cuts.

Medicaid funds to hospitals with a disproportionate share of low-income patients will be cut 50 percent, or $14.1 billion, from fiscal 2014 through 2019, according to draft regulations to be published in the Federal Register tomorrow. The American Hospital Association wants to delay by two years the start of the cuts for Medicaid and for $49.9 billion in reductions by Medicare, the health program for the elderly and disabled.

“They decided not to look at the effect of health care reform,” Tom Nickels, senior vice president for federal relations in Washington for the hospital association, said in a telephone interview today. “They don’t penalize states that have chosen not to expand.”

The reductions are mandated by President Barack Obama’s Affordable Care Act, and were supposed to be offset by an increase in the number of patients who would gain insurance through an expansion of state Medicaid programs. With some Republican-led states deciding not to cooperate, a loss of funding without a gain in more insured patients would hamper hospitals ability to keep caring for underserved populations.

“It’s a kick in the gut,” said John Bluford, chief executive officer of Truman Medical Centers in Kansas City, Missouri, which estimates it may lose as much as $150 million in Medicaid payments over seven years. “These are real dollars. It would wipe out our margins.”

Tenet Profit

The rules being circulated this week show Medicaid would reduce the so-called DSH payments by $500 million in the fiscal 2014 year starting in October. For 2015, $600 million more would be cut with the annual reductions reaching $5.6 billion in 2019.

For the first two years, the funding cuts won’t be based on whether states have opted to expand Medicaid. Tenet Healthcare Corp. (THC), the third-largest for-profit hospital chain in the U.S., estimated in February the Medicaid and Medicare cuts would cost it $35 million in government payments in the fourth quarter. Dallas-based Tenet has 26 percent of its beds in Florida and 20 percent in Texas, both states where the Republican governors have opted not to expand Medicaid.

HCA Holdings Inc. (HCA), the largest for-profit U.S. hospital chain, has 25 percent of its beds in Texas and 25 percent in Florida, according to said Brian Tanquilut, an analyst at Jefferies LLC in Los Angeles.

Saving Grace

For-profit hospitals like Tenet are unlikely to pass along the costs of the cuts to consumers in the way of raising rates to non-government payers, Tanquilut said. “They’ll eat it.”

Cuts in the Medicare DSH payments also will be offset by a separate April 26 regulatory proposal that would lead to a 0.8 percent net raise in overall Medicare payments for services that elderly and disabled patients get after being admitted to hospitals, Tanquilut said by telephone.

The overall Medicare rate — which includes the Medicare cuts to hospitals that treat a large number of low-income patients — should keep HCA’s earnings before interest, taxes and amortization expenses within its February 2013 guidance, R. Milton Johnson, president and chief financial officer, said on an April conference call with investors.

The saving grace for for-profit hospitals, Tanquilut said, is that the Affordable Care Act will bring financial benefits that nonprofit and public hospitals like Truman Medical won’t see. Large, urban hospitals that provide the biggest share of charity care and treat more Medicaid patients are most at risk, Moody’s Investors Service Inc. said in a March 14 report.

Tight Bind

With only about one-fifth of their patients having commercial insurance, these safety-net hospitals typically have profit margins of about 2.3 percent, a third of the industrywide average for all hospitals, according to 2010 data from the National Association of Public Hospitals and Health Systems. Losing Medicaid funding and not gaining more insured patients would swing that margin from a profit to a loss of 6.1 percent.

Hospitals may try to recoup losses by limiting the amount of care they provide to the uninsured or reducing staff, John Graves, an assistant professor at the Vanderbilt University School of Medicine in Nashville, Tennessee, said by telephone.

“They’re in a tight bind,” Graves said. “They have to recoup those losses through fewer services, shutting down.”

Death By A Thousand Cuts Indirect Hostage-Taking

To the surprise of many, the Obama administration called for a delay in the Medicaid cuts for states that opt-out of the expansion. So are the hospitals out of the danger zone? Well….another predictable consequence of all this is that, given the choice to expand healthcare coverage for poor people vs sticking it to Obama, sticking it to Obama was going to be a clear winner in a lot of states. What wasn’t obvious, however, was that the GOP might be willing to shut down the Federal government in order to stop Obamacare’s implementation. Granted, they were most likely going to threaten to shut down the government over something, but limiting healthcare access to poor people was never the obvious play from the GOP’s playbook:

Talking Points Memo
Conservatives Step Up Push To Undercut GOP On Obamacare
Sahil Kapur September 13, 2013, 6:00 PM

Obamacare is becoming a huge headache for the Republican Party.

Conservative advocacy groups are rallying behind House legislation backed by 43 Republicans to threaten a government shutdown unless Obamacare is defunded, undercutting GOP leaders’ efforts to lock in low spending levels by goading the party into a self-defeating confrontation.

Within 24 hours of its Thursday release, Sen. Mike Lee (R-UT) threw his support behind the bill, as did the well-funded groups Club For Growth, FreedomWorks and Heritage Action.

“The Club for Growth strongly supports the legislation offered by Congressman Tom Graves to save America from Obamacare,” said Chris Chocola, the group’s president, boasting that “momentum is building” to stop the health care reform law.

House GOP leaders, who have few votes to spare, are determined to pass their proposal to continue spending at sequestration levels and force a Senate vote to defund Obamacare without risking a shutdown. House leadership is open to tweaking the specifics but they want to achieve three goals: continue the sequester, give Senate Republicans a chance to fight Obamacare and maintain leverage against the health care going into the debt limit fight. The 43 Republicans behind the Graves bill haven’t implicitly committed to opposing leaders’ version.

Conservatives, meanwhile, are undercutting — and infuriating — Republican leaders who want to be pragmatic about what they can achieve in the continuing resolution. Democrats, they recognize, are vulnerable on spending levels but won’t cave on Obamacare. As a result, if the hard right’s desires get in the way of reaffirming sequestration cuts (even temporarily), the GOP may lose on all fronts. Veteran Republicans realize the party out of power will be blamed if the government shuts down, and their negotiating hand weakened over how much it should spend upon re-opening.

The conservative opposition to Obamacare has become unappeasable and it’s tearing the GOP apart. The base is anxious to make a stand now because implementation of the law is set to accelerate on Oct. 1 and its major components poised to take effect on Jan. 1. Advocates privately gloat about their chances of sticking it to GOP leaders as they mobilize in favor of a standoff. Stare down President Barack Obama until he blinks on his own signature achievement, they demand of the GOP, even if it means shutting down the government. But Republican leaders aren’t optimistic that he’ll blink, and worry that initiating this battle could damage their already weak brand and threaten their otherwise secure House majority.

The House GOP leadership proposal entails a two-pronged bill to fund the government until Dec. 15 at sequestration levels and force the Senate to vote on defunding Obamacare. The Senate can reject the Obamacare component, as is expected, and send the rest of the continuing resolution straight to the president’s desk.

Republican leaders tentatively plan on bringing up a stopgap measure next week, and aides maintain an air of confidence about success. They face a tough road to securing the votes for just about any bill to keep the government open. Will they succeed?

“That remains to be seen,” said a House GOP leadership aide.

The latest proposal by House Majority Whip Eric Cantor to threaten a default on the US debt in place of a government shutdown threat is another very non-obvious play for the GOP to call at this point. It’s not actually all that out of character for the GOP, but threatening to default on the national debt unless we all agree to keep limiting health care to the poor isn’t the obvious best move for the GOP in this situation. Everyone is used to a little zealotry for the GOP at this point but this just might be another overreach:

TPMDC
Cantor: If We Can’t Defund Obamacare, Let’s Delay It
Sahil Kapur September 12, 2013, 10:40 AM

In order to persuade conservatives lawmakers to vote to keep the federal government funded past Sept. 30, House Republican leaders are proposing to stare down President Barack Obama over the debt ceiling by seeking a one-year delay of Obamacare.

At a closed-door meeting Tuesday, House Majority Leader Eric Cantor (R-VA) floated a strategy to delay the rollout of Obamacare for one year in exchange for lifting the debt ceiling. The meeting was focused on pitching a plan that lets Republicans vote to defund Obamacare without risking a government shutdown if the Senate rejects the idea, a move that is meeting fierce resistance on their right flank, which wants to go further.

A senior Republican aide familiar with Cantor’s remarks said he was essentially trying to persuade his members that the debt limit, which the federal government is expected to hit in mid-October, provides a better opportunity than a threatened government shutdown to undermine Obamacare.

“He didn’t draw any red lines,” said the GOP aide. “He said it’s a better opportunity than [the continuing resolution] and a delay there is very doable.” The aide added that the concession wouldn’t necessarily just involve Obamacare; there could be other reforms. The aide admitted that it depends in part on what the president is willing to give up.

It all sounds far-fetched. After all, trading a government shutdown for default would be like trading a common cold for cancer. And it remains to be seen whether GOP leaders would let the economy collapse if they don’t get their way, or if they’re merely saying what they have to say to get through the shutdown crisis.

An upside to proposing the debt ceiling idea now is that it helps persuade Republican lawmakers not to withhold their support for keeping the government open. Cantor’s suggestion this week comes as Republicans are taking heavy fire from conservative advocates for refraining from risking a government shutdown over Obamacare. House leaders have postponed consideration of the continuing resolution until next week to build support.

Last month, Speaker John Boehner (R-OH) floated the idea of delaying or defunding the health care reform law in a debt ceiling package. But he, too, stopped short of drawing any red lines. A leadership aide described it at the time as an “option.”

Despite the anti-Obamacare frenzy consuming their right flank, Republican leaders recognize that both a shutdown and default would be a disaster for their party, potentially threatening their House majority ahead of a mid-term election when they hope to win back the Senate. Their balancing act to satisfy conservatives enough to avert a shutdown but not to create expectations that threatening debt default is the way to go.

Then again, maybe this isn’t overreach at all that we’re looking at. Maybe it’s really an incredibly sneaky plan to simultaneously limit access to healthcare for people (a core value held by much of the contemporary GOP base) AND blame it all on Obamacare. At least in some states…states that don’t accept the Medicaid expansion. Because by threatening to shutdown the government or defaulting on the debt over their opposition to Obamacare the GOP is still going to destroy the finances of hospitals in the states that refuse to accept the Medicaid expansion. That’s because that delay in the Medicaid cuts that the Obama administration agreed to in May can’t actually be implemented until Congress passes a budget. Now all they have to do is ensure that the public blames all the hospital closures and healthcare problems that results from these cuts on Obamacare and not the perpetual budget and healthcare warfare waged by the GOP which shouldn’t be too hard to do. If this wasn’t an accident, it was kind of brilliant. Except for the part about how the GOP has to explain shutting down the government or defaulting on the national debt. So it’s possible that the GOP is operating in “Mad Dog” mode right now, and given the larger debt battles that are swirling around this issue, this is potentially a much scarier story about politically and ideologically-driven attempts to restrict health care to poor people than stories about politically and ideologically-driven attempts to restrict health care to poor people normally are:

TPMLivewire
Without New Budget, HHS Finalizes $1.1 Billion in Medicaid Hospital Cuts
Dylan Scott 4:58 PM EDT, Friday September 13, 2013

Because a gridlocked Congress won’t be passing a new budget anytime soon, the U.S. Department of Health and Human Services finalized a rule Friday for $1.1 billion in Medicaid cuts to hospitals under the Affordable Care Act, cuts that could hit hospitals particularly hard in states that don’t expand Medicaid through the law.

President Obama proposed postponing the cuts one year in his FY 2014 budget because not every state is expanding Medicaid as originally planned. The cuts, which are to payments for hospitals that perform a lot of uncompensated care, were included in Obamacare because the law would cover more people, decreasing the overall amount of uncompensated care.

The president’s proposal reflected the reality that 20-plus states have refused to expand Medicaid coverage under the health care reform law. If the cuts went into effect, hospitals in those non-expanding states would receive smaller reimbursements from HHS without the compensatory expansion of coverage.

But without a new budget from Congress, HHS wasn’t able to implement the president’s proposal.

“HHS has no flexibility to institute a delay of the DSH allotment reductions without congressional action,” the rule released Friday said.

For those governors that still fear a dystopian world free of uninsured poor people It might worth reminding them that there would still uninsured people left in their states even if they accept it. It’s a long shot, but it just might work.

Discussion

52 comments for “The GOP Pulls Off the Medicaid Band-Aid. Ouch.”

  1. No manner what one may think about Obamacare, the Republican have nothing to offer. Even my dog understands that.

    Posted by David | September 15, 2013, 5:13 pm
  2. @David: What makes the whole situation even sadder is that the GOP used to have an alternative to offer before Obamacare was created. That alternative was, of course, Obamacare:

    Mother Jones
    25 Republicans Who Supported Obamacare Before Obama

    —By Erika Eichelberger
    | Tue Aug. 27, 2013 3:00 AM PDT

    Republicans have pulled out all the stops to kill Obamacare, the president’s landmark health care law that requires every American to purchase health insurance by 2014. There have been lawsuits; there have been bills (40 in the House so far); there has been a Supreme Court case—all aimed at rolling back a law that that the GOP says is an assault on individual liberty. Now, with only a few more months to go until the individual mandate—the requirement that we all have coverage—kicks in, Republicans are frantic; some are even threatening to force the United States to default on its debts if Democrats don’t agree to delay the law.

    This is odd because the individual mandate, the cornerstone of Obamacare, was originally a conservative idea. It was first proposed by the Heritage Foundation in 1989. And scores of Republicans—not just Mitt Romney—have backed the idea in the past couple of decades. Here are some of the GOPers who supported Obamacare before Obama:

    1. Rick Santorum? The Allentown Morning Call reported several times in 1994 that Santorum wanted to “require individuals to buy health insurance rather than forcing employers to pay for benefits.” Santorum denies allegations that he ever supported an individual mandate.

    2. President George H.W. Bush: In 1991, Mark Pauly, an adviser to the first Bush, and now a conservative health economist, came up with a Heritage-style health care proposal for the president as an alternative to the employer-based mandate that Democrats were pushing at the time.

    3. Former Vice President Dan Quayle: He was down with the Heritage idea too.

    4. Mitt Romney: Romneycare was Romney’s signature legislative achievement as governor of Massachusetts, and it served as a model for Obamacare. During the 2012 campaign, the presidential contender had trouble deciding what his position was on Obamacare, and he deflected the blame for having conceived a similar plan; at one debate he noted that “we got the idea of an individual mandate…from [Newt Gingrich].”

    5. Newt Gingrich: Though he reversed his position in May 2011, Gingrich had been a big supporter of the individual mandate since his early days in the House. In 1992 and 1993, when Republicans were looking for alternatives to Hillary Clinton’s health care plan, many, including then-House minority whip Gingrich, backed the Heritage idea. (Gingrich has said that most conservatives supported an individual mandate for health insurance at the time.)

    Twenty of his fellow GOPers cosponsored a 1993 health care bill which included an individual mandate and vouchers for poor people. As health scholar Avik Roy wrote at Forbes in 2012, “Given that there were 43 Republicans in the Senate of the 103rd Congress, these 20 comprised nearly half of the Republican Senate Caucus at that time.” Here are those lawmakers:

    Posted by Pterrafractyl | September 16, 2013, 8:35 am
  3. Here’s a nice preview of what’s coming:

    TPMLiveWire
    Rubio: Obama Should Stop Threatening Government Shutdown

    Igor Bobic – September 18, 2013, 3:26 PM EDT

    Sen. Marco Rubio (R-FL) thinks President Barack Obama is the one who should stop threatening to shut down the government, despite a newly announced plan by House Republicans adding language to a stopgap measure that would defund Obamacare in order to avert a government shutdown.

    “The American people have made clear they want Washington to keep the government open but also need protection from ObamaCare’s harmful effects,” Rubio said in a statement. “Today’s announcement would accomplish what the American people have been asking of Congress.”

    “A solution is within sight in order to avert another crisis of Washington’s creation,” he added. “President Obama and his allies in Congress should abandon their threats of shutting down the government and instead work with Republicans to pass this proposal that would keep government open while preventing taxpayer dollars from being used to inflict ObamaCare’s damage on people’s jobs, incomes, current health plans and doctor relationships.”

    If that sounds familiar, it’s because it’s a preview we’ve seen before:

    The Hill
    Rubio blames Obama for threats of shutdown
    By Jonathan Easley – 07/25/13 09:44 AM ET

    Sen. Marco Rubio (R-Fla.) argued Thursday that it’s President Obama, not Republican leaders in the House and Senate, who is responsible for threats of a government shutdown over the implementation of ObamaCare.

    “This September, Congress will have to pass another short term spending bill to fund the federal government,” Rubio wrote in an op-ed for Fox News.

    “We should pass one that keeps the government open, but doesn’t waste any more money on ObamaCare. The president and his allies – and even some Republicans – will accuse us of threatening to shut down the government. In fact, it is President Obama who insists on shutting down the government unless it funds his failed ObamaCare experiment.

    Sen. Mike Lee (R-Utah) says he’s recruited more than a dozen Republican colleagues willing to shut down the government by blocking a continuing resolution to fund the government beyond Sept. 30 if it includes funding for ObamaCare.

    The second- and third-ranking members of Republican leadership, Sens. John Cornyn (Texas) and John Thune (S.D.), have said they support Lee’s plan, as do influential conservatives and potential presidential candidates Sens. Marco Rubio (Fla.) and Ted Cruz (Texas).

    Rubio on Thursday said the law should be replaced with “market-based” reforms.

    “It is time to admit that ObamaCare isn’t going to work, decide not to waste a single cent more on it, and replace it with market-based reforms that will give people more health insurance choices and options,” he wrote.

    Posted by Pterrafractyl | September 19, 2013, 8:04 pm
  4. What’s that? The Cleveland Clinic just announced a bunch of layoffs that are all caused by that dastardly Obamacare?

    Cleveland Clinic announces job cuts to prepare for Obamacare

    By Kim Palmer

    CLEVELAND | Wed Sep 18, 2013 5:23pm EDT

    (Reuters) – The world-renowned Cleveland Clinic said on Wednesday it would cut jobs and slash five to six percent of its $6 billion annual budget to prepare for President Barack Obama’s health reforms.

    The clinic, which has treated celebrities and world leaders such as musician Lou Reed, former Italian Prime Minister Silvio Berlusconi and former Olympic gold medal skater Scott Hamilton, did not say how many of its 44,000 employees would be laid off. But a spokeswoman said that $330 million would be cut from its annual budget.

    “Some of the initiatives include offering early retirement to 3,000 eligible employees, reducing operational costs, stricter review of filling vacant positions, and lastly workforce reductions,” said Eileen Sheil, Executive Director of Corporate Communications for the Cleveland Clinic Foundation.

    The clinic is Cleveland’s largest employer and the second largest in Ohio after Wal-Mart. It is the largest provider in Ohio of Medicaid health coverage for the poor, the program that will expand to cover uninsured Americans under Obamacare.

    “We know we are going to be reimbursed less,” under Medicaid, Sheil said.

    Cleveland Clinic has almost 100 locations around Ohio employing 3,000 doctors. Its main campus is world renowned for cancer and cardiovascular treatment.

    “To prepare for healthcare reform, Cleveland Clinic is transforming the way care is delivered to patients,” Sheil said without elaborating.

    A 2009 study by the clinic concluded that it accounts for nearly eight percent of the economic output of northeast Ohio.

    A key part of Obamacare, officially known as the Affordable Care Act, goes into effect on October 1, when states are supposed to begin offering Americans health insurance options through online exchanges to compare prices.

    Uh oh, it sounds like Obamacare is a job killing destroyer of worlds…it’s just like Fox News warned us!

    Oh wait, no it isn’t:

    The Atlantic
    Obamacare Isn’t Really Taking Away Jobs: Cleveland Clinic Edition
    The prestigious system says budget cuts have more to do with the need to find efficiencies. “We felt health-care reform was absolutely necessary,” a spokeswoman said.
    David A. Graham Sep 20 2013, 11:08 AM ET

    As the clock ticks down to full implementation of the Affordable Care Act, a trickle of stories about job losses related to the law has turned into a steady flow. Over the weekend, the story was that Emory Healthcare was axing 100 jobs in response — an explanation that turned out not to be true.

    It didn’t take a long time for another example of hospitals cutting back in the face of Obamacare to pop up, though. On Wednesday, the Cleveland Clinic announced it would cut its budget and staff. Here’s how Reuters reported the news:

    The world-renowned Cleveland Clinic said on Wednesday it would cut jobs and slash five to six percent of its $6 billion annual budget to prepare for President Barack Obama’s health reforms.

    The clinic, which has treated celebrities and world leaders … did not say how many of its 44,000 employees would be laid off. But a spokeswoman said that $330 million would be cut from its annual budget.

    Later on, the story quoted Eileen Sheil, the clinic’s Executive Director of Corporate Communications, saying, “We know we are going to be reimbursed less” under Medicaid.

    That explanation seemed questionable, because the cost reductions to Medicaid in the ACA are much smaller than reductions to Medicare — the government will reimburse providers less for giving care to Medicare patients than before. While the mechanisms aimed at providing universal insurance have gotten more attention, this is part of the law’s other goal: an attempt to “bend the cost curve” (administration-speak for slowing the growth of health-care spending) in the law During the 2012 presidential campaign, the Romney campaign attacked Obama for cutting Medicare, though the administration says patients should receive the same care; will just be paid less for it.

    In fact, the “Obamacare is killing jobs” story isn’t really accurate. It’s not totally false — the Cleveland Clinic will in fact take in less money because of the law — but it’s a more complicated story about changes in medicine. When I reached Sheil on Thursday, she seemed a bit confused by the emphasis on Obamacare in reports. “We’ve been working on reducing costs for years,” she said.

    “We felt health-care reform was absolutely necessary,” Sheil said. “This is the new normal. This is where hospitals have to focus to be viable in the long run. This is not doomsday for the clinic. We’re still growing — we’re still hiring. The hardest thing is when it affects people.”

    Actually, much of what the Cleveland Clinic system is doing follows the recommendations of health-care analysts closely. For example, it has consolidated closely located neonatal intensive care units, because high volumes tend to lead to better results. It’s working to reduce the number of procedures its staff performs, since in the current system “physicians are rewarded to do more, not to do the right thing for the patient,” as Sheil put it. And there’s a new focus on chronic diseases, which are an increasingly important and costly area for treatment.

    Think of it this way: These are all steps that the Cleveland Clinic was likely to take, but Obamacare implementation is acting as a catalyst, spurring the clinic to adopt them now rather than on a slower timeline.

    This isn’t to absolve the ACA of any role in the cuts at all. The revenue reduction because of the law is real. Pretty much everyone agrees that the spiraling costs of health care in the U.S. threaten — through Medicaid and Medicare — the nation’s long-term fiscal health.

    Ah, so it looks like all planned cuts to health care costs – including the reduction in Medicaid reimbursements and uncompensated care (payments for services to people without healthcare) that are vital to attempts to “bend the [healthcare cost] curve” – are going to be portrayed as some sort of sign that Obamacare is destroying healthcare in America…even in the states that reject the Medicaid expansion:

    UPDATE 1-Obamacare supporters in Ohio begin petition drive to expand Medicaid
    Thu Sep 19, 2013 7:20pm EDT
    By Mary Wisniewski

    (Reuters) – An Ohio panel on Thursday approved a petition designed to pressure the Republican-led state legislature to expand the Medicaid health program for the poor as part of President Barack Obama’s health reform law.

    The aim is to allow about 275,000 additional Ohio residents to be eligible for Medicaid under the new reform law, a proposal supported by Republican Governor John Kasich but not yet acted on by state lawmakers.

    Kasich, who opposes Obamacare, had endorsed the expansion of Medicaid last February, raising hopes that Ohio would join some 25 states and the District of Columbia moving forward with expanding Medicaid. Another 22 states are opposed to Medicaid expansion and three, including Ohio, are still debating the issue, according to the Kaiser Family Foundation.

    The expansion of Medicaid is a major plank of the health reform law which aims to ensure that all Americans have access to affordable health insurance.

    The ballot board’s decision came a day after the world-renowned Cleveland Clinic, Ohio’s largest provider of Medicaid coverage, announced that it would cut jobs and slash five to six percent of its budget, partly because of an expected decline in federal reimbursements for the cost of treating poor people who lack insurance.

    Obamacare will begin reducing payments to hospitals for uncompensated care for the poor next year. But hospitals in states that expand Medicaid are expected to require substantially less money, because more of their poor patients will have health coverage through the expansion.

    Posted by Pterrafractyl | September 23, 2013, 7:56 am
  5. Well this is kind of interesting: the fight over Obamacare and the Medicaid expansion is creating a split between the Tea Party base and what’s left of the non-Tea Party contingent of the GOP. Denying health care to poor people and higher revenues for big businesses are rarely in conflict, but right now they are. And, to their credit, the Tea Party is advocating the non-revenue-maximizing policy. If senselessly denying health care to poor people wasn’t so morally reprehensible one could almost congratulate the Tea Party for their principled stance:

    Bloomberg
    Hospitals Brace as Republicans Fight Over Medicaid
    By Mark Niquette & Brian Chappatta – Sep 19, 2013 12:24 PM CT

    Phil Ennen runs a rural hospital system in northwest Ohio that admits about 2,500 people a year, many of them poor or elderly. He’s got the only emergency cardiac catheterization lab between Toledo and Fort Wayne, Indiana.

    Ennen estimates he’d be out $1.3 million a year and struggle to stay independent if business groups and Governor John Kasich can’t persuade fellow Republicans to expand Medicaid to cover more poor people under President Barack Obama’s Affordable Care Act.

    “I don’t have any time to be political about this,” Ennen, 50, said in a telephone interview from Bryan. “I’m going to have people walking through our door needing care who should have a source of payment and won’t, and that’s frustrating.”

    Ohio is among U.S. states where Tea Party Republicans have blocked Medicaid expansion, in some cases over the objections of other Republicans and business lobbies that have traditionally supported the party. Hospital leaders say the cost will be lost payments and jobs. The financial effect is evident: Facilities in states broadening the program are already enjoying lower borrowing costs.

    The fight reflects an intensifying rift between business and the Tea Party over high-profile issues, said John Green, a University of Akron political-science professor. Besides Medicaid, they include efforts in states including Indiana and North Carolina to halt or delay Common Core education standards to prepare students for college or careers, the right to bring guns to work in Alabama and on immigration in several places.

    Breaking Ranks

    “Once upon a time, if the big economic interests said, ‘This is what we’re for,’ almost all Republicans would get in line,” Green said in a telephone interview. “The calculus is just a lot different today.”

    Twenty-five states and the District of Columbia are proceeding with Medicaid expansion, including eight with Republican governors. Twenty-two aren’t and debate is continuing in New Hampshire, Ohio and Tennessee, according to the Kaiser Family Foundation, a nonprofit group that studies health in Menlo Park, California.
    State Lines

    In Ohio, a presidential battleground that Obama won twice, Republicans control all statewide offices and the legislature. Its lawmakers have blocked a push to expand Medicaid by Kasich, the state Chamber of Commerce and groups including the anti-abortion organization Ohio Right to Life.

    A coalition of business groups is collecting signatures to force a referendum on the question next year if lawmakers won’t act, and Kasich is considering ways to open the program without a vote by the full legislature.

    If all states participated in the Medicaid expansion, hospitals would see a $12.5 billion spending boost in 2014, according to an analysis by Bloomberg Government. About $7.8 billion, or 63 percent, won’t be spent in the 25 states that have so far decided not to expand. The increased spending in Ohio would be $458.4 million, the analysis said.

    Ohio hospitals will lose $7.4 billion during the next decade from reduced reimbursements if the state doesn’t expand Medicaid, said Mike Abrams, president of the Ohio Hospital Association. Hospitals that are the largest employers in 78 of Ohio’s 88 counties may fire employees or close, he said.

    Covering Action

    The governor is trying to appeal to independents for his re-election in 2014, while business groups and the “hospital-industrial complex” are exaggerating to get “free money,” said Matt Mayer, president of Opportunity Ohio, a Columbus group that promotes free markets.

    “It doesn’t solve the business problem, which is how do we make sure that our vulnerable populations who truly need medical care and access thereto that’s affordable, get it?” Mayer said by phone. He called hospitals’ threats “a scare tactic,” and said states opposing expansion are saving the nation billions of dollars.

    Even so, investors in the $3.7 trillion municipal-debt market are already penalizing bonds from hospitals in states that aren’t expanding Medicaid compared with those in states that are.

    Republican leaders who cater too much to business are out of step with the rank and file, said Whitney Neal of FreedomWorks, a Washington-based group connected with the Tea Party movement.

    “You’re seeing the guys that care about their constituents versus the guys that care about the people who they’re beholden to, the special interest groups,” Neal said in a telephone interview.

    Supporting issues such as Medicaid expansion could draw a primary opponent for Republican lawmakers in conservative districts, Green said. The ability of party leaders to influence policy also has waned as social media and technology connected conservatives and gave them a platform, said Kevin Madden, a Republican strategist in Washington who advised Mitt Romney’s 2012 presidential campaign.

    “Technology has really empowered a lot of grassroots voices within the party,” Madden said in a telephone interview. “As a result, I think that they’ve gained a much greater market share of influence in these debates in states and in Washington.”

    Ah, the Tea Party, fighting for the little guy. When you have patriots like this looking out for the common good having a government almost seems unnecessary!

    TPM LiveWire
    Poll: Vast Majority Of Tea Party Prefers Government Shutdown Over Compromise
    Tom Kludt – September 23, 2013, 1:42 PM EDT
    A huge majority of tea party types want likeminded lawmakers to defend by their convictions even if it results in a government shutdown, placing the ultra-conservative contingent sharply at odds with the rest of the country.

    The latest findings released Monday by Pew Research Center found 71 percent of tea party Republicans want lawmakers who share their views to stand by their principles even if doing so leads to a government shutdown. Only 20 percent of tea partiers said they want those lawmakers to compromise, even if it leads to a budget with which they disagree. Republicans in general were more divided, but a plurality — 49 percent — still said they would rather have their lawmakers stand by their principles rather than compromise.

    Another poll released Monday found a majority of Americans opposed to a government shutdown over the quixotic effort to defund the health care law.

    Posted by Pterrafractyl | September 23, 2013, 1:43 pm
  6. It’s increasingly looking like the GOP’s grand strategy for the Obamacare government-shutdown debacle is going center around pretending that it’s the Democrats that are threatening a government shut down/debt default while simultaneously basking on the Tea Party glory that comes from obstructing the implementation of Obamacare. It’s a boldly strange strategy. Bombs away Teddy! You’re right on target:

    TPM LiveWire
    Ted Cruz: Harry Reid Engaging In Brinkmanship Over Budget, Debt

    Igor Bobic – September 23, 2013, 5:01 PM EDT

    Sen. Ted Cruz (R-TX) believes Senate Majority Leader Harry Reid (D-NV) is the one engaging in brinkmanship over the budget and debt limit, and he staged a series of procedural motions Monday that involve defunding Obamacare in order to say so.

    After Reid objected to Cruz’s request for unanimous consent to pass a House GOP continuing resolution that funds the government but also defunds Obamacare on the Senate floor, the junior senator from Texas cast the majority leader as the one threatening to take the country over the edge.

    “I wish the majority leader had agreed to my request to take a government shutdown off the table by passing the House continuing resolution,” Cruz said. “If we listen to the American people, we will, number two, take any default on the debt off the table. I wish the majority leader had not objected to doing so right now.”

    “I wish the majority leader had not said he intends to continue to use the threat of a default to engage in brinkmanship to try to force it on the American people — to try to force obamacare on the American people,” he added.

    Posted by Pterrafractyl | September 23, 2013, 6:25 pm
  7. This is kind of amusing: One of the consequences of rejecting the Medicaid expansion in states like Ohio and Texas is that the future cost of healthcare in those states is going to be a lot more dependent on the costs of the new private health insurance exchanges that are about to open. So these states should be cheering the news that the cost of these private options looks to be 16% lower, on average, than originally projected. Then again, maybe governors like Rick Perry in states that rejected the Medicaid expansion don’t feel like reminding people that – by forcing lower-income patients onto private health insurance instead of Medicaid and leaving more people uninsured than otherwise would be – they’re also pushing up the costs of private insurance for everyone else in their state:

    Dallas News
    Study says Texas premiums will rise with Medicaid expansion opposition

    By ROBERT T. GARRETT

    Austin Bureau

    rgarrett@dallasnews.com

    Published: 02 September 2013 10:54 PM

    Updated: 02 September 2013 11:26 PM

    AUSTIN — Texas’ refusal to expand Medicaid will cause private health insurance premiums to rise by an average of 9.3 percent for people who buy their own coverage, a new study finds.

    GOP lawmakers, strongly encouraged by Gov. Rick Perry, decided not to add poor adults to Medicaid’s rolls. That means about 1.3 million fewer Texans will have health coverage by 2016 than if the federal Affordable Care Act were fully implemented in the state, according to the study by the nonprofit research organization Rand Corp.

    About 320,000 adult Texans just above the poverty line will take advantage of the Affordable Care Act’s federal subsidies and buy coverage in the individual insurance market, the researchers said. Those are people who would have been enrolled in Medicaid as the federal law was written and before that part of it was altered by a Supreme Court ruling.

    The study said that because low-income people generally are not as healthy as wealthier people, their inclusion in private health insurance exchanges will increase costs. That will force a 9.3 percent increase in premiums for all 3 million Texans who will be enrolled in the individual market by 2016, the study said.

    In Texas, the private health insurance exchange that will open next month will be run by the federal Health and Human Services Department because Perry threatened in 2011 to veto a Republican House lawmaker’s bill calling for a state-run exchange.

    In this year’s legislative session, no Republican proposed a state-run exchange, and the Obamacare debate was mainly about Perry’s insistence that Texas shouldn’t enlarge Medicaid, even if it meant turning down about $100 billion more in federal matching money over the coming decade.

    He and other Republicans have said the Medicaid expansion would be too costly. Although the federal government would pay nearly all the cost of the expansion, critics say the program is not sustainable.

    Officials also have noted that the cost of caring for the uninsured falls largely to county taxpayers who support large public hospitals, such as Dallas’ Parkland hospital, rather than to the state itself.

    The study suggests that the federal health care legislation will cause more than a tripling of the share of Texas’ nonelderly population that will be enrolled in the individual insurance market in 2016 — from 2.9 percent, if the legislation had not passed, to 11.3 percent.

    Spurring that increase is the Affordable Care Act’s subsidies that the study says could go to 69 percent of people buying their own coverage.

    If Texas expanded Medicaid, the percentage of the state’s nonelderly population that would be uninsured would drop in 2016 from 28.2 percent to 12.4 percent, the study said.

    Hmmm…so by denying the Medicaid expansion, governors like Rick Perry are increasing costs to hospitals AND the public at large. What’s not to love?

    Texas Public Radio
    Perry Rejects Medicaid Expansion (Again), But Still Wants Federal Block Grant Waiver
    12:17 pm Tue September 24, 2013

    By Ryan Poppe

    Gov. Rick Perry has sent the final instructions to the state’s health commissioner ahead of a meeting with federal officials regarding the implementation of Medicaid expansion in Texas.

    The letter sent this week to Texas Health and Human Services Commissioner Dr. Kyle Janeck begins by questioning the wisdom behind the Obama administration’s expansion of Medicaid coverage under the Affordable Care Act.

    Perry tells the commissioner he wants a federal block grant that would allow Texas to set up its own form of Medicaid with a waiver. Other states that have filed similar waivers have been denied.

    Lance Lunsford with the Texas Hospital Association said Perry’s waiver wouldn’t extend coverage to 1.6 million Texans who don’t qualify for Medicaid and can’t afford private healthcare.

    “When you look at the fact that the private market has to account for that uncovered population through cost-shifting you’re looking at $1,800 a year on average in higher private health insurance premiums due to uncompensated care for the uninsured,” Lunsford said.

    Lunsford said he doesn’t expect the federal government to approve the request for a block grant, leaving uninsured Texans the option of going to local hospital ERs to be treated.

    While this is obviously a decision rooted in love, it’s still not very reasonable. Maybe it’s a faithbased thing.

    Posted by Pterrafractyl | September 25, 2013, 11:43 am
  8. Ohio’s Governor Kasich (R) supports Medicaid expansion. The problem is the GOP dominated legislature. My state senator (D) said on a local radio program that the legislature will not support the expansion because it’s associated with Obama and “Obamacare”. Period. Even Kasich knows this; he advised my senator not to invoke “Obama” in any discussion of Medicaid with the GOP legislators. He also told him to ouse term “Medicaid Reform”, not “Medicaid Expansion”.

    Posted by Kathleen | September 25, 2013, 1:47 pm
  9. @Kathleen: It’s one of those unsettling signs of the times that John Kasich is a voice of relative sanity. But here we are, where if you can refrain from comparing expanded healthcare coverage for the poor to the threat of Nazi Germany you’re damn near qualified to win a “Goodness” award.

    In related news, the set of demands coming out of the House GOP in exchange for not shutting down the government just got a lot longer and crazier:


    The bill, obtained by the National Review, tacks on items including a one-year delay of Obamacare; tax reform in the image of Rep. Paul Ryan (R-WI); approval of the Keystone pipeline; expanded offshore drilling and other pro-oil and coal energy reforms; increases in military spending coupled with deeper cuts to domestic programs; repealing a fund in the financial regulatory reform bill; means testing for Medicare; repealing the Obamacare prevention and public health fund and medical malpractice reform.

    Posted by Pterrafractyl | September 26, 2013, 2:13 pm
  10. I’m glad to hear PBO and members of his administration calling them out for what they are. And, yes, the fact that Kasich seems relatively not bat crap crazy is scarey. How low is the bar!

    Posted by Kathleen | September 26, 2013, 3:54 pm
  11. According to Paul Ryan, it’s preposterous to believe that Obama won’t readily agree to negotiated with the GOP’s threat to shut down the government and/or default on the US debt. After all, these kinds of “negotiations” have been going on for years. This is all perfectly normal and expected behavior:

    TPMLiveWire
    Ryan: ‘Nobody Believes’ Obama Won’t Negotiate On Debt Limit

    Daniel Strauss – September 28, 2013, 4:50 PM EDT

    Nobody actually believes President Barack Obama’s vows to not negotiate on raising the debt ceiling, House Budget Committee Chairman Paul Ryan (R-WI) said.
    “Oh, nobody believes that. Nobody believes that. He himself negotiated Bowles Simpson on the debt limit with Democrats. That was Kent Conrad’s requirement,” Ryan told National Review. “He himself negotiated the Budget Control Act with the debt limit. Graham Rudman. Bush Andrews Airforce Base. Clinton Gore ‘97. All of those major budget agreements were debt limit agreements. I see this time as no different and I believe he does too. I think most people believe he’s just posturing for now.”

    Ryan’s comments come as the House seeks to pass a new continuing resolution bill that also delays Obamacare for one year and also includes a medical device tax repeal. Top Democrats were quick to criticize the proposal after it was unveiled.

    Ryan also said he expects the ongoing fight over funding the government to eventually fold into negotiations over raising the debt ceiling.

    “I think it will fold into the debt ceiling fight. I think that’s inevitable. And preferable in my opinion. I like combining all of our leverage, which is sequester and the debt limit,” Ryan told the magazine.

    Yes, this is all just part of the standard governing process. Historically, every bill that the minority party found ideologically displeasing was treated like a hijacked airplane on a suicide mission heading towards the capital:

    Think Progress
    GOP Congressman Compares Republicans Trying To Take Down Obamacare To Heroes Of 9/11

    By Judd Legum on September 28, 2013 at 3:39 pm

    This afternoon, House Republicans decided to tie continued funding of the federal government — which will run out of funds on Monday — to a one year delay of Obamacare and a repeal of a tax on medical devices. The move, by all accounts, makes a government shutdown quite likely.

    During a meeting of the House Republican Caucus, Congressman John Culberson (R-TX) compared the relentless Republican effort to defund Obamacare to the heroic efforts of the passengers on United Airlines Flight 93 who overpowered terrorists who had gained control of the plane.

    Benjy Sarlin
    @Benjy Sarlin

    Rep. Culberson (R-TX) on the big applause moment after GOP resolved to vote for CR: “I said, like 9/11, ‘lets roll!'”
    12:00 PM – 28 Sep 2013

    Asked lasted about the analogy by a skeptical reporter, Culberson didn’t back down calling it “a good historical analogy.”

    The path forward endorsed by Speaker Boehner and the House GOP leadership is quite popular with the more extreme elements of the party. Michele Bachmann gushed, “this is exactly what we asked for and we got it.”

    But there’s still the question of what the GOP leaders and their billionaire backers really want. Sure there are the obvious motivations: A good cry that just let’s it all out. Unconditional love. Feeling like you belong. These are all possible motivations. Another possibility, of course, is that all of this acting out is merely reflecting a pent up desire to fulfill a long held pledgeto drown people in bathtubs. So it could be a loyalty thing. But if so, normalizing the idea of a government shutdown and default is also sort of a necessity because when you publicly pledge to drown people in the bathtubs for years on end, the only way to truly accomplish that pledge is to convince enough of your neighbors that you are, in fact, protecting them by drowning people in bathtubs. You’re drowning the community for the greater good. And a great baby-step towards getting people to accept the idea of drowning the community is by first convince your neighbors that shutting down the government and defaulting on the debt are tiny prices to pay to thwart the existential threat presented by healthcare for the poor. Once you’ve accomplished that, drowning people in bathtubs doesn’t sound all that unreasonable.

    Posted by Pterrafractyl | September 28, 2013, 5:11 pm
  12. Now that the House GOP has decided to follow Grover’s lead and demand a one year delay to the Individual mandate and creation of individual marketplaces. In return for the Democrats accepting this “compromise” the GOP will refrain from shutting down the government and/or defaulting on the debt. So, previously, we were informed by the GOP that Obamacare represented a mortal threat to the health of both the American economy and the American public itself. Now, it appears, a delay of the individual mandate for small businesses will give Congress enough time to fix all the kinks and create a positive, workable bill that can achieve bipartisan support. Time, it appears, really does heal all wounds. Health insurance coverage also helps with the healing process but it will have to wait. Because that’s how we roll.

    Posted by Pterrafractyl | September 29, 2013, 1:47 am
  13. What do you do when you’re hostage taking scheme isn’t going as planned? You take more hostages of course!

    The New York Times
    Ryan Links Budget Impasse to Debt Ceiling Fight
    Oct 1, 6:50 pm
    Jeremy W. Peters

    WASHINGTON — Representative Paul D. Ryan of Wisconsin, chairman of the House Budget Committee, suggested on Tuesday that the government shutdown may not be resolved for more than two weeks.

    That would come, he said, when the country reaches its debt limit.

    Noting that previous agreements over the budget had come together around the deadline when the country has reached its statutory borrowing limit, Mr. Ryan said, “We think that will be the forcing mechanism to bring the two parties together. Our goal and motivation here is to get a budget agreement. And we think this is a way to do that.”

    Yep, first you take more hostages, but that’s not all. You also need to strap yourself with even more explosives and then demand that negotiators on the other side publicly decry values they hold dear while slitting their throats on live TV. It’s only after your negotiators realize that you’re batshit insane that they’ll begin to take you seriously:

    The Hill
    Ryan says grander endgame possible on debt ceiling
    By Erik Wasson – 09/26/13 01:46 PM ET

    House Budget Committee Chairman Paul Ryan (R-Wis.) told reporters Thursday that he still thinks the upcoming debt ceiling fight could yield massive changes to entitlements like Medicare and Medicaid, even though such changes are not proposed in the House’s new list of debt ceiling demands.

    Ryan supports the leadership plan, and his comments appeared directed at some House conservatives who are pushing for more spending cuts in the package unveiled by Speaker John Boehner (R-Ohio).

    The House is seeking smaller entitlement and regulatory reforms in addition to a timetable for tax reform, approval of the Keystone XL pipeline and a delay in ObamaCare in exchange for avoiding a debt ceiling default.

    Absent from the bill are the kind of major changes Ryan has pushed for years, such as the partial privatization of Medicare, block granting Medicaid or partially converting Social Security into a system of private accounts.

    The House-passed budget contains the Medicare and Medicaid proposals.

    “We are at the beginning of these negotiations. Our goal is to get a big fiscal package at the end of the day,” Ryan said. “Don’t confuse our tactics with our end goal.”

    Ryan said that just because larger reforms are not in the offer “does not preclude these things from being in a final package” after negotiations with the Senate and President Obama.

    “We want to get a big down payment on the debt; we want to delay ObamaCare; we want pro-growth solutions. This is our way of entering into these negotiations,” he said.

    To reiterate: When being an insane asshole doesn’t get the job done, just be a bigger, even more insane asshole. Only then will you see your plans come to fruition:

    Think Progress
    GOP May Hold Debt Ceiling Hostage To Enact Paul Ryan’s Budget

    By Igor Volsky on July 7, 2013 at 12:09 pm

    House Republicans will hold the national debt ceiling increase hostage until President Obama agrees to mandatory spending cuts to Social Security, Medicare, and Medicaid, the National Journal reports, and will seek to use the leverage of default to force Democrats to enact the policies in Rep. Paul Ryan’s (R-WI) budget.

    Since slashing discretionary spending to historic lows — the discretionary side of the ledger has grown at a slower rate than inflation since 2007 and now makes up a smaller share of the economy than it did before the Great Recession — the GOP has shifted from demanding dollar-for-dollar immediate spending cuts and is now focusing on drafting a range of options to significantly restructure mandatory benefit programs.

    The idea is to throw in the “kitchen sink” and allow Obama to pick and choose the cuts. “If what makes it easier to find the deal is to go in and pick and choose among a dozen different programs and just grab a little bit from all 12 — instead of a lot from one them — then that works just fine,” Rep. Rob Woodall (R-GA), who heads the Republican Study Committee’s budget and spending task force, told the Journal:

    For a long-term deal, one that gives Treasury borrowing authority for three-and-a-half years, Obama would have to agree to premium support. The plan to privatize Medicare, perhaps the most controversial aspect of the Ryan budget, is the holy grail for conservatives who say major deficit-reduction can only be achieved by making this type of cut to mandatory spending. “If the president wants to go big, there’s a big idea,” said Rep. Steve Scalise, chairman of the Republican Study Committee.

    For a medium-sized increase in the debt-limit, Republicans want Obama to agree to cut spending in the SNAP food stamp program, block-grant Medicaid, or tinker with chained CPI.

    For a smaller increase, there is talk of means-testing Social Security, for example, or ending certain agricultural subsidies.

    While the menu includes plenty of variables, the underlying strategic goal is to reduce mandatory spending — whatever the scope of the deal. Even at the smallest end of the spectrum — another months-long extension of debt-limit — there is talk of pushing back the eligibility age for Social Security by an equal number of months.

    Hostage-taking can be a fun and enjoyable experience for people of all ages. Just be sure to remember what you’ve been taught and everything should be fine.

    Posted by Pterrafractyl | October 1, 2013, 8:06 pm
  14. And we’ve almost hit the “we’re going to do a ‘Grand Bargain’ and extract entitlement-cuts”-phase of the GOP’s principled opposition. How does an apparently suicidal madman with a nuke strapped to his chest pull himself off the ledge? By threatening an even bigger explosion once he gets more nukes and climbs back on:

    The National Review
    Boehner to GOP: Grand Bargain in the Works
    By Robert Costa
    October 2, 2013 6:36 PM

    House Republicans tell me Speaker John Boehner wants to craft a “grand bargain” on fiscal issues as part of the debt-limit deliberations, and during a series of meetings on Wednesday, he urged colleagues to stick with him.

    The revelation came quietly. Boehner called groups of members to his Capitol office all day, taking their temperature on the shutdown and the debt limit. It became clear, members say, that Boehner’s chief goal is conference unity as the debt limit nears, and he’s looking at potentially blending a government-spending deal and debt-limit agreement into a larger budget package.

    “It’s the return of the grand bargain,” says one House Republican, who requested anonymity to speak freely. “There weren’t a lot of specifics discussed, and the meetings were mostly about just checking in. But he’s looking hard at the debt limit as a place where we can do something big.”

    Beyond Boehner’s office, the leadership is sending out a similar message through its emissaries. The House GOP’s most influential fiscal strategists, Dave Camp and Paul Ryan, are privately reassuring nervous Republicans that the federal shutdown may be painful in the short term, but a budget deal is in the works — and they should be enthused about what they’re cooking up.

    “Ryan is selling this to everybody; he’s getting back to his sweet spot,” says a second House Republican who’s close with Ryan. “He and Camp are going to be Boehner’s guys. That’s why Boehner put them on the CR conference committee; he knows these guys are going to be his point men.”

    And during Wednesday huddles, Ryan, Camp, and other House Republicans spoke openly about what kind of concessions they could potentially win from Democrats. Late Wednesday, “the CR-debt limit idea was what people were talking about on the floor,” says a GOP aide.

    Per sources, entitlement reforms, such as chained CPI, an elimination of the medical-device tax, and delays to parts of Obamacare are all on the table as trades for delaying aspects of sequestration and extending the debt limit. Camp, especially, is pushing to have a tax-reform framework included.

    From what I hear, this combined deal is being softly sold to members; Wednesday’s talks were about getting them engaged. And it’s all about what Republicans could win – and little about what they’ll give in return.

    What’s not being discussed: increased tax rates or revenues. That doesn’t mean, however, that revenue as part of a tax-reform pact has been ruled out.

    We just have to wait and see at this point to find out the “Grand Bargain” talk being bandied about in the GOP caucus is about a “Grand Bargain” or a “Grand Bargain” but it’s unclear how it could end up being the former because that would sort of require the lead hostage negotiator dealing with a pack of suicide bombers agreeing to defuse the situation by putting on his own suicide vest and blowing it up in close proximity to the oldest and poorest hostages. It’s just not a very compelling offer.

    One thing is becoming clear: by being as batshit crazy as they’ve been, Ted Cruz and the House GOP have managed to, uh, ‘position‘ Grover Norquist and Paul Ryan as “compromisers” that are merely interested in the Ryan Budget. They’ll offer the only way out of this situation, and therefore be practical and reasonable:

    Washington Post
    Grover Norquist on Ted Cruz: ‘He pushed House Republicans into traffic and wandered away’

    By Ezra Klein, Published: October 2 at 2:58 pm

    Grover Norquist is the president of Americans for Tax Reform and the creator of the anti-tax pledge that nearly every Republican in Congress has signed. We spoke on Tuesday about the government shutdown and its consequences for his agenda. A transcript of our conversation, edited for length and clarity, follows.

    Ezra Klein: So, do you think a shutdown is good for the issues and ideas you’re trying to push?

    Grover Norquist: Not necessarily. I think the original plan for the Republicans was to move the continuing resolution past the debt ceiling and then to sit down with Obama and decide whether he would be willing to trade some relaxation of the sequester for significant reforms of entitlements. That was something Obama might well do. Democrats in the House and the Senate are very concerned about caps and limits in sequestration. Republicans could get significant long-term entitlement reform — all on the spending side, I’m assured by leadership — for some relaxation of sequester.

    Something like that might’ve worked out. There was also the possibility, and I was an advocate, of pushing for delay. I thought Obama might do that. And even if he didn’t, I liked the idea of a two-month conversation over how Obama has delayed Obamacare for big business and big contributors and organized labor but not for you. So how about all Americans get treated equally and we have rule of law and delay everything? Obama was thoughtful enough to time Obamacare and its taxes to kick in after he was safely reelected. Those senators running in 2014 were not given the same courtesy. Why not give them that?

    EK: That sounds like the strategy that got us the shutdown, though.

    GN: No, the leverage isn’t the debt ceiling. It’s not the CR. It’s the sequester. Democrats think this is desperate privation. It’s like the Kennedy kids with only one six-pack. They feel they’ve never been so mistreated. So there’s something they want. And there’s something Republicans want. So you could see a deal there. And the leverage was the sequester. That’s what struck me as what leadership was thinking about, and it made a great deal of sense.

    The second thought was to have a conversation over the one-year delay. A two-month conversation about delay would be healthy for the body politic. And maybe you’d get the delay. There’s no shame in the delay. Microsoft is always delaying Office. You could do it without humiliating the president.

    But that’s not what we did. Ted Cruz, from left field, said we have to defund Obamacare permanently in this CR. If they offered the Keystone pipeline and the privatization of Fannie and Freddie you couldn’t take that. We only want this, and we only want it on Tuesday — Wednesday is no good. The debt ceiling is no good. So that got locked in as a principle. And people went out on talk radio and said if you’re not for this you’re a coward, you’re a RINO.

    EK: And that got in the way of the larger strategy?

    GN: I’m cheerful because every Republicans is for repeal of Obamacare. When’s the last time we passed a big government entitlement and every Republican opposed it and kept pointing out that it’s a mistake? There’s unanimity among Republicans. They all voted against the thing being created and for it being repealed.

    The only confusion that comes out is that Cruz stood on the side and confused people about the fact that every Republican agrees. He said if you don’t agree with my tactic and with the specific structure of my idea, you’re bad. He said if the House would simply pass the bill with defunding he would force the Senate to act. He would lead this grass-roots movement that would get Democrats to change their mind. So the House passed it, it went to the Senate, and Ted Cruz said, oh, we don’t have the votes over here. And I can’t find the e-mails or ads targeting Democrats to support it. Cruz said he would deliver the votes and he didn’t deliver any Democratic votes. He pushed House Republicans into traffic and wandered away.

    So then the House said, breaking completely with Cruz because Cruz thinks if you’re not defunding the whole thing it’s treason, that there’s delay. There’s getting rid of medical device taxes. They’ve done a series of things to hold together Republicans and break with Cruz. But because we started with the Cruz approach this got to the shutdown.

    EK: What do you think happens next?

    GN: I think the president must think he can spin a government shutdown. I think he’s already screwed it up. Putting up barriers so guys in wheelchairs can’t go to the World War II memorial. It’s an open-air memorial. They put up those barriers in the middle of the night. They did it on overtime!

    EK: Walk me through the endgame though. The day before the shutdown ends, what will have happened in Washington?

    GN: Unlike some other institutions in this town, I work to give some reasonable advice to members of Congress and shape public opinion. But I don’t micromanage the negotiations of House and Senate guys with the White House or stand outside the negotiations and announce somebody should lay down a nonnegotiable demand with a tactic and a date attached to it.

    Republicans have their principles. Let’s have health-care be more consumer-oriented, let’s not raise taxes, let’s reform government. I could imagine many things that would work inside those principles, but I’m not in Obama’s head. I don’t know how he values those things. If I were him I’d trade some money off the sequester today for reforms in entitlements that take place a long time from now. Those reforms will be done by somebody. You might as well get something for them. Someday Republicans will hold the White House and the Senate and they’ll pass the Ryan plan. You might as well get something for it.

    EK: One aspect of this that you mention quite a bit, but that’s been somewhat lost in the debate, is that Republicans have really managed to hold the spending levels in the CR down. They’re below the original Ryan budget, for instance, and well below what President Obama and the Senate Democrats wanted. Yet Republicans feel like they’re failing because they’re focused on Obamacare. Do you think Republicans are winning on spending?

    GN: Yes, absolutely. We won in 2011 and then again with the president making 85 percent of the Bush tax cuts permanent. We really did get caps and sequestration that limits government spending. If we just went home and put the government on autopilot it would be a win. This Republican Congress has made a fundamental shift in the size of government equation.

    Sequester is the big win. It defines the decade. You still have to fix long-term entitlements, but the other team isn’t willing to do that. So you either wait for a Republican president and the Ryan plan or you get people so concerned about sequestration that they’re willing to come to the table and fix entitlements long-term.

    Oh my, well it sounds like Grover is proposing something real in return for substantial entitlement cuts. It’s something grander than the possible resolution from the current Shutdown/default showdown. Grover sees the real “leverage” for the GOP residing in a negotiation of removal of the sequester that was put in place as a part of the resolution to the 2011 budget conniption fit.

    Since the sequester is scheduled to stay in place even if the current shutdown/default crisis is resolved this isn’t a trivial concession. The sequester involves a large amount of unhelpful austerity policies. It is a grand bargaining concession indeed! Like the suicide bomber offering to remove the not only his new bomb-vest, but also his old one at the same time! How noble. And the only thing Obama and the Democrats have to do to get this awesome deal is agree to blow everyone up with the Paul Ryan Budget Plan. And hey, Grover suggests, why not just embrace the Ryan Plan as an act of preemptive defeat because, at some point, a Republican House and Congress will come along and implement the Ryan Plan anyways so the Democrats might as well do the implementation of the Ryan plan themselves if they want to get any concessions. According to Grover.

    It’s a fascinating strategy we’re seeing unfold because Paul Ryan and Grover Norquist are now being cast as the ‘adults’ in the room relative the the Ted Cruzites. But Grover’s proposed “reasonable” strategy is, in his own words, centered around the same goal as Ted Cruz. “Everyone [in the GOP] agrees” on the same goals (the insane Ryan Plan) it’s over methods.

    And the new method Grover is advocating for the GOP appears to involve publicly acknowledging that the GOP has adopted a permanent policy of pushing for entitlement cuts that will be much harsher than what the Democrats would dare consider. When Grover says “If I were him I’d trade some money off the sequester today for reforms in entitlements that take place a long time from now. Those reforms will be done by somebody. You might as well get something for them. Someday Republicans will hold the White House and the Senate and they’ll pass the Ryan plan. You might as well get something for it,” that sure sounds like the implementation of the Ryan Plan is non-negotiable with the GOP permanently. So the Obamacare fight is about the become the Obamacare + privatization of entitlements fight. What an awesome new GOP branding effort.

    Posted by Pterrafractyl | October 2, 2013, 11:27 pm
  15. David Atkins has a good summary piece on why the GOP almost can’t win the showdown with the debt-ceiling/default: Even if Grover gets everything in his wishlist, the political “win” will be due almost entirely to threats and tactics. Actual public support for the Grover Norquist/Paul Ryan long-term vision for society only exists in the Tea Party base, and that same Tea Party base determines which GOPers actually end up in Congress due to overzelous GOP congressional redistricting in 2010. And as David points out, long-term spending policies are relatively easy to change as some point (as evidence by the demands for long-term entitlement cuts by Grover & Friends…it’s self-apparent that these laws can change).

    So even if Grover wins in the short-run, Grover can’t really win in the long-run unless the US is somehow prevented from ever reversing Norquist-inspired policies. And preventing a reversal of Grover’s laws is going to be increasingly difficult as the GOP’s traditional voting base shuffles off to demographic oblivion. In other words, the stable political equilibrium for the GOP over the next decade (due to gerrymandering) that is driving the current shutdown fever is simultaneously destabilizing the GOP’s long-term prospects by forcing deeply unpopular policies.

    Sure, it could be argued that the US is aging overall and the elderly have historically voted for the GOP. But the elderly of the future may not be so pro-GOP when they have no meaningful Social-Security or Medicare. Grover & Friends can’t really have a viable electoral future unless doing things like privatizing entitlements actually leads to a more secure future for the vast majority of Americans. It’s not just demographic trends that are ruining the GOP’s long-term viability. Grover’s far-right socioeconomic utopia had better actually work because the “implosion of goverment would be fun and awesome!“-meme only works as long as a society is still wealthy enough to afford the government programs needed to avoid mass poverty. The “government isn’t the solution, it’s the problem”-meme isn’t going to be a very easy sell after you’ve already trashed the government. It’s kind of like the GOP’s current Obamacare conundrum: Telling the populace that Obamacare would destroy lives and ruin the nation is a pretty easy sales pitch…as long as Obamacare is never allowed to actually come into effect.

    While the GOP’s long-term troubles are, generally, a sign of hope for the future, they also raise a chilling question: If the GOP’s oligarch-run utopia really does become an electoral impossibility, would folks like the Koch Brothers and Peter Thiel even be willing to just sit back, makes tons of money, and relinquish their peculiar dreams for dominating the future of humanity? Or will smashing economies for power and profit be replaced with smashing economies for revenge? Then again, maybe the elites will finally drop the mask, smash the economy into the ground and shift their focus to a completely different set of solutions to problem of winning elections…the kind of solutions that don’t require elections. Or maybe the solution will something like what’s going on in the eurozone. But potentially much bigger.

    Posted by Pterrafractyl | October 3, 2013, 10:54 pm
  16. Paul Krugman has a post that highlights the serious existential damage the GOP is risking to itself with the shutdown/default crisis entering its second week. It’s becoming increasingly difficult for a growing number of stakeholders in the GOP to avoid the reality that their party has gone insane in a highly destructive manner with potentially long-term repurcussions:

    The Conscience of a Liberal
    October 5, 2013, 3:51 pm
    Shorting Out The Wiring
    Paul Krugman

    For the moment, at least, the shutdown and the general scene of insanity in Congress is clearly hurting the Republican brand. And there’s a whole small industry of crunching numbers on the 1995-6 shutdown, etc., to estimate the likely impact on next year’s elections. For now the conventional wisdom is that the impact will be small, not nearly enough to restore Democratic control.

    I have no idea whether that’s right. But as I was reading the various news reports, it occurred to me that there’s a subtler but possibly profound form of damage the GOP is doing to itself, one that will cast its shadow for a long time.

    It goes back to something Josh Marshall of Talking Points Memo used to say — that Washington is, in effect, wired for Republicans. Ever since Reagan, the Beltway has treated Republicans as the natural party of government. Sunday talk shows would feature a preponderance of Republicans even if Democrats held the White House and one or both houses of Congress. John McCain was featured on those shows so often you would think he won in 2008.

    And there was a general presumption of Republican competence. It’s hard to believe now, but Bush was treated as a highly effective leader who knew what he was doing right up to Katrina, while Clinton — now viewed with such respect — was treated as a bungling interloper for much of his presidency. Even in the last few years there was a rush to canonize Paul Ryan as a superwonk, when it was quite obvious if you looked that politics aside, he was just incompetent at number-crunching.

    But I think the last two years have finally killed that presumption. It wasn’t just that Romney lost — his shock, the obvious degree to which his campaign was deluded, was an eye-opener. And now the antics of the Boehner bumblers.

    Suddenly the old Will Rogers line — I’m not a member of any organized political party,I’m a Democrat — has lost its sting; the upper hand is on the other foot. And that’s going to color narratives and shape campaigns for a long time.

    Part of what makes the GOP’s aggressive public abandonment of the “we’re the adults in the room” mantle is that it was always sort of inevitable that it would come to this. Or something kind of like this…some sort of seemingly unresolvable crisis. It was just a matter of the timing and the particular nature of the crisis. While the current shutdown/default crisis is clearly a crisis of choice future crises that threaten the very foundations of the socioeconomic structure of society may not be so voluntary because the entire socioeconomic paradigm being put forth by the far-right architects of the Tea Party – billionaires like the Koch brothers and Peter Thiel and their partners on Wall Street – is a deeply unsustainable paradigm that necessitates both economic and social collapse. Is that by design? Who knows, because these Tea Party billionaires are clever but also kind of nuts.

    Some sort of systemic collapse isn’t inevitable just because of corporate-driven policies that are guaranteeing ecological collapse (which will eventually kill any society). A collapse of some sort is also being made inevitable by the ideological opposition to the existence of an empowered, well-informed middle-class operating in a meaningful democratic system. A middle-class with a real opportunity to earn a living wage and have time to do other things with their life too. How are the market-driven societies of the future – where capitalism replaces democracy and education is limited to those with parents that can pay – supposed to operate with mass unemployment and poverty and minimal consumer demand? We know that economies can function with mass poverty and gross inequalities but there aren’t really any examples of those economies functioning well and in ways that solve long-term problems. Without a government making investments for the future and providing some sort of meaningful level of support of the populace, where exactly is the feedback loop in the economy going to come from where the profits accrued by the top 0.01% are fed back into the economy? What’s going to drive the demand on behalf of the poor? Because there will be a lot of them. The billionaires planning on replacing government must have plans to do so. They should flesh them out more.

    And how do the Koch Brothers and Peter Thiels of the world propose to address the reality of robotics and automation dramatically upsetting the balance between the supply and demand of labor between the elites and the rest of us? Is the global economy going to be dedicated to building bigger and better castles and yachts and the robots to protect them? You can only employ so many people to run the robots that build Elysium, so where does everyone else fit into this picture? Is it going to be billionaires living in their private cities and private societies vs everyone else living in larger, crappier quasi-privatized public societies where the government services are provided by companies owned and operated by the people that live in the private cities? Is there any convincing case publicly put forward by the top 0.01% that this endless race of the bottom won’t result in socioeconomic cannibalism?

    And if the Tea Party’s billionaire benefactors haven’t made the case for how their utopian future could possibly work then when are we going to see a revolt by the millionaires and billionaires against folks the Tea Party billionaires? Are even lower taxes for plutocrats worth the risk of social upheaval? If everyone can agree that poverty and the availability of advanced technology exacerbates the threat of terrorism and social upheaval then why is that the top 1% don’t view their Tea Party leaders (the Koch and Thiel-like figure especially) as vital threats to their futures? They’re selling an austerity future as the way forward permanently. It seems like an insane long-term strategy for the vast majority of millionaires and even billionaires.

    Imagine if the Gulf monarchies didn’t even bother trying to provide some sort of basic welfare to the populace but instead just allowed for mass poverty while the Sheikhs accrued even more of the national wealth. How long would those governments have lasted?

    These larger questions of the general sustainability of the Tea Party paradigms are even more relevant now that the “defund Obamacare or we shut down the government” fight in Congress has morphed into a larger “defund entitlements or we shut down the economy” war. It’s a long-term paradigm that’s alarmingly close a kingdom without a social contract. The only social contract in this Libertarian Tea Party future one can really see is the promise that legal contracts are enforced by the law. That’s pretty much it. Everything else is left up to the “free-market”, friends and family, or luck in the kind of future being offered by the people like Grover Norquist and Paul Ryan. And those two are the visionaries in the movement so what they say envision is potentially the future. It’s scary.

    Why would we expect that kind of society to result in anything other than a highly fragmented economy of a handful of ‘haves’ and hordes of ‘have nots’? How many millionaires and billionares can exist in a society with just a handful of ‘haves’ and hordes of ‘have-nots’ plus lots of robots? Some millionaires and billionaires will be there, by definition. But how many millionaires and billionaires will exist in Tea-topia society that abandons a social safety-net and embraces harsh “you’re on your own, get a job if you want your disease treated, slacker!”-policies, say, 30 years from now compared to a society that, for instance, actually tries provide people with some meaningful economic and political power and resources – so the robots have something to do other than chase people and the masses aren’t just utterly screwed – and also provides general social justice that can’t otherwise be achieved through the “free-market”. Which society will have more millionaires and billionaires a generation from now?

    That kind of multi-decade timeframe is what we need to be considering in the US now that the government shutdown fight over Obamacare has begun to morph into a GOP threat to default on the US debt unless the nation agrees to the kinds of significant long-term entitlement cuts/privatizations that earn Grover Norquist’s approval. This is a continuation of the divide-and-extort strategy championed by Grover and intended to hand control of society over to Grover’s Tea Pary billionaire backers and create a borderline anarcho-capitalist future. That’s where this crew wants to take us and it’s a multidecade-long process.

    Robotically enforced cardiovascular-fitness regimes are, of course, fantastically silly scenarios to think about. But it wasn’t that long ago that the idea of debasing the dollar would just become this casual thing that political parties do when the party really really doesn’t want to have to admit to their political base that the party has been lying to them for years about a particular law. These are nearly unthinkable political threats that are being made routine and in no instance have we seen any real indication that the GOP is interested in giving up this “give us what we want or it’s shutdown/default!” strategy now or for good. Even if there was a giant cave by the Obama administration next week and a massive long-term entitlement cut was agreed upon in order to free up this budget/existential impasse is there any reason to believe this wouldn’t happen again at the next opportunity? Or at least during the rest of the Obama administration? Or during any future Democratic administration? No matter what they say? The Tea Party’s billionaires and their far-right cohorts around the world have been making it abundantly clear for years that they’re intent on fundamentally reshaping society. If the eurozone experience is any indication, these folks are really really serious. So who knows how far they’re willing to go to press an austerity agenda but, at least in some of the worst case scenarios, your surviving grandchildren (the poor ones) will be in really really good shape and that should cut down on healthcare costs.

    Posted by Pterrafractyl | October 6, 2013, 12:16 am
  17. Ok, yikes. Now they’re telling us that not raising the debt ceiling “would bring stability to world markets“:

    TPM Editor’s Blog
    Get Ready. It’s Going to Happen.
    Josh Marshall – October 6, 2013, 9:49 PM EDT

    The Post has a profile in motion of freshman House Republican Ted Yoho (FL). The focus is how he’s part of the faction who forced John Boehner to trigger the government shutdown and now wants to move along to default on the national debt. How bad will default be? “I think, personally, it would bring stability to the world markets,” Yoho told the Post.

    Absorb that for a moment. He’s on the team that’s driving this bus. What would at best be a huge jolt to the global economy and more likely trigger a global financial crisis and do irreparable harm to the country, he thinks will actually improve things.


    So professional Republican spokesmen are freaked out by what they’re hearing.

    Couple this with the Times article from this morning detailing how the current shutdown and soon to be default crisis was planned by a working group of top GOP money men and the major far right and Tea Party pressure groups in the immediate aftermath of the 2012 election.

    There many roots of this crisis. Demographic, ideological, regional, some parts tied to accidents of history (the existence of the debt ceiling itself), others to the structure of our government. But I think most people, as crazy as this looks, are underestimating the scope of the crisis we’re in the midst of. The pieces are in place to resolve the matter quickly, in the narrow sense of the votes. But the House Tea Party (and it really does look more like a distinct party or faction at this point) is forcing the matter, despite having well under a hundred seats in the House. Behind them they have an aggrieved GOP base and sustaining them the vast tranches of money provided by the Kochs and other top GOP mega-funders. John Boehner, not structurally in the sense of his office or position but personally, is simply too weak a figure to avert what’s coming. Get ready.

    So does that mean that I can just start selectively not paying back my creditors (specifically US creditors) once I decide to get ‘decisive’ about tacking my debt? Because that might actually be a really popular policy pivot although I’m not sure it would calm the markets. Maybe it’s like 11-dimension Chess, Tea Party-style at work. On the other hand, keep in mind that the full description of Rep. Yoho’s comment on the awesomeness of a default was:

    I think we need to have that moment where we realize [we’re] going broke,” Yoho said. If the debt ceiling isn’t raised, that will sure as heck be a moment. “I think, personally, it would bring stability to the world markets,” since they would be assured that the United States had moved decisively to curb its debt.

    That sounds awfully similar to one of the popular memes floating around in the right-wing-o-sphere about how refusing to raise the debt ceiling won’t force a default at all because there will still be plenty of money left over to pay the interest on the debt with existing revenue streams. All we have to do is casually slash or eliminate federal programs and entitlements to balance the budget. We’ll just have to suddenly decide that right now is a really important time to suddenly sucker punch the economy and create our own little GOP Troika of one to implement the Ryan Plan. That’s all (because if we don’t we’ll go bankrupt very soon). Once the Troika is satisfied, the debt-limit will be lifted and everything will return to the new normal. Elections had consequences. Now it’s all fun and games.

    Posted by Pterrafractyl | October 6, 2013, 9:43 pm
  18. With polls showing 70% disapproval for the GOP’s handling of the shutdown/default crisis, you have to wonder how how much time was spent planning this whole thing. Because it’s not like there’s been a lack of time. Or money. Or experienced secret plotters:

    The New York Times
    A Federal Budget Crisis Months in the Planning

    By SHERYL GAY STOLBERG and MIKE McINTIRE
    Published: October 5, 2013

    WASHINGTON — Shortly after President Obama started his second term, a loose-knit coalition of conservative activists led by former Attorney General Edwin Meese III gathered in the capital to plot strategy. Their push to repeal Mr. Obama’s health care law was going nowhere, and they desperately needed a new plan.

    Out of that session, held one morning in a location the members insist on keeping secret, came a little-noticed “blueprint to defunding Obamacare,” signed by Mr. Meese and leaders of more than three dozen conservative groups.

    It articulated a take-no-prisoners legislative strategy that had long percolated in conservative circles: that Republicans could derail the health care overhaul if conservative lawmakers were willing to push fellow Republicans — including their cautious leaders — into cutting off financing for the entire federal government.

    “We felt very strongly at the start of this year that the House needed to use the power of the purse,” said one coalition member, Michael A. Needham, who runs Heritage Action for America, the political arm of the Heritage Foundation. “At least at Heritage Action, we felt very strongly from the start that this was a fight that we were going to pick.”

    Last week the country witnessed the fallout from that strategy: a standoff that has shuttered much of the federal bureaucracy and unsettled the nation.

    To many Americans, the shutdown came out of nowhere. But interviews with a wide array of conservatives show that the confrontation that precipitated the crisis was the outgrowth of a long-running effort to undo the law, the Affordable Care Act, since its passage in 2010 — waged by a galaxy of conservative groups with more money, organized tactics and interconnections than is commonly known.

    With polls showing Americans deeply divided over the law, conservatives believe that the public is behind them. Although the law’s opponents say that shutting down the government was not their objective, the activists anticipated that a shutdown could occur — and worked with members of the Tea Party caucus in Congress who were excited about drawing a red line against a law they despise.

    A defunding “tool kit” created in early September included talking points for the question, “What happens when you shut down the government and you are blamed for it?” The suggested answer was the one House Republicans give today: “We are simply calling to fund the entire government except for the Affordable Care Act/Obamacare.”

    The current budget brinkmanship is just the latest development in a well-financed, broad-based assault on the health law, Mr. Obama’s signature legislative initiative. Groups like Tea Party Patriots, Americans for Prosperity and FreedomWorks are all immersed in the fight, as is Club for Growth, a business-backed nonprofit organization. Some, like Generation Opportunity and Young Americans for Liberty, both aimed at young adults, are upstarts. Heritage Action is new, too, founded in 2010 to advance the policy prescriptions of its sister group, the Heritage Foundation.

    The billionaire Koch brothers, Charles and David, have been deeply involved with financing the overall effort. A group linked to the Kochs, Freedom Partners Chamber of Commerce, disbursed more than $200 million last year to nonprofit organizations involved in the fight. Included was $5 million to Generation Opportunity, which created a buzz last month with an Internet advertisement showing a menacing Uncle Sam figure popping up between a woman’s legs during a gynecological exam.

    The groups have also sought to pressure vulnerable Republican members of Congress with scorecards keeping track of their health care votes; have burned faux “Obamacare cards” on college campuses; and have distributed scripts for phone calls to Congressional offices, sample letters to editors and Twitter and Facebook offerings for followers to present as their own.

    One sample Twitter offering — “Obamacare is a train wreck” — is a common refrain for Speaker John A. Boehner.

    As the defunding movement picked up steam among outside advocates, Republicans who sounded tepid became targets. The Senate Conservatives Fund, a political action committee dedicated to “electing true conservatives,” ran radio advertisements against three Republican incumbents.

    Heritage Action ran critical Internet advertisements in the districts of 100 Republican lawmakers who had failed to sign a letter by a North Carolina freshman, Representative Mark Meadows, urging Mr. Boehner to take up the defunding cause.

    “They’ve been hugely influential,” said David Wasserman, who tracks House races for the nonpartisan Cook Political Report. “When else in our history has a freshman member of Congress from North Carolina been able to round up a gang of 80 that’s essentially ground the government to a halt?”

    On Capitol Hill, the advocates found willing partners in Tea Party conservatives, who have repeatedly threatened to shut down the government if they do not get their way on spending issues. This time they said they were so alarmed by the health law that they were willing to risk a shutdown over it. (“This is exactly what the public wants,” Representative Michele Bachmann of Minnesota, founder of the House Tea Party Caucus, said on the eve of the shutdown.)

    Despite Mrs. Bachmann’s comments, not all of the groups have been on board with the defunding campaign. Some, like the Koch-financed Americans for Prosperity, which spent $5.5 million on health care television advertisements over the past three months, are more focused on sowing public doubts about the law. But all have a common goal, which is to cripple a measure that Senator Ted Cruz, a Texas Republican and leader of the defunding effort, has likened to a horror movie.

    “We view this as a long-term effort,” said Tim Phillips, the president of Americans for Prosperity. He said his group expected to spend “tens of millions” of dollars on a “multifront effort” that includes working to prevent states from expanding Medicaid under the law. The group’s goal is not to defund the law.

    “We want to see this law repealed,” Mr. Phillips said.

    A Familiar Tactic

    The crowd was raucous at the Hilton Anatole, just north of downtown Dallas, when Mr. Needham’s group, Heritage Action, arrived on a Tuesday in August for the second stop on a nine-city “Defund Obamacare Town Hall Tour.” Nearly 1,000 people turned out to hear two stars of the Tea Party movement: Mr. Cruz, and Jim DeMint, a former South Carolina senator who runs the Heritage Foundation.

    “You’re here because now is the single best time we have to defund Obamacare,” declared Mr. Cruz, who would go on to rail against the law on the Senate floor in September with a monologue that ran for 21 hours. “This is a fight we can win.”

    Although Mr. Cruz is new to the Senate, the tactic of defunding in Washington is not. For years, Congress has banned the use of certain federal money to pay for abortions, except in the case of incest and rape, by attaching the so-called Hyde Amendment to spending bills.

    After the health law passed in 2010, Todd Tiahrt, then a Republican congressman from Kansas, proposed defunding bits and pieces of it. He said he spoke to Mr. Boehner’s staff about the idea while the Supreme Court, which upheld the central provision, was weighing the law’s constitutionality.

    “There just wasn’t the appetite for it at the time,” Mr. Tiahrt said in an interview. “They thought, we don’t need to worry about it because the Supreme Court will strike it down.”

    But the idea of using the appropriations process to defund an entire federal program, particularly one as far-reaching as the health care overhaul, raised the stakes considerably. In an interview, Mr. DeMint, who left the Senate to join the Heritage Foundation in January, said he had been thinking about it since the law’s passage, in part because Republican leaders were not more aggressive.

    “They’ve been through a series of C.R.s and debt limits,” Mr. DeMint said, referring to continuing resolutions on spending, “and all the time there was discussion of ‘O.K., we’re not going to fight the Obamacare fight, we’ll do it next time.’ The conservatives who ran in 2010 promising to repeal it kept hearing, ‘This is not the right time to fight this battle.’ ”

    Mr. DeMint is hardly alone in his distaste for the health law, or his willingness to do something about it. In the three years since Mr. Obama signed the health measure, Tea Party-inspired groups have mobilized, aided by a financing network that continues to grow, both in its complexity and the sheer amount of money that flows through it.

    A review of tax records, campaign finance reports and corporate filings shows that hundreds of millions of dollars have been raised and spent since 2012 by organizations, many of them loosely connected, leading opposition to the measure.

    One of the biggest sources of conservative money is Freedom Partners, a tax-exempt “business league” that claims more than 200 members, each of whom pays at least $100,000 in dues. The group’s board is headed by a longtime executive of Koch Industries, the conglomerate run by the Koch brothers, who were among the original financiers of the Tea Party movement. The Kochs declined to comment.

    While Freedom Partners has financed organizations that are pushing to defund the law, like Heritage Action and Tea Party Patriots, Freedom Partners has not advocated that. A spokesman for the group, James Davis, said it was more focused on “educating Americans around the country on the negative impacts of Obamacare.”

    The largest recipient of Freedom Partners cash — about $115 million — was the Center to Protect Patient Rights, according to the groups’ latest tax filings. Run by a political consultant with ties to the Kochs and listing an Arizona post office box for its address, the center appears to be little more than a clearinghouse for donations to still more groups, including American Commitment and the 60 Plus Association, both ardent foes of the health care law.

    American Commitment and 60 Plus were among a handful of groups calling themselves the “Repeal Coalition” that sent a letter in August urging Republican leaders in the House and the Senate to insist “at a minimum” in a one-year delay of carrying out the health care law as part of any budget deal. Another group, the Conservative 50 Plus Alliance, delivered a defunding petition with 68,700 signatures to the Senate.

    In the fight to shape public opinion, conservatives face well-organized liberal foes. Enroll America, a nonprofit group allied with the Obama White House, is waging a campaign to persuade millions of the uninsured to buy coverage. The law’s supporters are also getting huge assistance from the insurance industry, which is expected to spend $1 billion on advertising to help sell its plans on the exchanges.

    “It is David versus Goliath,” said Mr. Phillips of Americans for Prosperity.

    It’ll be interesting to learn how much direct involvement Peter Thiel has with “Team David” in the showdown between a band of plucky billionaires and the Obamacare Goliath. After all, Thiel views social safety-net policies – like women voting – as social cancers. He was also an early investor in Cruz Co. So this seems like exactly the kind of issue that we should expect to receive more than just of spoonful of that sweet sweet Thiel sugar.

    Posted by Pterrafractyl | October 7, 2013, 2:34 pm
  19. It looks like the “What, me worry?” Congressional Brigade is still accepting members:

    USA Today
    Debt limit breach no big deal, some GOP lawmakers say
    Gregory Korte and Susan Davis, USA TODAY 9:26 p.m. EDT October 7, 2013

    Everyone agrees that the nation is coming up against the $16.7 trillion debt ceiling. The debate is over when that will happen, and what comes next.

    WASHINGTON — Republican lawmakers are voicing increasing skepticism about dire warnings that failing to raise the debt ceiling would result in catastrophic default.

    “I would dispel the rumor that is going around that you hear on every newscast, that if we don’t raise the debt ceiling, we will default on our debt,” said Sen. Tom Coburn, R-Okla., Monday on CBS This Morning. “We won’t. We’ll continue to pay our interest.”

    Coburn and other Republicans argue that the Treasury Department could prioritize interest payments while delaying others. The House has passed a bill requiring the Treasury to do just that.

    “I think one of the things that’s been so disturbing about this period is that you’ve actually had the House leadership pass proposals to implement how you would do prioritization, as if that would be an acceptable solution. It is not acceptable. Prioritization is default by another name,” said Gene Sperling, director of the National Economic Council, at a Politico breakfast Monday. He said President Obama prefers a long-term raise in the $16.7 trillion debt limit, but did not rule out support for a short-term increase.

    Washington’s attention is turning to the debt limit even as it enters its second full week of a partial shutdown caused by Congress’ inability to pass a spending bill. Although most of the 350,000 civilian Defense employees are going back to work this week, more than half a million federal workers remain furloughed. The House voted Saturday to give all federal workers back pay, but the Senate has yet to schedule a vote on the measure.

    It’s increasingly likely that a bill ending the shutdown will be packaged with a measure to raise the debt limit. But House Speaker John Boehner, R-Ohio, is seeking budget cuts from the White House as part of that measure.

    The White House says it wants a “clean” debt limit increase, and that it must happen by Oct. 17. That’s the day Treasury Secretary Jacob Lew says the United States would run out of borrowed money, putting the government in uncharted territory and creating the prospect of a first-ever default.

    But some Republicans aren’t buying it.

    “I will hear language like, ‘Well, we are heading toward the debt ceiling and you are going to default.’ Anyone that says that is looking you in the eyes and lying to you, either that or they don’t own a calculator,” Rep. David Schweikert, R-Ariz., said in a House debate Friday.

    And Rep. Ted Yoho, R-Fla., even argues that reaching the debt limit could help the economy, by showing the world the U.S. is serious about its debt problem. “I think, personally, it would bring stability to the world markets,” he told The Washington Post Monday.

    “The bottom line is, Treasury has the ability to manage that, so the date is whatever Secretary Lew claims the date will be,” said Rep. Jeb Hensarling, R-Texas.

    Veronique de Rugy, an economist at the free-market Mercatus Center at George Mason University, said the debt ceiling will have to be raised sooner or later — and Republicans should know that.

    “I do not believe that past Oct. 17 the country’s going to hell,” she said. “But I agree that failing to pay interest on our debt has very serious consequences. And there’s no budget out there that doesn’t require us to raise the debt ceiling. If Republicans put a balanced budget proposal out there, they would have a lot more credibility in my eyes.”

    When folks like Veronique de Rugyfrom the Koch-financed Mercatus Center – are questioning your debt-ceiling showdown tactics you know you’ve entered overreach-territory. Enjoy the ride.

    Posted by Pterrafractyl | October 7, 2013, 11:03 pm
  20. It’s time to get excited! America’s own lil’ homegrown Troika-system of Billionaire Justice is coming soon:

    Esquire
    Oct 8, 2013
    Avengers, Assemble!
    By Charles P. Pierce at 3:45PM

    No. Stop it. Seriously. You’re killing me here.

    A senior House aide said Republicans are considering legislation to create a new panel to find deficit reductions similar to a failed 2011 “supercommittee” of Republicans and Democrats from the House and Senate that was asked to find trillions of new budget savings.

    I have lived through a number of instances in which the problems of actual democracy were seen as being so intractable and icky that they were beyond the strength of mortal men to solve. On these occasions, the people actually elected to make democracy worked called upon gatherings of wise men — men of leadership, of vision, of considerable expense accounts — to lead the nation out of darkness and into the light of their innate genius. And you know what? Almost all of them sucked.

    The Warren Commission? A fiction. Sucked.

    The Tower Commission on Iran-Contra? A whitewash. Sucked.

    The Gramm-Rudman Budget compromise? A delusion. Sucked.

    The previous SuperCommittee? Sucked. Made me agree with N. Leroy Gingrich. Double-sucked.

    Simpson-Bowles? Don’t even get me started. Feeders of Vaal. Sucked.

    And now, this. The institutions of self-government have been sabotaged by a collection of vandals and so, now, it’s time to give Bob Rubin or someone another chance to mingle the financial services industry with the operations of government because that always has worked out so well for the rest of us. First of all, we shouldn’t be talking about Teh Deficit now — or later, but that’s another gin fizz entirely — and the Democrats at last seem to have become aware of this simple fact, although they still talk very much as though they’d like to get the current unpleasantness out of the way so they can get back to being “serious” about Teh Deficit, thereby continuing to ignore the blog’s First Law Of Economics, and acting as though the Republicans are going to be any more reasonable after the possibly apocalyptic denouement of the current unpleasantness as they were before. Steve King, I am sure, is desperate to get back to sanity again.

    But what makes me truly angry about proposals like this is that they bespeak a certain lack of faith in the political institutions through which we’re supposed to work all of these things out. If Congress is broken, then, dammit, let Congress — and the people who elect it — fix itself.

    It’s an implicit rejection of self-government, and this is only one of the manifestations of that rejection that afflicts our political class. Craven politicians love that stuff. The courtier press hungers for this kind of ad hoc parade of ambulatory resumes. (Save us, Lawrence Eagleburger, you’re our only hope.) It is a validation of their own well-tailored belief that the only wisdom in the country can be found within the Beltway, and that the entire apparatus of self-government exists only to power and to feed a company town. It also comforts them because, in all of the cases cited above, the gathering of elders produced a report or answers that soothed the nervous systems of the political elite, the members of which worry night and day that actual political energy might break out beyond the far shores of the Potomac. My dear young people, that simply is not done.

    Part of what’s making this latest round of acting out by the GOP so disturbing is the number of notable people that seem more than willing to just suddenly publicly endorse the notion that selectively not paying interest to US creditors wouldn’t be damaging to the US credit and credibility at all. In fact, the argument goes, global community might be even more confident in the US because we would have engaged in preemptive eurozone-style austerity to demonstrate to the world how responsible we are as a nation. Plus, the argument goes, if we don’t immediately make radical commitments to dramatically scaling back the safety-net for generations to come, the US will soon suffer a crisis of global confidence and fall into hyper-inflation and the Weimar 2.0.

    That’s the growing meme and sure, the “hyperinflation! Too much debt!” arguments have been a regular part of US politics for decades, but are we now witnessing the introduction of “hey, there’s no such thing as default…just helpful austerity!” as part of the new New Normal? A new Amerozone Truism? Now, apparently, the world gets to know that every time one of the US’s political parties decides an uncrossable budgetary line has been crossed, the government shuts down until a Super Committee is created to overhaul the social safety-net? Can’ just being sorry be enough? Are cabals of billionaires that take things into their own hands and smash them really necessary? And…Yes, such cabals are apparently necessary.

    And just today, we have reports of a respected Harvard economist dismissing concerns about a default and making the exact same claim that a selective default would be just fine. It raises the question: Is the debt-bug up everyone’s ass of the brain-eating variety? Because that sounds like a public health concern that calls for expanded healthcare coverage.

    Oh wait, never mind. That respected Harvard economist was Martin Feldstein. Parasites ate his brain years ago. So it may not be a brain-eating parasite infestation, although it still leaves open the question of what’s causing the uptick in mass-insanity levels. BodyThetans? Maybe?

    Posted by Pterrafractyl | October 8, 2013, 9:13 pm
  21. Just because a band of homocidal puppets go on a rampage doesn’t mean you can automatically blame the Puppet Master. Maybe the Puppet Master has a perfectly good excuse for the rampage. Or not. Either way, you can’t blame the Puppet Master:

    The New York Times
    Kochs Deny Pushing for Shutdown Over Health Law
    Sheryl Gay Stolberg, 11:15 am

    WASHINGTON – Koch Industries, whose co-founders, Charles and David Koch, are major donors to Tea Party-inspired conservative causes, accused Harry Reid, the Senate majority leader, on Wednesday of spreading “false information” about the brothers by suggesting they are behind the move to end financing for President Obama’s healthcare law and the partial shutdown of the federal government.

    “Koch believes that Obamacare will increase deficits, lead to an overall lowering of the standard of health care and raise taxes,’’ Philip Ellender, the company’s chief spokesman, wrote in a letter to senators. “However, Koch has not taken a position on the legislative tactic of tying the continuing resolution to defunding Obamacare, nor have we lobbied on legislative programs defunding Obamacare.’’

    The Koch brothers have long worked against the health law, and have contributed to organizations, like Heritage Action for America, that are pressing lawmakers to end financing for it.

    Other Koch-backed groups, like Americans for Prosperity and a new group, Generation Opportunity, which is aimed at young people, are working to sow doubts about the health law and to undermine it in other ways, including by persuading Americans not to enroll for health insurance and pressing state lawmakers not to expand Medicaid under the law. Americans for Prosperity alone has run $5.5 million in television advertising against the law over the past three months.

    So if we can’t blame the Puppet Masters when their puppets go on a rampage maybe we could at least require that they get something like liability insurance for the puppets? Would that be acceptable? Ah, that would probably be a ‘no’.

    Posted by Pterrafractyl | October 9, 2013, 9:29 am
  22. A somewhat surprising twist in the recent hostage-taking pivot by the GOP – from demanding an end to Obamacare to demanding major reforms to social security and Medicare – is that it seemed to be a pivot towards a policy position that explicitly attacks America’s youth in a such a way that the GOP gets virtually all of the blame. When it was just a fight about defunding Obamacare at least the GOP could posture in a way that seemed to say “hey uninsured young people, we’re stopping Obamacare in order to save you from the horrors of health insurance”. But now, thanks to the new demands that the US now suddenly implement long-term entitlement cuts, it’s going to be a lot harder for the GOP to walk away from this situation without looking like a cabal that hijacked the normal democratic process in order to wage a long-term attack on young people’s retirements. It’s a high-risk response to the much feared “demographic Winter” for the US far-right. You can’t have your preferred brand of mindless tribalism dominate the future political landscape when your tribe is systematically alienating the future members of the tribe. And now the grand hostage-taking strategy being advocated by thought-leaders like Grover Norquist is to take attention completely away from the Obamacare fight. Instead, they’ll refocus on offering the Democrats a short-term lifting of the debt-ceiling in exchange for partial implementation of the Ryan Plan to be phased in over decades. That appears to be the offer Grover is now pushing as ‘Plan B’:

    A GOP plan B: a deal to get a win-win from shutdown and debt ceiling crises

    Ted Cruz’s strategy failed Republicans, but neither Obama nor Democrats are ahead. Yet we all gain by a sequester cuts trade

    Grover Norquist
    theguardian.com, Tuesday 8 October 2013 10.12 EDT

    OK. Plan A didn’t quite work as advertised.

    Texas Senator Ted Cruz said that if the House Republican majority attached a “defunding” of Obamacare to the continuing resolution (CR) budget, he and his allies would force the Democratic majority in the Senate to pass same and coerce President Obama into signing the repeal of his signature legislation. The Democrats failed to co-operate in this effort.

    So now what?

    President Obama is insisting that Republicans pass the “clean” continuing resolution – an agreement to keep the present budget going without changes – and the upcoming debt ceiling increase without attaching any budget reforms or changes to Obamacare.

    Republicans in the House walked away from Cruz’s “everything or nothing” non-negotiable demand and have offered a series of compromise deals: a one-year delay in Obamacare, a one-year delay in the mandate to buy health insurance, the repeal of the tax on medical devices, and a law overturning Obama’s Office of Personnel Management ruling that congressional staff would not have to live under Obamacare.

    With no agreement, the previous continuing resolution lapsed. The government shutdown, which means that President Obama largely chooses what to fund and what to not fund – subject to rules established (and therefore changeable) by the executive branch: read, the president’s appointees.

    What does each party want? What do they fear? What is their leverage against the other?

    ..

    There is leverage in the sequester, the 2011 law that caps the growth of domestic discretionary and military spending. Many Democrats find those caps smothering. They want them lifted. Republicans fear the unfunded liabilities of the pay-as-you-go entitlement spending that, unchanged, will bring federal spending to 40% of GDP (from 20%) by 2050.

    Here, there is a possible trade: a temporary and limited lifting of the sequester to allow some more spending now, in return for reducing some of the $64tn (in present value) of the unfunded liabilities in the future. That future overspending is not sustainable. It will have to be culled back someday. Why not get something here and now in exchange?

    The sequester, like Obamacare, is the law of the land. Republicans might trade some more spending today for much less far into the future. Entitlement laws can be changed – as Reagan and the Democrats did to delay the retirement age for social security from 65 to 67, over 24 years. The traditional, and wholly rational, fear that promised spending cuts would evaporate is reduced or even eliminated when cuts are gained through such changes in entitlement law.

    Deal?

    What a deal! Who wouldn’t be tempted by “temporary and limited lifting of the sequester to allow some more spending now, in return for reducing some of the $64tn (in present value) of the unfunded liabilities in the future”? It’s an especially tempting offer coming from the guy that recently suggested the Ryan Plan was going to be implemented no matter what, it’s just a matter of time. Oh goodie!

    It’s still unclear, though, how America’s youth is going to appreciate the Ryanization of their financial futures as the payout for the whole hostage-taking thing since it seems to involve handing their futures over to Wall Street. Sure, that kind of fully Ryan-compliant grand bargain is unlikely to happen in this first second pass, but as Grover promised, it’s coming. It’s just a matter of time. Bit by bit, the financial security if today’s youth gets traded away for decades to come in exchange for those awesome Norquist revenue increases. And lots of future debt-ceiling fights.

    Since this is all just a taste of future safety-net fights to come, it raises the question of just how far the GOP is interested in going in terms of privatizing the future entitlement system of the youth because any short-term agreement is implicitly a long-term agreement to repeated hostage-taking sessions. The long-term visions is pretty important for at least the short-to-medium-term because the US is apparently going to be forced into some sort of New Koch and Tea Deal via legislative capitulation or the US is going to be forced into insolvency. So what are the long-term terms of the deal being offered to the US? Especially the youth? Do any of us get to know? Is there at least a fixed crazy-rate that young adults to rely on in their far-right thought leaders while these leaders are planning the youth’s retirements or is it one of those fancier loans that just follows the crazy-market? Because the crazy-market looks scary.

    Posted by Pterrafractyl | October 9, 2013, 11:57 pm
  23. I read today that Kasich may use an Executive Order to accept Medicaid expansion.

    Posted by Kathleen | October 10, 2013, 12:50 pm
  24. @Kathleen: Yep, and now the next step, if Kasich chooses to go through with the executive order, would be to seek the approval of a seven-member GOP-dominated Control Board. And, according to Ohio’s Senate President Keith Faber, if the board rejects Kasich’s order he can either reverse the executive order or Ohio’s entire Medicaid system will go bankrupt. ‘Tis the Season New Climate of Endless Shutdown Showdowns and Happy Healthcare Holidays! At least in Ohio:

    The Columbus Dispatch
    Kasich Medicaid-expansion plan puts heat on GOP legislators
    By Jim Siegel

    The Columbus Dispatch Wednesday October 9, 2013 6:15 AM

    If Gov. John Kasich moves ahead with Medicaid expansion via an executive order, legislators could be pressed to approve the funding or face bankrupting the massive health-care system in Ohio.

    Speculation is rampant that on Oct. 21, Kasich will ask the seven-member legislative-spending oversight panel to give him the authority to spend federal money to cover an estimated 275,000 low-income Ohioans under Medicaid. The expansion, made possible under Obamacare, would be 100 percent federally funded for the first three years and bring in an estimated $13 billion in federal money over seven years.

    “The governor, I think, has the authority to do that,” said Senate President Keith Faber, R-Celina. “It’s certainly within his prerogative. I’m a defender of legislative rights, and I would think the better solution would be a legislative option, but the governor does have that authority.”

    Faber noted that the governor could do the expansion by executive order and then seek Controlling Board authority to spend the money. He then described what could happen if the board denies the request.

    “If you don’t do that, Medicaid … goes bankrupt,” Faber said. “It’s premature to discuss what would happen or not happen, but I don’t think anyone wants a bankrupt existing Medicaid program.”

    So if the governor pushes ahead, could GOP legislative leaders who have thus far resisted expansion argue that they are being forced to go along — or else bankrupt a system that serves 2.4 million Ohioans?

    Some conservatives argue that Kasich could simply reverse his executive order if the board rejects the request.

    The Controlling Board is made up of one governor’s appointee and six legislators — two Republicans and one Democrat from each chamber. The appointee and the Democrats would likely vote for expansion, and at least one Republican must join them. But who?

    Faber said he has no intention of replacing either of his members on the board — Sens. Bill Coley and Chris Widener. No one thinks Coley would vote for the expansion. Widener, the No. 2 Senate leader, has not indicated support.

    The dynamics are interesting on the House side of the board. Reps. Ron Amstutz and Cliff Rosenberger are the GOP members — and considered the top two contenders to replace Speaker William G. Batchelder when he is term limited at the end of 2014. It’s hard to imagine a scenario where one takes the heat for a “yes” vote while letting the other skate.

    Posted by Pterrafractyl | October 10, 2013, 8:20 pm
  25. Paul Ryan, the GOP’s official “adult in the room”, just dropped the mask a little more. In addition to holding on to their dreams of repealing Obamacare, he’s encouraging the GOP to “completely rethink government’s role in helping the most vulnerable” and “completely rethink government’s role in our lives”. Considering that radically overhauling and privatizing the government has been a GOP OCD fetish for decades, you have to wonder if there’s anything new that Paul thinks we should rethink…

    TPM Livewire
    Paul Ryan: GOP Shouldn’t Give Up On ‘Repealing And Replacing’ Obamacare
    Igor Bobic – October 11, 2013, 2:31 PM EDT

    Addressing a conservative confab in Washington on Friday, Rep. Paul Ryan (R-WI) reprised a familiar Republican refrain — made popular by his and Mitt Romney’s presidential ticket in 2012 — to “repeal and replace” Obamacare with a viable alternative that would extend health insurance to millions of poor Americans.

    “The way I see it, our job is to preserve our values in the 21st century,” the ranking member on the House Budget Committee said in a video address at Values Voter Summit. “We need to apply our principles to the challenges of today. And that means we need to completely rethink government’s role in our lives.

    “We need to completely rethink government’s role in helping the most vulnerable,” Ryan added. “We need to completely rethink government’s role in health care. That means we can never give up on repealing and replacing Obamacare.”

    The refrain is largely a blast from the past because the Republican Party, led by a group of conservative senators and House representatives, largely ditched the latter in favor of a quixotic effort to defund Obamacare in exchange for funding the government — with nary a mention about alternative proposals.

    Hmmm…something tells me this “complete rethinking” called for by Paul Ryan involves a lot of old thoughts:

    The New York Times
    Republicans and Medicare

    By PAUL KRUGMAN
    Published: February 11, 2010

    “Don’t cut Medicare. The reform bills passed by the House and Senate cut Medicare by approximately $500 billion. This is wrong.” So declared Newt Gingrich, the former speaker of the House, in a recent op-ed article written with John Goodman, the president of the National Center for Policy Analysis.

    And irony died.

    Now, Mr. Gingrich was just repeating the current party line. Furious denunciations of any effort to seek cost savings in Medicare — death panels! — have been central to Republican efforts to demonize health reform. What’s amazing, however, is that they’re getting away with it.

    Why is this amazing? It’s not just the fact that Republicans are now posing as staunch defenders of a program they have hated ever since the days when Ronald Reagan warned that Medicare would destroy America’s freedom. Nor is it even the fact that, as House speaker, Mr. Gingrich personally tried to ram through deep cuts in Medicare — and, in 1995, went so far as to shut down the federal government in an attempt to bully Bill Clinton into accepting those cuts.

    After all, you could explain this about-face by supposing that Republicans have had a change of heart, that they have finally realized just how much good Medicare does. And if you believe that, I’ve got some mortgage-backed securities you might want to buy.

    No, what’s truly mind-boggling is this: Even as Republicans denounce modest proposals to rein in Medicare’s rising costs, they are, themselves, seeking to dismantle the whole program. And the process of dismantling would begin with spending cuts of about $650 billion over the next decade. Math is hard, but I do believe that’s more than the roughly $400 billion (not $500 billion) in Medicare savings projected for the Democratic health bills.

    What I’m talking about here is the “Roadmap for America’s Future,” the budget plan recently released by Representative Paul Ryan, the ranking Republican member of the House Budget Committee. Other leading Republicans have been bobbing and weaving on the official status of this proposal, but it’s pretty clear that Mr. Ryan’s vision does, in fact, represent what the G.O.P. would try to do if it returns to power.

    The broad picture that emerges from the “roadmap” is of an economic agenda that hasn’t changed one iota in response to the economic failures of the Bush years. In particular, Mr. Ryan offers a plan for Social Security privatization that is basically identical to the Bush proposals of five years ago.

    The bottom line, then, is that the crusade against health reform has relied, crucially, on utter hypocrisy: Republicans who hate Medicare, tried to slash Medicare in the past, and still aim to dismantle the program over time, have been scoring political points by denouncing proposals for modest cost savings — savings that are substantially smaller than the spending cuts buried in their own proposals.

    And if Democrats don’t get their act together and push the almost-completed reform across the goal line, this breathtaking act of staggering hypocrisy will succeed.

    In related news, now might be a good time to start rethinking your personal moral paradigm. It’ll ease the existential angst in the event of a thoughtless future.

    Posted by Pterrafractyl | October 11, 2013, 12:46 pm
  26. Hi, Pterrafractyl: Here is the latest on Kasich/Medicaid (from 10-12 edition of Cincinnati Enquirer)It’s intersting to me that Right to Life and Chamber of Commerce support the expansion:

    COLUMBUS — Gov. John Kasich’s plan to use a seven-member board to expand Medicaid has drawn praise from Democrats, while infuriating tea party Republicans, who say Kasich has abandoned the base that elected him – voters he may need in 2014.

    After failing to win support from Republicans in the full General Assembly, the Kasich administration on Friday asked Ohio’s Controlling Board to let the state accept federal money to expand Medicaid to as many as 366,000 new Ohioans. On Oct. 21, a Kasich appointee and six state legislators – four Republicans and two Democrats – will vote on the administration’s proposal.

    “At this point, I’m pretty much good with whatever realizes Medicaid expansion for the state of Ohio,” House Minority Leader Tracy Heard, D-Columbus, said this week, summing up Democrats’ reaction. A spokesman for Kasich’s presumptive 2014 gubernatorial opponent, Cuyahoga County Executive Ed FitzGerald, called Kasich out for his inability to get a bill through the Legislature, but said getting health care coverage for low-income Ohioans was “what ultimately matters.”

    Kasich’s former Republican supporters, tea partiers such as Union Township’s Ted Stevenot, accused Kasich of bypassing the Legislature and ignoring voters who elected him.

    “How can he campaign over and over again that he’s against Obamacare and then turn around and do this?” said Stevenot, who is president of the Ohio Liberty Coalition. “At a certain point, enough is enough.”

    What is the Controlling Board?

    Take our poll: Should Gov. John Kasich use the Controlling Board to expand Medicaid?

    Tell Kasich where you stand using the Enquirer’s “Talk to Your Government” tool.

    What you’re telling Kasich about using the Controlling Board to expand Medicaid

    The disagreement between pro-Medicaid Republicans such as Kasich and anti-Medicaid conservatives is a challenge for GOP leaders trying to keep the party together. Matt Borges, chair of the Ohio Republican Party, on Friday released a statement that sought to embrace both sides and focus on the “shared missions” of overcoming Democratic opponents.

    “Conservatives all oppose Obamacare,” Borges said. “On the separate matter of Medicaid, good conservatives have worked to make the program better.”

    Letting the full Legislature make the decision on Medicaid expansion would have been ideal, Medicaid supporters and opponents agree. But federal money becomes available Jan. 1, and Kasich’s administration has decided it can’t wait any longer.

    “From the beginning, we viewed this as a partnership with the Legislature,” said Greg Moody, who has overseen Kasich’s Medicaid expansion efforts. “The vehicle of the legislative Controlling Board seemed the most direct route to get this done on time.”

    The move is legal, supporters say: One of the Controlling Board’s routine functions is to approve increases in federal money, including requests from the state Medicaid Department.

    But it’s unusual to use the board for what is essentially a policy change: expanding Medicaid to adults who earn less than 138 percent of the federal poverty level – currently less than $32,500 for a family of four. Any Controlling Board approval is expected to invite a court challenge, and Kasich’s action might be enough to push a conservative Republican into a primary to challenge his 2014 re-election bid, Stevenot said.

    The sevenControlling Board members, contacted by The Enquirer this week, were generally coy about how they would vote. Kasich needs four “yes” votes. With the approval of his appointee and, presumably, the two pro-Medicaid Democratic legislators on the board, he would need only one of the four Republican lawmakers.

    While none of the GOP lawmakers on the board are vocal Medicaid supporters, House Speaker Bill Batchelder, R-Medina, is expected to replace at least one of the House Republicans before Oct. 21. That will likely get Kasich the votes he needs.

    A group of Republicans, plus organizations such as Ohio Right to Life and the pro-free-market Cincinnati USA Chamber of Commerce, support Kasich on Medicaid expansion.

    Subs for the Controlling Board may come from term-limited House members who are members of that group: Rep. Ross McGregor, R-Springfield, openly supports expansion, and Rep. Lynn Wachtmann, R-Napoleon, this week told The Enquirer he was open to extending Medicaid benefits to the additional group of Ohioans. Rep. Gerald Stebelton, R-Lancaster, is also thought to be willing to consider expanding Medicaid; The Enquirer was unable to reach him Friday.

    The Kasich request asks for 18 months of federal Medicaid money, worth $2.5 billion. That’s because the board’s authority is limited to each two-year spending cycle, said Moody, Kasich’s Medicaid-expansion point person. Unless the General Assembly passes a bill expanding Medicaid for the long-term, the governor’s administration would have to renew its request with the Controlling Board when the state spending cycle resets in June 2015.

    Many Republicans have been wary of Medicaid expansion because they’re worried the federal government could back out on its commitment to pay for 100 percent of the new Medicaid members’ care through 2016, phasing down to 90 percent after that. The Kasich request includes a line that affirms the Controlling Board would only be accepting the federal money, not agreeing to use state money if federal funds disappeared.

    “If that financial situation somehow changes,” Moody said, “state funds will not be used to supplant the coverage of this group.”

    Here’s the link to the story: http://news.cincinnati.com/apps/pbcs.dll/artikkel?NoCache=1&Dato=20131012&Kategori=NEWS010801&Lopenr=310110079&Ref=AR■

    Posted by Kathleen | October 12, 2013, 10:51 am
  27. @Kathleen: It looks like Ohio Right to Life’s support for Medicaid expansion is the exception to the rule. One reason the Chamber of Commerce’s support for the Medicaid expansion might not be entirely unexpected (although still unexpected) is that, unlike groups like the Club for Growth, the Chamber of Commerce has so many local chapters that have to at least pretend to have the interests of local businesses in mind that rejecting the Medicaid expansion is like saying “please go die” to many local healthcare economies. Local people too.

    Posted by Pterrafractyl | October 12, 2013, 11:15 pm
  28. @Pterrafractyl: I was surprised, too, by Ohio Right To Life support. We’ll see what happens. I was initially told by ACA hot line that I would qualify for Medicaid, so I have a stake in the expansion being accepted.

    Posted by Kathleen | October 13, 2013, 6:07 am
  29. @Kathleen: Fortunately, based on today’s reports, it sounds like Ohio’s Medicaid expansion is expected to pass the seven member Controlling Board. Let’s hope that’s right, because as Senate President Keith Faber reiterated today, if the board doesn’t pass the expansion Ohio’s Medicaid system goes broke. So it sounds like the situation is that either folks like yourself will become eligible for Medicaid or Medicaid in Ohio acquires a nasty case of Tea-Party-shutdown-itis and no one gets Medicaid because Tea-Party-shutdown-itis is potentially fatal:

    The Columbus Dispatch
    Medicaid expansion expected to pass Controlling Board

    By Jim Siegel

    The Columbus Dispatch Tuesday October 15, 2013 2:13 PM

    Senate President Keith Faber said today that he expects the Controlling Board will approve the spending needed for Gov. John Kasich to move ahead with expanding Medicaid in Ohio.

    The Celina Republican did not say which GOP member of the board would provide the needed vote on Monday, but he reiterated that failure to approve the spending could cause the entire system to go bankrupt. The expansion would cover an estimated 275,000 low-income Ohioans.

    “On this issue, the legislature gave the governor authority a number of years ago,” Faber said. “We tried to take that authority away in the budget and the governor used his line-item veto to keep his authority.”

    Faber stressed that the board would not specifically approve Medicaid expansion – the governor would do that via executive order – but rather would authorize the spending.

    “If we don’t move the money…Medicaid goes bankrupt,” Faber said. If it’s not approved, “ that money from the expansion will be spent down and current Medicaid recipients, kids and moms, would not have services. I don’t think that’s necessarily a good result.”

    And be sure to send the following article to your friends and family that may not understand how important the Medicaid expansion and Obamacare/ACA is to Ohio’s hospitals. It does a great job of laying out why it is that the Medicaid expansion isn’t just required to save lives and prevent medical-related bankruptcies. It’s needed to save the jobs that the GOP and Tea Party claim to care so deeply about. It also explains how an additional $95 billion in Medicare cuts on top of those already in the ACA (including an $11 billion cut in Medicare fees to hospitals due to the sequester) has been impacting healthcare providers across the nation. The refusal to accept the Medicaid expansion has been a major factor in forcing cuts to hospitals’ staffs and services but it’s far from the only factor:

    The Plain Dealer
    Is Obamacare really to blame for cuts at the Cleveland Clinic and other hospitals?
    By Stephen Koff, Plain Dealer Washington Bureau Chief
    Follow on Twitter
    on October 11, 2013 at 6:06 PM, updated October 13, 2013 at 7:44 AM

    WASHINGTON, D.C. – The Cleveland Clinic’s recent news that it would soon cut staff, seeking to save $330 million, brought immediate reaction: This is what happens under Obamacare.

    This was the sentiment in Tennessee, too, when Vanderbilt University’s medical center announced cuts.

    And certain elements were true, say health care and hospital analysts who note how changes in the way hospital get paid under the Affordable Care Act will affect their bottom line. But they say the criticism, voiced by commentators and scores of other critics of health-care reform, lacked context or failed to explain how other forces – including a U.S. Supreme Court ruling and decisions made in Washington, Columbus and other state capitals since the act passed – are playing a direct role in the hospitals’ worries. It so happens that all of these forces are coming together now, they say.

    The Plain Dealer asked the Cleveland Clinic and health care policy analysts to break down the parts of the act that affect hospital revenues in order to better understand the factors at play. Those parts are:

    MEDICARE REIMBURSEMENTS: Medicare is the federal health insurance program that pays for people age 65 and older. It was passed in 1965 and retirees signed up starting the next year. Money comes from premiums that retirees pay, and from payroll taxes that most working Americans pay. Concern about the program’s financial viability arises regularly because the elderly population is rising and the cost of medical care generally outpaces inflation and wage growth.

    The Affordable Care Act, or ACA, championed by President Barack Obama and passed by congressional Democrats in 2010, demanded new cuts: $716 billion over ten years. Some of these were tied to premiums that CMS paid to private insurers managing what was effectively a Medicare privatization project, called Medicare Advantage. But other Medicare cuts in the ACA were specifically for hospitals.

    These included federal payments linked to hospitals’ performance. Under the ACA, hospitals with an excessive number of preventable patient readmissions were to be penalized. Those penalties were up to 1 percent of hospitals’ Medicare payments in 2013, and will be 2 percent this year and 3 percent in 2014.

    The effect on the Cleveland Clinic has not been that severe, thanks to its lower readmission rate. It lost over $1 million last year – 0.74 percent of its Medicare total – but only 0.33 percent this year, cutting the losses in half, according to a Plain Dealer review in August.

    But the ACA also cut what are known as Medicare’s Disproportionate Share Payments, or DSH, starting in 2014. These are payments given to hospitals that treat a high number of uninsured patients, or what is known as charity care. Hospital associations accepted the cuts because they believed the ACA would expand insurance coverage to non-elderly patients.

    “All of a sudden you’d have millions of people with an insurer behind them paying their bills, so they would recoup some of their losses from reduced payment rates through the fact that a lot of their previously uncompensated care patients were now insured,” said John Graves, an assistant professor specializing in health economics and policy at Vanderbilt University’s School of Medicine.

    The DSH cuts nationwide came to $22 billion over ten years, according to the American Association of Medical Colleges and the Commonwealth Fund.

    From the White House perspective, the ACA-related cuts actually helped Medicare. Through cost-cutting and the elimination of waste, fraud and abuse, the Medicare Trust Fund – the account that holds the taxes and premiums before paying providers – gained 12 years of solvency, CMS projected initially. Medicare trustees later pared that back to eight years.

    And, the White House says, seniors already see more of their prescription drug costs and preventive exams covered, thanks to other portions of the ACA.

    Eileen Sheil, the Cleveland Clinic’s executive director of corporate communications, did not have specific figures available for the Clinic’s loss of DSH money. But she said the loss was among the factors in the decision to cut costs and pare staff through attrition.

    The Ohio Hospital Association estimates that statewide, the Medicare and Medicaid reductions will come to $7.4 billion over ten years.

    If the ACA’s decade-long Medicare DSH cuts nationally seem severe, the American Hospital Association says it might help to note: Congress has done a lot more cutting since the ACA passed. And there has been little if any political outcry.

    “There have been about $95 billion of other Medicare cuts enacted since the ACA, the most recent being the sequester, that have caused a hit to hospital finances,” said Caroline Steinberg, vice president for trends analysis at the American Hospital Association.

    Budget sequestration, or automatic cuts that started this year under a bipartisan agreement by Congress in 2011, took away $45 billion, she said. That’s more than double the ACA’s DSH cuts.

    And a budget deal that Congress made last New Year’s Eve will cut another $35.3 billion, the association said.

    The cuts “just keep coming,” Steinberg said.

    MEDICAID: The major thrust behind health reform was the desire for millions more Americans to gain better access to medical care. Doctors’ offices and hospitals would see their paying-patient rosters grow. They would not have to write off as much bad debt from patients who could not pay their bills. And patients would not have to worry about bankruptcy, or simply avoid getting care, if they got injured or sick.

    One way this was supposed to occur, starting in 2014, was through expanded insurance coverage for those now uninsured. They could buy policies on the new insurance exchanges that are now enrolling people – with widely reported technical glitches so far — for January coverage, and many could get government subsidies to help cover premiums, depending on their incomes.

    Many of the poorest Americans, particularly women with minor children at home, could already qualify for Medicaid, a joint federal-state program that shares the cost of covering people with low incomes. Medicaid had its limits, but the Affordable Care Act was supposed to expand them.

    That is, the ACA would open Medicaid to people with slightly higher incomes, up to 138 percent of the poverty level. Those earning more would be directed to the insurance exchanges and might qualify for subsidies if their family incomes were less than 400 percent of the poverty rate.

    States normally share the costs of Medicaid. They worried about the added expense if they expanded enrollment. So under the ACA, the federal government agreed to pay all the new Medicaid costs through 2016, and 90 percent thereafter.

    This was a powerful incentive for hospitals. They could get more paying patients (with the government as the payer). It was a big part of the logic behind accepting lower Medicare DSH payments.

    And it was the reason the ACA cut a parallel DSH program under Medicaid, whose DSH money flows first to states before redistribution to hospitals. The Medicaid DSH cuts are supposed to total $18 billion from 2014 to 2020. Some $500 million of that will be cut in 2014 and $600 million in 2015, according to a final rule CMS announced Sept. 13.

    To ACA supporters, this and the Medicare DSH cuts sounded like a fair tradeoff: Less money for uncompensated care in exchange for more patients whose bills would actually be paid.

    But the U.S. Supreme Court in 2012 threw water on those plans. While the court upheld the ACA’s provision requiring most Americans to get insurance or face a fine (a tax, as Chief Justice John Roberts put it), it also held that states were not obligated to expand their Medicaid programs.

    State lawmakers in places with Republican legislative majorities, such as Ohio and Tennessee, said they worried that the federal government would someday shirk its obligation and make the states pay a bigger share for the expanded Medicaid programs. They said their states could not afford that.

    So they have refused to expand Medicaid.

    And for many hospitals including the Cleveland Clinic, that poses a problem. Ohio will have an estimated 275,000 fewer residents on Medicaid than projected, the Cleveland Clinic’s Sheil noted.

    “Most of the problems that we have been seeing do relate to the Medicaid expansion that has not panned out as planned,” said Steinberg, of the American Hospital Association.

    Put simply, the tradeoff — more patients who would go on Medicaid and stop qualifying as charity care or bad-debt cases, and less money needed (and provided) for that latter care — is not happening in Ohio and other states that refuse to expand Medicaid. Because of reluctant state legislatures, Medicaid will not grow as the ACA anticipated.

    “The important thing to remember is the reaction the hospitals are having in particular has to do with uncompensated care, and that’s interacting a bit with the Supreme Court decision on Medicaid expansion,” said Vanderbilt’s Graves.

    Hospitals expected to gain thousands of new paying patients – through newly enrolled exchange clients and expanded Medicaid – to make up for the Medicaid and Medicare DSH cuts. Roughly 20 to 30 percent of their uncompensated care money is being cut, Graves said.

    “Which is a significant amount, particularly for safety net hospitals,” Graves said. “Hospitals across the country, in particular in non-expansion states, are going to have to make that up somehow. That’s what we’re seeing at the Cleveland Clinic and elsewhere.”

    UNPAID BILLS: Americans who decide to buy their insurance on the exchanges have a number of choices, just as they do when they buy insurance through a broker. They cannot be turned down for preexisting conditions and their out-of-pocket costs are capped in even the lowest-cost or stingiest policies at around $6,000.

    But whether they buy such a policy or go with a more deluxe plan that has better coverage is up to them and their finances.

    There are four tiers of coverage, and the federal subsidies are pegged to costs in the second-lowest tier (a “silver” plan, in the color-coded, metallurgical lingo of the exchanges). In practical terms, that means one buyer might choose the lowest-level plan (bronze), with higher co-payments or deductibles and subsequently lower premiums. Or a buyer might choose a gold or platinum plan, with extensive coverage but higher premiums. Each buyer must make his or her own calculation and decide what is or isn’t affordable after subsidies are factored in.

    This poses a challenge for hospitals: What if most people choose plans that still leave them obligated for several thousand dollars in co-payments and deductibles?

    That is already the trend in the employer-provided insurance market, with rising deductibles fairly common, according to surveys by the Kaiser Family Foundation. Data from the Ohio Hospital Association’s most recently available survey on this shows hospitals in the state reporting a collective $645 million in bad debt in 2010. They reported providing another $1.1 billion that year in charity care.

    Asked about the fear that bad debt will expand even though more patients will be insured, Megan Neuburger, a senior director at Fitch Ratings who analyzes the industry, said, “That makes a lot of sense.”

    “I think typically a third of a hospital’s bad debt is made up of people who have some level of insurance,” Neuburger said. “It’s been a growing issue with the growth of these high-deductible health plans, which has been a trend in the last couple years.”

    Neither the Obama administration nor analysts who study health care say they know how many or what percentage of buyers will purchase exchange plans with thousand-or-more-dollar out-of-pocket requirements. But analysts say they think it will be high, since many of these buyers do not currently have insurance and affordability has often been a factor.

    “That certainly is a trend that pre-dated the ACA, but if anything I would say the ACA jumps on that trend, in that the exchange plans have pretty substantial cost sharing,” said Graves.

    Note that the last section of the article – the part about the problems of unpaid bills potentially growing and impacting hospitals even more under the ACA/Obamacare because you’ll have more people signing up for insurance with deductibles that they can’t afford – has an unspoken but pretty clear implication: For the Affordable Care Act to work, we kind of need an economy that pays workers enough to actually save the thousands of dollars needed to pay their deductibles. In other words, in contrast to the fevered concerns about Obamacare creating a nation of poor people dependent on the government, the reality is that the ACA/Obamacare simply can’t work in a broken economy that doesn’t pay growing numbers of low-income workers enough to save for that eventual expensive healthcare cost. It might take a decade or more of ongoing trends of low US savings and wage stagnation – with the resulting impacts of lower Medicare and private reimbursements due to an inability to pay the deductibles and starving hospitals – before the ties between the cost of healthcare and gross inequality and long-term economic hopelessness for people left out the New Economy becomes part of the national conversation.

    So, on a positive note, it’s possible that one of the lessons the US eventually takes away from this whole experience is that living wages are required for the sustainability of the US’s healthcare system if the US decides to avoid a single-payer solution and continue pushing most individuals towards private insurance plans. It also means that the economic pain inflicted by crazy politicians is systematically poised to trickle down to the hospitals (sequesters, reduced Medicaid coverage, etc) but also bubble up to the hospitals as the economic consequences of mass insanity percolates through the economy.

    Will valuable lessons be learned about the relationship between paying a living wage and living in a decent economy that can maintain a viable healthcare sector? Probably not, but something is probably going to be learned from this Obamacare default-debacle. Maybe it’ll be a positive lesson although it’s quite possible it’ll be negative. A confused mishmash of positive and negative lessons that in no way lead to coherent solutions for the challenges of the day is also very possible so we’ll just have to wait and see.

    Returning to the topic of Ohio’s Medicaid expansion: Good luck Kathleen. And good health too. With the way things are going good luck and/or good health may be a requirement for decent healthcare so such salutations that include “and good health” may become obligatory. The new economy, like the old economy, still sucks. It may or may not become a costlier and deadlier economy. That will depend heavily on things like whether or not a state accepts the Medicaid expansion and generally cooperate and creating a viable future.

    Or maybe these state-based battles over healthcare and the social contract will become moot because the GOP in the House preemptively tanks economy…

    ….

    Good luck and good health Kathleen!

    Posted by Pterrafractyl | October 15, 2013, 11:10 pm
  30. Well, now that this flick this flick has finally ended, it’s on to the next obvious question: When’s the sequel?! Because that flick was sweet! I haven’t been that transfixed with horrified befuddlement since Mulholland Drive.

    So when is all the bickering, bombast and betrayal returning to the big screen?

    What’s that?? The next shutdown debt ceiling breach could be as soon as February 7th? Wow, that’s a pretty ambitious schedule. Are they filming these sequels all at once? Because that sounds expensive. And if the GOP hasn’t been planning a sequel, then who are they going to find to direct a February sequel on such short order? It would take someone with Peter Jackson’s fantastical vision and David Lynch’s flair for otherworldly torment. That isn’t a directorial position easily filled, especially when some of the top talent in modern American horror recently expressed disinterest.

    Hmm…who could it be that could fill such shoes on such short notice….?

    Hmmm…

    Oh man, this sequel could be awesome.

    Posted by Pterrafractyl | October 16, 2013, 11:26 pm
  31. Now that a sequel to the Great Shutdown Default is looking increasingly possible in 2014, one of the big questions for all the Alt Hist Horror fanboys is going to be whether or not the sequel will include a new villain. Especially a villain with a weapon just as powerful as Obamacare. Maybe Bane with a new secret weapon? How about Scarecrow makes some sort of pro-public-health anti-Gay gas? Just think of the possibilities. So many possibilities.

    BizzarObamcare is coming for you in 2014.

    Posted by Pterrafractyl | October 18, 2013, 12:43 pm
  32. Pterrafractyl: Thanks so much for the good wishes and additional information. As a side note, a friend of mine who is in the medical field (she trains hospital personnel in the new medical records software required for Medicare reimbursements)said that many people are conflating doctors’ resistance to the new software with resistance to ACA implementation. The two events are not related. Some doctors have closed their practices because they didn’t want to use the software for record keeping. Right wing email chains are claiming they’re closing practices because of ACA. Thanks again!

    Posted by Kathleen | October 18, 2013, 4:28 pm
  33. @Kathleen: Well, according to one of the GOP’s top 2016 presidential candidates that happens to be a doctor, spreading misinformation amongst your fellow citizens can be totally acceptable behavior. And that apparently includes misinformation about healthcare policies:

    National Journal
    The Truthiness of Rand Paul
    The junior senator from Kentucky could transform the GOP—if the facts don’t get in his way.
    Jill Lawrence
    By Jill Lawrence

    October 17, 2013

    LOUISVILLE, Ky.—Rand Paul was talking with University of Louisville medical students when one of them tossed him a softball. “The majority of med students here today have a comprehensive exam tomorrow. I’m just wondering if you have any last-minute advice.”

    “Actually, I do,” said the ophthalmologist-turned-senator, who stays sharp (and keeps his license) by doing pro bono eye surgeries during congressional breaks. “I never, ever cheated. I don’t condone cheating. But I would sometimes spread misinformation. This is a great tactic. Misinformation can be very important.”

    He went on to describe studying for a pathology test with friends in the library. “We spread the rumor that we knew what was on the test and it was definitely going to be all about the liver,” he said. “We tried to trick all of our competing students into over-studying for the liver” and not studying much else.

    “So, that’s my advice,” he concluded. “Misinformation works.”

    Paul’s little riff had the students laughing hard. And it was amusing—but also amazing. Why would he set himself up with an anecdote like that? He knew reporters were in the lecture hall. He’s also well aware that watch- dogs are compiling a growing file of evidence that he plays loose with the facts. He had offered a few examples to the students that very afternoon.

    “Under Obamacare and the current evolution of things, we have 18,000 diagnostic codes. We’re going to 144,000 diagnostic codes,” Paul told them. It wasn’t the first time he had implied that the number of codes—complete with seemingly absurd categories for injuries from macaws, lampposts, and burning water skis—was exploding as a result of the Affordable Care Act. But fact-checkers across the spectrum, from the conservative website The Blaze to USA Today to the liberal site Think Progress, had thoroughly debunked that notion months earlier. As Paul must know, the new diagnostic codes were approved by the Bush administration and have nothing to do with Obamacare.

    Spreading misinformation is what good patriots do!

    Posted by Pterrafractyl | October 19, 2013, 6:19 pm
  34. Get ready for the next manifestation of the GOP’s plans for healthcare reform:

    TPM Livewire
    Ron Paul Calls For ‘Nullification’ Of Obamacare: ‘Pretty Soon … We’re Just Going To Ignore The Feds’
    Tom Kludt – November 5, 2013, 7:36 AM EST

    Stumping on behalf of Virginia gubernatorial hopeful Ken Cuccinelli on Monday, former congressman and presidential candidate Ron Paul predicted that states will soon “ignore the feds” and nullify the Affordable Care Act.

    “Jefferson obviously was a clear leader on the principle of nullification,” Paul said at a rally in Richmond, Va., according to Politico.

    “I’ve been working on the assumption that nullification is going to come. It’s going to be a de facto nullification. It’s ugly, but pretty soon things are going to get so bad that we’re just going to ignore the feds and live our own lives in our own states.”

    As Politico noted, Paul was invoking a term with deep roots in the Civil War era while speaking in a former capital of the confederacy. He also decried the taxes associated with the health care law.

    “The taxes involved there, they’re evil,” Paul said. “They’re going to create class warfare, generational warfare.”

    Posted by Pterrafractyl | November 5, 2013, 8:58 am
  35. Here’s an important update regarding the impact on the healthcare systems in states that refuse to accept the Medicaid expansion: Nothing has changed. Hospitals and patients in those states are still extra-screwed and it’s getting worse:

    The New York Times
    Cuts in Hospital Subsidies Threaten Safety-Net Care

    By SABRINA TAVERNISE
    Published: November 8, 2013

    SAVANNAH, Ga. — The uninsured pour into Memorial Health hospital here: the waitress with cancer in her voice box who for two years assumed she just had a sore throat. The unemployed diabetic with a wound stretching the length of her shin. The construction worker who could no longer breathe on his own after weeks of untreated asthma attacks and had to be put on a respirator.

    Many of these patients were expected to gain health coverage under the Affordable Care Act through a major expansion of Medicaid, the medical insurance program for the poor. But after the Supreme Court in 2012 gave states the right to opt out, Georgia, like about half the states, almost all of them Republican-led, refused to broaden the program.

    Now, in a perverse twist, many of the poor people who rely on safety-net hospitals like Memorial will be doubly unlucky. A government subsidy, little known outside health policy circles but critical to the hospitals’ survival, is being sharply reduced under the new health law.

    The subsidy, which for years has helped defray the cost of uncompensated and undercompensated care, was cut substantially on the assumption that the hospitals would replace much of the lost income with payments for patients newly covered by Medicaid or private insurance. But now the hospitals in states like Georgia will get neither the new Medicaid patients nor most of the old subsidies, which many say are crucial to the mission of care for the poor.

    “We were so thrilled when the law passed, but it has backfired,” said Lindsay Caulfield, senior vice president for planning and marketing at Grady Health in Atlanta, the largest safety-net hospital in Georgia.

    It is now facing the loss of nearly half of its roughly $100 million in annual subsidies known as disproportionate share hospital payments.

    Memorial is also facing steep reductions in the subsidies. Cancer care may be among the services reduced, administrators here said. Memorial is now one of only a few hospitals in the state with a tumor clinic that accepts poor patients without insurance. Many show up coughing blood or having trouble breathing because their cancers have gone untreated for so long.

    Patients with chronic conditions like hers often go in and out of emergency rooms for years without treatment because doctors are only required to treat immediately life-threatening conditions. Dr. Christopher Senkowski, a surgeon at Memorial, recalled examining a farmer with pancreatic cancer that had spread throughout his body after months of referrals to specialists that he could not afford.

    The cuts in subsidies for safety-net hospitals like Memorial — those that deliver a significant amount of care to poor, uninsured or otherwise vulnerable patients — are set to total at least $18 billion through 2020. The government has projected that as much as $22 billion more in Medicare subsidies could be cut by 2019, depending partly on the change in the numbers of uninsured nationally.

    The cuts are just one of the reductions in government reimbursements that are squeezing hospitals across the country. Some have already announced layoffs. In Georgia, three rural hospitals have closed this year.

    Medicaid expansion may not have replaced all of the lost subsidies, but it would have helped, hospital administrators said.

    “I understand that the state needs to balance its budget, and control the runaway costs of Medicaid, but to turn a blind eye and say, ‘Let the chips fall where they may,’ you’ll end up with a gutted health care system,” said Maggie M. Gill, chief executive at Memorial Health.

    Traditionally, safety-net hospitals have played a special role in caring for poor people. They make up just 2 percent of acute care hospitals in the country, but provide about a fifth of all uncompensated care, according to Dr. Arthur Kellerman, dean of the F. Edward Hébert School of Medicine in Bethesda, Md. The subsidy was created in the 1980s to help hospitals with large shares of patients who were uninsured or had government insurance that did not pay very much. Many hospitals came to depend on it.

    A full third of Grady’s patients have no insurance, and, if that does not change, the hospital will have no choice but to cut services, said John M. Haupert, Grady’s chief executive. The hospital’s large outpatient mental health program, which handles 58,000 visits a year and is critical to keeping poor patients with behavioral problems from seeking treatment in the emergency room, would most likely be hit, Mr. Haupert said.

    Some experts say the cuts in hospital subsidies are part of a larger problem: government programs like Medicaid do not pay enough to cover the actual costs of care. The cheapest private insurance on the new health care exchanges, the Bronze Plan, covers just 60 percent of costs, leaving low-income people who buy it with a lot of out-of-pocket costs that hospitals worry the patients will not be able to pay.

    Yep, if people can’t afford to pay their out-of-pocket expenses, hospitals will be increasingly on the hook for the costs. And if the economy sucks, it’s even worse for the health of the healthcare system (and people) because more and more people are either going to be pushed into the Medicaid-Gap No-Man’s Land, or they just be driven into financial distress from the crappy economy and unable to cover their deductibles. It’s a reminder that that any real long-term reform of the US healthcare system is going to require an end to the larger problem of socioeconomic cannibalism.

    Until then…

    Posted by Pterrafractyl | November 10, 2013, 12:33 am
  36. Well, now we know a little more about the GOP’s alternative to Obamacare: Free Keggers with that Creepy Uncle Sam. Hopefully you won’t have much more than a sore muscle, though, because he appears to mostly just offer massage therapy:

    Policy Mic
    The Republican Alternative to Obamacare is a Sweet Kegger
    By Tom McKay November 12, 2013

    Remember that series of insanely creepy anti-Obamacare ads featuring a disturbing, smiling Uncle Sam playing doctor with various young people’s private parts? Produced by Generation Opportunity — a Virginia-based, Koch-brothers-funded advocacy group that’s trying to convince young people to throw caution to the wind, chug a cold one, and say “Screw you, Nobama!” to purchasing health insurance — these ads had something important to say about flag-wearing dudes in giant plastic masks and your millennial genitals (millennitals?).

    Something you might not have noticed about those ads: the young people in them were receiving subsidized health care. Double eww, if you’re a Republican!

    Well, now sleazy Uncle Sam (whose slogan has presumably changed from ‘Uncle Sam wants you!’ to ‘Uncle Sam wants you’) is taking his opt-out-of-Obamacare message to another subset of young people: Florida frat bros.

    A tailgate party at the University of Miami-Virginia Tech football game at UM on Saturday had a DJ, this much free beer, hard liquor, pizza, and a personal visit from the man himself, who took the time to get some terrifying mugshots with some hard-drinking sorority girls:
    [see pics]
    So, there you have it: one leading anti-Obamacare organization’s alternative to Obamacare is not getting health insurance while getting wicked trashed with your bros, while a creepy dude in a mask stares at you.

    If this seems like the kind of healthcare option you’re looking for but you missed the event don’t die too soon because it sounds like we can look forward to a more free “Freedom School” experiences in the future. From sea to shining sea.

    Posted by Pterrafractyl | November 15, 2013, 1:27 pm
  37. Remember this threat from Senate minority leader Mitch McConnell back in July? If the Democrats remove the filibuster of pending judicial and cabinet nominees the republicans will remove the filibuster for everything once they regain control:

    Talking Points Memo
    McConnell To Reid: If You Go Nuclear On Nominations, I’ll Go Nuclear On Everything When I’m Majority Leader

    Sahil Kapur – June 18, 2013, 3:00 PM EDT

    Senate Minority Leader Mitch McConnell (R-KY) on Tuesday starkly warned Majority Leader Harry Reid (D-NV) not to eliminate the filibuster on presidential nominations, threatening to end the 60-vote threshold for everything, including bills, if he becomes the majority leader.

    “There not a doubt in my mind that if the majority breaks the rules of the Senate to change the rules of the Senate with regard to nominations, the next majority will do it for everything,” McConnell said on the floor.

    With at least half a dozen key judicial and cabinet nominees pending, all of whom Republicans have problems with, Reid has threatened to invoke the so-called nuclear option to change the rules of the Senate and eliminate the filibuster on nominations — but not anything else.

    Backed up by Sen. Lamar Alexander (R-TN), who echoed his warnings in a floor colloquy Tuesday, McConnell said his hypothetical majority would take it a step further.

    “I wouldn’t be able to argue, a year and a half from now if I were the majority leader, to my colleagues that we shouldn’t enact our legislative agenda with a simple 51 votes, having seen what the previous majority just did,” he said. “I mean there would be no rational basis for that.”

    The minority leader sketched out what a Republican-led Senate would do with 51 votes. Job No. 1, he said, would be to repeal Obamacare. He also mentioned lifting the ban on oil drilling in the Arctic National Wildlife Refuge, approving the Keystone XL pipeline and repealing the estate tax (which he called the “death tax”).

    “These are the kinds of priorities that our members feel strongly about, and I think I would be hard pressed,” McConnell said, “to argue that we should restrain ourselves from taking full advantage of this new Senate.”

    So if the filibuster was repealed for judicial and cabinet nominees, would the GOP really pledge to repeal Obamacare and everything else they could in the Senate using a simple majority if they retake the Senate in 2014? The president could still veto such a bill, but if the GOP takes the White house and a simple majority in 2016…bye bye Obamacare (and hello Norquistcare). And bye bye to just about any other social program (it’s all part of the Norquistcare package).

    So the stakes for upcoming elections would potentially go a lot higher if the GOP actually took that pledge to go global in their nuclear response. But would they actually make that pledge as part of the GOP brand if the Democrats decide to ‘go nuclear’ and end the filibuster for judicial and cabinet nominees? We just might find out:

    McClatchy DC
    Harry Reid goes nuclear, Senate changes filibuster rules for some nominees

    Posted by William Douglas on November 21, 2013 Updated 2 hours ago

    Frustrated by what he considers Republican obstruction, Senate Majority Leader Harry Reid Thursday implemented the so-called “nuclear option” to alter chamber rules to restrict the filibuster of judicial and executive branch nominees. Reid’s vote was the 51st, passing a change to procedures.

    “It’s time to change the Senate before this institution become obsolete,” Reid said on the Senate floor as senators sat at their desks listening attentively.

    Reid, D-Nev., said a string of blocked presidential and judicial nominations highlighted the need to change the Senate’s long-standing rules on nominations from a 60-vote threshold to a majority-rules system.

    In recent weeks, Senate Democrats have been unable to overcome filibusters on the nominations of Rep. Mel Watt, D-N.C., to head the Federal Housing Finance Agency – the first time a sitting member of Congress was blocked since 1843 – and three nominees to the prestigious U.S. Court of Appeals for the District of Columbia.

    Reid railed against Republican filibusters against the nominations of former Rep. Chuck Hagel, R-Neb., for defense secretary. Hagel was eventually confirmed.

    “It’s a troubling trend that Republicans are willing to block executive branch nominations even when they have no objection to the qualification of the nominee,” Reid said. “Instead they block qualified executive branch nominees to circumvent the legislative process.”

    Senate Minority Leader Mitch McConnell, R-Ky., blasted Reid’s move, calling it a Democratic power grab in order to implement President Barack Obama’s agenda. Reid and McConnell accused each other of violating an agreement they reached last July to avert a “nuclear option” move.

    Could a complete repeal of the Senate filibuster now be an implicit component of every GOP Senate candidate: vote for me, and we’ll get rid of all the filibusters and then nominate the most conservative Supreme Court justices we can possibly find. That type of electoral strategy could play well with the GOP primary voters and in gerrymandered House races, but will this new branding that make the GOP even more unrestrained work well for the part in the state-wide Senate races? It’s going to be really interesting to see how this impacts the GOP’s ‘brand’ because the filibuster is one of those things that’s given the GOP in the Senate an excuse to be slightly less crazy than their House counterparts. Are pledges to appoint more far-right Supreme Court justices really going to help the brand? Maybe:

    TPM Livewire
    Norm Ornstein: Republicans Forced Reid’s Hand On The Nuclear Option
    Sahil Kapur – November 21, 2013, 1:02 PM EST

    Norm Ornstein, a congressional scholar at the conservative American Enterprise Institute, told TPM that Republicans forced Harry Reid to “go nuclear” after his Democratic majority took the historic step Thursday and ended the filibuster for executive nominees and non-Supreme Court judicial nominees.

    For whatever reason, the Republicans decided to go nuclear first, with this utterly unnecessary violation of their own agreement and open decision to block the president from filling vacancies for his entire term, no matter how well qualified the nominees,” Ornstein told TPM in an email. “It was a set of actions begging for a return nuclear response.”

    He also speculated that Senate Minority Leader Mitch McConnell (R-KY) secretly wanted Democrats to go nuclear so he could use the same tactic to end the filibuster entirely if and when Republicans takes the majority.

    “McConnell’s threat, it seems to me, makes clear the strategy: let Dems take the first step, and we will then bear no blame when we entirely blow up the Senate’s rules after we take all the reins of power,” he said. “That other Republicans like Corker, McCain, Alexander, Murkowski and so on, went along, shows how much the radicals and anti-institutionalists now dominate the Republican Party. Which is sad indeed.”

    Then again, maybe going full-scale nuclear won’t actually be part of the strategy. A quiet nuclear war might be their preferred option:

    McCain: Dems Will Pay ‘Heavy, Heavy Price’ For Changing Filibuster
    Dylan Scott – November 21, 2013, 12:44 PM EST

    Sen. John McCain (R-AZ) said that Democrats would “pay a heavy, heavy price” for changing the Senate rules for judicial and executive nominees.

    “They’re governed by the newer members… who have never been in a minority, who are primarily driving this issue,” McCain told reporters after the vote. “They succeeded and they will pay a very, very heavy price for it.”

    McCain said moments later, though, that he did not believe it would be a major election issue. “I don’t think Americans understand it very well,” he said.

    Hmmm…the emerging theme appears to be, “Vote for us and we’ll completely unleash the GOP Kraken! But don’t spend too much time thinking about, you simpletons”. It’s hard to say how this will play out in the campaigns, especially in 2016. But, from a purely political standpoint, it’s probably an improvement.

    Posted by Pterrafractyl | November 21, 2013, 12:28 pm
  38. It turns out you don’t need a computer to conduct a denial of service attack against Obamacare. A phone will do:

    Talking Points Memo
    Boehner Fails to Fail on Obamacare
    Josh Marshall – November 23, 2013, 4:00 PM EST

    Late last week Speaker John Boehner (R-OH) made a big show of trying but failing to sign up for Obamacare because of the notoriously buggy website. (Actually he appears to have been using the DC exchange site.) He even did a special tweet noting his hopeless situation. Not terribly surprising given the frustrating experiences so many have had.

    Actually, it turns out he had successfully enrolled and got a call confirming that about an hour after his tweet. But it gets better.

    According to Scott MacFarlane, a reporter for the local NBC affiliate in Washington, eports that a DC Health Care exchange representative actually tried to contact Boehner by phone during the enrollment process but was put on hold for 35 minutes, after which time the representative finally hung up.

    It also tursn out that you don’t need a computer or phone to conduct a denial of service attack against Obamacare:

    GOP seeks a groundswell of opposition to Obamacare
    By Tom Cohen, CNN
    updated 12:23 PM EST, Thu November 21, 2013

    Washington (CNN) — Use any metaphor you like — predators smelling blood, invaders storming the castle, a snowball growing in size and momentum as it rolls downhill.

    All describe efforts by opponents of President Barack Obama’s signature health care reforms to kill the 2010 law after the botched launch of the HealthCare.gov website provided a new opening for attack.

    Critics led by conservative Republicans target the Affordable Care Act itself, not just the website woes, in hopes of creating a public groundswell of opposition.

    “Obamacare is much more than a bad website; it’s a bad law,” says a House Republican playbook for GOP members to follow in the campaign.

    The document obtained from a Republican source Thursday by CNN lays out a strategy of talking points, videos, op-eds and social media outreach intended to spread as negative a perception of the health care reforms as far and wide as possible.

    For Republicans, the goal is to bolster GOP prospects in next year’s congressional elections by vilifying the health care reforms and making them the main campaign issue.

    Holding their House majority and winning back the Senate from Democratic control next year would increase leverage for weakening and perhaps even dismantling the reforms they despise as government overreach run amok.

    Huh, so the GOP is basing its electoral strategy for 2014 on the failure of Obamacare. At least according to the “playbook” memo. That sure sounds like the kind of political strategy that could benefit from some more denial of service attacks.

    Posted by Pterrafractyl | November 24, 2013, 1:03 am
  39. The millions of the still-uninsured must be really thankful that they aren’t being ‘placed on the Titanic’. That sounds awful:

    TPM
    Americans Discover They’re Trapped In GOP’s Medicaid Expansion Gap
    Dylan Scott – December 9, 2013, 6:00 AM EST

    With HealthCare.gov working better and the first deadline to sign up for health coverage that starts in January approaching, Obamacare’s so-called navigators — the people and organizations receiving federal funds to help people enroll — are seeing more and more people come through the doors and out to their events.

    Navigators are community organizations, higher education institutions and government agencies. They keep offices and phone hot lines open and go out to community events, handing out flyers and giving presentations so people know how they can get insurance under the health care reform law. If somebody needs help navigating the insurance websites, they provide it. And with HealthCare.gov finally functioning, this has been their busiest time since the Oct. 1 launch.

    But in 25 states, that robust interest has a downside: Navigators are forced to tell more and more people that they probably won’t be able to get covered because their states, all of which had a GOP-controlled legislative chamber or governor, have refused to expand Medicaid. Lynne Thorp, who is overseeing the University of South Florida’s navigator program in that state, told TPM that about one in four people who contact her team fall into that Medicaid gap.

    “Those are hardest phone calls because it doesn’t make any sense to them,” Thorp said. “We have to explain that they fall into this gap where this program can’t assist them.”

    It makes sense if you look at the numbers. According to the Kaiser Family Foundation, 38 percent of the U.S. uninsured have an income that’s below the poverty line — the population that won’t qualify for either Medicaid expansion or any financial help to purchase private coverage through the law in non-expanding states. About 5 million people fall in that gap in those states.

    But these people probably don’t know that when they walk into a navigator’s office or attend an outreach event. They just want to find out what options are available to them — though it turns out the answer is not many.

    So how are the navigators handling it?

    Well, officially, they’re asked to let those people that they can still apply to purchase insurance through the Obamacare marketplaces. There’s always the possibility that the state will expand Medicaid at a later date, and this way, their information is already on file. The navigators also direct them to free clinics and other non-government assistance that can help them get care.

    But without Medicaid or any tax help, actual insurance is likely to be too expensive for them to afford. These are the people with the lowest incomes. For them, Obamacare isn’t going to make much difference at all.

    In some cases, those being left out seem to understand, having been left out of the health insurance complex for a while, said Cynthia Rahming, who is heading the Houston, Texas, navigator program. She did agree, though, that her team is “often” coming across people who are part of the Medicaid gap in that state.

    “They were excited. They were trying to see what’s available to them,” she said. “But they’re still okay. They know it’s just a chance.”

    But Thorp described angry and confused people who didn’t understand why they wouldn’t be able to get coverage under Obamacare. Like Rahming’s group in Texas, her team refers people to free health clinics. But she acknowledged that they’ve started to become “desensitized” to those experiences, focusing instead on those they can help.

    “It’s awful,” one navigator in a non-expanding state said. “It’s basically: ‘Here are the really great options, and you can’t have them.'”

    In other news, extending unemployment insurance for the long-term unemployed is sort of like buying them a ticket for the Hindenburg…

    Posted by Pterrafractyl | December 9, 2013, 1:28 pm
  40. Increasingly radicalized far-right movements can be quite a problem, but it’s especially problematic for the groups trying to harness that radicalism when the movement is literally dying:

    Salon
    The real problem with the American right: Aging, white radicals
    Everyone knows the GOP has been unable to moderate its image or agenda. But less understood is the true reason why

    Brian Beutler
    Wednesday, Jan 22, 2014 06:44 AM CST

    The Republican Party’s total failure to make even cosmetic changes to its image and policy agenda last year has at this point become the kind of cliché-cum-running joke that often attaches itself to accepted truisms in American politics. Like chucking about Bill Clinton’s inability to contain himself in the company of women, or noting that Dick Cheney actually ran the show during George W. Bush’s first term, observing that Republicans have failed to moderate or reinvent themselves after losing badly in 2012 is the kind of thing even sympathetic political wise men can say to signal that they get it. That in what was a tough year for President Obama, Republicans screwed up too.

    But the observation of these symptoms is less crucial than the diagnosis. Why are Republicans so stuck?

    When it became clear about a year ago that Republican leaders would have a much harder time advancing immigration reform than they realized — that GOP activists and conservatives were livid about the idea that Republicans were going to help illegal immigrants gain citizenship — it started to look like the party had an insoluble problem on its hands. Watching Republicans attempt to broaden their appeal to growing, traditionally Democratic constituencies has been like watching someone try to cover a bedroom floor with a poorly cut carpet, fastening it into one corner but pulling it out of the others in the process.

    They can’t connect with traditionally Democratic constituencies without breaking connection with their reliable supporters. They can tug in every possible direction, but at some point they need to acknowledge that the carpet’s too small.

    For a long time now, people have argued that the solution to the GOP’s problems will resemble the slow, painful, but steady moderation process Democrats went through in the 1980s and through the Clinton presidency. The adherents to this theory include Barack Obama himself, as he told the New Yorker’s David Remnick during an interview for a new profile:

    “There were times in our history where Democrats didn’t seem to be paying enough attention to the concerns of middle-class folks or working-class folks, black or white. And this was one of the great gifts of Bill Clinton to the Party—to say, you know what, it’s entirely legitimate for folks to be concerned about getting mugged, and you can’t just talk about police abuse. How about folks not feeling safe outside their homes? It’s all fine and good for you to want to do something about poverty, but if the only mechanism you have is raising taxes on folks who are already feeling strapped, then maybe you need to widen your lens a little bit. And I think that the Democratic Party is better for it. But that was a process. And I am confident that the Republicans will go through that same process.”

    If the theory were correct, you’d think repeated election defeats would have set the process in motion already. Maybe a third defeat, in 2016, will catalyze a more rapid transition. But over time, I think the important differences between the Democrats’ old challenge and the challenge Republicans now face have started to show.

    Democrats didn’t have an easy go of it, exactly, but they were able to modify their positions across a range of issues without, for instance, creating a left-wing-primary perpetual motion machine, or giving rise to a permanent population of resentful protest voters. Maybe Republicans can do the same. But the 2013 experience suggests they are so in hock to aging, white, conservative reactionaries that taking on new debts with minorities, gay people, single women and so on entails the risk of defaulting on the old ones.

    Another way of saying this is that Republicans have depleted most of their crossover potential. And that’s a pretty novel problem for a modern American political party. It’s manifest in the GOP establishment’s pusillanimous relationship with conservatives. They didn’t cry “Hallelujah” when “Duck Dynasty’s” Phil Robertson preached a bigoted sermon about gay people and the Jim Crow South, but they also notably didn’t treat his remarks as an opportunity to instigate a Sister Souljah-style confrontation with the right. To the contrary, they rallied to Robertson’s defense and to a defense of conservative revanchism in general. And when they have mustered the courage to confront the extreme elements in their party, it’s been over tactics, money, campaigns, rhetoric and other shades of window dressing. John Boehner and Mitch McConnell will (finally!) criticize moneyed pressure groups for misleading voters and attacking Republicans, and they’ll dump on unrepentant hard-liners when they say insensitive but revealing things about gay people, poor people and ethnic minorities. But they haven’t cut the Gordian knot by admitting that these people’s motivating beliefs have failed or been rejected by the public. It’s a consultant-class conflict, not the deeper turbulence that would accompany an ideological course correction.

    Meanwhile tax increases and new social spending are completely out of the question. House Republicans have basically admitted they won’t hold a vote on Senate-passed legislation to prohibit workplace discrimination against gay people. And as for women?

    A faction of conservatives will introduce a resolution at this week’s meeting of the Republican National Committee urging GOP candidates to speak up about abortion and respond forcefully against Democratic efforts to paint them as anti-woman extremists,CNN reported Tuesday.

    Hmmm…well, maybe the GOP’s resolve to ‘speak up about abortion and respond forcefully against Democratic efforts to paint them as anti-woman extremists’ will make inroads with the youth vote and solve this pesky “aging, white radicals” problem. If not, there’s still no reason for a GOP freak out. They can always just retool Plan A again:

    Salon
    GOP’s apocalyptic new debt limit strategy: One enormous lie
    With Obamacare repeal impossible, conservatives need a new villain to attack. Introducing: The “Obamacare bailout”

    Brian Beutler
    Thursday, Jan 23, 2014 06:44 AM CST

    Back in December, just two months after the previous debt limit deadline forced Republicans to end their government shutdown without extracting any unreciprocated concessions from Democrats Rep. Paul Ryan, R-Wis., and Senate Minority Leader Mitch McConnell became the first two leading Republicans to predict that the GOP will stage yet another debt limit hostage drama.

    I’m pretty confident the pattern will hold this time around, too — but with one very important difference. Last time around Republicans entered the combined shutdown and debt limit fights completely clueless about what they hoped to extort, other than that they knew it should come out of the hides of Obama and his supporters. They floated a laughably comprehensive list of demands — the entire roster of Obama accomplishments in exchange for a temporary increase in borrowing authority — but then let it dwindle and dwindle until it disappeared altogether.

    This time around, a shutdown is off the table — the government is funded through September. Which means the fight will be centered entirely around the much more dangerous, but much less politically black-and-white debt limit deadline. And this time, I think Republicans will have a single, concrete ransom demand.

    When Obamacare first launched and Healthcare.gov’s initial failure delayed millions of enrollments, conservatives celebrated, because they believed worse-than-expected enrollment to be synonymous with an actuarial “death spiral” and the law’s rapid collapse. Not so fast, the law’s supporters cautioned. First, don’t forget that the open enrollment period is six months. But then keep in mind that the law outfits the exchanges with shock absorbers — known as reinsurance, and risk corridors — so that if first- and second-year enrollments lag behind expectations, insurers will be insulated from unexpected losses and the need to jack up premiums.

    This came as a tremendous disappointment to conservatives, most of whom had never heard of reinsurance and risk corridors — and who, worse, had blithely convinced themselves that Obamacare was already collapsing because its authors had been too inept to backstop their own creation.

    But they regrouped quickly. The right’s basic approach to fighting Obamacare is pretty simple: Since full repeal is impossible conservatives take aim at the embedded provisions that make the law viable. This explains their obsession with delaying the individual mandate. And it explains their new obsession with repealing the risk corridors. But the individual mandate is and always has been unpopular, whereas nobody’s ever heard of risk corridors. So to make the risk corridors just as unpopular as the mandate, conservatives agreed, in an unusually brazen and public way, that they would lie about that provision and dub it an “Obamacare bailout.” Linking the word “Obamacare” to the word “bailout” serves approximately the same role in building support for the fight against Obamacare as the insinuation of an alliance between Saddam Hussein and Osama bin Laden served in building support for the Iraq War. And it’s only slightly less dishonest.

    Risk corridors are a bit complicated in design, but essentially reflect an agreement between the government and insurance companies participating in the exchanges that the government will share in unexpectedly large losses, but that the government will also recoup large insurance company windfalls. It is for that reason an inducement against insurers setting premiums too high or too low and against cherry-picking healthy customers. In a very bad year for all insurers — if Healthcare.gov had failed entirely, or if a plague sweeps the country this spring — the government would be on the hook for a fair amount of money. Under normal conditions, risk corridors function as a transfer from carriers with healthier clients to carriers with sicker clients. But in an unexpectedly good year for insurers, the government would recoup its losses. Government analysts thus expect the risk corridor program to be budget neutral over its three-year lifespan.

    It’s thus only a bailout in the same way that possessing a bottle of Advil is a catastrophic drug overdose. But that hasn’t stopped conservatives from plotting in broad daylight to frame it as a bailout anyhow, in a cynical campaign to build support for its repeal and, as Ramesh Ponnuru wrote, in mustache-twiddling prose, “raise premiums [making insurance] plans even more unattractive than they already are … Obamacare would, in other words, become even less likely to succeed than it already is.”

    He might as well have said conservatives won’t abandon their Obamacare sabotage campaign unless George Soros gives them one zillion, fafillion dollars.

    But Ponnuru’s relatively late to the party. This idea really morphed from a secret plot to wreck Obamacare into a Bond villain audition on Jan. 2, when, after finally discovering these dreaded risk corridors, Charles Krauthammer advised: “Attach the anti-bailout bill to the debt ceiling. That and nothing else. Dare the president to stand up and say: ‘I’m willing to let the country default in order to preserve a massive bailout for insurance companies.’”

    Which is exactly what I think Republicans will do. Treasury Secretary Jack Lew announced on Wednesday that Congress will need to increase the debt limit before the end of February, weeks earlier than expected. House Speaker John Boehner, who declined to demand any debt limit ransoms just last week, sent his spokesman Michael Steel out to announce in response to Lew that “a ‘clean’ debt limit increase simply won’t pass in the House.”

    So it’s pretty clear where Republicans are headed. Sen. Marco Rubio, R-Fla., even authored a “bailout” repeal bill last year. And they’ll probably get their talking point. But for anyone reading who isn’t in the business of laying fraudulent intellectual groundwork for partisan campaigners, you can be absolutely secure in the conclusion that this is a huge scam — indeed that almost everyone who crashed the bailout rhetoric party knows they’re lying.

    Why? Because they’ve since learned that Medicare Part D has a risk corridor program as well! And it’s dawning on them that they must now square their apocalyptic bailout rhetoric with the fact that some of them helped design that very entitlement a decade ago.

    And if another Obamacare-shutdown doesn’t mesmerize the populace and expand the base, the GOP could always try to convince young voters that it actually cares about their civil liberties and futures. It’s a long shot, but it just might work:

    Slate
    The New, Snowden-Loving Republican Party

    By David Weigel
    Jan. 24 2014 3:58 PM

    Benjy Sarlin has a nice read on the other news emerging from the RNC meeting. Supporters of Ron Paul, chiefly Nevada’s Diana Orrock, were able to sell the whole committee on a resolution “renouncing” the NSA’s data collection programs. As of today, the RNC “encourages Republican law makers to call for a special committee to investigate, report, and reveal to the public the extent of this domestic spying” and “calls upon Republican lawmakers to immediately take action to halt current unconstitutional surveillance programs and provide a full public accounting of the NSA’s data collection programs.” It basically endorses Rep. Justin Amash’s legislation in the House.

    Andrew Kaczynski commemorates the occasion with a flashback to the August 2006 RNC attack on the “liberal judge” who ruled against another NSA program, and was “praised by Dems.” Not long after that, one of the party’s endangered moderates, Connecticut Rep. Nancy Johnson, attacked her Democratic opponent for daring to oppose the program.

    So it’s taken seven-odd years for the GOP to come fully around and realize the groovy politics of civil liberties, but that should have been obvious even before Snowden.

    Could we see a new young, hip, civil-liberties-loving GOP sweep the nation off its feet in 2014? We’ll see!

    But either way, the GOP clearly has to make a pivot away from its socially conservative base and embrace its Libertarian future someday and right now might be as good an opportunity as the GOP will ever get to rebrand the party not as the last refuge of aging, white radicals but as the party of youthful revolutionary spirit…a sort of stopped clock for the future. So we should probably expect a lot more youth-friendly embraces of the Ron Paul/Rand Paul Libertarian wing of the party, especially if the upcoming “Obamacare-bailout shutdown” doesn’t go well. And who knows, we might even see a few more rebranding attempts by the Libertarians themselves as this trend progresses.

    Still, the GOP should definitely avoid embracing its inner Libertarian too aggressively during this rebranding phase. That might solve the GOP’s “aging, white radicals” problem a little too soon.

    Posted by Pterrafractyl | January 25, 2014, 5:35 pm
  41. Congrats GOP: Mission accomplished! Mission accomplished!

    TPM Livewire
    Study: Thousands Of People Will Die In States That Don’t Expand Medicaid

    Updated 11:45 AM EST, Fri Jan 31 2014

    Dylan Scott – January 31, 2014, 11:00 AM EST

    As many as 17,000 Americans will die directly as a result of states deciding not to expand Medicaid under Obamacare, according to a new study.

    Researchers from Harvard University and City University of New York have estimated that between 7,115 and 17,104 deaths will be “attributable to the lack of Medicaid expansion in opt-out states” in a study published in Health Affairs.

    “The results were sobering,” Samuel Dickman, one of the authors, said, according to the Morning Call. “Political decisions have consequences, some of them lethal.”

    They projected that 423,000 fewer diabetics would receive medication to treat their disease. If opt-out states had expanded Medicaid, 659,000 women who are in need of mammograms and 3.1 million women who should receive regular pap smears would have become insured, the study found.

    “Low-income adults in states that have opted out of Medicaid expansion will forego gains in access to care, financial well-being, physical and mental health, and longevity that would be expected with expanded Medicaid coverage,” the authors wrote.

    In terms of health coverage, expanding states will experience a 48.9 percent decrease in their uninsured population compared to a 18.1 percent decrease in non-expanding states. Eight million people will remain uninsured because their states didn’t expand Medicaid, according to the study.

    Posted by Pterrafractyl | January 31, 2014, 9:23 am
  42. It’s only fool’s gold if folks find out:

    TPM DC
    The GOP Has It Wrong: Obamacare Won’t ‘Cost’ 2 Million Jobs

    Dylan Scott – February 4, 2014, 2:28 PM EST

    Republicans thought they found a gold mine when the Congressional Budget Office released its latest report Tuesday on the federal budget and Obamacare. They seized on one line in particular:

    The reduction in CBO’s projections of hours worked represents a decline in the number of full-time-equivalent workers of about 2.0 million in 2017, rising to about 2.5 million in 2024

    They had a new talking point: President Obama’s hated health care reform law would cost more than 2 million American jobs.

    “Obamacare To Print Even More Pink Slips,” read the subject of the Senate Republican conference email blasted out after the report’s release.

    “Obamacare will cost our nation about 2.5 million jobs,” tweeted Sen. Lindsey Graham (R-SC):

    “For years, Republicans have said that the president’s health care law creates uncertainty for small businesses, hurts take-home pay, and makes it harder to invest in new workers,” Speaker John Boehner (R-OH) said in a statement. “The middle class is getting squeezed in this economy, and this CBO report confirms that ObamaCare is making it worse.”

    The New York Times summed it up by claiming that the CBO report is “providing Republican opponents of the law a powerful political weapon leading up to this year’s midterm elections.”

    But is that what the CBO actually said or meant? No.

    What the CBO really found was that the numbers of hours worked would decrease under Obamacare, by roughly 1.5 percent to 2 percent between 2017 and 2024. The report then translated those lost hours into the equivalent of 2.5 million jobs. But that doesn’t mean 2.5 million jobs are going to disappear from the U.S. economy.

    The CBO report, in fact, specifically undermines that claim. Those lost hours will “almost entirely” be the result of people choosing to work fewer hours because of Obamacare — not because they lost their jobs or can’t find a full-time job.

    The estimated reduction stems almost entirely from a net decline in the amount of labor that workers choose to supply, rather than from a net drop in businesses’ demand for labor, so it will appear almost entirely as a reduction in labor force participation and in hours worked relative to what would have occurred otherwise rather than as an increase in unemployment (that is, more workers seeking but not finding jobs) or underemployment (such as part-time workers who would prefer to work more hours per week).

    The report explicitly says that Obamacare isn’t going to force businesses to cut jobs on any grand scale. What it is going to do is change how much Americans work.

    “I think it’s important to distinguish between people choosing to work less and jobs being lost,” Larry Levitt, vice president at the non-partisan Kaiser Famiy Foundation, told TPM. “That is something important to keep an eye on, since you don’t want to discourage work. But, it’s not in all cases a bad thing.”

    “For example, some people in their late 50s and early 60s would like to retire because they have health issues but have kept working for the health benefits. Some of them can now retire because they can’t be discriminated against for having a pre-existing condition and may get help paying their premiums.”

    So how exactly will the law influence Americans? It is, of course, complicated.

    The main takeaway is: Obamacare will affect how much Americans decide to work. Why? Benefits like tax subsidies to purchase private health coverage and expanded Medicaid are based on income. The more money you make, the fewer benefits you receive. In general, the law’s added financial security will likely give Americans a little less incentive to work.

    Some Americans will therefore decide to work less. That could manifest in different ways: some people might chose to transition to part-time work; others might wait longer between jobs. One population — those nearing retirement age — might opt to retire early because the law allows them to continue receiving health coverage even if they don’t work.

    But the ultimate impact of those decisions is the same: Americans will be working less. But not because there will be so many fewer jobs, as Kaiser’s Levitt explained to TPM.

    “If you guarantee people insurance even if they don’t get it on the job and you give them help based on their income, that’s likely to lead to people working somewhat less,” he said. “That’s going to be true of any means tested program. The only way around it is not to give people the help.”

    *gasp* You mean poor people aren’t going to have to work quite as many hours in order to keep their healthcare? Well, there goes another great American tradition.

    But don’t worry GOP, thanks to the brave actions of the state legislatures around the country that refused to expand Medicaid the great American tradition of working until you die in a ditch is being kept alive. And because the hospitals in those states aren’t getting the Medicaid patients they were expecting, hospital jobs are also being lost which can then be blamed on Obamacare! And these job losses are involuntary, just like they should be…none of that wussy Obamacare-“I don’t want to work so much because I’m old and need healthcare” nonsense.

    Refusing to help: it’s the gift that keeps on giving:

    news-leader.com
    Medicaid expansion: Hospitals feel pinch as Missouri, other states debate
    Feb. 3, 2014

    Written by
    Sarah Okeson

    HOUSTON — Former President Harry Truman spoke in 1958 at the dedication of the Texas County Memorial Hospital in Houston, located in the middle of the county so residents in communities such as Elk Creek and Clara wouldn’t have to drive far.

    Truman had unsuccessfully pushed for Congress to approve universal health insurance, but he was able to get the Hill-Burton Act passed in 1946, which helped build rural hospitals such as the Texas County Memorial Hospital. The law of the land now mandates universal health care coverage, but the way that law is being implemented in Missouri could eventually contribute to some of the state’s most financially precarious hospitals closing or merging with other hospitals.

    “I think all rural hospitals are at risk of losing ground or losing jobs or losing services,” said Wes Murray, the CEO of the hospital, who voluntarily took a 5 percent pay cut in 2013. “More people would have to travel elsewhere either for a job or for their care.”

    The Houston hospital lost about $700,000 that year, according to its unaudited financial statements.

    Hospitals had counted on the expansion of Medicaid to help offset cuts in payments to hospitals that are part of the federal health care reform law. But Missouri’s conservative legislators have balked at expanding Medicaid after a decision by the U.S. Supreme Court allowed states to opt out.

    Missouri’s decision not to expand also left an estimated 193,420 uninsured adults who could have been covered by Medicaid in the lurch. They make too little to qualify for federal subsidies to help pay for insurance under the Affordable Care Act, but they make too much to be able to get Medicaid.

    Former Missouri senator Kit Bond said that if Medicaid isn’t expanded, people “with limited resources will either wind up going without health care or go to hospital emergency rooms and none of those are acceptable.”

    Researchers from Harvard University and the City University of New York recently projected that Missouri’s decision to reject Medicaid expansion could lead to more than 200 deaths statewide. The study estimated that 12,947 diabetics won’t get their medications, 7,770 people will have catastrophic medical expenses and 21,816 people won’t get their depression recognized and treated.

    “The Missouri legislature needs to act now and draw down federal funds in order to expand health care access for all Missourians,” said Michelle Trupiano, the director of the Missouri Medicaid Coalition.

    The state’s hospitals are just starting to feel the financial impact of not expanding Medicaid, according to the Missouri Hospital Association. The hospitals face an estimated $700 million reduction in Medicaid payments from 2014 to 2019 and a $3.3 billion reduction in Medicare payments from 2013 to 2019 that are partially connected to the health care law, according to association.

    The association looked at the finances of the state’s 142 hospitals. The analysis found that overall, the hospitals made less than two cents before interest for every $1 in sales in 2012.

    Herb Kuhn, the president and CEO of the Missouri Hospital Association, said hospitals have laid off or not filled about 1,000 jobs.

    “We’re really starting to fill the pinch,” Kuhn said.

    In Springfield, Mercy Hospital Springfield isn’t hiring employees who don’t care for patients.

    Dr. Robert Steele, the president and CEO of Mercy Hospital Springfield, said Mercy is expected to lose about $16.6 million in federal payments in 2014. But Steele said Mercy is healthier than rural hospitals, which tend to have a larger share of patients on Medicaid and Medicare.

    “I have very serious concerns about our surrounding rural hospitals,” Steele said. “They were already under difficult challenges anyway. At best, I believe that what you’ll see is that hospitals have struggled so much that they get acquired by someone else.”

    In West Plains, Ozarks Medical Center laid off 32 employees in June. The 114-bed hospital is projected to face about $41 million in cuts in federal payments from 2013 to 2019.

    Jeannie Looper, the interim president and CEO of Ozarks Medical Center, is trying to grow services such as orthopedic surgery, oncology and cardiac care.

    “We cannot cut our way out of that reduction, as you can imagine,” Looper said.

    Now you know why Arkansas’s GOP legislators are all excited.

    Posted by Pterrafractyl | February 4, 2014, 2:37 pm
  43. A snapshot of our contemporary din:
    Altruism. Is it bad or good?

    If ongoing debates over the merits of altruism leave you feeling stressed out and concerned for the future, don’t let the stress get to you too much. Stress induced by an observed lack of empathy in others can be a self-reinforcing problem. Instead, find ways to de-stress as many other people as possible. How might we accomplish that? What should be avoided at all cost?

    Posted by Pterrafractyl | March 25, 2014, 1:41 pm
  44. Posted by Pterrafractyl | March 28, 2014, 10:07 am
  45. “The GOP’s Most Cynical Anti-Obamacare Attack Yet?” That’s a pretty high bar. Let’s see how this one does:

    The New Republic
    The GOP’s Most Cynical Anti-Obamacare Attack Yet

    BY NOAM SCHEIBER @noamscheiber

    My colleague Jonathan Cohn has done heroic work cataloguing and rebutting some of the most nonsensical right-wing attacks on Obamacare as the enrollment deadline looms. But I fear he may have missed a leading candidate for the top spot: Tennessee congresswoman Marsha Blackburn.

    Appearing on MSNBC this morning, Blackburn was asked whether she disputed poll numbers showing the percentage of uninsured Americans to be steadily falling. Here’s how Blackburn responded:

    Well, I think what we, there again, have to do is look at what you find in those numbers. And I would direct you to the 2012 Kaiser report that said 33% of all physicians are not seeing new Medicare enrollees. Now, if we have a lot of Medicaid enrollees—excuse me, I mean Medicaid enrollees. They’re not expanding their Medicaid population in their patient base.

    At which point anchor Chris Jansing rightly pointed out that Tennessee, along with several other Republican states, has refused to sign on to the very Medicaid expansion Blackburn says isn’t happening. “But you didn’t offer that in Tennessee, correct?” Jansing said.

    Back to you Rep. Blackburn:

    Let me finish my thought here, then we’ll talk about Tennessee. What we are doing, if we are giving an insurance card to those individuals who do not have access to the doctor. Basically, it’s a false promise, because you say, “You have insurance to the queue, not to the physician.”

    Now the reason there was not a Medicaid expansion in Tennessee is because we have been to this dance before. It was in the mid-‘90s, the test case for Hillarycare. It was an abysmal failure. We have Secretary Sebelius, who has called the rollout of Obamacare a debacle. That is exactly what happened in Tennessee. A debacle. The legislature has chosen not to expand Medicaid in Tennessee, and with good reason. They know it’s not an affordable premise. And they are very concerned about the impact that would have on the access to health care within our state.

    So, to review: Blackburn says Obamacare is a failure because the promised Medicaid expansion isn’t happening. Journalist points out that Blackburn’s own state has blocked Medicaid expansion from happening. In response to which Blackburn says, Damn right! No way would we ever let Medicaid expand!

    OK, it’s definitely a double.

    Posted by Pterrafractyl | March 31, 2014, 5:56 pm
  46. Just imagine how awesome healthcare could be in the US without the ‘awesome evilness’:

    Washington Monthly
    April 09, 2014 9:40 AM
    “Almost Awesome in its Evilness.” Jon Gruber on States’ Rejection of Medicaid Expansion

    By Harold Pollack

    Over at healthinsurance.org, I interviewed MIT economist Jon Gruber on the state of ACA. We discussed a huge range of things, ranging from the case for the “Cadillac tax” to lessons of the botched rollout. It was a pretty upbeat conversation. But Jon was characteristically blunt regarding states that have declined ACA’s Medicaid expansion:

    Jon: I think, Harold, the single thing we probably need to keep the most focus on is the tragedy of the lack of Medicaid expansions. I know you’ve written about this. You know about this, but I think we cannot talk enough about the absolute tragedy that’s taken place. Really, a life-costing tragedy has taken place in America as a result of that Supreme Court decision. You know, half the states in America are denying their poorest citizens health insurance paid for by the federal government.

    So to my mind, I’m offended on two levels here. I’m offended because I believe we can help poor people get health insurance, but I’m almost more offended there’s a principle of political economy that basically, if you’d told me, when the Supreme Court decision came down, I said, “It’s not a big deal. What state would turn down free money from the federal government to cover their poorest citizens?” The fact that half the states are is such a massive rejection of any sensible model of political economy, it’s sort of offensive to me as an academic. And I think it’s nothing short of political malpractice that we are seeing in these states and we’ve got to emphasize that.

    Harold: One of the things that’s really striking to me is there’s a politics of impunity towards poor people, particularly non-white poor people that is almost a feature rather than a bug in the internal politics in some of these states, not to cover people under Medicaid, even if it’s financially very advantageous to do so. I think there’s a really important principle to defeat this politically, not just because Medicaid is important for people, but because it’s such a toxic political perspective that has to be … It has to be shown that that approach to politics doesn’t work because otherwise, we will really be stuck with some very unjust policies that will be pursued with complete impunity in some of these places.

    Jon: That’s a great way to put it. There are larger principles at stake here. When these states are turning – not just turning down covering the poor people – but turning down the federal stimulus that would come with that.

    […]

    They are not just not interested in covering poor people, they are willing to sacrifice billions of dollars of injections into their economy in order to punish poor people. It really is just almost awesome in its evilness.

    More here.

    Well at least we don’t have to worry about states acting with complete impunity. It’s still a democracy under the rule of one man one vote and politicians that use the poor as a political effigy can still be voted out, especially by the people getting targeted by awesome evilness. Right? Maybe?

    Posted by Pterrafractyl | April 11, 2014, 8:19 am
  47. The National Republican Congressional Committee just issued a public cry for help over its inability to stop fixating on Obamacare. Fortunately, help is on the way! Ironically.

    Posted by Pterrafractyl | April 17, 2014, 2:45 pm
  48. Ok then:

    Slate
    Federalist Rolling Papers
    Two states’ rights advocates are pursuing a silly lawsuit to the Supreme Court that could undermine states’ rights.
    Dec. 30 2014 11:49 AM
    By Mark Joseph Stern

    The attorneys general of Nebraska and Oklahoma have decided that they should have a say over what happens in the state of Colorado. Just before the holidays, the two men, Jon Bruning and Scott Pruitt, filed a lawsuit against Colorado for legalizing marijuana. The suit is a long shot, but some respected legal scholars think Bruning and Pruitt have a fighting chance. Should they succeed, their case could lead to epic battles among the states over regulation of guns and pollution—and give Congress unprecedented power.

    Bruning and Pruitt’s crusade against Colorado’s marijuana laws conflicts with their ostensible support of states’ rights. As attorney general of Nebraska, Bruning has fought Obamacare with the fanaticism of a zealot, arguing in a legal challenge that the law tramped upon states’ rights. As attorney general of Oklahoma, Pruitt has led the next major challenge to the act, insisting that the federal government must respect states’ decisions not to set up their own exchanges and to deny their citizens cheap access to good insurance. Both men believe their states have a right to control their own health insurance systems.

    But when another state decides to experiment with a new drug policy, Bruning and Pruitt’s support for state sovereignty dries up. They are arguing that Congress’s prohibition against marijuana should force every state to prohibit it as well. (These attorneys general aren’t opposed to all intoxicants. Their position on marijuana might have something to do with the fact that both Bruning and Pruitt have received significant campaign contributions from alcohol industries.)

    This strange little lawsuit against Colorado is so astonishingly hypocritical, so brazenly antipodal to Bruning and Pruitt’s professed philosophy, that even admirers of both men are aghast. Case Western Law’s Jonathan H. Adler, the mastermind behind the latest Obamacare suit, noted with disgust that “it is as if their arguments about federalism and state autonomy were not arguments of principle but rather an opportunistic effort to challenge federal policies they don’t like on other grounds.” Georgetown Law’s Randy Barnett, who brought the first Obamacare suit from the fringe to the mainstream, wrote that “I see no other way to interpret Nebraska and Oklahoma’s lawsuits than as an example of ‘fair weather federalism.’ ” (Federalism describes the balance of power between states and the central government; self-described federalists favor increased state autonomy.)

    What has Adler and Barnett so riled up about the marijuana lawsuit isn’t just the rank hypocrisy. It’s the precedent. Federalists may have lost their argument against Obamacare’s individual mandate at the Supreme Court, but they won the other half of their suit: the claim that the federal government can’t coerce states into participating in the law’s generous Medicaid expansion. (That’s why red states are still able to squabble over the program today.) Federalists have long strived to establish that Congress can’t dragoon states into adopting certain policies or programs. By pushing the Supreme Court to rule that the federal government can’t force states to expand Medicaid—even on Congress’s dime—federalists scored a huge win.

    If Nebraska and Oklahoma succeed in their lawsuit against Colorado, that victory would effectively be reversed. The two states are arguing that federal law outlawing marijuana doesn’t just make the use and sale of marijuana federal crimes. Rather, they’re arguing that Congress intended to force state legislatures to criminalize marijuana, and to use their states’ police power to punish marijuana users. If this claim is true, then the law itself constitutes a federal infringement upon state autonomy far, far greater than any part of Obamacare. Bruning and Pruitt read Congress’s marijuana ban to coerce every single other state into enacting, maintaining, and vigorously enforcing its own marijuana ban.

    If Adler and Barnett are truly shocked that these two conservative Republican attorneys general are fair-weather federalists, then they haven’t been paying attention. Pruitt joined an amicus brief in United States v. Windsor arguing that the Supreme Court should uphold Congress’s ban on same-sex marriage—even though the law encroached upon state sovereignty by limiting the states’ ability to protect a certain class of citizens. Bruning also supported the federal gay marriage ban, and is currently defending his state’s ban in court.

    With marriage equality and health insurance, it’s easy for Bruning and Pruitt to stand up for their alleged federalist convictions. They already despise gay rights and universal health care, but attacking gay people and poor people is a bit gauche these days—so instead, both attorneys general can degrade and disadvantage their citizens under the ostensibly principled banner of states’ rights. When it comes to marijuana, however, Bruning and Pruitt’s true colors show. For these politicians, federalism was never anything more than opportunistic camouflage, a façade to conceal their discriminatory designs. Fair-weather federalism is too kind a term for what Bruning and Pruitt believe. Their vision of federalism was never anything more than a sham.

    Well, at least these two attorneys general might accidentally expand access to healthcare. That may not have been their intent but, hey, it’s still sort of a good deed. Sort of.

    Posted by Pterrafractyl | December 31, 2014, 2:16 pm
  49. The History of Mother’s Day 101. Lesson 1: The mother of Mother’s Day wasn’t very proud of her offspring.

    Happy Mother’s Day:

    National Geographic
    Mother’s Day Turns 100: Its Surprisingly Dark History
    By Brian Handwerk, for National Geographic

    PUBLISHED May 09, 2014

    As Mother’s Day turns 100 this year, it’s known mostly as a time for brunches, gifts, cards, and general outpourings of love and appreciation.

    But the holiday has more somber roots: It was founded for mourning women to remember fallen soldiers and work for peace. And when the holiday went commercial, its greatest champion, Anna Jarvis, gave everything to fight it, dying penniless and broken in a sanitarium.

    It all started in the 1850s, when West Virginia women’s organizer Ann Reeves Jarvis—Anna’s mother—held Mother’s Day work clubs to improve sanitary conditions and try to lower infant mortality by fighting disease and curbing milk contamination, according to historian Katharine Antolini of West Virginia Wesleyan College. The groups also tended wounded soldiers from both sides during the U.S. Civil War from 1861 to 1865.

    In the postwar years Jarvis and other women organized Mother’s Friendship Day picnics and other events as pacifist strategies to unite former foes. Julia Ward Howe, for one—best known as the composer of “The Battle Hymn of the Republic”—issued a widely read “Mother’s Day Proclamation” in 1870, calling for women to take an active political role in promoting peace.

    Around the same time, Jarvis had initiated a Mother’s Friendship Day for Union and Confederate loyalists across her state. But it was her daughter Anna who was most responsible for what we call Mother’s Day—and who would spend most of her later life fighting what it had become.

    “Mother’s Day,” Not “Mothers’ Day”

    Anna Jarvis never had children of her own, .but the 1905 death of her own mother inspired her to organize the first Mother’s Day observances in 1908.

    On May 10 of that year, families gathered at events in Jarvis’s hometown of Grafton, West Virginia—at a church now renamed the International Mother’s Day Shrine—as well as in Philadelphia, where Jarvis lived at the time, and in several other cities.

    Largely through Jarvis’s efforts, Mother’s Day came to be observed in a growing number of cities and states until U.S. President Woodrow Wilson officially set aside the second Sunday in May in 1914 for the holiday. (See pictures of animal mothers and babies.)

    “For Jarvis it was a day where you’d go home to spend time with your mother and thank her for all that she did,” West Virginia Wesleyan’s Antolini, who wrote “Memorializing Motherhood: Anna Jarvis and the Defense of Her Mother’s Day” as her Ph.D. dissertation, said in a previous interview.

    “It wasn’t to celebrate all mothers. It was to celebrate the best mother you’ve ever known—your mother—as a son or a daughter.” That’s why Jarvis stressed the singular “Mother’s Day,” rather than the plural “Mothers’ Day,” Antolini explained.

    But Jarvis’s success soon turned to failure, at least in her own eyes.

    Storming Mother’s Day

    Anna Jarvis’s idea of an intimate Mother’s Day quickly became a commercial gold mine centering on the buying and giving of flowers, candies, and greeting cards—a development that deeply disturbed Jarvis. She set about dedicating herself and her sizable inheritance to returning Mother’s Day to its reverent roots. (See National Geographic’s pictures of motherly love.)

    Jarvis incorporated herself as the Mother’s Day International Association and tried to retain some control of the holiday. She organized boycotts, threatened lawsuits, and even attacked First Lady Eleanor Roosevelt for using Mother’s Day to raise funds for charities.

    “In 1923 she crashed a convention of confectioners in Philadelphia,” Antolini said.

    A similar protest followed two years later. “The American War Mothers, which still exists, used Mother’s Day for fund-raising and sold carnations every year,” Antolini said. “Anna resented that, so she crashed their 1925 convention in Philadelphia and was actually arrested for disturbing the peace.”

    Jarvis’s fervent attempts to reform Mother’s Day continued until at least the early 1940s. In 1948 she died at 84 in Philadelphia’s Marshall Square Sanitarium.

    “This woman, who died penniless in a sanitarium in a state of dementia, was a woman who could have profited from Mother’s Day if she wanted to,” Antolini said.

    “But she railed against those who did, and it cost her everything, financially and physically.”

    Mother’s Day Gifts Today: Brunch, Bouquets, Bling

    Today, of course, Mother’s Day continues to roll on as an engine of consumerism.

    According to the National Retail Federation, Americans will spend an average of $162.94 on mom this year, down from a survey high of $168.94 last year. Total spending is expected to reach $19.9 billion. The U.S. National Restaurant Association reports that Mother’s Day is the year’s most popular holiday for dining out.

    As for Mother’s Day being a hallmark holiday, there’s no denying it, strictly speaking.

    Hallmark Cards itself, which sold its first Mother’s Day cards in the early 1920s, reports that Mother’s Day is the number three holiday for card exchange in the United States, behind Christmas and Valentine’s Day—another apparent affront to the memory of the mother of Mother’s Day.

    About 133 million Mother’s Day cards are exchanged annually, according to Hallmark. After Christmas, it’s the second most popular holiday for giving gifts. (See "Father’s Day at 100: How It Began, Why Dad Gets Fewer Gifts.")

    Now you know: The second most popular holiday for giving gifts was created in the memory of the mother of its founder, Anna Jarvis, a peace activist who died penniless and broken in a sanitarium after trying to end the holiday after seeing it deviate from its roots:

    But the holiday has more somber roots: It was founded for mourning women to remember fallen soldiers and work for peace. And when the holiday went commercial, its greatest champion, Anna Jarvis, gave everything to fight it, dying penniless and broken in a sanitarium.

    It all started in the 1850s, when West Virginia women’s organizer Ann Reeves Jarvis—Anna’s mother—held Mother’s Day work clubs to improve sanitary conditions and try to lower infant mortality by fighting disease and curbing milk contamination, according to historian Katharine Antolini of West Virginia Wesleyan College. The groups also tended wounded soldiers from both sides during the U.S. Civil War from 1861 to 1865.

    In the postwar years Jarvis and other women organized Mother’s Friendship Day picnics and other events as pacifist strategies to unite former foes. Julia Ward Howe, for one—best known as the composer of “The Battle Hymn of the Republic”—issued a widely read “Mother’s Day Proclamation” in 1870, calling for women to take an active political role in promoting peace.

    Happy Mother’s Day.

    So in the spirit of Mother’s Day, here’s a fun story about a man that used the memory of his mom to end but then re-embraced his senseless opposition to an offer by the Federal government to pay for the healthcare of a large number of uninsured poor people that are almost poor enough to qualify for Medicaid, but not quite. Happy Mother’s Day:

    MSNBC
    Rick Scott’s stunning health care ‘ruse’ in Florida
    05/08/15 04:54 PM

    By Steve Benen

    In early 2013, Florida Gov. Rick Scott (R) surprised nearly everyone by announcing he’d changed his mind about Medicaid expansion through the Affordable Care Act. The Republican governor had long condemned the idea, but he apparently had a change of heart.

    “I cannot, in good conscience, deny the uninsured access to care,” he said at the time. Scott added that Medicaid expansion is “a compassionate, common sense step forward.” The governor even referenced the death of his mother when explaining his rationale.

    “A few months ago, my mother passed away, and I lost one of the only constants in my life,” Scott said. “Losing someone so close to you puts everything in new perspective … especially the big decisions…. As I wrestled with this decision, I thought about my Mom’s struggles raising five kids with very little money.”

    That was February 2013. In April 2015, Scott reversed course again, announcing his renewed opposition to the policy he’d endorsed. And today, the local CBS affiliate in Miami reports that that the governor offered an unexpected explanation for his posture two years ago.

    Scott conceded this week that was all a ruse. He now says his support for Medicaid expansion was a calculated move designed to win support from the Obama administration for the state’s proposal to hand over control of Medicaid to private insurance companies. At the time, he denied that his support was tied to a deal with the federal government.

    Now that he’s succeeded in privatizing Medicaid, Scott is again railing against Medicaid expansion and is suing the federal government for allegedly forcing it on him.

    Oh my.

    Of course, if you notice that CBS/Associated Press excerpt, you’ll notice that it’s missing something: a quote. The entire report appears to be a paraphrase of Scott’s comments, and the exact wording always matters.

    Indeed, the governor’s office this afternoon pushed back against the AP’s reporting, saying the piece “editorialized” Scott’s comments.

    So, which is it? On Twitter, Gary Fineout, an AP reporter in Florida, fleshed this out in a little more detail, explaining the argument Scott presented yesterday. As Fineout described it, the governor may have claimed at the time that his mother’s death inspired him to change his perspective, but in reality – according to Scott’s comments yesterday – the Florida Republican only supported Medicaid expansion as part of “a quid pro quo” to get a waiver from the Obama administration for Medicaid privatization.

    Scott may have publicly claimed in 2013 that his position was about his “conscience” and deceased mother, but according to the governor’s new version of events, the rhetoric wasn’t actually sincere – his previous position was a calculated move to gain approval for his privatization plan.

    In other words, the governor didn’t literally use the word “ruse” yesterday, so much as he effectively described a scheme in which he told the public something untrue in order to get what he wanted at the time.

    ..

    “Scott may have publicly claimed in 2013 that his position was about his “conscience” and deceased mother, but according to the governor’s new version of events, the rhetoric wasn’t actually sincere – his previous position was a calculated move to gain approval for his privatization plan.”

    Extra-happy Mother’s Day.

    And yes, instead of expanding Medicaid, Rick Scott, who made his fortune starting a chain of private hospitals, suddenly announced that the Medicaid expansion isn’t happening and his administration is now suing the Federal government over charges that the Feds are was trying to coerce Florida into accepting the Medicaid expansion by saying the “Low Income Pool” (LIP) program was supposed to be replaced by the Medicaid expansion would expire as scheduled.

    But that’s not all. It turns out that Rick Scott just convened a commission to study how publicly funded hospitals spend their money. And the entire panel will be selected by the governor. And the last time Rick Scott convened a commission like this it recommended the widespread privatization of Florida’s hospitals. Super extra-Happy Mother’s Day:

    Tampa Bay Times
    Gov. Rick Scott officially convenes commission on hospital spending

    Kathleen McGrory, Times/Herald Tallahassee Bureau

    Tuesday, May 5, 2015 11:51am

    TALLAHASSEE — Wednesday could be an awkward day for Gov. Rick Scott, who is scheduled to meet with U.S. Health and Human Services Secretary Sylvia Burwell to talk about renewing a $2.2 billion hospital funding program for Florida.

    After all, he’s suing her.

    Burwell is named as the defendant in Scott’s suit alleging that the Obama Administration is trying to coerce Florida into expanding Medicaid by ending the so-called Low Income Pool (LIP). The agency has not commented directly on the suit, but says Medicaid expansion is and has always been a “state decision.”

    Despite the legal tussle, Scott is optimistic about his trip to Washington.

    “The reason I’m doing this is we’ve got to get a budget done,” he said on his way to the airport Tuesday. “And it’s hard to get a budget done not knowing exactly (the feds) decision.”

    Uncertainty over the future of the LIP program has paralyzed state lawmakers tasked with building the state budget. The program, which provides supplemental funding to safety-net hospitals and county health departments, is scheduled to end on June 30 — unless the federal government approves a proposed successor program. A special session will be held, but it’s unclear when lawmakers will return to Tallahassee.

    It is not clear what role Medicaid expansion will play in the decision.

    Federal health officials have said Medicaid expansion and the continuation of the Low Income Pool are linked because they would cover some of the same people. But because of strong opposition from the Florida House, the Legislature is unlikely to accept federal Medicaid expansion money this year. The Senate is pushing for expansion and has proposed its own plan to do so.

    Scott, a former hospital executive, opposes Medicaid expansion. In recent weeks, he has been trying to drive a parallel conversation on the issue of health care and hospital funding.

    On Tuesday, Scott signed an executive order creating a new commission to explore the issue. In addition to investigating outcomes at taxpayer-supported hospitals, the working group will examine executive compensation and spending on lobbyists, advertising and political campaigns.

    With Medicaid spending accounting for one-third of the state budget, Scott said the commission makes sense.

    “We ought to know how those dollars are being spent,” he said. “What’s the outcome of those dollars? Are they being spent efficiently?”

    The executive order did not specify how many members would be appointed to the commission, what kind of qualifications would be required, or when the group would begin meeting. It did, however, say that all members of the commission, its chair and its executive director would be appointed by the governor.

    Scott said he planned to make appointments “promptly,” adding that the information would be useful to lawmakers under pressure to pass a budget by June 30.

    Democrats were quick to bring up the fact that he resigned his job as the CEO of a for-profit hospital chain in 1997 after federal agents went public with an investigation into the company. Columbia/HCA later agreed to pay a record $1.7 billion in government penalties and fines.

    “Now, Rick Scott — who resigned from the health care company he founded amid federal fraud investigations — has decided his time would be well spent auditing the books of Florida hospitals,” Florida Democratic Party Chair Allison Tant said in a statement. “How does that help resolve the gridlock in the legislature? The only hospital management advice Rick Scott knows how to offer is training executives how to fleece the federal government for billions.”

    Happy Mother’s Day.

    Posted by Pterrafractyl | May 10, 2015, 11:01 pm
  50. Imagine that: Some public hospitals win, others lose with Obamacare. Specifically, if your state expanded Medicaid instead of kicking the poors, your hospital probably won. Otherwise…:

    Reuters
    Some public hospitals win, others lose with Obamacare

    SAN FRANCISCO | By Robin Respaut
    Thu Jul 23, 2015 7:49am BST

    A year and a half after the Affordable Care Act brought widespread reforms to the U.S. healthcare system, Chicago’s Cook County Health & Hospitals System has made its first profit in 180 years.

    Seven hundred miles south, the fortunes of Atlanta’s primary public hospital, Grady Health System, haven’t improved, and it remains as dependent as ever on philanthropy and county funding to stay afloat.

    The disparity between the two “safety net” hospitals, both of which serve a disproportionate share of their communities’ poorest patients, illustrates a growing divide nationwide.

    In states like Illinois that have opted to accept federal money to expand Medicaid, some large, public hospitals are finding themselves on solid financial footing for the first time in decades, and formerly uninsured patients are now getting regular care.

    But in states that did not expand the government medical program for the poor, primarily ones with conservative electorates opposed to Obamacare, including Georgia, the impact of the Affordable Care Act on public hospitals has been negligible.

    While the public exchanges established by the federal government and 14 states have brought coverage to many previously uninsured people in all parts of the country, the effect on the poorest Americans varies drastically from state to state.

    Nearly four million low-income, uninsured Americans living in states that didn’t expand Medicaid would have qualified for coverage had their states chosen to expand it, according to the Kaiser Family Foundation. And public hospitals in those states, many of which rely on bond markets for funding, are likely to feel the pinch even more acutely over time, experts said.

    “Providers in these states are going to be at a disadvantage,” said Jim LeBuhn, senior director at Fitch Ratings. “It’s going to make it that much more challenging for these providers to maintain their financial profiles.”

    Since the Affordable Care Act’s first open enrollment in 2013, the number of Americans covered under Medicaid has risen by 21 percent, to 71.1 million.

    Nonprofit hospitals in the 30 states that expanded Medicaid reported on average 13 percent less bad debt from unpaid bills last year, according to Moody’s Investors Service. In contrast, according to Moody’s, such “hospitals in non-expansion states saw bad debt increase through much of the year.”

    Hospitals in Medicaid expansion states, according to Kaiser, reported an average 32 percent decrease in uninsured patients and a 40 percent cut in unreimbursed costs of care for patients without the ability to pay, known in the industry as charity care costs. In non-expansion states, the number of uninsured patients declined by 4.4 percent and charity care costs dropped by 6.2 percent.

    New recipients of Medicaid benefited, too. After one year, adults who gained the coverage were 55 percent more likely to have their own doctor than those who did not, Kaiser found. Medicaid also increased the likelihood of receiving preventive care, such as mammograms and cholesterol checks.

    A TALE OF TWO HOSPITALS

    Both Cook County and Grady are safety-net hospitals based in urban counties where the poverty level is slightly higher than the national average, and both have handled high numbers of uninsured clients in recent years: about half of the patients at Cook and nearly a third at Grady.

    Since Obamacare took effect, the numbers at the Georgia hospital have remained about the same. But things have changed dramatically at the Illinois hospital, in large part due to the area’s enrollment of about 170,000 of an estimated 330,000 eligible for the expanded Medicaid.

    Within two years, the percent of uninsured patients at the hospital had dropped from more than a half to about a third, almost entirely driven by increased Medicaid coverage, hospital data show. And for the first time in the hospital’s history, a majority of the patients it treated had coverage.

    A third of the new Medicaid enrollees treated at Cook County were patients new to the system. And, hospital administrators say, those with chronic diseases such as diabetes, who used to be frequent emergency room visitors, now have personal physicians to help them manage their conditions.

    In the fiscal year ending in November 2014, uncompensated charity care dropped to $342 million from $500 million the year before. Funding from Medicaid nearly doubled the health system’s operating revenues, a major reason that, after ending 2013 with a net loss of $67.6 million, Cook County Health finished its most recent fiscal year in the black.

    Now, the provider, like other safety-net hospitals, has a new challenge: holding onto old clients.

    “For the first time in our history, we need to compete for our patients,” said Shannon. “A world of improved access is also a world of choice.”

    At Grady Health System in Atlanta, meanwhile, the number of patients covered by insurance increased by less than 2 percent last year. Bad debt from unpaid bills has continued to climb, to $396 million from $269 million in 2013. And the percentage of patients covered by Medicaid didn’t change.

    “We’ve seen no difference from the Affordable Care Act,” said John Haupert, Grady’s chief executive. Many patients “are still coming to us as a safety-net provider and falling under our charity care.”

    Georgia is one of 20 states, disproportionately clustered in the South, that didn’t expand Medicaid. About 89 percent of those left out of the new Medicaid coverage, because their states chose not to expand the program, live in the South, Kaiser Family Foundation found.

    Grady has a better financial outlook than many hospitals in states that didn’t expand Medicaid, thanks to a philanthropic campaign that has raised $350 million since 2008 to fund new infrastructure and expand clinical services. But, unlike Cook County, which has reduced some dependence on local government support with the help of Medicaid expansion dollars, Grady remains reliant on $57 million in tax support from two local counties. Without the local funding, Grady would be running a deficit.

    “From a global perspective, it seems like the ACA is working,” said Kevin Holloran, senior director at Standard & Poor’s. But in non-expansion states, like Georgia, “it’s really a neutral. It’s just the status quo.”

    Wow! So in addition to turning down federal Medicaid dollars that the states’ tax-payers are legitimately owed, the states that refuse to expand Medicaid are forced to fill the gap with local funding:


    Grady has a better financial outlook than many hospitals in states that didn’t expand Medicaid, thanks to a philanthropic campaign that has raised $350 million since 2008 to fund new infrastructure and expand clinical services. But, unlike Cook County, which has reduced some dependence on local government support with the help of Medicaid expansion dollars, Grady remains reliant on $57 million in tax support from two local counties. Without the local funding, Grady would be running a deficit.

    And on top of all that, in the states that expanded Medicaid, hospitals are now facing more competition in the healthcare marketplace:


    A third of the new Medicaid enrollees treated at Cook County were patients new to the system. And, hospital administrators say, those with chronic diseases such as diabetes, who used to be frequent emergency room visitors, now have personal physicians to help them manage their conditions.

    In the fiscal year ending in November 2014, uncompensated charity care dropped to $342 million from $500 million the year before. Funding from Medicaid nearly doubled the health system’s operating revenues, a major reason that, after ending 2013 with a net loss of $67.6 million, Cook County Health finished its most recent fiscal year in the black.

    Now, the provider, like other safety-net hospitals, has a new challenge: holding onto old clients.

    “For the first time in our history, we need to compete for our patients,” said Shannon. “A world of improved access is also a world of choice.”

    At Grady Health System in Atlanta, meanwhile, the number of patients covered by insurance increased by less than 2 percent last year. Bad debt from unpaid bills has continued to climb, to $396 million from $269 million in 2013. And the percentage of patients covered by Medicaid didn’t change.

    Lower taxes and increased competition. Head for the hills!

    Posted by Pterrafractyl | July 23, 2015, 8:58 am

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