Spitfire List Web site and blog of anti-fascist researcher and radio personality Dave Emory.

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Killing Granny: The GOP’s “One Size Fits All” Death Panel for Health Care

In this post we’re going to be tak­ing anoth­er look at the GOP’s health care reform agen­da. And since it’s the GOP’s health care reform agen­da it’s inevitably going to include an exam­i­na­tion of how it’s actu­al­ly a pri­va­ti­za­tion agen­da that “saves health care” by reduc­ing access to afford­able health care and thus reduc­ing the over­all health care costs (and then prob­a­bly let­ting you die ear­ly from the lack of health care via pre-exist­ing con­di­tion waiv­er loop­hole).

We’ll be return­ing to the “block grant­i­ng” of Medicare and Med­ic­aid to the states and then hav­ing those states either erode the pro­grams over time or issu­ing anoth­er “block grant” to indi­vid­u­als in the form of a vouch­er.

But we’re also going to look at anoth­er dimen­sion to the GOP’s health care reform agen­da: reform­ing who is going to car­ry that health care cut­ting agen­da out and, in turn, reform­ing who gets blamed. Specif­i­cal­ly, how the GOP plans on trans­fer­ring blame for that agen­da from Con­gres­sion­al Repub­li­cans to state-lev­el gov­er­nors and law­mak­ers by block grant­i­ng Med­ic­aid and Medicare to the states — but not let­ting those block grants grow fast enough to keep up with ris­ing health care cots — and let­ting state gov­er­nors and leg­is­la­tors decide what specif­i­cal­ly gets cut. Blame redistribution/diffusion is a key part of this agen­da but it could have inter­est­ing con­se­quences. In addi­tion to the pre­dictably trag­ic con­se­quences of cut­ting health care costs by cut­ting health care.

*********************************

Change is com­ing to Wash­ing­ton DC. Most­ly hor­ri­ble changes. But as we’ll see in this post, there is one very sig­nif­i­cant and pos­i­tive change com­ing as a con­se­quence of the uni­fied GOP con­trol of the White House and Con­gress: GOP is actu­al­ly going to start get­ting the blame it deserves for all the dam­age its pro-oli­garch/an­ti-every­one-else agen­da rou­tine­ly inflicts upon the Amer­i­can peo­ple. Pol­i­tics can be frus­trat­ing for a myr­i­ad of rea­sons, but one of the biggest sources of frus­tra­tion is the cloud of per­pet­u­al obfus­ca­tion and con­fu­sion that tends to per­me­ate the polit­i­cal dis­course and col­lec­tive under­stand­ing of what’s actu­al­ly hap­pen­ing, why it’s hap­pen­ing, and who should be reward­ed or blamed for it. But for the next cou­ple of years, at a min­i­mum, it’s going to be very clear who to blame for the dam­age DC is about to unleash, and it’s not just going to be Don­ald Trump:

Talk­ing Points Memo
Edi­tor’s Blog

The Repub­li­can Con­gress is Respon­si­ble

By Josh Mar­shall
Pub­lished Jan­u­ary 28, 2017, 4:00 PM EDT

For polit­i­cal and moral rea­sons, it is impor­tant to remem­ber that very lit­tle of what the Pres­i­dent is now doing is pos­si­ble with­out a com­pli­ant Con­gress. Exec­u­tive orders in most cas­es fill in the blanks that leg­is­la­tion leaves to the Pres­i­den­t’s dis­cre­tion. So this isn’t just a mat­ter of the sway a Con­gress of the Pres­i­den­t’s par­ty can exer­cise over him, which is sub­stan­tial. In many or most cas­es, Exec­u­tive Orders and Actions can lit­er­al­ly be over­ruled with new leg­is­la­tion.

Since Pres­i­dent Trump is unpop­u­lar, Democ­rats have a clear polit­i­cal incen­tive to tar the Repub­li­can Con­gress with Trump’s unpop­u­lar­i­ty. But this is not sim­ply a polit­i­cal gam­bit. They make his actions pos­si­ble. They are respon­si­ble for vir­tu­al­ly every­thing he’s doing.

How unpop­u­lar is he? The lat­est rep­utable poll (Quin­nip­i­ac) puts Trump’s approval rat­ing at 36%, an unheard of lev­el of unpop­u­lar­i­ty for a new Pres­i­dent. Gallup’s num­ber has gen­er­al­ly been more favor­able to Trump. But accord­ing to num­bers released today, his net approval rat­ing dropped 8 points dur­ing his first week in office. Again, vir­tu­al­ly unheard of.

Mean­while a new AP-NORC poll shows weak for repeal­ing Oba­macare and that 56% of Amer­i­can are either “extreme­ly” or “very” wor­ried that many Amer­i­cans will lose their health care cov­er­age if Oba­macare is repealed. An addi­tion­al 27% are “some­what” con­cerned.

The Pres­i­dent is unpop­u­lar. His main poli­cies are unpop­u­lar. His behav­ior is unpop­u­lar. The Con­gress makes every­thing he’s doing pos­si­ble. Most of them are up for reelec­tion in less than two years.

“Since Pres­i­dent Trump is unpop­u­lar, Democ­rats have a clear polit­i­cal incen­tive to tar the Repub­li­can Con­gress with Trump’s unpop­u­lar­i­ty. But this is not sim­ply a polit­i­cal gam­bit. They make his actions pos­si­ble. They are respon­si­ble for vir­tu­al­ly every­thing he’s doing.

Yep, the Amer­i­can peo­ple did­n’t just elect a new man-child for pres­i­dent. They also reelect­ed the Repub­li­can-con­trolled Con­gress that’s going to be car­ry­ing Trump’s water and giv­ing him a green light to car­ry out his agen­da.

And what is that agen­da? Well, for the most part, it’s the clas­sic GOP agen­da of pri­va­tiz­ing enti­tle­ments, slash­ing tax­es on the rich, and burn­ing down the social safe­ty-net. Sure, Trump did­n’t actu­al­ly cam­paign on pri­va­tiz­ing enti­tle­ments and gut­ting the safe­ty-net, but as we’re going to see in the arti­cle excerpts below, he’s now made it abun­dant­ly clear that the GOP’s agen­da is his agen­da too...especially when it comes to enti­tle­ments and the safe­ty-net. And the GOP Con­gress will be hold­ing his hand and guid­ing his path every step of the say. So when the GOP-con­trolled Con­gress is car­ry­ing water for Trump they’re actu­al­ly car­ry­ing their own water...without the help of the Democ­rats to take the blame like they might have been with divid­ed con­trol of the fed­er­al gov­ern­ment in case every­one becomes all wet.

The Repub­li­cans Appear to Have a Guilty Con­science Fear of Get­ting Caught on Health Care Espe­cial­ly

So the GOP and Trump have a par­tic­u­lar­ly pre­car­i­ous mutu­al water-car­ry­ing oper­a­tion ahead of them. And the fact that the water the GOP and Trump are car­ry­ing hap­pens to be poi­so­nous water — both polit­i­cal­ly poi­so­nous — isn’t going to make it any eas­i­er. Espe­cial­ly when it comes to all the poi­so­nous water they’re going to car­ry­ing in rela­tion to health care reform since that’s going to be lit­er­al­ly poi­so­nous for the health and well-being of their con­stituents and there­fore extra polit­i­cal­ly poi­so­nous too.

And while it’s clear that the GOP does­n’t actu­al­ly care about the phys­i­cal harm it inflicts upon the Amer­i­can peo­ple they real­ly do care about the polit­i­cal harm they’re about to inflict upon them­selves

The Wash­ing­ton Post

Behind closed doors, Repub­li­can law­mak­ers fret about how to repeal Oba­macare

By Mike DeBo­nis
Jan­u­ary 27, 2017 at 11:08 PM

PHILADELPHIA — Repub­li­can law­mak­ers aired sharp con­cerns about their party’s quick push to repeal the Afford­able Care Act at a closed-door meet­ing Thurs­day, accord­ing to a record­ing of the ses­sion obtained by The Wash­ing­ton Post.

The record­ing reveals a GOP that appears to be filled with doubts about how to make good on a long-stand­ing promise to get rid of Oba­macare with­out explic­it guid­ance from Pres­i­dent Trump or his admin­is­tra­tion. The thorny issues with which law­mak­ers grap­ple on the tape — includ­ing who may end up either los­ing cov­er­age or pay­ing more under a revamped sys­tem — high­light the finan­cial and polit­i­cal chal­lenges that flow from upend­ing the cur­rent law.

Sen­a­tors and House mem­bers expressed a range of con­cerns about the task ahead: how to pre­pare a replace­ment plan that can be ready to launch at the time of repeal; how to avoid deep dam­age to the health insur­ance mar­ket; how to keep pre­mi­ums afford­able for mid­dle-class fam­i­lies; even how to avoid the polit­i­cal con­se­quences of defund­ing Planned Par­ent­hood, the women’s health-care orga­ni­za­tion, as many Repub­li­cans hope to do with the repeal of the ACA.

“We’d bet­ter be sure that we’re pre­pared to live with the mar­ket we’ve cre­at­ed” with repeal, said Rep. Tom McClin­tock (R‑Calif.). “That’s going to be called Trump­care. Repub­li­cans will own that lock, stock and bar­rel, and we’ll be judged in the elec­tion less than two years away.”

Record­ings of closed ses­sions at the Repub­li­can pol­i­cy retreat in Philadel­phia this week were sent late Thurs­day to The Post and sev­er­al oth­er news out­lets from an anony­mous email address. The remarks of all law­mak­ers quot­ed in this arti­cle were con­firmed by their offices or by the law­mak­ers them­selves.

“Our goal, in my opin­ion, should be not a quick fix. We can do it rapid­ly — but not a quick fix,” said Sen. Lamar Alexan­der (R‑Tenn.). “We want a long-term solu­tion that low­ers costs.”

Sen. Rob Port­man (R‑Ohio) warned his col­leagues that the esti­mat­ed bud­get sav­ings from repeal­ing Oba­macare — which Repub­li­cans say could approach a half-tril­lion dol­lars — would be need­ed to fund the costs of set­ting up a replace­ment. “This is going to be what we’ll need to be able to move to that tran­si­tion,” he said.

Rep. Pete Ses­sions (R‑Tex.) wor­ried that one idea float­ed by Repub­li­cans — a refund­able tax cred­it — would not work for mid­dle-class fam­i­lies that can­not afford to pre­pay their pre­mi­ums and wait for a tax refund.

Repub­li­cans have also dis­cussed the idea of gen­er­at­ing rev­enue for their plan by tak­ing aim at deduc­tions that allow most Amer­i­cans to get health insur­ance through their employ­ers with­out pay­ing extra tax­es on it. Sen. Bill Cas­sidy (R‑La.), who has draft­ed his own bill to reform the Afford­able Care Act, said in response, “It sounds like we are going to be rais­ing tax­es on the mid­dle class in order to pay for these new cred­its.”

Rep. Kevin Brady (R‑Tex.), who chairs a key tax-writ­ing sub­com­mit­tee, coun­tered, “I don’t see it that way,” adding that there is “a tax break on employ­er-spon­sored health care and nowhere else” equal to $3.6 tril­lion over 10 years.

“Could you unlock just a small por­tion at the top to be able to give that free­dom [to self-employed Amer­i­cans]? That is the ques­tion,” Brady said.

Rep. John Faso (R‑N.Y.), a fresh­man con­gress­man from the Hud­son Val­ley, warned strong­ly against using the repeal of the ACA to also defund Planned Par­ent­hood. “We are just walk­ing into a gigan­tic polit­i­cal trap if we go down this path of stick­ing Planned Par­ent­hood in the health insur­ance bill,” he said. “If you want to do it some­where else, I have no prob­lem, but I think we are cre­at­ing a polit­i­cal mine­field for our­selves — House and Sen­ate.”

The con­cerns of rank-and-file law­mak­ers appeared to be at odds with key con­gres­sion­al lead­ers and Andrew Brem­berg, a top domes­tic pol­i­cy advis­er to Trump, who have laid out plans to repeal the ACA using a fast-track leg­isla­tive process and exec­u­tive actions from the admin­is­tra­tion. How­ev­er, these lead­ers acknowl­edged in Thursday’s meet­ing, as they have before, that Oba­macare can­not be ful­ly undone — or replaced — with­out Demo­c­ra­t­ic coop­er­a­tion.

...

House Speak­er Paul D. Ryan (R‑Wis.) dis­missed the con­cerns aired in the meet­ing dur­ing an inter­view at a Politi­co event Fri­day.

“We have a respon­si­bil­i­ty to work for the peo­ple that put us in office,” he said. “That’s the oath we take: to defend the Con­sti­tu­tion, to fight for the peo­ple we rep­re­sent, and this is a fias­co that needs to be fixed.”

Of par­tic­u­lar con­cern to some Repub­li­can law­mak­ers was a plan to use the bud­get rec­on­cil­i­a­tion process — which requires only a sim­ple major­i­ty vote — to repeal the exist­ing law, while still need­ing a fil­i­buster-proof vote of 60 in the Sen­ate to enact a replace­ment.

“The fact is, we can­not repeal Oba­macare through rec­on­cil­i­a­tion,” McClin­tock said. “We need to under­stand exact­ly: What does that rec­on­cil­i­a­tion mar­ket look like? And I haven’t heard the answer yet.”

Sev­er­al impor­tant pol­i­cy areas appeared unset­tled. While the chair­men of key com­mit­tees sketched out var­i­ous pro­pos­als, they did not have a clear plan for how to keep mar­kets viable while requir­ing insur­ers to cov­er every­one who seeks insur­ance.

At one point Cas­sidy, a physi­cian who co-found­ed a com­mu­ni­ty health clin­ic in Baton Rouge to serve the unin­sured, asked the pan­elists a “sim­ple ques­tion”: Will states have the abil­i­ty to main­tain the expand­ed Med­ic­aid rolls pro­vid­ed for under the ACA, which now pro­vide cov­er­age for more than 10 mil­lion Amer­i­cans, and can oth­er states do sim­i­lar expan­sions?

“These are deci­sions we haven’t made yet,” said House Ener­gy and Com­merce Com­mit­tee Chair­man Greg Walden (R‑Ore.).

Rep. Tom MacArthur (R‑N.J.) wor­ried that the plans under GOP con­sid­er­a­tion could evis­cer­ate cov­er­age for the rough­ly 20 mil­lion Amer­i­cans now cov­ered through state and fed­er­al mar­ket­places and the law’s Med­ic­aid expan­sion: “We’re telling those peo­ple that we’re not going to pull the rug out from under them, and if we do this too fast, we are in fact going to pull the rug out from under them.”

Repub­li­cans are also still wrestling with whether Obamacare’s tax­es can be imme­di­ate­ly repealed, a pri­or­i­ty for many con­ser­v­a­tives, or whether that rev­enue will be need­ed to fund a tran­si­tion peri­od.

And there seems to be lit­tle con­sen­sus on whether to pur­sue a major over­haul of Med­ic­aid — con­vert­ing it from an open-end­ed enti­tle­ment that costs fed­er­al and state gov­ern­ments $500 bil­lion a year to a fixed block grant. Trump and his top aides, includ­ing coun­selor Kellyanne Con­way, have pub­licly endorsed that idea. But doing so would mean that some low-income Amer­i­cans would not be auto­mat­i­cal­ly cov­ered by a pro­gram that cur­rent­ly cov­ers 70 mil­lion Amer­i­cans.

Many of the con­cerns aired Thurs­day were more polit­i­cal than pol­i­cy-ori­ent­ed. Faso’s remarks about Planned Par­ent­hood gen­er­at­ed tepid applause. Ryan said this month that he expects the House to pur­sue the organization’s defund­ing in the rec­on­cil­i­a­tion bill.

Those express­ing qualms includ­ed some of the top con­gres­sion­al lead­ers who are in line to draft the health-care leg­is­la­tion. Alexan­der, for one, is chair­man of the Sen­ate Health, Edu­ca­tion, Labor and Pen­sions Com­mit­tee.

Ryan and oth­er lead­ers have said they intend to pur­sue a piece­meal approach, fol­low­ing the rec­on­cil­i­a­tion bill with small­er ones that address dis­crete aspects of reform.

...

Faso warned that by defund­ing Planned Par­ent­hood in the rec­on­cil­i­a­tion bill, “we are arm­ing our ene­my in this debate.”

“To me, us tak­ing ret­ri­bu­tion on Planned Par­ent­hood is kind of moral­ly akin to what Lois Lern­er and Oba­ma and the IRS did against tea par­ty groups,” he said, a ref­er­ence to accu­sa­tions that the Inter­nal Rev­enue Ser­vice improp­er­ly tar­get­ed con­ser­v­a­tive polit­i­cal groups for audits.

Faso con­tin­ued: “Health insur­ance is going to be tough enough for us to deal with with­out hav­ing mil­lions of peo­ple on social media come to Planned Parenthood’s defense and send­ing hun­dreds of thou­sands of new donors to the Demo­c­ra­t­ic Sen­ate and Demo­c­ra­t­ic con­gres­sion­al cam­paign com­mit­tees. So I would just urge us to rethink this.”

““We’d bet­ter be sure that we’re pre­pared to live with the mar­ket we’ve cre­at­ed” with repeal, said Rep. Tom McClin­tock (R‑Calif.). “That’s going to be called Trump­care. Repub­li­cans will own that lock, stock and bar­rel, and we’ll be judged in the elec­tion less than two years away.””

Is the GOP pre­pare to “live with the mar­ket we’ve cre­at­ed”? Well, it’s not quite the right way to phrase the ques­tion since it’s the Amer­i­can pub­lic, and not the GOP mem­bers of Con­gress, who are going to have to be “liv­ing” with the mar­ket the GOP cre­ates. Or dying with it. The ques­tion is whether or not the GOP is ready to polit­i­cal­ly own what they’re about to do to Amer­i­can health care.

And if the con­cerns expressed by the con­gress­men above are any indi­ca­tion of an answer to that ques­tion, no, the GOP is not ready to polit­i­cal­ly own what they’re about to do. In part because they real­ly, real­ly want to block grant Med­ic­aid and get anoth­er doomed grand exper­i­ment in neolib­er­al aus­ter­i­ty but are very mixed about keep­ing the Oba­macare Med­ic­aid Expan­sion. By block grant­i­ng it and putting the grand game of fed­er­al-state Med­ic­aid-cuts Polit­i­cal Hot Pota­to start­ed. You don’t want to rush a game of Hot Pota­to of that nature. And set it on a path towards pri­va­ti­za­tion. They aren’t sure they’re ready to start that quite yet. But Trump’s already on board so that’s not going to be an obsta­cle:

...

Rep. Tom MacArthur (R‑N.J.) wor­ried that the plans under GOP con­sid­er­a­tion could evis­cer­ate cov­er­age for the rough­ly 20 mil­lion Amer­i­cans now cov­ered through state and fed­er­al mar­ket­places and the law’s Med­ic­aid expan­sion: “We’re telling those peo­ple that we’re not going to pull the rug out from under them, and if we do this too fast, we are in fact going to pull the rug out from under them.”

Repub­li­cans are also still wrestling with whether Obamacare’s tax­es can be imme­di­ate­ly repealed, a pri­or­i­ty for many con­ser­v­a­tives, or whether that rev­enue will be need­ed to fund a tran­si­tion peri­od.

And there seems to be lit­tle con­sen­sus on whether to pur­sue a major over­haul of Med­ic­aid — con­vert­ing it from an open-end­ed enti­tle­ment that costs fed­er­al and state gov­ern­ments $500 bil­lion a year to a fixed block grant. Trump and his top aides, includ­ing coun­selor Kellyanne Con­way, have pub­licly endorsed that idea. But doing so would mean that some low-income Amer­i­cans would not be auto­mat­i­cal­ly cov­ered by a pro­gram that cur­rent­ly cov­ers 70 mil­lion Amer­i­cans.
...

And here’s the thing: when you hear GOP­ers fret­ting about “We’re telling those peo­ple that we’re not going to pull the rug out from under them, and if we do this too fast, we are in fact going to pull the rug out from under them,” don’t for­get that all the GOP’s plans for health care reform involve pulling the rug out. It’s just sup­posed to hap­pen slow­ly. That’s what block grant­i­ng is all about. So con­cern about pulling the rug out too quick­ly aren’t real­ly con­cerns about pulling the rug out from under­neath their con­stituents. They’re con­cerns about doing it so rapid­ly and notice­ably the the pub­lic real­izes what’s hap­pen­ing and the GOP ends up own­ing their polit­i­cal­ly poi­so­nous poli­cies.

It’s a Mat­ter of When, Not If, the GOP Block Grants Med­ic­aid and the Death Spi­ral Begins. So Says Team Trump

But it’s just a ques­tion of when, not if, the GOP has to seri­ous­ly wres­tle with the polit­i­cal con­se­quences block grant­i­ng Med­ic­aid and set­ting it on a path towards a death by a thou­sand state-lev­el cuts since Trump’s team is already sig­nal­ly its ready to car­ry­ing the GOP’s water on to the Med­ic­aid block grant plan:

The New York Times

Trump’s Health Plan Would Con­vert Med­ic­aid to Block Grants, Aide Says

By ROBERT PEAR
JAN. 22, 2017

WASHINGTON — Pres­i­dent Trump’s plan to replace the Afford­able Care Act will pro­pose giv­ing each state a fixed amount of fed­er­al mon­ey in the form of a block grant to pro­vide health care to low-income peo­ple on Med­ic­aid, a top advis­er to Mr. Trump said in an inter­view broad­cast on Sun­day.

The advis­er, Kellyanne Con­way, who is Mr. Trump’s White House coun­selor, said that con­vert­ing Med­ic­aid to a block grant would ensure that “those who are clos­est to the peo­ple in need will be admin­is­ter­ing” the pro­gram.

A block grant would be a rad­i­cal change. Since its cre­ation in 1965, Med­ic­aid has been an open-end­ed enti­tle­ment. If more peo­ple become eli­gi­ble because of a reces­sion, or if costs go up because of the use of expen­sive new med­i­cines, states receive more fed­er­al mon­ey.

If Con­gress decides to cre­ate block grants for Med­ic­aid, law­mak­ers will face thorny ques­tions with huge polit­i­cal and finan­cial impli­ca­tions: How much mon­ey will each state receive? How will the ini­tial allot­ments be adjust­ed — for pop­u­la­tion changes, for gen­er­al infla­tion, for increas­es in med­ical prices, for the dis­cov­ery of new drugs and treat­ments? Will the fed­er­al gov­ern­ment require states to cov­er cer­tain pop­u­la­tions and ser­vices? Will states receive extra mon­ey if they have not expand­ed Med­ic­aid eli­gi­bil­i­ty under the Afford­able Care Act, but decide to do so in the future?

Ms. Con­way, speak­ing on the NBC pro­gram “Sun­day Today,” said that with a block grant, “you real­ly cut out the fraud, waste and abuse, and you get the help direct­ly” to intend­ed ben­e­fi­cia­ries.

Med­ic­aid cov­ers more than 70 mil­lion peo­ple at a com­bined cost of more than $500 bil­lion a year to the fed­er­al gov­ern­ment and the states. More than 20 mil­lion peo­ple have gained cov­er­age under the Afford­able Care Act, more than half of them through Med­ic­aid.

...

As a can­di­date, Mr. Trump said he want­ed to “max­i­mize flex­i­bil­i­ty for states” so they could “design inno­v­a­tive Med­ic­aid pro­grams that will bet­ter serve their low-income cit­i­zens.” On Fri­day, in his first exec­u­tive order, he direct­ed fed­er­al offi­cials to use all their author­i­ty to “pro­vide greater flex­i­bil­i­ty to states” on the health law.

As part of their “Bet­ter Way” agen­da, House Repub­li­cans said in June that they would roll back the Afford­able Care Act’s expan­sion of Med­ic­aid and give each state a set amount of mon­ey for each ben­e­fi­cia­ry or a lump sum of fed­er­al mon­ey for all of a state’s Med­ic­aid pro­gram — “a choice of either a per capi­ta allot­ment or a block grant.”

Gov­er­nors like the idea of hav­ing more con­trol over Med­ic­aid, but fear that block grants may be used as a vehi­cle for fed­er­al bud­get cuts.

“We are very con­cerned that a shift to block grants or per capi­ta caps for Med­ic­aid would remove flex­i­bil­i­ty from states as the result of reduced fed­er­al fund­ing,” Gov. Char­lie Bak­er of Mass­a­chu­setts, a Repub­li­can, said this month in a let­ter to con­gres­sion­al lead­ers. “States would most like­ly make deci­sions based main­ly on fis­cal rea­sons rather than the health care needs of vul­ner­a­ble pop­u­la­tions.”

Gov. Robert Bent­ley of Alaba­ma, a Repub­li­can, said that if a block grant reduced fed­er­al funds for the pro­gram, “states should be giv­en the abil­i­ty to reduce Med­ic­aid ben­e­fits or enroll­ment, to impose pre­mi­ums” or oth­er cost-shar­ing require­ments on ben­e­fi­cia­ries, and to reduce Med­ic­aid spend­ing in oth­er ways.

In Louisiana, Gov. John Bel Edwards, a Demo­c­rat, said he was trou­bled by the prospect of a block grant with deep cuts in fed­er­al funds. “Under such a sce­nario,” he said, “flex­i­bil­i­ty would real­ly mean flex­i­bil­i­ty to cut crit­i­cal ser­vices for our most vul­ner­a­ble pop­u­la­tions, includ­ing poor chil­dren, peo­ple with dis­abil­i­ties and seniors in need of nurs­ing home and home-based care.”

Gov. John W. Hick­en­loop­er of Col­orado, a Demo­c­rat, said that block grant pro­pos­als could shift costs to states and “force us to make impos­si­ble choic­es in our Med­ic­aid pro­gram.”

“We should not be forced to choose between pro­vid­ing hard-work­ing old­er Col­oradans with blood pres­sure med­ica­tion or chil­dren with their insulin,” Mr. Hick­en­loop­er said.

“Gov­er­nors like the idea of hav­ing more con­trol over Med­ic­aid, but fear that block grants may be used as a vehi­cle for fed­er­al bud­get cuts.

That’s some healthy fear right there. And why should­n’t gov­er­nors, espe­cial­ly GOP gov­er­nors, fear what there fed­er­al GOP brethren have planned for them? It’s a plan that makes the gov­er­nors and state leg­is­la­tures the new lead­ers in imple­ment all those cuts the GOP has been try­ing to do at the fed­er­al lev­el for decades

...

“We are very con­cerned that a shift to block grants or per capi­ta caps for Med­ic­aid would remove flex­i­bil­i­ty from states as the result of reduced fed­er­al fund­ing,” Gov. Char­lie Bak­er of Mass­a­chu­setts, a Repub­li­can, said this month in a let­ter to con­gres­sion­al lead­ers. “States would most like­ly make deci­sions based main­ly on fis­cal rea­sons rather than the health care needs of vul­ner­a­ble pop­u­la­tions.”

Gov. Robert Bent­ley of Alaba­ma, a Repub­li­can, said that if a block grant reduced fed­er­al funds for the pro­gram, “states should be giv­en the abil­i­ty to reduce Med­ic­aid ben­e­fits or enroll­ment, to impose pre­mi­ums” or oth­er cost-shar­ing require­ments on ben­e­fi­cia­ries, and to reduce Med­ic­aid spend­ing in oth­er ways.

...

“Gov. Robert Bent­ley of Alaba­ma, a Repub­li­can, said that if a block grant reduced fed­er­al funds for the pro­gram, “states should be giv­en the abil­i­ty to reduce Med­ic­aid ben­e­fits or enroll­ment, to impose pre­mi­ums” or oth­er cost-shar­ing require­ments on ben­e­fi­cia­ries, and to reduce Med­ic­aid spend­ing in oth­er ways.”

Ok, so Gov­er­nor Bent­ley of Alaba­ma does­n’t appear to fear actu­al­ly mak­ing the cuts to block grant­ed pro­grams like Med­ic­aid. Instead he fears not being able to make those cuts when the GOP cuts the per-capi­ta block grant size that the fed­er­al gov­ern­ment is inevitably going to make, which is a some­what sil­ly fear since get­ting the states to cut health care expen­di­tures is the whole point of block grant­i­ng these pro­grams.

But what about the rest of the GOP gov­er­nors like Gov­er­nor Bak­er of Mass­a­chu­setts? Are they also going to read­i­ly embrace the free­dom to “reduce Med­ic­aid ben­e­fits or enroll­ment, to impose pre­mi­ums” or oth­er cost-shar­ing require­ments on ben­e­fi­cia­ries, and to reduce Med­ic­aid spend­ing in oth­er ways,” like Gov­er­nor Bent­ley clear­ly had no prob­lem doing? We’ll find out, but that’s all part of the GOP’s plan: con­vert Med­ic­aid to a block grant and then let the state gov­er­nors and leg­is­la­tors car­ry the water on imple­ment­ing the actu­al cuts. It’s a GOP-style redis­tri­b­u­tion scheme: a scheme for the per­ma­nent redis­tri­b­u­tion from Con­gress to the states of the polit­i­cal fall­out that will inevitably come from the imple­men­ta­tion of the GOP’s dream of slow­ly, but even­tu­al­ly, killing the safe­ty-net:

The Wash­ing­ton Post

The GOP plan to fund Med­ic­aid through block grants will prob­a­bly weak­en it

By Ryan LaRochelle
Jan­u­ary 18, 2017

Repub­li­cans in the 115th Con­gress are wast­ing no time try­ing to remake the social pol­i­cy land­scape. Bare­ly a week after the new Con­gress was sworn in, GOP mem­bers took an ini­tial step toward repeal­ing aspects of the Afford­able Care Act, the major domes­tic piece of Pres­i­dent Obama’s lega­cy.

Repub­li­cans seem like­ly to set their sights on oth­er com­po­nents of the U.S. wel­fare state, includ­ing Med­ic­aid, Medicare and Social Secu­ri­ty. Pres­i­dent-elect Don­ald Trump may not go along with con­gres­sion­al Repub­li­cans if they try to alter Medicare and Social Secu­ri­ty.

But many key Repub­li­cans are espe­cial­ly inter­est­ed in chang­ing Med­ic­aid, the nation’s health insur­ance pro­gram for the poor — includ­ing Trump, House Speak­er Paul D. Ryan (Wis.) and Tom Price (Ga.), Trump’s nom­i­nee to head the Depart­ment of Health and Human Ser­vices. Each of those three has pro­posed con­vert­ing Med­ic­aid from a pro­gram fund­ed joint­ly by the fed­er­al gov­ern­ment and the states into a block grant pro­gram. Doing so would send a set amount of mon­ey to each state, thus cap­ping total Med­ic­aid spend­ing, and would let each state decide how to dis­burse those funds.

Turn­ing Med­ic­aid into a block grant would result in less fund­ing. Here’s how we know.

Under the cur­rent arrange­ment, the fed­er­al gov­ern­ment pays states a cer­tain per­cent­age of pro­gram expen­di­tures based on cri­te­ria, such as per capi­ta income. The per­cent­ages are reg­u­lar­ly adjust­ed at three-year inter­vals based on changes in the econ­o­my. How would chang­ing that into a block grant change the pro­gram?

1. Data shows that the move to block grants leads to less fund­ing over time.

His­tor­i­cal data sug­gest that a shift to block grants would result in a grad­ual decline in Med­ic­aid fund­ing. A 2016 report by the Cen­ter on Bud­get and Pol­i­cy Pri­or­i­ties (CBPP) showed that when the fed­er­al gov­ern­ment uses block grants, the fund­ing for the pro­grams shrinks over time:

[O]ur analy­sis of the 13 major hous­ing, health, and social ser­vices block grant pro­grams that pol­i­cy­mak­ers have cre­at­ed in recent decades shows that fund­ing for all but one has shrunk in infla­tion-adjust­ed terms since their incep­tion, in some cas­es dra­mat­i­cal­ly. … Over­all fund­ing for the 13 block grants has fall­en by 37 per­cent since 2000, adjust­ed for infla­tion and pop­u­la­tion growth.

Does that mean that the switch to block grant­i­ng is the fac­tor that drove down spend­ing? It’s hard to say. But here’s one exam­ple that is instruc­tive. From 1935 to 1996, under Aid to Fam­i­lies With Depen­dent Chil­dren, the fed­er­al gov­ern­ment matched state expen­di­tures based on need. Poor­er states received a high­er fed­er­al match rate than wealth­i­er states. And fed­er­al expen­di­tures respond­ed to cycli­cal vari­a­tion in the econ­o­my. From 1970 until the mid-1990s, state and fed­er­al expen­di­tures for AFDC were rel­a­tive­ly sta­ble.

But in 1996, the Clin­ton admin­is­tra­tion and con­gres­sion­al Repub­li­cans teamed up to replace it with Tem­po­rary Assis­tance for Needy Fam­i­lies (TANF), in which fund­ing was dis­trib­uted via block grants so that states could exper­i­ment with how they would deliv­er it. As the CBPP report points out, after adjust­ing for infla­tion, TANF fund­ing has dropped by 32 per­cent since its incep­tion. Or to put it dif­fer­ent­ly, before the fed­er­al gov­ern­ment con­vert­ed AFDC into the TANF block grant, 68 out of 100 poor fam­i­lies received cash assis­tance. By 2014, only 23 out of 100 poor fam­i­lies did.

2. Reform­ers argue that block grants need less fund­ing because they reduce costs. But they don’t.

When reform­ers pro­pose switch­ing a pro­gram to a block grant, they increas­ing­ly ask to have the fund­ing reduced at the same time.

In the 1960s and 1970s, both Demo­c­ra­t­ic and Repub­li­can admin­is­tra­tions used block grants pri­mar­i­ly to con­sol­i­date exist­ing pro­grams, which did not auto­mat­i­cal­ly result in fund­ing reduc­tions. In some cas­es, block grant­i­ng actu­al­ly increased fund­ing for the pro­grams involved — as hap­pened with the Com­mu­ni­ty Devel­op­ment Block Grant and the Omnibus Crime Con­trol and Safe Streets Act.

But since the 1980s, most new block grant pro­pos­als have gone in the oth­er direc­tion. Pro­po­nents argue that the dif­fer­ence would be made up by increased effi­cien­cy and admin­is­tra­tive sav­ings.

That’s the approach with Med­ic­aid, as well. Trump’s health-care reform web­site claims that under a Med­ic­aid block grant, “States will have the incen­tives to seek out and elim­i­nate fraud, waste and abuse to pre­serve our pre­cious resources.”

Pub­lic admin­is­tra­tion schol­ar Carl Stenberg’s analy­sis of block grants, how­ev­er, found no empir­i­cal evi­dence that the shift to block grants reduced total admin­is­tra­tive costs. Rather, these costs are passed from the fed­er­al gov­ern­ment to the states.

3. Block grant­i­ng leads to drops in fund­ing because the poli­cies don’t get reg­u­lar tune­ups.

Cor­nell polit­i­cal sci­en­tist Suzanne Mettler’s research shows that just like cars and hous­es, poli­cies need peri­od­ic upkeep to remain effec­tive. Leg­is­la­tors can main­tain poli­cies by reau­tho­riz­ing them to guar­an­tee fund­ing streams, adjust­ing them for infla­tion, and peri­od­i­cal­ly reassess­ing and reform­ing them.

But leg­is­la­tors often don’t main­tain exist­ing poli­cies, leav­ing them to fall into dis­re­pair. That neglect is not unique to block grants. But cer­tain fea­tures of block grants make them par­tic­u­lar­ly sus­cep­ti­ble to deferred main­te­nance and pol­i­cy drift. Block grants typ­i­cal­ly do not keep pace with infla­tion, pop­u­la­tion changes, ris­ing pover­ty rates or increased hous­ing costs.

Fur­ther, many block grant pro­grams are designed to help low-income peo­ple — a group that is least like­ly to mobi­lize polit­i­cal­ly. Unlike, say, the elder­ly — drawn from every eco­nom­ic stra­ta — the peo­ple who rely on pover­ty pro­grams prob­a­bly won’t orga­nize to pro­tect their pro­grams from cuts or call for improve­ments. And so those pro­grams atro­phy.

With TANF, for instance, research finds that what cit­i­zens need isn’t the fac­tor that push­es states to make sure its poli­cies are effec­tive. Rather, three fac­tors make the dif­fer­ence in how well TANF is designed: the race of most of the state’s ben­e­fi­cia­ries, the state’s polit­i­cal ide­ol­o­gy and the state’s wealth. Poor, con­ser­v­a­tive states with a high pro­por­tion of African Amer­i­cans tend to have less gen­er­ous ben­e­fit pack­ages, firmer eli­gi­bil­i­ty rules and stricter work require­ments than com­par­a­tive­ly well-off states that are more racial­ly homo­ge­neous. Some states take bet­ter care of their low-income res­i­dents than oth­ers because of race, ide­ol­o­gy and capac­i­ty, not because of need.

In oth­er words, while pro­po­nents argue that block grants let states bet­ter respond to their res­i­dents’ needs, the results show sig­nif­i­cant inequal­i­ty across the states.

...

“Pub­lic admin­is­tra­tion schol­ar Carl Stenberg’s analy­sis of block grants, how­ev­er, found no empir­i­cal evi­dence that the shift to block grants reduced total admin­is­tra­tive costs. Rather, these costs are passed from the fed­er­al gov­ern­ment to the states.”

And that, right there, is part of sin­is­ter clev­er­ness of the GOP’s grand poi­soned water polit­i­cal fall­out redis­tri­b­u­tion scheme: Con­gress pass­es a law now that will set in motion a mul­ti-decade long cycle of ben­e­fit cuts and squeezed state bud­gets that will even­tu­al­ly evis­cer­ate pro­grams like Med­ic­aid and state leg­is­la­tures and gov­er­nors will be tak­ing a big share of the blame. But not all of the blame obvi­ous­ly, and there’s going to be plen­ty of blame to go around since this is an incred­i­bly unpop­u­lar agen­da that Trump and the GOP are about to impose. It’s why the GOP Con­gress, and Trump, still have major rea­sons to be seri­ous­ly wor­ried about any of the blame for their poi­so­nous agen­da.

The Begin­ning of the End of Med­ic­aid Could Be the Begin­ning of the End of the GOP’s Own Vot­ers. Espe­cial­ly the New Ones

And let’s not for­get one of the oth­er sig­nif­i­cant fac­tors in the fed­er­al-to-state blame redis­tri­b­u­tion scheme: The GOP con­trols most of the states. Not only that, but the coun­ties where Don­ald Trump pick up the most sup­port vs the 2012 elec­tion hap­pen to be poor­er coun­ties that will be most heav­i­ly impact­ed by the GOP’s poi­son agen­da:

The Wash­ing­ton Post

Trump’s plan to roll back Med­ic­aid will espe­cial­ly affect his vot­ers

By Andrea Cer­ra­to, Francesco Rug­gieri and Fed­eri­co Maria Fer­rara
Jan­u­ary 27, 2017

On Sun­day, the Trump admin­is­tra­tion sig­naled its inten­tion to con­vert Med­ic­aid to a block-grant pro­gram, giv­ing states more flex­i­bil­i­ty in how they finance health care for low-income res­i­dents. If imple­ment­ed as part of an Oba­macare repeal, the change would like­ly result in over­all less fund­ing for the states.

Although the details of an over­haul would deter­mine where and how large any cuts would be, Pres­i­dent Trump may have rea­son to wor­ry about the elec­toral effects of a Med­ic­aid roll­back.

Our research shows that a sig­nif­i­cant por­tion of Trump’s sup­port in 2016 came from low-income areas that would like­ly be harmed by cuts to Med­ic­aid. And even though those vot­ers did not aban­don Trump dur­ing the cam­paign because of his oppo­si­tion to Oba­macare, an actu­al reduc­tion in ben­e­fits is eas­i­er said than done.

The pol­i­tics of Med­ic­aid expan­sion

Med­ic­aid has been a major polit­i­cal issue since its cre­ation in the 1960s, but it became even more con­tentious after the pas­sage of the Afford­able Care Act in 2010.

Under the ACA, the pro­gram was expand­ed to include all non-dis­abled adults whose Mod­i­fied Adjust­ed Gross Income (MAGI) is below 138 per­cent of the fed­er­al pover­ty lev­el. After a 2012 Supreme Court deci­sion, states had the choice to imple­ment the new eli­gi­bil­i­ty stan­dards in exchange for addi­tion­al fed­er­al funds, or to opt out alto­geth­er. As of today, 31 states and the Dis­trict of Colum­bia have adopt­ed the Med­ic­aid expan­sion.

Giv­en Trump’s cam­paign pledge to repeal Oba­macare, one might have expect­ed him to per­form poor­ly in states where the ACA’s expan­sion of Med­ic­aid gave low-income Amer­i­cans bet­ter access to health care. But our analy­sis sug­gests that Trump did not lose sup­port among low-income vot­ers in Med­ic­aid expan­sion states.

How Med­ic­aid expan­sion played out (or didn’t) in the elec­tion

The Med­ic­aid expan­sion was imple­ment­ed in Jan­u­ary 2014, so we exam­ined Trump’s per­for­mance rel­a­tive to that of 2012 Repub­li­can nom­i­nee Mitt Rom­ney. In par­tic­u­lar, we com­pared the president’s gains in coun­ties where Med­ic­aid has not been expand­ed to his show­ing in coun­ties where more adults are now eli­gi­ble to ben­e­fit from the pro­gram. By tak­ing the dif­fer­ence in vote share between Trump and Rom­ney, we tried to cap­ture Repub­li­can vot­ers’ sen­si­tiv­i­ty to the Oba­ma administration’s health-care poli­cies.

We also col­lect­ed demo­graph­ic and finan­cial data from IPUMS-CPS, an inte­grat­ed set of indi­vid­ual and house­hold-lev­el vari­ables in the Unit­ed States. Fol­low­ing IRS guide­lines, we esti­mat­ed the nation­al share of non-dis­abled adults whose MAGI is below 138 per­cent of the fed­er­al pover­ty lev­el, the thresh­old for Med­ic­aid expan­sion eli­gi­bil­i­ty.

Then, we weight­ed these shares using a coun­ty-lev­el indi­ca­tor of pover­ty, which pro­duced a mea­sure of the degree of poten­tial eli­gi­bil­i­ty for the Med­ic­aid expan­sion in each coun­ty, shown in the map below.

[see map of poten­tial eli­gi­bil­i­ty for expand­ed Med­ic­aid]

Low-income house­holds are con­cen­trat­ed in the South­east (Mis­sis­sip­pi, Louisiana, Arkansas, Alaba­ma, Geor­gia, Flori­da, South Car­oli­na, North Car­oli­na), in the South­west (New Mex­i­co, Ari­zona, Cal­i­for­nia), and in the North­west (Ore­gon, Wash­ing­ton, Mon­tana). Thus, dark­er coun­ties are locat­ed in both tra­di­tion­al­ly Demo­c­ra­t­ic and Repub­li­can states.

Final­ly, we per­formed a regres­sion analy­sis to esti­mate the effect of extend­ed Med­ic­aid eli­gi­bil­i­ty on the shift in the Repub­li­can vote share between 2012 and 2016. We weight­ed the obser­va­tions for each county’s pop­u­la­tion and added con­trols for eth­nic and racial com­po­si­tion and edu­ca­tion­al attain­ment, as well as state fixed effects.

Per­haps sur­pris­ing­ly, Trump’s gains were uni­form across coun­ties with more low-income house­holds, regard­less of whether they were in Med­ic­aid expan­sion states. Indeed, on aver­age Trump out­per­formed Rom­ney in tra­di­tion­al­ly Demo­c­ra­t­ic states that extend­ed health-care eli­gi­bil­i­ty.

This coun­ter­in­tu­itive result cor­rob­o­rates one of the main trends of the 2016 pres­i­den­tial elec­tion. Over­all, Trump per­formed bet­ter than any oth­er Repub­li­can can­di­date in the recent past among low-income vot­ers. His oppo­si­tion to Oba­macare had a neg­li­gi­ble effect in areas that one would expect to be affect­ed by Med­ic­aid expan­sion.

Why Med­ic­aid cut­backs could be risky

On the one hand, this could sug­gest that Trump has lit­tle to wor­ry about if the GOP con­verts Med­ic­aid to a block grant, effec­tive­ly reduc­ing the size of the enti­tle­ment pro­gram. After all, if low-income vot­ers were not con­cerned about Trump’s oppo­si­tion to Oba­macare dur­ing the cam­paign, why would they be now?

But two fac­tors sug­gest cau­tion might be in order. First, a pledge to roll back a wel­fare ben­e­fit may not have the same impact as its actu­al repeal. As polit­i­cal sci­en­tist Paul Pier­son has argued, “frontal assaults on the wel­fare state car­ry tremen­dous elec­toral risks.”

One rea­son is that inter­est groups and vot­ers often oppose direct threats to wel­fare pro­grams. And already, the specter of a reduc­tion in health-care ben­e­fits appears to have mobi­lized unhap­py con­stituents in some parts of the coun­try.

Sec­ond, to the extent that a reduc­tion in Med­ic­aid ben­e­fits weak­ens Trump’s sup­port among low-income vot­ers, their shift­ing alle­giances could prove piv­otal, either in the 2018 midterms or in the 2020 pres­i­den­tial elec­tion. This is espe­cial­ly true in light of his nar­row mar­gin of vic­to­ry in key bat­tle­ground states.

...

“Our research shows that a sig­nif­i­cant por­tion of Trump’s sup­port in 2016 came from low-income areas that would like­ly be harmed by cuts to Med­ic­aid. And even though those vot­ers did not aban­don Trump dur­ing the cam­paign because of his oppo­si­tion to Oba­macare, an actu­al reduc­tion in ben­e­fits is eas­i­er said than done.”

Yep, while it might take years for the the GOP’s health care attri­tion agen­da to get ful­ly imple­ment­ed via this ‘death by a thou­sand cuts’ block grant strat­e­gy and the polit­i­cal fall out to be ful­ly felt, it may not take very much fall out to start seri­ous­ly impact­ing the GOP. Espe­cial­ly since Trump’s gains for the GOP were often in coun­ties with the most to lose from any cuts at all:

...
Per­haps sur­pris­ing­ly, Trump’s gains were uni­form across coun­ties with more low-income house­holds, regard­less of whether they were in Med­ic­aid expan­sion states. Indeed, on aver­age Trump out­per­formed Rom­ney in tra­di­tion­al­ly Demo­c­ra­t­ic states that extend­ed health-care eli­gi­bil­i­ty.

This coun­ter­in­tu­itive result cor­rob­o­rates one of the main trends of the 2016 pres­i­den­tial elec­tion. Over­all, Trump per­formed bet­ter than any oth­er Repub­li­can can­di­date in the recent past among low-income vot­ers. His oppo­si­tion to Oba­macare had a neg­li­gi­ble effect in areas that one would expect to be affect­ed by Med­ic­aid expan­sion.
...

So after Trump makes big gains for the GOP with low-income vot­ers, the GOP and Trump imme­di­ate­ly start work­ing togeth­er to screw over that exact group in a mas­sive way that will only get worse for years to come. It’s hard to see how imple­ment­ing a scheme to shift future blame for safe­ty-net cuts from Con­gress to the states is going to blunt the imme­di­ate fall out for imme­di­ate­ly imple­ment­ing that scheme. And even if the GOP decides to skip the Med­ic­aid block grant­i­ng scheme for now and instead just do the Oba­macare “repeal and replace­ment” alone, that’s still prob­a­bly going to involve rolling back the Med­ic­aid expan­sion in these same low-income coun­ties that swung for Trump.

And After Med­ic­aid, It’s Medicare on the Block Grant Chop­ping Block. Of Course

All in all, it’s extreme­ly unclear what the GOP can do at all to avoid mas­sive blame if they actu­al­ly imple­ment their agen­da which is prob­a­bly why they haven’t decid­ed yet on what exact­ly they’re going to do and when they’re going to do it. Their agen­da is a polit­i­cal­ly Phyrric vic­to­ry. And the more of it they imple­ment the Pyrric it’s going to be. Which could be extreme­ly Pyrrhic:

The Huff­in­g­ton Post

Not Just Oba­macare: Med­ic­aid, Medicare Also On GOP’s Chop­ping Block
The health care safe­ty net as we know it could be bound for extinc­tion.

Jonathan Cohn Senior Nation­al Cor­re­spon­dent, The Huff­in­g­ton Post
Jef­frey Young Senior Reporter, The Huff­in­g­ton Post
11/15/2016 11:50 am ET | Updat­ed Nov 15, 2016

Don­ald Trump and Repub­li­can lead­ers in Con­gress have made clear they are seri­ous about repeal­ing Oba­macare, and doing so quick­ly. But don’t assume their dis­man­tling of gov­ern­ment health insur­ance pro­grams will stop there.

For about two decades now, Repub­li­cans have been talk­ing about rad­i­cal­ly chang­ing the government’s two largest health insur­ance pro­grams, Med­ic­aid and Medicare.

The goal with Med­ic­aid is to turn the pro­gram almost entire­ly over to the states, but with less mon­ey to run it. The goal with Medicare is to con­vert it from a gov­ern­ment-run insur­ance pro­gram into a vouch­er sys­tem — while, once again, reduc­ing the mon­ey that goes into the pro­gram.

House Speak­er Paul Ryan (R‑Wis.) has cham­pi­oned these ideas for years. Trump has not. In fact, in a 2015 inter­view cam­paign web­site high­light­ed, he vowed that “I’m not going to cut Medicare or Med­ic­aid.” But the health care agen­da on Trump’s tran­si­tion web­site, which went live Thurs­day, vows to “mod­ern­ize Medicare” and allow more “flex­i­bil­i­ty” for Med­ic­aid.

In Wash­ing­ton, those are euphemisms for pre­cise­ly the kind of Medicare and Med­ic­aid plans Ryan has long envi­sioned. And while it’s nev­er clear what Trump real­ly thinks or how he’ll act, it sure looks like both he and con­gres­sion­al Repub­li­cans are out to undo Lyn­don Johnson’s health care lega­cy, not just Barack Obama’s.

Of course, when­ev­er Trump or Repub­li­cans talk about dis­man­tling exist­ing gov­ern­ment pro­grams, they insist they will replace them with some­thing bet­ter — imply­ing that the peo­ple who depend on those pro­grams now won’t be worse off.

But Repub­li­cans are not try­ing to repli­cate what Med­ic­aid, Medicare and the Afford­able Care Act do now. Nor are they try­ing to main­tain the cur­rent, his­tor­i­cal­ly high lev­el of health cov­er­age nation­wide that these pro­grams have pro­duced. Their goal is to slash gov­ern­ment spend­ing on health care and to peel back reg­u­la­tions on parts of the health care indus­try, par­tic­u­lar­ly insur­ers.

This would mean low­er tax­es, and an insur­ance mar­ket that oper­ates with less gov­ern­ment inter­fer­ence. It would also reduce how many peo­ple get help pay­ing for health cov­er­age, and make it so that those who con­tin­ue to receive gov­ern­ment-spon­sored health ben­e­fits will get less help than they do now.

It’s dif­fi­cult to be pre­cise about the real-world effects, because the Repub­li­can plans for replac­ing exist­ing gov­ern­ment insur­ance pro­grams remain so unde­fined. Ryan’s “A Bet­ter Way” pro­pos­al is a broad, 37-page out­line with­out dol­lar fig­ures, and Sen­ate Repub­li­can lead­ers have nev­er pro­duced an actu­al Oba­macare “replace­ment” plan.

But the Repub­li­can plans in cir­cu­la­tion, along with the vague — and shift­ing — health care prin­ci­ples Trump endorsed dur­ing the cam­paign, have com­mon themes. And from those it’s pos­si­ble to glean a big-pic­ture idea of what a ful­ly real­ized ver­sion of the Repub­li­can health care agen­da would mean.

Oba­macare

Oba­macare has expand­ed and bol­stered health insur­ance main­ly through two sets of changes: a straight­for­ward expan­sion of Med­ic­aid eli­gi­bil­i­ty, which the 31 states and the Dis­trict of Colum­bia now offer, and a makeover of the insur­ance mar­ket for peo­ple buy­ing pri­vate cov­er­age on their own rather than through employ­ers. The net effect of the Afford­able Care Act is an esti­mat­ed 20 mil­lion few­er unin­sured than before the law.

Obamacare’s makeover includ­ed writ­ing new rules for insur­ers: All poli­cies must now include com­pre­hen­sive ben­e­fits, for exam­ple, and car­ri­ers can no longer deny cov­er­age to peo­ple with pre-exist­ing con­di­tions nor charge them high­er rates than healthy peo­ple.

The new­ly reformed insur­ance sys­tem also offers sub­si­dies: to assist peo­ple who could nev­er afford cov­er­age before; and to off­set the high­er prices insur­ers charge now that they must cov­er more ser­vices, with­out turn­ing away the peo­ple most like­ly to use them.

Repeal­ing the law out­right would increase the num­ber of unin­sured Amer­i­cans by 22 mil­lion, accord­ing to the Con­gres­sion­al Bud­get Office. Repub­li­cans have vowed to replace Oba­macare with some­thing bet­ter — “great health care for much less mon­ey,” as Trump put it on “60 Min­utes” Sun­day.

But GOP plans would scale back the fed­er­al com­mit­ment to Med­ic­aid, then unwind the changes to the indi­vid­ual insur­ance mar­ket by reduc­ing the reg­u­la­tions on cov­er­age. GOP plans would also elim­i­nate the health insur­ance exchanges through which more than 10 mil­lion peo­ple get access to pri­vate insur­ance and those all-impor­tant sub­si­dies. Repub­li­can schemes envi­sion new forms of finan­cial assis­tance, but gen­er­al­ly low­er income peo­ple would get less mon­ey, and (depend­ing on the details) many mid­dle-income peo­ple would too..

Some of the reg­u­la­to­ry changes would be indi­rect. Allow­ing insur­ers to sell across state lines — an idea Trump men­tioned fre­quent­ly — would let all insur­ers relo­cate to states with the fewest rules, effec­tive­ly gut­ting require­ments more pro­gres­sive states might impose on cov­er­age. Over­all, the result would be less cov­er­age and pro­tec­tion than Oba­macare pro­vides.

And while some peo­ple would ben­e­fit, oth­ers would suf­fer. To take one exam­ple, healthy 25-year-olds could buy cheap­er, skimpi­er poli­cies than the law now allows. But 55-year-olds with high blood pres­sure would tend to face high­er pre­mi­ums — because insur­ers could resume charg­ing them more — and big­ger copay­ments at the phar­ma­cy.

Repub­li­cans talk a lot about pre­serv­ing Obamacare’s most pop­u­lar pro­vi­sions, like pro­tec­tions for peo­ple with pre-exist­ing con­di­tions.

But the fine print of their pro­pos­als shows their guar­an­tee is dif­fer­ent — and less iron­clad. Insur­ers could still turn away peo­ple who don’t main­tain “con­tin­u­ous cov­er­age.” That’s no small thing. Peo­ple who lose jobs fre­quent­ly let cov­er­age lapse — and it’d hap­pen more com­mon­ly in a world with­out the gen­er­ous finan­cial assis­tance Oba­macare pro­vides.

Con­ser­v­a­tives say they have a solu­tion for this: They would cre­ate spe­cial insur­ance plans, called “high-risk pools,” for peo­ple insur­ers won’t cov­er.

This idea has been tried before, at the state lev­el — and it didn’t work very well. The plans typ­i­cal­ly offered weak­er cov­er­age at high­er prices, and required vast infu­sions of mon­ey that state gov­ern­ments rarely pro­vid­ed. Telling­ly, Ryan’s bud­get allo­cates just $25 bil­lion over 10 years for high-risk pools. Even con­ser­v­a­tive experts believe it would take far more mon­ey for the pools to be the viable alter­na­tives that Repub­li­cans imag­ine.

In Sep­tem­ber, RAND Corp. researchers ana­lyzed Trump’s health care reform prin­ci­ples and deter­mined that his plan would increase the num­ber of unin­sured by 16 mil­lion to 25 mil­lion peo­ple, with a par­tic­u­lar­ly tough impact on peo­ple with seri­ous med­ical con­di­tions who would face high­er out-of-pock­et charges.

That’s a very rough guess, and a worst-case sce­nario. You can find ana­lysts who make assump­tions more favor­able to con­ser­v­a­tive plans and end up more san­guine about the results. But the basic effect of all GOP replace­ment plans is clear: few­er peo­ple with insur­ance, less pro­tec­tion for peo­ple who have it, or some mix of the two.
Gallup

Med­ic­aid

As of August, 73 mil­lion Amer­i­cans had ben­e­fits from Med­ic­aid or the Children’s Health Insur­ance Pro­gram, accord­ing to the Cen­ters for Medicare and Med­ic­aid Ser­vices, which doesn’t break up the num­bers for the two pro­grams. All but around 16 mil­lion of them are cov­ered by pre-Oba­macare rules, but all Med­ic­aid ben­e­fi­cia­ries stand to be affect­ed by the GOP’s plans.

Until the Afford­able Care Act, work­ing-age adults with­out dis­abil­i­ties were inel­i­gi­ble for this ben­e­fit in most cas­es, with some excep­tions, includ­ing low-income preg­nant women and very poor par­ents of chil­dren who qual­i­fied for Med­ic­aid or CHIP.

As an enti­tle­ment like Medicare and Social Secu­ri­ty, Med­ic­aid gets how­ev­er much mon­ey it takes to cov­er the med­ical expens­es for every­one enrolled.

Over a 10-year time peri­od, the Med­ic­aid plan the House Bud­get Com­mit­tee approved this year would reduce fed­er­al spend­ing on the pro­gram by about one-third, or rough­ly $1 tril­lion, not even count­ing the effects of repeal­ing Obamacare’s expan­sion of the pro­gram, accord­ing to the Cen­ter on Bud­get and Pol­i­cy Pri­or­i­ties.

Repeal­ing the Afford­able Care Act and its Med­ic­aid expan­sion ful­ly would elim­i­nate the cov­er­age for the rough­ly 16 mil­lion peo­ple the Cen­ters for Medicare and Med­ic­aid Ser­vices reports have enrolled under this pol­i­cy.

The fed­er­al gov­ern­ment paid for 62 per­cent of the $532 bil­lion in Med­ic­aid expen­di­tures in fis­cal year 2015, the most recent year for which such a break­down is avail­able. In 25 states, the fed­er­al share of spend­ing is high­er still, so even states that may want to main­tain today’s Med­ic­aid ben­e­fits would find it extreme­ly dif­fi­cult, if not impos­si­ble, to replace the fed­er­al dol­lars that would dis­ap­pear under GOP pro­pos­als.

One result could be 25 mil­lion few­er Med­ic­aid ben­e­fi­cia­ries, accord­ing to the RAND Corp.’s analy­sis of Trump’s plans.

Trump and oth­er Repub­li­cans have long pro­mot­ed “flex­i­bil­i­ty” that would enable states, which joint­ly finance and man­age Med­ic­aid with the fed­er­al gov­ern­ment, to alter the pro­gram.

While this may seem on its face like sim­ple fed­er­al­ism, the pur­pose is not to allow states to cov­er as many peo­ple as they do now in dif­fer­ent ways, but to sig­nif­i­cant­ly reduce fed­er­al spend­ing on Med­ic­aid and to per­mit states to cut back on who can receive Med­ic­aid cov­er­age and what kind of ben­e­fits they have.

Ryan’s lat­est ver­sion of this 35-year-old idea idea would estab­lish either “block grants” to states — that is, a flat amount of mon­ey each state would get from the fed­er­al gov­ern­ment each year to spend on Med­ic­aid as they like — or “per capi­ta allot­ment” — mean­ing a flat amount of mon­ey for each per­son enrolled. These approach­es would dif­fer in terms of how much mon­ey states would receive year­ly and how much the fund­ing would increase from year to year.

In any case, the fund­ing wouldn’t be high enough to main­tain cur­rent cov­er­age, inevitably lead­ing to mil­lions of cur­rent­ly cov­ered indi­vid­u­als los­ing their ben­e­fits. And the financ­ing would grow at a slow­er rate than health care costs, por­tend­ing more lost cov­er­age over time. For those who remain on Med­ic­aid, Ryan would per­mit states to charge them month­ly pre­mi­ums and add oth­er strings, such as a work require­ment.

...

Medicare

The Medicare revamp in “A Bet­ter Way” would result in whole­sale changes to the enti­tle­ment — ones that would real­ize Ryan’s long-term goal of pri­va­tiz­ing the pro­gram.

Today, most of the 55 mil­lion Medicare ben­e­fi­cia­ries enroll in the tra­di­tion­al, gov­ern­ment-run pro­gram and then buy pri­vate sup­ple­men­tal insur­ance to cov­er remain­ing out-of-pock­et costs. A siz­able minor­i­ty opts to buy pri­vate insur­ance plans, through the Medicare Advan­tage pro­gram. The gov­ern­ment reg­u­lates these plans tight­ly, to make sure they pro­vide cov­er­age at least as gen­er­ous as the tra­di­tion­al Medicare pro­gram does.

Ryan would replace this arrange­ment with a “pre­mi­um sup­port” sys­tem, under which each senior would get an allot­ment of mon­ey — vouch­er, in oth­er words — he can use to get insur­ance. When Ryan intro­duced the first for­mal ver­sion of his pro­pos­al, in 2010, he envi­sioned end­ing the tra­di­tion­al gov­ern­ment pro­gram alto­geth­er. Now he says it should con­tin­ue to exist along­side the pri­vate plans, com­pet­ing with them for busi­ness.

What would this mean for ben­e­fi­cia­ries? A great deal would depend on details Ryan has yet to pro­vide, par­tic­u­lar­ly when it comes to the val­ue of that vouch­er — and how quick­ly it would increase every year — com­pared to the cost of the insur­ance. But the whole point of the sys­tem is to ratch­et down the val­ue of the vouch­ers over time.

That would reduce spend­ing on Medicare, which Ryan always says is a goal, and some seniors would like­ly end up sav­ing mon­ey, because they could eas­i­ly switch to cheap­er plans. The ques­tion would be what hap­pens to every­body else. With­out ade­quate reg­u­la­tion of ben­e­fits and oth­er safe­guards tai­lored to the spe­cial needs of an old­er, fre­quent­ly impaired pop­u­la­tion of seniors, the con­se­quence of mov­ing to pre­mi­um sup­port could be high­er costs for indi­vid­ual seniors who have seri­ous health prob­lems — with low-income seniors feel­ing it most intense­ly.

If at the same time Repub­li­cans shrink Med­ic­aid, those seniors will suf­fer even more, since today the poor­est seniors can use the pro­gram to pay for what­ev­er med­ical bills Medicare does not.

Ryan promis­es that the pro­pos­al would not affect seniors who are 55 or old­er, since the new sys­tem wouldn’t begin oper­at­ing for 10 years. But real­is­ti­cal­ly the entire Medicare pro­gram would change once pre­mi­um sup­port took effect — pri­vate plans would almost cer­tain­ly find ways to pick off the health­i­est seniors, for instance — and, at best, the dam­age would sim­ply take longer to play out.

Ryan’s Medicare scheme includes one oth­er ele­ment — a pro­vi­sion to raise the eli­gi­bil­i­ty age grad­u­al­ly, so that seniors would even­tu­al­ly enroll at 67, rather than 65. Par­tic­u­lar­ly in a world in which the Afford­able Care Act no longer exists, 65- and 66-year-olds search­ing for pri­vate cov­er­age would find it hard­er to obtain, more expen­sive and less gen­er­ous than what they’d get from Medicare today.

The end result would almost sure­ly be high­er out-of-pock­et costs for those younger seniors — and a sig­nif­i­cant num­ber of them, maybe into the mil­lions, with no insur­ance at all.

“The Medicare revamp in “A Bet­ter Way” would result in whole­sale changes to the enti­tle­ment — ones that would real­ize Ryan’s long-term goal of pri­va­tiz­ing the pro­gram.”

Pri­va­tized Medicare. That could actu­al­ly hap­pen. Soon. And almost cer­tain­ly will hap­pen soon if the GOP is con­fi­dent it can avoid the fall out. But it’s very unclear how that fall out can be avoid­ed unless the GOP can fig­ure out how to sell the pub­lic on replace Medicare with a vouch­er. Although we do any an idea of what they might do: block grant Medicare while simul­ta­ne­ous­ly offer the vouch­er pri­va­tized vouch­er sys­tem so they can claim that Medicare isn’t going away (while ignor­ing the fact that the whole point of the block grant scheme is to make sure Medicare even­tu­al­ly erodes away...along with the vouch­ers):

...
Ryan would replace this arrange­ment with a “pre­mi­um sup­port” sys­tem, under which each senior would get an allot­ment of mon­ey — vouch­er, in oth­er words — he can use to get insur­ance. When Ryan intro­duced the first for­mal ver­sion of his pro­pos­al, in 2010, he envi­sioned end­ing the tra­di­tion­al gov­ern­ment pro­gram alto­geth­er. Now he says it should con­tin­ue to exist along­side the pri­vate plans, com­pet­ing with them for busi­ness.

What would this mean for ben­e­fi­cia­ries? A great deal would depend on details Ryan has yet to pro­vide, par­tic­u­lar­ly when it comes to the val­ue of that vouch­er — ant ome seniors would like­ly end up sav­ing mon­ey, because they could eas­i­ly switch to cheap­er plans. The ques­tion would be what hap­pens to every­body else. With­out ade­quate reg­u­la­tion of ben­e­fits and oth­er safe­guards tai­lored to the spe­cial needs of an old­er, fre­quent­ly impaired pop­u­la­tion of seniors, the con­se­quence of mov­ing to pre­mi­um sup­port could be high­er costs for indi­vid­ual seniors who have seri­ous health prob­lems — with low-income seniors feel­ing it most intense­ly.

...

So a few wealth­i­er and health­i­er seniors might befit from Paul Ryan’s Medicare vouch­er plan, and every else gets screwed. Slow­ly. Or maybe quick­ly depend­ing on how it all plays out. Either way, there’s going to be an abun­dance of polit­i­cal fall out that’s going to have to be redis­trib­uted over the com­ing decades if the GOP is going to main­tain its grip on Con­gress.

That’s part of what’s going to make this whole fias­co so depress­ing­ly fas­ci­nat­ing: the Con­gres­sion­al GOP’s plans for destroy­ing the US health care sys­tem is simul­ta­ne­ous­ly a plan to make the GOP-dom­i­nat­ed gov­er­nors and state leg­is­la­tors much, much less pop­u­lar with the elec­torate. And while that might seem like a decent trade off if you’re a GOP con­gress­man, don’t for­get that one of the secrets to the GOP’s suc­cess at the fed­er­al lev­el is all the ger­ry­man­der­ing that’s almost guar­an­teed the GOP a lock on the House of Rep­re­sen­ta­tives. And future GOP ger­ry­man­der­ing requires state-lev­el con­trol.

And don’t for­get that one of the oth­er secrets of the GOP’s suc­cess at the state lev­el is polit­i­cal pos­tur­ing against “DC” and all the things that hap­pen at the fed­er­al lev­el that vot­ers are pay­ing more atten­tion to than state-lev­el issues. But with this block grant­i­ng scheme, one of the biggest polit­i­cal light­ning rods in DC becomes a state-lev­el light­ning rod too and the kind of light­ning rod that the GOP’s ‘kick the poor’ ortho­doxy might not mesh well with. Espe­cial­ly after Trump and the GOP Con­gress fin­ish off what’s left of the US mid­dle class and the wealthy own basi­cal­ly every­thing. The more suc­cess­ful the Trump and the GOP are in imple­ment­ing their broad­er socioe­co­nom­ic agen­da (which is still basi­cal­ly the Koch broth­ers’ agen­da despite the Trumpian veneer), the more polit­i­cal poten­cy health care for the finan­cial­ly strug­gling is going to be in com­ing decades. So we real­ly could be see­ing the Con­gres­sion­al GOP’s fed­er­al-to-state block grant­i­ng switcha­roo scheme sow­ing the seeds for GOP’s future demise. The GOP con­trols the fed­er­al branch of gov­ern­ment relies heav­i­ly on its con­trol of the states, so if it los­es its grip on state con­trol the loss­es at the fed­er­al lev­el are pret­ty much inevitable. That’s what hap­pens if you undo egre­gious ger­ry­man­der­ing.

So if Paul Ryan and the GOP Con­gress screw this up mas­sive­ly — by first screw­ing up US health care and then screw­ing up their blame redis­tri­b­u­tion scheme — they’re obvi­ous­ly going to hurt their polit­i­cal prospects. But if they suc­ceed — by first screw­ing up US health care (screw­ing it up is suc­ceed­ing for the GOP) and then suc­ceed­ing in their fed­er­al-to-state blame redis­tri­b­u­tion scheme — they might end up being even more screwed in the long run by los­ing con­trol of state leg­is­la­tures and gov­er­nor­ships and los­ing the abil­i­ty to ger­ry­man­der the hell out of the House of Rep­re­sen­ta­tives. Don’t under­es­ti­mate how unpop­u­lar state gov­ern­ments could become if they start car­ry­ing the Con­gres­sion­al GOP’s poi­so­nous water. After all, the “pre­mi­um sup­port” (vouch­er) plan that Paul Ryan has for Medicare means that we’re not just look­ing at block-grants to states. Those states are going to in turn cre­ate block-grants for indi­vid­u­als. That’s what a vouch­er is: an indi­vid­ual block grant that’s designed to shrink over time and not be able to deal with sud­den fund­ing emer­gen­cies. Is a mul­ti­di­men­sion­al block grant scheme polit­i­cal owned by fed­er­al and state GOP­ers going to endear that par­ty to the Amer­i­can peo­ple?

It all rais­es the ques­tion of when the state-lev­el GOP is going to join the rest of the coun­try in oppos­ing the like­ly ‘Trump­care’ mod­el of block grant­i­ng enti­tle­ments and send­ing them into a planned slow-death spi­ral. Pure­ly out of a sense of per­son­al polit­i­cal sur­vival. Oth­er­wise it’s time for the GOP to play Poi­so­nous Hot Pota­to Death Spi­ral. Do state-lev­el GOP elect­ed offi­cials want to see pro­grams like Medicare and Med­ic­aid slashed and burned? Almost assured­ly. They’re Repub­li­cans. But do they want to do those cuts them­selves? That’s a very dif­fer­ent ques­tion. But their Con­gres­sion­al brethren are about to make sure they do.

What should the GOP do? Well, they could stop hav­ing a psy­cho agen­da, but since that’s appar­ent­ly not an option it’s very unclear what they should do. It all rais­es the ques­tion of when the GOP’s vot­er sup­pres­sion agen­da is going to expand past minori­ties, the poor, and the youth, to include tar­get­ing the elder­ly too.

And, of course, there’s the ques­tion of what the GOP’s plan is after they’ve com­plet­ed their enti­tle­ment privatization/evisceration agen­da and ade­quate health care access is a pipe dream for tens of mil­lions more Amer­i­cans than were lack­ing health insur­ance in the pre-Oba­macare era for the kinds of health care needs that even heart­less oli­garchs should want to see the rab­ble have access to. Like health care for com­mu­ni­ca­ble dis­ease. Will hos­pi­tal emer­gency rooms be just expect­ed to pick of the slack? For­ev­er? How about all the new com­mu­ni­ca­ble dis­eases of the future? Do Trump and the and his fel­low GOP trav­el­ers in Con­gress have a plan for that? Unfor­tu­nate­ly, maybe.

Discussion

9 comments for “Killing Granny: The GOP’s “One Size Fits All” Death Panel for Health Care”

  1. Remem­ber how Jim O’Neill, Don­ald Trump’s like­ly choice to head the FDA based on the rec­om­men­da­tion of tran­si­tion-advi­sor Peter Thiel, was known for want­i­ng to cham­pi­on the idea that the FDA should approve drugs with­out proven effec­tive­ness as long as they’re con­sid­ered safe? Well, it sounds like Trump has a sim­i­lar idea in mind. Sim­i­lar, except the oppo­site:

    The New York Times

    Trump’s F.D.A. Pick Could Undo Decades of Drug Safe­guards

    By KATIE THOMAS
    FEB. 5, 2017

    Pres­i­dent Trump’s vow to over­haul the Food and Drug Admin­is­tra­tion could bring major changes in pol­i­cy, includ­ing steps to accel­er­ate the process of approv­ing new pre­scrip­tion drugs, set­ting up a clash with crit­ics who say his push for dereg­u­la­tion might put con­sumers at risk.

    Mr. Trump has been vet­ting can­di­dates to run the agency, which reg­u­lates the safe­ty of every­thing from drugs and med­ical devices to food and cos­met­ics. Among them is Jim O’Neill, a for­mer offi­cial at the Health and Human Ser­vices Depart­ment who is an asso­ciate of the Sil­i­con Val­ley bil­lion­aire and Trump sup­port­er Peter Thiel. Mr. O’Neill has argued that com­pa­nies should not have to prove that their drugs work in clin­i­cal tri­als before sell­ing them to con­sumers.

    Oth­er can­di­dates also have called for reduc­ing reg­u­la­to­ry hur­dles.

    If the most sig­nif­i­cant pro­pos­als are adopt­ed — and many would require an act of Con­gress — they will reverse decades of pol­i­cy and con­sumer pro­tec­tions dat­ing to the 1960s. Con­gress tough­ened the drug approval process in the wake of the world­wide cri­sis over thalido­mide, which caused severe birth defects in babies whose moth­ers had tak­en the drug in preg­nan­cy. Since then, the F.D.A. has come to be viewed as the world’s lead­ing watch­dog for pro­tect­ing the safe­ty of food and drugs, a gold stan­dard whose lead oth­er coun­tries often fol­low.

    Mr. Trump’s most recent state­ments, made at a White House round-table dis­cus­sion last week with lead­ers of the nation’s top drug com­pa­nies, have rever­ber­at­ed through­out the med­ical and phar­ma­ceu­ti­cal indus­tries. Sup­port­ers of dereg­u­la­tion have long want­ed to reduce bureau­cra­cy and lessen over­sight of drugs and devices, while crit­ics say the mar­ket for drugs could be desta­bi­lized and the door opened to unproven prod­ucts based on junk sci­ence.

    “Every­one depends on the agency, from the drugs in our med­i­cine cab­i­net to the food on our din­ner table, to our blood sup­plies,” said Dr. David Kessler, who was com­mis­sion­er of the F.D.A. dur­ing the pres­i­den­cies of the elder George Bush and Bill Clin­ton. “We are the envy of the world because our hon­ey is our hon­ey. Our foods are not laced with pes­ti­cides. Our drugs work.”

    Mr. Trump said at the meet­ing that he was close to nam­ing a “fan­tas­tic” per­son to lead the agency. In addi­tion to Mr. O’Neill, can­di­dates whose names have recent­ly sur­faced include Dr. Scott Got­tlieb, a for­mer F.D.A. offi­cial with long­stand­ing ties to phar­ma­ceu­ti­cal and biotech com­pa­nies, and Dr. Joseph Gul­fo, a for­mer biotech and med­ical device exec­u­tive.

    All three have called for stream­lin­ing the drug approval process, but Mr. O’Neill’s stance has drawn the most atten­tion. He is a man­ag­ing direc­tor of Mithril Cap­i­tal Man­age­ment, an invest­ment firm Mr. Thiel co-found­ed, and pre­vi­ous­ly led the Thiel Foun­da­tion, Mr. Thiel’s phil­an­thropic orga­ni­za­tion. Dur­ing the George W. Bush admin­is­tra­tion, Mr. O’Neill held a series of roles in the Health and Human Ser­vices Depart­ment, includ­ing as prin­ci­pal asso­ciate deputy sec­re­tary, where he worked on pol­i­cy, includ­ing for the F.D.A., accord­ing to his LinkedIn pro­file.

    Mr. O’Neill is a lib­er­tar­i­an who is on the board of the SENS Research Foun­da­tion, a char­i­ty that funds anti-aging research, and until recent­ly served on the board of the Seast­eading Insti­tute, an effort to cre­ate new soci­eties at sea.

    At an anti-aging con­fer­ence in 2014, Mr. O’Neill advo­cat­ed some­thing he called “pro­gres­sive” approval, in which drugs that were proved safe, but not yet proven effec­tive, could be allowed on the mar­ket. “Let peo­ple start using them, at their own risk,” Mr. O’Neill said. “Let’s prove effi­ca­cy after they’ve been legal­ized.”

    Com­pa­nies have been required to prove that their drugs work since 1962, when Con­gress passed leg­is­la­tion requir­ing that licens­ing for sale be based not just on safe­ty but also on “sub­stan­tial evi­dence” of a drug’s effi­ca­cy. That law, and oth­ers passed since, forced com­pa­nies to rig­or­ous­ly test their prod­ucts, run­ning them through a gant­let of clin­i­cal tri­als whose results are then vet­ted by the F.D.A. before any sales to con­sumers. Nine­ty per­cent of drugs that enter clin­i­cal devel­op­ment fail these tri­als. (The F.D.A. also reg­u­lates med­ical devices, but they under­go a sep­a­rate approval process.)

    As a result, new­ly dis­cov­ered drugs can take years to reach the mar­ket, a peri­od that Mr. Trump said last week was too lengthy.

    “When you have a drug, you can actu­al­ly get it approved if it works, instead of wait­ing for many, many years,” he told the phar­ma­ceu­ti­cal exec­u­tives. “We’re going to be cut­ting reg­u­la­tions at a lev­el that nobody’s ever seen before, and we’re going to have tremen­dous pro­tec­tion for the peo­ple.”

    Some have sug­gest­ed that a com­mis­sion­er deter­mined to weak­en the effi­ca­cy stan­dard need not seek con­gres­sion­al action, but could inter­pret exist­ing reg­u­la­tions loose­ly so that require­ments for cer­tain clin­i­cal tri­als — par­tic­u­lar­ly the cost­ly, large-scale ones that can take years and involve thou­sands of patients — can be rolled back.

    That could have seri­ous impli­ca­tions for patients. Last month, the F.D.A. released a study of 22 drugs that appeared promis­ing in ear­ly stud­ies but failed in final, large-scale tri­als. Drug safe­ty watch­dogs point to exam­ples like the painkiller Vioxx, which was with­drawn from the mar­ket in 2004 over safe­ty con­cerns, as proof of the high stakes involved in drug approval.

    While Mr. Trump’s call to cut reg­u­la­tions has been warm­ly received by oth­er indus­tries, some biotech exec­u­tives have react­ed to his remarks with alarm. Those affil­i­at­ed with some small­er com­pa­nies have pri­vate­ly described the choice of Mr. O’Neill as a worst-case sce­nario that could send the drug indus­try into chaos. The F.D.A., they say, is not per­fect, but its stan­dards pro­vide a lev­el play­ing field on which both big and small com­pa­nies can com­pete.

    “We’re not sell­ing Coca-Cola and Pep­si, where patients can taste the Coca-Cola and decide if they like it,” said John M. Maraganore, the chief exec­u­tive of Alny­lam Phar­ma­ceu­ti­cals, a Mass­a­chu­setts biotech firm. “Our prod­ucts are life­sav­ing med­i­cines.”

    Indus­try exec­u­tives said big changes to the agency would also be bad for busi­ness, mak­ing it dif­fi­cult for com­pa­nies with break­through treat­ments to dis­tin­guish their prod­ucts from those that are shams. If stan­dards at the F.D.A. are rolled back, “then we might as well be adver­tis­ing in the mid­dle of the night on how ter­rif­i­cal­ly we can cure all your ill­ness­es,” said Dr. Leonard S. Schleifer, the chief exec­u­tive of Regen­eron, a phar­ma­ceu­ti­cal com­pa­ny in Tar­ry­town, N.Y. “That’s not the busi­ness that I think most of us want to be in.”

    Daniel Car­pen­ter, a pro­fes­sor at Har­vard Uni­ver­si­ty who stud­ies the F.D.A., said its role is not just to ensure the safe­ty of a drug. “The under­pin­nings of belief among patients, pay­ers, even investors, is that some­body out there has test­ed these things and has shown, with some evi­dence, that they work,” he said.

    ...

    Drug indus­try lead­ers say that they want the F.D.A. to be more open to allow­ing new kinds of clin­i­cal tri­als, and that it needs to become more nim­ble in keep­ing up with the breath­tak­ing pace of med­ical advances. They have also been prod­ding the agency to fill an esti­mat­ed 1,000 staff vacan­cies so that deci­sions can be made on more quick­ly. But that is appar­ent­ly delayed because the pres­i­dent ordered an across-the-board hir­ing freeze.

    “The only way you would make it short­er is you staff up,” said Michael Gilman, an entre­pre­neur who has found­ed sev­er­al biotech com­pa­nies. “You cer­tain­ly don’t do it by slash­ing staff. So the log­ic of the whole thing doesn’t com­pute for me.”

    “If the most sig­nif­i­cant pro­pos­als are adopt­ed — and many would require an act of Con­gress — they will reverse decades of pol­i­cy and con­sumer pro­tec­tions dat­ing to the 1960s. Con­gress tough­ened the drug approval process in the wake of the world­wide cri­sis over thalido­mide, which caused severe birth defects in babies whose moth­ers had tak­en the drug in preg­nan­cy. Since then, the F.D.A. has come to be viewed as the world’s lead­ing watch­dog for pro­tect­ing the safe­ty of food and drugs, a gold stan­dard whose lead oth­er coun­tries often fol­low.”

    No more expen­sive safe­ty stan­dards. Along with no more need to prove effec­tive­ness. These are the kinds of inno­v­a­tive pol­i­cy pre­scrip­tions the US gets for the next four years to eight years inde­ter­mi­nate peri­od of time. You have to won­der if Trump Uni­ver­si­ty is about to open up a drug devel­op­ment research divi­sion.

    And note that gut­ting stan­dards isn’t the only plans for keep drug prices down that Trump recent­ly uttered. For instance, how about blam­ing Medicare, which is cur­rent­ly banned from nego­ti­at­ing drug prices thanks to a Bush era law, for “price-fix­ing” and pre­vent­ing young small start-ups from bring­ing drugs to the mar­ket. And while it’s unclear what exact­ly Trump meant by all that, it pre­sum­ably means he’s going to have Medicare pay more for drugs to increase com­pe­ti­tion to bring in more drugs to bring down drug prices. Or some­thing

    Politi­co

    Trump tells drug­mak­ers he’ll tack­le prices

    By Sarah Kar­lin-Smith and Nolan D. McCaskill
    | 01/31/17 10:03 AM EST
    | Updat­ed 01/31/17 01:45 PM EST

    Pres­i­dent Don­ald Trump vowed today to speed up drug approvals while reit­er­at­ing his pledge to bring down drug costs.

    “For Medicare, for Med­ic­aid, we have to get the prices way down,” Trump said dur­ing a White House meet­ing with phar­ma­ceu­ti­cal exec­u­tives and the indus­try’s top lob­by­ist.

    Dur­ing the cam­paign and since his elec­tion, Trump has often talked of phar­ma in tough terms. Just ear­li­er this month, he accused the indus­try of “get­ting away with mur­der” and said he want­ed to com­pet­i­tive­ly bid drug pur­chas­es. But in pub­lic remarks on Tues­day, he took a con­cil­ia­to­ry tone, pledg­ing to reduce reg­u­la­tions and low­er the bar for drug approvals.

    “We’re also gonna be stream­lin­ing the process so that from your stand­point, when you have a drug, you can actu­al­ly get it approved if it works instead of wait­ing for many, many years,” Trump said. “The U.S. drug com­pa­nies have pro­duced extra­or­di­nary results for our coun­try, but the pric­ing has been astro­nom­i­cal for our coun­try.”

    Trump, who’s pledged to unwind the nation’s reg­u­la­to­ry regime, sig­naled a poten­tial­ly rad­i­cal approach to over­haul­ing the Food and Drug Admin­is­tra­tion. He expressed a will­ing­ness to approve some drugs before they have been proven safe, which would be a big depar­ture from the FDA’s cur­rent prac­tices. And he said he would soon name an FDA com­mis­sion­er who will be “stream­lin­ing” the agency.

    ...

    Trump also appeared to reit­er­ate his sup­port for drug nego­ti­a­tions. He con­tend­ed that drug­mak­ers need to face increased com­pe­ti­tion and bid­ding. Yet he appeared to sug­gest that Medicare, which is banned from nego­ti­at­ing with drug­mak­ers, is hurt­ing com­pe­ti­tion.

    “I’ll oppose any­thing that makes it hard­er for small­er, younger com­pa­nies to take the risk of bring­ing a prod­uct to a vibrant­ly com­pet­i­tive mar­ket,” he said. “That includes price-fix­ing by the biggest dog in the mar­ket, Medicare, which is what’s hap­pen­ing. But we can increase com­pe­ti­tion and bid­ding wars big time — we have to — into that pro­gram.”

    Trump also said he plans to work on glob­al trade and tax pol­i­cy that could ben­e­fit U.S. drug­mak­ers.

    “We’re gonna be chang­ing a lot of the rules. We’re going to be end­ing glob­al free­load­ing,” Trump said. “For­eign price con­trols reduce the resources of Amer­i­can drug com­pa­nies to finance drug and R&D inno­va­tion,” he said, also encour­ag­ing drug­mak­ers to bring more of their man­u­fac­tur­ing back to the Unit­ed States.

    ...

    “Trump also appeared to reit­er­ate his sup­port for drug nego­ti­a­tions. He con­tend­ed that drug­mak­ers need to face increased com­pe­ti­tion and bid­ding. Yet he appeared to sug­gest that Medicare, which is banned from nego­ti­at­ing with drug­mak­ers, is hurt­ing com­pe­ti­tion.

    So no more safe­ty or effi­ca­cy stan­dards for drugs that Medicare will pay more for. It’s going to be a brave new world of expen­sive inef­fec­tive drugs. Maybe. It’s unclear what exact­ly he meant:

    ...

    “I’ll oppose any­thing that makes it hard­er for small­er, younger com­pa­nies to take the risk of bring­ing a prod­uct to a vibrant­ly com­pet­i­tive mar­ket,” he said. “That includes price-fix­ing by the biggest dog in the mar­ket, Medicare, which is what’s hap­pen­ing. But we can increase com­pe­ti­tion and bid­ding wars big time — we have to — into that pro­gram.”

    ...

    But keep in mind that Trump’s pol­i­cy on Medicare drug nego­ti­a­tions is more opaque that his vague state­ments above sug­gest. And sort of the oppo­site:

    Politi­co

    Trump backs Medicare nego­ti­at­ing drug prices

    By POLITICO Pro Staff

    01/25/16 11:23 PM EST

    Don­ald Trump said tonight he could save Medicare bil­lions of dol­lars by allow­ing it to nego­ti­ate drug prices direct­ly with phar­ma­ceu­ti­cal com­pa­nies — embrac­ing a posi­tion Democ­rats have cham­pi­oned and Repub­li­cans have opposed for years.

    The Asso­ci­at­ed Press quotes Trump as telling a crowd in Farm­ing­ton, N.H., that Medicare, a huge buy­er of pre­scrip­tion drugs, could “save $300 bil­lion” a year if it nego­ti­at­ed dis­counts.

    “We don’t do it,” he said. “Why? Because of the drug com­pa­nies.”

    Democ­rats have want­ed to give Medicare that pow­er at least since 2003, when the Medicare drug ben­e­fit law was passed — but the Repub­li­cans have always blocked it.

    The Democ­rats, includ­ing the 2016 pres­i­den­tial can­di­dates, sup­port Medicare drug nego­ti­a­tions, and Pres­i­dent Barack Oba­ma has called for that pol­i­cy in his bud­gets.

    ...

    “The Asso­ci­at­ed Press quotes Trump as telling a crowd in Farm­ing­ton, N.H., that Medicare, a huge buy­er of pre­scrip­tion drugs, could “save $300 bil­lion” a year if it nego­ti­at­ed dis­counts.”

    So it looks like what­ev­er mind-alter­ing drugs Big Phar­ma has been giv­ing to Con­gress since 2003 just got ped­dled to Trump. And he liked the way they made him feel. A lot, which is unfor­tu­nate. They aren’t cheap.

    Posted by Pterrafractyl | February 6, 2017, 12:56 am
  2. It looks like Don­ald Trump may have back flipped on his posi­tion over whether or not Medicare should be direct­ly nego­ti­at­ing its drug prices with drug com­pa­nies. After decry­ing the absur­di­ty of the rule that pre­vents Medicare from using its immense mar­ket pow­er to nego­ti­ate low­er prices for drugs, Trump appeared to reverse that pledge last week, blamn­ing Medicare for “price fix­ing” and hurt­ing young drug com­pa­nies. Well, accord­ing to his spokesman, Trump is again sup­port­ing Medicare nego­ti­at­ing drug prices, as is evi­dent from the sink­ing phar­ma stocks:

    Bloomberg Mar­kets

    Trump Sinks Phar­ma Stocks on Medicare Drug Price Nego­ti­a­tion

    * ‘He’s for it, yes,’ spokesman says at press brief­ing
    * Stocks slump, then pare loss­es as investors pon­der posi­tion

    Cécile Dau­rat and Toluse Olorun­ni­pa
    Feb­ru­ary 7, 2017, 1:40 PM CST Updat­ed on Feb­ru­ary 7, 2017, 7:57 PM CST

    Pres­i­dent Don­ald Trump sup­ports Medicare drug price nego­ti­a­tions, his spokesman said Tues­day, remarks that sent phar­ma­ceu­ti­cal stocks swing­ing again as investors tried to assess whether drug­mak­ers will be forced into bid­ding wars for gov­ern­ment busi­ness.

    “He’s for it, yes,” White House spokesman Sean Spicer said at a press brief­ing in response to a ques­tion ask­ing to clar­i­fy Trump’s posi­tion on the mat­ter.

    Trump has giv­en con­flict­ing sig­nals in the past weeks on whether he would let the gov­ern­ment inter­vene direct­ly in drug prices to reduce health-care costs. The Medicare pro­gram for the elder­ly is the biggest pur­chas­er of health ser­vices in the coun­try, and bid­ding for its busi­ness could have a major impact on Big Pharma’s prof­its. Unlike most coun­tries in the world, the U.S. doesn’t direct­ly reg­u­late med­i­cine prices, and drug­mak­ers have strong­ly resist­ed it.

    “The eas­i­er way to look at this is to look at what oth­er coun­tries have done: Nego­ti­at­ing costs to keep those down,” Spicer said at the brief­ing. The ris­ing costs of health care and pre­scrip­tion drugs are a “huge bur­den” on seniors, he said.

    The Nas­daq Biotech­nol­o­gy Index fell as much as 0.8 per­cent in the moments after Spicer’s remarks. The gauge pared the decline and was down 0.4 per­cent at the New York close. The Stan­dard & Poor’s 500 Health Care Sec­tor Index was lit­tle changed.

    Sur­pris­ing Com­ments

    Spicer’s com­ments took investors by sur­prise because Trump appeared to have backed down from the idea last week after a meet­ing at the White House with top phar­ma­ceu­ti­cal CEOs. Although the pres­i­dent said at the time that com­pe­ti­tion was key to low­er­ing drug prices, which he called “astro­nom­i­cal,” he also added that he was against price fix­ing.

    “My new thing is going to be phar­ma, because we pay too much,” Trump said in a Fox News inter­view that aired Tues­day night. “We are the largest drug pur­chas­er in the world, and they don’t nego­ti­ate.”

    ...

    Phar­ma­ceu­ti­cals stocks had plunged last month when Trump, then pres­i­dent-elect, made a sur­prise attack against the indus­try and sug­gest­ed price nego­ti­at­ing to save the gov­ern­ment bil­lions of dol­lars. Until then, drug­mak­ers had seen the busi­ness­man-turned-pres­i­dent as a friend of the indus­try.

    Trump also has made con­flict­ing com­ments about how and when he plans to replace Oba­macare, whose dis­man­tling was one of his campaign’s top pri­or­i­ties. The pres­i­dent said Sun­day that the process to come up with a replace­ment for the Afford­able Care Act could stretch into next year, a longer peri­od then he pre­vi­ous­ly indi­cat­ed. Repub­li­can law­mak­ers are fac­ing major chal­lenges to undo the mas­sive law, which has brought cov­er­age to 20 mil­lion peo­ple since it passed in 2010.

    “Trump has giv­en con­flict­ing sig­nals in the past weeks on whether he would let the gov­ern­ment inter­vene direct­ly in drug prices to reduce health-care costs. The Medicare pro­gram for the elder­ly is the biggest pur­chas­er of health ser­vices in the coun­try, and bid­ding for its busi­ness could have a major impact on Big Pharma’s prof­its. Unlike most coun­tries in the world, the U.S. doesn’t direct­ly reg­u­late med­i­cine prices, and drug­mak­ers have strong­ly resist­ed it.

    We’ll see if this is Trump’s final posi­tion on the mat­ter, but for now it’s pret­ty clear that Big Phar­ma has some more lob­by­ing to do.

    Still, even if Trump does some­how end up fol­low­ing through on his tepid pledge to allow Medicare to direct­ly nego­ti­ate drug prices, it’s worth not­ing that the rest of the GOP’s health care reform pack­age could end up impact­ing the pri­vate insur­ance mar­ket’s drug prices too. How so? Well, part of the ‘mag­ic’ that the GOP has long ped­dled as an Oba­macare alter­na­tive is to use a “con­sumer-dri­ven” health­care. And what’s that? It’s a euphemism for hav­ing con­sumer pay direct­ly for med­ical ser­vices, includ­ing drugs, out of their pock­ets instead of hav­ing insur­ance com­pa­nies pay for it. And it typ­i­cal­ly gets paired with a high-deductible plan (so pre­mi­ums are cheap­er), and a “health sav­ings account” that lets indi­vid­u­als save mon­ey tax-free for those out-of-pock­et expens­es. This way, the the­o­ry goes, con­sumers and ‘the mar­ket’ will low­er the cost of health care because they’ll be be incen­tivized to shop around and find the cheap­est ser­vices. Or the cheap­est drugs.

    As the arti­cle below notes, it’s a rather ques­tion­able the­o­ry based on the empir­i­cal evi­dence so far where health sav­ing accounts have already been tried. Health care costs did indeed drop, but large­ly due to indi­vid­u­als skip­ping things like pre­ven­tive care or fill­ing their pre­scrip­tions. And a sub­stan­tial num­ber of Amer­i­cans can’t pos­si­bly afford to mean­ing­ful­ly save any­thing in their health sav­ings accounts which pre­sum­ably means a lot less gets spent on drugs by these low­er-income indi­vid­u­als. So that has to give the phar­ma­ceu­ti­cal indus­try pause.

    But at the same time, with all these con­sumers run­ning around indi­vid­u­al­ly shop­ping for the cheap­est med­ical ser­vices that pre­sum­ably means they — or their pri­vate insur­ers — won’t be col­lec­tive­ly bar­gain for cheap­er drug prices in the pri­vate insur­ance mar­ket:

    The Atlantic

    GOP: Shop Around for Surgery

    For peo­ple sick of high deductibles, Repub­li­cans offer high-deductible plans as replace­ments for Oba­macare.
    Jonathan Ernst / Reuters

    Olga Khaz­an Jan 24, 2017

    Obamacare’s days are num­bered. That was the mes­sage of the exec­u­tive order Pres­i­dent Don­ald Trump signed Fri­day, instruct­ing gov­ern­ment agen­cies to “min­i­mize the unwar­rant­ed eco­nom­ic and reg­u­la­to­ry bur­dens of the [Afford­able Care Act].”

    When I spoke with a hand­ful of Trump sup­port­ers after the inau­gu­ra­tion Fri­day, they said they eager­ly await­ed Obamacare’s end. Tanya, a woman from Vir­ginia who was rolling a walk­er down I Street to the inau­gur­al parade, said she was strug­gling with her $6,750 deductible. “As a busi­ness per­son who is self-employed, it’s killing me,” she said.

    Near­by, Mar­li­ta Gogan, from Hous­ton, said she just wants Trump to “do what he says”—repeal and replace Oba­macare. Her daughter’s insur­ance pre­mi­um has risen from $250 to $375, with a $5,000 deductible. “It’s too much,” she said. “You can’t even use it.”

    But what’s less clear is whether the crown jew­el of most of the Repub­li­cans’ replace­ments for Obamacare—health sav­ings accounts—will ease the finan­cial strain some peo­ple feel under Oba­macare. The idea of these accounts is that peo­ple will sock away mon­ey, in some cas­es with the help of a gov­ern­ment sub­sidy, to pay for their health care. Typ­i­cal­ly, they will simul­ta­ne­ous­ly enroll in an insur­ance plan with a large deductible. The amounts will vary depend­ing on the whims of the insur­ance mar­ket, but past stud­ies of firms with HSAs have used a deductible of about $4,300 for a fam­i­ly, with a $1,300 employ­er con­tri­bu­tion to the HSA. The high deductible would encour­age them to com­pare prices among dif­fer­ent doc­tors and find the cheap­est one, while the sav­ings account would, the­o­ret­i­cal­ly, allow them to store mon­ey to cov­er their planned med­ical expens­es.

    The Repub­li­can Study Committee’s recent­ly unveiled plan calls for the “Enhance­ment of Health Sav­ings Accounts.” The one pro­posed by Sen­a­tors Bill Cas­sidy and Susan Collins would help states cre­ate HSAs for low-income adults. House Speak­er Paul Ryan’s “Bet­ter Way” plan touts “Health Sav­ings Accounts” as one of the “four major suc­cess­ful health reforms” of the 21st cen­tu­ry, and says that “improv­ing the flex­i­bil­i­ty of health sav­ings accounts and oth­er con­sumer-ori­ent­ed health care options will fur­ther enhance indi­vid­ual choice.”

    The plan put out by Rep­re­sen­ta­tive Tom Price, a Geor­gia Repub­li­can and Trump’s choice to lead the Depart­ment of Health and Human Ser­vices, pro­vides for the cre­ation of high-risk pools that “offer at least the option of one or more high-deductible plan options.” These high-deductible plans would then be paired with a health sav­ings account, where peo­ple can save mon­ey before tax­es to pay for their med­ical care.

    Health-sav­ings accounts are already avail­able in some insur­ance mar­kets. Writ­ing in Health Affairs, Tim­o­thy Jost explains how they would change under the var­i­ous GOP replace­ment plans:

    Replace­ment pro­pos­als would gen­er­al­ly increase the amount that could be deposit­ed in HSAs, make them avail­able for more gov­ern­ment pro­grams, and oth­er­wise lib­er­al­ize pro­gram require­ments. Some would even offer tax cred­its to par­tial­ly fund HSAs. Sup­port­ers of HSAs argue that they reduce health care expen­di­tures: When peo­ple spend mon­ey from HSAs they are effec­tive­ly spend­ing their own mon­ey rather than an insurer’s mon­ey; they will spend less and shop around to find low­er-cost, and per­haps high­er-qual­i­ty, care.

    The think­ing is that forc­ing peo­ple to reck­on with the true cost of med­ical pro­ce­dures is our only hope in con­trol­ling health-care costs. “Med­ical prices are so dis­tant from con­sumers that there’s no way we’re going to get costs under con­trol,” said Steve Par­ente, a pro­fes­sor at the Uni­ver­si­ty of Min­neso­ta who has ana­lyzed Bet­ter Way and oth­er con­ser­v­a­tive health-care pro­pos­als. “HSAs are not a per­fect mech­a­nism to get you there, but it’s a nudge.”

    By way of exam­ple, he explained that he saved sev­er­al hun­dred dol­lars on a pre­scrip­tion drug because he heard from some­one that a Cost­co in town had the med­ica­tion for dirt cheap. While this kind of bar­gain-hunt­ing isn’t pos­si­ble in emer­gen­cies, but hav­ing a high-deductible plan might prompt you to press your sur­geon on just how much that shoul­der oper­a­tion is going to cost, he says. Par­ente said ide­al­ly, these high-deductible plans could be “bespoke”—tailored to someone’s med­ical con­di­tions, so that, say, aller­gy shots could be cov­ered before the deductible for some­one with hay fever. Yes, he acknowl­edges, it might be painful at first to spend your own mon­ey on med­ical care; high deductibles are a major rea­son for American’s dis­sat­is­fac­tion with their health plans. Peo­ple on high-deductible plans tend to go through stages of grief: “First, they’re like, ‘this is screw­ing us,’ then they get hard­ened, but then they sur­vive it,” he said.

    The push for high-deductible plans is part of con­ser­v­a­tive pol­i­cy­mak­ers’ fond­ness for “con­sumer-dri­ven” health­care, says Renee Hsia, direc­tor of health-pol­i­cy stud­ies at the Uni­ver­si­ty of Cal­i­for­nia in San Fran­cis­co, “where we see patients as empow­ered shop­pers who can and should be mak­ing deci­sions about their health care with their wal­let.”

    But accord­ing to Hsia, the prob­lem is that health care doesn’t work like most oth­er con­sumer goods. “For exam­ple, if I want to go buy a loaf of bread, I can eas­i­ly see the ingre­di­ents, I can look at the nutri­tion­al infor­ma­tion, I can look at the price, and I know the con­se­quences of buy­ing the loaf of bread and not buy­ing the loaf of bread (i.e., it either means hav­ing it or not),” she explained. “If I have chest pain, there is no much infor­ma­tion I don’t have: I don’t know what the diag­no­sis is, I don’t know what it will require if I do see a doc­tor to get to a diag­no­sis and what tests I will require, I don’t know the con­se­quences of not get­ting treat­ed are, I don’t know what pro­ce­dures I will require even once I do get to a diag­no­sis.”

    Mul­ti­ple stud­ies have shown that the amount dif­fer­ent hos­pi­tals charge for the same tests can vary by thou­sands of dol­lars. That’s the kind of thing a con­sumer could “shop around” for, in theory—but not if there’s only one hos­pi­tal in town. And past stud­ies have shown that hos­pi­tals are more forth­com­ing with the price of their park­ing lots than they are about the prices for rou­tine tests.

    What’s more, sev­er­al of the Trump sup­port­ers I’ve inter­viewed, includ­ing Tanya, say they want to be able to keep see­ing their favorite doc­tors. That might not be an option if they’re forced to seek out the one that’s cheap­est.

    High-deductible health plans do cause peo­ple to spend less mon­ey on med­ical care—by about 5 to 7 per­cent. They espe­cial­ly avoid things like get­ting lab tests and fill­ing their pre­scrip­tions, par­tic­u­lar­ly in the first year they have the plan.

    That’s because it takes a while for mon­ey to build up in the health-sav­ings account, and also, there’s a “new­ness fac­tor,” said Antho­ny Lo Sas­so, a health-pol­i­cy pro­fes­sor at the Uni­ver­si­ty of Illi­nois. “There’s a learn­ing curve, and that prob­a­bly tamped down spend­ing.

    They also become more care­ful about going to the doc­tor. “You might give that upper-res­pi­ra­to­ry infec­tion a few more days,” Lo Sas­so said.

    But the intend­ed effect—that peo­ple will learn to shop around for the cheap­est doctor—doesn’t always kick in. A 2015 study of a firm that switched to a high-deductible health plan found that the employ­ees didn’t learn to price-shop after two years. Instead, they just reduced the amount of med­ical ser­vices they received, includ­ing poten­tial­ly valu­able ser­vices like pre­ven­tive care. Peo­ple with chron­ic con­di­tions delayed care for them­selves and their chil­dren. This is a recur­ring issue with high-deductible health plans, accord­ing to Paul Fron­stin, an econ­o­mist at the Employ­ee Ben­e­fit Research Insti­tute who led a study of a large employ­er who adopt­ed a high-deductible plan. Peo­ple don’t know that cer­tain services—like, say, flu shots—are exclud­ed from the deductible. Or, they wor­ry that while they’re at the (cov­ered) appoint­ment, the doc­tor will find a poten­tial­ly-can­cer­ous lump, which would then com­pel them to get a scan that’s not cov­ered before their deductible. That sug­gests peo­ple on high-deductible plans are get­ting less care, not just cheap­er care.

    Anoth­er ques­tion is whether peo­ple will be able to fig­ure out how much they need to con­tribute to their health-sav­ings accounts to off­set their deductibles, or to parse which tests and pro­ce­dures are skip­pable, and which aren’t. Insur­ance is already a domain that few Amer­i­cans under­stand per­fect­ly.

    “If peo­ple don’t under­stand the cost-shar­ing of insur­ance, one should have very lit­tle hope that peo­ple are going to under­stand how they are going to take up and enroll in an HSA, and how to off­set the bur­den of the high-deductible plan,” said Saurabh Bhar­ga­va, a behav­ioral econ­o­mist at Carnegie Mel­lon Uni­ver­si­ty.

    Final­ly, many econ­o­mists doubt that most work­ing-class Amer­i­cans have enough spare mon­ey to put in their health-sav­ings accounts to com­pen­sate for these high deductibles. Near­ly half of Amer­i­cans would have trou­ble scrap­ing togeth­er $400. And because health-sav­ings accounts shel­ter mon­ey from tax­es, they tend to favor the rich, whose tax­es are high­er.

    The tax cred­it Price pro­pos­es doesn’t increase at low­er income lev­els like Obamacare’s sub­si­dies, which might mean low- and mid­dle-income peo­ple will con­tin­ue to be squeezed by high deductibles.

    Sara Rosen­baum, a pro­fes­sor of health pol­i­cy at George Wash­ing­ton Uni­ver­si­ty, took the dimmest view of the GOP’s plans. She called health-sav­ings accounts “a device that wealthy peo­ple can use to sock away pre-tax out­come to par­tial­ly off­set out-of-pock­et costs for the health care [they] can afford to get.”

    ...

    “But what’s less clear is whether the crown jew­el of most of the Repub­li­cans’ replace­ments for Oba­macare—health sav­ings accounts—will ease the finan­cial strain some peo­ple feel under Oba­macare. The idea of these accounts is that peo­ple will sock away mon­ey, in some cas­es with the help of a gov­ern­ment sub­sidy, to pay for their health care. Typ­i­cal­ly, they will simul­ta­ne­ous­ly enroll in an insur­ance plan with a large deductible. The amounts will vary depend­ing on the whims of the insur­ance mar­ket, but past stud­ies of firms with HSAs have used a deductible of about $4,300 for a fam­i­ly, with a $1,300 employ­er con­tri­bu­tion to the HSA. The high deductible would encour­age them to com­pare prices among dif­fer­ent doc­tors and find the cheap­est one, while the sav­ings account would, the­o­ret­i­cal­ly, allow them to store mon­ey to cov­er their planned med­ical expens­es.

    And that right there is your like­ly Oba­macare replace for the pri­vate insur­ance mar­ket: high-deductible plans plus a tax-free health sav­ings account to save for that high deductible. And if every­thing goes right, con­sumers will mag­i­cal­ly find cheap­er health care ser­vices, or cheap­er drugs, once they start pay much more of the cost of their health care out of pock­et:

    ...
    The think­ing is that forc­ing peo­ple to reck­on with the true cost of med­ical pro­ce­dures is our only hope in con­trol­ling health-care costs. “Med­ical prices are so dis­tant from con­sumers that there’s no way we’re going to get costs under con­trol,” said Steve Par­ente, a pro­fes­sor at the Uni­ver­si­ty of Min­neso­ta who has ana­lyzed Bet­ter Way and oth­er con­ser­v­a­tive health-care pro­pos­als. “HSAs are not a per­fect mech­a­nism to get you there, but it’s a nudge.”

    By way of exam­ple, he explained that he saved sev­er­al hun­dred dol­lars on a pre­scrip­tion drug because he heard from some­one that a Cost­co in town had the med­ica­tion for dirt cheap. While this kind of bar­gain-hunt­ing isn’t pos­si­ble in emer­gen­cies, but hav­ing a high-deductible plan might prompt you to press your sur­geon on just how much that shoul­der oper­a­tion is going to cost, he says. Par­ente said ide­al­ly, these high-deductible plans could be “bespoke”—tailored to someone’s med­ical con­di­tions, so that, say, aller­gy shots could be cov­ered before the deductible for some­one with hay fever. Yes, he acknowl­edges, it might be painful at first to spend your own mon­ey on med­ical care; high deductibles are a major rea­son for American’s dis­sat­is­fac­tion with their health plans. Peo­ple on high-deductible plans tend to go through stages of grief: “First, they’re like, ‘this is screw­ing us,’ then they get hard­ened, but then they sur­vive it,” he said.
    ...

    “By way of exam­ple, he explained that he saved sev­er­al hun­dred dol­lars on a pre­scrip­tion drug because he heard from some­one that a Cost­co in town had the med­ica­tion for dirt cheap. While this kind of bar­gain-hunt­ing isn’t pos­si­ble in emer­gen­cies, but hav­ing a high-deductible plan might prompt you to press your sur­geon on just how much that shoul­der oper­a­tion is going to cost, he says”

    By trans­fer­ring the cost of health care onto con­sumers who will pay direct­ly for as much of their health care as pos­si­ble, peo­ple will all of sud­den learn about all the local ‘dirt cheap’ deals on every­thing from drug costs to shoul­der surgery. That’s the GOP’s big plan to bring down health care costs. And keep in mind that one of the pro­vi­sions of Oba­macare is a require­ment that insur­ance poli­cies cov­er pre­scrip­tion drugs and that pro­vi­sion would almost cer­tain­ly be going away under a GOP low-pre­mi­um/high-deductible/H­SAs Oba­macare replace­ment scheme. So what­ev­er reduc­tion in drug prices that insur­ers may have been nego­ti­at­ing with drug man­u­fac­tur­ers is pre­sum­ably going away too. Big Phar­ma must be shud­der­ing in its big boots.

    Although keep in mind that there is one big rea­son Big Phar­ma should be con­cerned about the GOP’s “con­sumer-dri­ven” health care plan: since most Amer­i­can’s don’t have the finan­cial abil­i­ty to cre­at­ing any mean­ing­ful sav­ings in their health sav­ings account, that also means most Amer­i­cans prob­a­bly aren’t going to have the mon­ey they need to pay for their pre­scrip­tion drugs. It’s a poten­tial pit­fall that high­lights one of the most sin­is­ter aspects of the “con­sumer-dri­ven” health care plan: It does­n’t actu­al­ly have to pro­vide bet­ter, or even ade­quate, health care in order to decrease health care costs. It can reduce those costs sim­ply by reduc­ing the amount of health care ser­vices (or drugs) admin­is­tered:

    ...
    What’s more, sev­er­al of the Trump sup­port­ers I’ve inter­viewed, includ­ing Tanya, say they want to be able to keep see­ing their favorite doc­tors. That might not be an option if they’re forced to seek out the one that’s cheap­est.

    High-deductible health plans do cause peo­ple to spend less mon­ey on med­ical care—by about 5 to 7 per­cent. They espe­cial­ly avoid things like get­ting lab tests and fill­ing their pre­scrip­tions, par­tic­u­lar­ly in the first year they have the plan.

    ...

    High-deductible health plans do cause peo­ple to spend less mon­ey on med­ical care—by about 5 to 7 per­cent. They espe­cial­ly avoid things like get­ting lab tests and fill­ing their pre­scrip­tions, par­tic­u­lar­ly in the first year they have the plan.”

    Reduc­ing health care costs by reduc­ing the amount of health care ser­vices actu­al­ly admin­is­tered and pre­scrip­tions filled. That’s one way to do it. Although prob­a­bly not the doc­tor-rec­om­mend­ed way to do it since the reduced med­ical ser­vices appears to include reduced pre­ven­tive care:

    ...
    But the intend­ed effect—that peo­ple will learn to shop around for the cheap­est doctor—doesn’t always kick in. A 2015 study of a firm that switched to a high-deductible health plan found that the employ­ees didn’t learn to price-shop after two years. Instead, they just reduced the amount of med­ical ser­vices they received, includ­ing poten­tial­ly valu­able ser­vices like pre­ven­tive care. Peo­ple with chron­ic con­di­tions delayed care for them­selves and their chil­dren. This is a recur­ring issue with high-deductible health plans, accord­ing to Paul Fron­stin, an econ­o­mist at the Employ­ee Ben­e­fit Research Insti­tute who led a study of a large employ­er who adopt­ed a high-deductible plan. Peo­ple don’t know that cer­tain services—like, say, flu shots—are exclud­ed from the deductible. Or, they wor­ry that while they’re at the (cov­ered) appoint­ment, the doc­tor will find a poten­tial­ly-can­cer­ous lump, which would then com­pel them to get a scan that’s not cov­ered before their deductible. That sug­gests peo­ple on high-deductible plans are get­ting less care, not just cheap­er care.

    So, as we can see, it’s not just Trump’s on-again-off-again threats to allow Medicare to nego­ti­ate drug prices that should be drag­ging down Big Phar­ma’s stock prices. It’s also the fact that the GOP’s like­ly health care reform pack­age is actu­al­ly a stealth plan to reduce health care costs by reduc­ing the amount of health care ser­vices pro­vid­ed. Includ­ing pre­scrip­tion drugs. Under the GOP’s vision for health care, every­one’s pock­et­book will be their own per­son­al death pan­el. It’s the kind of reform that real­ly prob­a­bly should have Big Phar­ma shak­ing at last a lit­tle in their boots.

    Also keep in mind that since the future of health care spend­ing is going to become reliant on the fis­cal health of all these indi­vid­u­als health sav­ings accounts, that means the future rev­enues of Big Phar­ma and the rest of the health care indus­try is also going to be reliant on all those HSAs. And those HSA funds are pre­sum­ably going to be sit­ting in a sav­ings account or invest­ed in the stock mar­ket. And that means it’s not just the chron­i­cal­ly low rates of sav­ings that will threat­en future health care spend­ing. A big messy finan­cial cri­sis that threat­ens the US finan­cial sys­tem could do the trick too. So while Big Phar­ma and the rest of the health care indus­try is no doubt watch­ing close­ly how exact­ly Trump and the GOP decide to ‘repeal and replace’ Oba­macare, that’s not the only sig­na­ture law from the Oba­ma years that the indus­try needs to be keep­ing an eye on.

    Posted by Pterrafractyl | February 7, 2017, 10:02 pm
  3. It sounds like the GOP’s long-held pledge to ‘repeal and replace’ Oba­macare might be get­ting replaced: ‘repeal­ing and repair­ing’ Obamacare...presumably so they can keep call­ing it ‘Oba­macare’ and blame Oba­ma for the mon­stros­i­ty they’re about to inflict on the vot­ers:

    Bloomberg Pol­i­tics

    GOP Rebrands Oba­macare Strat­e­gy From ‘Repeal’ to ‘Repair’

    * Law­mak­ers advised to shift to friend­lier Oba­macare mes­sag­ing
    * Some try out ‘repair’ as oth­ers stick with stronger words

    by Anna Edney, Bil­ly House, and Zachary Trac­er
    Feb­ru­ary 1, 2017, 4:10 PM CST Feb­ru­ary 2, 2017, 8:21 AM CST

    Some Repub­li­cans in Con­gress are start­ing to talk more about try­ing to “repair” Oba­macare, rather than sim­ply call­ing for “repeal and replace.”

    There’s good rea­son for that.

    The repair lan­guage was dis­cussed by Repub­li­cans dur­ing their closed-door pol­i­cy retreat in Philadel­phia last week as a bet­ter way to brand their strat­e­gy. Some of that dis­cus­sion flowed from views that Repub­li­cans may not be head­ed toward a total replace­ment, said one con­ser­v­a­tive House law­mak­er who didn’t want to be iden­ti­fied.

    Using the word repair “cap­tures exact­ly what the large major­i­ty of the Amer­i­can peo­ple want,” said Frank Luntz, a promi­nent Repub­li­can con­sul­tant and poll­ster who addressed GOP law­mak­ers at their retreat.

    “The pub­lic is par­tic­u­lar­ly hos­tile about sky­rock­et­ing costs, and they demand imme­di­ate change,” Luntz said in an e‑mail response to ques­tions. “Repair is a less par­ti­san but no less action-ori­ent­ed phrase that Amer­i­cans over­whelm­ing­ly embrace.”

    Repub­li­cans are grap­pling with their party’s desire — and Pres­i­dent Don­ald Trump’s promise — to dis­man­tle Oba­macare, as well as the polit­i­cal dis­as­ter that could ensue if mil­lions of Amer­i­cans lose cov­er­age as a result of leg­is­la­tion.

    A Jan. 6 Kaiser Fam­i­ly Foun­da­tion poll found that 75 per­cent of Amer­i­cans either are opposed to Con­gress repeal­ing Oba­macare or want law­mak­ers to wait until they have a replace­ment ready before repeal­ing it. While Trump has promised a plan of his own, Repub­li­cans have yet to coa­lesce around any of the plans that have been float­ed in recent years to end Oba­macare while main­tain­ing a sta­ble insur­ance mar­ket.

    ‘Repair the Dam­age’

    “Our goal is to repair the dam­age caused by Oba­macare where we find dam­age,” Sen­ate Health, Edu­ca­tion, Labor and Pen­sions Chair­man Lamar Alexan­der, a Ten­nessee Repub­li­can, said at the start of a hear­ing he held Wednes­day on the indi­vid­ual insur­ance mar­ket.

    Sen­a­tor Susan Collins, a Maine Repub­li­can, echoed Alexan­der dur­ing the hear­ing: “Regard­less of who was elect­ed pres­i­dent, we were going to have to do major repairs on the Afford­able Care Act.”

    While Trump ran on the promise he would repeal Oba­macare, he appears to have soft­ened his view a bit after the elec­tion. Late­ly, he has piv­ot­ed to pledg­ing insur­ance for every­one.

    Speak­er Ryan

    House Speak­er Paul Ryan, a Wis­con­sin Repub­li­can, has also tried out “repair.”

    “We’ve been work­ing with the admin­is­tra­tion on a dai­ly basis to map out and plan a very bold and aggres­sive agen­da to make good on our cam­paign promis­es and to fix these prob­lems — to repeal and replace and repair our bro­ken health care sys­tem,” Ryan said at a news con­fer­ence dur­ing the Philadel­phia retreat.

    Ryan was asked about the “repair” strat­e­gy Thurs­day on Fox & Friends and said there was a “mis­com­mu­ni­ca­tion.”

    “So what kind of got going on here is, I’ve got a con­flu­ence of words,” Ryan said dur­ing the tele­vi­sion inter­view. “To repair the Amer­i­can health-care sys­tem, you have to repeal and replace this law, and that’s what we’re doing.”

    ...

    “Repub­li­cans are grap­pling with their party’s desire — and Pres­i­dent Don­ald Trump’s promise — to dis­man­tle Oba­macare, as well as the polit­i­cal dis­as­ter that could ensue if mil­lions of Amer­i­cans lose cov­er­age as a result of leg­is­la­tion.”

    Yeah, when your par­ty’s sig­na­ture leg­isla­tive agen­da is going to involve mil­lions of vot­ers los­ing their health insur­ance — or at least los­ing mean­ing­ful insur­ance is get­ting throw onto use­less joke plans so Trump can declare that ‘every­one is insured’ — it’s prob­a­bly a good idea to do every­thing you can to avoid the label ‘Trump­care’. Or ‘GOP­care’. Espe­cial­ly when polls are indi­cat­ing that half of Trump vot­ers don’t want Oba­macare repealed (yowza).

    So we’ll see if the GOP real­ly does stick with the ‘repeal and repair’ lan­guage so they can claim they’re offer­ing a ‘repaired Oba­macare’ to vot­ers (that’s going to result in a nation­al health cat­a­stro­phe). While they aren’t com­mit­ted to the rebrand­ing scheme yet they’re def­i­nite­ly tempt­ed. But it’s worth not­ing that there’s one type of Oba­macare repair that it looks like Trump and the GOP are going to have to do right away. Specif­i­cal­ly, repair­ing the dam­age the GOP did to Oba­macare back in 2014 when they removed the insur­er sub­si­dies designed to keep pre­mi­ums downs:

    Talk­ing Points Memo
    DC

    Insur­er Scores A $200M Court Win After GOP Move To Block O’Care Pay­ments

    By Tier­ney Sneed
    Pub­lished Feb­ru­ary 10, 2017, 2:02 PM EDT

    An Ore­gon-based insur­er scored a $214 mil­lion court vic­to­ry this week in a case brought after con­gres­sion­al Repub­li­cans in 2014 hob­bled the fed­er­al gov­ern­men­t’s abil­i­ty to fund an Afford­able Care Act pro­gram.

    The pro­gram, known as risk cor­ri­dors pay­ments, sought to blunt some of the risk insur­ers were tak­ing on in the first three years of Oba­macare’s imple­men­ta­tion. The pro­gram shift­ed mon­ey from insur­ers that over-per­formed on expec­ta­tions to those that under­per­formed. How­ev­er, GOP law­mak­ers insert­ed an amend­ment in must-pass leg­is­la­tion bar­ring the gov­ern­ment from draw­ing fund­ing for the pro­gram from else­where in the Depart­ment of Health and Human Ser­vices to make up any short­falls between the mon­ey col­lect­ed from insur­ers and the mon­ey owed. (Flori­da’s GOP Sen. Mar­co Rubio, pic­tured above, led the charge against the risk cor­ri­dors pro­gram.)

    As a result, insur­ers, on aver­age, have received around 12 per­cent of the pay­ments they have been owed.

    A U.S. Court of Claims ruled Thurs­day that the feds had “breached the con­tract by fail­ing to make full risk cor­ri­dors pay­ments as promised,” and hand­ed over to the Ore­gon insur­ance com­pa­ny Moda the $214 mil­lion sum­ma­ry judge­ment:

    There is no gen­uine dis­pute that the Gov­ern­ment is liable to Moda. Whether under statute or con­tract, the Court finds that the Gov­ern­ment made a promise in the risk cor­ri­dors pro­gram that it has yet to ful­fill. Today, the Court directs the Gov­ern­ment to ful­fill that promise. After all, “to say to [Moda], ‘The joke is on you. You shouldn’t have trust­ed us,’ is hard­ly wor­thy of our great gov­ern­ment.” Brandt v. Hick­el, 427 F.2d 53, 57 (9th Cir. 1970).

    In effect an attack against the ACA Repub­li­cans launched under Pres­i­dent Oba­ma is now a mess that Pres­i­dent Trump’s admin­is­tra­tion will need to clean up.

    ...

    There are a few oth­er per­co­lat­ing law­suits brought by insur­ers against the U.S. gov­ern­ment for the short­falls in the pay­ments. Accord­ing to Uni­ver­si­ty of Michi­gan Law School pro­fes­sor Nicholas Bagley, the major ques­tion isn’t whether courts will side with insur­ers (he believes they will), it is how law­mak­ers will move for­ward in mak­ing the pay­ments as the insur­er vic­to­ries pile up in court. Bagley esti­mat­ed that gov­ern­ment could ulti­mate­ly be on the hook for as much as $15 bil­lion in total.

    “Refus­ing to pay is a shab­by way to treat insur­ers, which entered the exchanges in reliance on the fed­er­al government’s promis­es,” Bagley wrote at the blog, Inci­den­tal Econ­o­mist. “Our pres­i­dent, how­ev­er, has a track record of stiff­ing busi­ness part­ners. I wouldn’t be sur­prised if he signed a law doing just that.”

    “In effect an attack against the ACA Repub­li­cans launched under Pres­i­dent Oba­ma is now a mess that Pres­i­dent Trump’s admin­is­tra­tion will need to clean up.”

    Yep, if the GOP was actu­al­ly going to repair Oba­macare, it would most­ly involve undo­ing the dam­age the GOP did to it. So while they prob­a­bly aren’t going to be using a ‘repeal and repair the dam­age we did — although we can nev­er repair to dam­age to real lives that was done as a con­se­quence of our end­less, and some­times suc­cess­ful, attempts to under­mine Oba­macare by rais­ing pre­mi­ums and restrict­ing access’ slo­gan, it would be much more appro­pri­ate.

    Posted by Pterrafractyl | February 10, 2017, 8:14 pm
  4. One of the big ques­tions for US pol­i­tics as we enter into the Trump era is whether or not Trump’s polit­i­cal oppo­nents will be able to main­tain the his­toric lev­els of activ­i­ty that we’ve seen in the first month. And while it’s impos­si­ble to pre­dict whether or not the anti-Trump inten­si­ty will be sus­tained, it’s worth keep­ing in mind that while a great deal of the pub­lic ani­mos­i­ty towards Trump has to do with the caus­tic nature of Trump’s own per­son­al­i­ty and author­i­tar­i­an lead­er­ship style, a great deal of that oppo­si­tion is also due to the fact that the Trump White House is by and large sim­ply try­ing to imple­ment the clas­sic GOP agen­da. The clas­sic polit­i­cal­ly tox­ic GOP agen­da that gets more and more loathed the more peo­ple learn about it:

    Talk­ing Points Memo
    DC

    GOP Reps Skip Out On Town Halls As O’Care, Trav­el Ban Con­cerns Flare Up

    By Alle­gra Kirk­land
    Pub­lished Feb­ru­ary 6, 2017, 4:05 PM EDT

    Con­stituents request­ing that Rep. Jim­my Dun­can Jr. (R‑TN) hold a town hall on repeal­ing the Afford­able Care Act aren’t being met with a polite brushoff from staffers any­more. Instead, Dun­can’s office has start­ed send­ing out a form let­ter telling them point-blank that he has no inten­tion to hold any town hall meet­ings.

    “I am not going to hold town hall meet­ings in this atmos­phere, because they would very quick­ly turn into shout­ing oppor­tu­ni­ties for extrem­ists, kooks and rad­i­cals,” the let­ter read, accord­ing to a copy obtained by the Maryville Dai­ly Times. “Also, I do not intend to give more pub­lic­i­ty to those on the far left who have so much hatred, anger and frus­tra­tion in them.”

    In the first weeks of the 115th Con­gress, elect­ed offi­cials drop­ping by their home dis­tricts were sur­prised to find town halls packed to the rafters with con­cerned con­stituents. Caught off guard and on cam­era, law­mak­ers were asked to defend Pres­i­dent Don­ald Trump’s immi­gra­tion poli­cies and pro­vide a time­line on repeal­ing and replac­ing the Afford­able Care Act.

    Now, many of them are skip­ping out on these events entire­ly. Some have said large meet­ings are an inef­fec­tive for­mat for address­ing indi­vid­ual con­cerns. Many oth­ers have, like the Pres­i­dent him­self, dis­missed those ques­tion­ing their agen­da as “paid pro­test­ers” or rad­i­cal activists who could pose a phys­i­cal threat.

    Vot­ers turn­ing out to town halls are push­ing back hard on this char­ac­ter­i­za­tion, argu­ing that they rep­re­sent var­ied ide­o­log­i­cal back­grounds and have diverse issues to raise. Con­stituents unable to meet with their elect­ed offi­cials over the week­end told TPM that they’re not attend­ing town hall events to make trou­ble. Instead, they say they want account­abil­i­ty from the peo­ple they pay to rep­re­sent them.

    Kim Mat­toch, a moth­er of three and event plan­ner, told TPM that she tried to go to a Sat­ur­day town hall in Roseville, Cal­i­for­nia with GOP Rep. Tom McClin­tock but couldn’t make it in. The 200-seat the­ater host­ing the event was quick­ly filled to capac­i­ty, leav­ing hun­dreds wait­ing out­side.

    “I’m a con­stituent of McClin­tock and a reg­is­tered Repub­li­can in a very Repub­li­can district—though I don’t real­ly align very well these days with the Repub­li­can Par­ty,” Mat­toch said in a Mon­day phone call. “So I want­ed to go to the town hall because I legit­i­mate­ly had ques­tions for the con­gress­man.”

    Mat­toch said the pro­test­ers wait­ing out­side had a wide range of “legit­i­mate con­cerns.” She per­son­al­ly hoped to ask her rep­re­sen­ta­tive about how the GOP was pro­gress­ing on repeal­ing and replac­ing the ACA and why House Repub­li­cans last week vot­ed to kill a rul­ing aimed at pre­vent­ing coal min­ing debris from end­ing up in water­ways.

    Yet McClin­tock told the Los Ange­les Times that he thought an “anar­chist ele­ment” was present in the crowd out­side his event, and said he was escort­ed to his car by police because he’d been told the atmos­phere was “dete­ri­o­rat­ing.”

    Ramon Fliek, who attend­ed the McClin­tock event with his wife, told TPM on Mon­day that police “were kind enough to block the whole road” to make space for the over­flow crowd, and that he over­heard pro­test­ers thank­ing law enforce­ment for “doing their jobs.”

    “If you look at the videos from the event, you can’t get any notion that it was aggres­sive,” he said. “There was an old­er woman with a poo­dle that ran after him and it’s like, okay, the old­er lady with the poo­dle is not going to threat­en you. I under­stand that he might want to give that impres­sion, but it was very pleas­ant.”

    ...

    “Now, many of them are skip­ping out on these events entire­ly. Some have said large meet­ings are an inef­fec­tive for­mat for address­ing indi­vid­ual con­cerns. Many oth­ers have, like the Pres­i­dent him­self, dis­missed those ques­tion­ing their agen­da as “paid pro­test­ers” or rad­i­cal activists who could pose a phys­i­cal threat.”

    Yep, all these town hall protests are all just “paid pro­test­ers”. At least that’s the nar­ra­tive Trump and the GOP are clear­ly invest­ing in. So if we see sus­tained, or even grow­ing, town hall protests going for­ward, we’re pre­sum­ably going to see a sus­tained and grow­ing right-wing nar­ra­tive that it’s all fake.

    It’s a rather fas­ci­nat­ing tac­tic because, thanks to sur­pris­ing­ly slow progress of the GOP con­gress despite uni­fied con­trol of both cham­bers, there’s been almost no sub­stan­tive leg­is­la­tion passed so the pub­lic has only got­ten a taste of what Trump and the GOP have in store for them. Includ­ing what’s in store for the GOP’s plans to over­haul Amer­i­ca’s health care sys­tem. Plans that go far beyond ‘repeal­ing and replac­ing’ Oba­macare, like the block grant­i­ng of Medicare and Med­ic­aid. We still have yet to see what kind of town hall protests the block grant­i­ng of Medicare and Med­ic­aid will gen­er­ate. But Trump and the GOP would like you to believe that all those future town hall protests are going to be paid fake actors too (you know, like the kind Trump hired for his cam­paign launch).

    So get ready for the GOP to make a sus­tained effort to char­ac­ter­ize its oppo­si­tion as fake. Amer­i­cans, accord­ing to the GOP, don’t actu­al­ly want a guar­an­teed health care safe­ty net:

    CNN

    Trump’s HHS pick: Right to Med­ic­aid may not be guar­an­teed under block grants

    by Tami Luh­by
    Jan­u­ary 24, 2017: 8:58 PM ET

    Pres­i­dent Trump’s health sec­re­tary pick acknowl­edged Tues­day that Med­ic­aid may cease to be an enti­tle­ment for the nation’s low-income res­i­dents if Repub­li­cans turn it into a block grant, send­ing a fixed amount of fund­ing to each state.

    In a con­tentious hear­ing before the Sen­ate Finance Com­mit­tee, Demo­c­ra­t­ic Sen­a­tor Robert Menen­dez pressed nom­i­nee Tom Price on whether chang­ing Med­ic­aid into a block grant pro­gram would mean few­er peo­ple would be eli­gi­ble in the future.

    Menen­dez not­ed Med­ic­aid is cur­rent­ly an enti­tle­ment pro­gram, mean­ing any­one who meets the cri­te­ria has the right to be cov­ered.

    “When you move to a block grant, do you still have the right?” Menen­dez asked.

    “No,” Price said. “I think it would be deter­mined by how that was set up.”

    The ques­tion of what to do with Med­ic­aid — par­tic­u­lar­ly how to han­dle the low-income adults who gained cov­er­age thanks to Oba­macare’s expan­sion pro­vi­sion — came up repeat­ed­ly dur­ing the hear­ing. Trump senior advis­er Kellyanne Con­way said Sun­day on ABC News that the pres­i­dent is look­ing at turn­ing Med­ic­aid into a block grant pro­gram.

    Block grants would give more pow­er over to the states to decide how to give out Med­ic­aid funds and, experts say, reduce over­all fed­er­al spend­ing.

    Demo­c­ra­t­ic sen­a­tors defend­ed the exist­ing pro­gram, which they called cru­cial for many dis­abled Amer­i­cans and low-income preg­nant women, chil­dren and senior cit­i­zens. Near­ly 73 mil­lion Amer­i­cans are on Med­ic­aid or the relat­ed Chil­dren’s Health Insur­ance Pro­gram (CHIP). Under Oba­macare, low-income adults are now allowed to sign up for Med­ic­aid in states that expand­ed their pro­grams.

    Repub­li­cans have long want­ed to turn Med­ic­aid fund­ing into a block grant or a per-capi­ta grant, where states receive a fixed sum for each par­tic­i­pant. Sev­er­al of the Oba­macare repeal plans that have been float­ed in Con­gress — includ­ing Price’s 2015 Empow­er­ing Patients First leg­is­la­tion — also call for elim­i­nat­ing Med­ic­aid expan­sion.

    Trump list­ed turn­ing Med­ic­aid into a block grant pro­gram on his cam­paign and tran­si­tion web­sites, and Con­way’s com­ments Sun­day affirmed that it’s on the top of the new pres­i­den­t’s list.

    Democ­rats fought back at Tues­day’s hear­ing.

    “I feel like the Admin­is­tra­tion is cre­at­ing a war on Med­ic­aid,” said Sen­a­tor Maria Cantwell.

    Price acknowl­edged Med­ic­aid is vital, but said it is trou­bled. Lat­er, he said that the fed­er­al gov­ern­ment should leave it to gov­er­nors and state insur­ance com­mis­sion­ers on how best to cov­er their low-income res­i­dents. But he said he sup­ports mak­ing sure that any replace­ment bill would pro­vide cov­er­age options for every Amer­i­can, includ­ing those now at or near Med­ic­aid eli­gi­bil­i­ty.

    Block grant pro­pos­als usu­al­ly pro­vide more flex­i­bil­i­ty for states to tai­lor their pro­grams to their res­i­dents’ needs. While the fed­er­al gov­ern­ment has set a floor for who must be cov­ered and what ser­vices must be pro­vid­ed, states cur­rent­ly have some lee­way to widen eli­gi­bil­i­ty to more peo­ple and to cov­er more ser­vices. They can also impose some require­ments to qual­i­fy for care, such as man­dat­ing co ‑pay­ments, though the Oba­ma admin­is­tra­tion has turned down some gov­er­nors’ requests.

    Since one goal of block grants is to slow the growth of health care spend­ing, states could like­ly wind up with less fund­ing than they have now. Then they would have to choose how many res­i­dents to cov­er and what ben­e­fits to pro­vide.

    Sup­port­ers wor­ry that will erode the safe­ty net that the nation’s largest health care pro­gram pro­vides.

    “It’s telling states, here’s the amount of mon­ey we’ll give you. You fig­ure out how to take care of 70 mil­lion peo­ple,” said Sara Rosen­baum, pro­fes­sor of health pol­i­cy at George Wash­ing­ton Uni­ver­si­ty.

    But those who want to reform the pro­gram say that block grants will force states to be more effi­cient in cov­er­ing their low-income res­i­dents and end the incen­tive for states to pad their pro­grams in order to receive more fed­er­al fund­ing. Med­ic­aid and CHIP cost $532 bil­lion in fis­cal 2015, with the fed­er­al gov­ern­ment shoul­der­ing 63% of the bill and states pay­ing 37%.

    Low­er­ing the cost of care makes the pro­gram more afford­able, which would poten­tial­ly allow states to cov­er more peo­ple, said Paul Howard, direc­tor of health pol­i­cy at the Man­hat­tan Insti­tute.

    ...

    “Demo­c­ra­t­ic sen­a­tors defend­ed the exist­ing pro­gram, which they called cru­cial for many dis­abled Amer­i­cans and low-income preg­nant women, chil­dren and senior cit­i­zens. Near­ly 73 mil­lion Amer­i­cans are on Med­ic­aid or the relat­ed Chil­dren’s Health Insur­ance Pro­gram (CHIP). Under Oba­macare, low-income adults are now allowed to sign up for Med­ic­aid in states that expand­ed their pro­grams.”

    73 mil­lion Amer­i­cans are on Med­ic­aid or CHIP. And part of the rea­son so many are on the those pro­grams is because they’re a right. But under the Trump/GOP plan, that’s about to change:

    ...

    Menen­dez not­ed Med­ic­aid is cur­rent­ly an enti­tle­ment pro­gram, mean­ing any­one who meets the cri­te­ria has the right to be cov­ered.

    “When you move to a block grant, do you still have the right?” Menen­dez asked.

    “No,” Price said. “I think it would be deter­mined by how that was set up.”

    ...

    So long Med­ic­aid enti­tle­ment. Clear­ly the Amer­i­can peo­ple vot­ed for this.

    Now remem­ber, when Trump and the GOP get ready to make this kind of block grant­i­ng sys­tem into law and we see lots of town hall protests in response, all those protests are paid and don’t actu­al­ly reflect the fact that 73 mil­lion Amer­i­can’s are going to see their access to health care at risk and ALL Amer­i­cans will see that safe­ty-net (that they might need some­day even if they don’t today) on track for per­pet­u­al ero­sion. Yep. Espe­cial­ly after the pub­lic finds out that the block grant­i­ng of Med­ic­aid can lead to things like unpaid com­mu­ni­ty ser­vice work require­ments, and that Trump’s choice for Cen­ters for Medicare and Med­ic­aid Ser­vices admin­is­tra­tor, Seema Ver­ma, designed the pro­gram in Ken­tuck­y’s Med­ic­aid expan­sion pro­gram that has exact­ly that unpaid-work-for-med­ical-ser­vices-for-the-poor require­ment up to 20 hours per week (and this will be unpaid work for the future erod­ed Med­ic­aid ben­e­fits). And then there’s Ohio’s pro­pos­al to strip Med­ic­aid recip­i­ents of cov­er­age for 6 months if they missed a pre­mi­um pay­ment that was also designed by Ver­ma’s firm. Accord­ing to Trump and the GOP, any oppo­si­tion to plans like that must be paid oppo­si­tion:

    The Guardian

    Trump’s pick for key health post known for puni­tive Med­ic­aid plan

    Seema Ver­ma, the president-elect’s choice for Cen­ters for Medicare and Med­ic­aid Ser­vices admin­is­tra­tor, pushed lock­out peri­ods for low-income peo­ple

    Jes­si­ca Glen­za in New York
    Sun­day 4 Decem­ber 2016 07.00 EST Last mod­i­fied on Mon­day 23 Jan­u­ary 2017 05.11 EST

    Seema Ver­ma, Don­ald Trump’s choice to head the two largest pub­lic health insur­ance pro­grams in the US, is a con­ser­v­a­tive dar­ling who has intro­duced work require­ments and lock­out peri­ods for impov­er­ished recip­i­ents into the med­ical safe­ty net in three states.

    A close advis­er to vice-pres­i­dent-elect Mike Pence, Ver­ma – Trump’s nom­i­nee for admin­is­tra­tor of the Cen­ters for Medicare and Med­ic­aid Ser­vices (CMS) – made her name devis­ing Indiana’s Med­ic­aid plan, one of the most puni­tive in the coun­try.

    Med­ic­aid is a pub­lic health pro­gram that ensures America’s poor and dis­abled have health insur­ance. Oba­macare dra­mat­i­cal­ly expand­ed the pro­gram, which now serves more than 73 mil­lion peo­ple.

    The unique require­ments Ver­ma and her con­sul­tan­cy firm SVC Inc designed for Indi­ana require that the des­ti­tute in that state have “skin in the game” by pay­ing “pre­mi­ums”, even if they were just $1.

    In Ken­tucky, her com­pa­ny devel­oped a plan to require the poor to per­form “work activ­i­ty”, which could include unpaid com­mu­ni­ty ser­vice, in order to receive health insur­ance. Approval of that plan is still pend­ing at the CMS, the agency she could soon lead.

    In Ohio, a plan designed by Verma’s com­pa­ny and reject­ed by the cur­rent lead­ers of CMS required peo­ple with low incomes to be barred from pub­lic health insur­ance until all “pre­mi­um” arrears were up to date.

    Her plans were “about sav­ing the dol­lars by any means pos­si­ble”, said Indi­ana Rep­re­sen­ta­tive Char­lie Brown, the rank­ing Demo­c­rat on the pub­lic health com­mit­tee.

    As a con­sul­tant in each state, Ver­ma was the dri­ving force in design­ing Indiana’s “HIP 2.0” pub­lic insur­ance plan for the poor, and is high­ly regard­ed in con­ser­v­a­tive cir­cles because of its empha­sis on per­son­al and fis­cal “respon­si­bil­i­ty”.

    Though her plan expand­ed Med­ic­aid to near­ly 400,000 Hoosiers, she has argued that new recip­i­ents are “able-bod­ied” enough to not need “the same set of pol­i­cy pro­tec­tions” as the “aged, blind, or dis­abled”. Instead, Verma’s plan forces recip­i­ents to pay up to 2% of their income to “pre­mi­ums”, held in a sys­tem sim­i­lar to tax-free accounts avail­able to com­mer­cial plans.

    It is a plan meant to mim­ic the com­mer­cial mar­ket, as a finan­cial les­son for its recip­i­ents. It remains one of the most com­plex and puni­tive Med­ic­aid expan­sions in the coun­try, an out­lier in a sys­tem of state-run safe­ty nets large­ly free for the poor.

    Fur­ther, it is built on the back of the Afford­able Care Act, a law that her poten­tial future boss, Con­gress­man Tom Price, explic­it­ly oppos­es. Trump has nom­i­nat­ed Price to be health sec­re­tary.

    “She’s a hired gun,” said Brown, who described his inter­ac­tion with Ver­ma as “intense and dai­ly”. “That’s what she was in Indi­ana, that’s what the admin­is­tra­tion want­ed – to save dol­lars, and so she comes up with mas­ter­ful plans.” By 2014, Verma’s small com­pa­ny had secured $3.5m in state con­tracts with Indi­ana.

    She is often described as a behind-the-scenes Repub­li­can oper­a­tive. Regard­ed as smart and tal­ent­ed, she is also con­sid­ered sin­gle-mind­ed and con­ser­v­a­tive. She is a reg­is­tered Repub­li­can, and recent­ly agreed to par­tic­i­pate in the “lead­er­ship net­work” of the Amer­i­can Enter­prise Insti­tute, a rightwing think­tank.

    ...

    She and Price, if he is con­firmed by the Sen­ate, will be charged with helm­ing a more than $1.1tn bud­get dom­i­nat­ed by pub­lic health pro­grams for the very poor, dis­abled and elder­ly. Med­ic­aid alone cov­ers more than 73 mil­lion Amer­i­cans, near­ly one-quar­ter of the Amer­i­can pop­u­la­tion. Nei­ther Ver­ma nor a Pence spokesman replied to a request for com­ment.

    Verma’s best known work used a lit­tle-known pro­vi­sion of fed­er­al health law to push con­ser­v­a­tive ideas through despite the Oba­ma admin­is­tra­tion. The strat­e­gy made her an influ­en­tial con­sul­tant to Repub­li­can state admin­is­tra­tions.

    In Indi­ana, for exam­ple, some of the most con­tro­ver­sial pro­vi­sions of the state’s law were pushed through using this obscure 1115, or “eleven-fif­teen”, waiv­er. While Obama’s admin­is­tra­tor of the Cen­ters for Medicare and Med­ic­aid Ser­vices did not approve all of Verma’s plans – a puni­tive pro­vi­sion devel­oped with Ohio was denied – some were suc­cess­ful. Oth­ers are still pend­ing the approval of an agency she may soon run.

    “One exam­ple of a pro­vi­sion in Indi­ana, which I think is very severe, bur­den­some, and in fact does not pro­mote the objec­tives of the Med­ic­aid pro­gram, [is] if some­one [can’t pay pre­mi­ums], they get kicked off the pro­gram,” said Andrea Cal­low, a pol­i­cy ana­lyst at Fam­i­lies USA, a not-for-prof­it orga­ni­za­tion focused on con­sumer health.

    Pre­mi­ums are typ­i­cal of com­mer­cial insur­ance plans – they require ben­e­fi­cia­ries to make a month­ly pay­ment. But Med­ic­aid recip­i­ents typ­i­cal­ly do not pay pre­mi­ums because their incomes are so low. The Med­ic­aid expan­sion car­ried out under Oba­macare allows peo­ple to earn a salary of about 138% of the pover­ty lev­el, about $16,000 for an indi­vid­ual, and remain eli­gi­ble.

    In Indi­ana, if peo­ple on Med­ic­aid earn­ing between $11,000 and $16,000 don’t pay their “pre­mi­ums”, they can be locked out of the pro­gram for up to six months, a pro­vi­sion even com­mer­cial insur­ance does not impose.

    “If some­one can’t scrape up the mon­ey for pre­mi­ums for two months, they get dis-enrolled, and they get locked out for six months,” said Kal­low. “Then say they get can­cer, they get hit by a truck, they have an acci­dent. They have absolute­ly no place to turn for health cov­er­age.”

    Kentucky’s 1115 waiv­er, on which Verma’s com­pa­ny SVC also con­sult­ed, proved equal­ly com­plex and even more con­tro­ver­sial. The state asked CMS to allow Ken­tucky to impose work require­ments begin­ning three months after ben­e­fits began, some­thing no state in the coun­try requires as a con­di­tion of Med­ic­aid.

    “Kentucky’s new expan­sion pro­pos­al has work require­ments,” said Kal­low, “There’s even sort of unpaid com­mu­ni­ty ser­vice, which is very trou­bling.”

    After three months, “able-bod­ied” adults of work­ing age would need to par­tic­i­pate in a “work activ­i­ty” for at least five hours per week. After one year, that require­ment would increase to up to 20 hours per week. If that require­ment were not met, the state could end the person’s ben­e­fits.

    “There seemed to be a paral­y­sis of analy­sis as it relates to the down­trod­den, those who are in the great­est needs,” said Brown.

    Dur­ing a pub­lic com­ment peri­od on Kentucky’s 1115 waiv­er, 90% of the 1,700 com­ments received were neg­a­tive. Ana­lysts also con­tend that such require­ments mean build­ing a new, large bureau­cra­cy just to track whether Med­ic­aid ben­e­fi­cia­ries are com­ply­ing.

    “I have no prob­lem with the per­son­al respon­si­bil­i­ty fea­tures to the extent that they improve out­comes,” said Ed Clere, for­mer Repub­li­can chair of the Indi­ana House pub­lic health com­mit­tee. “One of the big ques­tions going for­ward, both for Indi­ana and now for the coun­try, will be: is there a link between these per­son­al respon­si­bil­i­ty fea­tures in the way of finan­cial par­tic­i­pa­tion and improved healthy out­comes?

    “I haven’t seen any evi­dence.”

    ...

    “Dur­ing a pub­lic com­ment peri­od on Kentucky’s 1115 waiv­er, 90% of the 1,700 com­ments received were neg­a­tive. Ana­lysts also con­tend that such require­ments mean build­ing a new, large bureau­cra­cy just to track whether Med­ic­aid ben­e­fi­cia­ries are com­ply­ing.”

    That 90 per­cent oppo­si­tion to Ken­tuck­y’s Med­ic­aid free-work require­ment dur­ing the pub­lic com­ment peri­od? Yeah, that was all paid fake oppo­si­tion. The pub­lic is actu­al­ly real­ly excit­ed about turn­ing its enti­tle­ment pro­grams and health care safe­ty-net into a pub­lic works(for free) sys­tem. Uh huh.

    And if the plan to make Med­ic­aid recip­i­ents pay a pre­mi­um, along with the threat that they lose their cov­er­age if they miss a pay­ment, does­n’t scare you because that plan was­n’t approved by the Cen­ters for Medicare and Med­ic­aid Ser­vices (CMS), don’t for­get that Seem is set to the the CMS’s next admin­is­tra­tor so such plans should be a prob­lem for Ohio or any oth­er state in the future after the GOP block grants the pro­gram:

    ...

    The unique require­ments Ver­ma and her con­sul­tan­cy firm SVC Inc designed for Indi­ana require that the des­ti­tute in that state have “skin in the game” by pay­ing “pre­mi­ums”, even if they were just $1.

    In Ken­tucky, her com­pa­ny devel­oped a plan to require the poor to per­form “work activ­i­ty”, which could include unpaid com­mu­ni­ty ser­vice, in order to receive health insur­ance. Approval of that plan is still pend­ing at the CMS, the agency she could soon lead.

    In Ohio, a plan designed by Verma’s com­pa­ny and reject­ed by the cur­rent lead­ers of CMS required peo­ple with low incomes to be barred from pub­lic health insur­ance until all “pre­mi­um” arrears were up to date.

    ...

    So get ready for Med­ic­aid to get block grant­ed and turned into a nation­al race to the bot­tom where nick­le-and-dim­ing the poor (so your state has an excuse to tem­porar­i­ly deny them health care cov­er­age) becomes the norm. And get ready for Trump and the GOP to declare the oppo­si­tion to this vision fake and ille­git­i­mate.

    And don’t for­get that Med­ic­aid isn’t the only pro­gram the GOP is plan­ning on block grant­i­ng. Medicare is also on the block grant chop­ping block. And while the kind of ‘kick the poor’ pro­vi­sions that could get tacked into Med­ic­aid will prob­a­bly be replaced with dif­fer­ent kinds of ‘soak the mid­dle class’ pro­vi­sions for a block grant­ed Medicare, don’t for­get that one of Don­ald Trump’s favorite things to rail against dur­ing his cam­paign was the 96 mil­lion Amer­i­cans out of work. And while there are indeed 96 mil­lion unem­ployed Amer­i­cans age 16 and old­er out of work in the US, that’s only if you count stu­dents, retirees, dis­abled, stay-at-home par­ents or oth­er­wise not in the work­force. So who knows, maybe all those retired peo­ple on Medicare will some day be expect­ed to get a job or do 20 hours of free work to keep that Medicare cov­er­age. And if they miss a pre­mi­um pay­ment they’ll lose cov­er­age for 6 months. And if they get sick dur­ing that peri­od of lapsed cov­er­age and get bank­rupt­ed in health care costs they’ll get kicked to the joke Med­ic­aid sys­tem of the future. Hope­ful­ly Medicare in the future will cov­er anx­i­ety dis­or­ders because there’s going to be a lot of it (don’t count on it).

    Also keep in mind that this loom his­toric shift in how Amer­i­cans design their pub­lic sys­tems — from pub­lic goods to puni­tive miser­ly for-prof­it-in-spir­it pro­grams intend­ed to keep tax­es low — and the pos­si­bil­i­ty that work require­ments is going to be one of the hot new ways to cut costs (it kicks the poor so it could be pop­u­lar with some peo­ple) is going to be tak­ing place dur­ing a time when there’s grow­ing con­cern that tech­nolo­gies like advanced AI and robot­ics is going to steadi­ly erode a grow­ing num­ber of job oppor­tu­ni­ties, lead­ing to an even­tu­al sys­temic cri­sis. Whether or not that’s going to hap­pen is very spec­u­la­tive and depends quite a big on whether or not the pub­lic decides to cre­ate jobs for peo­ple (or sup­port indus­try that will cre­ate jobs that can’t get auto­mat­ed). So the GOP’s plan to put peo­ple to work for crap pub­lic ser­vices (which are no longer enti­tle­ments) could even­tu­al­ly be coin­cid­ing with a peri­od where there real­ly is going to be a grow­ing need to a gov­ern­ment as employ­er of last resort mod­el.

    A poten­tial future employ­ment cri­sis brought on by automa­tion also inter­sects with anoth­er key aspect of the GOP’s health care reform agen­da: the voucher­iza­tion of Medicare and Med­ic­aid that Paul Ryan sees as the end goal. And vouch­ers have a lot in com­mon with uni­ver­sal basic incomes, anoth­er idea that’s being increas­ing­ly talked about as a mod­el for pos­si­bly nec­es­sary tool for a post-employ­ment soci­ety. And there are two very dif­fer­ent approach­es to the uni­ver­sal basic income. A pro­gres­sive approach adding a uni­ver­sal income on top of a strong safe­ty-net. And the the right-wing ver­sion of the UBI pro­mot­ed by peo­ple like Charles Mur­ray where all social safe­ty-net pro­grams are replaced with a check (Mur­ray pro­posed a year­ly $10,000 check when Mur­ray wrote a book about it in 2006, which would be dev­as­tat­ing for the poor).

    So assum­ing the GOP pro­ceeds ahead with their Medicare and Med­ic­aid block grant­i­ng schemes, it’s going to be impor­tant to keep in mind that this is all going to be play­ing into the anx­i­ety, war­rant­ed or not, about automa­tion and future job­less­ness. It also plays into the GOP’s larg­er long-term agen­da of pri­va­tiz­ing social ser­vices. If Amer­i­cans screw up this Medicare and Med­ic­aid reform peri­od and go down the path of block grants and, even­tu­al­ly, voucher­iza­tion, we’re also on track for a real­ly crap­py ver­sion of the uni­ver­sal basic income if the feared robot employ­ment-poca­lypse comes to pass decades from now. But if there is a future employ­ment issue (or a future liv­ing wage issue where there are plen­ty of super-low pay­ing jobs an that’s most­ly it), a uni­ver­sal basic income could be a real­ly use­ful pub­lic good. So it’s also going to keep in mind that the inevitable dis­cus­sion about uni­ver­sal basic incomes is going to have to make it clear that the right-wing plan to use a uni­ver­sal basic income to replace pro­grams like Medicare and Med­ic­aid and the over­all social safe­ty-net is a real­ly bad idea. And for many of the same rea­son block grant­i­ng and even­tu­al­ly voucher­iz­ing Medicare and Med­ic­aid is a bad idea.

    So let’s hope all those town hall pro­tes­tors and the broad­er pub­lic suc­ceed in keep­ing the block grant­i­ng of Med­ic­aid and Medicare from com­ing to pass and even­tu­al­ly fixed them (once the Trumpoca­lypse is over hope­ful­ly). That will put the US on a much bet­ter path, not just for health care tomor­row but also the pos­si­ble automa­tion night­mare of the future. And don’t for­get that if we’re ever forced to start hav­ing the gov­ern­ment think of job for peo­ple to do, doing what the town hall pro­tes­tors are doing is prob­a­bly one of the most use­ful things we could have peo­ple do. Just lob­by­ing our elect­ed offi­cials. Pub­lic lob­by­ists poten­tial­ly paid for by a uni­ver­sal basic income + pub­lic ser­vices. No boss­es required. Would­n’t that be fun way to run a democ­ra­cy in the future if the robots take all our jobs? If you don’t have a job, you can have a nice basic income (plus ser­vices) and you just become informed and then lob­by the gov­ern­ment. And vote when­ev­er pos­si­ble.

    The uni­ver­sal basic income and automa­tion top­ic isn’t going away (Elon Musk just pre­dict­ed the need for the UBI due to automa­tion again, but won­dered if peo­ple would find mean­ing in their lives with­out a job) and nei­ther is the GOP’s ongo­ing gov­ern­ment pri­va­ti­za­tion push. And both issues are inter­twined in ways that are direct­ly relat­ed to the cur­rent Medicare/Medicaid block grant­i­ng agen­da (that could lead to work require­ments) that Trump and his cab­i­net offi­cials all sup­port and helped pio­neer. So let’s not for­get that the UBI debate ties into the health care reform debate (espe­cial­ly the loom­ing work require­ment debate) and let’s also not for­get that if we feel the need ask peo­ple to work in order to get pub­lic ser­vices, there’s one job we all need as many peo­ple as pos­si­ble to do and it’s the job that those pro­tes­tors at the town halls were doing. Let’s not for­get that.

    Imag­ine all the dif­fer­ent areas of gov­ern­ment pol­i­cy that could use a large num­ber of ran­dom aver­age peo­ple keep­ing and eye on and effec­tive­ly lob­by­ing in the pub­lic good. If we ever have a uni­ver­sal basic income, let’s just declare being a pub­lic lob­by­ist the default job. The impact of a robust UBI + pub­lic ser­vice soci­ety that gives peo­ple lots of time to get informed, get orga­nized, and lob­by their gov­ern­ment could lead to a flood of new peo­ple get­ting involved with their gov­ern­ment. Imag­ine how many ran­dom peo­ple would end up run­ning for office. It will be a lot eas­i­er for aver­age peo­ple to run for office with a UBI + pub­lic ser­vices, espe­cial­ly if those pub­lic ser­vices include high qual­i­ty free edu­ca­tion (not like­ly).

    So while those pro­tes­tors weren’t actu­al­ly get­ting paid that like Trump and the GOP are shame­less­ly claim­ing, they should have been. They should have been paid a basic income and offered a bunch of pub­lic ser­vices so they could have lots of time to edu­cate them­selves about things like the GOP’s tox­ic agen­da, edu­cate the pub­lic (much of which is also act­ing as pub­lic lob­by­ist) about what they learned, and then edu­cate their elect­ed offi­cials.

    Posted by Pterrafractyl | February 19, 2017, 12:21 am
  5. You know how Don­ald Trump pre­vi­ous­ly indi­cat­ed he’s in favor of Medicare direct­ly nego­ti­at­ing drug prices with drug man­u­fac­tur­ers, but then flipped and sug­gest­ed that was “price fix­ing”, only to appar­ent­ly flip back. Well, if Seema Ver­ma, Trump’s pick to lead the Cen­ter for Med­ic­aid & Medicare Ser­vices and one of the GOP’s go-to indi­vid­u­als for design­ing kick-the-poor health care poli­cies, is any indi­ca­tion of what Trump’s final posi­tion on the mat­ter will be, there may be anoth­er flip in store for Trump’s stance on Medicare and drug prices:

    The Hill

    Trump’s pick to lead Medicare won’t say if she sup­ports nego­ti­at­ing prices with drug com­pa­nies

    By Jessie Hell­mann
    02/16/17 11:03 AM EST

    Seema Ver­ma, Pres­i­dent Trump’s pick to lead the Cen­ter for Med­ic­aid & Medicare Ser­vices, dodged ques­tions Thurs­day about whether she sup­ports the fed­er­al gov­ern­ment nego­ti­at­ing drug prices for its pub­lic health pro­grams.

    Dur­ing her con­fir­ma­tion hear­ing before the Sen­ate Finance Com­mit­tee, Ver­ma said increased com­pe­ti­tion could low­er drug prices for seniors but did not say she sup­ports allow­ing the fed­er­al gov­ern­ment to nego­ti­ate with drug com­pa­nies.

    “I think that com­pe­ti­tion is the key to get­ting good prices,” Ver­ma told Sen. Deb­bie Stabenow (D‑Mich.).

    Pressed on whether she sup­ports nego­ti­a­tion, Ver­ma said, “I don’t think that’s a sim­ple yes or no answer.”

    “The goal is to make sure we’re get­ting afford­able prices for our seniors,” she said.

    “I think we have to fig­ure out ways about how we can increase our com­pe­ti­tion and sup­port the (Medicare) Part D pro­gram.”

    ...

    “Dur­ing her con­fir­ma­tion hear­ing before the Sen­ate Finance Com­mit­tee, Ver­ma said increased com­pe­ti­tion could low­er drug prices for seniors but did not say she sup­ports allow­ing the fed­er­al gov­ern­ment to nego­ti­ate with drug com­pa­nies.”

    It sounds like the Trump team might be get­ting cold feet about Medicare nego­ti­at­ing drug prices again. It’s unclear how much Seema Ver­ma’s answers, or lack there­of, dur­ing the con­fir­ma­tion hear­ings reflect Trump’s think­ing on these mat­ters. Espe­cial­ly since it’s very unclear what Trump’s think­ing on these mat­ters is at all is at this point:

    The Wash­ing­ton Post

    Cum­mings: ‘No idea why Pres­i­dent Trump would make up a sto­ry about me like he did today’

    By Jen­na Port­noy Feb­ru­ary 16

    Rep. Eli­jah E. Cum­mings swat­ted away Pres­i­dent Trump’s claim that the Bal­ti­more Demo­c­rat wouldn’t meet with him after repeat­ed calls from the White House.

    Trump made the com­ment dur­ing a wide-rang­ing news con­fer­ence Thurs­day and spec­u­lat­ed that Cum­mings may have been dis­suad­ed from com­ing to the White House for polit­i­cal rea­sons, per­haps by Sen­ate Minor­i­ty Leader Charles E. Schumer (D‑N.Y.), whom Trump dis­missed as a “light­weight.”

    “I have no idea why Pres­i­dent Trump would make up a sto­ry about me like he did today. Of course, Sen­a­tor Schumer nev­er told me to skip a meet­ing with the Pres­i­dent,” Cum­mings said in a state­ment.

    Trump said Cum­mings “was all excit­ed and then he said, ‘Well, I can’t move, it might be bad for me polit­i­cal­ly. I can’t have that meet­ing.’ ”

    Trump con­tin­ued: “But he prob­a­bly was told by Schumer or some­body like that — some oth­er light­weight. ... He was prob­a­bly told: ‘Don’t meet with Trump. It’s bad pol­i­tics.’ And that’s part of the prob­lem with this coun­try.”

    The mus­ings came in response to a ques­tion about whether Trump would meet with the Con­gres­sion­al Black Cau­cus — of which Cum­mings is a high-pro­file mem­ber — to dis­cuss crime in poor, urban areas.

    The 11-term con­gress­man and rank­ing Demo­c­rat on the House Over­sight and Gov­ern­ment Reform Com­mit­tee said he planned to talk to Trump about the sky­rock­et­ing cost of pre­scrip­tion drugs.

    But first, he said, he want­ed to final­ize a pro­pos­al he has been work­ing on with Sen. Bernie Sanders (I‑Vt.) to allow the Depart­ment of Health and Human Ser­vices to nego­ti­ate drug prices — a con­cept that Cum­mings says Trump has sup­port­ed.

    “I also sin­cere­ly have no idea why the Pres­i­dent made this claim in response to an unre­lat­ed ques­tion about the Con­gres­sion­al Black Cau­cus. I am sure mem­bers of the CBC can answer these ques­tions for them­selves,” the congressman’s state­ment said.

    Cum­mings not­ed that pre­scrip­tion drugs affect “every Amer­i­can fam­i­ly — not just peo­ple of col­or.”

    The con­gress­man told reporters on Capi­tol Hill on Thurs­day after­noon that his office is work­ing on set­ting up a meet­ing. “We’re look­ing for­ward to it,” he said. “I’m excit­ed about meet­ing with the pres­i­dent. He’s my pres­i­dent, and I’m excit­ed about meet­ing with him.”

    ...

    ““I have no idea why Pres­i­dent Trump would make up a sto­ry about me like he did today. Of course, Sen­a­tor Schumer nev­er told me to skip a meet­ing with the Pres­i­dent,” Cum­mings said in a state­ment.”

    Accord­ing to Trump, Rep. Eli­jah Cum­mings decid­ed to pull out of talks with the White House about how to move for­ward on low­er drug costs because ‘it was bad for him polit­i­cal­ly’, and Cum­mings told Trump this as his expla­na­tion. And Trump told every­one this in response to a ques­tion about whether or not Trump would meet with the Con­gres­sion­al Black Cau­cus dur­ing his wacky press con­fer­ence:

    ...

    Trump said Cum­mings “was all excit­ed and then he said, ‘Well, I can’t move, it might be bad for me polit­i­cal­ly. I can’t have that meet­ing.’ ”

    Trump con­tin­ued: “But he prob­a­bly was told by Schumer or some­body like that — some oth­er light­weight. ... He was prob­a­bly told: ‘Don’t meet with Trump. It’s bad pol­i­tics.’ And that’s part of the prob­lem with this coun­try.”

    The mus­ings came in response to a ques­tion about whether Trump would meet with the Con­gres­sion­al Black Cau­cus — of which Cum­mings is a high-pro­file mem­ber — to dis­cuss crime in poor, urban areas.
    ...

    And what did Eli­jah Cum­mings say about this? Sim­ply that he has no idea what the hell Trump is talk­ing about, there was no can­celed meet­ing, but he did have a planned meet­ing over drug prices that was get­ting deferred until Cum­mings and Bernie Sanders worked out a pro­pos­al that allow for the Depart­ment of Health and Human Ser­vices to nego­ti­ate drug prices:

    ...

    The 11-term con­gress­man and rank­ing Demo­c­rat on the House Over­sight and Gov­ern­ment Reform Com­mit­tee said he planned to talk to Trump about the sky­rock­et­ing cost of pre­scrip­tion drugs.

    But first, he said, he want­ed to final­ize a pro­pos­al he has been work­ing on with Sen. Bernie Sanders (I‑Vt.) to allow the Depart­ment of Health and Human Ser­vices to nego­ti­ate drug prices — a con­cept that Cum­mings says Trump has sup­port­ed.

    “I also sin­cere­ly have no idea why the Pres­i­dent made this claim in response to an unre­lat­ed ques­tion about the Con­gres­sion­al Black Cau­cus. I am sure mem­bers of the CBC can answer these ques­tions for them­selves,” the congressman’s state­ment said.

    ...

    Eli­jah Cum­mings express­es a desire to work with Trump on drugs, works with Sanders on a pro­pos­al to bring to Trump for gov­ern­ment drug price nego­ti­a­tion, and Trump makes up a weird fake anec­dote dur­ing his off the wall press con­fer­ence about Cum­mings can­cel­ing meet­ing due to bad pol­i­tics. And then Trump sug­gests Chuck Schumer rec­om­mend­ed to Cum­mings that he can­cel the meet­ing. And this is all in response to an unre­lat­ed ques­tion about the Con­gres­sion­al Black Cau­cus.

    So, hope­ful­ly the nego­ti­a­tions in Trump’s alter­nate real­i­ty go well, but in the actu­al real­i­ty it looks like Trump stance on drug prices is to make up alter­na­tive real­i­ty expla­na­tions for why he can’t nego­ti­ate.

    Posted by Pterrafractyl | February 19, 2017, 9:18 pm
  6. Here’s a leak that does­n’t involve the Trump admin­is­tra­tion. At least not direct­ly, but since it’s a leak about the Oba­macare replace­ment that the House GOP has in mind it’s very Trump-relat­ed. It’s the plan for Trump­care. Although Ryan­care is prob­a­bly a more appro­pri­ate name:
    Politi­co

    Exclu­sive: Leaked GOP Oba­macare replace­ment shrinks sub­si­dies, Med­ic­aid expan­sion

    The replace­ment would be paid for by lim­it­ing tax breaks on gen­er­ous health plans peo­ple get at work.

    By Paul Demko

    02/24/17 11:07 AM EST

    Updat­ed 02/24/17 03:10 PM EST

    A draft House Repub­li­can repeal bill would dis­man­tle the Oba­macare sub­si­dies and scrap its Med­ic­aid expan­sion, accord­ing to a copy of the pro­pos­al obtained by POLITICO.

    The leg­is­la­tion would take down the foun­da­tion of Oba­macare, includ­ing the unpop­u­lar indi­vid­ual man­date, sub­si­dies based on people’s income, and all of the law’s tax­es. It would sig­nif­i­cant­ly roll back Med­ic­aid spend­ing and give states mon­ey to cre­ate high risk pools for some peo­ple with pre-exist­ing con­di­tions. Some ele­ments would be effec­tive right away; oth­ers not until 2020.

    The replace­ment would be paid for by lim­it­ing tax breaks on gen­er­ous health plans peo­ple get at work — an idea that is sim­i­lar to the Oba­macare “Cadil­lac tax” that Repub­li­cans have fought to repeal.

    Speak­er Paul Ryan said last week that Repub­li­cans would intro­duce repeal leg­is­la­tion after recess. But the GOP has been deeply divid­ed about how much of the law to scrap, and how much to “repair,” and the heat­ed town halls back home dur­ing the week­long recess aren’t mak­ing it any eas­i­er for them.

    The key House com­mit­tees declined to com­ment on specifics of a draft that will change as the bill moves through the com­mit­tees. The speak­er’s office deferred to the House com­mit­tees.

    In place of the Oba­macare sub­si­dies, the House bill start­ing in 2020 would give tax cred­its — based on age instead of income. For a per­son under age 30, the cred­it would be $2,000. That amount would dou­ble for ben­e­fi­cia­ries over the age of 60, accord­ing to the pro­pos­al. A relat­ed doc­u­ment notes that HHS Sec­re­tary Tom Price wants the sub­si­dies to be slight­ly less gen­er­ous for most age groups.

    The Repub­li­can plan would also elim­i­nate Obamacare’s Med­ic­aid expan­sion in 2020. States could still cov­er those peo­ple if they chose but they’d get a lot less fed­er­al mon­ey to do so. And instead of the cur­rent open-end­ed fed­er­al enti­tle­ment, states would get capped pay­ments to states based on the num­ber of Med­ic­aid enrollees.

    Anoth­er key piece of the Repub­li­can pro­pos­al: $100 bil­lion in “state inno­va­tion grants” to help sub­si­dize extreme­ly expen­sive enrollees. That aims to address at least a por­tion of the “pre-exist­ing con­di­tion” pop­u­la­tion, though with­out the same broad pro­tec­tions as in the Afford­able Care Act.

    It also would elim­i­nate Planned Par­ent­hood fund­ing, which could be an obsta­cle if the bill gets to the Sen­ate. And it leaves deci­sions about manda­to­ry or essen­tial ben­e­fits to the states.

    Accord­ing to the doc­u­ment, there’s only one sin­gle rev­enue gen­er­a­tor to pay for the new tax cred­its and grants. Repub­li­cans are propos­ing to cap the tax exemp­tion for employ­er spon­sored insur­ance at the 90th per­centile of cur­rent pre­mi­ums. That means ben­e­fits above that lev­el would be taxed.

    And while health care econ­o­mists on both sides of the aisle favor tax-lim­its along those lines, polit­i­cal­ly it’s a hard sell. Both busi­ness­es and unions fought the Oba­macare coun­ter­part, dubbed the Cadil­lac tax.

    The doc­u­ment is more detailed than the gen­er­al pow­er­point House lead­ers cir­cu­lat­ed before the recess. Law­mak­ers are still in dis­agree­ment about sev­er­al key issues, includ­ing Med­ic­aid and the size and form of sub­si­dies. Dis­cus­sions with­in the House, and between House lead­ers and the White House about the final pro­pos­al are ongo­ing. Pres­i­dent Don­ald Trump, who gives a major speech to Con­gress on Tues­day night, has said he expects a plan will emerge in ear­ly to mid March.

    The exact details of any leg­is­la­tion will also be shaped by find­ings from the CBO about how much it will cost and what it will do to the fed­er­al deficit.

    But the draft shows that Repub­li­cans are stick­ing close­ly to pre­vi­ous plans float­ed by Ryan and Price in craft­ing their Oba­macare repeal pack­age.

    “Oba­macare has failed,” said HHS spokesper­son Caitlin Oak­ley. “We wel­come any and all efforts to repeal and replace it with real solu­tions that put patients first and back in charge of their health care rather than gov­ern­ment bureau­crats in Wash­ing­ton, D.C.”

    Oth­er changes pro­posed by Repub­li­cans align with pre­vi­ous ideas for strength­en­ing the indi­vid­ual insur­ance mar­ket, which has been unsta­ble under Oba­macare with ris­ing pre­mi­ums and dwin­dling com­pe­ti­tion. For exam­ple, the leg­is­la­tion would allow insur­ers to charge old­er cus­tomers up to five times as much as their younger coun­ter­parts. Cur­rent­ly, they can only charge them three times as much in pre­mi­ums. The insur­ers have been push­ing for that change.

    The pro­pos­al also includes penal­ties for indi­vid­u­als who fail to main­tain cov­er­age con­tin­u­ous­ly. If their cov­er­age laps­es and they decide to re-enroll, they would have to pay a 30 per­cent boost in pre­mi­ums for a year. Like the unpop­u­lar indi­vid­ual man­date, that penal­ty is designed to dis­cour­age indi­vid­u­als from wait­ing until they get sick to get cov­er­age.

    ...

    Recent polling has shown that Oba­macare is increas­ing­ly pop­u­lar. Sup­port­ers of the health care law have been turn­ing out by the hun­dreds at town hall meet­ings across the coun­try to demand that Repub­li­cans answer ques­tions about what’s going to hap­pen to the 20 mil­lion indi­vid­ual who have gained cov­er­age under Oba­macare.

    Accord­ing to the lat­est Kaiser Fam­i­ly Foun­da­tion track­ing poll, released Fri­day morn­ing, the pub­lic now views the Afford­able Care Act more favor­ably than it has since the sum­mer of its enact­ment. Some 48 per­cent view the law favor­ably — up from 43 per­cent in Decem­ber. About 42 per­cent have an unfa­vor­able view of the ACA — down from 46 per­cent in Decem­ber. The poll­sters say Inde­pen­dents are most­ly respon­si­ble for the shift. A sep­a­rate bpoll by the Pew Research Cen­ter found 54 per­cent approve of the health care law — the high­est scores for Oba­macare in the pol­l’s his­to­ry. Mean­while, 43 per­cent said they dis­ap­prove.

    “But the draft shows that Repub­li­cans are stick­ing close­ly to pre­vi­ous plans float­ed by Ryan and Price in craft­ing their Oba­macare repeal pack­age.”

    Stick­ing with the Ryan plan. Oh joy. Now, instead of Oba­macare, Amer­i­cans will get awe­some fea­tures like replac­ing the Oba­macare sub­si­dies for low­er-income peo­ple, they’ll get a tax cred­it. $2,000 a year if you’re under 30 and a whole $4,000 if you’re over 60:

    ..

    In place of the Oba­macare sub­si­dies, the House bill start­ing in 2020 would give tax cred­its — based on age instead of income. For a per­son under age 30, the cred­it would be $2,000. That amount would dou­ble for ben­e­fi­cia­ries over the age of 60, accord­ing to the pro­pos­al. A relat­ed doc­u­ment notes that HHS Sec­re­tary Tom Price wants the sub­si­dies to be slight­ly less gen­er­ous for most age groups.

    ...

    And then there’s the Med­ic­aid expan­sion get­ting repealed. Plus the entire Med­ic­aid sys­tem get­ting block-grant­ed (which means states are going to be respon­si­ble for pay­ing for a greater and greater per­cent­age of the total Med­ic­aid spend­ing as fed­er­al con­tri­bu­tions don’t grow ade­quate­ly):

    ...
    The Repub­li­can plan would also elim­i­nate Obamacare’s Med­ic­aid expan­sion in 2020. States could still cov­er those peo­ple if they chose but they’d get a lot less fed­er­al mon­ey to do so. And instead of the cur­rent open-end­ed fed­er­al enti­tle­ment, states would get capped pay­ments to states based on the num­ber of Med­ic­aid enrollees.
    ...

    And remem­ber get­ting denied cov­er­age for pre-exist­ing con­di­tions? It’s back. But don’t wor­ry because now states will cre­ate high-risk pools for all the peo­ple with pre-exist­ing con­di­tions to join. Hope­ful­ly. Every­one is pret­ty sure they’ll be under­fund­ed to maybe you won’t be able to join. And maybe it’ll be expen­sive. But it’ll be there. Instead of the Oba­macare ban on denial of cov­er­age for pre-exist­ing con­di­tions:

    ...
    Anoth­er key piece of the Repub­li­can pro­pos­al: $100 bil­lion in “state inno­va­tion grants” to help sub­si­dize extreme­ly expen­sive enrollees. That aims to address at least a por­tion of the “pre-exist­ing con­di­tion” pop­u­la­tion, though with­out the same broad pro­tec­tions as in the Afford­able Care Act.
    ...

    It also elim­i­nates fund­ing for Planned Par­ent­hood, guar­an­tee­ing a health­care cri­sis for women and chil­dren across the coun­try. And all the spe­cif­ic cuts that will have to come from the repeal of the Med­ic­aid expan­sion and pay­ing for spend­ing on high-risk pools will be up to the states:

    ...
    It also would elim­i­nate Planned Par­ent­hood fund­ing, which could be an obsta­cle if the bill gets to the Sen­ate. And it leaves deci­sions about manda­to­ry or essen­tial ben­e­fits to the states.

    ...

    All that and more awful­ness is what Trump and the GOP is seri­ous­ly going to try to ped­dle to the pub­lic. Trump bet­ter hope every­one is focused on his ties to Rus­sia while this plan is put into law because this is prob­a­bly more polit­i­cal­ly tox­ic. It’s the decon­struc­tion of the admin­is­tra­tive state, as Steve Ban­non would put it, get­ting under­way for health care.

    And all those future cuts are going to get decid­ed by the states. Future undoubt­ed­ly bru­tal cuts because they’ll be cuts for pro­grams like Med­ic­aid where the peo­ple see­ing their sup­port cut are the least able to com­pen­sate. And the new high-risk pool scheme to allow for a return of denial of cov­er­age for pre-exist­ing is guar­an­teed to bring about a new peri­od of US pol­i­tics where health-care spend­ing crises are a per­ma­nent fix­ture for a grow­ing num­ber of states until the safe­ty net is shred­ded and poten­tial­ly tens of mil­lions lose their access to health care as a result of those cuts. Cuts year after year. All select­ed by the states.

    It real­ly is amaz­ing state politi­cians every­where aren’t more pissed about this. Although they prob­a­bly will be once the angry town halls that their fed­er­al coun­ter­parts are cur­rent­ly expe­ri­enc­ing come to a state house near you. indef­i­nite­ly. And don’t for­get that’s the plan: per­pet­u­al cuts man­dat­ed by the fed­er­al gov­ern­ment that the states won’t pos­si­bly be able to replace:

    Reuters

    Over­haul of Med­ic­aid expan­sion could cost states $32 bil­lion: report

    By Hilary Russ | NEW YORK
    Fri Feb 24, 2017 | 5:51pm EST

    Pro­pos­als in Con­gress that would effec­tive­ly end Med­ic­aid expan­sion in 31 U.S. states would cost those states at least $32 bil­lion alto­geth­er in 2019, accord­ing to a report released on Fri­day.

    “Few, if any, states could absorb such new costs,” the Cen­ter on Bud­get and Pol­i­cy Pri­or­i­ties, a Wash­ing­ton-based, left-lean­ing think tank, said in its report.

    ...

    One sce­nario to phase out enhanced fed­er­al fund­ing would con­vert the cur­rent sys­tem, in which states share the cost of Med­ic­aid enrollees with the fed­er­al gov­ern­ment, into fixed pay­ments, or block grants, sent to the states.

    But that would dra­mat­i­cal­ly affect the 31 states and the Dis­trict of Colum­bia that chose to expand Med­ic­aid, the gov­ern­ment health insur­ance pro­gram for low-income Amer­i­cans, and col­lect extra dol­lars that came with expan­sion.

    Those states would have to find the extra $32 bil­lion them­selves to main­tain their expan­sions, the cen­ter said in its report.

    The block grant con­ver­sion would “shrink fed­er­al Med­ic­aid fund­ing over time, result in even deep­er fund­ing cuts when needs increase, and ulti­mate­ly place cov­er­age for tens of mil­lions more Amer­i­cans at risk,” the cen­ter said in its report.

    The reduced fed­er­al fund­ing would cause the auto­mat­ic end of the expan­sion in sev­en states. Oth­er expan­sion states would “almost cer­tain­ly drop or sub­stan­tial­ly scale back their expan­sions,” the report said.

    Med­ic­aid sits at the heart of the fed­er­al-state fis­cal rela­tion­ship. Over $330 bil­lion in fed­er­al Med­ic­aid dol­lars flowed to states in fis­cal year 2016, account­ing for more than half of all fed­er­al grants sent to state and local gov­ern­ments and the largest indi­vid­ual pro­gram, accord­ing to Stan­dard & Poor’s.

    “The block grant con­ver­sion would “shrink fed­er­al Med­ic­aid fund­ing over time, result in even deep­er fund­ing cuts when needs increase, and ulti­mate­ly place cov­er­age for tens of mil­lions more Amer­i­cans at risk,” the cen­ter said in its report.”

    Assum­ing this ‘block-grants and end­less, fed­er­al­ly man­dat­ed state-direct­ed cuts’ mod­el does become law it’s going to be fas­ci­nat­ing to see what impact this has on the US polit­i­cal dynam­ic. Because the abil­i­ty to raise tax­es at the state lev­el real­ly is going to be a life and death issue more and more as the Ryan plan’s erod­ing effects take hold. What will that do to the GOP’s state-lev­el dom­i­nance? It’s not like the par­ty is sane. Or com­pas­sion­ate. It’s the GOP. Can it bring itself to raise tax­es at the state-lev­el to avoid peo­ple los­ing cov­er­age or ser­vices? Over and over indef­i­nite­ly? That does­n’t sound very GOP-ish.

    So we’ll see what hap­pens but move over Death and Tax­es. Wel­come to the age of Ryan­care. It’s now Death or Tax­es. Specif­i­cal­ly state-lev­el tax­es.

    Posted by Pterrafractyl | February 25, 2017, 2:34 am
  7. Well that’s omi­nous: Don­ald Trumps Trea­sury Sec­re­tary Steve Mnuchin tried to assuage fears that Trump’s declared mas­sive cuts to fed­er­al spend­ing need­ed to off­set the planned rise in mil­i­tary spend­ing would result in cuts to Medicare and Social Secu­ri­ty. Mnuch­in’s response? “We are not touch­ing those now...So don’t expect to see that as part of this bud­get.” How reas­sur­ing:

    Talk­ing Points Memo
    Livewire

    Mnuchin: Trump’s Bud­get Will Not Make Cuts To Social Secu­ri­ty, Medicare

    By Caitlin Mac­Neal
    Pub­lished Feb­ru­ary 27, 2017, 7:17 AM EDT

    Trea­sury Sec­re­tary Steven Mnuchin on Sun­day said that Pres­i­dent Don­ald Trump’s bud­get, which will be sent to Con­gress in March, will not pro­pose cut­ting fund­ing for all social safe­ty pro­grams.

    “We are not touch­ing those now,”Mnuchin said on Fox News’ “Sun­day Morn­ing Futures” when Maria Bar­tiro­mo asked if the admin­is­tra­tion planned to cut fund­ing for pro­grams like Social Secu­ri­ty and Medicare. “So don’t expect to see that as part of this bud­get.”

    ...

    Trump will push for an increase in mil­i­tary spend­ing and cuts at oth­er agen­cies so that the admin­is­tra­tion will not have to slash fund­ing for Social Secu­ri­ty and Medicare, the New York Times report­ed Sun­day. The White House will call for cuts at the Envi­ron­men­tal Pro­tec­tion Agency and the State Depart­ment, the New York Times report­ed, cit­ing four unnamed senior admin­is­tra­tion offi­cials. Social safe­ty net pro­grams oth­er than Social Secu­ri­ty and Medicare could be hit with fund­ing cuts, per the Times.

    The Pres­i­den­t’s bud­get out­line will also call for fund­ing increas­es for the Jus­tice Depart­ment, home­land secu­ri­ty, intel­li­gence, and law enforce­ment, Politi­co report­ed.

    “Trump will push for an increase in mil­i­tary spend­ing and cuts at oth­er agen­cies so that the admin­is­tra­tion will not have to slash fund­ing for Social Secu­ri­ty and Medicare, the New York Times report­ed Sun­day. The White House will call for cuts at the Envi­ron­men­tal Pro­tec­tion Agency and the State Depart­ment, the New York Times report­ed, cit­ing four unnamed senior admin­is­tra­tion offi­cials. Social safe­ty net pro­grams oth­er than Social Secu­ri­ty and Medicare could be hit with fund­ing cuts, per the Times.”

    So Trump is plan­ning on cut­ting tax­es and going on a mil­i­tary spend­ing spree, and while the admin­is­tra­tion acknowl­edges that pret­ty much all non-mil­i­tary spend­ing at the fed­er­al lev­el is going to have to be slashed in order to pay for it...except Social Secu­ri­ty and Medicare. They want to assure that the to largest fed­er­al spend­ing pro­grams aren’t going to have to be touched in order to pull off this scheme. At least now not. But who knows what will hap­pen lat­er? That’s the reas­sur­ing mes­sage, which hap­pens to be in direct oppo­si­tion to the GOP’s long-stand­ing desire to slash Social Secu­ri­ty and Medicare:

    The Wash­ing­ton Post

    Trump touts spend­ing plan, but promise to leave enti­tle­ments alone puts GOP in a quandary

    By Abby Phillip and Kelsey Snell
    Feb­ru­ary 27, 2017 at 7:57 PM

    Pres­i­dent Trump is prepar­ing a bud­get that would ful­fill some of his top cam­paign promis­es by boost­ing mil­i­tary spend­ing while cut­ting domes­tic pro­grams.

    But his reluc­tance to embrace cuts to enti­tle­ment pro­grams could lead to sharp ten­sions with Repub­li­cans in Con­gress who have long argued that Medicare and Social Secu­ri­ty must be over­hauled to ensure the government’s fis­cal health.

    The White House on Mon­day announced the first details of the president’s spend­ing plan, high­light­ing a $54 bil­lion increase in defense spend­ing and equal cuts to domes­tic pro­grams, such as the Envi­ron­men­tal Pro­tec­tion Agency, and for­eign aid.

    “We are going to do more with less and make the gov­ern­ment lean and account­able to the peo­ple,” Trump told reporters at the White House on Mon­day morn­ing. “We can do so much more with the mon­ey we spend.”

    White House offi­cials skirt­ed ques­tions about whether the bud­get would include pro­pos­als to slow the growth of Social Secu­ri­ty, Medicare and Med­ic­aid — the largest dri­vers of fed­er­al spend­ing. But Repub­li­can law­mak­ers, includ­ing House Speak­er Paul D. Ryan (Wis.), have for years argued that spend­ing increas­es must be accom­pa­nied by sig­nif­i­cant changes to enti­tle­ments.

    White House press sec­re­tary Sean Spicer insist­ed Mon­day that the pres­i­dent intends to keep his cam­paign promise to pre­serve the pro­grams, but avoid­ed com­ment­ing on whether there is any wig­gle room, such as pro­tect­ing cur­rent ben­e­fi­cia­ries while imple­ment­ing future changes.

    “Let me get back to you on the specifics,” Spicer told reporters.

    Repub­li­cans have long advo­cat­ed sig­nif­i­cant­ly chang­ing the pro­grams to address the nation’s debt, which is now near­ly $20 tril­lion.

    Inde­pen­dent bud­get ana­lysts said pol­i­cy pro­pos­als the admin­is­tra­tion has released would do lit­tle to fix the grow­ing red ink.

    “This is a pres­i­dent who loves to talk about easy choic­es and pret­ty much runs away from any hard choic­es when it comes to the bud­get,” said Maya MacGuineas, pres­i­dent of the non­par­ti­san Com­mit­tee for a Respon­si­ble Fed­er­al Bud­get. “This pres­i­dent has point­ed out that our nation­al debt is an impor­tant met­ric of this country’s health, but he has not put for­ward a plan for how to deal with it.”

    Monday’s announce­ment was the first indi­ca­tion of spend­ing pri­or­i­ties by the new admin­is­tra­tion, with the pres­i­dent set to arrive on Capi­tol Hill on Tues­day to address a joint ses­sion of Con­gress.

    In his speech, Trump is expect­ed to out­line an opti­mistic vision for the coun­try, tout­ing his intent to replace the Afford­able Care Act, imple­ment poli­cies to help work­ing par­ents and address nation­al secu­ri­ty con­cerns, includ­ing rebuild­ing the U.S. mil­i­tary.

    Ryan and oth­er Repub­li­can lead­ers have avoid­ed weigh­ing in on the specifics of the bud­get, say­ing they are wait­ing to see all the details that will be released in the com­ing weeks, while speak­ing pos­i­tive­ly of the president’s over­all agen­da.

    But Ryan has long advo­cat­ed chang­ing enti­tle­ment pro­grams, argu­ing that their finances are in a per­ilous state.

    “Medicare and Social Secu­ri­ty are going bank­rupt,” he said in Octo­ber 2012, dur­ing a vice pres­i­den­tial debate when he was Repub­li­can pres­i­den­tial nom­i­nee Mitt Romney’s run­ning mate. “These are indis­putable facts.”

    White House Bud­get Direc­tor Mick Mul­vaney in many ways embod­ies the fis­cal quandary Repub­li­cans face under Trump. As a con­ser­v­a­tive mem­ber of Con­gress from South Car­oli­na, he fash­ioned him­self a deficit hawk who opposed big increas­es in defense fund­ing and advo­cat­ed cut­ting spend­ing for Medicare, Med­ic­aid, Social Secu­ri­ty and oth­er enti­tle­ment pro­grams. Now he is over­see­ing Trump’s effort to great­ly increase defense spend­ing while offer­ing no plan to address enti­tle­ments.

    On Mon­day, he avoid­ed answer­ing spe­cif­ic ques­tions about the upcom­ing bud­get, not­ing that the first part will be final­ized by mid-March with more details set to arrive in May.

    Speak­ing to reporters at the White House, Mul­vaney empha­sized that the mil­i­tary and domes­tic spend­ing pri­or­i­ties out­lined Mon­day are intend­ed to send a clear sig­nal that Trump is seek­ing to ful­fill his cam­paign promis­es.

    “We are tak­ing his words and turn­ing them into poli­cies and dol­lars,” Mul­vaney said. “A full bud­get will con­tain the entire spec­trum of what the pres­i­dent has pro­posed.”

    ...

    Repub­li­can defense hawks, mean­while, are call­ing Trump’s request for defense spend­ing inad­e­quate.

    “With a world on fire, Amer­i­ca can­not secure peace through strength with just 3 per­cent more than Pres­i­dent Obama’s bud­get,” Sen­ate Armed Ser­vices Chair­man John McCain (Ariz.) said in a state­ment. “We can and must do bet­ter.”

    ...

    “White House Bud­get Direc­tor Mick Mul­vaney in many ways embod­ies the fis­cal quandary Repub­li­cans face under Trump. As a con­ser­v­a­tive mem­ber of Con­gress from South Car­oli­na, he fash­ioned him­self a deficit hawk who opposed big increas­es in defense fund­ing and advo­cat­ed cut­ting spend­ing for Medicare, Med­ic­aid, Social Secu­ri­ty and oth­er enti­tle­ment pro­grams. Now he is over­see­ing Trump’s effort to great­ly increase defense spend­ing while offer­ing no plan to address enti­tle­ments.”

    Yep, even Mick Mul­vaney, Trump’s direc­tor of the Office of Bud­get and Man­age­ment, has been call­ing for cuts to Social Secu­ri­ty and Medicare for years while he was serv­ing in Con­gress. And con­tin­ued call­ing for those cuts after becom­ing the head of the OMB. But Steve Mnuchin wants every­one to not wor­ry so much because he assures us that Trump has no plans on cut­ting those pro­grams. At least not yet.

    Feel­ing reas­sured yet? If not, per­haps some words from Trump him­self on the mat­ter will help reas­sure you. It turns out Trump addressed this very issue briefly dur­ing an inter­view on Fox and Friends this morn­ing where explained why cuts to Social Secu­ri­ty and Medicare won’t be need­ed. Or rather, Trump laid out a sce­nario under which Trump won’t need to cut Social Secu­ri­ty and Medicare. It’s a sce­nario he’s appar­ent­ly real­ly con­fi­dent will hap­pen. And as long as that sce­nario plays out, no cuts to Social Secu­ri­ty and Medicare. So what’s the sce­nario? An econ­o­my that’s “sail­ing” (pre­sum­ably indef­i­nite­ly):

    The Wash­ing­ton Post

    Pres­i­dent Trump’s friend­ly ‘Fox and Friends’ inter­view went exact­ly how you think it would

    By Chris Cil­liz­za
    Feb­ru­ary 28, 2017 at 9:46 AM

    Pres­i­dent Trump sat down with “Fox and Friends” on Tues­day morn­ing to pre­view his address tonight to a joint ses­sion of Con­gress. Using Genius, I anno­tat­ed it. You can too! Sign up for Genius and anno­tate along­side me! To see an anno­ta­tion, click or tap the high­light­ed part of the tran­script.

    DOOCY: Mr. Pres­i­dent, thank you very much for the invi­ta­tion.

    TRUMP: Thank you.

    DOOCY: And by the way, thank you very much for the shout-out you gave at your press con­fer­ence about 10 days ago.

    TRUMP: That’s true, I did. And you treat­ed me — you have treat­ed me very fair­ly and I appre­ci­ate it. I like your (INAUDIBLE)...

    DOOCY: Did you take much heat for that from the oth­er net­works?

    TRUMP: No, not real­ly. I think they know it’s true. You know, they know what’s fair and not. But you have treat­ed me very fair­ly. And I’ve been a friend of your show for a long time.

    Remem­ber those call-ins, right (INAUDIBLE)?

    DOOCY: For years.

    TRUMP: Maybe with­out those call-ins, some­body else is sit­ting here.

    AINSLEY EARHARDT, HOST: Let’s talk about your speech. You’re address­ing Con­gress tonight. You have talked about spend­ing $54 bil­lion in addi­tion­al mon­ey for our mil­i­tary.

    Sen­a­tor John McCain has said that is not enough.

    What’s your reac­tion?

    TRUMP: Well, we’re going to spend a lot more mon­ey on mil­i­tary. We real­ly have to. We have no choice. And a lot of peo­ple think it’s a tremen­dous amount of mon­ey. It could be, actu­al­ly, $30 mil­lion, $30 bil­lion more than that. We’re going to upgrade our mil­i­tary very sub­stan­tial­ly.

    Remem­ber this, I also am going to get involved in nego­ti­at­ing. we have many planes and boats and ships and every­thing that we are spend­ing too much mon­ey indi­vid­u­al­ly on.

    We’re going to get involved in nego­ti­at­ing. We’re going to be able to get, I think, a lot more prod­uct for a buck and I’m going to be very, very seri­ous about it.

    We saved $700 mil­lion plus on an F‑35 after I got involved. And I have to tell you, Lock­heed was ter­rif­ic.

    But we saved a lot of mon­ey on air­planes and that num­ber is going to increase very sub­stan­tial­ly as we keep going, We will be hav­ing the great­est mil­i­tary that we ever had by the time I fin­ish.

    ...

    KILMEADE: You have an OMB direc­tor, final­ly. He says you have to take an ax to enti­tle­ments. Your Trea­sury sec­re­tary says we’re not touch­ing it.

    Who’s right?

    TRUMP: Well, I’ll tell you what who’s right. If the econ­o­my sails, then I’m right, because I said I’m not touch­ing Social Secu­ri­ty.

    KILMEADE: So your OMB is wrong?

    TRUMP: I’m not say­ing any­body is wrong. I’m just say­ing this. If we — and I think this is what’s going to hap­pen, Bri­an. I think our coun­try is going to sail.

    ...

    “TRUMP: Well, I’ll tell you what who’s right. If the econ­o­my sails, then I’m right, because I said I’m not touch­ing Social Secu­ri­ty.”

    So Trump gets asked, who’s cor­rect? His OMB direc­tor who says enti­tle­ment cuts are nec­es­sary or the Trea­sury Sec­re­tary who says no cuts are need (for now)? And Trump responds by basi­cal­ly say­ing that as long as the econ­o­my “sails”, Trump will be cor­rect because he said he’s not touch­ing Social Secu­ri­ty. But then adds that his OMB direc­tor isn’t “wrong” in say­ing that enti­tle­ment cuts are required, but as long as the US econ­o­my “sails” he won’t be right either. So while it’s not entire­ly clear how to parse Trump’s response, it sure sounds like he’s say­ing that future Social Secu­ri­ty and Medicare cuts are going to be deter­mined by whether or not the econ­o­my “sails” going for­ward.

    And keep in mind that Trump isn’t sim­ply being opti­mistic about future US eco­nom­ic per­for­mance here, although he is being incred­i­bly opti­mistic. The Trump admin­is­tra­tion’s “sail­ing” opti­mism is actu­al­ly built into the mod­el it’s using in order to jus­ti­fy the pro­posed Trump bud­get:

    The New York Times
    The Con­science of a Lib­er­al

    Trump’s Rosy Sce­nario

    Paul Krug­man
    Feb 18, 2017 10:46 am

    The WSJ reports that the Trump administration’s bud­get plan­ning assumes very high eco­nom­ic growth over the next decade — between 3 and 3.5 per­cent annu­al­ly. How was this num­ber arrived at? Basi­cal­ly, they worked back­wards, assum­ing the growth they need­ed to make their bud­get num­bers add up. Cred­i­bil­i­ty!

    But the pur­pose of this post is main­ly to explain why such a num­ber is implau­si­ble — not impos­si­ble, but not some­thing that should be anyone’s cen­tral fore­cast.
    you should still be expect­ing growth of 2 per­cent or under
    The claimed returns to Trump­nomics are close to the high­est growth rates we’ve seen under any mod­ern admin­is­tra­tion. Real GDP grew 3.4 per­cent annu­al­ly under Rea­gan; it grew 3.7 per­cent annu­al­ly under Clin­ton (shhh — don’t tell con­ser­v­a­tives.) But there are fun­da­men­tal rea­sons to believe that such growth is unlike­ly to hap­pen now.

    First, demog­ra­phy: Rea­gan took office with baby boomers — and women — still enter­ing the work force; these days baby boomers are leav­ing. Here’s UN data on the 5‑year growth rate of the pop­u­la­tion aged 20–64, a rough proxy for those like­ly to seek work:
    [see chart]
    Just on demog­ra­phy alone, then, you’d expect growth to be around a per­cent­age point low­er than it was under Rea­gan.

    Fur­ther­more, while Trump did not, in fact, inher­it a mess, both Rea­gan and Clin­ton did — in the nar­row sense that both came into office amid depressed economies, with unem­ploy­ment above 7 per­cent:
    [see chart]
    This meant a sub­stan­tial amount of slack to be tak­en up when the econ­o­my returned to full employ­ment. Rough cal­cu­la­tion: 2 points of excess unem­ploy­ment means 4 per­cent out­put gap under Okun’s Law, which means 0.5 per­cent­age points of extra growth over an 8‑year peri­od.

    So even if you (wrong­ly) give Rea­gan poli­cies cred­it for the busi­ness cycle recov­ery after 1982, and believe (wrong­ly) that Trumpo­nom­ics is going to do won­der­ful things for incen­tives a la Rea­gan, you should still be expect­ing growth of 2 per­cent or under.

    ...

    “So even if you (wrong­ly) give Rea­gan poli­cies cred­it for the busi­ness cycle recov­ery after 1982, and believe (wrong­ly) that Trumpo­nom­ics is going to do won­der­ful things for incen­tives a la Rea­gan, you should still be expect­ing growth of 2 per­cent or under.”

    Yes, while real­is­ti­cal­ly we should­n’t expect aver­age growth to be much above 2 per­cent going for­ward, Trump’s bud­get plan assumes a “sail­ing” growth of 3–3.5 per­cent for the next decade. And as we saw from Trump’s above, the main fac­tor that will deter­mine who is cor­rect — his OMB direc­tor (who pre­dicts cuts to enti­tle­ments will be nec­es­sary) is cor­rect vs his Trea­sury Sec­re­tary (who pledges no cuts...for now) — is whether or not the econ­o­my “sails” going for­ward. So under Trump’s bud­get scheme, if the econ­o­my does­n’t expe­ri­ence unprece­dent­ed growth going for­ward enti­tle­ments get gut­ted.

    It’s some­thing to keep in mind as Trump pre­pares to give his first speech to Con­gress tonight and lay out an ‘opti­mistic’ vision of the future: It’s the kind of opti­mism that should leave you feel­ing very pes­simistic about the future. Grifter opti­mism is like that.

    Posted by Pterrafractyl | February 28, 2017, 4:28 pm
  8. The GOP’s quest for a health care ‘reform’ pro­pos­al to replace Oba­macare that it can stom­ach putting its name on made sig­nif­i­cant progress last week with the pas­sage of a rather impor­tant amend­ment. Impor­tant for Paul Ryan and peo­ple like him who want to ush­er in an unmit­i­gat­ed ‘let them die’ ethos into Amer­i­ca’s health care sys­tem: House Repub­li­can float­ed an amend­ment to their health care bill that would replace the pro­tec­tions for pre-exist­ing con­di­tions that were amongst the pop­u­lar pro­vi­sions in Oba­macare that were left in the ‘Trump­care 1.0’ bill. Instead of the “com­mu­ni­ty rat­ing” sys­tem that Oba­macare man­dat­ed — which pro­tect­ed peo­ple with pre-exist­ing con­di­tions by replac­ing the “indi­vid­ual-rat­ings” with a “com­mu­ni­ty-rat­ing” for deter­min­ing fees — the GOP amend­ment would let states opt out of that as they as they set up a “high-risk pool” sys­tem for peo­ple with pre-exist­ing con­di­tions to get held from the “high-risk pool” to cov­er their health care cost. Costs that will sud­den­ly spike for those indi­vid­u­als after get­ting rid of the “com­mu­ni­ty rat­ing” pro­vi­sion.

    That impor­tant mile­stone — switch­ing peo­ple with pre-exist­ing con­di­tions from a reg­u­lat­ed pri­vate insur­ance mar­ket to an increas­ing­ly under-fund­ed pub­lic saftey-net and then pulling the rug out from under the safe­ty-net — in Paul Ryan’s quest to undo the best parts of Oba­macare took a big step clos­er to being com­plet­ed this week. And the amend­ment would also allow states to opt out of the “Essen­tial Ben­e­fits” in Oba­macare that sur­vived Trump­care 1.0. It’s a pret­ty big amend­ment because the “Free­dom Cau­cus” is ful­ly behind it and it was pro­posed by a “mod­er­ate” House Repub­li­can, Tom MacArthur (R‑NJ), so it could be the unit­ing force for the GOP’s health care quest.

    So it’s look­ing like the few good things in Trump­care, which were just left-overs from Oba­macare, are going away soon if this amend­ment Because the GOP’s dom­i­nant pre-exist­ing con­di­tion — being real­ly mean to peo­ple in need and pre­tend­ing that’s help­ing — has no obvi­ous cure:

    Vox

    Repub­li­cans’ new health amend­ment lets insur­ers charge sick peo­ple more, cov­er less

    Updat­ed by Sarah Kliff
    Apr 25, 2017, 9:37pm EDT

    House Repub­li­cans are float­ing a new amend­ment to their health care bill, one that would like­ly cause even more Amer­i­cans to lose cov­er­age than the last ver­sion.

    The Amer­i­can Health Care Act that House Speak­er Paul Ryan intro­duced into the House last Feb­ru­ary dis­man­tled parts of Oba­macare. It also left pop­u­lar pro­vi­sions, like a ban on pre­ex­ist­ing con­di­tions and the require­ment that insur­ers cov­er things like mater­ni­ty care, intact.

    This new amend­ment, offered by Rep. Tom MacArthur (R‑NJ), would allow states to waive out of those key Oba­macare reg­u­la­tions too.

    In par­tic­u­lar, this amend­ment would allow some states to charge high­er pre­mi­ums to Amer­i­cans with pre­ex­ist­ing con­di­tions. States would also have the choice to opt out of the Afford­able Care Act’s essen­tial health ben­e­fits require­ment, as well as the pos­si­bil­i­ty of charg­ing old­er Amer­i­cans sig­nif­i­cant­ly high­er pre­mi­ums.

    Lead­ers of the staunch­ly con­ser­v­a­tive Free­dom Cau­cus have report­ed­ly endorsed this pro­pos­al. That makes sense: This amend­ment would take apart key Oba­macare reg­u­la­tions the group has spent years ral­ly­ing against.

    But this amend­ment doesn’t do much at all to assuage con­cerns about the old­er pro­pos­als. While it meets many of the demands of the party’s far-right wing — name­ly, the dereg­u­la­tion of the indi­vid­ual insur­ance mar­ket — it does noth­ing to address con­cerns about mas­sive cov­er­age loss. Instead, it like­ly makes those prob­lems worse.

    What’s more, it comes at a time when the spe­cif­ic Oba­macare pro­vi­sions that Repub­li­cans want to dis­man­tle are prov­ing the law’s most pop­u­lar. A Wash­ing­ton Post/ABC News Poll released Tues­day found that 70 per­cent of vot­ers sup­port requir­ing states to pro­tect peo­ple with pre­ex­ist­ing con­di­tions, and 61 per­cent want the fed­er­al gov­ern­ment to require insur­ers to cov­er a com­pre­hen­sive ben­e­fits pack­age with mater­ni­ty care and men­tal health ser­vices.

    ...

    Repub­li­cans want to let states waive two key Oba­macare pro­vi­sions

    The amend­ment takes aim at two Oba­macare poli­cies that have long been on the Free­dom Caucus’s hit list: com­mu­ni­ty rat­ing and essen­tial health ben­e­fits.

    Before the Afford­able Care Act, insur­ance com­pa­nies would “indi­vid­u­al­ly rate” each patient who want­ed to buy cov­er­age on the indi­vid­ual mar­ket.

    They would send out detailed ques­tion­naires about a poten­tial customer’s age, med­ical his­to­ry, and cur­rent behav­iors (whether she cur­rent­ly smokes, for exam­ple, or is preg­nant) and then set a spe­cif­ic pre­mi­um for that per­son. It was meant to reflect the insur­ers’ best guess of how expen­sive that individual’s health care would be.

    Oba­macare banned this so-called indi­vid­ual rat­ing. It required all insur­ers, instead, to use “com­mu­ni­ty rat­ing”: set­ting one pre­mi­um for the entire com­mu­ni­ty of peo­ple buy­ing cov­er­age. This had the prac­ti­cal effect of dri­ving down pre­mi­ums for sick peo­ple, who no longer had to bear the full bur­den of cov­er­ing their more expen­sive health needs.

    It also drove up the costs for healthy peo­ple, who were sud­den­ly asked to pay more to help cov­er those expen­sive bills from the sick­er peo­ple.

    The Oba­ma admin­is­tra­tion made this change because it felt like this was a good trade-off. It pri­or­i­tized get­ting sick­er peo­ple access to health insur­ance.

    This new GOP amend­ment to let states waive com­mu­ni­ty rat­ing would once again allow insur­ers to charge peo­ple based on their expect­ed health care costs, so long as the state par­tic­i­pates in the Patient and State Sta­bil­i­ty Fund. This is a pool of mon­ey in AHCA that states can use to set up high risk pools or shore up insur­ers that get stuck with real­ly expen­sive patients.

    Insur­ers could only charge these fees to peo­ple who had a break in health insur­ance cov­er­age, show­ing up on the indi­vid­ual mar­ket want­i­ng to pur­chase a plan. The lan­guage does not appear to allow an insur­er to ask ques­tions about the health sta­tus of some­one who is tran­si­tion­ing direct­ly from an insur­ance plan at work, for exam­ple, into the indi­vid­ual mar­ket.

    Repub­li­cans’ oper­at­ing the­o­ry here is that it’s okay for states to charge sick peo­ple high­er pre­mi­ums so long as they have some kind of fall­back option for cov­er­age, like a high-risk pool. But health law expert Tim Jost points out that states don’t have to use their sta­bil­i­ty funds to cre­ate high-risk pools, which means these peo­ple could find them­selves out of luck.

    “The idea was peo­ple who fall through the cracks would have a high-risk pool,” he says. “What hap­pens though if a state uses their mon­ey for rein­sur­ance instead?”

    States could also opt out of Obamacare’s essen­tial health ben­e­fits require­ment. This is the core set of med­ical ser­vices that the Afford­able Care Act requires all insur­ers to cov­er, includ­ing things like doc­tor trips, hos­pi­tal stays, mater­ni­ty care, and men­tal health ser­vices.

    These two Oba­macare require­ments have been at the top of the Free­dom Caucus’s hit list for some time. They also tack a third reg­u­la­tion they want to dis­man­tle onto the list in this new amend­ment, the one that lim­its what pre­mi­ums insur­ers can charge old­er enrollees.

    The GOP amend­ment would allow states to opt out of these pro­vi­sions if they show that the change would lead to “reduc­ing aver­age pre­mi­ums for health insur­ance cov­er­age in the State.” If the fed­er­al gov­ern­ment took no action when these appli­ca­tions came in, the waivers would be auto­mat­i­cal­ly approved after 60 days.

    This does not set an espe­cial­ly high bar for this waiv­er option. It means that states could, for exam­ple, end the essen­tial health ben­e­fits require­ment because they believe it will low­er pre­mi­um costs. And of course it would! Tell insur­ers they no longer have to cov­er expen­sive men­tal health ser­vices or mater­ni­ty care, and aver­age prices would almost cer­tain­ly drop. The same would hap­pen if insur­ers had the option to charge sick patients prices they couldn’t afford. Those peo­ple would drop out of the mar­ket, and pre­mi­ums would decline.

    “If it could be shown that states could low­er pre­mi­ums on an iden­ti­cal pol­i­cy, that would be one thing, but that is not the met­ric being used here,” Garth­waite said. “If you allow the essen­tial ben­e­fits to go away, you will have low­er pre­mi­ums because it’s a skin­nier prod­uct. The peo­ple work­ing on this don’t seem to under­stand the mar­ket ram­i­fi­ca­tions of what they are doing.”

    The obsta­cles to mov­ing this amend­ment for­ward are huge

    Repub­li­cans’ last ver­sion of the health care bill would have caused 24 mil­lion Amer­i­cans to lose insur­ance cov­er­age, way too large a num­ber for many Repub­li­can House mem­bers to stom­ach.

    Tack­ing on this new amend­ment would undoubt­ed­ly cause an even greater decline in cov­er­age, as sick­er patients would be priced out of the mar­ket in states that take up the waiv­er.

    This then invites the ques­tion: Who is this new amend­ment going to win over? Will House Repub­li­cans get behind a bill that caus­es more cov­er­age loss than the one they ditched a month ago? What has changed between now and then?

    One thing we’ve learned dur­ing the past month of the health care debate is that some top House Repub­li­cans like the ban on pre­ex­ist­ing con­di­tions and don’t want to loosen it. This is what House Deputy Whip Patrick McHen­ry (R‑NC) told Bloomberg a few weeks ago.

    GOP chief deputy whip P. McHen­ry says unwind­ing pre-ex man­dates won’t fly in House, evokes his own expe­ri­ence with insur­er dis­crim­i­na­tion. pic.twitter.com/BwV85Y3u6H— Sahil Kapur (@sahilkapur) April 5, 2017

    Then there’s the ques­tion of the Sen­ate. The more mod­er­ate Sen­ate Repub­li­cans would be unlike­ly to ral­ly behind a plan that caus­es mas­sive cov­er­age loss.

    They might not get the chance to. Many of the changes out­lined in the amend­ment would strug­gle to move through the rec­on­cil­i­a­tion process, which requires all poli­cies to be direct­ly relat­ed to the fed­er­al bud­get. It would be tough to make the case that re-reg­u­lat­ing the indi­vid­ual mar­ket counts as bud­get pol­i­cy, and that these changes ought to be allowed to move for­ward.

    Last, Amer­i­cans tend to be big fans of the exact parts of the bill that this amend­ment takes aim at. A new Wash­ing­ton Post/ABC Poll finds they are among the most pop­u­lar parts of the health care law.

    These are the exact type of changes that will make the Repub­li­can health care bill even less pop­u­lar than it already is. The most recent polling showed just 17 per­cent sup­port for the Amer­i­can Health Care Act, and the changes out­lined in this memo will make health insur­ance less gen­er­ous and the bill less pop­u­lar — mak­ing it hard to see how this becomes a win­ning approach.

    “This then invites the ques­tion: Who is this new amend­ment going to win over? Will House Repub­li­cans get behind a bill that caus­es more cov­er­age loss than the one they ditched a month ago? What has changed between now and then?”

    That’s the big imme­di­ate ques­tion raised by this amend­ment, if you put aside all the eth­i­cal ques­tions: just who on earth is going to vote for an amend­ment that pre-exist­ing con­di­tions pro­vi­sion that even Trump­care 1.0 (the Amer­i­can Health Care Act) kept because the GOP could­n’t stom­ach the polit­i­cal flak? Are GOP­ers going to actu­al­ly sign on to it? The fate of Trump­care 1.0 sug­gests not, but note one aspect of the scheme enabled by the amend­ment the GOP just passed that acts as a strong incen­tive for con­gres­sion­al Repub­li­cans to take the polit­i­cal hit: the amend­ment would get rid of the pre-exist­ing con­di­tions pro­tec­tion by offer­ing instead a pub­lic-financed “high-risk pool” option for peo­ple with pre-exist­ing con­di­tions to find cov­er­age. And the states all run their own high risk pools so the states become the enti­ties that do the steady work of cut­ting back on the avail­able pub­lic fund to keep peo­ple with pre-exist­ing con­di­tions alive. The ol’ bait-and-switch-and-pass-the-baton-for-slow-poi­sonin­ing switcha­roo. Trump and the GOP say “this is even bet­ter than pro­tec­tions for peo­ple with pre­ex­ist­ing con­di­tions and then states get the task of choos­ing whether or not to spend pub­lic funds on the “high risk pools” or some­thing else. That’s some pret­ty sweet buck-pass­ing right there:

    ...
    Before the Afford­able Care Act, insur­ance com­pa­nies would “indi­vid­u­al­ly rate” each patient who want­ed to buy cov­er­age on the indi­vid­ual mar­ket.

    They would send out detailed ques­tion­naires about a poten­tial customer’s age, med­ical his­to­ry, and cur­rent behav­iors (whether she cur­rent­ly smokes, for exam­ple, or is preg­nant) and then set a spe­cif­ic pre­mi­um for that per­son. It was meant to reflect the insur­ers’ best guess of how expen­sive that individual’s health care would be.

    Oba­macare banned this so-called indi­vid­ual rat­ing. It required all insur­ers, instead, to use “com­mu­ni­ty rat­ing”: set­ting one pre­mi­um for the entire com­mu­ni­ty of peo­ple buy­ing cov­er­age. This had the prac­ti­cal effect of dri­ving down pre­mi­ums for sick peo­ple, who no longer had to bear the full bur­den of cov­er­ing their more expen­sive health needs.

    It also drove up the costs for healthy peo­ple, who were sud­den­ly asked to pay more to help cov­er those expen­sive bills from the sick­er peo­ple.

    The Oba­ma admin­is­tra­tion made this change because it felt like this was a good trade-off. It pri­or­i­tized get­ting sick­er peo­ple access to health insur­ance.

    This new GOP amend­ment to let states waive com­mu­ni­ty rat­ing would once again allow insur­ers to charge peo­ple based on their expect­ed health care costs, so long as the state par­tic­i­pates in the Patient and State Sta­bil­i­ty Fund. This is a pool of mon­ey in AHCA that states can use to set up high risk pools or shore up insur­ers that get stuck with real­ly expen­sive patients.

    Insur­ers could only charge these fees to peo­ple who had a break in health insur­ance cov­er­age, show­ing up on the indi­vid­ual mar­ket want­i­ng to pur­chase a plan. The lan­guage does not appear to allow an insur­er to ask ques­tions about the health sta­tus of some­one who is tran­si­tion­ing direct­ly from an insur­ance plan at work, for exam­ple, into the indi­vid­ual mar­ket.

    Repub­li­cans’ oper­at­ing the­o­ry here is that it’s okay for states to charge sick peo­ple high­er pre­mi­ums so long as they have some kind of fall­back option for cov­er­age, like a high-risk pool. But health law expert Tim Jost points out that states don’t have to use their sta­bil­i­ty funds to cre­ate high-risk pools, which means these peo­ple could find them­selves out of luck.

    “The idea was peo­ple who fall through the cracks would have a high-risk pool,” he says. “What hap­pens though if a state uses their mon­ey for rein­sur­ance instead?”
    ...

    ““The idea was peo­ple who fall through the cracks would have a high-risk pool,” he says. “What hap­pens though if a state uses their mon­ey for rein­sur­ance instead?””

    What hap­pens if a state uses their mon­ey for rein­sur­ance instead, indeed? Pre­sum­ably peo­ple lose their cov­er­age. And then die. And Paul Ryan gets his wings. And that slow-motion death spi­ral could all get kicked off as long as the amend­ment to end the “com­mu­ni­ty rat­ing” rule that pro­tect­ed peo­ple with pre-exist­ing con­di­tions gets passed and states start stet­ting up ‘high-risk pool” safe­ty-nets instead. The blame gets spread around and the rab­ble ‘self deport’ from this cor­po­re­al exis­tence, reduc­ing health care costs. That’s Paul Ryan’s plan that’s now Trump’s plan.

    Although maybe that’s not the plan. Don­ald Trump gave an to inter­view CBS’s Face the Nation intend­ed to sell his ‘first 100 days’ accom­plish­ments and if it sold any­thing it’s the poten­tial upside of Don­ald Trump giv­ing inter­views. Because he appar­ent­ly total­ly reversed a bunch of hor­ri­ble pol­i­cy that GOP just imple­ment­ed into the health care reform pack­age. Although, since this is Don­ald Trump we’re talk­ing about, it was unclear if he was just mak­ing stuff up or gen­uine­ly con­fused:

    Vox

    An inter­view sug­gests Trump does­n’t know what’s in his health bill
    Either the pres­i­dent doesn’t under­stand the pro­pos­al — or isn’t telling the truth about it.

    Updat­ed by Sarah Kliff
    Apr 30, 2017, 5:30pm EDT

    Pres­i­dent Trump gave a lengthy inter­view Sun­day morn­ing to CBS’ John Dick­er­son about the Repub­li­cans’ health care plan.

    His respons­es to basic ques­tions — like what pro­vi­sions the bill includes or how it would change the health insur­ance sys­tem — sug­gest he either doesn’t under­stand how the Amer­i­can Health Care Act works, or doesn’t want to tell the truth about it.

    Dick­er­son is the first jour­nal­ist I have seen grill Trump on what, exact­ly, is in the Repub­li­can plan. He isn’t ask­ing about the pol­i­tics of the bill and whether it will pass. Rather, he focus­es on what are arguably basic ques­tions: what ele­ments are in this bill, and what do you think of them?

    Trump stum­bles. He says that peo­ple with pre-exist­ing con­di­tions will be pro­tect­ed. Under the lat­est amend­ment to the Amer­i­can Health Care Act — the one that got the Free­dom Cau­cus on board — they won’t be. He says that deductibles will go down under the Repub­li­can plan. Non-par­ti­san analy­sis expects deductibles would go up.

    The health care plan that Trump described on Face the Nation is not the one that the Repub­li­can par­ty has offered. His answers sug­gest an unfa­mil­iar­i­ty with basic pol­i­cy details of a plan that has been pub­lic for near­ly six weeks at this point — a plan that his admin­is­tra­tion has pushed Con­gress to pass.

    “For­get about the lit­tle shit,” Trump report­ed­ly told a room full of leg­is­la­tors dur­ing the health care nego­ti­a­tions. “Let’s focus on the big pic­ture here.”

    His answers on CBS sug­gest that, if he actu­al­ly read the Repub­li­can bill, he would find it sore­ly dis­ap­point­ing — and at odds with his health care goals.

    Trump says the updat­ed GOP plan pro­tects peo­ple with pre-exist­ing con­di­tions. No, it doesn’t.

    Much of the Trump inter­view cen­ters on Trump claim­ing that new changes to the Repub­li­can health care bill will pro­tect peo­ple with pre-exist­ing con­di­tions. In fact, its exact­ly the oppo­site: an amend­ment to the AHCA intro­duced this week would give states author­i­ty to let insur­ers charge sick peo­ple high­er pre­mi­ums.

    Dick­er­son starts with a rel­a­tive­ly sim­ple ques­tion that is basi­cal­ly: how will this bill help your sup­port­ers? Here is Trump’s response:

    Pre-exist­ing con­di­tions are in the bill. And I just watched anoth­er net­work than yours, and they were say­ing, “Pre-exist­ing is not cov­ered.” Pre-exist­ing con­di­tions are in the bill. And I man­date it. I said, “Has to be.”

    The first iter­a­tion of the Repub­li­can bill, intro­duced in the House on March 6, kept Obamacare’s pro­tec­tions for peo­ple with pre-exist­ing con­di­tions. But a new amend­ment intro­duced this week to win Free­dom Cau­cus sup­port changes all that. It caves to con­ser­v­a­tives’ demand that to dereg­u­late the insur­ance indus­try and let health plans once again use pre-exist­ing con­di­tions to set pre­mi­um prices.

    It cre­ates waivers that states can use to let health insur­ers charge sick patients high­er pre­mi­ums, a prac­tice out­lawed under cur­rent law.

    Trump knows there were changes to the bill. But he gets them back­wards, insist­ing that the updates strength­en pro­tec­tions for sick­er patients:

    This bill is much dif­fer­ent than it was a lit­tle while ago, okay? This bill has evolved. And we did­n’t have a fail­ure on the bill. You know, it was report­ed like a fail­ure. Now, the one thing I would­n’t have done again is put a time­line. That’s why on the sec­ond iter­a­tion, I did­n’t put a time­line.

    But we have now pre-exist­ing con­di­tions in the bill. We have — we’ve set up a pool for the pre-exist­ing con­di­tions so that the pre­mi­ums can be allowed to fall.

    Trump is describ­ing the evo­lu­tion of the Repub­li­can plan back­wards. The pro­tec­tions for those with pre-exist­ing con­di­tions have got­ten weak­er, not stronger. It sounds like Trump may be con­fus­ing pre-exist­ing con­di­tions with high risk pools — which an amend­ment last month would have pro­vid­ed $15 bil­lion more in fund­ing for — but it’s hard to tell.

    Even­tu­al­ly, Trump becomes insis­tent that any bill he signs with pro­tect peo­ple with pre-exist­ing con­di­tions. He appears to throw cold water on that new amend­ment, the one that won over the sup­port of the Free­dom Cau­cus. He describes it as “in one of the fix­es” and that its cur­rent­ly “chang­ing:”

    John Dick­er­son: In one of the fix­es it was dis­cussed pre-exist­ing was option­al for the states–

    Don­ald Trump: Sure, in one of the fix­es. And they’re chang­ing it–

    John Dick­er­son: –oh, okay. So it’ll–

    Don­ald Trump: –and chang­ing.

    John Dick­er­son: –be per­ma­nent?

    Don­ald Trump: Of course.

    John Dick­er­son: Okay. Well, that’s a devel­op­ment, sir.

    This part of the inter­view is a bit bizarre. House Repub­li­cans have, at the behest of the White House, been work­ing for weeks now to nail down a bill that their cau­cus can sup­port. They inched clos­er to that goal when the MacArthur amend­ment cre­at­ed the pre-exist­ing con­di­tion waivers, which clinched the Free­dom Cau­cus’ sup­port.

    Now Trump appears to be say­ing that he’s ready to reverse course, that this part of the Repub­li­can bill is cur­rent­ly “chang­ing.” So either Trump is announc­ing a big pol­i­cy shift that would like­ly lead to Free­dom Cau­cus oppos­ing the bill — or he’s mis­un­der­stand­ing what is actu­al­ly in the bill. From the inter­view, its hard to know.

    Trump says things are in the Repub­li­can health care bill that aren’t true

    This hap­pens a few times. There are a few exchanges like this one, where Don­ald Trump promis­es that his bill will lead to low­er deductibles than the Afford­able Care Act:

    Most impor­tant­ly, we’re going to dri­ve down pre­mi­ums. We’re going to dri­ve down deductibles because right now, deductibles are so high, you nev­er — unless you’re going to die a long, hard death, you nev­er can get to use your health care.

    Deductibles under the Repub­li­can plan would not go down. They would go up, accord­ing to the non-par­ti­san Con­gres­sion­al Bud­get Office analy­sis. The agency writes that they “expect that indi­vid­u­als’ cost-shar­ing pay­ments, includ­ing deductibles, in the non­group mar­ket would tend to be high­er than those antic­i­pat­ed under cur­rent law.”

    CBO expects that pre­mi­ums would go down, but that isn’t nec­es­sar­i­ly great news. Pre­mi­ums would decline under AHCA because high­er pre­mi­ums for old­er enrollees would essen­tial­ly price the elder­ly out of the indi­vid­ual mar­ket. CBO esti­mat­ed, for exam­ple, that a low-income 64-year-old would see her pre­mi­ums increase 750 per­cent under AHCA.

    There is “no mag­ic,” as Mar­got Sanger-Katz has writ­ten, in how the Repub­li­can plan low­ers pre­mi­ums. It does so by mak­ing pre­mi­ums unaf­ford­able for elder­ly.

    Else­where, Trump claims that his plan would allow insur­ance sales across state lines:

    Don­ald Trump: We’re tak­ing across all of the bor­ders or the lines so that insur­ance com­pa­nies can com­pete–

    John Dick­er­son: But that’s not in–

    Don­ald Trump: –nation­wide.

    John Dick­er­son: –this bill. The bor­ders are not in–

    Don­ald Trump: Of course, it’s in.

    Dick­er­son is right here: allow­ing insur­ers to sell across state lines is a pop­u­lar con­ser­v­a­tive pol­i­cy, but it is not one includ­ed in the cur­rent Repub­li­can bill. It is not includ­ed because it like­ly couldn’t pass as part of a rec­on­cil­i­a­tion bill, where all pro­vi­sions need to have a direct effect on the fed­er­al bud­get.

    Trump does relent on this point when pressed by Dick­er­son, say­ing that it will need to pass in a sep­a­rate bill. But again, he stum­bles. He says that bill will get “quick­ly get approved.” That is incred­i­bly unlike­ly. Because this bill would need to go through reg­u­lar order, it needs 60 votes in the Sen­ate — a tall order when Democ­rats have no inter­est in work­ing with Repub­li­cans on repeal­ing Oba­macare.

    Trump’s lies mat­ter because vot­ers will believe them

    Last Decem­ber, I report­ed a sto­ry about Oba­macare enrollees in Ken­tucky who vot­ed for Trump. These were gen­er­al­ly peo­ple who had fol­lowed the elec­tion close­ly and knew that Trump promised to repeal Oba­macare — the source of their health insur­ance.

    They vot­ed for Trump, how­ev­er, because he kept promis­ing some­thing bet­ter.

    Don­ald Trump made promis­es dur­ing cam­paign inter­views that sharply diverged from his actu­al cam­paign stances. He promised, “I am going to take care of every­body,” dur­ing an inter­view with 60 Min­utes — even though his cam­paign health plan would leave 21 mil­lion with­out cov­er­age.

    “That man has a head for busi­ness,” one enrollee said. “He will absolute­ly do his best to change things.”

    There is a moment where Dick­er­son press­es Trump on how his own sup­port­ers would be effect­ed by his own plan. Dick­er­son seems to be start­ing to cite CBO data about how pre­mi­ums could increase by 750 per­cent for a low-income, old­er Oba­macare enrollee.

    He can’t fin­ish his ques­tion before Trump begins wav­ing it away:

    John Dick­er­son: So but in the bill, as it was ana­lyzed, there were two prob­lems.
    One, and you talked about this with Con­gress­man Robert Ader­holt, who brought you the exam­ple of the 64-year-old who under Oba­macare the pre­mi­ums–

    Don­ald Trump: But that was a long time ago, John.

    John Dick­er­son: But has that been fixed?

    Pres­i­dent Trump: Total­ly fixed.

    John Dick­er­son: How?

    Don­ald Trump: How? We’ve made many changes to the bill.

    No, this prob­lem isn’t fixed. There is no change that House Repub­li­cans or the White House have offered pub­licly that would pro­tect the Oba­macare enrollees that are like­ly to be Trump vot­ers, gen­er­al­ly low­er-income and old­er.

    ...

    Now Trump appears to be say­ing that he’s ready to reverse course, that this part of the Repub­li­can bill is cur­rent­ly “chang­ing.” So either Trump is announc­ing a big pol­i­cy shift that would like­ly lead to Free­dom Cau­cus oppos­ing the bill — or he’s mis­un­der­stand­ing what is actu­al­ly in the bill. From the inter­view, its hard to know.”

    It is indeed hard to know what in the world Trump was was try­ing to com­mu­ni­cate. Edu­cat­ed guess­es are the best we can do. And if there’s one thing Trump’s firs 100 days has edu­cat­ed us all on it’s that Trump tends to ram­ble in a weird stream of con­scious­ness way where it’s unclear what’s real and what’s ‘Trump being Trump.’ And also that he’s ful­ly on board the Paul Ryan agen­da for health care and ful­ly will­ing to engage in stream of con­scious­ness ver­bal raz­zle daz­zle to obscure what he’s doing. We’ll even­tu­al­ly see if this amend­ment pass­es, but it’s hard to ignore the fact that short­ly before he sug­gest­ed the amend­ment was “chang­ing” and remov­ing pre-exist­ing con­di­tions changes, he was con­flat­ing the pre-exist­ing con­di­tions pro­tec­tions with high-risk pools:

    ...
    The first iter­a­tion of the Repub­li­can bill, intro­duced in the House on March 6, kept Obamacare’s pro­tec­tions for peo­ple with pre-exist­ing con­di­tions. But a new amend­ment intro­duced this week to win Free­dom Cau­cus sup­port changes all that. It caves to con­ser­v­a­tives’ demand that to dereg­u­late the insur­ance indus­try and let health plans once again use pre-exist­ing con­di­tions to set pre­mi­um prices.

    It cre­ates waivers that states can use to let health insur­ers charge sick patients high­er pre­mi­ums, a prac­tice out­lawed under cur­rent law.

    Trump knows there were changes to the bill. But he gets them back­wards, insist­ing that the updates strength­en pro­tec­tions for sick­er patients:

    This bill is much dif­fer­ent than it was a lit­tle while ago, okay? This bill has evolved. And we did­n’t have a fail­ure on the bill. You know, it was report­ed like a fail­ure. Now, the one thing I would­n’t have done again is put a time­line. That’s why on the sec­ond iter­a­tion, I did­n’t put a time­line.

    But we have now pre-exist­ing con­di­tions in the bill. We have — we’ve set up a pool for the pre-exist­ing con­di­tions so that the pre­mi­ums can be allowed to fall.

    Trump is describ­ing the evo­lu­tion of the Repub­li­can plan back­wards. The pro­tec­tions for those with pre-exist­ing con­di­tions have got­ten weak­er, not stronger. It sounds like Trump may be con­fus­ing pre-exist­ing con­di­tions with high risk pools — which an amend­ment last month would have pro­vid­ed $15 bil­lion more in fund­ing for — but it’s hard to tell.
    ...

    Trump is describ­ing the evo­lu­tion of the Repub­li­can plan back­wards. The pro­tec­tions for those with pre-exist­ing con­di­tions have got­ten weak­er, not stronger. It sounds like Trump may be con­fus­ing pre-exist­ing con­di­tions with high risk pools — which an amend­ment last month would have pro­vid­ed $15 bil­lion more in fund­ing for — but it’s hard to tell.”

    Note the switcheroo at work when Trump says, “But we have now pre-exist­ing con­di­tions in the bill. We have — we’ve set up a pool for the pre-exist­ing con­di­tions so that the pre­mi­ums can be allowed to fall.”: Trump is equat­ing the pre-exist­ing con­di­tions pro­tec­tions with state-run high-risk pools. And he’s claimin in the inter­view that these high-risk pools strength­en pro­tec­tions for peo­ple with pre-exist­ing con­di­tions. That’s going to be the sales pitch if they go ahead with this plan, and based on what he said there it sure sounds like that’s the plan.

    And then, of course, he says the exact oppo­site and asserts that the pre-exist­ing con­di­tions pro­vi­sion in that amend­ment are in the process of get­ting removed. Yep:

    ...
    Even­tu­al­ly, Trump becomes insis­tent that any bill he signs with pro­tect peo­ple with pre-exist­ing con­di­tions. He appears to throw cold water on that new amend­ment, the one that won over the sup­port of the Free­dom Cau­cus. He describes it as “in one of the fix­es” and that its cur­rent­ly “chang­ing:”

    John Dick­er­son: In one of the fix­es it was dis­cussed pre-exist­ing was option­al for the states–

    Don­ald Trump: Sure, in one of the fix­es. And they’re chang­ing it

    John Dick­er­son: –oh, okay. So it’ll–

    Don­ald Trump: –and chang­ing.

    John Dick­er­son: –be per­ma­nent?

    Don­ald Trump: Of course.

    John Dick­er­son: Okay. Well, that’s a devel­op­ment, sir.

    This part of the inter­view is a bit bizarre. House Repub­li­cans have, at the behest of the White House, been work­ing for weeks now to nail down a bill that their cau­cus can sup­port. They inched clos­er to that goal when the MacArthur amend­ment cre­at­ed the pre-exist­ing con­di­tion waivers, which clinched the Free­dom Cau­cus’ sup­port.

    Now Trump appears to be say­ing that he’s ready to reverse course, that this part of the Repub­li­can bill is cur­rent­ly “chang­ing.” So either Trump is announc­ing a big pol­i­cy shift that would like­ly lead to Free­dom Cau­cus oppos­ing the bill — or he’s mis­un­der­stand­ing what is actu­al­ly in the bill. From the inter­view, its hard to know.

    ...

    He sure likes to leave the crowd guess­ing! Devi­ous or mad? Senile? We can only guess. And while it’s hard to know what exact­ly the plan is, it seems high­ly like­ly that he’s behind the high-risk pools amend­ment based on the fact that he pre­ced­ed this con­fus­ing answer with a con­tra­dic­to­ry answer about how he was excit­ed about the high-risk pools plan to strength­en pre-exist­ing con­di­tions pro­tec­tions. Unless he changed his mind lit­er­al­ly right at that moment in the inter­view and sud­den­ly decreed that “they’re chang­ing it.” And real­ly, who knows, maybe he did. For mad/devious/senile rea­sons. Who knows. Regard­less, unless what Trump said last about remov­ing the pre-exist­ing con­di­tions stuff from the amend­ment was true, the stuff he said right before it about how excit­ed he is about the high-risk pools is what we should expect.

    So it’s not look­ing good for peo­ple with pre-exist­ing con­di­tions. Or any­one who gets them in the future. Or ages.

    On the plus side, a lot more peo­ple are prob­a­bly going to be vot­ing in state elec­tions. They’re get­ting an a ‘life and death’ dimen­sion once the high-risk pools and fund­ing for them become polit­i­cal foot­balls. And since the GOP dom­i­nates elec­tions at the state-lev­el, any ‘live and death’ dimen­sion is going to most­ly become a ‘death’ dimen­sion in prac­tice. In the vast major­i­ty of states. Unless lots of peo­ple with pre-exist­ing con­di­tions and those who care about them vote in large num­bers and ensure a great high-risk pool that cov­ers every­one. So that’s com­ing to US state pol­i­tics. A ‘more death than life on aver­age over the long-run’ dimen­sion is com­ing. That can all hap­pen, but it requires that amend­ment Trump endorsed before he reversed.

    Posted by Pterrafractyl | April 30, 2017, 11:01 pm
  9. One of the more grim­ly fas­ci­nat­ing dynam­ics of the US pol­i­tics in recent decades, as the GOP’s assault on gov­ern­ment and rea­son suc­ceed­ed in revers­ing much of the New Deal and Great Soci­ety social safe­ty-net infra­struc­ture, is how the ‘Rea­gan Rev­o­lu­tion’ and decades of attacks on enti­tle­ments and the safe­ty-net cou­pled with the pri­vate sec­tor move away from defined-ben­e­fit employ­ee pen­sions and towards defined-con­tri­bu­tion 401k retire­ment plans were obvi­ous­ly going to result in a mas­sive cri­sis of old age pover­ty some day. It was extreme­ly pre­dictable that defined con­tri­bu­tion plans that put retire­ment sav­ing almost entire­ly on the backs of employ­ees would result in a mas­sive old age finan­cial cri­sis. Espe­cial­ly if that retire­ment cri­sis coin­cides with a safe­ty-net cri­sis caused by the GOP shred­ding every­thing. This was obvi­ous decades ago when the US embarked on the 401k retire­ment mass exper­i­ment and it only gets more and more obvi­ous as the real retire­ment cri­sis con­tin­ues to grow and unfold. And yet the grow­ing Amer­i­can retire­ment cri­sis is almost nev­er talked about despite that fact that it impacts a major­i­ty of Amer­i­cans and the GOP is poised to shred enti­tle­ments. It’s grim.

    Mas­sive num­bers of Amer­i­cans today are more or less guar­an­teed to nev­er be allowed to retire thanks to the myr­i­ad of incred­i­bly unwise col­lec­tive deci­sions made past and present. The shift the move the bur­den of retire­ment sav­ings away from gov­ern­ment and cor­po­rate pen­sion and onto indi­vid­u­als was clear­ly going to result in mas­sive num­bers of Amer­i­cans not hav­ing enough sav­ings to retire. And the jobs that tend to wear the body down by the time peo­ple hit their 50’s and 60’s — man­u­al labor, food ser­vices, etc. — are the jobs that pay the least, with the weak­est retire­ment ben­e­fits, and thus the peo­ple whose bod­ies need retire­ment the most are the ones least like­ly to do so. It’s cru­el.

    Adding to the grim nature of the sit­u­a­tion is the present day push by the GOP to impose work require­ments on almost any­one seek­ing pub­lic ser­vices like Med­ic­aid or food stamps ensure that those seek­ing med­ical care for their bro­ken bod­ies are going to be forced to work to the break­ing point just to get that care. Some­how this grim sit­u­a­tion is almost nev­er talked about by Amer­i­cans them­selves, which just make the sit­u­a­tion even grim­mer.

    Although per­haps the grimmest part of it all is that these major struc­ture changes to the US retire­ment sys­tem and safe­ty-net were all large­ly done by and for ruth­less super-wealthy peo­ple who seem to gen­uine­ly not care at all about the poor and don’t care if they’re build­ing a sys­tem where most old peo­ple are forced to work until they die.

    Giv­en all that, here’s a peek at the kind of work a grow­ing num­ber of Amer­i­cans near­ing retire­ment (and even­tu­al­ly in ‘retire­ment’) are going to have to do just to do just to qual­i­fy for Med­ic­aid and oth­er gov­ern­ment ser­vices like food stamps after the work require­ments become the norm. Thanks to the far-right’s decades of wild suc­cess in con­vinc­ing the Amer­i­can pub­lic to get gov­ern­ment out of the busi­ness of grow­ing old and tak­ing care of each oth­er: elder­ly nomads liv­ing in RVs trav­el­ing the coun­try doing sea­son­al temp work like pick­ing fruit in the fields and pack­ages in Ama­zon’s ware­hous­es is an employ­ment growth sec­tor in the US:

    Mar­ket­Watch

    Many old­er Amer­i­cans are liv­ing a des­per­ate, nomadic life

    By Richard Eisen­berg

    Pub­lished: Nov 11, 2017 11:35 a.m. ET

    This arti­cle is reprint­ed by per­mis­sion from NextAvenue.org. It is part of a part­ner­ship between Next Avenue and Chas­ing the Dream, a pub­lic media ini­tia­tive on pover­ty and oppor­tu­ni­ty.

    In her pow­er­ful new book, “Nomad­land,” award-win­ning jour­nal­ist Jes­si­ca Brud­er reveals the dark, depress­ing and some­times phys­i­cal­ly painful life of a tribe of men and women in their 50s and 60s who are — as the sub­ti­tle says — “sur­viv­ing Amer­i­ca in the twen­ty-first cen­tu­ry.” Not quite home­less, they are “house­less,” liv­ing in sec­ond­hand RVs, trail­ers and vans and dri­ving from one loca­tion to anoth­er to pick up sea­son­al low-wage jobs, if they can get them, with lit­tle or no ben­e­fits.

    The “workam­per” jobs range from help­ing har­vest sug­ar beets to flip­ping burg­ers at base­ball spring train­ing games to Amazon’s “Camper­Force,” sea­son­al employ­ees who can walk the equiv­a­lent of 15 miles a day dur­ing Christ­mas sea­son pulling items off ware­house shelves and then return­ing to frigid camp­grounds at night. Liv­ing on less than $1,000 a month, in cer­tain cas­es, some have no hot show­ers. As Brud­er writes, these are “peo­ple who nev­er imag­ined being nomads.” Many saw their sav­ings wiped out dur­ing the Great Reces­sion or were fore­clo­sure vic­tims and, writes Brud­er, “felt they’d spent too long los­ing a rigged game.” Some were laid off from high-pay­ing pro­fes­sion­al jobs. Few have cho­sen this life. Few think they can find a way out of it. They’re down­ward­ly mobile old­er Amer­i­cans in mobile homes.

    Dur­ing her three years doing research for the book, con­duct­ing hun­dreds of inter­views and tra­vers­ing 15,000 miles, Brud­er even tried liv­ing the dif­fi­cult nomad life; she last­ed one work­week. I recent­ly inter­viewed Brud­er to learn more about the lives in Nomad­land and what the future holds for these peo­ple:

    Next Avenue: How did you come to write “Nomad­land?”

    Jes­si­ca Brud­er: It grew out of a sto­ry I wrote for Harper’s in 2014. I had read a sto­ry in Moth­er Jones and it men­tioned a woman work­ing in a ware­house who was liv­ing in an RV and said she couldn’t afford to retire. I went ‘Good­ness!’ Call me naive, but when I see an RV, I assume it’s owned by one of the last of great pen­sion­ers enjoy­ing retire­ment and going to see the Nation­al Parks. I regard­ed it as a life of lux­u­ry and a neat retire­ment choice. After all, they call them ‘recre­ation­al’ vehi­cles.

    I start­ed doing some research and learned there was a whole spec­trum of thou­sands of employ­ers hir­ing peo­ple in sim­i­lar sit­u­a­tions — in oil fields, har­vest­ing sug­ar beets and help­ing out at amuse­ment parks. These are not easy jobs or the kind typ­i­cal­ly asso­ci­at­ed with peo­ple in old­er stages. But nobody had been look­ing at it in con­text of the retire­ment cri­sis in the wake of the Great Reces­sion. And a lot of the recruit­ing mate­ri­als for these jobs made them look like sum­mer camps. Some for Amazon’s Camper­Force said if you come, you’ll make friends. It felt so strange to me, so I start­ed talk­ing to RV’ers out­side Ama­zon ware­hous­es in Neva­da and Kansas. Some lost their sav­ings; some thought they would retire on the equi­ty in their homes, but their homes dropped in val­ue dra­mat­i­cal­ly, while the cost of tra­di­tion­al hous­ing kept going up. A lot of them were liv­ing hand to mouth; it was hard for them to save for tomor­row.

    ...

    Why do you think so many old­er peo­ple are liv­ing and work­ing this way?

    I think it has been the pret­ty bad eco­nom­ic times. We saw in the 1980s a shift from pen­sions to 401(k)s; that was a raw deal for work­ers. These retire­ment plans were mar­ket­ed as an instru­ment of finan­cial free­dom, but they were real­ly trans­fer­ring risk from the shoul­der of the employ­ers to the backs of the work­ers.

    I met a lot of old­er women. The gen­der wage gap has meant women have low­er life­time earn­ings then men; they spend more time out of the work­force doing unpaid labor, rais­ing fam­i­lies or car­ing for par­ents..

    Do you have any sense about whether the num­bers of peo­ple in “Nomad­land” are grow­ing and why?

    Anec­do­tal­ly. Amazon’s Camper­Force says it’s get­ting more and more appli­ca­tions. And when I track Face­book groups of these peo­ple, they’re all explod­ing. There are prob­a­bly in the tens of thou­sands of peo­ple in Nomad­land, and that’s being con­ser­v­a­tive.

    Why do Nomads live like this?

    We live in a cul­ture where if your num­ber didn’t come up, you’re a bad per­son, you’re lazy, you should be ashamed of your­self. It eats away at peo­ple. It makes them more exploitable.

    What are the chal­lenges they face?

    I talked to one cou­ple, Barb and Chuck. He had been head of prod­uct devel­op­ment at McDonald’s before he retired. He lost his nest egg in the 2008 crash and Barb did, too. One time, Barb and Chuck were stand­ing at the gas sta­tion to get $175 worth of gas and the hor­ror hit them that their account had $6 in it. The gas sta­tion gen­tle­man said ‘Give me your name and driver’s license and if you write a check, I will wait to cash it.’ He wait­ed two whole weeks before he deposit­ed it.

    These jobs can be rough phys­i­cal­ly, right?

    I know some­one in his 70s who walked 15 miles on a con­crete floor, some­times for 10 hours. Your feet can get messed up, you can get repet­i­tive stress injury and a ten­don con­di­tion. The Nomads talked to me about soak­ing their feet in salt baths at night and being too tired to go out. When I went to the sug­ar beet har­vest, it was 12 hours a day in the cold, shov­el­ing. Oh my God, my body hurt! And I was 37!

    Tell me about Amazon’s Camper­Force pro­gram, which hires thou­sands of Nomads.

    It began in 2008, with­in months after the hous­ing col­lapse. Ama­zon con­tracts with an RV park and pays the Camper­Force to do ware­house work load­ing and pack­ing and order ful­fill­ment. From the out­side look­ing in, you’d say: ‘Why would you want old­er peo­ple doing this? The jobs seem suit­ed to younger bod­ies.’ But so many times, the recruiters in the pub­lished mate­ri­als talk about the old­er people’s work eth­ic and the matu­ri­ty of the work­force and their ‘life expe­ri­ence,’ which is a code word for ‘Hey, you’re old.’

    You write that some­times the Nomads are exploit­ed. How?

    I filed a Free­dom of Infor­ma­tion Act request with the For­est Ser­vice and learned that some of their work­ers aren’t get­ting paid for all their hours. They weren’t allowed to invoice.

    Some of the Nomads had to work along­side robots, such as in the Ama­zon ware­hous­es. How was that?

    The robots were mak­ing them bonkers. This is iso­lat­ing work and there’s one scene in the book where a robot kept bring­ing a woman in her 70s the same thing to count.

    What needs to change to pre­vent peo­ple from hav­ing to become Nomads or to help them live bet­ter if they are?

    For one thing, Ama­zon should pay its work­ers more and give them bet­ter work­ing con­di­tions. It’s laugh­able that the work­ers get a 15-minute break when they have to spend it walk­ing to the break room. It’s com­plete­ly insane.

    Nomads need a voice, but at the same time, it’s extreme­ly unlike­ly that they’ll orga­nize for bet­ter work­ing con­di­tions because they’re vul­ner­a­ble and always on the move.

    ———-

    “Many old­er Amer­i­cans are liv­ing a des­per­ate, nomadic life” by Richard Eisen­berg; Mar­ket­Watch; 11/11/2017

    “Nomads need a voice, but at the same time, it’s extreme­ly unlike­ly that they’ll orga­nize for bet­ter work­ing con­di­tions because they’re vul­ner­a­ble and always on the move.”

    Yep, vul­ner­a­ble elder­ly nomads always on the move and busy work­ing low wage jobs just to sur­vive prob­a­bly aren’t going to polit­i­cal­ly orga­nize very effec­tive­ly. It’s some­thing to keep in mind giv­en that cre­at­ing a large pool of low wage polit­i­cal­ly dis­em­pow­ered labor­ers is clear­ly a far-right oli­garch goal. And while the pool of RV and mobile home own­ers is going to be lim­it­ed, the larg­er les­son — that keep­ing as many elder­ly Amer­i­cans work­ing and poor effec­tive­ly hin­ders their abil­i­ty to polit­i­cal­ly orga­nize against things like safe­ty-net cuts — is cer­tain­ly a les­son the oli­garchy has learned by now.

    And notice the point when Ama­zon opened up its “Camper­Force” net­work of deliv­ery peo­ple liv­ing in RVs: Right after the stock mar­ket col­lapse of 2008. When a whole bunch of peo­ple at or near retire­ment saw their retire­ment sav­ings wiped out in a stock mar­ket col­lapse. It was the high­ly pre­dictable sce­nario that a 401k-style retire­ment sys­tem guar­an­tees at some point:

    ...
    Why do you think so many old­er peo­ple are liv­ing and work­ing this way?

    I think it has been the pret­ty bad eco­nom­ic times. We saw in the 1980s a shift from pen­sions to 401(k)s; that was a raw deal for work­ers. These retire­ment plans were mar­ket­ed as an instru­ment of finan­cial free­dom, but they were real­ly trans­fer­ring risk from the shoul­der of the employ­ers to the backs of the work­ers.

    I met a lot of old­er women. The gen­der wage gap has meant women have low­er life­time earn­ings then men; they spend more time out of the work­force doing unpaid labor, rais­ing fam­i­lies or car­ing for par­ents..

    ...

    Why do Nomads live like this?

    We live in a cul­ture where if your num­ber didn’t come up, you’re a bad per­son, you’re lazy, you should be ashamed of your­self. It eats away at peo­ple. It makes them more exploitable.

    What are the chal­lenges they face?

    I talked to one cou­ple, Barb and Chuck. He had been head of prod­uct devel­op­ment at McDonald’s before he retired. He lost his nest egg in the 2008 crash and Barb did, too. One time, Barb and Chuck were stand­ing at the gas sta­tion to get $175 worth of gas and the hor­ror hit them that their account had $6 in it. The gas sta­tion gen­tle­man said ‘Give me your name and driver’s license and if you write a check, I will wait to cash it.’ He wait­ed two whole weeks before he deposit­ed it.
    ...

    Des­per­ate old peo­ple who just had their life sav­ings wiped out but also own RVs. The Ama­zon work force of the near future. And present. In the dis­tant future robots will pre­sum­ably do that work and Ama­zon’s Camper­Force employ­ees will need to find some­thing even worse. But for now it appears to be an employ­ment growth sec­tor and has been since 2008.

    And note how long the hours can be doing the kind of stress­ful work for long hours that can dam­age ten­dons, which is poten­tial­ly per­ma­nent phys­i­cal dam­age that’s going to lead to future med­ical costs:

    ...
    These jobs can be rough phys­i­cal­ly, right?

    I know some­one in his 70s who walked 15 miles on a con­crete floor, some­times for 10 hours. Your feet can get messed up, you can get repet­i­tive stress injury and a ten­don con­di­tion. The Nomads talked to me about soak­ing their feet in salt baths at night and being too tired to go out. When I went to the sug­ar beet har­vest, it was 12 hours a day in the cold, shov­el­ing. Oh my God, my body hurt! And I was 37!

    Tell me about Amazon’s Camper­Force pro­gram, which hires thou­sands of Nomads.

    It began in 2008, with­in months after the hous­ing col­lapse. Ama­zon con­tracts with an RV park and pays the Camper­Force to do ware­house work load­ing and pack­ing and order ful­fill­ment. From the out­side look­ing in, you’d say: ‘Why would you want old­er peo­ple doing this? The jobs seem suit­ed to younger bod­ies.’ But so many times, the recruiters in the pub­lished mate­ri­als talk about the old­er people’s work eth­ic and the matu­ri­ty of the work­force and their ‘life expe­ri­ence,’ which is a code word for ‘Hey, you’re old.’
    ...

    I know some­one in his 70s who walked 15 miles on a con­crete floor, some­times for 10 hours. Your feet can get messed up, you can get repet­i­tive stress injury and a ten­don con­di­tion. The Nomads talked to me about soak­ing their feet in salt baths at night and being too tired to go out. When I went to the sug­ar beet har­vest, it was 12 hours a day in the cold, shov­el­ing. Oh my God, my body hurt! And I was 37!

    The Wal­mart greeter job for retirees is clear­ly the good ‘ol days in terms of being easy on the body, although the amount of stand­ing was prob­a­bly phys­i­cal harm­ful on long shifts.

    And note the ref­er­ence to the author try­ing out the sug­ar beet har­vest work. That’s pre­sum­ably not an Ama­zon job, unless Ama­zon’s pur­chase of Whole Foods has already put it in the fruits and veg­etable pick­ing busi­ness. It sounds like just gen­er­al fruit and veg­etable pick­ing sea­son­al work. It’s a reminder that while Ama­zon might be a new major play­er in the sto­ry of the elder­ly Amer­i­can migrant temp work­er nomads, there’s going to be a large num­ber of dif­fer­ent employ­ers who will find a use for sea­son­al elder­ly work­ers as that pool bal­loons in com­ing years and decades. And it might include employ­ers offer­ing work even more phys­i­cal­ly demand­ing than an Ama­zon ware­house. Like work­ing in the fields.

    But Ama­zon’s enthu­si­as­tic embrace of elder­ly ware­house work­ers also makes it clear that big play­ers who employ large num­bers of peo­ple for low wage jobs are going to be ready and will­ing to seek out old peo­ple for phys­i­cal­ly demand­ing jobs. That’s a thing now. Granny is stay­ing active. In the ware­house.

    And don’t for­get that the Christ­mas sea­son Ama­zon needs all the temp work­ers for prob­a­bly does­n’t over­lap with har­vest sea­son so a lot of peo­ple are prob­a­bly pick­ing fruit in one area of the US in the Fall and relo­cat­ing to work in Ama­zon’s ware­hous­es for Christ­mas. So now we know who will be pick­ing Amer­i­ca’s fruit after all the migrant work­ers are kicked out. Poor old peo­ple. Pick­ing fruit and veg­eta­bles and work­ing in ware­hous­es. That’s what Amer­i­cans are going to be doing instead of retir­ing in exchange for med­ic­aid ben­e­fits and food stamps. It’s like a safe­ty-net design to cull the pop­u­la­tion. In order to pay for tax cuts.

    And sure, it’s unlike­ly that states will sud­den­ly impose work require­ments that make elder­ly poor peo­ple over the retire­ment age face work require­ments for Med­ic­aid in the near future. The work require­ments will prob­a­bly be impose on peo­ple below retire­ment age unless there’s a mas­sive finan­cial cri­sis that destroys state bud­gets. But over the long run, it’s hard to see how there’s isn’t going to be a steady creep­ing up of that retire­ment age that creeps at a pace faster than the rise in life expectan­cies, espe­cial­ly for the work­ing poor since they can’t be expect­ed to par­tic­i­pate in a lot of future life-expectan­cy gains. The mas­sive cuts to fed­er­al enti­tle­ment spend­ing as a con­se­quence of the GOP’s war on gov­ern­ment is going to make a spik­ing work require­ment cut-off age a cer­tain­ty as more and more of the costs of enti­tle­ments gets dumped on states and a state-lev­el com­pet­i­tive race to the bot­tom begins. Rais­ing the retire­ment age will be how states stay ‘com­pet­i­tive’ and ‘attract jobs’ (and cut tax­es). That’s the dynam­ic that the enti­tle­ment block-grant­i­ng is intend­ed to unleash and in that kind of envi­ron­ment retire­ment ages are set to spike and the fed­er­al and state lev­els.

    So don’t for­get, it’s high­ly like­ly that Amer­i­ca is going to force peo­ple near­ing retire­ment to find what­ev­er work is avail­able just to get health care, and there are employ­ers, includ­ing major employ­ers like Ama­zon, who are inter­est­ed in hir­ing a lot of old peo­ple to do phys­i­cal­ly demand­ing work. Osten­si­bly in order to keep Med­ic­aid costs down. Phys­i­cal­ly demand­ing work for old peo­ple to keep down health care costs. That’s a real phe­nom­e­na that Amer­i­ca might inflict upon itself. All the ingre­di­ents are there.

    This is, of course, is why grow­ing num­bers of Amer­i­cans can’t have nice things. Like retire­ment.

    Posted by Pterrafractyl | November 19, 2017, 10:21 pm

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