Esquire

The Price of John McCain’s Republican Loyalty

He has a terminal illness. He’s on government healthcare. But he’s a Republican.

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By Charles P. Pierce      July 25, 2017

WASHINGTON—It was an ugly day in the United States Senate on Tuesday, as ugly a day as has been seen in that chamber since the death of Strom Thurmond, who used to make a day ugly simply by showing up. The Senate took up the Motion To Proceed on whatever the hell hash Mitch McConnell wants to make out of the American healthcare system. (The decision now seems to be between whether we kick 30 million, 22 million, or 18 million of our fellow citizens to the curb.) There was a loud protest in the Senate gallery, and the Capitol police, who were everywhere, went out of their way to prevent any media coverage of the ensuing arrests. (In this, they were helped immeasurably by a bunch of little omadhauns from the office of the Senate sergeant-at-arms, one of whom was so insufferable that he was even money to get thrown out a window.) That was really ugly.

The vote was 51-50, with Vice President Mike Pence breaking the tie. Back when he was becoming the very unpopular governor of Indiana, Mike Pence grabbed the Affordable Care Act’s Medicaid expansion with both hands. Now, he was the deciding vote in the first real test of whether the Republican congressional majorities will eviscerate Medicaid entirely. That was really ugly, too.

But the ugliest thing to witness on a very ugly day in the United States Senate was what John McCain did to what was left of his legacy as a national figure. He flew all the way across the country, leaving his high-end government healthcare behind in Arizona, in order to cast the deciding vote to allow debate on whatever ghastly critter emerges from what has been an utterly undemocratic process. He flew all the way across the country in order to facilitate the process of denying to millions of Americans the kind of medical treatment that is keeping him alive, and to do so at the behest of a president* who mocked McCain’s undeniable military heroism.

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For longtime McCain watchers, and I count myself as one of them, this is something of a pattern. In 2000, George W. Bush’s campaign slandered him and his young daughter, and radical fundamentalist Christians joined in so eagerly that McCain delivered the best speech of his career, calling those people “agents of intolerance.” By 2006, he was on Meet The Press, which ultimately always was the constituency he cared most about, saying that the late Jerry Falwell was no longer an agent of intolerance. He was hugging Bush, and he was speaking at Liberty University. All of this seems to support the theory that the best way to win over John McCain is to treat him as badly as possible.

So he got a standing ovation when he walked into the chamber, and that was all right, and then he cast the vote to proceed. And then, having done so, he climbed onto his high horse and delivered an address every word of which was belied by the simple “yes” he had traveled so far to cast.

“Our deliberations today – not just our debates, but the exercise of all our responsibilities – authorizing government policies, appropriating the funds to implement them, exercising our advice and consent role – are often lively and interesting. They can be sincere and principled. But they are more partisan, more tribal more of the time than any other time I remember. Our deliberations can still be important and useful, but I think we’d all agree they haven’t been overburdened by greatness lately. And right now they aren’t producing much for the American people. “Both sides have let this happen. Let’s leave the history of who shot first to the historians. I suspect they’ll find we all conspired in our decline – either by deliberate actions or neglect. We’ve all played some role in it. Certainly I have. Sometimes, I’ve let my passion rule my reason. Sometimes, I made it harder to find common ground because of something harsh I said to a colleague. Sometimes, I wanted to win more for the sake of winning than to achieve a contested policy.”

His “yes” won the day for a secret process that produced a bill that nobody’s seen yet.

“Let’s trust each other. Let’s return to regular order. We’ve been spinning our wheels on too many important issues because we keep trying to find a way to win without help from across the aisle. That’s an approach that’s been employed by both sides, mandating legislation from the top down, without any support from the other side, with all the parliamentary maneuvers that requires.”

He could have struck a blow for these noble sentiments—and, most notably, for “regular order”—by voting no. It would have been the most resounding vote of his long career. But he said, “yes.”

“I voted for the motion to proceed to allow debate to continue and amendments to be offered. I will not vote for the bill as it is today. It’s a shell of a bill right now. We all know that. I have changes urged by my state’s governor that will have to be included to earn my support for final passage of any bill. I know many of you will have to see the bill changed substantially for you to support it. We’ve tried to do this by coming up with a proposal behind closed doors in consultation with the administration, then springing it on skeptical members, trying to convince them it’s better than nothing, asking us to swallow our doubts and force it past a unified opposition. I don’t think that is going to work in the end. And it probably shouldn’t.”

God, this is gorge-inducing. Alone, he could’ve stopped the process he so dislikes in its tracks. He could’ve done it in a way that echoed through the ages. But he said, “yes.”

“The Obama administration and congressional Democrats shouldn’t have forced through Congress without any opposition support a social and economic change as massive as Obamacare. And we shouldn’t do the same with ours.”

Alas, this is an absolute lie, and an embarrassing one, and the Straight Talk Express is in the ditch. The Affordable Care Act was the product of endless hearings and at least 100 amendments proposed by Republicans. It was scored by the CBO. The Senate debated it for almost a month, and the senators knew what was in it. Right now, the bill that John McCain facilitated likely will be one that isn’t scored by the CBO, and the Freedom Caucus crackpots in the House are trying to defund the CBO and hand the job of scoring legislation to the Heritage Foundation. I would bet a substantial number of buffalo nickels that John McCain votes for whatever bill finally comes before him, no matter how many people’s lives that bill makes miserable.

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I wanted this to be different. In 2000, I thought McCain might be the person to lead his party back to marginal sanity at least. But he wanted to be president, so he became like all the rest of them. Yes, he scolded that person who said Barack Obama was a Muslim, but he chose as his running mate a nutty person who still may believe he is. Yes, he put his name on a campaign finance reform bill, but he also voted for every member of the Supreme Court who subsequently eviscerated that law, and others like it, and he’s been absent from that fight ever since. There have been very few senators as loyal to the party line as John McCain. He has been a great lost opportunity to the country. Now, he will end his career as the face of whatever wretchedness is brought on the country by whatever the bill finally is.

By the end of the afternoon, the Democrats had taken over one of the wide marble staircases outside the Capitol. They had walked across the piazza and onto the East Lawn of the Capitol to talk to some protesters, many of whom are struggling with diseases and disabilities that would be covered under the Affordable Care Act, and certainly under the Cadillac healthcare plan enjoyed by John McCain. It was a nice gesture, and they were warmly received, but there was something of the stunt to it.

The Republicans have the votes now. Dean Heller and Rob Portman and Shelley Moore Capito have lined up with their party once, and the likelihood is their respective prices will be met again because this is not a policy issue any more, it is pure politics now, a promise made by an extremist majority to its unthinking base. That’s what the end of this ugly day looked like, a day on which the final bloody death of Barack Obama’s legacy was placed on the fast track by people who know better, and on which Susan Collins of Maine was more of a maverick than John McCain ever was. It was an ugly day in the U.S. Senate, and there was nothing but ruin everywhere you looked.

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The Guardian

John McCain had the chance to do the right thing on healthcare. He failed

Lucia Graves     July 25, 2017

There are many reasons to respect the Arizona senator, but his remarkable stoicism and service can’t excuse his yes vote in the Senate

‘John McCain lost more than his good health – he’s lost his decency.’ Photograph: Aaron P. Bernstein/Reuters

John McCain often gets cast as a truth-teller to Donald Trump, but his voting record says otherwise. And nowhere was that more clear than on Tuesday when, despite his own ill health, when it came to the decision of whether to take other people’s healthcare away, he cast a decisive vote in the wrong direction.

Addressing his fellow lawmakers, McCain called passionately for a return to regular order, and for senators to work constructively across the aisle. “Why don’t we try the old way of legislating in the Senate, the way our rules and customs encourage us to act,” he said in his Tuesday speech. “If this process ends in failure, which seems likely, then let’s return to regular order!”

Though he has often railed against Trump as if he can’t actually affect what he is complaining about, McCain isn’t a helpless observer – he’s an influential senator. And on Tuesday, as the country draws closer than ever before to the death of the Affordable Care Act, he was a pivotal one.

Had McCain simply voted no to the question of whether the Senate should begin debate on a repeal or replacement of Obamacare, which squeaked by in the Senate with a vote of 51-50, the chamber’s leader Mitch McConnell might well have been forced to do the very thing McCain claimed to want: restore the chamber to order.

Instead, McCain, who was recently and tragically diagnosed with an aggressive form of brain cancer, and who returned to DC explicitly to help save the GOP healthcare bill, voted yes.

To put it another way, faced with a rare opportunity to make a real tangible difference, he risked traveling amid failing health to make possible the very thing he decried.

More damningly, he voted yes to take away healthcare from millions of Americans – including an untold number of other cancer patients – even as he continues to access benefits of the quality care afforded him as a senator, care subsidized by American taxpayers.

Never mind that at this point in time Republicans have little idea what the bill they would replace Obamacare with will contain. Never mind that we have arrived at this point through a secretive process devoid of public hearings, or even that Republicans would have the healthcare of millions of American women dreamed up entirely by men.

Politics appears to have triumphed over logic. Sadly, the politics that won out today are is not even a sort personally dear to John McCain – that much was made clear in his floor speech. It’s not even his own electoral politics that won out, either; after a tough re-election battle, he won’t be up again until 2022, freeing him up as much as electorally possible to act solely with his moral compass as the guide.

Instead, McCain did the very thing he had just railed against, acting out of partisan loyalty.

There are many reasons to respect McCain, a former prisoner of war who endured torture in the five and a half years he spent captive in North Vietnam, and has campaigned against torture by the US. His 2008 campaign against Barack Obama now looks like the very model of civility in the wake of Trump.

But even his remarkable stoicism and service can’t excuse what he just did.

The grim reality is that health insurance is of the utmost importance when it comes to surviving cancer, the second leading killer in America after heart disease. Put simply, the uninsured are much more likely to die than those with insurance – and sooner.

A recent study in the journal Cancer found the uninsured were 88% more likely to die of testicular cancer than those with insurance. For patients with Medicaid, the number dropped to a 58% greater chance of dying than privately insured patients like McCain.

The study found the same trend held true for patients with glioblastoma, the malignant brain cancer McCain was recently diagnosed with. It’s a terribly disease with a median life expectancy with his type of just 15 months, and that’s as true for McCain as anyone, but the uninsured still die faster than anyone.

Voting to subject any one of millions of Americans to go to meet such a fate without even the benefit of the best tools medicine has to fight it is cruel, given McCain’s new-found appreciation of the benefit.

The estimated cost of McCain’s recent surgery to remove the cancer above his eye is a sum that would bankrupt many Americans, using the Medicare rates for which McCain qualifies.

There’s a way to fix the fact that many Americans under the age of 65 don’t have access to any such care: let everyone under it buy in, a scheme for which many on the left have argued. But on Tuesday, McCain helped move the country in precisely the opposite direction.

We still don’t know which of several bills Republicans will bring up for a vote, but all of them involve millions of Americans losing the very sort of health insurance upon which McCain depends.

The only question is whether it’s a matter of 22, 32 or “just” 15 million people who will lose access. What we can say with confidence is whatever version moves forward, McCain’s lost more than his good health – he’s lost his decency.

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Slate       Jurisprudence-The law, lawyers and the Court

Unpresidential Command

Trump is ordering service members to support the Republican agenda. That is terrifying.

By Phillip Carter     July 24, 2017

President Donald Trump, with Navy Capt. Richard McCormack, commissions the USS Gerald R. Ford during a ceremony at Naval Station Norfolk in Virginia on Saturday.   Jonathan Ernst/Reuters

In a serious breach of presidential norms, President Donald Trump urged sailors attending the commissioning of the USS Gerald R. Ford on Saturday to wade into the political fray and help lobby Congress on health care and other topics. “I don’t mind getting a little hand, so call that congressman and call that senator and make sure you get it,” Trump said of his budget, highlighting the defense spending portion. This could have been interpreted as an order from the commander in chief to the service members in attendance to support the Republican Party agenda. “And by the way, you can also call those senators to make sure you get health care,” he added.

That Trump would so command the troops—who he apparently sees as his troops—should come as no surprise. Time after time, he has breached long-standing norms of civil-military relations: from evading presidential responsibility, to appropriating service members’ valor for political purposes, to politicking before military audiences. Saturday’s breach stands apart because of its directness and its implications. Trump’s verbal command in Norfolk, Virginia, incites the assembled troops to discard centuries of U.S. military ethics and break long-standing military rules, too. This is what leaders do in banana republics: Instruct the people with guns to join the political fray.

The military tradition of avoiding domestic politics literally predates the country, going back to a dispute over veterans’ benefits between then-Gen. George Washington and his officers. The officers planned to confront Washington at Newburgh, New York, with a thinly veiled threat of military takeover if they didn’t get Washington’s support in a plea to Congress. Washington deftly defused the plot, telling his troops they would “sully the glory” they earned on the battlefield with their plans to lobby Congress.

In the two centuries since, the U.S. military has increasingly professionalized and bureaucratized itself. Today, the rules against troops’ political activity exist in the Uniform Code of Military Justice and several Pentagon regulations. Article 88 of the military justice code makes it a crime for an officer to use “contemptuous words” against the president, vice president, Congress, or certain other officials, whether for political purposes or not. Military Rule of Evidence 508 gives service members an absolute right “to refuse to disclose the tenor of the person’s vote at a political election conducted by secret ballot.”

In addition to these parts of the military’s criminal code, numerous Pentagon rules and regulations aim to keep service members out of politics. DoD Directive 1344.10 bars active and reserve service members from conducting political activity in uniform or in ways that suggest they carry the military’s imprimatur. Other DoD rules limit the way troops can wear their uniforms, use their titles, or express themselves on political issues too.

President Trump’s comments on Saturday inject legal risk and uncertainty into this system of rules. On the one hand he—as commander in chief of the armed forces—can be seen as effectively giving an order to the troops that they must obey. As a legal matter, the president’s authority trumps the Department of Defense’s rules on political activity, if not the UCMJ’s criminal provisions, although the latter can be read to allow what Trump wants. If the troops obey Trump in this instance, however, they must essentially disobey their own regulations, not to mention service norms and values.

There is real danger in the troops actually following Trump’s guidance. Lobbying Congress and entering the political fray can only be a distraction from defending the nation—a point subtly made by retired Maj. Gen. Charlie Dunlap in his brilliant essay “The Origins of the American Military Coup of 2012” nearly 25 years ago. Our military today enjoys the highest approval rating of any institution in society, but sullying itself with the mud of political debates can only harm that reputation.

More broadly, Trump’s commands inject uncertainty and doubt into the military, which depends on order and discipline for cohesion and effectiveness and combat. Which rules, exactly, are troops to follow when the president himself casts such doubt as he did in Norfolk? If the president believes the rules governing political activity don’t suit him, how broadly will that apply? Are they now allowed to fly “Make America Great Again” or “Trump for President” flags from their personal cars on base? From military vehicles? (This presumably would be a unilateral allowance, and expressing support for Democrats would still be verboten.)

If Trump someday wants to upend other inconvenient regulations, like the military’s rules on torture and interrogation, can he do so with a mere suggestion like this? Georgetown law professor and my colleague Rosa Brooks rightly pointed out how unlikely it was that the military would disobey a presidential order. The greatest danger of all posed by Trump’s disregard for military values is that he will someday go further than he did this weekend and undermine rules or norms with far graver consequences.

There is real danger in the troops actually following Trump’s guidance.

We often take civil-military relations for granted in this country because we have it so good. The greatest civil-military eruptions in recent history involve things like then-Gen. Eric Shinseki’s sobering 2003 testimony contradicting George W. Bush’s White House, saying that it would take “several hundred thousand” troops to pacify Iraq, or impolitic comments by Gen. Stan McChrystal’s staff in a 2010 Rolling Stone article. These skirmishes stand in stark contrast to the civil-military brawls in countries like North Korea—where the dear leader regularly executes top generals—or Pakistan, where the military dominates politics and has on occasion overthrown the government. American civil-military relations even look tame next to those in France, where newly elected President Emmanuel Macron just fired his top general, reminding his remaining brass that “I am your boss.”

Our civil-military relations are fragile and are already being strained by the Trump presidency. In just six months, he has given hyperpolitical speeches to military and intelligence audiences, used the Pentagon’s Hall of Heroes to sign his controversial first travel ban, and whined about how tough he had it in his speech at the U.S. Coast Guard Academy graduation. Trump’s top lieutenants have also aided this corruption of the civil-military ethic. Vice President Mike Pence misstated the rule on obeying orders in his graduation speech—omitting the important exception for unlawful orders. The national security adviser, Army Lt. Gen. H.R. McMaster, has debased himself and the military ethic, too, by leaping to Trump’s political defense after Trump gave highly classified information to the Russians, and then did so again in a vapid Wall Street Journal op-ed defending Trump’s “America First” agenda.

If left unchecked, Trump and his team will likely continue to tear the fabric of American civil-military relations, leaving tattered shreds of the military’s ethics and values in their wake. That is, unless three groups step up to play their constitutional role in checking Trump.

First, Congress must police Trump’s excesses through aggressive oversight. In confirmation hearings, Senate committees should continue to demand that senior Pentagon civilian and military appointees testify candidly back to Congress when called upon to share their views. Congressional oversight committees should regularly call military witnesses to testify, and use their hearings to solicit views from America’s career military leadership about the wisdom and efficacy of the Trump administration’s military policies as has been historic practice.

Second, military leaders must assert their professional norms and ethics more forcefully. Such dissent should occur in private first to respect the chain of command. Gen. Joseph Dunford, the chairman of the Joint Chiefs of Staff, has a statutory duty to serve as “the principal military adviser to the President.” In that role, he must raise his voice in defense of long-standing military norms and ethics when they are threatened by the president in ways that ultimately threaten the country. Likewise, senior military leaders should candidly and publicly answer congressional inquiries about strategy, policy, and resources—even where doing so exposes rifts with the White House—to enable Congress to play its constitutional role in national security affairs.

Finally, Trump’s own inner circle must do more to restrain the rhetorical excesses and explosions that have so far defined this presidency. This includes the generals he has tapped to serve in his Cabinet—McMaster, Secretary of Defense James Mattis, and Secretary of Homeland Security John Kelly—who must now teach their principal why these long-standing rules matter both for the country and Trump’s interests. Our country cannot take its healthy civil-military relations for granted nor expect these norms to survive too many more barrages from the current president. It remains to be seen whether Trump will accept such tutoring—or fire the teachers—but these active and retired generals owe it to the country to do their best to keep the president from running the ship of state aground.

One more thing

The Trump administration poses a unique threat to the rule of law. That’s why Slate has stepped up our legal coverage—watch-dogging Jeff Sessions’ Justice Department, the Supreme Court, the crackdown on voting rights, and more.

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Phillip Carter is a senior fellow at the Center for a New American Security and adjunct professor of law at Georgetown University. The views expressed are the author’s alone and not representative of his organization.

The Guardian-U.S. Healthcare

How does the US healthcare system compare with other countries?

As Republicans decide what to do with the current healthcare policy, nearly 26 million Americans remain without insurance – and that number could soon rise

Josh Holder, Paul Torpey and Feilding Cage       July 25, 2017

Despite US legislation in 2010 that moved the country closer to achieving universal healthcare, costs have continued to rise and nearly 26 million Americans are still uninsured according to the Congressional Budget Office.

As Republicans decide whether to repeal or replace the struggling healthcare policy, how does the existing US healthcare system compare with those in other countries?

Broadly speaking, the World Health Organization (WHO) defines universal health coverage as a system where everyone has access to quality health services and is protected against financial risk incurred while accessing care.

A brief history of the healthcare systems used today

Among the 35 OECD member countries, 32 have now introduced universal healthcare legislation that resembles the WHO criteria.

In Germany, the world’s first national health insurance system shows how UHC often evolves from an initial law. Originally for industrial laborers, cover gradually expanded to cover all job sectors and social groups, with today’s German workers contributing around 15% of their monthly salary, half paid by employers, to public sickness funds.

Established in 1948 to be free at the point of use, the UK’s NHS has almost totemic status for Britain’s rising, ageing population who scrutinize it like perhaps no other policy area. While care from GP services to major surgery remains free as intended, the system is under unprecedented financial strain from a funding gap estimated to be in the billions.

Under France’s state-run equivalent of the UK’s NHS, the majority of patients must pay the doctor or practitioner upfront. The state then reimburses them in part or in full. Workers make compulsory payments into state funds used to reimburse between 70% and 100% of the upfront fees, while many people pay into other schemes to cover the balance.

In the mid-1960s, the United States implemented insurance programs called Medicare and Medicaid for segments of the population including low income and elderly adults. In 2010, Obamacare became the closest the US has come to a system of UHC. A legal mandate now requires all Americans to have insurance or pay a penalty. About 26 million people remain without health insurance despite these advances.

Spending compared with life expectancy

Life expectancy in the US is still lower than other developed countries, despite health funding increasing at a much faster pace.

Who provides healthcare and how is it paid for?

How healthcare is funded has a direct effect on the level of healthcare people have access to.

Single-payer

The state funds an agreed range of services through public clinics that are paid for through taxes.

For example, in Sweden there is a limit in how much you pay for healthcare in one year of between 900-1100 kronor (£80-£100)

Two-tier

Government healthcare may be less comprehensive and minimum level of coverage can be supplemented by private insurance.

In Australia, hospital treatment is covered by Medicare, yet most people pay a fee to see a GP or for ambulance services. 57% of adults have private insurance

Insurance mandate

A two-tier system underpinned by an insurance mandate where citizens are legally required to purchase cover from public or private insurers.

Most people in Japan receive health insurance from their employer, otherwise they must sign up for a national health insurance program. Medical fees are regulated to keep them affordable

How could the US healthcare system change?

Donald Trump ran on a campaign to repeal and replace the Affordable Care Act, popularly known as Obamacare, but discord among Republicans has highlighted the political challenges faced with implementing a healthcare system, much less trying to change it.

With millions still uninsured and the financial burden of healthcare still quite high, the current US policy falls short of the WHO threshold.

Thus far, separate bills introduced in the House and the Senate were estimated to see steep increases in the number of uninsured from current levels.

Estimated uninsured under existing and proposed healthcare plans

By 2016, the Senate Repeal Plan will create almost 60 million uninsured. Under the first two Republican House bills and the revised Republican Senate Bill, almost 50 million will be uninsured. Under the current Affordable Care Act (Obamacare), 27 million will still be uninsured. Congressional Budget Office.

https://www.theguardian.com/us-news/ng-interactive/2017/jul/25/us-healthcare-system-vs-other-countries