LA Times  Op-ed

Is Trump mentally fit to be president? Let’s consult the U.S. Army’s field manual on leadership

By Prudence L. Gourguechon   June 16, 2017

Since President Trump’s inauguration, an unusual amount of attention has been paid to the 25th Amendment to the Constitution. That’s the measure, ratified in 1967, that allows for removal of the president in the event that he is “unable to discharge the powers and duties” of the office. What does that mean, exactly? Lawyers surely have some ideas. But as a psychiatrist, I believe we need a rational, thorough and coherent definition of the mental capacities required to carry out “the powers and duties” of the presidency.

Although there are volumes devoted to outlining criteria for psychiatric disorders, there is surprisingly little psychiatric literature defining mental capacity, even less on the particular abilities required for serving in positions of great responsibility. Despite the thousands of articles and books written on leadership, primarily in the business arena, I have found only one source where the capacities necessary for strategic leadership are clearly and comprehensively laid out: the U.S. Army’s “Field Manual 6-22 Leader Development.”

The New York Times published a letter signed by 35 psychiatrists, psychologists and social workers. The letter suggests Trump’s “grave emotional instability… makes him incapable of serving safely as president.” (Feb. 21, 2017)

The Army’s field manual on leadership is an extraordinarily sophisticated document, founded in sound psychological research and psychiatric theory, as well as military practice. It articulates the core faculties that officers, including commanders, need in order to fulfill their jobs. From the manual’s 135 dense pages, I have distilled five crucial qualities:

Trust

According to the Army, trust is fundamental to the functioning of a team or alliance in any setting: “Leaders shape the ethical climate of their organization while developing the trust and relationships that enable proper leadership.” A leader who is deficient in the capacity for trust makes little effort to support others, may be isolated and aloof, may be apathetic about discrimination, allows distrustful behaviors to persist among team members, makes unrealistic promises and focuses on self-promotion.

A good leader ‘demonstrates an understanding of another person’s point of view’ and ‘identifies with others’ feelings and emotions.’

Discipline and self-control

The manual requires that a leader demonstrate control over his behavior and align his behavior with core Army values: “Loyalty, duty, respect, selfless service, honor, integrity, and personal courage.” The disciplined leader does not have emotional outbursts or act impulsively, and he maintains composure in stressful or adverse situations. Without discipline and self-control, a leader may not be able to resist temptation, to stay focused despite distractions, to avoid impulsive action or to think before jumping to a conclusion. The leader who fails to demonstrate discipline reacts “viscerally or angrily when receiving bad news or conflicting information,” and he “allows personal emotions to drive decisions or guide responses to emotionally charged situations.”

In psychiatry, we talk about “filters” — neurologic braking systems that enable us to appropriately inhibit our speech and actions even when disturbing thoughts or powerful emotions are present. Discipline and self-control require that an individual has a robust working filter, so that he doesn’t say or do everything that comes to mind.

Judgment and critical thinking

These are complex, high-level mental functions that include the abilities to discriminate, assess, plan, decide, anticipate, prioritize and compare. A leader with the capacity for critical thinking “seeks to obtain the most thorough and accurate understanding possible,” the manual says, and he anticipates “first, second and third consequences of multiple courses of action.” A leader deficient in judgment and strategic thinking demonstrates rigid and inflexible thinking.

Self-awareness

Self-awareness requires the capacity to reflect and an interest in doing so. “Self-aware leaders know themselves, including their traits, feelings, and behaviors,” the manual says. “They employ self-understanding and recognize their effect on others.” When a leader lacks self-awareness, the manual notes, he “unfairly blames subordinates when failures are experienced” and “rejects or lacks interest in feedback.”

Empathy

Perhaps surprisingly, the field manual repeatedly stresses the importance of empathy as an essential attribute for Army leadership. A good leader “demonstrates an understanding of another person’s point of view” and “identifies with others’ feelings and emotions.” The manual’s description of inadequacy in this area: “Shows a lack of concern for others’ emotional distress” and “displays an inability to take another’s perspective.”

The Army field manual amounts to a guide for the 25^th Amendment. Whether a president’s Cabinet would ever actually invoke that amendment is another matter. There is, however, at least one historical precedent. The journalists Jane Mayer and Doyle McManus tell the dramatic story in their 1988 book, “Landslide: The Unmaking of the President 1984-1988.”

Before he started his job as President Reagan’s third chief of staff, in early 1987, Howard Baker asked an aide, James Cannon, to put together a report on the state of the White House. Cannon then interviewed White House staff, including top aides working for the outgoing chief of staff, Donald Regan. On March 1, the day before Baker took over, Cannon presented him with a memo expressing grave concern that Reagan might not be sufficiently competent to perform his duties. Reagan was inattentive and disinterested, the outgoing staff had said, staying home to watch movies and television instead of going to work. “Consider the possibility that section four of the 25^th Amendment might be applied,” Cannon wrote.

After reading the memo, Baker arranged a group observation of Reagan for the following day. On March 2, Baker, Cannon and two others — Reagan’s chief counsel, Arthur B. Culvahouse Jr., and his communications director, Tom Griscom — scrutinized the president, first at a Cabinet meeting, then at a luncheon. They found nothing amiss. The president seemed to be his usual genial, engaged self. Baker decided, presumably with relief, that Reagan was not incapacitated or disabled and they could all go on with their business.

Much has changed since the Reagan era, of course. Because of Trump’s Twitter habits and other features of the contemporary media landscape, far more data about his behavior are available to everyone — to citizens, journalists and members of Congress. And we are all free to compare that observable behavior to the list of traits deemed critical for leadership by the U.S. Army.

Prudence L. Gourguechon, M.D., is a psychiatrist and psychoanalyst in Chicago.

Washington Post    PowerPost

GOP health-care debate turns to stark question: help vulnerable Americans, or help the rich?

By Sean Sullivan, Juliet Eilperin and Kelsey Snell        June 29, 2017

The Republican debate over how to overhaul the Affordable Care Act turned sharply Thursday to a divisive and ideological question: How much money should the Senate health-care bill spend on protecting vulnerable Americans, and how much on providing tax relief to the wealthy?

Senate Majority Leader Mitch McConnell (R-Ky.), in an effort to strike a balance between centrists and conservatives, is now making concessions to both factions of his caucus, according to lawmakers and aides.

But this effort was complicated by a new Congressional Budget Office estimate Thursday finding that the Republican plan to change how Medicaid payments are calculated starting in 2025 would lead to significantly deeper reductions in its second decade than at the end of the first decade.

By 2036, the new analysis says, the government would spend 35 percent less on Medicaid than under the current law, compared with a 26 percent decrease in the first decade.

McConnell is rewriting his proposal to provide tens of billions more for opioid treatment and assistance to low- and moderate-income Americans, in part by potentially preserving a 3.8 percent tax on investment income provided under the Affordable Care Act that the current draft of the Senate bill would repeal. At the same time, the new draft aims to placate the right by further easing the existing law’s insurance mandates and providing higher tax deductions for the health-savings accounts that conservatives favor, Republicans said.

By Thursday afternoon, Senate leaders agreed to dedicate $45 billion to opioid funding, according to GOP aides, a concession that Sens. Rob Portman (R-Ohio) and Shelley Moore Capito (R-W.Va.) had been seeking for weeks. The draft released last week includes only $2 billion.

It remains unclear whether these changes, if adopted, would garner enough support for the bill to pass. But they may represent the most viable path forward if Republicans want to rewrite the 2010 health law known as Obamacare without any help from Democrats.

“We will, it appears to me, address the issue of ensuring that lower-income citizens are in a position to be able to buy plans that actually provide them appropriate health-care,” said Sen. Bob Corker (R-Tenn.). “And with that, my sense is that the 3.8 percent repeal [in the current draft] will go away.”

The 3.8 percent tax applies only to individuals making over $200,000 a year, and married couples earning more than $250,000. Repealing it as of Dec. 31, 2016, as the bill does now, would cost the federal government $172 billion in revenue over the next 10 years, according to a recent CBO analysis.

The updated Medicaid estimate from the CBO, which shows how spending would shrink over the next 20 years, underscored the extent to which McConnell’s plan would squeeze the longstanding public insurance program.

The current draft already cuts $772 billion over 10 years from Medicaid, which covers poor Americans as well as the elderly, children and pregnant women.

The updated analysis, requested by Sen. Ron Wyden (D-Ore.) and other Senate Democrats, calculated the impact of pegging the program’s inflation rate to the Consumer Price Index for urban consumers, as opposed to the medical inflation rate.

According to analysts at the health consulting firm Avalere and the Committee for a Responsible Federal Budget, this would translate into a cut of at least $330 billion in 2036.

The report suggested that as the spigot of federal funding constricted over time, “states would continue to need to arrive at more efficient methods for delivering services (to the extent feasible) and to decide whether to commit more of their own resources, cut payments to health care providers and health plans, eliminate optional services, restrict eligibility for enrollment, or adopt some combination of those approaches.”

Senate Minority Leader Charles E. Schumer (D-N.Y.) used the report as an opportunity to push GOP leaders to abandon plans to repeal the ACA and begin negotiations with Democrats over how to fix the health-care system.

“Rather than pushing a partisan bill that cuts taxes for the rich and slashes Medicaid, Senate Republicans should start over on health care and work with Democrats on a bipartisan plan to improve our health care system,” Schumer said in a statement.

With senators leaving town Thursday for a 10-day break over the July 4th holiday, Republicans are not likely to announce any new deal or unveil full legislation until after their return next month. That would give time for the CBO to analyze the new proposals and for senators to hear from constituents, setting up a few more days of haggling when they return July 10 and a vote possible the week after that.

Corker, who met with GOP leaders Wednesday, said he believes “the route being pursued” is to preserve the tax and use that money to provide subsidies for lower-income people.

He added that he voiced directly to President Trump his unease with the idea of slashing taxes for the wealthy while “increasing the burden” on lower-income Americans.

Minutes later, Senate Majority Whip John Cornyn (R-Tex.) acknowledged that keeping the tax was being discussed, but he underscored that no final decision had been made.

In a sign of the sharp disagreements that continue to plague Senate Republicans, Sen. Patrick J. Toomey (R-Pa.) disputed Corker’s notion that the tax cut would be jettisoned, calling the proposal a “very bad idea.”

“I’m not at all convinced that that’s where it’s going,” Toomey said.

Sen. Tim Scott (R-S.C.) said that while he thought it was a bad idea to use the investment tax to help fund the ACA’s existing programs, lawmakers may need to keep the tax. Scott said there is clear pressure from at least three senators to preserve it, and their votes are critical to passing the bill.

“Keeping it now is a whole new conversation,” Scott said. “particularly when you have three senators already heading in that direction.”

The dispute underscores the challenge Senate leaders face as they reexamine the tax portion of their Better Care Reconciliation Act. One bit of wiggle room in their negotiations is the CBO’s analysis of the bill’s impact on the federal deficit, which allows them to spend as much as $198 billion without violating Senate budget rules.

The draft bill that stalled this week would phase out the program’s expansion under the ACA over three years and rein in spending on the overall program, especially starting in 2025. It would also repeal or delay $541 billion in taxes, primarily on wealthy Americans and insurers.

The measure eliminates every tax imposed under the ACA except the “Cadillac” tax on employers offering generous health plans. That tax is suspended until 2026 to comply with congressional budget rules.

The move to cut Medicaid, which covers nearly 70 million Americans, helps offset the bill’s generous tax cuts. But it has generated significant opposition among more than a half-dozen centrists who fear the reductions will impede the nation’s effort to address the opioid crisis and could leave many vulnerable Americans without any health coverage at all.

With Vice President Pence prepared to cast the tiebreaking vote, Republicans need the support of all but two of their 52 senators.

Pence was in the Capitol Thursday as the health-care talks continued in small and large group settings. Asked if he was changing any minds, the vice president replied: “We’re working hard.”

McConnell hopes to send a revised version of the bill to the CBO as soon as Friday to get a vote on the bill before Congress’s August recess.

Meanwhile, according to lobbyists briefed on the matter, negotiators are looking at how to provide states with more ways to opt out of the Affordable Care Act’s insurance mandates — a key demand of conservatives. These rules include an essential benefits package that any ACA-compliant plan must offer, such as maternity and newborn care as well as preventive care and mental-health and substance-use treatment.

Republican Sens. Ted Cruz of Texas and Mike Lee of Utah have indicated they could potentially support the bill if leadership tacked on an amendment offered by Cruz, allowing insurers to opt out of all the Obamacare insurance regulations as long as they provided one fully compliant plan.

House conservatives also asserted themselves in the upper chamber’s debate Thursday, as House Freedom Caucus Chairman Mark Meadows (R-N.C.) came over to the Senate side of the Capitol. Meadows said Cruz’s amendment, or something similar, would be essential to win his support.

A growing number of senators have said they back the Cruz proposal but leaders worry that it may run afoul of Senate rules. McConnell is using the budget process to pass the health bill with a slim majority of 51 votes, rather than the 60 votes needed for most other legislation. But that also restricts the legislation to policies that have an impact on taxes, spending and the deficit.

Cornyn told reporters that leaders held a special meeting on Thursday to figure out if the Cruz amendment fits within those rules.

“We’re trying to figure it out,” Cornyn said. “Because there is a lot of support for the idea.”

Lee spokesman Conn Carroll said he also wants a provision to ensure the executive branch can’t single-handedly block states from revamping their ACA marketplaces. The current measure makes it much easier for states to use an existing federal waiver system, under Section 1332 of the law, to make changes as long as they are approved by the Centers for Medicare and Medicaid Services.

While the Senate bill gives states wide latitude to alter the marketplaces through this system, it would preserve a requirement that CMS has to determine that these changes would not increase the federal deficit. Lee wants an independent agency, such as the Government Accountability Office, to make that determination rather than a division of the Health and Human Services Department.

But if leadership added on the Cruz amendment, that might be enough to win over Lee’s vote. “I think that would be enough for us,” Carroll said in an interview.

The main tax change conservatives are now seeking — allowing people to put more money into health-savings accounts — would also benefit wealthier Americans. Families earning over $60,000 made up nearly 65 percent of the total that contributed to HSAs in 2014, according to recent data from the Treasury Department. Nearly two-thirds of those people earned between $75,000 and $200,000.

Paige Winfield Cunningham, Mike DeBonis and Amy Goldstein contributed to this report.

Washington Post  Plum Line

Whatever happens, the GOP is bringing us a whole lot closer to single payer

By Paul Waldman     June 27, 2017

The Republican health-care bill is not dead yet, but it’s in rough shape. Whether it passes or not, it has been an utter debacle for the GOP, making the Affordable Care Act they’re trying to undo more popular than ever, energizing the Democratic base, complicating the relationship between President Trump and Congress and sowing justified distrust of Republican motives among the broader public.

It has also done something else: moved the debate on health care in America to the left and made single payer much more likely.

Even if the Senate bill fails, Republicans give up and move on to tax reform, and the status quo remains in place, this debate will have had profound effects on our politics. While the Democratic Party may have been moving to the left on health care anyway, its momentum in that direction may now be unstoppable. And the entire country will be more receptive than ever to the arguments Democrats will make. This, by the way, will also be the case if the GOP repeal effort succeeds, because it will make so much that people hate about our health-care system a lot worse.

Let me point to one politician as an illustration. For years, Sen. Elizabeth Warren’s position on single payer has essentially been “Maybe someday” — not opposed to it, but focused in the short term on the more urgent priority of defending and enhancing the ACA. But in an article in today’s Wall Street Journal, we learn that she is now ready to take that plunge:

“President Obama tried to move us forward with health-care coverage by using a conservative model that came from one of the conservative think tanks that had been advanced by a Republican governor in Massachusetts,” she said during an interview in her Senate office last week. “Now it’s time for the next step. And the next step is single payer.”

Warren is not going to be the last Democrat to take this step. In fact, any Democrat who runs for president in 2020 — and there will be a lot of them — will have a hard time explaining to the primary electorate why they don’t want single payer, and most or all of them will probably say they do.

We can make an analogy with what happened in the GOP after the failure of comprehensive immigration reform. In 2013, the Senate passed a comprehensive bill with the support of many Republicans. But after it died in the House, Republican politicians went in exactly the opposite direction, telling their base that the only question was how much they hated “amnesty” and how tough they would be on undocumented immigrants. Then their party nominated someone who said he would build a wall on our southern border, create a “deportation force” and ban Muslims from entering the country.

The situations aren’t exactly the same, but the point is that a dramatic political failure — whether it’s yours or the other party’s — can have profound effects on the choices politicians make about how to approach the electorate. And it’s important to understand that while there are some Democratic politicians who emphatically favor single payer and would be unsatisfied with anything less, most of them would be willing to advocate for a range of policy options, depending on what looks politically achievable and what their base demands at a particular moment.

All the ups and downs of the past eight years, from the beginning of the debate on the ACA to the end of the debate on Republican repeal plans, hold many lessons for Democrats who are still eager to address the problems in the American health-care system. Among other things, we know that voters are risk-averse, that they’re extremely sensitive to out-of-pocket costs, that they want security and that arguments about the glories of the free market aren’t going to be persuasive to them. After seeing how desperately unpopular this Republican plan is, Democrats are going to be much less afraid to defend government health care and advocate its expansion.

And they know that whatever they propose next has to be simple and understandable. We can debate whether the ACA had to be as complex as it was, but next time around, no Democrat is going to believe that you can take on President Trump with a technocratic approach to health care. Saying “Here are the 10 tweaks I’d make to the ACA” isn’t going to cut it.

That isn’t to say that whatever plans they propose won’t be fully fleshed out under the hood, but they’ll have to be presented in a way that is easy for voters to understand. And, yes, Republicans will cry about “Washington bureaucrats making decisions for you,” but Democrats are less likely to be intimidated. Ask your parents or grandparents on Medicare how they feel about their coverage — Medicare is the most popular health insurance program we have, and it’s run by Washington bureaucrats.

It’s important to keep in mind that “single payer” isn’t one thing — if you look around the world at highly developed countries, there is a spectrum of health systems with various levels of public and private involvement. But what they have in common is that they achieve universal coverage while working better and costing less than ours. We could well have 15 Democratic presidential candidates proposing 15 different kinds of single payer. Some may be highly socialized systems — what Bernie Sanders would likely advocate if he runs again — but the ones that are most appealing could be hybrid systems of the kind that have been successful in countries such as France. The way it works is that there’s a government plan that covers everyone’s basic needs, but you can also buy supplemental private insurance to get as many more benefits as you want.

Among the advantages of a hybrid system is that one can actually see a path from where we are now to there. That path runs through Medicaid, which now covers nearly 75 million Americans. What if we auto-enrolled everyone under 65 in Medicaid — it’s there if you need it, but if you have different insurance you’d prefer, go ahead and use that instead. No one would be without coverage. Private insurance would evolve into something you buy to fill in the gaps and get perks that Medicaid wouldn’t provide. Instead of covering all your health care, employers could provide the supplemental private insurance.

As a political matter, you could sell this as something that we could transition to over an extended period, and as a system that satisfies the goals of both liberals and conservatives. Liberals get the universal coverage and security they want, and conservatives get the freedom they want — if you’re rich enough to buy a supplemental plan that includes deliveries of Dom Perignon during any hospitalization, go right ahead.

That isn’t to say that Republicans wouldn’t resist and there won’t be more intense arguments about health care, because they would and there will be. But by handling this debate so terribly and proposing something so monstrous, Republicans have opened up the space for Democrats to go much further than they’ve been willing to before. It’s not impossible to foresee Democrats winning the House in 2018, then taking the presidency and the Senate in 2020 — and then taking the first steps toward making single-payer health care in America a reality.

The Great Obamacare Conundrum

John Hanno    June 26, 2017

The Patient Protection and Affordable Health Care Act was a game (life) changer for many 10’s of millions of workers locked into a dead-end crap job, because they needed (often because they or a family member had a pre-existing condition) the mediocre health insurance plans offered by their employers.

Soon after the ACA was passed and folks were allowed to participate in the exchanges, and after concerned, responsible or self-serving employers advised many of their low wage employees that it would then be financially beneficial for these workers (and also the employer, who would no longer have to subsidize their premiums) to switch to the ACA, the shackles were finally thrown off these indentured servants. 10’s of thousands of workers changed jobs or were finally able to leave the workforce altogether.

Even after the U.S. Congress stripped some common sense parts of the original ACA, including the public option, the ACA was head and shoulders above many of the pre-Obamacare plans. That’s the reason every individual ACA benefit, with the exception of the mandate, is overwhelmingly popular with Americans (even conservatives) and why the Republi-cons are having such a hard time trying to now Indian-give these life saving benefits.

The ACA finally eliminated all restrictions to pre-existing conditions and allowed young people to stay on their parents policies through age 26, a huge benefit to families with students in college. All ACA plans cover the same set of essential health benefits. Every health plan must cover the following services: Ambulatory patient services (outpatient care you get without being admitted to a hospital.) Emergency services. Hospitalization (like surgery and overnight stays). Pregnancy, maternity, and newborn care (both before and after birth.) Mental health and substance use disorder, including behavioral health treatment (this includes counseling and psychotherapy.) Prescription drugs. Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills.) Laboratory services. Preventive and wellness services and chronic disease management. Pediatric services, including oral and vision care (but adult dental and vision coverage aren’t essential health benefits). Additional benefits: Plans must also include the following benefits: Birth Control coverage. Breastfeeding coverage

Essential health benefits are minimum requirements for all plans. Specific services covered can vary based on each state’s requirements. Plans may offer additional benefits, including: Dental coverage. Vision coverage. Medical management programs (for specific needs like weight management, back pain, and diabetes.)

I think if any of us were tasked with formulating a quality, comprehensive healthcare plan that we wouldn’t mind paying for, if we had premium subsidies based on our income, Obamacare (the Patient Protection and Affordable Care Act) would be exactly what we would come up with.

The Republic-con House and Senate plans would eliminate or diminish most of these essential requirements of Obamacare, probable 8 of 10. This is ‘Back to the Unhealthy Future.’

The ACA, admittedly, didn’t do enough to control healthcare costs. The ability to negotiate with drug companies, hospitals and other providers was booted from the original ACA proposals in order to get 60 votes in the senate. Both Republicans and some Democrats in health insurance and Pharma states objected to holding insurance and drug companies greedy feet to the American health care system run-away wild-fires. And the public option (another erstwhile Republican idea that was removed) would have added more competition to the insurance companies mix. But the Republi-cons rejected their own common sense prescription.

Unfortunately, too many healthcare providers complain about the reimbursement rates typical for Medicare, Medicaid and even treatments for Veterans and consequently refuse to participate in these plans or treat these patients.

But the poop hit the reality fan long ago. American’s on average spend $9,541 per person on healthcare, almost 3 times what other developed countries spend and with lower health outcomes to boot. Trump and the Republi-cons really need to stand up for the American consumer, not the Koch brothers and the super rich. We are at a tipping point. Healthcare is 1/6th of our economy and climbing.

Big Pharma, for profit health insurance companies, hospitals, doctors and other health care providers should prepare themselves for more scrutiny and lower incomes and profits, and take advantage of the reprise and grace period granted by the Obama administration and the Democrats to fundamentally restructure their business model. America can no longer afford the 30% or more they skim off the top of America’s unsustainable health care gravy-train.

Reluctant doctors and other healthcare providers should prepare themselves for a healthcare system that will rely on more inclusive government plan participation and on reduced reimbursement rates for their services, just like the rest of the developed world. Doctors in Germany and the rest of Europe and Scandinavia (who’s other workers earn substantially more on average than those in the U.S.) earn approximately half of what doctors earn in the U.S. and doctors in the rest of the developed world earn even less, between 25 and 30%.

Unscrupulous and greedy employers, who are supporting the Republi-con Obamarcare replacement boondoggle, should in reality, prepare themselves for paying much better wages and compensation if they want to attract and retain valuable employees. Baby Boomers are retiring by ten’s of thousands a month and employers who abet or stand silent while Republi-cons in Congress punish the remaining workers between 50 and 65 years of age, (pre-Medicare) with sky-rocketing health insurance premiums and deductibles, and with renewed obstacles to pre-existing conditions and over-all crappier insurance plans, will only exacerbate their self-inflicted worker shortage dilemma.

And transferring the Medicaid program to States who can’t run deficits, minus the substantial backing of Federal dollars (now more than 95%), will not end well. Medicaid covers more than 76 million Americans. Medicaid covers 12 percent of all adults, 20% of all Americans, 30% of all adults with disabilities, 39% of all children, 40% of all poor adults, 49% of all American births, 60% of all children with disabilities,  64% of all nursing home residents and 76% of all poor children.

Trump and the Republi-cons scream daily that Obamacare is dead and dying but that’s only in Red States where Republicans are in control of the levers of governance, the apparatus that can and has opposed or crippled implementation and support of their own citizens access to Medicaid and the Obamacare exchanges.

Obamacare attempted to not only “protect patients” but to also “control costs.” They succeeded for the most part on both counts; with the exception of many Red States controlled by Republi-con governors and legislatures, in particular those that not only refused to support their own citizens, by disallowing their expansion of Medicaid, but by doing everything they could to oppose and cripple the ACA exchanges. They either refused to set up their own state exchanges and or refused to support the federal ones.

Obamacare reduced the typical cut for the insurance industry from 30% to 15% of premiums. And for the first time, the ACA substantially emphasized preventative care, in order to head off expensive emergency room visits and ultimately to avoid the astronomical costs for untreated end stage health care consequences like cancer and diabetes. Many of the issues in the ACA were originally “conservative Republican” proposals. But no matter how Trump and the Republi-cons try to obfuscate the truth, increases in premiums under Obamacare were at the lowest rates in 20 years.

But it’s obvious the Republic-con lapdogs in congress and the right’s media (not true conservatives at all) take their marching orders from the rich and powerful like the Koch brothers empire. Their modus operandi is and will continue to be: (1) To keep employees poor and desperate enough to stay at crappy jobs offering substandard wages and benefits, (2) To return control of our healthcare back to the insurance industry, (3) To refuse to allow the American health care consumer (just like the rest of the world) negotiate equitable prices for drugs and health supplies and services, (4) Propose policies like killing Obamacare, to somehow attempt to reverse the tanking American labor participation rate (5) Propose a plan, as the Trump administration just did, to have the government and public schools pay for training or retraining workers for the growing number of job openings, left unfilled because industry refuses to pay living wages for these touted mythical openings. (6) Attack the Veterans Administration Health System, as Trump just did. The V.A., just like Medicare and Medicaid, has long ago negotiated lower drug prices and costs for services. In spite of some past problems at the historically underfunded V.A., veterans overwhelming hold their V.A. system in high regard and want control of their healthcare to remain with the V.A., not the private sector, as Trump and the Republi-cons propose. (7) And of course above all else, A-to cut taxes, B-to cut taxes and C-to cut taxes for the richest 1% or 1/10th of 1%, while passing the bill off onto the rest of American taxpayers and health care consumers, including small businesses.

Only 16% of American’s approved of the House passed AHCA and the new Senate proposed plan doesn’t fare much better (12 to 17% approval).

And all this “repeal and replace pain” will be foisted on the unsuspecting American middle class, poor, elderly and disabled, just so the Republi-con panders can reward their rich benefactors, with what they gleefully hail as the largest tax cut in our history. Their goal was never to improve Obamacare, never to actually “improve” our healthcare system; that was obvious to anyone with half a brain. This is a tax cut plan, pure and simple. All the lipstick on this pig can’t cover that up. Repeated attacks on the exchanges and the Medicaid expansion for the most vulnerable Americans was a primary goal; and of course trying to overturn or diminish anything accomplished by President Obama and the Democrats to reverse the right’s decades long campaign to reverse New Deal remedies, was gravy on the Republi-cons anti-labor and anti-middle-class agenda.

Trump and the Republi-cons should take note that California and other states are already on their own “yellow brick road” to single-payer, universal health insurance plans. It could be 3 years or 5 years or a bit longer, but most or all of America will soon have a single payer, universal healthcare system, just like the rest of the developed world.

But unless voters in the Red States held back by Republi-con ideologues, demand the same, they will remain crippled by the evildoers loyal to campaign contributors and not the American public. We may ultimately have 2 separate health systems. One for blue states and one for red.

Women, including those that depend on Planned Parenthood for their primary healthcare, nurture and build better families. Families unburdened by overwhelming healthcare debt and the threat and consequences of bankruptcy contribute to better communities. Better communities build better states. A healthy America, with healthy states is a more prosperous and stronger country.

John Hanno,   www.tarbabys.com

Associated Press

Donors to GOP: No cash until action on health care, taxes

Steve Peoples, Associated Press     June 26, 2017 

COLORADO SPRINGS, Colo. (AP) — At least one influential donor has informed congressional Republicans that the “Dallas piggy bank” is closed until he sees major action on health care and taxes.

Texas-based donor Doug Deason has already refused to host a fundraiser for two members of Congress and informed House Majority Leader Kevin McCarthy, R-Calif., his checkbook is closed as well.

“Get Obamacare repealed and replaced, get tax reform passed,” Deason said in a pointed message to GOP leaders. “You control the Senate. You control the House. You have the presidency. There’s no reason you can’t get this done. Get it done and we’ll open it back up.”

Indeed, there was a sense of frustration and urgency inside the private receptions and closed-door briefings at the Koch brothers’ donor retreat this weekend in Colorado Springs, where the billionaire conservatives and their chief lieutenants warned of a rapidly shrinking window to push their agenda through Congress and get legislation to President Donald Trump to sign into law.

No agenda items mattered more to the conservative Koch network than the GOP’s promise to overhaul the nation’s tax code and repeal and replace President Barack Obama’s health care law. At the moment, however, both are bogged down by GOP infighting that jeopardizes their fate.

At least one Koch official warned that the Republican Party’s House majority could be in jeopardy if the GOP-led Congress doesn’t follow through.

“If they don’t make good on these promises … there are going to be consequences, and quite frankly there should be,” said Sean Lansing, chief operating officer for the Koch network’s political arm, Americans For Prosperity.

Deason, who is keeping the “Dallas piggy bank” closed for now, said he was recently approached by Rep. Mark Meadows, R-N.C. and Rep. Jim Jordan, R-Ohio, about hosting a fundraiser.

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

“There is urgency,” said AFP president Tim Phillips. “We believe we have a window of about 12 months to get as much of it accomplished as possible before the 2018 elections grind policy to a halt.”

The window for action may be even smaller, some Koch allies warned at the three-day donor retreat that drew roughly 400 participants to the base of the Rocky Mountains. The price for admission for most was a pledge to give at least $100,000 this year to the Kochs’ broad policy and political network. There were also at least 18 elected officials on hand.

Some hosted private policy discussions with donors while others simply mingled.

In between meetings, Rep. Dave Brat, R-Va., predicted dire consequences in next year’s midterm elections should his party fail to deliver on its repeated promises.

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

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

While some donors threatened to withhold campaign cash, Koch’s team outlined a broader strategy to help shape the debate.

Already, Americans For Prosperity claims a paid staff of more than 400 full-time activists in 36 states. Koch officials said that the network’s midterm budget for policy and politics is between $300 million and $400 million.

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

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

At the same time, Koch’s allies are aggressively pushing forward on taxes.

The network is running what it describes as “a first wave” of digital ads calling on more than 50 House and Senate Republicans in both parties to overhaul the tax code. Later in the summer, Philips said, his organization will begin hosting rallies and other events to generate momentum for a tax overhaul in all 36 states where they have full-time operations.

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

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

 

Chicago Tribune

CBO: 22 million more would be uninsured by 2026 under Senate health bill

Amy Goldstein, Washington Post

Senate Republicans’ bill to erase major parts of the Affordable Care Act would cause an estimated 22 million more Americans to be uninsured in the coming decade — about 1 million fewer than similar legislation recently passed by the House, according to the Congressional Budget Office.

The forecast issued Monday by Congress’ nonpartisan budget scorekeepers also estimates that the Senate measure, drafted in secret mainly by Majority Leader Mitch McConnell and aides, would reduce federal spending by $321 billion by 2026 — compared with $119 billion for the House’s version.

The CBO’s analysis has been awaited as a crucial piece of evidence as McConnell and other Republican leaders try to hurry a vote on the bill this week. But they are navigating an expanding minefield of resistance from their own party’s moderate and conservative wings, while Democrats are united against it.

Several moderates have said they will decide whether they can support the Better Care Reconciliation Act based on how it will affect Americans who have gained coverage under the ACA during the past few years, while their conservative colleagues are focused on its impact on the federal deficit.

Of the 22 million who stand to lose coverage, 15 million of them would have no insurance next year, the nonpartisan budget office said. That could be a particular concern to Sen. Dean Heller, R-Nev., who faces perhaps the toughest 2018 re-election race of any Senate Republican and who’s said he can’t support a health care package that cuts Medicaid like the GOP plan and takes coverage from “tens of millions of Americans and tens of thousands of Nevadans.”

The fresh figures come as President Donald Trump, in a sharp pivot from the praise he initially lavished on the House bill, is urging the Senate to provide Americans more generous help with health insurance. On Sunday, the president repeated during a “Fox and Friends” TV appearance a word he had used in a private White House lunch earlier this month with a group of GOP senators: that the House’s version is “mean.”

The CBO has been regarded over its four-decade history as a source of neutral analyses devoid of political agenda. Its current director, Keith Hall, is a conservative economist who served in the administration of President George W. Bush and was appointed to his current role two years ago by a Republican Congress.

Nevertheless, senior Trump aides have repeatedly sought to cast doubt on the budget office’s credibility. “If you’re looking at the CBO for accuracy, you’re looking in the wrong place,” White House press secretary Sean Spicer said on the March day that the budget office issued its cost estimate of a preliminary version of the House GOP’s health-care legislation.

While they differ in important details, both the Senate GOP’s plan and the American Health Care Act narrowly passed by House Republicans in May share the goal of undoing central aspects of the sprawling health-care law enacted by a Democratic Congress seven years ago.

Both bills would eliminate enforcement of the ACA’s mandate that most Americans carry health insurance, relying on subtler deterrents to keep people from dropping coverage. The House version would let insurers temporarily charge higher rates, while the Senate added a provision Monday that would let health plans freeze out customers for six months if they let their coverage lapse.

In different ways, both would replace federal subsidies that help the vast majority of consumers buying coverage through ACA marketplaces, instead creating smaller tax credits that would provide greater assistance to younger adults while making insurance more expensive for people from middle age into their 60s.

After two years, both also would end subsidies that now help about 7 million lower-income people with ACA health plans afford deductibles and co-pays. And both would repeal an array of taxes that have helped to pay for the ACA’s benefits, including levies on health insurers and on wealthy Americans’ investment income.

For the Senate bill, the CBO’s estimates of insurance coverage and federal spending are influenced by the fact that its forecast covers a 10-year window and the legislation’s most profound changes for the nation’s health-care system are tilted toward the latter part of that period.

The bill would, for instance, leave in place the ACA’s expansion of Medicaid through 2020. After that, it would begin a three-year phaseout of the federal money that under the ACA has paid almost the entire cost of adding 11 million Americans to the program’s rolls in 31 states.

That means the extra funding wouldn’t disappear until the mid-2020s — roughly when sharp new restrictions on federal payments for the entire Medicaid program would take effect.

Over the weekend, the senior Democrat on the Senate subcommittee that oversees the CBO said in a tweet that he had asked the budget office to estimate the Senate bill’s effect on insurance coverage over a longer time horizon. “GOP is hiding the worst Medicaid cuts in years 11, 12, 13 and hoping CBO stays quiet,” wrote Sen. Chris Murphy, D-Conn.

The Associated Press contributed to this report.

Business Insider

Medicaid cuts in the Senate healthcare bill could be brutal for people living in nursing homes

Lydia Ramsey,  Business Insider    June 26, 2017

• Medicaid covers health care expenses of 74 million low-income Americans, including nursing home care for those who can’t afford it.
• Medicare, a program that covers medical expenses for Americans over 65 does not cover nursing homes.
• The New York Times reports that 42% of Medicaid spending goes to services like nursing home care. Cutting spending in the program would hit the elderly, or put pressure on nursing home operators to cut back.

Republicans in Congress are eager to make cuts to government spending on health insurance plans for low-income people. On June 22, Senate Republicans released their version of a plan to repeal and replace Obamacare. The plan, like one passed by the  House of Representatives, rolls back many of the provisions of Obamacare, including taking deep cuts from Medicaid — the federal program that covers medical expenses for low-income Americans.

That rollback in Medicaid funding could particularly hit one unexpected group of people: elderly people living in nursing homes. Even though elderly Americans get medical coverage from Medicare — that program doesn’t cover long-term stays in nursing homes. For the most part, people pay out of pocket for nursing homes. Once that gets depleted, residents start to qualify for Medicaid to cover their stay.

Medicaid covers more than 74 million Americans, including low-income people, families, and kids, as well as pregnant women, people with disabilities, and the elderly. The New York Times detailed the impact of Medicaid cuts on nursing home care in a story this weekend, and reports that — even though they only make up 6% of all Medicaid enrollees — those who use long-term services like nursing homes account for about 42% of total Medicaid spending.

Cuts to Medicaid spending could put those services on the chopping block.

“Moms and kids aren’t where the money is,” Damon Terzaghi, senior director at the National Association of States United for Aging and Disabilities told the Times. “If you’re going to cut that much money out, it’s going to be coming from older people and people with disabilities.”

Under the Senate’s bill, titled the Better Care Reconciliation Act, the Medicaid expansion that took place under the Affordable Care Act (or Obamacare) would be phased out. In other words, those who gained coverage through the expansion would be without once again, though they could access coverage through the individual insurance market.

The bill also scales back federal funding for Medicaid — which is more than half the spending for the program at the state level. That would leave states — which also fund the program — with fewer resources.

By law, state Medicaid programs have to cover nursing homes. If those states receive less funding from the federal government, it could increase the pressure on the operations of nursing homes, in turn possibly limiting who can qualify for care.

Here’s a breakdown of the percentage of federal funding each state receives, with those in dark blue receiving the most support. Ultimately it’s these dark blue states that are most likely to feel the cuts being proposed by Republicans.

Daily Kos

Trump Threatens Blackmail if Murderous Republican “Health Care” Scam Is Not Passed.

By Dartagnan     June 26, 2017 

It’s no surprise that threatening the lives of Americans comes remarkably easy to an Administration knee deep in an FBI investigation of its own criminality. With its willing Republican allies in the U.S. Congress, apparently it comes even easier:

During an off-camera briefing on Monday, Press Secretary Sean Spicer signaled that the Trump administration is willing to use low-income Americans’ health insurance as a bargaining chip to persuade Congress to pass Trumpcare, which will result in tens of milliuons of Americans losing their health insurance.

The “bargaining chip” is the lives and health of seven million Americans who receive Federal subsidies (known as cost-saving reductions or “CSR’s”) in order to afford co-payments and deductibles for their health insurance under the Affordable Care Act (“Obamacare”). The issuance of this thinly veiled blackmail threat was delivered today by the White House Occupant’s mouthpiece, Sean Spicer:

Spicer made clear that the administration will do what it can to continue to destabilize Obamacare exchanges by only committing to the CSR payments one month at a time.

“We committed to making them last month, and that’s as far as we will go at this time,” Spicer said. “We’re not committing to them this month.”

But Spicer then signaled that the “dynamic” will change if the Senate passes a health care bill.

So with the lives of seven million “expendables,” i.e., Americans without the political clout to buy off a Republican Senator, in the balance, and with the insurance exchanges and insurers that support the only lifeline those people have threatened with ruin due to deliberate underfunding by a malevolent President, this Administration today coldly revealed its inner Ratfucking Self to anyone who hadn’t already taken note of the complete lack of concern anyone in the Trump regime has ever expressed towards the welfare of the American people it was elected to serve.

Let’s go over that again, just to clarify what Trump told Americans today:

“If we can pass health care overall, then that changes the dynamic,” Spicer said. “It will ultimately be up to the president to decide.”

We are told it would “change the dynamic” if Americans are willing to trade their health and lives and those of their families so that some sociopathic billionaires like Robert Mercer and Sheldon Adelson are allowed to shove their snouts deeper into the public trough via some massive tax cuts. Because that’s what this charade of Republicans actually “caring” about ordinary Americans’ health care has always been about. It’s certainly not about keeping people healthy or alive.

The Blackmailer-in-Chief let his support flow from his mentally disturbed fingers earlier today: Yes, let it “crash and burn” along with the lives of all of those expendable people in need of basic health care. Just another threat, like the non-existent tapes of his conversations with the former FBI Director.

What a heartless thing to say, even for this…person in the Oval Office. But no one should be surprised:

In an interview with The Economist in May, Trump signaled he will eventually stop paying CSRs — the only question is when.

“[T]here is no Obamacare, it’s dead. Plus we’re subsidizing it and we don’t have to subsidize it. You know if I ever stop wanting to pay the subsidies, which I will,” Trump said. “Anytime I want.”

It’s difficult to imagine a real American President saying something so blithe, callous and juvenile.  He makes Nixon look positively angelic by comparison.

CNN

Koch brothers’ political network critical of Senate healthcare bill

By Maeve Reston, CNN        June 25, 2017

Story highlights:

• Donor group plans up to $400 million in spending in run-up to 2018 midterm elections
• “Senate bill needs to get better,” says top lieutenant

Colorado Springs (CNN) As growing opposition imperiled passage of the Senate version of the healthcare bill, leaders of the conservative Koch network voiced sharp criticism of the legislation at their donor retreat here — stating that the bill needed dramatic changes before they would support it.

The Koch network announced Saturday that they plan between $300 and $400 million on their political and policy objectives during the 2018 political cycle as Democrats wage an intense battle to win control of the House. The network has made the repeal of Obamacare a central focus of their political and policy work. They believe that neither the House, nor the Senate version achieve that goal.

“This Senate bill needs to get better. It has to get better,” said Tim Phillips, a top lieutenant in the network who recently met with White House officials to outline their proposed changes to the health care system.

The proposed changes to Medicaid, Phillips said, were unacceptable, because they just amount to tinkering around the edges rather than reforming the program. The Senate bill would dramatically scale back federal support of Medicaid and phase out the money that the government has provided to expand eligibility for Medicaid in the states.

Several GOP senators have announced their opposition to the Senate bill in its current form. Among them are conservative senators Mike Lee and Ted Cruz, who believe the bill does not go far enough and are attending the Koch network donor retreat this weekend. For several other senators, like Nevada Sen. Dean Heller, the cuts to Medicaid go too far. Senate Majority Leader Mitch McConnell can only lose two members in order to win passage for the bill.

        ‘The bill is not going to fix healthcare’

The Koch network has strongly opposed the expansion of Medicaid under Obamacare — arguing that by adding people to the rolls, the quality of care for the most vulnerable Medicaid recipients has plummeted.

“It was a struggling — frankly failing — program before this dramatic expansion,” said Phillips, President of Americans for Prosperity, the Koch network’s political organizing arm.

“To simply say we’re going to do a slight nip and tuck to a program that — because of Obamacare — has added millions and millions of people is frankly immoral. It’s not right to do that.”

“At the end of the day, this bill is not going to fix healthcare,” said James Davis, a spokesman for the network during an afternoon session with reporters. “We are going to be focusing our efforts out into the future on how we can fix it.”

Phillips, a top lieutenant with the network, noted that the organization was louder in their opposition to House version earlier this year, because they wanted to remind White House and Congressional officials that repealing Obamacare “was a promise that had been made to repeal Obamacare during four consecutive national elections beginning in 2010, and that the vast majority of members had pledged that.”

Republicans now living some of Democrats’ Obamacare nightmares.

Activists with the network have been more engaged in negotiations on the Senate bill, which is one reason they are in a wait-and-see mode.

                  ‘We are more optimistic’

Charles Koch, who was a vociferous critic of Donald Trump during the 2012 presidential campaign, did not mention the bill or the President as he welcomed hundreds of donors to the historic Broadmoor Hotel at the foot of Cheyenne Mountain Saturday evening. (Koch met with Vice President Mike Pence on Friday). Instead he praised the depth and breadth of his organization, which will hold a series of seminars this weekend focused on their legislative priorities, including criminal justice reform, education, tax reform and poverty.

“We are more optimistic now about what we can accomplish than we have ever been,” he said in remarks to donors, noting the group’s work propelling the confirmation of Neil Gorsuch to the Supreme Court.

Earlier Saturday, the network announced a new partnership with football star Deion Sanders. The Koch network pledged to spend $21 million on the joint initiative with Sanders to reduce persistent poverty in Dallas.

Six senators are taking part in the seminars this weekend: Senators John Cornyn, Cory Gardner, Jeff Flake, Ben Sasse, Ted Cruz and Mike Lee; along with four Governors: Greg Abbott of Texas, Matt Bevin of Kentucky, Eric Greitens of Missouri, and Doug Ducey of Arizona.

ThinkProgress

White House threatens to sabotage insurance of low-income people if Trumpcare isn’t passed

The Trump administration is putting poor people in a lose-lose situation.

Aaron Rupar, Journalist ThinkProgress     June 26, 2017

During an off-camera briefing on Monday, Press Secretary Sean Spicer signaled that the Trump administration is willing to use low-income Americans’ health insurance as a bargaining chip to persuade Congress to pass Trumpcare, which will result in tens of millions of Americans losing their health insurance.

Spicer detailed the administration’s position in response to a question about whether the Trump administration will cover next month’s cost-sharing reduction (CSR) payments for low-income people who purchase health insurance on the Obamacare exchanges. As Thinkprogress has previously detailed, the payments “partially subsidize deductibles and co-payments for more then 7 million low-income Americans, making it possible for many of them to afford their insurance. Cutting off the payments could potentially kick millions of people off the state exchanges, pushing some private insurers to withdraw as well. Premiums could shoot up across the board.”

Spicer made clear that the administration will do what it can to continue to destabilize Obamacare exchanges by only committing to the CSR payments one month at a time.

“We committed to making them last month, and that’s as far as we will go at this time,” Spicer said. “We’re not committing to them this month.”

But Spicer then signaled that the “dynamic” will change if the Senate passes a health care bill. The bill on the table — which was written in secret by Republican senators and hasn’t been subject to a hearing — is in some ways harsher than the House version that would result in 23 million Americans losing their health insurance. But unlike the House bill, the Senate version continues to temporarily provide tax subsidies for consumers to buy health insurance on exchanges, albeit ones that are much less generous than Obamacare.

“If we can pass health care overall, then that changes the dynamic,” Spicer said. “It will ultimately be up to the president to decide.”

Spicer then made an explicitly political case for why Trump won’t commit to making the CSR payments — an assurance that would undermine the administration’s ongoing effort to blow up Obamacare by encouraging insurance companies to continue to offer plans on the exchanges.

“If the president were to hypothetically say he’s going to make the payments in perpetuity or for a year, I think that continues to prop up a failed system and continues to do wrong by the American taxpayer and it also doesn’t lend itself to the expediency that I think we want to help get a new health care system in place,” he said.

Trump himself alluded to the chaos ending the CSR payments would sow in insurance markets in a tweet earlier Monday in which he threatened to let Obamacare “crash & burn!”

In an interview with The Economist in May, Trump signaled he will eventually stop paying CSRs  — the only question is when.

“[T]here is no Obamacare, it’s dead. Plus we’re subsidizing it and we don’t have to subsidize it. You know if I ever stop wanting to pay the subsidies, which I will,” Trump said. “Anytime I want.”

As The Weekly Standard detailed, the administration’s posture on CSRs “has already accelerated the collapse of health care exchanges as insurers move to limit their risk by raising prices or withdrawing from markets altogether.”

Washington Post Analysis

Another day, another poll showing how deeply unpopular the GOP health-care bill is

By Philip Bump     June 22, 2017

The day that Republican members of the House were first supposed to vote on the American Health Care Act, the legislation that would overhaul the Affordable Care Act (a.k.a. Obamacare) by cutting taxes on wealthy Americans and reducing spending on Medicaid, Quinnipiac University dropped a big, juicy fly in the ointment.

Only 17 percent of the country approved of the bill, a poll from the university showed — including less than half of Republicans.

Over time, those numbers haven’t really improved. Earlier this month, the most recent Quinnipiac poll showed the same figure: 17 percent approval. Support from Republicans, which had come oh so close to 50 percent in late May, was back down to about 4 in 10.

On Thursday, Senate Republicans introduced their own bill, the Better Care Reconciliation Act. It was crafted behind closed doors, and there’s no polling available on Americans’ views of it. But at noon on the day it dropped, so, too, did a new poll from NBC News and the Wall Street Journal.

Only 16 percent of Americans said the House bill was a good idea — including only a third of Republicans. That’s down 7 percent from last month.

It’s hard to overstate what a disaster those numbers are for the Senate Republicans. The best possible defense — and the defense that appears to have motivated the manner in which the bill was drafted — is that this is a poll number on a different piece of legislation. This is probably what Senate Majority Leader Mitch McConnell (R-Ky.) et al. are hoping will happen: They say, “Hey, this is the BCRA, not the AHCA, not sure how you made that mistake,” and then rush the bill to a vote before people realize how similar the two pieces of legislation are.

And they are similar, in the places that will affect the most people. A Washington Post analysis shows that the big-picture effect is to cut certain taxes (that mostly benefit the wealthiest Americans) and to cut Medicaid benefits (that heavily benefit the poor and disabled) with the likely net effect of substantially increasing the number of Americans who don’t have insurance. It won’t take much time for the similarities between the two bills to be made obvious, and therefore, for this bill to similarly fare poorly in the polls.

The Kaiser Family Foundation polled on the elements of the AHCA (that’s the House bill; these acronyms are confusing) a month ago. Even among Republican voters, most of the components were pretty unpopular.

The work requirement is in the Senate bill, in a form, and that’s popular with most Republicans, as are the high-risk pools. But so are the Medicaid cuts, the tax reductions — and the least popular provision, charging more for older customers.

Again: This is among Republicans. Is this a recipe for a more popular piece of legislation?

Republican senators are being asked to stand with party leadership on this bill to meet the Republican commitment to repeal Obamacare. That commitment powered a lot of grass-roots energy within the Republican base — but while that’s enough to ensure victory for some members of the party’s caucus, others need an awful lot of votes from independents (and even some Democrats) for whom that commitment was never appealing.

Shortly after Obamacare passed in 2010, the Kaiser Family Foundation found that it was more popular than not, although still had less than 50 percent approval. By that November, polling was about even — but the Democrats were demolished in House elections in part (but by no means solely) because of the party’s efforts to reform health care. Some Democrats took a tough vote for Obamacare — and lost their jobs.

On a bill that was about as popular as it was unpopular.

What’s the case McConnell makes to Republicans from moderate states who are up for reelection next year on voting for his unpopular bill?

Yahoo News

Trumpcare fixes nothing

Rick Newman     June 22, 2017 

There are a lot of big problems with the US healthcare system. Costs and spending are way too high, with Americans shelling out far more per person on healthcare than other advanced nations and generally less for their money. Employers that provide insurance bear a huge cost burden their competitors in other countries don’t. The difficulty getting insurance outside an employer leads many workers to stay in jobs they’re not well-suited for, depressing economic dynamism and entrepreneurship. All told, an outdated and inefficient healthcare system is one reason economic growth in the US is chronically weak.

Congress is hard at work on sweeping healthcare legislation—that addresses none of these issues. Instead of aiming at the biggest problems affecting the most people, Republicans and Democrats are waging legislative war over a part of the system that affects only about 8% of everybody with healthcare. As for everybody else, well, if there are problems with cost or coverage, Congress doesn’t seem to be aware of that.

The battle over the Affordable Care Act, which Republicans are now trying to repeal, is, of course, a proxy war for bigger questions of government: Should Uncle Sam solve all big problems? Or have we gone too far in doling out benefits funded by wealthier taxpayers?

The latest move is a new Senate plan similar to one that passed the House in May, which President Trump praised. In general, Trumpcare, as the Republican approach is known, would rescind tax cuts passed in 2010 that help finance coverage for lower-income people who don’t get insurance from an employer. Trumpcare would also reduce the number of people who qualify for Medicaid, while killing the unpopular ACA requirement for nearly all Americans to have coverage. In general, fewer people would end up with health insurance and the government would be less involved in America’s healthcare system. If you’re a small-government conservative who won’t lose benefits under the GOP plan, you’re probably pleased.

Less popular than Obamacare

But the majority of Americans are not. The House bill introduced earlier this year is considerably less popular than Obamacare, which it is meant to replace, and the Senate version seems unlikely to win any new converts. The GOP approach is even less popular than the Wall Street bailouts of 2008 and 2009. AARP opposes Trumpcare because it would raise costs and reduce coverage for some people over 50. The American Medical Association is against it. The American Cancer Society is against it. Three Republican governors oppose it and none has come out in favor of it. It’s hard to think of another instance in which Congress pushed legislation opposed by so many constituents.

If Trumpcare passes and becomes law, America will still have an antiquated, dysfunctional healthcare system—with more uninsured people. The US spends about $9,450 per person each year on healthcare—150% more than the median for advanced nations. Yet the United States ranks 28th in life expectancy and infant mortality. Thirty-eight percent of adult Americans are obese, the highest rate by far among 36 advanced nations. There’s nothing in either the House or Senate bill meant to improve any of this.

If Trumpcare fails to pass in the Senate, and simply dies…. America will still have an antiquated, dysfunctional healthcare system, with no other plans on the books in Congress to do anything about it. In addition to lousy health outcomes, the American healthcare system distorts economic decisions affecting millions of ordinary families. Economists would like to see the “portability” of healthcare benefits, which means workers would get the same benefits for the same price, more or less, regardless of where they work. This would eliminate “job lock,” or the decision to stay in a job simply for the benefits, and allow more workers to start businesses or do something they’re more enthused about. Data is patchy on how widespread job lock is, but some estimates suggest it could affect 25% of the 156 million people who get healthcare through an employer. That’s 34 million Americans who might be more productive and more satisfied in a different job.

The enormous cost to employers

Another growing problem is age discrimination in the workplace, which has a lot to do with the higher cost of healthcare for older workers. Data on this is also incomplete, but many older workers who get laid off and can’t find work insist employers don’t want to hire them because of medical costs. Famed investors Warren Buffett and Charlie Munger addressed the burden healthcare costs put on companies at this year’s Berkshire Hathaway annual meeting. “Our manufacturers have a huge competitive disadvantage caused by the health system, because the manufacturers are providing medical care for all the employees,” Munger told Yahoo Finance editor-in-chief Andy Serwer at this year’s event.

With healthcare costs rising much faster than ordinary inflation, companies that provide healthcare benefits have an enormous cost problem to manage. But don’t worry, they’re handling that by cutting back on the raises everybody gets. While basic wages have barely risen since 1970, when adjusted for inflation, real compensation—which includes healthcare and other benefits—has jumped by 60%. So if you’re wondering where your raise went, it went toward healthcare.

The Affordable Care Act, aka Obamacare, was a flawed attempt to deal with some of these problems, by first extending coverage to more people. Over time, in theory, that ought to improve healthcare outcomes, as more people get better care. Obamacare critics are correct to point out that the law did nothing to lower healthcare costs for most people, and it actually hiked costs for many who buy individual plans and suddenly had to pay for new tiers of mandated care.

But killing the ACA isn’t going to make anything about the US healthcare system better, and it would probably lead to worse healthcare outcomes as more people lose coverage. There’s a chance it won’t pass, since even some Republicans are squeamish about bouncing people off insurance. That may be the best possible outcome, for now. But all the other problems will still be there. Somebody should tell Congress.

The National Memo

Smart, Sharp, Funny, Fearless

Like House Bill, Senate Trumpcare Version Would Deprive Millions Of Coverage

Steven Rosenfeld, June 22, 2017    Reprinted with permission from Alternet.

Senate Majority Leader Mitch McConnell released a summary of the latest Obamacare repeal legislation late Wednesday, ending a Washington waiting game after secret drafting sessions, but depicting a bill that will have dire consequences for much of America.

McConnell’s summary tries to put a softer spin on the Republicans’ most strident attack on health safety nets in decades. It preserves most of the features of the House-passed bill, which repeals Obamacare, shrinks future Medicaid funding by a quarter and rewards the rich with tax cuts. The non-partisan Congressional Budget Office said the House bill would leave 24 million Americans without health care while increasing insurance costs and reducing coverage for almost everyone apart from healthy young adults.

Unlike the House, the Senate bill phases in the cuts to federal health spending over the next few years, instead of immediately pulling the carpet out from millions of Americans who were resting a little easier because they had some measure of health security. It will “rejigger” Obamacare subsidies for lower-income people buying private insurance, while gradually limiting their eligibility.

That’s the takeaway as first reported by the Washington Post. On Thursday morning, McConnell is to meet with “wary senators,” the Post reported, adding he will likely tinker with the bill’s details to try to get to 51 votes to pass it.

“The bill largely mirrors the House measure that narrowly passed last month but with some significant changes,” the Post said. “While the House legislation pegged federal insurance subsidies to age, the Senate bill would link them to income as the ACA [Affordable Care Act, or Obamacare] does. The Senate proposal cuts off Medicaid expansion more gradually than the House bill, but would enact deeper long-term cuts to the health-care program for low-income Americans. It also removes language restricting federally subsidized health plans from covering abortions, which may have run afoul of complex budget rules.”

It’s likely many nasty details will come to light as interest groups, health policy experts, Senate Democrats and their staff parse the legislative language, as opposed to McConnell’s talking points.

In many respects, McConnell’s revisions are not a surprise. They resemble the anti-Obamacare bill he shepherded in late 2015, which included closing government health care exchanges, scrapping subsidies for premiums, repealing Medicaid expansion in 30 states, ending tax penalties for people who don’t buy insurance and employers who don’t offer it, repealing its taxes on businesses, individuals and medications, and eliminating funding for Planned Parenthood. Variations of those features have been resurrected in the new Senate bill, although there is new language giving states some flexibility in how they will draw down their Medicaid spending. The brunt of that may not take effect until 2020. But the end result is the same: Republicans have used the rallying cry of repealing Obamacare not just to gut the law, but to structurally change and shrink Medicaid and give wealthy people a tax cut.