Archive for July 2017

Normalcy and Compromise

That's what this morning's news is about.  First we go on and on about General Kelly taking over the Chief of Staff position and establishing order and normalcy.  Ha!  Maybe the illusion of normalcy.  Their first action was to get rid of Anthony Scaramucci.  Not that anything changed, just the crude spokesman for telling it as it is, is gone.  But does that change any of the dynamics?  Time will tell, but the pundits are hoping Kelly will put a discipline in policy making.  I don't think you can put anymore lipstick on this pig which is really bad policies and chaos.

That has been really the pundits, mostly hopeful Republicans, who have tried to say things will settle down, Trump will learn, and normal policy will return.  Again, Ha!  Have we learned nothing in the last 6 months?  He is who he is and we will see how Trump destroys Kelly's reputation.  Even the most smooth and coordinated administration, with the policies of Donald Trump, will and does look like chaos.  It is chaos and bad policy based on an alternate reality.

The other talking point today is "compromise".  Maybe now the two sides will sit down and try to fix Obamacare.  We have this foolish idea that in this day and age that compromise is the best of all possible outcomes.  But what if you are compromising with policy based upon alternate facts that set up failure?  What if one side is so tied to ideology, that thinking outside the box is impossible?  Compromise is highly overrated.

Saturday, I tried to give you a blog that looks at proposed solutions to healthcare provided by Republicans and why they make no sense.  If you want to scream, "that's your opinion you liberal pig!" actually no when you get CBO (Congressional Budget Office) scores that tell you it doesn't work.  Republicans then decry the report as false from their own guy because they did not like the answer. And that is critical here.  We need to quit the ideological bullshit and just evaluate an approach and any possible compromise by whether or not it will actually be effective and efficacious.

Somehow we have gotten to think that both sides are as ideologically wedded to a certain solution and that is simply not true.  Republicans are because the market place must solve all problems and big government is bad.  If the market place would have solved all problems, we would not have needed Obamacare.  Obamacare was the Democrats trying to accommodate market place solutions and we have seen where that fell short. Paul Krugman today (Who Ate the Republicans Brains?) tried to explain how Republicans have created an alternate reality to uphold their ideology and they are now locked in a world of  dishonesty:

And that kind of behavior doesn’t come out of nowhere. The Republican health care debacle was the culmination of a process of intellectual and moral deterioration that began four decades ago, at the very dawn of modern movement conservatism — that is, during the very era anti-Trump conservatives now point to as the golden age of conservative thought.

A key moment came in the 1970s, when Irving Kristol, the godfather of neoconservatism, embraced supply-side economics — the claim, refuted by all available evidence and experience, that tax cuts pay for themselves by boosting economic growth. Writing years later, he actually boasted about valuing political expediency over intellectual integrity: “I was not certain of its economic merits but quickly saw its political possibilities.” In another essay, he cheerfully conceded to having had a “cavalier attitude toward the budget deficit,” because it was all about creating a Republican majority — so “political effectiveness was the priority, not the accounting deficiencies of government.”

The problem is that once you accept the principle that it’s O.K. to lie if it helps you win elections, it gets ever harder to limit the extent of the lying — or even to remember what it’s like to seek the truth.

Does that mean healthcare should be single payer only.  Of course not.  Medicare is not single payer only.  It is supplemented by market policies that fill the gaps.  But it does need to be universal care which is what the rest of the world's experience tells us.  The bottom line here is that we need to get to a place where not compromising is okay if the compromise is not the end in itself and will not solve the problem.

We just looked at three plans submitted by the Republicans and we all saw where they would lead, to a failure of healthcare.  So sure, go talk, see if we can get a consensus.  But don't stupidly kick the can down the road to hold hands and say we compromised when the solution is destined for failure.  We have data and metrics.  We know what will and won't work, and we have a Congressional Budget Office that will give us a real score.  Let's use it. Sure some solutions will give us unintended consequences so we need to then fix them.  Ideology is what has prevented us from fixing Obamacare. They hate it on made up facts and ideology so they can't stand to fix it.

One last thing, I and many progressive would like  Medicare for all, but we are open to anything that stands the test of reality.  Republicans, whether it is flow down works (tax cuts pay for themselves), big government is always bad (so how come Medicare works and Social Security saves many people?), or the market place left unfettered by government provides the best solutions (see the Financial Crisis 2007-2008), have had it wrong with a capital WRONG.  They are very good at identifying problems, but then their ideology gets in the way of evaluating solutions.  It is time to end that and not be afraid to not compromise with bad ideas.  Just evaluate the ideas with an open mind in the reality we live in, not the alternate one the Republicans have created.

Are We A Legitimate Democracy Anymore?

Well, we never were. We were and are a representative democracy as distinct from a pure democracy, but the point is still the same. Is our government illegitimate? Sure it follows the “rules”, but does it represent the people anymore? And I don’t ask this in some esoteric way, what I am asking is that has the majority of Americans recognized that what we call the American system of government does not represent or respond to them any more? And if the answer is yes, and I think it is, are we not setting up the conditions for the failure of America or violence to arise? I think we are close. Look at the number of people who don’t bother to vote anymore.

We have a system of government established by our Constitution. It tells us how to elect Congressmen, Senators, and Presidents. It sets up a Supreme Court that adjudicates laws and the Constitution. It balances powers between the three branches of government so no branch can get out of control. And yet many of us think the system has gone off the rails.

We have a President and a Congress that does not represent the will of the people. How do you explain the Healthcare repeal and replace that only had a 17% approval rating and yet almost passed except for the political courage of three Republicans? How did the Supreme Court back in 2000 stop the vote count and anoint George W. Bush president? How did the Senate block even considering a nomination by Barack Obama to that same court? How did a President so profoundly unfit for the job get elected by a minority of Americans? How does legislation favored by a majority of Americans (immigration reform for one) and would have passed if brought up, not get a hearing?

All this comes to mind as I read an op-ed by Ross Douthat in the NYT called the Empty Majority. Ross, a conservative, was asking how the present-day Republican Party is so successful at getting elected when “it is a majority party that behaves like it’s in the political wilderness, an election-winning machine that has no idea what to do with national power…The same feckless G.O.P. that exists in a constant state of low-grade civil war controls not only Congress and the White House, but most statehouses and state legislatures as well. All of the contemporary Republican Party’s critics — left-wing and centrist and conservative — keep saying that the G.O.P. is broken and adrift, and years of government shutdowns and Obamacare debacles and everything about the Trump era keep proving us correct.” And yet they keep getting elected.

He goes on to try to explain it in terms of the incompetence of the Democrats (true), “a party that’s terrible at governing can still win elections if the other party is even worse at politics.” And then he leaves us with this:

So that leaves the Democrats as the only people with the power to put an end to the current spectacle of Republican incompetence and folly. All they need to do is persuade Americans that they have more to fear from conservative hackwork than from a liberalism in command of politics as well as culture.

Sure the Democrats are idiots and have a philosophy of a herd of cats. But Obama gave us a steady ship even while the Republicans took both houses of Congress. And the thing that Congress wanted had very little to do with what the American people really wanted as shown in poll after poll on the issues. So Douthat did not really answer the question which is my fundamental question that started this blog, is our government legitimate any more. But we are saved by his readers who answered that question:

The big issue that Mr. Douthat ignores here is that the Republicans are not actually the majority party. Yes, they hold the large majority of offices at federal and state levels. But such results do not reflect the will of the majority. For example:

– Trump, of course, lost the popular vote by at least 3 million, and the GOP has lost the popular vote in six out of the last seven elections.

– The Senate is not a majoritarian body, as states like Wyoming and the Dakotas each have as many Senators as California.

– The House is gerrymandered beyond recognition, as are many of the GOP-run state legislatures throughout the country.

– The GOP has engaged in comprehensive voter suppression efforts for the past 10 to 20 years to limit voting by Democratic-leaning populations, which skews the results of elections even in districts that are not gerrymandered.

– The dismantling of campaign finance reform by the Supreme Court has given billionaires and millionaires a massively outsized voice in our political system in comparison to that of average voters.

All of this adds up to a system where conservative Republicans have been able to take virtually all of the reins of power despite not having the support of the majority of Americans. The result is a party that doesn’t have to figure out how to govern in a way that is responsive to the voters but, instead, can create the type of dysfunctional mess we are witnessing today.

Has our system of rules become either obsolete (the electoral college and Senate representation) in reflecting the nation, or bent by money, gerrymandering, and voter suppression to create a system that no longer is the legitimate representative of the people? I think we ought to think long and hard on this one. As Republicans game the system for power, they may be setting up the chaos and violence they say they so abhor. We have entered dangerous times when the majority in power do not represent the majority in the country.  Rember what our own Declaration of Indepence told us:

“…when a long train of abuses and usurpations, pursuing invariably the same Object evinces a design to reduce them under absolute Despotism, it is their right, it is their duty, to throw off such Government, and to provide new Guards for their future security.”

Are we getting there?

Why There are No Republican Solutions for “Fixing” Obamacare – Wonkie

I have made the claim that Republicans have nothing to fix Obamacare, assuming fix is to make healthcare more affordable for everyone while maintaining minimum requirements for the things the plan covers to make it meaningful. Remember this is what Donald Trump promised as a candidate (No one will lose coverage. There will be insurance for everybody. Healthcare will be a “lot less expensive” for everyone — the government, consumers, providers.). In other words, strengthen what we have in Obamacare and fix the high co-pays, lower premiums, and make sure there are affordable plans in all exchanges. So why do I say Republicans have nothing to fix these problems? Well you need to first understand, which apparently most Republicans do not, a business plan and how insurance works.

Okay, let’s start with how insurance works. Remember those commercials on TV for term life insurance without a physical? How do they do that (assuming it is not a scam)? Well they play with statistics. At a certain age, say between 50-60 years of age, what are the odds you will keel over within a ten year period (term life insurance)? Say it is 1 in 50 for ten years at that age. If the payout is say $500,000 and you have only 50 plans then each plan is going to cost a minimum of $10,000 plus profit and admin fees so that when the 1 in 50 kicks off, they still made a profit ( 1 payout of $500,000 equals 50 people times $10,000). Okay, now what happens if you expand your pool of subscribers to be say the 40-60 age group? Then the numbers get better because someone 40-60 might have a 1 in 100 chance of keeling over in a ten-year period. So again to make the numbers simple say you have 50 people in that age range (40-60) then the cost to the buyer gets cut in half.

You get the drift? The larger the pool of enrollees, especially when you include more healthy people (less risk of a pay out), the less it cost the group. Take car insurance. While insurance is priced based upon your risk pool (teenagers and bad drivers pay more), it is still highly subsidized by the rest of us that have not had an accident in many years. With a larger pool of subscribers (required of everyone who drives a car), especially those that may not incur many costs, but still need the insurance, it drives the costs down for every one and makes it affordable. That is how insurance works

Now let’s look at a business plan for health insurance. First, what do we know about healthcare? Young people are basically healthy and will cost little, old people and poor people (with little care) will cost a ton. That is why we have Medicare/Medicaid. The private market place for insurance back in “the good old days” could not offer affordable plans for older people, so finally the government stepped in to do that.

Next, what is the goal of a private company/corporation? Maximize profits for share holders. Or said another way, maximize share value by maximizing profits. That is where all the incentives are in managing a company. Now it does not take a rocket scientist to figure out how to maximize profits. Insure healthy people and deny claims based upon existing conditions or said another way, maximize premium payments and minimize claim payouts.

That was basically the system we had before Obamacare. People with existing conditions could not get coverage, coverage for older people cost exorbitant amounts (until Medicare kicked in), and many plans, while very cheap, really did not cover much, and of course, many poor had no coverage at all. As noted earlier private insurance is not in this to maximize insuring people, they are in this to maximize profits for their share holders by limiting payouts. They are not a philanthropic organization, but a capitalist venture to make a profit. CEOs are rated by how they maximize share value for their company. Connect the dots yet? Many of us did not see the problem because our employer took care of our insurance*. But as cost grew in healthcare, companies started offloading these costs to employees, and when many more of us found ourselves forced to self insure, these problem became severe.

So along comes Obamacare to solve a giant crisis in healthcare, uninsured people, unaffordable plans, escalating healthcare costs, hollow plans, and out-of-pocket expenses that was the leading cause of bankruptcy in this country. It did it by regulating the insurance companies which is anathema to Republicans (regulations). Let’s take these one at a time (it did a lot more than this, but here is the gist):

  • First it established a baseline of what has to be covered to prevent hollow plans. Now this certainly raises costs since before insurance companies could sell plans that covered the common cold, but drug addiction, mental health, major hospitalization were written out in the small print. Most people thought they had great affordable plans until shit happened and they had to use them
  • Next it said you cannot exempt people for pre-existing conditions. Now this also raises costs because now you are bringing into the risk pool people who are actually going to use the benefits, and soon. It also said people could keep their kids on till age 26 recognizing the horrible job market we were now in adding some more costs
  • Then it capped out-of-pocket expenses. At some level of out-of-pocket expenses ($6000), the insurance companies could no longer charge you a co-pay for your costs. You were not going to go broke when shit happened.
  • Then to fund all this which included subsidies for the poor and high risk individuals to make their premiums affordable, it raised taxes (medical device manufacturers, and on wealthy) and did what every insurance company does, made everyone enroll so you had a much larger risk pool paying in to offset all those costs (see how insurance works above). That was the dreaded insurance mandate. And it started initiatives to try to lower the cost of healthcare live preventative care and end of life counseling that sent the Republicans into the stratosphere on “death panels”
  • It set up exchanges where health insurance companies could compete for your enrollment in each state hopefully reducing costs and giving the consumer some choice in plans
  • Finally it created subsidies for markets in high risk areas to keep the premiums down, and instituted cost control measures (focusing on outcomes, not services) to bend the growing cost curve of healthcare.

Okay now enter the problems, affordability and availability.

  1. Depending on the local markets, some exchanges had a majority of older enrollees in rural areas. Now think about this: Fewer people (smaller risk pool), and sicker people (larger pay outs). So plans offered were expensive and had large copays. They depended on subsidies to be affordable and some enrollees did not qualify for the subsidies based upon income.
  2. Subsidies earmarked to recognize this situation were not large enough to control the cost of plans in some areas
  3. Add to this that many young and healthy people were not fazed by the penalties for not having insurance, so they did not get it, reducing the pool for subsidizing higher risk enrollees.
  4. Throw in the Republicans who have been on a crusade to repeal and replace, a President who threatens to not pay the subsidies or enforce enrollment in the program, and blocking measures that would allow Medicare to negotiate drug prices or to allow the government to effectively incentivize cost-effective treatments, and what you have is insurance providers either pulling out of these markets because they cannot adequately price the risk with these unknowns or applying rapidly rising premium prices to cover their risk.

So finally, how do we fix it, and why won’t Republican solutions work. To answer that we have to draw from our analysis of what is the basis of a functioning system? they are:

  1. Large (universal?) risk pool (mandates for insurance) to reduce average premium and make them affordable. Everyone contributes and subsidizes the sicker enrollees
  2. Minimum basic insurance coverage (Regulations) and copay limits to prevent catastrophic events that bankrupt enrollees
  3. Stable subsidies for high risk markets to encourage private insurance participation where risk is high or unknown
  4. Tax base to afford these subsidies and expansion of the coverage in Medicaid
  5. Policies that start to curb the cost of healthcare and bring it more in line with the rest of the world

Okay, lets take what the Republicans are offering and show why they don’t address or in fact undermine the basis of a functioning system (which is maybe what they mean by fixing it):

  1. More Choice driving down the cost – That would be the Cruz Amendment to allow the removal of minimum coverage so plans could be tailored to individual needs. Gee, that seems reasonable. I don’t need maternity care, drug counseling, a heart transplant, so why should I pay for it? So yes, the plans for this group would be cheap. The plans for everyone else would get way more expensive because you have done is reduced the amount of enrollees subsidizing those other services (item 1 in a functioning system). Second for some, shit will happen, and when their insurance won’t cover it, you will be dHow removing the individual manadate willestroyed financially. That would be a violation of item 2 in a functioning system above. Some choice. In many ways this idea is logically identical to the idea that after your kids have grown why should you have to pay taxes that pays for schools. So Republican.
  2. Remove Covering Existing Conditions Mandate – Yes this adds cost to the whole risk pool, and removing it will certainly reduce costs for those who don’t have any existing conditions and can get insurance, but do we really want to go back to the days where people could not get insurance for minor ailments in their youth, or denied further coverage as insurance companies argue whatever is wrong with you now is related to something earlier in your life not fully disclosed? Violates item 1 and 2 in a functioning system above and drives the cost for those who do have existing conditions through the roof if they can get coverage at all.
  3. Removing the Individual Mandate – This is universal from Republicans in that from their point of view, the mandate to have insurance is just big government taking over everything. Well, first of all if you own or drive a car, you have to be insured. How is this different? We all breath and will get sick so why should you not contribute to healthcare so when you do need it, you have helped subsidize your costs? But that is the moral argument, lost on I got mine generation (Conservatives). By having everyone pay in, this is how lower premiums are subsidized by item 1 by creating large risk pools. If the healthy can opt out, you have far fewer to pay the bills and when they do get older and have issues, then they can’t buy insurance because they have a pre-existing condition and if they can get in, they have not paid into the system to offset their costs later raising the costs for everyone. Again item 1 in a functioning system above and affects item 3 because it reduces pool of resources (premiums) to subsidize those who can’t afford insurance.
  4. Deregulate Healthcare and let the market place respond to needs – This is the holy grail of Republican ideology where the high priest of competition will solve all problems. It is a combination of Republican solutions 1, 2, and 3 above. Now go back to understanding the business plan of insurance companies to maximize profits/share price. It destroys large multi-varied risk pools because then the market is incentivized to go after low risk enrollees, those enrollees that don’t cost very much, but those elderly or sick get ignored or are offered plans they can’t afford unless they cover nothing. Why would health insurance companies compete by lowering prices in high risk pools where they are going to have a minimal profit margin? The other part of this is let healthcare companies compete nationwide instead of controlled by state markets. Okay, then who regulates them, makes sure they offer real services for premiums, and does not deny claims capriciously? We know this will happen because it did before Obamacare and then is it the Feds Republicans want to step in? This is the just repeal Obamacare option, send the poor back to the emergency rooms, and if they are sick, they must have deserved it. Flown lately? How well did deregulation work out in that market? This violates 1 an 2 in a functioning system above.
  5. Removing the Taxes on the Wealthy and Medical Device Manufacturers – This really has no bearing on healthcare except that it guts the funding available to fund the program including subsidies and allows Republicans to cut taxes, their other Holy Grail (Market Place solves all problems, and Tax cuts raises all boats). This destroys items 3 and 4 above in a functioning system. They are starving the beast.
  6. Block Grants to the States – This an old GOP strategy for managing Medicaid, the federal-state insurance plan that covers low-income people — turning control of the program to the states and capping what the Federal government will pay each year. Again, Republicans make an argument that who better than local control to decide how to spend Medicaid dollars since the states know their own needs best. Now on local control I could make an argument that who needed the Feds to breakup segregation in the South back in the 60s, since the South was doing just fine with local control. More recently, watch local control of school boards and curriculum which allow local jurisdictions to dumb down education and put religion back in the curriculum. Sometimes it works sometimes it does not and becomes the tyranny of the majority. In the present system, federal funding is open-ended, but in return states must cover certain services and people — for instance, children, pregnant women who meet income criteria and parents with dependent children. Under a block grant, states would have more freedom to decide who qualifies, and for what services. And what happens when things get tight in a state, where do they steal money from? A better description of the failure of this idea is here, but you get the drift. It is just away to unload the costs onto the states and eventually put the system in crisis, but it is the state’s problem then.

So are you getting the drift? There are no Republican solutions for fixing Obamacare if you truly want to improve it and make it better. And have you heard anything from the Republicans about ways to set policy to actually reduce the cost of delivering health care services (we have the most expensive system in the world by a factor of 2) like incentivizing outcomes not fee for service or allowing Medicare to negotiate with big Pharma to reduce drug costs? These and many more ideas are out there to reduce the actual cost of care, but that would require someone setting policy and incentivizing it and that again is anathema to Republicans. That would be big government. The market place will solve it, except it won’t, it will go for easy big profits unless government forces it to compete in all markets with defined standards. That is the fatal flaw in everything they are proposing.

So if you want to fix it, and by that I mean improve it, the Republicans got nothing. That is why the plans they presented were so unpopular. The way to fix it is fairly straight forward but anathema to Republicans:

  • We need to increase the risk pool and we do that by enforcing and strengthening the mandate. In the best of possible worlds we expand the risk pools to universal coverage.
  • Where you can’t get the private insurance markets to compete, you bring in Medicare for everyone. In a way this is the real “choice” solution. Let Medicare compete with the private insurance providers.
  • You strengthen the subsidies for the poor (Medicare for everyone will take care of markets where there is too much risk) through fair taxes.
  • You stabilize the markets by making clear you are going to make it work, not make it fail.
  • Finally you start to take initiatives to make healthcare affordable by reducing the cost of services like negotiating with Big Pharma and implementing incentives to utilize more effective and efficient treatments.

None of this is in the Republicans bag of what I call “free-ride” tricks, which is the market place left alone will solve the problem. There are tons of systems out there operating universal health care systems with and without single payer, with or without private insurance companies. They are all highly regulated. Couldn’t we learn something from them? But the one thing we do know is that after 8 years, Republicans got nothing and they won’t let real solutions even get on the table. When you finally recognize how the system works, you know that nothing is going to change because Republicans cannot accept the solutions that will work. We will have a failing system until voters finally throw these people out of office.

*Note: Ever wonder why most of us get insurance from our employer (mostly through health insurance companies) while that is not the model in the rest of the world? Back in the days of WWII, the United States was gearing up a massive industrial military complex to produce ships, planes, tanks, bullets, bombs, etc., etc., etc. So there was high demand for workers. In those days the government had taken over the economy to prevent wages and prices from spiraling out of control (inflation) so wages were fixed. What is a company to do to make working at their bomb making factory more attractive than someone else’s if wages are fixed by the government. Offer them benefits, healthcare in particular. And that is how we got a system of employer based healthcare, and the only one in the modern world. Given that this is a cost that makes our goods and services more expensive to consumers than foreign products, you would think that most corporations would be chomping at the bit to offload health insurance to the government.

Now What?

First, let's not forget what got defeated last night, a bill that no Republican liked, was in Lindsey Grahams words a "disaster as policy", yet he and all but three Republicans voted for it. Those three saved Obamacare for now. That should tell you something about where the problem is when people say partisanship. Republicans claim this was no different than the Democratic approach to Obamacare and nothing could be farther from the truth where Obamacare had a year of public debate, Republicans added 100 amendments to it, and then voted against it. Democrats did not even see this bill until two hours before they voted.

And again, I want you to remember that Obamacare is the conservative fix to healthcare originated in the Heritage Society and then implemented and proved out by Mitt Romney in Massachusetts. It keep in place private health insurance companies and allowed them to compete with defined benefits. So if they are against that what did they have to offer?

It was a terrible bill that would have thrown an estimated 16 million off healthcare and set up the very collapse that Republicans claim falsely is already happening. Since the Republican Senate could not figure out what replacement looks like, they thought if they sent it to a conference committee of further clueless Republicans, they would fix it. They had seven years to fix it and it is not as the conventional wisdom tells us, they did not try, they simply don't have any solutions in their conservative arsenal.

So now what? We know that healthcare is not collapsing, but there are real issues in some niches of the market, including rising premiums, little or no competition on some exchanges, the high cost of drugs, and lack of funding for the subsidies. So how to fix that? Well if you listened to Mitch McConnell last night he claimed the Democrats refused to cooperated, which was a blatant lie for the white mob, and then said now maybe they have an idea and then disparaged single payer.

But here is the really important thing, of course they do, but Mitch and the boys (since most of the girls defected last night) will never have that. We are back to the basic question, what does fix mean. Said another way what is the goal? That has always been the problem at the heart of the Republican proposal. They never had a unified goal. If you say it was to repeal Obamacare, then remember that one failed by a large margin (that was Mitch's Scenario II). That would be the Rand Pauls of the world and the Ted Cruzs, They just think government should not be involved in healthcare. I want to see if they reject their Medicare when they are eligible and need it.

Then there is the group that wants to just get the Feds out of it and send it to the states and there are a million reasons why this is a bad idea. Remember that the last bill (skinny) got rid of coverage for existing conditions, not to mention no mandate to ensure a large risk pool to spread costs. Then there was the Collins/Murkowski/McCain faction that at leasts wants to keep people insured, but have no idea how to do it. So if there is no unified goal, how can you possibly fix it when you don't agree on the word fix? See the Republicans for the last eight years.

Democrats are starting to see the light. That light is not necessarily single payer, but universal coverage. Note that if conservatives were really concerned about costs, they would look at the rest of the world that does have universal coverage as a constant, and then a plethora of ways to do that from government owning the healthcare system (single payer), government simply insuring everyone (single payer again but with healthcare providers competing for the pie), to a combination of private and public insurance. And in some of the best systems with better outcomes than ours, their costs are half.

So the goal for Democrats, who will never get the current crop of Republicans to go along, is universal coverage. It would seem that the simplest way forward would be to start with combined markets with Medicare for anyone on exchanges that are not competitive. I have opined what the Democratic plan should be, but that is not really the question here, but what happens next. Nothing. The President has already tweeted that he wants to further destabilize Obamacare and make Democrats come crawling to him. Republicans can never accede to the the things necessary to get to universal care. Until the voters finally understand this, nothing is going to happen.

Now what needs to happen is that the Democrats submit a general outline of what fix looks like and they all get behind it. The details can be negotiated, but in general it is to improve Obamacare, reduce costs, expand the risk pool, lower drug costs, hold the line on minimum coverage, expand competition in the exchanges, and expand coverage with minimum acceptable coverage. That way it is not both sides, but one actually has a solution. Then when nothing happens, maybe they will see who is the problem.

While the base of the Republican Party (the White Mob) are going to be mad as hell with the failure to repeal Obamacare, those in the middle, the undecided voter, just got an education on whether Republicans can govern. This could be major in 2018 if the Democrats can now draw distinct lines. We shall see.

Meanwhile the North Koreans have possibly launched a missile that landed on Japanese land, It could be wag the dog time with a preemptive strike that distracts everyone from the failure of Republican leadership and the Russia investigation. It will be a total disaster. Hey White Mob! How is this working out for you?

The Maverick is Back

John McCain casting one of the three Republican “No” votes that saved healthcare for millions of Americans (Collins of Maine and Murkowski of Alaska). These were three Republicans who put their country before their Party.  There still are profiles in courage. So Obamacare did not end tonight, but it is likely that The Village Idiot in Charge will do what he can to make it fail. He has already tweeted as much:

Reality is the Republicans will never agree to things that might fix it and until we get a Democratic majority, we will not fix it. Mitch McConnell tried to re litigate a pack of lies speaking only to the Republicans after the defeat, while Chuck Schumer tried to reach across the aisle. Clearly you can see that if Democrats put up real ideas to fix it, they will be turned away. Tomorrow with all the fallout will be interesting.

The Big Cop Out

From the NY Magazine:

Lindsey Graham, John McCain, and Ron Johnson twist themselves into a pretzel. Photo: Bill Clark/CQ-Roll Call,Inc.

“Four Republican senators — Lindsey Graham, John McCain, Ron Johnson, and Bill Cassidy — announced at a press conference that they would only support the Republican “skinny repeal” if they can be promised the House will not pass it into law. They described the law they are about to vote on as a disaster, and proceeded to explain why they could vote for it anyway.

Their arguments are a bundle of illogic. If there is a bill Senate Republicans would pass, they don’t need a conference to write it for them. They can pass it themselves. Why do they think a collection of House and Senate Republicans could do a better job of figuring out what Senate Republicans want to pass than the Senate Republicans could do themselves? Why not imagine their fantasy version of the greatest piece of legislation they could imagine emerging from the conference with the House, and then passing that in the Senate?

McCain made a slightly different, and even more absurd, argument. The elder statesman repeatedly called for Republicans and Democrats to work together, insisting Obamacare had failed because it had the support of only one party, and insisting bipartisanship offered the only path forward. And then he offered his probably decisive support for a bill that would prevent exactly that thing from happening. The conference committee McCain is explicitly hoping to convene would consist entirely of Republicans. It is a vehicle for a Republican-only health-care bill written through restrictive budget-reconciliation rules.

There are many Democrats and Republicans in both chambers eager to work together to shore up the exchanges. The only way that can happen would be if the Republican plan to repeal Obamacare, in whole or part, through budget reconciliation fails. McCain could have made it fail, and started bipartisan negotiations, by opposing it. Instead he is closing off the very thing he insists must happen.”

Could it get more absurd? Remember the Republicans have nothing to fix it it, only dismantle it. Once you finally admit that the free market works very poorly for healthcare, something many of them cannot bring themselves to believe after years of evidence to the show just that, they are out of ideas. Second, you have to understand how healthcare insurance, or for that matter any insurance works, by understanding that risk pools have to be expanded (universal coverage), and allowing “choice” simply reduces and aggregates risk pools into very risky and little risk, then you understand there is no Republican solution, only destruction. Tomorrow should be quite a day.

Dunkirk

Actual picture at Dunkirk on a Lorrie Dock waiting for a ship

Wow. A truly great movie. I think as the best I know combat and war, the reality was so well displayed about the human soul in desperate conditions. Don’t look for the John Waynes or frivolous violence, just the story of an army in very desperate straights. When one soul faltered, another stepped up, and oh we all falter. And the representative of the real heroes here, the people who got in their boats and went to get their army off that beach was a father, a son, and his son’s friend. And how they handled a horrible situation is a moment is quiet dignity and wisdom. What a truly beautiful movie.

From one source (Slate):

In terms of accuracy, it rates pretty highly. There are no big, glaring historical whoppers. The characters whom Nolan invents to serve his narrative purposes are realistic, and his scenes depict genuine events or hew close to firsthand accounts. And why not, since fiction could hardly outdo the drama and emotion of the reality? Nolan made clear that he intended the film to be a kind of history of an experience, and he succeeds about as well as any filmmaker could in conveying what it might have felt like to be on that beach.

That was what I thought too. It was about the experience and he nailed it. I also wondered about how many French got off and I found this:

It’s true that after the British and other Allied troops were evacuated—there was an effort focusing on the French that resulted in 75,000 rescues. But the scene of the French Army manning the sandbag barricade while Tommy escapes through them is a bit more true to life, because the fact is that many tens of thousands of French and French colonial troops fought and died as a rearguard for the escaping British.

The vast majority of the French who’d been evacuated returned to France after it came to terms with Germany. This isn’t because most were particularly fond of their conquerors or Nazism but because their country was no longer at war and their officers and government told them to come home. Besides, Germany was essentially holding the country hostage to assure their good behavior.

Now, let me just comment on the movie experience since I have not been to the movies in about six months. They are trying to create an experience you can not achieve on your couch and I believe they have arrived. The first thing I noticed was beer and wine in the lobby. Just what I need is more trips to the bathroom, but great idea. The next were the “seats”. You now can buy your tickets online and you have reserved seating (pick your seats). The seats themselves are full padded recliners operated by electric controls. The seat itself moves slightly with the action, i.e. slightly shakes as the bombs go off. Super comfortable and realistic. Then there is the sound which is now all around you including in the ceiling. It is about as close as you can get to being there.

But I think in the end a good movie experience depends on the story and the actors. There are plenty of really good actors out there, but most of the movies they make these days is for 12-year olds just off a gamer binge. But Dunkirk wasn’t one of those and there was much about the human condition. Go see it.

Stay on Topic

Sarah Huckabee Sanders opened the White House press conference by telling the press corps that she had several speakers and warned the Press Corps to stay on topic.  Okay I will translate for you:  “We are going to open the fire hose and spew non sequitur information at you, and you must not ask anything other than what we want to talk about.”  Why the hell do we even attend these things anymore?  Press wake the fuck up and walk away. It is about pressing their propaganda with hostile and ill informed push back.  Walk Away!

Skinny Replace and The Village Idiot, or Part III

Actually you should not connect the two topics. The Village Idiot in Charge has no clue what is in healthcare, who it helps and who it hurts (healthcare wise), and only cares about a win. Now in case you are wondering, the skinny replace is really a bill that (we are guessing here because nobody has seen it, and it has not been scored by the CBO) “would repeal the insurance mandate for individuals and larger employers under the banner of choice and freedom — both standard objectives of conservatives. It also would repeal taxes on medical-device manufacturers and, perhaps, also on insurers, with the goal of reducing the costs that must be reflected in premiums.” This would be a disaster for how insurance works and drive premiums out of sight, not to mention cut the funding necessary to fund those who get risk sharing subsidies. But don’t believe me, here is ex-insurance CEO J.B. Silvers explaining how insurance works:

To survive, an insurer has to predict the risk of costly claims and to obtain sufficient enrollment to balance customers who need a lot of health care with enrollees who have few or no claims. This works because while an insurer can’t know the timing or severity of illness for an individual, it can estimate the average claims of a group of individuals fairly well.

In health care, some individual needs are predictable — young people use less, and those with chronic conditions demand more. The only way to obtain a reasonable average is to have a broad pool, like the employees of a company covered by a group plan.

The individual market never had this natural grouping, so premiums varied widely, as did coverage, if it was available at all. The Obamacare individual mandate was intended to produce a representative group and to keep average premiums in bounds.

But a variety of problems resulted in predictably higher premium rates for insurance exchanges. The mandated coverage for qualified health plans was broader, enrollment was skewed by pricing that favored older customers, and risk-reduction mechanisms were insufficiently funded. Most of those can be laid at the feet of the Republican Congress and of President Trump for his sabotage in limiting enforcement of the mandate, cutting enrollment efforts and threatening to withhold the risk-sharing payments for low-income enrollees.

So what will it mean for individuals if the mandate is jettisoned in a “skinny repeal”? Those receiving subsidies will be largely immune to higher costs — their increased premiums will be offset by larger government subsidies — but it’s actually middle-income people without subsidies who will be priced out of the market.

Without the mandate, they will just return to their previous uninsured status, frequently turning into emergency-room patients and bad debts for hospitals and doctors. The Congressional Budget Office has estimated that, in a decade, about 15 million people would be hurt, including independent professionals and small-business employees.

Those remaining in the exchanges will be receiving much higher subsidies because of the higher premiums, making them very similar to existing Medicaid beneficiaries. This is why the likely outcome is a much bigger tab for the government.

In effect, a “skinny repeal” will result in an unintended expansion of ever larger government subsidies to the working poor. The difference is that those people will have higher incomes than allowed under normal Medicaid or the expanded Medicaid coverage that has been so controversial in red states.

That about sums it up. It is just a plan to make Senators feel good because it does not gut Medicaid, but then kicks the legs out of what makes healthcare affordable and its funding source. In other words, a further erosion of healthcare. What would fix it are not, as I have said over and over, in the Republican quiver, expansion of subsidies, Medicare for everyone in exchanges that do not have competition, and more enrollment through more vigorously enforced penalties (the mandate) for those who do not (expanding the risk pool).

What are Democrats to do? Well don’t join in thinking it is better than nothing. Their original plan was to flood it with amendments, but they withdrew that plan thinking it would fail on its own and they were not going to try to amend something they had not seen. It may not fail on its own, but then it does have to go to conference with the House and no telling what would come out of there. My advice would be to stick to your original guns, fix Obamacare, don’t rape it. See above. Note the Wicked Witch of the White House (Kellyanne) said all the Democrats have to offer is single payer. Hmm. Beside that being a lie from the White House, that would be Medicare for all and that systems seems to be working fairly well. Today will be interesting.

Now on to the Village Idiot in Chief. Many pundits were saying, why doesn’t he just fire Sessions. I hope they aren’t that stupid and that was just being rhetorical. He is setting the table for a recession dismissal. But wait! Even conservative Republicans (Chuck Grassley) have warned him not to do that. “There could be a conservative revolt! Why doesn’t he knock off this stuff and just cooperate with the investigation.” Okay, maybe you all ought to be bitch slapped. The Village Idiot in Chief is now in a corner. He is not rational and he has something very big to hide. All the rest is noise. This is not hard to follow. If he doesn’t stop the investigation he is toast. So what does he care about a hissy fit from Republicans who need his base’s vote to stay in office. Now you understand the transgender tweet. Misdirection and shoring up the base.

Here’s where you need to really be afraid. The one big distraction would be a preemptive strike on North Korea (Syria is the other option, but North Korea is my bet). Who cares about some Russian collusion when nukes are flying around in the Pacific Theater, and millions will die, all to cover financial miss dealings and money laundering. Almost everything you see him doing goes back to a way to thwart that investigation, and as noted above, that could get very dangerous. I wonder if the generals have met behind closed doors to find a way to delay such an order until Congress could act? Think about that thought. Mutiny to save us. That is where we are on this Thursday morning. Hey you Trump supporters, seen any jobs, a job bill, coal job coming back, a wall, or infrastructure bill? Nope, it is all about the soap opera of Russia and the investigation because your guy is a nut job who is a criminal and has no idea how to lead. Nice job people. We certainly do have change.

Repeal and Replace Part II

The Republican Repeal and Replace plan (that includs the Cruz and Portman amendments) went down and did not even get 50 votes when it needed 60 (Part I).  Nine Republicans voted against it.  Now there next brilliant idea (oxymoron when referring to Republicans on healthcare) is to repeal Obamacare with a 2 year lag, while they negotiate a replacement.  Now this seems like it could get 50 votes, but it won’t.  Here is why.

It seems like a dream bill because it cleanly gets rid of Obamacare 2 years down the road, with a replacement, yet undefined down the road, and this might make Democrats come to the table to “save as many as possible” in a worst case scenario.  What could be wrong with that?

Well it actually fairly simple.  After 7 years the Republicans could never come up with a replacement they could agree on.  And Republican ideas scored by the CBO are draconian.    So say you passed this.  In 2018 you just handed the Democrats the biggest club anybody ever handed them besides Donald Trump as President.  Who in their right mind would trust the Republicans to come up with anything human and rational as they have shown they cannot do.  Republicans get that and are depending on a few stalwarts to vote against it to save them.

Then it will be Repeal and Replace Part III where we have unlimited amendments to something we don’t know what it is yet.  See chaos in our future?