November 6, 2016

I'm #NeverTrump: Immigration + Health Care

Yesterday, I mowed the law for likely the last time this season. I’ve always loved doing that; it gives me plenty of time to think about things: the yard and gardens, of course, but also about work, and life, and love, and politics. Especially politics, these days.

The obvious outcome of the mowing? Damn, the yard looks really good for early November. The outcome of the thinking? For me, unequivocally, it’s Never Trump. In this post, I'll first look at Trump's immigration plan, followed by his thoughts on health care reform. 

Funding additional immigration agents, and equipping them with the tools they need to do their jobs are two things I'm all for. Another thing I'm for is deporting illegal immigrants convicted of crimes here. Trump is for those things too, and while his plan talks about getting illegals with criminal records out, but he neglects to mention one problem.

We need to clear the current backlog of cases and ensure that a similar backlog does not reoccur. We apparently have the money, and the appetite, for enforcement activities, but not for funding the immigration court process, which has been significantly overloaded as a result of the aggressive enforcement activities. I saw no plan to correct this.

I cannot support Trump's overarching vision to vet applicants to ensure they support America's values, institutions and people. I vehemently disagree with Trump's vision of our country, that we are a couple of steps removed from a third world cesspool that only he can fix. That's not my America now, and it has never been my America. I do not trust him to bring along people who can accurately and honestly describe our values and institutions, who would then pass judgment on immigrants. Truth be told, I suspect the immigrants may well have a better understanding of that than their inquisitors.

I also disagree with his temporary suspension of immigration from regions that export terrorism and where safe vetting cannot presently be ensured. America already has the strongest vetting process and Trump's plan doesn't mention how it needs to be strengthened.

Vermonters for a Just Peace in Palestine/Israel
His signature position, building The Wall, A Great Wall, A Beautiful Wall, across our southern border and making someone else pay for it, or building it and paying for it ourselves and getting reimbursed later? Yeah, I  admit I have a hard time picturing our border looking like the one between Israel and Palestine, a part of which is shown here. More details are needed on that as far as I'm concerned, and they have not been forthcoming. And not for nothing but given the known proficiency of Mexicans to build tunnels, I'm not convinced a wall is the best bet anyway.

My last word on Immigration? Trump's vision includes prioritizing the jobs and wages of Americans, and he wants to establish new immigration controls to boost wages and ensure that open jobs are offered to American workers first. This, from a man who brings in temporary foreign workers to wait tables, clean rooms, and serve drinks at his properties. I'm not sure why, exactly, he won't hire Americans to do that, but it's certainly consistent with his overall message: ignore what I do, for it means nothing.

On health care reform, I struggle with how his plan to repeal and completely replace the Affordable Care Act (ACA) with the ACA makes any sense at all.

Trump says that, as long as the plan purchased complies with state requirements, any vendor ought to be able to offer insurance in any state. But here's the thing: insurers can already sell their products in multiple states, as long as they meet the requirements of each state's Insurance Department or equivalent agency not just for the products they sell, but for their consumer protections, sales practices, financial practices, quality programs, and the like. So yes -- there are lots of hoops to jump through, and having to jump through as many as 50 individual hoops may be too much for some insurance companies but if they want to do that, they can have at it now. So why do we need to repeal the ACA?

He also suggests that we must make sure that no one slips through the health insurance cracks because of an affordability issue and we must review basic options for Medicaid and work with states to make sure that anyone who wants insurance can get it. All 50 states currently offer some kind of Medicaid program, whether or not they took advantage of the federally funded Medicaid expansion that was part of the ACA. So I'm unclear on what will be different between having Medicaid offer coverage to people who need insurance, or having Medicaid offer coverage to people who need insurance? 

Is the difference that he wants to deliver Medicaid funds via block grant? According to his plan, nearly every state offers more Medicaid benefits than are required (which may be because they want to do that?) and the block grant will allow them to focus on reducing fraud, waste and abuse, apparently at the expense of offering benefits to their residents. Is repeal of the ACA necessary simply to change the way Medicaid funding is delivered?

His plan calls for importing safe, effective and cheap prescription drugs. I'm OK with just about any reasonable effort to reduce health care costs however he doesn't indicate how his administration will make the determination on what drugs can be imported, where they come from, and how we make a determination that they're safe. Do we do it by reducing safety requirements of the FDA? If yes, do we then have one set of rules for foreign companies and products, and another set of rules for those produced right here by American workers, American researchers, American patent holders? No word on that.

His plan also mentions pricing transparency requirements for hospitals, clinics and doctors. Many insurance companies, including the largest - Blue Cross Blue Shield, UnitedHealthcare, Aetna, Cigna, and Humana, for example, already offer cost estimator tools. Some states also offer pricing transparency; so does the ACA to some degree. Does the party of limited regulation really want there to be more regulations?

There are health savings accounts, which Trump envisions as tax fee, permanently accumulating, fully transferable to heirs, without fear of any death tax.  HSAs are allowed, to some extent, under the ACA, however there have been concerns that this would change effective with plans offered next year. Rather than repealing the entire program, why not just fix what's wrong with the HSA portion?

The last major component mentioned in Trump's plan is reforming our mental health programs and institutions. His plan notes that families cannot get information they need and so don't have access to the tools to help their loved ones. I'm not exactly sure what he's looking for here, but the Affordable Care Act enhanced coverage for mental health and substance abuse treatment, on top of the enhancements that were implemented as part of federal mental health parity legislation over the past several years. Again, many states have also required additional coverage and parity, in response to addiction and eating disorder crises, high rates of bullying, teen suicide, and so on. 

The sum of all of this, to me? Why exactly are we repealing the ACA and dropping coverage for some 20-odd million or so people, only to replace it with the ACA? There are flaws in the program, to be sure -- so fix them, in a bipartisan way. Pulling the plug on the whole thing doesn't make sense -and Trump's plan has no guarantee of working, given 50 states rowing in multiple directions. 

Immigration and health care -- just two of the reasons why I'm #Never Trump. I'll discuss other reasons in the next post.