Repeal First, Replace Later?

Rand Paul and Donald Trump are suggesting that the GOP repeal the Affordable Care Act now, to keep their promise to America and then work on the hard part of coming up with a health care plan at some other point down the road

First, Trump's tweet, followed by Paul's (wrapped in some context):

As I've said a million times, I'm no expert on how to build a health care bill, but I can pretend to repeal one, so here goes. Note that my assumptions are that 'repeal' means all provisions of the bill will be immediately removed, not continued until such time as a completely new healthcare plan is passed, which is what "repeal now and replace later' means to me. (I'm not sure what other interpretation there could be?)

1. Immediately shut down Healthcare.gov and the 28 federally facilitated marketplaces and the five state-based marketplaces using the federal platform. 
2. Cancel the coverage for individuals and families who were covered under the now-defunct marketplaces.
3. Return any unused premium to them.
4. Immediately repeal the voluminous taxes required under the Affordable Care Act, whether charged to a business, a health insurer, any medical facilities, and so on. This will of course require an immediate rewriting of the tax code just to get us back to where we were before the Affordable Care Act went into effect.
5. Immediately repeal the individual mandate.
6. Immediately kick over-aged dependents off their parents' policies in any location such coverage is not mandated under any other jurisdiction.
7. Immediately remove the Medical Loss Ration (MLR) requirements, which dictate the percentage of health care premium dollars insurers must pay for benefits (base around 80%) and requires insurers to rebate premiums to insureds when they don't meet the MLR percentage.
8. Immediately eliminate the full coverage for pre-existing conditions at no additional premium - let the games begin.
9. Remove no-cost-sharing coverage for preventative care, including things like lead screening, mammograms and paps, prostate screenings, annual physicals, a whole host of lab tests, and countless other benefits - those can all go back to whatever pricing structure was in place before.
10. Remove all subsidies which currently help people pay for coverage - all of them.  
11. Similarly, remove all supports that are paid to insurance companies to help cover the costs of  insuring the people who got coverage under the ACA. 
12. Eliminate requirements for 'essential benefits' including outpatient services; emergency services; hospitalization; pregnancy, maternity and newborn care; mental health and substance abuse, prescription drugs, and more.
13. Immediately end all funding for Medicaid expansion.
14. Immediately reintroduce annual and lifetime limits on benefits.
15. Immediately increase the population of uninsured by the number of people covered under a marketplace (~10 million or so as of February 2017) and the number covered under Medicaid expansion, ~14 million).

I'm sure there's more, but that's what comes to mind right off the bat. 

Seems like lots of benefits would be lost, lots of tax revenue would be lost, lots more people would immediately be uninsured. And lots of people would be unemployed, I'm sure, if there was no need to support the Affordable Care Act's infrastructure. 

On the plus side for Republicans? Taxes would go down, Medicaid expansion would disappear, and lots of people would be uninsured.   

Poll Watch: Opportunities and Blessings

I'm sure by now you've heard about the bizarre, "someone put something in the juice cups again" public portion of Trump's cabinet meeting. You know, the one where everyone sat around and told their fearless leader how fabulous he was?

Trump, of course, tooted his own horn.

Never has there been a president, with few exceptions - case of FDR, he had a major depression to handle - who has passed more legislation and who has done more things than what we've done. I think we've been about as active as you can possibly be at just about record-setting pace.

Oh, the #winning and the #recordsetting, #Icantstandit I truly can't. I don't know that anyone was prepared for Reince Priebus and his remarks, though.

On behalf of the entire senior staff around you, Mr. President, we thank you for the opportunity and the blessing that you've given us to serve you agenda and the American people. And we're continuing to work very hard every day to accomplish those goals. 

In light of his statement, and that of the others talking about the "honor" and "privilege" to serve this president, when they were simply asked to introduce themselves and the department they work in, I thought it would be fun to juxtapose the Cabinet members' sentiments with those of the American people.

Here are some key callouts from a recent Gallup poll

• Trump's approval - 37% 
• his weekly disapproval - 58%, highest of his administration
• only 8% of Democrats approve; 83% of Republicans do.

The approval rating among republicans is down three points from his average, which is not a great sign, I don't think.  Among independents, his approval rating of 41% is five points lower than his average there. 

And, let's see what people are saying over at Public Policy Polling.

• Angela Merkel (+11), Justin Trudeau (+11), Emmanuel Macron (+7) and even Theresa May (+4) are seen more favorably by Americans than our own president (-14) based on their net favorability scores/
• Clinton voters particularly like Merkel and Trudeau; Trump voters only like the British PM.
• Only 24% of all voters support the AHCA (aka the WeDon'tCare Act), with 55% opposing; only 42% o Republicans support the darn thing
• Staying on health care, the ACA is the preferred path, with 51% approving vs. 34% not, and 35%  think the Republican's repeal and replace the right answer; 59% favor keep and fix.  

Dean Debnam, the president of PPP, tells us that

Six weeks after the initial passage of the AHCA voter anger over it isn't subsiding. It continues to be the biggest issue driving a Democratic advantage in 2018.

Why? Because, according to their polls, voters says they're less like to vote for a member of Congress who supported the ACHA (48%) than someone who favored it (24%).

Quinnipiac polling tells a similar story, one that is not all that positive for the president, regardless of his bigly opinion of himself. Let's look at Russia for example.

• A majority of Americans think there's something amiss with Trump's own dealings with Russia; 31% this he did something illegal, with another 29% saying he did something unethical.
• When it comes to Trump's campaign advisors, 40% think there was something illegal going on and 25% think there was unethical behavior. 
• 54% think Trump is too friendly with Russia; 68% are "very" or "somewhat concerned" over Trump's relationship with Russia, a country 45% of voters think is our adversary, not our ally (only 8%). 

Those numbers aren't out of line, given the general lack of consideration for ethical behaviors show by everyone from the lawyers to the cabinet members, and of course there's the Trump Organization, and the bad charities, and the Access Hollywood tape, and more.  Back to the poll:

• Trump's approval rating is even lower -- 34%, down from 37% in May and 35% in April.  

It gets worse.

• 68% say Trump is not level-headed (although 64% of Republicans think he is).
• 59% think he is not honest
• 58% think he doesn't have good leadership skills
• 58% think he doesn't care about average Americans
• 64% think he doesn't share their values

There was some good news, though, which I'm sure will make it into an early morning tweet.

• 62% think he's a strong person; 57% think he's intelligent. 

Even at Fox News, the poll is not showing great things.

• 53% think Trump's agenda and presidency are coming apart
• On taxes, 54% think our current system is worth keeping, with some tweaks - but not major changes
• On the AHCA, 54% oppose the bill; 45% strongly oppose it. 
• 53% think Obamacare has been good for the country (in 2014, 52% thought it was bad for the country)
• Only 51%  are concerned about illegal immigration, a drop from 71% back in September 2010
• And, finally, on climate change, the pendulum has swung from 46% concerned (February 2013) to 60% in the most recent poll

Sure, Reince, the blessings are great, but even among his most friendly audience, things are not looking so good. 

Perhaps there are some other opportunities out there you might want to look at?

Wondering on Wednesday (v90)

Where do we start, this Wednesday?

The president is on a big foreign trip: he went to "Israel, Saudi Arabia and the Middle East" and then headed off to the Vatican and Brussels, to meet with the Pope and NATO, respectively.

From all accounts, he was warmly welcomed, at least on the first part of the trip. There were Harleys, and horses, and limos and bigly red carpets everywhere. I wonder if even Trump thought his face would ever be splashed in lights on buildings in a foreign countries?

Social media had fun with the sword dance and the glowing orb, positing that the latter could have been the key to the sinkhole that mysteriously appeared outside Trump's Mar-a-Lago club in Florida; many argued that it wasn't a sinkhole, but rather the gates of hell. I'm not religious, but I'm sure not going to stick my toes into that water.

What else is going on?

Well, the CBO released their assessment of the WeDon'tCare Act, also known the American Health Care Act. The Republicans retooled their plan, you recall, after it failed to garner support pass back in March, and April. When it was revisited earlier this month, it passed with no Democratic support, and 20 Republicans voting no. The new plan, according to the CBO, will cut the deficit by $119 billion, and leave 51 million people without insurance, over the next decade - including as many as 14 million who would lose coverage by next year.  That 51 million uninsured number? That's 23 million more than would be uninsured if the Affordable Care Act were left in place but better than the first version by 1 million people. Yay Republicans!

You know how politicians always claim to "know someone" or "are friends with someone" who is gay, or is looking for work because their job was sent to China or was taken by an illegal immigrant, or who is afraid of being attacked by a Muslim terrorist, or who was killed by the Clintons? Yeah, I wonder how many Republicans are going to be standing in front of  the TV cameras telling us they're "friends with someone" who's going to lose their insurance this year, or who will see an 800% increase in premiums, which is possible, per the CBO, for an older person in a waiver state? Any ideas?

And speaking of standing in front of the cameras, you'll remember the outcry when the president met with those Russian dudes? And allegedly shared military intelligence with them in what seems to have been an off-the-cuff, look-at-me way, according to sources?

I get great intel. I have people brief me on great intel every day.

After initially saying there was nothing to see here, the Administration changed their tune and said that Trump could share intel if he wanted because he's the president, and so on. Detractors called him loose with classified info; supporters point to Obama and Clinton disclosures, as if two lefts make a right.

The point of all this? At that meeting, no members of the American media - not even Fox News or InfoWars - were in the room. Only someone, a photographer, I believe -  from the Russian media. I mean, Putin even offered to give us details on the call, since he had them and no one else did. But that's not what has me wondering.

Nope -- it's the press conference in Saudi Arabia that Secretary of State Rex Tillerson held. Without any members of the American media present.  Now I know the Trump administration thinks that only they tell the truth, and that the main stream media is fake news, and they they prefer alternative facts, and they like to tape plastic over the windows at Mar-a-Lago so the press can't look out at the golfer in chief, but do they really think it's appropriate when traveling overseas to hold a press conference with foreign media only?

And finally, there are multiple reports, including one in my local paper, that Carrier will be laying off people at the plant Trump 'saved' in Indianapolis, including close to 300 just before Christmas. I wonder, can this air conditioning plant be saved? And how will the administration spin the job losses? Do they still get credit for the temporary save, if none of the positions move to Mexico?

And in which foreign paper will I find the story?

Who Should Pay for Ordinary Healthcare?

Uh. Oh. Budget Director Mick Mulvaney, who might be the most honest person in the Trump Administration, stuck his right foot in and shook it all around again.

Mulvaney, you may recall, was the guy who told us that Trump was an #AmericaFirst candidate, and we elected an #AmericaFirst president and there should be no surprise that his budget was an #AmericaFirst budget, the sketch of which was put together from Trump's speeches, campaign promises and the like.  So there should also be no surprise that he thinks we should have an #AmericaFirst health insurance system.

Mulvaney was speaking at Stanford, and was asked a question about the Jimmy Kimmel test. Here's Senator Bill Cassidy, Louisiana Republican, explaining what that means.

The Jimmy Kimmel test, I think, should be that no family should be denied medical care, emergency or otherwise, because they can't afford it. Can that be the Jimmy Kimmel test? Is that oversimplifying it?

Here's what Mulvaney had to say about it

I do think it should meet that test. We have plenty of money to deal with that. We have plenty of money to provide that safety net so that if you get cancer you don't end up broke... that is not the question. The question is, who is responsible for your ordinary healthcare? You or somebody else?

That doesn't mean we should take care of the person who sits at home, eats poorly and gets diabetes. Is that the same thing as Jimmy Kimmel's kid? I don't think that it is. 

Wow. I  thought the Republican argument that Only Skanky Whores Need Birth Control was bad -- but now, Mulvaney is attacking not just Mitt Romney's 47%, but the whole basket of deplorables who voted for Trump. Yowser, as my sister-in-law would say. Yowser!

I shared the Only Skanky Whores Need Birth Control argument back in July of 2014, when we in dealing with the 'corporations have deeply held beliefs' case we all remember.  Here's how I started that post:

I've been torturing myself reading comments posted on various Burwell v. Hobby Lobby articles. And out of fairness, I've tortured myself leftly and rightly, not wanting to miss anything. Trust me, there's a lot that's worth missing.

After reading through opinions ranging from the ridiculous to the sublime, it seems that people have no clue how insurance works. There's a huge misconception out there that a health insurance policy should be completely individualized, so that for example a man would never have to pay for maternity coverage, seeing as how he would never have to use that specific benefit. And now that thinking has been extended to include contraception, because a guy would never have to use The Pill or an IUD so why the (insert curse words of your choice) should he have to pay for it for anyone else?

That argument is one of the Republicans' favorites. Birth control is a lifestyle choice, not a health care issue. Here's more from my post:

In reality, the hatred and vitriol (spliced with an occasional very detailed description of natural birth control) isn't about health insurance, it's about lifestyle and about women and about the 47%.  Because "if those whores would just keep their legs closed this wouldn't be an issue" and if they were good girls not "those skanks who sleep around and expect someone else to pay for their goddamn birth control" we probably wouldn't be having this discussion at all...

But of course wife, daughter, sister, and mother on insurance-covered-birth control, and men with insurance paid-for vasectomies, and honest-to-God hardworking me, well, those are the antithesis of skank, whore, and 47%er.

So now, the wife, daughter, sister and mother feeding their kids Big Gulp sodas, fast food and crappy school cafeteria lunches because their school district prioritizes cheap salty sugary food ahead of nutrition, and the husbands, sons, brothers and fathers hanging out at the bowling alley or chugging a few cheap draft beers in the corner dive after their shift in the mine or the factory, or killing a bag or two of Doritos watching NASCAR on FOX?  Yeah, they're the equivalent of those skanky whores and their birth control, if they think we should pay for their diabetes treatment, it would seem.

What Mulvaney is suggesting, and what others before him have suggested, is not a health insurance program. Again, from the previous post:

Most people would recognize this as a draconian way to finance health care, if we all were individually underwritten (that means no family coverage folks - we are all on our own), based on a complete medical history going back a few generations, a comprehensive medical exam including tests for all things known to man, God and nature, and an NSA-style examination of what we eat and drink and how we exercise or don't and how long we sleep or don't and with whom, and so on.  Full invasive medical and lifestyle exams for all -- paid for out of your own pocket, of course, because you can't have insurance that covers medical exams until you prove you're worthy. And done on a regular basis, because we know that lifestyles change, with age and circumstance and environment.

Mulvaney may be brutally honest, but wherefore art thou, cojones?

If he and the rest of the Trumpians really don't want to pay for Joe the Plumber's diabetes and Larry the Cable Guy's heartburn and Billy Joe Jim Bob's erectile dysfunction stuff (oh wait -- it's OK to pay for that - heaven forbid we don't let a good ole boy have an erection) and Sally's depression because her husband spends all his time and all their money at the bowling alley, Mulvaney would slash all funding related to health care and health insurance, other than pools for non-self-inflicted pre-existing conditions, from our #AmericaFirst budget.

• No tax credits to buy insurance - that's money that should go to the federal kitty to pay for our $54B military build-up. 

• No Health Savings Accounts to help pay for deductibles and coinsurances and stuff, that can be passed on from one generation to the next, because that's money that should go to the federal kitty to pay for that Aesthetically Pleasing on the North Side Only Border Wall.

• No Medicaid block grants to states to allow them to cover benefits for citizens - that's money that should go to the federal kitty to pay for banning Muslims.

#AmericaFirst, 'ordinary healthcare' paid for, right there,  Mr. Mulvaney: every man, woman and child fending for themselves. 

Who Knew This Could Be So Confusing?

Darn it all, just when I think I have this health care stuff figured out, those pesky Republicans go and confuse the HDHP out of me.

Take access to care, for example. Some people believe that TrumpCare, or RyanCare, or the American Health Care Act-- actually, I think I will refer to it as WeDontCare - will take away access for people who are covered under plans paid for with Medicaid.  And according to the bill summary  published on GovTrack, if you are on Medicaid

• The ACA expanded Medicaid eligibility in 32 states that opted into it. (WeDontCare) would reverse the eligibility expansion beginning in 2020 (anyone enrolled by then would remain enrolled) and it would reduce federal support for Medicaid with caps on coverage. And, if you have a gap in coverage for more than one month after the end of December 2019, you won't be able to re-enroll unless you live in a state that wants to pick up the cost. 
• The ACA expanded required benefits under Medicaid, such as mental health and addiction services, which would not longer be required. 

You should recall the president promised - he PROMISED! - he would not cut Medicaid, so it's a little confusing why WeDontCare was estimated by the Congressional Budget Office (well, the early versions of the bill - we don't have an estimate on the one that passed) - to drop some $880B from Medicaid. 

And, to the second bullet above, the president promised - he PROMISED! - to end the opioid epidemic. 

Our terrible drug epidemic will slow down, and ultimately stop.

Not only that, but he announced this plan when he was a candidate which, in addition to building The Big, Beautiful, Busty, Bodacious Border Wall and closing shipping loopholes, would

• Fix the misguided rules and regulations that have made this problem worse: Speed up the approval and availability of abuse-deterring drugs; lift the cap on the number of patients that doctors can treat with recovery medications, provided they follow safe prescribing practices and proper treatment supervision; and reduce the amount of Schedule II opioids (drugs like oxycodone, methadone and fentanyl) that can be made and sold in the US, and 

• Get people struggling with addiction the help they need: Support the Comprehensive Addiction and Recovery Act; expand incentives to use drug courts and mandated treatment; expand access to treatment slots and end Medicaid policies that obstruct inpatient treatment; and distribute widely naloxone/narcan (opioid antidote to treat OD) to first responders and caregivers.

So it seems a bit surprising that he would so strongly support (and celebrate the passage of) a bill that chops a limb or three off Medicaid, and allows coverage for substance abuse treatment under Medicaid to be eliminated, doesn't it? Or is it just me?

And we learned, a long time ago, that people were appalled with conditions at the Veterans Administration, when people were dying waiting for care. You remember that, right?

• Trump says 300,000 veterans died waiting VA care
• Hundreds of veterans died waiting for care at Phoenix VA hospital, watchdog report finds
• Paul Ryan Slams VA Secretary, But Stops Short of Calling for Resignation
• Veterans Are Dying While They're Waiting Months to Get Healthcare From the Government

Those are just a few of the headlines letting us know that people do die waiting for healthcare, and it's a horrible situation, whether it's a veteran or anyone else. It's a situation we all should be concerned about - folks like you and me, and politicians too. Really concerned, not fake concerned or politically expediently concerned. 

So then, what's wrong with this guy, Idaho Congressman Raul Labrador, that he doesn't understand this? When an attendee at Labrador's town hall mentioned her concern that the cuts in Medicare benefits might result in people dying, Labrador disagreed.

That line is do indefensible. Nobody dies because they don't have access to health care.

Well, I guess someone should tell that to all those veterans the Republicans told us about?

No wonder I'm so confused. Am I supposed to believe the Republicans, or the Republicans? Do I believe the promises of the president, and his indignation or do I just throw that all aside?

Of course, for clarity, there's always this interpretation of things.

It is hardly indefensible to say that people don't die from lack of access to healthcare. It is, rather, a basic fact of life. So perhaps Raul should just be honest and say "Sure, some people are going to die, but look at all the money we'd save rich people who don't like paying taxes? Isn't that worth it? They should be proud of their sacrifice! This country would hardly exist were it not for the poor nobly sacrificing their lives to that rich people can be slightly more rich than they would be otherwise!"

Yeah, that seems to help.