Tag Archives: ACA

Dishonesty And Healthcare

As the blizzard of political television ads becomes ever more annoying–and less informative–one thing about them has become very interesting. Even Republicans who have previously made it clear that they don’t want government involved in healthcare are airing advertisements touting support for Medicare and willingness to protect pre-existing conditions.

I’ve been particularly struck by the U Turn in Indiana’s Fifth District, where a radically-reactionary, pro-Trump Republican noted for opposing “socialism” (which she has defined to include pretty much anything done by government) has begun running commercials supportive of Medicare and coverage of pre-existing conditions. Evidently, her polling has overcome her previously expressed belief that government should have no role in health care.

She’s not alone.

When the Affordable Care Act (aka Obamacare) passed, several Republicans went on record with their concern that its trajectory would mirror that of Medicare and Medicaid: despite initial resistance, the public would come to expect/demand/approve of the program. Survey research has confirmed those fears, which is why GOP officeholders continue to pretend that they will protect access to healthcare at the same time as they are feverishly working to eviscerate it.

The Brookings Institution recently published a report detailing six ways Trump has sabotaged the ACA.The report began by stressing that its authors did not use the term “sabotage” lightly.

For analytic purposes, the term “sabotage,” should not be used lightly. Presidents upon taking office typically have priorities that trigger executive actions strengthening some programs while weakening others. The losing programs often face resource reductions, pressure to deemphasize certain goals, directives to alter their administrative approaches, and other measures that can undermine their effectiveness. In doing so, a president often pays lip service to the program, claiming it has been “modernized” or otherwise improved. In contrast, Webster’s defines “sabotage” as efforts to foster “destruction and obstruction” and to “cause the failure of something.” In the context of the administrative presidency, it reflects a commitment to program emasculation and termination through executive action. As such, it sharply departs from the constitutional requirement that the president “take care that the laws be faithfully executed.”

There were six actions detailed in the report.

1) The administration dramatically reduced outreach about, and opportunities for enrollment in, the ACA’s insurance exchanges. The administration sharply reduced support for advertising and exchange navigators and reduced the annual enrollment period to about half the number of days. 

2) Together with Congressional Republicans, it reneged on commitments to private insurance companies. Those insurers had been offered various subsidies that reduced the risks of participating in the exchanges. The GOP failed to honor those commitments.

3) The administration has constructed what the report calls “off-ramps to cheaper, lower-quality insurance.” One goal of the ACA was to improve the quality of health insurance by specifying essential benefits, guaranteeing coverage of those with preexisting conditions at reasonable rates, and prohibiting insurers from imposing certain spending caps. The Trump administration expanded access to coverage that was cheaper because it didn’t meet these standards and that siphoned off the healthier enrollees whose participation is needed to make the ACA work.

4) It allowed–indeed, promoted– a variety of state waivers that decreased ACA enrollments and undermined its regulatory structure.

5) It discouraged legal “aliens” from enrolling in Medicaid. In a particularly evil move, Homeland Security promulgated a “public charge” rule authorizing officials to treat Medicaid enrollment as a negative factor when reviewing the requests of legal non-citizens to extend their stays or change their status (e.g., from temporary to permanent resident).

6) And then there’s the existential threat. The Trump Administration brought the lawsuit that is now pending at the Supreme Court, attacking the constitutionality of the ACA. If that suit is successful–despite a legal argument that has been widely characterized as ridiculous, despite its endorsement by an appellate court composed of Trump-appointed judges– millions of Americans will lose access to health care.

As a student once reminded me, the United States doesn’t have a health-care system; we have a health-care industry. As a result, millions of Americans remain underinsured or completely uninsured, other millions are bankrupted each year by medical costs, and our health outcomes are among the absolute worst in the developed world. 

Deeply dishonest political rhetoric to the contrary, the current Republican Party wants to keep it that way.

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What White Supremicists Are Also Voting Against

There’s a theme emerging in the depressing story of current American political behavior. Call it karma, irony or profound stupidity leading to a boomerang effect.

A couple of days ago, I described a local election campaign in which the dishonest and unethical efforts of a State Senator who had previously had a reputation as one of the more honorable contemporary Republicans had instead brought disrepute on a family name that, until now, had identified admirable members of a Hoosier political family.

Tuesday, Paul Krugman pointed to yet another example of probable karma–in their determination to re-elect Donald Trump and their haste to co-opt the Supreme Court (ostensibly to “save”  babies they refuse to feed once they’re born), the GOP is facilitating the death-knell of Obamacare and the ability of both Republican and Democratic Americans with pre-existing conditions to obtain health insurance.

If you or someone you care about are among the more than 50 million Americans suffering from pre-existing medical conditions, you should be aware that the stakes in this year’s election go beyond abstract things like, say, the survival of American democracy. They’re also personal. If Donald Trump is re-elected, you will lose the protection you’ve had since the Affordable Care Act went into effect almost seven years ago.

The death of Ruth Bader Ginsburg has made this even more obvious. In fact, it’s now possible that coverage of pre-existing conditions will be stripped away even if Trump loses to Joe Biden, unless Democrats also take the Senate and are prepared to play serious hardball. But health care was always on the line.

Naive members of the GOP base either don’t understand this, or don’t care, or believe Trump’s repeated promises to issue a “wonderful plan” that will replace the Affordable Care Act and protect those with pre-existing conditions.

As Krugman points out, we’ve been hearing about how imminent that plan is for four years, and there’s still no sign of it. (Krugman suggests that  administration officials may have been” too busy botching their response to the coronavirus” to get to the task of crafting a healthcare plan. “Did I mention that, as we pass the 200,000 deaths mark, cases appear to be rising again?”)

In 2017, the last time Republicans did offer their own health care plan, the Congressional Budget Office calculated that it would cause 32 million Americans to lose health insurance, and others would face much higher premiums. That calculation didn’t come from “fake news” sources, but from the budget office of a Republican administration.

And what about that promise to people with pre-existing conditions?

The Trump administration is backing a lawsuit, now before the Supreme Court, claiming that a fairly minor provision in the 2017 tax cut somehow rendered the whole Affordable Care Act unconstitutional. It’s a ludicrous argument — but Republican judges in lower courts have backed it anyway, and a court without Ginsburg is more likely to let partisanship override any pretense of respect for logic.

The odds that the court will destroy Obamacare, and with it protection for pre-existing conditions, will obviously go up if Trump is able to install a right-wing partisan to replace Ginsburg.

For many members of the Trumpian base, loss of their health insurance would be karma– their overwhelming desire to hurt people who look, love and pray differently would have brought disaster on themselves. Much like the situation with masks–if the only people being hurt were the selfish know-nothings and bigots refusing to be inconvenienced to save the lives of their neighbors– the rest of us could probably live with that result. (I know–that’s horrible. But I never said I was nice.) Unfortunately, however, the trite sentiment is also true: we really are “all in this together.”

Dishonesty, stupidity and bigotry do come back to bite their promoters–the problem is, they get the rest of us, too.

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Red Myths, Rural Realities

Paul Krugman recently looked at the effects of Trump’s policies on rural America, and found–to no sentient person’s surprise–that the effects have been disastrous.

Economists, reports Politico, are fleeing the Agriculture Department’s Economic Research Service. Six of them resigned on a single day last month. The reason? They are feeling persecuted for publishing reports that shed an unflattering light on Trump policies.

But these reports are just reflecting reality (which has a well-known anti-Trump bias). Rural America is a key part of Donald Trump’s base. In fact, rural areas are the only parts of the countryin which Trump has a net positive approval rating. But they’re also the biggest losers under his policies.

As Krugman points out, whatever Trump’s campaign rhetoric might have promised, his actual policies have been aligned with (okay, dictated by) Congressional Republican priorities–what Krugman calls “G.O.P. standard”: big tax cuts for corporations and rich people, accompanied by cuts to the social safety net.

The only real deviation from GOP orthodoxy has been the tariffs, and Trump’s evident belief that trade wars are “easy to win.” Even the farmers who have been a reliable part of Trump’s base are beginning to recognize that they will bear the brunt of the substantial injuries caused by those wars.

As for the tax and social safety net cuts…

The Trump tax cut largely passes farmers by, because they aren’t corporations and few of them are rich. One of the studies by Agriculture Department economists that raised Trumpian ire showed that to the extent that farmers saw tax reductions, most of the benefits went to the richest 10 percent, while poor farmers actually saw a slight tax increase.

At the same time, the assault on the safety net is especially harmful to rural America, which relies heavily on safety-net programs. Of the 100 counties with the highest percentage of their population receiving food stamps, 85 are rural, and most of the rest are in small metropolitan areas. The expansion of Medicaid under the Affordable Care Act, which Trump keeps trying to kill, had its biggest positive impact on rural areas.

It is fair to suggest that many rural Americans are unaware of the variety of ways in which Medicaid expansion and other social programs support farm country; some of those benefits are indirect (which doesn’t mean they aren’t critically important). The impact of the tariffs, however, is hard to miss.

What about protectionism? The U.S. farm sector is hugely dependent on access to world markets, much more so than the economy as a whole. American soybean growers export half of what they produce; wheat farmers export 46 percent of their crop. China, in particular, has become a key marketfor U.S. farm products. That’s why Trump’s recent rage-tweeting over trade, which raised the prospect of an expanded trade war, sent grain markets to a 42-year low.

If Trump succeeds in plunging us into a full-blown trade war, which certainly seems more likely than not, Krugman says American imports and exports will both shrink — and since farmers rely disproportionately on exporting, they will be the biggest losers.

The harm being done to rural America by Trump leads to that perennial question: why do so many of the people bearing the brunt of his ignorance continue to support him?

Krugman delicately suggests that it has to do with “cultural factors”–by which he means hostility to immigrants and resentment of coastal elites they believe look down on rural America. (What Krugman calls hostility to immigrants is, if the research is to be believed, part of a much larger and more ingrained hostility to non-whites and non-Christians.)

Krugman thinks that rural America’s support for Trump may start to crack as the negative effects of his policies become too obvious to miss. I’m less sanguine.

When we so-called “elitists” talk about “voting ones interests,” we are almost always referring to economic interests. When I listen to Trump supporters–when they post angry diatribes on Facebook or are interviewed for a new program–what I hear is a very different view of what constitutes their interests.

Economic reality be damned. Trump voters are defending their vision of America, and that vision is white, heterosexual, and fundamentalist Christian. So long as they believe Trump is hurting people who fall outside that narrow category, he’s their guy.

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About Those Right-Wing Judges…

As most of you know by now, a conservative judge in Texas struck down the entire Affordable Care Act, ruling it unconstitutional.

The decision is a reminder that when judges are appointed on the basis of party loyalty rather than legal acumen, the results can hurt a lot of innocent people.

Legal scholars who have reviewed the decision believe it is badly flawed and will be overturned, but Daily Kos recently enumerated the consequences should it be upheld.

The most obvious loss would be that part of the law that forbids insurance companies from excluding coverage of pre-existing conditions. But as the author noted, if the law were really to disappear, that’s just a part of what would be lost.

As many as 17 million people could lose their coverage in a single year. The 15 million people covered under Medicaid expansion could lose their coverage. The improvements to Medicare that have saved the program billions of dollars—and reduced prescription drug costs for seniors—would be erased. Young people wouldn’t be able to stay on their parents’ insurance until they’re 26. The ban on annual and lifetime caps would be gone, and medical bankruptcies would escalate. Having lady parts would again cost women more than men, and being over age 50 would cost everyone more again. Limits on out-of-pocket costs would be gone. The tax credits that 9 million people are receiving to help them pay premiums would be gone.

The post focused on the political fallout of the threatened losses. (Even Republicans concede that the issue hurts them.) But the real lessons aren’t partisan.

There are two obvious “take-aways” here.

First is the incredible amount of damage that can be done by elevating ideologues to the bench. This sort of “smash and burn” judging is a direct result of viewing the federal courts as a partisan political prize rather than a constitutional safeguard to be protected by the appointment of dispassionate, knowledgable and qualified legal scholars.

The second is equally obvious. As important as the ACA is, as much of a step forward that it represents, it falls far short of what Americans need and most other wealthy countries have long had. Not only is it vulnerable to the sort of judicial assassination we’ve just experienced, it is simply insufficient.

It would be poetic justice–not to mention actual justice–if this effort by a radical judge prompted Congress to pass Medicare for All, or at least a “public option” allowing citizens of all ages to “opt in” to the program.

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Did Your Health Insurance Premium Go Up? Thank Donald Trump

There’s a reason the Republicans are frantically trying to load the federal bench–including the Supreme Court– with ideological conservatives: given Congress’ refusal to discharge its constitutional duty to oversee the executive branch, the courts are the only recourse for Americans opposed to the criminal enterprise that is the Trump Administration.

There are currently hundreds of challenges to that administration making their way through the courts, and a number of them are critically important. One of those involves the “take care” portion of the chief executive’s job description–the duty to “faithfully execute” the laws of the land.

People who depend on the Affordable Care Act–and all citizens who believe that Presidents have such a duty –should be rooting for the success of a lawsuit recently filed by four cities. 

Vox introduced its report on that lawsuit thusly:

Abbe Gluck argued, in October 2017, that President Trump’s “sabotage” of the Affordable Care Act violated his duty under the Constitution to ensure laws passed by Congress are executed. This week four cities — Baltimore, Chicago, Columbus, and Cincinnati —filed a suit making that very claim.

Here’s the essence of the argument:

Modern American history has never seen as full-scale an effort to sabotage a valid law as we have with President Trump and the Affordable Care Act — a law whose legality has been upheld twice by the US Supreme Court.

The president has a legal obligation, under Article II of the US Constitution, to “take Care that the laws be faithfully executed.” That means he must make sure that our laws are implemented in good faith and that he uses his executive discretion reasonably toward that end.

His agencies likewise have a legal obligation, under the Administrative Procedure Act — the statute that sets the rules for our entire federal regulatory apparatus — not to use their power to engage in arbitrary action.

The intentional, multi-pronged sabotage of the ACA that we have seen during Trump’s presidency — reaching new heights since attempts by Congress to repeal the law failed — violates both Trump’s constitutional obligations and quite possibly the obligations of his Department of Health and Human Services.

Like the pending lawsuits alleging violations of the Emoluments Clause, the take care clause has rarely–if ever–been the basis of a lawsuit.  At least in modern times, it certainly hasn’t been the basis of a case against a president, and that is entirely understandable: most legal scholars agree that presidents need a fair amount of discretion in enforcing the laws. Demonstrating that the person in the Oval Office is purposely undermining a law rather than exercising discretion is extremely difficult. Usually.

But this, of course, is Donald Trump–idiot extraordinaire. Far from masking his motives (making proof difficult),  he has trumpeted and tweeted them.

The ACA requires the federal government to support the open enrollment period — in which individuals must sign up for insurance or lose their chance to do so. The ACA requires the federal government to, among other things, maintain a website and work with local “navigators” and other groups to educate consumers and encourage them to sign up for insurance.

Trump instead set out to make open enrollment a failure.

He cut the enrollment period in half, from three months to six weeks. He shut down the federal enrollment website for nearly 12 hours every Sunday during the period — a crucial window when working Americans might enroll. He has canceled already- scheduled events in which federal officials had planned to visit states and help with enrollment. He cut advertising for enrollment by 90 percent, from $100 million to $10 million, even though his administration charged insurers on the exchanges user fees to generate money for that same advertising. (Those fees far exceeded $10 million.)

One day before the new budget year began on September 1, he announced a 40 percent cut to those navigator programs — after promising them $60 million in grants in May, and afterhis administration had said it would support navigators in order to partly offset the obstacles erected by the curtailed enrollment period.

Why would President Trump want to stifle open enrollment? Because that would seriously weaken the ACA’s insurance markets, which require a mix of healthy and sick customers to be stable. In line with that ambition, he also signed an executive order last week that directs his agencies to consider policies that would allow the sale of new group and short-term plans lacking many ACA protections. These alternative plans are likely to pull even more healthy individuals out of the insurance markets.

The same day, Trump announced his plan to cut off important cost-sharing payments that the ACA promises to insurers to compensate them for reducing what individuals have to pay in premiums…  creating extreme instability in the insurance industry… And Trump made clear that his goal in cutting off the funds was to harm he law. He tweeted the same day the policy was announced: “ObamaCare is causing such grief and tragedy for so many. It is being dismantled …”

Knowledgable observers calculate that premiums would have declined this year, rather than increasing, if not for Trump’s sabotage. That’s bad enough, but if a President can get away with eviscerating rather than enforcing valid laws with which he personally disagrees, the rule of law becomes meaningless.

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