Tag Archives: Affordable Care Act

Listing The Obscenities

On Tuesday evening, I participated in a Zoom hosted by Indivisible of Central Indiana. It was focused on Trump’s “Big Beautiful Bill,” and if you can stand yet another enumeration of that insult to Americans, I’m posting my comments below.

__________________-

As Heather Cox Richardson has said, the Republicans’ “One Big, Beautiful Bill” is MAGA’s attempt to replace the government we’ve had since the 1930s with one that reflects the goals of Project 2025.

It is also an effort to rob the poor to further enrich the wealthy.

The Bill is 1000+ pages, but in this brief presentation I want to highlight the major elements—and alert you to the fact that, despite the fact that it is billed as a “budget,” it has numerous, damaging non-fiscal provisions which should be ruled non-germane in the Senate, but may not be.

Before getting to the truly horrifying fiscal mischief, let me share with you some of the most egregious non-fiscal provisions:

  • A measure to cripple the courts by prohibiting any funding from being used to carry out court orders holding executive branch officials in contempt. Passage of this measure would enable Trump and his officials to defy court orders at will.
  • The addition of billions to various parts of Trump’s deportation efforts, ramping up those efforts to the tune of an additional trillion dollars That includes $45 billion for construction of immigration jails (more than 13 times ICE’s current detention budget.) In addition, it would allow the indefinite detention of immigrant children and would charge families $3,500 to reunite with a child who arrived alone at the border. Asylum seekers will be charged an “application fee” of at least $1,000.
  • The administration would be given authority to label nonprofits as “terrorist-supporting organizations,” and terminate their tax status- an open invitation to suppress the free speech and activism of climate and civil liberties organizations, among others of which Trump and MAGA disapprove.
  • The bill would eliminate the National Weather Service, making local weather reports far less accurate.
  • One provision would allow the administration to sell off national parks.
  • A particularly ugly provision repeals the $200 excise tax on the sale of gun silencers, which have no lawful purpose other than concealing shootings.

Other bits of “fine print” more directly support the major goal of the bill, which is, as I’ve noted, to protect the extremely wealthy against efforts to get them to pay their fair share of taxes–basically, the bill exempts rich people from paying their dues to the country that made their accumulation of wealth possible. (For example, the bill would basically eliminate an Estate Tax that is already massively favorable to the top 1%.)

The “guts” of the bill are the fiscal provisions. Basically, the bill is an effort to fund the extension of Trump’s tax cuts for the rich by eliminating health care for the poor and middle class.

The Congressional Budget office estimates that as many as 16 million people would lose health insurance under the House-passed version of the bill. The annual cuts to Medicaid would average over 70 billion dollars a year—the same amount millionaires and billionaires would gain in tax cuts. The media has focused on those Medicaid cuts, but a number of analysts have explained that measures that have been minimized as “technical revisions” would essentially repeal Obamacare.

Not only would millions of individuals lose their health insurance, the consequences of these cuts would close many, if not most, rural hospitals and would have a dramatically negative impact on local economies, ironically mostly in Red states like Indiana. Economists have estimated that depressed local spending under the House bill would force the loss of 850,000 jobs. (Health care is the largest employer of any sector of the economy; it employs 18 million workers.)

Republicans who claim that they’re just adding “work requirements” to Medicaid are lying—the budget cuts 715 billion from Medicaid and 335 billion from Obamacare (the Affordable Care Act). And prior experience in the states has demonstrated that work requirements do nothing but erect paperwork barriers that throw eligible people off Medicaid; as we’ve learned from those previous efforts, Medicaid recipients who are able to work are already working—most Medicaid recipients are disabled, elderly or children.

There’s much more. The bill weakens the Child Tax Credit, by lowering the eligibility income threshold, so millions of children will suddenly become ineligible. It expands school vouchers–continuing the GOP effort to destroy public education and shift tax dollars to religious institutions, in violation of the First Amendment. It includes a variety of “Stealth Cuts’ to the Affordable Care Act that will increase out-of-pocket costs and make insurance more expensive for those people who are fortunate enough to retain it.

As if the assault on poor folks wasn’t mean-spirited enough, the bill also has deep cuts to SNAP. The House-passed version would cut nearly $300 billion from SNAP, the Supplemental Nutrition Assistance Program, according to Congressional Budget Office (CBO) estimates. That would be by far the largest cut to SNAP in history, and it would mean that millions of low-income families would lose some or all of the food assistance they need to afford groceries and feed their children.

SNAP has been the nation’s most effective anti-hunger program, and the bill cuts it by roughly 30 percent. These extreme cuts are actually deeper than the $230 billion in cuts the original budget resolution called for because the bill adds tens of billions of dollars in new spending for farm programs, and pays for those dollars by taking more food assistance away from people with low incomes.

And despite the GOP’s purported concerns about budget deficits, the bill blows up the budget deficit. According to the Congressional Budget Office, the bill will increase borrowing by a total of $2.4 trillion by 2034, because the $1.3 trillion in cuts to Medicaid, food stamps, and other programs don’t even come close to canceling out $3.7 trillion in tax cuts for the rich. Just the tax cuts going to the richest 5 percent outstrip the cuts to Medicaid and food stamps by 300 billion. If you add in interest costs, the total debt the bill creates exceeds $3 trillion.

This is just a horrible bill, and it needs to be defeated.

Comments

Prescriptions from the Doctor

It’s interesting that most of the public opposition to the Affordable Care Act has come from politicians–not infrequently, from politicians whose most generous donors have a vested interest in the medical status quo–and not from providers of medical care.

Perhaps we should listen to the people on the front lines–the doctors. This is from my cousin, a cardiologist whom I often quote here:

As a physician who had been in practice for many years, I remember the hardships suffered by many of my elderly patients prior to the initiation of Medicare in 1965. During that time, I was forced to sit painfully by as many unfortunate sufferers lamented that, even though they desperately needed to be hospitalized or needed expensive tests and additional services, they had only received small monthly social security payments with or without a small pension that barely sustained them at a subsistence level. In short, that situation afforded not only insufficient medical care, but threatened their financial security during those so-called “golden years.”

Then, in 1965, something abruptly and miraculously changed the landscape—the advent of Medicare. Suddenly our elderly could receive a standard level of medical care, which included, among others, diagnostic tests and hospitalizations. The financial burden was lifted from both the patients and us physicians, because we were no longer confronted with agonizing daily decisions about how we could provide decent medical care on a shoestring budget without threatening our patients’ health or survival.

He writes that two other doctors have recently weighed in via the New England Journal of Medicine (November 20, 2014). In “Civil Disobedience and Physicians—Protesting the Blockade of Medicaid,” C. van der Horst, MD, wrote that, when he anticipated passage of the Affordable Care Act, he thought he would no longer need to worry about patients’ affording necessary medications, preventive care services and hospitalizations.

But then van der Horst’s home State of North Carolina (like Indiana) blocked Medicaid expansion (even though, as it bears repeating, the federal government would pay 100% of the costs for the first 3 years and 90% thereafter). Over the protests of health care workers, teachers, union workers, immigrants, environmentalists, and people of all races and religions, North Carolina lawmakers have stubbornly refused to expand coverage.

The second article–written by Michael Stillman, MD–detailed the very different experience of Kentucky. Kentucky approved Medicaid expansion and “fundamentally altered our medical practice, allowing us to provide data-driven and thorough care without first considering our patients’ ability to pay” and giving 650,000 Kentuckians access to decent, comprehensive medical care. Most had previously lacked health insurance, had avoided routine preventive care—and worried that a medical emergency would leave them bankrupt. Medicaid expansion lightened their financial and emotional burden–and as a bonus, provided better physician education.  (Previously, doctors in training had become accustomed to offering substandard and incomplete care to indigent populations.) Now they are able to provide appropriate, evidence-based care.

As my cousin concludes:

This country will eventually—and inevitably—support decent medical care for all its constituents. Perhaps the process would be enhanced if our politicians were forced to spend time on the “front lines” of medical care in our clinics and hospitals and actually have dialog with those patients who are most vulnerable and under-served.

Listen to the doctor.

Comments

When Success is Failure…

There are lies, damn lies and (misrepresentation of) statistics.

Before the Affordable Care Act passed–when the country was debating the whys and wherefores of reform–proponents of major change (of whom I was one) pointed to the undeniable problems with America’s patchwork health delivery: the fact that we spent more per-person than any other country (by massive amounts) with significantly worse outcomes; that millions of Americans couldn’t obtain coverage either because they couldn’t afford it or due to pre-existing conditions; and that millions of people were stuck in jobs they hated because they’d lose coverage if they quit. 

How many new businesses, we asked, weren’t started because the would-be entrepreneur had a child with a pre-existing condition? How many people of a “certain age” wanted to cut back, but couldn’t because they’d lose their health coverage? How many Americans were effectively “slaves” to a job they didn’t want, staying solely for the health insurance?

Eliminating that “slavery” was a major goal of reform. It was one reason that many of us argued for decoupling health insurance from employment entirely, and making it part of social security, as it is elsewhere. We didn’t get that done, but the ACA is at least a step in the right direction.

A couple of days ago, the Congressional Budget Office issued a report showing real progress toward that goal of freeing people from jobs they hated:

With the expansion of insurance coverage, more workers will choose not to work and others will choose to work fewer hours than they might have otherwise, according to the Congressional Budget Office.

The usual suspects immediately went into propaganda mode. “See,” they screamed, “Obamacare is killing jobs.”

Of course, that isn’t what the CBO said. It said people were voluntarily leaving jobs. The jobs are still there, and will need to be filled when the newly-freed depart–which should be good news to unemployed folks looking for work.

Somehow, in the fevered imaginations of the uninformed–and the dishonest rhetoric of the politically self-serving–meeting one of the original goals of health reform is evidence that it doesn’t work.

I’m getting dizzy from the spin cycle.

Comments

Bottom-line Ideology Bites

The news-magazine show Sunday Morning had a fascinating piece this week on a new approach to debt collection. The story reported on a collection company that refuses to employ the typical tactics–harassing phone calls, threats and the like. Instead, the collectors work respectfully with the debtors, helping them to renegotiate what they owe and manage their finances more prudently. The founder’s basic premise: people would pay their bills if they had the money, and hounding them is unlikely to give them the means to pay.

According to the company’s owner, his firm is twice as profitable as those using the more traditional tactics.

Respect for people–what a concept!

Respect for the worth of one’s employees can also boost profits, no matter how counter-intuitive some “hard headed” businesses might find that simple premise.

I’ve written before about the difference between the approach of Costco and Sam’s Club to  their workers. Costco pays its workers, on average, twice as much per hour as Sam’s Club, and provides them with health insurance to boot. Yet it is far more profitable.

There is a self-defeating belief among some businesspeople to the effect that a healthy bottom line depends on cutting costs wherever possible, especially personnel costs. There is plenty of evidence to the contrary: employee turnover and disaffection can cost more than skimpy payrolls can save. That is a lesson that even Walmart appears to be learning. The company recently announced that some 35,000 part-time workers will be returned to full-time status–entitling them, not so coincidentally, to heath coverage as required by  the Affordable Care Act.

As Forbes reported, Walmart’s unwillingness to pay most of its workers a living wage has left the company without enough full-time workers to properly run a retail outlet. The result has been that the company has placed dead last among department and discount stores in the Customer Satisfaction Index for the last six years.

Furthermore, again according to Forbes, Walmart sales have been “sinking dramatically”–a state of affairs that even Walmart has concluded is the result of its relentless effort to avoid paying decent wages and offering health insurance.

This was a lesson learned by Home Depot in the early 2000s, when its CEO cut full-time staffing in hopes that the savings would boost the bottom line. It worked–briefly. Then customer service declined, and with it, same-store sales. Home Depot reversed course–and profits rose.

As the Forbes columnist noted,

Who  would have guessed that a well-staffed store filled with competent and reasonably paid employees might actually have an impact on the success of a company?

Comments

Talking the Talk, Avoiding the Walk

Tea Party types love to talk about the Constitution. Evidently, the only thing they like more is evading its requirements.

George W. Bush showed the way. With his aggressive use of signing statements, he avoided that pesky “veto override” problem. (Recall the tactic: he would sign a bill he didn’t like, rather than vetoing it, but he’d issue a signing statement to the effect that he wouldn’t enforce the law if he didn’t feel like doing so. That “veto by another name” avoided an override vote by Congress.  Mission–i.e., end run around the Constitution– accomplished!)

Today’s Congressional zealots are doing George one better. As Robert Reich recently pointed out,

The Constitution of the United States does not allow a majority of the House of Representatives to repeal the law of the land by de-funding it (and threatening to close the entire government, or default on the nation’s full faith and credit, if the Senate and the President don’t come around).

If that were permissible, no law on the books would be safe. A majority of the House could get rid of unemployment insurance, federal aid to education, Social Security, Medicare, or any other law they didn’t like merely by deciding not to fund them.

Like it or hate it, the Affordable Care Act was passed into law by affirmative votes of both Houses of Congress. It was signed (without the crossed fingers of a Signing Statement) by the President, who subsequently ran for re-election on a record that prominently included it and who handily won. Its constitutionality has been upheld by the Supreme Court.  There are not nearly enough votes to repeal it using the proper process.

But none of that matters to the arrogant ideologues who want to circumvent the Constitution they claim to revere by failing to fund the law of the land.

The truth of the matter is, the only Constitutional provision they really care about is (their version of) the Second Amendment.

Comments