Health Care 2019

Barring something unexpected, as discussed in Doc Jess’s post, the major action for the rest of this Congress on health care is likely to be at the administrative level with Tom Price doing his best to undermine the Affordable Care Act.  However, there have been some unanticipated holes that have developed over the past seven years that do need to be fixed.  As such, if Democrats regain control of the House and Senate in 2019 what issues should they be looking to address.

At the top of my list is the Medicaid expansion hole.  Back in 2012, the Supreme Court ruled that states did not have to participate in the Medicaid expansion.  The Affordable Care Act assumed that every state was going to participate in the expansion and only provided for subsidies for those who did not qualify for Medicaid.   When a significant number of states opted to not expand Medicaid coverage, this created a group who earned to much to sign up for Medicaid, but too little to get subsidies to purchase insurance.  The obvious fix is to expand the subsidies to cover this gap group.

The second issue concerns the exchanges.  Again, the Affordable Care Act assumed that most (if not all) states would opt to set up exchanges just on principles of state autonomy.  (Why would Republicans who complain about the feds taking over the insurance market let the feds take over the insurance market in their states?)  It turned out that Republicans in the state wanted the symbolism of resisting more than actual local control.  This problem offers a chance to offer the Republicans a two-edged sword.  The Republicans complain that one of the problems with health insurance is that companies are unable to offer policies that cross state lines.  (Placing the blame on regulations is not accurate, and the biggest restraint on such policies is the need of insurance companies to have deals with the local hospitals.)  So I would offer up for discussion an exemption for policies offered on the federal exchange.  If a state does not have its own exchange, policies on the federal exchange will be exempt from state regulations and will only be subject to federal regulations.   If a state wants to regulate those policies, it can take over the exchange.  If not, a state will not be permitted to sues state regulations to obstruct the federal exchange.  My hunch says that the states will not opt to set up their own exchanges and that the exemption of insurance companies from state regulations will not increase the number of policies that cross state lines.

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Healthcare: Next Steps

We had our day of glee over the abject failure of the GOP. And let’s recap: they had SEVEN YEARS to come up with a replacement and chose not to. It’s critical to understand why they didn’t, because it affects what we do moving forward. The Republicans never developed a replacement because they don’t want government to have any part of healthcare (or social services of any sort). Their goal is to dismantle not just the ACA, but Medicaid, Medicare and then Social Security. As a side dish – public education, environmental protection, etc. That’s their goal. And when your goal is death, you’re never looking to develop a treatment plan.

The AHCA bill was a tax bill, plain and simple. Its thrust was to create a trillion dollars in savings so that Ryan and crew could enact the tax cut bill they want: without the savings, it will be harder to decrease monies paid by individuals making over a million a year. They’ll likely make some progress, however, on corporate tax dismantling. More on that below.

It went down in flames for several reasons: yes, the protests certainly gave cover to Republican in moderate districts, especially those that Hillary Clinton carried last year. Don’t underestimate that, and DON’T STOP!!! But the overarching reasons are all on the Republican side: they have to do with the Freedom Caucus which stood en bloc in the face of direct threats from the White House. They couldn’t care less what their party thinks of them, they’re not afraid of Trump and Bannon, they don’t even care that much about their constituents. They are ideologues with no understanding of how government functions, only how to stop it. Their goal is NO government, and they’re too stupid to understand that “NO government” is synonymous with “Failed State” and “Anarchy”. In our planning, we need to consider the best ways to leverage them. Remember, this was never going to pass the Senate, and we suspected that when the first draft was published in early March. (See paragraph six in this link.)

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The Week in Review

There is an old saying that a week is a lifetime in politics.  In most weeks, there is a lot happening either behind the scenes or at lower levels (e.g., committee hearings and markups on bills that nobody is watching).  It is the rare week, however, that so much is taking place front and center competing for the attention of the American public.

The big story of the week was the non-vote on and the collapse of the Republican effort at major health care reform — the so-called Affordable Health Care Act (a name that in itself was an attack on the bill that it was trying to “repeal and replace,” the Affordable Care Act.   There are several significant aspects to this non-event.

First, despite their efforts, Donald Trump and Paul Ryan could not get the sizable Republican majority in the House to pass a bill (forget the exact details of the last version of the bill, they could not get a majority behind any version) on one of the top Republican priorities of the past seven years.  While Trump may have been a great negotiator, it is very easy to reach a two-sided deal.  (Of course, it’s possible that Trump’s belief in his negotiating skill may be one of his great delusions.  He may have just been offering the right deal at the right time and actually have been taken to the cleaners in his business negotiations.)When you have three or more sides to a deal, however, it becomes very difficult to keep everybody on board.  This problem is particularly true in politics — when one faction thinks that a bill is too conservative and the other faction thinks that the bill is too liberal, there really isn’t any change that could make both sides happy.  At that point, it’s not really about negotiating but selling.

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“Deep State” Paranoia

In the past several weeks, we have heard ranting out of the White House about a “deep state” conspiracy to frustrate Donald Trump’s objectives.  It is only this current fact-free administration which could turn a well-understand aspect of the American government — mentioned in political science courses for over half a century — into a sinister conspiracy aimed at President Trump.  It’s no secret that bureaucracies across the world (not just in the U.S.) function in their own peculiar ways to keep the government functioning — even when elected officials would rather destroy the government.  There are, of course, some features that are driving the Trumpistas crazy.

  1.  The United States is not a dictatorship.  The jobs and duties of the various departments and agencies are defined by statutes and existing regulations.  Because there are grey areas in these statutes and regulations, the executive branch does have some discretion in interpreting them (as discussed regularly in the posts about legal issues).  However, the President can’t on his own enact new laws or repeal existing laws.  Thus, however, much a President might see a need for new revenues to balance the budget, he can’t simply order the Treasury Department to start collecting a new $1 per day tax on every hotel room in the country.  Similarly, the President can’t simply order the permanent resident status of a legal immigrant revoked simply because that permanent resident posts a tweet criticizing the President.

2.  At the federal level, most individuals working for the federal government are careerists who have civil service protection.  Even for agencies that are exempt from civil service protection (which includes many state and city governments), there are First Amendment protections against discharge for political reasons.  Barring gross insubordination, these individuals can keep on doing their jobs as they understand their responsibilities.

3.  Most career civil servants identify with the mission of their department or agency.  It was not a shock that the organizations representing Immigrations and Customs Enforcement and Border Patrol employees were sympathetic to Trump’s proposals to beef up border security and to step up deportation activity.   Similarly, you would expect that career attorneys in the Civil Rights Division believe in enforcing civil rights laws and that those working in the foreign service believe in diplomacy and the traditional foreign policy objectives of the U.S. government.  You may have some temporary influx of “rookies” when government changes hands that agree with the goals of the new administration.  In the long term, however, it is hard to stay in a job when you disagree with the basic goal of the job.  Additionally, many jobs in the federal government (e.g. EPA and the FDA) require a certain educational background.  Most rational persons do not choose their college majors or graduate/professional schools for the purpose of one day undermining a government department.

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Donald Trump Is/Is Not Nehemiah Scudder

One of the advantages that science fiction has as a genre is the ability of writers to recast issues by presenting them in another place and time.  On occasion, the transformation of our problems into another situation can be forced (e.g., the original Star Trek episode in which the racial conflict was between those who were black on the left side of the face and those who were black on the right side of the face).

During the third quarter of last century, one of the top science fiction writers was Robert Heinlein.  While most famous for his novel Stranger in a Strange Land, his early career consisted of a series of short stories and novellas that formed a “future history” — taking the United States from the mid-20th Century until around 2200.   In several of the stories in this sequence, Heinlein mentions Nehemiah Scudder, a preacher who became popular enough to be elected president in 2012.  Scudder then establishes a religious dictatorship which governs until it is overthrown around 2100.  While Heinlein never got around to writing a story focused on Scudder’s rise to power, his summary of that rise in other stories identified some aspects of American politics that were not immune to the rise of a demagogue.  So in what ways does the election of Donald Trump mirror those aspects and in what ways do they differ.

The obvious difference is that Donald Trump is not a fundamentalist preacher.  However, writing in 1941, (well before the rise of the Moral Majority), Heinlein noted the power of fundamentalism in American power.  While Trump should not have been the natural candidate for fundamentalists, somehow he managed to get the support of fundamentalists over other “better fitting” candidates during the primary followed by the usual support for the Republican nominee in the general election.

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Friday Rant: Idiots and Morons

A long time ago I had a boss my family referred to as “Bad Eric”. (I later had a boss named “Good Eric”). Anyway, Bad Eric thought he was a really smart guy. I’m not talking about any of those esoteric views of intelligence, he thought his actual, tested, IQ was higher than anyone else’s in the company, especially mine. This was a big deal to him. He liked to say hello to me in the following way “Good Morning, you dumb b***h”, although in fairness, he sometimes used the “c” word in lieu of the “b” word.

Working for Bad Eric was no picnic, but I did end up learning the difference between “idiot” and “moron”. It turns out that “moron” used to have a technical meaning in DSM classifications of someone with an IQ of 80 or below. (100 is average on a Bell Curve.) And so, when I talk about the stupid things that voters do, I no longer refer to them as morons, I use the strictly pejorative term “idiot”. And today, I’m going to rant about idiots. Feel free to skip to the end to find out what happened when Bad Eric and I went head to head in the quest for who was smarter.

In the past few days, a number of media outlets have gone out and interviewed Trumpkin voters who will now be affected by changes to the ACA. Their overall response is that while they do understand that they will no longer be able to afford insurance, and thus cancer treatments, insulin and other necessary medical care, they believe that  #TheAngryPumpkin will actually save them because he’ll negotiate with Paul Ryan and let them keep, basically, the ACA as it is. I kid you not. Idiots.

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Notes from your Doctor: Protecting Yourself

One of the microbiology journals recently reported on the transference of MRSA and C.diff in hospitals. Why do you care? Because you, or someone you love, is going to end up in the hospital and this may save a life. A group of researchers were puzzled about how secondary infections often showed up in patients who were in rooms where the patient a week earlier had had the infection. Over that week, the room was cleaned top to bottom, and possibly had an uninfected patient in said room. What they found was that MRSA and C.diff were washed down the sink, where the bacteria colonized and grew in the S-curve of the drain pipe and then worked its way up the drain, and ended up splashing out when someone washed his/her hands. How long did that process take? Yup, a week.

They’re still experimenting to see how to best take care of this issue. My guess is that they’ll need a viscous bleach that clings like drain cleaner to make sure all the bacteria is killed. But while they’re still working on it, what can you do? Personally, I’ll be pouring a cup of bleach down the sink in any hospital rooms I visit.

Next: The Muslim Ban may affect your health. Any idea how many doctors are from foreign countries? Tens of thousands. Of note, 8,400 are from Syria and Iran. And we need them, we have a huge doctor shortage because we don’t produce enough doctors to meet demand. (More on that further down.) The effects are in two general areas: newly minted doctors for hospital residency programs, and practitioners in Appalachia and the Rust Belt. If you think people won’t die because of the ban, you’re wrong. (Source 1, Source 2.)

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Random Thoughts for 7 March 2017

Years before Facebook, there was blogging. And as blogging was making a crescendo to its brief heyday, I used to send out an email every day about what was going on in the world. It took a while for the readership to hit 1,000 recipients, and then gmail decided I was a spammer, and luckily Matt and Tom let me join them here at DCW.

Almost a decade later, the world has changed, and attention spans have greatly decreased. But here is the list of what I’m thinking about today…see how far you can get.

The New House ACA Repeal Bill: Have you read it? If not, you can do so here.  (You’ll need to use the PDF download link as the front page is just lies.)  As I always tell you READ IT. Otherwise you’re just going with someone’s interpretation and it’s hard to quote your favourite insanity verbatim. It’s short, 123 pages. Nothing like the original 3,000+ ACA bill. And that matters, because the new bill lacks CBO scoring, and answers to the kind of important questions that make #NotMyCheeto complain that healthcare is difficult. Of course it’s difficult you moron, human lives are involved.

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The Never-ending Battle — Redistricting 2011

One of Charles Dickens’s lesser known novels is “Bleak House,” dealing with a legal case over an estate that lasted so long and was so expensive that the expenses of the case exceeded the value of the estate.  The same is unfortunately true of disputes over the redistricting process.   We are now almost six years into the current ten-year cycle of district lines.  The run-up to the next cycle begins with elections in several states this year and next that will pick some of the governors and legislators that will be in office in 2021 when the redistricting process begins again.  You would think that, by this point of the cycle with three congressional elections and two or three state legislative elections (depending on the state) under the new lines, all court cases about those lines would be over.  Unfortunately, we are not at that point yet.

This week, the Supreme Court decided the most recent redistricting case (and it has another one under submission).  This week’s decision involved the Virginia House and whether the  drawing of its lines represented a “racial gerrymander” that violates the Equal Protection Clause of the Fourteenth Amendment.  The key issues in a racial gerrymander case is whether race is the predominate reason for the drawing of the lines of a particular district and (if race is the predominate reason) whether there is a sufficiently compelling reason for the reliance on race.  Such a challenge focuses on particular district lines.

In this case, the challenges concerned twelve districts.  The original three judge panel found that race was only the predominate reason for one of the twelve districts.  In part, this decision relied on the fact that the other eleven districts did not have unusual shapes and the lines could be justified by “traditional” redistrict considerations.  While the panel found that race was the predominate explanation for the twelfth district, the panel found that the need to bump up minority votes in that district to survive pre-clearance (as the Virginia lines were drawn before the Supreme Court abolished the pre-clearance requirement of the Voting Rights Act) was a sufficiently compelling reason.

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Deciphering the Federal Budget

Tonight 45 will speak about the budget plan his folks leaked out yesterday.  He’ll likely speak about other things, also, but that budget is all over the news and he’ll capitalize on that.  However, it’s rare that Congress actually passes a budget (the last time was in 2015, and that was the first time in six years) and rarer still that the presidential framework made it through the process.

So, let’s take a look at what was proposed, where it falls apart, and then what the process actually involves. Go get a cup of coffee, you’re going to need it.

First, the good news. Appropriations come from Congress, not from the Executive branch.  Per the Origination clause in the Constitution, all appropriations bills must start in the House, although the Senate may concur and/or offer amendments. In real life, normally this leads to negotiations between the Chambers prior to anything being enacted. Thus, nothing is happening quickly. That means there is time to lobby your reps for things that matter to you.

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