Smoking is for poor people

It really is kind of amazing how much American society has bifurcated on smoking.  It is more than ever a class marker of being poorer and less educated.  As I hate smoking and being around it, I will confess to being glad that my particular social stratum has moved away most dramatically.  Here’s a chart from Wonkblog:


This explains why I can literally think of only a single friend/acquaintance who is an active smoker.

The CDC with some nice charts, too:

Current Use of Cigarettes, Cigars, and Smokeless Tobacco Among Adults Living Below Poverty Level Compared With Those Living At Or Above Poverty Level

Current Use of Cigarettes, Cigars, and Smokeless Tobacco Among Adults With Less Than High School Education Compared With Adults With College Degree


Republican health care– the short version

Two great charts from Drum:

Any questions?

The political culture war

If you didn’t have a chance to read Lee Drutman’s terrific piece on the 2016 election, consider this interview with him in TNR an excellent TLDR.  Here’s the conclusion:

The fault lines that Trump exposed in 2016 aren’t going anywhere. Even with Democrats confident that the unpopularity of American Health Care Act will propel them to victories in 2018 and 2020, Trump seems to be set on hitting immigration and identity over and over again.

Hitting immigration and identity is what brought him to the White House. If that’s the most salient issue for voters, they will stay supporters no matter what he does because he’s picked the right enemies and he’s signalled that he’s on their side. If the focus is on whether he’s still hanging on to his promises of delivering government entitlements, he loses. If the question is over American identity, he has a chance of retaining support.

If you think about it, the takeaway—which is a broad takeaway on American politics—generally on economic issues, on welfare issues, the country’s overwhelmingly liberal. On cultural issues, the American population is conservative, particularly in rural areas that tend to be overrepresented in our system of government.

Trump was able to pitch himself to voters as a marriage of social conservatism and economic liberalism, arguing that he would maintain (and possibly even expand) the welfare state. He’s clearly going back on many of the promises he made on the campaign trail and he won’t be able to run as a unicorn in 2020. Could that cost him his presidency?

Well, it may. That may be the case, but it may also be the case that as long as Trump maintains the right enemies, then he seems like he’s still the lesser of two evils to many voters. Republicans may succeed by making Democrats look like the party of globalist multiculturalism undermining American Christian greatness. That could still be enough to win.

The case for Pelosi

I’m not some huge fan of Nancy Pelosi.  She strikes me as an effective legislative leader and a helluva a fundraiser.  I’ll take it.  Sure, she’s got her flaws, but of all the dumb takeaways of Georgia 6 “Pelosi has to go” has got to be the dumbest.  A nice defense from Jeet Heer:

The case against Pelosi is by no means clear cut. Her detractors note that Republican attack ads in the Georgia race gave her prominence, apparently evidence that her unpopularity is a drag on the party. “The fact that Republicans spent millions of dollars on TV ads tying Democratic hopeful Jon Ossoff to Pelosi — and the brand of progressive policies she represents — shows that she will once again be an issue for Democratic challengers in the very districts that the party needs to win to make her speaker again,” Politico notes. Yet as Dartmouth political scientist Brendan Nyhan tweeted:

The ads that featured Pelosi were aimed at energizing highly partisan Republicans, the type of people who would know and hate any Democratic leader. Pelosi is a villain in these ads almost by default, since more prominent party leaders—Barack Obama and Hillary Clinton—have stepped aside, and thus lack sufficient scariness as bogeymen. Moreover, getting rid of Pelosi just because Republicans hate her would be a singularly craven move for Democrats—and would probably be ineffective to boot, in this regard. Her successor would become the GOP’s new top enemy. [emphasis mine]

The ideological critique of Pelosi is equally confused. To Republicans, she’s the archetypical “San Fransisco Democrat,” committed to unrestrained liberalism and out of touch with heartland values. Yet to Pelosi’s left-wing critics, she’s utterly without principles and cares only about holding the reins. “The Democratic House leadership is dedicated to retaining power for themselves and nothing else,” arguesMatt Stoller, a fellow at the New America Foundation. “Nancy Pelosi is utterly incoherent. She’s not a leader, she’s in charge of making sure no other leaders emerge.”

Both these critiques miss the central fact about Pelosi: She’s been an extraordinarily effective parliamentarian.

I’m sure there’s some decent takes for why Pelosi should be replaced in favor of new leadership– I just haven’t seen them in the wake of GA 06.

The Senate health bill omnibus post

In one sense, not much new to say.  It has been eminently and transparently predictable for some time that the Senate Bill is a complete policy disaster.  And, at heart, little more than a massive transfer of wealth from the sick and poor to the rich and healthy.  That said, today’s CBO score confirms just how bad it is.  I think quite notably– from a political perspective– it predicts millions of Americans to lose employer-based coverage next year.  Now, that ought to scare the hell out of just about everybody.  Democrats need to use this like a barb-wire-wrapped club.

Some various excerpts, but stick around to the end for my final political thoughts…

1) Drum with a very nice summary in bullet point form:

  • By 2026, spending on Medicaid will be slashed $772 billion. (Page 5)
  • There will be 15 million fewer people on Medicaid. (Page 16)
  • By 2026, spending on subsidies for private insurance will be slashed $408 billion. (Page 5)
  • There will be 7 million fewer people with private insurance. (Page 17)
  • This sums to a total of 22 million more uninsured people by 2026, compared to 23 million under the House version of the bill…
  • Because of the reduced value of health care policies under BCRA, premiums will go down. (Page 9) However, net premiums after accounting for subsidies will go up for most people. Among those with modest incomes, net premiums for silver plans would go up $500 for 21-year-olds; $1,300 for 40-year-olds; and $4,800 for 64-year-olds. Among those with higher incomes, net premiums would go down except for 64-year-olds, who would face increases as high as $13,000. (Table 5)
  • The share of uninsured older folks with low incomes would skyrocket from about 11 percent to 26 percent. (Page 16)…

Reading the CBO report in its entirety, it’s hard to see that BCRA offers any improvements over Obamacare aside from cutting taxes for the rich. Net premiums go up for most people—quite massively in the case of older consumers; deductibles go up; out-of-pocket expenses go up; the working poor are virtually shut out of the insurance market; the quality of coverage gets worse; and 22 million people lose insurance. [emphasis mine]

Yep, there you go.

2) Atul Gawande with an excellent post in the New Yorker:

To understand how the Senate Republicans’ health-care bill would affect people’s actual health, the first thing you have to understand is that incremental care—regular, ongoing care as opposed to heroic, emergency care—is the greatest source of value in modern medicine. There is clear evidence that people who get sufficient incremental care enjoy better prevention, earlier diagnosis and management of urgent conditions, better control of chronic illnesses, and longer life spans.

When more people get health-insurance coverage, as they did following the implementation of the Affordable Care Act, they get more incremental care. This week, the New England Journal of Medicine published a paper that I co-authored with Katherine Baicker and Ben Sommers, two health economists at the Harvard T. H. Chan School of Public Health, in which we analyzed the health effects of insurance coverage. We looked at dozens of studies put out over the last decade, and found that insurance-coverage expansions—including not just the A.C.A but also past Medicaid expansions and the health-care reform that Massachusetts passed in 2006—have consistently and significantly increased the number of people who have a regular source of care and who can afford the care they need. Insurance expansions have made people more likely to get primary and preventive care, chronic-illness care, and needed medications—including cancer screenings, diabetes and blood-pressure medicines, depression treatment, and surgery for cancer before it is too late.

These improvements in care help explain why people who have health insurance are twenty-five per cent more likely to report being in good or excellent health. It also explains why they become less likely to die. Proper health care saves lives, and the magnitude of the reduction in deaths increases over time… 

Conservatives often take a narrow view of the value of health insurance: they focus on catastrophic events such as emergencies and sudden, high-cost illnesses. But the path of life isn’t one of steady health punctuated by brief crises. Most of us accumulate costly, often chronic health issues as we age. These issues can often be delayed, managed, and controlled if we have good health care—and can’t be if we don’t. [emphasis mine]

3) Drum also with an excellent post on the importance of Medicaid.  Yes, the Oregon study showed no real impact on short-term mortality, but raise your hand if you feel you have had value from your health care plan other than, you know, not dying.

4) Chait on the pathetically dishonest lies from Republicans:

There is one solid, coherent argument for the Senate health-care bill: If you believe the government redistributes too much money from the medically and financially fortunate to the unfortunate, then Trumpcare is a huge step forward. Its large regressive tax cuts and even larger cuts to low-income health-care subsidies would rebalance the tax-and-transfer system in a way that’s more fair, from a certain moral perspective.

But since that moral perspective is shared by very few people, Republicans have long ago internalized the need to find different public rationales. In the health-care case, what they have come up with is a simple, blunt-force denial that their plan to reduce health-care spending is anything of the sort. Fanning out on the media. Republican officials have spread word that nobody would lose any benefits at all. “We would not have individuals lose coverage,” says Health and Human Services Director Tom Price. “No one loses coverage,” echoes Republican senator Pat Toomey. “These are not cuts to Medicaid,” insists Kellyanne Conway.

Trump has taught Republicans one new big thing– be utterly shameless in the boldness and brazenness of your lies.

5) Here’s the Post’s main story.  Just wanted to get this graph in here:

6) EJ Dionne with the lies, lies, and more lies Republicans are telling about the bill.

7) Meanwhile, this score has supposedly really upset the GOP “centrists ” (please don’t ever call them that!!).  Give me a giant, giant break.  This bill is similar enough to the House bill and so transparent in its motives (take away Medicaid from poor in exchange for tax cuts for the rich) that it is breattakingly disingenuous to pretend that this score is actually news at all.  I’m shocked, shocked that there’s gambling in Casablanca. I still think it very possible, if not likely, that there will be some minor tweaks– only 21 million lose insurance!!– that allow these “centrists” to vote for the bill after all their hand-wringing.

8) That said, I think we might be putting a little too much faith in Mitch McConnell.  Yes, he really is an evil genius.  but even evil geniuses make mistakes.  This bill with this CBO score really may be a road too far for at least 3 member of his caucus.

9) Thus my case for optimism.  I think there’s actually a decent chance that Republican health care “reform” dies here.  And, if not, I really do think passing this “reform” will be politically disastrous and ultimately lead us to better, more universal health care.  Downside to that– many millions of Americans seriously suffer in the interim.

The two Americas

The real one and the one’s Republicans live in where literally the most empirically-proven dishonest person in public life (aka Trump) is seen as more credible than James Comey (who, say what you will about his mistakes in judgment regarding HRC has pretty much never been accused of being dishonest– till now).  Some charts from an NBC poll:

Of course, Trump just literally admitted to lying about having tapes.  But so what.  As Brendan Nyhan likes to say, partisanship is a hell of a drug.

And, there’s this:

I’d like to ask all these Republicans whether they are generally inclined to reject the combined judgments of CIA, NSA, and FBI?  Who are you going to believe, a well-known fabulist or the collective judgment of career civil servants who’s primary occupation is to try and keep the country safe?

How health care will pass

Honestly, I think the scenario Drum lays out is probably the most likely one to happen:

This is just a note about the Senate health care bill. Do not believe any prattle about Mitch McConnell “being OK with a loss.” Or about “moderate Republicans” who will vote against it. Or about conservatives who are “revolting.” Or about “desperate attempts” to hold the Republican caucus together. [emphases mine]

Next week the CBO will release its score of the bill. They will confirm that it doesn’t increase the deficit. The Senate will debate for a day or two; pass a few minor amendments; and then pass the bill. The vote will be 51-50, with Vice President Pence breaking the tie.

If Paul Ryan is smart, he will simply bring up the Senate bill for a vote and be done with it. It will pass because everyone will understand that this is their only chance. Either vote yes, or else give up on repealing Obamacare and give Democrats a big win.

The only way to break this cycle is to generate some new opposition. Senate Republicans already know that Democrats oppose the bill, AARP opposes the bill, hospitals oppose the bill, and so forth. They don’t care. The Democrats won’t vote for them no matter what they do and the others aren’t threatening to withdraw campaign support. They oppose the bill, but only on paper. They also know that their bill will take away health coverage from millions. They don’t care about that either. They never have.

Yep.  It may not turn out this way, but honestly, given what we’ve seen already this strikes me as the most likely outcome.

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