The Medicaid piece

Margot Sanger-Katz’s headline pretty much gets it, “Shifting Dollars From Poor to Rich Is a Key Part of the Senate Health Bill.”  And, the biggest way this shift happens is cutting Medicaid.  Of course, many people don’t realize how vital Medicaid is to so many Americans and so many aspects of American health care.  Sanger-Katz has another Upshot piece on that.  Here’s the key chart.

Paul Waldman lets loose on the matter:

Then there’s Medicaid, the bill’s most prominent target for assault. It also not only eliminates the ACA’s expansion of Medicaid, phasing it out beginning in 2021, but goes much farther. Medicaid would no longer be an “entitlement,” which means that anyone who meets the eligibility criteria gets the benefit, even if in some years that means its budget gets unexpectedly bigger. Instead, Medicaid would be subject to new, slow-growing per capita caps, which represents hundreds of billions in cuts in coming years. In addition, states would be given “flexibility” over whom they cover, meaning they’d be allowed to reduce benefits or kick people off the program entirely. And who are the beneficiaries of Medicaid? The poor, the disabled, and the elderly (even though they get coverage through Medicare, Medicaid pays for a large portion of the country’s nursing home expenses). These are the people to whom the GOP is showing the back of its hand so it can offer a large tax cut to the rich…

What does it say about the values and priorities of the people who wrote this bill, and the people who will vote for it? It says that they are deeply concerned about maximizing the wealth of the wealthy — so concerned, in fact, that they’re willing to take away health coverage from millions of people in order to provide the wealthy a large tax cut. It says that they think that poor people have it too easy. It says that they believe health care is a privilege, not a right — if you can afford it, good for you, but if you can’t, too damn bad. And it says that their vision of America’s health-care future is one that is surpassingly cruel, where alone among the world’s industrialized democracies, we’ll intentionally leave millions of our citizens without health coverage and allow them to be bankrupted by medical bills. [emphasis mine]

And Greg Sargent on how the Republicans’ successful news hack has allowed these giant Medicaid cuts to go largely unnoticed:

The single most glaring feature of the Republican health-care plan is how massively regressive it is. Whether in the Senate or House version, it cuts health-care spending on poor people by hundreds of billions of dollars, to finance (relative to current law) an enormous tax cut for the rich. The regressiveness of the plan is a feature, not a bug. Even if you allow that Republicans believe in a principled way that this will benefit America, it is the plan’s overriding ideological goal. Cutting spending on the poor to facilitate a huge tax cut for the rich, in many ways, is the plan.

But what if a large majority of Americans don’t have a clear sense that the plan even does this? A new Kaiser Family Foundation poll out today suggests this may be the case, which hints at a number of troubling things about where this debate is headed next.

The Kaiser poll finds that only 38 percent of Americans know that the GOP plan makes “major reductions” in Medicaid spending. Another 27 percent say it makes “minor” reductions; 13 percent say it makes no reductions; and 20 percent say they don’t know. If this polling is right, that means at least 6 in 10 Americans are unaware of the central feature of the GOP plan to reconfigure one-sixth of the U.S. economy, one that will impact many millions of people over time…

At the same time, though, the poll finds that the public broadly approves of Medicaid as it is and supports continued spending on it — and that very few Americans support the GOP cuts when asked. Sixty-one percent of Americans say that Medicaid is “working well” for most low-income people it covers. But only 36 percent support cutting funding for Obamacare’s Medicaid expansion; and only 35 percent support changing Medicaid’s funding to limit how much states get each year. The GOP plan phases out the Medicaid expansion and uses per-capita caps to limit payments to states, in what could shape up as a dramatic overhaul of Medicaid well beyond ending the expansion, resulting in deep cuts to the program’s assistance to poor children, people with disabilities and the sick.

But, will Americans vote based on this in coming years?  Sadly, I fear too few of them will, as such cuts will be forgotten when you can scare too many Americans with all those scary immigrants and Muslims coming to ruin our country.

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“News” and Republican health care plans

Loved this take from Brian Beutler on how McConnell so adroitly used the media’s actual bias against it on health care coverage.  Among, the actual bias, is that for news that is actually new.  And by keeping it secret, Republicans did their damnedest to give them the sort of new, daily details that typical reporting craves.  Beutler:

Senate Majority Leader Mitch McConnell didn’t lock down the bill-writing process in order to block liberals from going over the bill with a fine-tooth comb. His chief insight was in recognizing a bias—not among liberals, but within the news industry—toward what you might call “new news.” Things we didn’t know before, but do know now. [emphases mine] It is that bias, more than anything else, that has brought us to the brink of living under a law that almost nobody on the planet has seen but that will uninsure millions to pay for millionaire tax cuts.

Exactly.  I even have a “news bias” bullet point in my Media lecture that talks exactly about this fact.

What ultimately got Trumpcare a modicum of mass coverage wasn’t a critical mass of liberal outrage about secrecy, preventable deaths, or bloodless, soak-the-poor, right-wing ideology. It was that Democrats, responding to grassroots pressure, stopped cooperating with Republicans to run the Senate in an orderly fashion, and made Republicans actively reject requests to open up the process, protect children and veterans and so on. Which is to say, Democrats made a little bit of news.

The reason the Affordable Care Act debate was so thoroughly covered eight years ago wasn’t that the reporters who covered it were better, but that the debate then was like the Sutter’s Mill of news. Reporters had a surfeit of hearings, drafts, amendments, CBO reports, speeches, symposia and votes to cover, and those stories commanded prime media real estate…

This is what makes Republican denunciations of the debate over Obamacare so outrageously dishonest. While Republicans fakedhysteria over the supposed secrecy of the process, what McConnell recognized about the 2009 debate is that nearly all of the Democrats’ struggles and setbacks stemmed from its openness. It wasn’t Democrats who set the template for Trumpcare; what Republicans are doing now is a through-the-looking-glass adoption of the lies they told about Obamacare…

All of this underscores the importance of treating the coming bill text, and next week’s Congressional Budget Office analysis, as if they were vaguely-written letters from James Comey. There will be mere days if not hours to distill the contents and effects of the secret bill to the public before senators cast their final votes.

But it would be better in the long run for the news industry to migrate toward a more nuanced standard of newsworthiness that doesn’t cede all agenda-setting power to people who can commandeer front pages with misleading information just because it’s new, or escape scrutiny for moral crimes whenever they want to, simply by going dark.

Yes, yes, yes.  Just another example of how McConnell has so effectively used the actual biases of the news media to effectively further his agenda.

Health care, mean-style

Plenty of good takes out there on the Senate bill.  Some highlights from some I enjoyed the most:

Ezra, “The Senate GOP health bill in one sentence: poor people pay more for worse insurance,”

There are a lot of moving parts in the health bill Senate Republicans just released, but the bigger picture is straightforward. Health care expert Larry Levitt condensed it to fewer than 140 characters:

That’s it. That’s what this bill does. In fact, it does it over and over again. Policy after policy in the bill is built to achieve the same goal: making poor people pay more for less health insurance. [emphasis mine]

Ezra, again, “The Senate health bill takes what Americans hate about Obamacare and makes it worse”

The Senate GOP’s health care bill is a strange document. It doesn’t fix what conservatives dislike most about Obamacare. But it takes what everyone else hates about Obamacare and makes it much, much worse.

The plan keeps Obamacare’s basic structure intact. The tax credits remain tied to income. Many of the insurance regulations remain in place. Medicaid is, in theory, gutted down the road, but the cuts don’t even begin until 2021 — raising the fear for conservatives that they’ll never happen at all. Even the cost-sharing reductions to insurers — which Republicans bemoaned as an illegal “bailout” — are restored.

So Obamacare — the government program that makes it the state’s responsibility to cover people with health insurance — mostly survives. If you are a conservative angry that the federal government has created a new health care entitlement, this bill doesn’t solve your problem.

But under the Senate bill, Obamacare’s ability to actually cover people with health insurance is sharply diminished. Because the plan shifts hundreds of billions of dollars in insurance subsidies to tax cuts for the wealthy, there’s not enough money in it to cover nearly as many people, with nearly as good insurance, as there is now.

Atul Gawande, “there will be deaths.”

Sarah Kliff on why Republicans are supporting such unpopular legislation:

So why do Republicans keep persisting with their health care bill? I attended a breakfast with a Republican member of Congress this morning who gave a pretty frank answer. They are moving forward with Obamacare repeal because they believe their base will stick with them and that they don’t need to pay too much attention to the protesters, this member of Congress said. Here’s how this person thought about the recent barrage of calls his office has received:

The way I look at is there is no question we’re getting inundated with calls and emails and protests. There is all this energy and anger on the left. The people who lost are the ones who are angry. We won the entire elected government. So I remind my staff after a long day of hostile calls, it was less than six months we got more votes than a person on the other side in [my state]. The people who voted for me are still out there.

Jamelle Bouie tackles the same question.  Short version: because they can:

As a general matter, lawmakers don’t pass hugely unpopular legislation that might harm constituents in such a direct way. It’s easy to say that, for House and Senate Republicans, their “constituents” are those wealthy Americans who receive huge tax cuts under the bill. Still, it’s also true that winning donors isn’t the same as winning elections. Politicians don’t need to value the public interest to reject a bill like the AHCA; a survival instinct should be enough…

At most, it exists to fulfill a promise to “repeal Obamacare” and cut taxes.

Perhaps that’s enough to explain the zeal to pass the bill. Republicans made a promise, and there are forces within the party—from hyperideological lawmakers and conservative activists to right-wing media and Republican base voters—pushing them toward this conclusion. When coupled with the broad Republican hostility to downward redistribution and the similarly broad commitment to tax cuts, it makes sense that the GOP would continue to pursue this bill despite the likely consequences.

But ultimately it’s not clear the party believes it would face those consequences. The 2018 House map still favors Republicans, and the party is defending far fewer Senate seats than Democrats. Aggressively gerrymandered districts provide another layer of defense, as does voter suppression, and the avalanche of spending from outside groups. Americans might be hurt and outraged by the effects of the AHCA, but those barriers blunt the electoral impact.

The grounds for political combat seem to have changed as well. If recent special elections are any indication—where GOP candidates refused to comment on signature GOP policies—extreme polarization means Republicans can mobilize supporters without being forced to talk about or account for their actual actions. Identity, for many voters, matters more than their pocketbooks. Republicans simply need to signal their disdain—even hatred—for their opponents, political or otherwise. Why worry about the consequences of your policies when you can preclude defeat by changing the ground rules of elections, spending vast sums, and stoking cultural resentment? [emphasis mine]

Also, the Medicaid cuts are particularly wrong-headed and cruel.  More on those later.

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