Thursday, March 16, 2017

Are Republican Legislators Terrorists? Some Thoughts on Rumpcare

I’m being only half facetious with this question. Well, maybe not at all. As Bernie Sanders put it after the nonpartisan Congressional Budget Office revealed its analysis of Ryancare/Trumpcare (let’s maybe just call it Rumpcare), one result of this misbegotten excuse for a health-care plan, if passed, would be that “thousands will die.” Although Bernie was speaking off the cuff and doesn’t have a source for his claim, it certainly doesn’t take much imagination. Since the estimate is that 24 million Americans will lose health insurance in the next ten years if the Republican legislation is passed, and costs will keep many older working Americans from being able to afford insurance, the idea that thousands could die prematurely is hardly hyperbole.
So, when nineteen men, for perverted religious reasons, hijacked four commercial planes, crashed them into buildings, and killed 2,996 people, we called it terrorism. But what do we call it when a body of legislators, for perverted political reasons, rush to pass a horribly constructed law that could easily result in even more untimely deaths than the attack on 9/11? Do we even have a name for such silent, callous carnage? Maybe we ought to call it terrorism. It is certainly terrifying to those who will lose health insurance or be priced out of the market by purely partisan politicians who are more interested in giving tax breaks to billionaires than in preserving the health of the poor and the aging.

The ACA, a Republican Plan
So, why are we in this mess in the first place? For one reason and one reason only. The Republican Party chose to oppose health-care reform. Why? Well, that’s pretty much a head-scratcher. If the Democrats had done what they should have done, and what many of them wanted to do, they would have tried to join the rest of the civilized world and implement some sort of single-payer system. Country after country has shown us, in a variety of formats, that single-payer systems provide decent care for everyone at a lower cost than anything we’ve been able to come up with. But the Democrats let the moment pass and opted instead for a plan that was, essentially, a knock-off of Romneycare, which was based on conservative ideas, was implemented by a Republican governor of a blue state, and became his signature achievement (which he then had to repudiate when he ran for president because it was too similar to the accursed Obamacare). If the Republicans had been smart and had had the interests of the American people at heart, they would have seen this as a win, embraced it, and tried to help iron out the wrinkles. Instead, primarily because the ACA became attached to Obama’s name, they had to oppose it, since they had vowed at the outset to oppose everything Obama did. And so now they find themselves between a rock and, well, Trump. They have voted scores of times to repeal Obamacare. They have promised again and again that they would repeal the ACA. But that leaves them without a realistic alternative, except to move back in the direction of less coverage and higher costs—and then try to sell their creation as the best thing since sliced bread.

Three Basic Options
When it comes to health care, there are really three basic options: (1) a single-payer system that covers everyone; (2) a hybrid system like the ACA that keeps insurance companies in the loop, includes a mandate with penalties to keep young and healthy people in the pool, and offers subsidies so that the poor can afford to participate (with the subsidies being largely funded by taxes on the wealthy); and (3) a more market-oriented system, like what we had before the ACA, which leaves millions of people uninsured and relegates them to the most expensive sort of catastrophic care possible—the emergency room.
Since option 1 is a nonstarter for Republicans, they have only two other possibilities, but they have basically declared war on option 2 (which should be their option of preference). So in order to “repeal Obamacare” while providing some sort of acceptable replacement, they can move in only one direction, toward a market-oriented system. The only problem, as the CBO score indicates, is that the more you involve the market and restrict government participation, the more people end up losing out. There is a reason for this.

How Insurance Works
The market, if properly constrained, works wonderfully in some industries. Unfortunately, for a number of reasons, health care is not one of them. The market always creates winners and losers, and it doesn’t care what happens to the losers. This is fine if the market is jewelry or high-definition TVs. But in health care, the losers are the sick and the poor. Allowed market freedom, insurance companies would exclude the sick from their pool of customers. They exclude the poor simply by pricing their product so that the poor cannot afford it. It’s really just a numbers game. Insurers will charge as much as they can and stack the pool of participants so that they bring in a lot more money than they pay out. They will lower premiums for some customers, but only when they can also reduce their payouts by limiting coverage and increasing deductibles. They will charge the elderly more than younger customers because the elderly have worse health. The entire point is to make a profit. Profit-driven insurance companies are not really interested in who is covered and who is not. They are only interested in turning a profit. They do this by having more healthy customers who can afford their product than unhealthy customers who can’t.
And that is the problem. There are lots of unhealthy and poor people. And so we have to find a way of providing an acceptable level of health care to the unhealthy and the poor. We can’t do this without having the healthy and the wealthy pay for it. But Republicans, whose ideology is sometimes downright blind, just can’t stand for this. Literally, they would rather have people die than have the wealthy subsidize health care for the poor or the healthy subsidize the sick.
Stephen Colbert had a little fun with Paul Ryan’s description of the fatal flaw of Obamacare. In a clip of the House Speaker explaining this concept, we hear Ryan explaining, “The mandates are arrogant and paternalistic. . . . The whole idea of Obamacare is . . . the people who are healthy pay for the people who are sick.” Colbert then points out, “You’ve just described how insurance works.” Exactly. That is the whole notion of how insurance works. On average, the healthy pay for the sick, and the wealthy pay for the poor. The idea is to get enough healthy and wealthy people in the pool so that you have sufficient revenue to cover the care of the sick and subsidize the premiums of the poor. And if you take out the profit motive, then you just have to break even.
All civilized countries (notice I didn’t say “all other civilized countries”) have figured this out. They understand that the only way to provide decent health care for everyone at a reasonable cost is to create the largest pool possible (all rich and poor, all healthy and unhealthy in the country) and eliminate the profit motive. Many Democrats have also figured this out. No Republicans have. You think I’m being biased here? Well, name one then.

The “Freedom” Caucus
The so-called Freedom Caucus is convinced that if government is involved, freedom is removed or restricted. What they really should call themselves, though, is the Freedom for the Wealthy Caucus. It apparently hasn’t occurred to them that sometimes government involvement increases freedom. Without regulations on corporations regarding everything from pollution and truth in advertising to worker and product safety, American citizens would be far less free. By the same token, my friends in Germany consider themselves far more free in obtaining health care than many Americans. A nationalized system creates more options for care, and no one worries about going bankrupt over an unexpected medical emergency. That is a sort of freedom many Americans do not experience.
But the conservatives in Congress are opposed to Rumpcare not because it doesn’t cover enough people, but—believe it or not—because it covers too many. They want to go back to the system we had before the ACA, or worse. The CBO evaluation of Rumpcare indicates that within ten years, 24 million Americans would lose insurance coverage. That is more people than Obamacare added to the insurance rolls, so we would actually be worse off than before under Rumpcare. And what the Freedom Caucus wants is to have even fewer people covered. That is absolutely mind-boggling.

Spin, Spin, Spin
Once the CBO score was released, Republicans cranked up the spin machine. The Trump White House, consistent with what we’ve come to expect, tried to discredit the CBO, even though this is a nonpartisan institution led by an economist who was installed by George W. Bush. Paul Ryan didn’t discredit the CBO, but instead tried to put the best face on the report. He claimed that he was “encouraged” and that it exceeded his expectations, which left Fox News host Bret Baier stunned (yes, even Fox News couldn’t believe this reaction). Ryan’s contortionist act insisted that of course millions of Americans would lose their insurance. That’s because, since there is no mandate, they now have “choice,” and many will choose not to have insurance.
Like this is a good thing? Even if it were true? Of course it is only minimally true. Some younger people will choose to lose their insurance, but most of the losers here are either the poor who will be left out by the cuts to Medicaid or people my age who don’t have insurance through an employer and don’t earn enough to afford the higher premiums. But what about all those young, healthy people who choose to give up their insurance? Well, let me tell you a story.
On July 24, 2009, our family was at Lake Powell enjoying a nice vacation. Near Wahweap Marina is a narrow canyon that has filled up with blown sand. It can only be reached by boat. The sandhill is very steep and looks to be over 100 yards high. It is a hot and difficult climb, but when you reach the top, you can run down the hill and jump into the water at the bottom. On this particular trip, our oldest son, Matt, who was 23 at the time, ran down first and dove into the water. Somehow, when he hit the water, he turned straight down and hit his head on the compacted sand under the water. He was lucky he didn’t knock himself out. But when he came up out of the water, he knew something was wrong. When I reached the bottom of the hill, he walked over to me and said he’d done something to his neck. We carefully laid him down in the boat and took him back to our camp at Lone Rock Beach. From there, we moved him carefully into my truck, reclined the seat, and drove slowly up to the highway and then to the hospital in Page, Arizona, about ten miles away.
The physician’s assistant in the emergency room strapped Matt to a board to immobilize his head and did a CT scan. Because the PA was not permitted to interpret scans, he had to email them to a radiologist in Phoenix. But he did tell us he didn’t like what he saw. After the radiologist had weighed in, the PA showed us the scan. Even I could have interpreted what we saw. Matt’s C-1 vertebra had burst in four different places. To make a long story short, Matt and his mom got the $32,000 plane flight to the University of Utah Medical Center in Salt Lake. Our youngest son and I packed up and drove home as fast as we could.
The orthopedic surgeons put Matt in a halo brace, which he got to wear for the next twelve weeks. When the brace came off, they did another scan, and, lucky Matt, everything had healed right. Fortunately, he was still on my insurance, but the bills were rather impressive.
My point here, though, is that Matt was young and healthy, and if he had been on his own, he, like so many others in his age group, might have just foregone health insurance, considering it an unnecessary expense. And who would have paid for his bills. Well, you and I would have. I saw an estimate from before the ACA took effect showing that people with insurance averaged paying about $1,000 a year to cover those who did not have insurance. So, covering fewer people doesn’t really save us money in the long run.

Right or Privilege?
We sometimes still see the question raised, usually by Republicans, as to whether health care is a right or a privilege. They usually argue that it is a privilege. And this is how they justify denying health care to millions of Americans. But there really is no debate on this question. It was decided in 1986 when Congress passed the Emergency Medical and Treatment Labor Act, which forbids both public and private hospitals from denying indigent or uninsured patients care in an emergency. And just for the record, this act was passed by a Democratic House, a Republican Senate, and was signed into law by a Republican president. There is no debate. Health care is a right. Which raises the question of why we don’t do what almost all other countries do and just cover everyone in the most cost-effective and humane way.
But for some reason, Republicans still fight this notion tooth and nail. Instead of doing the civilized and sensible thing, they insist on making the indigent and uninsured obtain the most expensive care possible, which is not only expensive but usually late and less effective. The result is that a lot of people die who don’t need to. Which brings us back to the question asked in the title of this post. What word do we use to describe politicians who enact policies that cost thousands of American citizens their health and even their lives?

The Price of Shallow Ideology
In a March 6 New York Times column titled “A Party Not Ready to Govern,” Nobel Prize–winning economist Paul Krugman gets to the heart of mess that I’ve called Rumpcare. The problem, he says, isn’t just that we have a president who is “the least qualified individual, temperamentally or intellectually, ever installed in the White House.” The primary problem is that “the whole [Republican] party, it turns out, has been faking it for years. Its leaders’ rhetoric was empty; they have no idea how to turn their slogans into actual legislation, because they’ve never bothered to understand how anything important works.”
This reveals itself in their efforts to deregulate both Wall Street and corporate polluters, but especially in their opposition to and efforts to repeal the ACA. The Republicans threatened for seven years to “repeal and replace Obamacare.” But this was more political rhetoric aimed at scoring points at the polls than a realistic policy proposal. In seven years they came up with nothing workable. But now they have to come up with something, and the best they can do is Rumpcare, a piece of legislation that is feared by moderates, detested by conservatives, laughed at by Democrats, and opposed by nearly every significant medical interest group in the country.
How do we explain such a massive failure? According to Krugman, it is because many years ago, the GOP stopped dealing with the difficult intellectual work of understanding our complex modern society with its competing needs and demands. They settled for simple obstruction all through the Obama years. And they sold their intellectual souls for a cheap ideology that is easily encapsulated in bromides such as “return to the Constitution” (whatever that means), “reduce taxes” (no matter what), and “let the free market work its magic.” Their ideological devotion to the free market fails to understand how that market works best, why it needs to be constrained, and where it simply doesn’t work. One concept Republicans have shown no evidence of understanding is that a truly free market is unsustainable. Because it creates winners and losers, and the winners tend to absorb the losers and their market share, we eventually get monopolies. In other words, the free market, if left to its own devices, erodes the conditions in which a free market can exist. And this is just one of the many complexities modern society presents that are not easily solved by simplistic ideology.
Consequently, we have a governing party without a coherent plan for anything, particularly health care. As Krugman concluded, “Whatever the eventual outcome, what we’re witnessing is what happens when a party that gave up hard thinking in favor of empty sloganeering ends up in charge of actual policy. And it’s not a pretty sight.”

The Failure of Obamacare
One final point. For years, the Republicans have been claiming that Obamacare is a train wreck and that it is failing. I will be the first to admit that it is far from perfect. We would be far better served by any of several single-payer systems. But let’s get one thing straight. Obamacare was not failing. It was working particularly well in states that bought into it, such as California. It worked less well in states like Utah that sought to undermine it. And this has been the Republican strategy all along: undermine Obamacare without really having a realistic replacement. Perhaps the hope was that if they could cause Obamacare to fail, then we could return to the “system” we used to have, which was a mess.
Now, however, the Republicans are in a position to do very real damage to Obamacare. For starters, they can simply starve it, in which case it will die. And they are doing all they can to make it fail. In fact, this is Trump’s backup plan, in case Rumpcare doesn’t fly. Kill Obamacare and then blame it on the Democrats. Again, it’s all a political game. But this is a game the Republicans simply cannot win. If they kill Obamacare, the backlash will be severe. Many of those who voted for Trump believed his lie that he would give them health care that covered everyone and at a lower price. His support of Rumpcare has proved that, as with so many of his claims, this too was just another alternative fact. When millions of people who voted for Trump lose their health insurance, they will not be so forgiving. In fact, in this case, circumstances may ironically prove one of Trump’s statements true. It likely will be a “bloodbath” for Republicans in 2018. But not the bloodbath real terrorists expect.


  1. It is always possible for the Executive Branch to claim that they do not have the resources to enforce the law-- as President Obama did (correctly) with illegal immigration.

    Absent the Congress specifically allocating funds for enforcement, and directing the President to use said funds, this is within the President's discretion.

    President Trump has already ordered the Executive Branch to cease enforcement of the Affordable Care Act, with the expectation that it will soon be repealed. If the law is not enforced, then it has effectively ceased to exist, whether it has been repealed or not.

    When the insurance industry is convinced that they can, with impunity, issue or deny policies in a manner that would otherwise be inconsistent with the ACA, the law will be essentially dead.

    And with this self-fulfilling prophecy, Obamacare will have collapsed.

  2. Your premise that Healthcare is a right -- no debate about it (as usual from those with this misbegotten idea) -- perhaps you are unaware that Congress does not create rights. Rights are constitutional and not derived from government. Even if indigent care amounted to some form of entitlement right, the authority to define what constitutes indigency remains with Congress because Congress created the obligation on hospitals (not a general healthcare right).

    There is so much that is just nonsensical in your approach I am not sure where to begin. Let's begin here: after the ACA ruined my and the vast majority of those receiving insurance benefits plans even the Dems admit it must be overhauled to be viable. Give me a comparison of how folks will be without insurance, will lose coverage, will not be able to afford premiums if Obamacare remains the law compared to any plan taking its place. You see, once Obamacare collapses (as all agree it is on the precipice of doing) it will not save anyone's life or provide a real option for insurance to anyone. Already many markets have only one provider -- and soon at least 4 states will have none. That is what you think is a great plan? Only a blind ideologue would argue as you do.

  3. I also love your circular reasoning: Obamacare failed because the Republicans did not like it and tried to ruin it. Really? How does one deal with such damned if you do damned if you don't logic? No iObamacare failed because of the costs of adding 26 million people with extremely high-cost medical needs to the plans. It failed because anyone could just wait until they had an actual medical condition and then sign up for coverage (even considering the penalties that were levied for choosing not to buy). It failed because of sheer mathematics and the fact that Americans are not idiots to pay for something when they can just wait until they need it to sign up.

  4. A righteous rant, Terry. By and large, Republicans have cynically thrown sand in the gears at every opportunity.

    Blake just made a great case for a more robust individual mandate. Also, I'm not a lawyer, but Congress certainly does create legal rights. Examples aren't hard to find (e.g. labor rights).

    1. Jared: Well I am a lawyer and rights are things that cannot be abridged just by Congress changing a law -- and in this case Congress can certainly simply repeal the act recognizing a duty for indigent services. Remember that Government is not the source of rights in American legal theory.

    2. Government public relations documents often tell you what your 'rights' are under a particular law. Maybe those aren't actually rights as you are using the term, but I think in the average mind that's a semantic argument. Many people believe that in a prosperous civilized society, health care ought to be accessible and affordable to all, and that the government should help make it so. In that sense, common folks call it a right.

  5. Oops. Sorry to call you by your last name, Roger.

  6. All I will say in response is that it is difficult to argue with the results dozens of other countries are achieving with their health-care systems and our results. We are too exceptional to learn anything from any of these countries. And despite some problems, which all systems will have, I know of no other country that would want to try American-style health care.