What’s a little fraud among friends? Medicare, Medicaid fraud enforcement

There is a 31 year old Las Vegas, Nevada resident who recently pleaded guilty to two felony counts related to health care fraud. [LVSun] There were 100 prosecutable health care fraud cases in Nevada in 2012, that would be 100 too many.  The frauds come in a variety of manifestations: drug abuse, bogus claims, over-billing, identity theft, and staged “accidents and injuries.”  Some felony-minded souls appear to believe that a little fraud is allowable in order to reap a bit of reward from the burgeoning coffers of the health insurance corporations.  It isn’t.  The situation becomes unconscionable when Medicare and Medicaid are the targets of the fraudulent activities.

Last year saw some particularly egregious cases, such as the following:  “federal authorities announced on May 2 they had arrested 107 health care providers, including doctors and nurses, in several cities and charged them with cheating Medicare out of $452 million.”  [Forbes]

Speaking of Medicaid, in  April 2012 an Inspector General’s report for FY 2011 informed us:

In fiscal year 2011, MFCUs conducted 10,685 Medicaid fraud investigations and saw 824 convictions. MFCUs conducted 4,134 investigations into patient abuse and neglect, including patient funds cases, and saw 406 convictions. [FHC] *MFCU: Medicaid Fraud Control Units

The top five states for Medicaid fraud prosecutions were: California, Texas, New York, Ohio, and Kentucky.  [IG2012]  The report on Medicare wasn’t any more comforting:

Federal officials set up the Medicare Fraud Strike Force in 2007, which visited at random nearly 1,600 businesses in Miami, ground zero for Medicare fraud, that had billed Medicare for durable medical equipment.  Officials found that nearly a third of the businesses, 481, didn’t even exist, yet they had billed Medicare for $237 million over the previous year, according to National Public Radio. [Forbes]

Medicare and Medicaid aren’t functions of those ravenous profit centers otherwise known as the health care insurance corporations, thus even the dubious rationalization doesn’t apply.  That hasn’t stopped the fraudsters:

“Since their inception in March 2007, Medicare Fraud Strike Force operations in seven districts have obtained indictments of more than 825 individuals who collectively have falsely billed the Medicare program for more than $2 billion .  In addition, the HHS Centers for Medicare and Medicaid Services, working in conjunction with the HHS-OIG, are taking steps to increase accountability and decrease the presence of fraudulent providers.”  [DoJ]

That’s the bad news, there is some good news to report on the subject of Medicare fraud:

“The Obama Administration has made important strides in reducing fraud, waste, and abuse across the government. Over the last two years, the Centers for Medicare & Medicaid Services (CMS) has implemented powerful new anti-fraud tools and designed and implemented large-scale, innovative improvements to our Medicare program integrity strategy to shift beyond a “pay and chase” approach to preventing fraud before it happens. CMS is also collaborating more with the private sector, law enforcement, and our state partners to harness best practices in our fight against health care fraud.

These efforts are paying off. In FY 2012, the government recovered a historic $4.2 billion and has returned a record-breaking $14.9 billion dollars to taxpayers between 2009 and 2012, up from $6.7 billion dollars over the prior four years.”  [DHHS]

We could happily note the improvement in Medicare fraud enforcement efforts and the returns that accrue to American taxpayers, BUT the House Republicans — in the “interest” of saving taxpayer dollars (and not raising taxes on millionaires and billionaires) — offer their “serious” budget proposal which transforms Medicare into a voucher/coupon program in which the Every Man For Himself policy extends into the health care insurance domain.

What could possible go wrong? Let us count the ways.  (1) Nothing in the GOP or Ryan Plan puts the brakes on the increases in health care costs — only in the individual’s remuneration for health care insurance costs.  There is no inducement in this proposal to reduce either the costs or the urge to game the system because of the mounting out of pocket costs.  (2) It is assumed that if Medicare as we know it is mutated into a privatized system that the fraud enforcement costs will be reduced at the federal level, which totally ignores the expenses incurred at the state levels wherein much of the anti-fraud activities take place.  (3) We cannot assume that the expenses involved in prosecuting national cases of interstate health care insurance fraud will be magically disappear by merely transferring the locus of funding — the Department of Justice might still exercise its authority to prosecute such cases — of course at public expense for the benefit of the health care insurance industry.

What we should be considering, in our own economic self interest, is the enhancement of funding for Medicaid Fraud Control Units, and the efforts to increase the effectiveness of the Health Care Fraud Prevention and Enforcement Action Team (HEAT), a joint project of the Department of Health and Human Services and the Department of Justice.

Bait and Switch Political Economy

So, why are we really stuck in the Silli-quester?  The one option that was supposed to be so distinctly unpleasant and irrational that both major political parties would eschew any connection to it and thereby be inclined to adopt compromise measures?  Bait and Switch.

Why are the punditocracy chattering on about how both sides should exercise some political rationality (if that isn’t an oxymoron) and move to the discussion about serious economic needs, such as job creation (without all the inanity of trickle down hoax-isms) and debt stabilization?  Bait and Switch. Why Bait and Switch?

Beneath all the chatter are some very different world views, political ideologies, and priorities.  In an ideal world there would be less reason to discuss who is to blame for the economic mess in which we find ourselves, and more reason to sit down and talk about how we (1) encourage economic growth and (2) stabilize our indebtedness.  This obviously isn’t a perfect world.

It’s going to take some good old fashioned rational discussion in a FACT based universe to get out of this muddle.  The facts are unpleasant on both sides of the polarized political flanks, but they do need to be the main topics of conversation before we can get out of the Bait and Switch model.

The Bait

This is all about stabilizing the national debt.  Yes, and no.  Those who are truly of sound mind and reasonable thinking recognize two things: (a) We have a situation in which health care costs are driving up federal expenditures just as they are taking a larger chuck out of family finances; and (b) our tax laws need some reform — real reform — not merely another excuse to reduce taxes on the economic elite who are more inclined to indulge in speculation than in the less profitable but more productive investment in industrial and commercial development.   The third fact of life is that we engaged in not one, but two wars, an activity designed to suck the sustenance out of any consumer based economy.

The Switch

This is all about the national debt.  Is it? Or, is it cover for indulging in the enaction of Austerity economics which calls for the reduction of government spending without increasing government revenue?  Consider the vehement opposition of the Tea Party caucus of the House GOP to any suggestion that we need to enhance revenue to reduce and stabilize the national indebtedness.  If this group were truly speaking to the unsustainability of our current debt trajectory then revenue increases would be a logical portion of the debate.  However, it’s not.  The debt level becomes the bait, and the unwillingness to even consider revenue increases signals that their real object is what it has always been — an adherence to the mythology that government (even a government trying to serve the needs of 330 million people) is Too Big and needs to be restricted.  As usual, Robert Reich has summarized the problem succinctly:

“Tea Party Republicans are crowing about the “sequestration” cuts beginning today (Friday). “This will be the first significant tea party victory in that we got what we set out to do in changing Washington,” says Rep. Tim Huelskamp (Kan.), a Tea Partier who was first elected in 2010.

Sequestration is only the start. What they set out to do was not simply change Washington but eviscerate the U.S. government — “drown it in the bathtub,” in the words of their guru Grover Norquist – slashing Social Security and Medicare, ending worker protections we’ve had since the 1930s, eroding civil rights and voting rights, terminating programs that have helped the poor for generations, and making it impossible for the government to invest in our future.”

These are the people who took President Ronald Reagan’s message to heart, “The government is the problem,” and then took the philosophy further than that former President ever considered.  The radical right wing of the Republican Party has created an environment in which even the Speaker of the House can’t get legislation to the floor, or must break his own “Hastert Rule” to get anything passed.  There may be a core of rational Republican members of Congress who might give thought to compromising and indulge in some serious discussions about government spending, taxation, and infrastructure investment — BUT each one of them sits beneath the Damocletian Sword of a primary challenge from some candidate even more conservative than themselves.

Real Problems Should Have Realistic Solutions

While it would be nice to assume that social safety net programs such as Medicare and Medicaid are sustainable in the present context, that really isn’t a reasonable conclusion.  Recognition of the problems associated with maintaining an acceptable level of service to Medicare beneficiaries is essential.

The solution presented by Rep. Paul Ryan to privatize the Medicare system and transform it into a coupon-care or voucher program doesn’t solve the problems any more than calling for the program to continue without further improvements.   The real problem is the rising cost of health care delivery, and until we can address how to reduce the costs increases the programs for health care assistance will be financially unsustainable.

Those who have not yet read Steven Brill’s excellent piece in Time magazine should do so immediately.   Here’s an essential part of the reporting:

“When you look behind the bills that Sean Recchi and other patients receive, you see nothing rational — no rhyme or reason — about the costs they faced in a marketplace they enter through no choice of their own. The only constant is the sticker shock for the patients who are asked to pay.  Yet those who work in the health care industry and those who argue over health care policy seem inured to the shock. When we debate health care policy, we seem to jump right to the issue of who should pay the bills, blowing past what should be the first question: Why exactly are the bills so high?”

Nailed It!  And Brill goes on to explain or describe the basic issues involved, such as the inflated prices for common products, the perverse economics of medical technology, bills to match the catastrophic nature of the illness or injury, and the handcuffs on Medicare.

Tea Party Caucus radicals would have us believe there is no middle ground between transforming the Medicare program into a privatized voucher system and turning Medicaid into a parsimoniously funded block grant program and Socialized Medicine.  This is not the case.  It’s certainly not the case when we examine what happens in the health care market, when “insurance isn’t insurance” and chargemasters determine “opening bids” for costs.  Health care cost containment is the essential issue — we should be asking, as Brill suggests, not who should pay, but how much should be paid — by anyone, public or personal.

The Affordable Care Act has some features which will reduce the costs of medical services and treatment, but it is not the answer to the dilemma of how to fix a “broken market.”  Ideological squabbling over Repeal or Not To Repeal is a waste of time, and of time which would be better spent trying to solve the Gordian Knot of health care cost containment.

There are two things, often suggested, and in the past often done, which would alleviate some of the problems associated with Medicare and Medicaid funding. First, we could allow the Department of Health and Human Services to negotiate prices for prescription medication. Secondly, we could get serious about regulating and rationalizing the pricing structures of hospital and medical services.

The inclusion of Social Security “reform” in the Silli-quester debate is informative,  since the program is self funding and doesn’t add to the national level of indebtedness, the only reason for incorporating it into the “entitlement” discussion is to cut it — as radical right wing adversaries have wanted to do since it was enacted during the Depression.  We could, for example increase the liability cap above the current $113,700 in income for the Social Security program. There’s a boatload of difference in the financial resources of a family with an annual income of $1,113,700 and a family with annual resources of $113,700.  Surely those in the upper 0.1% of the income pyramid could afford to pay in a bit more?

The use of the Chained CPI isn’t a popular suggestion, but the chains may not be shackles.

“While no one knows what a full elderly CPI will show, we do know that switching the COLA to a chained CPI will reduce lifetime Social Security benefits by an average of about 3 percent. This doesn’t raise a huge amount of money, but it would be a big hit to seniors, 70 percent of whom rely on Social Security for more than half of their income.” [CEPR]

The problem, of course, is that elderly people don’t purchase items that show up in the inflation calculations (cars, electronics, etc.) as often as younger people; but, they do spend on housing and health care. (See health care cost containment above).   There is nothing essentially wrong with discussing the Chained CPI if it can be done reasonably.  For example, could the index be adjusted to account for the variance in inflation associated with the consumption patterns of elderly individuals?  Or, if we can achieve some kind of stable economic growth would the reductions in benefits associated with the Chained CPI be mitigated?  Bellowing, “Social Security is a Ponzi Scheme,” or “There won’t be anything left for Junior,” isn’t the way to start a discussion about these details any more than the absolute “Don’t Touch Social Security“  in any way, shape or form is on the other hand.   Note that both the Medicare and the Social Security inflation adjustment issues are related to the bug-bear of health care cost containment?

It’s not just our population that’s aging. So are our bridges, highways, parks, and other public facilities.  We have aging public building that could lower their utility costs with upgrading, and we have aging public structures which should be replaced.   And, then there are schools:

About one-fourth (28 percent) of all public schools were built before 1950, and 45 percent of all public schools were built between 1950 and 1969 (table 1).Seventeen percent of public schools were built between 1970 and 1984, and 10 percent were built after 1985. The increase in the construction of schools between 1950 and 1969 corresponds to the years during which the Baby Boom generation was going to school. [NCES]

Not to put too fine a point on it, but after 60 years most school buildings need so much renovation that they aren’t functional and most are abandoned.

Since we probably can’t build everything at once, how about focusing on roads and bridges?  Various suggestions have been made concerning upgrading American infrastructure, and if we want to have a serious discussion about this topic we might begin with the obvious — crumbling roads and bridges.  Why not allow the U.S. Treasury to issue some long term bonds (30 year) expressly for the purpose of addressing transportation infrastructure needs?  This could be a win-win proposition.  The bondholders have a safe haven investment which is interest earning, the public gets better roads and bridges, and if we must have a “pay for” element we could consider increasing fees or use taxes by a minimal amount, again expressly for the purpose of paying off the bondholders.

These kinds of suggestions deserve more attention than they are getting, but they will not get serious consideration until ideologues stop screeching “the government can’t create jobs,” or “we can’t increase taxes any taxes any time,” as the bridge slowly crumbles beneath us.   The bond issuance idea deserves a serious moment — the public assets values increase, the bonds earn interest for the investors, and everyone’s safer.   Little wonder then that the AFL-CIO and the U.S. Chamber of Commerce are both supportive of infrastructure investment.   Short term, the construction sector of the economy gets a boost; long term the investors and the public benefit from the proposal.

Taxing Issues

We do need tax reform.  What we don’t need is one more scheme to shift the burden of financing government from the economic elites to working men and women in America.  Yes, that would be the old Flat Tax canard.   In case Speaker of the House Rep. John Boehner would like to find the President’s plan for revenue and budget stability it’s located in plain sight right here.  The proposal includes one tax reform that should be given some attention.

The President proposes that itemized deductions be limited to 28% for wealthy individuals.   What should be on the table in addition to this suggestion is the variance in the way we tax earnings.  As former FDIC Chr. Sheila Bair has noted, “Why does a hedge fund manager pay lower tax rates than a shoe store manager?“  Good question. Additionally, no one has yet put forth a credible argument (complete with some hard data) to sustain the idea that the investors are really “job creators,” but factory and office  managers definitely are those making staffing and hiring decisions.   We might also give some time to the issue of allowing corporations to indefinitely defer taxes on profits made overseas.

Republicans in the 2012 campaign season often spoke of closing loopholes, however vaguely those were described.  Let’s get specific.  Why are there loopholes for corporate jets? For yachts?  For highly profitable oil corporations?   Both sides of the aisle might want to talk about the possibility that if a sufficient number of these loopholes were closed then perhaps the overall rates could be reduced?

In short, if we are truly looking toward stabilizing our national debt, as opposed to merely trying to drown our government in a bath tub,  there are rational ways to do it — but in order to accomplish that we need to have some rational discussions about the route we choose.  Bait and Switch is never a good starting point, but abatement in the hyperbole and switching to a more reasonable level of civic discourse would be an excellent place to begin.

Playing Percentages With Grandma? Romney-Ryan Medicaid Budget Cuts in NV

The median annual household income in Nevada is $55,726. [Census]  The total population estimate for 2011 is 2,723,322 and of these approximately 12.5% are over 65 years of age.  Some simple arithmetic shows that about 340,415 Nevadans are over 65 years old.   So what?

The question is important because some of these individuals will need home care services to deal with infirmities, some will need assisted living to remain independent, and others will require institutional care, aka nursing facilities.

As we can see from the Kaiser Family Foundation graph above,  more Medicaid resources have been allocated for home and community based care since 1995.  Long term care, which prior to 1995 meant institutional care for the most part, is now 43% home/community based health care services.   The issue now becomes do we want to fund the Medicaid program at a level which will allow more low income  Nevada residents over the age of 65 to remain at home, or do we cut program services such that we cope with only the most medically fragile?

The family issue, for that household earning the $55,726 annually, is how to provide care for an elderly relative who requires medical assistance beyond the financial capacity of the family to provide but who doesn’t need institutional care?  There is no answer to this inquiry from the Romney/Ryan budget.

In fact, if as Senator Heller and some of his colleagues recommend,  we repeal the Affordable Care Act (Obamacare) and do what the Republican ticket suggests — transform the Medicaid program into a block grant scheme — we cut approximately 38% from Medicaid services. [KFF pdf]  If we drill down into state by state statistics, if Obamacare were repealed and the Ryan Budget was adopted our Medicaid program in Nevada stands to lose about 44% of its funding. [KFF pdf]

No one would (or should) be so callous as to suggest we slash funding for those with the most serious medical needs, especially those who need nursing facility care.  However, if we’re looking down the line at a 44% reduction in Medicaid funding for state services then the obvious cuts would come “at the margins.”

Who’s marginal?  Are low income single mothers with two dependent children under the age of 6 marginal?  Are low income elderly persons who can still function — albeit barely –  independently marginal?

The Medicaid program in Nevada* is an insurance program which pays servicers to perform some or all of the following tasks:

-Adult Day Care
-Assistance Shopping for Essentials
-Caregiver Respite
-Case Management
-Companion Care
-Homemaker
-Housekeeping
-Laundry
-Meal Preparation
-Personal Care
-Personal Emergency Response System (PERS)

* In order to qualify for the Nevada Home and Community Based Waiver as of 2012, the applicant’s monthly income must be less than $2,094.  Their countable assets must be valued at less than $2,000.

Now, how many families can afford privately financed adult day care, companion care, housekeeping help, meal preparation, personal care, and shopping assistance? On $55,726 a year?  On an income of approximately $2,000 per month?

The obvious conclusion is that perhaps the Republicans are advocating for Crowded Housing?  If they bemoan the fact that recent college graduates are staying home with parents in a tight economy, think how much more familial the entire living situation becomes when the grandparents — or Uncle Festus or Aunt Minerva — move in?  Especially when the elderly relatives are simply in need of the kinds of home or community based services likely to be declared marginal in cost cutting binges?

While this might all sound a little facetious, the fact is that most houses in the U.S. ( some 67%) have two or three bedrooms. [Census] Every parent’s dream for when the offspring depart, be it the new guest room, the man cave, the sewing room — whatever — fails when a no long total independent older relative needs a safe place to live.

A modicum of concern for middle income families who are struggling to maintain their standard of living might be in order.   If we can assist middle income families with the costs associated with the care of a low income elderly relative; if we can chip in a bit so that a low income  elderly person can remain independent as long as possible — then why is is necessary to cut 44% of the Medicaid program in Nevada so that millionaires and billionaires won’t have to revert to paying the income taxes they were paying back in the Clinton years –  39.6%.  (They are current paying 35%.   All this for 4.6%. )

Let’s guess that the hedge fund managers and Wall Street wizards won’t be decimated by a 4.6% tax increase, but a 44% reduction in Medicaid funding in Nevada will have a profound effect on the other 99.99%.

Romney’s Pig in A Poke Tax Plan: Robin Hood In Reverse

Let’s be blunt and tactless about this — the numbers don’t add up. They have never added up. They never will add up.   We could be having a very honest debate about whether or not to privatize Social Security, or whether to transform Medicare into a voucher/coupon program in which Seniors would revert to buying their own private health insurance plans.  But, we won’t.  We could be having a discussion about spending for education, for nutrition programs, for veterans health care … but we probably won’t.  Let’s take a look at a handful of specifics.

Social Security

The Romney campaign won’t say “let’s privatize Social Security.”  Instead, he’s offering a plan which: “Would increase Social Security’s eligibility age by one month per year beginning in 2022 and index future program eligibility to life expectancy. He also wants to slow the rate of benefit growth for high-income recipients.”  [KCStar]

Who is living longer? The “people are living longer” theme is catchy.  However, it’s not a universal trend.  For example, we’ve known since 2006 that the life expectancy of most Americans is 77.9 years, but the life expectancy of a low income white person in Appalachia and Mississippi is 75 years.  For African-Americans in middle America the life expectancy is 72.9 years, however for African-Americans in high risk urban areas the life expectancy is 71.1 years.  Unfortunately, for Native Americans in South Dakota the life expectancy was reported at 58 years.  [DNCentral]   The trends are holding; a white male has a current life expectancy of 75.9 years, an African-American male 74.3 years. A white female can expect to live 82.4 years, but a black female can only expect 79.2 years.  [Census pdf] Thus, for white people in the U.S. the increasing longevity rate would tend to support raising the tables — however, for non-white citizens the numbers aren’t that congenial.

Then there’s the slow the rate of benefit growth for high-income recipients part — that’s a polite way to say means testing.   The AARP explains its opposition:

“The notion that the benefits are an earned right separates Social Security from means-tested income-support programs. Social Security can help everyone. Means testing is a feature of taxpayer-funded welfare programs designed to help the poor. A means test would inevitably erode the universal and contributory nature of Social Security and some of the popular support that has sustained it for nearly 75 years.”

Imposing new limits for the well-off could backfire in various ways. A means test could adversely affect retirement planning and lower the personal savings rate if people concluded the program would penalize them for having higher retirement incomes or larger nest eggs. It would discourage older persons from continuing to work beyond eligibility age, depriving them—and the economy—of additional money. It would create incentives for people to take lump-sum distributions from pension plans, strategies that could prove shortsighted and harmful.”

That just about sums it up.

Medicare

There’s nothing harder to analyze than a moving target.  If the Romney Campaign is incorporating “savings” into its tax formulation by assuming reductions in Medicare costs — good luck with that.  The campaign appears to have settled — for the moment — on the revisions made to the Ryan Plan for FY 2013.   However, the campaign hasn’t released the details necessary to make a thorough examination of the impact of the plan.  [Politifact]

“…there are two big differences between the new plan and the earliest one: The newer version allows beneficiaries under 55 a choice of using their payment to buy private insurance or a plan that acts like traditional Medicare. The amount of their payment would be set by the price of the second-cheapest plan.”  [Politifact]

Acts like traditional Medicare?  What is that?  Medicare Advantage?  Are Medicare Advantage really more cost effective — or do the plans tend to attract healthier (and wealthier) participants, and to avoid costs included in traditional Medicare such as supplemental payments to hospitals which take Medicare patients?  This is one topic in which numbers and terms are often massaged to present the ideology in the best possible light.  Enter the Free Market Fairy.

“Aides to the GOP candidate say the plan would rely on competition — without caps or a cost-cutting board — to control spending and avoid cost shifts to seniors.”  [ABC]

IF competition were the magic answer to cost savings in medical programs for the elderly — then why doesn’t the Medicare Advantage program (the free market alternative to traditional Medicare) eschew the federal subsidy paid to insurance corporations to offer health care insurance to elderly people?  IF the Free Market Fairy could dust our landscape with health care insurance at lower cost than the traditional Medicare, why have any subsidy at all?

However, when the Affordable Care Act (Obamacare) sought to reduce the subsidies to the Medicare Advantage offering corporations, Republicans squealed about “cutting Medicare” to every elderly audience who would listen.

Medicaid

The cuts to Medicaid are far more profound than those for Medicare.   The Romney/Ryan plan could slash $1.4 billion over the next ten years — a cut of approximately 34%.  [Philly.com]   The discretionary spending cuts in total would look like this:

The CBPP explains:

“Medicaid and the Children’s Health Insurance Program (CHIP) would face cumulative cuts of $1.5 trillion through 2022 if Medicare is subject to cuts and $1.9 trillion if Medicare is exempt.  Repealing health reform’s coverage expansions, as Governor Romney has proposed, would reduce Medicaid spending by $618 billion over the next ten years and account for 30 to 40 percent of the reductions.  Repealing health reform by itself would leave uninsured 30 million people who would have gained coverage under health reform, according to CBO.  Analysis by the Urban Institute suggests that the additional Medicaid cuts would likely add at least 14 million to 19 million more people to the ranks of the uninsured.”

Medicaid now provides health care coverage for approximately 52 million Americans.  Over 13 million of these are individuals who are elderly or disabled.  It pays about half of all nursing home expenses, about 60% of nursing home residents are covered by Medicaid. 26% of Medicaid spending is for services to the elderly, 43% is for low income disabled persons, 12% is for low income adults, and 19% is spent for low income children.  [Kaiser pdf]  Now, which of these categories do we want to cut? Do we want to cut pre-natal care for low income women?  Cut funds for the care of the elderly in nursing homes?  Cut funding for the care of the disabled?

This is the program confidently cited by Governor Romney as the “safety net” for low income Americans this week:

ROMNEY: Actually, we had health care in America before Obamacare came along. And we still have health care in America…Each of us today in America has a choice of the type of health care plan we might choose. People who are poor are able to get Medicaid, which is a government support effort for those who can’t afford to have insurance. And these things aren’t going to disappear without Obamacare. [emphasis in original] [TP]

Really?  There’s that 47% again?  With the discretionary spending cuts illustrated the little graph from CBPP what chance do we have to maintain program services for Medicaid?  How do we accomplish this by cutting $1.4 billion, or 34%, over the next ten years.

SNAP

Thus much for being a Food Stamp President, actually the number of people enrolled in the SNAP program has declined since the Recession ended.

This hasn’t stopped the Romney Campaign from suggesting that the way to preserve the income of the top 0.1% is to reduce the SNAP program further  by $135 billion, or 17% in the next decade.   Note that when the economy is growing, as it is now, the SNAP spending is reduced:

The CBPP has done an extensive analysis of what the Ryan Budget proposal would do to, not for, 99% of the American people.   Governor Romney’s rhetorical flourishes about wanting prosperity for 100% notwithstanding, the budget and tax plans he is advocating knock the props out from under families with an elderly relative in a rest home, children of a family with one or more wage earners unemployed at the moment, elderly Americans seeking basic cancer screenings, middle class families trying to keep their offspring in college.  Unemployed Americans seeking job training to upgrade their skills and employability.  Or, veterans’ health care services. [CBPP]

And all this to protect the incomes of the top 0.1% of American income earners…

 

Sunday Stroll: Ladies Day

Elections have consequences.  There could be significant consequences for the Medicaid program in Nevada depending on the outcome of the 2012 election.  Here are two, improved graphics from yesterday’s post illustrating who is served by the Nevada Medicaid program — and who will be impacted by proposals from the GOP (Ryan Budget) to transform Medicaid into a block grant program, and to cut funding by approximately one-third.

The question becomes — where will we cut? From the 58% of the program which serves children?  If we cut all funding from adults, that would save only 19% and we should remember that 150,200 of the people served are adult females, some of whom are pregnant receiving pre-natal care.

Speaking of women:  Planned Parenthood Federation of America informs us there were 133,246 uninsured women in Nevada as of 2008-2009.  Thanks to the Affordable Care Act (Obamacare) 66,623 are likely to qualify for Medicaid in 2014, and  55,963 are likely to qualify for premium credits in the health insurance exchanges.

Laying aside the Republican hyperbolic hysterical generalities about Socialism, Non-existent Death Panels, and Killing Grannies — the Affordable Care Act has some definite benefits for women, which ought to be considered before voting in favor of a candidate who wants to repeal it:

#1. Preventative and wellness visits to a physician — coverage must include screenings for breast and cervical cancer.  #2. Coverage for gestational diabetes screening. #3. HPV-DNA testing for high-risk human papillomavirus (HPV) DNA testing every three years, regardless of Pap smear results. Early screening, detection and treatment have been shown to help reduce the prevalence of cervical cancer. #4. STI counseling and HIV testing.  #5. Contraceptive and contraceptive counseling — and no the government isn’t paying for this, and employers aren’t paying for this — the insurance has to cover it.  #6. Breast feeding support, supplies, and education.  #7. Domestic violence screening and counseling services.  [Time]  And, by the way — health insurance corporations may no longer charge women more for an insurance policy just because they are — you know — female.

Women on the Reservation:  While the Republican controlled House of Representatives stews about expanding efforts to extend protection for Native American women under the provisions of the Violence Against Women Act, [The Hill] there’s still a major domestic violence problem on Reservations.   If one applied the GOP logic to the situation: “Suppose your sister was with you in Washington, DC, and her husband beat her up,” Moore says, “but because he was from Virginia, Washington couldn’t do anything about it.” [MJM]

There’s a little bit of help on the horizon from the Obama Administration’s Department of Justice.  Help for at least four tribes.

“Through this special initiative, OVW will support salary, travel and training costs of four tribal SAUSAs, who will work in collaboration with the U.S. Attorneys Offices in the Districts of Nebraska, New Mexico, Montana, North Dakota and South Dakota.  Specifically, OVW will award cooperative agreements to four federally recognized tribes to select qualified applicants in cooperation with the U.S. Attorney Offices to serve as cross-designated prosecutors.  These prosecutors will maintain an active violence against women crimes caseload, in tribal and/or federal court, while also helping to promote higher quality investigations, improved training and better inter-governmental communication.”

The ladies on the following Reservations will be a bit safer — Pueblo of Laguna in New Mexico,  Fort Belknap Tribe in Montana, Winnebago Tribe in Nebraska, Standing Rock Sioux Tribe, in North Dakota and South Dakota. Or, the House Republican leadership could stop hiding behind technicalities and vacation days and pass the re-authorization of the Violence Against Women Act.

Twenty Three Cents Worth:   Lily Ledbetter (video) spoke to the disparity of pay in too many American workplaces, 23 cents worth on average.  Let’s play with the calculator — the median expected salary for an entry level accountant in this country is $44,456 dollars per year.   [Salary.com] If a husband and wife were both entry level accountants, and the pay was equal, their combined earnings would be $88,912.   However, if her salary is only 77% of her husband’s she earns about $34,231.  Their combined earnings are reduced to $78,687.12.   Wonder what they could have done with $9,000?  Wonder what the local economy could have done if family earnings were what they should be?  Do the arithmetic.

Republican YOYO Home Economics: Medicaid Slashed, Other Support Burned

Former President Clinton advised the delegates to the 2012 Democratic Convention to listen carefully to what the Republicans were offering in regard to Medicaid, and those of us in Nevada should be “listening with both ears.”  Here’s the description of the Medicaid program as stated by the Nevada Department of Health and Human Services, the program:

“Provides health care coverage for many people including low income families with children whose family income is at or below 133% percent of poverty, Supplemental Security Income (SSI) recipients, certain Medicare beneficiaries, and recipients of adoption assistance, foster care and some children aging out of foster care. The DHCFP also operates five Home or Community-Based Services waivers offered to certain persons throughout the state. The Division of Welfare and Supportive Services (DWSS) determines eligibility for the Medicaid program.”

Listing those categories focuses on the aims of the program — it is to serve (1) low income families with children; (2) elderly Nevadans; (3) low income Nevadans over 65 years of age; (4) families receiving assistance for adopted children; (5) children in foster care.  Who was enrolled in Nevada’s Medicaid program as of fiscal year 2009:

What services were provided to those enrolled in Nevada’s Medicaid program?

During fiscal year 2010, 68.1% of the spending from the Medicaid program went for acute care, 25.6% was allocated for long term care, and 6.3% was used for “disproportionate care – hospital payments.”

The spending for long term care breaks down as illustrated in the following chart:

11.1% of the long term care funding was allocated to facilities for the intellectually disabled, 2.9% went to services for the mentally ill — and notice – 86% was used to provide home health & personal care, and nursing facility care.  In other words, 86% of Nevada’s Medicaid expenses for long term care went toward serving those least able to care for themselves.  The other 14% was used to provide intermediate and long term care for those unable to care for themselves because of intellectual limits or mental illness.

Here is exactly why President Clinton told his audience to “listen up:”

My view is get the federal government out of Medicaid, get it out of health care. Return it to the states.” – Romney, South Carolina GOP Primary Debate, Jan. 20, 2012.

In case anyone is remotely confused about what that statement from the former Massachusetts Governor means, he’s speaking about transforming the Medicaid program into Block Grants.

More specifically, the former Governor is adopting the block grant proposal for Medicaid set forth in his running mate’s “Path to Prosperity” budget plan:

“The plan also would repeal health system reform law provisions that will expand Medicaid coverage starting in 2014. Instead, states would receive block grants, which would free states “to tailor their Medicaid programs to the unique needs of their own populations,” the budget says.”  [AMA]

The tailoring is to be done with less cloth:

The Ryan budget would cut $2.4 trillion from Medicaid and other health programs. Reduced spending would increase the number of uninsured dramatically, Park* said. “Those who retain coverage will have benefits scaled back and have higher cost-sharing.” [AMA] (emphasis added)

We can drill down further into what Governor Romney and Representative Ryan have in mind for the Medicaid program by looking at the Congressional Budget Office’s analysis of the Ryan position:  Medicaid and the Children’s Health Insurance Program (CHIP)—from 2 percent of GDP in 2011 to 1¼ percent in 2030 and 1 percent in 2050.

Now is the moment to recall that 58% of those who receive Medicaid assistance for their health care needs in Nevada are children, and the AAP isn’t thrilled at cuts to that constituency:

“American Academy of Pediatrics President Robert W. Block, MD, said the proposal would undo investments in health programs for children. More than half of Medicaid recipients are children, but their care accounts for up to only one-quarter of the program’s costs.

“Whether considering fiscal year 2013 federal spending bills or reviewing long-term budget proposals, Congress must seize this opportunity to invest in the future of our country by protecting children’s health,” Dr. Block said.” [AMA]

Dr. Block has reason to be concerned, if we return to the Congressional Budget Office’s analysis we can see why.  In two paragraphs from their analysis of the Ryan “Path” the non-partisan office explains why the proposal would make deep cuts, and place greater burdens on the states:

“The specified path (Ryan Plan) would cause federal spending on Medicaid and CHIP to decline relative to GDP in coming decades, rather than to rise sharply as in the other policy scenarios that CBO has analyzed, and would include no exchange subsidies (see Figure 3). As a result, by 2050, such spending would be 76 percent below what would occur for Medicaid, CHIP, and exchange subsidies under the baseline scenario and 78 percent below what would occur under the alternative fiscal scenario. Because spending on CHIP and exchange subsidies represents a relatively small share of the amounts in the baseline and alternative fiscal scenarios, most of the reduction would have to come from the Medicaid program.” [CBO] (emphasis added)

The Republicans do, indeed seem serious about eliminating Medicaid as a federal program and shifting the expenses for health care access to low income elderly, the disabled, the intellectually disabled, elders in nursing facilities, and children in poverty to the states.  The CBO explains the nature of this shift:

The responses of the states would be of particular importance. If states were given additional flexibility to allocate federal funds for Medicaid and CHIP according to their own priorities, they might be able to improve the efficiency of those programs in delivering health care to low-income populations. Nevertheless, even with significant efficiency gains, the magnitude of the reduction in spending relative to such spending in the other scenarios means that states would need to increase their spending on these programs, make considerable cutbacks in them, or both. Cutbacks might involve reduced eligibility for Medicaid and CHIP, coverage of fewer services, lower payments to providers, or increased cost-sharing by beneficiaries—all of which would reduce access to care. (emphasis added)

Translation: Even if the states were able to achieve all the vaunted efficiencies a “flexible” plan might provide — the cuts proposed are so deep and so drastic that citizens in the United States who are lower income elderly or the disabled in nursing homes, and those who are low income and living in foster care, or families in poverty — would have reduced access to care. Period.

These aren’t generic numbers and pie in the sky statistics we’re talking about, we’re speaking of 25,841 elderly Nevadans, 40,898 disabled Nevadans, 55,626 adult Nevadans – mostly women, and 168,070 Nevada children.

So, here’s a question for Governor Romney and Representative Ryan — If no matter how much efficiency the state of Nevada squeezes from your block grants for Medicaid, Nevada and the other states will still have to either appropriate significantly more revenue, or drastically reduce services — how is your plan anything other than a proposal to shift the burden of health care costs, for the least able among us, from the federal treasury to the state treasuries and the pockets of low income Americans?

Where, Governor Romney and Representative Ryan, does the Nevada Legislature start cutting? From the acute care services for adopted or foster children? From the acute care for pregnant women? From acute care for children in poverty who have asthma, autism, broken arms, or sprained ligaments?  From the long term care for the elderly who need home health care services and personal care to avoid institutional living?  From the long term care for the indigent mentally ill?  From elderly residents of nursing facilities?  From disabled children who need home health care? Where?

Perhaps cuts aren’t the only option. Must the Nevada government raise the eligibility standards such that only those living at “25%” of the official federal poverty level can receive assistance?  Here are the 2012 guidelines from the Department of Health and Human Services –

How much more should a family of four living on $1,920.83 per month  have to pay for basic health care?  How much more should a young man and his pregnant wife living on $1,260.83 per month have to pay for pre-natal care, and expenses associated with the birth of their first child?  For a political party which lauds its “Pro-Life” stance — asking low income families to dig deeper to pay for health care to make up for federal and state budget issues (while proposing more tax cuts for the top 1% of American income earners), makes it sound as though the GOP is the Pro-Birth, not Pro-Life party.

How much more should a young family have to pay for health care before the cost of health care begins to impinge on the capacity to put a roof over their heads?

Or their ability to put food on the table?  It’s likely going to cost our young family with two children under the ages of 19 approximately $366.40 to $578.40 per month to keep everyone fed. [USDA] Our hypothetical family might be lucky to have $764.43 per month remaining after housing and food for utilities, clothing, transportation costs (auto payments or bus fare) — that $764.43 translates to about $25.48 per day to cover ALL the basic family needs listed previously… including Health Care.  But wait, the Romney/Ryan budget cuts nutrition assistance too, drawing fire from the U.S. Conference of Catholic Bishops:

“Cuts to nutrition programs such as the Supplemental Nutrition Assistance Program (SNAP) will hurt hungry children, poor families, vulnerable seniors and workers who cannot find employment. These cuts are unjustified and wrong.” [The Hill]

And what other program do the Republicans fantasize about turning into a Block Grant Program and then cutting?  Housing subsidies. [TO.org]  There was some discussion of the Ryan proposal on this topic at the March 21, 2012 House Budget Committee hearing:

“Rep. David Price (D-NC) asked Donovan what the implication of the Ryan budget cuts would be on HUD programs such as public housing, Choice Neighborhoods, HOME and others.  Donovan responded that, under the proposed Ryan budget, approximately one million households could lose their housing.  Of the one million households at risk under the Ryan budget, Donovan estimated that 585 thousand would come from the Housing Choice Voucher Program, 425 thousand from the Project-Based Voucher Program, and 110-180 thousand from homeless assistance programs.  He also mentioned that an estimated 17 thousand jobs would be lost from CDBG, and cuts to the HOME program would mean tens of thousands of new affordable housing units would not be built.”  [CLPHA] (emphasis added)

So, no help for financially fragile families for health care, or housing, or food — or anything, but tax payers in the top 1% of all our income brackets will get more, yet more generous, tax breaks.  Little wonder the Bishops were annoyed.  Less wonder Sister Simone Campbell from Nuns on the Bus received a standing ovation at the Democratic National Convention.

A person doesn’t have to be Roman Catholic to find the Republican proposals supported by Governor Romney and created by Representative Ryan astonishing in their parsimony and appalling in their avarice.

Perhaps one has to be incited by the fact that a family in Las Vegas might have an air-conditioner, or a DVD player, or a functional motor vehicle — “Look,” cry the miserly, “They have nice stuff, and they got it by doing nothing.” Not. So. Fast.   As of 2010 not that many Nevadans were receiving public  assistance. [Census] In fact, about 3% of Nevadans were receiving public assistance. [Census pdf]

Thus much for the Miserly Myth that “They’re all sitting around collecting welfare, and learning to be dependent on Guv’mint.”  Perhaps we should add the usual follow up, “and they’re doing it on my hard earned tax dollars.”  The latter portion is correct, we do pay taxes which support assistance programs for fragile families.  However, the Grinches among us appear to believe they are the only ones chipping in.

S’cuse me Mr. Grinch, but I really don’t mind paying a fractional portion of my income to insure NO child goes to bed hungry, NO elderly person with dementia is left alone, NO foster child is left with an untreated case of pneumonia, NO pregnant woman is without pre-natal care, NO family is homeless, NO mentally ill person is abandoned, NO disabled child is without care.

This is what Democrats mean when we say, “Just Say No.”

References and Resources:  * Edwin Park, CBPP.  Congressional Budget Office, Ryan’s Specified Paths, March 2012. (pdf) “House Republican Budget Seeks to Slow Medicare, Slash Medicaid,” American Medical Association, April 2, 2012.   Kaiser Family Foundation, State Health Facts, Database.  “Public Assistance Relief,” Census, Department of Commerce, pdf.  “HUD Secretary Defends FY13 Budget Before House Appropriators,” CLHPA.   “Four Ways Romney and Ryan Would Roll Back the 20th Century ,” Jake Blumgart, AlterNet, September 5, 2012.  “What Paul Ryan’s Budget Actually Cuts,” Brad Plumer, Washington Post, August 12, 2012.  USDA, Cost of Food Plans, Center for Nutrition Policy and Promotion, May 2011 (pdf).  ASPE, Department of Health and Human Services, HHS Poverty Guidelines 2012. Congressional Budget Office, “The Long-Term Budgetary Impact of Paths for Federal Revenues and Spending Specified by Chairman Ryan,” March 2012, pdf.   Kaiser Family Foundation, link to interactive database for state health care statistics.

Oh, those little women in the manufacturing sector?

The NVProgressive picks up the torch illuminating the fact that the Democratic Party doesn’t have to manufacture a War on Women — it’s right out there in the GOP legislative agenda for all to see.  Or, as one wag put it: “Finally, the GOP is actually manufacturing something…”  So, what armaments have come from the Republican Legislative Machine Shop?

Anti-Choice and Women’s Health

Return with us now to H.R. 3, introduced on January 20, 2011, sponsored by Rep. Chris Smith (R-NJ) which, “Prohibits federal funds from being used for any health benefits coverage that includes coverage of abortion. (Currently, federal funds cannot be used for abortion services and plans receiving federal funds must keep federal funds segregated from any funds for abortion services.) Prohibits the inclusion of abortion in any health care service furnished by a federal or District of Columbia health care facility or by any physician or other individual employed by the federal government or the District.” [CRS]

In the midst of the controversy over the bill the Republicans inserted a bit of legerdemain exempting those who had been the victims of “forcible” rape.  Huh? All rapes are “forcible,” unless perhaps, “she was asking for it?” [TCWC] The language was stripped from the bill, but remained in documents establishing legislative intent.

Nevada Republican Representatives Dean Heller (R-NV2) and Joe Heck (R-NV3) voted in favor of the bill on May 4, 2011. The bill passed in the House of Representatives on a 251-175 vote.  Representative Shelley Berkley (D-NV1) voted in opposition. [vote 292]

The same day H.R. 3 was introduced Rep. Joseph Pitts (R-PA) brought out H.R. 358, the Protect Life Act.  The bill would, “Amends the Patient Protection and Affordable Care Act (PPACA) to prohibit federal funds from being to used to cover any part of the costs of any health plan that includes coverage of abortion services. (Currently, federal funds cannot be used for abortion services and plans receiving federal funds must keep federal funds segregated from any funds for abortion services.) Requires any qualified health benefit plan offered through an Exchange that includes coverage for abortions to also offer a qualified health benefit plan through the Exchange that is identical in every respect except that it does not cover abortions. “  [GovTrack]  This restrictive bit of legislation passed the House on October 13, 2011 on a 251-172 margin, again with Rep. Shelley Berkley (D-NV1) voting against the measure while Rep. Mark Amodei (R-NV2) and Rep. Joe Heck (R-NV3) voted for it. [vote 789 GovTrack]  The bill attracted the nickname, “The Let Women Die Act,” because it would allow a hospital to let a pregnant woman die rather than allow a life-saving abortion procedure.

Republican John Fleming (R-LA) introduced H.R. 361, to “Amend the Public Health Service Act to codify provisions that prohibit the federal government and any state or local government that receives federal financial assistance from subjecting any health professional, a hospital, a provider sponsored organization, a health maintenance organization, an accountable care organization, a health insurance plan, or any other kind of health care facility, organization, or plan to discrimination on the basis that the entity refuses to participate in abortion-related activities.” [Thomas]

H.R. 374 was introduced by Rep. Duncan Hunter (R-CA) establishing that life begins at contraception: “Declares that the right to life guaranteed by the Constitution is vested in each human being beginning at the moment of fertilization, cloning, or other moment at which an individual comes into being. Prohibits construing this Act to require the prosecution of any woman for the death of her unborn child.” [Thomas]

Amendment #95 to H.R. 1 was introduced by Representative Mike Pence (R-IN) on February 17, 2011, removing Planned Parenthood from eligibility for any federal funding.  His amendment was adopted by the House on a 240-185 vote.  Representatives Dean Heller (R-NV2) and Joe Heck (R-NV3) voted in favor of the amendment, Representative Berkley voted against it. [vote 93]

Then there was the Great Contraception Flap, with Republicans arguing that the implementation of the health care reforms would violate “religious freedom,” (read a “violation” of the Catholic bishops’ violation of other people’s consciences.)  [NYT] The Senate shot down a GOP offering, [S.Amdt 1520]  to exclude contraceptives from insurance plans, when the Blunt Amendment was tabled on a 51-49 vote.  Senator Dean Heller voted for the amendment.  Senator Harry Reid voted to table it. [vote 24]

The Republicans who ran on “Jobs, Jobs, Jobs” in the 2010 elections spent their first days introducing anti-abortion legislation.   The Republican War on Women began early in the 112th Congress with some substantial volleys, and continues into the immediate present.

Equal Pay for Equal Work

The distinctly anti-woman opening of the 112th Congress should not have come as a surprise, considering the actions of Republicans in the 111th session.   The House of Representatives passed the Lilly Ledbetter Fair Pay Act (H.R. 11) on January 27, 2009, but without  help from the Republican minority.  The bill passed on a 250-177 vote, with Nevada Representatives Berkley and Dina Titus voting in favor of the bill, and Rep. Dean Heller (R-NV2) voting against it. [vote 37]

Nevada’s congressional contingent had a second opportunity to support the requirement of equal pay for equal work during consideration of the Fair Pay Act.  The bill, S. 3220,  introduced by Senator Barbara Milkulski (D-MD) “would require employers to prove that differences in pay are based on qualifications, education and other “bona fides” not related to gender. It also would prohibit employers from retaliating against employees who ask about, discuss or disclose wages in response to a complaint or investigation. And it would make employers who violate sex discrimination laws liable for compensatory or punitive damages.” [USAT]  We should note that the Ledbetter Act simply allows cases to come to the courts after a woman has discovered she’s been paid less for performing the same job as a male cohort — it doesn’t cover women who’ve been fired for finding out about unequal compensation.  (Remember the movie “9 to 5″ when the ladies find out about the pay differentials?)

Once more Senator Heller had an opportunity to support equal pay for equal work, and once more he begged off [roll call 115] excusing himself by saying those “floodgates of litigation” would spill forth if women were allowed access to their day in court should they discover they were not being compensated fairly.  He’s not publicly indicated if he supports the actions taken by Jane Fonda, Dolly Parton, and Lily Tomlinson in the movie version.  The filibuster of the bill by Senate Republicans remains in effect.

No member of the Democratic Party delegation to the Congress initiated H.R. 3, or H.R. 358, or H.R. 361, or H.R. 374, or H.R. 1 amendment 95, or S. Amdt 1520.  These were Republican actions, taken by and for the Republicans.  Democrats had no hand in “manufacturing” these controversial proposals.  Nor did the Democrats “manufacture” long standing opposition to the Lily Ledbetter Fair Pay Act, nor to the contemporary Fair Pay Act.   Whingeing that it is icky to make Republicans vote on measures they don’t like during an election season is not only unseemly and a bit juvenile, it’s not like major parties haven’t been demanding votes on controversial issues during election seasons since time out of mind.

If the War on Women were solely a federal level assault there might be more support for the argument that anti-women measures are a distraction. However, legislation and legislative intent cease to be distractions when they become national patterns.  This list from Jezebel compiles a state by state list of anti-women measures in state legislatures as of May 11, 2012.

And then there’s the Republican federal budget proposal

The Ryan Budget was analyzed by the National Women’s Law Center and found wanting. Under the provisions of this budget:

# approximately 17,000,000 women in this country would lose access to affordable health insurance and Medicaid, they would be subject to higher costs for prescription medications in the Medicare program, and would find preventative care (including contraception) harder to obtain.

# the repeal of the Affordable Care Act assumed in the Ryan budget would mean that health insurance corporations could continue to charge higher rates for women than for men.

# women make up about 70% of the Medicaid beneficiaries in this country, and cutting the program by 20% would mean that over 14,000,000 low income women would lose their health insurance coverage by 2021.

# the majority of Medicare recipients are women, and raising the eligibility age to 67 would therefore affect more women than men — further, the “voucher” program for Medicare which replaces the current Medicare program increasingly pushes costs onto the beneficiaries — mostly women.

# women constitute 66% of Social Security beneficiaries and about 86% of adult TANF beneficiaries.  Plans to cut $463 billion from these income support programs would predominantly affect women.

# in 2010 women made up 62% of adult SNAP (food stamp) recipients, and 66% of elderly SNAP benefit recipients.  [NWLC] The Ryan budget calls for cutting back these benefits by 17% over the next decade, no matter what the economic situation is at the time.  Proposed cuts to the WIC program could hurt about 8.9 million low income mothers and their infants.

… and we’ve not even touched what would happen to women who need assistance from programs to provide housing for elderly women in poverty, women who rely on Child Care, Head Start, Pell Grants, and energy assistance…

War is, indeed, a strong word.  However, when the attacks are coming from both the federal and the state legislative bodies, when the attacks are primarily aimed at women, when the attacks are accompanied by the slurs, jeers, and epithets from right wing media, then perhaps “war” conveys a more precise meaning than merely using terms like  hostility, fights, antagonism, or assault.

It is time to ask our politicians — Which side are you on?