Incentives? What’s good for Geese and Ganders: Medicaid Work Requirements

We can rest assured the Nevada Policy Research Institute (aka Koch Bros) will be staunchly defending the notion that poor or working Nevadans are so debauched that any form of financial support will cause them to head for the couch and the TV remote, witness their position on work requirements for Medicaid recipients:

“Medicaid is supposed to provide a safety net for those who are unable to help themselves — an admirable goal,” said NPRI policy analyst Daniel Honchariw. “Unfortunately, as the system currently works, it actually encourages many able-bodied adults to stay out of the workforce. As a result, the program isn’t just draining public finances, it’s eroding the self-sufficiency of those it’s purportedly supposed to be trying to help.”  [h/t Nevada Independent]

Dear Lord, I’d hate draining away anyone’s “self sufficiency.”  However, I’m not prone to illusions about innumerable people who for reasons beyond comprehension prefer “getting welfare” to having a job.  But Wait!  Nationally, 42% of those non-SSI, non-elderly with Medicaid health insurance are working full time, another 18% are working at part time jobs.  14% are not working because they are ill or disabled.  12% are caregivers for someone who is ill or disabled.  6% of the enrollees are in school, and 7% give other reasons for not being able to work. [KFF] So, let’s be rid of the Medicaid as Welfare motif — it’s not welfare, it’s a health insurance program.  Further, 60% of the recipients are working full or part time.  So, what are the income requirements for Nevadans in the Medicaid insurance program?

“In addition to the basic Medicaid requirements, petitioners must qualify by earnings. What are the income requirements for Medicaid in Nevada? Nevada Medicaid eligibility requirements pertaining to income are structured around the federal poverty level (FPL). This financial marker of determining Medicaid benefits eligibility considers the size of the family and larger households will have higher income limits. Medicaid can provide health care coverage to households with income up to 138 percent of the FPL. However, children younger than 19 years of age with incomes up to 205 percent of the FPL will also be eligible for medical coverage.” (emphasis added)

Now we come to the Income Trap phase of the argument.  We can’t, dare not, increase the minimum wage from a paltry $7.25 per hour, argue the Conservatives, because to do so would “cost jobs.”  However, if one takes out the plastic brains, punches in the numbers for a person working 40 hours per week at a minimum wage job the conclusion displayed in the little calculator window will be below the 138% FPL line.  Here’s a thought: If the Republicans are bent on removing working people from the Medicaid rolls, how about raising the minimum wage to a living wage?  And, now we continue on to the Geese and Gander finale.

We’ve just survived the enaction of the Republican Tax Cut, Tax-Scam, in which it was argued that if middle and working class Americans would shoulder the burden of supporting the federal government and allow the corporations and hedge fund managers to “keep more of their hard earned money,” then our prosperity will soar, the economy will boom and those hard-working wealth management titans will work even harder at their investment strategies.  So, pay them more and they will work harder, and make their money work harder.  Funny, this principle never seems to apply to working people who drive trucks, serve food, repair fuel injection systems, build houses, landscape properties, clean hotel rooms, sell merchandise, type memos, file records, stock shelves,… you get the idea.

Thus, what is sauce for the Geese (those hard working wealth management, upper 1% of the income earners, etc.) i.e. more benefits and breaks from the government is toxic bilge water for the other 99% Ganders, who if given even the least disincentive in the form of affordable health care will shed their uniforms and work clothes, head for the nearest couch and dissipate into a mere shadow of their former selves as their “self sufficiency” is drained by the system.

Perhaps we should call this out for what it is — yet another attempt to reduce the number of people eligible for assistance with their health care expenses because rich people don’t want to pay for it.  Because they imagine some otherwise healthy soul taking advantage of their fellows merely because the are “unworthy.”  If this sounds selfish, it’s because it is, essentially, a fundamentally selfish argument.  The saddest part of the entire issue is that the Geese having quacked for years about Welfare Queens (non-existent) and Unworthy Lazy Bums have convinced numerous Ganders of the horrors of expending any funds in support of those less fortunate.   There is one last point illustrative of the moral deficiency of the conservative argument.

Opioids.  Remember those 7% who gave other reasons for not working?  Some of them have been laid off from jobs and are seeking new employment, and some others are finding it difficult to secure employment because of opioid addiction.  Just for the record, Medicaid covers about 4 in 10 non-elderly adults with opioid addiction.  13.9% are white non-Hispanic; 6.6% are Black, and another 4.6% are Hispanic.  13.7% are males, 7.3% are females.  [KFF]  If we want to address opioid addiction in this country then we need to be taking care of those who are seeking help with this scourge, and not lecturing them about the wonders of the free market system and healthy lifestyles.

We could use a few less lectures on the Great American Rugged Individual and a few more mentions of our collective responsibility to care for our fellow citizens as we would wish to be cared for by them.

Scary Stuff Indeed

Yesterday was an extremely interesting day, replete with all manner of scary stuff compliments of social media platforms and a Special Counsel. However, not all of the frightening items were associated with the Trump Campaign’s eagerness to get the produce of Russian hacking, and Russian assistance.  Here’s some other stuff in the GOP treat basket:

ICE again proves its ultimate heartlessness and horrifying lack of understanding of what it means to “protect” Americans; illustrated by the case of Rosa Maria Hernandez — a ten year old with cerebral palsy undergoing gall bladder surgery.  And, this isn’t the only case — there was the story of parents arrested while their child was having brain surgery, the arrest of an undocumented Iraqi man who was serving as a bone marrow donor for his niece, and a brain tumor patient pulled from a hospital.  ICE thus becomes the ultimate Halloween Scary Story.  Candidates for public office ought to be ask outright how they would assist in the process of getting immigration officials to adhere to their own guidelines on “sensitive locations.’

Nobody in the GOP appears to be all that outraged that the Trump Campaign not only accepted assistance from the Russians, but actively sought to get the goods on Secretary Clinton from Russian sources.  This isn’t normal, or even paranormal — it’s the kind of thing that would make any other campaign (Democratic or Republican) call the FBI if the Russians showed up at the door with treats.  But still, #45 refuses to accept the fact that the Russians at least meddled and at most attacked the US with campaign “assistance” — social media help; opposition research; and, (the part we keep ignoring) attempts to hack into the voting systems of at least 21 and possibly 39 states.  We do need much more attention paid to the last item on the list since the Cult-45 group persists in saying this is a Spook, there’s nothing to see here.

Somehow a tiny company in Montana got a whopper contract, now cancelled, to supply power to the entire island of Puerto Rico.  Nothing puts a place like Whitefish, Montana on the map like having the Secretary of the interior stammering he’s nothing to do with this — and if I believe this then you could easily get me to believe that all the little spookies at the door are Real!

It’s been 30 days since the tragic Las Vegas Shooting, and what has the Congress done to limit high capacity magazines? Bump stocks? Anything?  This month has been a nightmare for the families of the deceased, and the families of the injured.  The nightmare will continue until politicians stop being terrified of the National Rifle Association.

Republicans have been unable to explain away the specter of Opioid Abuse while cutting massive amounts of funding from Medicaid.  The GOP budget calls for cutting some $1.5 trillion from the program over the next decade — while 30% of opioid treatment is covered by Medicaid insurance.   States, already strapped by the crisis will have to either come up with more funding or ration care — speaking of Death Panels…

The Senate of the United States believes that individual Americans are perfectly capable of taking on The Big Banks all by themselves — Super Heroes in Litigation.  So, on October 24, 2017 the Senate voted to dismiss a CFPB rule that would have allowed class action law suits against the Big Banks by ripped off customers; forcing those customers into individual arbitration.  Senator Dean Heller was pleased to vote in favor of this nightmare.

This list seems long enough to send sentient beings into the closet for the Halloween Season, one almost shudders to think what more the Republicans have in mind — like the tax cuts for the 1% and questionable benefits for the rest of the population…

Senator Heller’s Second Shot at Slashing Medicare and Medicaid

“This morning, the Senate Budget Committee will consider a resolution that instructs lawmakers to find ways to reduce Medicaid spending by $1 trillion (and Medicare spending by $473 billion) over the next decade, according to supporting documentation that Democrats are publicizing.” [WaPo]

Here’s the strategy: “A fast-track “reconciliation” process that would allow for tax cuts costing $1.5 trillion over ten years that require only a simple majority to pass.  The $1.5 trillion cost would not have to be offset by closing tax loopholes or ending unproductive tax breaks, and thus would add to the nation’s deficits, which are already growing as the baby boomers retire.  In addition, the resolution would allow the Senate Finance Committee to cut critical programs under its jurisdiction, including Medicaid, Medicare, and basic assistance for poor seniors and people with disabilities, and then use those savings to make the tax cuts even larger (so that the net cost of the tax cuts and the budget cuts combined equaled $1.5 trillion).  The reconciliation process is the same process that Congress tried to use to repeal the ACA and requires only a simple majority to enact law.”  [CBPP] (emphasis added)

And, there we have it: (1) If it’s a Republican budget, then adding to the federal deficit doesn’t matter; (2) in order to provide for tax cuts to the top 1% of income earners in the United States, the Committee can slash funding for Medicaid, Medicare, basic assistance for senior citizens, and people with disabilities.

The trick is that the Senate Republicans have to pass a “budget” slashing spending for those aforementioned Medicare and Medicaid beneficiaries, elderly people in poverty, and disabled people, in order to create ‘space’ for the “reforms” in their tax legislation.  The buck slashing needs to stop here.

Please contact Senator Dean Heller, and let him know that these are not Nevada priorities.

202-224-6244

702-388-6605

775-686-5770

While We’re Ducking and Dodging

While we’re ducking, dodging, and otherwise attempting to avoid damage from the GOP, they’re still busy with legislation to make our lives just a bit more difficult.  Cases in point:

The House leadership has delayed, but hasn’t promised to discard, a bill, HR 367, to allow the general sale of silencers — which the proponents tell us will mitigate hearing loss for gun owners.  Pro Tip: A nice pair of headset style ear protectors will set you back about $30.00 (if the foamies will do you can buy’em for about 12 cents each in a bucket of 200) as opposed to spending $1300.00 on a suppressor for your AK/AR-some number or another.

The GOP tax cut legislation, which somehow is being titled “reform,” is a walloping giveaway to the top income earners in the U.S.  Not sure about this? See the Institute on Taxation and Economic Policy, that tells us those in the bottom 20% will see 1.3% of the tax benefits while the top 1% will enjoy 67.4%. Bringing this closer to home, the top 1% of income earners (which amounts to about 0.4% of our population) will get a 70.7% share of the tax cuts. For all that chatter about the Middle Class, the plan doesn’t really help middle class Nevadans:

“The middle fifth of households in Nevada, people who are literally the state’s “middle-class” would not fare as well. Despite being 20 percent of the population, this group would receive just 4.6 percent of the tax cuts that go to Nevada under the framework. In 2018 this group is projected to earn between $38,900 and $60,600. The framework would cut their taxes by an average of $380, which would increase their income by an average of 0.8 percent.”

Just to put this in context, a family in Nevada’s middle income range would see a tax cut of about $380…meanwhile back at the home mortgage, if that family is in Reno where the average home loan is about $187,000, the monthly payments are about $855 per month.  Congratulations Middle Class Nevadans, you may receive an annual prize of 44% of one month’s mortgage payment.  Color me unimpressed.

The GOP passed its version of the FY 2018 budget on a 219-206 vote.  Representative Mark Amodei (R-NV2) voted in favor of the bill; Representatives Kihuen, Titus, and Rosen were in Las Vegas attending to their constituents in the wake of the massacre at the music concert.   The AARP was quick to notice that the Republican plan calls for $473 BILLION to be cut from Medicare over the next 10 years.   Expect a cap on the Medicaid program funding; it wouldn’t be too far off to estimate cuts of about $1 TRILLION in that category.   Beware when Republicans speak of “entitlement reform,” that simply means cutting Social Security benefits and Medicare.  When they say “welfare reform,” they often mean cutting Food Stamps, Housing Assistance, and Medicaid.   Representative Amodei might want to explain why he supports cutting Medicare by $473 billion over the next decade?

Those in Nevada’s 2nd Congressional District can reach Representative Mark Amodei at 202-225-6155 (Washington DC) 775-686-5760 (Reno), or 775-777-7705 (Elko);  the office addresses are — 332 Cannon Building, Washington, DC 20515; 5310 Kietzke Lane #103, Reno, NV 89511; 905 Railroad Street, Ste 104D, Elko, NV 89801.

GOP assault on health care in rural Nevada

There’s a tendency to see social needs as an element of urban living in major cities like New York City, Los Angeles and Chicago, and rural poverty as something that happens in Appalachia.  This perspective obfuscates two features of life in Nevada.  For all intents and purposes Nevada is an urban state.  Not only is Nevada “urban” it is getting more so.  In 1970 about 80.9% of Nevada residents lived in urban areas, in 1990 the percentage was 88.3, and as of 2010 the percentage was 94.2% [ISU.edu]

By contrast, New York state as of 2010 was 87.9% urban, and Illinois 88.5% urban, while Nevada is closer to California’s 95% urban population. [ISU.edu]  However, to perceive rural Nevada as a wonderland of “freedom” and rugged individualism is to miss some crucial figures describing life in the “cow counties.”

For example, Pershing County has an 18.3% poverty rate; the US poverty rate is 12.7% [census] but the county does support a critical care hospital with a skilled nursing facility  with a maximum capacity of 25 residents.  The county’s population also includes 11.1% disabled people under the age of 65.   Given these figures, perhaps some politicians would like to explain why slashing Medicaid now and all but eliminating the national program by 2027 would be a good idea for Pershing County, Nevada.

Neighboring Humboldt County has a lower poverty rate, at 9.4% and a lower rate of disabled individuals under the age of 65 at 8.3%, but reducing the Medicaid program would have a deleterious effect on its 53 bed hospital, with an ICU, Obstetric services, and skilled nursing facility for 30 residents.  What effect of cutting Medicaid might be seen in the county’s ability to care for its aging population, including its hospital’s plans to incorporate a “memory care services unit” in its offerings?  [hgh] Recall that some 60% of all skilled nursing home residents get their health insurance coverage from Medicaid.

More populous Elko County has a poverty rate of 9.9% and an 8.4% rate of individuals with disabilities under the age of 65.  The county is home to a short term acute care hospital with 59 beds, and a resident center for 110 people needing skilled nursing care.   Again, if 60% of those SNF residents rely on Medicaid for their insurance coverage then cutting funds in 2027 then 66 families will be under increased pressure to find suitable and appropriate care for elderly family members.

Now, consider that Nevada is an urban state, and that should the Republicans get their wish for a capped Medicaid system of block grants then the state would be tasked with allocating increasingly spare resources to maintain nursing home and hospital facilities statewide.  Given the 2.115 million people in Clark County contrasted with the 52,168 population of Elko County, the 6,650 in Pershing County, and the 16,842 in Humboldt County — where are the monetary resources likely to go?

If Congressman Mark Amodei (R-NV2) and Senator Dean Heller are truly representing the needs of rural Nevada, then offering platitudes about “freedom,” “free enterprise,” and “individual initiative” are a poor substitute for enacting legislation to maintain and improve the health care facilities and the insurance availability to those facilities for northern Nevada rural citizens.

It’s not over until the fat lady sings adios to the current Congress

This is your Monday morning reminder that Republican attempts to kill the Affordable Care Act and Medicaid aren’t history.  The Graham-Cassidy Bill, which would mean a net loss of coverage for 243,000 Nevadans, still lives, and at long as it does so we have to keep those phone lines busy.

Please let Senator Heller know that his latest attempt to foist off a “Repeal and Replace” effort onto Nevadans is actually worse than his last performance on behalf of the Senate’s “skinny bill.”

“Graham-Cassidy’s impact on coverage in 2027 would be similar to that of the Obamacare Repeal Reconciliation Act (ORRA), the so-called “repeal and delay” bill that the Senate failed to pass in July. Under both the ORRA and Graham-Cassidy, these three major policies would be in effect a decade from now:

• Repeal of the mandates for individuals to obtain health insurance coverage and large employers to offer insurance

• Elimination of subsidies for nongroup health insurance

• Elimination federal funding for the ACA’s Medicaid expansion” [CAP]

No individual or employer mandates to stabilize the insurance market, no assistance for those trying to find insurance in the private market, and the loss of Medicaid assistance for working Americans.  And, why all of this effort?

The Republican plan to lower taxes for those in the top 1% of American income earners won’t “add up” without cutting help for average Americans under the ACA and without pulling the rug out from under those (including retirement center residents and children) who are insured by Medicaid.

Senator Heller can be contacted at:  202-224-6244; 702-388-6605; and 775-686-5770

You may also want to thank Senator Catherine Cortez Masto for her support of Nevada families who rely on the ACA and Medicaid for their health care insurance needs.  202-224-3542; 702-388-5020, and 775-686-5750.

It’s Official: GOP Hates Women — Scamcare Edition

In case there’s anyone left who thinks the Republican Party is representing the needs of women in this country, the contradiction is right in front of us in the form of the Graham-Cassidy+Heller (tagging along) bill.

Amy Friedrich-Karnik, senior federal policy adviser at the Center for Reproductive Rights, pointed to a statistic from progressive think tank the Century Foundation that estimates 13 million women will lose access to maternity care services if the ACA is repealed. Friedrich-Karnik explained that the bill also blocks Medicaid patients from using Planned Parenthood, which bars access to essential preventative care like birth control, cancer screenings, and STD testing and treatment. “It also slashes Medicaid overall and into the future, and so really impacting particularly low-income women and women of color who rely on Medicaid broadly for their health care,” she said. According to the Kaiser Health Network, Medicaid pays for nearly half of all births in America and covers family planning services for 13.5 million women. [Jez]

Not only is the bill a golf ball shot to the back of the head for Nevada women, it could cost the state some $250 million in funding:

Specifically, the proposal would eliminate the marketplace subsidies and federal dollars that states that chose to opt-in to Medicaid expansion under the ACA, like Nevada, currently receive, replacing them with block grants to be doled out to states, which would be left with the responsibility of deciding how to spend that money. It also converts almost the entire Medicaid program to a per capita cap, under which the federal government would set a limit on how much it reimburses states per enrollee, and allows states to waiver certain provisions from the ACA that require insurance companies to cover certain services and bars them from placing annual or lifetime caps on coverage. [NVInd]

Got that? Nevada gets a per capita cap, AND insurance corporations could refuse to cover pre-existing conditions, maternity care, family planning, women’s health care services, AND the corporations could revert to that wonderful old scam — the lifetime limit on coverage.  This isn’t as bad as the former “skinny” bill — it’s worse.

Senator Heller might have wanted to give this version some thought before he inked his name on the paperwork to co-sponsor the bill, but he didn’t.

It’s understandable that Nevadans are tiring of calling, writing, and sign making, but if Republicans are nothing else they are persistent.  They’re counting on public apathy, ignorance, and fatigue.  Not this time. Not on American health care. Not on our watch.

Senator Heller’s Washington DC office number is 202-224-6244.  Calls are tallied, and at some point the number of calls opposing this iteration of scam-care needs to impinge on the amount of money Republicans are counting on from the Koch Brothers and other right wing radicals.

It’s A National Emergency, we think…

Since his attempt to revive Nancy Reagan’s “Just Say No” campaign in the face of a crisis in the increased addiction to opioid drugs in this country fell flat,  Dear Leader appeared to suggest the problem is a matter of law enforcement — a major mistake.  The genesis of the issue comes from the over-prescribing and over use of opioid medication once advertised as “virtually addiction free.”  Indeed, Purdue Pharma is still facing litigation from the state of New Hampshire over its advertising of Oxycontin. This, in addition to the 2007 guilty plea from the corporation for mislabeling the drug, and the payment of  $634.5 million to resolve a DoJ investigation.  Meanwhile, Nevada holds its unfortunate position in the top ten states when counting opioid death rates.  There were 224 overdose deaths in 2014, another 259 in 2015 [CDC] related to natural and semi-synthetic opioids; Nevada’s statistics were more bleak citing some 465 opioid related deaths in 2015.

Since we probably can’t arrest our way out of this mess, in Nevada or anywhere else, the answer in the long run is prevention (better guidance for physicians and tracking, combined with better public education on the nature of opioid addiction) and treatment.  And, for treatment, people have to have a way to afford it.

Medicaid has been a Godsend for many suffering through an opioid addiction.

“The authors of the report (Urban Institute) draw a parallel between the Affordable Care Act’s Medicaid expansion and spending on addiction medications, saying it has brought addiction treatment to previously underserved populations.

“What we saw was this gigantic, rapid, ongoing expansion in treatment,” says co-author Lisa Clemans-Cope. “It was particularly fast after 2014 when the big Medicaid expansion came into play. There’s definitely an effect of people getting access to treatment. That’s the primary driver of growth of spending.”

So, Medicaid spent more on treatment after 2014 – because more people were in a position to afford the treatment programs available to them.  Therefore, the next time a Republican politician stands before us with plans to slash Medicaid spending, and turn the Medicaid program into a block grant lottery for the states, we might well ask:  What does your proposal do to assist the states, like Nevada, deal with the treatment expenses of individuals trying to cope with opioid addiction and who are seeking assistance to make that treatment affordable.

Gee, the states are supposed to “benefit” from greater flexibility?  Would that be the flexibility to choose between supporting special education children with speech and physical therapy and opiate addicts?  Or choosing between the needs of the families of opiate addicts and the severely disabled?  Or choosing between the needs of opiate addicts seeking treatment and women seeking mammograms and other cancer screenings?  Santa doesn’t come without some expense.

Somehow the Republicans have managed to entangle themselves in their own rhetoric.  We can cut taxes, expand the military, all by cutting social safety net programs, and still have money for fighting opioid addiction in this country!  Santa will bring us tax cuts and another Santa will keep Granny in the skilled nursing facility, help cousin Elwood find a job in a new industry, make sure the family can get immunizations, cancer screenings, treatment for acute and chronic medical conditions, and insure that the Interstate Highway System is continually maintained.

It’s Jude Wanniski’s Two Santa Theory — a position only definable as something coming from an opiate induced delusion:

“Unfortunately, Mr. Wanniski opened Pandora’s box when he let loose the two-Santa theory. Republicans are now bound to it, whether they know it or not. As Keynes once put it, “Madmen in authority, who hear voices in the air, are distilling their frenzy from some academic scribbler of a few years back.”

**For more information: See the following excellent articles in the Nevada Independent — “Another side of the opioid heroin crisis,” “For Many Governors…” “As Out of Control opioid epidemic rages..”

Rest and Repair: Going Forward With The ACA

Breathe, regroup, and re-enlist in the movement to #Resist the egregious GOP agenda to dismantle the 20th century.  The health insurance bill was the first fight, but it won’t be the last.

First, expect the GOP to repeat ad nauseam all the old talking points about the Affordable Care Act, and to keep working in the background to eliminate key elements of health care assistance, and we need to be prepared to counter them.

“Premiums have skyrocketed” — Counter: While there are some states in which premiums for health care insurance have increased dramatically, there are others like Indiana and Rhode Island in which premiums have actually decreased. Nevada’s increase was a modest 8% when compared to pre-ACA rate increases.  [See KFF chart for all 50 states.]  Counter: Premiums are only part of the consumer costs.  If an insurance policy offers low premiums, but includes higher co-payments and deductibles then it really isn’t “cheaper.”

“Democrats want to bail out the Health Insurance Corporations.”  The Republicans used this line when attacking the legislation to get ourselves out of the Great Recession, the product of unfettered financialism on the part of investment banks. This line has served them well, and Senator Dean Heller (R-NV) utilized it almost constantly to impress Nevada voters with his “independence” when bragging about how he voted against “bank bailouts” in the Dodd Frank Act, legislation which applied common sense regulation to investment bank practices.

A much better frame for this argument from the pro-ACA side would be that we want to stabilize the insurance markets.  Including a re-insurance element to the ACA would be helpful.  There is a way to introduce these topics without resorting to protracted arcane discussions about the nuances of the insurance market:  Explain the Three R’s.  Risk Adjustment. Reinsurance. Risk Corridors.

“Government is forcing people to buy insurance they don’t want.”  I’m fond of hauling out my auto insurance — even though I’m fully aware of the fact that this is far from a good analogy.  I have one vehicle which works and one that doesn’t.  For the one that works I have a comprehensive policy, and for the one that doesn’t I have a basic policy.  What the ACA does is require a “basic policy.”  The old rig isn’t going to hit anyone or anything unless a tornado picks it up and moves it — but I still have some liability insurance for it. The policy pools all car owners, and basic is basic, so there’s liability insurance on a vehicle that isn’t moving and isn’t going to without a tow truck.  (Please don’t ask why I still have it…the answer is irrational.)

Individual mandates and employer mandates aren’t popular.  That’s fairly irrefutable. However, those mandates are an essential part of creating a widening POOL of policy holders, which in fact serves to help contain health care cost increases.

“But everyone has access to health care…in the emergency room.”  No, all this means is that everyone has access to EMERGENCY health treatment, which, as we all know is the most expensive place to receive care.  Further, “having access” is not the same as being able to pay for it — thus the pre-ACA misery of personal bankruptcies and hospitals with disturbing amounts of uncompensated care on their books.

Secondly, have a plan.  A plan to address specific needs for specific problems.  If health care costs are rising faster than other consumer needs, then address this directly.  (1) Allow the government to negotiate prescription drug prices for Medicare the same way the VA negotiates prices for veterans’ medication. (2) Incentivize prescription drug research while limiting excessively high prices.  This sounds impossible, but really isn’t.  A paper from the Brookings Institution (pdf) explains how this might be accomplished.   If about $1 out of every $6 spent on health care is related to prescription drugs, holding the line in this realm would be helpful.  (3) Allow the importation, or re-importation, of medication.  This probably isn’t as efficacious as some of the other proposals, but it, too, could be helpful.

(4) Encourage practices which yield better health care outcomes.  Thus far we have a system which pays for services rendered — as it should — however, efforts to study and promote best practices.  This is a component of the ACA and one that should be publicized more effectively.  (5)  Emphasize preventive medicine.  This, too, is an element incorporated into the ACA, and deserves more attention.  It’s far better for all concerned to promote annual health check ups, healthy lifestyle and nutrition programs, and vaccinations than it is to cover the costs of heart attacks and preventable diseases.  The insurance corporation doesn’t have to pay out the claims for the heart attack, the hospital doesn’t risk providing uncompensated care, the physician doesn’t run that same risk, and the person who avoided the heart attack in the first place is working and continues being a productive member of society.

(6) The slippery slope message is already in the public domain.  “What the Democrats really want is ‘single payer.’” Yes, some do.  The Republican cognitive dissonance hits the surface when some conservatives decry socialized medicine while famously exhibiting their “Get Government Hands Off My Medicare” signs.  However, this argument is both accurate and speculative at the same time.  Some Democrats are, indeed, in favor of single payer. Some are more likely to support a public option where private corporations are reluctant to enter the private health insurance market.  Others would simply prefer to sustain the present health insurance exchange marketplace system under the current provisions of the ACA.  There’s no monolithic, lock step, Democratic position on this issue, which is both a political problem for massing support for a specific proposal, and a political opportunity to let local voters select the candidate who best represents their views.

Third, we need to recognize that “repeal and replace” was never a serious proposal in the first place.  Had it been serious, then surely in the seven years since the passage of the ACA the Republican party would have come up with something more substantial than cutting Medicaid, limiting jury awards for malpractice, defunding Planned Parenthood, and giving tax breaks to the ultra-wealthy among us.  They were perfectly happy to vote in favor of complete repeal of the ACA until the burden shifted to their own backs, then the GOP controlled Senate couldn’t come up with 50 votes for a sham bit of legislation no-one wanted.

Slogans are effective public relations, but they are woefully inadequate policy proposals.  No, the ACA isn’t “socialized medicine.”  If it were then the Heritage Foundation wouldn’t have provided the framework of the plan as a response to Hillary Clinton’s health care proposals back in the ’90s.’  Granted, the Heritage Foundation didn’t include increasing Medicaid coverage, and it did include ‘tort reform,’ but the other similarities are striking even if hard-line Republicans in 1993 opposed the bill based on the framework, and it never came to a floor vote.

The GOP Zombie Bills may be gone, but the fight isn’t over.  And the obese ladies who would do better to follow the advice given by their doctors (covered as part of the ACA mandated insurance) aren’t yet singing.

The Moderate Heller Myth: Health Insurance Edition

Senator Dean Heller (R-NV) has cultivated his “moderate” image to the point that this adjective is attached to him with remarkable consistency — when if a person does even a perfunctory piece of research on his actual voting record what emerges is the model of a hard line conservative.  There is a pattern.  The Senator expresses “concerns” with a bill; then announces with ranging degrees of fanfare his opposition to a bill “in its current form,” then when the rubber grinds on the road surface the Senator votes along with the Republican leadership.

Why would anyone seriously believe he would support fixing the Affordable Care Act’s problems and not ultimately support what is now being called the “skinny repeal” version in the Senate based on the following voting record:

In 2007 then Representative Heller voted against the Medicare Prescription Drug Price Negotiation Act (HR 4).  Then on August 1, 2007 he voted against HR 3162, the State Children’s Health Insurance Program reauthorization.  The next day he voted against HR 734, the Prescription Drug Imports bill.  On March 5, 2008 he voted against HR 1424, the Mental Health Coverage bill.  Further into 2008 he voted “no” on HR 5501, the bill to fund programs fighting AIDS, Malaria, and Tuberculosis, and “no” again on the concurrence version of the bill in July.   If he had a ‘flash’ of moderation during this period it happened in the summer of 2008 when he voted in favor of HR 5613 (Medicaid extensions and changes), HR 6631 (Medicare), the latter including a vote to override the President’s veto.  By November 2009 he was back in full Conservative mode.

He voted against HR 3962 (Health Care and Insurance Law amendments) on November 8, 2009, and HR 3961 (Revising Medicare Physician Fee Schedules and re-establishing PAYGO) on November 19, 2009.

In March 2010 Heller voted against HR 4872 (Health Care Reconciliation Act), and HR 3590 (Patient Protection and Affordable Care Act).  He also voted against the concurrence bills.

January 19, 2011 he voted in favor of the Repealing the Health Care bill (HR 2).  He also signaled his stance on Planned Parenthood when he voted in favor of H.Amdt. 95 (Prohibiting the use of Federal funds for Planned Parenthood) on February 18, 2011.    He was in favor of repealing the individual mandate (HR 4), of repealing the Prevention and Public Health Fund (HR 1217).  May 4, 2011 he voted to repeal funding of the construction of school based health centers (HR 1214).

There was another “soft” period in some of his initial Senate votes in 2011, especially concerning the importation of medication from Canada (interesting since many prescription drugs are manufactured in other overseas sites).  See S. Amdt 769, S. Amdt 2111, and S. Amdt 2107 in May 2012.  On March 31, 2014 he voted in favor of HR 4302 (Protecting Access to Medicare).

He was back riding the Republican rails in September 2015, supporting an amendment to defund Planned Parenthood, (S. Amdt 2669) which failed a cloture vote.   Then on December 3, 2015 he voted in favor of another ACA repeal bill (HR 3762).    If we’re looking for patterns in this record they aren’t too difficult to discern. (1) Senator Heller can be relied upon to vote in favor of any legislation which deprives Planned Parenthood of funding for health care services, (2) Senator Heller can be relied upon to vote in favor of repealing the Affordable Care Act, and (3) Senator Heller’s voting record, if it illustrates any ‘moderation’ at all, comes in the form of dealing with prescription drug prices, but even that is a mixed bag of votes.

Thus, when he makes comments like the following:

“Obamacare isn’t the answer, but doing nothing to try to solve the problems it has created isn’t the answer either,” the statement read. “That is why I will vote to move forward and give us a chance to address the unworkable aspects of the law that have left many Nevadans — particularly those living in rural areas — with dwindling or no choices.

“Whether it’s my ideas to protect Nevadans who depend on Medicaid or the Graham-Cassidy proposal that empowers states and repeals the individual and employer mandates, there are commonsense solutions that could improve our health care system and today’s vote gives us the opportunity to fight for them. If the final product isn’t improved for the state of Nevada, then I will not vote for it; if it is improved, I will support it.”

We should examine them with some caution.   If he is referring to rural Nevada voters as ‘victims’ of the Affordable Care Act he might want to note that before the ACA there was one insurer in the northern Nevada rural market and if there is only one now that’s really not much of a change, much less a “nightmare.”  Nor is he mentioning that the proposed cuts to Medicaid will have a profoundly negative effect on rural Nevada hospitals. [DB previous]

That Graham-Cassidy proposal isn’t exactly a winner either:

“The new plan released Thursday morning and written by Republican Sens. Lindsey Graham (S.C.) and Bill Cassidy (La.) would block grant about $500 billion of federal spending to the states over 10 years to either repeal, repair or keep their ObamaCare programs.”

We have no idea if the number is an accurate estimate of what would keep the health care systems of all 50 states afloat — no one seems to want to ‘score’ anything these days.  Additionally, Americans should be aware by now that when Republicans chant “Block Grant” they mean “dump it on the states, wash our hands, and walk away” while the states struggle to keep up with demands to meet needs and provide services, operating on budgets which cannot function on deficits.

Then, there’s that perfectly typical Hellerian comment: “If it is improved, I will support it,” leaving the issue entirely up to Senator Heller’s subjective assessment if “it” has improved his re-election chances enough to go along with it while not upsetting his very conservative base.  Meanwhile, the media persists in repeating the “Moderate Heller” mythology, and we haven’t even begun to speak of his actions to thwart and later repeal any common sense regulations on the financial sector.