Tag Archives: ACA

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.

 

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Filed under conservatism, Health Care, health insurance, Heller, Medicaid, Medicare, Nevada Test Site, Politics, public health, Republicans, Rural Nevada, SCHIP

Embattled Bill Entangled Senator

While the Russians are in, or not in, meetings which are, or aren’t important, and which do or don’t offer trade-craft dangles — there’s a Senate version of the health insurance bill as egregious as its predecessors.  The hold music of the morning on Senator Dean Heller’s DC office phone is a static infused version of The Battle Hymn of the Republic while a person waits for an opportunity for leave a message for the Senator urging opposition to the health care insurance bill.

There’s a reason no one likes this bill — it puts insurance corporations back into the bifurcated market  with high premiums for those older and lower premiums (with higher co-payment and deductible out of pocket expenses) for younger, or less affluent, customers.  It puts state budgets at extreme risk. It slashes Medicaid funding (in conjunction with the proposed budget), thus placing services for children and the elderly in peril.

Senator Heller is described as being wedged into a hard place — between the desires of the hard right (and perhaps the bounteous coffers of Sheldon Adelson) and the hopes of his constituents and the Governor who want reasonable access to affordable health care insurance.

“Heller, in other words, has backed himself into a corner. Either he honors the concerns he raised just a few weeks ago, or reverses course and completes a very public betrayal – the year before his re-election campaign.” [NBC]

It’s time to offer Senator Heller a way out of this box — encouraging his continued opposition to the health insurance bill — call 202-224-6244; or 702-388-6605; or 775-686-5770.

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Filed under Health Care, health insurance, Heller, Politics

Health, Wealth, and Senator Heller: Recommended Reading

Health care continues as a high priority item for Nevadans, and Greg Sargent’s article for the Washington Post points out how the “GOP Stunt Backfired…and why,” is highly recommended for pulling the tarpaulin off the GOP obfuscation concerning the Affordable Care Act.  The New York Times reports on the impact of the health insurance battle on other elements of the GOP agenda.  Ian Millhiser warns us that if we stop paying attention, the GOP wins.  Meanwhile,…

Senator Dean Heller continues to spout the party lines (the part under the tarp) while ostensibly opposing the repeal bill:

“Under the ACA, premiums have increased 7 times faster than wages, and federal regulations under the law’s employer mandate have cut workers’ hours, wages, or both.”

Nothing like tossing one’s apples and oranges together and expecting to get grape juice.  Some significant elements are missing from this pithy bit of prose.  First, premiums have increased, but not at an equal pace in all states. Secondly, the rate of premium increases have slowed during the implementation of the ACA.  Third, wages have been stagnant during the past decade, but that has little to do with the enactment of health care insurance reform — in fact, lower wage working Americans were included in the Medicaid expansion– the very program the GOP wants to slash in order to provide tax cuts to wealthy Americans.

Senator Heller believes that re-importation of prescription drugs and allowing insurance purchases across state lines are part of the solution.  Notice that he’s not in favor of so much competition as to allow Medicare to negotiate drug prices in the manner allowed to the Veterans Administration.  Also notice that he’s not mentioning that some states have rather more lax requirements for the sale of comprehensive health insurance than others.  The “across state lines,” or “portability argument” sounds good until we recall that states build in consumer protections into their regulatory frameworks.  If we could be guaranteed that portability would be a function of the most rigorous consumer protections there’s something to be discussed herein; if not, it’s simply a formula for a race to the bottom.

This is no time to remove our attention to the decimation of health insurance affordability —

Senator Heller can be reached in Las Vegas at 702-388-6605; Reno at 775-686-5770; and DC at 202-224-6244.

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Filed under Health Care, health insurance, Heller, nevada health, Nevada politics, Politics

It Ain’t Over Until The Fat Golfer Sings

Senator McConnell’s Secret Health Insurance Shop is still working, with the Lobbyists/Elves seeking a way to offer goodies acceptable to the wavering and the wanton.  Keep calling!  and if you’d like more information to substantiate your comments there are some excellent sources.

Kaiser Family Foundation:   Your one stop center for research and analysis on health insurance issues.  Definitely a “bookmark this” recommendation.  Today, KFF notes that before the implementation of the ACA individual insurance plans for health care did not cover delivery and maternity care  in 75% of the policies; 45% of the policies didn’t cover substance abuse treatment; and 38% failed to cover any mental health care services.

If terms like “risk adjustment,” “re-insurance,” and “risk corridors” seem like something written in Minoan Linear A, the KFF has an excellent summation of these technical terms in easily understood American English.

There are also some analytical pieces on the impact of Republican suggestions for health care insurance “reform” as they relate to rural health care in the following:

Human Rights Watch — Senate Health Care Bill A Swipe At Rural United States.

MSNBC/Scarborough – Rural Health Care Would Be Savaged By This Bill.

There’s a narrative going around that Democrats haven’t brought anything to the table, which depends on whether we’re taking the long or short term view.  In the short term this would be true — because the McConnell Secret Health Insurance Shop didn’t invite any Democratic participation,  for that matter there seems to have been some Republican Senators who were left in darkness.  The longer view would note some of the following:

Senator Franken’s “Rural Health Care Quality Improvement Act of 2016” (pdf) S. 3191 (114th Congress) was introduced in July 2016 and “died” in the Senate Finance Committee.  The bill would have amended two titles of the Social Security Act to improve health care in rural areas of the United States.

There is Representative Jan Shakowsky’s CHOICE Act, H.R. 635, which would establish a public option under the ACA.  See also S. 194, Senator Sheldon Whitehouse’s CHOICE Act.  There’s Rep. Gene Green’s HR 2628 to stabilize Medicaid and the Children’s Insurance program.  Rep. John Conyers introduced his form of “single payer” in his Medicare for All bill, HR 676.  On the topic of making pharmaceuticals more affordable:  Senator Sanders – Affordable and Safe Prescription Drug Importation Act S. 469.  Senator Klobuchar has a bill “… to allow for expedited approval of generic prescription drugs and temporary importation of prescription drugs in the case of noncompetitive drug markets and drug shortages.” S. 183. Rep. Kurt Schrader introduced H.R. 749 to increase competition in the pharmaceutical industry.  Senator Ron Wyden introduced S. 1347, RxCap Act of 2017.

Senator Klobuchar has also introduce a bill supporting Alzheimer’s caregivers in S.311.  Rep. Derek Kilmer’s bill, H.R. 1253, seeks to improve access to treatment for mental health and substance abuse issues.   This is by NO means an exhaustive list of what can be gleaned from Gov.Track, but it does illustrate that the Democrats are not without suggestions — negotiating drug prices for Medicare, stabilizing the current system, public options, single payer — it’s just that these bills won’t get out of Republican controlled committees and they didn’t make it into Senator McConnell’s Secret Shop.

Indulge in no victory dance, we’ve seen this movie before … don’t believe that some minor blandishment won’t be enough to lure Senator Heller from his current position …don’t think that the products of McConnell’s Secret Shop have stopped coming off their assembly line.

Senator Heller can be reached at 202-224-6224;  702-388-6605;  775-686-5770

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Filed under Health Care, health insurance, Medicaid, Medicare, nevada health, Pharmaceuticals, Politics, public health

What Nevada Loses under Trump-Doesn’t-Care

Here’s what Nevada loses under the egregious Trumpcare Bill:

(1)  138,100 citizens in Nevada will lose their health insurance coverage.

(2) 81,000 Nevadans will lose their Medicaid coverage.

(3) 439,000 Nevadans with pre-existing conditions will be put at risk.

(4) The bill cuts funding for care for 125,056 Nevadans with disabilities.

(5) It would raise the average health insurance premium for Nevadans by $677 in 2018.

(6) $288 million in new costs will be added to Nevadans in order to keep their Medicaid expansion.

Not a very good deal for the Silver State!

Call. Call. Call Senator Dean Heller.  702-388-6605    775-686-5770    202-224-6244

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Filed under health, health insurance, Heller, Medicaid, nevada health, Nevada politics, Politics

Rural Nevada Health Care and the Great Bamboozle AHCA

The state of Nevada consists of 110,567 square miles of miles and miles and miles.  271,985 people live in those miles and miles and miles out of a total population of  2,940,058.  A quick poke at the calculator shows a state in which 93% of the population is urban, while most of the real estate is rural.   This situation poses some easily apparent problems for health care services and the delivery thereof.

Rural health services must literally cover wide spans of territory in which there is a small population.   There is one hospital in Battle Mountain (Lander County, NV) to serve a total population of 5,702.  There is one hospital in Winnemucca (Humboldt County, NV) serving a total population of 16,528.  There is one hospital in Lovelock (Pershing County, NV) with a total population of 6,753.  There is one hospital in Elko (Elko County, NV) serving a population of 48,818.  Two conclusions can be reasonably drawn from this quick view of the northern tier of rural counties: (1) In none of these areas can a hospital draw upon “economies of scale” in terms of hospital services.  The obvious example may be that an expectant mother will usually require the same obstetric services in Battle Mountain, as in Winnemucca, as in Las Vegas or Reno.  (2) These rural hospitals serve populations which are generally not as affluent as in urban areas;  the rural per capita income lagging slightly behind urban areas. [RH] This places the northern tier of counties in a predicament similar to other western states:

“In the rural West, many farmers, ranchers and other agricultural workers are self-employed, so they can’t get coverage through an employer. Hence, a higher percentage of agricultural employees are covered by Medicaid (11 percent) than in non-agricultural industries (8 percent). Before the ACA was enacted in 2010, workers in the agricultural sector had fewer options, so many remained uninsured. But under the Obama-era plan, many states expanded Medicaid, increasing the percentage of those covered. Under the AHCA, that expansion would be significantly scaled back, according to the Joint Economic Committee report.”

Thus, the National Rural Health Association issued this warning:

“Though most rural residents are in non-expansion states, a higher proportion of rural residents are covered by Medicaid (21% vs. 16%). Congress and the states have long recognized that rural is different and thus requires different programs to succeed. Rural payment programs for hospitals and providers are not ‘bonus’ payments, but rather alternative, cost effective and targeted payment formulas that maintain access to care for millions of rural patients and financial stability for thousands of rural providers across the country. Any federal health care reform must protect a state’s ability to protect its rural safety net providers. The federal government must not abdicate its moral, legal, and financial responsibilities to rural, Medicaid eligible populations by ensuring access to care.”

In short,  cuts to the Medicaid program will disproportionately affect rural health care providers serving rural populations.

But, but, but, sputter the advocates of the Republican offering — We’re Giving People A Choice — you can buy what you want!  Not. So. Fast.

“Though some provisions in the modified AHCA bill improve the base bill, NRHA is concerned that the bill still falls woefully short in making health care affordable and accessible to rural Americans. For example, the modified bill contains a decrease in the Medical Expense Deduction threshold from 10% to 5.8% in an attempt to assist Americans between the ages of 50 and 64 who would see their premiums skyrocket under the current plan. However, this deduction is not a credit and therefore would be of little use to low income seniors that are in very low tax brackets or do not pay income tax at all. Additionally, the new amendments to freeze Medicaid expansion enrollment as of Jan. 1, 2018, and reduce the Medicaid per-capita growth rate will disproportionately harm rural Americans.”

Well, that didn’t go well.  What about that “get what you want argument?”  The first question might well be — What can you afford?  The annual earnings of a farm or ranch owner (manager) in Nevada is reported at an annual mean of $91,970.  However, the range runs from 10th percentile $39,850 to 90th percentile $150,410.  The annual mean wage for a farm or ranch worker is $34,520. [BLS]  Nevada’s reported average annual mean for farm and ranch workers is slightly higher at $36,480. [DETR download] Now we have a problem — 138% of the federal poverty level is $16,374 for a single person or $33,534 for a family of four.   Our hypothetical average annual mean earnings for a farm or ranch worker isn’t eligible for Medicaid expansion enrollment, but has an income well below the Nevada average household income average of $52,431, or 63.96% of the annual average household income level.

How to market an insurance policy this hypothetical average family could afford?  Either offer a comprehensive insurance plan and provide premium assistance to make up the difference between what the premium costs and what the family can reasonably afford — or there’s always the Junk Insurance option.   Consumer Reports offered some excellent advice concerning what constitutes Junk Insurance — aka “affordable plans” —  watch out for fixed benefit indemnity plans, and medical discount cards.  Another Consumer Reports bulletin specified the elements of Junk Insurance, your insurance plan could be very hazardous to your physical and financial health if it contains: Limited benefits; Low overall coverage limits; unrealistic “affordable” premiums; No coverage for important health care services; Ceilings on categories of care; No limits on out of pocket costs; Random catches — like covering hospital care after the second day, when it’s known that the first day is usually the most expensive.

The problem at this juncture for rural Nevadans is that those in the agriculture sector may or may not have earnings allowing them to enroll in Medicaid.  If “yes” then a reduction in Medicaid — whether it happens now or just after the 2020 elections — will have a negative impact on many citizens in the northern tier of “cow counties;” similarly, a return to the Bad Old Days pre-ACA makes those who are certainly less than affluent vulnerable to the offerings of Junk Insurance, which is fine as long as they don’t mind paying for a product which will not cover their medical expenses at the time they actually need it.  Exacerbating this issue is the fact that jobs in agriculture (farming and ranching) are listed by Forbes as the 4th most dangerous occupations in the country.

There’s no way to bestow a bright face to the Republican tax cut disguised as a health insurance ‘reform’ bill in terms of what happens to rural Nevadans and their health care providers.  Those it doesn’t cut out completely it leaves vulnerable to incomplete and almost useless “catastrophic coverage” plans — which for too many policy holders leaves them facing health care costs well beyond their ability to pay for out of pocket.  If there were a recipe for increasing the “uncompensated care” costs for local hospitals and clinics this is definitely IT.  Rural hospitals and clinics, already stretched to meet costs, would be especially at greater risk — and we haven’t even touched on the topics of long term care for the aging or home health care services which prevent individuals from having to reside in more expensive residential care facilities in rural areas.

NOW is the time to contact, and continue to contact, our Senators (Heller and Cortez-Masto) and urge their opposition to this assault on medical care for northern Nevada citizens and their health care providers.

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Filed under Health Care, health insurance, Heller, Medicaid, nevada health, Nevada politics, Politics

Amodei’s Bubbles: Republican Dreams for the AHCA

Nevada Representative Mark Amodei (R-NV2) is eager to let his constituents know that the District will not be negatively impacted by the GOP health insurance/tax cut bill currently being drafted in secret on Capitol Hill.  Not. So. Fast.

First, there will be losses.  Total coverage losses are projected to be felt by 37,500 under the AHCA, and 5,700 of those will be children, another 700 are disabled individuals in District 2.   Representative Amodei is optimistic about what will happen to these constituents —

Any Nevadan who has enrolled in the expanded Medicaid program from its inception in 2014 through the end of 2019 is free to remain in the program so long as their income does not exceed 138% of the national poverty level; …

In short, according to Rep. Amodei, his constituents are to be carefree and happy about their health insurance coverage until the end of 2019.  It’s now 2017.  Thus the recipients are to be reassured for another two years because:

  • Nevada will continue to receive the enhanced federal Medicaid funding for enrollees that it is currently receiving for as long as that enrollee stays in the program;

  • Present expanded enrollees lose eligibility only if they exceed income of 138% of the national poverty level, or if they elect to take employer provided or private health insurance;

Lovely, until we peek into the House version (the basis for the Senate version) and find:

“Medicaid provides coverage for over 70 million individuals and relies on both federal and state funding to continue growing. Under current law, the federal government covers, on average, 57 percent of each state’s total Medicaid costs, no matter the amount. The states pay for the remainder.

In contrast, under the AHCA’s per capita cap Medicaid program, starting in 2020, the federal government would provide states with a flat, capped dollar amount of funding for each person they enroll. The dollar amount is based on states’ 2016-level per-enrollee spending.”

One way to interpret this is that the District’s enrollees will be fine for the moment, but should be aware that the sword labeled ‘the Medicaid Per Capita Lid’ is swinging over head.  This has the potential to burst the first of Amodei’s bubbles.

Secondly, there’s this part of Representative Amodei’s eternal optimism:

“While we understand that Medicaid Expansion will eventually be phased out, we expect the recovery of our economy to continue, giving us reason to believe we will not need as robust of a safety net as we once needed at the height of the recession.  Additionally, with Nevada leading the nation in job growth in 2016, we also can expect employer-based coverage to become available to more people.”

A bit of confusion reigns here — don’t worry about Medicaid expansion cuts because Nevadans will be covered — but notice that the Medicaid expansion will “eventually be phased out.” One really doesn’t get to have it both ways.  But, there’s more.

Yes, the Gallup 2016 Job Creation Index gives Nevada top marks for job creation, but remember that this polling is based on asking workers if the employer is increasing hiring.   It is also statewide.  If we drill down we find positive news, but an incomplete picture.

“Employment increased in Nevada’s two large counties from September 2015 to September 2016, the U.S. Bureau of Labor Statistics reported today. (Large counties are defined as those with 2015 annual average employment of 75,000 or more.) Washoe County’s employment rose 5.0 percent and Clark County’s employment rose 3.7 percent.” [BLS]

What we are required to believe  is that employment increases in District 2 will be sufficient to cover some 37,500 people who will need to find employer paid insurance coverage by 2020.  Exactly how this is supposed to happen isn’t all that clear.

There are too many “ifs” in the proposition to adopt it with any enthusiasm.  IF there is continued employment increases — in the face of the financial deregulation legislation in the House and Senate which threaten to recreate the Wall Street Casino environment that wrecked Nevada’s economy in 2007-2008.  IF the employment increases in the rural portions of District 2 are sufficient to put Medicaid expansion enrollees into employer plans.

And then, there are the problems intrinsic in the AHCA in the employer sponsored insurance plans.  Those believing that the AHCA will deliver the same level of health insurance coverage in employer sponsored plans as the ACA may be in for a rude shock.

“The amendment (to the AHCA) would allow states to apply for waivers to rescind two major regulations of Obamacare, if the state can prove that healthcare costs would decrease as a result. That has led to concerns about its potential effects on the individual insurance market, but it could also change insurance for people that get coverage through their employers.

One of those Affordable Care Act-implemented protections — called essential health benefits (EHB) — requires insurers to cover a baseline of 10 health procedures and items including emergency-room visits, prenatal care, mental-health care, and some prescriptions.

Under Obamacare, employer plans could not place a lifetime limit on the amount that the plans pay out on EHBs, and required plans to limit the amount of out-of-pocket costs an employee had to pay annually, according to The Journal. That made plans more costly for employers but also provided better coverage for employees.”

Thus, there are three problems — junk plans might be back in the market; essential benefits can be reduced; and lifetime and annual benefit limits could be reintroduced.  We can safely assume that Representative Amodei’s analysis contains the usual measure of Trickle Down Happy Talk (if only the tax cuts are big enough all employers will hire enough people to make the magic happen! — See Kansas) and assumptions which sound superficially rationale but don’t hold up to much scrutiny.

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Filed under Amodei, health insurance, Medicaid, nevada health, Nevada politics, Politics