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Democrats’ Aim Should Be Universal Coverage – Improving the ACA is the Right Vehicle

Democrats’ Aim Should Be Universal Coverage – Improving the ACA is the Right Vehicle

I get why the liberal wing of the Democratic Party is obsessed with enacting Medicare-for-All as the vehicle to universal coverage. I do. There’s no question that if we got it right, it would be both far more equitable and cost-effective than the present chaotic patchwork of a “system” that we’re currently lumbered with. I was raised in England and I know what a blessing the National Health Service has been, warts and all, in providing first class health care to everyone and without driving any of anybody into bankruptcy.

I also understand only too well the frustration of forever being told that it simply can’t be done, that the odds are stacked against it. How do we know unless we try, right?

Nevertheless, reality must intrude. First, as we have already seen with the few states that have tried to add a public option to their ACA markets that the health care industry will wage total war on any suggestion of even a modest expansion of of a public health care option. And when I say the health industry, we’re talking the insurance companies, the hospital industry, the pharmaceutical industry and much of the medical profession, particularly specialists, surgeons and the hospitals each of whom gain the most from the present lack of price controls on any but Medicare patients, and who will fight tooth and nail to keep it that way. Added to the health industry’s implacable opposition will be the Republican Party and the entire right-wing universe complete with relentless fear mongering and lies. And they will have a powerful issue that lends itself to demagoguery. Socialized medicine! Egads!! The fact that they’ve called the ACA, modest insurance reform at best, the same thing will of course be lost in the din.

Second, a total reform of the entire US health care system, one that dwarfs the enactment of the ACA, will require the support of most Americans, 180 million of whom currently have employer-provided health insurance which most of them believe is just fine, thank you very much. And Democrats would be asking them to give that up and see their taxes increase to boot – a hard sell even though insurance premiums will go away. All of this on the promise that expanding Medicare to include everybody, entirely rationale but something we’ve never tried before, would be better. And then there’s the seniors who are currently well satisfied with their Medicare and will be scared into believing (by you know who – see above) that somehow they will lose much of what they have if their health care is folded into a national scheme for the whole population.

In short it will not merely be an uphill struggle to enact Medicare-for-all but the policy equivalent of free climbing Half Dome in Yosemite National Park and to believe otherwise is delusional.

But there are other ways to universal coverage. In fact there are many models among developed countries that have achieved and did so with a system that incorporates private insurance albeit heavily regulated. Switzerland is one, for example. Check this link to the non-partisan Commonwealth Fund for a thumbnail sketch of the Swiss system and that of other developed nations from whose systems we can draw lessons .

Which brings us to the Affordable Care Act. Like all compromises on huge and complex pieces of legislation, the ACA is manifestly imperfect and in need of substntial improvement, for example by vastly reducing out-of-pocket expenses and greatly expanding the income cut off to receive premium subsidies. Yet the law has significantly increased the number of people with health insurance whilst proving unexpectedly resilient in surviving GOP efforts to repeal it and the Trump administration’s attempts to weaken it. If Democrats win the White House and Congress in 2020, they have an opportunity to undo all the damage of the Trump era and to make the ACA a far bigger success in providing affordable health coverage to a vulnerable population.

As well, Democrats have other costly priorities to address such as climate change and relieving our kids of the huge debt burden of college loans, to name but two. A full throated battle for a single payer health system will suck all the political oxygen out of the air and leave us with little energy to seriously tackle those issues. And that would be a tragedy.

Donald Trump Tweets Flag Burners belong in Jail and should Lose their Citizenship

Donald Trump Tweets Flag Burners belong in Jail and should Lose their Citizenship

Early this morning, Donald Trump woke up and sent off a flurry of tweets including this one:

“Nobody should be allowed to burn the American flag – if they do, there must be consequences – perhaps loss of citizenship or year in jail”!

6:55 AM – 29 Nov 2016

What are we to make of this tweet that defies the U.S. Constitution? In 1989 the Supreme Court in Texas v. Johnson ruled that burning a flag in protest is political expression protected by the First Amendment. In 1967 the Supreme Court ruled in Afroyim v. Rusk that the 14th Amendment forbids the government from taking away the citizenship of natural born Americans. Is Donald Trump suggesting that congress enact laws to punish flag-burning protesters by incarcerating them for a year and/or stripping them of their citizenship? Based on Supreme Court decisions, if congress did pass such laws, they would immediately be ruled unconstitutional.

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High price paid by states that did not expand Medicaid under Obamacare

High price paid by states that did not expand Medicaid under Obamacare

There has been no shortage of good news about the beneficial effects of the Affordable Care Act, particularly for those states that embraced it; and on the overall reduction in the percentage of uninsured adults in the country.

However, research by the Urban Institute also highlights the steep price paid by states that fought it tooth and nail, notably in the South.

For example, as of June 2014, 49% of the remaining uninsured adults in the United States live in the South, up from 41.5% before the act took effect in September 2013. Furthermore, almost 61% of uninsured adults reside in states that did not expand Medicaid under the ACA compared to less than 50% before the ACA.

And the bad news doesn’t stop there. The Urban Institute has quantified the billions in federal money lost by (mostly Red) states that rejected expanded Medicaid, as explained in this piece from Jonathan Cohn in the New Republic, again based on research by the Urban Institute. The excuse offered by Republican governors that they are simply being fiscally responsible is exposed for the nonsense it is by the map in Cohn’s piece.

Georgia, for example, saves $2.5 billion in what it would have spent to expand Medicaid over the course of a decade, but stands to lose $33.5 billion in federal funds, more than ten times as much. And of course it does nothing for the 20.2 % of Georgia adults who are still uninsured; in fact and as lamented in this piece from The Atlanta Journal-Constitution, the state now has the third highest rate of uninsured behind the perennial champs, Texas and Mississippi.

Talk about cutting off your nose to spite your face!

Democratic Presidents have the Advantage over Republicans when it comes to Economic Growth

Democratic Presidents have the Advantage over Republicans when it comes to Economic Growth

You can read about it here or here, but the graphs (via tell you all you really need to know .

Start with this one on GDP since the second Truman Administration.

Democratic GDP Dominance

Democratic Presidents following Republican Presidents presided over stronger growth in every instance except Reagan’s second term compared to Carter’s term. But if you average Reagan’s two terms and compare it to Carter’s one, it’s close to a tie. Obama’s first term was far superior to Bush’s second and, by all current indicators, his second term will be much better than Bush’s first term in spite of Republican obstructionism.

What’s really interesting is this graph (via The Atlantic).

Democratic Economic Indicator Dominance

Democrats have led in every category for the past 70 years. Coincidence? I don’t think so. And just think how much better our economy would be doing now if Republicans hadn’t been kneecapping Obama and the Democrats every step of the way for the past six years.

Based on what the Republican’s and their phony policy wonk Paul Ryan have been peddling as their economic solution for the past six years, if a Republican were somehow to be elected in 2016, the economy would surely suffer if they were able to implement their plans to cut taxes for the rich and corporations and to drastically cut entitlement programs and repeal Obamacare.

So come this November and then again in November 2016, do the right thing: Vote for Democrats. It’s good for the economy and it’s good for you.

US healthcare system ranks last again. Obamacare will raise its future rankings.

US healthcare system ranks last again. Obamacare will raise its future rankings.

A recent study by the Commonwealth Fund ranking healthcare systems in eleven advanced countries found the United States in last place. And while we languished at the bottom the study, which ranked healthcare delivery on such metrics as quality of care, access, efficiency and healthy outcomes, rated the United Kingdom at number one (take that, Fox News know-nothings). Just to add insult to injury, the UK spends $3,405 per capita on health (second lowest behind New Zealand) while we spend a whopping $8,508, the most of any in the study by a country mile.

Unsurprisingly, we fared poorest in categories associated with access and equity thanks to our lack of universal insurance coverage, and in efficiency where we are burdened with such deficiencies as excessive insurance company administrative overhead, medical duplication and overuse of emergency room treatment.

We also performed the worst in healthy outcomes as measured by infant mortality, healthy life expectancy, and mortality amenable to medical care (i.e. unnecessary or avoidable deaths).

As if this study wasn’t bad enough, we also have the International Federation of Health Plans 2013 Comparative Price Report which annually measures the cost of medical procedures and drugs among selected countries. Guess who regularly emerges as the most expensive? Even Switzerland (where a hamburger meal can cost $50) is way cheaper. As Ezra Klein noted about the iFHP 2012 price report in the Washington Post:

This is the fundamental fact of American health care: We pay much, much more than other countries do for the exact same things. For a detailed explanation of why, see this article. But this post isn’t about the why. It’s about the prices, and the graphs.

One note: Prices in the United States are expressed as a range. There’s a reason for that. In other countries, prices are set centrally and most everyone, no matter their region or insurance arrangement, pays pretty close to the same amount. In the United States, each insurer negotiates its own prices, and different insurers end up paying wildly different amounts.

So the US healthcare system is definitely ailing. But relief may be at hand. In noting the results of the Commonwealth Fund report, a New York Times  editorial states:

The poor results for the United States reflect the high cost of its medical care and the absence of  universal health insurance, a situation being addressed by the Affordable Care Act. The federal law is already increasing the number of Americans with health coverage and will substantially cut the number of uninsured in coming years. Other advanced nations are far ahead in the game because they have long had universal health coverage and promoted strong ties between patients and doctors.

Already the ACA’s beneficial effects on the rate of uninsured are being felt, particularly in states that embraced it wholeheartedly, as this piece about Minnesota from Jonathan Cohn in the New Republic shows.

So, despite the best efforts of Republicans to keep us mired in a rotten system that is inefficient, inequitable, prohibitively expensive, and too often lacking in overall effectiveness, there is hope that the future will be significantly brighter for American healthcare, thanks to Obamacare.

GOP’s selective outrage on display with VA scandal.

GOP’s selective outrage on display with VA scandal.

Over at, Ezra Klein puts the current Veterans Administration healthcare scandal into much needed perspective by wondering why there isn’t similar outrage over the 4.8 million Americans who fall into the Medicaid gap because their GOP governors and/or legislatures have refused that program’s expansion under Obamacare – an expansion paid for 100% by the federal government for the first three years and 90% thereafter.

Of that 4.8 million, about 250,000 are poor veterans. Their situation is far more precarious, as Klein points out, than that of veterans caught up in the VA’s care backlog.  However long and outrageous the wait times may be for VA care, those eligible for it at least know that quality care will come eventually.  Veterans not eligible for VA care but eligible under the Medicaid expansion who happen to reside in one of the 24 states which have opted out can expect no relief, no help. For them it is not just a delay in care that is at issue but its complete absence.

So where is the outrage for the almost 5 million souls affected, particularly from those Republicans and conservatives who are practically frothing at the mouth over the VA revelations? We know the answer from the din of silence, and it’s not difficult to figure out why. There’s political mileage to be made out of the VA’s problems even though they’ve been a long time building. But the lack of coverage for those in the Medicaid gap is the GOP’s exclusive shame and the less said about it the better.

No one would argue that our wounded veterans don’t deserve the very best care we can provide. But why stop there? It’s not a zero-sum game, after all? We can show our concern for both vets and the uninsured working poor can’t we?

Klein provides the roll of shame of states which have refused the Medicaid expansion and the total number of people in each who would be eligible, together with a separate figure for vets. It’s nothing short of a disgrace and as a civilized society we should be every bit as outraged over the plight of those in the Medicaid gap as we are over the VA’s deficiencies.

The case for Obamacare just keeps getting stronger.

The case for Obamacare just keeps getting stronger.

Two recent news items lend strong support to the notion that the Affordable Care Act will be a very significant benefit to the country going forward.

First, Sarah Kliff at Vox reports on recent evidence that the percentage of uninsured Americans is at its lowest rate since before the economic meltdown in 2008. The decrease in the uninsured is particularly strong among lower income Americans who were a particular focus of the law:

The gains of insurance coverage have been especially large among lower-income Americans – the people who qualify for Medicaid or insurance subsidies under the Affordable Care Act. There’s been a 5.2 percentage-point drop in the uninsured rate, for Americans who have a household income lower than $36,000 since the end of 2013.

Second, Jonathan Cohn in The New Republic has a piece on a newly published study in the Annals of Internal Medicine by highly regarded researchers showing that the overall mortality rate in Massachusetts fell significantly following the introduction of the state’s health care law (“Romneycare”), the one on which Obamacare is largely based.

This last is important for several reasons, not least because conservative opponents of the ACA have gleefully cited a different study, of Oregon Medicaid recipients, which seemed to show that having medical insurance did not equate to better health outcomes.

Cohn explains that for the Massachusetts study, the researchers

….obtained figures on mortality and, better still, they were able to isolate causes of mortality “amenable to health care.” In other words, they were able to get data on cancers, various cardiac problems, and other conditions that, with better medical care, people should be more likely to survive. Then they compared how the people in Massachusetts fared relative to groups of people from around New England, who were similar in almost every meaningful way—age, income, and so on—except that they lived in states where similar expansions of health insurance were not underway.

The results were clear. In those other places, outside of Massachusetts, the death rate from “amenable” causes went down by only a little bit and the overall death rate actually increased a tad. But in Massachusetts, deaths overall and deaths from “amenable” causes both went down—significantly. The authors calculated that, for every 830 people who got insurance in Massachusetts, about one person avoided a premature death.

The Massachusetts study covered a broader population than did the Oregon Medicaid research and a longer period. And the greatest improvement came, unsurprisingly, in counties where there were more low-income and uninsured adults. The researchers also examined whether factors other than expanded insurance could conceivably account for the decrease in mortality but concluded they could not.

Some caution is necessary. Certainly this is only one study in one state. But as Cohn puts it

The findings from a Massachusetts are consistent with a long line of similar, previous work. In the 1990s, for example, economists Janet Currie and Jonathan Gruber found that expanded eligibility for Medicaid led to lower infant mortality and fewer low birthweight babies.  “More work is clearly needed,” says Gruber, an MIT professor who was an architect of both the Massachusetts and federal health reforms, “but we should basically be back to our presumption that health insurance improves health.”

Conservatives continue to be in denial about Obamacare and to insist on dire predictions of the ill that will befall us if we do not repeal it. The decreasing percentage of uninsured in America and the Massachusetts study showing the benefits of health insurance, however, seriously undermine that narrative.

Nebraska US Senate Candidate Ben Sasse hates Obamacare – We know because his daughters tell us so.

Nebraska US Senate Candidate Ben Sasse hates Obamacare – We know because his daughters tell us so.

Midland University President Ben Sasse, who is running for the US Senate in the Nebraska Republican primary this month, uses his daughters; 10-year-old Alex and 12-year-old Corrie, in a political ad that expresses how much he despises the Affordable Care Act.

Alex: “He does not like ObamaCare. He’s read it and he realizes how bad it is, and he wants to find a way to, um, destroy it and rebuild something that’s successful”.

Corrie: “He despises it. When people say bad things about him, he tries to ignore it, and we always pray for the opposing candidates at breakfast”.

Alex: “My Dad wants to go there as the outsider and he wants to fix Washington”.

Corrie: “Can I put in now that I want a horse very badly”?

Awwww…. isn’t that cute? She supports her father in his quest to destroy ObamaCare, and prays with him at breakfast for God’s help to defeat his political enemies. But she wants a horse, so it’s all good!

Actually it’s a pretty creepy ad. He enlists his little girls to go negative because it would seem unbecoming of a University president to say he despises the Affordable Care Act and wants to destroy it. Best to leave the attack ads to the kids.

I suppose he could star in an ad that explains how he would “rebuild something that’s successful”, but he can’t. Just like all the other Republicans who hate Obamacare, he is stuck with the law because it was their idea to begin with.

The Republicans left with any brains at all know that the only way a free-market based system designed to cover everyone, including those with pre-existing conditions, can work is to get healthy people to pay into the pool. To do that there must be a mandate and, since some people are poor, they need help paying the premiums. If you take away any of the three most important features of the law: coverage for everyone, a requirement for everyone to have insurance, and subsidies for those who can’t afford to pay the premiums – the whole thing falls apart.

The Republican Party has had years to propose an alternative solution, but so far we’ve heard nothing tangible. We’ve only heard that they want to keep the parts they like and get rid of the parts they don’t like.

So tell us Mr. Sasse, after you destroy ObamaCare how will you successfully rebuild it? What will be better about it and will it be affordable?

Mitch McConnell has nothing to offer Kentucky. He’ll be re-elected anyway.

Mitch McConnell has nothing to offer Kentucky. He’ll be re-elected anyway.

Kentucky is one of the poorest states in the union. It vies with West Virginia and Mississippi for bottom place in any well-being list. Its rates of poverty, obesity and general ill-health are among the worst in the country. It has high unemployment. And residents of Kentucky are among the most miserable in the nation, attributable in part to the high incidence of poor health.

In the 30 years he has served it as a United States senator, Republican Mitch McConnell, who is up for re-election this year, has provided little substantive help to the state. Oh sure McConnell steered a good chunk of earmark money to Kentucky over the years; but, as this Huffington Post profile on his career found, the money was directed scattershot fashion primarily in ways that would best cement McConnell’s own power and support in the state rather than as part of any strategy to enhance the state’s welfare. And since 2011 the earmark well has dried up, banned by McConnell’s own party in a largely symbolic show of fiscal rectitude.

Thanks to its Democratic governor’s wholehearted embrace of the Affordable Care Act, however, Kentucky stands to benefit enormously. Already about 360,000 people have signed up for health insurance under the ACA, of whom 75% were previously uninsured. All but 20,000 of the new enrollees are covered under the ACA’s expanded Medicaid, thanks to Kentucky’s low median income level and high poverty rate.

There are few states whose residents need it more. As the 24/7 Wall Street summary of the Gallup-Healthways Well-Being Index 2014 noted:

Kentuckians had some of the most unhealthy behaviors last year. Less than 60% of those surveyed said they ate well all day, the worst among all states, while the smoking rate was the highest in the nation. Unhealthy habits in the state likely contributed to poor physical health. Respondents from Kentucky were among the most likely to complain about lack of energy and sleep, and nearly 30% said health issues prevented them from going about their normal lives. The state’s population was the nation’s most reliant on prescription drugs, with 19.3 prescriptions filled per capita in 2011, tied with West Virginia.

And since approximately 640,000 or 17.5% of residents under 65 lacked insurance prior to the ACA, the law may be a game changer for a state that has traditionally struggled. While there is as yet no clinically proven connection between health insurance and good health, research indicates that having insurance coverage at the very least relieves stress and depression by ameliorating the strain of financial insecurity. Over time it is not unreasonable to hope that the expansion of health coverage in Kentucky will have an enormously significant and positive impact on its population’s well-being.

One would think that this might change the political landscape in this very conservative state. After all a law passed by Democrats in Washington and implemented brilliantly in Kentucky by Democratic Governor Steve Beshear through a remarkably trouble-free website, is already benefitting scores of thousands and has reduced the rate of uninsured by over 40%.

Alas not so. Hatred for Obama and anything associated with him overshadows any actual benefit from the ACA. According to Yahoo News:

Far from being seen as a success story, though, in Kentucky, the health care law and Beshear’s strong embrace of it remain deeply controversial. A recent poll showed that a plurality of Kentuckians continue to favor repealing the law. Other than Beshear, many of the state’s leading Democrats, aware of the lingering tensions around the ACA, avoid speaking about it publicly, wary of being seen as too supportive of “Obamacare.”

Assuming McConnell survives a GOP primary challenge, his Democratic opponent in November will be Allison Lundergan Grimes. In a rational world, Grimes would be trumpeting the success of the ACA in Kentucky and its promise of a better future for so many. Instead:

Alison Lundergan Grimes, the Democrat challenging McConnell in a closely watched U.S. Senate race, does not include any mention of the law on her campaign website and has avoided associating herself with Beshear’s embrace of it.

The Economist wonders:

Why are Kentucky Democrats running away from a law that has for the first time brought free or affordable health insurance to hundreds of thousands of their constituents— mainly at the expense of wealthy out-of-staters? This is one of the poorest, unhealthiest, least-insured states in America, the state with the fourth-highest rate of Social Security disability status in the country, a state that is a byword for cancer-ridden smokers and black-lung-plagued coal miners. Why, among these voters especially, is Obamacare such a losing issue?

Because it was conceived and passed by Democrats and pushed by a black Democratic president, that’s why.

McConnell, of course, has nothing to offer Kentucky but his usual manipulations of the feeble-minded on issues like gun-control, and the promise to repeal a law that stands as the most positive development for the welfare of ordinary Kentuckians in a generation or more. Yet Grimes is a distinct underdog and current trends suggest that Democratic office holders will soon be rarer than unicorns in the state.

In his trenchant book, Thomas Frank asked the question: What’s the Matter With Kansas? People in Kentucky should be asking the same question of themselves.

Cathy McMorris Rodgers’ response to President Obama’s 2014 SOTU: Let us pray

Cathy McMorris Rodgers’ response to President Obama’s 2014 SOTU: Let us pray

Representative Cathy McMorris Rodgers (R-WA) responded to President Obama’s State of the Union speech last night with a vague outline of “hopeful” plans the Republicans have to “form a more perfect union”.

She said the plan “helps working families rise above the limits of poverty and protects our most vulnerable”. Obama has a plan for that too.

She said she “came to Congress to help empower people, not politicians; To grow the working middle class, not the government; And to ensure that everyone in this country can find a job”. Obama is trying hard to do that too.

She says that our mission as Americans is “to ensure that we are not bound by where we come from, but empowered by what we can become”. I’ve heard the same sentiment expressed by Obama in many speeches before and since he became president.

She said “We’re working on a step-by-step solution to immigration reform by first securing our borders and making sure America will always attract the best, brightest, and hardest working from around the world”. I’ve heard Obama say nearly the exact same thing.

She said that the real gap we face today is not one of income equality that the president spoke about but of “opportunity equality”, and that the gap keeps getting bigger. She did not define “opportunity inequality”. What did she mean? Was she talking about how kids born to the super wealthy one percent have way more opportunities than kids born into poverty? Maybe and, if so, that is a problem that Obama recognizes and addressed in his speech.

She said the Republican’s plan to close that gap is to “focus on jobs without more spending, government bailouts, and red tape…” and that they have “plans to improve our education and training systems so you have the choice to determine where your kids go to school…so college is affordable…and skills training is modernized.”

Obama has been focused on jobs, and yes he does want to spend government money to jump start the economy because there’s a whole lot of infrastructure that needs rebuilding, and now is a great time to do it. Money is cheap and the projects would create jobs. He also wants to improve our education system. Sometimes that takes more money too.

On healthcare reform, she said “we shouldn’t go back to the way things were, but this law is not working”. Obama certainly doesn’t want to go back to the way things were, and, contrary to her declaration, the law is working. It’s not perfect, but over ten million citizens that didn’t have coverage before now have coverage under Obamacare.

McMorris Rodgers tossed in some key words like “compassionate” and “exceptional” because if you refer to Americans with lesser terms, you can’t be a Republican, and you probably aren’t a real American, or human for that matter.

At this point I was expecting to hear some policy proposals for how Republicans will help people get out of poverty; create new jobs; empower people regardless of race or class; reform immigration laws; and improve our healthcare system by finding ways to cover everyone and lower costs; but she did not introduce even one policy proposal.

Instead of offering policy details, she became more patriotic and much more ambiguous:

But all of us will wake up and do what is uniquely American…

We will look forward to the boundless potential that lies ahead. We will give thanks to the brave men and women who have answered America’s call to freedom, like Sgt. Jacob Hess from Spokane, who recently gave his life to protect all of ours.

How is looking forward to “the boundless potential that lies ahead” uniquely American? Does she really think that the billions of people who don’t live in the USA don’t think about what lies ahead of them? And how will she and her party capitalize on the “boundless potential that lies ahead” to improve the lives of all Americans?

She didn’t say. All she could do was:

…simply offer a prayer…

A prayer for Sgt. Hess’s family, your family, and for our larger American family.

That, with the guidance of God, we may prove worthy of His blessings of life … liberty … and the pursuit of happiness.

For when we embrace these gifts, we are each doing our part to form a more perfect union.

So if I interpret this right, she’s praying to God for guidance on how to make our country better. Okay then, so what did God tell her? We’d like to know if they’re good ideas.