The Profound Social Cost of American Exceptionalism
by Eduardo Porter - NYT - May 31, 2018
When I wrote my first Economic Scene column six years ago, the unemployment rate languished at 8.2 percent as the job market painfully recovered from the jolt of the Great Recession. By last month, only 3.9 percent of working-age Americans who sought a job didn’t have one.
You are welcome.
I’m kidding, of course. How could anybody claim credit for the performance of something as vast and complex as the American labor market? My columns probably didn’t have anything to do with the doubling of the Standard & Poor’s 500-stock index, either, or even with the sixfold rise in digital-only subscriptions to The New York Times.
To the contrary, as I write what will be the last column of my tenure, I can’t help but acknowledge how little purchase my writing has had on the substance of reality. In particular, it has had no discernible effect on what one might call America’s fundamental paradox.
The United States is one of the richest, most technologically advanced nations in the history of humanity. And yet it accepts — proudly defends, even — a degree of social dysfunction that would be intolerable in any other rich society.
My first column pondered why Americans didn’t care more about the nation’s income gap, so much starker than that of any other advanced democracy. I suggested that my compatriots might come to a consensus that inequality is harmful when they realized how vast inequities could gum up the cogs of economic and social mobility.
Well, inequality hasn’t abated much. In 2015, the richest 1 percent of American taxpayers drew more than 20 percent of the nation’s income, including capital gains, according to the tabulations by the French scholar Thomas Piketty and his colleague Emmanuel Saez.
You can bet it has gone higher, given the bull run in the stock market since then. And Republicans just passed another round of tax cuts to offer a helping hand to the upper crust.
Most interestingly, Americans still don’t care that much. Sure, two-thirds say they are dissatisfied with the way income and wealth are distributed, according to Gallup. Still, more than three out of five — compared with just over half six years ago — are satisfied with “the opportunity for a person in this nation to get ahead by working hard.”
Republican orthodoxy is that inequality is not necessarily a problem. And if rising tides substantially lifted everybody’s boat, it might matter less that the yachts parked at the North Cove Marina, a stone’s throw from Goldman Sachs, rode a bigger swell. Tides in America don’t work like that anymore, though.
As my column has aimed to highlight, too many Americans are, well, sinking. Seventeen percent of Americans are poor by international standards — living on less than half the nationwide median income. That’s more than twice the share of poor people in France, Iceland or the Netherlands.
Forget about income, though. It’s hard to square Americans’ belief in their society’s greatness with the life expectancy of its newborn girls and boys. It is shorter than in Australia, Austria, Belgium, Britain, Canada, Chile, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Israel, Italy, Japan, Luxembourg, the Netherlands, New Zealand, Norway, Portugal, Slovenia, South Korea, Spain, Sweden, Switzerland and probably a few other countries I missed.
Or let’s measure our progress in terms of infant deaths. Scientists in the United States invented many of the technologies used around the world to keep vulnerable babies alive. So how come our infant mortality rate is higher than that of every nation in the Organization for Economic Cooperation and Development with the exceptions of Mexico, Chile and Turkey?
Our dismal rank, by the way, is not driven by the babies of white, affluent Americans. The impact of the nation’s fundamental paradox mostly fails the nonwhite and the poor. Black males born in the United States today will probably live shorter lives than boys born in Mexico, China or Turkey.
This set of facts seems to me problematic. Your heart doesn’t even have to bleed to care. The United States risks its prosperity by leaving so many Americans behind.
The children of poverty who survive will most likely hobble through life with mediocre educations — lagging their more affluent peers even before their first day in school and then falling farther behind, deprived of the resources that disadvantaged children in other advanced nations routinely enjoy.
Unequipped to cope with the demands of a labor market in furious transformation, they will give “social mobility” a new, all-American meaning: the tendency to move in and out of prison. It’s hard to believe any country could waste so many resources and prosper.
And yet for all the ink spilled by so many excellent journalists — from The Times’s own Neil Irwin to Vox’s Matt Yglesias, Bloomberg’s Noah Smith and many others — America is doubling down on its exceptionalism. The rich got a tax break. Bankers got a break from the pesky rules written in the shadow of the financial crisis to protect the little guy. The poor and near poor were freed from their ability to afford health insurance.
As Catherine Rampell noted in The Washington Post, populism — understood as a political movement shaped around giving the working class a “fair shake” — is pretty much dead.
And yet writing is, in fact, indispensable. It is because of the writing of journalists and social scientists — economists and political scientists, historians and sociologists — that we know what we know about the workings of American society, its economy and its political system.
From Lawrence F. Katz and Alan B. Krueger, I learned that the very meaning of the word “job” is changing, as fixed employment gives way to contract, part-time, gig and temp work. David Autor, David Dorn and Gordon Hanson enlightened me about the cost to many American communities of China’s rise. Michelle Alexander’s writingtold me about the impact of America’s ruthless criminal justice system on the nation’s blacks. Arlie Russell Hochschild’s shed light on the politics of its struggling whites.
To my colleagues in journalism, I owe the deepest debt of gratitude. From them I have learned how important it is to shine light on power. In this peculiar political moment, as the powerful promote self-serving realities, hoping to bend perceptions to their will, my colleagues’ work to communicate a reality undistorted by political ambition amounts to the last line of defense against autocracy.
I will miss writing the column. But I relish the opportunity this opens to write in another form, free of a column’s weekly demands to explore the drama of American life in greater depth.
I will be devoting the next few weeks to figuring out what to focus on next — chatting with my editors, as well as with the sources I have come to rely on for sober, authoritative thinking. The important question, however, remains: What kind of society does “America” mean?
When I wrote my first Economic Scene column six years ago, the unemployment rate languished at 8.2 percent as the job market painfully recovered from the jolt of the Great Recession. By last month, only 3.9 percent of working-age Americans who sought a job didn’t have one.
You are welcome.
I’m kidding, of course. How could anybody claim credit for the performance of something as vast and complex as the American labor market? My columns probably didn’t have anything to do with the doubling of the Standard & Poor’s 500-stock index, either, or even with the sixfold rise in digital-only subscriptions to The New York Times.
To the contrary, as I write what will be the last column of my tenure, I can’t help but acknowledge how little purchase my writing has had on the substance of reality. In particular, it has had no discernible effect on what one might call America’s fundamental paradox.
The United States is one of the richest, most technologically advanced nations in the history of humanity. And yet it accepts — proudly defends, even — a degree of social dysfunction that would be intolerable in any other rich society.
My first column pondered why Americans didn’t care more about the nation’s income gap, so much starker than that of any other advanced democracy. I suggested that my compatriots might come to a consensus that inequality is harmful when they realized how vast inequities could gum up the cogs of economic and social mobility.
Well, inequality hasn’t abated much. In 2015, the richest 1 percent of American taxpayers drew more than 20 percent of the nation’s income, including capital gains, according to the tabulations by the French scholar Thomas Piketty and his colleague Emmanuel Saez.
You can bet it has gone higher, given the bull run in the stock market since then. And Republicans just passed another round of tax cuts to offer a helping hand to the upper crust.
Most interestingly, Americans still don’t care that much. Sure, two-thirds say they are dissatisfied with the way income and wealth are distributed, according to Gallup. Still, more than three out of five — compared with just over half six years ago — are satisfied with “the opportunity for a person in this nation to get ahead by working hard.”
Republican orthodoxy is that inequality is not necessarily a problem. And if rising tides substantially lifted everybody’s boat, it might matter less that the yachts parked at the North Cove Marina, a stone’s throw from Goldman Sachs, rode a bigger swell. Tides in America don’t work like that anymore, though.
As my column has aimed to highlight, too many Americans are, well, sinking. Seventeen percent of Americans are poor by international standards — living on less than half the nationwide median income. That’s more than twice the share of poor people in France, Iceland or the Netherlands.
Forget about income, though. It’s hard to square Americans’ belief in their society’s greatness with the life expectancy of its newborn girls and boys. It is shorter than in Australia, Austria, Belgium, Britain, Canada, Chile, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Israel, Italy, Japan, Luxembourg, the Netherlands, New Zealand, Norway, Portugal, Slovenia, South Korea, Spain, Sweden, Switzerland and probably a few other countries I missed.
Or let’s measure our progress in terms of infant deaths. Scientists in the United States invented many of the technologies used around the world to keep vulnerable babies alive. So how come our infant mortality rate is higher than that of every nation in the Organization for Economic Cooperation and Development with the exceptions of Mexico, Chile and Turkey?
Our dismal rank, by the way, is not driven by the babies of white, affluent Americans. The impact of the nation’s fundamental paradox mostly fails the nonwhite and the poor. Black males born in the United States today will probably live shorter lives than boys born in Mexico, China or Turkey.
This set of facts seems to me problematic. Your heart doesn’t even have to bleed to care. The United States risks its prosperity by leaving so many Americans behind.
The children of poverty who survive will most likely hobble through life with mediocre educations — lagging their more affluent peers even before their first day in school and then falling farther behind, deprived of the resources that disadvantaged children in other advanced nations routinely enjoy.
Unequipped to cope with the demands of a labor market in furious transformation, they will give “social mobility” a new, all-American meaning: the tendency to move in and out of prison. It’s hard to believe any country could waste so many resources and prosper.
And yet for all the ink spilled by so many excellent journalists — from The Times’s own Neil Irwin to Vox’s Matt Yglesias, Bloomberg’s Noah Smith and many others — America is doubling down on its exceptionalism. The rich got a tax break. Bankers got a break from the pesky rules written in the shadow of the financial crisis to protect the little guy. The poor and near poor were freed from their ability to afford health insurance.
As Catherine Rampell noted in The Washington Post, populism — understood as a political movement shaped around giving the working class a “fair shake” — is pretty much dead.
And yet writing is, in fact, indispensable. It is because of the writing of journalists and social scientists — economists and political scientists, historians and sociologists — that we know what we know about the workings of American society, its economy and its political system.
From Lawrence F. Katz and Alan B. Krueger, I learned that the very meaning of the word “job” is changing, as fixed employment gives way to contract, part-time, gig and temp work. David Autor, David Dorn and Gordon Hanson enlightened me about the cost to many American communities of China’s rise. Michelle Alexander’s writingtold me about the impact of America’s ruthless criminal justice system on the nation’s blacks. Arlie Russell Hochschild’s shed light on the politics of its struggling whites.
To my colleagues in journalism, I owe the deepest debt of gratitude. From them I have learned how important it is to shine light on power. In this peculiar political moment, as the powerful promote self-serving realities, hoping to bend perceptions to their will, my colleagues’ work to communicate a reality undistorted by political ambition amounts to the last line of defense against autocracy.
I will miss writing the column. But I relish the opportunity this opens to write in another form, free of a column’s weekly demands to explore the drama of American life in greater depth.
I will be devoting the next few weeks to figuring out what to focus on next — chatting with my editors, as well as with the sources I have come to rely on for sober, authoritative thinking. The important question, however, remains: What kind of society does “America” mean?
Senior advocates say new draft guide to Medicare distorts facts. Here’s what you need to know
by Philip Moeller - PBS - May 25, 2018
Medicare & You is the government’s seminal guide to all things Medicare, and is a primary resource used by consumers in each year’s annual enrollment season beginning Oct. 15. As such, it is or should be the gold standard of reliable information for more than 65 million people already enrolled in Medicare and the millions of people who newly enroll each year.
After reviewing the draft, three groups said it contained false statements that appear designed to convince people that private Medicare Advantage plans are superior.
According to three leading senior advocacy groups, however, the 2019 draft version of Medicare & You has unfairly tilted the playing field. After reviewing the draft, the three groups – the Center for Medicare Advocacy, Justice in Aging, and the Medicare Rights Center – said it contained false statements that appear designed to convince people that private Medicare Advantage (MA) insurance plans are superior to original Medicare.
“Medicare & You is the core Medicare communication to beneficiaries,” the groups said in a joint letter to Seema Verma, head of the Centers for Medicare & Medicaid Services (CMS). “It is critical that the information in the Handbook be fairly and accurately presented. Beneficiaries making important choices about their coverage need to be able to rely on the Handbook for unbiased information that they can trust. However, when comparing Original Medicare and Medicare Advantage, the 2019 draft Handbook does not meet this standard, distorting and mischaracterizing the facts in serious ways.”
A spokesperson for CMS provided what I can only construe as a non-responsive response. It said, in part, “CMS is committed to empowering seniors and people with disabilities to make informed choices related to their Medicare coverage. We continue to look for better ways to explain to consumers the options they have under the Medicare program. Through feedback and consumer testing, we continue to modify and improve the content to help consumers make informed health care decisions.” The spokesperson added that a final version of the handbook would be mailed in September to 43 million households.
So what should you know? Here are some highlights of the original Medicare and MA plans and how the new handbook frames them:
Original Medicare
This includes Parts A and B. Part A helps pay for covered care in hospitals, nursing homes, and other institutions. It includes hospice, which is covered in institutions and also in a person’s home. Part B covers expenses for doctors, outpatient expenses, and durable medical equipment. Part B pays only 80 percent of covered expenses. Original Medicare is managed by the government, using a network of private Medicare administrative contractors (MACs) around the country.
This includes Parts A and B. Part A helps pay for covered care in hospitals, nursing homes, and other institutions. It includes hospice, which is covered in institutions and also in a person’s home. Part B covers expenses for doctors, outpatient expenses, and durable medical equipment. Part B pays only 80 percent of covered expenses. Original Medicare is managed by the government, using a network of private Medicare administrative contractors (MACs) around the country.
Many people with original Medicare also get a Medigap supplemental policy from a private insurer to pay for things that aren’t fully covered by original Medicare. People with original Medicare who want prescription drug coverage must purchase a standalone Part D drug plan.
Medicare Advantage
These are private insurance plans that were authorized in their current form by the 2003 law that created Part D drug plans. They usually are health maintenance organizations (HMOs) that require people to use doctors and hospitals in their plan’s provider network and include Part D coverage. The plans’ provider networks usually can offer cheaper coverage more cheaply than traditional Medicare, which permits enrollees to use any doctor or health-care institution in the country that participates in Medicare and accepts its payment rates.
These are private insurance plans that were authorized in their current form by the 2003 law that created Part D drug plans. They usually are health maintenance organizations (HMOs) that require people to use doctors and hospitals in their plan’s provider network and include Part D coverage. The plans’ provider networks usually can offer cheaper coverage more cheaply than traditional Medicare, which permits enrollees to use any doctor or health-care institution in the country that participates in Medicare and accepts its payment rates.
MA plans must cover everything that’s covered by original Medicare. Most MA plans use some of their provider network cost savings to cover things that original Medicare does not cover, including limited dental, vision and hearing benefits — plus gym-club memberships. They also offer annual limits on out-of-pocket expenses. People with MA plans are not allowed to purchase Medigap policies.
How popular are these plans?
MA plans have surged in popularity during the past 15 years. They now represent roughly a third of all Medicare, with original Medicare holding two-thirds of the market. CMS bureaucrats consistently supported expansion of MA plans during the Obama years and Trump appointees have if anything stepped up their advocacy.
MA plans have surged in popularity during the past 15 years. They now represent roughly a third of all Medicare, with original Medicare holding two-thirds of the market. CMS bureaucrats consistently supported expansion of MA plans during the Obama years and Trump appointees have if anything stepped up their advocacy.
Who supports which plans?
Under both administrations, there is support for MA plans because managed care has the potential to produce better health outcomes for less money than does original fee-for-service Medicare. The latter doles out health care regardless of whether it is cost effective or even good for a patient’s health. MA plans, by contrast, are better vehicles for tying health spending to positive outcomes.
Under both administrations, there is support for MA plans because managed care has the potential to produce better health outcomes for less money than does original fee-for-service Medicare. The latter doles out health care regardless of whether it is cost effective or even good for a patient’s health. MA plans, by contrast, are better vehicles for tying health spending to positive outcomes.
In the Trump White House, there also is strong support for private insurance solutions versus government-run programs. The bottom line of the concerns by Medicare advocacy groups is that CMS is improperly putting its hand on the scales to tilt them further in favor of MA plans.
What critics say
The Medicare Rights Center released a copy of the draft 2019 Medicare & You handbook along with detailed examples of what it saw as improper comparisons between MA plans and original Medicare.
The Medicare Rights Center released a copy of the draft 2019 Medicare & You handbook along with detailed examples of what it saw as improper comparisons between MA plans and original Medicare.
In several comparative discussions of the two approaches to Medicare, CMS downplays the possible shortcomings of getting care from a limited network of health providers in an MA plan, which involve not only a limited number of providers but also geographic limitations of where a plan provides coverage. At the same time, the draft handbook fails to emphasize that users of original Medicare can use any Medicare-licensed providers anywhere in the nation.
The bottom line
The handbook also creates the impression that MA plans are less costly to seniors than original Medicare. This may or may not be true; it depends on the types of coverage selected and a beneficiary’s individual medical needs.
The handbook also creates the impression that MA plans are less costly to seniors than original Medicare. This may or may not be true; it depends on the types of coverage selected and a beneficiary’s individual medical needs.
After Years of Trying, Virginia Finally Will Expand Medicaid
by Abby Goodnough - NYT - May 30. 2018
WASHINGTON — Virginia’s Republican-controlled Senate voted on Wednesday to open Medicaid to an additional 400,000 low-income adults next year, making it all but certain that the state will join 32 others that have already expanded the public health insurance program under the Affordable Care Act.
Republican lawmakers in the state had blocked Medicaid expansion for four straight years, but a number of them dropped their opposition after their party almost lost the House of Delegates in elections last fall and voters named health care as a top issue.
The vote, on a budget bill that included the Medicaid expansion, came almost three months after the House approved a similar plan. Gov. Ralph Northam, a Democrat also elected last fall, has been a vocal proponent of the expansion and can now claim a victory that his predecessor, Terry McAuliffe, desperately wanted but never got.
The House passed the Senate bill within hours; it will now go to Mr. Northam’s desk. The measure includes a requirement that many adult recipients who don’t have a disability either work or volunteer as a condition of receiving Medicaid — a provision that was crucial to getting enough Republicans on board.
“This budget is the culmination of five years of effort to bring our taxpayer dollars home from Washington and expand Medicaid,” Mr. Northam, a pediatrician, said in a statement. “As a doctor, I’m so proud of the significant step we’ve taken together to help Virginians get quality, affordable health care.”
The Affordable Care Act gave states the option to expand Medicaid starting in 2014, and required the federal government to pay no less than 90 percent of the cost. Opponents said that even 10 percent was unaffordable for most states, and that the federal government might renege on paying its share, especially if the health law were repealed.
On a day when Virginia neared becoming one of the biggest states, by population, to expand the program to date — an important step forward for the Affordable Care Act — President Trump boasted inaccurately at a bill signing that “for the most part we will have gotten rid of a majority of Obamacare.”
Efforts to expand the program are actually gaining steam in some other Republican states. With midterm elections approaching, advocates in Idaho and Nebraska are trying to get Medicaid expansion initiatives on their ballots. Their state legislatures have repeatedly refused to expand the program. Utah’s measure officially qualified for the ballot on Tuesday, and officials in Idaho are determining whether supporters have gathered enough signatures for their question to qualify.
Maine voters were the first in the nation to approve Medicaid expansion through a referendum last fall. But Gov. Paul LePage, a Republican, has blocked it from moving forward, and the matter is now tied up in court.
The federal government shares the overall cost of Medicaid with the states; the program covers about 75 million Americans, or 1 in 5. About 11 million of them were able to enroll as a result of states’ decisions to expand the program under the Affordable Care Act. Republican attempts to repeal the health law last year would have largely undone the Medicaid expansion and caused most of the new recipients to lose their coverage.
Virginia’s House of Delegates voted to approve Medicaid expansion during the regular 60-day legislative session that ended in March. But the Senate, whose members were not up for re-election last fall, remained opposed. Lawmakers failed to pass a state budget then because of the issue.
“That is debt, and I have four kids who are going to be having to pay for that for the rest of their lives,” Senator Amanda Chase, a Republican from Chesterfield, said of the federal funds spent on Medicaid expansion, explaining her vote against it on Wednesday. “It’s not just a fiscal burden, but it’s not the best solution for people who want real, quality health care.”
The turning point came in April when State Senator Frank Wagner, a Republican from Virginia Beach, said he had changed his position and would support Medicaid expansion, joining one other Republican, Senator Emmett W. Hanger Jr. of Augusta, and all 19 Senate Democrats. Mr. Wagner changed his mind after a work requirement was added to the plan.
Two other Republican state senators, Ben Chafin and Jill Holtzman Vogel, also voted for Medicaid expansion on Wednesday.
“I came to the conclusion, for me and my district, that no just wasn’t the answer any longer,” Mr. Chafin. who represents an economically struggling district in southwestern Virginia, said on the Senate floor. “Doing nothing about the medical conditions, the state of health care in my district, just wasn’t the answer any longer.”
The approval did not come without last-minute drama: Thomas Norment, the Senate majority leader and steadfast opponent of Medicaid expansion, tried unsuccessfully to block it in the Senate Finance Committee on Tuesday, and again on the Senate floor on Wednesday, when he pushed to pass a version of the budget that did not include it. Instead, a substitute budget including amendments that allowed for Medicaid expansion, offered by Senator Hanger, was approved.
Virginia’s plan would tax hospitals to generate revenue for the state’s 10 percent share of the roughly $2 billion annual cost.
The state currently has one of the most restrictive Medicaid programs in the country, covering mostly children and disabled adults. Childless adults are not eligible, and working parents cannot earn more than 30 percent of the federal poverty level, or $5,727 a year.
The Affordable Care Act allows states to expand Medicaid to adults earning up to 138 percent of the poverty level, which comes out to $16,643 for an individual.
Most of the remaining states that haven’t expanded Medicaid are in the South and Midwest, and are led by Republicans. Along with 32 states, the District of Columbia has expanded the program already.
This year, Republican governors and state lawmakers, encouraged by the Trump administration, have focused on adding new requirements for Medicaid eligibility, such as requiring adults without disabilities to work or volunteer, and many beneficiaries to pay premiums. Virginia would first expand Medicaid, then ask the federal government for permission to add a work requirement, under the plan the Senate approved Wednesday.
The Daily 202: Why Virginia’s Medicaid expansion is a big deal
by James Hommann - The Washington Post - May 30, 2018
THE BIG IDEA: As Joe Biden put it a little differently when Barack Obama signed the Affordable Care Act eight years ago, Virginia’s expansion of Medicaid on Wednesday is a big dang deal. And not just because 400,000 low-income citizens will now have access to government health insurance.
It’s another nail in the coffin for efforts to repeal Obamacare and a fresh reminder of how difficult it is to scale back any entitlement once it’s created. Many Republicans, in purple and red states alike, concluded that Congress is unlikely to get rid of the law, so they’ve become less willing to take political heat for leaving billions in federal money on the table.
Years of obstruction in the commonwealth gave way because key Republicans from rural areas couldn’t bear to deny coverage for their constituents any longer, moderates wanted to cut a deal and, most of all, Democrats made massive gains in November’s off-year elections.
As President Trump steps up efforts to undermine the law, from repealing the individual mandate to watering down requirements for what needs to be covered in "association health plans," the administration’s willingness to let states impose work requirements on Medicaid recipients has paradoxically given a rationale for Republicans to flip-flop on an issue where they had dug in their heels.
-- Effective Jan. 1, Virginia will join 32 other states and the District in expanding Medicaid coverage under the ACA. There are indications that several more will soon follow.
Maine became the first state to expand Medicaid by ballot initiative last fall, but Republican Gov. Paul LePage has blocked funding for its implementationand continues to fight the will of the voters in court. But he’s term limited and deeply unpopular, and it seems more likely than not that his successor will open the door for 70,000 poor Mainers to get insurance.
Utah will vote on a referendum in November to further expand Medicaid to an additional 150,000 residents. The measure officially qualified for the ballot on Tuesday.
Enough signatures have been submitted to qualify a ballot measure in Idaho. They’re now being reviewed by elections officials to make sure they meet that state’s strict requirements.
Nebraska’s governor opposes Medicaid expansion, but there is a grass-roots campaign underway to get enough signatures to put the measure on the November ballot. Organizers say they’re on track to get what they need before the deadline.
In blue states, meanwhile, Democratic governors are taking steps to protect the expansion. Yesterday in New Jersey, Gov. Phil Murphy (D) signed a law creating an individual mandate for people in his state to offset the repeal of the federal mandate (which was included in the December tax bill). This will help keep insurance markets stable in the Garden State.
-- Expanding Medicaid in Virginia wasn’t easy. Big things never are. Four Senate Republicans defected to allow the measure to pass 23 to 17 in a special session. Then the House of Delegates, which passed its own version of expansion earlier in the year, approved the Senate’s measure 67 to 31.
There were 10 hours of procedural moves in the Virginia capitol on Wednesday. Police had to separate protesters who got into a shouting match. Former senator Rick Santorum (R-Pa.), of all people, even held a news conference to speak out against expansion. The majority leader of the state Senate tried a last-ditch parliamentary gambit to pigeonhole expansion during a Finance Committee hearing on Tuesday. But that was nothing compared to the five years of steadfast GOP obstruction.
“Opposition in the House crumbled after Democrats nearly won control of the chamber in November, amid a blue wave widely viewed as a rebuke to Trump,” Laura Vozzella and Gregory S. Schneider report from Richmond. “A chastened House Speaker M. Kirkland Cox (R-Colonial Heights), seeking to rebrand Republicans as results-oriented pragmatists, came out in favor of expansion if work requirements, co-pays and other conservative strings were attached. In February, 19 of the 51 Republicans in the House joined Democrats to pass a budget bill that expanded Medicaid, apparently concluding that they have more to fear from energized Democrats and independents than from potential primary challengers on the right.”
Easing their evolution was Democratic Gov. Ralph Northam’s assumption of the governorship in January: “The former state senator and lieutenant governor, a soft-spoken pediatrician and former Army doctor once wooed by Republicans, has close friends on both sides of the aisle. His predecessor, Terry McAuliffe (D), tried to expand Medicaid for four years but did not enjoy the same respect and trust from Republicans in Richmond.”
Virginia’s bill requires that most adult recipients who don’t qualify for disability either work or volunteer as a condition of receiving Medicaid.Cox, the Republican speaker, said the Trump administration’s openness to work requirements “was probably the biggest key” in garnering Republican support.
-- Rural conservatives also provided critical support. One of the four Republican senators who supported expansion, Ben Chafin, is a cattle farmer from a rural district where health care is hard to find. “I came to the conclusion that ‘no’ just wasn’t the answer anymore, that doing nothing about the medical conditions, the state of health care in my district, just wasn’t the answer any longer,” he told my colleagues.
The first Republican in the House of Delegates to explicitly endorse expansion was Del. Terry G. Kilgore, the chairman of the powerful House Commerce and Labor Committee. He broke the dam of GOP opposition when he announced in mid-February that the struggling swath of coal country he represents in southwest Virginia would get a desperately needed “hand up” if the uninsured could access Medicaid. “For my district, for my part of the state, it’s the right thing to do,” Kilgore said. Others from poor parts of the state quickly followed his lead.
-- These GOP defectors have experienced few repercussions back home.Americans for Prosperity, a political arm of the network led by the billionaire industrialist Koch brothers, ran ads attacking several of the 19 GOP delegates who voted for expansion in hopes that they would change their minds when the issue came up again in the special session. It showed that the anti-expansion effort was more bark than bite.
In Kilgore’s district, which went heavily for Trump, AFP radio ads broadcast his office phone number and urged people to call. “No calls, no comments,” Kilgore told Vozzella back in March. “I’ve been to Republican mass meetings. I’ve been out and about, ballgames, this and that. What I’ve heard people say is, ‘Hey, what you said made sense. We don’t mind helping people if they’re helping themselves.’”
The milder than expected blowback for those who walked the plank emboldened additional Republicans to break ranks. (To be sure, some of these incumbents might wind up drawing primary challengers in low-turnout 2019 elections.)
-- Another pivotal moment came in early April when state Sen. Frank Wagner (R-Virginia Beach), who unsuccessfully sought the GOP gubernatorial nomination last year and has served a quarter century in the legislature, announced that he had changed his mind. He said he could support Medicaid expansion on two conditions: that recipients not suddenly lose coverage if their earnings rise and that new tax credits be created to help middle-income people who already have insurance but are struggling to pay soaring premiums. Wagner played a key role negotiating the final deal.
“This is not just about helping this group of people,” Wagner said yesterday. “This is about getting out there and helping to bend the cost of health care for every Virginian. … It is the number one issue on our voters’ minds. By golly, it ought to be the number one issue on the General Assembly’s mind.”
-- Some Virginia GOP strategists have been eager to take the Medicaid issue off the table. The most recent credible survey is from Christopher Newport University in January and February, which found that 58 percent of registered Virginia voters supported the expansion while 38 percent opposed it. The survey provided detailed arguments for and against the idea, which can lead to different results than a simple support-oppose question.
That poll corroborated a Quinnipiac University poll in April 2017, which found a similar 59 percent of registered Virginia voters saying a Medicaid an expansion is a “good idea” while 30 percent said it was a “bad idea.” Support was similar, 57 percent, when respondents were told the federal government will cover 90 percent of the costs while the state would cover just 10 percent.
-- Democrats believe they can play offense on health care in 2018 for the first time. Republicans used Obamacare to their advantage in 2010, 2012, 2014 and 2016. But the law has become more popular as the GOP tried to repeal it, and the fear of losing coverage might galvanize lower-propensity voters to turn out in the midterms.
More than half of all ads run by Democratic House candidates since the start of this year have mentioned health care (53.3 percent), according to data from Kantar Media. That’s more than any other issue, including anti-Trump messages (which have appeared in 43 percent of Democratic commercials).
-- Democrats are taking a victory lap after Virginia’s vote last night:
What Virginia’s expansion of Medicaid means
by Jennifer Rubin - The Washington Post - May 31, 2018
The [Virginia] state Senate approved expanding Medicaid to cover 400,000 low-income residents, putting an end to years of Republican intransigence and opposition. As health-care advocate Topher Spiro put it: “This is a major victory that will transform the lives of thousands of families.”Wednesday’s decision is a tribute to the power of voting and the resistance to President Trump, which flipped 15 seats in Virginia’s House of Delegates from Republican to Democrat in last fall’s state elections. The expansion is attached to the state budget, which Gov. Ralph Northam (D) — who campaigned for office last fall on a promise to expand Medicaid in Virginia — is expected to sign as soon as it reaches his desk.
Achieving Medicaid coverage for 400,000 additional people is a mammoth victory for Democrats in a state that has been trending blue for years, but now seems firmly in that party’s column. The vote holds multiple lessons for both parties.
(1) Republicans have made the mistake of treating Medicaid as a budget issue — a piggy bank to be raided — not a health-care issue. They’ve had ample opportunity to reform the program but, aside from a few waivers to allow states to innovate, whenever Medicaid comes up in GOP circles the topic is usually about limiting coverage and cutting cost.
(2) This is a victory for the Affordable Care Act, no question. Obamacare made Medicaid expansion possible and, whatever you think of the efforts by the administration and Congress to chip away at the ACA, an expansion of this size suggests President Barack Obama’s health-care legacy is on firmer footing than Democrats feared when they lost the White House, as well as their majorities in the House and Senate.
(3) This will be a big issue in November when multiple states (Utah, Idaho, Nebraska) will vote on Medicaid expansion, which delights Democrats. Democrats are returning to their bread-and-butter issues (e.g., wage stagnation, lack of access to health care) as they remind voters which party defended the ACA, and which party voted to eliminate it without an adequate replacement. The Medicaid issue will help the Democratic Party turn out its base, which is already pumped up to cast a symbolic vote against Trump.
(4) The Medicaid issue affects nearly every state and federal race. Democrats will argue that Republicans “want to take away health care” while Republicans will be forced to defend their votes and take a stance on expansion. That’s a problem given how popular Medicaid expansion has become. (“A poll conducted late last year by Public Opinion Strategies and the Virginia Hospital and Healthcare Association found 83 percent of the state’s residents supported the expansion, including a majority of self-identified Republicans. . . . Polls show that two thirds of Utah voters support the Medicaid expansion in their state. So it’s unlikely to be close,” The Post report continued.) Meanwhile, Maine’s controversial Republican Gov. Paul LePage is being sued for failure to expand Medicaid after a state referendum approving it passed with 59 percent of the vote.
(5) Virginia will be the 33rd state (along with the District of Columbia) to approve Medicaid expansion. Medicaid expansion appears here to stay, and despite the best efforts of the GOP House and right-wing pundits, has widespread, bipartisan support in every geographic region, with the exception of the Southeast (which includes some of the poorest states) and the Great Plains (although Nebraska and Idaho could join Virginia). “In a nutshell, Medicaid is the absolute star of the Trump presidency despite every effort on their part,” said Andy Slavitt, the former head of Centers for Medicare and Medicaid Services, who served during the Obama administration. “By the end of his term, you could see five more states expand. And there is a tipping point for the hold out states at that point. The irony of course is that this is a far more Democratic idea than exchanges, a Republican idea [originating at the Heritage Foundation].”
(6) For all the talk of democracy’s dysfunction the 2017 elections in Virginia showed how the system worked. Democrats ran on expanding Medicaid, voters overwhelmingly chose Democrats, and now Virginia voters got what they wanted. (By the way, it may surprise political watchers who focus solely on Washington to learn that a lot of state governments are responsive to and demonstrate bipartisan cooperation.)
(7) Democrats are seeking to make health care the top issue in November while Republicans want to wave the bloody shirt on immigration (which will hurt them in states with large numbers of Hispanic voters) and to tout tax reform (which has not impressed many voters). Democrats have the advantage on the issue mix — and likely should heed House Minority Leader Nancy Pelosi (D-Calif.), who warned to talk about health care and jobs, not Russia and impeachment.
Editor's Note:
People power seems to work - at least in Virginia. Let's keep it up, and expand it to other states.
-SPC
The Plot Against Health Care
by Paul Krugman - NYT - May 31, 2018
On Wednesday, Virginia’s legislature voted to expand Medicaid, accepting a key piece of the Affordable Care Act. Around 400,000 people will gain coverage.
The politics of the move aren’t hard to understand. Virginians overwhelmingly support Medicaid expansion; last fall, Democrat Ralph Northam won the governorship by a landslide after a campaign largely focused on health care. But wait: Don’t we keep hearing that Democrats are running on nothing except opposition to Trump? Hey, influential commentators say it, so it must be true.
Anyway, the will of the people on health care is clear: Whatever qualms voters may have had about Obamacare, a strong majority want to keep and expand the gains in coverage that America has achieved since the law went into effect.
On the surface, these stories may seem contradictory. Expanding health coverage is a winning issue for Democrats; trying to take it away is a losing issue for Republicans. Why would the G.O.P. want to keep charging into that buzz saw?
But the growing popularity of key parts of Obamacare is precisely the reason Republicans are highly likely to make a last-ditch effort to kill the A.C.A. For them, it’s now or never.
Here’s what history tells us: Expansions of the social safety net are relatively easy to demonize before they happen — before people get to see what they actually do. Opponents declare that they’ll destroy freedom, that they’ll be wildly expensive, that they’ll be a national disaster. American politics being what it is, opponents of a stronger safety net also tap into racial resentment, convincing white voters that new programs will benefit only Those People.
Once social programs have been in effect for a while, however, and it turns out that they neither turn America into a hellscape nor break the budget — and also that they end up helping people of all races — they become part of the fabric of American life, and very hard to reverse.
This has happened again and again. When F.D.R. famously spoke about his opponents and declared, “I welcome their hatred,” he was talking about Republican demonization of the just-passed Social Security Act. But eventually Social Security became effectively untouchable, as George W. Bush learned when he tried to privatize it in 2005.
Medicare went through the same cycle. Before it was enacted, Ronald Reagan warned that it would bring socialism and “invade every area of freedom as we have known it in this country.” Today, Medicare has overwhelming public support, so much so that Republicans attacked the A.C.A. with the (false) claim that it would steal money from Medicare.
And this gets at the heart of conservative opposition to social safety-net programs: It’s not about the belief that they will fail, but about fear that they will succeed, and in so doing become irreversible — which means that they must be stopped before they can start showing results.
So it has been with Obamacare. Before 2014, when the program went fully into effect, conservatives were quite successful at turning public opinion against it. It would lead to “death panels”; it would lead to “rate shock”; it would cause the budget deficit to balloon.
But public opinion has shown a steady turnaround since then. The share of voters believing that it’s the government’s responsibility to ensure that all Americans have health coverage has shot up since its 2014 nadir. Approval of the A.C.A., while still not overwhelming, has shown a more or less steady upward trend.
When Republicans held town halls over A.C.A. repeal last year, they were shocked by the intensity of public opposition. And elections, both state elections like Virginia’s and special elections for Congress, keep showing that trying to roll back coverage is a big political loser.
Again, you might think this would lead the G.O.P. to drop the whole issue. And if Republicans lose the House this November, they probably will, and America will become like every other advanced country: a society in which access to essential health care is considered a basic right.
But that hasn’t happened yet; conservatives still cling to the dream of denying health care to another 20 million or 30 million Americans.
Unable to repeal the A.C.A. outright, they’ve tried to sabotage it — using last year’s tax cut to get rid of the requirement that people buy insurance even if they’re currently healthy, using administrative gimmicks to try to undermine the requirement that insurers cover people with pre-existing conditions. But the A.C.A. is proving, from their point of view, annoyingly robust; and most indications are that voters are, rightly, blaming Republicans for rising premiums.
So it’s looking as if Republicans won’t manage to kill health care on the sly. And that means that we can expect one final push at outright repeal — a push that will succeed if Republicans hold the House.
https://www.nytimes.com/2018/05/31/opinion/republicans-health-care.html
MAURICE A. JONES, NEW YORK
Lagging on Health Care
Letter to the Editor - NYT - May 31, 2018
To the Editor:
“Medical Mystery: Something Happened to U.S. Health Spending After 1980” (The Upshot, nytimes.com, May 14) offers several explanations for why Americans have poorer health than people in other wealthy countries, despite paying more for their care.
The strongest explanation for why the United States lags its peers is its underinvestment in basic human needs like housing, education and good jobs, which are the primary predictors of life expectancy.
Progressive hospitals are addressing these needs, both driving improvements in patient health and cutting costs. ProMedica Health System in Toledo is connecting its hungry patients to healthy food, helping to slash clients’ hospital readmission rates by 53 percent in 2016.
And now it is linking arms with my organization, LISC, to invest $45 million in a hard-hit neighborhood to build quality housing, spur the local economy and increase access to good jobs.
MAURICE A. JONES, NEW YORK
The writer is chief executive and president of the Local Initiatives Support Corp.
