A One Man Think Tank

As of June 28, the American public’s opinion of the GOP Senators’ health care plans is starkly negative. In three separate polls, only 12-17% approve of the plan and 53-58% disapprove or think the ACA should be left alone or tweaked.

With such a strong condemnation of the process and plan, you might think that Republican lawmakers will listen to the electorate and work on a health care plan that the voters want. There are a few Republican senators who are openly calling for the bipartisan approach, but they are very much in the minority.

So why are so many Republican senators ignoring the wishes of the voters and trying to push through a Republican-only health care plan which gives $700 billion in tax breaks primarily to the wealthy while kicking about 15 million people out of Medicaid? Oddly enough, they are listening to the voters – they’re listening to their primary voters and the big money on the far right.

Just ask Senator Dean Heller of Nevada. The day after the release of the Senate GOP bill, the Better Care Reconciliation Act or BCRA, he stated that he would not support the proposed legislation in its current form. Mr. Heller explained that the BCRA would not protect the most vulnerable in Nevada – the elderly, those with mental health and substance abuse issues, and people with disabilities. He noted that half of the Medicaid expansion money goes to pay for mental health and opioid addiction treatment.

The response from the right to Mr. Heller’s reasoned arguments was swift. The political action committee (PAC) America First Policies – which was founded and is run by top Trump campaign officials – launched a TV, radio and social media campaign attacking the Senator. The TV ads claimed that now that there is “a chance to repeal and replace Obamacare with patient-centered care that protects American families, Sen. Dean Heller is saying ‘No.’”

The radio and social media ads went further accusing Mr. Heller of saying  “‘No’ to tax cuts to help small business, ‘No’ to ending Obamacare penalties, and ‘No’ to families who can’t afford to see the doctor of their choice.” Per Political, “over the weekend, America First Policies launched an aggressive digital campaign deriding the senator as a liar, labeling his behavior ‘unacceptable,’ and even likening him to House Minority Leader Nancy Pelosi, a reviled figure in conservative circles.”

The reported $1.3 million campaign by the PAC against the senator was cut short by outrage and complaints from the vast majority of Republican senators. The program stopped after senators complained to White House officials over the weekend and to the president on Tuesday, but the message was clear to Sen. Heller. The attack reminded him of The Godfather movies, and in that spirit he reportedly told the Senate Majority Leader, “It’s going to be very difficult to get me to a yes …have to make us an offer we can’t refuse, me and the governor.”

So even though 3 to 5 times as many people disapprove of the Republican health care plans than approve, most GOP lawmakers are not worried. The threat from the right in a primary election is much more of a concern than a large disapproval rate in the general election. Due to gerrymandering, only a small percentage of districts in the House of Representatives are competitive. For more than 90% of the candidates in safe Republican districts, they will be re-elected as long as they survive the primary.

Senate elections are statewide, but most states are predictable in whether their senators are Republican or Democrat. For those in purple states – those who sometimes elect Republican senators and sometimes go for Democrats – the senators need to be more moderate. Nevada is one of those states and Mr. Heller must be more centrist to retain his seat in next year’s election. A far right candidate is less likely to win the primary election because that candidate would be less likely to win in the statewide general election. As a result, Sen. Heller can weather the attack from America First Priorities and make a Godfather reference about it.

The majority of Republican senators, however, fear a primary challenge from the right and will not concern themselves with that 56% disapproval rate with respect to the BCRA.

It’s politics, not doing the best for the American people.

It’s politics, not making sure there is enough money for nursing home care for the elderly.

It’s politics, not protecting rural hospitals from an onslaught of uninsured patients who have no other options than the emergency room.

It’s politics, not worsening the national debt by giving $700 billion in tax breaks – more than two-thirds to those making more than $220,000/year and nearly 45% to those making more than $500,000/year.

It’s just politics, and the risk of not keeping the campaign promise to repeal and replace Obamacare is a much more insidious threat to Republican lawmakers than having the majority of the nation disapprove of your actions. And that is why opinion polls don’t matter to our elected officials.

It seems like a good time to have a viable, centrist third party in the United States.

Quick one – the numbers speak for themselves. Per the Congressional Budget Office (CBO) analysis, versus the current law (the Affordable Care Act or Obamacare), the Senate Republicans’ Better Care Reconciliation Act of 2017, would:

• leave 22 million fewer people with medical insurance in 10 years,
• cut about $700 billion in taxes (with nearly 45% of the tax cuts go to the top 1% of income, that is making more than $875,000 per year), and
• reduce the cumulative federal deficit by a total of $321 billion over the next ten years,
• premiums would drop because insurance plans would be skimpier and 50-64 year-olds will drop out of the market,
• even with lower premiums, most people would pay more for insurance coverage because there would be less financial help and their deductibles will be higher.

Yes, that’s right. Reduce the growth in federal debt by $321 billion while giving more than twice that in tax cuts, primarily to the wealthy.

How? By cutting health care to the majority of Americans (less Medicaid which mostly goes to seniors and the disabled and less help paying premiums).

This makes no sense. The Republicans seem to be saying that only the wealthy people in this country matter.

A ray of hope today though. Susan Collins, the least conservative Republican in the senate, tweeted: “I want to work w/ my GOP & Dem colleagues to fix the flaws in ACA. CBO analysis shows Senate bill won’t do it. I will vote no on mtp.”

That’s what should have been the plan all along – a bipartisan approach to do the best thing for the most Americans. Thank you, Susan Collins.

… or person with special needs, or pre-existing condition, or lady parts.

I can’t understand what’s going on in Congress these days. The House and Senate Republicans’ healthcare bills send a clear message that unless you have a lot of money, you are not worthy. You’re not worthy of support, you’re not worthy of preventative healthcare, you’re not worthy of living longer. The healthcare bills cut taxes on the rich and gut Medicaid and their supporters are attempting to sell it as a good thing.

And it may be working.

The Republicans have a long track record of framing issues in such a way that people who are harmed by a policy support it anyway. They have been sold on the idea that they will benefit from the policy.

A good example is “tax relief.” That phrase has been used for decades as a way to cut taxes which greatly benefit the wealthy and harm the middle class and poor. For the middle class, they see a few hundred or thousand extra dollars in their net pay over a year and think they are winners, but then they complain about bad roads, poor schools and incompetent staff at the VA. They don’t seem to make the connection that the vast majority of the tax cuts went to the rich and for them, a car repair from bad roads won’t break the bank, there are many good private schools to send the kids, and they don’t really need VA benefits, even for the few who are entitled.

So how are the Republicans framing their healthcare bills?

Health and Human Services Secretary Tom Price: “Nobody will fall through the cracks, nobody will have the rug pulled from under them. We believe we’ll get more individuals covered than are covered now.”

Sen. John Thune (SD): “We’ve got to be able to make Medicaid sustainable, which it’s not today, and give states flexibility to design plans that work better for their populations but that don’t pull the rug out from people who really, really need help.”

Sen. Ron Johnson (WI): “We are mortgaging our children’s future. A compassionate society doesn’t impoverish future generations for benefits in the here and now.” (Sen. Johnson is not in support of the bill as proposed, but wants to include additional cuts in federal healthcare spending.)

In brief, the Republicans frame the message as (1) Obamacare is failing, (2) We spend too much on healthcare, (3) States know better than the federal government, and (4) “Trust us – nobody will fall through the cracks.”

The Democratic response is (1) It hasn’t been Obamacare since Trump was elected and told insurers he would cut support, (2) Then why does the bill give a $765 billion tax break to the wealthy (mostly), (3) Really? States will be able to care for many more people with much less money?, and (4) Are you kidding me?

See how much better Republicans are at framing the message?

Because the Republican healthcare bills provide hundreds of billions of dollars in tax breaks primarily to the wealthy (40% to the top 1%) and cut Medicaid by billions of dollars, they are a hardship for tens of millions, but they are a death sentence for those in nursing homes and other long-term care facilities. Only 6% of Medicaid enrollees use these services, but they account for 42% of all Medicaid spending.

If you were coldhearted, the decision is easy – get rid of those who use expensive services. Kill off the elderly poor, the disabled poor, the poor with cancer, diabetes or kidney disease. You don’t have to get your own hands dirty. If you’re a member of Congress, all you have to do is pass these healthcare bills. That will cut the funds that keep these people alive, and in the process, you’ll improve the social security trust fund’s health because there will be fewer payees. It seems that these healthcare bills are a win-win for Republicans in Congress.

And they can pass the blame. It’s the states’ fault for not using the money better. It’s the patients’ fault for not living a better quality of life which may have kept them from getting cancer, diabetes or old. It’s the Democrats fault. The Republicans don’t really need to justify why it’s the Democrats fault – it’s just what they say these days – “Democrats are obstructionists toward this legislation” (in which we didn’t even want them involved, but don’t say that part out loud.) Strange times indeed.

Since Donald Trump’s election, my wife has wondered on several occasions whether we should consider moving to another country because most actions planned by Congress and the president will harm the country in the long term. For six months I have answered that while income and wealth inequality is bad for the country as a whole, we are on the better side of the divide. I have even suggested early retirement in Sedona, AZ, where we would go hiking and play golf every day as a better alternative to moving to another country.

But these Republican healthcare bills are changing my mind. They are an attack on old people and I hope to be old one day. If the U.S. has a healthcare policy engineered to kill you off once you reach a certain age and have less than a certain level of assets, that is scary. Not just a policy – the Republicans are intent on getting this written into federal law. Canada is looking pretty good right about now. I should start learning French.

Many people believe that refugees & immigrants work harder than native born Americans. There’s anecdotal evidence in the form of stories about immigrant doctors who work two menial labor jobs to support their families and reports that immigrants do the difficult jobs that Americans don’t want.

The theory goes that once you have lost everything in your old life and have a chance to start over (refugees), you throw everything you have into it so your children will have the best chance to succeed in America. Or, once you have gotten the opportunity to live and work in the United States (immigrants, documented or undocumented), you exploit that opportunity to the fullest in order to give your family – home and abroad – the money they need to get ahead. And it works. The children of immigrants learn more at school and make a much better transition to college and adulthood than native born Americans.

Refugees and immigrants have two different motivations. Refugees had a stable life and lost it, then were offered the chance to start over in another country. Immigrants saw the beacon of the United States as the Promised Land – a place full of riches available for those willing to work for them. While the motivations are different, the effect is the same – hard workers willing to do the jobs that we native born Americans don’t want to touch.

History gives us a domestic parallel. The Great Migration describes the movement of more than six million African-Americans from the South to the North and West between 1915 and 1970. In her introduction of author Isabel Wilkerson, Terry gross of NPR’s “Fresh Air” put it this way:

“The decision was to stay in the South’s segregated caste system or make the pilgrimage North or West in the hope of escaping racism and having more access to jobs, housing and other opportunities.”

Ms. Wilkerson wrote about the Great Migration in The Warmth of Other Suns.

A class of people who had been promised certain rights but been denied again and again was tempted to pick up and move in order to improve their lives. More than six million did so, and it changed everything. As Ms. Wilkerson puts it, “The suburbanization and the ghettos that were created as a result of the limits of where [African-Americans] could live in the North [still exist today.] And … the South was forced to change, in part because they were losing such a large part of their workforce through the Great Migration.”

The next domestic migration may begin soon and it will be prompted by Republican policies to grant more power to the states and limit federal oversight of many programs. This is hardly a secret. President Trump, his advisors and his cabinet all express this desire as do the vast majority of Republicans in Congress. They want to put the states in charge of deciding what to teach students, how many people to insure through Medicaid, how to implement environment policies, how to allow businesses to operate (wages, worker safety, waste disposal, etc.). And the Republicans want the states to decide how to treat women.

In many conservative states, there seems to be a bias against women who do not conform to widely held beliefs of appropriate behavior. If Roe v. Wade is overturned by an increasingly conservative Supreme Court – once thought impossible, but now probable in the next 5-10 years – most of those states would outlaw abortion. Even though they would force a single mother to have a child she is unable to support on her own, those states would also likely increase the burden of being a single mother by cutting or limiting assistance to social support programs.

And then there is the animosity directed toward women in some of these states. A physically abused woman seeking a restraining order to protect herself is arrested in the courthouse in El Paso, Texas and deported. There are only 18 domestic violence shelters in the 46 counties of South Carolina, the state with the highest murder rate of women by men. The map below shows the per capita murder rate of women for 2013. A darker color represents a higher murder rate (no data available for Florida and Washington, D.C.). Many conservative states seem to have a high murder rate of women, and most of these murders are at the hands of the woman’s husband or partner.

Finally, let’s not forget that prior to the Affordable Care Act (ACA), Viagra was covered under most health insurance plans, but birth control was not. The Republican replacement plan is likely to strip out the ACA’s ten essential benefits requirement which mandates that insurance plans cover, among other things, birth control, pregnancy, maternity and newborn care. More women-centered services will be lost with the Republicans’ repeal and replacement than men’s services.

Remember that this is a states’ rights push. Some states will strip these coverages, and others will keep them as a requirement. Some will have a rigorous curriculum for their students and others will ‘dumb down’ graduation requirements to push students through the system. Some states will have strong support for special needs students and others will do as Texas does now – limit the number of special needs students allowed to receive benefits by picking an arbitrary maximum percentage regardless of need.

And some states will adopt a ‘good old boy’ attitude toward domestic violence and discrimination and other states will have strong protections for women in the workplace and in the home.

So will women make up the next Great Migration? If the states in which they live become hostile, the answer could certainly be yes. We very well could find a movement from the South and rural West to the more populated centers in the country which generally provide better support for women’s issues. Some may move from rural areas to cities within the same state because they may find more support there, but if the state takes legislative action to restrict local governmental control, that may not be far enough. (Not exactly a ‘women’s issue,’ but when Flagstaff was considering a ban on plastic bags, the Arizona state government passed a law stripping such control from local government.)

Remember that just as with refugees, women will have lost rights and privileges they once had, and just like immigrants, women will see the Promised Land – in this case it’s the places in the country which offer better support for their needs. That is what drives people to move, and once it begins in tentative steps, it will likely grow quickly.

Companies will have a dilemma on their hands. While conservative states are more likely to allow companies to pay low wages, pollute the air and water, have unsafe work conditions, and other ‘business friendly’ situations, the potential migration of the women (and the men who will follow them because that’s where the women are), plus a potentially inadequate education system may make expanding operations in these states a poor business decision. This is especially true in a growing economy with fewer desperate job applicants.

Businesses are perhaps better off expanding where the workers are going to be, and that is likely where the local economies have been doing well since 2012 or so – midsize and large cities along the west and east coasts of the country. There are pockets of strength in many cities throughout the country, but few in rural areas which are so dependent on government assistance. Under Republican plans, those rural areas are likely to suffer more, especially if many of the women migrate to places in which they feel better supported and protected.